A-COMI’ARATIVE STUDY OF .FOUR MICHIGAN CHILD GUIDANCE CLINICS THESIS FOR THE DEGREE OF MASTER OF SOCIAL WORK MICHIGAN STATE. UNIVERSITY WAYNE BABCOCK, RAYMOND HUGHES, ELEANOR KEYS, THOMAS RUHALA, AND . MARIORIE SHARPE I '9 6 1 "' " "' " T” ' "' "”"'W"”V¢~dd§am . , _ - -3.Nu'+*‘1|' _,. A. a“ IJ_ LIBRARY ' .. aggchigan 5”” L “University 40‘ I I \A commm srum OF FOUR mam 5. cum) 001mm cmms/ , l I LPROJE‘I'EPOR! Submitted t0 the School of Sock]. Hark Michigan State University in Partial mum of flu , Roquiromts fur tho I degree at mmwmm Jun 1961 App-Nd: IHESIS --—..~.-.,__~ QJ *-—~‘---I" TAKE 01“ COM‘ENI'S Page u“ 0: T313109 eeeeeeeeeeeeeeeeeeeeeeeeeeeeeeeeeeeeeeeeooeoeoeoeoeeoo 111 cm I. II. III. IV. V. 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Child Guidance Clinic .u MWt at the Kalamazoo Child Guidance 611m O...O...OOOOOOOOOOOCOOOOOO...O...OOOOOOOOOOOOOOOOOOOO mun.-me at the Immflhfld Guidance Clinic . m and (Inclusions eeeeoeeeeoeeoeeeeeeeeeeeeeeeeeeeeeee m cme OOOOOOOOOOOOOOOQCO0.0...OOOOOOOOOOOQOOOOOOOOOOC Amorrucmmatmmuemcmam we .00...O..................C00......OCOOOOOOOCOCCOOOOOC Initiation of the Fee Charging Policy at Bettie Creek Child W Clinic eeeeeeeeeeeeeeeeeeeeeeeeeeeeeeeeeeeeeo Staff AttiMS Tmrd F” 0mm eeeeeeeeeeeeeeeeeeeeeeee M m Oeuclusiene eeeeeeeeeeeeeeeeeeeeoeeeeeeeeeeeeeee mm Ewan-Es eeeeeeeeeeeeeeeeeeeeeeeeeeeeeeeeeeeeeeeeee Initial mm a“ W eeeeeeeeeeoeeeeeeeeeeoeeeeeee IO . 16 h? Tim or com (cmtinned) 63mm VI. VII. VIII. W1C M oooooooooooooeeeoooooeooooooooooooooooo mm Tmm .......................C............C..... The Developent of Child Guidance Philcecpl'w an! Operatiml coma” ooooooooooooooooooooooooooooooeoooo Criteria for Acceptance and/or Rejection for Treatment... Functions and Purposes of the Intake m.oooooeooo km“! 01' Intake oeoeoooooooooooooooooooooooeoooooooooe Follow-Up Studies on Intake Pram oooooooooooooooooo Fm DEGREE Am MTMEM 0.0.00.00.000.000.0000... JCM mm in Damn ooooooooooooeeoooooooooo Diagnostic Indicatims f” Fm Treatmnt eooooooooooo R018 Cf tb Therapist in Joint heatnent ooooooooooooooo AWM‘OB cf Joint WW oooooooooooooooooooooee (h-oupwork Techniques in Joint Interviewing ............. Stills Required ooooooooooooooooooooooooooooooooooooeooo SUIIIEY oooooooooooooooooooooooooeoeoooooooooooooooooooo Tm ”mm O...0.00..OOOOOOOOOOOOOOOOOOOOOOOOOO. treatment Orientatim and Participation in Treahnnt Activities oooooooooooooooooooooooeooooeoooooooooooooooo ~ "£1191“ List Priority 81‘ karmic: oooooooooeoooooooo httl. creekooooooooooooooooooooooooooooooooooooooooooeo Ming ooooooooooooeooooeoooooooooooooooooooooooooooooo Fm oooooeooooooooooooooooooooeoeooooeoooooeoooooeeeoo W” eeooeoooooooeoooooooooooooooooooeoooooooeooooo ”limilf 08808 ooooooooeooooooooooooooooooooeeooooo Frequency cf'l‘reatmnt Intervieweandfiethodeef mmnt ooooooeoooooooooooooooooooooooooooooooooooooeo Group Thcropy as a Method of Treatment ................. Treatment (2me oooooooooooooooooooooooooooooooooo TWti“ Practices and Criteria oooooooooooooooeooooo m ooooooooooooooeooooeooeoooooooooooooeooo'oeoeoooo calms.“ I‘m MWtim oooooeoeoooooooooooooooo TMTION oooooooooeoooooooooooooooooeeooooooooooooooo Termination in PWChmaj-a ooooooooooooooooooeooooooo Tormimtim 111 8mm WDI'k oooeooooooooooeeoooooooooooeo A 30le SM on In” Criteria for Termination ooooooo 'Pmnlly mud'ooooeooooooooeoooooooooooeoooooooooo 'WWOd'ooooooeooooooooooooooooooooooooooooooooooooo ii Page 72 8h 61323883 10h um (F BORDERS (contained) m L XL III. 0.91”“ oooooooooooooooooooooooooooooooooooooooooooooo “MIMI-”8 ooooooeooooooooooeooooooooooooooooeooooooo In ROLE OF THE CLINICS IN THEIR COMES ............. (Immunity services ooooooooooooooooooooooooooooooooooooooe MROB “oat Maj-29d ooooooooooooooo'ooooooooooooooooeo CW8 35b served eooooooooeooooooooooooooooeooooooooooooo~ Distribution Of MOB eoooooooooooooooooooooooooooooooo Nature or 0119317019 oooooooooooooooeoooooooooooooooooooooo A‘m memtim oooooeoooooooooooooooooooooooooooooo OOOOCOCOOOOOQOOOCO0.00000000000000000000.0.0000... W Am commsmm 00.0.0.0...OCOOOOOOOOOOOOOOOOOOOO. mm 00.00.000.00...0.00.00.00.00...0.00.00.00.00... A. W ME C0.00.00.00.000000000000000000000000 B. mm SCWEOOOOOOOOOOOOOOOOOOOOOOO0.0.0.0.. 0. “CE SMOOOOOOOOIOOOOOOOOOOOOOOOOOOOOOOOOCOOOOOO D. Ptopceed Fee Scale, kttle Creek Child Guidance elm OCOOOOCOOOOOO...OOOOOOOOOOCOOOOOO0.00.00... HMMOOOOOCOOOOOOOOOO0.0.00.0000...0.000.000.0000. Page 161 163 1614 165 171 . 172 173 17h 176 178 180 188 188 189 191 193 19h Table 1. 2. 3. II. 5. LIST OF TABLES Staffs of Four Michigan Child Guidance Clinics as of MCh, 1961 0.00.00.00.00...OOOOOOIOOOOOOOOOOOO...O....0... Specific Functions of Three Disciplines in Intake ”wanna OOOOOOOOOOOOOOOOO0.0.0....OOOCOOICOOOOOOOOOOOOOO Sources of hands of Four Michigan Chfld Guidance Clinics and Amounts Recieved From Each Source in 1959-60 .......... Rate of Intake Before and After Family Unit Diagnosis at the nut cmd 6‘1me Clinic OOOCCOCOOCOOCOOOCOOOOOOO Calamity Services of Child Guidance Clinics, July 1, 1958 to JW 30’ 1959 C.COCO....OOOOCOOOOOOOOOOOOOO00.00.0000... Final Service Classification of Child Guidance Clinic Cases Closed, July 1, 1958 - June 30, 1959 ................ Page 25 26 37 102 170 171 CHAPTER I INTRODUCT ION This isadescriptive stuck offour lflchiganChildGuidanceCIinies located in the cities of Battle Creek, Flint, Kalanaaoe, and Lansing. The purpose is to canine operational sinilarities and differences anong those clinics. The first area of stucv is an analysis of staffing patterns. A description of the existing staffing patterns is given'te show how these affest .the philossplv and operatin of the clinics. This covers the process that begins than the client first contacts the clinic, through the diagnostic stunt, to deterninatini.af the disposition. Then treat-eat nsthsds are explored. Thia covers the period between acceptance roe treatnent and terdnatisn. The various nethods of financing are described next. This includes financial arrangenents between state and local clinics, resem'ces, none of soliciting funds, budgeting, and apenditures. Finally, a stw is node of csmunity relations as affected In each clinic's interpretation of- its function. This includes activities devoted to interpretation of the clinic, cos-unity education, and public relations. This stw was undertaken by five students in their second year of training in the Hiehigan State University Graduate School of Social work. Two students sore placed atthe Battle Creek clinic while one student's at oachefths others.J.s each clinic servesafairly cuparable geographical area, it use felt that a conparative study of these clinics could be ado. The following table gives the population and nunber of counties served by each clinielz' 91% P tion cmue Battle Creek 1111.169 2 Flint 196,910 3 Kalonaaoo 82,089 5 Lon-m . 107,807 b ; Even though there is substantial difference in the sine of population served by these clinics, they have a comparable clientele, drain partially frna highly industrial urban areas and partially fru the smsundingruralaroas. Bach calamity also has a network of social agencies that is availabla for collaboration. Theplanto carry outastucw efthe four clinics urged as the result of discussions anoug the five students placed in these clinics. The students noticed sinilaritios an! differences in the procedures of their clinics, and cans to the conclusion that an exploration of the reasons for these variationsnould be interesting to then and night revealcertainpstterns thatvouldbe of inpertanco tothe clinic adninistrations. Pernission to proceed with the stow was secured fren the School of Social Work, and‘the administrators of the four clinics. The State Departnsnt of Mental Health. expressed interest and provided cooperation. The next step was to determine what specific areas of clinic operation to study. The njor decision was whether to exanine one area 1“0.9“, Bureau of the Census, U.S. Census of Population, 1960 pp. 10—13 of clinic process intensively or to study the entire clinical procedure nore generally. The later was decided upon because of the lack of general studies on clinic operations. It was felt that an exploratory enaninatien of the entire clinic process might point to areas in need of further intensive stw. A nunber of possibilities, such as client perceptions of the clinic and censunity attitudes concerning the clinic were discarded. It was felt that these areas fell outside the purpose of the stucw and were large enough areas to nsrit a sore intensive separate analysis. It was finally decided to cover the five areas of clinic operationsnoted above and to examine then in each of the clinics. A variety of techniques were used in eliciting the information for the stunt. There was first a preliminary phase in which unstructured interviews were conducted in some of the clinics as well as with ‘ officials in the State Department of Mantel Health. A review was made of some clinic docunents such as bylaws, minutes, and rules and regulations. in examination of current literature revealed few comparable studies, however, there was considerable information that could be used for specific related topics. A more specific interview schedule was then devised as a basis for obtaining detailed information from each clinic. Interviews were mm with various members cfdifferent disciplines of the clinics' staffs using the interview schedule“. The State Departnent of lbntal Health and the four Lamps cooperated in giving the students m relevant documents, reports, statistics and other information they thought would be of help. Other procedures ani techniques were used in the student's selected areas of study. These are described in the following chapters in the individual presentations. All of the above information was then coupiled into a written account of what had been found in each clinic. Each student selected one of the five areas for a more intensive exanimtion and report of his findings, using the compiled material as a guide. Each student approached his project through an analysis of one I aspect of operation canon to each clinic. Following this, the student explored a more specific amect of clinic policy drawing upon sources in the literature as well as data from the clinics. Thu, fie‘anor Keyee completed an analysis of staffing patterns which was reviewed against the wider background of interdisciplinary relatiomhipe on the psychiatric tea: and the kinds of problem and issues involved in these relationshipso Chapter IIcoversteanrelatimshipswhileChapter IIIdealswith staffing patterns of tho four clinics. I A pattern of adequate fanancing met be established by eagh clinic to provide service. In Chapter IV m Babcock describes the patterns of financing found in the four clinics. Fee charging has become more prominent in all social agencies. The issues involved in charging fees for service are explored in Chapter Vo in examination of intake procedures is described by Marjorie Slarpe in Chapter VI which is followed by theoretical discussion regardingintalne inChaptor VILThcnasRuhala usedthis asapoint of departure to discuss Joint interviewing of the family in Chapter VIII. AstheFlintandIansingChfldGuidanceClinics arsengagedinexperinental projects using the technique of Joint interviewing, a review of these " " "9J1"; I I 'I ! io 5. Ce 4 I. :1 I ‘ W is ,4 4 . Che P7 Flint clinic an Thain: Clinics. In Cha; mics if ire. {slim filming: W‘- t’ ever! C: '5: Idiots .330“ 555233133 in :39” III. R Shoal; .‘Iflm Mela: . ”Whack; ‘Msklm : 9. V e " o developnnts is included as pertimnt to a descriptive stucv of thse four clinics. The practices of Joint interviewing used in diagnosis at the Flint clinic and in troatnent at the Lansing clinic are reported. Wismeefflteprimyfunctionsofallchildguidance clinics. In Chapter 11 Rn Hughes reviews the various philosophies and policies of treatnent which prevail in the four clinics. Termination follows treatment and isdiscussed in Chapter 1:. Continuity relations are an integral part of every clinic's service to its cammiiw.-1‘honas Ruhala analyzes the various‘procedures used by these four clinics inChapter XI. Finally, similarities and differences anong the four clinics are mined in Chapter XIIo . It should be noted that the mterial presented does not necessarily reflect policies or statemnta at either the State. Department of babel Health or the Child Guidance Clinics. Rather, it is a commits of findings from new sources, and is, therefore, the sole responsibility of the studentso cm II Tum~ minnows in discussion, or even thought, regarding staffing of a Child Guidance Clinic leads automatically to the tea! approach of orthopsychiatry. Webster defines orthopsychiatry as 'hopiwlactic psychiatry, concerned especiallywith incipient nental and behavioral disorders in childhood and youth."lg_lj§ychiatrio Glenn; states: “Orthopsychiatry: Psychiatry concerned with the stuiy of children. Wis is placed on preventive techniques to pronote normal, health enotionol growth and devdopnnt.'2Win Dictiona'q_gf_ Wise]. ferns defines orthopsychiatry as "the study of nental disorder with emphasis upon osrlytreatnent and prevention, an! based u the codoimd resources of psychiatry, pediatrics, psycholog, and social work."3'1'hus the important factors are preventive psychiatry using the tons! approach. Hones defines the erthopsychiatric clinic as: '...one in which the services of all three professional W -- psychiatry, psycholog, and social work - are available and coordinated as necessary in the interest of litebster's new International Dicti (2nd ed. unabridged Springfield, 3 o o .o, , Po 17211 2Amrican Psychiatric Association, A ohiatric Glosssgrfilashington, D.C. : American Psychiatric Association, p. 3Horace B. English and Ava Chanpney English, A C ehensive Dictionary of Paychological and magical Tern w or z , .o 3 , po ‘ 6 the patient. In such a clinic, the psychiatrist alms has the responsibility for the treatmt of the patient whether he does the treatment himself or delegates it. It is not necessary that the psychiatrist be the administrator of the clinic. It is essential that all three pofessiom participate in the pinning and review of cases and in policy mung." Wield Bugged!“ then psychiatry, social work, and psycholon were brought together in the early 1920's orthopqchiatry was born. They wsrebrought together as full fledged nsnbers of the teen in Child We Clinics. These were first established shortly after World War I as a means of learning about the emotional life of children and instituting a treatment program to elininate emotional conflict. Psychiatry, profoundly impressed by the research findings of psychoanalysis, had cone to recognise that emotional conflicts in the early years caused the serious enotioml tonflicts and illnesses of adult life. These three disciplines found- that by working together they could obtain a comprehensive picture of the inportant factors in a child's national life. Histrically there had already} developed a close kinship between psychiatry and social werk. The psychological concepts of hdolph Meyer, that at _ this tine (1916-1917) were coming to be progressively are accepted by psychiatrists, led a new groundwck and rationale for activities of nental health associations. lbyer's ideas turned attention to the individual's interaction with his environsnt...'l'ho M ncheloa of Freudwas aluhaving a significant hlhriaa HcBee, Chair‘s, “Synposiua, 1950 Training in the Field of Orthopcychia‘try: Fifiings of the I'bmbsrship Study in Relation to .Trainézng ad Worship," American Journal of Orthopsychiam, Oct. 1950 PP. “693 , influeme. The imights into hm behsvior it afforded were to be a factu‘ in the collaboration of psychiatry and social work...floroover, the application of psychiatric principles to social work techniques proaessed with a sweep an a speed that left a profound influence on the entire social work profession. is a result, the ally-lent of social work and psychiatry for collaborative service tothenontallyillseenstohavebecmeapernanent develop-oat. Significantly too, in the field of emotional disorder of childhood, the col-unity environ-ant cans to be seen as a nest important factor in treat-ant program for disturbed children.5 In addition to the psychiatrist's developing interest in the enviroment and the socialworker's interest in Freudian psycholog there is another area these tw’o disciplines share in canon. Basically, thesimofbothisgreater imividualsclf-realisation.1'hisis practiced through freed- of choice, self-motivation and self-dire ction. These are principle- under-137ml the hbelthe growth and development or personalities. Both disciplines can flourish only in a democracy so this regard for the individual's personality nukes denocracy more than a political qsten. It is the life's blood of these professions as practiced in the United States. In addition to this basic alliance of social work and psychiatry in the democratic tradition. emu first principle of temk develops this inruier when he states: romeo-k is inoaupotible with .. authoritarian ideology. Without a first conviction of the essential dignity and worth of all non, withoit the recognition of the" responsibility of each of us fa his fellow nan, teanmrk and the welfare philosoply which it is designed to ilplenent make little sense. Thus the “tow is not an end. 5Group for the Advancement of Psychiatry The P chiatrist and his Roles in a butal Health Association Report e on ucat on or a Group for the Advancement of Psychiatry, February 1960) p. M. It is a neans designed to serve the ultinte realisation of the6potentiality of those whom we are dedicated to serve. Connery then develops the team relationship still further, swing: 2. Tee-rorkisafellowship ofnenandideas.’l¢o uoupcanlong endure as ananingful entity without cannon ethos. The bond which unifies theclinicalteanisthebondofservicearrlthededicationofthe collective talents of its individual nenbers to the realisation of that end. It is a fellowship of interdependent inquiry. Differences nay am do wrist between individual members and disciplines, but without some canon denominator of effective tea-work lies in the conception of men as the product of a biological, psychological, and social catimmooi'hs mthed of the tea- is the method of discipli-d scientific inquily Jointly pursued... 3. Effective tea-tck'rests on the Iranian that the whole is greater than the sun of the parts...Teamerk is...a.conviction that the integration of distinct and overlapping skillagives rise to unique insights and unique therapeutic possibilities. Jeni-dork is predicted on the individuality of the participating disciplines. The team is’an huogenised whole. Its strength derives fruit the preservation of difference. Befce one can becuee a usefulaenber of an interdisciplinary process‘he nust first have established his identity withiahis own profession... h. Teanrork is an interpersonal process...teanrork does ”not just happen, itdevelops fruadiscovery ofsolfandof othorsandfrona conscious effort to iaplesent this insight iathe Joint activity. 5. Tea-rerk ilplisna capacity for youth and change. Teamwork is a chrnaaic process... 6. Tea-tor]: ilplios the understanding and acceptance 1 authority... each clinical decision is an expression of greater c lesser probablity' inwhich each nust share, sons to a greater and some to alesser degree. But all must be bound by the validity of group decision...The authority ofthoteanistheauthority afroasonaficonpetenceurhenatare individual finds little difficulty in relating to this concept.7 The psychiatric experiences of World War I increased interest in working with children and stimulated the development of psychiatric clinics for children. At this tine : ' 6Maurice F. Comedy, I"The Clinate of Effective Teamork", Journal of mghiatric Secial Work, XIII (January 1953) p. 59 71nd. 131359-60 10 Child analysts devoted their major efforts to the study and modification of conflicting trends within the child, drawing the parents into the treatment situation in a widely variable W, often through the parents' personal analysis. A specifically American contribution to child psychiatry was the Child Guidance Clinic, a structure which developed out of the interest of psychiatry, psychology, and social work in how to help disturbed children and their parents. The professional knowledge of these groups gradually head all nude clearer the concept that a child is in a We relation to significant people in his environment. (hat of this concept evolved a therapeutic philosopr which included nedificaticn of both environment all! child in ways nest favorable for his psychological growth. This philosophy was imlenented in the team or collaborative approach, which provided for active participation of parents in a therapeutic process focused on the disturbances in the parent child relatiomhip. Parent participation was felt to be a necessity since, in nest instances, the child is brought for help because the parents are concerned about him—a child does not seek help because of his own insight. kperience in childguidance practice demonstrated also that a child can sustain a change in his personality only with the support of his parents or their substitutes. mm it is clear that child guidance clinics did not discover the important influence of the parent on the emotional development of the child, the fact remains that the collaborative work of these clinics has refined the professional skill needed to include parents in the clinic sefivice designed to help a child with his emotional difficulties. with the change in eIphasis from diagnostic to therapeutic, the aha-tag. of therapeutic pan-come: becane acute. s... .r the therapeutic work had to be tuned over to non-medical personnel. Over the years, snore of the theraw has been carried on by social. workers and psychologists. The role of the social worker developed from history taking into casework, which eventually developed into therapy. At first this was carried on with the parents; later social workers found thq could treat the children themselves. Along with the peyoholegiet's testing there developed BGroup for the Advancement of Psychiatry, Basic Concefi in Child chia Report #12 Formulated by the sy try opeka, : Group for the Advancement of Psychiatry, April 1950) p. 3 ll the inclusion of work on educational medial problems which led to the recognition that reandial problem fundamentally involve general personality m‘oblens requiring the usual pqchotherapeutic methods. This experience concuitant with the use of these methods led to its application to other types of problu. Concurrently, the psychiatrist made some shifts in the direction of his interests 1y sonetines taking the parents for therapy as well as child patients. Team Configurations: Today, there are m definitim of “tean' and new different kinds ofteansinoperation. Itiealmtysagroupofpersons givincdirect advice to an individual or a family treating the emotional climte in which a child grows. The nest cannon composition of the team consiets of the three disciplines of psychiatry, social work, and psycholoy. I'Here the lines of specialisation are hazy. Sens attenpts have been made to make a clear distinction as to the division of labcn'. However, the consensus seem to be that clear cut distinctions are difficult to nako."9 There are several configurations found in «causation of recognized standing. Each requires separate consideration. In sons organizations the three professions provide two types of service - theram and casework. Sons diagnostic formulation is a basis for therapy but psychological moaninations, as such, have been sharply curtailed or alncst elinilmted as part of the routine for handling cases. This has been 9Daniel 11. View and Otto N. Raths, Jr., ”Contribution s of the Montal Ibrg ions Clinic Team to Clinic Decisions", Amricen Journal of whom an (April 1959) p. 350 12 done deliberately because of the conviction that psychological examinations areno't indicated in the process of treat-out offered by the organisation. The three professions are still represented on the staffs ofnestefthese agencies, butwshovethreeprofessiens withtwobesic functions «— psychotherapy and casework. This situation seem to have developed as . result of changes inpractice, such asthe increased use of nomedically trained personnel for treat-mt, and the grouting emphasis on the selective, rather than the routine use of aw procedure in a smcific case. It is felt that an early developmnt of a treatmt relationdlipisfosteredandtineisnotloetwithsuchapoliq. A second type is found in organisations where the psychiatrist in a regular staff leather, has supervisory adninistrative duties, participates in the farmlation of policy, but does not devote an appreciable tine to direct service to patients. Instead, psychiatrists in these organisations fumtion as;comultants to other staff numbers who carry nest of the cases. This might be a logical outgrowth of the poetics of using psychologists and social workers ft therapy, hastened, perhaps, by the shortage of personal} The two kinds of situations Just described represent changes in function for the three disciplines. There are two other groups of organisations which represent 'a greater departure he. the original pattern of the clinic teen. In one group of organisations the basic cocposition of the clinic “ A— mharic Krugman, ”A Study of Current Trends in the Use and Coordination of Professional Services of Psychiatry, Psycholog, and Social Work in ' Mental $81612 Clinics all Other 331W Agencies affl- Institutions”, ' Aggrican Journelpof W I! (January 1950) PP. 58.62 13 teanhas been chained. Only two disciplines are represented onthe staff of certain clinics, either psychiatrist or social wa'ker, or psychologist and social worker. In these organisations the services of the third are available 11 en. special arrangement. The psychiatrist or psychologist mbeaconsultautonafeebasis, ahistinewbeuadeavailableby another agenoyteseereferralcases. Themerofcases seenbythis outside cusultant is usually a smllpreportionof the total case load. This consultant takes nopartinfomlationnoipelicy onthe work done by theorganizationoronthetypeofcasetobereferredtohin. fiehasno responsibiliw fa:- decidinguhenerheusspeeixieeese shouldbe handled orreferred. Heseesthecases sonttohinandnnkesareport, eitherin writing or at a staff conference which he attends. It would be rare for this outside consultant to carry aw cases for the annoy on a continuinc basis,bothenvbeconsultedaboutchmeswhichoccurincaseshehas mu Teas Functions: Asmntionedproviausly, thereismohthatis basically cm botveen psychiatq- afl. aociathork leadingta considerable overlappim in functions resulting in some lack of clarity in functions. The pqchiatrist's special contribution to the tea is his cutimling interest in medicine with an emphasis upon pediatrics. This includes continuing stuck and learning in the processes involved in somatic expessims of psychic mhenonena as well as knowledge regarding the development of the norm]. infant. Another specific contribution of psychiatry to the team “an; 11; is the psychiatrist's ability to deal directly with the unocnscicus. Socialwork brought tothe teanthe knowledge that the child is not an indepenient individual but is inflamed In his envirounnt including his family upon whon he is dependent. Therefore, treat-ant of- the child could not disregard familial situations fron which he cannot be separated. Thus the social worker's \mderstanding of pvche-social factu's, with emphasis upon social aspects brings into focus the difficulties created by the individual's problem in carrying out his various social roles. Although the caseworker may never deal with the unconscious material directly, he met understand it in order to relate treatment to the realities of daily life. Most schools of internal medicine todw recognise the social implications of illness an! teach students the social side of medicine. No other discipline is more complex than social work and it actively touches more people than our other. there there are human relations, there is social work, as whatever affects the behavior of nan in his relations to others is input-tint to social woo-R12 This is again an actual overlapping of the two fields. There are severalareasotherthanaotualpsychiatlywhichisnosalsoemasised as important to the psychiatrist. .e.hc list have knowledge of, and ability to work with, commi‘w organisations. He not know sonething about calamity resources, and how they on be used fr the benefit of the clinic patients. As a nonbor of the clinic organisation, he does not need to know all the details, 1Zaporreo-d Ackerly ”The Clinic Tean', Anorinan Journal of mm XVII (April 19h? p. 12 15 but he certa ' should be alert to the over-all picture of the calamity. Required in the curriculum of graduate schools of social work are courses in Commity Organisation and Social welfare Organisation. The similarity between these subjects and Dr. Lauren's statemnt of psychiatric requiremnts is obvious. The psychiatric and social work approach to the . patientissinilarbecauseitisthrough interviewingasepposedtothe psychological approach through testing. Both disciplines are involved in the intake procedure while the psychologist is usually later with his testim. Just as mdicine now recognisesthe social implication of illness, the social work training period includes psychiatric components and its implications which establishes another omen bond. Of the three disciplines involved in the clinic team, psychiatric social work has taken its task most seriously and made the most definite efforts to deternine its functions and to train for these in an organised fashion. In no recent years and in a somewhat less organised wq, psychiatry has also attempted to establish standards of training. Clinical psycholog is the last discipline to establish itself. It was necessary for clinical psychology to go through the stage of breaking am from academic weheloy inordsrteestablish its field ofworkonan. adequate practical basis. There is now, a trend toward reanalganation with the parent bow. Because the other"two disciplines did not have this sharp contrast with theirorigins, thqr were able to deal with their problem earlier and so establish themselves in the field of psychopatholoy MA- J~3inmioh 6.1mm, usymposium 1950 Training in the Field of (h'thcpsychiatry, Findings of the Membership Strip in Relation to Traing and Membership" American Journal of Orthopgchiatg, ChairnanHarianJicBee, n(6ct. 1950) We “ 16 earliery' Todq the psychologist's contribution has mm sides, am of which nu be enphasisod according to his training, experience, and interest. Be my be a psychometrist, a diagnostician of personality structure, or a psychotherapist. Basically, his functions are changing in the direction of broader responsibility in cases, particularly in treatment. The field of clinical psycholog isexpecting consistence in three mjor areas: "...diagnesis...research...and theraw, the use of techniques for inprovim the condition of the person who cues for help}; In 1959, The Amrican Orthopsychiatric Association culpleted a stat of orthopwchiatric clinics, agencies, and hospitals frail six regions: Chicago, Cleveland, Detroit, New England, New York City, and Washth D.Ca'6 This report iniicates that alLthree discipline engage in psychotherapy. Abeutahalftoathirdofthoseusingmorethanonediscipline fr psychotheraw said there were no differences in methods and goals, although sons of these had previously made differences in assigrunents. However, a little less than a third actually made no differential between professions in assigment, methods or goals. The attempts of others to describe methods and goals of treatnent were not aluays successful. The descriptions of social service treatment were the clearest, involving ego- supportive methods geared toward rather well-defined goals, but again the differentiation frail I'caseuork" was often discussed. Psychiatric treatment was more usually described accordiu to method by such terms as "intensive", "deep", or "uncovering". Also mentioned were certain types of cases to be treated ty psychiatrists such as psychosmatic diseases, or additions in which drugs were beilg used. There was seldon “maid sicko-o, "Clinical Psychology: An Evaluation", arth chia 12 -1h8:RetrospectandPro§p_ectJEd.IusonG.Lewory& or gleam IE ioflc: Amrican Orthopsychiatric Association, 19118) pp. 231-2147 15min. 1». 237 16w. Meson anthers, ”The Psychotherapwtic Function of the Orthopsychiatric Teen: Report of the Comittee on PsychothertPJ. Panel, 1959", American Journal of Orthggchiatg, m (Janisry 1960) pp. 19-86 """"" 17 aw attempt to describe the methods and goals of psycholoylo'7 Only a few clinics specified types of cases or kinds of psychotherapy appropriate for psychologists. In those settings where pachologists do psychotherapy, they do not work with cases selected fa- then specifically because of their profession. It again emphasises that the psychologist doesnot present a clearly percieved image with respect to his therapeutic role. ‘fhe stucéaindicates that there is no established basis for distinguishinghow assignments .to the different disciplines are determined or that the therapist' s experience and attitudes are considered. The general pattern in child guidance clinics is for social workers most frequently to treat the parents and psychiatrists and psychologists to tract the children. flavour, in contarst to this, in one region social workers do the largest amount of psychotherapy with children. Reasons for assigment to the mchiatrist were most often given in term of severity of pathology, depth of nterialato be one with, or goals involving persomlity change. -‘fhis policy was not always followed because in some clinics the nest severly disturbed‘patients were assigned to social workers and the psychiatrist was assigned those patients with particularly good prognosis. A sizable number of clinics responding stated that social work focused on reality and did supportive casework. These clinics differentiated casework from poychotheram as a fern of treatment. Sometimes expediency is thedecisive factor inassignnentwhichneansusingthe “solo: a. Beisor, *3: mom of Treatmt', inerican Jon-mi of Orthopsychiag, In (January 1960) pp. 59-60 189, cit. Mathews 18 available personnel. There are the two extremes where at one end the medical responsibility for pq'chotherapy is taken In limiting this function to the puchiatrist. it the other extreme, responsibility is on the basis of administrative structure, that is, a pivsician holds an adndnistrative post but has no comection with therapy. The majority plans fa' a psychiatrist to have sane contact in supervision, comultation, or case conference. The bulk of supervision is done by psychiatrists who also do the nest unsupervised psychotheraw. Most of the cross-discipline supervision is inthefornofapsyohiatristsupervismsocialworkorora psychologist (oven in social agencies). More psychiatrists are consultants than aw other profession. Most chief-administrators (hence, policy makers) are psychiatrists. A situation cannon primarily in Michigan is that of non medical clinic directors sharing supervisory responsibility with a part-time consulting Mcmm.-rm, the director, who m be a social worker or a psychologist, supervises representatives of the other disciplines. ”The most striking finding of this portion of our survq was the relative infrequoncy of psychologists functioning in a supervisory role."]9 Ordinarily the psychiatrist is acknowledged as the senior sis-berefthetean. Thoreisatendencytoprocenceivoofhim as the team leader and the focus of vital team decisions. Freoeudata, hewever,thisdoesnotappeartobetrueor Justified for the specific decisions studied. There are indications that the social worker is closer to the center of team activities and decisions and a tendency for psychologists and psychiatrists to save in his direction, atleast in our 19Soul. I. rho-risen, "5: Direct Supervision of .the Psychotherapist as a Teaching Method" , imrican Journal of.“ Orthopgchiatgz, Chairman w. lhson Mathews , anusry l9 . p ' ———..._.——-—'-'- ---— ten m hwhm W, W be with 3mm 31 in 131 t a comm Echelon: | :73. the “pg ”6 me Hi] {aim , d”: we 358:8. 1'11," 5‘39. hertz harm at! “lat Waits llthm iii-.153 be “i in. p, shuns J “tint?! ‘efi‘. s.‘ ““73 to Q ‘- ’ .s. , opt-Q‘s 1 19 teen process";Q Thismbetruefor tworoasons. The socialworker, because ofhistory taking, say be here familiar with the past history of the patients and with current environmental stress factors. He appears to have pester optinisn and enthusiasm concerning help for patients and their fan-flies as contrasted to the more pessimistic and cynical attitudes of the psychologist and psychiatrist. As a result, social workers are frequently given the "green light" on their own terms. The social worker, additionally, seem more willing to admit and accept disequilibrium: among teen members. To have a democratic poop, it is necessary to have people who accept emotionally as well as intellectually the relative equality of other group where. There not be freedom of discussion_ani decisions node by the group. kperience .in workingnith one's teamteabrings about a deeper understanding of cos-unication. Acceptance of each other leads to positive working relationships with the ability to talk about difficulties and uncertainties in teen conferences. Although it is difficult to distinguish psychotherapeutic differnces betweent he various disciplines, there remains a tendency toward the preservation of original professialal identity with the disciplines Jomd in the cannon enterprise of pwchotherapoutic teamork.2’}he majority of organisations sake use of the specific skills pertaining to each discipline. thintenance of original professional identity thus appears to be important to the members of the different disciplines ZOWiener, gp.cit. 2114athews, gp.cit. 20 also there would not be the struggle for this. There is considerable obscuring of professional boundaries which appears to be due to the methods and goals set by the administration. Yet, the orthopsychiatric team was formed to bring a mltidisciplinary approach using the knowledge and skills of the three professions. The original aim was for each profession to contribute its own special and particular functions which would be integ'ated to the solution of the presenting problem. One way that a discipline's focus is able to prserve its original integrity is for a;tean member to be supervised by one of his own field, e.g. the social worker's supervisor and not the team leader remains responsible for management of the social worker's treatmnt. Relationships between team naenbers can easily influence the course of treatment. Hostility agaimt a team mate can include members of the family being traeted by the teanmate. It has been said that teams in their relationships tend to reproduce relationships of family numbers they treat. “Jean members relate to each other as inlividusls, but each participant's identification with his member of the family influences his relationship with his teamte in new wars; and feelings for a teammate 3 color ene's perception of other ate-bore of the family. lfitwasthwghtthateneteamtewasdmgingratherthanhelping hismewerofthefanily. others ontheteannightfeelthqconldnot work with this therapist and become discouraged about working with him in other cases. If a therapist feels criticised he may lose confidence. Yet nanbers m gain support and encouragement from each other and 22kt“ Peruts, "Treatment Teams at the James Jackson Putnam Children' s Center", Snith CelliStudies in Social Work, XXVIII (Oct. 1957) pp. 1-31 #7 21 obtain growth through new knowledge, broadened viewpoints, and the ability to cooperate.‘ Problems of professional rivalry and personal differences can be faced in a mture way which develops personal growth and professional ethics. Currentcasenaterisls canbethefocusfor teaching. Ina favorable setting, teanstork increases rapport between disciplines and enables more adequate supervision by senior members. It can be used as a tool for the assimt of caseloads and responsibilities, and for generating therapeutic enthusiasm. Perutz believes that the close relationship between therapists as well as the relationship of clients and teen members is the reason parent and child frequently work on the ease material simltaneously.23Alm with this is the sharing of responsibilities which are easier to carry tun if this rests on one individm alone. Fran the study of our Interial one comet avoid the impression that in function, -as well as in training and teaching, interdisciplinary teamerk-psychotheraw is only in its early phase. Whatever it actually exists, it is usually only partially applied, its structure and concepts are vague, and its inner cohesion weak or not definitely established. lack of training standards, lack of available personnel, lack of inner conviction, lack of security, and competition for status in the relations of the different disciplines are manifest 2b in mm of the orthopsychiatric settings which we have explored. There is lack of clarity regarding the professional boundaries in the practice of psychotherapy within a given setting as well as between settings. In new clinics, the three disciplines have become so 23 2W 0. Rules and Mortimer Schiffer, "h: The Psychetherapentic Training of the Team Members and its Influence on the Team" , Amrican Journal of mnm Chairmen w. Mason ththews, m (Jan. p. 35 22 inter-mined as to lose an semblance of specificity. The direction has been to mks to psychotherapist of everyone on the staff with sane abadonnent of what the sooiel worlnr and psychologist have to offer free their specialized training(the obvious status seeking implications involved would provide material for another paper). inst social workers and pqchologists w in effect he swim is that their own specializations here little to offer to the help of emotionally- disturbed people unless they transform thesselrea into psychiatrists. Thisnsy force pqchiatrists to learn social work and psychology. The growth of the team should rest in its effective integration .omeowledge from these three disciplines plus related fields. Its strength should be in the checks and balances of this canpesiticne am: The foregoing review of interdisciplinary relations indicates a tendency for the functions of the three disciplines to overlap considerably. Despite ennhasis on therapeutic activity, it is likely that there willcontime-“ be specinlisntioninthose aspects which a discipline's training emphasizes: the psychiatrist tends to work with the unconscious and the handling of psychesenstic problem; the social worker tends to esphasise social and environs-ital aspects of presenting problem; and the psychologist tends to emphasise diagnostic and research responsibilities. One naJer value of the team approach is the availability, where app'opriate, of Joint stuw representing three disciplinary orientations. This interchange and textual sharing are important because problem of disturbed human personalities are so complex that without it we run the 23 danger of omission rather than emission. We have the beginnings of an integrated interdisciplinary psychotherapeutic team. Ve have far to go before we can expect uniformly satisfactory results. CHAPTER III SPAFFIM} PATTERIB We can understand the. operation of orthopsychiatric team through a stucw of the staffin; patterns of existinchild guidance clinics. All child guidance clinics infiehigannperate--undor the State Department of Mental Bealih which Ins. established a basic staffing pattern whereby "...the departmt will supply funds for times professional workers consisting of a psychiatric director, a psychiatric social worker, and a clinical psychologist; or in those instances when a psychiatrist director is not available and a psychiatric service is supplied on a consulting or part tine basis, the department will supply funds for one additional psychiatrii social worker or psychologist as the administrative director." . After a clinic has been in operation for two years and conditiom so warrant, the state department will furnish funds fr additional psychiatric social worker or clinical psychologist. ,‘fhe local board must assure the respomibility when there develops a need for a fifth staff reenter. Awhu'ther staff additionsafterthiswillbe node oathe basis of equal sharing of financial support between the local board and the Department of Mental Health.2 Hhen possible, the director of each clinic should be a psychiatrist, 1shots of Michigan, Department of hotel Health, His an Child Guidance Clirlics: Reg?! and Policy Statenent,(Lansing, c an: State of m, 9 ’ Po 211316.. 2!: 25 however, exceptions an be made when a psychiatrist is not available. In such cases, a mnber of either of the other disciplines m be appointed andthepsychiatrist (fullorparttine) shouldbeusedinaclinical relationship. The director is responsible for the development an administration of the clinic's services, supervision of clinic persomel, recmndation of policies to the board and department, and provision of professional leadership in calamity mental I'vgiene activities, and development of sound inter-agency and community relations. The staffs shall be coupesed of child psychiatrists, psychiatric social workers, and clinical psychologists who shall be directly responsible to the director.3 . series We can understand the operation of clinic staffs only in the frame work of a specific setting. In our stuck we found differences am sinilaritiesin the staff composition and function of four Michigan Child Guidance Clinics. with l Staffs of Four Hinhigan Child Guidance Clinics as of March 1961 _ 33:1,: momma Social Hcrker PM Nurse Spppch Therap_i__st_ Creek consultants hi 2 m T a; r Q27“ “1 LifiiTzaer lit 7 T §L ions 1* 2 in" h «IDiscipline of Administrative Director «ao- The psychiatrist is clinical director and the psychologist is administrative director ope- 26 As can be seen from Table 1, all clinics have more or less followed the basic staffing patterns reconnended to the Department of Mental Health. All clinics have vacancies in various disciplines which do not show in the above table. hpediancy has been involved in the selection of new of the persemel. Availability of staff is considered one of the prime determining factors. Clinics generally attempt to follow the recomnded staffing patterns but my be unable to do so due to lack of personnel available. is a result, there are frequently openings for one discipline when another m be available. The four clinics train social work students and so develop a resource from which they may draw. In addition, one administrative assistant stated that social workers have the least definite diagnostic skills but the greatest all around skills which is indicated by the social in social work. Therefore, social workers are the preferred discipline to add to a staff. Lansing and Flint have mohaledstiinternsrtmnfdeuelopmmnurce for themselves. Intake Procedures: Intake is an important function of the professional staff. The following table points out the nary similarities and few differences that exist in the four clinics studied. TABLE 2 Specific Functions of Three Disciplines in Intake Hocedures Clinic Psychiatrist Social Worker ngholmr Creek 1.3. 2.12;; 2.139} M" 1.2.3. 2.3. 1.3. Kalamazoo 1.24.}. 2.a. 11a. hug 1.2.3g 2.a. 1.3. 27 TABLE 2 "Contimsd' 2. interviews parent 3. unless clinical clinical diagnosis ' a. refers parent or child to psychiatrist when needed b. decides who should see child *.Flintusesasetteanapproach forintakeprooedure Interpretation of this table shows that intaloe procedures for Kalamazoo and Lansing are identical. Saial workers interview all parents; psychologists test childru. Eithera'bothlwreferhisclienttothe psychiatrist uhen waded. Flint operates in this sans manner with the addition that they have definite team who are assigned to was]: together regal-Irv. The psychiatrist is a neuba of one of these teams. With one exception, these team are couposed of Issuers of two disciplines. The ' emception is the one team cmoeed of two socisleworkers. 0n occassion awstaffnsberuydoanintakealone seeing bothpereutandchild. Battle Creek has either social worker or psychologist interviewing parents at the time of intake. The intake worker determines whether the child should be included in the study. Walters at all four clinics refer the child toths psychiatristwhenthsrsappoarstobe anodicala' serious psychiatric problem. The psychiatrist is the only one permitted to make aclinicaldiagnosisinKalamsoouflLansing. Thisisconsidereda medical problem with personal responsibility resting with the radical person. Flint permits all disciplines to participate in diagnosis. Aw one staff member may make the final diagnostic decision, however, in practice this rarely happens. The supervisor of the staff person would enter into the decision in soon w. No one individual or discipline has final and exclusive responsibility for the diagnosis. The psychiatrist 28 m assume responsibility for noting the final diagnostic decision at Battle Creek, but froqunstly those m be made by the clinic administrator in the absence of the psychiatrist. This is definitely contrary to policies of Kalansoo and Lansing though it concurs with Flint which permits etha- than the psychiatrist to make diagnosis. Treetmnt: A Allthree disciplines are involved in traetnent inall four clinics although the psychiatrist does only limited treatment at Battle Creek becausa thereis no staff psychiatrist. Flint does not see aw difference in the treatsmt functions of the disciplines but rather a difference in individual. skills. Kalamzeo questioned. whether there is an distinction between psychotherapy and casework. Definshle distinctions intraetnont methods are netdeliniatedhy aw ofthe clinios' staff members, although specific mdical problems are always referred to the medical authority of each clinic. This is the area that the American Orthopsychiatric Association stuwyemphasised needed further understanding and clarification. is pointed out inthat study, there is a lack of clarity and understanding of the roles of the therapeutic teal whereby social workers and psychologists do psychotherapy. The four clinics studied appear to be members of the 'paychothoraw group" which stresses the overlapping of the functions of the three disciplines. In contrast to this nethod the Ansrican Orthopsychiatric Association emphasises the special oquipumt and contribution that each discipline would offer to treatment. theChap‘terII. 29 nay-saber ofthe fanilynq be assignedfcr treatmnt teary ne‘er of am discipline with consideration given to age, sex, problem, and particular abilities of the therapist. Thus it is in the function of treatnsnt that all four of the clinics follow an identical pattern: all medical problem are referred to the psychiatrist but am Ieaber of any ofthe disciplines m be assignedtoamnenber ofthe client teen. Battle Creek operates in a slightly differentnsmer. Due to the shortage of psychiatriapersmnel on the staff, the administrator me new of the duties perfused he the psychiatrists at the other clinics. The psychiatrists wwk m a consultative basis with diagnosis their primary function. Teaasvork hthodg: As each of these clinics emphasises early treatment and prevention and utilizes. the services of the three wofessionalnoups - pqchiatry, paycheieg, and cesarean: - each M11 orthopsychiatric. The services of the threadieciplinesmncre or less available for each patient and are coordinated in the interest of the patient. They seek to obtain a comprehensive picture of the important facta's in the child's emotional life in order to give the best diagnostic, ccnsultive, and therapeutic service possible..Thus the services of the team are available to clients and so each clinic functions with orthopvchiatric teams. These teens are utilised to serve the realisation of the potentialities of its clients. ‘ The previous chapter points out that teen work and authoritarian ideolog are incompatible. lime of the-four_clinics studied presents a 30 picture of an authoritarian setting., In three of the clinics, the psychiatrist automatically assunes the role of leader by reason of position as administrator. In addition, this is accepted by satff members because of the belief of the psychiatrist's superior training. All three clinics have case conferences with psychiatrists whenever they are believed necessary because of diagnostic or therapeutic problem. This leadership role does not lessen the importance of the team approach. During case conferences, nonworking on the case gives his interpretatim of facts ani expression of ideas. Others on the staff w also express thoughts. The psychiatrist then ashes decisions regarding the case generally and specifically. Inonesense, Kalamaooandlansingnybeconsiderodncre authoritarian because only the psychiatrist nay diagnose. 0n the other hand, this nw be a clearer definition and perception of roles. Thus the basic administrative composition of the clinics may affect leadership. The staffinglpattsrns of the foam clinics are given below. The profession of each clinicls administratine diameter and the composition of the clinic staffs are shown; Battle Creek 1 Social Worker- Administrative Director 3 Social. Workers 2 Psychologists 2 Psychiatric Consultants Kalamazoo 1 Psychiatrist—Administrative Director 1 Social Worker—Administrative Assistant 3 Social Workers 1 Psychologist ”.32: l Psychologist-Administrative Director 1 Psychiatrist—Clinical Director 1 Psychologist 35* Social ‘worloers w ‘ 1 Psychiatristmidninistrative Director 1 Social Worker-Administrat ive Assistant 3 Social workers 2 1/10 Psychologists 3]. Flint and Kalamazoo are different from the other two clinics in that each has a fourth profession represented on its staff; Flint has a registered nurse and Kalamazoo has a speech therapist. Both of these professional persons were added to the staffs in order to cable the clinics to offer what it regarded as essential services to the calamity. The nurse has knowledge of medical aspects of clients, acts as a liason between county health depart-ants in making referrals to the clinic, and is able to help train mdical.personneLin the community to look fu- emotional overtones to plwsical illmss. -In addition, sin is a mnber of an intake team pu'ticipating inboth intake and treatmnt under the supervision of the chief social worker. She carries a caseload cmparable to a member of an other discipline and sometimes conducts group therapy with parents. The speech therapist in Kalamoo is considered experimental. She was added to the staff because of the socialuork philosopr of beginning where the client feels the problem is. -Just as a child who is unable to read feels this is his problan and the area where he needs help, the child who has a speech problem wants help with this. Each of the three Injar professional disciplines working in child guidance clinics deals with cammmication. The speech therapist is an additional facility the clinic has available to learn more about commnicatiome m: The State Department of Mantel Health, under which these clinics operate designates only the duties of the director and the basis composition ofthestaff. Itisuptothedirectortostaffhisclinicsanddstsrmine policies. Therefore, there are variations in staffing patterns, intake 32 procedures, treatmnt policies, and interpretations of teamwork reflecting the director's philescplv. These variations are also a reflection of the democratic philosophy of individual self-realisation practiced through freedom of choice and self-direction which are underlying principles of the disciplines cuposing the orthopsychiatric team. CHAPTER I? amines The finmialnrrangements ofthe child guidance clinics in Michiganaredifferent innany aspects fronthe pattern of financing usually foundinsocislagcncies. Inaquiteextensive searchofthe literature, the writer could find few reports on cuparable arrangements, although there have been somewhat similar developments in other states such as New York and California at later periods. In Michigan, responsibility for financing is divided betwoen the State Department of Phntal I-balth and the local commnity. Local soin'ces are quite varied, but the state is the biggest contributor in all cases. The arrangemnt began by the Children's Find of Michigan establishing the Children's Center in Detroit in 1930 ani later a child guidance clinic in Traverse City in 1937. This served as the impetus for the later growth of child guidance clinics in Michigan.-The Children's fund offered money to the Depart-eat of Mantel Health for a demonstration project to be located ina commnity that would share in the cost. This clinic was established in Lansing, Michigan in 193 8o The present statute of Joint financim by state and local cousainitiee was inbodied in state legislation in 1938. ‘ Since 1938 the Michigan legislatm‘e has ammlly appropriated funds to the Departsant for the administration, supervision, and development of the child guidance clinic program. Out of this appropriation come the fundafor the salaries and expenses of the basic professional clinic staffs and 33 3b the expenses incidmtal to departmental administration and supervision. The establistment of new clinics is determined ty legislative wowmioml Since1938, thechildguidancep'ogrsmhasbeengraduallycxpanded.hll the counties in the state are presently assigned for service to one of the eighteen clinics.2 This principle of combined financing between the gevermnt and the local cos-unity isinlinewith scale ofthe currenttheory offinancing social services. Thisauthor Joinswithmaxw otherswhoviewwith pride, rather than alarm, the partnership of goverrnnent and voluntary agencies in joint efforts fa- hunan welfare. ...In the final analysis, the attitude of the citizen, an! the statosmnship of the health and social work professions will determine the price to be paid for the conservation of human resources.3 A more recent lrogram based on a similar financial arrangement to Michigan, was established in New York in 1951; after considerable planning. An act was established for a permanent system of State Aid to localities for the operation of columnity mental health services. Perhaps the most fundamental principle in the act is its placing of operating responsibility on local government, with the state wing half the cost. This emphasis on local responsibility is consistent with the 'home rule' principle embodied innuch of Newlork State hm. Itis also based onthe professional conviction that a local nantal health .7: 1Hichigan Child Guidance Clinics, Pr an and P011 Statement State Depart-mt of Mental Health, 1% Mcfilg’ an, 19%, p. 3 2Ibid, pp. 8-9. 3Leonard w. Mayo The ill-Iggy, Vol. 86 No. 2 February 1950 (Survey Associates Inc.: may vania), p. S; ’ ’ 35 program can succeedonly tothe extent tlocal citizem accept it and identify with it. A mher of other states have also instituted similar programs in the past decade or so within variations of arrangements. There are a nunberofwaars inwhich clinics canbefinancedandadministered. The range runs non state cache]. to local autonow, with the usual arrangement falling somewhere between the two extremes. There are, of course, arguments both for and against each type of arrangement. However, it is not the pm'poseofthisstthodeterminewhatthebettertypeofarrangement is, rather to report on the arrangemnt in Michigan, specifically as applies to the four clinics under study. In Michigan the local finances, coupled with the State's monetary support, suppr the necessary funds for the operation of the clinics. At the present time the Sttte is supplying approximately 60% of the total operating funds for clinic operations. The remaining hoz is derived from local tax resources or private local funds. Inordertoentertheprogramthe local cummitymlsthave established a base for the financing of its stare of total costs. Itmlstbeunderstoodtha‘tifsuchaclinisis established that; evidence shall be furnished of continuing financial. support from local govormlental and/or other sources for local operating expegses, supplies, materials and secretarial services. After the Departnnt of butallfiealth approve the counumity' 3 application for a clinic, the Department includes the State's share of the cost in the 1'Boher‘t Hum, American Journal of Pfichinggi Vol. 113, February 1957 (The Lord Bel ess, ., e ., 1957), pp. 680-685 5W Poliq Statement,-1956, op.cit., p. 10 . 36 nut budget :request. If the appropriation is approved, the clinic can startdrawingflnadsthefollmdngJuly.Theclinicboardistotake responsibility for the raising of local funds needed for the support of theclJnic, mistoworkwiththeStatoDepartmnt oflbrrtalflcalth in matters concerning finances.. Thedistributionoffinancialsupportbetweonfltenepartnentand the clinic board is established in the department's Policy and Program Statement and consists of the followings During the first two years of a clinic's operation, the Department will sumly funds It three “$9331,ng workers, consisting of a psychiatric director, a pqchiatric social worker, and a clinical psychologist; or in those instances when a psychiatrist is not available and pqchiatric service is supplied on a consulting or part-time basis, the Department will supply funds for one additional psychiatric social worker or psychologist as the administrative director. “The Department will supply funds for essential. travel expenses of state paid staff on! occasimally to professionaLconferences approved tythe Department. Thelocalboard shallsupply funds for such expenses of locally paid staff members."6 After the clinic has been in endstence for two years, arr! if the need warrants it, the Department will supply another social worker or psychologist. If still additional staff is required, the funds for the neat staff number are the responsibility of the local clinic board. If further staff is required, the funds for them will be supplied on an. equalsharingbasisbetweenthenepartnentandthelocalclinicboard. 6mm and Polio; Statement, 1961, op.cit., p. 27 37 Throughout all the clinic's operation, the clinic board will continue to supph funds for the operating expenses for the local clinic and its memo. Financial Base of the Four Clinics under Stu : Ietusnoweramimtheoperartingbudgetsofeachofthefom‘ clinics, Battle Creek, Flint, Kalamazoo, and leasing for the fiscal year of 1959-60. TABLE 3 Sotlrceo ofFums ofFour HinhiganChildGuidance Clinics an! Amounts Reciegedégron Each Source in 199- Battle Creek Flint- Kslsmoe Iansing___ State h2,2h1 143,209 38,1400 70,168 County 31,283 6,000 7,000 15,135 Schools 11,881; 8,263 Cities 1,500 Chest 37,910 17,053 30,h87 Foundations 11,550 3,2210 11,500 Fees (now) Other 1,200 2,629 3,700 1,083 Total 86,271: 92,988 91,037 125,126 Themnberafresourcesforeacheftholocalclinicsisquite variedascanbenotethhe above, rangingironfourto sevensources. This range is above the average of sources per clinic noted in a national stuch' w the American Psychiatric Association, which found that; Complete responses to the questions concerned with financing were received from 73 of the 9S responding clinics...None of the clinics received support from only one financial source. Thirteen oldnias recieved “E.“ from two sources, 19 from three sources, 21; from four, from 38 five and five from six different sources.7 . Thevidevariety of sources is perhaps also due tothe following of recanendations laid down In the State Department of hntal Health; The use of may sources of local financial participation is to be encouraged. This results in a nore equitable plan of responsibility on the part of the mam different cannunities served iv the clinic. It is advisable, however, to encourage local tax sources to provide the basic operating budget as a 8 public service and to ensure continuity of progran. TheDepartnentelsorecounendsthat long-ternpledgesend allocations should be managed, rather than less sure sources, and it would appear that this Ins been carried out nest cases. The funds nannielocal seurcesaretobeturned overtothe clinicboardand deposited to the clinic's account, fm‘ exclusive use t; the board. Funds are to be given 0.1:ch to the beard, rather than having the clinic's requisition funds for specific purposes. It was felt this would deter financial sou-cos from putting pressures on the clinic for services that nightpot be in the clinic's best interest. it the tins of the 1959-60 statistics, no clinic charged a fee. This is especially interesting in the light of the present popular trend of fee charging by social agencies. However, one clinic has since instituted the fee policy, and the entire subject of fees will be dealt with more extensively in Chapter X. 7Jcint Infernation Service of the American Psychiatric Association and the National Association for Mental Health, Variations in '» :anization Practices . ..h; Child Guidance Clinics ‘ ac . , ‘o. o, une Fl; I"; V'Mengh 8Program and Policy Statement, 1956, op.cit., p. 19 39 The amount of state fundsnllocated to each local clinic is determinedb'the salariedandtravelexpenses incurredinclinicwork In state paid staff ushers. The mint is fairly constant, with only yearly increments for salary or staff changes brimim about an change of an amount. The funds are kept within the State Department treasury and they periodically..seni out the funds. in forms of checks to the clinics. There is very little contact betweenthe Department and the local cmniiw clinic concerning their financialmtters. The Departmnt is available for consultation -on local fimncialntters, and also makes an animal audit of State funds each clinic receives, but there is no organized working together, the Department preferring to allow’ the cummiw to operate autonomously. The clinics do submit a budget to the Department, preferably six months before it is to becaue effective to allow for ample time to obtain the required moxieys. There is some variation in the fimncing practices of local calamity clinics. A description of the local financing will be given for each of the few clinics. Financial Arrangemnts at the Battle Creek Child Guidance Clinic: Battle Creek Child Guidance Clinic is a corporated enterprise and the details for financirg are curtained in its ty-laus. A standiu c‘elmittee an the finance determines the planning for financial needs. The director determines the budget from the past year's expenditures and anticipated changes for the ensuing year. The board inspects and approves the budget, with this usually occuring in crewman the lasting with the County Board of Supervisors Cannittee on Child Guidance Clinics. Battle Creek receives funds from the State, KelloggFoundation (this grant was ho cm'tailed December 1, 1960, howsnrelyand from membership fees am! contributions, and the primry local source - the County Board of Supervisors. There are two contributing counties, with each asked to contribute a proportionate share to the number served in their cm. The clinic board, with or without the director, presents the budgetary requesttoh'anchcounty, andiftheyapprovetherequest, theywill write a check fm' the amual request to be deposited in the clinic's account. The process is considerably more conplicnted with Calhoun County. TheBoard ofSupervisors ofCalhounCounty appoints aChild Guidance Clinic Committee which goes over the budget with the Clinic Board and the dimotorlinebylim.4ftersuchrevisions astheymayrequesthavebeen made, the clininboard, with or without the clinic director, will present the budget request before the entire board of supervisors for their consideration. After it has been approved, the clinic mist submit a request for a third of its appropriated funds every four months, to be deposited in the clinic's account. Fees have been recently instituted, but has not beenineffectlongenoughtodeterninetheamountofincomethsywill furnish. The membership fees and contributions make between one and two thousand dollars anmally with a total. mubership .f 15000 wing members. The housing of the Battle Creek Child Guidance Clinic and the furnishings and the equipment are the property of the clinic corporation. The funds ft the above were obtained from donatimssnd special drives. Thehandlinganddisbursement offundsiscaredforbythe treasurer, with the responsibilities outlined in the bylaws. 1:1 The treasurer shall be chosen non the members of the Board of Directors. He shall have custow of all corporate funds and securities, and shall keep in books belonging to the corporation, complete and accurate accounts of all receipts and disbursemts made by the Corporation. He shall deposit all moneys, securities an! other valuable effects in the name of the Corporaticmas may be ordered by the Board, taking proper vouchers for such disbursemnts and render a couplets and accurate account of alletransactions 3s treasurer, an! of the financial condition of the Corporation. The actual disbursement of funds is prescribed in the following stateumt. "All checks, drafts, and orders for the mat of money shall besignedinthenameoftheCorporationardshallbesignedbythe treasurer, and countersigmd by one other officer."10 The finance comittee and the director of the Battle Creek Child Guidance Clinic are currently studying other possibilities for additional finances in order to compemate for the withdrawal of the Kellogg Foundation funds which oocured December 1960. The school systems are presently comidensd the primary source for these funds. The Commnity Chest was not able to contribute when the agency was first initiated, and it was felt the schools were not reach at that time. Financial Arrangement at the Flint Chiligpidance Clinic: The Flint Child Guidance Clinic is a cerporated enterprise with . the financial arrangements for the clinic stated in the ly-laws. The Board of Directors, consisting of not less than thirty members is distributed anong three counties. The Board of Directors is responsible for the raising of local funds in the counties served, which is needed 9The inenoeo Jews of the Battle Creek Child Guidance Clinig, Inc. (53585, 131.5% N, SectionT. loIbid, Article v, Section 1. 1.2 for the support, maintenance and operation of. the clinic. The Board has a standixg comnittee on finance which consists of not less than three members and is to handlaall financial matters relevant to the clinic's operation. The financial base of the clinic is distributed among the following resmn‘ces; State Department of Mental Health, Commnity Chest, County, Foundations, and the other category, consisting of miscellaneous finances and mnbership fees. The sources are ranked in descending order, according to the amount contributed. All financial matters of the clinic rest with the financial comittee, ofwhichthetreaswereftheBoardofDirectorsisthe chairman. Itshallbethedntyofthisconnitteetoconsider all matters relating to the financing of the clinic and recommend to the Board of Directors measures to hears the continuing financial stability of the Clinic and to assist in the receiving of and accounting for such funds. The Finance Cmittee shall sulmit for adoption by the Board of Directors a budget of estimted expenses of operating the Clinic for the ensuing year. The budget my be revised frm time to time, but total expenditures shall be made only in accordance with the at which has been approved by the Board of Directors. The Flint Child Guidance Clinic, as with all the clinics under stuck, is attempting to widen its financial base in order to procure more staff. In a smry of facts by the Advisory Board, thq noted the following in relation to fimncial operations; In the fiscal year 1957-58, of the 13 child guidance n‘F'lint Child Guidance Clinic Constitutionand Article VI, on , anuary , MiclifganT mm 143 in southern Michigan,-_the Flint Clinic ranked 12th in percentage of state tax funis received for its support (10.66%), and llth in terms of the allocation per capita (80.093). In respect to local tax funds made available for its support, the Flint. Clinic ranked 13th of the 13 clinics.12 The funds received from the various sources are paid directly to the clinic and deposited in the Corporation's account. Disbursemnts are administered w the treasurer. ‘ Fee charging has been investigated as a further possibility for the obtaining of funds. Fee charging was regarded as a wise move and preparation for fee charging in the future has been initiated. Financial Arraggents at the Kalmnaaoo Child Guidance Clinic: The Kalamazoo Child Guidance Clinic is a corporated enterprise with the outline of financing contained in its tar-laws. Kalamazoo Clinic has the widest financial base of the four clinics under study. In addition to state funds its sources include city, Community Chest, county, schools, foundations, plus membership fees and contributions. .Kalanasoo Clinic has a Standing Finance connittee composed of the director, treasmr and five members of the Board of Trustees, representing the counties served. It is the duty of the finance cannittee to advise the Board of Trustees in regard to property, investments, and administration ' of financial setters of the corporation and to act as a budget omittee. The budget is cenpoeed ty the director, his'adninistrative assistant along with the finance conmittee, and is approved by the total board. Originally the director, along with the board, interpreted the clinic to the various sources and explained wry their help was needed 2414 fimncially. He was consequently able to arrange the wide base they now have. Presently the finance committee along with the director, present their operating budgets and requests for funds to each of the different sources annually. Counties contribute funds to the clinic through County Boards of Supervisors, Boards of Education, Calamity Chest and miscellaneous voluntary cmtributiom with the conception of Kalamazoo County. The Boards of Education give 31¢ per school child. Because Kalamazoo Counw contributes more through the community chest and the city contributes a flat amount, their quota per school child is considerably less. The mudaer of cases accepted for service per county is figured on a basis of the percentage of referrals undo the previous year plus the percentage of contributions divided by two. This, too, correlates with the assessed valuation. G The disbursement of funds is handled by the treasurer in a similar manner to the procedure of the other clinics. "The treasurer of this corporation shall have the custochr of its funds and property and such other duties and authority as the Board of Trustees may confer upon him."13 Nearly 50% of the financing for the present clinic building and furnishings was paid for by the Office of Hospital Survey and Construction utilizing funds appropriated by the Hill-Burton Act. The balance was paid for by donations ani service club drives. The property is owned by the City of Kalamazoo, as a govermnental unit who required to be eligible l3 Kalamzeo Child Guidance Clinic .1.“ ll . ’ L4 Kalamazoo, Michigan, 1:5 for the Hill-Burton funds. TheBoardis stillplaguedbytheproblemoffindingaway by which the financing of the clinic can have a greater degree of certainty than exists at present. A cannittee has been appointed to study the total fiscal problem and make recommendations. The cannittee is presently stlrtvim fee charging, and will be making a decision concerning this in the near future. The Kalamazoo. Clinic also plans to attempt to get additional funds frm tax sources in order to stabilise finances. Financial Arrangements at the Lansing Child Guidance Clinic: The Lansing Child Guidance Clinic was the earliest clinic in the state of Michigan and is an incorporated clinic. The financial base for the lensing Clinic includes the following resources; State Department of Mantal Health, Commmity Chest, County, Schools, membership fees, donations and etc. The resources were listed in descending order, accerdiu to the amount given. The management of the property of the clinic, its funds and the business of the Corporation, is vested in the Board of Directors which consists of 2b mmbers. The funds are handled In the treasurer whose duties are described in the by-laws. The treasurer shall attend to the finances of the corporation and has the custody of its funds and such funds shall be deposited in the corporation name in banks , designated by the Board of Directors and subject to checks signed as designated by the Board of Directors.1h The clinic administration and the executive -comittee of the clinic ”Constitution and hires of the Lansing Child Guidance Clinic,July 1952 ArtEle V, §ection E, Lansing, Michigan, p.2 1&6 board (5-7nenbers) decide the budget for the ensuing year, according to the needs of the Clinic. This is determined w the studying of the past year’s expenses and adding Vary increased costs or anticipated expenditures for the next year. After the budget is drawn up, it is submitted to and mst be approved w the total Board of Directors. The budget is then also suhnitted to the Lansing Camuunity Chest and these other resources that my request it. In the past year three resources, besides the community chest, requested that the budget be subnitted to them. The finances are paid directly to the clinic to be deposited in the Corporation's account. There is a flat rate per child charged to the schools with Class A schools expected to pay 30¢ per child and Class B schools 20¢ per child. Because the large percent of children served are referred from schools, the clinic feels justified in requesting a certain percent of its funds from the Boards of Education. The amounts expected from the comunity chests of counties contributing to the clinic varies. The amounts requested are determined according to the number of children served from the different areas and this amount increases or decreases according to the number served. (he of the budget problems is the time that is involved. In addition to the bookkeeng time and preparation of the budget, much time is required in procuring the requested amounts from the various resources. As noted before, the budget must be submitted to a number of different sources, which demands time in explaining the budget. Fees are not beingmsed as a financial resource, although it has been considered tar the staff. It was feared that it would Jeopardize the present sources and could result in a reduction of their contributions h? at this time. Summary and Conclusions : Thoro are several similarities and differences which were noted in the financial arrangements of the four clinics. . The main difference appear to be the variations in the number of types of sources from which funds are solicited. When anticipated changes in the neact several years occur, however, this area of difference will. break down. For example, Battle Creek Child Guidance Clinic is the only agency presently charging fees, but this move is now under consideration In the other three clinics. Three clinics receive grants from the Coonmnity Chests and-two from schools. Again, Clinics not new obtaining funds from such sources are meeting to approach them in the future. The present financial arrangements seem to be the result of convenience and availabiliiar of funds at the time the clinic was initiated. As costs of services are growing and some of the sources are withdrawing their support, the clinics are beim forced to widen their financial base with the pattern becoming more similar between the four clinics. There are slight variations in budgetary procedure. This seems to be in response to local sources requiring certain arrangemnts in reviewingthe budget. Inallthe clinics, thebudgetisdrawnuptnra finance comittee of the board, with the assistance of either the director of the clinic or his assistant. The similarities are by far greater than the differences. All clinics are incorporated with property and funds under control of the Board of Directors of the Cerpcn'ation. 148 Disbtu'semsnt by all four clinics are made through the treasurer, in two clinics with the sanction of the beard, and in the other two clinics In a co-signature of another designated member of the board. is noted above the budgetary procedure is similar in its Joint nuke-up between staff and board. The actual steps followed in gaining approval. of the budget by different sources varies in response to established requirements. Another sinilarityis found in the increasing budgets of all four clinics as they try to meet the rising costs of services and needs for expansion. The final similariiar, is. the attenpt ofveach of the four clinics to widen its financial base, alums with the desireof finding a more sure means of fimnce. In cmclusion," all four clinics have carried out the reconnendations of the State Department as outlined in its Pragram am Policy Statemt. The trend waald appear to be toward geater similarity in financing between the clinics, even though they represent four quite different metropolitan areas. CELEB V m CHARGED” Lem of Fee We. the BattlLGreeLGhild Guidance cums: a users WWn policies in regard to chargingJeee.which_are,mqationaLpantn£thefinaneial base for child guidance clinics..Lt present Wthe four clinics under straw, the Battlefireekfihild.flnidance.fllinic,.haaimtitmted a fee systole Hm It. is-me..ef thatnendaimfinansiwlef modern dw social services, amthepessihiliiaef fees isalsebeingceneidered Iv several more of the clinics unier stub. Several procedures were used in staying the fee aster at the Battle CroekClinic. First, thelita'aturewassmqedinerdertedeternimtln cm‘rent status of fee charging. Second, an open ended questionnaire consisting of ten questiom was devised in an attemt to learn the staff's attitudes concerning fee charging. In this chapter the thecratieal aspects of fee charging will be examined. The experiences with fee charging tar other agencies as reported in the literature will be described. The fee system of the Battle Creek Clinic as it is currently operating willjhen be" discussed. Following this, an analysieef the staffls attitude toward fee charging at the Battle Creek Clinic will be reported. The chapter will then be concluded 149 So withaaanlysieoffeechargingforathreeannhperiedasreported in the agenq records. Feoohargingiaeecialagencieswasinitiatedinthemdle forties. Albivalent feelings marked the initiation of the fee charging policy. On the one hand, there was comiction that the psei'essmsi cometency of the sociaZLwerker had reached the level where he was qualified to charge a.~ fee..It was also. felt that with increasing numbers of clients cmingfrn theniddlaclasa on above who had the ability to pa for the services, an! infant, expected to pay, warranted the charging ofafee. Onthe otherhaml, the concept of offerings free service to all who requested it was being questioned. There was the additional belief that an agency instituted Iv the calamity should not charge a fee for services to the clientele of the caninity.-The result has been slow mmsnttowand fee charging, uncoordinated in. approach, and with considerablalisgirims and hesitancy. Inch of the acne deliberateness and hesitant; in entering the foe cknrgingpolicyisstillbeingreflectedintheliteratmoftodveThere islittle comensur onthe anounttobepaid, andwlntainimam maxim fees should be. A stuck in New York in 1958 found the following; Tmemtofeveryfourclinicschargedfeesefsono oralloftheirpatientsfcrsoueoralloftheservices provided. In one clinics, high income groups received servicesfreeandinetherslowinccne gz'cnpsworechu‘ged a substantial fee for clinic services. There was no cit-emit: wide patterninfee charging inthisarea of service. The above stuck is one of severaleattenpts todaternine a more uniform 1"Fee Charging in Voluntary Psychiatric Outpatient Clinics in New York City”, Calmnig GoumiLef (beater New York, .(New,1enk,_N.I., Feb. 1958), p. ii . 51 neansanderdorinfee charging.inotherexanpleisthepolicy forfee chergiegsetuptvtheDepartmentofl‘isntelflealthinl‘iichigan.2 Thegrowthofthepraotme ofcharging fees seenstoreflect growing feelings of competency on the part of the profession of social work. The preiessies feels that it has both tin knurledge and skill to stable its practitioners- to serve peremiroa achlasses. The idea is boomingnore- prevalent that fees have a therapeutic ralue, and that those who can afford to pq for servicesexpect to do so.eThere is the further impression that not chargingafee, frat those who- can afford to pay, w indicate ssveralnagative thingato them. First, that we are not culpetent enough to denand a fee fr our services. as the other professions do. Sec“, that those who can In foeLroduced to a. pauper like status in tam services and netbsing required to 1333.3 The social worker has meant that their services exist for clients in all econuic strata. The public, on the other hand, has unused that social services exist for people who cannot pay. Charging a fee for casework services has partially helped to bridge this gath Sons of the positives in fee charging would include: (1) Pciu for goods or services is an integral part of our cultm'e; 2Manual for o ,5?“ Fee Collection in ' t ‘ I 'f: ‘9‘ D O '7 9 3Rnth Fizdale, u New Look at Fee Charging", Social Casework Vol. mun No. 2, (Albaw, Nszork, Feb” 1957), pp.63"@""""‘“‘. 3 ¥ Tina C. Jacobs, ”Attitudes of Social Workers Toward Fees", Social Casewor J Vol. XXXVIII, No. 5, March 1957, pp. 198-202; . Alice T. Dashiell, "Fees for SociaLHelfars 3min " The Social Welfare Forum 1251,(Celmbiallninersity_ Press, Nszork, 1951 , pp. 0 hi New Look at Fee Charging, op. cit. p. 67 52 (2) The growth of Warrants charging fees; (3) The Mailing of fees can be a therapeutic tool; (10A source of ma in wideningithojaee. of fimncing; (S) Attowts to nuke the clinic noose self supporting; (6) The upper class client and the co-mnity expect the agency to charge fees; (7) Aids client- imrelvoluont in treatment; (8) Can be used as a eoasure of netiratinjr to. interpret resistance. W, nest of theseminpnossima only._m.s.tndy which instituted a “810.011” honrifoo for intmimfoundthat they reached a substantiallplargonpertimnf. the upper c1assas.than do the agencies with a slidinfee,_(5m.as opposed to lSX).-Thia_stu