The Psychiatrist and Public Welfare Agencies

Volume IX Report No. 94 November 1975

The Psychiatrist and Public Welfare Agencies Formulated by the Committee on Psychiatry and the Community

Group for the Advancement of Psychiatry

This publication was produced for the Group for the Advancement of Psychiatry by the Mental Health Materials Center, Inc., New York.

Additional copil'.r of this GAP Publirntion No. 9-1 ar" amilfllh ot the fii llowi 11 U" p ric1's: 1-Y copies, $2.50 each; 10-2-1 rnpies, li.,t less 15 /m n·nl: 25-99 ro/!il'.; _ lt.,t l,,.u 20 per Cl'nl; I 00-/ Y'J ropio, list le.r.1 30 /!1'1" 1"1'11/.

Upon l"l'!f'.'esl till'. Publil."ation.1 Ojfil"1' o/ the Grn11/1 .for th1· ,·frf l' flnu·11w11/ 0/ P.rycl11al1)' w1U f!rm•1de O com/!ll'tl' listing of"GAP tit/l's {1/ITl'll/ly in /nit)/, 1/11(1/l(ity prrce.1, and m/ormatwn on s11b1cripti1m.1 assuring th,· rn,,,j,1 of 11r·1u Jmbli,rrtiow· 1;, the)" tll"l' re!Msed.

Oi·dn, amo11nting tu ll'ss than $5.00 1rwst be a1·rn111/Hntil'd /,y 1-,,mittana. All _ /!/"/Ct'.\" tll"I' rnbil'l't to cl1ang1' u•itlw11/ 110/in'.

Pleosr' smd _)'0111 order and r1•111itla1111' to: l'11/1lirnlio11s 0//1u·, Cn11t/J jii r the Admncement t(/ l'.1y-hio11y, -119 Part, A1•l'll/lf' South ' Nnt• York • JV,,,;, York 10016.

TABLE OF CONTENTS STATEMENT OF PURPOSE

438

INTRODUCTION ... , ............................ 445 2 THE WELFARE WORKER AND THE WELFARE AGENCY ...... , ....... : .. , .... , .... . ... .. . .... 449 3 THE DEVELOPMENT OF THE WELFARE SYSTEM ... 453 4 PSYCHIATRY AND PUBLIC WELFARE ............. 461 5

THE PSYCHIATRIST'S ENTRY INTO THE WELFARE SYSTEM .. , . , .......... , . . ...... . ..... . . . ....... 465

6 MENTAL HEALTH CONSULTATIONS .............. 469 The preparatory phase ...... , .............. , .

Case consultations ....... , ............ , .......

Case illustration 1 ....... , . ... . .... ..... . ..

Administrative consultations . , ................

Case illustration 2 .........................

Programmatic consultations ...... , ... , ........

Consumer advocacy ....... , . , ...... , .........

International Strmdarrl Book N1111dm 087 318-1 31-x Lihrmy of' Congress Catalug (;(!rd N 11111 /J(')"

7 SUMMARY ..... , ......

4 72 4 75 4 79 482 483 485 486 489

REFERENCES ....................... , ........... 490

Printl'd m th,, United States of Amt'/"/C(I

Co/;yrighl © I 975 by /he Cn)//p .for th,• Adm1u1·m1•11t of Psycltiat,y, -1 I y Par// Ai•enue South, Nt'l<' York, Nno Yur// /0016. All righ1., r1•s,•nwl. Tlii.1 11•pur111111st not be ll'/>rod1u:,, d in any form willw11t u•ritlm J1ermi.1sio11 o( the Gro,rf, for t!tr _ Advanceinen/ of P.1ych.iahJ, except by a rl'l•iewer, re/mrln, or ro111111e1Uo/or who wishes lo quote brief pns.\t/gPs.

This is the founh in a series of" publications comprising Volume IX. For a list of other GAi' pu!Jlications on current topics of interest, please see last page of hook

herein.

STATEMENT OF PU RPOSE

--l- 3 9

T i n: G RO L' I' FO R T I IE A D \ ' AN cuv 1 1-: :-s1 T o v J > syc 1 1 1 AT RY h as a membe rsh i p of' a pp rox i m ately 3 00 ps ych iatri sts, most of whom are orga n i1.ed i n the fo rm of a n u mbe r o f' workin g com mittees . Th ese com m i ttees d i rect t h c i 1 c ffons towa rd th e study of ,·;,i rio us as p ects o! psych iatr y and th e a p pl ica­ tion of' th is k nowled ge to t h e f i e l d s of men t;t l health a n d h u man relatioris.

Collabo ration with s peci alists 111 oth e r di sci pl ines h.ts been and i s one of GA P's work in g p rinci p les. S i n ce the l<irmarion of G AP in 1 94 6 i ts membe rs l i a \'e worked cl osely w i t h such other specialists as a n th rn p olo gi sts, biolo g ists , econom ists , statisticians, cd 1 1cato rs, la wyers , n u rses, psych ologists, so­ ciol ogi sts, socia l workers, and e x pe rts in mass co mm un ica­ tion, p h i loso p h y , and seman tics. G A P e rn·isages a conti n u­ i n g pro g ram or work accordi n g to the follo,ving a i m s : l . To col lect an d appra ise sign i fican t data in the f i e l d s of psych iatJ)' , mental health , and h u m an rel a tions 2. To ree\ a l uate o l d conce p ts and to dn elop a n d test new ones 3 . To apply th e know l ed ge th u s obtai ned f'o r the p ro mo­ tion of mental h ealth and good h u man rela t ions GAP is an inde pende nt gro u p , and its reports re p rese n t th e com p osite findi n gs and o p i n i ons of i ts membe rs o n l y , guided by its man y consultants.

THE l'SYC H I AT R IST /\N D l' l : B I . J C W E I.FARE ,\ C E N C I ES il '{I.I /or­ m11fated by the Committee un Psych iat;y (Ind thr Cmm11un ity, n•liich aclmuwledges on pagf' ./ -1-3 the po rticijx1lion oj , orio11s rn11unittl'I' members in the /m'/mra lion o/ th is re/H! r/ . Th e 1ne1n/Jen o/ tlw committee, as well as other wmmittl'C.1· and tlw n//l cn1 o/ (;AJ > , r1 1P li.1ted below.

1

COMMITTEE ON P.SYCHJATRY A N D THE CO!vt M U l\' ITY

Alexander S. Rogawski, Lo, Angeles, Ch r.

C, Knight Aldrich, Charlottesville, V a .

43 8

Herbert C. M od li n , Topeka J ohn C. Nemiah, Boston J ohn J . Sch wab. Lo uisville, K r.

C harles B . Wil kinson, Kansa, City, Mo.

COM!\-1 1TTt-: r ON AnoLE:'iiC:ENCE

Wan-en J. Gadpailk. Englewood. Colo., Chr, Ma urice R. Friend, New York Charles A. Malone, Philadel phia J oseph D. l'\ osh pin, \\'ashington . D.C. Sih·io J . Orn·· sti, J r . , Belmont, Mass.

Jeanne Sptirlock, Sih·er Spring, Md. Sid ney L. YVcrkman, fk nve1 CoM:-.1 1TTEE ON A<; cN(; P 1 ·esrntt \V. Th ompson. San Jose, Chr. R,,berc t-.' B u tler, Wash ington, D.C. Charl es �L Caitz, Holl." ton L1 \'\•re nee F. Grccnleigh I ., )" A ngcles Maurice £ . Linden, Philadelphia Robert D. Panersou, Le xington, M ass.

F. Conre> s Thom pson, J r., Atlanta J;ick W cinbcrg. Chicago I

COM M lTTEE ( ) ;\' Cl!I I.D p_.,.\'(: 1 1 1 ..:.. Tl<V J oseph rvL (;reen, Tucson, Ariz .. C h r .

Pa 1 1 I L . Adan1s, Miam i E.. James Ant hony, St . Louis J « mcs M . Hell. Ca uaa n. N . Y .

H a rl ow Don,,lct Dunton, N e w York Jose ph Fisclwff, Detroit John F. KenwaHi , Ch i<.:;1gu A ke M" t.tsson , Ch arlottes\'i I le . J ohn F McDermmt, J r , Hvnol 11l11 Theodoi-e Shapi ro, New York.

Exie E. Welsc h , New York Vtrgini.1 N . \\' ilking, New York Cu M I\I ITTH; o� THL Co 1.1.r< ;1,: STt·nn,:i ·1 M ct l ka h Tol p in N otm,, n , B rookl int', C h r.

Rohen L. A rnsteir 1 , Ha mrlt· n , Con n . l· l a ni:mn P. lckly, f\e\\' York Glor i�1 C . O nq ue, Pittsburg- h Kt'. I l l E. Robin�on, To,,·son . !'vi d .

E;1rte Silber. CJic,·y Cl i�1�e, M d .

Tom C . S1;1 11fft:r. \\' hi1c Pl;_t in!-, '.\' .Y. Co,1:i-t nTn. u:-: Tllr F.,u1] l .\ J w;eph S;1tte11, S�1n F ranri sn>, C l ir.

C. C b risti;iu l3ecls. Bro 11:,; , N .Y .

I r a n Bus1.onne ny i•Na gy, \V yn co t c . P;1 .

M ur r;1y 1{.owt'n . Chc\·y Ch;1st:· H e n 1y L. Cnrneba u rn . Boston :Vb r g;1 ret M . L1 ,,Te nce, l'rnno n,1, N .Y .

D:1 1 i d Mendell; Houston Carol Nadelso n . Boston

�orman L Paul. Boswn l sr"':I Zwerling, l'l1iladel p h ia CoM :-..1 n-n-;1-: 0:,.. (;( )VERNM t:�•H ,\ 1 . Aca-J,; c : 1 �:s Sidne y S. Goldensohn, J a maica , N . Y . C lw.

W'illiarn S. Allerto n , RidHnond A lben \1 . Biele. Phi ladel phia Paul C hodo lf, Washington, D.C. Donald B. l'etcrso n , Fulton , Mo. Ha rl'c y L. I'. Resnik, C hevy C hase. M d .

Ha rold Rosen, Balllmore H a rvey Lee R ube n , �ew H a ven 1

Co�t fl.lITT�:t: ON l � TE R l\;ATIO/\"A.1. R1::1.,\T10 :,.is ll tvant '.vi , Wcd �c . Washi ngton , D.C., C h r.

Fr; ncis I.-. Barnes, Chevy C h ,rse Eric A. Baum, Camhridgc.Alexand t: r Gral nick, Pon Che�te1·, N .Y. Rita R. Rogers, Torrance, Cali L B t" nl'�im H. S<..:lrnt'fm:..-, :\1 ew York Mouram P. Torre. N C:'\'\' Orlt·•in� Ro y M. VVhi t m a n , Cin1..:i nnati Ronald M . Win troh, H a n to n!

C o M M 1rn:1-: ON Mu1 i c : A 1. Enn;..-..Tro� Sa ul I Harrison , Ann A rbo1 -, Chr. Ravmond Feldman, B oul der, Colo.

Da�·i<l R. Hawkins, Ch�u-lottes\' i l k: H ;iro l d ! . Lid, Philadd p h ia John E. Ma<k, Chestn ut H i l l . �fass.

1 lcrbcrt J'ardcs, B roo klyn . ;\ , Y, Roben Alan Scriescu, N e w York B 1-ycc Tem pleton , Phi ladelph ia l'a ul Tyler Wi lson, Bet hesda , /\I d .

Co,, 1M 1Tn-.1-. o:,.,· M r:N1',H. H t:ALT I ! Sr l-l,·tt:F.S \\i . VValter Menoin gr. r, To pcbt. C h r Allan Bei g: d. TLi cson, 1\.l ' iz.

Eug�ne rvl . C;i ffe y, J r - , \V;1 sbi11g1on, D .C . \f e1-ril l T. Ea l.nil . Omah,1 J ose ph T. En g l ish, N c•i,· York J ,nn e:-. B. Funkho11scr, Richmond. \'a Rohen S. ( ;a 1·bc 1·. Belle Mead, N . J .

Drn1,dcl S<..: l u ..: rl. H uqon H erzl R. Spi ro. Prln ceio ll, � .J _j ;1<..:k A. \\\,l l"ord. PiH s lrn rg:h

H e n ry 1 1 . \·\ <>rk, \,\'as h i n � 1011 , D.C .. Chr. H o w a rd \'. B.a i r , Parsons, Kans .

HO

Norman R. Bernste i n . Bost.on Leo M adow, l'hiladel phia Carol y n H. . Robt nowiLz, Bet. hc_-;da Gl!c>rge Ta1:j;tn, Los Angeles \Nancn T. Vaugh an, J r. , B u rling'1 mt', Ca lif.

Thorn as G. Webster, ½lash ington. O.C. Col\•t M nTn: 1L\' Pan'Et'\'TJ\'r Psvc : 1 1 1 A T l-n E. J ames Li ebermc.rn, \Vas!1 ing-to n , D . C . , Chi C. Mand B t·yant. Boslo11 J u les V, Coleman, New l · L:t\'e n . Conn .

Stephen Flt-ck, New H.1\·c n , Conn Frcde,·ick ( ; 01 tl 1eb, !lei Air, Cal i f.

Benjamin .J e !lrics, Harper Woods, M i c h .

R u t l 1 \V. Lici z , V\o' oodhrid ge , Corm.

M a ry 1::. Mercer, Nyac k , N .Y. Ric hard (;_ Morrill. Roxbllry, M,m .

H11 rri!-i g_ l'c,:k, H nmx, N.Y. M;1 n·i n E. Perkins, \V hitr.: Plcttns, N . Y .

C o M .\.1 ITTEJ·: ON l'sYC l l l•\ Tl{f .\:"l: l J J...\\\.

C.irl P. M �dmquisc \1 i n n ca polis . C hr.

Ed,,·ard T . Auer, St. Lo t i l!i .John Donnelly, H : i rt l ,,, d J le1er Brown ing 1-loffm�m, Chadoltes,·i lk A . Louis McGarry, Brookl i n e , Ma s�.

Seymour l'oll.1t k, Los A nge les Loren H. Rot h , Ro,k,·illc, M d . ( ;enc L . U s d i n , N e w Orlt:ans C1 1:-.t ;1.1 1TTI-T. o:,.,: Ps\T.1 1 1.-\ T RY A'.\ ll Rr. 1 _1 ( ; 10:\· Sid nt.')' Furst , Bronx, N .Y . , Chr. s,�tnley A. l .c aYy, NcK H�l\TI) Rltl1ard C. Lewis. Ne,,· 1-Lt,·en Alber< .J . l .uhi 1 1 , W,K,d,idc. Ca li !".

M o rtimer Osto w , Bron x , :\f . \'.

Mi<.:h a el R. Zaks, (;n.:enh·lt h , Conn Co11. 1 .\1 1Tn:1·: os P.'ff Cl i UTK\' J !\' I �!►\'.'-Tin Herlicn L K!enrnH:, Topck;1 , Chr. l"lioma� l .. H rarn1i<:k. l mola. C a l i f.

Barrie San ! O rd Crci ff, Bosto n l)u;me Q. H agen. St. Louis R . .Edward H u llrni1 ll, Ashe,·i lll' , N .C .

Ah111 A. M d .ean. Ne,,· York D<tYid E . Mo rriso n , ·Topeka Clarcll�C .J . Rm,t,, St. Paul John W" kelicld, Lo, (;;itos, Ca l i ! ".

11 1

C,1Mr-.-1 nTEE (>N Psv c : H OPA·r11<11.ocv Charles Sh;igass, l'i>iladel phia. Chr. Aaron T. Beck, \1'1/yn11e\'\.• ood, l'a.

Wagne,· H. Bridge;·, Brnnx, N.Y. l'aul E, �uston, lo,va Cit.y Richa,·d E. Renneker, I .os Angd�s Albert .J . Silvenna11, Ann Arbor. \.J ich.

CoMM ITTl.E o:,.;, l ' L ' HI.IC E1H·c,, T10:--.· Miles F. Shure, Boston , Chr. Mild red M itchell 13,llema n , Charleston Rohen J Ca mpbe ll, :slew York James A. Knigh t, Nt'w Orleans John P. Lambert, Katonah, N . Y. !\'orman L Loux, Sel ltTS\·il k , Pa .

Mabel Ross. Chicago J utiw; Schreiber, VVashin gton , D.C. Robert H. Sharpley, Cambridge, Mass.

Rohen A. Solow . Beverly H ills Krnt A. Zi mmerm a n , ll erkeky Co:-.TM ITnr o:-.; R 1·::,1-:,.1. f,:t:1 1

Al lred A . S1.; , n 1 o n , Wellesley H 1 l ls, .',,f cm. , Chr Stan k)' H . Eld red , Bel mont., Mass.

Louis A . (;ousrh�tlk, l n·i11e, C,ilif.

Gerald L. Klcrnrn n , Ho,•Hon Morri, A. l.ip1.011, Ch ape! l·I ill Ralph R . Nol man. B roo kline, Ma �s.

Ebcrhanl H. L.: hle n h u t h , C l11c1g" Co:o. f:\11T!T. t-: o:,..,· Snu_.1. 1 . l ssu:_:,.; Roy \,\' . Menninger, T!1 pck;1. Clir.

Viola W, Bernard. �:ew York Roderic Con1cy. Los An�des L.c:-.ter {;rinspoml . Bosl on _J oel S. Handler, J::,a nston. I l l . .J udd M;trmor. Los i\ ngcl c:-; Pcny Ot lt�nherg. iVfe rion Slatlo n , Pa .

Kc11don \,V . S m i L h , Pi ermo111 . :\· .11 .

H e rzl R. Spi ro, Prin<.:�ton , l'\ .J .

R;1yinond C. \\' i l kt'rson , Chic..:;1go Co�IM 1rru-� 1 1 :-,: · 1 · 1 1 F1-t.-\t �:t-nc : CAHE 1

Thom;is E. Cortis. C h .,pd H il l , C h r .

Be rnard lbn<llcr, llosr o n Robert W. Cihson , To\\· so n , M d .

I L, rold A . G reenberg, Sih er Spring, M d .

M i l r o 1 1 K ra m<� r. C i n ci n n a t i

Orlando B . Lightfm,L, Boston Melvin Sabshin, Wash ington, D. C .

Benjamin Sitnon, Boston Robert E. Swi tzer, Trevose, Pa. COMM fTTEE ON THf.KAP\' Justin Simon. Berkeley, Chr. Henry \N, Brosin, Tucson , A riz.

Peter H. Knapp. Boston Robert Michels, New York Andrew P. Morrison, Cambridge William C. Olfrnkrantz, Chicago Franz K. Reichsman, Brnoklyn Lewis L. Robbins, Glen Oaks, N . Y .

Joseph P . Tupin, Sacramento H erbe rt Weiner, Bronx. N .Y. CONTR I B l.lTlNC M F. M nE RS

Carlos C. Alden, Jr. , Buffalo Ch ;1 rlot1e G. Babcock, Pittsburgh Grace Baker, ?\:ew York Walter E. Bartori, Hanland, Vt. Spencer Bayles, I lo,1ston, Tex .

Anne R. Benj a min, Chicago Ivan C. Bcrlien, Coral Gables, Fla. Sidney Berman, \\.'ashington, D.C. Grete I.. Bibring. Cambridge Carl A. L. B inger, Cambridge H. Waldo E>ird , St. l.iuis Wil free! Bloomberg, Boston H. Keith H. Brodie, Durha m , N .C .

Eugene Brody, Baltimore 1vl atthe,, Brody, Brooklyn, N.Y. E"·ald W. Busse, Durham Dale Cameron, Guilford , Conn Ian L. W. Clancey, M a i tland, Ont. , Can .

Sanford I . Cohen, Bosten Robert Coles, Cambridge Frank J. C11 rran, New York Willi;i,n D. Davidson, Washington, D.C. Leonard J. Duhl, Berkeley Lloyd C. Elam, Nashville Louis C. English, Pomona, N .Y .

0. Spurgeon Englis h , Narbert.h. Pa. Dana I .. Farnswotth, B oston Stuart M. Floch, Tucson, Ariz.

Al fred Flarsheim, Chicago Archie R. Foley, New York Alan Fran k, Albm1uerque, N . M .

Daniel X. Freedma n, Chicag-o

Albert J. Glass, Chicago Alvin I . Gold farb, New York Louis A. Gottschalk, Irvine, Calif" Milton Greenblatt, Sepu lveda, Calif.

Maurice H. Greenhi ll, Rye, N.Y. John H. Greist, I ndianapolis Roy R. Crinker, Sr. , Chicago Ernest M. Gruenberg, Poughkeepsie, N .Y, Stanley Hammons, Frankfort, Ky. Edward 0. Harper, Cleve.land, Ohio Ma l)' O'Neill Hawkins. New York J. Coner l-lirscl1berg. Topeka Edward J . Hornick, New York Joseph Hughes, Philadelphia Portia Bell H u me , Berkeley l i e11e M. Josselyn, Phoenix Jay Kat7., Ne\,, H avc:n Sheppard G, Kellam, C:lncago Donald F. Klein, Glen Oaks, N.Y. Gerald L. Klerman, Boston Othilda M. Krug, Cinci n n ati Zigmond M. Lebcnsohn , Washington, D.C. Hen1y D . Lederer, Wash ington, D.C. RDbert L. Leopold , Philadelph ia Alan I . Levenson, Tuu-.on , Ariz. .

Earl A. Loomis, New York Regin<1ld S. Lourie, Washington, D.C. Alfred 0. Ludwig, Boston Jeptha R, MacFarlane, We.1 tb11ry, N .Y .

John A. MacLeod, Cincinnati Sidney C. Margolin, Denver Peter A. Martin, Southfield, Mic h .

Helen \'. Mcl.e,m, Chicago . Jack H. Mendelson , Belmont, Mass.

Karl A. Menn inger, Topeka Eugene Meyer. llaltimure James C. Millu, LouisYil l c , Ky. J ohn A. I'. Millet , Ny;tck, N .Y. John E. Nardini. Washington, D.C. Pe ter H. N� ubauer. New York Rudol ph G. Nm·ick, Lincolnwood, 111.

Lucy D. Charin, Betl,e,da , Md. Bernard L. l'acella, New Ymk \Vi l l i a m L. Pe l Lz., ManchcsLer, Vt. l n·ing Philips, San Frnn ciscu Cha rles A. l'i nderhughes, Boston l::\"eo\een N. Rexi"urd, Cambridge Milton Rose nbaum, Brn nx, :-1 .Y. Vv". Donald Ross, Cincinn ati Lester H . Rudy, Chic;1go George L Ru ff, Philadclph ia

442

David s·. Sanders, Beverly Hills Kun 0. Schlesinger, San Franci.sco Calvin F. Scctlagc. Sau<alito, Calif.

Richarci !. Shader, New1on Ccnr.i-t', Mass.

Harley C. Shands, ;,..•ew York Alben J. Siln,rman, Ann Arbor Benson R. Snyder, Cambridge · John P. Spiegel. Waltham. Mass.

Brando F. Steele, Oenver Eleanor A. Steele, Denver Rutherford B. Stevens, New York Alan A. Stcme, Cambridge, Mass.

Perry C:. Talk_ington, Dallas Grah:.un C, Taylor, Montre;1l Lloyd ,I. Thompson, Chapel I I ill Harvey J. Tompkins, New York Luda E. Tower, Chic.:ago Monr.aguc Ullman, Ardsley, N.Y. George E. Vaillan.t, Cambridge, i\.1 as s.

Suzanne T. van Amcrongcn, l.loston Robert S. Wallerstein, San Francisco Andrew S. Watson, Arm Arbor Edward M. Wcinshcl, San Francisco Joseph 8. Wheelwright, Kemfielcl, Calif.

Robert L. Williams, Houston David G. Wright, Providence Stanley F. Yollcs, Stony Brook, N.Y. Lm: M,.,1111.:Rs S. Spafford Ackerly, Louisville Kenneth E. Appel, Ardmore, !',1.

Leo H. Banemcier, Baltimore Malcolm J. Farrell, Waverly. Mass.

Marion £. K�nwonhy, ,ew York Wilfom S. Langford, New Yo,·k Benjamin Simon. B 1,ston Francis 11. Sleeper, Augusta, Me. Li..-t: CONSl.'!.TANT

Mrs. Ethd l.. Gimb11rg, 1\' rw York BOA!<!) OF DIREC7-0RS

Pus1.1cAT1o�·s BoARO Chninrvm

Jack A. Wolford, M.D. �811 O'Harn Su'eet.

Pittshu rgh, Pa. / 5213

Ronald M Wintrob, M.D. Department of Psychiatry University of Connenicut Health Center Farmington, Conn. 06032

St'c re/11 .,J .Iack Weinberg I 60! W. T"rlnr Street Chicago, Ill. 606 I 2

C. Knight Aid ,·ich Merrill T. Eaton Margaret M. Lawrence

Carl I'. Malmquist Robert A. Solow Alfred H. Stanto,1 Con.Jultar,tJ john C. Nemiah Melvin Sabshin ex Officio

Gene L. \;sdin Jack A. Wolford

Gene L. Usdin, M.D. 1522 Aline Sto ect New Orle:ins, La. 70115 Immediate PnJt P rt•sidni t Judd Marmor, M.D. 2025 Zonal ,\ v,inue Los Angeles, Calif. 9003:l

COMMITTEE ACKNOWLEDGMENTS At the time the Committee on Psychiatry and the CommL1nity issued its last report (No. 8!'.i), it was known as the Committee on Psychiatry and Social Work. The Committee began LO prepare this statement under the chairmanship of John A. Macleod, M.D., currently a contributing member of GAP. In the early stages, Maurice R. Friend, M.D., was a member of the Commiuee before his transfer 10 rite Committee on Adolescence.

We are indebted to two of GAl''s Ginsburg Fellows for their assistance in the early formulation of the report: Harvey J. Schwed, M.D., and Robin Wooten, Jr., YI.D.

BtM1rd ."-1nnhn.r.

Robert N, Butler Leo i\fadow W;,rren T. Vaughan, Jr. Roy Whitman llm10,ru)' 1\f rmJ,,.,, ½alwlrn

J.

farrell

Pa.�t Pr{,.r;dn,t.I, t·.-.:.-(�f/i oo Wah.er t:. Banon Dana L. Fnrn.sh•onh Marion E. Kcn,"·orth y Henry W. B ros ,n Leo H. Bitnemei cr Rohen S. Gar11'.'r Herbert. C. Mndli 11 John Don11eJJy (;em·ge ·r\uja;1

1953.55 1957-59 195()-61 196!-fi3 1963-65 1965-67 1%7-69 1969-iJ 1971-73

Dt•rN1Jt•d Pu.\'/ 11 rrs idt•nt.\ John C. Ncmiah, M.D. �;10 lhookline A,·enue Boston, Ma.s.s. 02215

William C. Menninger J;,ck R. Ewal, Sol W. Ginsburg

l9·16,51 1951-53 1955-57

443

446

The psychiatrist and we!Lire agencies

functioning and greater self-esteem, and will be less dis­ affiliated from society at large, hence less resentful of their circumstances. 1 (pp 369-3 70)

With all its deficiencies, however, the present welfare s ys­ tem is a reality, and affects the lives of a larg·e number of the nation's poor. In the opinion of the Committee on Psy­ chiatry and the Community, psychiatrists and other mental health professionals can make a substantial contribution to the clients and workers of the current welfare system, in­ adequate as it is. We have found relatively few psychiatrists who are informed about welfare problems and even fewer who are involved in work with the welfare system-too few in view of the important contributions psychiatrists could make to an institution that has become a significant social support system to an appreciable pan of our total popula­ tion. This companion report to the position statement is addressed to psychiatrists and to those planning to enter this speciality, as well as to the staffs of welfare departments interested in a collaborative relationship with psychiatrists.

In this report we present our reasons for greater psy­ chiatric involvement in welfare systems, describe some characteristics of welfare staff and the conditions under which they work, review briefly the historic development of the welfare system, and describe ways that psychiatrists can initiate professional relationships with welfare agencies. Fi­ nally, we outline a model of mental health consultations ,vhich has been effective in influencing staff and agency policies.

Psychiatrists receive the same subjective in formation about welfare issues as the public, and are likely to develop the same slanted attitudes on this highly controversial topic.

The complexity of public welfare issues, the range of diver­ gent expert opinions, the fluctuations of social policy and welfare legislation, the administrative morass of local regu-

Introduction

447

lations, all make it as difficult for the professional as for the lavman to gain a fair picture of the welfare situation.

'A starting point is to recognize that welfare agencies do more than distribute money to the poor. Among the broad range of social services provided by various welfare de­ partments are aftercare for patients discharged from men­ tal hospitals; child placement and licensing of foster homes; child abuse programs; preschool compensatory education; emergency crisis services; homemaker services; family social services; information and referral services; family planning; premarital counseling; social services for single adults, the blind, the aged, and the disabled; protective services for children and adults; supervis ion of children who have be­ come wards or the court.; day-care programs; and evalua­ tion and licensing of adult care facilities. ln these and other ways welfare agencies have an impact on the lives of many poor people, including many mencally ill people who do not receive financial aid. Welfare clients belong to a population that has a high rate of overt and covert psychopathology-of definable mental illness,. social dependency, and social deviance. The grave economic and social problems of welfare clients are often aggravated by mental and emotional distress and by related interpersonal failures.

Recently, the tendency to discharge as many psychiatric patients as possible from state hospitals to boarding homes or other residential facilities has added a substanual number of these former patients to the welfare rolls. Welfare agen­ cies therefore can be co nsidered an important element in the network of psychiatric services. Furthermore, if' the capacity of welfare agencies to provide preventive services is strengthened, the agencies may reduce the number of po­ tential patients and so reduce demands for direct clinical services by public mental health agencies later on.

Changes i-n the economics ot medical care have brought

448

The µsychiatl"ist and welfare agencies

an increasing number of psychiatrists into clinical contact with welfare patients. Through the funding mechanism of Medicaid, welfare patients have become eligible for care by psychiatrists in private practice as well as for psychiatric services in public or private clinics. As a result, poor people now can get psychiatric treatment outside of state and county or city hospitals, and, sooner or later, psychiatrists who treat the poor will encounter some aspects of public welfare through their patients. If they know about the ser­ vices available to their patients, they can enhance the effects of their therapeutic regimens by guiding the patients to· ward these resources. Furthermore, a collaborative re­ lationship with the public social service worker makes it possible for the patient to receive coordinared supervision and guidance during the intervals between visits to the physician.

2

THE WELFARE WORKER AND THE WELFARE AGENCY

Many welfare agency workers have limited formal profes­ sional training and little or no experience in the 1nental health field. Yet they are often called upon to minister to some of the most disturbed people in the community, some with frank and severe psychopathology and others whose grave interpersonal, medical, or social problems are related to or aggravated by emotional distress. 2 These workers must f perform their dif icult and demanding tasks under great pressure. Their case loads are huge; they are inundated with paper work; they must cope with constantly changing administrative regulations and reorganization; and the re­ sources to which they and their clients have access are lim­ ited and often ineflecti\·c. They are exposed to criticism of their work by citizens, politicians, and public media whenever the public welfare system is under attack. They must endure the hostility of their frustrated and dissatisfied clients, and al times e,·en their personal safety is in quest.ion.

In the past, welfare workers seldom had access to psy­ chiatric consultation. Psychiatrists generally did not realize how much they could contribute to a welfare agency, assum­ ing that the "adequate use" of their services by a social agency was "predicated upon the assumption that the agency has attained and maintained certain professional standarcls.":3 Although as early as 1909 Adolf Meyer 4 urged psychiatrists to include welfare workers in their planning

450

The psychi;11risr and welfare agencies

for comprehensive psychiatric care, this recommendation was generally ignored for more than five decades.

In 1947, Jules Coleman !i deplored the fact that psy­ chiatrists wei:e reluctant to work with welfare agencies be­ cause they erroneously assumed that only educationally sophisticated workers could make use of psychiatric con­ sultation. He pointed out that public agencies discharging social responsibilities "often have too few workers trained or untrained, and rarely have enough psychiatric consulta­ tion." But at that time, psychiatrists focused so closely on psychodynamics that they saw little value in becoming in­ volved with problems heavily burdened with harsh realities.

Thus, for the most part Coleman's words were unheeded.

The advent of community psychiatry, however, brought with it expanded roles and functions for psychiatrists. and' for other mental health professionals. As community psy­ chiatry has grown, a few psychiatrists have established mutually rewarding collaborative contacts with community agencies that are staffed by workers who have had little training and experience in the mental health field (see GAP Reports No. 64 6 and No. 69 7 ). 'They found that when a psychiatrist elects to consult with welfare wo1·kers and in­ dicates his interest in and respect for them he can be a significant morale builder. If a welfare worker has access to a relationship with a psychiatrist, he may be better able to cope with psychiatric problems in his clients and will often be able to see them through crises that otherwise might require hospital care.

As a result of these experiences, increasing numbers of" psychiatrists now believe that the effectiveness of workers in all human services, regardless of the degree of their educa­ tion and training, can be enhanced by appropriate use of a consultative relationship with a psychiatrist. Even though the primary goals of other s ervice providers may seem sub­ stantially different from conventional mental health goals, and the conditions under which services are rendered may

Welfare worker and welfare ;1gency

+51

be completely different from those pre':'ailing i� the clinical situation, the functions of these providers often comple­ ment or overlap those of mental health workers. Prov1d1�g consultations to agencies staffed by master's level soc�al workers continues to contribute substantially to commurnty_ mental health, but providing consultat�on to �ther types of agencies, whose staffs serve a wider chentele m great need of service, is an equally significant mental health respon sibility. . _ _ Many of the psychiatric problems. of welfare_ clients require psychiatrists to give more weight to envno_nmental _ causes than they are accustomed to give in w�rkmg wnh affluent patients. Thus, for the poor, the ne�d for_c_oncrete services usually has priority over the resolution of mternal conflict: "I don't lie awake worrying about how my mother treated me," said one welfare client, "I lie awake becaus e I'm scared the junkies in the abandoned house next door will set a fire that will burn up me and my children-and I haven't the money to Ftnd a decent place to live." The priority so often given �o con�rete services does not m_�an, however, that the welfare client cannot also pro�t horn treatment aimed at the resolution of internal conflict.

Welfare clients generally have limited access to regular medical and dental care, so that psychiatrists workmg m welfare settings are frequently called upon to. employ their medical as well as their psychiatric knowledge m the evalua­ tion and management of complex p_1:oblems. I� fact, n�ost psychiatrists who wish to work effecuve'.y with welfare clients and welfare staff will have to acquire enough new in.formation about the field to permit adaptation of their customary professional approach to the specihc conditions system. of this nonmedical social f believe it is. The overworked,_ We ort? ef the Is it worth s are at the cutting edge of worker underappreciated welfare America's greatest mental health challenge-the prevention and treatment or alleviation of the mental health problems

452

The p�ychiatrist and welfo re agencies

of the poorest and most vulnerable of its citizens. Here is w�ere the action is an d here is where psychiatrists may _ le,irn how to make an important contribution.

To make this contribution, the psychiatrist needs to un­ erstand some of the history and fundamental characteris­ � tics of the welfare system. The history of welfare is varied .=ind extensive; in this condensed review we have selected for �mp h as1s those historical events m ost pertinent to current issues and problems.

3

THE DEVELOPMENT OF THE WELFARE SYSTEM

Welfare agencies have not always provided social services. 8 The Huctuating relationship or social services to economic support or "income maintenance" has been influenced by two opposite beliefs: the belief that the economically de­ pendent person requires assistance by social services to move toward a greater degree of independence, and the opposite assumption that obligatory services for the poor person, implying that he and not society causes him to be poor, attack his sense of dignity and interfere with his right to self-determination. These contrasting beliefs have af­ fected the development of both public (g overnmental) poor relief and private charity, which evolved independently of one another and are only now in the process of becoming intertwined.

Public poor relief American public poor relief had its origin in England where, as in most pre-Rerormation ,Europe, charity was for centuries primarily the concern of the Church.!' With the dissolution of' the religious orders under Henry VII I, all the poor were thrown on the mercies of' the State, ;vhich lintil then had dealt only with the "undescn·ing" poo,r, the "rogues, vagabonds and sturdy beggars." It. treated the un­ desen·ing poor :ts Cl"iminals, by hounding them mercilessly, branding them, cutting off their ears and even executing --IYl

45-1

The psychiatrist and welfare agencies

them. During the reign of Elizabeth I, however, a series of enactments, culminating in 1601 with a Poor Law statute, acknowledged the role of society in caring for its less fortu­ nate members. This law formed the basis of the American Colonial poor law, which was entirely local in character and made eacl: town responsible for the care of" its poor.

Th1s_ atlltude has had a fa r-rcach ing impact on American w � lf _ ar� �dministratio�. It :estricted the geographic mobility _ , clients �rntil a few years ago when the Supreme of welfate Court declared residence requirement s unconstitutional as a created wide divergencies in prac­ �asis of eligibilit _ _y. It ,1lso _ tices and qu�ht1es of support among the several st.ates, a _ _ ond1t1 1s only µan ly remedied by recent legislation wh1cl1 � �� l:ederalizmg pans of Public Welfare.

Although the ,�merican public accepted the responsibility _ to h elp its destitute, the Puritan and P ro testant climate _ contm�ed to emphasize se l f-sufficiency, independence, and _ self-rel1 �nce. Anyone physically able to work and fai ling to do s? w<1s Jo�)ked upon as morall y bankrupt and deserving __ While the avowed intent was that no one of h1s suffering. should starve, the apparently able-bodied indi crent was _ forced to suffer many indignities as the price of reITer. For a _ l�ng tl�1e S(:cia! f,:ctors were not recognized as in pan 1 espons,ble for md1v1dual poverty, and punitive legislation attempted to make charity so unattractive that all who could, would work. �f.ter seq:!ral _decades into the ninetcenrh century, the _ op i nion _ t!_iat ddfere�1: forms of poi eny . are brought on by ddferent condmons began to be recognized. Some people, for example, could not provide for themse lves be­ cause they were the victims of mental disorders. These "insane," previously lumped together with other poor, were now seen a� a group requiring specif-ic forms of care. On ly the state, with a central administration and with a tax base insuring sufficient funds, could provide adequate facilities

De1·eloprnent of the welfare syst�m

455

for their appropriate management. Some welfare functions, therefore, were gradually shifted from the local govern­ ment to the state, and shortly after 1850 several states created Boards of Charity to provide proper administration and control of the ne,v facilities.

In 1874 the first National Conferenc e of Charities and Correction was convened, providing a forum for the scien­ tific discussion of welfare issues.· The Conference has met annually ever since, continuing from 191 i as the National Conference of Social Work and since 1950 as the Social Welfare Forum. Basic relief problems, however, continued to be dealt with locally, often by people poorly trained for the task and in a manner demeaning to the recipients. � the seco nd decade of the twentieth century, state Durina departments of public welfare began t o employ trained caseworkers (a profession that developed from the dispens­ ing of private charity and the ministrations of the "lady almoners" in England), but even then no significant changes in the provision of relief were made. lt took the shock of the Great Depression of 1929 to demonstrate that well­ motivated and industrious citizens could become innocent victims of poverty.

The Depression altered the course of the poor-relief policies. Cndcr the administration of franklin D. Roosevelt, a host of collectivist social concepts were put inco practice and for the first time poor relief was accepted in part as a responsibility and a function of the federal government. In 1934, by executive order, President Roosevelt created a Committee on Economic Security, authorized to rec­ ommend a program to provide "safeguards against misfor­ tunes which cannot be wholly eliminated in this man-made world. of ours."

The original Social Security Act, which became effective in August 1935, contained several provisions. It made grants available to states to aid them in providing "categ ori-

456

The psychiatrist and 1velLtre agencies

cal" assistanc e to the aged, to families of dependent children (AFDC), and to the blind. It established a fed e ral-state system of unemployment insurance and a federal system of old age insurance. It provid e d grants to states for public health services ,and for vocational rehabilitation, and other grants for imp roved maternal and child health, and for crippled children's and child welfare services. Thus, the Act represented a combination of modern social insurance and conventional assistanre legislation in th e poor relief style.

The Social Security Act has been altered, broadened, and modified by a series of amendments. Amendments of spe­ cial interest to psychiatrists established a new category, the aid to the totally disabled, and introduced l'v1eclicaid, medi­ cal care for the medically indigent. The 92nd Congress provided for fed e ralization of the categoric.al aids to adults but not of aid to families with dependent children (AFDC).

It d e feated the so-called Family Assistance Plan on two occasions.

As relief began to be perceived not only as a duly of the state but as a right of citizens who needed iL, service com­ pon ents were included in the welfare programs. The Social Security Amendments of 1962 re Aected the spirit of the reform-minded sixties by emphasizing the social service functions of agencies r esponsible for the administration of financial aid programs and by sp ecifying the kinds of ser­ vices to be furnished. In 1967, additional amendmenLs and new federal require ments initiated the separation ol' income ,maintenance and service functions and stressed the right of clients who received financial aid to reject any se rvices that were not specificall y mandated by law, as in the areas of employment or proLective services. ·The services were expected to make many welfare cli e nts self-suppor:ting and so to reduce swelling welfare rolls.

When these expectations were not fulfill e d, politicians and administrators became disenchanted with social s ervices,

457

Oe\'elopment of the welfare system

withdraw their supp ort. To and in the early 1970s began to hdrawal of s:1pp ort including this committee, this wit in the history of p ubhc P? 0r ::��d to be a step backward the welfare syste m req mr� s re ri e f. We are convinced that re fo�ms. to rem edy its comprehen siv e reassessments and de 1enc1es, as set forth obvious and generally agreed-upon �� mon stat e n:ent, THE in t he recently published GAP pos We also believe, how­ .'

WEI.FARE svsTEM AND MENTAL 11EALTH . trative chan�e 1_n_ the welf�re sy ste � ever, that no adminis 1lab1hty of read1�y _access1-_ will eliminate the need for the ava for the rec1p 1ents of ble social and mental health services w elfare.

Private poor relief

.

.

me prima:ily a p ublic func­ Although poor relief has _bcco _ practice� owe m�ch �o tion, current welfare policies10,and States, as m · In the United s· · .

• · s be _ private d onors ancl res·ource evolved trom r.ehg10u py hro lant phi ate priv d, lan Eng charity could increase the liefs and the notion that acts of n admission to heaven. In ch;nce s of the well-to-do to gai borly s u pport had � an y Colonial times, mu t ual ne igh asionally an op ule� t otiz�n earthly adva n tage s as well. Occ help support ��e p oor m would leave money in his will to status and friendly r e: his locality. He thereby gained e he at the same • tim · memb.1 anc.e o f himself and disits ability to sustain strengthened the community's . advantaged. nu 1 t becomc pre �alent t: o did py hro lant � phi .

Large-scale at hantable msu�ut}o� s the nineteenth century, when pnv � � 1g1 us groups_p nmanly were set up by specific ethnic anc� re� � 1tut1ons _were freq uently to assist new immigrants. These mst They often handed out moralistic and evange lical in ton e . assessment of the rea l the dole indiscriminately without leading to c�n:ern that needs of che individual recipient, lize the reop1ents and well-meaning charity might demora ent on the support of encourage them to remain depend 11

The psychiatrist. and welfare agencies

others. As a result of this concern, Charity Organization Societies were formed, first in England and later in the United States, which attempted to bring order into the chaos of philanthropic organizations and tried to reduce the incidence of pauperism by restricting benefits to those who seemed d eserving of help and by developing principles to guide the charitable activities. These principles, later in­ tegrated into the administration of public poor relief, in­ cluded the following: 1. Investigation, not only to detect fraud but also to deter­ mine the specific needs of the destitute person or family.

The correlate in public welfare is the elaborate determina­ tion of the eligibility of the applicant. For many years it has been strongly debated ,vhether the potential benefits of investigation to the taxpayer, the agency, and rlic client warrant the amount of staff time and efforts expended on it. For the welfare worker special difficulties were creared when he or she had to act both as a helper and as an investigator.

2. Registration, to show who has been helped and what agencies have been helping.

3. Coordination and organiz(/,tion, so that the appropriate agency could be enlisted to meet the specific needs of the individual client. (These efforts led cventuallv to coordina­ tion of fund-raising activities and to the ct'.eation of the contemporary community Red Feather org·,rnizations.)

4. Friendly visiting, provided by well-to-do volunteers wish­ ing to perform "good deeds" to help the client resume his independence and self-sufficiency. Although the approach of the early friendly visitors was moralistic and often judgmental, they were the forerunners of modern profes­ sional caseworkers, and the early classes in schools or social work were developed in order to conceptualize and to en-

De1·cloµrnent of the welfare system

459

ession of s�cial wo;� hance their act1v1t1es. Thus, the prof as private p I . ' ma . ted i'n work with the poor, and ong · · f.' s0C1· a I workers ' to public poor rehe , 'e W'lY ant 11ropy g,n · · t significant contn-6 uuons t.o the went on to make the mos of publ',c we Ifare philosophy, the policies, and the methods ' work. ·· 1 f · SOCla In the course of their brief history as a pro ess1on, ·espon­ workers have alternated between focusing on the � sm stres d ar ? the sibility of each individual for his_ fate : c espon :�ngly, importance of sociocultural determmants, Corr ted affec · much there were periods when socia I workers w ere a co cep t_s, �d by psychiatry and especially by ps�choanalytJC � mo1 e of th e�r other periods when social agencies turned _ o soCial atmg entr attention to socioeconomic issues, conc _ � at reliev'.ng the . action and community movements aimed _ , ical surroundings and social 111st1tut1ons 1es · of phvs · d e fi nenc A m�J or c?nthat contribute to the breeding of poverty.

1atry 1s to find s:'ch d temporary task for both social work ar_i � l app r �aches a productive synthesis of social and md1V1dua a synthesis _ca� to the reduction of human suffering._ Such _ of the two d1s0best be achieved by close collaboration plines.

462

The psychiatrist and welfare agencies

pu?lic welfare age ncies, in part because most psychiatric residency programs still fail to provide their students with an understanding of public welfare or with the practical expe rience of working with a welfare agency. Although . medical students and psychiatric residents are often ex­ posed to poor patients, they seldom have contact. with their patients' families and almost never make home visits, and the task of investigating the social and financial conditions of their patients is usually delegated to the social worker.

The student and resident thus lose an important opportu­ _ ntt% to b�come fam1ltar with a critically important pan of their patients' real world, and to discover for themselves how they might make effective contributions to mental healt� thro�gh the welfare system. A period of supervised experience m consultative relationship to a welfare agency would do much to overcome these deficiencies and should be an integr�l p�rt of every psychiatric resident's program.

Any psych1atnst, even the psychiatrist in private practice, has much to gam, both professionally and personally, from exposure to a welfare agency. 15 In agency work he will be challenged to apply his psychiatric knowledge and skills in new way.s, and with more concrete and pragmatic concerns than he 1s accustomed to use. He will miss out on a stimulat­ ing and fascinating aspect of his profession and he will miss o�t on � cl1a�ce to �earn how to improve his understanding _ of all his patients if he does not consider seriouslv an offer to serve as consultant or othe r contributor to 'a welfare agency.

B:iefly stated, the involvement of psychiatrists with the welfare system may result in benefits in the following areas: l. Education and information by psychiatrists may enhance tlu; /Jrofe.1·-1:ional effectiveness of welfare workers �ho 11:ust deal with severe mental health problems m their chent population. Effective casework \viii ease suffering in the welfare population and may

Psychiatry and public wdlare

forestall the psychological decompensation of clients and prevent their entry into the psychiatric care system, with all the personal and social im­ plications. The strengthening or welfare agencies, an important element of the network of preven­ tive psychiatry, may reduce the worker's request for dire ct psychiatric services.

2. Psy2hiaLrists with whom welfare workers can con­ sult can provide useful professional and f!e rsonal sujJ/JUrt to overburdened and generally underap­ preciated community care-givers.

3. The rnedical knowledge of psychiatrists can help workers in their assessment and management of problems of the poor of all ages, who often suffer from physical illnesses as much as from psycho­ logical and social stresses.

4. Finally, involvement with the problems of the poor provides a broadening experience for the f1sy­ chiatrists themselves, challenging their professional imagination and skills, and providing a back­ ground for the deeper understanding of all pa­ tients, their families, and the communities in which they live.

Although there is ample evidence that psychiatric con­ sultation with welfare agencies often works out to mutual benefit ;md that because of it some welfare clients obtain better care, the experience has not always been satisfactory.

In some areas where psychiatrists have been involved with welfare departments, the reg·ularity of contacts has dimin­ ished over the years. This diminution has occurred not so much because the psychiatrist has lost interest, but because frequent policy changes in tlie welfare system have led to deprofessionalization, which has exhausted and discouraged the welfare staff. Conservative policies esp oused by the

464

The psychiatrist and welfare agencies

national government in recent years and increased attacks the public and by politicians on welfare programs have discouraged many local administrators from exposing themselves to liberalizin� approaches. These developments h �ve strengthened the widely held assumpt ion that welfare will never be decisively reformed from within and that di­ re�t tr�nsactions with the system will at best result only in ep 1sod1c and short-lasting relief of suffering. These de­ velor�ments al�o require the psychiatrist who proposes to enter _the welf are system to do so with particular tact and _ restramt, �akmg sure that he secures appropriate sanction and interests _are unde1·stood and per­ an � that his motives _ ce i \ed to be m the best interests of all who are invoh·ed.

br

5

THE PSYCHIATRIST'S ENTRY INTO THE WELFARE SYSTEM

In recent years prov1s10ns for compensation on a fee-per­ session basis by Medicaid and Medicare have made it possi­ ble for welfare clients to be referred to private practitioners.

During such incidental contacts, psychiatrists have an op­ portunity to cooperate with welfare workers and to learn about the welfare system. In situations requiring joint man­ agement, the workers inform the doctors about their com­ mon client-patient's home setting, and about the degree of cooperation which may be expected from the patient and his family. A collaborative approach enhances the execution of a treatment plan and strengthens the links between t he p hysician and such significant supportive agencies as the residential facilit y in which the patient lives. If the col­ lahoration between doctor and welfare worker is effective, the psychiatrist may wish further involvement with the welfare agency. At the same time, the supervisory and man­ agerial staff of the agency may become aware of the agen­ cy's need and the doctor's interest and may invite him to take pare in an in-service training project or a consultation program for the agency staff.

The psychiatrist in private practice is the agency's only psychiatric resource in localities where no public mental health facilities or other consultation programs have been developed..In other localities, however, the local mental +65

466

The psychiatrist and welfare agencies

!1ealth facility is more likely to respond to the agency's mterest or to initiate a consultation relationship with the local welfa�c department. The mental health facility may be a commumty mental healt h cent.er; a state, county, or city mental health department; a psychia tric hospital with an outread: program; or a psychiatric reside ncy training pro­ gram with a community psychiatric component.

An invitation to a psychiatrist to participate in a welfare agency's activities may lead to case consultations, or to a :cquest to participate in efforts to plan or to develop and implement mental health programs for welfare clients or w:lfarc staff. In one m etropolitan welfare department, an _ office of �sychiatr y was established as an integral pan of the _ ?�gamzatton. This office, budgeted by the agency under a JOmt agreement with the local mental health commissioner, is responsible for client evaluations, consultaLions, and whatever mental health services may be requested by the divisions of the welfare d epartment.

Full-time employment of a psychiatrist by a ,velfare agency is rare, however, and welfare agencies more often employ psychiatrists on a pan-time basis within their medi­ cal s�rv_ices divisions to administer the psychiatric aspects of' Medz_caid. programs or to assess the extent of d isability in cenam clients who have exhibited symptoms of mental or emotional disorders. Some welfare agencies hold weekly or monthly case �onferences to obtain diagnostic evaluations and therapeutic recommenc.Lnions for clients and at rhe same time LO provide in-ser vice training for the staff. In other agencies these functions are separated and the staff turns to an outside public or private mental health service for it� psychiatric evaluations and to its consultanL for in­ service training.

Consultations should strengthen the welfare worker's capaciLy Lo manage his client by himself. When a client remains in the care of the welfare worker who is famil iar

Entry into the welfare system

467

with his case and its circumstanc es, he avoids the loss of continuity inevitable in a transfer to a mental health agency.

He does not have to become acquainted with a new group of helpers and build his faith in them. Furthermore, it is rarely possible to transmit all the accumulated knowledge and experience with a case from one ag ency to another.

Finally, the worker who copes effectively with the mental health prob lems of one client tackles the next case with enhanced compe tence. He experiences a greater measure of professional gratification than he would have gamed by referring the client to another resource.

472

The psychiatrist and welfare agencies

The preparatory phase

The skill with which the preparatory phase of any mental health consultation relationship is conducted may deter­ mine its eventual success or failure. Regardless of the details of his recruitment, the future consultant (or the administra­ tive representative of the m ental health service) should ar­ range for a personal meeting with the director of the wel­ fare agency as one of the first steps in the relationship. ln this and subsequent meetings the consultant needs: a. To gather first impressions of the overt and coven expectations and apprehensions which his arrival arouses b. To get an impression of' the director's administra­ tive style so that he can gauge his inAuence on the psychological climate in the agency c. To obtain the sanction and the support of the top administrator for arranging consultation services for the agency d. To discuss how the director wis hes him to familiarize himself with the agency and with the staffs needs so that he can develop a proposal for the type of service he will provide e. To determine the commitments the agency is will­ ing to make with respect to time allotment, space assignment, staff availability and compensation The psychiatrist may be paid either by a mental health facility ·without any charge to the welfare agency, or by the f welfare agency itself if its staf development budget permits it. Each method of remuneration has some advantages.

Payment by the consumer agency is a clear indication that someone in the agency really wants the consultations and that the contract will be terminated if the agency loses interest. Payment by an outside resource underscores the

Mental liealtli consultations

independence of' the consultant from the administration of the agency and helps him to establish himself as a friendly outsider.

If the welfare director approves the consultation program in principle, he usually arranges for the consultant to meet the staff. In so doing, the consultant can learn at first hand about the various purposes, services, limitations, and poten­ tials of the agency. In large agencies, individual interviews with the various bureau chiefs and program directors will probably be set up. \ileanwhile, as the consultant goes about his orientation in the agency, he exposes himse lf to the staff so that they have an opportunity to get acquainted with him. If' he makes it clear that he is sincerely interested in learning about the agency and not in criticizing it, he may even have a chance to accompany some welfare workers on home calls or lO observe staff conducting client interviews, processing intake, determining eligibility, obtaining affirmations, and provid­ ing services for clients. Welfare oprrations vary con­ siderably from methods employed in the medical and psy­ chi.itric care syst.ern, and direct obsen-ation of welfare procedures is the most ef'ficient education for sensiti\'e con° suiting.

The consultant should watch for any signs uf apprehen­ sion that his presence may arouse in the system, and shou'ld maintain an impartial stance with respect to all levels of the hierarchy. He should use the initia l period to establish easy channels or communication, and to dissipate distortions of perception and expectation.

After he has become familiar with the structure and rhe functions of the agency, he is ready to develop, with rep­ resentatives ol' the staff, a format for his consultations, either a single approach or a combination of approa(:hes which may he modihed to meet specific needs. Some psy­ chiatrists prefer to consult alone with an individual worker, which permits them to acquaint the mselves more intimately

--l-7--l-

The psychiatrist and welfare ;1gencics

with each consultee. Others, including the majority or this committee, prefer to consult with groups of workers in order to reach more people at each occasion and to allow group process to intensify the impact of the intervelllion.

The agency's preference rn ust be respected, but usually it is possible to work out an agreement between the consultant's and the agency's wishes. It is worth pointing out, however, that in group consultations the gre;ir.est benefit is often obtained not by the person who presents a case, but by other members of the group or by individuals in the au­ dience who are not the focus of attention.

If a group format is preferred, the consultant usually meets with a work unit consisting of a team of line workers and their supervisor. Such groups customarily spend a great deal of time with each other, and develop filial and sibling relationships not unlike those of a true familv. One advan­ tage of consulting with this kind of '·work b;mily"26 is that the group may later convene with its supervisor to review and digest the content and the message of the consultation.

The unit discussion may also reveal ambiguities and misun­ derstandings that can be brought back later to the con­ sultant for clarification.

Consultations may be scheduled at regular intervals, an arrangement usually more convenient for the cuusulldnt, or they may be set up only at times of crisis when the consultee is especially receptive to the consultant's interventions.

There may be minimal preparation for the consultation, and the proceedings may be kept informal, or consultees may be requested to prepare an outline of the problem and distribute it to all consultation p:irticipams. A free style of presentation is more likely than a formal one to reveal the presenter's conceptions and responses related to his work difficulties. Thus, consultants may gain insight into the hid­ den agenda of the problem more easily if' they discourage the consultee from presenting the problem by reading from written notes prepared in advance.

Mental health consultations

475

Whatever format is decided upon by consultant and staff, clear and succinct delineation is required of such details as the time, place, and length of consultation and the in­ dividuals or groups to be included. Agreement should _be reached on whether only one session or several consecutwe sessions should customarily be devoted to a single case.

A meeting called for all who might be involved in the consultation program may be useful in the prepa�atory_ phase. At this meeting the consultant can introduce himself to the entire staff, present his professional credentials, and explain his role in the agency. He can go on to describe the model and purpose or the consultation program, outlining its format, and inviting questions. Once the conditions of the consultations are agreed upon by consultant and key personnel of the consultee agency, a more or less formal "consultation contract" is drawn up. This completes the preparatory phase, which Caplan defines as "building re­ lationships with the consultee institution and with the con­ sul'tees."11 Case consultations

To help the welfare system retain responsibility for clients who might otherwise be referred to a psychiatric facility, the psychiatrist needs to be primarily concerned with those who provide the care, the welfare workers, and with those who influence them most directly, their supervisors. To make the best use of case consultations, the staff may need a preliminary prngram of in-service education about psycho­ social factors, recognition of psychiatric symptoms, or ap­ . plication of theoretical concepts to casework. The psy­ chiatrist may take part in the planning of a segment in the staff development program, or he may suggest and contact other resource persons for these tasks. In these roles he functions primarily as an educator rather than as a con­ sultant. This kind of program can be useful in preparing the staff for client-centered_ case consultations.

476

The. psychiatrist. and welfare agencies

Educational programs reach large groups of people with a comparatively modest investment of time and effort.

Client-centered c.ase consultations provide insights and guides to management which workers can apply to similar cases. But neither is effective when idiosyncratic blocks pre­ vent specific individuals from assimilating and utilizing knowledge. Attempting to overcome some blocks may be a function of either the supervisor or the mental health con­ sultant.

The supervisor ordinarily assists line workers whose effi­ ciency is hampered by lack of knowledge or skill or by ignorance of specific interpersonal techniques. The super­ visor may at times encourage the peer group to support a worker who is not functioning at his best, perhaps because he lacks self-confidence in a new situation. Other kinds of problems defined as "lack of professional objectivity and loss of normal professional distance," appear to respond best to the consultee-centered case consultation.

In this kind of consultation, the worker, with or without his supervisor, presents a problematic case to the mental health consultant. According to the prearranged plan, the consultant may meet with the worker alone or with the worker and his supervisor, or the consultation experience may be shared with the work unit or other staff. As he carefully listens to the case presentation, the consultant tries to gain insight imo the elements in the ,vorker or in the worker's situation whid1 interfere with his professional functioning;. Interfering elements may include: direct per­ sonal in\'olvcmcnt •with the client, simple identification, transference, characterological distort ions of perception and behavior, and so--called "theme interfr1-er1ce," 1• which will be elaborated upon later. Workers may be upset not only by person:11 psychological problems or by disturbing dients, but also by diflirnlties within the agency, inrra­ organizational stresses, system-wide disequilibria in the

Mental health consultations

-177

institution of welfare, tensions between the welfare es­ tablishment and the surrounding community, and by stress­ es and events in their private lives. As in any work. situa­ tion, whatever combination of stresses affects the worker's customary efficiency will result in part in a symbolic distor­ tion of the ,way the worker perceives and responds to the work problem. The consultant as an outsider can usually perceive organizational stress more objectively than can the -welfare employees. He also can help the employee to relate the general stress to the specific situation and to reduce its adverse effects.

When the factors that are most significant in interfering with a worker's customary efficiency are personal rather than orga nizational, the consultant's task is more difficult.

Then the task may require the reduction of the "theme interference," a concept that requires some clarification.

Caplan introduced the concept of "theme interference," using the term "theme" in a way analogous to its use by .H. A. Murray when he developed the Thematic Apperception Test. The "theme" refers to an emotionally toned cognitive constellation persisting in a person's preconscious or un­ conscious mentation when an actual or fantasied conflict has not been adequately resolved. "Theme interference" occurs when a generally well-functioning worker displaces such an unsolved present or past personal problem or "theme" to his task situation so that it interferes temporarily with his ability to deal appropriately with a segment of his work field. The phenomenon is particularly important because it reduces the worker's ability to deal effectively with all cases having a similar configuration. The impact of a worker's f reduced ef iciency with one client, therefore, reduces his effectiveness with a series of clients. The frustrations result­ ing from reduced effectiveness create tensions in the worker and have disturbing implications for a series of clients.

,.j.80

The psychiatrist. and well a re ,igencies

ated with requests and she had continuous problems with her children, who showed severe consequences of maternal rejection.

Nevertheless, the current caseworker had heen successful in establishing a mutually gratifying relationship with the client. As a result of her concern and care, the client gave up her usual abrasive conduct. She developed some sclf­ esteem, manifested by greater attention to her personal hygiene and grooming, and she enrolled in a training pro­ gram in preparation for a working career. The caseworker was very proud of her achievement until one day­ apparently after a personal disappointment-the client ab­ ruptly complained that her children "drove her nuts" and demanded that they be placed in a foster home or offered for adoption. The caseworker reacted with shock and re­ fused to consider placement. When the client persisted in her demands, the worker stalled for time, and requested consultation to "find out how you can help a mother accept her children" since in her opinion "any mother is better than a foster mother."

Others in the work unit, including the supervisor, were convinced that in spite of her improvement in some areas, this client was still an unsuitable mother and that tem­ porary, if not permanent, placement would be in the best interest of the children. On several occasions she could noi contain her rage and had attacked the children physically, nearly causing them permanent harm. School authorities, alarmed about the signs of physical mistreatment and about the children's deviant. behavior, had initiated an evaluation by a psychologist which revealed that the children lived in terror and functioned considerably below their age level.

But the caseworker, although admitting all the facts, st.ill could not allow herself to accept the separation of the children from her client.

During the consultation it became evident that the caseworker had "mothered" the client far beyond the call of

Mental health consultations

481

duty. At one time she had borrowed a typewriter from a friend and had taken it to the client's home so that the client could practice on it, and there were many other ''extra" kindnesses. In the course of the consultation the worker volunteered the personal information that her own sister had been placed in a foster home with rather unfortunate consequences. The consultant did not encourage or pursue this personal revelation and did not use it during the con­ sultation, recognizing that if he had done so the consultee might afterwards have regretted revealing herself to peers and consultant. Instead, the consultant concenLrated on dis­ cussing the client's role as mother. He poimcd out, citing incidents from the case report, how dangerous this woman was to her children, who showed many scars from J)hysical and emotional mistreatment. He also observed that some mothers wish to control their children to such a degree that the children cannot feel free to grow up and to make their own decisions. Here, then, was a demonstration that every natural mother is not. automatically good for her children.

The caseworker revealed that the "message" had gotten through to her when she responded, half questioningly, "Perhaps I am doing too much for my client-and I do not allow her to decide for herself." Thus, it became clear that the caseworker had projected her own need to be a controlling mother on the client and felt threatened when the client no longer met her expectation about how a mother should behave.

As the group discussed the issue of' restraining and crip­ pling mothering, the caseworker began to change her at­ titude. She abruptly decided that. she would initiate proce­ dures for voluntary placement of the client's children on the following day and commented that she didn't feel un­ comfortable about it any more. At the end of the consulta­ tion, the caseworker was visibly relieved. She confirmed that the theme interference had been correctly identified by saying: "You know, itjust occurs to me that when my client

482

The psychiatrist and 1velfare agencies

gives up her children for placement, I shall have to give her up too because then she must be transferred to another unit.''

This condensed vignette illustrates how a relatively brief contact helped a caseworker to overcome a crisis with a modest investment of consultant time. Neither supervisor nor colleagues had been able to change the caseworker's prejudicial stance, although in repeated discussions they had stressed the client's unsuitability as a mother. The con­ sultant's confrontation with the face that some controlling mothers prevent their children from growing up to in­ dependence touched the worker's unconscious needs and reduced the strength of the interfering theme.

The consultant did not "expose" any more of the worker's personality to her colleagues than they already knew; he did not attempt to treat her so that she would no longer have a need to "mother" others. Instead, he restricted his interven­ tion to helping her cope more realistically with her need to "mother" in the work situation. This caseworker had 35 families in her file, amounting to about 140 people. After a brief contact with the psychiatrist-consultant, this important community caregiver could emerge from her professional crisis not only feeling supported, but also having undergone some liberating change so that she could continue her es­ sential activity more effectively.

Administrative consultations

Everv consultation teaches the consultant more about the welf�re field in general and about the special conditions prevailing in his consultee agency, helping him prepare to be useful, on request, in a somewhat different form of the consultation relationship. Meanwhile, occasional visits to the district director can keep communication channels open, permitting feedback from the staff and reinforcing the sanction of the consultation program by the administration.

Mental health consultations

483

These drop-in visits also provid� opp?rtuniti�s to let the director know that the consultant 1s w1llrng to discuss agency policies or programs with him and th_e managerial s_taff...

A subsequent invitation to help with the resolution of agency problems is usually a sign of acceptance and recogrn­ tion, although on occasion it may also rep�ese�t an attem�t of a faction in the agency to use the psych1atnst as a _to�! m intraorganizational politics. _While we!c �ming the 111v1tat1on, therefore he should carefully scrunmze both covert and overt mo�ives for its issuance in order to keep from being trapped in a power struggle and losing his future usefulness to the agency. . . .

Once the psychiatrist has reviewed the mv1tauon to participate in the inner workings of the system and has decided to accept it, he may use his professional. knowkdge. and skills, now enriched by his welfare expenences, m either adminis trative or programmatic consultation.

Administrative problems may develop because of the p�r­ sonal characteristics of a particular executive or managerial staff person. In chis sensitive situation the consultant should look for a way to set up a consultee-centered consultation _ which includes this person. This is a much easier undertak­ ing when the consultant has established his reputation . wi thin the agency as a professional helper who 1s �ot iden­ _ tified with any specific level of the bureaucratic hierarchy.

The manifest content of the consultation is focused on the administrative problem and its implications for staff and clients. As in the consultee-centered case consultation the consultant chooses those aspects of the problem for elucida­ tion which seem to have special meaning for the person whose work efficiency he wishes to improve.

Case Illustration 2

The director of the welfare district of a major metropoli­ tan area was puzzled by the frequency of transfer r equests

484

The psychiatrist and welfare agencies

from his staff. He saw himself as a fatherly person who had the well-being of his staff very much in mind and who often tried to help them, even before he received a clear request for assistance. Time and again he would deal with welfare clients himself, always with the best of intentions, but his meddling behavior angered staff, who felt humiliated bv his interference. As a result, many clients realized that they c�uld bypass lower echelons and would insist on getting direct access to the director.

Several of the director's close associates tried repeatedly to confront him with his behavior, bu, t succeeded only i� arousing his irate denial. Finally he acceded to the rec­ ommendation of the deputy di;ector to call on the con­ sultant for help. In the initial meeting alone with the director, tl e consultant inquired what staff problems were espe­ _1 cially disturbing in the district. The director replied that he was concerned about transfer requests for which he never obtained <j.ny plausible explanation. Furthermore, the direc­ tor felt that the supervisors in his district seemed to have f more than the usual dif iculties with their line workers. The consultant suggested that a consultation be scheduled at which supervisory problems might be discussed and invited t�e director to attend the conference. During the consulta­ tion, a number of supervisors reported on problems they had encountered. In all instances, the consultant could dem­ onstrate that difficulties had arisen when supervisors did not give their workers an oppo rtunity to Gnd their own solut10ns. The group came to the agreement that helping someone without enough respect for his potential to develop his own answers was infantilizing and could interfere with personal and professional growth.

The district director remained silent for the major part of' the session. Not being the target of criticism allowed him to listen without his usual defenses. Toward the end of the cons�tltation he expressed himself positively about the pro­ ceedings and allowed that he had learned a great deal

485

Ment,il health consultations

himself just by listening to his staff. He realized that super­ visors would have to take the risk at times that their workers make a mistake in order to learn and to grow through their experience. In an almost innocent fashion, he added: ''You know, sometimes I feel I make the mistake of being too eager to help others. Perhaps I am not patient enough to allow people to try their own thing." According to reports, the work climate improved considerably in the district after this consultation and significantlv fewer transfers were requested. ,

I

Programmatic consultations

The situation is different when the consultant is asked to evaluate the mental health implications of a current or in­ tended program. ln this case he is functioning as a source or information in his own professional area. In order to carry out this task, he needs to devote enough time in advance to study all the conditions that have a bearing on the problem. He should gather necessary information, search the relevant literature when indicat ed, and prepare a written consultation report. The report should contain a systematic statement of Lhe problem, of actual or expected implications for the mental health of the persons affected. by the program, and suggest approaches to forestall adverse consequences.

Since the local welfare agency is part of the national welfare program, the psychiatrist who has become involved in a welfare agency and familiar with local programs often hopes to be consulted at higher levels of government so that he can contribute his speci al knowledge, reinforced by his welfare experience, to social policy decisions. These hopes usually have been frustrated, even when the political scene seemed favorable and receptive to the findings and opinions of mental health experts. It now seems unrealistically op­ timistic to expect that psychiatrists would soon be invited to participate in the decision-making prncess effecting we!-

References

REFERENCES l. Group for the Advancement 2.

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Ell

Gerald Caplan, Ed (New York: Basic Books, Inc., 1974) Chapter 51, pp 749-772. lvfilton Wittman. "The Social Welfare System: Its Re­ lationship to Community Mental Health," in HAND BOOK OF C0MML'NITY MENTAi. HEALTH, Stuart E. Golann and Carl Eisdorfer, Eds (New York: Appleton-Century­ Crofts, 1972) Chapter 7, pp 127-1'.--\5.

Gerald Caplan. TIIE THEORY AND PRACTICE OF MENTAL I IL-\1.TII coNsL·1.TATio:s: (New York/London: Basic Books, Inc., 1970).

David Rosenstein. Using Community Psychiatry Methods in Private Practice. HosjJita/ and Community F.1ycl1ir1try 26,2 (1975):99-101.

JF. Maddux. Psychiatric Consultation in a Public Wel­ fare Agency, .//mNicrm Juurn(I/ of OrthojJsyc:hiatry 20, 4 (October 1950):754-764.

B. Parker. PSYCHIATRIC C0NSlJLTATI0;'of FOR '.\/01\"l'SYCHIATRIC PROFESSIONAL \,VORKERS (Washing-ton, D.C.: U.S. Department of Health, Education, and \Nel­ f'are, P.H. Monograph No. 5'.--1, P.H.S. Publication No. 558, 1958).

V. Kazanjian, S. Stein, and W. Weinbetg..�N lN­ TRODL.:cTl<>N TO MENTAL HEALTH (vVashington, D.C.: U.S. Department of Health, Education, and ·welfare, P.H. Monograph ;\'o. 69, P.H.S. Publication No. 922, 1962).

H. Nitzberg and M. W. Kahn. Consultations with Wel­ fare Workers in a Mental Health Clinic, Socio/ vVorh 7,3 (1962):84-92.

I.I-I. Bei-lin. Mental Health Consultation for School Social Workers: A Conceptual Model, Community ,vlen­ tof Her,lt/i Joumril 5,4 ( 1969):280-288.

F.V. Mannino. C:ONSL'I.TATION IN \11':NTAL HEAi.TH ,·\ND RELATED FIELDS: .., REFERENCE cuol (Chevv Chase, \1aryland: National Institute of l\ilcntal Healci'1, 1969).

B.W. MacLennan. S.L. Montg-omery, and E.C. Stern.

CIIIATRY,

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Psychiatry. THE \-VEL· FARE SYSTE:Vt AND MENTAL HEALTH, Vol. VIII, Report No. 85 (New York: GAP, 1973).

H. Herrick. MENTAL HEAL.TH PROF\l.E\,IS OF PUBLIC AS· CLIENTS (Sacramento Office of Planning, Cal­ �ISTANCE _ ilorn1a Department of Mental Hygiene, 1967).

Croup for the Advancement of I�sychiatry. TIH'. CON­ SULTANT PSYCHIATRIST IN A FAMILY SERVICE AGENCY, Vol. II, Report No. 34 (New York: GAP, 1956).

Adair Meyer. "Ho� Can O_ur State Hospitals Provide a Pra �t�cal Interest m Psychiatry Among the Practition­ ers, m THE PAPERS OF AOOLF MEYER, Vol. 4 (Baltimore: Johns Hopkins Press, 1952).

J. V. Coleman. Psychiatric Consultations in Case Work ��en_cies, American .Journal of' Ortlw/J.1ychiatry l 7 (194 7): a33-::>39.

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Blanche D. Coll. PERSPECTIVES IN PL'.BLIC WELFARE: A HISTORY (Washington, D.C.: U.S. Dcpanrnent of Health, Education, and Welfa re, Social and Rehabilita­ tion Service, 1970).

Kathleen Woodroofe. FROM CHARITY TO SOCIAL \VORK IN EN(;J.AND ·\ND TH[ l:N !TED STATES (London/Toronto: Rout.ledge & Kegan Paul, 1968).

Robert H. Brenner. AMERICAN PIHLANTHROFY (Chicago and London: University of' Chicago Press, 1960). l'hillip Klein. FR0I\I PlfIL\NTHROP'\'. TO SOCIAL WELFARE (San Francisco: Jossey-Bass Inc., 1968).

Alexander S. Rogawski. "Mental Health Programs in Welfare Systems," in ,\ME RICAN H.\ND11001,' or PSY-

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THE ANALYSIS AND E\'Al.l.:ATION OF TltE C0NSL:l.TATI0N

COMPONENT IN ;\ COMMUNITY MENTAL HEALTH CENTER

OTHER PUBLICATIONS OF INTEREST GROUP FOR THE ADVANCEMENT OF PSYCHIATRY No.

Title

Price

93

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494