xx AACP Newsletter, Volume 13, Number 1, Winter 1999
APA Candidates Respond to AACP Concerns
It has become a tradition to pose several questions to APA candidates for President-Elect each year. This year is no exception. The questions, their responses and a brief bio-sketch of each candidate are provided below.
Larry Stone, MD is a life fellow of the APA and has been an active member for thirty years. He is the immediate past president of the American Academy of Child and Adolescent Psychiatry and has been the leader of a National Initiative Against Violence. He is Clinical Professor of Psychiatry at the University of Texas Health Science Center at San Antonio and is the Executive Medical Director of the Laurel Ridge Hospital of the Brown Schools. He is also in private practice.
Daniel B. Borenstein, MD is in private practice and is currently APA Vice President. He has also served as Secretary, and is in his tenth year on the APA Board of Trustees and has chaired or served on over 20 APA components. This is his seventh year on the California Medical Association's Board and he is an AMA Delegate. As Clinical Professor in the UCLA Department of Psychiatry, he has published scholarly articles on managed care, psychotherapy, ethics, peer review and confidentiality.
1. Many community psychiatrists have not joined the APA due to the high costs of membership and a perceived lack of relevance to issues related to their practice. What measures would it take to attract these psychiatrists?
2. What experience have you had in the practice of community psychiatry and what plans do you have to enhance the interest of the assembly and the board in issues of importance to public sector practice?
3. A large number of people with mental illnesses are currently incarcerated, usually receiving inadequate care. What specific measures do you think the APA should undertake to address this circumstance?
Dr. Stone's Response:
Thank you for inviting my comments to my colleagues in Community Psychiatry.
It has been especially meaningful to think about and inspect closely our field of Community Psychiatry during this session of holidays with the special giving, receiving and sharing that takes place. Every community observes these special times in some way. It was the ways, however, that attracted most of my attention. There was real love, thankfulness, friendship and happiness. Unfortunately, there was also real hate, selfishness, aloneness and sadness.
My own respect and compassion for all peoples are intensely heightened during these times, as I am sure yours are also. After all, our clinical interests start in the development of the individual, and expands concentrically to eventually include knowledge and understanding of the family/caretakers, neighbors, community, state, region, country and the world.
Even though, growing up in a small rural town in South Texas was segregated, my family never practiced isolationism nor bigotry. They could get by with this since my father was an outstanding medical and surgical practitioner, and only 1 of 2 doctors near by. After my college, and medical school years and marriage of four children, I returned as a general practitioner of medicine and surgery.
I was most sensitive to the Community, and the limitations that impacted so many people; the frustration, anxieties, anger, withdrawal or assaultiveness and the depression. Additionally, the community had the highest rate of tuberculosis of any community and high fetal death rates because it was a center for migrant farm laborers who were constantly moving.
At that time I became a real "community doctor". In the next four years I organized and integrated Junior Chamber of Commerce, became President of and integrated the powerful Rotary Club; election of Hispanics and blacks to our school board and city council; built the first integrated public park and swimming pool; started integrated neighborhood recreation and avocation functions; county-wide immunization programs; clean water and sewage to the living "shacks" outside the city limits; and a county-wide mobile TB X-Ray program with follow-up.
The satisfaction from these many events became the motivation for me to become a real "community psychiatrist." At McLean and Beth Israel Hospitals of the Harvard Training Program and the Boston Psychoanalytic Institute, I was privileged to be exposed to some of the greatest psychiatrists, psychoanalysts, social workers, educations and community advocates and activists.
Very early I organized a Community Mental Health Center including five hospitals around McLean; established the support and was Director of Building the Hall Mercer Children's Center at McLean; participated in writing the first Standards for Children's Psychiatric Facilities for the APA; later wrote the Accreditation Manual for Psychiatric Facilities Serving Children and Adolescents, for the JCAH; and later the first Accreditation Manual for Community Mental Health Centers for the JCAHO.
I have spoken and consulted with well over a hundred community programs and organizations. I have also emphasized the connectedness of the bio-psycho-social aspects of human individual, groups and systems growth. From work early with the Peace Corp, Headstart, Special Education, and Delinquency programs, I have more lately been involved in Violence Prevention Initiatives, locally, state and federal and international.
Regarding question #1, my above past agenda speaks for my future agenda. I am committed. We in the APA must lower dues, work closely with members, and recruit hard all non-members. Community Psychiatry is an integral part of all that we do and this special expertise should be available on all components of the APA, not competing, but complimenting.
Without being specific to question #2, I believe my life and current work speaks for the leadership and the demands that I will make of our organization to respond more to community psychiatry. My training in child, adolescent, adult psychiatry and psychoanalysis, plus my experience in wide ranges of community psychiatry will dictate these parts of my leadership.
Regarding #3, it is clear that we must exercise to the fullest our knowledge of human dynamics, systems analysis, group process, in leadership capacities on behalf of the un-or-under-served population. We are leaders by training if not by nature. We must form effective collaborations with other civic, social, private, public or governmental groups. At the same time we must be watchful and be proactive or reactive when lessor-trained individuals, or greed-driven groups attempt to emulate our participation without accountability.
Again, this time of the year brings out the best of happy thoughts, feelings and memories, while also bringing along the saddest. Let us all take heed of this phenomena and carry the best forward for ourselves, our family, our friends, our community and our country. We are each blessed by our hard work to have training, experience, and knowledge and may all of us return as much as possible to our communities.
Dr. Borenstein's Response:
1) As the premier psychiatric organization, APA must represent all patients and all psychiatrists. APA needs to know the concerns and special issues confronting psychiatrists practicing in public settings and treating disabled, poor and homeless patients to help inform and shape our national policies. The Community Psychiatry Caucus, which I support wholeheartedly, is an excellent beginning to reach out to members practicing in the public sector and as an information conduit to APA. It is the most active, new APA group and appears effective in communicating its concerns to the Council on Psychiatric Services. I am hopeful that, as this effort becomes better known, more community psychiatrists will participate, leading to more formal representation within APA's governance structure.
Moreover, APA must publicize the important role community psychiatrists are serving in the delivery of high-quality patient care under adverse circumstances. We must remain vigilant and work effectively to prevent inadequate patient care secondary to insufficient funding or the imposition of managed care on the less able segments of our population. Shortened psychiatric hospital stays and denials and restrictions of hospital admissions have greatly increased the work load of community psychiatrists who provide "hospitals without walls" and prevent relapses. These actions demonstrate the vital role of psychiatrists working in the public sector for many of our most vulnerable patients. When APA has demonstrated its interest in and support for community psychiatrists and their patients, has publicized the crucial role community psychiatrists play in our cities and has worked closely with the Community Psychiatry Caucus, I believe more AACP members will be attracted to organized psychiatry. I plan to push APA to provide this well deserved recognition.
2) My District of the Los Angeles County Medical Association founded the Venice Family Clinic which provides free and low fee care to the uninsured and Medicaid population. Most of the care is provided by volunteer physicians and most ancillary medical services are donated by our local hospitals. When I was President of the District and as a long-term member of its Board of Directors, I work closely with the Venice Clinic's Medical Director and initiated her election to the District's Board. During that time, I successfully encouraged and supported an expansion of the limited psychiatric treatment provided by the clinic, helped recruit volunteer psychiatrists for the clinic, visited the clinic on numerous occasions and provided financial support for its activities.
In order to enhance the interest of the APA Assembly and Board in issues of importance to public sector practice, in addition to the actions outlined in my answer to the first question, I plan to make sure that community psychiatrists play an active role on all appropriate components. I will encourage the development of a separate treatment code for psychiatric services delivered in the public mental health system, highlighting the importance of this work, and I will ask that more specific attention be devoted to increasing public sector funding including Medicaid.
3) Inappropriate incarceration of patients with mental illnesses is a major public health problem. Fully 15% of inmates nationally have severe mental illnesses. The Los Angeles County jail is, in effect, the largest public mental hospital in the United States. Unfortunately, it doesn't have the necessary staffing or provide adequate levels of psychiatric evaluation and care for its inmates. There are a number of actions APA can take to help rectify this situation. As a member of the APA Board of Trustees, I strongly supported the formation of a number of psychiatric caucuses, including the Caucus on Correctional Psychiatry. This group will provide the information needed by APA to approach the problem with constructive solutions. From my perspective, the APA must push for sufficient psychiatric staffing of correctional facilities to provide adequate care to inmates. Similarly, APA must push for adequate education of correctional staffs about mental illnesses and their treatments. State and local legislation can be helpful, requiring that hospital standards be met so long as the jails are filled with a significant number of psychiatric patients. APA must encourage the formation of community psychiatric structures to facilitate the transition from correctional systems to the community which will help reduce recidivism. APA should also urge that diversion programs for patients with mental illnesses be developed to move these patients out of correctional settings and into community psychiatric systems. These are my views and I plan to work for their implementation.