By John S. Lyons Praeger, 2004 Review by Gerda Wever-Rabehl, Ph.D. on Mar 7th 2006
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.
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 historyof children's public
mental health services.
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
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
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.