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Journal

of Public
Health

Interpersonal relations institutes have been used for about a decade


to help public health workers to understand themselves and their
relations to others. It is postulated that these efforts will hell)
them be more effective in their work. Are they? Here is
one attempt to arrive at an answer.

THE INTERPERSONAL RELATIONS INSTITUTE IN


MENTAL HEALTH EDUCATION-METHOD
AND EVALUATION
Hyman M. Forstenzer, M.S. in Ed., F.A.P.H.A.; Dorine Loso, R.N.; and
Joseph J. Downing, M.D.

SINCE 1950, the Departments of Health Despite their popularity, it is unlikely


and Mental Hygiene in New York that the institutes would have been con-
State have jointly conducted eleven in- tinued if the premises on which they are
terpersonal relations institutes for public based were not so strongly held and
health personnel. In time spent by par- widely accepted. Briefly stated these
ticipants, faculty members and staff, and are:
in actual dollar outlay, these institutes While treatment of mental illness is the
have been costly. Nevertheless appro- responsibility of psychiatry and related clini-
priations have been made annually with- cal disciplines, the prevention of mental ill-
out objection from state fiscal authorities ness and promotion of mental health are
and there has been no lessening of in- responsibilities shared by all the helping
professions.'
terest or drop in demand. The institutes In primary prevention, some notable suc-
have been highly satisfying to sponsors, cesses have been achieved with several mental
staff, participants, and faculty. Like illnesses with organic causes which are pre-
many other mental health program ac- ventable. Although no such clear results have
been achieved in the area of psychologicaI
tivities, popularity has been sufficient to causation, there does exist a set of hypotheses
offset lack of definitive evaluation and for mental health which can be applied by the
to justify continuance. service professions in efforts to prevent mental

JULY, 1958 837


illness and which can also be helpful to them public health units. In addition to the
in their interpersonal relations.2 health officer, a local health unit can
Public health organizations are in a key
position in relation to both the physical and send a supervising nurse, sanitarian,
the psychological environment to help in the health educator, nutritionist, or other
prevention of mental disorders and the promo- staff member with administrative and/or
tion of mental health.3 supervisory responsibilities. Team rep-
Public health workers need an understand- resentation is favored because we believe
ing of their clients, of themselves and of the
significance of their activities for individual that the effect on an organization of a
people. They need such understanding and learning experience shared by two or
human relations skills for all preventive work, more of its members is greater and more
whether it be directed toward mental or physi- lasting than when the experience is
cal illness, since many public health programs
fail or succeed because of the way in which carried back by one individual. We try
people participate in or resist them.4 to limit the number of participants to
twenty-five. In practice, sufficient in-
Starting with the 1948 Berkeley In- vitations are sent out to obtain a be-
stitute as a model, New York State ginning list of acceptances numbering
gradually developed an institute pattern slightly more than thirty. There ensues
markedly different in procedures and a period of vacillation and fluctuation
technics. The specific objective remains with withdrawals, re-acceptances, last-
the same-namely, to provide state and minute illnesses and the emergence of
local public health personnel with an other obligations. Meanwhile, institute
opportunity to explore with a group of staff struggle to achieve a balance among
psychiatrists the mental health implica- the different professions and to maintain
tions of public health programs and the the principle of team representation.
significance for these programs of inter- The institute starts with an orienta-
personal relationships within health de- tion session on Sunday evening and
partment staffs and between staff and closes on Friday afternoon with an
individuals receiving health services. A evaluation discussion. This schedule
study of the Berkeley Institute report5 allows five full days, with a minimum
and discussion with several psychiatrists of encroachment on off-duty time and
who served as faculty at that institute the most commonly accepted maximum
led to some initial changes in length of time off from one's job for inservice
time and composition of the participat- training. Because proximity to office
ing public health group. Other changes and home militates against continuity of
were made as experience accumulated attendance and full participation in un-
with this type of institute. This paper de- scheduled evening discussions, we try
scribes the pattern which emerged after to locate the institutes in small and rela-
four institutes, and which has now been tively isolated communities. These, how-
used seven times with public health per- ever, must have health services of suffi-
sonnel and once with public welfare cient size to provide the fairly large
workers. number of health clients needed for the
Participation in the institute is on a interviews which make up a large part
voluntary basis with invitations issued of the program. Housing for partici-
by the State Health Department through pants, staff and faculty is arranged in a
its director of professional training. The hotel or inn small enough to permit, or
invitation indicates clearly that the pro- more correctly to make inevitable,
gram has the full support and interest contact and informal communication
of the state commissioner of health. It throughout the week and to minimize
also indicates that the sponsors prefer the risk of dispersal of conference per-
team to individual representation from sonnel among other guests of the hotel.

838 VOL. 48. NO. 7. A.J.P.H.


MENTAL HEALTH EDUCATION

Interview sessions are held in a health ally into a full conference group dis-
facility, rather than in the hotel, so that cussion.
the setting is a familiar and secure one To provide a focus for both the inter-
for the interviewees. views and discussions, a topic is assigned
Faculty and staff consist of one psy- for each day. In order, these are:
chiatrist for each five participants, the Parent-Child Relationships; Emotional
director of professional education for Components of Acute Illness; Emotional
the Health Department, the director of Components of Chronic Illness; Emo-
mental health education for the Depart- tional Factors in Aging; and Emo-
ment of Mental Hygiene, and a mental tional Factors in the Use of Authority.
health nurse consultant on the latter's There is only one scheduled evening
staff, who is assigned to the Health De- meeting and this is held on Tuesday
partment. Each psychiatrist conducts night. It is devoted to a talk and dis-
one demonstration interview, gives one cussion on Mental Health in Public
informal talk on an assigned topic, and Health.
serves as group leader each afternoon Each day except the last opens with
for five of the participants. Among a demonstration interview conducted by
other responsibilities, the nurse consult- one of the psychiatrists. The interviewee
ant works with health personnel serving has been selected on the basis of the
the locality in which the institute is held topic assigned for that day. For ex-
to select from their regular clientele per- ample, on the first day when the topic
sons who are willing to serve as inter- is Parent-Child Relationships the inter-
viewees. She also has responsibility for viewee is a user of the child health serv-
final selections. The process of selection ices in the area. The interview lasts
is worth a separate paper: One can only about 45 minutes and is followed by a
say here that a prime consideration is one-hour general discussion. After a
the screening out of persons with known coffee break, another psychiatrist talks
or suspected mental disorders. At one informally on the day's topic for 30
of the early institutes it was necessary minutes, tying his points as much as pos-
to leave a psychiatrist in the area for sible to the content of the earlier in-
an extra week. Selection of interviewees terview. The next hour is used for
had been left to the local health person- discussion of both the talk and the in-
nel. There were no psychiatric facilities terview. The afternoons are spent in
in their area and they used the institute small groups consisting of one psychia-
to get psychiatric help for some of their trist and five participants. Each partici-
citizens. pant has an opportunity during the week
The mental health educator serves as to conduct one interview with the inter-
discussion leader whenever the entire viewees selected and scheduled in the
group meets together. On two occasions, same manner as in the morning demon-
an additional psychiatrist replaced the stration interviews. Discussion, led by
educator as discussion leader. At one the group's psychiatrist, follows each
institute, too, a clinical psychologist interview. Much of what happens in
served on the faculty in place of a psy- the small group gets carried into the
chiatrist. All faculty and staff members general discussion' on the following
are expected to participate in the general morning.
discussions and to be available evenings The demonstration interviews in the
throughout the week for informal ses- morning are viewed through a one-way
sions with one or several participants. vision mirror. Each participant listens
It has not been uncommon for a one-to- through a set of headphones. The in-
one postdinner interview to grow gradu- terviewee is told at time of selection and

JULY, 1958 839


again just before the interview that terview and as they gain confidence in
thirty public health people will be listen- the integrity of the entire group and
ing in and that this is part of their conviction that none would improperly
training. The microphone is on the use information disclosed in the inter-
table between the two chairs and is un- view.
concealed and unadorned. To date, the The critical point in the shift in iden-
interviewees have not been told about tification has occurred so regularly on
the mirror, and not one has commented Wednesday night that it has become an
about it, despite its obtrusiveness and institute phenomenon and weathervane.
inappropriateness in the room setting. In at least 7 of the 11 institutes, the par-
This lack of disclosure-concerning the ticipants almost to a man, singly and in
mirror-has troubled many participants groups, deserted the faculty and the hotel
and faculty members. The issue is dis- on Wednesday night, even foregoing
cussed with the faculty before each in- their prepaid dinner. Thursday's break-
stitute and invariably a majority favor fasts find participants stoutly maintain-
nondisclosure. ing that their particular group's psychia-
Mirrors are not used in the afternoon trist is the outstanding member of the
interviews conducted by the participants. faculty. There is staff consensus that
The furniture is arranged so that the when this phenomenon occurs the in-
participant-interviewer and the inter- stitute is a success.
viewee are separated somewhat from the The growing identification with the
others in the group. These interviews psychiatrist appears to be an essential
start out on a one-to-one basis, and may ingredient of the learning process, as
become a group interview at the option does the anxiety regarding the listen-
of the interviewer. The psychiatrist is ing-in. The latter brings into the open
free to intervene whenever he believes the participants' reluctance to ask people
it necessary for the protection of the about their life situations. This reluc-
interviewee. tance, in turn, seems to be associated
In the demonstration interviews, the with general resistance to self-exami-
interviewee's ability and willingness to nation and self-appraisal, a resistance
forget or ignore the microphone as a which accounts in part for the initial
symbol of the listening audience and tension so evident at the opening of
the speed and frequency with which each institute.
emotionally charged material is brought One hypothesis has been developed
out invariably amazes the participants. and requires further exploration in re-
Suspicion and disbelief are regularly ex- gard to the relationship between the
pressed in the discussion periods. The anxiety and resistance present when the
anxiety they show over the listening-in institutes open and the learning which
is frequently equalled or exceeded by occurs. Teaching becomes less effective
that of the faculty. The discussions of in a group situation as tension and
the first two days consistently reveal anxiety diminish among the members of
initial identification by the participants the groups. A dynamic state conducive
with the interviewees. By the third day, to learning exists while tension is pres-
there appears fluctuation between this ent; a static adjustment which makes
identification and a developing identifi- for slow or no learning occurs where the
cation with the psychiatrists. The dis- participating group is completely re-
cussions also show that the participants' laxed. At one institute a brief but sharp
anxiety over the interviews is reduced clash on the first day between two faculty
as they come to recognize and believe members put the participants completely
that the interviewee is helped by the in- at ease. This institute was considered

840 VOL. 48. NO. 7. A.J.P.H.


MENTAL HEALTH EDUCATION

by staff to be one of the poorest, although low. A county health commissioner,


it is true that other possible reasons for more than a year after his participation
failure were noted. If the tension de- in one of the institutes, asked for and
creases too rapidly, the stimulus of the obtained an institute for his supervisory
institute setting is destroyed, the par- personnel. A district health officer,
ticipants' prepared defenses come out, three years after one of the institutes,
are reinforced by the defenses of others, commented that his original negative
and group and individual attitudes re- impressions had been replaced by a con-
main unchanged. If they are never re- viction that he had profited enormously
laxed, there is no chance for spontaneous from the experience.
informal relationships to develop, the Trying to understand more clearly
participants identify only with the pub- and objectively the changes in attitudes,
lic health clients who were interviewed, working relationships and technics re-
and they leave with many of their un- sulting from the institutes, the Mental
certainties and hesitancies about engag- Health Research Unit of the Department
ing in psychologically oriented public of Mental Hygiene undertook to evaluate
health work reinforced. But if the ten- the institutes through objective psycho-
sion falls steadily over the week, reach- logical tests. For the convenience of
ing its lowest point on the very last day, the researchers, an institute in Syracuse,
then each session is a rich learning ex- N. Y., was selected to be evaluated first.
perience. The total institute then results It turned out to be somewhat atypical.
in invigoration, an increase in self- Department of Public Welfare personnel
respect and enhanced respect for all the participated rather than public health
other people at the institute, less need workers. Furthermore, welfare depart-
for defenses, and a sensation of having ment casework supervisors from only
worked intensively for long hours with one county (Onondaga) participated in
great accomplishment and practically no an institute given in their home city
fatigue. (Syracuse). Previous experience sug-
With so much time, money, and gested certain disadvantages in such
energy invested in this specialized type "hometown" institutes: pre-existing close
of mental health education, one is curi- personal and working relationships; the
ous about the results. The participants necessity for returning each evening to
seem convinced that they had enjoyed a routine home living; limiting the in-
unique interpersonal experience. Is this stitute to a working hours schedule; and
conviction reflected in their subsequent the use of local clients known to the
work relationships? Can the change, if caseworkers. All were thought to at-
any, be evaluated? tenuate or retard the optimal develop-
Reported anecdotal evaluation from ment of the characteristic interpersonal
institute participants is favorable. They relationship. This opinion was con-
tell us that their approach to fellow firmed by the observations of psychia-
workers and to clients is easier, more trists in this institute who had previously
pleasant, and more rewarding. Follow- participated in others.
up interviews by the mental health nurse During the evaluation planning, a
consultant confirmed these favorable review of previous attempts at the psy-
statements. Several have written to the chological evaluation of mental health
State Health Department's director of education programs was of little help.
professional training asking for an op- Therefore, a test battery was devised
portunity to participate in another in- to measure changes in the following
stitute and expressing confidence that areas:
even greater personal gains would fol- 1. Attitudes toward clients

JULY, 1958 841


2. Sensitivity to clients' problems viduals in a group, expressing and ex-
3. Over-all perspective on interpersonal hibiting their own ideas and feelings.
dynamics No other statistically significant changes
4. Personality dynamics of the participants
themselves. in personality were shown.
In the areas of sensitivity and atti-
The test battery was given the week tudes toward clients' problems, the ob-
before the institute, the week following, served changes were consistent with
and six months after the institute. A those found in personality dynamics.
comparison group, consisting of all case- The institute appeared to have the im-
workers who did not participate in the mediate effect of dulling the clinical dis-
institute, was tested at the same time as criminatory senses of the participants
the experimental group who attended the to the extent that they become tempo-
institute. Since institute attendance was rarily less acute in picking out meaning-
voluntary, the two groups cannot be con- ful material from case histories. After
sidered random samples, and group six months a second change returned
changes as measured by the psychologi- them to their pre-institute acuity.
cal tests were not necessarily due to the The over-all perspective on interper-
institute. However, at the time of initial sonal dynamics did not change. This
testing no statistically significant differ- area was tested in terms of knowledge
ences were found between the two about and conscious understanding of
groups. personality factors. This finding was
The individual tests will not be dis- expected, as the institute was directed
cussed here, as they will be reported toward changing attitudes rather than
elsewhere. In summary, it was found providing information.
that no lasting changes occurred in the The participants were asked to give
comparison group. The experimental their opinions of the institute. A num-
group showed certain statistically signifi- ber expressed disappointment that so
cant changes between successive test ad- little direct teaching or information was
ministrations. Interesting changes in provided. On the whole, the written
personality dynamics were found. How- evaluations of about one-half of the par-
ever, the immediate post-institute testing ticipants expressed specific gains, and
showed certain temporary changes in the remainder rather diffuse, platitudi-
the experimental group. At this time, nous appreciation. Criticism was di-
the group was significantly less able to rected mostly toward the general plan-
perceive interpersonal relationship, as ning and structure of the institute,
measured by a sample caseworker. Also particularly the interviews.
the group was temporarily or easily In summary, this institute seems to
swayed by authoritative statements. have jarred the participants out of their
These changes had vanished at the six- accustomed ways of thinking and feel-
month retest. ing, producing some intellectual confu-
A permanent greater self-assertiveness, sion and uncertainty immediately follow-
expressed through outgoing, self-confi- ing the experience. At the same time,
dent behavior was found in members they became more sure of themselves,
of the experimental group. They seemed readier to assert their individual opin-
to feel freer to express their underlying ion rather than hide in group anonymity.
feelings in a manner which could be The six months follow-up showed that
characterized as self-assertive and show- the intellectual confusion and uncer-
ing independent ability to judge and tainty had subsided, while their greater
criticize. Less fear was found when self-confidence remained. Our assump-
they put themselves forward as indi- tion that these changes were in a favor-

842 VOL. 48. NO. 7. A.J.P.H.


MENTAL HEALTH EDUCATION

able direction seems supported by the contributed significantly to them and to the
participants' administrative superiors. evaluation.
They reported a general change toward REFERENCES
increased self-confidence and capacity 1. Brockington, Fraser. "The Development of a Pre-
to accept responsibility. ventive Approach to Mental Disorder," in Mental
Health and the World Community, London, England:
These general findings should be World Federation for Mental Health, 1957.
further investigated in subsequent in- 2. Lemkau, Paul V. "The Prevention of Physical
Damage to the Brain," and Hargreaves, G. R. "The
stitutes for public health personnel. It Protection of the Personality against Lack of Neces-
is our plan to do this as a second stage sary Relationships and the Presence of Damaging
Relationships," in Elements of a Community Mental
of this investigation. Health Program. New York, N. Y.: Milbank Memo-
rial Fund, 1956, pp. 101-148.
ACKNOWLEDGMENT-We wish to express our 3. Norton, J. W. R.; Applewhite, C. C.; and Howell,
deep appreciation to Esther M. Flemming, Roger W. Efforts to Define and Help the Health
R.N., mental health nurse consultant, New Officer to Fulfill His Role in Mental Health Programs.
A.J.P.H. 47 :813-818 (July), 1957.
York State Department of Mental Hygiene, Gruenberg, Ernest M. Application of Control Methods
assigned to the State Health Department, and to Mental Illness. Ibid. 47:944-952 (Aug.), 1957.
Dr. Franklyn B. Amos, director of professional 4. New York State Mental Health Commission (Albany).
training, New York State Health Department. Second Annual Report, 1951.
Both have served on the staff of all eleven in- 5. Ginsburg, Ethel L. Public Health Is People. Cam-
stitutes for public health personnel and have bridge, Mass.: Harvard University Press, 1950.

Mr. Forstenzer is director, Community Mental Health Services, New


York State Department of Mental Hygiene, Albany, N. Y.; Miss Loso is mental
health nurse consultant, Public Health Service, Denver, Colo.; and Dr. Downing
is acting director, Mental Health Research Unit, New York State Department
of Mental Hygiene, Syracuse, N. Y.
This paper was presented before the Mental Health Section of the American
Public Health Association at the Eighty-Fifth Annual Meeting in Cleveland,
Ohio, November 12, 1957.

Minneapolis Events Highlight WHO


A number of events in Minneapolis contributed to and exploited the 11th World
Health Assembly meeting there. Most extensive-of these was a series of two seminars
daily, or study courses, on the WHO, in which members of WHO's technical staff
took part. Those invited were physicians, medical students, social workers, public
health officials, and others, chiefly from the Minneapolis area.
Two days before the Assembly's opening Minneapolis dedicated its new, modern,
six-story health center. Surgeon-General Leroy E. Burney gave the dedication address
and Howard A. Rusk, M.D., spoke at the dedication banquet. A series of open houses
was held for professional, civic, and community groups. St. Paul had also recently
opened its new health center, one of four in the state.
The 105th annual meeting of the Minnesota State Medical Association, held in
the city just previous to the Assembly, devoted a special session to WHO's objectives,
activities, and accomplishments. Congressman Walter H. Judd, M.D., presided and
speakers were WHO Director General M. G. Candau, M.D., Surgeon-General Leroy
E. Burney, and Charles W. Mayo, M.D., of the Mayo Clinic.
Brock Chisholm, M.D., first WHO Director General, addressed the convention
banquet of the United World Federalists meeting in Minneapolis May 22-25.

JULY. 1958 843