Communfty Mental Health Yournal Volume 2, Number 1, Spring, 1966
COMMUNITY
PSYCHIATRY
A DEVELOPING
A NEW
SUBSPECIALTY,
CLINICAL
PROFESSION,
OR
PSYCHIATRY
EFFECTIVE ?
ROBERT S. DANIELS, M.D.* than good psychiatry. We have been practicing in this way for 15 years." "Our training program has always offered broad training in the use of community facilities. That is all that this so-called 'new psychiatry' amounts to." "The community psychiatry movement is being imposed upon us by the National Institute of Mental Health, the Federal Government, and certain individuals." "There is no basis of knowledge or experience for community psychiatry practice. It is a gigantic boondoggie. We will raise the public hopes for help with their myriad social problems and then we will disappoint them." "Community psychiatry is not psychiatry but a new specialty." This paper attempts to examine the development of community psychiatry, assess its place in the history of our science and practice, explore the additions and modifications which may be indicated in many of our residency training programs, and indicates some directions in which community psychiatry may influence psychiatric theory and practice. It is based on interrelated but somewhat dissimilar personal experiences and interests during the last several years: (a) A long standing interest in social psychiatry and the interface between individual psychodynamics and the current environment; (b) participation in the planning and execution of the first Institute on Training in Community Psychiatry, jointly sponsored by the University of Chicago, Department of Psychiatry, and the Training Branch of the National Institute of Mental Health, in October 1963; (c) continuing discussions within the Group for the Advancement of
Developments in community psychiatry are creating great controversy within the profession. This paper examines community psychiatry, assesses its place in the history of our science and practice, explores possible additions and modifications in residency training, and suggests possible patterns of practice. Community psychiatry is based on more than 20 years of developments within the profession. As such, there is a solid but limited base for its operation. Extensive program and basic research are essential More psychiatrists will spend more time in the future in community psychiatry activities. Some will become specialists in community psychiatry, a subspeciahy within the field of psychiatry. The controversy associated with community psychiatry developments is best illustrated by a series of statements which have been frequently heard during the last few years. Advocates have said, "Community psychiatry is the psychiatry of the future. We are in the midst of a third psychiatric revolution which will result in new patterns of psychiatric practice. The community psychiatrist will play an important part in community organization and planning. In this planned society the psychiatrist is a key figure. Social and psychiatric facilities will be coordinated. Any contact with an individual or family will be noted and that record will be available to all planning and treating facilities and individuals." "Psychiatrists must be gotten out of their ogices and into the community." "Our training programs need modification. They do not offer enough training in community psychiatry." Opponents make statements such as, "Community psychiatry is nothing more
*Dr. Daniels, a psychiatrist, is Associate Professor and Acting Chairman, Department of Psychiatry, University of Chicago, Chicago, Illinois. This paper was initially presented at a Joint Meeting of the Ohio Medical Association and the Ohio Psychiatric Association in May, 1965. 47
48
THE 'COMMUNITYMENTAL HEALTH JOURNAL
Psychiatry Committee on Medical Education; and (d) the evaluation of the residency training program at the University of Chicago in the Department of Psychiatry's Residency Curriculum Review Committee. WHAT IS COMMUNITYPSYCHIATRY? Community psychiatry is a developing body of knowledge and practice which relates psychiatric and social science principles to large population groups. Its body of theory is known as social psychiatry and is derived from ecology and epidemiology, public health and preventive medi. cine, social systems theory, and community organization. It is also based on the psychologic insights of individual and small group dynamics and an understanding of family structure and organization. It has as its broad goals the establishment of programs for early diagnosis and treatment, rehabilitation, and, so far as currently possible, prevention. Psychiatrists practicing in this area do so as consultants to community facilities, as planners for the establishment of social and psychiatric resources within population groups, or as providers of traditional psychiatric services through clinic and hospital facilities serving a specified population. In most community psychiatry programs, certain fundamental principles are followed. These principles are: 1. The population group to be served is defined. It must be small enough that communication among professionals and between professional and client is facilitated. 2. The principle of minimal intervention is the core of the service provided. Maximum use is made of the client's adaptive capacities. 3. The firing line professional manages most cases. 4. The service is close to the client and especially devised to meet his individual needs. 5. Emphasis is on increased awareness, early detection, and immediate intervention, particularly at times of crisis.
6. Simple and immediate services are available first. 7. Complex, special or lengthy services are obtained by referral to centrally located facilities. 8. The ability to pay is not a primary requisite for service. 9. The community psychiatry specialist spends more time in consultation with firing line professionals than in direct contact with patients. 10. Individual cases are viewed as examples of groups of cases. Case finding in similar populations and in families is important. 11. At the time of referral, there is a free flow of client and information from one professional to another. On completion of the service, referral back to the original source is not only possible but encouraged. 12. Institutions have an optimum size. Large institutions are psychologically, socially, and economically unsound. In some instances, they may lead to sustaining mental illness rather than to treating it. A typical community psychiatry program might take as its focus a population unit varying from tens of thousands to several hundred thousand people. This unit could be defined politically as a city or a county, geographically as a neighborhood or section, or functionally as an industry or school system. Centrally located within this unit would be a community mental health center which would consist of a large consultation and outpatient facility and a small hospital of several hundred beds. The inpatient facility would be composed of several units which provide flexible services for particular ages or special problems. Special services might consist of units for children, adolescents, aged, alcoholics, and the mentally retarded. Halfway house, day care, night care, and full-time units would be included. Emphasis within this setting would be on diagnosis and brief reconstitutive treatment. Long-term treatment and custodial treatment would occur in a separate and different setting.
ROBERT S, DAMELS This center would emphasize its outpatient and consultative functions. Therapy in the outpatient section would be brief, and the focus would be crisis and reality oriented. Whenever possible the staff avoids direct patient contact; evaluation is accomplished, rather, by utilizing the information the referring person or agency already has available. When referring a patient or client, the consulting agency or individual participates in the consultation and continues its primary responsibility. Relinquishing responsibility is ordinarily temporary and occurs when the consultant has a service available which is indicated for the patient and which the referrer cannot provide. Examples of such services might be comprehensive psychiatric diagnosis, the evaluation of certain medical-legal problems, or specialized psychiatric treatment. If the center accepts the client or patient in transfer, it is for a brief period and the accomplishment of explicit goals, after which transfer back to the referring individual or agency is indicated. If possible, the original referrer continues to be active while the specialty facility performs its particular function.
49
Consultation services are provided for individuals and institutions in the community. Attempts are made to appraise collaboratively the programs of emotional support available through schools, churches, social agencies, legal institutions, and others, and to relate them to one another in order to provide a variety of services available in continuity. Consultation may be offered on classes of problems such as delinquency, school failure, school dropouts, illegitimacy, alcoholism, mental retardation, broken families, child care, etc. It is hoped that such consultations are educational as well as problem oriented and will increase the capacity of the individual or the agency to manage similar problems in the future. Under ordinary circumstances, the firing line professional is an individual who does not define his role as a primary mental health one. Included in this group are physicians, public health and visiting nurses, teachers, clergymen, lawyers, policemen, and others. Their advice or counsel is frequently sought early by individuals with emotional problems. They are usually readily available in the community. Also
FIGURE I AN EXAMPLEOF A COMMUNITYPSYCHIATRYPROGRAM Level I Major Firing Line Professionals
Level II Agencies for Social and MedicalDiagnosis and Brief Treatment
Nonpsychiatrie Physician
Community psychiatric clinics Psychiatric services in general hospital
Visiting or Pubic Health Nurse Teacher Minister Lawyer
Guidance-counseling systems in schools
Policeman
Diagnostic services in courts
Other
Other
Social agencies Vocational and psychologic rehabilitation services
Level HI
Level IV
CommunityPsychiatry Centers
Large Hospital Facilities
Consultation services to fellow professionals a) To all levels h) To all individuals Consultation services to patients (outpatient)
Inpatient services (200300 beds) a) Diagnosis and short-term treatment b) Specialservices
Long-termtreatment and custodial facilities
50
THE COMMUNITY MENTAL HEALTH JOURNAL
the troubled person often has a preexistent relationship which facilitates contact. These firing line professionals already manage most instances of emotional disorder. These principles are demonstrated in Figure 1.
themselves as community psychiatry specialists, the mental health consultation has become the major vehicle of their practice. Kiesler (1963) is responsible for the psychiatric and social services in a threecounty area in rural northern Minnesota. His staff consists of himself, a psychologist, and a social worker. They insist that the EXAMPLES OF COMMUNITYPSYCHIATRY referring individual or agency retain priPRACTITIONERS mary responsibility for the patient or Many psychiatrists spend some time in family in distress. Whenever possible, the activities which could be called community clinic staff sees the referring professional, psychiatry. These activities often involve rather than the patient, using his informaa half-day or a day each week. They are tion to understand the case and plan with a break in their usual private practice, the professional his course of action. Apacademic or institutional routine. In such proximately 80 per cent of their staff time activities, the psychiatrist usually visits a is spent in indirect and program consultacommunity facility such as a clinic, hos- tion with such widely diverse professionals pital, social agency, court, or school. His as physicians, visiting nurses, teachers, purposes are to offer consultation and welfare workers, and ministers. Only 20 educational opportunities to the staff of the per cent of their time is occupied with agency or institution. Although he may see direct patient service. patients, usually he does not. His consultAnother model of community psychiatry ing activities may be patient centered, either practice results from a request to a psydirectly or indirectly, staff centered or pro- chiatrist by an organization, institution, gram centered (Caplan, 1964). or population unit to plan and organize An example will clarify these various social and psychiatric services. Examples kinds of activities. A psychiatrist consults may be found in colleges, industry, and the a half-day each week at a halfway house military services. This model also exists in and rehabilitation agency. The agency is population and political units such as cities, staffed by social workers, nurses, occupa- counties, or states. The activities of this tional therapists, vocational rehabilitation psychiatrist include planning for primary, workers, and volunteers. The client popula- secondary, and tertiary prevention. The tion is a group of approximately 200 head of a department of mental health for chronic ambulatory schizophrenics. At a political unit, such as a large city or times the psychiatric consultant sees clients state, is an illustration. He recommends and directly. More often he is presented data implements the establishment of programs by a staff member about a client. In this of maternal care and adoption which will type of consultation, he emphasizes the provide adequate and consistent care for training aspects of the interaction, helping children with absent or disturbed maternal to increase the staff's capacity for under- relationships (primary prevention). He esstanding and dealing with the problems tablishes clinics which are available for the presented by their clients. At other times, early detection and treatment of a patient's the psychiatrist may consult with staff disability (secondary prevention). He orabout intrastaff problems or about plan- ganizes state hospitals and a continuity of ning new programs. On still other occa- post-hospital services to provide social and sions he plays a more clearly educational vocational rehabilitation (tertiary prevenrole with staff and volunteers. The con- tion). sultant might be asked to perform any or The mental health consultation model all of these functions during a particular and the planner and implementer model day. are currently the two primary modes of For a few practitioners who conceive of functioning for the community psychiatrist.
ROBERT S. DANIELS
51
understanding patients also contributed their share. Family diagnosis and therapy, short-term treatment, and crisis-oriented therapy are examples. For the first time hospital populations began to decrease and it became apparent that most patients could be maintained in the community. Changes were also occurring in education. Increasing time in the medical undergraduTHE HISTORICALAND THEORETICAL BASE ate curriculum and mushrooming residency training programs, led to increasing human OF COMMUNITY PSYCHIATRY resources both in number and quality of Some psychiatrists have felt that the personnel. Literature, the popular press, community psychiatry movement has been and various art forms became preoccupied imposed from outside the profession and with psychiatry and psychoanalysis. The is not based on developments occurring public was enthusiastic about what psynaturally and spontaneously from within. chiatry seemed to know and the possiSome have complained that the Federal bility that this discipline might have inGovernment, the National Institute of formation which would promote improved Mental Health, or their representatives are mental health and a vague entity called imposing the community psychiatry pro- happiness. gram onto an unwilling and uncertain As a result of these changes and an inprofession. creasing recognition of the nature and However, a careful evaluation of psy- extent of the problems faced, the Joint chiatry since 1940 demonstrates certain Commission on Mental Illness and Health trends which are the bases for the commu- (1961) was empowered by Congress to nity psychiatry development. During World make a five-year study. Thirty-six national War II, many psychiatrists left their pri- agencies concerned with mental health and vate offices or institutions and entered welfare participated in this multidisciplimilitary service. There, they provided di- nary study. Included were many respected rect services to personnel and often ad- and experienced psychiatrists. As a result vised command about questions concerning of this report President Kennedy proposed the organization of psychiatric and social legislation which would promote services services, education for officers and enlisted for mental health and retardation. His personnel, policy formation, and problems proposals led Congress to enact legislation of morale. The beginnings of many of the which, when it is implemented, will proprinciples currently utilized in community mote community psychiatry programs. psychiatry are to be found in these military This brief examination of recent history experiences; e.g., early recognition, treat- suggests that community psychiatry is ment close to the source of disability, based on sound developments within gencrisis-oriented treatment promoting adapta- eral psychiatry. Application of this knowltion and return to duty, and consultation edge could lead to better treatment and to command about issues of general con- rehabilitation, and possibly even prevencern. tion for broader population segments. HowIn the late forties and early fifties, a ever, the theoretic and experimental bases series of developments occurred which for community psychiatry continue to be significantly changed the large mental hos- uncertain. Since psychiatry is at the bepital. They included the therapeutic com- ginning of this endeavor and our results munity development, milieu therapy, the are likely to be uncertain and erratic, open hospital, and the new tranquilizing ongoing methods of appraisal must be and anti-depressive drugs. Experimentation included with programs. Without research in new techniques for approaching and with careful design, clinical impressions In urban or well developed areas most general psychiatrists, who spend a limited time in community psychiatry activities, will follow a consultation model. In areas poorly supplied with social and psychiatric services, the psychiatrist may be asked to assist in planning, facilitating, and arranging services for his community.
52
THE COMMUNITY MENTAL HEALTH JOURNAL
wiU emerge, but these may not be translatable into principles. Psychiatry must move as rapidly as possible to confirm or deny these impressions so that new programs may be based on solid data and old mistakes will not be repeated. Out of such research may come a scientific basis for what is currently a beginning discipline. EDUCATION IN COMMUNITY PSYCHIATRY FOR PSYCHIATRIC RESIDENTS
Varying opinions are common when questions arise, such as how, when, and to what extent community psychiatry should be included in our residency curriculum. Many psychiatric educators believe that the curriculum is already crowded and could not possibly be extended to include new or different training. Others express the opinion that community psychiatry is nothing new. It only represents a formal expression of what they have been doing all along. A few discuss community psychiatry training as unimportant and unnecessary. Some educators conceive of these community psychiatry experiences as the basic ones within their residency program. For others, the solution has been to conceive of training in community psychiatry as occurring in the post-residency period and as comparable to subspecialty training, such as child psychiatry. Many residency programs are including some training in the community psychiatry arena. A few have decided, either because of lack of facilities or interest, that this training will not be included in their program. At the University of Chicago, Department of Psychiatry, a committee has examined these issues. The following paragraphs summarize a program which seems possible and productive within a particular setting. In order to understand accurately a new training development, a brief examination of the environment in which it occurs is essential. It is only with such information that it becomes possible to evaluate criti. cally the reasons for certain decisions, planning, and action. This Department is staffed by a complete, full-time staff which is permitted no outside compensation. The
University of Chicago Hospitals and Clinics include a 750-bed general hospital complex that serves a private socioeconomic population, ranging from upper lower class to lower upper class. Almost no indigent patients are treated. The Department and training are psychoanalytically and socially oriented. Biological psychiatry is not strongly represented. Organization within the Department is according to clinical function and includes the following sections: Inpatient, Consultation and Liaison, Outpatient, Child Psychiatry, and Student Mental Health. In addition, the Department is affiliated with a 60-bed unit at the Illinois State Psychiatric Institute, a research and educational state hospital approximately 20 minutes away by car. There are 15 residents in adult psychiatry equally divided between three years. The residency program has consisted of three- or six-month rotations on each of these services, ongoing outpatient contacts, intensive supervision of both of these, a didactic curriculum, and a six-month elective period in the third year. In addition, each resident spends a half-day a week for several months in community facilities including a home for the aged, the municipal court, a social agency, a community receiving hospital, and a state hospital. In the past, residents completing this program have predominately entered analyticallyoriented private practice (almost 80 per cent) or academic settings (about 20 per cent). Significantly, 24 of the last 25 residents to complete the program are spending at least one-half day a week in work which follows the community psychiatry model. Recent changes in psychiatry, particularly the community psychiatry development, and in increasing interest in research training led the Department to reevaluate its curriculum. The question repeatedly asked during this evaluation was whether a core program can be defined for the education of residents. What is essential? What is superfluous? Where does the resident learn? Where are there service demands which exclude optimum learning? What is resident training for? Is part of
ROBERT S. DANIEL$ this training general and for all? Is a part of the training specialized and for a few? In the course of this evaluation a core curriculum was devised. The core includes a two-year sequence of clinical rotations, ongoing outpatient treatment, supervision of both of these, and a series of didactic seminars. The third year will be elective; opportunities for a fourth year will also be available. The resident may choose one of the following four paths at the third year level: (a) individual psychotherapy, (b) child psychiatry, (c) community psychiatry, or (d) research. Each path has a coordinator who facilitates the arrangement of an individually different curriculum for each resident during the third and elective fourth year. The core of the first two years is in basic clinical psychiatry plus diagnostic and therapeutic work with individual patients, families, and small groups. In addition, the first two years will encompass an introductory experience in each of the other potential paths. These introductions involve a 3-month rotation in child psychiatry, an 18-month seminar in research methods, a half-day a week clinical experience in community psychiatry, and a 24-month seminar in community psychiatry. For the purposes of this presentation, attention will be focused on the community psychiatry segment of the curriculum. Daniels and Margolis (1965) have commented previously on the integration of community psychiatry attitudes and knowledge into traditional service rotations. Emphasized in that presentation were the understanding of small group or family diagnosis and therapy, community organization, leadership, decision-making, communication with experienced and inexperienced collaborators, leading a team, becoming a team member, teaching, consultation in the medical setting, the use of community resources, and case finding. Simultaneously with these experiences on the clinical services, residents will spend a half-day a week in a community facility where, in the first year, he will be a member of a working team. This rotation will include three months at each of four facili-
53
ties: a home for the aged, a family court, a social agency, and a community-oriented state hospital. During the second year, the resident will have a prolonged experience with one agency or facility and brief observational experiences in several others. He will actually participate in consultative and educational roles under the supervision of the full-time staff. In addition to those mentioned above, further possibilities for such community experiences in depth include a school, a halfway house, an agency for the physically handicapped, a visiting nurses association, work with ministers, and work with the police. Members of the faculty have already established consulting relationships with these facilities and professionals. The seminar will provide the opportunity to share and examine the different experiences that residents have had. In addition, it will be a place to probe the structure of the Chicago community and interact with its political and social leaders. Among the participants in the seminar will be individuals such as the Chief of Police, aldermen, representatives of the Board of Health, directors of community organizations and agencies, and others. Also considered, will be a basic introduction to ecology and epidemiology, public health psychiatry, social psychiatry, and community structure and organization. Understanding and applying research methodology to the evaluation of programs of practice will be emphasized. The third- and fourth-year programs will include additional intensive field experiences with one or more placements. The training will be tailored to the individual needs and goals, but research will play a significant part. Opportunities are available through other segments of the University for intensive work in basic science areas or for consultation with experts in specialized areas of research interest. The purpose of this program is to provide all trainees with experience and supervision which will lead to competence for part-time functioning in community psychiatry. For a few trainees it will provide
54
THE COMMUNITY MENTAL HEALTH JOURNAL
a specialized opportunity comparable to subspecialty training.
in planning programs of treatment and rehabilitation, it does not have ready or easy answers. The public should not be led to THE FUTURE OF COMMUNITY PSYCHIATRY expect more than psychiatry can deliver and there must be constant interaction Predictions are difficult and uncertain. about psychiatry's strengths and its limitaHowever, psychiatric educators attempt to tions. To promise a great deal and to acorient their educational endeavors to the complish little courts disaster where conpractitioners of the future. Thus, the future tinuing public and political support are of community psychiatry must be appraised essential. The broad trends seem dearer although whether, eventually, the appraisal proves right or wrong. Some psychiatrists will the details remain obscure. Community certainly choose to remain uninvolved in psychiatry will attract an increasing numthis type of practice. However, as interest ber of psychiatrists. For most it will be within psychiatry increases, as social and integrated into their usual practice activipolitical support is intensified, and as edu- ties. For others it will be a part-time encational programs are improved, most psy- deavor which will offer a welcome break in chiatrists will probably devote more time ordinary office and hospital routines. For to this type of activity. For most, this effort an increasing number it will become a subwill continue to be limited and partial. specialty. It seems unlikely that community But for an increasing number of psy- psychiatry will develop into a new profeschiatrists, community psychiatry will be- sion. Psychiatric training programs are come a predominant area of practice. These undergoing changes which will probably psychiatrists will be receiving increasing result in more effective training in comtraining opportunities and ultimately there munity psychiatry. Training will include may well be a subspecialty comparable to experiences in the community, opportunities for supervised consultation, and didacchild psychiatry. Experiences and research in community tic teaching. Most residency programs will psychiatry will certainly influence general include part or all of these. A few programs psychiatric practice. Now community psy- will continue to offer specialized training. The arbitrary and unreconcilable arguchiatry programs are largely based on inments which introduced this paper have sights derived from the rest of psychiatry been examined. An appraisal of the current and other disciplines. As experiences multiply and program and basic research is state of affairs reveals that community accomplished, certainly valuable clinical in- psychiatry is neither without basis nor sights will be translated back into the certain of success. However, community theory and practice of general psychiatry. psychiatry clearly has developing potential which requires attention and exploraHowever, there are certain danger signals tion. in current public support and pressure. REFERENCES Constructive developments will require more than money and community approval. CAPLAN, G. Principles o] preventive psychiatry. Too often the general public has believed New York: Basic Books, 1964. that the psychiatrist has solutions to its DANmLS, R. & MARCOLIS,P. The integration of community psychiatry training in a traditional many problems: e.g., delinquency, criminal psychiatric residency. Ment. Hyg., N.Y., 1965, behavior, drug addiction, alcoholism, ille49, 17-26. gitimate pregnancy, school dropouts, unem- JOINT COMMISSION ON MENTAL ILLNESS AND ployment, automation, mental retardation, HEALTH.Action ]or mental health. New York: Basic Books, 1961. school integration, and aging. Although psychiatry has a contribution to make to- KmSLF~, F. Is this psychiatry? In S. Goldston (Ed.), Concepts o] community psychiatry. ward understanding these syndromes and Bethesda: Public Health Service Publication, problems, and although it may participate 1965.
COMMUNITY
PSYCHIATRY
A DEVELOPING
A NEW
SUBSPECIALTY,
CLINICAL
PROFESSION,
OR
PSYCHIATRY
EFFECTIVE ?
ROBERT S. DANIELS, M.D.* than good psychiatry. We have been practicing in this way for 15 years." "Our training program has always offered broad training in the use of community facilities. That is all that this so-called 'new psychiatry' amounts to." "The community psychiatry movement is being imposed upon us by the National Institute of Mental Health, the Federal Government, and certain individuals." "There is no basis of knowledge or experience for community psychiatry practice. It is a gigantic boondoggie. We will raise the public hopes for help with their myriad social problems and then we will disappoint them." "Community psychiatry is not psychiatry but a new specialty." This paper attempts to examine the development of community psychiatry, assess its place in the history of our science and practice, explore the additions and modifications which may be indicated in many of our residency training programs, and indicates some directions in which community psychiatry may influence psychiatric theory and practice. It is based on interrelated but somewhat dissimilar personal experiences and interests during the last several years: (a) A long standing interest in social psychiatry and the interface between individual psychodynamics and the current environment; (b) participation in the planning and execution of the first Institute on Training in Community Psychiatry, jointly sponsored by the University of Chicago, Department of Psychiatry, and the Training Branch of the National Institute of Mental Health, in October 1963; (c) continuing discussions within the Group for the Advancement of
Developments in community psychiatry are creating great controversy within the profession. This paper examines community psychiatry, assesses its place in the history of our science and practice, explores possible additions and modifications in residency training, and suggests possible patterns of practice. Community psychiatry is based on more than 20 years of developments within the profession. As such, there is a solid but limited base for its operation. Extensive program and basic research are essential More psychiatrists will spend more time in the future in community psychiatry activities. Some will become specialists in community psychiatry, a subspeciahy within the field of psychiatry. The controversy associated with community psychiatry developments is best illustrated by a series of statements which have been frequently heard during the last few years. Advocates have said, "Community psychiatry is the psychiatry of the future. We are in the midst of a third psychiatric revolution which will result in new patterns of psychiatric practice. The community psychiatrist will play an important part in community organization and planning. In this planned society the psychiatrist is a key figure. Social and psychiatric facilities will be coordinated. Any contact with an individual or family will be noted and that record will be available to all planning and treating facilities and individuals." "Psychiatrists must be gotten out of their ogices and into the community." "Our training programs need modification. They do not offer enough training in community psychiatry." Opponents make statements such as, "Community psychiatry is nothing more
*Dr. Daniels, a psychiatrist, is Associate Professor and Acting Chairman, Department of Psychiatry, University of Chicago, Chicago, Illinois. This paper was initially presented at a Joint Meeting of the Ohio Medical Association and the Ohio Psychiatric Association in May, 1965. 47
48
THE 'COMMUNITYMENTAL HEALTH JOURNAL
Psychiatry Committee on Medical Education; and (d) the evaluation of the residency training program at the University of Chicago in the Department of Psychiatry's Residency Curriculum Review Committee. WHAT IS COMMUNITYPSYCHIATRY? Community psychiatry is a developing body of knowledge and practice which relates psychiatric and social science principles to large population groups. Its body of theory is known as social psychiatry and is derived from ecology and epidemiology, public health and preventive medi. cine, social systems theory, and community organization. It is also based on the psychologic insights of individual and small group dynamics and an understanding of family structure and organization. It has as its broad goals the establishment of programs for early diagnosis and treatment, rehabilitation, and, so far as currently possible, prevention. Psychiatrists practicing in this area do so as consultants to community facilities, as planners for the establishment of social and psychiatric resources within population groups, or as providers of traditional psychiatric services through clinic and hospital facilities serving a specified population. In most community psychiatry programs, certain fundamental principles are followed. These principles are: 1. The population group to be served is defined. It must be small enough that communication among professionals and between professional and client is facilitated. 2. The principle of minimal intervention is the core of the service provided. Maximum use is made of the client's adaptive capacities. 3. The firing line professional manages most cases. 4. The service is close to the client and especially devised to meet his individual needs. 5. Emphasis is on increased awareness, early detection, and immediate intervention, particularly at times of crisis.
6. Simple and immediate services are available first. 7. Complex, special or lengthy services are obtained by referral to centrally located facilities. 8. The ability to pay is not a primary requisite for service. 9. The community psychiatry specialist spends more time in consultation with firing line professionals than in direct contact with patients. 10. Individual cases are viewed as examples of groups of cases. Case finding in similar populations and in families is important. 11. At the time of referral, there is a free flow of client and information from one professional to another. On completion of the service, referral back to the original source is not only possible but encouraged. 12. Institutions have an optimum size. Large institutions are psychologically, socially, and economically unsound. In some instances, they may lead to sustaining mental illness rather than to treating it. A typical community psychiatry program might take as its focus a population unit varying from tens of thousands to several hundred thousand people. This unit could be defined politically as a city or a county, geographically as a neighborhood or section, or functionally as an industry or school system. Centrally located within this unit would be a community mental health center which would consist of a large consultation and outpatient facility and a small hospital of several hundred beds. The inpatient facility would be composed of several units which provide flexible services for particular ages or special problems. Special services might consist of units for children, adolescents, aged, alcoholics, and the mentally retarded. Halfway house, day care, night care, and full-time units would be included. Emphasis within this setting would be on diagnosis and brief reconstitutive treatment. Long-term treatment and custodial treatment would occur in a separate and different setting.
ROBERT S, DAMELS This center would emphasize its outpatient and consultative functions. Therapy in the outpatient section would be brief, and the focus would be crisis and reality oriented. Whenever possible the staff avoids direct patient contact; evaluation is accomplished, rather, by utilizing the information the referring person or agency already has available. When referring a patient or client, the consulting agency or individual participates in the consultation and continues its primary responsibility. Relinquishing responsibility is ordinarily temporary and occurs when the consultant has a service available which is indicated for the patient and which the referrer cannot provide. Examples of such services might be comprehensive psychiatric diagnosis, the evaluation of certain medical-legal problems, or specialized psychiatric treatment. If the center accepts the client or patient in transfer, it is for a brief period and the accomplishment of explicit goals, after which transfer back to the referring individual or agency is indicated. If possible, the original referrer continues to be active while the specialty facility performs its particular function.
49
Consultation services are provided for individuals and institutions in the community. Attempts are made to appraise collaboratively the programs of emotional support available through schools, churches, social agencies, legal institutions, and others, and to relate them to one another in order to provide a variety of services available in continuity. Consultation may be offered on classes of problems such as delinquency, school failure, school dropouts, illegitimacy, alcoholism, mental retardation, broken families, child care, etc. It is hoped that such consultations are educational as well as problem oriented and will increase the capacity of the individual or the agency to manage similar problems in the future. Under ordinary circumstances, the firing line professional is an individual who does not define his role as a primary mental health one. Included in this group are physicians, public health and visiting nurses, teachers, clergymen, lawyers, policemen, and others. Their advice or counsel is frequently sought early by individuals with emotional problems. They are usually readily available in the community. Also
FIGURE I AN EXAMPLEOF A COMMUNITYPSYCHIATRYPROGRAM Level I Major Firing Line Professionals
Level II Agencies for Social and MedicalDiagnosis and Brief Treatment
Nonpsychiatrie Physician
Community psychiatric clinics Psychiatric services in general hospital
Visiting or Pubic Health Nurse Teacher Minister Lawyer
Guidance-counseling systems in schools
Policeman
Diagnostic services in courts
Other
Other
Social agencies Vocational and psychologic rehabilitation services
Level HI
Level IV
CommunityPsychiatry Centers
Large Hospital Facilities
Consultation services to fellow professionals a) To all levels h) To all individuals Consultation services to patients (outpatient)
Inpatient services (200300 beds) a) Diagnosis and short-term treatment b) Specialservices
Long-termtreatment and custodial facilities
50
THE COMMUNITY MENTAL HEALTH JOURNAL
the troubled person often has a preexistent relationship which facilitates contact. These firing line professionals already manage most instances of emotional disorder. These principles are demonstrated in Figure 1.
themselves as community psychiatry specialists, the mental health consultation has become the major vehicle of their practice. Kiesler (1963) is responsible for the psychiatric and social services in a threecounty area in rural northern Minnesota. His staff consists of himself, a psychologist, and a social worker. They insist that the EXAMPLES OF COMMUNITYPSYCHIATRY referring individual or agency retain priPRACTITIONERS mary responsibility for the patient or Many psychiatrists spend some time in family in distress. Whenever possible, the activities which could be called community clinic staff sees the referring professional, psychiatry. These activities often involve rather than the patient, using his informaa half-day or a day each week. They are tion to understand the case and plan with a break in their usual private practice, the professional his course of action. Apacademic or institutional routine. In such proximately 80 per cent of their staff time activities, the psychiatrist usually visits a is spent in indirect and program consultacommunity facility such as a clinic, hos- tion with such widely diverse professionals pital, social agency, court, or school. His as physicians, visiting nurses, teachers, purposes are to offer consultation and welfare workers, and ministers. Only 20 educational opportunities to the staff of the per cent of their time is occupied with agency or institution. Although he may see direct patient service. patients, usually he does not. His consultAnother model of community psychiatry ing activities may be patient centered, either practice results from a request to a psydirectly or indirectly, staff centered or pro- chiatrist by an organization, institution, gram centered (Caplan, 1964). or population unit to plan and organize An example will clarify these various social and psychiatric services. Examples kinds of activities. A psychiatrist consults may be found in colleges, industry, and the a half-day each week at a halfway house military services. This model also exists in and rehabilitation agency. The agency is population and political units such as cities, staffed by social workers, nurses, occupa- counties, or states. The activities of this tional therapists, vocational rehabilitation psychiatrist include planning for primary, workers, and volunteers. The client popula- secondary, and tertiary prevention. The tion is a group of approximately 200 head of a department of mental health for chronic ambulatory schizophrenics. At a political unit, such as a large city or times the psychiatric consultant sees clients state, is an illustration. He recommends and directly. More often he is presented data implements the establishment of programs by a staff member about a client. In this of maternal care and adoption which will type of consultation, he emphasizes the provide adequate and consistent care for training aspects of the interaction, helping children with absent or disturbed maternal to increase the staff's capacity for under- relationships (primary prevention). He esstanding and dealing with the problems tablishes clinics which are available for the presented by their clients. At other times, early detection and treatment of a patient's the psychiatrist may consult with staff disability (secondary prevention). He orabout intrastaff problems or about plan- ganizes state hospitals and a continuity of ning new programs. On still other occa- post-hospital services to provide social and sions he plays a more clearly educational vocational rehabilitation (tertiary prevenrole with staff and volunteers. The con- tion). sultant might be asked to perform any or The mental health consultation model all of these functions during a particular and the planner and implementer model day. are currently the two primary modes of For a few practitioners who conceive of functioning for the community psychiatrist.
ROBERT S. DANIELS
51
understanding patients also contributed their share. Family diagnosis and therapy, short-term treatment, and crisis-oriented therapy are examples. For the first time hospital populations began to decrease and it became apparent that most patients could be maintained in the community. Changes were also occurring in education. Increasing time in the medical undergraduTHE HISTORICALAND THEORETICAL BASE ate curriculum and mushrooming residency training programs, led to increasing human OF COMMUNITY PSYCHIATRY resources both in number and quality of Some psychiatrists have felt that the personnel. Literature, the popular press, community psychiatry movement has been and various art forms became preoccupied imposed from outside the profession and with psychiatry and psychoanalysis. The is not based on developments occurring public was enthusiastic about what psynaturally and spontaneously from within. chiatry seemed to know and the possiSome have complained that the Federal bility that this discipline might have inGovernment, the National Institute of formation which would promote improved Mental Health, or their representatives are mental health and a vague entity called imposing the community psychiatry pro- happiness. gram onto an unwilling and uncertain As a result of these changes and an inprofession. creasing recognition of the nature and However, a careful evaluation of psy- extent of the problems faced, the Joint chiatry since 1940 demonstrates certain Commission on Mental Illness and Health trends which are the bases for the commu- (1961) was empowered by Congress to nity psychiatry development. During World make a five-year study. Thirty-six national War II, many psychiatrists left their pri- agencies concerned with mental health and vate offices or institutions and entered welfare participated in this multidisciplimilitary service. There, they provided di- nary study. Included were many respected rect services to personnel and often ad- and experienced psychiatrists. As a result vised command about questions concerning of this report President Kennedy proposed the organization of psychiatric and social legislation which would promote services services, education for officers and enlisted for mental health and retardation. His personnel, policy formation, and problems proposals led Congress to enact legislation of morale. The beginnings of many of the which, when it is implemented, will proprinciples currently utilized in community mote community psychiatry programs. psychiatry are to be found in these military This brief examination of recent history experiences; e.g., early recognition, treat- suggests that community psychiatry is ment close to the source of disability, based on sound developments within gencrisis-oriented treatment promoting adapta- eral psychiatry. Application of this knowltion and return to duty, and consultation edge could lead to better treatment and to command about issues of general con- rehabilitation, and possibly even prevencern. tion for broader population segments. HowIn the late forties and early fifties, a ever, the theoretic and experimental bases series of developments occurred which for community psychiatry continue to be significantly changed the large mental hos- uncertain. Since psychiatry is at the bepital. They included the therapeutic com- ginning of this endeavor and our results munity development, milieu therapy, the are likely to be uncertain and erratic, open hospital, and the new tranquilizing ongoing methods of appraisal must be and anti-depressive drugs. Experimentation included with programs. Without research in new techniques for approaching and with careful design, clinical impressions In urban or well developed areas most general psychiatrists, who spend a limited time in community psychiatry activities, will follow a consultation model. In areas poorly supplied with social and psychiatric services, the psychiatrist may be asked to assist in planning, facilitating, and arranging services for his community.
52
THE COMMUNITY MENTAL HEALTH JOURNAL
wiU emerge, but these may not be translatable into principles. Psychiatry must move as rapidly as possible to confirm or deny these impressions so that new programs may be based on solid data and old mistakes will not be repeated. Out of such research may come a scientific basis for what is currently a beginning discipline. EDUCATION IN COMMUNITY PSYCHIATRY FOR PSYCHIATRIC RESIDENTS
Varying opinions are common when questions arise, such as how, when, and to what extent community psychiatry should be included in our residency curriculum. Many psychiatric educators believe that the curriculum is already crowded and could not possibly be extended to include new or different training. Others express the opinion that community psychiatry is nothing new. It only represents a formal expression of what they have been doing all along. A few discuss community psychiatry training as unimportant and unnecessary. Some educators conceive of these community psychiatry experiences as the basic ones within their residency program. For others, the solution has been to conceive of training in community psychiatry as occurring in the post-residency period and as comparable to subspecialty training, such as child psychiatry. Many residency programs are including some training in the community psychiatry arena. A few have decided, either because of lack of facilities or interest, that this training will not be included in their program. At the University of Chicago, Department of Psychiatry, a committee has examined these issues. The following paragraphs summarize a program which seems possible and productive within a particular setting. In order to understand accurately a new training development, a brief examination of the environment in which it occurs is essential. It is only with such information that it becomes possible to evaluate criti. cally the reasons for certain decisions, planning, and action. This Department is staffed by a complete, full-time staff which is permitted no outside compensation. The
University of Chicago Hospitals and Clinics include a 750-bed general hospital complex that serves a private socioeconomic population, ranging from upper lower class to lower upper class. Almost no indigent patients are treated. The Department and training are psychoanalytically and socially oriented. Biological psychiatry is not strongly represented. Organization within the Department is according to clinical function and includes the following sections: Inpatient, Consultation and Liaison, Outpatient, Child Psychiatry, and Student Mental Health. In addition, the Department is affiliated with a 60-bed unit at the Illinois State Psychiatric Institute, a research and educational state hospital approximately 20 minutes away by car. There are 15 residents in adult psychiatry equally divided between three years. The residency program has consisted of three- or six-month rotations on each of these services, ongoing outpatient contacts, intensive supervision of both of these, a didactic curriculum, and a six-month elective period in the third year. In addition, each resident spends a half-day a week for several months in community facilities including a home for the aged, the municipal court, a social agency, a community receiving hospital, and a state hospital. In the past, residents completing this program have predominately entered analyticallyoriented private practice (almost 80 per cent) or academic settings (about 20 per cent). Significantly, 24 of the last 25 residents to complete the program are spending at least one-half day a week in work which follows the community psychiatry model. Recent changes in psychiatry, particularly the community psychiatry development, and in increasing interest in research training led the Department to reevaluate its curriculum. The question repeatedly asked during this evaluation was whether a core program can be defined for the education of residents. What is essential? What is superfluous? Where does the resident learn? Where are there service demands which exclude optimum learning? What is resident training for? Is part of
ROBERT S. DANIEL$ this training general and for all? Is a part of the training specialized and for a few? In the course of this evaluation a core curriculum was devised. The core includes a two-year sequence of clinical rotations, ongoing outpatient treatment, supervision of both of these, and a series of didactic seminars. The third year will be elective; opportunities for a fourth year will also be available. The resident may choose one of the following four paths at the third year level: (a) individual psychotherapy, (b) child psychiatry, (c) community psychiatry, or (d) research. Each path has a coordinator who facilitates the arrangement of an individually different curriculum for each resident during the third and elective fourth year. The core of the first two years is in basic clinical psychiatry plus diagnostic and therapeutic work with individual patients, families, and small groups. In addition, the first two years will encompass an introductory experience in each of the other potential paths. These introductions involve a 3-month rotation in child psychiatry, an 18-month seminar in research methods, a half-day a week clinical experience in community psychiatry, and a 24-month seminar in community psychiatry. For the purposes of this presentation, attention will be focused on the community psychiatry segment of the curriculum. Daniels and Margolis (1965) have commented previously on the integration of community psychiatry attitudes and knowledge into traditional service rotations. Emphasized in that presentation were the understanding of small group or family diagnosis and therapy, community organization, leadership, decision-making, communication with experienced and inexperienced collaborators, leading a team, becoming a team member, teaching, consultation in the medical setting, the use of community resources, and case finding. Simultaneously with these experiences on the clinical services, residents will spend a half-day a week in a community facility where, in the first year, he will be a member of a working team. This rotation will include three months at each of four facili-
53
ties: a home for the aged, a family court, a social agency, and a community-oriented state hospital. During the second year, the resident will have a prolonged experience with one agency or facility and brief observational experiences in several others. He will actually participate in consultative and educational roles under the supervision of the full-time staff. In addition to those mentioned above, further possibilities for such community experiences in depth include a school, a halfway house, an agency for the physically handicapped, a visiting nurses association, work with ministers, and work with the police. Members of the faculty have already established consulting relationships with these facilities and professionals. The seminar will provide the opportunity to share and examine the different experiences that residents have had. In addition, it will be a place to probe the structure of the Chicago community and interact with its political and social leaders. Among the participants in the seminar will be individuals such as the Chief of Police, aldermen, representatives of the Board of Health, directors of community organizations and agencies, and others. Also considered, will be a basic introduction to ecology and epidemiology, public health psychiatry, social psychiatry, and community structure and organization. Understanding and applying research methodology to the evaluation of programs of practice will be emphasized. The third- and fourth-year programs will include additional intensive field experiences with one or more placements. The training will be tailored to the individual needs and goals, but research will play a significant part. Opportunities are available through other segments of the University for intensive work in basic science areas or for consultation with experts in specialized areas of research interest. The purpose of this program is to provide all trainees with experience and supervision which will lead to competence for part-time functioning in community psychiatry. For a few trainees it will provide
54
THE COMMUNITY MENTAL HEALTH JOURNAL
a specialized opportunity comparable to subspecialty training.
in planning programs of treatment and rehabilitation, it does not have ready or easy answers. The public should not be led to THE FUTURE OF COMMUNITY PSYCHIATRY expect more than psychiatry can deliver and there must be constant interaction Predictions are difficult and uncertain. about psychiatry's strengths and its limitaHowever, psychiatric educators attempt to tions. To promise a great deal and to acorient their educational endeavors to the complish little courts disaster where conpractitioners of the future. Thus, the future tinuing public and political support are of community psychiatry must be appraised essential. The broad trends seem dearer although whether, eventually, the appraisal proves right or wrong. Some psychiatrists will the details remain obscure. Community certainly choose to remain uninvolved in psychiatry will attract an increasing numthis type of practice. However, as interest ber of psychiatrists. For most it will be within psychiatry increases, as social and integrated into their usual practice activipolitical support is intensified, and as edu- ties. For others it will be a part-time encational programs are improved, most psy- deavor which will offer a welcome break in chiatrists will probably devote more time ordinary office and hospital routines. For to this type of activity. For most, this effort an increasing number it will become a subwill continue to be limited and partial. specialty. It seems unlikely that community But for an increasing number of psy- psychiatry will develop into a new profeschiatrists, community psychiatry will be- sion. Psychiatric training programs are come a predominant area of practice. These undergoing changes which will probably psychiatrists will be receiving increasing result in more effective training in comtraining opportunities and ultimately there munity psychiatry. Training will include may well be a subspecialty comparable to experiences in the community, opportunities for supervised consultation, and didacchild psychiatry. Experiences and research in community tic teaching. Most residency programs will psychiatry will certainly influence general include part or all of these. A few programs psychiatric practice. Now community psy- will continue to offer specialized training. The arbitrary and unreconcilable arguchiatry programs are largely based on inments which introduced this paper have sights derived from the rest of psychiatry been examined. An appraisal of the current and other disciplines. As experiences multiply and program and basic research is state of affairs reveals that community accomplished, certainly valuable clinical in- psychiatry is neither without basis nor sights will be translated back into the certain of success. However, community theory and practice of general psychiatry. psychiatry clearly has developing potential which requires attention and exploraHowever, there are certain danger signals tion. in current public support and pressure. REFERENCES Constructive developments will require more than money and community approval. CAPLAN, G. Principles o] preventive psychiatry. Too often the general public has believed New York: Basic Books, 1964. that the psychiatrist has solutions to its DANmLS, R. & MARCOLIS,P. The integration of community psychiatry training in a traditional many problems: e.g., delinquency, criminal psychiatric residency. Ment. Hyg., N.Y., 1965, behavior, drug addiction, alcoholism, ille49, 17-26. gitimate pregnancy, school dropouts, unem- JOINT COMMISSION ON MENTAL ILLNESS AND ployment, automation, mental retardation, HEALTH.Action ]or mental health. New York: Basic Books, 1961. school integration, and aging. Although psychiatry has a contribution to make to- KmSLF~, F. Is this psychiatry? In S. Goldston (Ed.), Concepts o] community psychiatry. ward understanding these syndromes and Bethesda: Public Health Service Publication, problems, and although it may participate 1965.
