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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 i n the Child Guidance Clinic at Vancouver.  by ESTELLE CHRISTINE CHAVE  Thesis Submitted i n 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 Work s  School of Social Work  1952  The University of British Columbia  ABSTRACT The procedure known as the pre-clinical.conference i s uBed routinely as a diagnostic screen i n 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 i n Canadian.mental health clinics giving service to-children. In the Child Guidance Clinic at Vancouver, the procedure 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 i n which i t was not - to throw light on the purposes and results of the procedure. The background survey showed a wide variation i n pre-clinical procedures in Canadian mental health clinics. A small.minority used a conference of the f u l l team, i n 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 i n 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 f i e l d on the integration of professional skills and service. Conferencing is an important way i n which this principle i s implemented, and pre-clinical conferencing, an extension of the method, i s a further possible means of translating this principle into practice. The f i r s t 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 f i r s t 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 f a c i l i t a t i o n 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 screening i s held to represent the ideal practice, i t was seen to be unnecessary i n some clinics, impracticable i n 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 i n the Vancouver Clinic, where i t i s 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 indications for use of the.procedure and awareness of the desirability of extending its use, where possible, i n 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 f i e l d . The National Committee for Mental Hygiene and i t s programme. The structure, and function of the Child Guidance Clinic to-day. The conference 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 i n particular. The pre-clinical conference and its possible uses. The various personnel combinations i n 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 preclinical conferencing in these cases. Chapter 5.  The Pre-Olinical Conference Omitted  An analysis of three representative cases from the Vancouver Child Guidance Clinic, i n which pre-clinical conferencing was indicated but not implemented. Possible uses and results in each case had there been prec l i n i c a l conferencing. Chapter 6.  Conclusions and Implications  Comparisons with other studies. The concept of integration. trends. Recommendations for future goals.  Current  Appendices: A. B. C. D.  List of Canadian Mental Health Clinics canvassed i n the study. Questionnaire and covering letter used in the study. Some.extracts from letters in reply to questionnaire. Schedule used for case analysis. Bibliography.  iii TABLES IN THE TEXT Page Table  1.  Pre-clinical procedures i n Canadian practice  Table  2.  Uses and results of the pre-clinical conference  15, 16' 55  ACKNOWLEDGEMENTS  I wish to acknowledge my indebtedness to Dr. U.P. Byrne, Director of the Child Guidance Clinic, for permission to u t i l i z e 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, i s made of the helpfulness of Dr. L.C. Marsh, Mrs. Helen Exner, and other members of the Faculty of the School of Social Work.  vi  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 "nervous , or the delinquent child. 11  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 aggravated 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 f i e l d 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 c l i n i c .  "Historic-  ally, the f i r s t 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 r e a l i z e d . " ^  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 f i r s t 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 i t s "house was built upon the rock" of the principle of multiple causation. b r i l l i a n t and generous lay person, Mrs. W.F. credit for this development.  To a  Dummer, must be given much of the  She drew together a psychiatrist, Dr. Adolf  Meyer, and two social workers, Julia Lathrop and Allen Bums, to launch the f i r s t organized attempt at a child guidance c l i n i c .  This resulted in their  enlisting the services of Dr. William Healy, a psychiatrist, and Dr. Augusta Bronner, a psychologist, to found the f i r s t real child guidance c l i n i c , the (1) (2)  Martin L. Reymert, "The organization and Administration of a Child Guidance Clinic, in Handbook of Child Guidance, edited by Ernest Harms, 1947, p. 225. 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 i t s great strength and firm foundation.  Both of these clinics had been set up as ancillary to juvenile  It was hot surprising then, that, in 1910, the National Committee  courts.  for Mental Hygiene formed a Division on the Prevention of Delinquency, and set up an Advisory Committee to further i t s 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 f i e l d service.  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. follows:  Reymert describes these developments as  "... 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 f i r s t 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 i n one city after another a l l over the country and one was started, i n Canada.  They gathered  valuable experience i n the formulation of function,.. organization and administration. (5)  While these varied from community to community, some general statements  Reymert, op. c i t . p.228.  4 about these developments are possible.  The child guidance c l i n i c has come to  be the "out-of-hospital" manifestation of the mental health service for children that i s , the child guidance clinic is community-oriented.  Its functions are  basically threefold: the f i r s t 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 i s 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 f a c i l i t i e s , and (5) the education of the general population as to basic implications of mental health i n daily l i f e .  The child guidance c l i n i c treatment  programme is geared to deal with beginning behavior, habit and personality problems 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 c l i n i c operates under  the directorship of a psychiatrist, although, in most clinics, the administrative responsibility i s 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 s k i l l s to bear as needed i n 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 i n the child (4)  Actually i t i s possible to distinguish three types of clinics: the child guidance clinic (with i t s multi-disciplined approach), the mental health clinic (with i t s preventive, public health approach), and the psychiatric clinic (with f a c i l i t i e s for severely psychopathological cases). In this thesis the- f i r s t two types are given most consideration, and the terms "clinic", "child guidance c l i n i c " , and "mental health c l i n i c " are, for the most part, used interchangeably.  guidance setting.  It is generally used following the f u l l c l i n i c a l 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 project is that there appears to be some reason to ask whether i t s 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 i n initiating, enabling, fostering and maintaining 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?  I t has already  been used i n some child guidance clinics pre-clinically - that i s , i t has been found.to serve useful purposes when utilized before the f u l l c l i n i c a l 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 service, and to make the corollary decisions as to the types of examinations advisable, thus facilitating the economical use of the clinic's resources. too,  Then,  i n view of the fact that treatment is generally seen as beginning with the  client's f i r s t contact with the clinic,, the. team can jointly consider the handling of d i f f i c u l t cases during the period of work-up i n preparation for c l i n i c a l examination.  Utilized i n 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 i s used occasionally i n the Vancouver Child Guidance Clinic.  This sometimes takes the shape of a f u 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 i n reference to an isolated case. this practice be extended and improved?  The question i s : should  Would i t not result i n better service  to client and community, and in the saving of time, energy and money to the agency?  Conversely, i s i t not likely that, i n the absence of. the use of the  pre-clinical conference, there are certain hazards which may result i n damage to the client?  In relation to intake and the selection of cases, the process  of.possible referral of the client to another agency i s 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 i s 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, i n addition, may result i n actual damage t o 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 treatment planning. The research methodology used i n this study included a preliminary survey of the extent of the use of the pre-clinical conference i n Canadian practice. This was achieved by means of a questionnaire addressed to 20 Canadian mental health clinics giving service to children. (Example i n Appendix A)  In  addition, 12 cases were, analysed to exemplify and illustrate the use of a prec l i n i c a l 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 f i l e s of the Vancouver Child Guidance C l i n i c .  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 i n Canadian practice was carried put by means of a questionnaire. A l i s t of mental health clinics i n Canada, as of November, l ° 5 l > from the Canadian Mental Health Association.  w a s  obtained  Clinics to which the questionnaires  were addressed, were selected on the basis of the descriptive information included i n the C.M.H.A. l i s t , which indicated whether or not services to children constituted a l l or part of the clinic's work.  Questionnaires were also sent to  certain provincial public health o f f i c i a l s in order to ensure complete coverage of government-sponsored c l i n i c s .  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 i n Newfoundland."  It vras already known, that there were no mental  health clinics i n New Brunswick or Prince Edward Island.  In sum, this means  that there are mental health clinics giving services to children i n seven of the ten provinces. The number of these clinics i n each province varies considerably, and i s d i f f i c u l t 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 transpired that they were one and the same c l i n i c , in which the provincial Department 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 i n this study, therefore, refers to English-speaking, stationary mental health clinics giving service to children. of which 17 returned completed forms*  These make up a group of 20 clinics,  Of these-> two are i n B.C., two i n  Alberta, two in Saskatchewan, one i n 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 treasuries.  It is interesting that none i s 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 a b i l i t y to be fairly selective in accepting cases.  It i s 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, i n two cases, screening.was accomplished by the referring.agencies, and i n one case, considerations 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 i n the questionnaire.  Of these> one stated that, i n addition to agency policy and  function and diagnostic criteria, i t s 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 i t s 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 intake, but i t would seem that this i s impossible because of other factors which affect both the need and the ability to be selective.  The c l i n i c  mentioned above as extremely selective, i s able to be so partly because i t is situated in a city (Toronto) i n 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 c l i n i c giving service to children in its own city, and the only such c l i n i c 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 - i n some cases by school personnel such as. public health doctors and nurses, and by teachers, i n other cases, by other social agencies. I n i t i a l intake procedures, with particular regard to the specific  10 personnel responsible for them, formed the next point of inquiry i n thequestionnaire.  I t 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 i n this setting, "intake procedures do not play a role." two items.  Three clinics checked  It is interesting that, while the trend is toward the use of a  social worker for the f i r s t 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 i n 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 c l i n i c 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 c l i n i c used a physician, while another screened through the general outpatient psychiatric c l i n i c .  S t i l l another c l i n i c 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. were four clinics which did not use the procedure at a l l .  There  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 i n 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 f u l l team conference on a l l cases.  Only one c l i n i c used a  conference of social workers only, and that only i n selected cases.  Since four  clinics checked two items, i t follows that some sort of pre-clinical conference is used to some extent i n 1J clinics, while none at a l l i s used i n four.  Of  these four, one is a guidance c l i n i c where source of referral takes care of screening, one is., a hospital c l i n i c where cases are referred from the general outpatient psychiatric c l i n i c , one i s a civic public health c l i n i c where the referring source screens, and the last i s the juvenile court c l i n i c "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 i n 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 i n the appropriate categories.  12  extent is barely more than half.  The phrase, "to some extent", i s 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 i n selected cases•(roughly one and a half times more often) i n 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.  I t 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 i n 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 l i e around referral to or from other agencies, since seven clinics used the conference for this purpose i n selected cases-, and three i n a l l cases.  There were six  clinics.which stated that they used the pre-clinical conference for case selection only i n 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 i n 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 i n each category except one, (allocation of. diagnostic responsibilities).  Once more, the phrase, "to some extent", i s 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 i n 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  i s . f a i r l y 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 i s 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 c l i n i c .  Also, i t  has been usual, at least for the last few years, that the Clinic has been i n 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 i n the i n i t i a l 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 preclinically, the Vancouver Clinic, using this method in selected cases-only, is i n a middle-of-the-road position.  In relation to the extent of pre-  c l i n i c a l 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 i n the middle group of one-third to one-half of the clinics in the study which prefer to take or leave the prec l i n i c a l conference according to what may be their own needs or their own inclinations.^^ The following i s 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  TABLE 1. A.  5  PRE-CLINICAL PROCEDURES"IN CANADIAN CLINICS  CRITERIA FOR LIMITATION OF INTAKE Frequency Budgett Agency policy and function Diagnostic criteria Other (see text) Total (a)  -  10 2 27  (a)10 clinics reported intake limited by 2 criteria PERSONNEL CONDUCTING INITIAL' INTAKE INTERVIEW  ' o  Receptionist Stenographer Nurse Social Worker None Other (see text) ,  , *  . . . . . . . . . . . .  l  5 ll l .f.o\  . it P of l +W. f lll  ..  4  . oc\  (a)5 clinics reported using 2 types of personnel C. USE OF SOCIAL WORKERS FOR INTAKE SCREENING In .all .In selected ' ' Method cases cases only Special intake worker Social, v/orkers i n rotation Social work staff committee Other personnel Total (a) • • (a)  ..  ..  x  5 1 6 11  Total  1 2 . 0 0  "2 ' 5  5  14  l  6  clinics did no intake screening at a l l  COMPOSITION AND USE OF THE PRE-CLINICAL CONFERENCE Personnel Full team, a l l ..disciplines Partial team, 2 or 5 disciplines Social workers only Two of the above (a) Total (b)  In a l l cases  In selected cases only  Total  2  1  5  5 0 1  2 1 5  5 1  6  7  15  h,  (a) Of the 4 clinics checking- 2 items, 1 used a partial team i n a l l cases, and a f u l l team i n selected cases, and 5 clinics used a f u l l team i n selected cases and a partial team i n selected cases. (b) 4 clinics used no pre-clinical conferences at a l l .  16  E.  EXTENT OF PRE-CLINICAL CONFERENCING FOR SPECIFIC PURPOSES In a l l . In selected cases cases only  Purpose Selection of cases Referral to or from other agencies Planning diagnostic study and exploration Allocation of diagnostic responsibilities Delineation of tentative treatment plan Several of the above (a) Total  (b)  Total  0  0  0 '  1  0  1  0  0  0  0  0  0  0 10  0 12  10  15  0 2  '  5  (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 i s i n c l uded i n 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 In a l l cases  Purpose Selection of cases Referral to or from other agencies Planning diagnostic study and exploration Allocation of diagnostic responsibilities Delineation of tentative treatment plan Total  In selected cases only  Total (a)  2  6  8  5 .  7  10  2  8  10  0  5  5  1  8  9  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 i n social work has apparently come to be taken for granted, or at least taken as corollary to the team concept.  I f 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 c l i n i c a l examination of the child, but i s 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 teamwork and without which i t breaks down.  The formal conference as a technique,  of course, i s not limited to the c l i n i c a l setting;  i t i s 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 i n  the child guidance setting and, for this reason, i t w i l l be also considered i n this study. Child guidance clinic practice was responsible i n 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 integrating, and has articulated through i t s philosophy, the dynamic reasons under-  18 lying the success of the conference method.  I t i s 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 democraticprinciples 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 c l i n i c a l team ...  Members of the clinical team in the psychiatric hospital or mental  health clinic are constantly engaged i n a group process through which interaction, 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 administrative process i n social work.  Harleigh B. Trecker, a leader i n the group  work f i e l d , 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 organizational 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 i s concerned.  Here Mary Follett's  words become most meaningful : "The object of a committee meeting is f i r s t 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 w i l l 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 i n 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 i t s parts, and i t s 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 i t s democratic implications and greater productiveness, became a part of child guidance clinic practice earlier than i n other settings.  Stevenson.and Smith observed i n 19 h: y  "The conference enables each worker to interpret his own findings i n 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 i s 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 i n Boston and Chicago, from earlier services i n the same f i e l d , was not the introduction of new scientific data or treatment technique; i t was the bringing together of three professions i n a working combination. The capacity to cooperate was an essential qualification i n 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 i n which the contribution of each profession should be merged." It i s 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 i n many medical or psychiatric  (10) Steveriedri arid Smith, Child Guidance Clinics, Development, 1924, pp. 87, 109.  A Quarter Century of  20 clinics, or hospital settings, only l i p 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 I t i s the collaboration of equals - or integrated, i n 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 d i f f i c u l t to combine this function with that of a professional person contributing to the group process i n 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, i n some clinics, at the social worker's discretion.  The development of  the team concept was given impetus, however, by forward-looking field.  leaders in the  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 i n a structured social situation, a part of an organic social group, who is involved at a l l times i n 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 important 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 composing 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 i n other ways. .^^ n  The G-roup for the Advance-  ment of Psychiatry describes the team concept i n the following words:"Separate professional disciplines in the same place do not i n 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.  I t 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 i n the interest of patients. "(15)  Conferencing has been considered i n 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 i t s e l f , because i t i s , 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 i t s added productiveness directly proportionate to i t s democratic methods, and at group process.as i t operates specifically in administration 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. c i t . p. 1.  22 concepts of teamwork and group process in the c l i n i c a l setting - particularly in the child guidance c l i n i c .  To paraphrase-the observation of the Group for  the Advancement of Psychiatry that "Separate professional disciplines in the same place do not i n themselves make-a c l i n i c team, " - a clinic team does not in i t s e l f 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 i s 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 w i l l try to separate out specifically,, and to identify, the possible uses, and results of the use, of a pre-clinical conference i n selected illustrative cases. The term "pre-clinical-conference", therefore, w i l l 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 w i l l 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 i n 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 i n this study.  In actual practice, however, because of the social  worker s responsibilities in the. intake process, the pre-clinical conference 1  usually includes a l l three, or else the social worker and either the psychiat r i s t or the psychologist, i n 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 i n 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 prec l i n i c a l conference :  1.  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.  Intake and case selection Despite certain variation i n practice, the main body of professional  opinion supports the use of the psychiatric social worker to conduct the i n i 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 i n teaching clinics, the psychiatrist i s sometimes delegated. Usually, however, the psychiatric social worker represents the c l i n i c 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 psychiatric c l i n i c .  It is the concern of the entire clinic team, a l l of whose members  participate i n 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. (^' ) Witmer ,,  7  enlarges on this idea that intake "is the concern of the entire c l i n i c team", when she says : "It was - and s t i l l i s - customary i n child guidance clinics to (16) (17)  Ibid., p.2. Ibid., p.2.  24  have a case vrorker discuss with each applicant the nature of the child s 1  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 i s 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 i n 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 i s also part of the Mental Health Services which are taxsupported) - "The Institute i s an organization supported by the tax payers of I l l i n o i s and as such i t s services are available to a l l persons living i n Illinois.  For many years there have been more applications for examinations  than the Institute has been able to meet.promptly. been a waiting l i s t .  For many years there has  However, i f there were no more plan i n the making of  appointments than a system of f i r s t come, f i r s t served, many treatable children suffering serious maladjustments would be neglected in order to make possible the examination of t r i 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 i s evident that the case for  pre-clinical conferencing at intake has f a i r l y 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 i s a physical and economic impossibility for the c l i n i c . " ( ^ )  They add, "One of the f i r s t  2  and most c r i t i c a l of the problems which the child guidance c l i n i c must face is the selection of cases.  Out of all.the numberless children who might con-  ceivably benefit by service from the c l i n i c only a few can be studied or treated.  The clinic may block i t s 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 i t s own staff work which might be done equally well or better by other agencies. "(22)  They add : "It i s 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 c l i n i c in the  community is that of special consultant to other agencies maintaining primary contacts with the child population. agencies and pediatricians." (^5}  It complements schools, courts, social  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 c l i n i c operates, and the source of i t s 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 i s often faced with applications for service clearly beyond i t s . function, i . e . cases, i n which the need for legal protection of the child i s 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 proceedings and the c l i n i c a l 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 i n 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 f i e l d .  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 f u 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 f i l l e d . )  Thus, according to the staff of the Institute,  "The clinic is able to surmount some of the handicap of i t s disadvantageous and expensive complexity by sorting i t s cases and omitting special examinations in those cases i n which they do not seem especially indicated." The philosophy of the Vancouver Clinic i s that there i s a minimum standard c l i n i c a l 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.  I t is agreed, however, that planning,  timing, and coordination of the various examinations, i n 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 f i r s t contact with the clinic is widely accepted.  Is i t not  therefore important that every contact with a member of the c l i n i c 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 i n 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 predetermined 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 i n each case' on the basis of the particular circumstances 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 imperative that a child be examined by a pediatrician i n certain casesj  or again,  in some cases, i f a school v i s i t 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 f l e x i b i l i t y 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 f i r s t con-  tact with the clinic, the diagnostic process should be planned according to indications perceptible from the client's f i r s t contact with the. c l i n i c .  In  other words, the study and exploration, or the diagnostic processes, have treatment 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 assumptions as to the nature and.need o f the case are put to work.from the earliest interview, and formal diagnosis becomes an imaginary point in a growing under-  standing of the issues presented.  29 With more-or less data at hand - so much  as seems necessary i n the individual case — the-workers concerned meet for an i n 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 f i r s t contact with the psychiatrist, or after several, visits to him,. is a case in point;  whether the social worker, i n  conducting interviews-during which social, history material i s produced, should be advised to keep to reality matters, and away from feeling areas i n dealing with a particular patient, i s definitely part and parcel of treatment planning; whether a disturbed teen-ager, truanting from school, i s invited to the c l i n i c for aptitude tests, rather than for the usual medical, psychiatric and mental tests, i s 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 i s advisable i n a l l cases;  i t may be  quite unnecessary i n a few; but i t seems likely that i t can be shown to be useful i n a majority of cases but for different reasons.  The psychiatric social  worker, after the i n i 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 i n the conference.  An examination  of selected cases from the f i l e s of the Vancouver Child Guidance Clinic against a schedule based on the above considerations will, serve to exemplify the purposes 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 prec l i n i c a l 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,) i s operated under the auspices of the Government of British Columbia.  Included in the  Department of the Provincial Secretary, the Clinic Director i s 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 i t s 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 (children 545; No. of new cases (children 142; Repeat cases Total cases Total referrals  adults 71) adults 25)  264  619 I65  784 1072  For the same year the strength of the c l i n i c 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 Psychologists Psychiatric social workers Public health nurses  4 8 11 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 i n 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 i s 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 i s delegated by the clinic psychiatrist i n conference 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 psychiatrist and the other members of the clinic team."  I t should be noted i n 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 i n 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 i s assigned at the conclusion of the intake process.  The social worker would decide to call a pre-clinical conference for  certain reasons.  The reasons for which the. social worker would c a l l 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 i n certain cases, or multiple i n others.  I f 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 c a l l 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) i n 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 i s 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; not.  another doctor said, he might be blind, and another, said he was  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. agenesis" was established..  As a result of this, a diagnosis of "cerebral  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. f a c i l i t i e s , especially their play school. Society wanted a mental-evaluation  The  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.  boy, at six months, had had an operation for intussusception; had had measles.followed by 'flu, colds and croup;  The l i t t l e  at two years  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-  c l i n i c a l conference with the psychiatrist, at which i t was decided that the doctor should get i n 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 i s gained i n the usual routine clinic physical examination, and by relieving the social worker of the need to cover the medical history i n 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.  the parents' own words, he had been "an awful baby since".  In  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, i t s 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  56  i n t e l l i g e n t l y and s c i e n t i f i c a l l y .  She therefore sought a p r e - c l i n i c a l confer-  ence with the p s y c h i a t r i s t . •As a r e s u l t of the conference, the p s y c h i a t r i s t gave the s o c i a l worker considerable insight into the nature and effects of the disease i n question. It was decided that the s o c i a l worker should go ahead with the preparation of the s o c i a l history which she could do more e f f 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 o f the symptoms.  Uses:  Clearly, the p r e - c l i n i c a l conference i n t h i s case was very useful i n  planning the diagnostic study and exploration, and assisted the s o c i a l worker i n accepting and carrying out the diagnostic responsibilitj'- allocated to her. Results:  The pre-clinical-conference i n t h i s case, greatly f a c i l i t a t e d the  diagnostic process, by providing the s o c i a l 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 o f the s o c i a l history.  Group II : P r e - c l i n i c a l conference f o r psychiatric reasons  1. The D case This case was o r i g i n a l l y referred to the Child Guidance C l i n i c by the Vancouver General Hospital, where the mother was a patient. complaining of her c h i l d as a behaviour problem. the mother broke o f f contact with the C l i n i c .  She had been  A f t e r the i n i t i a l  referral,  A year l a t e r , she telephoned  the C l i n i c herself, and again complained of her child's conduct.  The  little  g i r l , aged f i v e , was said, to be stubborn, destructive, negative and enuretic. She was also given to p u l l i n g out her h a i r , b i t i n g and eating her n a i l s and sleeping poorly.  I t 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 g i r l ' s father* mother's f i r s t 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. care for some time and made a good adjustment.  She remained in their  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 i n need of protection.  The Children's Aid Society had indeed  received a complaint of neglect from neighbors, but f e l t the case was one for the Clinic. The worker who was assigned the case recognized that the mother was possibly pre-psychotic, and sought an immediate conference-with a psychiatrist. She f e l t 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 i n 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 c l i n i c psychiatrist should contact mother's ownpsychiatrist for information as to the mother's psychopathology, and should interview mother and step-father to confirm diagnostic 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 i n 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 i n 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. tense-, and as i f she had been crying. problem, she burst into tears again. fecal incontinence.  She found the mother looking tired and As the mother-began to t e l l about the Her son, a boy of 7» was troubled by  Two general practitioners whom the mother had consulted,  had both told her the boy was resenting her. to be placed.  One had suggested he might have  At the thought of this, the mother cried profusely and asked  dramatically, "Tell me that he won't have He is such a lovely boy.  to go away —  I can't give him up.  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 childhood 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.  Later she and her siblings were apprehended  She hated him.  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 i n 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 i n any activity. attitude.  Her school work had deteriorated because of her  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 i n her  own feelings and spent much time sobbing, without explaining the cause of her grief.  She remarked at times, "Nothing i s 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. treatment.  She mentioned she would like to go to Crease Clinic for  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 disturbed.  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 interview, to ascertain the nature of the psychopathology.  It was f e l t 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. been stealing, was out of control, and drifting around. and not interested in school or work.  The boy had  He was unsettled,  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 c l i n i c , but i t was uncertain that the boy could be involved i n 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 i n 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. enabled to reach out f  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 f u 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 i n 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  t e s t i n g f o r employment reasons, to explore how  the psychological t e s t i n g could  be made a s i g n i f i c a n t and therapeutic experience f o r the l a d , and to f i n d out about the p o s s i b i l i t i e s f o r special t e s t i n g f o r occupational i n t e r e s t s and aptitudes. was  also  The p o s s i b i l i t y of a d d i t i o n a l t e s t i n g f o r personality i n v e s t i g a t i o n  considered.  Uses: • I t can be seen that the uses served by the p r e - c l i n i c a l conference here were for planning diagnostic study and exploration, f o r a l l o c a t i n g diagnostic r e s p o n s i b i l i t y , and delineating a tentative treatment plan. Results:  The diagnostic process was  greatly f a c i l i t a t e d by t h i s approach, and  the results of the psychological t e s t s , e s p e c i a l l y of the personality t e s t s (the Thematic Apperception Test i n p a r t i c u l a r ) assisted greatly i n the  establishment  of treatment goals. 2. The H case This case was  referred to the Child Guidance C l i n i c by a private physician.  The c h i l d , a boy of seven, had been i n poor emotional health f o r 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 f o r two weeks, and he responded to t h i s j seeming happier and more outgoing. However, when he was reappeared.  expected to follow a normal routine, the former symptoms  At t h i s point, h i s own  doctor, who  could find no physical basis  f o r h i s condition, referred him to Child Guidance C l i n i c .  His mother, i n an interview at the C l i n i c , said that she and her husband were puzzled by the boy's behaviour and were anxious to help him overcome h i s difficulties.  She spoke of him becoming antagonistic toward school how  I I had appeared to be too much f o r him so he v/as repeating Grade I .  Grade  His  mother said he v/as Ijealous of his s i s t e r , aged f i v e , saying, "He las good reason to be, as she receives more attention from everyone as she i s younger and i s 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 himself.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 investigation.  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 establishment of treatment goals, and the-economical, use of the social worker's time, in that he made use of a short cut i n 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 i n 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 i n 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 " a l l 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 i n 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. a l l g i r l s , in the family. the antics of her children.  There were three younger siblings,  The mother admitted she had l i t t l e patience with 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 i n 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 i n a change of school), f e l t 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 investigation! could be made, to help estimate possible emotional factors which might have the-effect.of depressing the rating a r t i f i c i a l l y .  He therefore had a pre-  c l i n i c a l 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 i n 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 d i f f i c u l t i e s , 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, i n that i t resulted i n confirmation of the social worker's beliefs about the situation i n 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 v i s i t 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 i n a boarding home, and finally went to live with his father and step-mother. he went home, his behaviour deteriorated.  From the time  He would tiptoe around the house,  and would defecate i n 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). after time and refused to t e l l where he had been.  He ran away time  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 i n the boy, was  most positive i n 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 i n . and 100  lbs. at 15), anaemic and not strong.  He was an average "C" student i n  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 i n 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 sufficient 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 c l i n i c a l 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 i n 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 i n 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. as nervous and.enuretic.  The younger, he described  He then commenced a diatribe against his wife,  giving many examples of her "vicious temper", drunkenness, and w i l d 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 the Clinic.  arranged an appointment for herself and came to  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, f i r s t 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 i n  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  <•  i t i e s , 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:  get along in a group;  inability to  inability to compete with other group members or to  share the group leader's affection, and particular hostility and aggression toward g i r l s .  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 from Alexandra Neighborhood House was arranged. her contact with the boy.  with three representatives The A.N.H. worker summarized  She described him as demanding, overly-aggressive,  dominating in his play group, and a constant source of i r r i t a t i o n 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 i n 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 f i r s t meeting, he became very hostile when i t was time to leave. Gradually he got r i d of the other club members with whom he could not compete for recognition and affection. .which he wanted to join.  He was not accepted into the soccer group  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. food to him after his father had disciplined him.  For example, she took 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, i n 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 attending Alexandra Neighborhood House. Uses:  This case i s 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 i n 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 f i l e s , 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 i n this Clinic, but i s 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 f u l l team  conferences would be scheduled in the appointment book, they are not labelled as "pre-clinical , or distinguished in any way, anywhere, from other conferences, n  so that i t is d i f f i c u l t 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 . I t would be very d i f f i c u l t 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 i n each case, are set forth in a summary table:  55  TABLE 2.  USES AND RESULTS OF THE PRE-CLINICAL CONFERENCE  Group II  Group  Psychi.  Psycho.  GROUP "  Group  REASONS FOR CONFEREE  Medic.  'TEAM PERSONNEL (b) '  •S.W.& • S.W.& • S.W.& Psvohi Psychi. Psycho.  Full Team  CASE  A B C  J K L  D E F  in  G H I  Group IV Multi.  No. of cases  USES Selection of cases.  1 1  Referral to or from other agencies  1 1  Planning diagnostic study & exploration  1 1  111  111  111  11  Allocation of diagnostic responsibilities 111  111  111  1 1  11  111  1 1  111  10  111  111  111  12  111  111  1 1 1  Delineation of tentative . treatment plan 1  1 1  1  RESULTS Facilitation of . diagnostic process  111  Establishment of treatment goals Economical use of staff time  1 1  111  1 1  111  (a)  Code: Medic- Medical; Psychi. - Psychiatric; Psycho. - Psychological; Multi.- Multiple.  (b)  Code:  S.W.- Social Worker; Psychi.-Psychiatrist; Psycho. - Psychologist.  10  54 It seems obvious that, on •'.•the basis of the findings in these 12 cases, and. with the exception of the f i r s t two.purposes, the pre-clinical conference 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 i t s 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 -conferences being the exception rather than the rule.  As far as referral i s  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 i n the majority of these cases,' served the expected uses and had 1  the expected results.  However, until some broader statistical study is done,  i t w i l l 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 i n 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 i s not the writer s intention 1  to suggest,on the basis of the present study, that a pre-clinical conference should be used i n every case, but i t i s suggested that i t be more extensively used, and that social workers be more alert to the possible advantages of i t s use.  There is no evidence from these three studies that the omission of a  pre-clinical conference i s always poor practice. its use i s clearly not necessary;  There are cases in which  there are circumstances - for example, in  travelling clinics - where i t s 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 i s only one technique i n the whole clinic process.  But i t i s 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. emotion.  She seemed very matter of fact and displayed no  She explained that her daughter was retarded and she wondered i f she  $6 should send her to school i n the f a l l , saying, " I f she can't go to school, I don't know what I ' l l do, as I can't stand her around home f o r another year." She spoke e a s i l y of her rejection of the c h i l d , 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 centrate and has a poor memory.  She i s stubborn, uncooperative and antagon-  i s t i c , and fights and quarrels with s i b l i n g s and playmates. shape because of her large stomach and t h i n legs. and she finds i t d i f f i c u l t to run. soundly.  con-  She has an odd  Her coordination i s poor  She has a tremendous appetite, but sleeps  She has been on thyroid medication f o r years.  The mother was very  much a f r a i d of her family doctor finding out that they had consulted the C l i n i c . The parents had t r i e d to teach the c h i l d the alphabet, numbers and nursery rhymes, without success, as her progress i s so labored the parents u s u a l l y lose t h e i r tempers.  The mother then compared the child with her own never worked, and i s an extreme problem.  s i s t e r , who,  at 57 j has  She takes no interest i n her  appearance,and makes things very d i f f i c u l t f o r her parents. said, "I am a f r a i d my c h i l d w i l l make my home as uncomfortable  The mother then 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 c h i l d . manner, and could not remember developmental  She was defensive i n her  facts about her c h i l d .  The  mother showed a constant lack of understanding of her c h i l d , and lack of desire to understand her, seeing her behaviour as undesirable t r a i t s needing eradication.  She did not think the c h i l d needed preparation f o r coming to C l 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 t h i s 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 i n 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. wanted an evaluation of the child's capacity.  She stressed that she  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 f u l 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 possib i l i t y of extra personality investigation of the child, i n 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 f i r s t 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 i n the intake process, and has an important bearing on case selection.  There i s the possibility that the conference might, i n  the event of a decision that the parents were-not yet ready to use clinic services, have become interested i n 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, i n which case the conference would have become involved in planning diagnostic study and exploration.  It i s 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 f i r s t step i n delineating a tentative treatment plan.  I f 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 f u l l clinical examination, and the parents  were informed that their child was-not retarded - being low i n 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 i s at least in order to ask-the question:  is i t not possible that a pre-clinical conference-would have focussed the problem i n time for the parents' anxiety to be harnessed before i t was a r t i f i c i a l l y dispelled by the results of the mental, testing?  They were given this  information i n their f i r s t 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 c l i n i c .  This might have happened  anyway, but at least the,.team would have tried every technique at i t s 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:  I t would appear that a pre-clinical conference of the f u l l team i n this  case might have been useful around case selection and intake, referral,  v  planning diagnostic study and exploration, allocation of diagnostic responsibi 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 f a i r to ask how much was wasted).  i The N case This case i s representative of those cases i n the clinic f i l e s which are classed as re-opened.  It is not hard to see. the advisability or the usefulness  of a pre-clinical conference i n 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 i n 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 f l y 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 f a i r l y normal.  The mother complained that her son was irritable,  other children, and caused trouble with the neighbours.  bullied  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 i s 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 i n 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 f e l t he should attend clinic regularly for remedial reading with the psychologist. that the family relationships were poor.  It was f e l t  The mother was obviously dull and  unable to control the boy, and the father an alcoholic who took no interest i n his  son.  It was felt there were no resources i n 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 l a t e r 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 i n the meantime* and the c l i n i c offered i t s services i f the mother was aware of a need f o r help at t h i s time. There was no p r e - c l i n i c a l conference held, and the boy was brought i n f o r re-examination.  He tested high i n the average group of general i n t e l l i g e n c e ,  but seemed to be very tense and anxious.  The school p r i n c i p a l , teacher and  nurser were given advice as to the boy's need f o r personal attention from a male adult, and f o r group a c t i v i t y .  Foster home placement was  f e l t to be  desirable i f the parents could cooperate. Uses;  The reasons for arranging a p r e - c l i n i c a l conference of the f u l l team  p r i o r to the re-examination of t h i s boy are numerous and p l a i n .  A f t e r the  previous experience with t h i s family, such a conference would have been useful, around considerations of selection of cases and intake.  The matter of r e f e r r a l  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 a f t e r the re-examination of the c h i l d , despite t h e i r intervening contact with the case). A p r e - c l i n i c a l conference could have considered, with the Children's Aid Society, planning of further diagnostic study and exploration, and a l l o c a t i o n of responsi b i l i t i e s f o r t h i s , and could have delineated a tentative treatment plan.  As  i t was, two months a f t e r the re-examinationbf the boy, the Children's Aid Society sent i n a request f o r information about the case.  Time and e f f o r t were involved  which would have been saved i f the case had been conferenced p r e - c l i n i c a l l y .  Results;  The lack.of use of a p r e - c l i n i c a l conference had obvious poor r e s u l t s .  The diagnostic process was impeded, and there was waste of time and duplication of  effort.  The 0 case  The mother of t h i s four and a h a l f year o l d boy came to C l i n i c to ask f o r  62 help with h i s t r a i n i n g . The  f a m i l y d o c t o r had  She  s a i d t h e problem was  t h a t he was  unable t o speak.  r e c e n t l y arranged f o r X-rays o f - t h e c h i l d ' s head, but  f i n d i n g s were n e g a t i v e , whereupon he warned t h e mother t h a t the boy's f u t u r e development would depend on h i s t r a i n i n g . help with t h i s task. t h a n mutism. The at  The  c h i l d was  The mother was  I t g r a d u a l l y appeared  a s k i n g the C l i n i c f o r  t h a t t h e r e was  more t o the  c h i l d c o u l d not take i n e x p l a n a t i o n s o r u n d e r s t a n d  problem  directions.  observed t o r o l l h i s head a i m l e s s l y and h i s eyes v a c a n t l y , w h i l e  times he squealed and g r u n t e d .  wept s i l e n t l y .  The  The mother's eyes f i l l e d w i t h t e a r s and  c h i l d appeared  o b l i v i o u s o f n o i s e a t times, y e t on o t h e r  o c c a s i o n s would p o i n t t o o b j e c t s which were the s u b j e c t o f the a d u l t s ' a t i o n , so he a p p a r e n t l y was  not deaf.  o b j e c t s t o which h i s a t t e n t i o n was  she  A t o t h e r times he appeared  drawn, but was  gagets, such as t y p e w r i t e r s and t o o l s .  convers-  not t o see  k e e n l y observant o f m e c h a n i c a l  While a t C l i n i c he would a g g r e s s i v e l y  and b o i s t e r o u s l y e x p l o r e the whole b u i l d i n g f o r a t i m e , and then l a t e r stand p e r f e c t l y q u i e t f o r t h r e e - q u a r t e r s o f an hour,  s t a r i n g out o f a window.  He  k i c k e d , screamed and stamped when r e s t r a i n e d from e n t e r i n g the room where a p s y c h o l o g i c a l t e s t was  i n p r o g r e s s * and the mother s a i d such tantrums  h a b i t u a l when the boy c o u l d n ' t have h i s own s t r a n g e r s a d d r e s s i n g him, soever; of  his  In  way.  He was  i n f a c t they seemed t o make no  were  not bothered  by  i m p r e s s i o n i n him what-  he seemed cut o f f from c o n t a c t w i t h o t h e r persons - l i v i n g i n a w o r l d own.  e x p l a i n i n g the c l i n i c s e r v i c e s t o the p a r e n t s , the worker t o l d them t h e i r  boy's c o n d i t i o n might be caused by v a r i o u s t h i n g s - a b i r t h i n j u r y , a g l a n d u l a r upset, or emotional f a c t o r s . to  She  e x p l a i n e d the u s u a l methods t h e C l i n i c  t r y i e f i n d such causes, i n c l u d i n g p s y c h o l o g i c a l t e s t i n g s .  mother was  adequately.  A t t h i s point the  f e a r f u l t h a t as he c o u l d n ' t t a l k , he c o u l d n ' t be t e s t e d .  v e r y anxious about the whole s i t u a t i o n , y e t was unable The  f a t h e r , t o o , was  employed  t o express h e r  She  feelings  most upset and i l l a t ease when t a l k i n g  t h e i r son, but he too seemed to have a p a u c i t y o f words and t o be  appeared  of  inarticulate  65 in expressing himself. Both parents gradually revealed a mechanistic, depersonalized component i n their handling of the child, and in their own relationship, 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. of case selection and referral.  In the f i r s t place, there were the questions 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? were not accepted, what then? ation were knotty.  If this suggestion  The questions around diagnostic study and explor-  Could this child be given adequate psychological testing?  Were there other medical devices than X9rays which could be employed? electroencephalograms be used? considered?  Should  Should admission to a psychiatric hospital be  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. have been.  The diagnostic study was not planned to the extent i t might  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. goals from the very outset.  There was no establishment of treatment  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 goaldirected from the beginning, on the basis of team consideration and groupintegrated 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 i s 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 w i l l 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 i s being devoted to the description and definition of those facets of casework practice which distinguish i t s professional activity. One of these components is the ability of the caseworker to function effectively and responsibly with representatives of other professional disciplines. The psychiatric social work group has been particularly active i n 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 interprofessional, integrated, therapeutic effort of the clinic staff i n f u l f i l l i n g the function and purpose of the agency ... The "team approach" is a relatively new departure in c l i n i c a l practice. Experiments with respect to i t s form and the appropriate allocation of responsibility are taking place constantly, bearing with them renewed proof of the basic validity of the concept ... A l 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 i s a d i f f i c u l t one and complicates l i f e considerably and unavoidably. Its problems are those of democracy, and the promige of the democratic way of l i f e is d i f f i c u l t 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 i n 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 i s 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 i n eaching centres under medical schools 27 travelling clinics in certain localities on regular schedule. (50) (Maurice, F; JDonne^y, "Problems i n Teaching the Team Concept", Journal of Psychiatric Social Work, December, 1951, p.81 etssq. Underlinings are the writer's. (51) Krugman, Morris, et a l . , 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 i n 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; attended;  in 36 organizations, psychiatrists and social workers  i n 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 organizations, claimed to provide.  They also considered i t desirable to v i s i t a certain  number of the organizations to gather some data, f i r s t hand.  They were able to  delineate three possible variations of "coordinated services" which were distinguished 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 i s considered essential ... Conferences 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, i n i t i a l and planning conferences, and progress and concluding conferences).  That part of  their study which has been reported i n detail here has perhaps some broad comparative 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 f u l l team prec l i n i c a l l y for this purpose i n 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 i n 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 i n both studies which are important for their implications.  The AOA study was interested i n e l i c i t i n g information  as to a l l types of conferencing by a l l combinations of the c l i n i c team i n an effort to estimate the degree of "coordinated services" practised i n American clinics.  The present study was interested in e l i c i t i n g information as to a  specific area of conferencing by a l l combinations of the clinic team i n 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 i s upheld by the findings i n 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 i n these 12 cases served the expected uses and had the expected results i n a majority of the cases. uses and results were desirable.  The  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 f a i r l y 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 f u 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 i s not a procedure widely used i n most Canadian  70 clinics.  However, professional personnel who have practised in American  clinics where pre-clinical conferencing is used are aware of i t s value. Perhaps the most important implication of this study i s that i t remains for social workers to demonstrate i t s value in Canadian clinics. Wide variations in practice i n 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 c l i n i c ) , although i t is s t i l l far from ideal practice.  This kind of compromise i n 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 w i l l also be demonstrating i t s usefulness, and bringing closer the day when i t s use w i l l 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 i s 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 w i l l 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 i t s 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 s o c i a l workers have the major r e s p o n s i b i l i t y f o r demonstrating the usefulness of the p r e - c l i n i c a l conference, they would also reap educational rewards from such a project.  In addition, the use of a p r e - c l i n i c a l  confer-  ence would be a safeguard against that unevenness i n the calibre of i n d i v i d u a l casework found i n any agency, and an added means of strengthening  standards.  In f a t , i t would promote higher standards not only i n casework, but i n the work of the other d i s c i p l i n e s as well, and i n the t o t a l service o f the c l i n i c .  The  educational value of the p r e - c l i n i c a l conference for a l l d i s c i p l i n e s 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 i s offered; by Kurt Freudenthal:  The closed shop o f our professional d i s c i p l i n e s has done much to develop our knowledge and s k i l l s to levels at which we can j u s t l y be proud o f 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 f o r a few notable e f f o r t s , cross f e r t i l i z a t i o n among the s o c i a l services has been generally held to be a matter of l i a i s o n , of good public and community r e l a t i o n s , rather than of integration o f t o t a l services to meet t o t a l needs. \55)  (55)  Kurt Freudenthal, "The - Contribution of the S o c i a l Work Intake Process to the Psychiatric Treatment Situation", Journal o f Psychiatric Social Work, Sept., 1950, p. 2 2 .  72  APPENDIX A (1)  #  MENTAL HEALTH CLINICS IN CANADA (November I 9 5 I ) to which questionnaires were sent  C l i n i c s marked thus did not return questionnaire  BRITISH COLUMBIA 1.  Child Guidance C l i n i c Vancouver. Director :  Dr. U.P. Byrne  Staffed by p s y c h i a t r i s t s , p s y c h i a t r i c s o c i a l workers, psychologists, secretaries; t r a v e l l i n g c l i n i c ; diagnostic and therapeutic; t r a i n ing centre f o r nurses, s o c i a l workers; under auspices P r o v i n c i a l Gov. 2.  Mental Hygiene D i v i s i o n Metropolitan Health Committee Greater Vancouver, City Hall, Vancouver. Director :  Dr. H.C. Gundry  Staffed by p s y c h i a t r i s t , public health nurses, psychologist (attached to Board of Education), secretaries; c l i n i c service to schools o f greater Vancouver and well baby c l i n i c s ; diagnostic and therapeutic; f i e l d t r a i n i n g f o r public health nurses.  ALBERTA 3.  C h i l d Guidance C l i n i c , Calgary. Director Staffed by p s y c h i a t r i s t , psychologist, s o c i a l workers, secretaries; community c l i n i c ; children-and adults; diagnostic and therapeutic.  4.  Child Guidance C l i n i c , Edmonton. Director *  Dr. R.A. Schrag  Staffed by p s y c h i a t r i s t , s o c i a l worker, psychologist, secretary; community c l i n i c ; children and adults; diagnostic and therapeutic; used as t r a i n i n g centre. A l l Alberta C l i n i c s under auspices o f Prov. Dept. o f Health, with Dr. Randall R. MacLean, Mental Health Commissioner d i r e c t l y i n charge.  75 SASKATCHEWAN 5-  Munroe Wing, Regina General Hospital, Regina. Acting Director : Dr. Gordon Russon In-patient and outpatient; and children.  diagnostic and therapeutic;  adults  Travelling clinics attached to Provincial Hospital, North Battleford and Provincial Hospital, Weyburn. 6.  MacNeill Clinic, Saskatoon. Children and adults;  community c l i n i c .  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 information 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 o f f i c i a l s , 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 i n therapy.  75 14.  Mental Health Department o f Hamilton. Director :  Clinic, Health,  Dr. A.  Community c l i n i c ;  15.  Mental Health Department o f Windsor.  Church c h i l d r e n and  adults.  Clinic, Health,  Director Community c l i n i c ; c h i l d r e n and p s y c h o l o g i s t , s o c i a l worker and  #  16.  Mental Health Department o f Sudbury. Director :  Clinic, Health,  Dr. T.  Community c l i n i c ;  17.  adults; s t a f f e d by p s y c h i a t r i s t , secretary.  Dixon c h i l d r e n and  adults.  York Township C h i l d and A d o l e s c e n t Guidance Toronto 10. Director :  • Dr.  D.  Clinic,  •  Cappon  Under a u s p i c e s York Township Board o f H e a l t h . S t a f f e d by p s y c h i a t r i s t , p s y c h o l o g i s t , s o c i a l worker, s e c r e t a r y ; c h i l d r e n and a d u l t s ; c h i e f l y diagnostic with therapy c a r r i e d out t h r o u g h case workers. 4  QUEBEC  18.  Mental Hygiene I n s t i t u t e , Montreal. Director :  Dr.  Baruch S i l v e r m a n  S t a f f e d by p s y c h i a t r i s t s , p s y c h o l o g i s t s , secretaries; used as a t r a i n i n g c e n t r e ;  p s y c h i a t r i c s o c i a l workers, a d u l t s and c h i l d r e n .  76  19•  Verdun P r o t e s t a n t Verdun, P.Q. Director  Hospital,  : Dr. George  A travelling  Reed  clinic.  NOVA SCOTIA  20.  Dalhousie H e a l t h C e n t r e , Halifax. 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 H e a l t h Centre, t h e Department o f P s y c h i a t r y , Dalhousie U n i v e r s i t y and the O u t - p a t i e n t c l i n i c , V i c t o r i a G e n e r a l H o s p i t a l , H a l i f a x , a l l under t h e d i r e c t o r s h i p o f Dr. R. Jones who i s P r o f e s s o r o f P s y c h i a t r y a t Dalhousie U n i v e r s i t y . I t i s s t a f f e d by p s y c h i a t r i s t s , p s y c h o l o g i s t s , p s y c h i a t r i c s o c i a l worker, s e c r e t a r y .  .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 i n this research project? What I am hoping to do i s to clarify the possibilities of extending and refining the use of the conference method which has already been so productive i n the multi-disciplined team approach characteristic ^f the Child Guidance Clinic. A study of the use of the conference method preclinically, - that i s to say, prior to the c l i n i c a l examination of the child - ought to help provide material for analysis. Apparently practice varies from c l i n i c to clinic, but the prec l i n i c a l conference seems to have been used i n 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 resources. However, to assess this probability, i t seems necessary to start by a preliminary survey to ascertain how far this method i s used i n Canadian practice. May I ask for your help i n furnishing the information on the attached form? I hope you w i l l not find this too great a c a l l on your time, and that you w i l l agree that the study i s 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 i n the appropriate spaces. 1.  Is your clinic supported by public funds  2.  Is your intake limited by budget , agency policy and function criteria , other (please specify) \  3.  Is your i n i t i a l intake interview conducted by a receptionist er , nurse , social worker , other (please specify)  4.  In the intake process do you screen by the use of 1  special intake worker social workers rotating on intake social work staff committee other (please specify)  , private funds  in a l l cases  , both  ?  , diagnostic ? , stenograph?  in selected cases  in no cases  Do you use the procedure of a pre-clinical conference composed of f u l l team ( a l l disciplines) partial team (2 or 3 disciplines) social workers  in a l l cases  in selected cases  in no caaes  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, qualification 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, i s rather different from the usual kind of.C.G.C, especially i n regard to preclinical 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 whatever 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 i n 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 unsuitable case.  In actual practice when a case does come in about whom  no previous information is available the Staff members free at the time w i l l 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 i s f i r s t seen at the Clinic.  80 From a provincial hospital mental health clinic Our organization i s not yet advanced to the point of using preclinical 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 i n 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 i s 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 v i s i t . 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 f i r s t 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 f e l t necessary only, not in a l l cases;  i f a case appears to pose a difficult  problem, a l l disciplines w i l l pool their findings and a plan of treatment w i l l 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.  A l l 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 i s  indicated, sharing functions. The pre-clinical conference, i f you mean a discussion of the patient's illness before he has come to the c l i n i c , 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 treatment 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. history when they refer a patient.  Agencies send us a  Their worker may also c a l l to discusB  this history feeling that in this way the worker here may have a l i v e l i e r impression of the case. Physicians give us a brief statement, sometimes including both physical and social factors. Our intake procedure is this: adult;  A Social Worker sees the patient, i f  the parents i f a child, and obtains a history.  evaluation is indicated the Psychologist does this next.  If an intelligence 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 interviews the patient.  In many cases his f i r s t interview may be therapeutic  as well as diagnostic. Informal conferencing takes place prior to the psychiatrist's f i r s t 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 w i l l 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.  5.  Sociotherapy  is undertaken by the social worker.  Patients may also be recommended  for speech or occupational therapy.  Electroplexy may also be indicated.  From a provincial hospital psychiatric clinic  This c l i n i c , being supported by the Province of Ontario, accepts in general the principle that a l l cases presented to the c l i n i c are accepted for investigation or treatment. As a service to the practising physician, appointments for consultation 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 i n 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 c l i n i c a l 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 i n such an effort.  We make use of numerous conferences  with Social Agencies, Educationalists and other clinical f a c i l i t i e s concerning some of our most d i f f i c u l t 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 i n 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. workers presently employed in this Department.  There are no social  With problems involving  these children more intensive investigation i f necessary usually occurs after the child is seen by the psychologist. may or may not be involved.  The public health nurse  Conference at the intake level i s 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. or may not be involved at this level.  The psychologist may  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 c l i n i c .  From a civic guidance clinic As this i s a Guidance Olinic, our Intake i s 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 i s 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 i s known as the "diagnostic conference", at which time the child or adolescent i s either referred on for more appropriate treatment, or a tentative treatment plan is outlined.  A third conference i s 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)  I f the parents are working and cannot, or w i l l not, co-operate in keeping i n touch with the Clinic.  (b)  I f the home situation i s such that i t i s judged  86 impossible to modify the home environment for the child's good. (c) I f 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 f a c i l i t i e s 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 f i n a l disposal i s attempted.  I  do not see how one can dispose-of anything very well before the c l i n i c a l 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 RESULTS  Facilitated  Impeded  Diagnostic process Establishment of treatment goals Economical use of staff time (a) Code: S.W. : Social Worker; Psychi. Psycho. : Psychologist.  J  Psychiatrist;  (a)  88 APPENDIX  D  B I B L I O G R A P H Y GENERAL REFERENCES  Books F o l l e t t , 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 i n 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 Publications, New York, 1947;. . . . Healy, William, " T w e n t y - f i v e . Y e a r 3 of Child Guidance", Studies from the Institute f o r Juvenile Research, Series C, No. .256, . I l l i n o i s Dept. of Public Welfare, 1954. Lowrey, Lawson G., and Sloane, V i c t o r i a , editors, Orthopsychiatry Retrospect and Prospect, George Banta Publishing Co., Menaeha, Wisconsin, 1948. Lowrey, Lawson G., and Smith, Geddes, The I n s t i t u t e f o r Child Guidance, I927-I933, The Commonwealth Fund, New York, 1955. Reynolds, Bertha, Learning; and Teaching i n the Practice .of S o c i a l Work, Rinehart and Co., New York, 1942. S t a f f of the I n s t i t u t e f o r Juvenile-Research, Child Guidance Procedures, D. Appleton and Co., Inc., New York, 1957• Witmer, Helen L., Psychiatric C l i n i c s f o r Children, The Commonwealth Fund, New York, 1940. Witmer, Helen L., S o c i a l Work - An Analysis o f a S o c i a l I n s t i t u t i o n , 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 i n Treatment Services, Proceedings of the Twelfth Canadian Conference on Social Work, Vancouver,. B.C. .1950. Connery, Maurice F., "Problems i n Teaching the Team Concept", Journal of Psychiatric Social Work, Dec, 1951* Finlay, Douglas, ."Intake Techniques in a Boys Guidance Centre", The.Social Worker, April, 1948. . Freudenthal, Kurt, "The Contribution of the Social Work Intake Process to the Psychiatric Treatment Situation", Journal of Psychiatric Social Work, Sept., 195C. Futterman, .Samuel, and Reichline, Philip P., "Intake Techniques i n 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 i n Mental Hygiene Clinics and Other Psychiatric Agencies", American Orthopsychiatric Association Membership Study Committee, American Journal of Orthopsychiatry, January, 195C. 1  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, 195 > King's Printer, Victoria, B.C. L  Group for the Advancement of Psychiatry, Committee on Psychiatric Social Work, "Psychiatric Social Work i n 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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