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The Program Committee's choice of the three speakers for this Annual Meeting session points up the fact that child psychiatrists have come from a variety of backgrounds and present different interests and opinions yet remain unified in their basic aims, namely, to provide professional help for children who are emotionally ill or likely to become so. I suspect that the Committee's choice reflects as well their hope for a little lively controversy this morning. Dr. Solnit and Dr. Eisenberg were trained in university settings and, as Professors of Child Psychiatry at Yale and Johns Hopkins, have continued their professional activities within the university milieu. Dr. Solnit came into psychiatry as a trained pediatrician; he is further a psychoanalyst of children and adults. His work as clinician, research investigator, teacher, and administrator reflects this wide range of professional preparation. Dr. Eisenberg has pursued an interest in the pediatric and neurological aspects of child psychiatry and of late has become a spokesman for those who believe social action a compelling function of the child psychiatrist. As a facile hard-hitting author and speaker, he has placed his trenchantly developed point of view before many audiences. He makes clear to us today, as always, that he is not a psychoanalyst. Perhaps my reaction when asked to follow Dr. Eisenberg in discussion of Dr. Solnit's paper illustrates nicely his impact upon all of us as a critic and challenger: my first thought as I put down the telephone some months ago was that I'd be a Daniel in Leon's den!

In recent years a number of programs have been developed to deal with various aspects of the lives of poor children and adolescents (for example, preschool education and job training). This paper reviews selected programs in order to examine their potential significance with respect to psychiatry and mental health. It conceptualizes the manner in which such programmatic interventions foster psychological growth and reach children who have been unreachable by more conventional mental health techniques. The paper develops a point of view which sees large-scale programs (for example, Head Start and Job Corps) as phase specific interventions having significant mental health relevance.

This paper describes the movement from a doctor-centred, fragmented mental health care delivery system to a system of collective responsibility on the policy level, and individualized attention on the client level. This may be achieved through the creation of a Human Services Council.

All of us in mental health circles are aware that, despite "Action for Mental Health" and the community mental health centers program, we are still far from having efficient and effective mental health care, at any level national, state, or local. One of the elements still missing in our delivery systems is appropriate coordination of services. The term "coordination" has come to have some unpleasant connotations: it conjures up visions of superfluous bureaucrats busily engaged in shuffling papers, drawing up organization charts, trying to fit people and services into boxes on those charts, and generally accomplishing little of value. I should like to suggest, however, that coordination in the true meaning of the word "to bring into a common action, movement, or condition" is essential in our efforts to improve the delivery of mental health services. In today Ts slang phrase, it means "getting it all together" so that comprehensive, continuous care

This paper traces the development of psychiatry in the People's Republic of China—with special reference to the social aspects of treatment and prevention—and delineates the salient features of the Chinese approach. Implications of this approach for mental health workers in other countries are discussed.

Associate degree mental health programs have developed rapidly since their inception 6 years ago and now constitute an important, new source of manpower. This paper is a report on the first national survey of these programs and illustrates their development by states. Data are included on current student enrollments in these programs, number of graduates, percentage of graduates employed, estimates of future numbers of graduates, constraints on programs' continued development, and other related variables.

The report of the Joint Commission on Mental Illness and Health( 1), a rising demand for local community mental health clinics and the Community Mental Health Centers Act of 1963 clearly point to the need for a more definitive community orientation by existing psychiatric services. However, it is not nearly so clear what a community-oriented service ought to be doing, what its operational goals should be and what is entailed in making the transition from an individual treatment program to a more inclusive community approach. Private psychiatric hospitals, which have played a significant role in the history of the treatment of the mentally ill in America, face additional problems. How shall such broad services be financed? How can sufficient staff be obtained? Is the previous history of being a “psychiatric hospital” an acceptable base for a community mental health center? This paper briefly traces three stages in the development of a private psychiatric hospital towards becoming a community mental health service. Illustrations of shifts in philosophy, program and financing as well as evidence of community resistance and support will be given. Prairie View was initiated 11 years ago as a private psychiatric hospital sponsored by the Mennonite Mental Health Services. It was opened as a 37-bed hospital with limited outpatient facilities for private pa

This paper is an attempt to look at mental health consultation from a variety of different points of view; to distinguish it from clinical consultation and direct services to patients; to relate it to mental health and mental illness, social handicap, and social functioning; to program goals and caretaker populations; and, finally, to discuss evaluation both in terms of current studies and future needs.

The pressure of the waiting list and the lack of resources have produced a state of emergency for the child guidance clinic. We have seen the development of 57 varieties of the traditional model without developing any clarity on why each previous model was not workable. To resolve underlying problems, this paper presents a “model” of a child mental health center.

IT iS still undoubtedly true, as Kotinsky and Witmer had occasion to remark in 1955,1 that the field of community mental health lacks a high degree of "coherence" and organization. A notable lack of clarity and often sharply conflicting views exist about such fundamental matters as the meaning of "preventing" mental illness; the appropriate conditions for practicing different methods of treatment and care of patients; and, not least of all, what the community itself can offer and how it can be used successfully in programs directed toward these ends. It may be naive to expect a unified viewpoint at this time when the field is being pushed forward with an intense sense of urgency that involves reshaping many traditional ideas about preventing and caring for emotional disorders. Nevertheless, the clear guidelines that are essential if we are to sort out and pick our way through the heterogeneous perspectives that exist on these and similar matters have hardly even begun to emerge. While it is neither a particularly fresh nor enlightening notion, it seems nonetheless true that this lack of coherence is the result of difficulties experienced in mounting and implementing a vigorous research program. Although the problems requiring solution in the community mental health field place the burden of research on "demonstration projects," efforts to evaluate the accomplishments of these are, as MacMahon, Pugh, and Hutchison have recently pointed out, "conspicuous by their absence."2 A demonstration project, defined in "ideal" terms by Elizabeth Herzog, is one which ". . . tests out a hunch or conviction based on experience or practice and systematically builds up evidence designed to show whether the hunch or conviction stands up to the test. The demonstration project combines the world of research and the world of practice."3 The question we ask, as the basis for this paper, is why the diverse "hunches and convictions" that have been and are currently being carried into practice in the field of community mental health, whether bearing the arbitrary label of "demonstra

This paper describes a pilot program in Pennsylvania to develop a link between the community and the State in program planning for children diagnosed as brain-damaged, retarded or emotionally disturbed. Through the vehicle of a comprehensive diagnosis by a multidisciplinary team, the Eastern Pennsylvania Diagnostic and Evaluation Center program was able to shed light on a number of related problems in the fields of child health, education, welfare and child psychiatry.

At a time when U. S. production know-how has fallen behind that of several other industrial societies, this paper reports encouraging results of job-adjustment counseling to workers at the site of employment, and consultation to management and union representatives.

This paper presents and discusses extensive data obtained from 30 employed graduates of associate-degree programs in mental health. Some biographical data are included along with a summary of their objectives as mental health workers and their perception of the relevancy of their training to these objectives. Further, information is presented relative to the utilization of these mental health associates by agencies and institutions. The problems they encountered on entering the mental health field and the characteristics of their work situations that provided, or failed to provide, them with a feeling of satisfaction in their new roles are discussed.

Family therapy is a relatively recent development. Consequently, there is still much confusion about it, as well as a dearth of systematic information on how it is currently being used. In this paper, a conceptual distinction is made between individual therapy (I.T.), family member therapy (F.M.T.) and family unit therapy (F.U.T.) in terms of their rationale, aims, the nature of the therapeutic relationship and confidentiality. Some types of F.U.T., which alone is viewed as novel, are briefly outlined, with special attention to their common core. This framework is further used in reporting the results of the first small scale survey of family therapy in Australia. Lastly, the implications of F.U.T. for health and welfare policies are considered, with specific recommendations for social action and further research on the F.U.T. approach.

This paper presents data about the less successful members of a sample of the 1960 intake to University College London. Sixteen per cent. of the sample of 198 students had not obtained a degree within four years of entry (wasted students). Five per cent. were delayed a year, but were ultimately successful (delayed students). Some of the social, personality and intellectual characteristics of the group are described and an estimate made of the proportion who were emotionally disturbed. Compared with successful students the "wasted" group were of lower social class and participated less in some social activities. They showed little difference in M.P.I. scores, but were of lower intelligence. More than half of the group were thought to be disturbed, and about a third severely so. Severe disturbances were disproportionately great in this group compared to successful students. It was concluded that both this morbidity and intellectual inadequacy were important aspects of the "wastage" problem, but that these factors were not themselves related.

There is little understanding and communication in many areas between East Africa and North America. Mental health programming is no exception, although similar factors—local beliefs, political philosophy, available manpower, economic strictures—largely determine program structure and services in both regions of the world. This paper describes certain program features in Tanzania, and suggests that in their simplicity they may have relevance for mental health practitioners in the Western world.

This paper describes an attempt to provide psychiatric and social care in an integrated fashion to multiproblem families. Six social agencies and psychiatrists from the University of Rochester are engaged in a three-year demonstration project. The authors suggest from their experience that a radical reorganization of the psychosocial services is required if the needs of the poor are to be met.

Clinical and social scientists can have an important role in coping with the effects of social change if they can translate knowledge into terms specific to the problems, develop new methods of intervention, and develop new role models for professional-client relationships. This paper is a report on the philosophy and methods of two experiments in this field.

Child guidance clinics are part of a large class of organizations concerned with the treatment of maladjusted individuals. Research findings indicate that such clinics are not adequately serving the needs of the community. The assumptive base of clinic organization is challenged in the paper, and alternate recommendations are presented.

Current planning and action efforts in the health and welfare fields are stimulating and demanding further reorganization of mental health programs. In this paper the social forces impinging on current mental health practices are noted, the direction of changes in mental health programs is described and speculations on the shifts in organizational and role relationships among mental health practitioners are provided.

This paper presents research findings on the perceptions of graduates of accredited schools of public health to the mental health training they received and to the place of mental health in public health work. The data reveal the extent of exposure to mental health in public health training and the limited impact of this training in schools of public health on the production of mental health manpower and public health workers capable of performing mental health functions. Policy considerations for strengthening mental health in public health training are suggested.

Increased demand for mental health services has focused increased attention on the nature of referral relationships between primary care physicians and psychiatrists in the delivery of psychiatric care. Using data collected from a population of internists in fee-for-service practice in the northern suburbs of Chicago, this paper focuses on issues involving the extent to which internists see psychiatric conditions in their practice; the extent of referral to and from psychiatrists; the most common conditions referred to psychiatrists; the most common treatment modalities used by psychiatrists; the most common reasons psychiatrists refer to internists; and internists ratings of satisfaction with various aspects of their psychiatric referral relationships. A contingency model is proposed as a framework for further understanding the process. Specific propositions to be tested in future research are presented.

This paper describes a conceptual model of human service program evaluation, and integrates three key components of the evaluation process: a) Levels of Evaluative Activity, b) Functional Roles of the Evaluator, and c) Program Information Capability. This model has been useful in assessing evaluation capability of mental health programs, and in suggesting itineraries for enhancing evaluation capacity.

PROGRAM evaluation studies are notable for the large number of people in favor of doing them and the small number of people who actually try. This is very understandable considering both the importance of good information about the usefulness of various health programs and the extreme difficulty of obtaining this information. In the area of mental health programs, the call for studies is, if anything, louder, and the number of studies, fewer. In a time of expanding programs and rising costs, this is an unfortunate situation which demands a high priority of attention. It is our purpose here to examine one type of program evaluation—evaluation of the quality of mental health services—and to suggest in what ways immediate progress in the field may be possible. The stimulus of our consideration is a paper by Donabedian 1 in which he discusses quality evaluation of medical care. We will not repeat what

In 1954 a programme of “occupation and liberalization” was started at this hospital. Attempts to assess this programme were made and have been reported (Clark and Hoy, 7; Clark and Oram, 8). As a result of these surveys, we possess a complete list of the male patients in the hospital in October 1954 and February 1961, showing the work they were doing at these times; many men's names appear in both lists. This paper reports the analysis of these lists and some interesting facts that emerged.

Growing demands for mental health service, training, and research are pressing psychiatric clinics to make pivotal decisions. One trend is to limit the selection of patients to those the clinic is best equipped to handle. An opposite trend is to modify clinic practices to meet the pressures placed upon it. 10 This paper follows the second trend and is based on the premise that effective service is the foundation of psychiatric training and the goal of clinical research. 2,5 In clinical medicine treatment is continually revised to bring it into closer harmony with the needs of the patient. Following this tradition we believe that the psychiatric clinic should respond to those who call upon it for service. If it fails to meet this responsibility, the clinic must anticipate declining usefulness to society. One way to increase service is to expand the clinic staff. It is

This paper demonstrates the feasibility of evaluating services without special research funds. The author examined mental health services in a semirural catchment area in Canada to assess how well they were reaching those in need, were helping those they did reach, were obtaining good results, and were working efficiently. The evaluation procedures included a new type of analysis of patient movement, a small community survey of alcoholism, a study of patients dropping out of treatment or seeking treatment elsewhere, and a survey of foster homes. A computer-based case register was used for part of the work, but the author states that most of the assessment procedures could be repeated elsewhere without the aid of special evaluation personnel.

The paper describes a comprehensive program for schizophrenic children and their families developed by the clinic on an outpatient basis. Group therapy, the major treatment modality, is supplemented by speech therapy, individual therapy and teaching. Maintaining an individualized and flexible approach has enabled a number of children to be helped significantly.

Attitudes toward and psychodynamics of waiting lists are discussed. The literature is reviewed. Organizational changes, procedures of intake, reduction of treatment time, the multiplying effect of consultation to social agencies are outlined together with suggestions for the use of volunteers. The future challenge and means of meeting it close the paper.

Hollander has described the organization and services of one of the most highly developed child placement agencies in the country, with particular reference to the young children under its jurisdiction who are in long-term foster care. Beres, in turn, has traced the case history-up to the age of nineteen--of one such child, who was admitted to that agency as an infant and has been in foster care from the beginning. These two papers lend themselves, therefore, to joint discussion. Maria, Beres's patient, currently exhibits ego disturbances which he assumes, and I think we would all agree, are causally related to her early deprivation. Concomitantly, Hollander has observed that there is growing evidence of increased emotional disturbance among the child population in foster care. He has suggested that this would seem to imply the need to change some of the existing patterns of child placement services, and that the problem ought to be considered in relation to the community mental health service program as a whole. I shall forgo the temptation to comment on many of the intrapsychic obstacles to Maria's normal psychological development, so vividly presented by Beres. Instead, I shall comment on the vicissitudes of Maria's case history within the broader frame of reference suggested by Hollander. In brief, I shall focus on the fact that this case illus

As presently constituted, juvenile courts serve neither the interests of society nor those of children. Partly as a response to this criticism, a child psychiatric clinic composed of a part-time child psychiatrist, social worker, and psychologist was introduced into an established juvenile court. This paper focuses on the process and difficulties of such an undertaking. The significance of this work for the future of the juvenile justice system is discussed.

The question for today is: are we really ready to offer the services needed? It has become evident during the past two years that there are many who do not care to exert the necessary effort to establish continuity of care-a principle we have been advocating for years. They are content to innovate by establishing a new clinic or a new ward, but feel they are not ready for continuity of care. There are also those who will not exert the effort to move forward-to change the status quo-and who are content to close their eyes to the existing level of mental health care in the United States. As I commented at the beginning of this paper, if we do not achieve consensus, resolve these issues and actually begin to provide continuity of mental health services and care, as we as a profession feel they should be designed, it may well be done for us by others. We have had 20 years of debate. The times now call for action by our profession. The people want adequate mental health services. We have the training and the knowledge to accept the responsibility of leadership. Many of us owe at least part of our professional training or support to scholarships, fellowships and research grants made possible by public funds. There is every reason-from enlightened self-interest to compassion for those whom we can help-for this profession to get about the business of adequately caring for the mentally ill, preventing mental disturbance where and when we can and building a healthier nation.

The paper has discussed the development of treatment services for severely emotionally disturbed children by an outpatient Mental Health Clinic adopting an approach which may be illustrated by such modern key-words as ‘Community Psychiatry’, ‘Total approach’, ‘Therapy in Crisis’ and ‘Family Therapy’. Basically, the approach we used has included: 1. The setting up of a special educational program for the child in close collaboration with school authorities. The details of such a program will vary with local legislation. 2. A program of intensive psychiatric treatment or play therapy with the child and with the parents individually, and in groups. 3. A program of instruction or counselling the parents in how to meet the special needs and problems in caring for their ‘exceptional’ child. This counselling was conducted on a group basis. 4. The intelligent but aggressive use of all other resources within the community, which might be able and willing to structure themselves to meet the child's needs. We do not pretend that we have offered ideal therapy. We do want to suggest that the lack of facilities for treatment of this psychiatric category, which exists almost everywhere, gives us no excuse to despair or give up. We submit that it is possible to offer a very real help in these cases by the intelligent and aggressive use of all the resources existing within the Community. The nature of the available facilities will vary but almost everywhere there are resources which are able and willing to structure themselves to meet some of the child's needs, if encouraged to do so. The Community Psychiatric Clinic is in a unique position to encourage and develop this.

This paper outlines the framework that has been developed within a state department of mental health to guide the acquisition of data relevant to resource deployment decisions. This Management Information System is being designed to include data concerning populations in need, populations currently receiving services, the nature of existing services, the effectiveness of existing services, and the cost of existing services. Ultimately it is intended that this system will contribute objective information to assist state and local management decision makers in maximizing the efficiency and effectiveness of scarce available resources.

This paper is an overview of the 6 years of existence of the Psychiatric Home Treatment Service and of the 4 clinical programs it pursued. The goal of the service was to define a new community approach to the care of those suffering from serious mental illness. An attempt was made to use home treatment as an alternative to hospitalization wherever appropriate with these patients. Of the patients referred to us, 30% did not appear to be hospital-bound. Of the remaining 70%, more than one-half could be managed outside the hospital using home treatment and/or other alternatives to hospitalization. It would seem from our experiences that a home treatment service can be a valuable facility attached to a state hospital, but perhaps could be even more valuable as an integral part of every community mental health center.

THE PROPOSAL to add community psychiatry to the ever-widening list of psychiatric specialties deserves a critical examination. Thus, my purpose in this paper is fourfold. First, I intend to examine the nature of community psychiatry as it is taking shape. Second, I want to consider our continuing uncertainty about mental illness which is manifested in a widening of its definition. Third, I discuss some of the historical landmarks and cultural forces that have brought about the proposal for this new subspecialty of psychiatry. Finally, I examine some of its hidden aspects with respect to the future role of psychiatry. Community Psychiatry: The Newest Subspecialty .—Let us begin by examining the nature of community psychiatry that is apparently emerging as judged by a mounting chorus of voices from those who jump on any bandwagon as long as it is moving. In doing this I will

This paper reports demographic and personality characteristics of student users and nonusers of a college psychiatric service. It describes, as well, techniques used to clarify the importance of the social structure of the college environment in stressing, shaping, or retarding the intellectual and emotional development of its students.

This paper examines health planning as a form of technocratic ideology in use both by proponents inside government and by outside interest groups in the health field. Ideology and the nature of technocratic power are defined. Health planning is analyzed as occupation, process, and ideology. The ideology in use is analyzed for the following American programs: Hill-Burton, Comprehensive Mental Health Planning, OEO Neighborhood Health Centers, Regional Medical Program, Comprehensive Health Planning. It is concluded that health planning cannot operate in the present sociopolitical context except as an ideology to justify the status quo in health services.

The goal of primary prevention of psychiatric disorder is a laudatory one, which unfortunately can not be realized in the absence of scientific knowledge about etiology. This paper focuses on an emergent strategy for acquiring such knowledge: the study of children who are vulnerable to the development of psychopathology in adulthood.

The importance of emphasizing research, and the problems of research training, its goals, the groups involved, the content and implementation of a training program, and its appropriate settings are dealt with in this paper. The goals are considered within the context of the Jamesian theme—how to obtain a greater use of the potentialities of men. Discussed are the four major problems in the field of mental health: (1) provision of the proper theoretical model, (2) reduction in status differentiations among the groups involved, (3) optimal training for all personnel in any way to be associated with research, and (4) the possible reorganization of the professions. A general program for research training, in terms of both substance and methodology, is proposed, with the assumption that each discipline or group would provide the specific program best designed for its own needs.

THIS PAPER is part of a series of studies aimed at clarifying treatment methods for alcoholics and the methods of assessing such treatment. Pattison1 has pointed out that much of the traditional pessimism regarding the treatment of alcoholism may be unjustified. When treatment is given in indiscriminate fashion to a random group of alcoholics in the hope that "something will take," or if only one treatment method is used for all alcoholics in the belief that it is "the" way to treat alcoholics, the results often have been poor. On the other hand, when treatment is carefully planned and selected for the particular needs of a specified alcoholic population the results often have been highly consistent and encouraging. In their recent book-length review of planning treatment programs for alcoholics, Blum and Blum2 underscore the need for multiple programs that can provide a broad range of treatments based on population selectivity. The next step in rational program planning then is to more clearly define the variables in treatment selection. Historically, alcoholism treatment pro¬ grams have often been based on a simple model of treatment that assumed that there is one population of alcoholics, to be treated by one best method, which would produce one therapeutic result—abstinence. However the published research of the past decade has suggested that each of these dimensions actually consists of several sub¬ sets of variables which are often combined in different permutations. Thus maximiza¬ tion of treatment efficacy may be affected by closer attention to the manner in which the variability of each of these three dimensions affects the others.

THIS PAPER outlines the background to the conceptualization, and the tentative instrumentation of "community adaptation." Data from an initial study using the "Community Adaptation Schedule" is presented. Applications for the evaluation of community mental health programs are discussed. The Need for Program Evaluation The interest being stimulated in the field of community mental health compels attention to the many voices 1 raised in warning about the need for research and evaluation. Properly feared is a possible digression that may cause embarrassment decades hence. The undertaking of carefully controlled studies in this field has been hampered by the lack of sound evaluation techniques. Besides the Well—known difficulties of measuring change after an intervention, the absence of an appropriate criterion relevant to the goals of community mental health makes the task that much harder. Approaches embodying crisis consultation, multilevel prevention, short-term treatment, sector analysis, and the

WHILE there is an extensive literature on the evaluation of mental health programs, the state of the art in mental health program evaluation is unsettled, given the various competing criteria and methodologies that have been proposed. In spite of the long history of psychiatry, psychiatric programs remain among the most difficult to evaluate in the field of medicine. A comprehensive view of a psychiatric program must encompass three related activities that are usually performed by groups of workers who are separated by training, tradition, and organizational barriers. These activities are (1) administrative and financial, involving the assignment of resources, eg, mental health workers, to a program; (2) clinical treatment; and (3) assessment of treatment outcome. In spite of the strong interrelationships, the three factors are usually treated as separate by the social system in which they are imbedded. This paper offers new

SINCE the earliest reports of college mental health activities, there have been many attempts to describe the distribution in the college population of the phenomena observed. Some of these attempts have been more successful and have had wider generalizability than others. It is the purpose of this paper to review the history and current status of such epidemiological reports. First a historical review of the development of student health services is presented and then a review of literature dealing with estimates of incidence and prevalence of psychiatric illness among college students, discussing studies both of facility usage and those based upon population surveys. Some of the methodological considerations in comparing these results and using them as a basis for developing rational approaches for intervention are discussed. The Early Development of College Psychiatry Dr. Stuart Paton is generally given credit for formulating 1,2 and developing 3 the first formal mental health