A SYSTEMS APPROACH TO MANAGEMENT TRAINING FOR MENTAL HEALTH PROFESSIONALS Solomon Hoberman Gabriel Laury, M.D. Sidney Mailick, Ph,D. Harry Miller, PhoD.
As an example of progress, a program is described, undertaken, by the New York School of Psychiatry,, to train and educate psychiatrists and related professional groups in management and administration.
INTRODUCTION Mental Health professionals, in the United States, are becoming more and more concerned about the administration of mental health programs. This realization of the importance of administration arises from administering programs that involve complex interrelationships among federal, state, and local agencies 1 and the recognition that well-designed therapeutic programs may fail to be successfully implemented because the persons directing them do not have sufficient administrative skills and knowledge of modern concepts of manangement. Indeed, the theoretical background in management of some high ranking mental health administrators seems to be limited to Parkinson's law and the Peter principles. Few mental health professionals are adequately prepared by their training to assume efficiently high administrative tasks. Most administrators administer on the basis of common sense, their charisma, or the skills of their subordinates. One reason for this situation is that there is little incentive or motivation to become a better administrator. Promotion in a department of mental health often depends almost entirely on knowledge and skill in a field or discipline such as psychiatry, psychology, psychiatric nursing, or psychiatric social work. There is little evaluation of management knowledge and skills. Furthermore administration generally has lower status in comparison Dr. Mailick is Coordinator of Spedal Programs at N,Y.U, Graduate School of Public Administration. T h e late Dr. Laury was with the New York State Department of Mental Hygiene. Dr. Miller is professor of Education at CUNY, H u n t e r College. Mr. H o b e r m a n is a management consultant and former personnel director for the city of New York. PSYCHIATRIC QUARTERLY, VOL. 49(4) 1977
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to the status of the clinical function. There maybe subtle contempt from colleagues for the professional turned administrator, who is often referred to as "only a bureaucrat, a paper pusher, involved in red tape." Finally, imparting administrative skills is no easy task. Aristotle noted long ago that men do not become good by listening to lectures on moral philosophy. Many of the qualifications of the effective administrator-courage, fortitude, justice, and prudence or practical wisdom----~:annot be developed in the classroom. However, formal training in administration supplemented by practice can help to develop these qualities and where they exist, make them more effective. Administrative training programs may have many objectives. These may range from helping administrators acquire specific skills to helping large organizations develop effective management corps. Some programs attempt to impart understanding of organizational policy to achieve effective uniformity of action within the organizational context. Others attempt to increase understanding of policy and administration through the study of theoretical models.
T H E NEED FOR MANAGEMENT T R A I N I N G FOR T H E PSYCHIATRIST-ADMINISTRATOR As is the case with other administrators, the psychiatrist-administrator is helped by a good knowledge of administrative theory and practice, an appreciation of the importance of the managerial component and administration, to assume more and more administrative duties. The engineer, lawyer, or physician, who works within a large bureaucratic system frequently advances in these systems to the point at which his activities relate less to his professional specialty and more to the practice of management and administration. An important reason for this is that generally the highest rewards, whether in terms of opportunity to contribute to organizational goals, prestige, salary, or power, are attached to administrative positions. As a consequence, there is a great need for training in administration in the field of psychiatry. This is certainly the case for the psychiatrist who holds the position of director of a state mental hospital who must plan, organize, and implement policy and deal with budgets and personnel affairs. Furthermore, the increased importance of units or sectors has increased the need for management training for the psychiatristadministrator. Today, not only the director of a mental health system needs management skills, but the unit chiefs as well. T h e y must deal with other agencies in their catchment areas and plan, organize, coordinate, and evaluate the work of their units or sectors. They are concerned with budgets, personnel matters, and legal affairs and no longer act primarily within the psychotherapeutic model.
293 S. HOBERMAN,G. LAURY,S. MAILICK, AND H. MILLER
As the interrelations among collateral pofitical, and social systems become more important, the psychiatrist-administrator needs a better understanding of the nature of these relationships. In particular, he must understand the relationships between the mental health system and the correctional, welfare, penal, health, and educational systems. In more general terms, he must emerge from his familiar, narrow mental health system and relate to the total environment. These are some reasons why training in management skills is becoming more important in the psychiatric field and for the growing understanding and acceptance of this need. However, despite this recognition of the importance of good administration for therapeutic effectiveness, few career training programs have addressed themselves to training mental health professionals in management skills. 2-'~
H I S T O R I C A L D E V E L O P M E N T OF T H E NEW YORK S C H O O L OF PSYCHIATRY In 1958, after years of experimentation, the New York State Department of Mental Hygiene authorized the establishment of a new graduate school, the New York School of Psychiatry. It was to become a pilot center for the psychiatric education of resident physicians in a group of state mental institutions in the New York Metropolitan area. Chartered by the Board of Regents of the University of the State of New York, the school operates under its own board of trustees, its own officers of administration, and an advisory committee head by the Commissioner of the Department of Mental Hygiene. The group of' state institutions associated with the New York School of Psychiatry had, in the late 1950s, a total bed capacity of 36,000 and 126 positions for resident physicians. The establishment of the New York School of Psychiatry was an attempt to insure the associated hospitals with an adequate supply of trained and competent physicians able to keep pace and actively participate in the scientific advances. At first exclusively involved in the teaching of psychiatric residents, the school has gradually moved into the continuing education and training of staff members in various disciplines and at all levels. It was in this context that the school embarked on a program of management training in the autumn of 1971, in cooperation with the Department of Mental Hygiene of New York State.
SPECIFIC PROGRAMS IN M A N A G E M E N T AND A D M I N I S T R A T I O N The management training program was intended for both clinical and nonclinical personnel who served, or were being prepared to serve, in policy making and in administrative positions in the state system. The program was designed for three levels of clinical and nonclinical personnel:
2~ MANAGEMENT TRAINING FOR MENTAL HEALTH PROFESSIONALS
1. Senior central office administrators at the levels of assistant commissioner, associate commissioner, and commissioner, director of state mental hospitals and schools, and director of county and local mental health board and department. 2. Psychiatrists, psychologists, social workers, psychiatric nurses, and others serving as unit chiefs in the state hospitals and schools of the New York City, Long Island and Mid-Hudson areas (i.e., the southern third of New York State where there is a heavy concentration of state psychiatric facilities). 3. Second-year residents in psychiatric training at the New York School of Psychiatry.
BOARD- AND DIRECTOR-LEVEL MANAGEMENT T R A I N I N G PROGRAM This program was conducted in two successive stages. The first was designed to increase the participants' awareness and understanding of concepts, theories, and newer practices in management and administration. Participants were the senior staff members of the New York State Department of Mental Hygiene. The program was conducted in 1971 and consisted of a five-session monthly presentation-discussion series. A group of eminent theorists in the field of management conducted the sessions as follows: Session 1: Long-Range Planning in the Design of the Future. Prof. Donald Michael, University of Michigan. Session 2: Leadership Styles and Administrative Effectiveness. Prof. Robert Kahn, University of Michigan. Session 3: Management by Objectives. Prof. Peter Drucker, New York University.* Session 4: The Organization as a Societal Change Agent. Prof. Warren Bennis, The University of Buffalo.* Session 5: The Implementation of Organizational Change. Prof. Chris Argyris, Yale University.* Each lecture was followed by open discussion which gave the participants the opportunity to compare the experience of the Mental Hygiene Department with the concepts and theory provided by the speaker. The series was very welt received and achieved its primary objective of stimulating interest in further management training and education. In addition, the sessions were videotaped and used in management training programs conducted for personnel at other levels. In the second stage in 1972, two additional workshops were conducted for board members, hospital directors, and community mental health di*Affiliation at time of presentation.
295 s. HOBERMAN,G. LAURY,S. MAILICK,AND H. MILLER
rectors, one for the Long Island region and the other for the Mid-Hudson area. The local participants were members of the community area committee, established by the Department of Mental Hygiene to meet periodically and consider mental health policy and administrative issues common to all in the local region. The goals of the program were: 1. To develop solutions to actual operational problems for implementation by the respective organizations represented by the participants. 2. To improve the working relationships between central staff and area committee members. 3. To expand understanding of the total mental health system, the interrelationships among the different elements of the system, and the functioning of the system and the environment. 4. To develop and increase knowledge and understanding of theories and concepts of administration needed to solve operational problems relating to the delivery of mental health services. The "modular" approach of instruction was used. Each workshop included three one-day meetings, individual assignments, and informal subgroup meetings spaced over a total period of four months. There were ten participants in the Long Island and fourteen in the Mid-Hudson workshop. The partidpants were expected to work separately and in subgroups during the six-week intervals between formal meetings. A modification of the syndicate, problem-solving format developed at the Administrative Staff College in Great Britain 1° was used. The specific problems to be analyzed were selected and defined by the participants in the first module of the program. These were based on areas on investigation which had been indentified by the training staff in preprogram interviews with participants and other observers. Each meeting included: I. Problem-solving subgroups chaired by a member of the staff (Meeting 1) and a member of the subgroup (Meetings 2 and 3). 2. Use of the training staff as consultants for assistance and understanding in the identification and solution of management problems. 3. Observation, analysis, and discussion by participants and staff of both the process and content of group problem-solving conferences. 4. Lectures and presentations to impart information and understanding in areas such as systems theory, community structure and the environment, and problem solving as a group activity. 5. Plenary discussion of lectures, problem areas, the workshop process, and group reports. 6. Management games and exercises designed to develop greater understanding and insight into group process, administrative problem solving, and leadership styles and patterns of group behavior. Between meetings, required activities included:
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1. Individual assignments relating to work group problems, e.g., data gathering, analysis and development of alternative solutions, etc. 2. Subgroup work on the problem and preparation of reports to be discussed at plenary meetings of the workshop. Prior to each meeting, readings pertinent to the substantive content of the meetings were distributed to the participant.
U N I T CHIEF WORKSHOPS In the spring of 1971, two workshops were conducted by the New York School of Psychiatry for unit chiefs serving in the state mental health institutions in the southern region of New York State. They focused on unit and team management and were designed to analyze the role of the unit chief in organizing and administering the activities of psychiatrists, psychologists, social workers, and psychiatric nurses and attendants on the ward and unit level. The workshops were held in a residential conference center, with overnight accommodations. T o plan the program, training needs, and the most appropriate training approaches were analyzed by: 1. Studying the activities of the department and the roles and behavior of people at different management levels in the system; 2. Interviewing top central management personnel, institutional directors, and other persons who had knowledge of departmental administration and the relationships among management personnel; 3. Studying the responses by unit chiefs, who were to participate in the program, to a number of questions relating to the tasks that they perform, the importance that they attach to different elements of the managerial role, and areas in which they would like to improve their performance. 4. Studying the responses by unit chiefs to the questions on an assessment instrument based upon a modification of the Likert Scale 1°. 5. Studying and acting on feedback from participants, faculty', and other observers during the course of the program. This last source of information "feedback" was of crucial importance. We were not at all certain at any stage that the program would satisfy the needs of the participants or even hold their interest. Consequently, we continuously monitored, evaluated, and, where we believed that it was desirable and possible, made changes. One result was that the two sections of the program for unit chiefs, while similar in design, were not exactly identical (as had been the case with the program for board and area committees). Another result was that the planning for a session was not fully completed until after the preceding session had been evaluated. We were, however, able to make early decisions about some basic elements in the design: (a) all programs sponsored for different levels of personnel should support and relate to each other; (b) consistent and basi-
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cally similar management philosophies and training approaches should be used; (c) to the extent that we could, while meeting the expressed needs of each group, the substantive content of each program should overlap with that of other programs; (d) all programs, as far as possible, should include strong ties between theory and practice; and (e) it was both feasible and desirable to give participants reading and work assignments between formal, group sessions. As a result of decisions such as these, it was decided to stress experiential educational approaches. Traditional lectures and seminar discussions, however, were also included. T h e educational goal was to give the unit chief greater knowledge of administrative theory, research findings, and techniques, some practice in applying these to his daily professional activities in public psychiatry, and a deeper understanding of the dynamics of interpersonal relationships in a work setting. Approximately thirty unit chiefs participated in each of two workshops. A multidisciplinary faculty team acted as conference leaders, facilitators, and resource consultants at the workshops, in addition to providing traditional impact on theory, research findings, etc. Subject matter discussed in the program included: Identification and definition of team goals. Administrative decision making and problem solving. Leadership styles and strategies. Motivating work teams. The development of effective administrative control systems and evaluation designs. Each workshop consisted of four one-and-a-half day meetings spread out over a period of four months. The following schedule illustrates a day-and-a-half program: First Day Arrival and registration Luncheon Session 1 Problems and Issues in Unitization Dinner Session 2 Management exercise Second Day Breakfast Session 3 Leadership and motivation theory Closing luncheon
11:00AM-12:00 noon 12:00 noon-1:30PM 2:00PM-5:00PM 6:00PM-7:3OPM 7:30PM-10:00PM 8:0OAM-9:00AM 9:00AM-I 2:45PM t2:45PM-t :45PM
At the first meeting, both the Commissioner of the Department of Mental Hygiene and the Deputy Commissioner for Mental Health participated, They gave the unit chiefs the opportunity to discuss with them the implications of the creation of units,
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Educational techniques used included role playing, management games, instrumented exercises, formal lectures, and small group discussions. Actual problems faced by the participants were discussed and new approaches were explored. Although the management games and instrumented exercises were at first greeted by some of the participants with a degree of skepticism as learning tools, they soon came to be regarded as very important mean~, for gaining understanding and skills. Indeed, some of the participants reported that they later made use of these techniques in the training and development of their own staffs. Before each meeting, participants read assigned articles and case studies which were discussed and analyzed at the meeting. Group discussion of the readings were considered helpful in reinforcing participants learning and imparting a deeper understanding of the author's views, and thus making their insights more useful operationally. Each learning technique was selected to develop or reinforce understanding. Thus a team role play was used, giving each participant the opportunity to play the role of a member of a therapeutic team, e.g., a psychiatrist, psychologist, social worker, or psychiatric nurse or attendant, to increase participants understanding of mixed-discipline team dynamics, and appreciation of the motivation and feelings of at least one occupational subgroup, other than his own, involved in team cooperation and the accomplishment of the unit's task. In addition, it helped the unit chief identify problems which must be solved if the team approach is to be effective and gave him useful practice in working with or leading a team. During the role play, there were several occasions during which the staff observers led discussions of the process and dynamics of group interaction and the adequacy of leadership and group participation. These helped to bring inherent role conflicts into the open and to encourage the unit chiefs to reconsider their role and task priorities. A negotiating game was played which was designed to increase the participants understanding of and insight into goal definition, value systems, forces which obstruct trust, and cooperation between different subgroups in an organization and the importance of personal communication. It gave the unit chief the opportunity to experience the conflicts caused by the need to trust and the tendency to distrust the motives of others and the desires to cooperate and to compete. Following the game, a discussion and analysis of trust and cooperation in organizational behavior helped the partidpants understand and appreciate more fully the dynamics and the decisions made during the game. Management case studies were prepared by the participants to provide experience in problem identification and analysis, to reinforce previous learning, and to deepen insight into and understanding of the dynamics of group problem solving. It was effective and efficient to have all participants spend 10 hours of continuous, residential studies in the span of 24 hours. T h e participants had a chance to meet and to compare their respective professional experiences and to discuss the training program. The tendency to discuss work
299 S. HOBERMAN,G. LAURY,S. MAILICK, AND H. MILLER
problems among the participants increased not only during the workshop sessions and during "free" time such as lunch or dinner, but also afterward, back at the home base. Participants from different hospitals who had never met but had communicated frequently by telephone, had the opportunity to meet faceto-face and talk "viva voce." Indeed, it was discovered that in some cases, unit chiefs were unaware of what others in the same hospital were doing to solve management problems similar to those they faced. During the workshop they finally related to one another. Every phase of the teaching process was carefully evaluated. The participants completed anonymous questionnaires which were closely examined by the faculty. An additional assessment instrument was based upon the modification of the Likert Scale 1° mentioned above. The responses of the unit chiefs to the role playing, management games, simulations, exercises, and cases, based on the questionnaires, was extremely positive. The staff of the workshop were impressed by the willingness and ability of the participants to enter into the spirit of these activities and cooperate with enthusiasm, despite their different backgrounds. In the spring of 1972, a "follow-up" meeting of participants was held. A case study was sent to the unit chiefs in advance and was discussed at the meeting. The schedule of the day further illustrates the educational approach: AM:
9:45-10:00 10:00-10:15 10:15-11:45 11:45-12:45
Registration Welcome and report on new programs Lecture on general systems theory Management exercise, followed by subgroup discussions and analysis with staff acting as observers and resource consultants. Pra: 1:00-2:00 Lunch 2:00-3:45 Discussion of case study and application of systems theory 3:45-4:30 Reports by staff observers on small group sessions for purpose of deepening insight into both group process and individual behavior. Discussion of future activities.
MANAGEMENT T R A I N I N G FOR PSYCHIATRIC RESIDENTS Beginning with the academic year of 1971, the New York School of Psychiatry introduced a course in management and administration into the second-year program of residential training. This course provides the psychiatric residents with a broad overview of the field of administration as well as with a concentrated study of selected areas. It is designed to help residents understand and appreciate the importance of management and the nature of the administrative component of their roles as psychiatrists in public mental health care systems. In addition to lectures and seminar discussions, role playing, case studies, and instrumented exercises are used.
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O f interest is the change in attitude toward the study and role of administration which manifested itself among many of the residents during the first year that the course was instituted. At the inception of the course, some of the students questioned the necessity and utility of a course in administration. More than one student indicated that since they were studying a medical specialty and were essentially clinicians, the study of management and administration would have no relevance to their role and performance as psychiatrists. As the class sessions continued, however, the attitudes of these residents changed markedly. They came to see the relevance of the study of administrative theory and practice not only to their possible future managerial concerns, but to their roles as clinicians. They reported that the analysis of such subjects as planning, communications, evaluation, decision making, leadership, and motivation were directly related to their work as clinicians. At the end of the year, when the residents were asked to evaluate the didactic courses of the program, they indicated that the course in management and administration had had great value for them. This course has become an integral part of the total school curriculum and represents one of the few examples of the incorporation of the study of administration and management into a psychiatric residency training program?' It is the purpose of this early training to equip the resident to function more effectively in an organizational setting as a member of a multidiscipline team and to prepare him for a position as unit chief in a public mental health facility.
CONCLUSIONS 1. Psychiatrists and other professionals engaged in administering mental health and retardation programs feel a strong need for management education and training, and are willing to devote considerable time and energy to obtain these. 2. Mental health systems have a number of administrative problems which, although not unique, are of greater importance than in other public service systems. Among these are (a) relationships between conflicting administrative styles and therapeutic approaches and the effects of these on the operation of systems; (b) effects on administrators and systems of operating in generally hostile internal and external environments; (c) equalization conflicts (power, status, career advancement, task distribution, etc.) in multidiscipline teams and in a multidiscipline system with one dominant discipline; (d) relationships between paraprofessionals and professionals and the effect of these on administration; (e) absense of generally accepted operationalized goals; and (f) effects of limited acceptance and support for any specific change in a system in which it is universally agreed that change is needed. 3. Strong backgrounds that mental health administrators have in the
301 s. HOBERMAN,G. LAURY, S. MAILICK, AND H. MILLER
use of the behavioral sciences for therapeutic purposes may not be an advantage to them as administrators and for using the findings and approaches of the behavioral sciences for administrative purposes. T h e difficulties are indicated by the following analysis of two similar processes, namely group therapy and a problem-solving work group:
Group Therapy
Worh Group
Requisite training of leader or administrator
In group therapy
In management
Goal of leader or administrator
Improve the mental health of the participants
Task oriented, i.e., achieve the purposes and aims of organization
Goal of group
Improve total functioning as individuals
Solve common work problems
"Irrelevancies" of participants
Acceptable
Unacceptable
Time element
Less important
hnportant
Participants
Generally not part of same system
Part of same system
Have emotional problems in common
Have work goals in common
4. It is possible and desirable to systemically interweave management training programs for residents, unit chiefs, and directors. Not only is this helpful for making learning progressive in terms of building upon earlier learning, but it also helps each professional and management level understand and accept the goals and thrusts of the others. 5. With only minor changes, it may be desirable to extend both the board-area committee and the unit chief programs to the other state departments of mental hygiene. The New York School of Psychiatry sees its role as a catalytic agent and experimental facility rather than an on-going inservice training organization. It is consequently considering the possibility of conducting "training of trainer programs" to prepare system members to conduct these management training programs themselves. 6. There is a need for formal graduate degree study for the administrators of public mental health systems which would provide the opportunity to learn the theory, practice, and research findings in policy-making administration, as well as the chance to use and evaluate, on the basis of experience, modern management theory, approaches, and techniques. The New York School of Psychiatry and the Graduate School of Public Administration of New York University have, in cooperation, developed a Doctoral Program in Public Mental Health Policy and Administration to meet this need. The first pilot class was admitted in December, 1972.
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REFERENCES 1. Foley AR: Administration and training in Administrative Psychiatry. Hosp Community Psychiatry 22:17, 1971. 2. Ah H. Mailick S: Training for mental health administrators. Hosp. Community Psychiatry 22:38, 1971. 3. Foley AR: Residency programs in Community psychiatry.Hosp communityPsychiatry 22:69, 1972. 4. Reese W: An essay on administration. AmJ Psychiatry 128:10-69, 1972. 5. Hutchins RM: The administrator.J Higher Educ 17:369, 1946. 6. Rado S: A graduate school. AmJ Psychiatry 117:885-886, 1961. 7. Reese WG: An essay on administration. AmJ Psychiatry 128:10, 1972. 8. Levinson DJ, Klerman GL: The clinican executive. Psychiatry 30:3-15, 1967. 9. Blake R, Mouton J: The Managerial Grid. Houston, Gulf Publishing Co., 1964. 10. Likert, Rensis: Profile of Organizational Characteristics. The Human Organization 196etseg. McGraw Hill, New York 1967. 11. Laury GV: The teaching of psychiatry in the U.S. Med Hyg 30:1074-1075, 1972.
As an example of progress, a program is described, undertaken, by the New York School of Psychiatry,, to train and educate psychiatrists and related professional groups in management and administration.
INTRODUCTION Mental Health professionals, in the United States, are becoming more and more concerned about the administration of mental health programs. This realization of the importance of administration arises from administering programs that involve complex interrelationships among federal, state, and local agencies 1 and the recognition that well-designed therapeutic programs may fail to be successfully implemented because the persons directing them do not have sufficient administrative skills and knowledge of modern concepts of manangement. Indeed, the theoretical background in management of some high ranking mental health administrators seems to be limited to Parkinson's law and the Peter principles. Few mental health professionals are adequately prepared by their training to assume efficiently high administrative tasks. Most administrators administer on the basis of common sense, their charisma, or the skills of their subordinates. One reason for this situation is that there is little incentive or motivation to become a better administrator. Promotion in a department of mental health often depends almost entirely on knowledge and skill in a field or discipline such as psychiatry, psychology, psychiatric nursing, or psychiatric social work. There is little evaluation of management knowledge and skills. Furthermore administration generally has lower status in comparison Dr. Mailick is Coordinator of Spedal Programs at N,Y.U, Graduate School of Public Administration. T h e late Dr. Laury was with the New York State Department of Mental Hygiene. Dr. Miller is professor of Education at CUNY, H u n t e r College. Mr. H o b e r m a n is a management consultant and former personnel director for the city of New York. PSYCHIATRIC QUARTERLY, VOL. 49(4) 1977
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to the status of the clinical function. There maybe subtle contempt from colleagues for the professional turned administrator, who is often referred to as "only a bureaucrat, a paper pusher, involved in red tape." Finally, imparting administrative skills is no easy task. Aristotle noted long ago that men do not become good by listening to lectures on moral philosophy. Many of the qualifications of the effective administrator-courage, fortitude, justice, and prudence or practical wisdom----~:annot be developed in the classroom. However, formal training in administration supplemented by practice can help to develop these qualities and where they exist, make them more effective. Administrative training programs may have many objectives. These may range from helping administrators acquire specific skills to helping large organizations develop effective management corps. Some programs attempt to impart understanding of organizational policy to achieve effective uniformity of action within the organizational context. Others attempt to increase understanding of policy and administration through the study of theoretical models.
T H E NEED FOR MANAGEMENT T R A I N I N G FOR T H E PSYCHIATRIST-ADMINISTRATOR As is the case with other administrators, the psychiatrist-administrator is helped by a good knowledge of administrative theory and practice, an appreciation of the importance of the managerial component and administration, to assume more and more administrative duties. The engineer, lawyer, or physician, who works within a large bureaucratic system frequently advances in these systems to the point at which his activities relate less to his professional specialty and more to the practice of management and administration. An important reason for this is that generally the highest rewards, whether in terms of opportunity to contribute to organizational goals, prestige, salary, or power, are attached to administrative positions. As a consequence, there is a great need for training in administration in the field of psychiatry. This is certainly the case for the psychiatrist who holds the position of director of a state mental hospital who must plan, organize, and implement policy and deal with budgets and personnel affairs. Furthermore, the increased importance of units or sectors has increased the need for management training for the psychiatristadministrator. Today, not only the director of a mental health system needs management skills, but the unit chiefs as well. T h e y must deal with other agencies in their catchment areas and plan, organize, coordinate, and evaluate the work of their units or sectors. They are concerned with budgets, personnel matters, and legal affairs and no longer act primarily within the psychotherapeutic model.
293 S. HOBERMAN,G. LAURY,S. MAILICK, AND H. MILLER
As the interrelations among collateral pofitical, and social systems become more important, the psychiatrist-administrator needs a better understanding of the nature of these relationships. In particular, he must understand the relationships between the mental health system and the correctional, welfare, penal, health, and educational systems. In more general terms, he must emerge from his familiar, narrow mental health system and relate to the total environment. These are some reasons why training in management skills is becoming more important in the psychiatric field and for the growing understanding and acceptance of this need. However, despite this recognition of the importance of good administration for therapeutic effectiveness, few career training programs have addressed themselves to training mental health professionals in management skills. 2-'~
H I S T O R I C A L D E V E L O P M E N T OF T H E NEW YORK S C H O O L OF PSYCHIATRY In 1958, after years of experimentation, the New York State Department of Mental Hygiene authorized the establishment of a new graduate school, the New York School of Psychiatry. It was to become a pilot center for the psychiatric education of resident physicians in a group of state mental institutions in the New York Metropolitan area. Chartered by the Board of Regents of the University of the State of New York, the school operates under its own board of trustees, its own officers of administration, and an advisory committee head by the Commissioner of the Department of Mental Hygiene. The group of' state institutions associated with the New York School of Psychiatry had, in the late 1950s, a total bed capacity of 36,000 and 126 positions for resident physicians. The establishment of the New York School of Psychiatry was an attempt to insure the associated hospitals with an adequate supply of trained and competent physicians able to keep pace and actively participate in the scientific advances. At first exclusively involved in the teaching of psychiatric residents, the school has gradually moved into the continuing education and training of staff members in various disciplines and at all levels. It was in this context that the school embarked on a program of management training in the autumn of 1971, in cooperation with the Department of Mental Hygiene of New York State.
SPECIFIC PROGRAMS IN M A N A G E M E N T AND A D M I N I S T R A T I O N The management training program was intended for both clinical and nonclinical personnel who served, or were being prepared to serve, in policy making and in administrative positions in the state system. The program was designed for three levels of clinical and nonclinical personnel:
2~ MANAGEMENT TRAINING FOR MENTAL HEALTH PROFESSIONALS
1. Senior central office administrators at the levels of assistant commissioner, associate commissioner, and commissioner, director of state mental hospitals and schools, and director of county and local mental health board and department. 2. Psychiatrists, psychologists, social workers, psychiatric nurses, and others serving as unit chiefs in the state hospitals and schools of the New York City, Long Island and Mid-Hudson areas (i.e., the southern third of New York State where there is a heavy concentration of state psychiatric facilities). 3. Second-year residents in psychiatric training at the New York School of Psychiatry.
BOARD- AND DIRECTOR-LEVEL MANAGEMENT T R A I N I N G PROGRAM This program was conducted in two successive stages. The first was designed to increase the participants' awareness and understanding of concepts, theories, and newer practices in management and administration. Participants were the senior staff members of the New York State Department of Mental Hygiene. The program was conducted in 1971 and consisted of a five-session monthly presentation-discussion series. A group of eminent theorists in the field of management conducted the sessions as follows: Session 1: Long-Range Planning in the Design of the Future. Prof. Donald Michael, University of Michigan. Session 2: Leadership Styles and Administrative Effectiveness. Prof. Robert Kahn, University of Michigan. Session 3: Management by Objectives. Prof. Peter Drucker, New York University.* Session 4: The Organization as a Societal Change Agent. Prof. Warren Bennis, The University of Buffalo.* Session 5: The Implementation of Organizational Change. Prof. Chris Argyris, Yale University.* Each lecture was followed by open discussion which gave the participants the opportunity to compare the experience of the Mental Hygiene Department with the concepts and theory provided by the speaker. The series was very welt received and achieved its primary objective of stimulating interest in further management training and education. In addition, the sessions were videotaped and used in management training programs conducted for personnel at other levels. In the second stage in 1972, two additional workshops were conducted for board members, hospital directors, and community mental health di*Affiliation at time of presentation.
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rectors, one for the Long Island region and the other for the Mid-Hudson area. The local participants were members of the community area committee, established by the Department of Mental Hygiene to meet periodically and consider mental health policy and administrative issues common to all in the local region. The goals of the program were: 1. To develop solutions to actual operational problems for implementation by the respective organizations represented by the participants. 2. To improve the working relationships between central staff and area committee members. 3. To expand understanding of the total mental health system, the interrelationships among the different elements of the system, and the functioning of the system and the environment. 4. To develop and increase knowledge and understanding of theories and concepts of administration needed to solve operational problems relating to the delivery of mental health services. The "modular" approach of instruction was used. Each workshop included three one-day meetings, individual assignments, and informal subgroup meetings spaced over a total period of four months. There were ten participants in the Long Island and fourteen in the Mid-Hudson workshop. The partidpants were expected to work separately and in subgroups during the six-week intervals between formal meetings. A modification of the syndicate, problem-solving format developed at the Administrative Staff College in Great Britain 1° was used. The specific problems to be analyzed were selected and defined by the participants in the first module of the program. These were based on areas on investigation which had been indentified by the training staff in preprogram interviews with participants and other observers. Each meeting included: I. Problem-solving subgroups chaired by a member of the staff (Meeting 1) and a member of the subgroup (Meetings 2 and 3). 2. Use of the training staff as consultants for assistance and understanding in the identification and solution of management problems. 3. Observation, analysis, and discussion by participants and staff of both the process and content of group problem-solving conferences. 4. Lectures and presentations to impart information and understanding in areas such as systems theory, community structure and the environment, and problem solving as a group activity. 5. Plenary discussion of lectures, problem areas, the workshop process, and group reports. 6. Management games and exercises designed to develop greater understanding and insight into group process, administrative problem solving, and leadership styles and patterns of group behavior. Between meetings, required activities included:
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1. Individual assignments relating to work group problems, e.g., data gathering, analysis and development of alternative solutions, etc. 2. Subgroup work on the problem and preparation of reports to be discussed at plenary meetings of the workshop. Prior to each meeting, readings pertinent to the substantive content of the meetings were distributed to the participant.
U N I T CHIEF WORKSHOPS In the spring of 1971, two workshops were conducted by the New York School of Psychiatry for unit chiefs serving in the state mental health institutions in the southern region of New York State. They focused on unit and team management and were designed to analyze the role of the unit chief in organizing and administering the activities of psychiatrists, psychologists, social workers, and psychiatric nurses and attendants on the ward and unit level. The workshops were held in a residential conference center, with overnight accommodations. T o plan the program, training needs, and the most appropriate training approaches were analyzed by: 1. Studying the activities of the department and the roles and behavior of people at different management levels in the system; 2. Interviewing top central management personnel, institutional directors, and other persons who had knowledge of departmental administration and the relationships among management personnel; 3. Studying the responses by unit chiefs, who were to participate in the program, to a number of questions relating to the tasks that they perform, the importance that they attach to different elements of the managerial role, and areas in which they would like to improve their performance. 4. Studying the responses by unit chiefs to the questions on an assessment instrument based upon a modification of the Likert Scale 1°. 5. Studying and acting on feedback from participants, faculty', and other observers during the course of the program. This last source of information "feedback" was of crucial importance. We were not at all certain at any stage that the program would satisfy the needs of the participants or even hold their interest. Consequently, we continuously monitored, evaluated, and, where we believed that it was desirable and possible, made changes. One result was that the two sections of the program for unit chiefs, while similar in design, were not exactly identical (as had been the case with the program for board and area committees). Another result was that the planning for a session was not fully completed until after the preceding session had been evaluated. We were, however, able to make early decisions about some basic elements in the design: (a) all programs sponsored for different levels of personnel should support and relate to each other; (b) consistent and basi-
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cally similar management philosophies and training approaches should be used; (c) to the extent that we could, while meeting the expressed needs of each group, the substantive content of each program should overlap with that of other programs; (d) all programs, as far as possible, should include strong ties between theory and practice; and (e) it was both feasible and desirable to give participants reading and work assignments between formal, group sessions. As a result of decisions such as these, it was decided to stress experiential educational approaches. Traditional lectures and seminar discussions, however, were also included. T h e educational goal was to give the unit chief greater knowledge of administrative theory, research findings, and techniques, some practice in applying these to his daily professional activities in public psychiatry, and a deeper understanding of the dynamics of interpersonal relationships in a work setting. Approximately thirty unit chiefs participated in each of two workshops. A multidisciplinary faculty team acted as conference leaders, facilitators, and resource consultants at the workshops, in addition to providing traditional impact on theory, research findings, etc. Subject matter discussed in the program included: Identification and definition of team goals. Administrative decision making and problem solving. Leadership styles and strategies. Motivating work teams. The development of effective administrative control systems and evaluation designs. Each workshop consisted of four one-and-a-half day meetings spread out over a period of four months. The following schedule illustrates a day-and-a-half program: First Day Arrival and registration Luncheon Session 1 Problems and Issues in Unitization Dinner Session 2 Management exercise Second Day Breakfast Session 3 Leadership and motivation theory Closing luncheon
11:00AM-12:00 noon 12:00 noon-1:30PM 2:00PM-5:00PM 6:00PM-7:3OPM 7:30PM-10:00PM 8:0OAM-9:00AM 9:00AM-I 2:45PM t2:45PM-t :45PM
At the first meeting, both the Commissioner of the Department of Mental Hygiene and the Deputy Commissioner for Mental Health participated, They gave the unit chiefs the opportunity to discuss with them the implications of the creation of units,
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Educational techniques used included role playing, management games, instrumented exercises, formal lectures, and small group discussions. Actual problems faced by the participants were discussed and new approaches were explored. Although the management games and instrumented exercises were at first greeted by some of the participants with a degree of skepticism as learning tools, they soon came to be regarded as very important mean~, for gaining understanding and skills. Indeed, some of the participants reported that they later made use of these techniques in the training and development of their own staffs. Before each meeting, participants read assigned articles and case studies which were discussed and analyzed at the meeting. Group discussion of the readings were considered helpful in reinforcing participants learning and imparting a deeper understanding of the author's views, and thus making their insights more useful operationally. Each learning technique was selected to develop or reinforce understanding. Thus a team role play was used, giving each participant the opportunity to play the role of a member of a therapeutic team, e.g., a psychiatrist, psychologist, social worker, or psychiatric nurse or attendant, to increase participants understanding of mixed-discipline team dynamics, and appreciation of the motivation and feelings of at least one occupational subgroup, other than his own, involved in team cooperation and the accomplishment of the unit's task. In addition, it helped the unit chief identify problems which must be solved if the team approach is to be effective and gave him useful practice in working with or leading a team. During the role play, there were several occasions during which the staff observers led discussions of the process and dynamics of group interaction and the adequacy of leadership and group participation. These helped to bring inherent role conflicts into the open and to encourage the unit chiefs to reconsider their role and task priorities. A negotiating game was played which was designed to increase the participants understanding of and insight into goal definition, value systems, forces which obstruct trust, and cooperation between different subgroups in an organization and the importance of personal communication. It gave the unit chief the opportunity to experience the conflicts caused by the need to trust and the tendency to distrust the motives of others and the desires to cooperate and to compete. Following the game, a discussion and analysis of trust and cooperation in organizational behavior helped the partidpants understand and appreciate more fully the dynamics and the decisions made during the game. Management case studies were prepared by the participants to provide experience in problem identification and analysis, to reinforce previous learning, and to deepen insight into and understanding of the dynamics of group problem solving. It was effective and efficient to have all participants spend 10 hours of continuous, residential studies in the span of 24 hours. T h e participants had a chance to meet and to compare their respective professional experiences and to discuss the training program. The tendency to discuss work
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problems among the participants increased not only during the workshop sessions and during "free" time such as lunch or dinner, but also afterward, back at the home base. Participants from different hospitals who had never met but had communicated frequently by telephone, had the opportunity to meet faceto-face and talk "viva voce." Indeed, it was discovered that in some cases, unit chiefs were unaware of what others in the same hospital were doing to solve management problems similar to those they faced. During the workshop they finally related to one another. Every phase of the teaching process was carefully evaluated. The participants completed anonymous questionnaires which were closely examined by the faculty. An additional assessment instrument was based upon the modification of the Likert Scale 1° mentioned above. The responses of the unit chiefs to the role playing, management games, simulations, exercises, and cases, based on the questionnaires, was extremely positive. The staff of the workshop were impressed by the willingness and ability of the participants to enter into the spirit of these activities and cooperate with enthusiasm, despite their different backgrounds. In the spring of 1972, a "follow-up" meeting of participants was held. A case study was sent to the unit chiefs in advance and was discussed at the meeting. The schedule of the day further illustrates the educational approach: AM:
9:45-10:00 10:00-10:15 10:15-11:45 11:45-12:45
Registration Welcome and report on new programs Lecture on general systems theory Management exercise, followed by subgroup discussions and analysis with staff acting as observers and resource consultants. Pra: 1:00-2:00 Lunch 2:00-3:45 Discussion of case study and application of systems theory 3:45-4:30 Reports by staff observers on small group sessions for purpose of deepening insight into both group process and individual behavior. Discussion of future activities.
MANAGEMENT T R A I N I N G FOR PSYCHIATRIC RESIDENTS Beginning with the academic year of 1971, the New York School of Psychiatry introduced a course in management and administration into the second-year program of residential training. This course provides the psychiatric residents with a broad overview of the field of administration as well as with a concentrated study of selected areas. It is designed to help residents understand and appreciate the importance of management and the nature of the administrative component of their roles as psychiatrists in public mental health care systems. In addition to lectures and seminar discussions, role playing, case studies, and instrumented exercises are used.
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O f interest is the change in attitude toward the study and role of administration which manifested itself among many of the residents during the first year that the course was instituted. At the inception of the course, some of the students questioned the necessity and utility of a course in administration. More than one student indicated that since they were studying a medical specialty and were essentially clinicians, the study of management and administration would have no relevance to their role and performance as psychiatrists. As the class sessions continued, however, the attitudes of these residents changed markedly. They came to see the relevance of the study of administrative theory and practice not only to their possible future managerial concerns, but to their roles as clinicians. They reported that the analysis of such subjects as planning, communications, evaluation, decision making, leadership, and motivation were directly related to their work as clinicians. At the end of the year, when the residents were asked to evaluate the didactic courses of the program, they indicated that the course in management and administration had had great value for them. This course has become an integral part of the total school curriculum and represents one of the few examples of the incorporation of the study of administration and management into a psychiatric residency training program?' It is the purpose of this early training to equip the resident to function more effectively in an organizational setting as a member of a multidiscipline team and to prepare him for a position as unit chief in a public mental health facility.
CONCLUSIONS 1. Psychiatrists and other professionals engaged in administering mental health and retardation programs feel a strong need for management education and training, and are willing to devote considerable time and energy to obtain these. 2. Mental health systems have a number of administrative problems which, although not unique, are of greater importance than in other public service systems. Among these are (a) relationships between conflicting administrative styles and therapeutic approaches and the effects of these on the operation of systems; (b) effects on administrators and systems of operating in generally hostile internal and external environments; (c) equalization conflicts (power, status, career advancement, task distribution, etc.) in multidiscipline teams and in a multidiscipline system with one dominant discipline; (d) relationships between paraprofessionals and professionals and the effect of these on administration; (e) absense of generally accepted operationalized goals; and (f) effects of limited acceptance and support for any specific change in a system in which it is universally agreed that change is needed. 3. Strong backgrounds that mental health administrators have in the
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use of the behavioral sciences for therapeutic purposes may not be an advantage to them as administrators and for using the findings and approaches of the behavioral sciences for administrative purposes. T h e difficulties are indicated by the following analysis of two similar processes, namely group therapy and a problem-solving work group:
Group Therapy
Worh Group
Requisite training of leader or administrator
In group therapy
In management
Goal of leader or administrator
Improve the mental health of the participants
Task oriented, i.e., achieve the purposes and aims of organization
Goal of group
Improve total functioning as individuals
Solve common work problems
"Irrelevancies" of participants
Acceptable
Unacceptable
Time element
Less important
hnportant
Participants
Generally not part of same system
Part of same system
Have emotional problems in common
Have work goals in common
4. It is possible and desirable to systemically interweave management training programs for residents, unit chiefs, and directors. Not only is this helpful for making learning progressive in terms of building upon earlier learning, but it also helps each professional and management level understand and accept the goals and thrusts of the others. 5. With only minor changes, it may be desirable to extend both the board-area committee and the unit chief programs to the other state departments of mental hygiene. The New York School of Psychiatry sees its role as a catalytic agent and experimental facility rather than an on-going inservice training organization. It is consequently considering the possibility of conducting "training of trainer programs" to prepare system members to conduct these management training programs themselves. 6. There is a need for formal graduate degree study for the administrators of public mental health systems which would provide the opportunity to learn the theory, practice, and research findings in policy-making administration, as well as the chance to use and evaluate, on the basis of experience, modern management theory, approaches, and techniques. The New York School of Psychiatry and the Graduate School of Public Administration of New York University have, in cooperation, developed a Doctoral Program in Public Mental Health Policy and Administration to meet this need. The first pilot class was admitted in December, 1972.
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REFERENCES 1. Foley AR: Administration and training in Administrative Psychiatry. Hosp Community Psychiatry 22:17, 1971. 2. Ah H. Mailick S: Training for mental health administrators. Hosp. Community Psychiatry 22:38, 1971. 3. Foley AR: Residency programs in Community psychiatry.Hosp communityPsychiatry 22:69, 1972. 4. Reese W: An essay on administration. AmJ Psychiatry 128:10-69, 1972. 5. Hutchins RM: The administrator.J Higher Educ 17:369, 1946. 6. Rado S: A graduate school. AmJ Psychiatry 117:885-886, 1961. 7. Reese WG: An essay on administration. AmJ Psychiatry 128:10, 1972. 8. Levinson DJ, Klerman GL: The clinican executive. Psychiatry 30:3-15, 1967. 9. Blake R, Mouton J: The Managerial Grid. Houston, Gulf Publishing Co., 1964. 10. Likert, Rensis: Profile of Organizational Characteristics. The Human Organization 196etseg. McGraw Hill, New York 1967. 11. Laury GV: The teaching of psychiatry in the U.S. Med Hyg 30:1074-1075, 1972.
