Commentary Ras Academic Psychiatry Abandoned the Community? John A. TaIbott, M.D.
In
1912, Adolf Meyer, then unarguably America's most prominent academic psychiatrist, said (1), The ideal will have to be an organization so made that as many districts as possible may form reasonably complete households within themselves. We thus attain a collaboration beyond the hospital walls. . . . It is necessary to go to the root of the evil...to straighten out the environment.
Caplan and Caplan (2) describe Meyer as visualizing an entire community mental health program in which the various overlapping jurisdictions of such care-giving agencies as schools, police, and welfare agencies could be unified into a single district containing a mental hospital. It would then be possible to conduct an integrated program of prevention, treatment, and after-care of mental disorder, with the psychiatrist in the hospital working in concert with teachers, police, welfare workers, and general practitioners in the community. Meyer also advocated the immediate implementation of a plan to involve family doctors in the treatment of hospitalized psychiatrie patients. He also advocated a program of public education to reduce the stigma of mental disorder and to develop mentally healthy attitudes and habits. He addressed many lay groups and often illustrated his belief that insanity should not be a cause for shame by talking openly about the mental illness of his mother.
Dr. Talbott is Professor and Chairman of the Department of Psychiatry, University of Maryland School of Medicine, and Director of the Institute of Psychiatry and Human Behavior, University of Maryland Medical System, Baltimore, Maryland. Address reprint requests to 645 West Redwood St., Baltimore, MD 21201. Copyright @ 1991 Academic
Psychiatry. " "
Is this American academic psychiatry's earliest articulation of interest in the community and was Meyer the "father of community psychiatry"? Was his vision of community psychiatry ever realized? What, indeed, is community psychiatry now? What connection is there between academic and community psychiatry? Does the university have a role or Tesponsibility in training psychiatrists for community work, in operating community services, and/or in performing research in or about community psychiatrie settings? Was academic psychiatry ever really involved with the commu\( 'l i \1 1 I , '
'..r
\11>1 I,': · ' ,I \1\ 11 [, ! " " :
nity? If it was, has it now abandoned the community? To attempt to answer these questions, in this artide I will present some historical definitions of community psychiatry, then provide my own ways of defining it, discuss whetheracademic psychiatry was ever truly involved in the community, review the evidence that there has been an abandonment of the community by the academic sector as well as evidence that there has not, and condude with some remarks about the ongoing challenges that face academic and community psychiatry.
WHAT 15COMMUNITY PSYCHIATRY? While we all have used or do use the term "community psychiatry" freely, there are considerable problems in defining it. Not only is it impossible to ascertain who actually used the term first, there seems to be no universally agreedupon definition. To illustrate, Meyer talks about a district concept, collaboration beyond the hospital walls, going to the root of the evil, etc., and Caplan and Caplan highlight Meyer's interest in bringing about an integrated program of prevention, treatment and aftercare; the involvement of teachers, police, welfare workers, and general practitioners; as well as public education (1,2). Same 70 years later, the Group for the Advancement of Psychiatry (GAP) Committee on Psychiatry and the Community, in a retrospective reappraisal of community psychiatry, placed the emphasis on the noninstitutional and nontraditional, on sociocultural conditions, on organization and delivery of mental health services, and on services that are "dose by" (3). Gerald Caplan's own definition focuses on populations, etiology, rehabilitation, positive mental health, research, and public-private jurisdictions (2). The American Psychiatrie Association (APA) Glossary and Hinsie and Campbell added some new concepts to the definition, those of coordination, public health, responsibility, continuity of care, the disadvantaged, and sodal change (4,5). Although there are many differences in these definitions, there are some common threads-those of prevention, catchment areas, extra-hospiral care, social-environmental issues, multi-professional staffing, and community-based treatment. DIFFERENT DOMAINS OF DEFINmON
To provide clarity, I have categorized five different elements that help to make up the term community psychiatry: \l \ 1'I
\ II ~
I '~ ')
\ : 11 \ 11\')
i il
1) alternatives, 2) concepts, 3) programmatic elements, 4) prevention models, and 5) buildings.
Alternatives. Since 1855, in this country we have seen the slow, steady development of alternatives to traditional inpatient hospital treatment of mental illness (6). Figure 1 depicts a timeline tracing the introduction of these alternative settings.
Concepts. A list of the concepts that underlie community psychiatry is displayed in Table 1 (6).
Programmatic elements. The programmatic elements that comprise community psychiatry are listed in Table 2 (6) . Prevention models. Caplan organized the concepts underlying community psychiatry along the traditional lines of prevention in public health seen in Table 3 (7) . Buildings. Fina11y, in what most of us confuse with community psychiatry itself, we have community mental health centers (CMHCs), the buildings that were intended to house the programs that embodied the concepts previously mentioned.
WAS ACADEMIC PSYCHIATRY EVER REALLY INVOLVED IN THE COMMUNITY? It seems apparent, therefore, that there are a number of different ways of looking at community psychiatry. However, the question remains, ''Was academic psychiatry ever really involved in the community?" The answer is unclear. On the one hand, some of our nation's most prestigious academic psychiatrie programs certainly were heavily involved. On the other hand, however, their involvement was in very different ways and to various degrees, and some were never involved at a11. Those university departments of psychiatry that were heavily in-
volved in the community in the 19505 and 19605 were involved in research, such as the Midtown and the Sterling County Studies; in training programs; and in actually running CMHCs and other community services. Why were they so involved? They were involved for the usual reasons: money, pasTABLE L Community psychiatry concepts Accessibility Accountability to the community Active treatment All ages served Alternatives to hospitalization Availability Avoidance of hospitalization Catchment areas (districts) Citizen partidpation Communication between workers and agendes Community care, better Community partidpation Community ties retained Comprehensive treatment Continuity of care Coordination among agendes Early detection, treatment Environmental influence
Expectancy
Geographie responsibility Health more important than illness
Immediacy
Indirect services Information exchange, easy Integration of state and local services Interdisciplinarycollaboration Linkages between human services networks Live in community Mental disorder only one part of Iife Minimal interventions Multi-disciplinary PIanning for gaps in service Poor, care for Prevention(l',Z',3"} Proximity Public health Rehabilitation Reintegration into the community Responsible person enters other systems when patient goes (e.g., hospital) Segmental treatment Sodal engineering Socio-cultural influence Transfer easy between elements Written agreements Reprinted by pe:rmission from Psychiatr Q (see ref. 6)
[ \1 1'.\ \ [ I
TABLE 2. Programmatic elements of eommunity psychiatry Aftercare Alternatives to asylums (psychopathie and general hospital) Alternatives to hospitalization Brief treatment Citizen participation Clinics (outpatient, traveling. and satellite) Community consultation Community education Community participation Crisis intervention Emergency treatment (24 hour) Familycare Fostercare General practitioners Halfway houses Homecare Hostels Indirect service (consultation and education) Integrated programs of prevention, treatment, and aftercare
Integration of state and eounty programs Interdisciplinary teams and training Non-medical personnel (social workers, nurses, etc.) Openwards Paraprofessionals Partial hospitalization (day, night, weekend) Prevention 0", 2", 3") Rehabilitation (social and vocational) Therapeutie community Unitization Walk-in clinics Reprinted by permission from PsychÜltr Q
(see ref.ö)
sion, and common sense. There was a great deal of National Institute of Mental Health (NIMH) money in those years; our science was slow to mature; and departments with intelligence and a degree of commitment to the community could get a sizable slice of the research, training, and/or services pie . As Alan Kraft put it, "Those were the days when you sent NIMH a postcard requesting money and you got the funds in the retum mail" (personal communication), Departments that one usually did not associate with a devotion to service provision happily applied for and received grants for planning, staffing, and constructing CHMCs. In addition, there was a great deal of passion about community psychiatry, particularly against it, from the "old guard," as is obvious from the titles of papers such as Roy Grinker Sr.'s "Psychiatry Rides Madly in All Directions," Warren Dunham's "Community Psychiatry: The Newest Therapeutic Bandwagon," and Lawrence Kubie's ''Pitfalls of Community Psychiatry" (8-10). Although it is currently fashionable to derogate the passion demonstrated by the adherents of community psychiatry for its naivete and its proponents for their overly ambitious and sometimes exaggerated claims, the movement did attract a great
TADLE 3. Caplan's prevention models of community psychiatry Typeof Prevention
Goal
Methods
I"
Reduction in the incidence of all mental disorders
1. Consultation to care givers 2. Education of community leaders 3. Socialaction
2"
Reduction in the duration of oE those incidents of mental illness that do occur
1. Early detection and screening 2. Early diagnosis and referral 3. Prompt and effective
3"
Reduction in impainnent resulting from mental illness
1. Education to eliminate prejudice 2. Communication with social networks 3. Avoidance oE hospitalization 4. Hospital-eommunity proxirnity
1"=Primary;2"=Secondary;3 "=Tertiary. Reprinted by permission from PSYChÜltrü: Administration: A Comprehensioe Test {ur the Clinician-Executite. New York, Grune and Stratten, 1983, p. 10
11 'I', \ ( \ 1)1 \ 11( 1'-·) ( 1I1
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FIGURE 1. Alternatives to hospitals priorto 1955
HomeCir. Sca.I ReMbilicalIOC\ Dey HoIpI!a1
s..-CItnicI TmeIIIIlg ClmICS
Oulpebem AIIetQre
..... ~Our
... eoa.ePlln F. . . . . . . . Fenn GISI. Anne
I 1750
I
1100
I
1850
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1950
Reprinted by permission from Recent Advances in Schizophrenia, New York, Springer-Verlag, 1990, p . 2BO
FIGURE 2. Community psychiatry dtations in the American Journal of Psychiatry (1964-1989)
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number of dedicated psychiatrists into public service, which is refreshing compared with the difficulty we now have attracting psychiatrists to programs serving underserved populations such as the homeless mentally ill. Finally, there were cooler heads who thought that it was time to change from the fortress mentality of a psychoanalytically oriented inpatient psychiatry to an attempt to provide early identification and treatment of mental illnesses, if not their prevention. This involved answering interesting epidemiological, organizational, and service delivery questions and training psychiatrists for what most graduates of training programs actually did even then-rough and tumble general outpatient psychiatry. In summary, then, I conclude that academic psychiatry during the 19505and 1960s was involved in the community-if not in service provision, at least in research or training. Has this level of activity been reduced? IDnDENCETHATACADaflC PSYCHlATRY HAS ABANDONED THE COMMUNITY The evidence is quite impressive that academic psychiatry is no longer as invested in the community as it once was. Look, for example, at the number of citations in the American Journal o{ Psychiatry of all papers indexed by the word "community," e.g., community, community mental health, community psychiatry, community care facilities, and community mental health centers . There was a marked jump from 1963 to 1966 (from 0 to 24 citations), with a jagged plateau of around 20 citations for an entire decade until1976, when there was a gradual decline to only about one article a year from 1983 to present (see Figure 2). Second, whereas in the 19608there was a spate of books and monographs by prominent academicians, such as Biegel and Levenson, Gruenbaum, and Gruenberg (11\ ( \ I )I \ 11( [", ,,\ 111 \ [ 1\',
13), one is hard pressed to recall a recent academically authored book about the community. Third, there is ample anecdotal and statistical confirmation that psychiatrists, particularly those who worked in CMHCs, left or were driven out of community psychiatry in droves after the full blush of the 19608. Thompson and Bass's 1984survey showed a 10.6% decline in staff psychiatrists per CMHC from 1973 to 1981, in the face of a 5.6% increase in other staff, and a more startling 22.4% decrease in average numbers of FTE psychiatrists per CMHC, versus a 13% increase in other full-time equivalents (FTEs) (14). Fourth, there has been a marked change in NIMH grants, from excess and plenty in the 1960s to an absolute absence of money for research, training, or service targeted to anything labeled "community" now. Aside from a shift in focus from social to biological and from services provision to services research, the services monies that remained were no longer targeted for CMHCs but for Community Support Programs and programs for the homeless mentally ill. Finally, further evidence that academic psychiatrists have abandoned the community is reflected by their abandonment of the term, although perhaps not the concepts, in the descriptions of their work. Individuals who might have once described themselves as "community psychiatrists" are now more likely to describe themselves as interested in public psychiatry, the chronie mentally ill, rehabilitation psychiatry, deinstitutionalization, long-term care, and the homeless mentally ill. However, perhaps this is too one-sided a picture. Is the abandonment argument that convincing? IDnDENCE THAT ACADEMIC PSYCHIATRY HAS NOT ABANDONED THE COMMUNITY The first pieceofevidence marshaled against this proposition is the survey of Faulkner et ! 1;
11 \ " \ ( \ l l I \11( I'e,'ll III \ 11,'r \1; \ '-10'-1
j)
al. (15) of the amount of involvement in CMHCs that academic departments of psychiatry had in 1982. In that year, 79% of university departments of psychiatry had a · relationship with a CMHC, 76% with astate hospital, and 66% with a Veterans Administration (VA) facility. Of the departments with these relationships, only 27% had what the authors described as elose integration with their CMHC, 12% with their state hospital, and 95% were integrated with their VA hospital. Appoximately 24% of the relationships with CMHCs were contractual arrangements, compared with even fewer such arrangements with state hospital (16%) and VA facilities (17%). Finally, most departments had predominantly clinical training rotations in CMHCs-73%, versus 83% in state hospitals and only 6% in VA hospitals . Second, there is less evidence that psychiatry has abandoned the community than that it has abandoned CMHCs. CMHCs, with their emphasis on buildings and federal monies rather than programs, may have presented a deflection in the slow but steady progress of academic interest in community psychiatry. In addition, there are still several notable community service programs where high-quality residency training occurs (16). There are also several strong university-affiliated or administered CMHCs. Finally, there is unmistakable evidence that while perhaps diminished, community psychiatry has been swallowed whole by general residency training programs and now appears as part and parcel of many programs. Academic colleagues frequently refer to concepts such as continuity of care, horne visits, and consultations to schools not as "community psychiatry" but as "good psychiatry." DISCUSSION If one looks at all of the RRC requirements, one finds some very familiar terms and concepts from the 1950s and 1960s (17).
11 1/ l ()\J\ll
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Understandingthe... social, economic, ethnicand family..Jamiliarity with...financingand regulation...including the structure of governmentaland private organizations...experience in...crisis intervention...responsibility in community mentalhealth activities...should include consultationwith at least one community agency...activecollaboration with psychologists, psychiatrie nurses, social workers and other professional and paraprofessional...personnel. Although the RRC requirements are overspecific and unattainable, the basic concepts of community psychiatry are definitely there. One can break down the answer to the question "Has academic psychiatry abandoned the community" into several subsets. If referring to rural areas, it was never there. If we mean CMHCs, academic psychiatry was involved at one point on anational basis, at least in terms of staffing and leadership. However, if we incorporate the community under the larger umbrella of public psychiatry, the answer is mixed-academic psychiatry has never abandoned the VA system but psychiatrists have certainly left state hospital and state mental health office leadership positions. Community consultation has also shifted its terminology and locusfrom more exotic involvements with police units (18)and the military (19), to work with agencies serving the homeless, persons receiving rehabilitation, and the chronie mentally ill. Referring to the list of programmatic elements above provides another mixed picture. There are some aspects of the term community psychiatry that academic psychiatry is often and routinely involved with, e.g., aftercare, brief treatment, clinics, emergency treatment, family care, family orientation, interdisciplinary teams, non-medical personnel, open wards, and walk-in clinics. On the other hand, there are a number of aspects of community psychiatry that academic psychiatry is only sometimes in-
volved with, e.g., alternative treatments, community education, community consultation, halfway houses, horne care, indirect services, paraprofessionals, partial hospitalization, rehabilitation, and therapeutic communities. There are also some aspects academic psychiatry is almost never involved with, e.g., citizen participation, community participation, foster care, general practitioners, hostels, integrated prevention / treatment/ aftercare, integrated state/county services, primary prevention, and unitization. CONCLUSION There is no simple answer to the question ''Has academic psychiatry abandoned the community?" I think it has incorporated the very best and most useful community psychiatry concepts and programmatic elements into mainstream general psychiatry. I think academic psychiatry has gradually become involved with the chronie mentally ill wherever they are, not always because it wanted to and more slowly than many other
voluntary community organizations, but more quickly than most government agencies. And I think, again perhaps faute de mieux, it is now, more than ever, heavily involved with society's most difficult and perplexing public mental health problems. That does not mean that there is not more to do . Clearly, more must be done in those areas in which 1) there are manpower problems, e.g., rural areas, CMHCs, and state hospitals; 2} there is absent or abysmal care, e.g., prisons, nursing hornes, and shelters; and 3} populations exist that still are largely ignored and underserved, e.g., the dually diagnosed and homeless mentally ill. It is, therefore, the time for neither self-congratulation nor self-eondemnation. Rather, now is the time for continued self-examination of which areas academic psychiatry can appropriately contribute to community psychiatrie activities by extending its research, training, and service energies.
This study was originally presented at the AnnualMeeting o[theAssociation for Academic Psychiatry, Seattle, Washington, March 8, 1990.
References 1. Winters EE (00): The Collected Papers of Adolf Meyer. Baltimore, MD, Iohns Hopkins University Press, 1952 2. Caplan G, Caplan RB: Development of community psychiatry concepts, in The Comprehensive Textbook of Psychiatry I, edited by AM Freedman and HI Kaplan. Baltimore, MD, Williams and Wilkins, 1967, pp . 1499-1514 3. Committee on Psychiatry and theCommunity of the Group for the Advancernent of Psychiatry:Community Psychiatry: A Reappraisal. New York, Group for the Advancernent of Psychiatry, 1983 4. Stone EM: American PsychiatricGlossary.Washington, oe,American Psychiatrie Press, 1988 5. Hinsie LE, Campbell RJ: Psychiatrie Dictionary, 4th 00, New York, Oxford University Press, 1970 6. Talbott JA: Twentieth eentury developments in American psychiatry. PsychiatrQ 1982;54:207-219 7. Talbott JA, Kaplan SR: Psychiatrie Administration: A Comprehensive Text for the Clinician-Executive. New York, Grune and Stratton, 1983, p. 10 8. Grinker R: Psychiatry rides madly in alldirections. Arch Gen Psychiatry 1964; 10:228-237
9. Dunham HW: Community psyehiatry: the newest therapeutie bandwagon. Arch Gen Psyehiatry 1965; 12:303-313 10. Kubie I.S: Pitfalls of eommunity psychiatry. Arch Gen Psychiatry 1968;18:257-266 11. Biegel A, Levenson AI (eds): The Community Mental Health Center: Strategies and Programs. New York, Basic Bocks, 1972 12. Gruenbaum H (00): The Practice of Community Mental Health. Boston, MA. Little, Brown and Company,1970 13. Gruenberg EM: Programs for Community Mental Health. New York, Milbank Memorial Fund, 1957 14. Thompson JW, BassRD: Changing staffing patterns in community mental health centers. Hosp Community Psychiatry 1984; 35:1107-1114 15. Faulkner LR, Eaton JS, Bloom 10, et al: The CMHC as a setting for residency education. Community Ment HealthJ 1982;18:3-10 16. TalbottJA, Robinowitz CB (OOs): Working Together: State-University Collaboration in Mental Health. Washington, oe, American Psychiatrie Press, 1986 17. Rabinowitz CD, Kay J, Taintor Z (OOs): Directory of
11 \" \ ~ \ 1)1\ 11 ( 1'-') ( 111\ 1I, ) \ 11\ -, I\( )-, I I , ! 111 ( ( )\ I \ 1l '\.11'\
Psychiatry Residency Training Programs. 4th edition, Appendix C: Special Requirements for Residency Training in Psychiatry and Neurology, American Psychiatrie Association et al., Washington,rx:,1988,803-809
18. Talbott JA: The elements of community consultation, Psychiatr Q 1977; 29:273-290 19. Talbott JA: Community psychiatry in the army: history, practiceand applications todvilian psychiatry. JAMA 1969;210:1233-1237
In
1912, Adolf Meyer, then unarguably America's most prominent academic psychiatrist, said (1), The ideal will have to be an organization so made that as many districts as possible may form reasonably complete households within themselves. We thus attain a collaboration beyond the hospital walls. . . . It is necessary to go to the root of the evil...to straighten out the environment.
Caplan and Caplan (2) describe Meyer as visualizing an entire community mental health program in which the various overlapping jurisdictions of such care-giving agencies as schools, police, and welfare agencies could be unified into a single district containing a mental hospital. It would then be possible to conduct an integrated program of prevention, treatment, and after-care of mental disorder, with the psychiatrist in the hospital working in concert with teachers, police, welfare workers, and general practitioners in the community. Meyer also advocated the immediate implementation of a plan to involve family doctors in the treatment of hospitalized psychiatrie patients. He also advocated a program of public education to reduce the stigma of mental disorder and to develop mentally healthy attitudes and habits. He addressed many lay groups and often illustrated his belief that insanity should not be a cause for shame by talking openly about the mental illness of his mother.
Dr. Talbott is Professor and Chairman of the Department of Psychiatry, University of Maryland School of Medicine, and Director of the Institute of Psychiatry and Human Behavior, University of Maryland Medical System, Baltimore, Maryland. Address reprint requests to 645 West Redwood St., Baltimore, MD 21201. Copyright @ 1991 Academic
Psychiatry. " "
Is this American academic psychiatry's earliest articulation of interest in the community and was Meyer the "father of community psychiatry"? Was his vision of community psychiatry ever realized? What, indeed, is community psychiatry now? What connection is there between academic and community psychiatry? Does the university have a role or Tesponsibility in training psychiatrists for community work, in operating community services, and/or in performing research in or about community psychiatrie settings? Was academic psychiatry ever really involved with the commu\( 'l i \1 1 I , '
'..r
\11>1 I,': · ' ,I \1\ 11 [, ! " " :
nity? If it was, has it now abandoned the community? To attempt to answer these questions, in this artide I will present some historical definitions of community psychiatry, then provide my own ways of defining it, discuss whetheracademic psychiatry was ever truly involved in the community, review the evidence that there has been an abandonment of the community by the academic sector as well as evidence that there has not, and condude with some remarks about the ongoing challenges that face academic and community psychiatry.
WHAT 15COMMUNITY PSYCHIATRY? While we all have used or do use the term "community psychiatry" freely, there are considerable problems in defining it. Not only is it impossible to ascertain who actually used the term first, there seems to be no universally agreedupon definition. To illustrate, Meyer talks about a district concept, collaboration beyond the hospital walls, going to the root of the evil, etc., and Caplan and Caplan highlight Meyer's interest in bringing about an integrated program of prevention, treatment and aftercare; the involvement of teachers, police, welfare workers, and general practitioners; as well as public education (1,2). Same 70 years later, the Group for the Advancement of Psychiatry (GAP) Committee on Psychiatry and the Community, in a retrospective reappraisal of community psychiatry, placed the emphasis on the noninstitutional and nontraditional, on sociocultural conditions, on organization and delivery of mental health services, and on services that are "dose by" (3). Gerald Caplan's own definition focuses on populations, etiology, rehabilitation, positive mental health, research, and public-private jurisdictions (2). The American Psychiatrie Association (APA) Glossary and Hinsie and Campbell added some new concepts to the definition, those of coordination, public health, responsibility, continuity of care, the disadvantaged, and sodal change (4,5). Although there are many differences in these definitions, there are some common threads-those of prevention, catchment areas, extra-hospiral care, social-environmental issues, multi-professional staffing, and community-based treatment. DIFFERENT DOMAINS OF DEFINmON
To provide clarity, I have categorized five different elements that help to make up the term community psychiatry: \l \ 1'I
\ II ~
I '~ ')
\ : 11 \ 11\')
i il
1) alternatives, 2) concepts, 3) programmatic elements, 4) prevention models, and 5) buildings.
Alternatives. Since 1855, in this country we have seen the slow, steady development of alternatives to traditional inpatient hospital treatment of mental illness (6). Figure 1 depicts a timeline tracing the introduction of these alternative settings.
Concepts. A list of the concepts that underlie community psychiatry is displayed in Table 1 (6).
Programmatic elements. The programmatic elements that comprise community psychiatry are listed in Table 2 (6) . Prevention models. Caplan organized the concepts underlying community psychiatry along the traditional lines of prevention in public health seen in Table 3 (7) . Buildings. Fina11y, in what most of us confuse with community psychiatry itself, we have community mental health centers (CMHCs), the buildings that were intended to house the programs that embodied the concepts previously mentioned.
WAS ACADEMIC PSYCHIATRY EVER REALLY INVOLVED IN THE COMMUNITY? It seems apparent, therefore, that there are a number of different ways of looking at community psychiatry. However, the question remains, ''Was academic psychiatry ever really involved in the community?" The answer is unclear. On the one hand, some of our nation's most prestigious academic psychiatrie programs certainly were heavily involved. On the other hand, however, their involvement was in very different ways and to various degrees, and some were never involved at a11. Those university departments of psychiatry that were heavily in-
volved in the community in the 19505 and 19605 were involved in research, such as the Midtown and the Sterling County Studies; in training programs; and in actually running CMHCs and other community services. Why were they so involved? They were involved for the usual reasons: money, pasTABLE L Community psychiatry concepts Accessibility Accountability to the community Active treatment All ages served Alternatives to hospitalization Availability Avoidance of hospitalization Catchment areas (districts) Citizen partidpation Communication between workers and agendes Community care, better Community partidpation Community ties retained Comprehensive treatment Continuity of care Coordination among agendes Early detection, treatment Environmental influence
Expectancy
Geographie responsibility Health more important than illness
Immediacy
Indirect services Information exchange, easy Integration of state and local services Interdisciplinarycollaboration Linkages between human services networks Live in community Mental disorder only one part of Iife Minimal interventions Multi-disciplinary PIanning for gaps in service Poor, care for Prevention(l',Z',3"} Proximity Public health Rehabilitation Reintegration into the community Responsible person enters other systems when patient goes (e.g., hospital) Segmental treatment Sodal engineering Socio-cultural influence Transfer easy between elements Written agreements Reprinted by pe:rmission from Psychiatr Q (see ref. 6)
[ \1 1'.\ \ [ I
TABLE 2. Programmatic elements of eommunity psychiatry Aftercare Alternatives to asylums (psychopathie and general hospital) Alternatives to hospitalization Brief treatment Citizen participation Clinics (outpatient, traveling. and satellite) Community consultation Community education Community participation Crisis intervention Emergency treatment (24 hour) Familycare Fostercare General practitioners Halfway houses Homecare Hostels Indirect service (consultation and education) Integrated programs of prevention, treatment, and aftercare
Integration of state and eounty programs Interdisciplinary teams and training Non-medical personnel (social workers, nurses, etc.) Openwards Paraprofessionals Partial hospitalization (day, night, weekend) Prevention 0", 2", 3") Rehabilitation (social and vocational) Therapeutie community Unitization Walk-in clinics Reprinted by permission from PsychÜltr Q
(see ref.ö)
sion, and common sense. There was a great deal of National Institute of Mental Health (NIMH) money in those years; our science was slow to mature; and departments with intelligence and a degree of commitment to the community could get a sizable slice of the research, training, and/or services pie . As Alan Kraft put it, "Those were the days when you sent NIMH a postcard requesting money and you got the funds in the retum mail" (personal communication), Departments that one usually did not associate with a devotion to service provision happily applied for and received grants for planning, staffing, and constructing CHMCs. In addition, there was a great deal of passion about community psychiatry, particularly against it, from the "old guard," as is obvious from the titles of papers such as Roy Grinker Sr.'s "Psychiatry Rides Madly in All Directions," Warren Dunham's "Community Psychiatry: The Newest Therapeutic Bandwagon," and Lawrence Kubie's ''Pitfalls of Community Psychiatry" (8-10). Although it is currently fashionable to derogate the passion demonstrated by the adherents of community psychiatry for its naivete and its proponents for their overly ambitious and sometimes exaggerated claims, the movement did attract a great
TADLE 3. Caplan's prevention models of community psychiatry Typeof Prevention
Goal
Methods
I"
Reduction in the incidence of all mental disorders
1. Consultation to care givers 2. Education of community leaders 3. Socialaction
2"
Reduction in the duration of oE those incidents of mental illness that do occur
1. Early detection and screening 2. Early diagnosis and referral 3. Prompt and effective
3"
Reduction in impainnent resulting from mental illness
1. Education to eliminate prejudice 2. Communication with social networks 3. Avoidance oE hospitalization 4. Hospital-eommunity proxirnity
1"=Primary;2"=Secondary;3 "=Tertiary. Reprinted by permission from PSYChÜltrü: Administration: A Comprehensioe Test {ur the Clinician-Executite. New York, Grune and Stratten, 1983, p. 10
11 'I', \ ( \ 1)1 \ 11( 1'-·) ( 1I1
\I I~)
\1)\'\, Il()'\,! [) 11 11
I
()\I\il '\, 1[ \
FIGURE 1. Alternatives to hospitals priorto 1955
HomeCir. Sca.I ReMbilicalIOC\ Dey HoIpI!a1
s..-CItnicI TmeIIIIlg ClmICS
Oulpebem AIIetQre
..... ~Our
... eoa.ePlln F. . . . . . . . Fenn GISI. Anne
I 1750
I
1100
I
1850
1S1OO
1950
Reprinted by permission from Recent Advances in Schizophrenia, New York, Springer-Verlag, 1990, p . 2BO
FIGURE 2. Community psychiatry dtations in the American Journal of Psychiatry (1964-1989)
\ ( )I 1 \! I ' , . '\, 1 \ J I, I !, .:: •
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number of dedicated psychiatrists into public service, which is refreshing compared with the difficulty we now have attracting psychiatrists to programs serving underserved populations such as the homeless mentally ill. Finally, there were cooler heads who thought that it was time to change from the fortress mentality of a psychoanalytically oriented inpatient psychiatry to an attempt to provide early identification and treatment of mental illnesses, if not their prevention. This involved answering interesting epidemiological, organizational, and service delivery questions and training psychiatrists for what most graduates of training programs actually did even then-rough and tumble general outpatient psychiatry. In summary, then, I conclude that academic psychiatry during the 19505and 1960s was involved in the community-if not in service provision, at least in research or training. Has this level of activity been reduced? IDnDENCETHATACADaflC PSYCHlATRY HAS ABANDONED THE COMMUNITY The evidence is quite impressive that academic psychiatry is no longer as invested in the community as it once was. Look, for example, at the number of citations in the American Journal o{ Psychiatry of all papers indexed by the word "community," e.g., community, community mental health, community psychiatry, community care facilities, and community mental health centers . There was a marked jump from 1963 to 1966 (from 0 to 24 citations), with a jagged plateau of around 20 citations for an entire decade until1976, when there was a gradual decline to only about one article a year from 1983 to present (see Figure 2). Second, whereas in the 19608there was a spate of books and monographs by prominent academicians, such as Biegel and Levenson, Gruenbaum, and Gruenberg (11\ ( \ I )I \ 11( [", ,,\ 111 \ [ 1\',
13), one is hard pressed to recall a recent academically authored book about the community. Third, there is ample anecdotal and statistical confirmation that psychiatrists, particularly those who worked in CMHCs, left or were driven out of community psychiatry in droves after the full blush of the 19608. Thompson and Bass's 1984survey showed a 10.6% decline in staff psychiatrists per CMHC from 1973 to 1981, in the face of a 5.6% increase in other staff, and a more startling 22.4% decrease in average numbers of FTE psychiatrists per CMHC, versus a 13% increase in other full-time equivalents (FTEs) (14). Fourth, there has been a marked change in NIMH grants, from excess and plenty in the 1960s to an absolute absence of money for research, training, or service targeted to anything labeled "community" now. Aside from a shift in focus from social to biological and from services provision to services research, the services monies that remained were no longer targeted for CMHCs but for Community Support Programs and programs for the homeless mentally ill. Finally, further evidence that academic psychiatrists have abandoned the community is reflected by their abandonment of the term, although perhaps not the concepts, in the descriptions of their work. Individuals who might have once described themselves as "community psychiatrists" are now more likely to describe themselves as interested in public psychiatry, the chronie mentally ill, rehabilitation psychiatry, deinstitutionalization, long-term care, and the homeless mentally ill. However, perhaps this is too one-sided a picture. Is the abandonment argument that convincing? IDnDENCE THAT ACADEMIC PSYCHIATRY HAS NOT ABANDONED THE COMMUNITY The first pieceofevidence marshaled against this proposition is the survey of Faulkner et ! 1;
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al. (15) of the amount of involvement in CMHCs that academic departments of psychiatry had in 1982. In that year, 79% of university departments of psychiatry had a · relationship with a CMHC, 76% with astate hospital, and 66% with a Veterans Administration (VA) facility. Of the departments with these relationships, only 27% had what the authors described as elose integration with their CMHC, 12% with their state hospital, and 95% were integrated with their VA hospital. Appoximately 24% of the relationships with CMHCs were contractual arrangements, compared with even fewer such arrangements with state hospital (16%) and VA facilities (17%). Finally, most departments had predominantly clinical training rotations in CMHCs-73%, versus 83% in state hospitals and only 6% in VA hospitals . Second, there is less evidence that psychiatry has abandoned the community than that it has abandoned CMHCs. CMHCs, with their emphasis on buildings and federal monies rather than programs, may have presented a deflection in the slow but steady progress of academic interest in community psychiatry. In addition, there are still several notable community service programs where high-quality residency training occurs (16). There are also several strong university-affiliated or administered CMHCs. Finally, there is unmistakable evidence that while perhaps diminished, community psychiatry has been swallowed whole by general residency training programs and now appears as part and parcel of many programs. Academic colleagues frequently refer to concepts such as continuity of care, horne visits, and consultations to schools not as "community psychiatry" but as "good psychiatry." DISCUSSION If one looks at all of the RRC requirements, one finds some very familiar terms and concepts from the 1950s and 1960s (17).
11 1/ l ()\J\ll
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Understandingthe... social, economic, ethnicand family..Jamiliarity with...financingand regulation...including the structure of governmentaland private organizations...experience in...crisis intervention...responsibility in community mentalhealth activities...should include consultationwith at least one community agency...activecollaboration with psychologists, psychiatrie nurses, social workers and other professional and paraprofessional...personnel. Although the RRC requirements are overspecific and unattainable, the basic concepts of community psychiatry are definitely there. One can break down the answer to the question "Has academic psychiatry abandoned the community" into several subsets. If referring to rural areas, it was never there. If we mean CMHCs, academic psychiatry was involved at one point on anational basis, at least in terms of staffing and leadership. However, if we incorporate the community under the larger umbrella of public psychiatry, the answer is mixed-academic psychiatry has never abandoned the VA system but psychiatrists have certainly left state hospital and state mental health office leadership positions. Community consultation has also shifted its terminology and locusfrom more exotic involvements with police units (18)and the military (19), to work with agencies serving the homeless, persons receiving rehabilitation, and the chronie mentally ill. Referring to the list of programmatic elements above provides another mixed picture. There are some aspects of the term community psychiatry that academic psychiatry is often and routinely involved with, e.g., aftercare, brief treatment, clinics, emergency treatment, family care, family orientation, interdisciplinary teams, non-medical personnel, open wards, and walk-in clinics. On the other hand, there are a number of aspects of community psychiatry that academic psychiatry is only sometimes in-
volved with, e.g., alternative treatments, community education, community consultation, halfway houses, horne care, indirect services, paraprofessionals, partial hospitalization, rehabilitation, and therapeutic communities. There are also some aspects academic psychiatry is almost never involved with, e.g., citizen participation, community participation, foster care, general practitioners, hostels, integrated prevention / treatment/ aftercare, integrated state/county services, primary prevention, and unitization. CONCLUSION There is no simple answer to the question ''Has academic psychiatry abandoned the community?" I think it has incorporated the very best and most useful community psychiatry concepts and programmatic elements into mainstream general psychiatry. I think academic psychiatry has gradually become involved with the chronie mentally ill wherever they are, not always because it wanted to and more slowly than many other
voluntary community organizations, but more quickly than most government agencies. And I think, again perhaps faute de mieux, it is now, more than ever, heavily involved with society's most difficult and perplexing public mental health problems. That does not mean that there is not more to do . Clearly, more must be done in those areas in which 1) there are manpower problems, e.g., rural areas, CMHCs, and state hospitals; 2} there is absent or abysmal care, e.g., prisons, nursing hornes, and shelters; and 3} populations exist that still are largely ignored and underserved, e.g., the dually diagnosed and homeless mentally ill. It is, therefore, the time for neither self-congratulation nor self-eondemnation. Rather, now is the time for continued self-examination of which areas academic psychiatry can appropriately contribute to community psychiatrie activities by extending its research, training, and service energies.
This study was originally presented at the AnnualMeeting o[theAssociation for Academic Psychiatry, Seattle, Washington, March 8, 1990.
References 1. Winters EE (00): The Collected Papers of Adolf Meyer. Baltimore, MD, Iohns Hopkins University Press, 1952 2. Caplan G, Caplan RB: Development of community psychiatry concepts, in The Comprehensive Textbook of Psychiatry I, edited by AM Freedman and HI Kaplan. Baltimore, MD, Williams and Wilkins, 1967, pp . 1499-1514 3. Committee on Psychiatry and theCommunity of the Group for the Advancernent of Psychiatry:Community Psychiatry: A Reappraisal. New York, Group for the Advancernent of Psychiatry, 1983 4. Stone EM: American PsychiatricGlossary.Washington, oe,American Psychiatrie Press, 1988 5. Hinsie LE, Campbell RJ: Psychiatrie Dictionary, 4th 00, New York, Oxford University Press, 1970 6. Talbott JA: Twentieth eentury developments in American psychiatry. PsychiatrQ 1982;54:207-219 7. Talbott JA, Kaplan SR: Psychiatrie Administration: A Comprehensive Text for the Clinician-Executive. New York, Grune and Stratton, 1983, p. 10 8. Grinker R: Psychiatry rides madly in alldirections. Arch Gen Psychiatry 1964; 10:228-237
9. Dunham HW: Community psyehiatry: the newest therapeutie bandwagon. Arch Gen Psyehiatry 1965; 12:303-313 10. Kubie I.S: Pitfalls of eommunity psychiatry. Arch Gen Psychiatry 1968;18:257-266 11. Biegel A, Levenson AI (eds): The Community Mental Health Center: Strategies and Programs. New York, Basic Bocks, 1972 12. Gruenbaum H (00): The Practice of Community Mental Health. Boston, MA. Little, Brown and Company,1970 13. Gruenberg EM: Programs for Community Mental Health. New York, Milbank Memorial Fund, 1957 14. Thompson JW, BassRD: Changing staffing patterns in community mental health centers. Hosp Community Psychiatry 1984; 35:1107-1114 15. Faulkner LR, Eaton JS, Bloom 10, et al: The CMHC as a setting for residency education. Community Ment HealthJ 1982;18:3-10 16. TalbottJA, Robinowitz CB (OOs): Working Together: State-University Collaboration in Mental Health. Washington, oe, American Psychiatrie Press, 1986 17. Rabinowitz CD, Kay J, Taintor Z (OOs): Directory of
11 \" \ ~ \ 1)1\ 11 ( 1'-') ( 111\ 1I, ) \ 11\ -, I\( )-, I I , ! 111 ( ( )\ I \ 1l '\.11'\
Psychiatry Residency Training Programs. 4th edition, Appendix C: Special Requirements for Residency Training in Psychiatry and Neurology, American Psychiatrie Association et al., Washington,rx:,1988,803-809
18. Talbott JA: The elements of community consultation, Psychiatr Q 1977; 29:273-290 19. Talbott JA: Community psychiatry in the army: history, practiceand applications todvilian psychiatry. JAMA 1969;210:1233-1237
