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ROLES AND FUNCTIONS OF CHILD PSYCHIATRISTS IN SOCIAL AND COMMUNITY PSYCHIATRY: IMPLICATIONS FOR TRAINING
ROLES AND FUNCTIONS OF CHILD PSYCHIATRISTS IN SOCIAL AND COMMUNITY PSYCHIATRY: IMPLICATIONS FOR TRAINING
Viola W. Bernard} M.D.
Current developments in the social, community, and public health aspects of psychiatry as a whole entail growing opportunities and obligations for child psychiatrists. There are commensurate needs for appropriate training. Recognition of this is already reflected in the broadened scope of child psychiatry training as evidenced, for example, by the inclusion within the formulations of the Committee on Certification in Child Psychiatry as well as by the A.A.P.C.C. of many facets of the field. Thus in the former's "Guide for Training Programs in Child Psychiatry," it is pointed out that the training program should contain provision for cooperative consultative work for various community child care agencies, observational visits to nurseries and other community child care agencies. It is also recommended that the trainee who has selected his areas of practice in child psychiatry be taught in appropriate areas of administration. (The description of examinations for certification in child psychiatry, as pub-
Dr. Bernard is Clinical Professor of Psychiatry; Director of the Division of Community Psychiatry in the Department of Psychiatry and in the School of Public Health and Administrative Medicine, Columbia University. This paper was prepared as one of the background working papers for the Preparatory Commission on Training Needs for the Conference on Training in Child Psychiatry, held in Washington, D. C., January 10-15,1963.
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lished, states that "contributions of collaborative personnel, and types of social planning will constitute a part of the examination.") The A.A.P.C.C. child psychiatry training prospectus indicates that the training should prepare a psychiatrist "for work within the broad spectrum of emotional disturbances in children." As this concept is defined in more detail it is suggested that the child psychiatrist receive instruction and supervision not only in diagnostic and therapeutic techniques with children and their parents and in the utilization of the integrated services of the psychiatric clinic team but also "in the coordination of clinic effort with the work of all health, welfare and educational agencies." The A.A.P.C.C. statement of Standards, Policies and Procedures for Training in Child Psychiatry lists, as a part of what a child psychiatric clinic should offer the trainee, "Opportunities for cooperative consultative work with child servicing agencies in the community, such as social, educational, protective and judicial agencies. It should enable a child psychiatric trainee to envision the field of child psychiatry in its relationship to the fields of child health, education and welfare." The same document stresses the value of experience for the trainee in specialized child psychiatric settings and asks that the training program "provide some supervised experience, consultative community mental health activities, in the administration of child psychiatric facilities and in the consultant role of the child psychiatrist." Among the topics around which didactic seminars are to be provided is included "administration in a child psychiatric clinic." These excerpts are cited as indicative of the degree of acceptance in principle of certain community psychiatry functions as part of child psychiatry. In fact, such traditional elements of child psychiatry as the clinical team approach, collaborative treatment, case consultation to social agencies, and emphasis on prevention may be viewed to some extent as conceptual and methodological forerunners of the newly emerging subspecialty of community psychiatry.1 While thus a special foundation within child psychiatry already exists for further 1 A confusion of terminology prevails; I use the term "community psychiatry" as inclusive of such differentiated emphases within it as social psychiatry, public health psychiatry, and administrative psychiatry. I also use the term to denote a psychiatric subspecialty within the more comprehensive field of community mental health work, which calls upon the collaboration of those with more diverse competencies than the clinical team or the psychiatrist.
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development of its community psychiatry aspects, and while these aspects have gained some official recognition within the subspecialty of child psychiatry itself, there is still considerable need to translate such general acceptance of principle into actual patterns of practice and specific training procedures, both didactic and practical. Appropriate training cannot be considered without reference to the roles and functions for which the training serves as preparation. It should be emphasized that the community functions appropriate to the child psychiatrist serve the same over-all goals as for all child psychiatry, i.e., protection, furtherance, and restoring of childhood emotional health, but are carried out at the collective level rather than on a one-to-one basis. The unique contribution of a child psychiatrist, as contrasted to many other community mental health workers, is his specialized clinical insight. His application of this through such indirect methods of helping children as social action, administration, or consultation on social policy, as examples, should be conceived of as an outgrowth of his clinical training rather than in conflict with it. The child psychiatrist is, of course, particularly aware of the significance to personality development and emotional status of the dynamic interplay between the growing child and his environment, especially the immediate social environment of the family, and, as the child grows older, his contact with successively larger social units as at school, with peer groups, etc. The "all-purpose child psychiatrist," if I may be permitted that term, should extend his understanding to wider ramifications of relationships between social forces, group experience, environmental conditions, and child mental health as a basis for appropriate interventions. For example, a customary therapeutic function of the child psychiatrist, as a clinic team member, is to influence parental attitudes which are such a significant part of the child's dynamic environment; a comparable intervention at a more widely ramified level could consist of the child psychiatrist's participation in framing or opposing certain types of legislation which would ultimately though indirectly affect child mental health by its impact on the life conditions of families. The community psychiatrist has much to learn from the child psychiatrist, and indeed in the training of community psychiatrists particular grounding in aspects of child psychiatry theory and practice is essential.
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As distinguished from "the all-purpose child psychiatrist," there are already those whose subspecialty within child psychiatry is "community child psychiatry." I make this distinction because it has relevance to intensity of training. For the all-purpose child psychiatrist, training is enriched by a certain amount of systematically taught content in such areas as consultancy, administration, community organization, program evaluation, mental health education, etc. Within the limits of the scarce curriculum time available in relation to the total training program, such content can be taught through a combination of seminars, courses, supervised field experience, and field visits. For those who would in a sense subspecialize in a subspecialty, as community child psychiatrists, the intensiveness and scope of training would naturally be greater. In view of the manifold activities that lie within child psychiatry, it is neither desirable nor probable that too many would be motivated to concentrate primarily on the community child psychiatry subspecialty. On the other hand, it seems important to the field as a whole that provision be made for the appropriate training of some such specialists in addition to orienting all child psychiatrists to this aspect of their discipline. The purpose of this paper is for consideration of Community and Social Psychiatry training for child psychiatrists at the national level. The description that follows is of the training center with which I am associated and thus most familiar. It is intended as illustrative only and with recognition of the many valuable alternative approaches that are being and can be developed elsewhere. At Columbia University, several interrelated training programs for psychiatrists are offered by the Division of Community Psychiatry under the joint auspices of the Department of Psychiatry and the School of Public Health and Administrative Medicine. The Division, as one of its several categories of training, offers a four-year combined psychiatric residency and training in the subspecialty of community and social psychiatry leading to either an M.P.H. or M.S., depending on the emphasis chosen. The first year is almost wholly devoted to basic psychiatry; the trainee's time during the next three years is divided between the regular residency and the training in community psychiatry, didactic and practical, with increasingly more time for the latter as the total sequence progresses, so that the bulk of the fourth year is spent in supervised field placements in social and com-
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munity psychiatry settings, with some time for carry-over of long-term supervised psychotherapy cases. A basic core curriculum of courses, seminars, and weekly field visits has been developed by the Division of Community Psychiatry. These courses are taken in common by the several categories of trainees in community and social psychiatry. Differentiation of each trainee's total program is assured by individual combinations of supervised field placements and selected elements from the full inventory of training resources in the Department of Psychiatry and the School of Public Health and Administrative Medicine. The Division of Community Psychiatry, of which I am the Director, is working closely with the Child Psychiatry Training Program headed by Dr. William S. Langford. Child psychiatry trainees can take certain selected courses from the community psychiatry core curriculum. For example, several of them are taking "Epidemiology of Mental Disorders." They can also attend single sessions of a seminar or single field visits of the weekly field trip series when these are particularly pertinent for the child psychiatrist. Field placements in community psychiatry settings, including social psychiatry research and demonstration projects, when appropriate, are available to child psychiatry trainees. (More detailed reference to these placements will be made below.) At a more intensive level of collaborative training, there are already two candidates enrolled, and one is under consideration, who are preparing themselves to be what was referred to above as subspecialists, i.e., community child psychiatrists. They will undertake combined training whereby over a five-year period (or less if they come in with advanced standing) they can fulfill requirements for certification by the Boards in both General Psychiatry and Child Psychiatry as well as for the degree of either M.P.H. or M.S. (in Community Psychiatry) . As we know, in the four-year training for career child psychiatrists the first of the two child psychiatry years is in lieu of the third year of the general residency. The combined residency and degree courses for community psychiatry also take four years. By adding one additional year, we are devising an integrated program for those who want to become community child psychiatrists. The five-year program would make them eligible for American Board Examinations in
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General Psychiatry and in Child Psychiatry (after the required years of experience) and eligible for a degree, M.P.H. or M.S. (in Community and Social Psychiatry). Although this is still in process of being worked out, the general plan for the five years is as follows, with appropriate modifications for those entering with advanced standing from either Public Health or Psychiatric Residency: First Year: General Psychiatric Residency. Second Year: General Psychiatric Residency and Community Psychiatry; about half time each. The Community Psychiatry fraction includes courses, seminars, and field visits. Third Year: General Psychiatry Residency and Community Psychiatry; about half time each. The Community Psychiatry fraction includes courses, seminars, and some field placements. Fourth Year: First year of basic Child Psychiatry residency. Fifth Year: Second year of Child Psychiatry. Community Psychiatry field placements in various types of child-focused settings. These may involve child psychiatric consultation in child care and educational agencies, for example, as well as such functions as program planning and evaluation and continuation of supervised long-term therapy cases in child psychiatry, as well as conferences and seminars. Since the second year of child psychiatry gives opportunities for assignments in areas of the candidates' major future activities, it may be suitably combined with the Community Psychiatry training for selected trainees. Such a joint program entails flexibility and cooperation by its leadership in the interpretation of essentials rather than on their forms per se, lest rigidities or rivalries as to respective requirements and schedules defeat the purposes of optimal comprehensive training. The division of trainee time for each of the five years should not be so hard and fast as to preclude some carry-over of certain activities into a succeeding year if this serves objectives of the training as a whole. For example, while the course, seminar, and field visits curriculum in community psychiatry would be mainly concentrated within the second and third years as outlined above, more time for experience with long-term supervised psychotherapy, extending over several years, may be gained if the community psychiatry course work is also spread, so that one course or so each semester could be taken in the first child psychiatry year, especially if courses are among those
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appropriate to the all-purpose child psychiatrist, such as "Epidemiology of Mental Disorder," "Principles of Administration." "Legal Aspects of Psychiatry," or "Psychiatric Consultancy of Various Kinds." In order for the fifth year to serve simultaneously as training in child psychiatry and community and social psychiatry, a considerable period of time would be devoted to supervised field experience in a setting or settings where practical experience in functions and roles of the community child psychiatrist could be gained. Such assignments would be made, however, in such a way that ongoing activities in the specific child psychiatry training center could be maintained. Among the field training settings which are affiliated with the Division of Community Psychiatry that can be selected for the child psychiatry trainees in particular are: (1) The Bank Street College of Education. (This placement may be supplemented by work at the Fieldston Schools and the New York City Board of Education.) (2) Louise Wise Services. (Adoption and Unmarried Mother Services.) (3) Wiltwyck School for Boys, Inc. (4) Henry Ittleson Center for Child Research. (5) Northside Center for Child Development. (6) Psychiatric Services for the newly consolidated State-Wide Family Court in New York City. In addition to these affiliated settings, several research projects within the Division's Community Psychiatry Research Unit which are already under way or contemplated, are appropriate for participation of community child psychiatry trainees. Each of these settings lends itself to a variety of different field training experiences to be planned for each trainee in terms of individual backgrounds, interests, and career plans. Some might profit more from the administrative, policy-making, and organizational aspects of a setting's program, and others from its various types of consultancy work, program evaluation, action research or program planning, and practice. Whichever the specific area chosen for concentration, however, it is approached from the over-all perspective of community and social psychiatry, with stress on the larger context within which it is an integrated component. An attitude of community-mindedness and an integrative way of
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seeing relevant connections between what is seemingly disparate are among the basic attributes of the community child psychiatrist. These are expressed through many different types of activity. As psychiatry and the provision of mental health services grows more complex, the need for subspecialization within psychiatry increases, as evidenced by the development of child psychiatry itself, with its many subdivisions. But the drawbacks of specialization increase correspondingly, so that the resulting isolation and compartmentalization require new modes of reintegration and intercommunication. The report Young Children of Mentally III Parents (April, 1962) , prepared by the Mental Health Section of the Citizens' Committee for Children of New York, Inc.,2 is illustrative of the assumption by child psychiatrists of pertinent responsibility for identifying and attacking a significant problem, and of coordination and integration at the community level. In this particular example of social action, the Mental Health Section which was comprised of child psychiatrists, psychologists, and social workers, convened two meetings, several months apart, with policy-making representatives of state and local, public and private, health, education, and welfare agencies in order to focus community attention on the needs of these particular children and their families. The first meeting gave rise to participation by the total group in preparing illustrative case material. Between the two community meetings, the Mental Health Section members worked together in jointly refining and clarifying the thinking for the report which was prepared. At the second meeting, ongoing concerted community activity was assured by arranging for its continuance under the official aegis of the New York City Community Mental Health Board. This description indicates in this particular instance of child psychiatry activity various ingredients such as group process, community organization, and collaborative patterns between child psychiatrists and others that differ from clinical team work both as to the enlarged composition of the partnership and in the nature of its work. The text of the report demonstrates a number of other functions of community and social child psychiatrists, among others: those of conceptual integration; of identification with both parents and children as interacting members of a family unit; of viewing both mental 2 Unpublished. Some mimeographed copies available at Citizens' Committee for Chilo dren of New York, Inc., 112 East 19 Street, New York 3, N. Y.
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hospital services and community-based services as functional components of a continuum of services to people as members of families both in and out of their own homes; of the use of public health approaches to data gathering and prevention; of techniques of communication; of providing clinically informed consultation on administrative policies and procedures; of stimulating appropriate demonstration projects; of the building of hypotheses and in designing research to test them as basic to the planning of improved kinds of service. I am currently engaged in two other illustrative instances of child psychiatrists functioning in community and social psychiatry. One concerns referral and screening policies of psychiatric services for children in municipal hospitals, the other planning and setting up appropriate psychiatric services for the newly consolidated state-wide Family Court in New York City. The Commissioner of Hospitals with the support of the Mayor has appointed a committee, co-chaired by two community child psychiatrists, composed of representatives from the public and private psychiatric, health, and social agencies that are significant to child mental health. Since referral, screening, and intake procedures occur at the interchange point between community and hospital-based mental health services for children, they are critically strategic for coordinated interprofessional and interagency effort to improve the total network of mental health services for children at the collective level. This committee typifies another important role for community and social child psychiatrists, i.e., that of implementing clinically sound changes in patterns of public care by working with governmental officials and involvement in governmental process. The second committee referred to above for planning child psychiatry services for the Family Court in New York City includes judges, city officials, child psychiatrists, psychologists, social workers, and child care experts. Here again, we see the child psychiatrist's function in a group made up of people with different kinds of specialized knowledge, in different positions of responsibility and authority, and in a joint effort to effect creative synthesis with respect to a vital and multifaceted community mental health issue. Although high-quality clinical training and experience are basic prerequisites, they are often not enough to qualify child psychiatrists to function effectively in such situations. Without supplementary training or experience along the lines suggested earlier, excellent
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clinicians have failed in necessary intergroup communication, in facility with group process, and in awareness of social realities. Reference was made earlier to the social contribution child psychiatrists can make in advising legislators or those who in turn use political process to effect legislation with respect to laws, either directly or indirectly affecting child mental health. For example, if child psychiatrists understand adoption as a form of preventive psychiatry and thus within their scope, they can recognize their share of responsibility for legislation toward insuring procedures and safeguards for adoptive placement of children in the kinds of families that are psychologically health-promoting. In connection with adoption another recent example of a somewhat different form of community child psychiatry functioning comes to mind. This concerned standards for agency practice in advising adoptive parents about how to tell the children of their adoption. This affected considerable numbers of children. The question centered on the optimal age, psychologically, at which adopted children should be told about their adoption. In this instance, theoretical considerations of personality development and child-parent relationships entered into such issues as the respective advantages and hazards of being informed at the oedipal or latency phases. A meeting was called of child psychiatrists and analysts and adoption agency administrators and supervisors. The child psychiatrists who could integrate their psychotherapeutic experience with disturbed adoptive children and parents with broader knowledge about pertinent variables in adoptive practice and general community handling of dependent and neglected children could offer more realistic and meaningful consultation than those who relied on psychotherapeutic experience alone. Case consultation to social agencies and educational institutions by child psychiatrists is accepted and familiar practice. As we are called upon, however, for consultation on issues of administration and program and in addition on matters of broad social policy, it becomes desirable to supplement clinical training for adequate fulfillment of this role. To illustrate by way of some current examples, child psychiatrists are being consulted by educators about the psychological implications of policies and procedures for conducting nuclear air raid drills, about school segregation-desegregation issues, and about special classes for autistic children in public schools. All of these
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questions, and the many more that might be cited, are directly related to mental health and illness of children; all of them can be dealt with more effectively when the child psychiatrist's clinical insight is augmented by knowledge of the social and educational contexts, and principles and techniques of consultation. Child psychiatrists are also called upon by health, welfare, and correctional agencies, and should sometimes take the initiative when not called upon, in relation to community approaches to such complex psychosocial problems as teenage drug addiction, juvenile delinquency, multi-problem families, and illegitimacy. No single discipline can plan or implement the total concerted remedial measures that such problems require; child psychiatrists can playa significant role, and should assume their distinctive share of responsibility. A community child psychiatrist gives high priority to developing innovations and improvements for therapeutic access to the large numbers of children who have been relatively untreatable by traditional methods. Among these many are underprivileged and suffer from combinations of serious social pathology and psychopathology. Furthermore, because the community child psychiatrist is in a special position to discern the pathogenic elements for children in various social conditions, he has a special role in mobilizing community concern for rectifying them. In general, greater sensitivity and sophistication as to dynamic interactions and relationships between social and intrapsychic processes, achievable during training, helps child psychiatrists, in cooperation with many other community mental health workers, to extend their sphere of therapeutic effectiveness at the community level. In the foregoing pages some of the educational implications for child psychiatry of current trends in social and community psychiatry have been discussed. Similarly, distinctive contributions which child psychiatry can make to the developing subspecialty of social and community psychiatry have been stressed. Differing intensities of appropriate training for the latter have been suggested, respectively, for "all-purpose" career child psychiatrists and those who would prepare themselves for a new kind of subspecialty within a subspecialty, i.e., "community child psychiatry." Ambiguities and differing opinions prevail, during the present evolving stage, as to what is meant by Community, Social and Public Health, both theoretically and prac-
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tically. For the sake of darity, therefore, the training implications in these areas for child psychiatrists have been presented here in terms of specific roles and functions, with illustrative examples of these, as well as of a pilot training program for "community child psychiatrists."
Viola W. Bernard} M.D.
Current developments in the social, community, and public health aspects of psychiatry as a whole entail growing opportunities and obligations for child psychiatrists. There are commensurate needs for appropriate training. Recognition of this is already reflected in the broadened scope of child psychiatry training as evidenced, for example, by the inclusion within the formulations of the Committee on Certification in Child Psychiatry as well as by the A.A.P.C.C. of many facets of the field. Thus in the former's "Guide for Training Programs in Child Psychiatry," it is pointed out that the training program should contain provision for cooperative consultative work for various community child care agencies, observational visits to nurseries and other community child care agencies. It is also recommended that the trainee who has selected his areas of practice in child psychiatry be taught in appropriate areas of administration. (The description of examinations for certification in child psychiatry, as pub-
Dr. Bernard is Clinical Professor of Psychiatry; Director of the Division of Community Psychiatry in the Department of Psychiatry and in the School of Public Health and Administrative Medicine, Columbia University. This paper was prepared as one of the background working papers for the Preparatory Commission on Training Needs for the Conference on Training in Child Psychiatry, held in Washington, D. C., January 10-15,1963.
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lished, states that "contributions of collaborative personnel, and types of social planning will constitute a part of the examination.") The A.A.P.C.C. child psychiatry training prospectus indicates that the training should prepare a psychiatrist "for work within the broad spectrum of emotional disturbances in children." As this concept is defined in more detail it is suggested that the child psychiatrist receive instruction and supervision not only in diagnostic and therapeutic techniques with children and their parents and in the utilization of the integrated services of the psychiatric clinic team but also "in the coordination of clinic effort with the work of all health, welfare and educational agencies." The A.A.P.C.C. statement of Standards, Policies and Procedures for Training in Child Psychiatry lists, as a part of what a child psychiatric clinic should offer the trainee, "Opportunities for cooperative consultative work with child servicing agencies in the community, such as social, educational, protective and judicial agencies. It should enable a child psychiatric trainee to envision the field of child psychiatry in its relationship to the fields of child health, education and welfare." The same document stresses the value of experience for the trainee in specialized child psychiatric settings and asks that the training program "provide some supervised experience, consultative community mental health activities, in the administration of child psychiatric facilities and in the consultant role of the child psychiatrist." Among the topics around which didactic seminars are to be provided is included "administration in a child psychiatric clinic." These excerpts are cited as indicative of the degree of acceptance in principle of certain community psychiatry functions as part of child psychiatry. In fact, such traditional elements of child psychiatry as the clinical team approach, collaborative treatment, case consultation to social agencies, and emphasis on prevention may be viewed to some extent as conceptual and methodological forerunners of the newly emerging subspecialty of community psychiatry.1 While thus a special foundation within child psychiatry already exists for further 1 A confusion of terminology prevails; I use the term "community psychiatry" as inclusive of such differentiated emphases within it as social psychiatry, public health psychiatry, and administrative psychiatry. I also use the term to denote a psychiatric subspecialty within the more comprehensive field of community mental health work, which calls upon the collaboration of those with more diverse competencies than the clinical team or the psychiatrist.
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development of its community psychiatry aspects, and while these aspects have gained some official recognition within the subspecialty of child psychiatry itself, there is still considerable need to translate such general acceptance of principle into actual patterns of practice and specific training procedures, both didactic and practical. Appropriate training cannot be considered without reference to the roles and functions for which the training serves as preparation. It should be emphasized that the community functions appropriate to the child psychiatrist serve the same over-all goals as for all child psychiatry, i.e., protection, furtherance, and restoring of childhood emotional health, but are carried out at the collective level rather than on a one-to-one basis. The unique contribution of a child psychiatrist, as contrasted to many other community mental health workers, is his specialized clinical insight. His application of this through such indirect methods of helping children as social action, administration, or consultation on social policy, as examples, should be conceived of as an outgrowth of his clinical training rather than in conflict with it. The child psychiatrist is, of course, particularly aware of the significance to personality development and emotional status of the dynamic interplay between the growing child and his environment, especially the immediate social environment of the family, and, as the child grows older, his contact with successively larger social units as at school, with peer groups, etc. The "all-purpose child psychiatrist," if I may be permitted that term, should extend his understanding to wider ramifications of relationships between social forces, group experience, environmental conditions, and child mental health as a basis for appropriate interventions. For example, a customary therapeutic function of the child psychiatrist, as a clinic team member, is to influence parental attitudes which are such a significant part of the child's dynamic environment; a comparable intervention at a more widely ramified level could consist of the child psychiatrist's participation in framing or opposing certain types of legislation which would ultimately though indirectly affect child mental health by its impact on the life conditions of families. The community psychiatrist has much to learn from the child psychiatrist, and indeed in the training of community psychiatrists particular grounding in aspects of child psychiatry theory and practice is essential.
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As distinguished from "the all-purpose child psychiatrist," there are already those whose subspecialty within child psychiatry is "community child psychiatry." I make this distinction because it has relevance to intensity of training. For the all-purpose child psychiatrist, training is enriched by a certain amount of systematically taught content in such areas as consultancy, administration, community organization, program evaluation, mental health education, etc. Within the limits of the scarce curriculum time available in relation to the total training program, such content can be taught through a combination of seminars, courses, supervised field experience, and field visits. For those who would in a sense subspecialize in a subspecialty, as community child psychiatrists, the intensiveness and scope of training would naturally be greater. In view of the manifold activities that lie within child psychiatry, it is neither desirable nor probable that too many would be motivated to concentrate primarily on the community child psychiatry subspecialty. On the other hand, it seems important to the field as a whole that provision be made for the appropriate training of some such specialists in addition to orienting all child psychiatrists to this aspect of their discipline. The purpose of this paper is for consideration of Community and Social Psychiatry training for child psychiatrists at the national level. The description that follows is of the training center with which I am associated and thus most familiar. It is intended as illustrative only and with recognition of the many valuable alternative approaches that are being and can be developed elsewhere. At Columbia University, several interrelated training programs for psychiatrists are offered by the Division of Community Psychiatry under the joint auspices of the Department of Psychiatry and the School of Public Health and Administrative Medicine. The Division, as one of its several categories of training, offers a four-year combined psychiatric residency and training in the subspecialty of community and social psychiatry leading to either an M.P.H. or M.S., depending on the emphasis chosen. The first year is almost wholly devoted to basic psychiatry; the trainee's time during the next three years is divided between the regular residency and the training in community psychiatry, didactic and practical, with increasingly more time for the latter as the total sequence progresses, so that the bulk of the fourth year is spent in supervised field placements in social and com-
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munity psychiatry settings, with some time for carry-over of long-term supervised psychotherapy cases. A basic core curriculum of courses, seminars, and weekly field visits has been developed by the Division of Community Psychiatry. These courses are taken in common by the several categories of trainees in community and social psychiatry. Differentiation of each trainee's total program is assured by individual combinations of supervised field placements and selected elements from the full inventory of training resources in the Department of Psychiatry and the School of Public Health and Administrative Medicine. The Division of Community Psychiatry, of which I am the Director, is working closely with the Child Psychiatry Training Program headed by Dr. William S. Langford. Child psychiatry trainees can take certain selected courses from the community psychiatry core curriculum. For example, several of them are taking "Epidemiology of Mental Disorders." They can also attend single sessions of a seminar or single field visits of the weekly field trip series when these are particularly pertinent for the child psychiatrist. Field placements in community psychiatry settings, including social psychiatry research and demonstration projects, when appropriate, are available to child psychiatry trainees. (More detailed reference to these placements will be made below.) At a more intensive level of collaborative training, there are already two candidates enrolled, and one is under consideration, who are preparing themselves to be what was referred to above as subspecialists, i.e., community child psychiatrists. They will undertake combined training whereby over a five-year period (or less if they come in with advanced standing) they can fulfill requirements for certification by the Boards in both General Psychiatry and Child Psychiatry as well as for the degree of either M.P.H. or M.S. (in Community Psychiatry) . As we know, in the four-year training for career child psychiatrists the first of the two child psychiatry years is in lieu of the third year of the general residency. The combined residency and degree courses for community psychiatry also take four years. By adding one additional year, we are devising an integrated program for those who want to become community child psychiatrists. The five-year program would make them eligible for American Board Examinations in
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General Psychiatry and in Child Psychiatry (after the required years of experience) and eligible for a degree, M.P.H. or M.S. (in Community and Social Psychiatry). Although this is still in process of being worked out, the general plan for the five years is as follows, with appropriate modifications for those entering with advanced standing from either Public Health or Psychiatric Residency: First Year: General Psychiatric Residency. Second Year: General Psychiatric Residency and Community Psychiatry; about half time each. The Community Psychiatry fraction includes courses, seminars, and field visits. Third Year: General Psychiatry Residency and Community Psychiatry; about half time each. The Community Psychiatry fraction includes courses, seminars, and some field placements. Fourth Year: First year of basic Child Psychiatry residency. Fifth Year: Second year of Child Psychiatry. Community Psychiatry field placements in various types of child-focused settings. These may involve child psychiatric consultation in child care and educational agencies, for example, as well as such functions as program planning and evaluation and continuation of supervised long-term therapy cases in child psychiatry, as well as conferences and seminars. Since the second year of child psychiatry gives opportunities for assignments in areas of the candidates' major future activities, it may be suitably combined with the Community Psychiatry training for selected trainees. Such a joint program entails flexibility and cooperation by its leadership in the interpretation of essentials rather than on their forms per se, lest rigidities or rivalries as to respective requirements and schedules defeat the purposes of optimal comprehensive training. The division of trainee time for each of the five years should not be so hard and fast as to preclude some carry-over of certain activities into a succeeding year if this serves objectives of the training as a whole. For example, while the course, seminar, and field visits curriculum in community psychiatry would be mainly concentrated within the second and third years as outlined above, more time for experience with long-term supervised psychotherapy, extending over several years, may be gained if the community psychiatry course work is also spread, so that one course or so each semester could be taken in the first child psychiatry year, especially if courses are among those
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appropriate to the all-purpose child psychiatrist, such as "Epidemiology of Mental Disorder," "Principles of Administration." "Legal Aspects of Psychiatry," or "Psychiatric Consultancy of Various Kinds." In order for the fifth year to serve simultaneously as training in child psychiatry and community and social psychiatry, a considerable period of time would be devoted to supervised field experience in a setting or settings where practical experience in functions and roles of the community child psychiatrist could be gained. Such assignments would be made, however, in such a way that ongoing activities in the specific child psychiatry training center could be maintained. Among the field training settings which are affiliated with the Division of Community Psychiatry that can be selected for the child psychiatry trainees in particular are: (1) The Bank Street College of Education. (This placement may be supplemented by work at the Fieldston Schools and the New York City Board of Education.) (2) Louise Wise Services. (Adoption and Unmarried Mother Services.) (3) Wiltwyck School for Boys, Inc. (4) Henry Ittleson Center for Child Research. (5) Northside Center for Child Development. (6) Psychiatric Services for the newly consolidated State-Wide Family Court in New York City. In addition to these affiliated settings, several research projects within the Division's Community Psychiatry Research Unit which are already under way or contemplated, are appropriate for participation of community child psychiatry trainees. Each of these settings lends itself to a variety of different field training experiences to be planned for each trainee in terms of individual backgrounds, interests, and career plans. Some might profit more from the administrative, policy-making, and organizational aspects of a setting's program, and others from its various types of consultancy work, program evaluation, action research or program planning, and practice. Whichever the specific area chosen for concentration, however, it is approached from the over-all perspective of community and social psychiatry, with stress on the larger context within which it is an integrated component. An attitude of community-mindedness and an integrative way of
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seeing relevant connections between what is seemingly disparate are among the basic attributes of the community child psychiatrist. These are expressed through many different types of activity. As psychiatry and the provision of mental health services grows more complex, the need for subspecialization within psychiatry increases, as evidenced by the development of child psychiatry itself, with its many subdivisions. But the drawbacks of specialization increase correspondingly, so that the resulting isolation and compartmentalization require new modes of reintegration and intercommunication. The report Young Children of Mentally III Parents (April, 1962) , prepared by the Mental Health Section of the Citizens' Committee for Children of New York, Inc.,2 is illustrative of the assumption by child psychiatrists of pertinent responsibility for identifying and attacking a significant problem, and of coordination and integration at the community level. In this particular example of social action, the Mental Health Section which was comprised of child psychiatrists, psychologists, and social workers, convened two meetings, several months apart, with policy-making representatives of state and local, public and private, health, education, and welfare agencies in order to focus community attention on the needs of these particular children and their families. The first meeting gave rise to participation by the total group in preparing illustrative case material. Between the two community meetings, the Mental Health Section members worked together in jointly refining and clarifying the thinking for the report which was prepared. At the second meeting, ongoing concerted community activity was assured by arranging for its continuance under the official aegis of the New York City Community Mental Health Board. This description indicates in this particular instance of child psychiatry activity various ingredients such as group process, community organization, and collaborative patterns between child psychiatrists and others that differ from clinical team work both as to the enlarged composition of the partnership and in the nature of its work. The text of the report demonstrates a number of other functions of community and social child psychiatrists, among others: those of conceptual integration; of identification with both parents and children as interacting members of a family unit; of viewing both mental 2 Unpublished. Some mimeographed copies available at Citizens' Committee for Chilo dren of New York, Inc., 112 East 19 Street, New York 3, N. Y.
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hospital services and community-based services as functional components of a continuum of services to people as members of families both in and out of their own homes; of the use of public health approaches to data gathering and prevention; of techniques of communication; of providing clinically informed consultation on administrative policies and procedures; of stimulating appropriate demonstration projects; of the building of hypotheses and in designing research to test them as basic to the planning of improved kinds of service. I am currently engaged in two other illustrative instances of child psychiatrists functioning in community and social psychiatry. One concerns referral and screening policies of psychiatric services for children in municipal hospitals, the other planning and setting up appropriate psychiatric services for the newly consolidated state-wide Family Court in New York City. The Commissioner of Hospitals with the support of the Mayor has appointed a committee, co-chaired by two community child psychiatrists, composed of representatives from the public and private psychiatric, health, and social agencies that are significant to child mental health. Since referral, screening, and intake procedures occur at the interchange point between community and hospital-based mental health services for children, they are critically strategic for coordinated interprofessional and interagency effort to improve the total network of mental health services for children at the collective level. This committee typifies another important role for community and social child psychiatrists, i.e., that of implementing clinically sound changes in patterns of public care by working with governmental officials and involvement in governmental process. The second committee referred to above for planning child psychiatry services for the Family Court in New York City includes judges, city officials, child psychiatrists, psychologists, social workers, and child care experts. Here again, we see the child psychiatrist's function in a group made up of people with different kinds of specialized knowledge, in different positions of responsibility and authority, and in a joint effort to effect creative synthesis with respect to a vital and multifaceted community mental health issue. Although high-quality clinical training and experience are basic prerequisites, they are often not enough to qualify child psychiatrists to function effectively in such situations. Without supplementary training or experience along the lines suggested earlier, excellent
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clinicians have failed in necessary intergroup communication, in facility with group process, and in awareness of social realities. Reference was made earlier to the social contribution child psychiatrists can make in advising legislators or those who in turn use political process to effect legislation with respect to laws, either directly or indirectly affecting child mental health. For example, if child psychiatrists understand adoption as a form of preventive psychiatry and thus within their scope, they can recognize their share of responsibility for legislation toward insuring procedures and safeguards for adoptive placement of children in the kinds of families that are psychologically health-promoting. In connection with adoption another recent example of a somewhat different form of community child psychiatry functioning comes to mind. This concerned standards for agency practice in advising adoptive parents about how to tell the children of their adoption. This affected considerable numbers of children. The question centered on the optimal age, psychologically, at which adopted children should be told about their adoption. In this instance, theoretical considerations of personality development and child-parent relationships entered into such issues as the respective advantages and hazards of being informed at the oedipal or latency phases. A meeting was called of child psychiatrists and analysts and adoption agency administrators and supervisors. The child psychiatrists who could integrate their psychotherapeutic experience with disturbed adoptive children and parents with broader knowledge about pertinent variables in adoptive practice and general community handling of dependent and neglected children could offer more realistic and meaningful consultation than those who relied on psychotherapeutic experience alone. Case consultation to social agencies and educational institutions by child psychiatrists is accepted and familiar practice. As we are called upon, however, for consultation on issues of administration and program and in addition on matters of broad social policy, it becomes desirable to supplement clinical training for adequate fulfillment of this role. To illustrate by way of some current examples, child psychiatrists are being consulted by educators about the psychological implications of policies and procedures for conducting nuclear air raid drills, about school segregation-desegregation issues, and about special classes for autistic children in public schools. All of these
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questions, and the many more that might be cited, are directly related to mental health and illness of children; all of them can be dealt with more effectively when the child psychiatrist's clinical insight is augmented by knowledge of the social and educational contexts, and principles and techniques of consultation. Child psychiatrists are also called upon by health, welfare, and correctional agencies, and should sometimes take the initiative when not called upon, in relation to community approaches to such complex psychosocial problems as teenage drug addiction, juvenile delinquency, multi-problem families, and illegitimacy. No single discipline can plan or implement the total concerted remedial measures that such problems require; child psychiatrists can playa significant role, and should assume their distinctive share of responsibility. A community child psychiatrist gives high priority to developing innovations and improvements for therapeutic access to the large numbers of children who have been relatively untreatable by traditional methods. Among these many are underprivileged and suffer from combinations of serious social pathology and psychopathology. Furthermore, because the community child psychiatrist is in a special position to discern the pathogenic elements for children in various social conditions, he has a special role in mobilizing community concern for rectifying them. In general, greater sensitivity and sophistication as to dynamic interactions and relationships between social and intrapsychic processes, achievable during training, helps child psychiatrists, in cooperation with many other community mental health workers, to extend their sphere of therapeutic effectiveness at the community level. In the foregoing pages some of the educational implications for child psychiatry of current trends in social and community psychiatry have been discussed. Similarly, distinctive contributions which child psychiatry can make to the developing subspecialty of social and community psychiatry have been stressed. Differing intensities of appropriate training for the latter have been suggested, respectively, for "all-purpose" career child psychiatrists and those who would prepare themselves for a new kind of subspecialty within a subspecialty, i.e., "community child psychiatry." Ambiguities and differing opinions prevail, during the present evolving stage, as to what is meant by Community, Social and Public Health, both theoretically and prac-
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tically. For the sake of darity, therefore, the training implications in these areas for child psychiatrists have been presented here in terms of specific roles and functions, with illustrative examples of these, as well as of a pilot training program for "community child psychiatrists."