INTER-AGENCY USE OF CHILD GUIDANCE CLINICS

FROM THE POINT OF VIEW OF THE COOPERATIVE

EFFORT OF SOCIAL WORKERS*

ROSE GREENPhiladelphia Child Guidance Clinic

I N THE last years a good deal has been written about the relationship betweensocial worker and client. A good deal has been said about the relationship

between therapist and patient. Effort has been turned toward the study of thestudent-supervisory relationship, and toward the study of social worker relation­ships with psychologist and psychiatrist. As soon as the social case worker ac­cepts a job, she steps into new relationships with her community-be they withinstitutions, such as schools or courts, or with individuals. She steps into rela­tionships not only as an independent citizen, but as an individual who carriesout the function of her agency.

It seems important to me that we begin to study and understand the areas ofa social worker's relationships that exist between her agency job and the restof the community. I would like to discuss only one angle of these relationships,and that is the relationship between two social workers. This area is again de­limited in terms of those social workers in a community who make use of childguidance clinics. The purpose of this paper, therefore, is to attempt some defini­tion of point of view and philosophy concerning the cooperative effort betweensocial workers. In the symposium of last year I mentioned briefly this point ofview, and I take this opportunity to develop it more fully.

Before we consider how two social workers may work together, I find it neces­sary to go back to one social worker and the real unit of social work activity,which is the social agency. In comparison with other therapies, social case workmay be at a disadvantage in some ways; but in one particular respect a greatadvantage is in its hand. That great advantage lies in the utilization of the func­tional organization that social work has developed in response to specific needsin our society. The case worker in the abstract cannot exist alone. The power shehas comes from the functioning power of her agency. She is that function inaction. The social agency, through the individual worker, is one element in thesocial case work process. The other element in that process is man.

I think of man psychologically as a being of infinite needs. I also think of manpsychologically as a being of strength, in varying degrees, to objectify, if neces­sary, an inner need and to satisfy it. Need or desire in the abstract must remainunknown and immeasurable, and anyone who sets out "to discover" a man'sneeds in this psychological or abstract form is lost. Fortunately, we do not haveto linger over a philosophical contemplation of desire in the abstract. Our prac­tical world presents very real problems to man with such force and frequency thatfew are free of some feeling of difficulty in their living. By no means, do all people

* Presented at the 1938 meeting.

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who have difficulty in their lives, come to social agencies. There are other ways ofmeeting adequately a real trouble when it arises. But he who does come to socialagencies at a critical point of being in real trouble, whose coming is a first stepin getting himself out of the trouble, has selected the area in which he feels hecan begin to work with his difficult situation. A man may have many differentproblems-trouble with his employment, trouble with his wife, trouble with hischildren, trouble with his health. Is any social agency equipped to deal with allthese problems, interrelated as they may be? I think not. The community hasestablished various agencies, expressing many different functions related to par­ticular problems of life, such as the hospital, the child placing agency, the familysociety, or the child guidance clinic. I would like to emphasize the fact that agen­cies are set up in relation to particular and definite problems in living. To goback a bit-he who does come to a social agency, has selected tentatively thearea in which he feels he can begin to work with his problems, and he seeks fur­ther clarification through the help of the case worker. The strength of a caseworker who holds firmly to the purpose or function of her agency, knowing itsfull possibilities and its limitations, is potentially the most effective help to aclient. His coming indicates some readiness, although accompanied by some mis­givings, to work on the trouble. If he begins to realize under what conditions,on what terms, and in which way this particular agency does help, he can knowa little more surely his own willingness to accept the kind of help he has sought.

At this point we see the two individuals in a case work relationship: the clientwith a very real trouble in his life-the case worker professionally identified withthe function of her agency, willing and ready to give its service to the client, theonly service she is there to offer. The helping process is the dynamic relationshipbetween these two.

Our understanding of the helping process must be brought to bear at the veryfirst contact the client makes with the social agency. His coming is movement inthe direction of seeking a way out of his trouble and is accompanied by some feel­ing of fear. One cannot take a step into the unknown without some fear. But itis through the actual coming, the real contact with the worker who represents achild guidance function, that he comes to know, through his own experience,whether or not this is the thing that meets his need. As he learns and discusses thebasis on which this agency works, he tests out his need for the service and it isthis experience which materially lessens his fear. I think this could be true forall social agencies-each defining its own conditions under which it offers itsservices. I describe here one child guidance clinic, where practical matters suchas appointment hours, parental contact and fee involved, are some of the realconditions of the agency function. Against these limitations, which define someof the conditions under which the service can be offered, does the client expresshis willingness to take this sort of help for his trouble.

Recently a mother poured out to me a tale of protecting love for her 7 yearold only child, and a none to subtle criticism of the day nursery that suggestedher clinic visit. She maintained there was nothing wrong with him. I did not

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feel this mother was unconcerned over her boy. I felt she was blocked in express­ing her own worry by her great desire to protect her son in the face of the outsidecriticism, and blocked also by her deep fear of what the new agency might do toboth of them. As she was able to say much later, she had been afraid the ChildGuidance Clinic would take her child from her. I stated that I realized if she sawnothing the matter with him, she would feel no reason for this treatment, andmade it clear that the clinic's doing anything about her son would rest on whethershe felt any trouble with him, whether she, not the nursery, felt he needed anyoutside help. She accepted me for the first time as not being an extension of thenursery and could hesitantly talk of the worry she had over his development,perhaps with greater fear as she became aware that further clinic activity would beconnected with her feeling for the need. She brought out that she was just likeher son in his solitariness and pointed out how she came to be this way. She feltshe had achieved a solution of keeping away from most people, but also felt shepaid for it in many ways. I think it might be possible to get lost in further discus­sion of the mother's development, or the pain in her present living in terms ofher own individual self. Realizing all that she is, I think it is important to keepa firm hold on the purposes of the contact. In this specific situation I thoughtone purpose of the contact was to understand whether or not this mother couldlet her son have psychological treatment which held possibilities of his beingdifferent, perhaps even different from herself. If she were willing to yield him tosome change, that in itself would indicate some organization within the mother todo something about her trouble with her boy in this particular agency.

Only through a discussion of the conrete elements of her working hours, clinicappointments, fees, etc., could she get some experience of how she and her sonwould be involved in this new agency. For me, the discussion represented thebasis on which my agency could work; for the mother, this discussion helped tomake more compassable, some of the fearful uncertainties that surround whatmay be set in motion by one's asking for help.

For a deeper understanding and treatment of the psychological factors in­volved for the client and the case worker of a social agency in their first comingtogether, I would refer you to two papers read at the National Conference ofSocial Work in 1931 and 1937 by Miss Almena Dawley of the Philadelphia ChildGuidance Clinic. For a more complete conception of the philosophy of the rela­tion of the function of social agencies to the case work process, from the points ofview of various social agencies, I would refer you to "The Journal of Social WorkProcess" published by the Pennsylvania School for Social Work, November 1937.

I have tried to present what I feel is important in the case worker's identifica­tion with the purpose or function of her own agency, and the constructive possi­bilities of the active use of that function with the client who asks her help. Thesecond part of this paper is devoted to a discussion of how the integrity of thecase work process may be maintained for the client when two social workers rep­resenting two different social agencies-one of them a child guidance clinic-areactive in one problem situation.

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In broad terms, the function of the Philadelphia Child Guidance Clinic maybe defined as the diagnosis and the treatment of behavior disorders in children,and help to parents about those disorders. Anyone of these three-diagnosis,treatment for the child, or help for a parent about his child's difficulty, or morelikely a combination of all three-may bring a social worker of another agency tothis particular clinic. For the sake of objectifying this abstract discussion, forthe sake of clarity, I think it may be helpful to discuss a specific case situation.

A family welfare agency knew Mrs. Tobin and her two daughters, aged 10

and 7, through a whole miserable year when Mrs. Tobin was battling with thefact that her husband was suffering from a psychosis. Practical troubles throughlowered income, and emotional troubles attendant on this strain, enveloped thefamily. The mother was a timid soul who had left everything to her husbandexcept the care of the two little girls. And even in this area he had been the dis­ciplinarian. Hospitalization held not only the strain of facing his illness, and itseffect on her and the children, not only her fears about heredity, but it also heldthe struggle of putting away the rod and strong staff upon which she had leanedfor many years. Mrs. Tobin sought and used a skillful family case worker's helpto the point where she took the step, with some misgivings, of hospitalizing herhusband and making a new plan for living. Mrs. Tobin clung to the case worker,slowly developing her own strength in the face of family criticism over the hos­pitalization, and neighborhood and school criticism over Rachel's behavior.Rachel, the 10 year old, was a strong, wilful child. In the few months after herfather's removal, her misbehavior grew increasingly worse. She found many waysof managing her mother, sister, neighborhood and school. Mrs. Tobin could notstop her. The child's terrific outbursts of temper when crossed, fanned into aflame the mother's fear that Rachel would go crazy.

My interest today is not in the details of the treatment, but rather in theactivity and relationship of the two social workers.

The family worker felt that Rachel was very much disturbed over her father'sillness and removal from home, and thought the child might profit by clinic treat­ment. As the family worker referred the case in these terms, the clinic workerraised the question of Mrs. Tobin's visiting the clinic to discuss her problem withRachel, to find out how this clinic works, to participate in the plans aboutRachel and so map out her own connection with her daughter's treatment. Thefamily worker could see that it might be valuable for Mrs. Tobin to come toher own decision regarding the treatment of her child in this different agency. Itwas so planned.

Mrs. Tobin was so confused and fearful of the clinic project that she brokethe appointment she had made for an interview. In this instance it was veryimportant that the family worker not persuade or urge Mrs. Tobin to get intouch with the clinic, after the mother was well aware of this resource. A monthlater she appeared without an appointment on the very day and hour that wasfirst set. She came and discussed her problem about Rachel and made plans forclinic treatment.

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At this point, we see two social agencies, each having a specialized function inthe community, planning to meet different needs within the same family. Thefamily agency does not think it necessary to withdraw and transfer the family tothe child guidance clinic. Neither does the family agency think it necessary toconsult with the clinic about the situation and embark on the psychological treat­ment of the child. The family worker maintains her position, offering a serviceto Mrs. Tobin on family needs-finances, budgeting, school, and the still activeproblem of letting her husband remain at the hospital. The clinic worker main­tains her position, offering a service to Mrs. Tobin specifically in terms of thetrouble she is having with her child-clinical treatment for Rachel and help forthe mother with her fears concerning this child, fears that get in the way of themother's constructive control of her child.

The two social workers operate from equal, but different, professional bases­each limiting her activity to keep within the function which her agency was setup to perform.

Throughout the course of the case which ran about five months, there wereseveral conferences of all the people working with this family. The conferenceshad several objectives (a) to summarize from time to time the progress of thechild in treatment; (b) to keep the two social workers informed as to the mother'smovement with each worker; (c) to encourage further understanding of eachsocial worker's objective and her activity toward it. All of this led to the practicalsolution of problems which arose out of Mrs. Tobin's seeing two social workersfrequently.

Of course, there was overlapping of material and content and of course, Mrs.Tobin used one worker against the other. In the beginning she brought all hercomplaints of the child guidance clinic to the family worker, and all her com­plaints of the welfare society to the clinic worker, keeping a very sweet, patientand humble face with each. Progress with Mrs. Tobin was marked by her growingability to express her criticism in the right quarter-the place that could dosomething about the particular point she was criticizing. The whole process ofaccepting help was greatly expedited by each worker holding fast, in her activity,to those areas of the trouble which her particular agency was set up to serve.

In the above illustration we have seen the cooperative effort of a family agencyand a child guidance clinic, where the family agency worker in an advisory ca­pacity, suggests a referral of a child to the clinic. We shall now consider the co­operative relationship where the outside social worker stands in a much moreresponsible position to the child she refers to the clinic, as for example, a workerin a child placement agency.

J ames was 4 years old when the foster home, which his mother arrangedprivately before she disappeared, broke up. The court referred him to a childplacement agency for a new home. When the placement worker referred him tothe child guidance clinic he was past 7 years of age, he was still wetting and soilinghimself and had made no progress in learning at school. He was not a dull child.The placement worker was in a quandary. Sometimes James seemed like a boy

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who could make no constructive use of a foster home, but until she was reallyconvinced and ready to tell the court that James was unplaceable, it was herjob to try' to find him a private foster home. The placement worker thought ofclinic treatment as a possible help to this child about his own troubles-a specificand separate piece of work which is a guidance clinic's job, in the hope that witha different internal psychological organization, James might be able to make useof a foster home in a way that foster parents and placement agency could accept.

There are two sorts of difficulties inherent in this situation, as far as the agencyworkers are concerned. The clinic worker may be ready, and even eager, to adviseabout the placement work. Or the placement worker may be ready and eveneager to place on other shoulders, the responsibility for decisions concerning thechild in her care. With some such rationalization that clinic workers know thechild best and so can best decide where and how he shall live, the evasion ofthat responsibility is made easy. And all too readily, clinic workers have acceptedthe rationalization, believing they did know best just how and where a childshould live. As I see it, decisions for change of foster home or placement in an in­stitution are usually beyond the function of a child guidance clinic, as much withsocial workers as with individual parents, because I believe that such primarydecisions should be the responsibility of the placement agency. More effectivework may be done when each agency confines its activity to its own job, eachcontributing to the other specific knowledge gained in her own area. The clinicworker contributes her knowledge of the child's reactions in the treatment situa­tion. The placement worker contributes her broader knowledge of the child inthe many aspects of his real living. By no means does this inhibit discussion ofthe situation. On the contrary, it encourages greater freedom as each worker isfully aware of which one is responsible for any particular .step, There can be asmuch discussion as is necessary about the treatment situation, but it is theevaluation of this treatment in the light of what the placement worker knows abouther agency's resources and what she feels she can do in the placement situation,that she comes to her decision to change or retain a home.

I believe that each agency should stand on its own responsible base in orderto work out its own relationship to the child, in functional and practical terms.Each social worker has something to contribute to the understanding of theother, yet each is responsible in activity in a more limited area. As in a drama,each actor may understand the whole play but he carries responsibility for onepart. Such activity implies a full acceptance of the agency's job as it has beendefined and can be of great use to the client. If a worker has such a philosophyof social agencies, she must have as a corollary, the kind of responsible coopera­tive effort with other agencies doing different work that I have discussed above.

The idea that two or three social workers might settle in conference that oneagency is most important in a particular situation and should be responsible fora general plan of rehabilitation in which the other social workers carry out as­signed parts, also represents a cooperative effort of social workers. The point ofview presented in this paper derives its initial dynamic power from a different

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center-the individual who wants help and who organizes his strength to takehelp on a trouble which is very real to him. The social work effort is that set inmotion by the client himself, and it seems to me sound, he work on one particularproblem with one particular agency which he has sought out, for help with thatproblem.

In conclusion, this point of view may be summarized as follows: each socialworker, through the acceptance of her own job, represents a specialized agency,each different from the other-each having a particular function to perform. Thesocial workers meet to discuss professionally the problems in one case situation,and each worker inevitably sees those problems through the specific agency func­tion she is performing in that situation. Essential qualities in such cooperativeeffort are the feeling of equal but different contribution, a shared responsibilityfor the objective, and a respect for each other's job functions as real services tothe problem situation.

DISCUSSION

CHARLOTTE TOWLE: In discussing cooperative relationships (between agencies par­ticularly with reference to a Social Agency's use of a Child Guidance Clinic) Miss Greenlimits the function of anyone worker to the function of his agency. This presentation istimely in view of some of the present-day confusion about agency function.

In emerging from a period in which there has been drastic change in thinking as wellas change in function in certain agencies there has been a tendency on the part of someagencies to fortify their uncertainty through offering an all-embracing kind of service. Intrying to be everything to every applican t there is a particular need for workers in suchservices to see the therapeutic possibilities of limited function in anyone case. One mightnote here the program defined for private family welfare agencies. The manifold programof these agencies does not imply unfocussed practice but for those workers who may havebeen bewildered through the sudden acquisition of rather unlimited scope in function, ad­herence to the principles defined in this paper would seem to safeguard their situation inanyone case.

Also one of the weaknesses of the Child Guidance Clinic has been its tendency to as­sume too much rather than too little responsibility and in so doing it has frequently failedto help either the client or the social agency. For example, with reference to the emphasison the importance of a child-placing agency in its cooperative relationship with a clinicto decide on matters of child-placing rather than to relegate those decisions to the clinic;there is the longstanding and existent tendency on the part of some social agencies torefer cases to a clinic not so much to gain an understanding of the personality needs of theindividual as to be told what to do. When clinics take over this responsibility they notonly engender dependency but they also reap a harvest of hostility. Often this is expressedin criticisms of the naive recommendations made by those psychiatric folk, who beinguninformed in the area of the agencies' function, make impractical suggestions. It appearsalso in a projection of responsibility for failure onto the clinic when the recommendations,if tried, fail. There is furthermore the tendency in some social agencies to refer for psy­chiatric advice and treatment, cases on which they have long attempted much misguidedservice. They then refer the case to the clinic as a last resort with the attitude-maybethey will succeed now that we have failed or perhaps with a need to justify their ownfailure.

I believe that if social agencies had found clinics more useful in contributing to theirprofessional understanding of their clients and if they had been directed in utilizing thisunderstanding in their own case work process we would have a more constructive use of

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clinics. Instead they have been threatened by a service which presumed to dictate andthus in a sense to take over their own responsibility for the case. If this had not been so,we might find instead cases being referred to clinics with a view to getting help at anearly point, rather than at the stage of rejection when they are less promising for treat.ment by either agency or clinic. As it is the clinic frequently is used merely to confirm thehopelessness of a situation rather than as a treatment resource. Comprehension of themany implications of this point in Miss Green's presentation may lead to some modifica,tion in clinic-agency relationships.

It is maintained in this paper that it can be advantageous for two social agencies,each having a specialized function in the community to meet different needs within thesame family and in so doing to be on equal footing without centering major responsibilityin anyone agency. It is not yet general practice for major responsibility not be be centeredin one agency. In cooperative effort between agencies, it is generally decided in jointconference that one agency is more important and should be responsible for a generalplan of rehabilitation, in which other agencies carry out assigned functions. Often it isnot easy to determine which agency is of primary importance. So fixed is our idea that itwould be dangerous not to centralize responsibility, that frequently this selection is anarbitrary one made in the interest of assuring a coherent service to the client. The co­operative service based on common sharing of responsibility, described by Miss Green isbased as she states on a point of view that is "one which derives its initial dynamic powerfrom a different center .... The social work effort is that set in motion by the clienthimself." Case work effort then radiates from the client rather than from the workers inthe various agencies. Obviously this kind of cooperative effort presupposes a commonphilosophy and an identical case work emphasis. In those communities wherein there iswide variation in point of view with resultant basic differences in working methods andin the very nature of the client worker relationships established, it would not seem pos­sible for cooperative services to be maintained on this basis. One wonders in how manycommunities this kind of cooperative effort could be effected at this point in history.Would it work only in Philadelphia, that enviable Utopia of Inter-agency "at oneness."

To those who concur with Miss Green in her basic philosophy as to what the natureof the client worker relationship should be if the client is to be afforded an opportunity forgrowth, there is apparent an additional advantage to the client in the kind of cooperativeservice which she depicts-and that is the opportunity for a widening of his therapeuticrelationship experiences. For example, in the case of Mrs. Tobin cited by Miss Green,this woman was afforded an accepting understanding relationship in two agencies, ratherthan in one-thus doubtless deepening her security through easing her anxiety about theuniqueness of the first experience-and inevitably then increasing her capacity to trustothers-since the rare experience of being understood has not been centered in one rela­tionship. This is a vital point relevant tv our common observation of the unfortunate factthat when a client has experienced understanding in a particular service he may becomeabsorbed in its difference from others and may not move freely into other relationshipsbecause he feels this experience to be unique. There-should be real values then in thiskind of service, in helping the client to develop an enlarged capacity for relationship.

Even though the cooperative service described here may not be readily effected entoto, in many communities, there are certain principles inherent in this concept of inter­agency relationship which should challenge an evaluation of agency attitudes, which inturn might lead to some modification of cooperative practice within the limits of aparticular situation.

It is possible that cooperative efforts have in some instances become perfunctorythrough adherence to inter-agency routines because they have not been comprehendedas an integral part of case work process. This presentation strikes at the roots of traditionalpossessiveness in regard to cases. The need to cherish major responsibility and to share itwith apprehension may diminish when we see that these attitudes are vestiges of a case

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work philosophy which assumed responsibility for the client. Just as we have given upother proprietary practices we may modify this one.

In those agencies wherein case work practice is fooussed on the client as the center ofactivity we will cease to be anxious as he enters into other agency relationships when wesee them as an equivalent for other life experiences. Certainly it is clear that it is only asthe individual agency comprehends the therapeutic possibilities of limited function andgains some acceptance of its own limitations, that it will be able to move gradually towarda freer relationship with other agencies in its cooperative efforts.

We are indebted to Miss Green for this clear formulation in which she has helped usto see inter-agency relationships as an integral part of the case work process and as partand parcel of the professional point of view of its participants.

While almost everywhere there are persons who seem to be free from the needof logical thinking, this is assuredly not the case with those gamblers whosemental disintegration shows itself only with regard to gambling and who, atother moments of their existence, behave as scientists inured to the most rigorousmethods. A man will be quite different in his laboratory, when at grips with somescientific problem, from what he is in the gambling room seated at the rouletteor the baccarat table at the moment when chance is about to give its verdict.In other words, whereas at certain hours he is a slave to his unbridled passion,his frenzied imaginations, there are other hours when he is liberated-for a timeat all events-from this servitude, when he is not only in possession of himselfbut also of all that constitutes the civilized individual. The uncivilized man, onthe other hand, is magic-bound every moment of his life. He has occasionaloutbursts of common sense, but he never rises in rebellion against the belief thatcontrols his life. We should define the former as a human being, who, while notincapable of any belief in magic, is not dominated by it, but is able to reflect,deliberate and draw conclusions as though it were nonexistent; and the latter asthe human being in whom the belief in magic determines the essentials of hisinner Iife.e-Rxour. ALLIER