Mental Health Programs Research Paper

(a) A shift away from competing perspectives, disciplines, and models working on a small scale and

toward complementary perspectives, disciplines, and models working to create comprehensive systems of care.

(b) A shift away from segregating and toward integrating troubled children into ‘normal’ environments, with ‘normal’ defined in terms of family, school, community, and culture.

(c) A shift away from focusing on treatment and guidance only and toward focusing on prevention as well, especially on prevention for children deemed at risk.

This discussion will explain some of the main reasons for these shifts as well as explain why, despite the progress made in thinking about mental health programing, so many troubled children and adolescents still receive inadequate care or no care at all.

1. A Brief Historical Overview

Because of space limitations, this discussion focuses on developments in Europe and the United States Premodern Developments.

Just about every historical account of mental health programs begins with the fact that for a long time there were no such programs specifically for children and adolescents (Parry-Jones 1994). Rather, there were institutions for the mentally ill where young and old were housed together, sometimes cared for, but rarely treated. This fusion of programs for children, adolescents and adults no doubt reflected the relative lack of differentiation between childhood and adulthood—as evidenced by the fact that even the very young were forced to work for food and shelter. Prior to the modern era of mental health programing, the main developments in programing for children and adolescents with mental health problems had to do with making mental institutions more habitable.

This premodern focus on institutions without treatment is often mentioned to indicate the progress made in the way we now care for children and adolescents with mental health problems. However, it is possible that the appearance of progress masks a different reality, the reality that premodern times took care of most troubled children not within institutions but within fairly homogenous and defined communities— making the quality of life for those children actually superior to that of troubled children today. An absence of programs and systems of care does not mean, then, an absence of care. We will return to this theme of community and care at the very end.

1.1 The Nineteenth Century

The nineteenth century brought several important developments in the way children were understood and treated, developments that paved the way for the next century’s boom in both theory and programing. Two developments in particular bear special mention. The first is the development of public education and child labor laws that applied to all children. The second is the development of a science of psychopathology.

Public education and child labor laws did much to create a separation of childhood from adulthood and to usher in the modern era with its assumptions about children having ‘rights.’ However, initially, the rights of children were quite limited. Whether in home or school, most children experienced an authoritarian style of parenting and teaching that meant their mental health was informally measured according to how well they conformed to the rules and requirements of those in authority.

The nascent science of psychopathology did much to pave the way for the proliferation of twentieth century theories and diagnostic systems which have so shaped the development of today’s mental health programs. But that science was faulty and limited with respect to its applicability to children. For example, Emil Kraepelin’s system for classifying mental disorders was used in the same way that medical diagnoses defined discrete biologically based diseases. Furthermore, when referring to children with serious mental health problems, Kraepelin’s system was simply extended ‘downward’ (Cantwell and Rutter 1994). There was, then, no separate field of study and no separate mental health system focusing on psychopathology in childhood.

1.2 The First Half of the Twentieth Century

The first half of the twentieth century is significant for establishing separate fields of child study, mental health agencies for children, and child welfare systems all of which developed into the current fields, agencies, and systems for addressing the needs of troubled children and adolescents. With the establishment of juvenile court systems and child welfare laws, attention was drawn to the underlying causes of young peoples’ offenses and to developing child welfare agencies to deal with parental abuse and neglect. With Alfred Binet’s work in intelligence testing, attention shifted to developing special education for children with mental health problems. And with the establishment of a science of childhood and child psychopathology, mental health programs for children and adolescents became increasingly theory-driven.

Three theoretical perspectives that were developed during this time deserve special mention, not only because of their popular appeal but also because of their influence on mental health programing. Sigmund Freud and psychoanalytic theory laid the groundwork for the development of pyschotherapies for children and for dramatic changes in residential treatment. John Watson, B. F. Skinner, and behavioral theory

did the same for the development of the behavioral treatments so common today. Adolf Meyer and psychobiological theory forecast today’s comprehensive programs for preventing mental health problems and for providing systems of care.

In contrast to Freud’s psychoanalytic theory and Watson’s behavioral theory, Meyer’s psychobiological theory had an immediate impact on mental health programing. This theory (or perhaps framework is a better word—since Meyer and his followers placed so much emphasis on using common sense) changed the focus in discussions of mental illness from psychosis and disease to the prevention of psychosis and delinquency through attending to everyday problems. Meyer gave the term mental hygiene to a movement begun by Clifford Beers, a movement dedicated to the tasks of prevention and providing guidance. The most obvious and practical outcome of this movement was the establishment of child guidance clinics and the development of a new kind of interdisciplinary team made up of a psychiatrist, psychologist, and social worker. Child guidance clinics provided needed services, but they never came close to bringing prevention and treatment to an adequate scale.

The evolution of child psychiatry also belongs to this era. With the publication in 1935 of Leo Kanner’s text Child Psychiatry (1962), this new field took on an identity as a go-between. The child psychiatrist was to be rooted in science and pediatrics while also being rooted in education and the nonscientific traditions of advising parents. The new discipline of child psychiatry was to take from the emerging disciplines of child study and psychoanalysis but follow Meyer’s lead in valuing common sense. Kanner’s vision, then, was of the child psychiatrist as the wise physician eschewiing extremes, dogmatic positions on theory and practice, and narrow identities. This new discipline, then, lent itself to being open to what is unique about particular child patients—which may have been why, in 1943, Kanner became the first to distinguish infantile autism (his term) from mental retardation and psychosis.

The story of child mental health and mental health programing for children and adolescents in the first half of the twentieth century would not be complete without mentioning two other strands of theory. The first, cognitive developmental theory, had as its major proponents the Swiss ‘genetic epistemologist,’ Jean Piaget, and the German born psychologist, Heinz Werner. The second, Gestalt psychology (not to be confused with Gestalt therapy) had as its major proponents Wolfgang Kohler, Kurt Lewin, and several others working first in Germany and later in the United States.

During the first half of the twentieth century, neither of these theoretical traditions had much influence on child mental health or on programing for children, but over time, their influence has been enormous, though often hidden. However, the field of child mental health has yet to plumb all the riches within these two traditions. For example, Lewin’s work provides a powerful framework for promoting family-centered systems of care—yet few today have been trained to represent and analyze child and family problems using a Lewinian framework. In a similar vein, the constructivist child psychology of Piaget and the organismic-developmental psychology of Heinz Werner offer powerful means to assess children with problems and to provide special education that matches up with children’s developmental level and engages their interests and strengths. However, only a minority of special educators and clinicians have been trained in constructivist and organismic-developmental approaches to education and mental health.

There are, however, a few positive exceptions—for example, Edward Zigler. Zigler’s training within both the Piagetian and Wernerian traditions prepared him well to make significant contributions to how mentally retarded children should be assessed and treated as well as contributions to programing for poor children ‘at risk’ for developing problems, including mental health problems. More will be said about Zigler when we come to discussing comprehensive programing and programing designed to prevent mental health problems.

1.3 The Second Half of the Twentieth Century

With respect to programing for children and adolescents with mental health problems, the second half of the twentieth century can be usefully divided into three periods as follows: (a) from 1950 to the mid-1960s and America’s civil rights movement, (b) from 1965 to 1982 and Jane Knitzer’s ‘call to arms’ in her book Unclaimed Children (1982), and (c) from 1982 to the present and the era of ‘systems of care.’

During the first period, the development of psychoanalytic theory and its offshoots culminated in a number of innovative treatments and approaches to programing. This period also witnessed the cognitive revolution and the beginnings of an integration of developmental psychology with clinical child psychology. Also during this period, behavioral theory began to shift its principal home from the laboratories for academics to the clinics, hospitals, and special programs for children and adolescents with mental health problems (Lovaas 1977, Meichenbaum 1974, Patterson 1979).

During the second period, public policy instituted profound changes in mental health programing and special education—changes prompted less by theory and more by a newfound commitment to social justice. During this period, too, the rise of community mental health replaced residential treatment with alternative, community-based means of care. Also during this period, there was a renewed commitment to combining clinical research, assessment, and treatment with good science—as evidenced by the tremendous increase in money expended on mental health research, by breakthroughs in research on the biological determinants of several psychiatric disorders, by the commitment to revising systems for classifying disorders of childhood to make them more reliable and valid, and by scrutinizing therapies and mental health programs using scientific methods for evaluating program effects.

During the third and last period the new multidisciplinary field of developmental psychopathology has emerged as has the educational practice of ‘inclusion.’ But the hallmark of this period may well be the advent of ‘systems of care’ and its paradigm shift in mental health programing. Let us now backtrack a bit to discuss further the developments in each of these late twentieth century periods.

1.3.1 1950–65.

 When the second half of the twentieth century began, psychoanalytic perspectives dominated the mental health field. Many of these perspectives were constructive developments correcting old Freudian theory or extending psychoanalytic theory into areas uncharted by Freud (cf. Winnicott 1958). For example, Freud’s daughter, Anna, did much to develop the method of treating children through analyzing their play. Erik Erikson extended psychoanalytic theory into the study of culture—and simultaneously gave us today’s umbrella term, identity, for explaining adolescence. Margaret Mahler and Donald Winnicott corrected Freud’s overemphasis of the Oedipal complex by demonstrating the centrality of object relations in the process of an infant and young child’s ‘individuating.’ And Bruno Bettelheim, Fritz Redl and others extended psychoanalysis into the design of residential treatment. In a discussion of mental health programs, this last development requires some explaining.

Bettleheim, Redl, and others called their work ‘milieu’ therapy. By this they meant the shaping of virtually everything that went on in residential treatment to support a child’s ‘ego’—from picking out furniture that would withstand the not-so-occasional abuse of the troubled child to using a child’s tantrums to promote insight through ‘life space’ interviewing. The milieu of these residential treatment centers worked, then, o help children and adolescents develop their own ‘inner controls.’ The writings of Redl and Wineman (1965) in particular provide fresh insights into what it takes to support troubled children and their development. Sadly, much of this extraordinary history in mental health programing is forgotten today—another example of how younger practitioners with new ‘medicines’ may fare no better than older practitioners who knew how to use older ‘medicines’ in extraordinary ways.

Psychoanalytic theory in the 1950s and early 60s also helped to spawn a number of offshoots that defined themselves as reactions to features in psychoanalytic theory and practice. Humanistic psychology and Virginia Axline’s play therapy provide one example. Attachment theory and John Bowlby’s work on the ‘secure base’ phenomenon provide another. During this period, Axline’s play therapy had a widespread influence on how psychotherapy for children was conducted, but it was Bowlby’s (1973) work on the dangers of separating child from caregiver that influenced changes in mental health programing. Bowlby’s work and Renee Spitz’s (1945) previous work on institutionalized children provided conceptual fuel for the later trend toward family preservation and keeping even pathogenic families together.

However, during this first period, psychoanalytic perspectives and their offshoots were not alone. This was the period when Piaget, Vygotsky, and, to a lesser extent, Werner became widely read—ushering in the so-called cognitive revolution. As mentioned earlier, these cognitive perspectives on children did not at first have much impact on mental health programing, but, in subsequent periods, their influence has been increasing.

As mentioned before, behavioral theory developed into a clinical tool—to be used everywhere that clinicians could define dysfunction in terms of ‘target behaviors.’ From autism to anorexia, from infancy to adolescence, behaviorists worked to demonstrate that ‘All behavior is one.’ Most of these new behavioral therapies derived directly from the work on operant conditioning pioneered by B. F. Skinner. They differed from today’s behavioral treatments and programs mainly in the limited and sporadic nature of their interventions.

Finally, with respect to relevant developments during this period, family systems theory and family therapy developed rapidly to become a major alternative to the traditional therapies which focused on pathology within the child (Barnes 1994). Family systems theory demonstrated that children’s and adolescents’ dysfunctional behavior often serves important functions within a larger system, usually that of the family. The leading figures, such as Jay Haley and Salvadore Minuchin, gave the movement an almost swashbuckling style as they poked fun at traditional perspectives and challenged family members with provocative prescriptions and ways of labeling their family roles. But today, family therapists often do their work as part of a mental health team—as happens in many hospital based crisis centers where children and adolescents come to be stabilized, assessed, and referred.

1.3.2 1965–82.

As we have already seen, not every major development in mental health programing results from developments in clinical theory or innovations in clinical practice. A good many developments result from changes occurring in the larger society. This was certainly true during America’s ‘civil rights era,’ in the late 1960s and on into the 1970s.

The civil rights era began as a protest against the social injustices caused by racism, but it extended to the social injustices caused by sexism and discrimination against those with disabilities. The common themes throughout were those of integration and equal opportunity.

With respect to programing for children and adolescents with mental health problems, the civil rights movement’s main influence was on the education of children with disabilities. Prior to this movement, segregating these children had been the rule. That changed with the passage of Public Law 94–142 mandating education of all children with disabilities and in the least restrictive environment.

This law effectively established a new and separate system of special education—one that was intended to address the educational needs of children and adolescents with mental health problems. For this reason, the new special education can be considered a mental health program. Furthermore, special education’s being an entitlement program gives it added significance since poor and even middle-class families often could not afford adequate treatment. However, this new special education failed to deliver on its promise. Not only did children with problems continue to be unnecessarily segregated from the mainstream, but the education they received came to be a ‘curriculum of control’ (Knitzer et al. 1990).

The second major and relevant offshoot of the civil rights movement was the ‘Head Start’ program—a comprehensive program for poor children and their families and one implemented on a very large scale (Zigler and Muenchow 1992). Led by its first director, Edward Zigler, Head Start was and still is one of the most ambitious antipoverty programs for children. Furthermore, it embodies an approach to preventing mental health problems—one emphasizing improving the overall quality of living for poor families and their children. Within Head Start, parents have found jobs and job training, and children have found a variety of services to improve their health and education. Finally, from its inception, Head Start has been a social science laboratory—with built-in research funding for ongoing program evaluation and program development. Despite chronic problems associated with underfunding, Head Start remains an important program for thousands of children at risk for developing mental health problems. Furthermore, it represents a growing interest in and focus on multidisciplinary work directed at understanding the conditions underlying the phenomenon of resilience—as evidenced by the emergence of the new field of developmental psychopathology (Cicchetti 1990).

Within the field of mental health, this period also witnessed a major shift away from residential treatment for adults and toward community mental health as psychological and sociological studies such as Irving Goffman’s classic study (1961) emphasized the pathogenic influences of institutionalization. However, most funding for child and adolescent services continued to be applied toward inpatient and residential treatment. In fact, this period saw an increase in inpatient facilities for children and adolescents—as assessment units were established within for-profit hospitals to provide therapy as well as crisis management and assessment—with hospital stays lasting for several months. The last major contribution of this period is not one that can be described as a movement. Hard science has long been the aim of those working to understand and treat mental illness. However, during this period, the enormous increases in funding for research on mental illness provided the needed support to make hard science in this area a reality. As a result, there were numerous breakthroughs in the field of psychopharmacology as well as scientific confirmation of there being biological causes for such serious disorders as schizophrenia.

As important as these developments were in their own right, they were, perhaps, not as important as the establishment of a pervasive scientific paradigm or frame for thinking about ‘disorders’ of childhood and adolescence. Nowhere is this more evident than in the push during this period to revise classification systems—to make them not simply more reliable and valid but also atheoretical so that a variety of researchers and clinicians holding different theoretical perspectives could pool data and communicate with one another. For perhaps the first time in its history, the field of child mental health was joined together by its scientific frame of thinking.

One of the casualties of this frame was psycho- analysis and psychoanalytic theory. Deemed largely untestable, psychoanalytic theory lost its previous commanding influence to the newer, highly testable drug therapies. Behavioral and cognitive–behavioral therapies have flourished under the scientific frame—with their emphasis on precise measurement, controlled comparisons, and the use of data to drive therapies (cf. Lovaas 1980, Meichenbaum 1974, Patterson 1979).

However, despite its obvious strengths, the scientific frame has its limitations, especially when it comes to mental health programming for children and adolescents. The complexities involved in predicting, preventing, and treating mental illness in childhood and adolescence are often too large to fit within the scientific frame. The result has been a need to rely on alternative frames—such as the one operating during the third period under the label, ‘systems of care.’

1.3.3 1982–present.

In 1982, Jane Knitzer’s monograph, Unclaimed Children, documented what practitioners such as Fritz Redl had been arguing all along. She found that most children with serious emotional and behavioral disorders were not getting the services they needed. Neither the new special education nor the old mental health services were reaching the great majority of these children and adolescents. Furthermore, even when these children and adolescents were provided special services, they still were getting neither a proper education nor proper care.

The result of Knitzer’s ‘call to arms’ was the development of a new paradigm and approach to mental health programing, an approach called ‘Systems of Care.’ Several features define its identity (Stroul and Friedman 1996). First, the systems of care approach calls for extraordinary hierarchic organization between federal, state, and local agencies. Second, the systems of care approach pushes for ‘wraparound services,’ that is, for sets of services designed to meet the special needs of individual families. Third, the systems of care approach provides support for families lost in a confusing array of services—mostly through the efforts of case managers who help families set goals, make plans, and advocate for needed services. Fourth, the systems of care approach requires professionals and agencies to be culturally competent—to value diversity and to develop skills for establishing positive relationships with those from different cultures. To understand the significance of this new paradigm and approach, we need mention only a few comparisons with old ways of programing.

Children with serious emotional and behavioral problems often come from families with serious problems as well. In the past, this fact led to the practice of separating children from their families, on the assumption that the children would have a better chance of improving. However, this practice ignored the fact that problematic families often remain committed to their children long after the commitments by professionals have ended. This practice also ignored the fact that dysfunctional families have strengths to enlist in helping their children. Most important, this practice ignored the fact that with additional supports, dysfunctional families can become better able to meet the needs of their children. The systems of care approach has taken these facts to heart by making family support central.

Older approaches to mental health programing also ignored cultural differences or treated cultures as being disadvantaged,’ even dysfunctional. As a result, minority groups were subjected to subtle and not-sosubtle prejudice when being ‘helped’ by mental health professionals. For example, single mothers from cultures which value extended family members (grandparents, aunts, etc.), which feel that young children at night should be in their parents’ bed, which feel children need occasional physical reminders (i.e., spanks) to behave properly—these mothers often found themselves being judged harshly or unfairly as professionals referred to their ‘broken homes,’ their fostering overly dependent relationships between themselves and their children, and their authoritarian parenting styles. With the systems of care approach, the trend has been away from this kind of cultural insensitivity and toward providing services in culturally sensitive ways (Issaacs-Shockley et al. 1996). Older approaches to programing also presented few options for treatment: outpatient office-based therapy, inpatient hospital care, and residential treatment. Furthermore, educational, welfare and mental health programs often functioned separately and sometimes in conflict with one another. With the systems of care approach, the effort has been to coordinate work done by different agencies and different professionals. This effort at coordination shows in a variety of ways. It shows in the increase in interagency teams. Most especially, it shows in professional–family relationships as case managers and home visitors work to get families and children the services they need. In the systems of care approach, then, old barriers between mental health and other kinds of child-related programs are broken down. For example, child welfare programs designed to protect abused and neglected children—often by removing children from their homes—now work to have mental health programs train parents and foster parents so that children temporarily removed from their homes can return safely to their families.

The systems of care approach and the advent of managed health care has dramatically changed the nature and functions of inpatient and residential treatment for children and adolescents ( Woolston 1996). Now, the average length of stay in inpatient facilities has been reduced considerably—from several months to two weeks. The result has been a change in how inpatient facilities function. Where before, therapy was central, now inpatient facilities focus solely on crisis management (stabilization), assessment, and doing what they can to help establish the community-based system of care that children and adolescents will need when they leave the hospital. Residential treatment centers, too, are being hard-pressed to reduce length of stay and to turn outward toward the family and community. Financial constraints, public policy, and the difficulty of demonstrating empirically that inpatient and residential treatment are more effective, all have conspired to change the mental health programing landscape and to turn professionals toward developing community-based systems of care.

2. Concluding Remarks

The new era of systems of care may well have brought improvements in mental health programing. However, it has not brought a reduction in the percentage of children and adolescents with serious mental health problems. How can this be so? How can conceptual progress and progress in mental health programing fail to make a noticeable difference in the prevalence of problems?

There seem to be several reasons, not one. First, as long as schools exclude troubled children from the mainstream and educate them in classrooms with a curriculum of control, systems of care can do only so much. Second, as long as managed health care and inconsistent political support make it difficult for agencies to recruit trained professionals and to get done all that needs to get done to provide quality care, systems of care will be limited in their usefulness. Third, and perhaps most important, as long as there are mental health problems associated with the erosion of community life, systems of care will fail to make a significant difference. We may call our services ‘community based’ and our overall system ‘community mental health.’ However, surrounding families with systems of care will never substitute for surrounding families with communities that care. Perhaps community building will define the next era.

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