EDUCATING THE FUTURE MENTAL HEALTH EXECUTIVE: A Public Health Approach by Sheila W. Wellington and Elizabeth C. Bellis

The threshold questions for those concerned about developing administrators who can function effectively in the changing mental health world are: who should be trained, where should they be trained, and what should the training curriculum be. These are certainly not new questions. Training programs have come and gone over the years, sponsored by a variety of institutions. Mental health administrators have come out of the clinical disciplines, business, public administration, hospital administration, and public health schools. They have received academic, professional, special insititute, or on the job training. A less chancey, more promising approach to training may take shape if we recognize the basic requirements summarized by Feldman (1973). What mental health administrators should know (or at least be taught) must be a function of what they do. The content of training programs in mental health administration m u s t be determined by the nature of the

Sheila W. Wellington is a faculty member in the Departments of Psychiatry and Public Health, Yale University, and Associate Director, Administrative Services, Hill-West Haven Division of the Connecticut Mental Health Center. Elizabeth C. Bellis is Assistant Dean, Public Health Curriculum, Yale University.


administrative task. Knowledge of the way mental health administrators spend their time, the major decisions they make, the structures within which they work and the primary people with whom they interact is not yet available, at least in any comprehensive sense. Given the tendency of t e a c h i n g p r o g r a m s to b e c o m e e n t r e n c h e d once e s t a b l i s h e d , new training programs must be related to the real worm of mental health services in which the administrator functions. We agree with Feldman that training programs must be defined by the nature of the tasks that graduates will undertake. These tasks have in some ways changed so radically that new types of mental health executives are needed. Even a decade ago, Dr. Walter Barton, then president of the American Psychiatric Association, was calling for courses, institutes, field training, and programs to raise the status and expertise of those he called in his 1961 presidential address, "vanishing Americans-mental hospital administrators and commissioners." But federally sponsored programs of that period were geared mainly to training "clinical specialists." Administrators at top levels were usually physicians, charged not only with running large hospitals thought to be on their way out but also with the responsibility for treating thousands of sick patients and for such

training as still went on in these hospitals. In their beginnings, mental health centers also focused on treatment programs for sick individuals, this time in the community, the statutorily mandated consultation and education service being poorly understood and implemented. More prestige attached to the clinician-administrator in the center setting than the state hospital, particularly where the center had a university affiliation. But the nature of the task was changing. Out of the 60's came the push for a different interpretation of community, of mental health, and of mission for the centers. Similarly, but more slowly, the functions of the state hospital as well as of private institutions were changing as well. As patients in residence decreased, readmissions spiraled. The need for linkages, for developing programs at the interface of community services and state hospitals, for management of new varieties of personnel in new types of settings became clear. Indeed, even the patient population had changed. The shortage of psychiatrists trained for, and interested in, management of such programs became clear as well. A series of articles in the N e w York Times in the fall of 1974 describing the release of thousands of patients from New York mental institutions into communities lacking facilities to care for them brought into public view what professionals in the field have long k n o w n - that there is a growing crisis in mental health services both in New York and in much of the nation as well. The former President of the American Psychiatric Association, Dr. John P. Spiegel, is reported as saying (in the same Times series) that the crisis in the states "is going to bring a new breed into these (top administrative) jobs who can deal with the complexities of these systems. I think it is true that those who have charge of the mental health systems of the states are not competent to handle them."

Emphasis on Public Health It is the thesis of this article, and of the

evolving Yale programs, that this "new breed" should be public health administrators with non-clinical training in mental health. If one agrees with Feldman (1974) as we do, that mental health administration is "a professional career and a field of knowledge," it is difficult to understand why many physicians would want to increase the length of their already extensive training in order to become professional administrators. Further, physicians are educated to treat individual illness. The focus now needed is services in and for the community. Clinicians do have what business and public administrators lack k n o w l e d g e of illness, specifically an understanding of mental illness. It is not enough, in our opinion, to apply management skills to the mental health setting. Here the nature of the task shapes the process. Understanding the human service task does not come from intuition or good intent; it requires training and experience. It requires informed sensitivity to the dependent people involved in the service. In order to deal with mental health in any rational way, we need the larger health context as a starting point. The place to teach the concepts, principles, and skills necessary to focus on the prevention, treatment, and rehabilitation of sick individuals, to focus in on populations-at-risk, is in schools of public health. Content in public health is people and their health needs. This means that when we teach about the administration of health services we have a population in mind; we have a data base; and from these come a sensitivity to program needs. This may not be the case in schools where the content emphasis is on management or administration. Further, and here we take issue with the somewhat narrow "mental health" spectrum of Dr. Feldman's curriculum, it is only in schools of public health that emphasis can be given to: 1) the relatedness of mental health programs to general health and welfare services; 2) the importance of statistical analysis, evaluation, and research as tools in the development of organizationaland program excellence, and 3) 45

the significance of the health needs of a population as well as organizational efficiency. Thus, the curriculum supplies a background of facts and concepts and it stresses a mode of thinking about health care. In addition, the other service systems that are used by dependent clients are considered as part of the treatment network. The importance of these community systems is reflected in the trend toward training non-clinicians in health services administration programs located in schools of public health.

Core Curriculum The Yale mental health curriculum is geared to a two year M.P.H. program, with the first term devoted to core courses in public health and an introductory course in mental health management described later in this paper. The core public health curriculum is important in our planning because we believe that graduates should be problem solvers, able to transfer their health skills and knowledge from one practice setting to another as the needs of the field shift and programs change. We have certainly seen these sudden alterations of course in the mental health field. The ability to keep a solid base during transitions requires an understanding of general health care problems. Our students obtain this through an intensive survey course that includes a brief community based project experience, a course in biostatistics and a course in research methodology. The survey course, Introduction to Public Health, deals with central issues in public health practice and research. The emphasis is "on the process of critical and assumptive thinking, the data requirements needed in health planning, the socio-political complexities in planning, the strategic implications of systems, strategies for change, and the role of communities in policyformulation and planning (Yale School of Public Health 1975). 46

The basic course in health services administration describes the full range of health services, intra-organization and systems problems, the interdependence of financing problems, manpower, organization, facilities, construction, delivery, and quality of care. Students also learn how to search and analyze the health services literature. Data analysis skills are acquired in these two courses, in Biometry, and in the course, Introduction to Research Methods. Here students gain skills in evaluating the quality of public health research and in designing and carrying out applied research. In training mental health administrators, we are aware of how much these courses add to students' skills, developing their ability to conceptualize, to view health, mental health, and social policy as related to each other as well as to national moods and priorities.

Field Placements The second term adds more mental health content but general public health and the social sciences are still emphasized. In the third term students work in mental health or related field settings. This field placement experience is obviously a critical one, accepting as we do the premise that mental health administration sl~uld be defined pragmatically as what mental health administrators do. At the present time we have been successful in developing field placements in a variety of settings in the greater New Haven area. We see the need for placements at the federal and state government level, where policies are set and where many programs are implemented or short-circuited. With the federal cut back in training funds, most students now have to seek placements in agencies that provide them with at least a minimal salary. This imposes a real limitation on the potential variety of field placements as well as on the potential for placing students in agencies that might contribute most to their practice experience.

Linkage Course Experience, theory, and skills come together in the fourth term, which is given over to the completion of the Master of Public Health Essay, a continuation of the core mental health course, and to advanced electives in mental or public health. This paper describes only the newly-devised basic administrative course in mental health that links the four semesters together. The other mental health courses corespond closely to those outlined by Dr. Feldman in his curriculum. For example, we offer within the school of public health, courses in social psychiatry, mental health planning, mental health research, mental health program evaluation, epidemiology and social behavior, mental h e a l t h e d u c a t i o n , and c o m m u n i c a t i o n . Because we have strong and formal links to other parts of the university, including the medical school (in which we are a department), we can offer our students electives from administrative sciences, law, political science, sociology, and the department of psychiatry. F o r n o n - c l i n i c i a n s we offer a s h o r t "Orientation to Clinical Psychiatry," but we have decided against immersing our students in clinical material, thus avoiding, we hope, the production of the psychiatrist m a n q u e - - t h e bane of clinicians and non-clinicians alike. Although our students usually take a general course in financial management, we think that at least one additional course in management information systems should be added. The basic linkage course, Mental Health Policy, Programs, and Administration, ties together theory, program analysis, and practical experience. Students work through increasingly complex problem sets and exercises that the instructors have devised f r o m t h e i r o w n e x p e r i e n c e s in t h e administration of mental health programs. A catchmented community mental health center serving an inner city neighborhood and its adjacent industrial suburb is the chosen setting of the exercises. A table of organization is

distributed and the catchment described. Themes are developed early and resonate throughout the course. These involve issues of authority, structure, and task. As students gain experience, they develop an administrative awareness of interpersonal and policy issues, particularly the role of the non-clinician in developing programs for communities in need and for sick, dependent patients. An exercise early in the course prompts considerations of power, trust, and task. It comes from an actual experience. You are a student at the School of Epidemiology and Public Health on a field placement at the EPH Community Mental Health Center. You have been assigned by the director of the center to assist the chief of intra-mural services in developing a grant application that is due in Washington shortly. You are enjoying the work, think you are doing well, like both the chief, and the director and are eager to get a job offer from the center after graduation. After a meeting, as you are chatting with the intra-mural chief and a few other staff members, the center director approaches you and says he wants you to work directly with him on a report that he has to get out next week. The chief of intra-mural services indicates that you are still needed to assist him in the grant application. The director, in response, turns to you and says: "Look, you can certainly speak for yourself." a) You are the student. What do you do? b) You are the chief of intra-mural serv i c e s - W h a t do you do? Policy issues, questions of entry, of personnel composition and training, the differential functions and relationships between community-based facilities and state hospitals, and the value of direct patient care versus preventive efforts are explored at length in the context of the following exercise: You are the director of a two-year old 47

C M H C serving a poverty population. Your service consists of an intake and evaluation unit; an 11-bed, 30-day inpatient service; an outpatient unit; a day hospital; and a consultation service. Your catchment population is 60 percent Black; 45 percent are estimated to be on welfare. As you review your service figures, you find that the patient population is 35 percent Black, with 20 percent on welfare. The statistics on utilization of the state mental hospital serving your catchment indicate that it is seeing a higher proportion of poor Blacks than your C M H C . a) H o w do you account for this situation? b ) What program or personnel changes would you make to shift the utilization pattern? To discuss the analysis and presentation of data, we use an exercise in which a program director requests information on alcoholism treatment in the state mental hospital unit serving the center's catchment area. A series of tables is presented. Students are required to write a brief summary of each table and point out the overall program impact. They then propose services to meet the needs revealed in the tables. In this manner, data presentation and utilization are examined in the context of policies about alcohol treatment and about links between community-based facilities and state hospitals. Also explored through the class discussion are the differential roles and functions of various agencies, the implications of categorical programming, the classification of certain deviant behavior as mental illness, and "fad and fancy" in the awarding of federal funds. Reading assignments in administrative theory and practice, political science, eco-nomics, sociology, and mental health program and policy complement the exercise format. Mental health administration material is more difficult to find, although Feldman's book (1973) has filled some of the larger gaps. 48

In addition to exercises and readings, we have developed a series of mental health briefings or mini-lectures that relate directly to the content of the session and the exercise under consideration. During the latter part of the year, administrators, financial managers, planners,and evaluators come to discuss case material, to explain what they do and d e m o n s t r a t e h o w t h e y do it. T h e s e professionals are used sparingly and in context so that the course does not become haphazard. Although courses in organizational dynamics are available in the university, we ask experts in this field and in mental health to work with the students in classroom exercises around task, group, and intergroup behavior. Students also begin at this point to develop exercises that come out of their post-college experience and that they can now present within an analytic framework. In the fourth semester, the course becomes a practicum in mental health administration. Second year students, building on their field placements and introductory courses, present and analyze in their own seminar a variety of program questions and management techniques. They also review administrative issues raised in their essays and the literature. They develop their own exercises and case studies, presenting them to their own class and occasionally to the first year class. In this way, graduating students gain a sense of closure about their two years, while the first year students get some sense of what the field experience has to offer. As a result of this three semester course, the core public health curriculum, and the electives, students are expected to understand policy and program, to be aware of the special characteristics and needs of those receiving mental health services, and to be able to assess and implement organizational and personal goals. They learn how to work within systems and how to manage them, but they also study how to change and improve those systems, for that is essentially what public health is all about.



The mental health program we are developing at the Yale School of Public Health has as its basic element a broad introduction to the concepts and principles of public health and mental health administration and is rooted in concern for community well-being. It is our belief that this combination of public health mental health t r a i n i n g will p r o d u c e administrators for mental health, psychiatric and human resource agencies who will be able to design, implement, manage, and evaluate programs that improve mental health and help communities evaluate and structure the human services they need.

Feldman, S. (ed.) The Administration of Mental Health Services. Chas. C. Thomas, Springfield, Ill. 1973. Barton, W. Vanishing americans--mental hospital administrators and commissioners. Mental Hospitals, 55-61, February, 1972. Schumach, M. "State Mental System Called One of Worst." N.Y. Times, Sept. 25, 1974. 1:3. Feldman, S. Educating the future mental health executive - a graduate curriculum. Administration in Mental Health, 76, Summer 1974. Yale School of Public Health, Report to the Council on Education for Public Health, 18, 1975.

The Faculty-Fellow Consultation Firm: An Integrative Learning Experience by William G. Hollister In our search for more effective ways to educate and potentiate mental health administrators and program leaders for work in community programs, we have been experimenting for five years with faculty and trainee fellows cooperatively engaging in a "consulting firm" that contracts to do real live work. For 12 years, we have been involved in helping psychiatrists, psychologists, psychiatric nurses, social workers, hospital administrators and others acquire the performance skills that would enable them to William G. Hollister is Professor and Director, Community Psychiatry Division, Department of Psychiatry, University of North Carolina School of Medicine, Chapel Hill.

serve in leadership roles in mental health centers and other community mental health programs. As we attempted to blend tutorials, field placements, program development projects, apprenticeships, consultee-ships, and didactic seminars into an individualized curriculum to fit learning needs, we have become impressed with our trainees' critical need for integrative experiences. These are learning opportunities that "put it all together," that blend the didactic and the experiential learnings into new and more effective personal performance abilities. Supervised field experiences, on-thej o b projects, tutorials, role plays, and simulation laboratories help the trainees 49

Educating the future mental health executive: a public health approach.

EDUCATING THE FUTURE MENTAL HEALTH EXECUTIVE: A Public Health Approach by Sheila W. Wellington and Elizabeth C. Bellis The threshold questions for th...
601KB Sizes 0 Downloads 0 Views