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

JULY, 1958 837

illness and which can also be helpful to them
in their interpersonal relations.2
Public health organizations are in a key
position in relation to both the physical and
the psychological environment to help in the
prevention of mental disorders and the promo-
tion of mental health.3
Public health workers need an understand-
ing of their clients, of themselves and of the
significance of their activities for individual
people. They need such understanding and
human relations skills for all preventive work,
whether it be directed toward mental or physi-
cal illness, since many public health programs
fail or succeed because of the way in which
people participate in or resist them.4
Starting with the 1948 Berkeley In-
stitute as a model, New York State
gradually developed an institute pattern
markedly different in procedures and
technics. The specific objective remains
the same-namely, to provide state and
local public health personnel with an
opportunity to explore with a group of
psychiatrists the mental health implica-
tions of public health programs and the
significance for these programs of inter-
personal relationships within health de-
partment staffs and between staff and
individuals receiving health services. A
study of the Berkeley Institute report5
and discussion with several psychiatrists
who served as faculty at that institute
led to some initial changes in length of
time and composition of the participat-
ing public health group. Other changes
were made as experience accumulated
with this type of institute. This paper de-
scribes the pattern which emerged after
four institutes, and which has now been
used seven times with public health per-
sonnel and once with public welfare
workers.
Participation in the institute is on a
voluntary basis with invitations issued
by the State Health Department through
its director of professional training. The
invitation indicates clearly that the pro-
gram has the full support and interest
of the state commissioner of health. It
also indicates that the sponsors prefer
team to individual representation from
838
public health units. In addition to the
health officer, a local health unit can
send a supervising nurse, sanitarian,
health educator, nutritionist, or other
staff member with administrative and/or
supervisory responsibilities. Team rep-
resentation is favored because we believe
that the effect on an organization of a
learning experience shared by two or
more of its members is greater and more
lasting than when the experience is
carried back by one individual. We try
to limit the number of participants to
twenty-five. In practice, sufficient in-
vitations are sent out to obtain a be-
ginning list of acceptances numbering
slightly more than thirty. There ensues
a period of vacillation and fluctuation
with withdrawals, re-acceptances, last-
minute illnesses and the emergence of
other obligations. Meanwhile, institute
staff struggle to achieve a balance among
the different professions and to maintain
the principle of team representation.
The institute starts with an orienta-
tion session on Sunday evening and
closes on Friday afternoon with an
evaluation discussion. This schedule
allows five full days, with a minimum
of encroachment on off-duty time and
the most commonly accepted maximum
time off from one's job for inservice
training. Because proximity to office
and home militates against continuity of
attendance and full participation in un-
scheduled evening discussions, we try
to locate the institutes in small and rela-
tively isolated communities. These, how-
ever, must have health services of suffi-
cient size to provide the fairly large
number of health clients needed for the
interviews which make up a large part
of the program. Housing for partici-
pants, staff and faculty is arranged in a
hotel or inn small enough to permit, or
more correctly to make inevitable,
contact and informal communication
throughout the week and to minimize
the risk of dispersal of conference per-
sonnel among other guests of the hotel.
VOL. 48. NO. 7. A.J.P.H.

Interview sessions are held in a health
facility, rather than in the hotel, so that
the setting is a familiar and secure one
for the interviewees.
Faculty and staff consist of one psy-
chiatrist for each five participants, the
director of professional education for
the Health Department, the director of
mental health education for the Depart-
ment of Mental Hygiene, and a mental
health nurse consultant on the latter's
staff, who is assigned to the Health De-
partment. Each psychiatrist conducts
one demonstration interview, gives one
informal talk on an assigned topic, and
serves as group leader each afternoon
for five of the participants. Among
other responsibilities, the nurse consult-
ant works with health personnel serving
the locality in which the institute is held
to select from their regular clientele per-
sons who are willing to serve as inter-
viewees. She also has responsibility for
final selections. The process of selection
is worth a separate paper: One can only
say here that a prime consideration is
the screening out of persons with known
or suspected mental disorders. At one
of the early institutes it was necessary
to leave a psychiatrist in the area for
an extra week. Selection of interviewees
had been left to the local health person-
nel. There were no psychiatric facilities
in their area and they used the institute
to get psychiatric help for some of their
citizens.
The mental health educator serves as
discussion leader whenever the entire
group meets together. On two occasions,
an additional psychiatrist replaced the
educator as discussion leader. At one
institute, too, a clinical psychologist
served on the faculty in place of a psy-
chiatrist. All faculty and staff members
are expected to participate in the general
discussions and to be available evenings
throughout the week for informal ses-
sions with one or several participants.
It has not been uncommon for a one-to-
one postdinner interview to grow gradu-
JULY, 1958
MENTAL HEALTH EDUCATION
ally into a full conference group dis-
cussion.
To provide a focus for both the inter-
views and discussions, a topic is assigned
for each day. In order, these are:
Parent-Child Relationships; Emotional
Components of Acute Illness; Emotional
Components of Chronic Illness; Emo-
tional Factors in Aging; and Emo-
tional Factors in the Use of Authority.
There is only one scheduled evening
meeting and this is held on Tuesday
night. It is devoted to a talk and dis-
cussion on Mental Health in Public
Health.
Each day except the last opens with
a demonstration interview conducted by
one of the psychiatrists. The interviewee
has been selected on the basis of the
topic assigned for that day. For ex-
ample, on the first day when the topic
is Parent-Child Relationships the inter-
viewee is a user of the child health serv-
ices in the area. The interview lasts
about 45 minutes and is followed by a
one-hour general discussion. After a
coffee break, another psychiatrist talks
informally on the day's topic for 30
minutes, tying his points as much as pos-
sible to the content of the earlier in-
terview. The next hour is used for
discussion of both the talk and the in-
terview. The afternoons are spent in
small groups consisting of one psychia-
trist and five participants. Each partici-
pant has an opportunity during the week
to conduct one interview with the inter-
viewees selected and scheduled in the
same manner as in the morning demon-
stration interviews. Discussion, led by
the group's psychiatrist, follows each
interview. Much of what happens in
the small group gets carried into the
general discussion' on the following
morning.
The demonstration interviews in the
morning are viewed through a one-way
vision mirror. Each participant listens
through a set of headphones. The in-
terviewee is told at time of selection and
839
again just before the interview that
thirty public health people will be listen-
ing in and that this is part of their
training. The microphone is on the
table between the two chairs and is un-
concealed and unadorned. To date, the
interviewees have not been told about
the mirror, and not one has commented
about it, despite its obtrusiveness and
inappropriateness in the room setting.
This lack of disclosure-concerning the
mirror-has troubled many participants
and faculty members. The issue is dis-
cussed with the faculty before each in-
stitute and invariably a majority favor
nondisclosure.
Mirrors are not used in the afternoon
interviews conducted by the participants.
The furniture is arranged so that the
participant-interviewer and the inter-
viewee are separated somewhat from the
others in the group. These interviews
start out on a one-to-one basis, and may
become a group interview at the option
of the interviewer. The psychiatrist is
free to intervene whenever he believes
it necessary for the protection of the
interviewee.
In the demonstration interviews, the
interviewee's ability and willingness to
forget or ignore the microphone as a
symbol of the listening audience and
the speed and frequency with which
emotionally charged material is brought
out invariably amazes the participants.
Suspicion and disbelief are regularly ex-
pressed in the discussion periods. The
anxiety they show over the listening-in
is frequently equalled or exceeded by
that of the faculty. The discussions of
the first two days consistently reveal
initial identification by the participants
with the interviewees. By the third day,
there appears fluctuation between this
identification and a developing identifi-
cation with the psychiatrists. The dis-
cussions also show that the participants'
anxiety over the interviews is reduced
as they come to recognize and believe
that the interviewee is helped by the in-
840
terview and as they gain confidence in
the integrity of the entire group and
conviction that none would improperly
use information disclosed in the inter-
view.
The critical point in the shift in iden-
tification has occurred so regularly on
Wednesday night that it has become an
institute phenomenon and weathervane.
In at least 7 of the 11 institutes, the par-
ticipants almost to a man, singly and in
groups, deserted the faculty and the hotel
on Wednesday night, even foregoing
their prepaid dinner. Thursday's break-
fasts find participants stoutly maintain-
ing that their particular group's psychia-
trist is the outstanding member of the
faculty. There is staff consensus that
when this phenomenon occurs the in-
stitute is a success.
The growing identification with the
psychiatrist appears to be an essential
ingredient of the learning process, as
does the anxiety regarding the listen-
ing-in. The latter brings into the open
the participants' reluctance to ask people
about their life situations. This reluc-
tance, in turn, seems to be associated
with general resistance to self-exami-
nation and self-appraisal, a resistance
which accounts in part for the initial
tension so evident at the opening of
each institute.
One hypothesis has been developed
and requires further exploration in re-
gard to the relationship between the
anxiety and resistance present when the
institutes open and the learning which
occurs. Teaching becomes less effective
in a group situation as tension and
anxiety diminish among the members of
the groups. A dynamic state conducive
to learning exists while tension is pres-
ent; a static adjustment which makes
for slow or no learning occurs where the
participating group is completely re-
laxed. At one institute a brief but sharp
clash on the first day between two faculty
members put the participants completely
at ease. This institute was considered
VOL. 48. NO. 7. A.J.P.H.

by staff to be one of the poorest, although
it is true that other possible reasons for
failure were noted. If the tension de-
creases too rapidly, the stimulus of the
institute setting is destroyed, the par-
ticipants' prepared defenses come out,
are reinforced by the defenses of others,
and group and individual attitudes re-
main unchanged. If they are never re-
laxed, there is no chance for spontaneous
informal relationships to develop, the
participants identify only with the pub-
lic health clients who were interviewed,
and they leave with many of their un-
certainties and hesitancies about engag-
ing in psychologically oriented public
health work reinforced. But if the ten-
sion falls steadily over the week, reach-
ing its lowest point on the very last day,
then each session is a rich learning ex-
perience. The total institute then results
in invigoration, an increase in self-
respect and enhanced respect for all the
other people at the institute, less need
for defenses, and a sensation of having
worked intensively for long hours with
great accomplishment and practically no
fatigue.
With so much time, money, and
energy invested in this specialized type
of mental health education, one is curi-
ous about the results. The participants
seem convinced that they had enjoyed a
unique interpersonal experience. Is this
conviction reflected in their subsequent
work relationships? Can the change, if
any, be evaluated?
Reported anecdotal evaluation from
institute participants is favorable. They
tell us that their approach to fellow
workers and to clients is easier, more
pleasant, and more rewarding. Follow-
up interviews by the mental health nurse
consultant confirmed these favorable
statements. Several have written to the
State Health Department's director of
professional training asking for an op-
portunity to participate in another in-
stitute and expressing confidence that
even greater personal gains would fol-
JULY, 1958
MENTAL HEALTH EDUCATION
low. A county health commissioner,
more than a year after his participation
in one of the institutes, asked for and
obtained an institute for his supervisory
personnel. A district health officer,
three years after one of the institutes,
commented that his original negative
impressions had been replaced by a con-
viction that he had profited enormously
from the experience.
Trying to understand more clearly
and objectively the changes in attitudes,
working relationships and technics re-
sulting from the institutes, the Mental
Health Research Unit of the Department
of Mental Hygiene undertook to evaluate
the institutes through objective psycho-
logical tests. For the convenience of
the researchers, an institute in Syracuse,
N. Y., was selected to be evaluated first.
It turned out to be somewhat atypical.
Department of Public Welfare personnel
participated rather than public health
workers. Furthermore, welfare depart-
ment casework supervisors from only
one county (Onondaga) participated in
an institute given in their home city
(Syracuse). Previous experience sug-
gested certain disadvantages in such
"hometown" institutes: pre-existing close
personal and working relationships; the
necessity for returning each evening to
routine home living; limiting the in-
stitute to a working hours schedule; and
the use of local clients known to the
caseworkers. All were thought to at-
tenuate or retard the optimal develop-
ment of the characteristic interpersonal
relationship. This opinion was con-
firmed by the observations of psychia-
trists in this institute who had previously
participated in others.
During the evaluation planning, a
review of previous attempts at the psy-
chological evaluation of mental health
education programs was of little help.
Therefore, a test battery was devised
to measure changes in the following
areas:
1. Attitudes toward clients
841
 2. Sensitivity to clients' problems
3. Over-all perspective on interpersonal
dynamics
4. Personality dynamics of the participants
themselves.
The test battery was given the week
before the institute, the week following,
and six months after the institute. A
comparison group, consisting of all case-
workers who did not participate in the
institute, was tested at the same time as
the experimental group who attended the
institute. Since institute attendance was
voluntary, the two groups cannot be con-
sidered random samples, and group
changes as measured by the psychologi-
cal tests were not necessarily due to the
institute. However, at the time of initial
testing no statistically significant differ-
ences were found between the two
groups.
The individual tests will not be dis-
cussed here, as they will be reported
elsewhere. In summary, it was found
that no lasting changes occurred in the
comparison group. The experimental
group showed certain statistically signifi-
cant changes between successive test ad-
ministrations. Interesting changes in
personality dynamics were found. How-
ever, the immediate post-institute testing
showed certain temporary changes in
the experimental group. At this time,
the group was significantly less able to
perceive interpersonal relationship, as
measured by a sample caseworker. Also
the group was temporarily or easily
swayed by authoritative statements.
These changes had vanished at the six-
month retest.
A permanent greater self-assertiveness,
expressed through outgoing, self-confi-
dent behavior was found in members
of the experimental group. They seemed
to feel freer to express their underlying
feelings in a manner which could be
characterized as self-assertive and show-
ing independent ability to judge and
criticize. Less fear was found when
they put themselves forward as indi-
842
viduals in a group, expressing and ex-
hibiting their own ideas and feelings.
No other statistically significant changes
in personality were shown.
In the areas of sensitivity and atti-
tudes toward clients' problems, the ob-
served changes were consistent with
those found in personality dynamics.
The institute appeared to have the im-
mediate effect of dulling the clinical dis-
criminatory senses of the participants
to the extent that they become tempo-
rarily less acute in picking out meaning-
ful material from case histories. After
six months a second change returned
them to their pre-institute acuity.
The over-all perspective on interper-
sonal dynamics did not change. This
area was tested in terms of knowledge
about and conscious understanding of
personality factors. This finding was
expected, as the institute was directed
toward changing attitudes rather than
providing information.
The participants were asked to give
their opinions of the institute. A num-
ber expressed disappointment that so
little direct teaching or information was
provided. On the whole, the written
evaluations of about one-half of the par-
ticipants expressed specific gains, and
the remainder rather diffuse, platitudi-
nous appreciation. Criticism was di-
rected mostly toward the general plan-
ning and structure of the institute,
particularly the interviews.
In summary, this institute seems to
have jarred the participants out of their
accustomed ways of thinking and feel-
ing, producing some intellectual confu-
sion and uncertainty immediately follow-
ing the experience. At the same time,
they became more sure of themselves,
readier to assert their individual opin-
ion rather than hide in group anonymity.
The six months follow-up showed that
the intellectual confusion and uncer-
tainty had subsided, while their greater
self-confidence remained. Our assump-
tion that these changes were in a favor-
VOL. 48. NO. 7. A.J.P.H.
 MENTAL HEALTH EDUCATION

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