PUBLIC PSYCHIATRY TRAINING PROGRAM

Oregon Health Sciences University

Department of Psychiatry - OP02

A HITCHHIKER'S GUIDE TO COMMUNITY MENTAL HEALTH IN THE 1990s

An Introduction:

You suddenly awake one morning, realizing that something is different. You don't know what it is. You get out of bed. You put on your clothes. You have a headache. You enter a building and look around you. Surroundings are not familiar. There are several people in the room─they are all calling you by name, but none of them look familiar to you. Some seem to be avoiding you; others are asking you strange questions. You are terrified to discover that you don't know any of the answers. They bring in a person who looks like he is in bad shape. Someone asks, "What's wrong with him? You talk to him for a few minutes, but you don't understand anything he is saying. You scream, "I'm not sure what's wrong with him!"

This place you're in. Even the plants are arranged funny. You don't have your own office. There aren't any beds. No one wears a tie, and some don't wear shoes. You identify yourself as a third year resident in psychiatry. You ask, "Where is the ward, and where are the patients?"

They say, "This is the Orgonon Institute for Human Growth and Expansive Thinking. Sorry, Doctor, we're busy right now having a meeting, but we need someone to write prescriptions and sign treatment plans and there are 17 "consumers" lined up to see you in the waiting room. Oh, by the way, welcome to the community."

The enclosed document is designed to help you travel through the confusing and magical world of community mental health. It's important to remember that community mental health centers are not the same as hospitals. This is particularly true in Oregon, which has a predominantly rural mental health system. Roles, relationships, hierarchies, duties, structures, functions, players are all different. During the next six months we will be attempting to help you understand this new framework. We hope it will be an adventure that will stimulate your senses and expand your horizons. We know that in the short run it will be confusing and anxiety provoking. But, in the long run, we expect you to find a niche in these little environments.

The program has a history and an internal skeleton. The remainder of this manual will describe those aspects and should serve as a guide for making your way. Should you get lost, you have supervisors both at the medical school and at the mental health center who are anxious to help. At the end of the journey we will ask questions about what you saw and what you learned. Those questions are also included in this packet. If you don't hear the answers along the way, all you have to do is ask us, and we will tell you the answers at any point.

Good luck on your journey!

PUBLIC PSYCHIATRY TRAINING PROGRAM

Orientation to community psychiatry rotation

1. Introduction

Following several years of joint planning, Oregon's Community Psychiatry Training Program (now Public Psychiatry Training Program) was started in September of 1973. The program was initiated by the Emergency Board of the State Legislature and planned by the Oregon Mental Health Division, the Department of Psychiatry, and the resident training program at Oregon State Hospital. The organizational structure emphasized the statewide nature of the program, with responsibility for training all psychiatric residents in Oregon, and stressed the importance of interdisciplinary relationships in community mental health training. Six distinct groups (Oregon Mental Health Division, Oregon State Hospital, Oregon's Community Mental Health Center Directors, the Dean's office at the medical school, the department of psychiatry, and the state senate) worked in a collaborative effort to develop the proposal for community psychiatry training. It was felt that the diverse representation of mental health and public interests would assure the state-wide participation and relevant priorities for training placements.

The overall mission of this program is to develop psychiatric manpower for work in community programs and state hospitals in Oregon. Residents are required to spend to spend three months at Dammasch State Hospital in their second year, and half time for six months in the community in their third year.

2. Educational objectives

The curriculum in public psychiatry includes all activities of indirect services that would be performed by a psychiatrist in a community setting. These involve consultation, interdisciplinary team participation, administration, community educational tasks, supervision of co-professionals, and forensic psychiatry.

Skills: The ability ...

m To enter a community mental health delivery system with a working understanding of the psychiatrist's role

m To distinguish between levels of intervention and prevention

m To participate in and support case management activities (assessment, planning, linking, monitoring, and advocacy)

m To plan, work, and relate on an interdisciplinary team for the provision of direct or indirect services for mentally disabled persons

m To negotiate a consultation contract

m To conduct a mental health consultation with a community agency

m To collaborate in mental health program planning, quality assurance, and management activities

m To conduct pre-commitment evaluations and court examinations under Oregon's commitment statute

m To demonstrate a thorough understanding of the use of medications in collaboration with non-medical staff around issues of compliance and informed consent

KNOWLEDGE

m History of the community mental health movement

m Basic concepts in social and transcultural psychiatry and psychiatric epidemiology, including the service delivery system, to specific ethnic groups and disadvantaged minorities

m General principles of primary prevention, secondary prevention, crisis intervention, and tertiary prevention (the care of the chronic patient in the community)

m The role of social, cultural, and family stress in mental adaptation

m The theory and practice of different models of consultation and the identification of the characteristics of direct and indirect service.

m The structure of community mental health delivery systems in Oregon

m The general principles of forensic psychiatry with particular focus on the Oregon commitment process

ATTITUDES

m Appropriate respect for interdisciplinary mental health team members

m Responsibility to patients, their families, and significant others, including agency people, and appropriate respect for their opinions and welfare

m Willingness to consider and evaluate criticism and peer review of one's professional work

m Commitment to evaluation of treatment results as scientifically as possible

m Comfort in dealing with highly personal and emotionally charged situations

m Sensitivity to and willingness to explore a variety of opinions and attitudes and ideas set forth by patients, patient advocates, and community people at large

3. Educational experiences

The two main experiences provided residents are a weekly seminar and field placements in community clinics.

1. Public psychiatry seminar

Each Friday morning students of nursing, psychiatry, and social work meet at OHSU in a seminar that covers the following general areas:

m An introduction to the basic concepts of community psychiatry, historical review, epidemiology, concepts of prevention, and interdisciplinary relationships.

m The consultation process, describing the models and techniques of community mental health consultation.

m Specific categories in community psychiatry: program development, program evaluation, administrative psychiatry, forensic psychiatry, tertiary prevention, and the chronic mental patient.

(Attachment #1 is a detailed listing of the current seminar topics.)

2. Community clinic field placements

The program has developed ongoing training agreements with many of the county mental health programs in Oregon. Residents may choose from among these the one that best fits their needs. All residents are required to negotiate a specific contract with the agency in which they are placed. These contract negotiations take place during the first few weeks of community placement and are put in writing.

(Attachment #2 is an example of a contract.) They are designed to meet the educational objectives of the program as well as the needs of the resident and the community agency. Considerable flexibility is possible in the specific details of the contract, but we would generally like them to contain the following experiences:

m Residents are not to use any more than 50% of their time for direct service functions when in community clinics. Direct service is defined as face-to-face evaluation and treatment. Client-centered case consultation is not considered direct service.

m Residents will be expected to do two hours of work with children, adolescents, or their families, either in direct or indirect services. Indirect services include consultation to schools, Childrens Services Division, the juvenile department, residential treatment facilities, etc. Other indirect services such as program planning and evaluation are certainly acceptable. Any plan developed by the resident with this requirement will be reviewed. If a resident elects to do direct service in this area, the service component will be supervised by the department of child psychiatry here at OHSU.

m Residents are expected to work at least two hours a week with persons who have chronic mental illness. The expectation will involve some aspect of the development of a community support system for chronically mentally ill persons. Residents may do this by participating in consultation activities to natural network providers, family providers, church groups, etc., where these groups provide socialization, recreation, living skills or other types of training or psychosocial rehabilitation for the chronically mentally ill person. Residents can also participate with case management, case collaboration, or individual psychotherapy oriented towards helping the patient build a support system. This requirement is flexible, but should go beyond the activity of medication monitoring, which is also recommended, but not required during the community rotation.

m Residents are expected to spend two hours each month in administrative activities beyond the usual paperwork. This activity should be coordinated with the director of the community program. Residents should review the county mental health plan and become familiar with the administrative structure of the clinic, including the overt or covert organizational chart defining responsibility and authority, the functioning of the governing and/or advisory board, the mental health program's budget, and the personnel management system and mechanisms for policy and procedure development within the agency.

m In the area of civil commitment residents are expected to participate with the mental health investigator in at least one investigation of a petition and to arrange to be a mental health examiner within the county court system on at least one occasion during the six month rotation.

In order to more clearly appreciate the importance of planning and support, residents are encouraged to fill out a weekly log sheet outlining the amount of time they spend in a variety of different activities in the community. (Attachment #3 is an example of this log sheet).

3. Supervision

Residents receive supervision at their placement site and at the medical school. A specific time each week, at least one hour in the community and one hour at the medical school, is designated for supervision.

4. Evaluations

There are several types of evaluation of this educational experience:

m Supervisor evaluation of residents. Community and medical school supervisors formally evaluate each resident at the end of the resident's experience. (Attachment #4 is a sample of the form to be used).

In addition to formal evaluation, weekly meetings of the resident and his/her supervisor affords an opportunity for frequent informal feedback. Supervisors should attempt to direct comments to the specifics of the educational objectives for the course and the negotiated contract with the resident.

m Resident evaluation of placement and experience. Residents also formally and informally evaluate both the program and the experience at the end of the rotation. (Attachments #5 and #6.)

m Oral examinations for residents. Each resident will take an oral examination, given by an interdisciplinary team of examiners, after completing the public psychiatry experience. (Attachment #7.)

5. Faculty communication

To be effective, an educational program such as this must have faculty who understand the overall thrust of the program and who communicate openly with one another, especially at times of difficulty. We are committed to the concept of joint supervision at the medical school and in the community. If difficulties or questions arise about any aspect of the program or a particular resident, contact should be made with a member of the faculty at the medical school so that problems can be corrected as soon as possible.

PUBLIC PSYCHIATRY TRAINING PROGRAM

Training Agreement

TRAINING SITE: Network Behavioral Health Care

ADDRESS: Crisis Team & Geriatrics, 2020 S.E. Powell Blvd. (238-0780)

Plaza (Rehab) 2415 S.E. 43rd (238-0705)

COORDINATOR: (Crisis Team) Davis Clowers, PMHMP;

(Plaza Rehab) Julie Dailey, PMHNP

Objectives:

1. To gain appreciation of the daily life experiences of people with chronic mental illness and of the impact their illnesses have on their families.

2. To explore and experiment with the role of a psychiatrist in a community mental health clinic.

3. To gain experience doing psychiatric assessments and treatment both in the clinic setting as well as in various community locations.

4. To learn about the administrative structure of the mental health clinic.

Activities/Clinical Experience:

1. Visit various housing sites supervised by or affiliated with the agency and do psychiatric assessments as needed.

2. Attend family support group at Phoenix Center.

3. Participate in geriatric assessments with Davis Clowers.

4. Perform medication evaluation and follow-up in both crisis and rehab settings, including recovery services.

5. Participate in assessment of individuals for PIPHOH's.

Administrative Experience:

1. Attend crisis team meeting at 2020.

2. Follow and discuss program changes at the Plaza with staff there.

3. Meet with program directors to discuss administrative aspects of the agency.

4. Collaborate with agency to develop description of this rotation for future residents.

Consultation:

Work with staff at Belmont Terrace Nursing Home to develop a more collegial-professional relationship with Network staff.

Period of placement: 1/1/94 - 6/30/94

(above) Tom Welch, M.D.

Program Directors Site Coordinators Resident

PUBLIC PSYCHIATRY TRAINING PROGRAM

ORAL EXAMINATION PROCESS

The Oral Examination for the Public Psychiatry Training Program is intended to give residents an opportunity to share the knowledge, insights, and understanding they have gained during their community psychiatry rotations. It is hoped that residents will have given thought to the aspects of community psychiatry that they have encountered in the didactic and experiential presentations of the Friday morning seminars, as well as the consultation and other clinical experiences obtained at their chosen community locations. These experiences may be unique, requiring different abilities and activities than those required in the earlier phases of residency training.

The examination will be conducted by an interdisciplinary team of examiners with experience in public mental health programs. The exam will last approximately 40 minutes. The resident will be evaluated on his/her ability to formulate a creative, thoughtful response to the problems posed as well as the knowledge he/she displays in regard to public mental health issues. It is not intended to be a stressful process, but rather a means of encouraging the resident to draw upon various direct and indirect community psychiatry experiences to demonstrate his/her understanding of this field. The exam will not count in any evaluation of the resident's performance.

The examination will include two questions:

1. The resident will be given a choice of several hypothetical situations that relate to community mental health practice. The resident will be asked to address the situation in a problem solving manner. Depending on the particular situation, it may be helpful and/or necessary to consider the following areas of concern in formulating one's answer:

a. Mental health program structure and organization.

b. Mental health law

c. Epidemiological issues

d. Transcultural issues

e. Forensic issues

f. Mental health consultation process

g. Interdisciplinary relationships

h. Interagency issues

i. Program evaluation

2. The resident will be asked to describe his/her community experience and to identify prominent issues or principles of community mental health and how these issues or principles were related or involved in the experience. The resident will be asked to identify a specific problem or situation that he/she observed and to discuss possible strategies or approaches that could be utilized to understand and resolve a problem. If the resident is unable to identify a specific problem for discussion, then the senior examiner shall supply one from a list of hypothetical consultation problems.

It is important to stress that it is not the goal of the exam for the resident to come up with perfect solutions, nor that the resident will be penalized for incomplete or faulty responses. The questions shall be used as a means of assessing the resident's understanding of community mental health issues and to assess the ability of the Public Psychiatry Training Program faculty to convey the basic knowledge, attitudes, and skills required to successfully practice in public mental health settings.

Sample Questions

I. Program Development

1. Develop a mental health program for homeless persons in a moderately sized urban setting.

2. Develop a mental health program in a rural setting that has had no psychiatric resource in the past.

3. Develop a mental health program to deal with the excessive suicide/depression/ somatic illness rate in an urban community of recently settled immigrants from a third world country.

II. Consultation Problems

1. A CMHC is floundering and not meeting its contract goals. Staff morale is low. The executive director has recently been hired to "correct the problems." The chair of the community board is excessively involved and intrusive, dealing with clinic procedures and clinicians directly.

2. A rural county has a problem with the local judge, who routinely discharges virtually all allegedly mentally ill persons from commitment hearings. The county ICP staff are frustrated. The police are furious and have begun to refuse to respond to citizen complaints about dangerous-acting, apparently mentally ill persons.

3. The high school principal in a small city near an Indian reservation requests your consultation to deal with frequent outbreaks of violence and suicide within and between three distinct ethnic groups in the community: Native Americans, Hispanics from the farm labor community, and local white "crackers."

INTERDISCIPLINARY COMMUNITY MENTAL HEALTH SEMINAR SCHEDULE

JULY - DECEMBER 2000

OHSU-OPC 6318 (unless otherwise noted); Fridays at 8:00 - 10:00 AM

Faculty: David Cutler, David Pollack, Douglas Bigelow, Rupert Goetz, Neil Falk, Vikki Vandiver

Residents: Jim Harle, Dave Jeffery, Kristen Snyder, and JJ Valen

Date (Friday) 8:00 - 10:00	Location OPC 6318 (unless otherwise noted)	Subject	Presenters	Coordinators
Part I: Theory, Planning and Management
7/7/00	OPC 6318	Introduction	Pollack	Staff
7/14	OPC 6318	Theory and Practice of Mental Health Consultation	Pollack	Pollack **
7/21	OPC 6318	Commitment Services in Multnomah County	Bill Toomey	Pollack
7/28	OPC 6318	Developments at the Federal Level	Pollack	Pollack
8/4	OPC 6318	Dual Diagnosis	Mike Kaplan, Boverman	Pollack
8/11	OPC 6318	Community Mental Health Services Under Managed Care	Goetz	Goetz **
8/18	OPC 6318	Placement Discussion		Cutler
8/25	OPC 6318	Oregon Health Plan		Goetz
9/1	OPC 6318	Community Support System/Assertive Community Treatment	Cutler/Bigelow	Cutler
9/5 Tuesday	Salem	Field trip to Salem		Goetz
9/8	TC/5228 NE Hoyt, Bldg B	Acute Crisis Care Facilities/Crisis Triage and Ryles		Falk **
9/15		OPA
Part II: Services and Special Populations
9/22	Royal Palm 310 NW Flanders	Homeless Mentally Ill	Falk/Shapiro	Falk
* 9/29	OPC 6318	Families	Loaiza/Renaud	Pollack
10/6	OPC 6318	Consumer Issues/Consumer Technical Assistance