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Selected Readarounds in Child and Youth Care

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The Medical Model is Alive and Well and Killing Child and Youth Care

Gerry Fewster

A soft summer's evening. Through careless obligation, I’m at a dinner party organized to raise funds for a new mental health service. Through cruel destiny, I’m seated at a table with a group of medical types — two GPs, a surgeon, a shrink and a researcher specializing in some version of neurology. I’m unusually quiet, sipping contentedly on a cheeky little local chardonnay as they discuss the most recent stock market trends. Just as I stick my finger in my vichyssoise, the conversation shifts to the new wonder drugs that can massacre the symptoms of everything from Swine Flu to Schizophrenia (a good investment for those with a few bucks to spare).

Again, I reserve the right to remain silent, waiting patiently (no pun intended) for the host to deliver her specialty — baked salmon with couscous. Deflecting the barrage of technicalities and brand names, I discover that their major concern is that these drugs are not sufficiently available to help the growing numbers of patients they are now diagnosing with the most popular disorders. The price of my silence is rising but, to preserve the integrity of the salmon, I assure myself that I’m conducting my own research of the ethos of the medical community. Inevitably, the conversation switches to the treatment of their two favourite childhood diagnoses, Clinical Depression and Attention Deficit Hyperactivity Disorder.

I struggle to avoid contaminating my study with profound, even hostile, observer bias but I breathe and let them go on. Nobody expresses any curiosity about what might be happening for the child beyond the offensive symptoms. Nobody refers to research suggesting that these substances appear to work by numbing out higher cognitive functioning. Nobody expresses any concern about reports that in some North American schools, over fifty percent of the students are on some form of psychotropic medication. Nobody suggests that it might be the task of schools to respond to the needs of kids rather than the other way around. Nobody mentions the growing concerns about kids and families being coerced into using these substances through threats ranging from the removal from school to certification under mental health legislation. Nobody raises any questions about why so many of these kids will end up dependent on other drugs — legal and illegal. And, of course, nobody admits that they have no idea about what this stuff actually does to the brain, either in the short run or in the long run.

Yet, here they are, arrogantly congratulating each other and committing themselves to up the societal dosage wherever and whenever possible. My mind runs back to a case conference in 1972 when I had to be restrained from attempting to disembowel our “team” psychiatrist with a letter opener after he admitted giving eight series of ECT to a sad eleven year old girl — “to treat her depression.” Now, older a wiser, on a soft summer’s evening, I maintain my strategy of self-restraint, knowing that I’m about to destroy whatever pleasure they may be anticipating for the upcoming creme brulee.

Within our own profession

My purpose in telling this story is not to launch yet another attack on medical practices. Let’s face it, prescribing medication is what physicians and psychiatrists do — amen. Nor am I about to vilify the pharmaceutical companies or their well-remunerated researchers. They are in the business of selling their products and maximizing their profits, just like all other commercial enterprises. I’m not even going to pass judgment on those who support such practices with some version of “doctor knows best” even when the sinister and destructive consequences are staring them in the face. For the purposes of this editorial, my concern is with Child and Youth Care, as a profession, since it’s obvious to me that, along with other so-called “helping” disciplines, we are saturated in the type of thinking and methods that have become known as “the medical model.”

For the most part, Child and Youth Care Workers are concerned with the elimination (treatment) of particular problems (symptoms) presented by particular kids (patients). Most are educated and trained to see how such symptoms come together (syndromes) within the context of particular lives, families, groups and communities (etiology) while some are involved in addressing the incidence and prevalence of specific problems within a community (epidemiology). Whether they focus on normative (normal), deviant (abnormal) or persistent (pathological) problems, their concepts and theories are about fixing (curing) the identified malady (disease), often regarding the client’s (patient’s) own experience as being too subjective to be of value. However much they might express a distaste for “labeling,” there is constant pressure to produce assessment (diagnosis) methods for grouping kids according to their symptom clusters linked to particular (treatment) approaches (prescriptions).

Some work in community (out-patient) programs, while others work with the more serious “cases” in residential settings (hospitals). Like their medical counterparts many come to regard the “helping relationship” as a convenient oil can for lubricating their preferred methodologies. Whether they regard themselves as “generalists” or “specialists,” most want to be considered as professionals, experts, defined by themselves and others for what they do rather than for who they are. And, finally, they want their status and their practices to be protected from usurpers and impostors through academic qualifications and self-serving associations — professionals all.

Okay, so I might be going too far with all this, but look around. Tune into the international forum on the Internet (an excellent vehicle for sharing CYC ideas and experiences) and consider the questions being asked and the responses being given. Examine the curricula of Child and Youth Care educational or training institutions and look at the theories being taught and the methods being practiced. Attend any workshop or conference and examine the content – particularly of the most popular offerings and presentations. Purchase a complete set of the Journal of Child and Youth Care (please) and review the articles – start by scanning this issue. Go to any agency and ask them to describe their philosophy, their goals and their programs. And behind it all, you will find one pervasive ideology – if we use our specialized knowledge and skills, we can solve people’s problems, fix their lives and made them happy; all we need is your support, your respect and, of course, your money.

Unattainable goals

If you still consider my position to be overstated I would welcome your comments. Meanwhile, I continue to believe that the so-called medical model is an insidious trap that will always generate nothing but frustration and futility for Child and Youth Care workers and arrest the development of the profession as a whole. The underlying problem is that the goals are simply unattainable. No matter how knowledgeable and competent we become, we can’t cure kids or fix other people’s lives. Nor can medical practitioners, by the way, but at least they have the backing of the pharmaceutical industry to help create and maintain the illusion. Whatever illusions of “success” we might create, however, we will always be hiding behind a pretense – making the usual excuses (not enough money, resources, support, etc.) while running away from the realities of our own failures. If you question this, take a look at the history of psychotherapy – a branch of professional “helping” that was once embraced by the medical fraternity but subsequently dumped in favour of drug therapy. This left “clinical” psychologists, “clinical” social workers and a bunch of also-rans holding the abandoned baby with Child and Youth Care workers standing by to play the role of nursemaid. Sorry folks, but there's nowhere to go from here unless, of course, you enjoy spending your summer evenings at garden parties listening to those who still manage to make the model work – with a little bit of help from their friends.

So, what's to be done? Can we really break away from the grips of the monster that spawned so many of us? Of course we can. Are there alternative ways of working with kids and families? You bet there are. But, for me, this means delving into the soul of our profession, into the stuff of our own lives and the lives of those we call “clients.” It means throwing away the illusions of power, dropping the pretenses and approaching each life as a unique and fascinating part of the human experience. But this is not the place for such speculation.

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