Spring 1999 - Editor's Column: Alternative Perceptions

of Community Psychiatry

xxAACP Newsletter, Volume 13, Number 2, Spring 1999

Editor's Column: Alternative Perceptions
of Community Psychiatry

My journey to community psychiatry began with two uncles who are ministers and with my mother who is what my father has described as a "steeple chaser" because she was so involved in church activities. She and my grandmother also served on the World Council of the YWCA. I went to Yale in the late sixties and had the good fortune of singing in the Battell Chapel Choir where I heard William Sloan Coffin preach week after week. I became very involved in the anti-war and civil rights movements and went to divinity school in California as a way of pursuing these causes. My pastoral counseling training led to my ultimate interest in psychiatry. My longstanding interest in serving the underserved in turn led to my doing a rural community psychiatry fellowship in my last year of training at Dartmouth.

The principles of community psychiatry have inherent appeal. Among these are the following: assuring ready access; having a comprehensive continuum of services; treating in the least restrictive alternative; utilizing an interdisciplinary treatment team; involving families whenever possible; and assuring the preservation of patient/client dignity. Abrams wrote an article in the green journal a number of years ago entitled, "Beyond Eclecticism." He asserted that we must comprehensively diagnose and treat problems that are manifest not only in the biological, psychological, and social spheres, but also those in the spiritual realm, at least for those for whom this is an area of meaning in their lives. Treatment must also address itself to psychosocial rehabilitative needs, including socialization opportunities and employment, as well as housing needs.

Community psychiatry offers an extraordinary array of clinical, educational, and political opportunities: emergency, outpatient, intensive outpatient, partial hospital, and inpatient services; individual, couple, family, and group therapy; assertive community treatment; consultation to schools, nursing homes, and jails; education of staff, patients, families, and the general public; and advocacy with town, state, and federal governmental bodies. The AACP has established itself as an organization that embraces the multifaceted landscape of community psychiatry and has provided extraordinary leadership in advancing the recognition and value of this specialty. It has been a great pleasure to have been associated with the psychiatrists who comprise this organization since 1984. A great deal has happened since our group began as group of community mental health center psychiatrists, and as our organization has changed, my own professional life has taken a number of twists and turns as well.

Having been involved in social activism during college and graduate school, and having focused on ethics in addition to pastoral counseling in divinity school, I have naturally been a bit of a "crusader rabbit". Advocating for principles and causes in which I believe has not been without its price: I have been demoted once and fired twice. Once, when commiserating with Henry Harbin, CEO of Magellan Behavioral Health and former Commissioner of Mental Health for the State of Maryland who had been fired from that job, he said that you haven't earned your stripes in the public sector until you have been fired at least twice. While I remain committed to the public sector and, therefore, am currently serving as the part-time Medical Director for the Behavioral Health Network of Maine, comprised of CMHCs and substance abuse agencies across the state, I have determined that I must have my own safe haven. Consequently, when we moved to Maine four years ago, I formed my own interdisciplinary group practice. As President and Medical Director for Integrated Behavioral Healthcare in Portland, only I can fire me, and while that is not likely to happen, if it did, I would have only myself to blame!

As a private group practice, managed care has become more and more a part of our reality, just as it will in the public sector. Managed behavioral health care is, in many ways, community psychiatry revisited. You have responsibility for a given population for which you must provide care cost-effectively, utilizing the different clinical disciplines' expertise in targeted ways. While heretical to some, I am, having been a community psychiatrist, very comfortable in the role of providing medication management while the masters level clinicians in our group provide the individual, couple, and family therapy. Managed behavioral health care is also ideally integrated with general medical care. We work very closely with a large primary care physician group. We assure ready access for their patients, on their premises or ours; we provide ready consultation over the phone; and we provide regular written feedback on their patients.

While many other clinicians in our area have actively resisted managed care, we have viewed it as an opportunity to improve upon how we do what we do. We have sought to be managed care friendly, working closely with the managed care companies and with patients to help them effectively manage their limited behavioral health benefit. We internally do our own utilization review in peer supervision, so that requests for extended treatment do not leave Integrated without the benefit of collective clinical wisdom being applied to the case, and without collective authorization that extended treatmentis, indeed, medically necessary to eliminate symptoms and restore baseline functioning. In collaboration with the primary care group, we are engaged in two exciting projects. One is todevelop a comprehensive, interdisciplinary algorithm for the assessment and treatment of ADHD in kids. The other is to provide behavioral health screening, stress management, and, where appropriate, psychotherapyand medication management for the top ten utilizers of medical services (aka"frequent flyers") for each physician in one of this large group's primary care practice sites. We hope to demonstrate both a reduction in patient morbidity and a medical cost offset achieved through appropriate behavioral health interventions.

There have been numerous discussions about what comprises community psychiatry. These have often revolved around the concepts of public vs. private. I think that the experiences that I have just described indicate that the principles of community psychiatry can be adopted or adapted to the private practice setting. We should encourage our colleagues to think of these principles of community psychiatry, regardless of thesource of their reimbursement. It is the practice, not the payor, that counts.

Gordon Clark, Jr., MD, M.Div., FAPA This article has been developed from comments made by Dr.Clark, founding president of the AACP, as part of a workshop sponsored by the American Association of Psychiatric Administrators at the Institute on Psychiatric Services on October 3, 1998.

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