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Why Do a Community Psychiatry Fellowship?
A query from a medical student prompted a lively discussion among the members of the AACP Training Committee at the spring meeting of the AACP Board of Directors in San Diego. "How would I benefit from doing a fellowship in Community Psychiatry"? True to the usual course of events, there was no dearth of opinions on how to answer that question. I will try to summarize some of the thoughts that emerged during the course of this discussion and, hopefully, begin to answer the question.
It is always somewhat surprising to find that it is difficult to describe in words what some of us might refer to as a "calling". Working with the seriously and persistently mentally ill who have limited resources is often driven by a personal perspective or philosophy. Those of us who have made community psychiatry the focus of our careers clearly derive a great deal of satisfaction from this type of work. Although some might describe treating the people in our communities who are the sickest, without some of the benefits enjoyed by our private practice colleagues, as an altruistic endeavor, but few of us involved in this activity think of it as a sacrifice. Clearly, there is more to this specialty than we can teach. A potential fellow should have some understanding of the population that they will be serving and have some rudimentary commitment to it. It helps to bring a spirit of adventure and curiosity in order to benefit from the activities which are part of the fellowship experience.
Some of these intangible qualities will allow the fellow to engage in this difficult but rewarding work. The fellowship training will help to mold this raw energy and commitment into productive activity and skills. Few residency training programs give adequate exposure to the knowledge and skills that will be essential for effective work in a diverse array of community settings, and these are the focus of fellowship training in community psychiatry. Some of the specific training activities included in community psychiatry training programs are as follows:
The unique aspects of interdisciplinary team functioning in a well organized outpatient setting which employs a high degree of cooperation and sharing of responsibilities. It is generally an organization that is quite distinct from the physician-run, multi-disciplinary approach in most hospital-based settings.
Psychiatric rehabilitation is an approach to treatment that is taught in community psychiatry settings almost exclusively. Fellows will have the opportunity to understand its application and appreciate its results in a comprehensive way.
Expertise in engaging the homeless mentally ill is a part of community psychiatry training that is seldom available to residents in a general psychiatry program.
Treatment of the dually diagnosed mentally ill occurs in many settings, but the prevalance and challenges faced in community settings create an opportunity for development of expertise in an integrated multi-modal, multi-agency combined approach.
Community settings are ideal for gaining an expertise in crisis intervention and brief treatment models.
Evaluations in the community with the police and psychiatric mobile response teams are often available to fellows and help develop an understanding of the community and the diverse forms by which community mental health can be supported.
Treatment of the mentally ill in jails and prisons is usually available through fellowship programs and will be a setting that is important to understand as greater numbers of people with mental illness are detained in these settings.
Community psychiatry addresses the needs of clients of diverse cultural backgrounds, and developing cultural competence is an essential aspect of working with populations in the public sector.
Mental health services research is becoming increasingly important as new delivery systems evolve. Most fellowship programs offer opportunities to develop expertise in this area as well as other research opportunities.
Inter-agency consultation is an essential component of community psychiatry that can be a focus of fellowship training.
Educational skills development will be part of the fellowship program to enable fellows to become effective teachers in both community and professional education processes.
Community Assessment and Prevention activities are an important ingredient of public mental health programs and will provide the fellow with valuable skills for work in underserved areas.
Development of the appreciation of and skills for administrative activities which will often be a part of the psychiatrist's role in public settings.
There are a number of practical considerations as well. The fellowship year is a time to sharpen skills while preparing for board certification. It allows a more gradual transition from the highly supervised experience of residency training to one of almost complete independence. Many graduating residents want to pursue research interests or other academic activities before assuming the demands of full time employment. Most fellowships require 20 hours of clinical work and allow 20 hours to pursue academic interests or to work in alternative settings.
We believe that once exposed to communitiy psychiatry, you will never want to leave.
Kathleen Daly, MD
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