Читать книгу Riverview Hospital for Children and Youth - Richard J. Wiseman - Страница 14

[ CHAPTER 4 ]

A NEW DIRECTION

…

We assumed our new posts on 1 November 1969 and used that first month to get to know each other, to visit various children’s hospitals in Massachusetts, Rhode Island, and New York, and to begin to identify our various roles and responsibilities. While I had some experience both with CVH and with the Children’s Unit as a result of our working together on our camping program, Peter was relatively new to state service and the Children’s Unit.

We found this first month, a period of looking at other programs, developing trust in each other, and sorting out problem-solving ideas and strategies, to be very productive. We decided that we would meet at the end of each day, discuss what issues arose, and how we had handled or would handle them. We agreed that whenever possible we would talk about solutions to problems before implementing them; but when decisions had to be made in the absence of the other, complete support would be given, with any differences discussed privately. Any unresolved differences would be brought to the attention of the deputy commissioner for children, Charles Launi. We also used this time to review the functioning of the Children’s Unit—how it came into existence and what had happened to it in the succeeding years. We identified the key players and generally figured out what was in store for us.

Later in November 1969, after giving us the chance to get the lay of the land, the ad hoc subcommittee of the hospital’s Advisory Committee, which had been formed to develop a children’s program, invited the newly appointed co-directors to its meeting. Issues of construction were discussed. The plans called for three phases, each with its own bond issue. The first phase, which had already begun, was the building of three 16-bed cottage-type facilities and renovating the Silvermine Building as an administrative, clinical, and dining facility. The second phase was the construction a new school, and the third was the construction of four additional cottage-type residential units, totaling 112 beds.

Prior to the meeting, Peter and I surveyed several children’s programs nationally and found there was nearly unanimous agreement that the maximum size of a children’s psychiatric hospital should be no more than fifty or sixty beds. Also, while we supported the cottage-type facilities, we were concerned about the security of the design, especially for the autistic children and for those who might need a more secure setting. We also recognized that there was a need for additional beds but felt that they should be built in two different areas of the state. As a result of this discussion, the commissioner sent a letter to the Department of Public Works to stop planning the additional four residential units but instead to use the money to construct a specially designed facility for children with autism and an intensive care division. Since the latter would obviously take much more time, interim plans had to be revised to accommodate those children. Consequently, we made temporary accommodations in the Silvermine Building. We divided the third floor into an autistic unit and administrative offices, a medical records room, and a conference room. The middle floor became an intensive care unit. We discussed plans for the new school to accommodate up to one hundred children in order to offer a partial hospitalization program.

Up to this point, children would arrive in an ambulance, without notice, and be automatically admitted by the resident psychiatrist on-call on the basis of “cautious clinical judgment.” We assumed authority to control admissions, which now required a call to the hospital intake staff and a discussion with the referring agency. Our staff discussed each pending transport and assessed with the referring agency the appropriateness of hospitalization. In many cases alternative solutions made more sense. According to the statistics for that year, 324 children had been served, with 225 in residence, 157 new, and 148 discharged. As of the end of June 1970, the census was 74, that is, 59 boys and 15 girls.

Peter Marshall and I were acutely aware of Marge Stahl’s work to bring some sanity to the Children’s Unit. She had a strong, positive, and loyal relationship with her staff and we were newcomers, taking over her territory. Initially assuming we would have to win her over, we soon learned that this concern was unnecessary. Marge welcomed our help, support, and initiative.

Thus began a new era and an enormous challenge for all of us.

Since I had worked previously in the Psychology Department of CVH and the central office of the Department of Mental Health and knew the various departmental heads, it fell upon me to do most of the administrative work, dealing with old friends: Eugene O’Brien, the CVH business manager; Donna Dickson, the personnel director; Dwight Shuman, the director of nursing; and various others at the hospital and central office where I had previously worked.

Peter would be responsible for the education program, given his experience with boards of education and school operations. Marge reverted to her role as director of residential care. This group, along with Jacqueline Reardon, our secretary, became the administrative staff. Soon, the Yale Child Study came through for us again by assigning as consultants two child psychiatrists, Alan Gurwitt and Norton Garber. They not only gave guidance to our few clinicians but also were enormously supportive of Peter and me. Yale’s Psychology Department assisted by assigning one full-time psychologist and two part-time psychology interns.

STRUCTURE

Early in our talks, Peter and I had discussed the importance of milieu therapy, an approach we each had experienced. Milieu therapy embraces the need for the children’s entire environment to reflect a therapeutic mission—the landscape, the buildings, the staff, the policies and procedures, and in particular the residential units, where the children spend a good part of every day and night. To ensure that a milieu approach was taken, we chose to take direct responsibility for this segment of the program and philosophy. The book The Other 23 Hours by Brendtro, Whittaker, and Trieschman became our bible.¹

One of our first concerns, therefore, focused on the basic structure of the unit. As strong advocates of the other twenty-three hours (meaning the time spent between therapy sessions), we felt it important to devote most of our energy to revamping residential units, recreation, and schooling. There were three residential units. Ward 91 was a twenty-bed, all-girl unit. Peter Marshall, because of his previous extensive work with young adolescent girls, became the coordinator. Because of my previous work with autistic children, I became coordinator of the Autistic Unit, and Peter and I shared coordination of the boys’ ward. Marge Stahl took responsibility for the basic needs of the units, such as scheduling work hours and overtime, supervising staff, organizing medications, and providing all the other daily necessities of group living. Clinical services were provided primarily by social workers and caseworkers, with Marcia Pease-Grant as their supervisor. Additionally, psychology interns and resident psychiatrists were minimally available.

In our first annual report, we noted new members of the staff. David Hickox, a part-time pediatrician, proved to be an invaluable asset to the program. Each morning he would see any child on sick call, examine new admissions, and generally provide TLC to children and staff. He made himself available in emergency situations from his group practice in Middletown and was our primary liaison with Middlesex Community Hospital. This was a big improvement over a visit to the CVH infirmary serving primarily adult patients, a frightening experience for our kids and staff. We also hired during this period a caseworker for the Autistic Unit, Judith Deras; a psychiatric consultant for the Autistic Unit, Virginia Suttenfield; a behavior modification consultant, Joseph Cautella; two social group workers, David Merry and Roger Wehage; and two nurse clinical specialists, Diane St. Jean and Karen Fredricks. The first fieldwork placement from the University of Connecticut School of Social Work—Esther Adam—and three psychology interns—James Tracy, Margaret Hull, and Peter Bishop—also joined our growing clinical staff.

As encouraging as it was to welcome new colleagues, serious concerns were also reflected in our annual report:

By far the greatest problem we have encountered as co-directors of the Children’s Unit has been the great discrepancy between what is expected of our staff and what is possible given the resources available. Further, the coordination of services is often obtained only after interminable delays, unimaginable expenditures of time, energy, skill and paperwork. Even when the proper documents are forwarded to all parties concerned, there is no guarantee that the finances requested will be approved on time, in sufficient amount or at all. Under these circumstances, we understand why there is so much professional resistance to the need for change and a lack of commitment to our program and children; yet we are seeing an encouraging development of openness, of feelings and sharing of advocacy for our children by our staff.

The great shortage of skilled psychiatrists has made it mandatory for us to use non-medical psychologists, social workers and psychology interns to carry out the major clinical responsibility of diagnosis, treatment and discharge planning. Our psychiatric coverage has been poor, necessitating our decision and need to plan for and develop a Residency Training Program.²

On the other hand, Arafeh’s superintendent’s quarterly report of July–December 1970 stated: “The autistic program has improved greatly. It can be said that it is now one of the best such programs in the northeast. There is also evidence of improved overall programming This Service has succeeded in recruiting high level and dedicated staff and consultants, and enlisting the cooperation of the Association of Child Psychiatry and the Association of Child Psychiatric Clinics in the state.”³ These encouraging words gave us a significant boost in morale.

It was clear that the Children’s Unit was viewed by staff as a place for children to stay while a residential treatment center or other childcare facility was sought. There were at this time very few public or private psychiatric units in Connecticut equipped for children or adolescents. Psychiatric emergencies were dealt with in ill-equipped emergency rooms, and from there the children were sent to the Children’s Unit with a physicians’ fifteen-day certificate. This gave the hospital permission to accept a child without either the child’s or the parent’s approval. The hospital in turn had to decide whether or not the referral was appropriate. The policy at the time was to use “cautious clinical judgment.” Also, as the on-call physician was likely to be a resident in training with little or no previous training with children, admissions were almost automatic. Because children were sent to the Children’s Unit after failing in other placements, and were generally felt to be untreatable, they often stayed for many months and treatment consisted primarily of trying to hook them up with another program or with a family. The intake process improved when we created a position for our own intake staff.

A short conversation about a child marked a turning point in treatment philosophy at the Children’s Unit. When the assigned clinician asked, “This child could really benefit from treatment. Where can we send him?”

I replied, “I thought that’s why he was sent here.”

Until now, our staff members had thought of themselves as custodial/placement persons rather than as treatment agents, and the excitement they now felt was obvious. From this simple dialogue, a treatment philosophy gradually developed in which the role of the Children’s Unit was to provide extended treatment for children who needed more than a brief stay, and community hospitals, not us, needed to develop emergency, short-term treatment. This enthusiasm fed our goal to develop a milieu program and a residential facility, as we encouraged local hospitals to develop short-term emergency programs. In fact, eventually, we would not accept children unless all community resources had been exhausted. We actively helped local hospitals develop children’s units. At Saint Raphael in New Haven, for example, we helped develop ACUTE, a short-term emergency setting for children and adolescents. We had an understanding that, should they make a referral to us, we would accept it unquestionably because we knew they had done their job. Similar agreements were made with other programs as they developed.

Our annual report of 1970–1971 reflects this effort: “The reduction in admissions [from 157 in 1970 to 115 in 1971] reflects the new admission policy encouraging admissions of 14 and 15 year old boys to the community hospital serving their town of residence.” This not only reduced direct admissions to the Children’s Unit but improved communications and working relationships with community resources. Our report adds, “The referrals in general are also more appropriate.”⁴

Interestingly, despite the fewer admissions, a new category of “total children served” shows a significant increase from 324 in 1970 to 447 in 1971, signifying an increase in work with children, families, and family members, including pre-admission interviews and aftercare (a program requiring clinicians to follow up for brief periods after discharge). Part of the 1970–1971 report, “A Philosophy of Treatment and Education,” set forth our commitment to placing greater importance and emphasis on the residential component, or the milieu, and redefining the role of the childcare staff as an integral part of the total treatment program: “Our psychiatrists, doctors and clinical staff must work patiently towards delegating to nurses and aides an important wider spectrum of authority to make decisions than they are accustomed to accepting—or that doctors are accustomed to granting. By the same token, nurses and aides must learn to assume authority they have not had before.”⁵

Also, we emphasized the importance of including parents in all aspects of the hospital experience—intake, residency, and discharge. To complement our emerging philosophy, Peter and I offered a course called “The Life Cycle” to the entire Children’s Unit staff as well as staff members from CVH, Long Lane School, and the Department of Children and Families.

We addressed our educational philosophy, too, and modeled it after William Glasser’s Schools Without Failure,⁶ as was our basic principle: No child will be considered too sick emotionally, or too disturbed, or too unmanageable to be deprived of an opportunity to learn.

Summer school was very limited—half days, with special education graduate students from Central Connecticut State University providing the bulk of the work. Children’s Unit teachers were on a regular school schedule and not necessarily certified in special education. This was the fourth year that Central Connecticut State University provided this service, but the head of the program indicated it could not continue without supervising teachers. Recreation for the summer was equally short staffed. We had hit a hiring freeze and lacked the support of the Service Corps, which had been available the previous five years. Also, Camp Quinebaug was no longer available, because of a new rule that required overtime pay, despite the many staff members willing to give of their time and skills and work more than the mandated eight hours.

Upon the election of Governor Meskill, everything was put on hold—as is often the case with a new administration—particularly our ability to fill staff vacancies or to hire new employees. The timing couldn’t have been worse for the Children’s Unit, as we could not move forward or continue pursing plans to move to our new facility without the necessary staff. Construction was completed and the Silvermine Complex was officially turned over to the hospital. However, staff shortages, as well as delays in the shipment of furnishings and equipment, postponed the move even further.

We requested for the new facility fourteen psychiatric aides, one psychologist, and one psychiatrist. There was, at this time, no such title as “child psychiatrist,” and child psychology was not considered a specialty. Also, since CVH’S personnel office was not familiar with hiring people to work with children, there was large turnover of staff. Most had come from adult services. We therefore requested that we handle our own prescreening of applicants and set up our own personnel office. The prescreening was reluctantly agreed to and was cause for a lot of friction over the years between the Children’s Unit and CVH’s personnel office. Also, while the idea of setting up our own personnel office was rejected, CVH assigned one personnel officer to handle our matters, and this greatly improved our relationships with the office. Mehaden Arafeh’s quarterly report optimistically concludes: “[T]he new program structure could not open without the addition of some seventeen direct patient care positions (supportive staff positions are also deemed necessary). The Department of Mental Health was able to obtain a commitment on the addition of some $150,000 to the total hospital budget for this purpose. This is a notable exception to budgetary reductions in other areas, which will have the happy effect of making it possible to use the new structures without delay.”⁷

The money did not come.

In the midst of all our frustrations, Governor Meskill, in trying to downsize state government, apparently decided that two heads were not better than one. He declared that one of the co-directors be dismissed. Fortunately, the commissioner fought hard to keep both Peter and me, but he had to compromise by making one of us director and the other assistant director. We were told that we had to “work it out.”

After many hours of meetings at our homes, looking at our respective duties, trying to find some logical solution, we finally had to agree that the decision must be made by the commissioner. Several days later, Deputy Commissioner Charles Launi met with us to inform me that I had been selected as director. This was a very difficult time. Peter and I had worked hard to develop a trusting, rewarding relationship and cooperative working arrangement. We had taken what we knew was going to be a tough job and made the commitment that no matter what we would stick with it for at least five years. This split changed everything, and we agreed that should Peter be offered a directorship at another facility he would be free to accept it. In fact, it was not long afterward that such an offer was made and accepted and our unique working relationship ended.

The sense of frustration during this period comes across in the July–September quarterly report:

This quarter was one of the most difficult and frustrating periods of our experience. We had no idea of what was happening in the Department of Mental Health or the direction of the commissioner…. A great deal of our time was devoted to the many problems of our staff concerning their repeated frustrations in trying to run an effective program with the limitations of staff vacancies, facilities, etc. Although we were repeatedly told that the new positions would be available for the relocation of the unit, that vacancies would be filled, and that the $150,000 would be forthcoming—there was no clarification on any of these issues. During this period we were asked to work on a new budget for the ’71–’73 biennium, when we had no idea of our current budget or operating expenditures. We were asked to reorganize our unit (the new Table of Organization), to change the role and function of the co-directors, to develop our Philosophy of Treatment and Education, and the role of the program coordinators. Requests for new positions and the filling of old positions were repeatedly lost through the bureaucratic process.

We were repeatedly asked to submit new priorities for staff vacancies after each new deadline was passed.⁸

Early Sunday morning, 2 May 1971, I received a call from Commissioner Ernest Shepard, who had replaced Wilfred Bloomberg at the Department of Mental Health. He asked if I had read the front page of the Hartford Courant, which basically quoted a letter signed by many of the Children’s Unit staff deploring the governor’s action in holding up the funds to open the new facility. I had not read it but he said he would like to meet me at the hospital at 10 a.m. He was obviously very upset and angry. It took a lot to convince him that I had no idea (and I didn’t) who had called the paper with the story. That afternoon the governor was on television announcing that he fully intended to fund the necessary positions so that the children could move to their new facility. He told the reporter that he had ordered that the $150,000 be released for such purpose.

In July 1971, my “Six Year Progress Report of the Children’s Program,” as a follow-up to the 1965 Task Force on Mental Health Services for Children, expressed my philosophy of treatment, including “giving more responsibility to group living, those with the most direct patient contact.” I added, “To accomplish this we are considering the concept of program coordinators within each cottage.” This would mean opening the position to childcare workers (psychiatric aides) instead of restricting the positions to RNs. Additionally, in order to curb overcrowding and decrease the age range of kids living together, we limited the age of admission to fourteen for boys and sixteen for girls. It was also at this time that I reiterated my suggestion that the department’s future goals be to create several mental health centers, one in each third of the state, with the Children’s Unit serving the middle third, and to provide a full range of mental health services, both inpatient and outpatient.

In October 1971 we were able to hire our own child psychiatrist, Charles Rich, just after his discharge from the air force. It had taken us more than a year to convince the state personnel office that a child psychiatrist was needed and in fact, as mentioned earlier, there was no such job description. Rich describes what it was like for him at that time:

I was the only psychiatrist for over fifty kids and there was little control over admissions. Some parents would just drive up late at night with their child and would just leave them at our doorstep, just saying they couldn’t take it another second and had lost complete control of their child. Because of this large demand and lack of space, a lot of kids ended up having to stay on the adult ward. Arafeh called this “the red zone on the thermometer,” so at least that started to serve as a buffer to the amount of admissions.

I was trying to receive new kids, deal with meds and acute management. I had to keep up with all the problems kids presented and I could not do it all. It was totally overwhelming. When I returned [seventeen years later] I really felt Riverview had evolved a lot.⁹