UTILIZATION
OF
A
PEDIATRICIAN
IN
A
MENTAL
HEALTH
CLINIC
II. An
Affluent
Community
William E. Stone, M.D.
Department of Psychiatry, Harvard Medical School, Boston, and Director, Newton Mental Health Center, Newtonville, Massachusetts
ADDRESS: 398 Walnut Street, Newtonville, Massachusetts 02160.
SPECIAL ARTICLES 807
PEDIATRICS, Vol. 46, No. 5, November 1970
programs in areas of high needs or families will not use us. We must get to know and
respect our fellow team members and fel-low agencies in order to begin
approximat-ing some form of comprehensive care. As psychiatrists, we have learned many skills and techniques in order to work with fragmented egos in individual cases. Many
of these same principles apply to families
T
HE field of psychiatry, and certainlythe subspecialty of child psychiatry, is
currently involved in an identity crisis which has particular relevance to the
rela-tionship between the pediatrician and the psychiatrist in the delivery of mental health
services to children. This crisis is related to the move from patient-oriented psychiatric
treatment to the newer methods of
commu-nity mental health. A good community mental health program is founded on the
knowledge and skills learned from careful
work with individual patients, but the tech-niques and goals of treatment require modi-fication. While individual psychotherapy is still an essential part of patient care, it is
frequently impractical in the light of the
demands and needs of our current culture. In the community mental health center
which
I am serving, we are currently in-volved in a major reassessment of our tech-niques in order to meet the needs of thecommunity rather than the demands of a small group.
See Editor’s Note, page 803.
who are fragmented and receive frag-mented care. This is why I say
comprehen-sive care is an ideal and a goal. Having a pediatrician on our staff is one way toward
making comprehensive care available to the many families we serve. I feel a conference such as this vill gradually bring forth new hope and expertise in our effort to develop
better health care.
Ours is a relatively affluent community,
generally considered to be sophisticated, well-educated, and knowledgeable about
psychiatry. An easy pitfall in developing a
mental health center would be to
as-sume that this is an accurate picture of the
entire community and base the whole
pro-gram on the model of private psychiatric
care. However, the city has its pockets of
poverty and has large numbers of people who would not respond to insight therapy if
it were available to them.
Psychiatrists have been, until very
re-cently, poorly trained for work in the com-munity. Their work has been principally in
mental hospitals and in outpatient clinics that offered treatment to a very select
group of patients. Their experience with
other physicians, nursing groups, schools, homes for the aged, citizens’ action groups, and so forth has been notably deficient. Al-though psychiatry had its roots in
neurol-ogy and is a specialty of medicine, the
808 PEDIATRICIAN IN COMMUNITY
There seems now to be a
return
to themainstream of medicine, and this seems to
be by the channel of pediatrics. As pediatri-cians work more with healthy children
and
move out of their offices into civic and edu-cational activities, the psychiatrist and pe-diatrician are meeting with increasing
fre-quency in developing programs for improv-ing the general health and well being of all
children.
If we are to help whole children, whole families, and whole communities, it is
es-sential that both professional groups work
in concert to avoid the regrettable
fragmen-tation that can come from
overspecializa-tion. I am frequently impressed with the
amount of knowledge we expect from our
patients, who must often virtually diagnose
their own illnesses in order to know which specialist to consult. I say this in all
serious-ness as I recall a number of severe prob-lems presented to various clinics and social
agencies yet not in the specific domain of
any. The cooperation of our
two
specialties is essential if the patient is to be properlyserved and be assured that whichever doe-tor is consulted will be able to assume
re-sponsibility and arrange for the best quality
of professional care. In addition, the
short-age of physicians that we hear so much about would l)C less acute if we were more able to share our knowledge and effect a better utilization of our time and energy.
While Dr. Ackerly was speaking, I was
struck by the similarities in the patients he described and those we see a few miles
away. “Doctor-shopping” is practiced in up-per-middle class communities too. In ours, we find the patient who wants “the best” and seeks out the super-specialist to care
for him. Such a patient can be particularly
critical of his various physicians and may
move from one to another without ever
feeling completely satisfied. In the clinic
In contrast to these patients are those
who are hostile or suspicious of
psychia-trists and reluctant to accept any such re-ferral. They are frequently people who find
discussion of their feelings and attitudes
very difficult and are much more
comfort-able with someone who offers direct,
con-crete solutions and advice. Our experience has shown that such patients are much more responsive to a pediatrician or to a nurse. Thus, for a mental health clinic the
pediatrician and nurse are able to reach
further into the community to a large
seg-ment of the population who would not
ordi-narily receive mental health services.
Another benefit conferred by the
pedia-tnician on a mental health center is the
teaching of medical principles and the
su-pervision of patients in regard to their
mcd-ical care. In most mental health facilities a large share of the treatment and consulta-tion is done by psychologists and social
workers who, although working under the
direction of a psychiatrist, take a great deal of individual responsibility for the patients
they attend. They are expected to manage
their cases both diagnostically and
thera-peutically, in many instances even when the child or another member of the family
may have important medical conditions
that need the deeper understanding mcdi-cal training would have provided. Here, I
see the opportunity for the pediatrician to offer a service to the patient and to the staff.
There is one area of community mental health center programming that has been
seriously delayed in its development. I refer, of course, to mental retardation. Since community mental health is so intimately involved with the responsibility for the care of retarded children
and
adults, we cannotcontinue to allow them to suffer from ne-glect and ignorance. Both psychiatrists and
SPECIAL ARTICLES 809
from a fear of retardation in this culture
which puts much emphasis on ability and
independence. It is always surprising to me
that we can work so effectively with a
phys-ically handicapped child and so ineffec-lively with the intellectually handicapped. Are we victims of an I.Q. score that seems
to say more than it should? We need to
know much more about
intellectual
hand-caps than we do, and it would seem to me that this is impossible without the close col-laboration of pediatrics, child psychiatry, and neurology. The parents of retarded children may well be the most maltreated
group of patients we see. All too often, the
only advice they receive is that they should
get
rid
of their child and “forget” abouthim.
This is a prescription that, at best, can be considered naive, since it does notre-lieve the burden of guilt or help to
dis-charge the enormous anger and frustration these parents feel. The community also
tends to respond to these unfortunate fami-lies with rejection and hostility. The physi-cian who feels discouraged or helpless
of-fers very little to a family so much in need
of his support and counsel. The pediatrician
and psychiatrist working together should be able to help the child realize his maximum potential, thereby offering hope and chal-lenge to the family rather than despair.
Today’s symposium has opened the way
to consider greatly enhanced health
ser-vices for children of all communities. Coop-eration between pediatrician and psychia-trist is equally essential to good mental health care whatever the socioeconomic
