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Related Topics
Redressing the EmperorReview - Redressing the Emperor
Improving Our Children's Public Mental Health System
by John S. Lyons
Praeger, 2004
Review by Gerda Wever-Rabehl, Ph.D.
Mar 7th 2006 (Volume 10, Issue 10)

John S. Lyons' thoughtful commentary on children's mental health care systems, as well as his contemplations on the ways in which these systems can improve, makes Redressing the Emperor. Improving Our Children's Public Mental Health System a source of information and deliberation for parents, mental health care workers, teachers and other advocates for kids who need mental health care. He steers clear of that what would be all too easy- taking potshots at a spectacularly troubled system. Instead, he delivers a vision. Lyons supports his vision not only with a set of principles but, more importantly, with an abundance of pragmatic and often simple solutions to specific problems and contexts. The realities of children who need mental health care cannot be reduced to an academic or theoretical question, but can only be dealt with in the context of concrete situations. It has to do, as Gabriel Marcel would have it, with the effort to imagine the particular. Lyons' work embodies this imaginative effort, and connects it with a reconsideration of children's public mental health care.  This is the strength of Redressing the Emperor -- Lyons' ability to imagine the particulars of the context of the children, their families and communities, enables him to step across the traditional boundaries of disciplines and to offer a remarkably refreshing, novel, pragmatic and multidisciplinary vision.

Not surprisingly then, many of the topics discussed by Lyons are grounded in a solid understanding of their complexities and backgrounds. Moreover, in discussing the various aspects of children's mental health care, Lyons often departs from community-based contexts. For example, Lyons describes evidence-based practices in their historical as well as community contexts. Based on these contexts, Lyons suggests that evidence-based practices for kids can include many "things that are not traditionally thought of as treatment" (p. 40), for example, funding music lessons. Yet knowing that music lessons or other strength-building interventions work for kids can be -and is- at odds with the ways in which health insurance works.   Beginning in chapter 3, but throughout the text, Lyons offers a number of principles as well as pragmatic ideas and suggestions to foster working with practices such as evidence-based practices in more flexible and therefore more advantageous ways.

Lyons develops these and other principles and implications in chapter 5. In this chapter, titled, The Measurement and Management of Outcomes in a Total Clinical Outcomes Management Approach, Lyons presents a process, or a set of strategies, that allows for the management of service delivery across all levels- from children and families to the structural level of programs to the institutional level of organizations and further. Lyons' transparent and common sense approach shows that community development and a more effective Clinical Outcomes Management has the potential to alleviate many of the tensions identified in chapter 2, Problems with the Current System: Tensions and Syndromes. While presented with a healthy dose of modesty, Lyons' Clinical Outcomes Management Approach is a process that has the potential to do so, and as a consequence, to manage mental health care for kids more effectively.

Similarly perceptive in scope and insight is chapter 7, Creating Solutions across the System of Care in which Lyons offers practical suggestions to enhance family involvement and accountability across the spectrum of care. Lyons does not approach the question of accountability, unlike a number of other prominent texts on children's mental health care, as a general or theoretical issue. Lyons approaches it instead as a very pragmatic and multidisciplinary question and provides a refreshingly practical array of ideas and suggestions, indeed for all of those across the spectrum of care.

I would like to make some critical comments regarding chapter 1, The History of Children's Public Mental Health Services. While the chapter intents to provide the reader with an overview of historical trends in public mental health care for kids, it does not live up to its title. Rather than presenting The history, the chapter presents a brief, and somewhat troubled, overview of the contemporary history of children's public mental health services.

Lyon begins his history of children's mental health care with the Renaissance and the beginning of the industrial revolution, since this is the time when, according to Lyon, efforts are first made to meet the needs of children. Lyon writes that during that time a variety of strategies to address problems of children were introduced, initially "to contain them and eventually to help them" (p. 1).

I would argue that these efforts started much earlier on in history. In fact, I would argue that they are as old as mental illness itself.  Furthermore, I would argue that efforts to "contain" or to "help" are not made in a linear movement toward progress, but that they rather swing back and forth throughout history, like the movement of a pendulum.

Greek, Roman and Spartan societies for example, sought by and large, to "contain" the problem of mentally ill children by infanticide and, in some cases, eugenics. One of the very few ways in which children with a mental disorder could fulfill some kind of public position in these societies was to perform a role as a clown and to provide entertainment for the wealthy (although as always, there are exceptions- the pocket of humanity offered by the Roman emperor Vespasian comes to mind).

The rise of Christianity, accompanied by proclamations against selling, killing and mutilation of children with a mental illness caused not only a decline in these practices but also a change in the way in which mental illness was perceived. This change was no doubt further influenced by the introspective work of the "father of psychoanalysis", Saint Augustine. And the pendulum swung from "containment" towards "help". The Bishop of Myra, for example, ran a residential care and treatment centre in the fourth century. Yet later, influenced by, amongst other things, the inquisition, the pendulum swung back again toward "containment" and many people with a mental illness, including children, died on the stake.

The Reformation offered little relief and for a while, the only hope for children with a mental illness to find a place in society was, once again, to perform as clown for wealthy citizens.

With the age of Romanticism, the pendulum swung toward "helping" again. It was during this time that Jean Jacques Rousseau, Maria Montessori, and Jean Marc Gaspard Itard left their mark on the ways in which mental illness was understood and treated. It is here where Lyon starts off his historical overview. I agree with Lyon that Itard's work has been very important and influential (much of the work done with children with severe developmental delays is still, by and large, based on the same sensory-training approach developed by Itard while working with the Wild Boy of Aveyron). Yet Lyon's observation that Itard's work "represents a critical event in beginning to turn public opinion toward a less stigmatizing view of mental illness" (p. 3) is a far too optimistic observation, misled by a common but false faith in progress.

Dangerously optimistic is Lyons comment that "in the past century we have appeared to make progress in reducing the unfairly negative views" (p. 3). In this past century, and not long after Itard's work, the pendulum did swing back hard toward "containment" when the Eugenics came along. In the late eighteenth and early twentieth century, they aimed once again to protect society from the "defective element" by removing it altogether (compulsory sterilization continued on a broad scale well into the 1950' and 1960s).

Perhaps one reason why Lyons' historical analysis falls short is that the social construction of mental illness almost defies a systematic socio-historical analysis of mental illness. Looking at this social construction, especially in a historical context, does not simply mean, as Lyons maintains, to presume that "mental health challenges reside outside of the individual" (p. 33). Instead, post-modern and critical perspectives, so easily dismissed by Lyons, emphasize that we don't just see: we see as. The way we construct, or see (and consequently treat) mental illness is rooted in the past and this construction goes hand in hand with presumptions about the world, humanity, human potential and equality. Seen that way, the past is a central concern- for individual lives as well as for our social institutions.

Notwithstanding this note of criticism, Redressing the Emperor's multidisciplinary pragmatism makes it a worthy read for all professionals and parents concerned with the mental health of children. Lyons tackles public mental health in its complexity and helps the reader navigate its complex webs of services, practices and systems. Redressing the Emperor is a powerful commentary on the state of affairs of public mental heath care for children and an even more powerful commentary on what can be done to improve it. Regarding the latter, Lyons' Total Clinical Outcome has the potential to see and supported children in need of mental health care effectively, responsibly and with accountability.

 

© 2006 Gerda Wever-Rabehl

 

Gerda Wever-Rabehl holds a Ph.D from Simon Fraser University, and has published extensively in the areas of social science, philosophy and philosophy of education.


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