Experience in Primary Mental Health Care Felton Earls, MD Boston, Massachusetts

The author discusses his experience as clinical director of a small mental health unit in a neighborhood health center. Deep-rooted organizational and administrative conflicts resulted in the clinical compromise of this unit's capacity to deliver needed services. Essentially, two recommendations are made to protect and foster the vitality of "primary mental health care." The first is to reduce the organizational complexity that engulfs centers such as the one described. The second is to recognize how vital the community boards of directors are to the quality of care received by patients. Board members must be provided with support and technical assistance by professional advisors and supporting agencies in order to carry out their essential missions. Introduction The ascendancy of "primary mental health" is an essential new direction in the practice of psychiatry. 1-4 Borus, who coined the phrase, includes in his definition "not only indirect consultative services to nonpsychiatric primary care givers dealing with emotional difficulties of patients, but also the direct services of diagnostic and problem evaluation, crisis intervention, timelimited therapy, family therapy, supportive counseling, posthospital care, and psychiatric medications."5 An important locus of primary mental health care is the neighborhood health center. In its effort to provide comprehensive health care to small, well defined communities, it provides several distinct advantages to mental health care. Among these are geographic and cultural accessibility, coordination with general health care, and increased psychological acceptability by patients who find these centers more trustworthy than community mental health centers because they are medical institutions.5 So important is this pattern of service delivery that it seems necessary to make efforts to protect and encourage Felton Earls, MD, is Assistant in Psychiatry, The Children's Hospital Medical Center, and Assistant Professor in Psychiatry, Harvard Medical School, Boston, Massachusetts. Requests for reprints should be addressed to Dr. Felton Earls, Deparment of Psychiatry, Children's Hospital Medical Center, 300 Longwood Avenue, Boston, MA 02115.

its development. This paper describes an institutional crisis that occurred in a neighborhood health center with a small mental health component. The action takes place over a year's period, during which time the author served as the clinical psychiatric director of the mental health unit. The effect of the crisis was to lessen the quality of mental health service and ultimately to erode the service into virtual nonexistence. Rooted in the presentation of this experience is the anticipation that similar difficulties, or potential problems, experienced by others may be worked through to a more productive outcome than was possible in this case.

The Setting The community setting of the neighborhood health center (NHC) is similar to many deteriorated urban environments. This neighborhood, of about 20,000 persons (95 percent of whom are black and poor), is physically oppressive. Between 1965 and 1970 there was a rapid out-migration of whites, resulting in complete reversal of the racial composition in the area. With this transition, many stable social, cultural, and political institutions which had served the white community were replaced by a variety of government agencies and programs and newly created black institutions.


The NHC was established in 1969 under the Model Cities Act, and remained under that jurisdiction until the program ended in 1974. At that point, the local city government assumed responsibility for the NHC. In its eightyear history, the center became a landmark in the community, regarded as an accessible and concerned blackoriented institution. During the year of the author's tenure at the NHC, it moved from an inadequate facility to a renovated, thoroughly sufficient one. This new housing stood in marked contrast to the drabness of the neighborhood, a fact that further served to support the stature of the NHC in the


Relationship of the Mental Health Unit to the NHC and Area Community Mental Health Center (CMHC) The mental health unit has a complex and ambiguous tie to the NHC, based on its separate relationships with the area community mental health center (CMHC), the local Department of Health, and the community-based governing body of the NHC. These multiple administrative and clinical relationships are schematically represented in Figure 1. This organizational structure is important to elaborate on since it relates directly to the crisis described below. The mental health component of the NHC had been established by a National Institute of Mental Health (NIMH) staffing grant. The grant was awarded to the area CMHC, whose superintendent was designated the principal investigator. The purpose of this arrangement was to provide a linkage between the CMHC and the mental health unit of the NHC that would provide both administrative and clinical support. Since the NHC had an established administrative and fiscal tie to the city's Department of Health (DH) prior to the grant award, an agreement 779



Department of Health

Community Board of Directors


Administrative Director


Clinical Psychiatric Director

Figure 1. Schematic representation of the organizational structure of the mental health unit in the neighborhood health center NIMH -National Institute of Mental Health CMHC-Community mental health center NHC -Neighborhood health center MHU -Mental health unit

was made between the area CMHC and the DH to channel funds from the grant through the existing fiscal structure of the city's health administration to reach the mental health unit. The agreement was not intended to interfere with the administrative and clinical authority of the area CMHC over the mental health unit. It implied that the area CMHC and the NHC would operate the mental health unit jointly, but details of this arrangement were not clearly specified. The NIMH grant also required that the mental health unit set up an advi780

sory board composed of representatives from the area CMHC, the NHC, and the community. This advisory board was not part of the NHC's general board of directors. Both were composed of local citizens, but the mental health unit's board also had representatives from the area CMHC. Throughout the five-year history of the mental health unit, these separate boards had operated independently of each other. While this had not become an obvious source of administrative conflict at first, it did create a sharp

sense of autonomy for the mental health unit in its relationship to other service components of the NHC. The presence of these multiple relationships impinging on the clinical function of a small unit was perhaps predictably doomed to create disaster. It is not surprising that other service components in the NHC perceived the mental health unit as having a kind of privileged independence. The unit's administrative ties had a clinical equivalent. On one hand there was the clinical alliance of the mental health unit with the NHC's medical director, and on the other was a more traditionally honored tie to the area CMHC. Of the four patterns of linkage between NHCs and CMHCs described by Borus, the relationship of this NHC to the area CMHC is indeed an amalgam of several discrete models. Aspects of the "joint endeavor," "the autonomous NHC," and "the community mental health outpost" models all exist as ill-defined organizational tendencies between the mental health unit of the NHC and the area CMHC. It is within this administrative and clinical context that a picture of the institutional crisis that plagued this health center is presented.

Clinical Activities of the Mental Health Unit The mental health unit's staff consisted of the author, three master's level social workers, a nurse, and six psychotherapists. The clinical activities of this small unit were quite broad, as it served as a mental health resource within the NHC, as well as within the community at large. Its primary interinstitutional alliance involved the provision of aftercare services for patients hospitalized at the area CMHC. In fact, an agreement had been made between the NHC and the CMHC to notify the NHC of all patients in its catchment area (a subcomponent of the CMHC catchment area) who were discharged. The efficiency of this coordination varied, but there were instances in which the transition from hospital to neighborhood was carefully planned and coordinated. The unit also received a number of requests from other community-based agencies for mental health evaluations. About half the patients arrsving at the


unit were self-referred. An active liaison was maintained between the unit and other medical and social services within the NHC which also provided a steady source of referrals. With the author's arrival at the center, a decision was made to place particular emphasis on staff training. This was done to facilitate support and communication among staff members, and to provide a foundation on which program evaluation, peer review, and standardization of clinical practice procedures could eventually be established.

Situations and Crises Within the NHC and Its Mental Health Unit

Situation 1 A long-standing characteristic of the NHC was the high rate of staff turnover at all levels of the clinical and administrative hierarchy. Precise figures are not available, but during the first six months of the author's experience, the medical director, an assistant administrative director, an executive secretary, two nurses, and two paraprofessionals resigned or were fired, in some instances only a few weeks or months after being hired. This trend escalated during the second six months. With each termination a sense of turmoil was created. The void left by departure of the medical director was not filled for over a year. The frequency of terminations set a tone, a kind of "background noise," against which the center carried out its clinical activities. The mental health unit of the center was in no way immune from this atmosphere of turbulence.

Situation 2 Within a few months of the author's

arrival, a decision was made to discontinue the mental health unit's community board. It is perhaps too diplomatic to call this a decision, for the board had been gradually dissolving over a period of years. Its dysfunctional status was taken as an opportunity to simplify the policy-making structure of the NHC. It was thought that the general board of directors would takeover responsibility for policy determinations in the mental health unit. This was the first step towards structurally integrating the mental health unit in the NHC.

Situation 3 Soon after discontinuing the mental health unit's separate board, the unit itself became embroiled in a managerial crisis. This was precipitated by a staff change in the administrative directorship of the unit. Prior to the change, the unit had been gradually achieving greater cohesion in its clinical strengths, despite the general turbulence of the NHC. The new administrator assumed an aggressive managerial style and decided to quickly establish strategies for staff accountability, standardization of diagnostic and evaluative techniques, and a problemoriented record keeping system. The unit's staff was resistant and soon became openly hostile to these changes in clinical practice. The new administrator had failed to assess the strengths of this unit: the sensitivity and sense of commitment of staff members and the developing sense of cohesiveness. Tensions increased sharply when it was discovered that the administrator also advocated unorthodox clinical procedures. While this situation developed within the unit, the administrator presented quite a different posture to the board of directors, which had become involved in mediating the crisis. Attempts were made to persuade the board that the mental health unit was sluggish and inefficient, maintaining that this was due largely to staff reliance on traditional modes of psychotherapy and an orthodox pharmacotherapy. The board was told that the mental health unit resisted new strategies only to "save face." Even the aura of national health insurance was raised to suggest that managerial changes were inevitable. As demands for the administrator's removal were coupled with the administrator's own provocative rationale for immediate change, the issue of how to resolve this exchange was carried beyond the walls of the NHC. Representatives of the NIMH, the area CMHC, and the city's Department of Health were called to several meetings to review charges made by the mental health unit's staff that their professional practice was being jeopardized by the unacceptable ethical, scientific, and managerial standards of the new administrator.

Situation 4 The forum established to resolve the mental health unit's difficulty exposed


more problems than it solved. The purpose of these meetings was sidetracked to review the more general isssue of authority over the mental health unit. A more complex agenda evolved, including such items as who should determine policy for the mental health unit, and how to decrease the organizational discrepancy between the NHC's medical and social service units and the mental health unit. The National Institute of Mental Health took the position that the area CMHC should have direct authority over matters both administrative and clinical in nature. Indeed, the staffing grant had been awarded to the CMHC for this very purpose. The area CMHC had been slow to establish this authority for reasons intrinsic to its own organization. The Department of Health and the administrative staff of the NHC argued that the only effective way to integrate mental health into the primary care system was to weaken its linkage with CMHC. As an example, their position was that the medical director of the NHC (an unfilled position at the time), not the superintendent of the CMHC, should assume principal investigatorship of the staffing grant. As the negotiations intensified, the board of directors began to feel subjugated by the active presence of the other parties. They perceived the inter-institutional struggle for control of the mental health unit to be minimizing a fundamental issue of community control which they were primarily authorized to assume. But the board lacked access to independent medical, managerial, and legal advice. In some instances board members were able to give informed opinions, but there were critical areas of discussion in which independent professional advice to the board would have been beneficial. For example, in discussing the unorthodox clinical interests of the unit's new administrator, expert advice on accepted clinical practices would have aided the board in separating a substantive issue from what they saw as a personality clash between the administrator and the unit's clinical staff. The dissolution of the mental health unit's separate policy-making board further undermined these deliberations. If the board had been active, it might have been able to lend a sharper sense of history and objectivity to the negotiations with regard to how and why the grant had been set up as it was. Eventually, the 781

NIMH resolved who was to control the mental health unit. Renewal of the staffing grant was made contingent upon the CMHC's director being named principal investigator. The end of this three-month period of deliberations was marked by a series of resignations (including the author's). The board of directors, apparently swayed by the managerial style of the mental health unit's administrator, announced that this person would become the acting director for the entire center (creating a tumultuous response in the staff). The most important question at stake-clinical survival of the mental health unit-had an unfortunate resolution. The unit managed to continue giving services during the crisis, but at a reduced encounter rate and with a depleted staff. The stress associated with this work experience seriously compromised the sense of mission and accomplishment which had evolved in response to the recognized need for integrated comprehensive medical care in the community. At this writing, three years after the reported events, the mental health unit no longer exists and psychiatric services are not provided at the NHC.

Comments This year's experience caused reflections on how little communities have changed since the social upheaval of the 1960s. The physical blight and inefficiently organized, fragmented human service network of this neighborhood appear to merge with the emotional and social problems of patients. It was especially painful to work in a primary health care facility providing critically needed services that could not be properly governed. The struggles of this mental health unit seemed to mirror the crisis-living patterns of its clients so closely that it was hard not to draw a parallel between it and the many families with multiple health and social problems it served. It is difficult to decide whether or not the forces creating such environments come from outside or inside the family or institutional system. One thing is certain: once such an emotional climate is generated, the stress and strain it exerts on persons functioning within it is harmful and good clinical care is sacrificed.

There are two groups of issues that 782

need further exploration to ensure that a perspective that is both protective of and encouragihg to neighborhood psychiatry will be reached. First, there is the issue of the organizational complexity engulfing the mental health unit of the NHC. This complexity had grown out of proportion to the needs of the unit because none of the multiple linkages were particularly strong in themselves. The absence of a medical director at the NHC created a vacuum that could only be partially filled by a staff composed of part-time physicians and paraprofessionals. This limited the degree to which an active liaison could be developed between the medical and mental health units. The area CM$IC had its own institutional crisis which forced it to minimize the significance of its formal relationship with the NHC. Despite the final, if not fatal, position in regard to this case, regarding retention of the staffing grant with the area CMHC, the ultimate solution to this problem may be in creating autonomous NHCs. This is not to imply the NHCs should give up their affiliations with local hospitals and community mental health centers. Increasing autonomy, however, tnay serve the purpose of permitting the NHC to assess its own capabilities more realistically. This is a critical issue to resolve if the growth of such centers is to thrive. For instance, the mental health unit of this NHC attempted to provide all of the services, except inpatient care, that the area CMHC provided. In fact, demonstration of the provision of "12 essential services" defined in Community Mental Health Act of 1975 was a requirement for renewal of the staffing grant. Yet, it was clearly impossible for a unit of this size, with its particular level or skill, to approximate these ob-

jectives. Rather, the environmental context in which this NHC functioned served as an ideal place in which to develop limited, but highly desirable, services. Two types of services of central importance to the health demands of the NHC were liaison psychiatry and family therapy. The former was needed to assist in the evaluation and therapy of the high proportion of patients attending this NHC with stress-related medical illnesses, eg, hypertension. Family therapy was essential since it was recognized that the emotional problems of most patients had a direct relationship to patterns of family living.

A second group of issues involves the functions of the community board of the NHC. Perhaps the most unfortunate consequence of the board's lack of skill was the failure to realize the importance of obtaining independent assistance in evaluating professional competence. The creation of viable, autonomous NHCs must depend on the integrity and strength of community boards, whose members, as health consumers, will act as advocates for their neighborhoods. If they are to be successful, it will be mandatory that they make use of independent professional advisors in decisions that tum on issues of professional competence and the scientific and clinical quality of diagnostic and treatment techniques. The future of community control of health care will be determined by the capacity of community boards to constructively utilize such advice. Psychiatrists and other mental health professionals have an important role to play, not only as service providers, but also as policy advisors, if NHCs such as the one described here will fill an essential niche in our system of health care delivery. If external supporting agencies, such as the NIMH and state mental health departments, are finely attuned to the quality of care in the NHCs, they should also view the function and integrity of the community board as central to their success. A final issue involves the acceptability of outside support and assistance by community board members. It is safe to assume that as long as board members do not perceive their decision-making capacity encroached upon, outside help will be welcomed. Acknowledgements The author is indebted to the helpful comments and encouragement of Drs. Jonathan Borus and Leon Eisenberg during the drafting of this paper. This paper was written during a period in which the author was supported by the Medical Foundation, Inc, of Boston.

Literature Cited 1. Borus JE, Janowitch LA, Kieffer F, et al: The coordination of mental health services at the neighborhood level. Am J Psychiatry 132:1177-1181, 1975 2. Fink PJ: The role of psychiatry as a primary care specialty. Arch Gen Psychiatry 33:998-1103, 1976 3. Morrill RG: A new mental health services model for the comprehensive neighborhood health center. Am J Public Health 62:1108-1 1 1 1, 1972 4. Macht LB: Neighborhood health centers-perspectives on opportunity for comprehensive ambulatory health care. N Engl J Med 292: 591-592, 1975 5. Borus JF: Neighborhood health centers as providers of primary mental health care. N Eng J Med 295:140-145, 1976


Experience in primary mental health care.

Experience in Primary Mental Health Care Felton Earls, MD Boston, Massachusetts The author discusses his experience as clinical director of a small m...
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