Community Involvement ,in Mental Health Programs: The Wyandotte County Mental Health and Guidance Center Stanley A. Murrell, Ph.D.
ABSTRACT: In order to meet heavy service needs, and to extend preventative activities into the community as we~I, the Wyandotte County Mental Health and Guidance Center has developed a wide variety of methods and programs. Each of these programs has ties into the community, and derives assistance and collaboration from community agents. Included here is a description of the following programs: rapid evaluation procedures and short-term therapy methods for children and adults; suicide prevention telephone service; consulting and educative activities; prevention and early detection; research and evaluation; training; and a staff sensitivity group. This center is in an active transactional relationship with its community. Since its beginning there has been a continual process of modification, innovation, and expansion of services in response to community needs. This expansion in number of staff, number of patients, space, and variety of activities has been parallelled by continued involvement of the community. It will be noted that in all of the wide variety of activities of the center, an agent (or agents) of the community is present in a collaborative relationship. DESCRIPTION OF THE CENTER The Wyandotte County Mental Health and Guidance Center serves a population of approximately zoo,ooo. Most patients come from the urban area of Kansas City, Kansas, adjacent to Kansas City, Missouri. The center was founded in 2953 as a private, nonprofit organization. The funds for operation come from the county, from the United Fund, from fees based on a sliding scale or insurance coverage, and from contracts for service. The center contracts with the county to provide outpatient mental health services for residents of the county. Dr. MurreI~ is in the Department of Psychology, Illinois State University, Normal, IlL 61716. At the time this paper was written he was Chief Psychologist at the Wyandotte County Mental Health and Guidance Center, Kansas City, Kansas and Lecturer in Psychology at the University of Kansas. Other staff members who provided suggestions and counsel on this paper were: Elizabeth Gray, ACSW, Executive Director; Warren G. Phillips, M.D., Medical Director; and Lowelt E. Jenkins, ACSW, Chief Social Worker, of the center. Community Mental Health Journals Vol. 5 (1), 1969
82
Stanley A. Murrell
83
The fun-time staff includes one psychologist and four social workers. The part-time staff includes two psychologists, one social worker, three psychiatrists, and one nurse. The staff-in-training includes three clinical psychology graduate students, three social work graduate students, and two psychiatric residents. Over 3 ~ volunteers assist the staff in the various programs. PATIENT POPULATION The center was founded as a child guidance clinic. In response to community needs, the age limitations were dropped in ~963 and more and more adults have been seen for problems of their own. Adult patients now constitute 3o% of the patient load. The median annual income for patients is between $4,5oo to $5,5oo. The occupations of the males typically fall into the skilled or semi-skilled categories. The educational level is usually high school or lower. Most patients would fit into the dass III or class IV categories as described by Hollingshead and Redlich (~958)In x966 the average monthly caseload was 597. Over the last five years the average annual increase in number of patients seen has been approximately 30%. The mean number of interviews per patient is 5.6. Over the years, 6z% of patients seen were described at termination as improved, 38% as unimproved. EVALUATION AND TREATMENT The aim underlying the various methods of evaluation is that they be briefwin order that large numbers of patients can be seen soon after their initial contact--and that they be flexible. Treatment aims are oriented toward the here-and-now and the goal is to bring about changes in the family system which reduce presenting problems and improve problem-solving skills. Extensive historical exploration is not typically needed at the evaluation stage since the treatment is neither long-term nor directed at a deep change in personality structure. Group intake procedures provide a rapid response to referrals. A person can usually attend a group intake meeting for parents within a week after he first contacts the center. It frequently happens that the symptoms of a child or an adult are putting intense pressure on an agent of the community. In these cases an effort is made to see the patient immediately and to make an intervention which will reduce the pressure on all concerned. Thus while there are regularly scheduled evaluation times, it is almost routine that evaluations are set up on short notice in response to community needs. When it has been decided that an evaluation is necessary, several alternatives are available. The most frequently used evaluation mode is the screening evaluation which includes for the child an hour of psychological testing and a half-hour psychiatric interview, and for the parents an hour-anda-half social work evaluation. After the three staff members have completed
84
Community Mental Health Journal
their individual evaluations they have a short conference, decide on disposition, and interpret their findings and recommendations to the parents. The entire evaluation takes between two and three hours. Four or five families per week are seen in screening evaluations. Two to four families per week are seen in family evaluations which are usually completed in an hour. One staff member meets with the entire family, then has a brief interview with the referred member, after which the staff member usually makes his recommendations to the family. From three to eight adult evaluations are completed per week. These patients are typically seen for an hour interview, following which further evaluation is set up or recommendation is made. Despite the large numbers of evaluations completed per week, the number of referrals still builds up to the point where a "mass screening" is required in order to provide a rapid response to these people and their respective community agents. A mass screening is essentially a screening evaluation except that parents and children are interviewed in groups. Using eight staff members, as many as nine families have been evaluated in a half-day, using this procedure. Community effort has been of considerable help in reducing the staff time involved in evaluations. From six to ten volunteers per year score our psychological test battery for adults and parents (MMPI and Leary Interpersonal Checklist). They have also been trained to fill out a checklist report from the test data. This information is thus available at most regularly scheduled evaluations without expenditure of professional staff time. After the evaluation is made there are many alternatives open, including a wide range of treatment modalities. In the case of parent-child problems, the parents are nearly always also involved in treatment. Family therapy, child activity-therapy groups, child learning-problem groups (staffed by trained volunteers), adolescent groups (two boys' adolescent groups meet at a YMCA where part of the therapy hour is spent in physical activity), parent groups, marital-problem groups, mothers' groups, and separate sessions for individuals or couples are routinely available. In some instances, a family or couple have been seen by as many as four therapists at the same time. We have also seen families in all-day sessions where the aim is to accomplish a sufficient amount in that time so that no further treatment is necessary. Many adult patients are maintained on medication through the Sustaining Clinic where the patient is seen briefly every month or two by a psychiatrist or a nurse (two of whom are volunteers) for a check on medication and current functioning. A Day Activity Program is available three mornings and one afternoon per week. The local YWCA has donated space, facilities, and staff time to this program, and ~ volunteers help us in staffing this program. Patients can also be referred to Fellowship Club, a social opportunity group which receives support from the local mental health association and eleven volunteers. In the case of adult patients, the Office of Economic Opportunity (OEO)
Stanley A. Murrell
85
neighborhood counseling centers have collaborated in many ways; for example, they have made home visits, provided transportation to the center and to the State Hospital, and have worked with patients, checking that a patient is taking medication, and so on. A similar collaborative relationship has existed with the Visiting Nurse Association. The center participates in interagency committee work which plans and implements aftercare services for local patients released from the State Hospital. SUICIDE PREVENTION SERVICE This service was started in September, x966 and includes having a staff person of the center on call at all times, 24 hours a day and on weekends. Those persons who are reached through the telephone service can be given an appointment with a staff member at the center within z 4 hours. It is our understanding that we are one of the few community mental health centers in the country, if not the only one, to have integrated a suicide prevention center into the overall operation of such an agency. The suicide prevention service has required collaboration and communication with several sectors in the community: with law enforcement agencies, who have agreed to go out to homes if necessary; with the local hospitals who can be contacted or who will contact the service; with physicians; and with many other individuals and agencies in the area. This service serves an important recognized need, and the community has accepted it with appreciation. CONSULTATIVE AND EDUCATIONAL ACTIVITIES In x963, an active consultation program was started and has continued to expand. For every ten hours of staff time spent in evaluation or treatment, two and one-half are spent in consulting or educational activities. Mental health consultation is a novel idea for most agencies and at times the community's response to such activities has been ambivalent. As an agency the center is still viewed primarily as a diagnostic and treatment resource, and some no doubt would prefer that the time were spent in evaluation and treatment rather than in consultative and educational activities. The center has conducted the following consultative or educational activities: seminars for local ministers and ministerial interns in training at a local general hospital; consulting sessions with counselors, administrators, and teachers at the high school, junior high, elementary, and primary levels; ongoing contact with the judges and probation officers of the Juvenile Court; seminars for state parole officers; collaborative conferences with public health nurses and the Visiting Nurse Association, and a seminar series with nurses at one of the local hospitals; ongoing consultation conferences with two child residential agencies; consultation with a family service agency; workshops for PTA; and consultation contacts with four neighborhood counseling centers that are part of the OEO's local antipoverty program.
86
Community Mental Health Journal
PREVENTION AND EARLY DETECTION A pilot early detection program was started in the spring of ~966. School preparation appointments were offered at three local schools to mothers whose children were to begin school that fall. This program, with modifications, will be continued. We are currently working with a local PTA council in planning and staffing workshops to develop prevention programs for emotional problems of children. RESEARCH AND EVALUATION The research focus has been toward evaluating and improving our operations at the center, which agrees with the orientation suggested by Smith and Hobbs (5966). The research program has been aided significantly by cooperation with Donnelly College, a local junior college, which has placed a part-time student here through a work-study program supported through Economic Opportunity and Higher Education legislation. As an example, one research project has been to evaluate the effectiveness of a ten-session, time-limited, parents' group using pre- and posttesting, questionnaire data, and extensive follow-up contacts. Another research endeavor has been the examination of the psychological test battery data in the light of the patient's subsequent treatment career. A rather complete description of the patient population in terms of psychological characteristics is now available. These data have provided an empirical basis for prediction of response to treatment and have suggested information relevant to prevention. TRAINING The active training program at this center has been an important contribution to its growth and flexibility. This has been a field work agency for second-year social work students from the University of Kansas Graduate School of Social Work for xz years. Four to six residents in psychiatry from the University of Kansas Medical School have taken a part of their training here each year since :t963. Graduate students in clinical psychology have trained at the center almost since its inception. In "r966 a formalized training program in community mental health was started for graduate students in psychology at the University of Kansas. They spend about half of their time at the center in direct clinical work, and the other half in collaborative or liaison relationships with other agencies in the community. In "r966-~967 the social work students at the center worked onethird of the time directly in schools, as school social workers. Students in occupational therapy at the University of Kansas Medical Center assist in the day activity program. STAFF SENSITIVITY GROUP Being human, and perhaps having a higher percentage of prima donnas than other professions, participants found intra-staff con-
Stanley A. Murrell
87
flicts arose which hampered communication and reduced effectiveness. Partly to try to work out some of these problems, partly to increase the effectiveness of staff members in group therapy, and partly just to see how it would work, a Sensitivity or Staff Development Group (no one title has yet been fully agreed upon) was inaugurated. The group has had its ups and downs. On the whole, however, the staff seems to feel that the group serves a useful function and it is expected that it will continue to operate. REFERENCES Hollingshead, A. B., & Redlich, F. C. Social class and mental illness. New York: John Wiley, I958. Smith, M. B., & Hobbs, N. The community and the community mental health center. Washington, D.C.: American PsychologicalAssociation, 2966.
Reminder
Readers who have not renewed their subscriptions to the Journal will receive this issue and can continue to receive copies without interruption, if they renew subscriptions immediately.
ABSTRACT: In order to meet heavy service needs, and to extend preventative activities into the community as we~I, the Wyandotte County Mental Health and Guidance Center has developed a wide variety of methods and programs. Each of these programs has ties into the community, and derives assistance and collaboration from community agents. Included here is a description of the following programs: rapid evaluation procedures and short-term therapy methods for children and adults; suicide prevention telephone service; consulting and educative activities; prevention and early detection; research and evaluation; training; and a staff sensitivity group. This center is in an active transactional relationship with its community. Since its beginning there has been a continual process of modification, innovation, and expansion of services in response to community needs. This expansion in number of staff, number of patients, space, and variety of activities has been parallelled by continued involvement of the community. It will be noted that in all of the wide variety of activities of the center, an agent (or agents) of the community is present in a collaborative relationship. DESCRIPTION OF THE CENTER The Wyandotte County Mental Health and Guidance Center serves a population of approximately zoo,ooo. Most patients come from the urban area of Kansas City, Kansas, adjacent to Kansas City, Missouri. The center was founded in 2953 as a private, nonprofit organization. The funds for operation come from the county, from the United Fund, from fees based on a sliding scale or insurance coverage, and from contracts for service. The center contracts with the county to provide outpatient mental health services for residents of the county. Dr. MurreI~ is in the Department of Psychology, Illinois State University, Normal, IlL 61716. At the time this paper was written he was Chief Psychologist at the Wyandotte County Mental Health and Guidance Center, Kansas City, Kansas and Lecturer in Psychology at the University of Kansas. Other staff members who provided suggestions and counsel on this paper were: Elizabeth Gray, ACSW, Executive Director; Warren G. Phillips, M.D., Medical Director; and Lowelt E. Jenkins, ACSW, Chief Social Worker, of the center. Community Mental Health Journals Vol. 5 (1), 1969
82
Stanley A. Murrell
83
The fun-time staff includes one psychologist and four social workers. The part-time staff includes two psychologists, one social worker, three psychiatrists, and one nurse. The staff-in-training includes three clinical psychology graduate students, three social work graduate students, and two psychiatric residents. Over 3 ~ volunteers assist the staff in the various programs. PATIENT POPULATION The center was founded as a child guidance clinic. In response to community needs, the age limitations were dropped in ~963 and more and more adults have been seen for problems of their own. Adult patients now constitute 3o% of the patient load. The median annual income for patients is between $4,5oo to $5,5oo. The occupations of the males typically fall into the skilled or semi-skilled categories. The educational level is usually high school or lower. Most patients would fit into the dass III or class IV categories as described by Hollingshead and Redlich (~958)In x966 the average monthly caseload was 597. Over the last five years the average annual increase in number of patients seen has been approximately 30%. The mean number of interviews per patient is 5.6. Over the years, 6z% of patients seen were described at termination as improved, 38% as unimproved. EVALUATION AND TREATMENT The aim underlying the various methods of evaluation is that they be briefwin order that large numbers of patients can be seen soon after their initial contact--and that they be flexible. Treatment aims are oriented toward the here-and-now and the goal is to bring about changes in the family system which reduce presenting problems and improve problem-solving skills. Extensive historical exploration is not typically needed at the evaluation stage since the treatment is neither long-term nor directed at a deep change in personality structure. Group intake procedures provide a rapid response to referrals. A person can usually attend a group intake meeting for parents within a week after he first contacts the center. It frequently happens that the symptoms of a child or an adult are putting intense pressure on an agent of the community. In these cases an effort is made to see the patient immediately and to make an intervention which will reduce the pressure on all concerned. Thus while there are regularly scheduled evaluation times, it is almost routine that evaluations are set up on short notice in response to community needs. When it has been decided that an evaluation is necessary, several alternatives are available. The most frequently used evaluation mode is the screening evaluation which includes for the child an hour of psychological testing and a half-hour psychiatric interview, and for the parents an hour-anda-half social work evaluation. After the three staff members have completed
84
Community Mental Health Journal
their individual evaluations they have a short conference, decide on disposition, and interpret their findings and recommendations to the parents. The entire evaluation takes between two and three hours. Four or five families per week are seen in screening evaluations. Two to four families per week are seen in family evaluations which are usually completed in an hour. One staff member meets with the entire family, then has a brief interview with the referred member, after which the staff member usually makes his recommendations to the family. From three to eight adult evaluations are completed per week. These patients are typically seen for an hour interview, following which further evaluation is set up or recommendation is made. Despite the large numbers of evaluations completed per week, the number of referrals still builds up to the point where a "mass screening" is required in order to provide a rapid response to these people and their respective community agents. A mass screening is essentially a screening evaluation except that parents and children are interviewed in groups. Using eight staff members, as many as nine families have been evaluated in a half-day, using this procedure. Community effort has been of considerable help in reducing the staff time involved in evaluations. From six to ten volunteers per year score our psychological test battery for adults and parents (MMPI and Leary Interpersonal Checklist). They have also been trained to fill out a checklist report from the test data. This information is thus available at most regularly scheduled evaluations without expenditure of professional staff time. After the evaluation is made there are many alternatives open, including a wide range of treatment modalities. In the case of parent-child problems, the parents are nearly always also involved in treatment. Family therapy, child activity-therapy groups, child learning-problem groups (staffed by trained volunteers), adolescent groups (two boys' adolescent groups meet at a YMCA where part of the therapy hour is spent in physical activity), parent groups, marital-problem groups, mothers' groups, and separate sessions for individuals or couples are routinely available. In some instances, a family or couple have been seen by as many as four therapists at the same time. We have also seen families in all-day sessions where the aim is to accomplish a sufficient amount in that time so that no further treatment is necessary. Many adult patients are maintained on medication through the Sustaining Clinic where the patient is seen briefly every month or two by a psychiatrist or a nurse (two of whom are volunteers) for a check on medication and current functioning. A Day Activity Program is available three mornings and one afternoon per week. The local YWCA has donated space, facilities, and staff time to this program, and ~ volunteers help us in staffing this program. Patients can also be referred to Fellowship Club, a social opportunity group which receives support from the local mental health association and eleven volunteers. In the case of adult patients, the Office of Economic Opportunity (OEO)
Stanley A. Murrell
85
neighborhood counseling centers have collaborated in many ways; for example, they have made home visits, provided transportation to the center and to the State Hospital, and have worked with patients, checking that a patient is taking medication, and so on. A similar collaborative relationship has existed with the Visiting Nurse Association. The center participates in interagency committee work which plans and implements aftercare services for local patients released from the State Hospital. SUICIDE PREVENTION SERVICE This service was started in September, x966 and includes having a staff person of the center on call at all times, 24 hours a day and on weekends. Those persons who are reached through the telephone service can be given an appointment with a staff member at the center within z 4 hours. It is our understanding that we are one of the few community mental health centers in the country, if not the only one, to have integrated a suicide prevention center into the overall operation of such an agency. The suicide prevention service has required collaboration and communication with several sectors in the community: with law enforcement agencies, who have agreed to go out to homes if necessary; with the local hospitals who can be contacted or who will contact the service; with physicians; and with many other individuals and agencies in the area. This service serves an important recognized need, and the community has accepted it with appreciation. CONSULTATIVE AND EDUCATIONAL ACTIVITIES In x963, an active consultation program was started and has continued to expand. For every ten hours of staff time spent in evaluation or treatment, two and one-half are spent in consulting or educational activities. Mental health consultation is a novel idea for most agencies and at times the community's response to such activities has been ambivalent. As an agency the center is still viewed primarily as a diagnostic and treatment resource, and some no doubt would prefer that the time were spent in evaluation and treatment rather than in consultative and educational activities. The center has conducted the following consultative or educational activities: seminars for local ministers and ministerial interns in training at a local general hospital; consulting sessions with counselors, administrators, and teachers at the high school, junior high, elementary, and primary levels; ongoing contact with the judges and probation officers of the Juvenile Court; seminars for state parole officers; collaborative conferences with public health nurses and the Visiting Nurse Association, and a seminar series with nurses at one of the local hospitals; ongoing consultation conferences with two child residential agencies; consultation with a family service agency; workshops for PTA; and consultation contacts with four neighborhood counseling centers that are part of the OEO's local antipoverty program.
86
Community Mental Health Journal
PREVENTION AND EARLY DETECTION A pilot early detection program was started in the spring of ~966. School preparation appointments were offered at three local schools to mothers whose children were to begin school that fall. This program, with modifications, will be continued. We are currently working with a local PTA council in planning and staffing workshops to develop prevention programs for emotional problems of children. RESEARCH AND EVALUATION The research focus has been toward evaluating and improving our operations at the center, which agrees with the orientation suggested by Smith and Hobbs (5966). The research program has been aided significantly by cooperation with Donnelly College, a local junior college, which has placed a part-time student here through a work-study program supported through Economic Opportunity and Higher Education legislation. As an example, one research project has been to evaluate the effectiveness of a ten-session, time-limited, parents' group using pre- and posttesting, questionnaire data, and extensive follow-up contacts. Another research endeavor has been the examination of the psychological test battery data in the light of the patient's subsequent treatment career. A rather complete description of the patient population in terms of psychological characteristics is now available. These data have provided an empirical basis for prediction of response to treatment and have suggested information relevant to prevention. TRAINING The active training program at this center has been an important contribution to its growth and flexibility. This has been a field work agency for second-year social work students from the University of Kansas Graduate School of Social Work for xz years. Four to six residents in psychiatry from the University of Kansas Medical School have taken a part of their training here each year since :t963. Graduate students in clinical psychology have trained at the center almost since its inception. In "r966 a formalized training program in community mental health was started for graduate students in psychology at the University of Kansas. They spend about half of their time at the center in direct clinical work, and the other half in collaborative or liaison relationships with other agencies in the community. In "r966-~967 the social work students at the center worked onethird of the time directly in schools, as school social workers. Students in occupational therapy at the University of Kansas Medical Center assist in the day activity program. STAFF SENSITIVITY GROUP Being human, and perhaps having a higher percentage of prima donnas than other professions, participants found intra-staff con-
Stanley A. Murrell
87
flicts arose which hampered communication and reduced effectiveness. Partly to try to work out some of these problems, partly to increase the effectiveness of staff members in group therapy, and partly just to see how it would work, a Sensitivity or Staff Development Group (no one title has yet been fully agreed upon) was inaugurated. The group has had its ups and downs. On the whole, however, the staff seems to feel that the group serves a useful function and it is expected that it will continue to operate. REFERENCES Hollingshead, A. B., & Redlich, F. C. Social class and mental illness. New York: John Wiley, I958. Smith, M. B., & Hobbs, N. The community and the community mental health center. Washington, D.C.: American PsychologicalAssociation, 2966.
Reminder
Readers who have not renewed their subscriptions to the Journal will receive this issue and can continue to receive copies without interruption, if they renew subscriptions immediately.
