The Medical School and The Community Mental Health Center IS PHS > a S Ghd TX atlloa. CLEARINGHOUSE FOR MENTAL HEALTH INFORMATION U.S.S.Di ''''The Medical School and the Community Mental Health Center Report of a conference sponsored by the Southern Regional Educa- tion Board and the National Institute of Mental Health (Contract No, PH-43-67-43) held in Atlanta, Georgia, December 13-15, 1966. U.S. DEPARTMENT OF HEALTH, EDUCATION, AND WELFARE Public Health Service - Health Services and Mental Health Administration National Institute of Mental Health Chevy Chase, Maryland 20203 For sale by the Superintendent of Documents, U.8. Government Printing Office Washington, D.C. 20402 - Price 40 cents ''Public Health Service Publication No. 1858 ''RA 790 — 43581 Public Foreword Health In the December 1966 conference, 'The Medical School and the Community Mental Health Center," we explored some of the issues and problems a medical school depart- ment of psychiatry encounters when it plans a community mental health center to be a part of its teaching facilities. In this report of the conference we have tried to organize the chapters according to those issues and problems. Thus all the related items that developed either in formal presentations or in the group discussions have been put together in a single chapter. The formal presentations are quoted and are condensed; they are not printed as they were presented. We gratefully acknowledge the assistance of the National Institute of Mental Health in supporting this conference under PHS Contract Number PH-43-67-43, and in publishing this report. This kind of conference and report helps us fulfill our goals of facilitating mental health training and research in the South. Harold L, McPheeters, M.D. Associate Director for Mental Health Training and Research Southern Regional Education Board 130 Sixth Street N.W. Atlanta, Georgia 30313 9/28/67 01465 iii ''II. III, IV. VI. VII. VIII. Contents INL ELOGUCELON Gorse cies ce ie Foie cise e+ Sxe elile econo cies 6 eheveusvatehiue. ser susastere Community Psychiatry--The Medical School's Obligation?.........cee. Planning the Community Mental Health Center--What Are the Problems MedicalSchool Encounters 25: <1.) hse 'eos.0.c wc ine 0 6 etele e oie ose tete bo 8 6 Programming the Services--What Are the issues? @linseal SERVICER Gee sis oo ecerbi-e: c's chee allie Sie alleabceo die dicativie te da ets te Clitidiren andvAdolescents 3.6.6 's 46 eves occ orate ode beaks eiteve Pietb outee NWONe GHnIGAlGerVviGes: ie soso oie 615: Uae he due gic il cites «ee What About the Training of All Kinds of Manpower in the Teaching Community Mental Health Center? i ie ie er WY Or I cc bc se kw dene What Are the Issues in Financing and Administration? PSUR CAI Gs 32s a so elapece.c 0's 0. the 6.0; 0i4 0, b-08e ie MAGMAINISEEOLION .: sicve tre. ee. 60 60100 What Are the Center's Relationships? To the Rest of the University ...... To Other Community Agencies ..... To the State Mental Health Authority . Roster. of Participants: 6%... 62.055 euaie Sec 6 iv Page 13 14 15 17 21 24 25 31 33 35 38 ''CHAPTER I Introduction This publication is essentially the report of a conference sponsored by the Southern Re- gional Education Board and supported under Contract No. PH-43-67-43 by the National Institute of Mental Health in Atlanta, Georgia, December 13-15, 1966. From our discussions with psychiatrists and others from the medical schools of the South in 1965-66, it appeared that nearly all of the departments of psychiatry were giving some attention to the teaching of community psychiatry. The degree of commitment to the teaching of this newer mode of psychiatric practice varied greatly from a cursory ex- posure of some residents to community ac- tivities, together with a feeling that com- munity psychiatry was perhaps only a passing fad, to the establishment of a division of com- munity psychiatry with planned programs of post residency training. There seemed to be varied notions of what community psychiatry was all about, and whether it was really the concern of the medical center. At the same time, nearly everywhere, there was the uneasy feeling that with the develop- ment of community mental health centers un- der the leadership of the National Institute of Mental Health, the training centers had better make it their business to give their residents some acquaintance with community psychiatry, since many of the residents would likely spend some part of their professional careers in these new centers. In several medical centers there was active planning for either the construction of a com- munity mental health center to be part of the medical school's teaching resources, or there was exploration of ways in which the medical school could use the resources of a nearby community mental health center for teaching purposes. In the medical centers where these plans and explorations were underway, there was preoccupation and perplexity over similar problems--the same kinds of obstacles, blind alleys, and oversights were confronting plan- ners in center after center. It occurred to us in the Southern Regional Education Board that we might convene a conference of persons from the various med- ical centers of the South to explore some of these issues. We are quite aware that the solutions to these questions will vary from center to center, depending on the geographic, social, political, financial and administrative structures available to each, But it still seemed to us that all could benefit from an exploration of the questions with some of the nation's experts who have been working on these problems the longest and with others who are grappling with them at present. A conference of persons from the medical centers and States of our region, therefore, seemed like a logical way for us to facilitate the teaching of community psychiatry and the development of teaching mental health centers of the South. We approached NIMH about funding for such a conference and found them enthusiastic and most helpful. Contract No. PH-43-67-43 was negotiated to cover the ex- penses and planning went forward. We are indeed grateful for their assistance. There are a number of definitions of com- munity psychiatry, but one that appeals the most to us is that of Dr. Leigh Roberts... "a subspecialty of psychiatry, focusing on the prevention, diagnosis, treatment and rehabili- tation of emotional illness and its sequela in a given population."’ Perhaps the most critical word in this definition is "population." The activities of psychiatry always must focus on individual sufferers, but in com- munity psychiatry the focus is on the given population rather than solely on the individuals who are presented for treatment. By extension and by definition the focus of the community mental health center is also on a given popu- lation, called its catchment area. The com- munity mental health center is primarily a service facility which is expected to meet all of the needs of the population of its catchment area for treatment, rehabilitation, and pre- vention and the center is responsible for the ''development of generally good mental health in that population. But medical centers and departments of psychiatry have traditionally not been con- cerned with meeting all of the service needs of a population. To be sure, the medical schools have rendered direct services, but generally such services have been secondary by-products of teaching and research which are, after all, the basic functions of the uni- versity. How, then, shall we resolve this dilemma in the case of the medical school and the com- munity mental health center? Perhaps the problem lies more in community psychiatry itself than in the community mental health center where it is practiced. At least this is so if we define community psychiatry, as Dr. Roberts does, as the subspecialty which focuses on the control of emotional disorders in a given population. The practice of community psychiatry im- plies the use of complex social strategies of intervention: public education, consultation, and social planning, to name a few. These are quite different from the traditional focus on individual pathology and therapeutics. Is it the universities’ role to become involved in these kinds of community planning and com- munity action programs? Here is another dilemma we face in having a community men- tal health center as part of the medical school's operation. Are there models for these kinds of activ- ities in other areas of higher education? Perhaps there are more than we realize. For instance, colleges of agriculture, through their extension services, have long been concerned with increasing and improving the agricultural production and efficiency of the rural com- munity. Extension services have been involved in the planning and coordinating of Federal, State, and local agencies. It seems ironic that agriculture has made such strides in serving the needs of a dynamic community while men- tal health is only now moving toward this goal. Many universities have established com- munity extension services, bureaus, or in- stitutes--Minnesota, Wisconsin, North Caro- lina, Kentucky, and New York among them--to plan community services in such diverse areas as business research, pest eradication, wel- fare services, water resources, banking, engineering counsel, industrial relations, municipal operations, forestry management, wildlife management, urban planning, and homemaker services. Demonstration and pilot projects conducted by universities are legion. In health related areas such models are especially common in public health. Perhaps community psychiatry in its final analysis is only public health psychiatry. At any rate there do seem to be ample models and prec- edents for the universities to assume obli- gations for service and community planning. In fact, the universities have changed greatly from the traditional concern with only aca- demic truth in the sense of the arts and sciences as taught by Plato and Aristotle. One of the most remarkable changes was the in- clusion of professional training in varied areas ranging from medicine, nursing, and law, to journalism, engineering, and teaching. This change is not yet complete as we still have a few independent medical colleges, nursing schools, and law schools. A third area which has now become the concern of the university--especially the 'multiversity"'--is public service, The land grant colleges pio- neered this work before World War I, In ''The Uses of the University,'' Clark Kerr has listed one of the major uses of the uni- versity as "involvement in the life of society," and notes that one of the major current con- cerns of the university is the relationship of the university to public service. Perhaps the community mental health center and com- munity psychiatry provide the opportunity for the medical school to move into the vanguard of the university's concern for public service. Another problem that presents itself to the medical schools that are planning community mental health centers is the question of the role of other disciplines in practice and train- ing. Is community psychiatry practiced only by psychiatrists, or do psychologists, social workers, nurses, and others need the same skills? Perhaps psychiatry is only for psy- chiatrists while the sum total of all that is done by the disciplines together is more properly called "community mental health." At any rate, the other disciplines clearly will work in the community mental health center and should be prepared for this work. How, then, is the training for them to be planned in our teaching mental health center? ''And what about research? Surely in a de- parture as unique as community psychiatry the new approaches must be researched-- especially in a university setting. Research is one of the university's major functions, and it surely is an obligation of academic psychiatry to assume this role as it moves into community psychiatry. Social scientists and epidemiologists become most crucial, but how do we involve them in our planning? There are always the questions of how to program the services, clinical and non- clinical, in this new center. The traditional services of the department of psychiatry have been inpatient, outpatient, and children. Are these still appropriate in the community mental health center? If not, what is ap- propriate? Several medical schools reported questions about the financing of both the construction and staffing of the teaching mental health center. Shall it come from the State? From the university? From the community? How can we expect the community to build more facilities than it actually needs in order to meet the teaching needs of the university? Who puts up the difference? How are these centers administered? By whom? What are the legal and administrative alternatives and their advantages and dis- advantages; What about staffing--especially if these are community operations? Which staff should have appointments at the medical school or elsewhere in the university? And then there is a group of questions about how this center should relate to various other agencies (for instance, the rest of the uni- versity; the community service agencies, such as health departments, welfare departments and juvenile courts; the community support agencies, such as fiscal courts, City commis- sions, and united funds; and to the State mental health department), What kinds of contracts or agreements are desirable? What are the administrative mechanisms? What are the alternatives? These were some of the major issues that seemed to present themselves to the medical school planners of community mental health centers, We structured our conference pre- sentations and discussions around them, and we have organized this book in the same way. There were 110 persons in attendance at the conference representing 25 of the South's medical school departments of psychiatry, several departments of psychology, vocational counseling, schools of nursing, schools of social work, local public health departments, State mental health departments and com- munity agencies. Over half of the conference time was devoted to group discussions in which all the participants from certain con- tiguous States were together. In this book we have not attempted to repro- duce the papers exactly as they were presented, Instead, the papers are considerably con- densed, although there are many literal quo- tations. Relevant points from the group dis- cussion sessions are included with the appropriate presentations. ''CHAPTER II Community Psychiatry-- The Medical School’s Obligation? Within the medical specialty of psychiatry, which is concerned with mental illness in individuals or in social units, community psychiatry in a broad definition includes at- tention to population groups as_ subjects for diagnostic study and therapeutic care-- approaches to individual patients marked by inclusion of social determinants of behavior in the development of etiologic formulations, by the utilization of the resources of the inter- personal and material environment in pro- grams of treatment, by emphasis on prevention and rehabilitation, by greater flexibility in the use of traditional modalities including all forms of inpatient and outpatient services. Community mental health programs are based on community psychiatry. They include the wide range of sub-professional, non- medical professional, and non-professional activities and agents supporting the efforts and practices of the community psychiatrist. With these statements as background, Dr. Israel Zwerling, professor of psychiatry, Albert Einstein College of Medicine and di- rector, Bronx State Hospital, delivered a paper prepared by himself and Dr. Milton Rosenbaum, professor and chairman of the Department of Psychiatry, Albert Einstein College of Medicine, which defined community psychiatry and outlined, for the conference, the responsibility medical schools have for teaching the subject. Dr. Zwerling describeu five new aspects of community psychiatry to the conferees: 1. "The basic sciences are new. In addition to relevant specialists at the biological and psychological levels of behavioral determi- nants, Community psychiatry demands ex- pertise at the social level as well. The traditional clinic team of psychiatrist, clinical psychologist and psychiatric social worker must be augmented by the epi- demiologist, social psychologist, sociolo- gist, group process specialist, community organizer, social anthropologist, and ever political scientist. "Formulations concerning illness proc- esses in individuals, as well as in popu- lation groups, are new. In addition to biological and psychodynamic formulations, mechanisms at various social levels-- family, community, social class, national group, cultural value orientation--are pro- vided, . . .In our view, the great conceptual challenge of our day to psychiatry is in developing articulations between the med- iate social determinants and the immediate intrapsychic determinants of psychopatho- logic behavior. . "The concept of diagnosis is altered, both with regard to who is diagnosed, and what is diagnosed....the diagnostic label no longer aims solely to describe the illness in an isolated individual. It may also in- clude the pathogenic qualities of the family, the community, the shop, the classroom or school. It may include the ward of a mental hospital. The entities are likewise changed, from individualistic intrapsychic entities like 'passive-aggressive character disorder’ or 'chronic brain syndrome’ to designations such as 'survivor syndrome,' ‘alienation syndrome,' and 'pseudomutual family syndrome.' . ''Techniques of treatment are altered. It is easy to forget in the centripetal pressure towards the patient who is the object of our particular therapeutic interest, that it is the family unit, the ward unit, and the shop unit which are the focus of the interven- tional effort. . "The site or locus of professional opera- tions is new. The community psychiatrist and his team are more likely to be found where the community is--in the churches ''and synagogues, the settlement houses and community center, the courts, schools, health centers, the executive offices of government where decisions concerning housing or welfare or community planning are made, in any of a growing number of strategic sites where community processes may be observed and diagnosed or where intervention appears promising with re- gard to the potential impact of the intro- duction of health-enhancing ideas or pro- cedures or practices." Dr. Zwerling, speaking about why community psychiatry has assumed such a commanding position in psychiatry today, said he and his colleague, Dr. Rosenbaum, felt that two re- lated components must be considered: The supply of and demand for mental health services. "We are hopelessly behind in our supply of trained psychiatrists and ancillary profes- sionals and we fall further behind-every day," Dr. Zwerling said. "With regard to the numbers of consumers of mental health services, complex and subtle factors at many levels are at work enormously multiplying the effective demand for help," Dr. Zwerling said, The increased number of facilities, the suc- ceeding efforts to diminish the fear of mental illness, and the decrease inthe shame attached to mental illness are some of the factors con- tributing to the demand for services. "At a broader social level, a number of forces are operative towards increasing the acceptance of shared responsibility for the cost of medical care. Insurance programs and other third-party payment plans are rapidly multiplying the numbers of those who not only can increasingly accept the need for help, but now also increasingly can afford to purchase it,'' he told the conference, Dr. Zwerling listed the Great Society, the Peace Corps, the civil rights movement, medi- care, and the anti-poverty program as "slogans which speak for the sweeping change which in part, includes a view of health as a human right rather than a privilege." He said the reservoir of demand to be loosed by current welfare programs and social movements is likely to be enormous. "Caught between an increasingly acute short- age of trained manpower, and an explosively 317-230 O-68—2 growing need for services, psychiatry must, in truth, either face the problem of mental ill- ness in the community, or surrender leader- ship in this area to other disciplines." Dr. Zwerling said academic psychiatry has been almost exclusively devoted to the problem of illness in an individual patient. "We have been teaching students and train- ing residents to do what we have been doing-- diagnosing and treating individual patients. Our research has been directed toward learn- ing how to do what we already are doing even better. "To continue to devote exclusive attention to teaching and research in the traditional medi- cal model is to search near the lighted corner of the room for an object we lost in the dark corner. The light is better where we labor, but the object of our search just is not there. "The issue is not should academic psychiatry enter into the planning and operation of com- munity mental health programs, but how should it and to what extent and at what rate and with what concerns in mind,"' Dr. Zwerling said. One conference participant said, in a group meeting, medicine is preparing students to practice privately. Psychiatry is doing the same. If medical schools are to undertake an involvement in comprehensive public health, they must decide whether or not the community is the appropriate place for medicine to go. Other groups have been contending with com- munity problems a long time and might ques- tion whether they are primarily medical problems. The challenges of community psychiatry to medical education are extensive and deep, Dr. Zwerling told conferees. To choose be- tween an attempt to survey the scope of the problems raised or to explore the depth of some one or two of the problems is difficult. As a starting point for a discussion, he posed six questions; 1. "What should be taught with regard to content and skills in graduate programs designed to train community psychiatrists? "The didactic content in most fellowship training programs includes family sociol- ogy, group process, community organiza- tion, and epidemiology. The skills taught include family therapy, group therapy, and mental health consultantship. We have hardly begun to confront such problems as ''whether separate criteria should determine the selection and recruitment of community psychiatry trainees or whether training for individual psychiatry ought not to follow, rather than precede training in community psychiatry. "How much of the content and skills relevant to the specialized training of a community psychiatrist should be included in the gen- eral residency training program? During the present academic year, our De- partment includes the following in the main body of the residency training curriculum: a. First Year (1) A weekly clinical seminar on family process for six months. (2) A weekly clinical seminar on group process for six months. (3) A weekly reading seminar on Social Determinants of Behavior for two months; this is part of the twin didactic seminars--one on Psycho- analysis and one on General Psy- chiatry--which run through all three years of training, b. Second Year (1) A four-month rotation, at half-time, through the Walk-In or Emergency Clinic. (2) A seminar, plus supervision on Fam- ily Therapy. (3) A seminar, plus supervision on Group Psychotherapy. c. Third Year A four-month rotation, at half-time, through the Division of Social and Com- munity Psychiatry, for a seminar, plus supervision on Community Agency Men- tal Health Consultation, "How much of the content and skills rele- vant to the specialized training of a com- munity psychiatrist should be taught to medical students? "It appears likely to us that, at least in some schools, the teaching of social and community psychiatry will evolve from the courses in medical sociology currently finding their way into medical school cur- ricula rather than from the courses in psychiatry. "How much of a service 'overhead' is nec- essary in order to establish a suitable base for the teaching of community psy- chiatry? "Although there is wide concern ex- pressed about the issue of service with regard to mental health, it seems to me that there is no less scope to the range of possible answers to this question than to any of the others related to community psychiatry. If we once admit the relevancy of the community as a determinant of well- ness and illness, then we are clearly ob- liged to . . . deal with all aspects ofillness in its population, The size of the commu- nity selected for study, however, will vary with the interest of the university--not only the department of psychiatry of its medical school, but its departments of sociology, anthropology, education, and others as well. "A psychiatric teaching service can be developed on a 20-bed ward or a 2,000-bed hospital; in a clinic which admits 50 pa- tients a year or 5,000. If the community is the target of diagnosis and treatment, a teaching and research unit can as readily be developed around service toa population of 20,000 as to the federally defined popu- lation unit of 200,000. "It seems to us an inescapable obligation of an academic department of psychiatry to develop, study, and test alternative thera- peutic approaches to patient groups not previously treated, as well as new ap- proaches to our more familiar patients. "Is there not the danger of losing the free- dom to pursue teaching and research di- rections in accordance with the dictates of one's own judgment by the availability of growing amounts of money for community psychiatry programs and correspondingly shrinking amounts for other directions? "The creation of the National Institute of Mental Health and its program of support for psychiatric training centers 20 years ago was the major factor in freeing uni- versity departments from the political ''control and service obligations which local support always involved. It remains, how- ever, a sorely regrettable bit of reality that, from intra-university to national levels, resources are finite and limited and there is then the attendant risk that he who pays the piper will call the tune. "Clinical research, any more than clin- ical teaching, cannot be a spectator sport. So long as the commitment made by a university is to a social issue in relation to illness and not to a particular solution, the community can be studied with as much freedom and scientific objectivity as can an individual patient." Another consideration relevant to this issue, according to Dr. Zwerling, is the influence of the role model in the learning process. "In most instances at the present time, the chairmen and senior staff of departments of psychiatry are identified with the traditional individual approach to mental illness," he said. "To some extent, an imbalance in effort and funds for community psychiatry programs is likely to be corrected by, the impact of the elder statesmen of the training centers who serve as ego ideals for the trainees," Dr. Zwerling said. 6. “Is community psychiatry to be seen as a special area or sub-specialty within psy- chiatry, or is it better seen as a new specialty as different from psychiatry as public health medicine is from internal medicine? "We believe that in time we will witness the emergence of social and community psychiatry as a related, but separate dis- cipline from psychiatry. ...It seems to us that before very long, given the present rate of growth or information, there will have been accumulated a sufficient body of knowledge to force the physician interested in mental illness into a career choice. "In a department of psychiatry in which the view of mental illness as an entirely biological and intrapsychic process is held, specialists in psychotherapy and individual approaches to treatment and patient care will be trained. In a department of psy- chiatry in which the view of mental illness as an entirely interpersonal and social process is held, specialists in group and family process and in community ap- proaches to treatment and patient care will be trained. Most departments, we would assume, will in the period immediately ahead continue to teach and train in both modes, and will continue to explore for articulations between the two." Dr. Zwerling concluded that the question of mental illness in the community must be ap- proached with the same disciplined rigor with which the question of mental illness in a patient is approached; "With that unique blend of knowledge, skill, and compassion which are the hallmarks of the physician seeking to relieve suffering." In the group discussions, there was con- siderable debate about community psychiatry and the difficulties it has in being established into a department of psychiatry which is strongly oriented to individual patients and to the traditional practice patterns of medicine and psychiatry. One group reported its deliberations in this way: "Much of our discussion seemed to reflect a continuing effort to grapple with some fundamental questions--questions which would appear to require some partial answers at least before the working through of strategies and procedures to relate the medical school and the community mental health center. We apparently have not reached complete con- sensus in regard to some of the issues. It has been suggested that this is due partly to the differences between public and privately sup- ported institutions with which we are affiliated. We seem to sense, however, that it is due more to the complexity of the matters under consideration, the ordeal which is experienced when one is confronted with change, and the underlying uncertainty in our minds concern- ing the most appropriate goals and the most expeditious means of attaining whatever we do establish as goals. "Although we seem not quite sure what the comprehensive community mental health cen- ter concept really entails--how drastically new, how radically different this approach is or should be from those we have been using-- we sense from developments and projections that the nature and scope of the center is such that the traditional doctor-patient relationship cannot serve as the sole model at least for ''its operations. We had some difficulty con- ceptualizing alternative or associative models although several saw potential yield from what was referred to as the ecological model. In this regard it seemed to be agreed that while schools of public health emphasize the ecologi- cal model, this has had little impact as yet on most medical school curricula. "We seemed to be saying that when we move outside the individual treatment modality in mental health work there apparently exists some role confusion among the various pro- fessions. While there was no indication that the blurring of roles in attacking a social problem is necessarily bad, we seemed to want some guidelines as to the appropriate functioning of the various mental health pro- fessionals and some improved ways of de- veloping coordination and teamwork between professionals in the areas of community mental health. We seemed in complete agreement that the community mental health center requires staffing by a number of related professions. We did not seem to be in complete agreement, however, in regard to the relationship between them. For instance, conflicting views were expressed concerning the necessity for medi- cal administrative leadership. "There has been agreement that community mental health developments are needed. There was agreement that the medical school andthe university as a whole should--and, in fact, must--keep informed about the community mental health developments and services in its area. There seemed to be agreement that the medical school and other components of the university should play an appropriately helpful role in these community endeavors. There seemed to be no question but that the community mental health center provides val- uable training opportunities for the profes- sional school student and resident. We seem to have much difficulty, however, in deter- mining in our own minds what the functional relationship should be between the medical school and the community mental health center. some of us see service and education as not only compatible, but also mutually beneficial. Some of us, however, are fearful that too heavy a commitment to community service by a medical school may be detrimental to its primary educational function." Many persons conceived of community psy- chiatry as dealing with a few selected com- munity agencies and problems; almost none conceived of it as assuming responsibility for the comprehensive mental health of the entire population, ''CHAPTER III Planning the Community Mental Health Center-- What Are the Problems a Medical School Encounters? As professor and chairman of the Depart- ment of Psychiatry, University of Missouri School of Medicine, Dr. Robert H, Barnes told the conference his experience in planning a community mental health center would be the reverse of most schools of medicine rep- resented at the conference, because the Mis- souri program was the outgrowth of a com- prehensive community mental health center developed before the formal academic pro- grams of the university. "In approaching the question of whether to become involved with a comprehensive com- munity mental health center, the medical school administration and the departmental faculty need to have a clear idea and rea- sonable consensus as to what they consider a comprehensive community mental health center,'' Dr. Barnes told conferees. There was general discussion regarding the meaning and functioning of the compre- hensive centers and the desirability of the university's use of these centers for training purposes. Dr. Barnes implied that most teaching hos- pitals can get into the community mental health center business by doing things much as they have in the past and without any major strains on the administration, faculty, or curriculum. "On the other hand if the school and psy- chiatric faculty see a need to change the way psychiatric care is being rendered and dis- tributed, if they see a need to take a signifi- cant role of responsibility in such endeavors; then, the comprehensive community mental health center as a concept offers a new start- ing point and a new base to undertake some very interesting and significant innovations in service, research and training." The community mental health center, as Dr. Barnes conceptualizes it, has as its major goal to provide a broad range of services to people with behavioral difficulties. It must be a medical agency, a social agency, an educa- tional-training agency for those presenting behavioral difficulties, and at times a cor- rectional-custodial agency. "It has to hang together in such a way that those entering services can move easily from service to service as necessary with a con- certed effort to offer, on a progressive basis, the service most appropriate to their need and the one that interferes the least with their life pattern. Information must flow readily from service to service." The service versus teaching dilemma was discussed at length by conferees, and the consensus seemed to be that the universities and teaching centers should definitely be in- volved with comprehensive community mental health centers, using their facilities for train- ing. Where training did take place within the comprehensive center, the university or teach- ing faculty should have responsibility for the teaching program and control over the amount of service rendered by those persons intrain- ing. Many expressed concern lest the service overwhelm the teaching. Others felt that clear definition of goals would avoid this conflict. Dr. Barnes said a major commitment must be made to provide the full range of services to any who wished it within the designated catchment area regardless of the severity or chronicity of the individual's behavioral difficulties or his ability to pay for the service. Such a center, according to Dr. Barnes, represents a system for the delivery of serv- ices, and this raises the issue of service ''versus education--issues involving which ef- fort takes priority. "Our basic philosophy is that the center must provide the opportunity for the best possible care available at the current de- velopmental level of the art with the oppor- tunity for some experimentation in ways of providing such care. We believe that it rep- resents an ideal environment for clinical training of professionals at a number of dif- ferent levels and that with reasonable ingenu- ity and flexibility the issue of service versus educational propriety is largely avoided," Dr. Barnes told the conference. In the conference's group discussion ses- sions, the problem of the medical schools in rural areas participating in a community mental health service was raised. One of the problems is transportation. It was pointed out that a bus service is planned for the Florida mental health program. Florida also uses mental health workers (persons trained to the master's degree in various mental health disciplines) in rural communities to give consultation. Speaking of administrative control of a center, Dr. Barnes said a medical school must determine whether it wants the com- prehensive center as its major and possibly only training base or whether it wants it only as one of a number of affiliated training programs. "In our department the comprehensive cen- ter is the one and only base of operation and provides a setting for the training of medical students, residents, fellows, psychologists, nursing students, etc. The governing body is a citizens group from the Kansas City metro- politan community tied to the city health de- partment and the State division of mental diseases by contractual arrangements and closely affiliated with the curators of the University of Missouri by other contractual agreements. "These various articles have provided the University of Missouri with complete control over issues of training and academic standards and the local citizens group and governmental units with control over clinical operations, salaries and financing," Dr. Barnes said. In the Kansas City metropolitan community, but across the State line in Kansas, an entirely 10 different model of relationship with a compre- hensive center exists. The psychiatric program of the University of Kansas Medical School has an affiliation arrangement with a neighboring community mental health program providing part-time experience to their third-year residents in community psychiatry on an elective basis. Supervision is given by one of the psychiatrists on the local program's staff who has aclinical faculty appointment within the university de- partment. "In a sense this is the opposite extreme of interpenetration of a medical school and a comprehensive mental health center. Between these extremes many variations are possible and reasonable," he said, Some conferees felt that initiative for de- velopment of a center should come from the community with cooperation, as far as pos- sible, rendered by the university or medical teaching center. Another related issue has to do with the administrative and institutional "fit'' between a comprehensive community mental health center and the other clinical facilities within a large medical center or a general teaching hospital, "While we are the Department of Psychiatry of Kansas City General Hospital and Medical Center and are on the same grounds physi- cally, we are removed by about a block and have traditionally had separate administration, particularly from the clinical management standpoint, "Non-medical people in psychology, social work, and nursing play major roles in oper- ating the enterprise and exerting much greater influence than non-medical professionals in the clinical operation of the general hospital. This difference has always given rise to difficulties for first year residents coming to us directly out of a general hospital internship and for medical students from junior and senior clerk- ships from the Medical Center in Columbia." In the discussion there was great concern about whether the centers had to be under psychiatric direction. It was agreed that only the treatment services actually required psy- chiatric direction. Dr. Barnes said he would guess that the hierarchical structure in most general teach- ''ing hospitals cannot be carried over into the operation of an effective comprehensive com- munity mental health center. When non-med- ical, but professional, people are expected to handle a major service responsibility in an independent fashion, they must have a major share in decision-making and administration. As greater responsibility for services to the clearly physically ill is taken on by non-M.D. professionals, then the medical hierarchical structure of the general teaching hospital will also erode. It may be that the association of a comprehensive community mental health center with the university teaching hospital will pave the way for these changes. The Federal regulations covering Public Law 88-164 require certain guarantees of continuity of care and free flow of information between psychiatric services. Basically the concern is that a patient can be easily transferred from inpatient to outpatient or day care, etc,, without administrative barriers and that clinical rec- ords canbe readily transferred with the patient. "Our experience of many years with large multiple services, each operated by its own team or teams, indicated that even though a formal record was easily transferred, real, definitive, important information about the pa- ‘tient was not readily transferred from one group of therapists to another,” Dr. Barnes said. A system recently instituted, according to Dr. Barnes, allows one team to take respon- sibility for a given patient throughout a given treatment episode and even for subsequent episodes assuming they are reasonably close together. This assures a truly personal con- tinuity of care. "This presents training problems in terms of the more traditional division of a residency into a period on the inpatient service and another period on outpatient, etc. However, it assures the trainee much more experience with a longitudinal exposure to a patient in his career of psychiatric treatment," Dr. Barnes said. "The system, which we have developed, de- pends rather heavily on certain basic full-time medical and paramedical staff,'' Dr. Barnes said. Beginning trainees, suchas medical students or first-year residents fit remarkably well into the system. They are placed in the treat- 1l ment system and called on to function very much as beginning first-year residents custo- marily do. Their supervision and assistance are given by the full-time medical and para- medical staff with clinically-oriented teaching and supervision possible in daily staff con- ferences. "Another problem posed by the use of a treatment system staffed by experienced, multi-discipline teams is the decreased re- sponsibility of the individual physician for a given patient. In a treatment system such as we have developed, patients are the respon- sibility and the ‘property’ of a single team although the team delegates special tasks to its members," he said. Issues such as--"Who has the patient, the physician or the system?" must be carefully thought through in establishing a comprehen+ sive center, Dr. Barnes told conferees. "Despite such problems, the development of such a center can give the department of psy- chiatry a chance to take a leadership role within the medical school in establishing close community relationships and in initiating new ways of providing more effective mental health services. Those departments that feel psy- chiatry has a major contribution to make in resolving the social crises facing us today will find the comprehensive community health center an excellent vehicle for channeling these efforts. Those who do not, will find it a dis- turbing interruption in 'business as usual,'"' Dr. Barnes concluded. In State groups, existing comprehensive community mental health centers and related programs were outlined and discussed. For example, it was pointed out by Florida participants that the psychology department of the University of Florida has actively as- sisted in planning for and establishing com- prehensive community mental health centers. Florida has eight comprehensive community mental health centers approved and six "inthe mill.'' Community mental health consultation is given through the county health departments. For teaching purposes, the student population and county health department setting are used. A special service developed in Florida is suicide prevention centers. In planning com- prehensive community mental health centers, the focus is on direct service, but field ex- periences are provided for university students. ''Communities have the responsibility for op- erating the comprehensive community mental health centers in that State. In the University of Alabama's Department of Psychiatry, a division of community psy- chiatry offers training in community psychia- try and consultation to community agencies. The Alabama State Division of Community Serv- ices has the responsibility for promoting and establishing community mental health centers. 12 Many expressed concern about whether the university should be involved in the operation of a community mental health center because of its cost and service obligations. They wanted the community to assume these responsibil- ities with the university using only selected portions of the center for training. Others felt this was an overly restricted view and that the university could and should assume the full responsibility. ''CHAPTER IV Programming the Services--What Are the Issues? Clinical Services Dr. Robert L. Leon, professor, University of Texas Southwestern Medical School, told the conference that the programming of serv- ices for community psychiatry requires a broad frame of reference and a theoretical formulation, which encompasses the patient's interactions in his social milieu, "We must be able to see the patient asa human being participating in the institutions of life and functioning in one or more social units. The concepts inherent in community mental health include, but go beyond the whole person to the social milieu," he said. Dr. Leon said a resident should have the time, freedom, and support to reach out to the family and community in orthodox and new ways. ‘We do not drop or delegate psychodynamic and biological understanding to a lower posi- tion, but rather we incorporate this knowledge into our social and community approach," he said. Partial hospitalization has recently been added to programs which have previously given residents an inpatient, outpatient, con- sultation and child experience. "In my opinion, community orientation should be built into each experience from the begin- ning." Dr. Leon told the conference that psycho- dynamics should not be reserved for study in the psychiatrist's office, but if the psychia- trist's concepts are valid, he can just as well see the same dynamics operating in the family, a work situation, or with the vocational rehabilitation counselor. "The resident's counter-transference often operates as blatantly with the public welfare worker or a patient's mother as with a therapy patient," he said, If services are to be programmed to meet the needs of training in community psychiatry, the doors of the hospital must be opened not only to patients, but to the community so that 317-230 O-68—3 13 it may reach patients and psychiatrists alike, Dr. Leon told the conference. The beginning resident should not only learn to work within the framework of an institution and to deal with institution values as they af- fect patient care, but also to deal with family pathology as it affects his patient. "A good psychiatric evaluation should in- clude an evaluation of ego skills in the area of social competence. By social competence we mean the skills necessary to cope with the environment. The resident who attempts to find a remedy for his patients' defects in social competence will be forced to utilize proper social agencies and deal with the workers in those agencies," Dr. Leon said. Brief-treatment walk-in clinics are a great help in teaching residents to use available community services, according to Dr. Leon. If a patient can only be seen three or four times, a conscientious resident will look for and find other resources to work with the pa- tient for a longer period. "A major problem in programming of serv- ices is the isolation of one service from another, Thus, the resident thinks in terms of hospital, clinic, psychosomatic service, or children's service, but does not bridge the gap. He tends to fit patients to service rather than service to patients." Using the unit system in the training pro- gram is one way to overcome this major ob- stacle, according to Dr. Leon. “This can be integrated with the catchment area concept. A resident can be responsible for all patients from a given area. He will then fit the treatment program to the patient's needs and follow the patient through whatever service is indicated. 'To further expand the unit system into the community, we need ‘clinical outposts’ such as health department clinics where residents can do clinical work in the patient's social setting, with relation to that setting and to other community workers in the setting,” Dr. Leon said. ''One university is planning its community mental health center so that each floor will serve all residents from certain neighbor- hoods for inpatient, outpatient, consultation, etc. This is contrary to the usual inpatient service, outpatient service, children's service of a department of psychiatry, but it does seem to serve the catchment area better and perhaps is a more effective way to teachcom- munity psychiatry. There was discussion of the role of the min- ister, vocational counselor, and other profes- sionals in rendering services, What is their relationship to the psychiatrist and to the patients, for payment, etc.? Children and Adolescents Dr. Frank Rafferty, director, Division of Child Psychiatry, University of Maryland School of Medicine, offered several target assumptions a department of psychiatry should examine in planning children's services for a community mental health center. These were the basis for the Inner City Community Mental Health Center they are planning in Baltimore. This plan is available, 1. The present procedures for providing child psychiatric services should be re- placed. 2. The present procedures cannot be made effective by merely expanding budgets and increasing personnel. 3. A publicly supported child psychiatric program should provide service to all children and their families when needed. 4, The present structure of child psychia- tric service is appropriate to private practice--the one doctor, one patient ap= proach, This should be retained, but tax supported institutions should seek a wider base of operations. 5. There is not at present a well defined, proven set of procedures that will accom- plish the desired goals. 6. Commitment to solving the problem is a necessary prerequisite to finding the solution. 7. These assumptions require concepts of mental illness that differ from those de- scribed in most text books. 8. The ultimate goal of the program is the optimal development and the conservation 14 of human potential of the population of children of the community. 9. This goal is a common one of education, health, and welfare. This goal is the legitimate responsibility of medicine, psychiatry, psychology, so- cial work, and of the agencies and pro- grams served by these professional dis- ciplines, Psychiatry and the related professions have the specific skills, attitudes, and a traditional position in society that make their participation in this community effort necessary. The community agencies, including psy- chiatric services, must organize around one common task with modification of traditional roles. The age of a child is the most important single variable influencing organization or services, skills required, location of effort, responsibilities, etc. The dependency needs of a child for sur- vival and socialization provide the single most important limitation of programming and unfortunately is an unsolved problem of the community. 10. 1l. 12. 13. 14, Dr. Rafferty said a major share of decisions leading to the shaping of programs comes from the age range of a child, Children under three years will be primarily related to pediatric health services, nurseries, and pediatric hospitals. The serious mental de- ficiencies of this age range will usually be the responsibility of pediatrics with psychiatric consultation, In most communities children are officially nonexistent from the time they graduate from baby clinics to the time they enter school, Dr. Rafferty said. "In our area, kindergarten is the first feasi- ble time a population oriented psychiatric service can count on its target population. The usefulness of special therapeutic nursery schools for those three to five is well demon- strated on a small scale, and lessons learned there may be valuable if Head Start survives and if pre-school group programs become general," he said. Dr. Rafferty said the use of the kindergarten year in partnership with the school system, as a diagnostic check point on developmental ''status of each child, is being proposed and ex- plored. Children who require specific diag- nostic procedures and treatment would be identified, and referred to the more traditional services located in a community mental health center. "The natural break in age groups, particu- larly adolescents, is at the end of elementary school. I would recommend the 11 to 16 age group as one set of programming and from 16 up as another set." It is remarkable how little discussion there was on children's services. This has generally been true in discussions of community mental health centers. Non-Clinical Services Dr. William Hollister, director of the Com- munity Psychiatry Program, University of North Carolina, outlined some of the problems and program possibilities in mental health education, mental health promotion, preven- tion, consultation, and the social action com= ponents of a mental health center program. "|. whether we like it or not, every one of these five services should be built into our centers ...as part of our consultation and education program--one of the five required services under the National Mental Health Centers Act," Dr. Hollister told the con- ference. Consultation programs to build strength into all the helping agencies will be needed. A strong, fully-manned, consultation service will be needed to help integrate and upgrade all services into a truly comprehensive array of resources, according to Dr. Hollister. "We will need to continuously program pub- lic education about mental health problems, resources, and unmet needs if we are to fi- nancially survive. No public is going to raise taxes and pass bond issues to provide money needed if we don't make a continuous educa- tional effort to lay down a ‘baseline of public understanding' about what we are trying to do and why," he said. "We must avoid the mistake medicine made in dragging its feet on prevention... . If to- day's mental health clinicians run off with all the center money for clinical work and ignore the task of prevention and health promotion, an unhappy history might repeat itself,"' Dr. Hol- lister warned conferees. 15 "One of the major operational problems in medical school mental health centers will be how to become a part of the community, de- serving of community tax support and coopera- tion from other agencies," Dr. Hollister said. He raised such questions as; “Will we be able, as new invaders in the tax dollar competition, to win a big slice of new funds if we stick strictly to pro- viding traditional clinical services? Will we have to broaden our spectrum of services in order to reach more of the citizens . . .? Will we be willing to devote staff and money to providing behavioral science knowledge and skills to com- munity-wide collaborative efforts to deal with the broad human problems of pov- erty, deprivation, dependency, misbehav- ior, marriage breakdowns, andothers?” Dr. Hollister offered five program develop- ment questions that conferees must face and discuss: 1. “What kind of staff will man our consulta- tion education and prevention service? "What kind of competencies must we re=- cruit or train into this staff? "What are reasonable goals for this service? How can we prevent ourselves from getting overextended, diluted, or se- duced out of role? "How are we going to articulate our clinical and non-clinical services? "How will we evaluate these programs?” Dr. Hollister said in summary that non- clinical services of community mental health centers will be difficult to organize. "They will inevitably carry us into strange new endeavors. The flexibility and imagination with which we meet these challenges may well determine whether we achieve status in the eyes of the community as a part of it, meeting the needs as they are defined by the com- munity." Considerable discussion centered around who would offer the non-clinical services with a feeling that the other disciplines might be more involved than psychiatry. The University of Alabama Department of Psychiatry appeared to be the only one that has established a firm mechanism for meet- ing regularly with a group of agencies to offer consultation and community planning assistance. 2. 3s 4, 5. ''Many discussants talked of offering consul- tation to schools on the assumption that this was the best place to do prevention. There was much less discussion of consultation to other 16 agencies, such as corrections, orphanages, and welfare departments. There was almost no discussion of mental health education or programs of anticipatory guidance. ''CHAPTER V What About the Training of All Kinds of Manpower in the Teaching Community Mental Health Center? Dr. Morton Miller, assistant director of special programs, National Institute of Mental Health, said there are two basic dilemmas in listing the disciplines for which a medical school related community mental health center would have to program. The first and perhaps more classic is the attempt to establish priorities for research, training, and service in the curriculum. The second is that posed by the conflicting de- mands of the public, private, and academic sectors. With the realization that things will be changing in the field of mental health, "we are fairly sure the trainee of 1966 will in all likeli- hood be functioning in a markedly different ethos in 1975,'' Dr. Miller said. One of the most difficult tasks confronting the training programmer, according to Dr. Miller, is the provision for a future orientation, "| | I would hazard a guess that the cutting edges in provision of mental health services are slicing in at least two directions. On the one hand, we are witnessing the development of a renewed interest in comprehensive medi- cine,"' Dr. Miller told conferees. The second and perhaps more perplexing and challenging recent innovation is "the concept that the so-called medical model is itself no longer adequate, when one recognizes the multiple social, cultural, and economic factors which bear on health." Dr. Miller suggested that the improvement of health in a given population might be as dependent on efforts to improve income, hous- ing, and transportation as on provision of either curative or even traditional preventive services. "This concept has been embodied in the so- called multi-service neighborhood center and has, at least in part, contributed to the de- velopment of exciting possibilities for training 17 new types of mental health workers." Dr. Miller said he would like to think that in the next 10 to 20 years both of these con- cepts will be evolving and that, at the same time, strong development of more customary patterns of medical care will be continuing. Programming the teaching of persons to be employed in the mental health network of the future is a challenge to the university setting rather than the medical school alone, Dr. Miller said. "JT feel that the development of this concept can be a mechanism for a much more fruitful collaboration between the medical disciplines and the university at large. For the purposes of developing adequate community mental health services, ties need to be developed between the specialized medical curriculum and what I might call 'under' undergraduate education,"' Dr. Miller said. Cooperative ventures such as the success- ful affiliation of a medical school with a junior college, which recognize the need for techni- cal skills in all branches of medicine, can contribute to development of a comprehensive health approach across the board. "Departments of psychiatry and commun- ity mental health centers are perhaps best equipped to be the leaders in such efforts," he told the conference. A recent survey of psychiatric residency training programs has indicated that the trainee of 1961 has less contact with his conferees in the medical and surgical services than he had in 1950. This has occurred in institutions where physical proximity of mental health and general medical services is present. "The message is clear for the community mental health center training programmer that mere affiliation of his unit with the gen- eral hospital is not enough to insure a signifi- cant working relationship with other members ''of the comprehensive health team," Dr, Miller said. He told the conference that an alternative model for the future community mental health center is the multi-service center, "This still emerging concept embodies a functional approach towards solving mental health problems, attempting to integrate the provision of what might be called life-support services. Somewhat analagous to the compact life-support system developed for extra-ter- restrial human activities, this mechanism brings together welfare, employment, legal rehabilitation, and health agencies." Models of multi-service centers vary with some serving a triage function, a few offering a full range of services, but many being pri- marily facilitative or expediting in their ap- proach. With the development of these centers has emerged a new class of trainee--the indige- nous non-professional, Usually this is a person with minimal educational background, and often he has recently been a recipient of a community service. "The indigenous non-professional worker shows great promise not only as a positive addition to the manpower pool, but also as a key link to many population groups which have been up till now, relatively inaccessible to the traditionally trained mental health worker," Dr. Miller told the conference, Dr. Miller focused on two aspects of the indigenous non-professional trainee--one of great promise and the other a potential pitfall implicit in the concept. "A number of workers have recognized that the training of previously unemployable or socially disruptive persons might have an ad- vantage above and beyond simply stocking the manpower pool, The training experience serves to change attitudes toward one's self, to en- hance the degree to which a person realizes his potentialities through action, to unify func- tions in the individual's personality, to develop independence of social influences, to change his view of the world around him, and to in- crease his ability to take life as it comes and master it,"' Dr. Miller said, He said one of the difficulties implicit in any non-professional or sub-professional dis cipline is the limited advancement. After reaching the top of a rather short and rickety 18 ladder, this person's only choice for the most part is to transfer out of the field, "Some creative new input is necessary which recognizes that especially in this area there is a critical difference between training and education,'' Dr. Miller said. From an organizational standpoint, Dr, Mil- ler continued, it is evident that the community mental health center will be involving itself not only with junior colleges, but with high schools (academic and vocational), manpower training and development programs, Job Corps, VISTA, etc. "The center might very well see itself as principally a training laboratory for students whose primary education is carried out else- where," Dr. Miller said. One group discussing the multidisciplinary approach and the training of personnel at the community mental health centers made the comment that field experience was most im- portant and could be accomplished in the center with accompaning courses in the com- munity college. A conferee said the question was probably not either/or, but combining education and service. For example, he said, in Florida many non-clinical roles are being filled by non-professional personnel with the placement of these people in progressively more difficult roles, Such a proposal was made to the State of Florida and was picked up and financed by the State. These people are called Mental Health Workers. They serve in roles from assistants in epidemiologic studies to film projectionists and clinic associates. They work through the public health centers. In discussion sessions the questions of what psychiatric and general medical reaction to less than full residency training will be were raised. Also to what extent will such alterna- tive approaches hurt the profession adopting such an approach? Public acceptance is based primarily on the level of predictable morality, identification of practitioner, psychiatrist, psychologist, etc., with the ethics of a known profession. If stand- ards for lower level training are as rigid as those for higher levels, people at lower levels will be dissatisfied and unwilling to remain at this level. ''The group suggested that it may be neces- sary to specify functions, then select and develop people who have the skills to carry out these functions. The substitution of the term "preprofes- sional" for the more customary titles of "sub" or "nonprofessional" has been proposed. This is more than a semantic change because of the multiple implications for planning a training program. "Of crucial importance is the need to ex- amine all the possible systems which might eventually utilize the trainee. Concern needs to be directed toward providing lateral bridges which allow easy access to other training systems. The basic , mental health worker training program should have the potential for identifying and transferring outstanding individuals without regard for the point of entry," Dr. Miller said. The highly developed system will be able to identify, develop and train at least Some per=- sons from the high school to the medical school. While this may sound extreme, Dr. Miller pointed out, studies of career choices of med- ical students as they relate to their socio- economic backgrounds would seem to indicate that careers in public health are more likely to be the choice of students from the lower socio-economic scale than those with a more prosperous background, "Allowing for the fact that identification with the aggressor is not unknown as a factor in determining career choice of medical students, a case could be made that the numbers of com- munity health and mental health oriented phy- gicians might be increased by such a plan," he said. A discussion group suggested that maybe ‘there is a need for training a general mental health worker, creating a new profession not identified with existing specialities. This could be a two-year M.A. program. An alternative might be one year of general training with a second year of specialization. Dr. Miller pointed out that the incorporation of training of physicians for community mental health into the medical school curriculum raises many problems. "Community mental health concepts, such as continuity of care, are not easily reconciled with the common pattern of psychiatric resi- 19 dency training which divides the curriculum into blocks of time devoted to intensive work in categorical services. "One or two years of inpatient work, fre- quently with a limited number of patients, with a third-year outpatient experience is probably the norm in most academic centers. Some ex- perience on a liaison service, a well chaper- oned foray to a family service agency anda school, and emergency room work are usually included. However, the opportunity to pass through the continuum of treatment without regard to jurisdictional lines of inpatient, out- patient, or day care services can be just as meaningful for the trainee as for the patient," Dr. Miller told the conference. He said training for the academic setting where community mental health will be the focus of research, service, and training de- mands some heterodoxy. It would also require serious rethinking of the philosophy and pur- pose of the university's department of psy- chiatry. "The majority of trainees spend the bulk of their professional careers inclinical practice. The diversity of future opportunities for all types of mental health workers creates pres- sure for more training in some specialty areas at the same time as it points to the critical importance of a flexible, generalized approach." Dr. Miller told the conference serious con- sideration should be given to the development of some model curricula which may be tested and evaluated for the specific purpose of de- terming how one achieves optimal training for a task. He suggested a regional organization such as the Southern Regional Education Board as an ideal matrix in which such an effort could be developed. "In the area of training, we need to go be- yond looking at pure numbers as an indication of efficacy of a system. The production of an ever expanding pool of mental health workers becomes much less meaningful if the vast majority of these are being trained to perform one-to-one therapy," Dr. Miller said. In the. development of standards, the spe- cialty of mental health needs to take a broad approach in examining the problems germane to this discipline, Dr. Miller said. ''A commission could be organized to review and approve the basis of an institution's ap- proach to training. It would not address itself to the specific problems of specialty education, but would rely primarily on specialty residency review committees. Dr. Miller said it would focus on the interrelations among the various specialties, the relation of graduate to under- graduate medical education, and the changes in graduate medical education that changing times and conditions make desirable. Dr. Miller told conferees the charge to training programmers in the 1970's will be, "Innovate or deteriorate!" Discussion groups considered the training of other professions in the community mental 20 health centers--especially nurses. This led to discussions of the various levels of nurs- ing training in one-year courses, two-year courses, four-year courses, etc, The question of maturity of the one or two-year nurse was raised. Most of these girls are sufficiently mature at age 19 or 20. There was also dis- cussion of the notions of developing an Asso- ciate of Arts level Mental Health Worker who would be a generalist. New roles (education, consultation, social planning) were suggested for the social workers and psychologists. The community mental health center would be an ideal place to train for them, ''a. CHAPTER VI What About Research? Current interest in community mental health is not derived from research, Dr. Simon Dinitz, Department of Sociology, Ohio State University, told the conference, Dr. Dinitz said there are forces operating in society which led to the creation of the community mental health center and to some of the research that has been done, He discussed four topics for conferees: 1, "What gave rise to the community mental health center apart from research?" Dr. Dinitz listed five major factors he believes led to the creation of the com- munity mental health center: "The intervention of the Federal gov- ernment in health and welfare ac- tivities, primarily following World War II," The experience with 380,000 men who were discharged for neuropsy- chiatric reasons; the problems of keeping psychiatrically or neuropsy- chiatrically impaired people active at the front lines; the problem of what to do with these people after they were discharged, and the prob- lem of draft boards which rejectedas few as five and as many as 95 percent of their potential inductees for medical reasons, led to the question of what kind of care could be provided other than in State hospitals which dealt only with the hard core problem. "The Federal government was almost compelled to intervene and ob- viously to move away from the State hospital program," Dr, Dinitz said, "For a long time there have been some changing trends in psychiatric practice, <...'' Many people trained in the medical schools no longer wanted to work in isolated, custodial institutions, They wanted to practice medicine essen- tially in the community. 317-230 O-68—4 21 Cc. The impact of psychodynamic theo- ries, which made a tremendous im- pression in the United States and in many European countries, was im- portant in two respects, according to Dr. Dinitz; "First, the psychodynamic people, I think, succeeded in getting the idea across that mental illness was after all only a matter of degree, and that we were not dealing with an ‘either-or' population, but with an ‘'if-when' population, This being the case, a new kind of care was desirable. "Second, psychodynamic theories moved psychiatry into the inter- personal realm as opposed to the purely biological, to say nothing of the demonological realm," The development of the therapeutic community--the open door, open ward, open hospital, "The therapeutic community as you know was a response to limited facil- ities and personnel in England, and elsewhere for that matter, It caught on in the United States for a variety of reasons, "I think, for example, all of the work that has been done on the total institution led to the search for an idea of developing institutional care that was therapeutic as opposed to anti-therapeutic--a non-restrained environment . . . This obviously led later to the development of the com- munity mental health center." The drug revolution, "With a tranquilized hospital or with the wards no different in a sense from general hospital wards, it be- came possible therefore to deal with patients as people rather than as in- dividuals who are dangerous or diffi- cult or in fact even deviant." ''Dr, Dinitz said research did not lead to these five developments; in fact, it played a "very insignificant role in these achieve- ments," What kinds of previous non-biological re- search were there? "Essentially we had three or four dif- ferent kinds of research that predated or ante-dated the development of the com- munity mental health center," Dr, Dinitz told conferees, a. There was the research which dealt with the ward--the hospital as a small society, Three aspects of this are the problems of patient versus staff; patient versus patient and the development of the inmate culture (which in effect subverts what the staff is trying to do); and staff versus staff, A group of studies on the outcome of psychiatric treatment followed two lines of research, First of all, the attempt to show that certain kinds of patients classified in certain ways had one kind of outcome and patients in other categories had other kinds of outcome, "Generally speaking, the studies that followed this line cameto naught, It became very difficult to show that previous psychiatric treatment is a guarantee of outcome,' Dr, Dinitz said, Second was a line of argument that in effect one looked at the environ- ment to which the individual was re- turned to measure what his treatment outcome was likely to be, c, A group of studies questioned the hospitalization of certain patients in the first place, Consequently a new stream of research was begun on the prevention of hospitalization, Some have argued that by keeping patients in the community, their hospitalization is merely being delayed, "So there is an interesting conflict over whether you prevent or delay by some of the community programs, This is certainly a researchful ques- tion,"’ Dr, Dinitz told the conference, Another series of studies that pre- date the situation are the so-called epidemiologic studies, This is anarea 22 4, for interdisciplinary work for pro- gram research, "I know of no real good epidemi- ologic studies in this area which have not been interdisciplinary in char- acter,'' Dr, Dinitz said, "Where are we going in the future?" As the hospital gives way to the com- munity mental health center, the new set- tings for study are no longer the ward, but the family and other community insti- tutions such as the school, Speaking of the kinds of problems that ought to be programmed, Dr, Dinitz asked: "How do you manage patients in the community? For example what do you do with treatment drop-outs? "How do you measure adaptation of people in the community? What are the standards for adequate functions? What are the standards for marginal functions? These are very real questions, "We need standards of performance, What is marginal, acceptable, adjusted performance? "What do we mean by coping behavior? I don't really know what it is and I don't think anybody else knows, but we had better find out precisely what the dimen- sions of coping are likely to be," Another question Dr, Dinitz posed was: What are the effects on family and com- munity of sick or even deviate people who are out of hospitals? The multi-problem family which a com- munity center will have to deal with must be considered, "We are going to have to program not only training for dealing with these fami- lies, but research on what has evolved from this training in the way of action programs," Dr. Dinitz said. "We had better take a look at the new organization of care and what this means from a research standpoint, For example, we are going to have to evaluate how effec- tive different levels of preprofessionals are compared to professionals. And what this training or education means in terms or pro- viding service. Dr, Dinitz raised the question of how ef- fectively will we be able to train people to work with other agencies--urban renewal, ''education, vocational training and welfare agency people? "|. we have got to see this not only in terms of mental health, but in terms of comprehensive services for people who need all kinds of services. I think this gets back to the idea of comprehensive medi- cine," he said, He listed two focal viewpoints with major themes developing as he perceives them: "Neuropsychiatric disorders ought to be seen principally as diseases, The model which prevailed for the study and eventual control and prevention of other diseases will be the appropriate model to follow at this point. "The second orientation and the one that worries me a great deal as we move into the community mental health center idea is that mental disorder is not a disease, Rather, neuropsychiatric dis- orders are forms of either deviation or something else, Programs are being developed with increased sophistication and involvement of many subaspects, but are these programs effective?" Dr, Dinitz asked, "It seems to me that before these pro- grams become hardened and we develop an interest in maintaining them, we had better find out which aspects are effective for what clientel, under what conditions, and somehow try to evaluate what we are doing, If you are going to program research, you program it at the time you are estab- lishing the program so that the nature of the program and its evaluations are built in at the same time," In a later discussion group, the question was raised: "What will universities do to carry out research and avoid putting mental 23 health service funds and manpower down a rat hole?" Dr. Dinitz replied that if practitioners allow social scientists to assist in the formulation of questions to be researched so that these can be posed in researchable terms, the research help will be forthcoming, There was much discussion about record- keeping and the need to establish at the outset the kind of data to be included for future research, The same group asked; 1. When research has been done, how will changes be brought about based upon re- search findings? 2. To plan research, the group said they thought it was necessary to first define such topics as; a, What constitutes improvement? b. When is a patient ready to go home? c, How is a patient's discharge deter- mined? d, What are the criteria for patient selection, treatment methods and cure or improvement? One participant expressed concern about how a research team can be put into a service-oriented unit. Service people get con- cerned about evaluation, he said. It would seem two people-~one part of the service team and the other not involved with service--would be necessary to avoid the development of prejudices. Another participant pointed out that there is an opportunity to build an evaluative system in the development of centers. This way, research is not necessarily threatening to the clinical team, but is simply a part of program evaluation. ''CHAPTER VII What Are the Issues in Financing and Administration? Dr. Samuel L, Buker, deputy director, Divi- sion of Mental Health Service Programs of the National Institute of Mental Health, gave a brief report on the experience of the Fed- eral Community Mental Health Center Program in relation to financing, administration, and staffing of centers sponsored by or closely affiliated with medical schools or teaching centers, Dr. Buker noted that through fiscal year 1966 the National Institute of Mental Health had funded 126 Community Mental Health Centers; 72 for construction only, 21 for both construction and staffing, and 33 for staff- ing only. Since July 1, 1966, applications from another 20-25 centers have been approved, Of the 126, 15 centers (eight centers re- ceiving construction grants, seven centers re- ceiving staffing grants--one receiving both) were sponsored by, or located at or near, and had an essential affiliation with, a medical school-teaching center complex. The staff of NIMH had hoped that some of the initial applicants would be medical schools or training centers and were pleased that this was true of something over 10% of the initial successful applicants.’ These applications have already provided some outstanding examples of planning for particular aspects of services, studies of catchment area needs and re- sources, and patterns for training, research and evaluation services. The extent to which these centers can serve the country as overall operational models is not so clear, Since the staffing grant applications neces- sarily provide more detailed information about financing, staffing, and administration of pro- gram, Dr. Buker reviewed the staffing grant applications of the seven Centers sponsored by or affiliated with medical schools-teaching centers, with an occasional comparison of a statistic with the total 54 staffing grant applications, 24 Limitations of this Federal experience should be stated, The sample is extremely small, and the review deals only with plans, not with actual program implementation experience, Following is Dr, Buker's report: "Of the seven special centers, three are medical school sponsored and four closely affiliated with medical school complexes. Of the latter four, three are operated by theState department of mental hygiene, The fourth is operated by a Board of County Commissioners, This is the only one of the seven clearly initiated and operated by the local community, Of the seven, five are located in major metro- politan areas (three of the five in the same city), one is located in a midwestern farming region, and one is located in one of the more rural States. Average population per catchment area for the special seven centers (166,000) is the same as for all 54 (165,000). "The average Federal staffing grant for new services was approximately thesame for these seven centers ($300,000) as for all 54 centers ($286,000), Range of grants to the seven cen- ters was $37,000 to $609,000, Estimated total operating costs for all services for the first year for these special seven centers, however, is considerably higher, averaging $1,260,000 (range $314,000 to $3,006,000) for the seven compared with an average of $780,000 for all 54 centers, "All ofthe centers predicted multiple sources of income for support of operating costs, in- cluding Federal, State, and local public funds, private funds, patient payments, andinsurance sources, There are, however, important dif- ferences between the average pattern for the seven special centers and the average pattern for all 54 centers, The seven predicted 40% support from State funds compared with 22% for all 54, and 1% local public funds compared with 9% for all 54, It is also of interest that both the special centers and all 54, on the average, predicted only 10 to 12 percent of ''support for operating costs of new services would come from patient payments combined with insurance reimbursements of all kinds, "Ror six of the seven special centers, the basic center operation is a single organi- zational and program unit within a larger organizational and program unit that has existed for a long time. In effect, the larger unit (e.g., a department of psychiatry) has organized a distinct portion of program to pro- vide a center program for a particular catch- ment area. The larger unit will continue to pro- vide some services to a larger area in most cases. This builds in many direct and support- ive administrative and program strengths for these particular center operations. "All seven of these special centers are aim- ing toward a very comprehensive service pro- gram (7-15 services, depending upon how defined), including inpatient, outpatient, partial hospitalization, emergency services, consul- tation and education, rehabilitation services, precare and aftercare, diagnostic and referral services, research and evaluation, training, and specialized services for children, alco- holics, addicts and geriatrics, Six of the seven plan to achieve comprehensive programs al- most at once--only one will start with only the five essential services. Among the rest of the 54 grantees the initial focus is more limited, "Staffing patterns for both new services, and the total center, are considerably richer for six of the seven special centers, in com- parison with the others, Six of the seven have approximately twice as many staff for the total center as they have requested support for in terms of new services, The average number of new professional and technical staff supported for new services was 19 for these six special centers, Staffing patterns (pro- portions) differ primarily in terms of one profession--psychiatry, The median number of psychiatrists per center across all 54 centers is only 3.4. For the six special centers a total of 36 psychiatrists are budgeted for new serv- ices only, with many more available for the total center operation, For example, one ofthe six will have 29 psychiatrists (full-time equiv- alents) for the total center operation, "As indicated above, only one of the seven special centers was created by the community with the clearest of local public mandates, 25 It was initiated by a Community Council survey and planning study which led to a bondissue to support construction, and is sponsored by the Board of County Commissioners, "What about the other six? All, of course, have been given public mandate at the State level, All have described extensive liaison, collaborative, and integrative efforts with other agencies (schools, courts, health and welfare), Most of these activities are project or special problem oriented, Two of the cen- ters further indicate initial official sanction by a local mental health planning board, How- ever, only one has acommunity representative advisory board and one other indicates plans for establishing such a board, Provisions for ongoing contact with the community on the level of overall community public program planning appear limited, "In view of the limitations in local com- munity sponsorship and support, additional means of involving public community leader- ship might be of value in carrying out the basic center charge, that of responsibility for the mental health of the people of the catch- ment area, and in effecting maximum mental health contributions to the solution of other human services problems of the community, In addition, in view of the importance of the training mandate, each of these special cen- ters should consider methods that will further assure that trainees receive training exper- iences in a milieu that will prepare them for, and motivate them toward, leadership posi- tions in centers not affiliated with training centers," Administration John F, O'Connor, administrator of the Connecticut Mental Health Center, gave acap- sule description of the Yale Department of Psychiatry, the State Department of Mental Health and some pertinent community fac- tors, before describing the Connecticut Mental Health Center as it was formed and as it begins its first full year of operation in 1967, The Department of Psychiatry at Yale has been described as a loose confederation pre- sided over by the chairman, Fritz Redlich, Mr. O'Connor told the conference, The main components of the confederation are: ''1, The Yale Psychiatric Institute--a private 44-bed psychiatric hospital, owned by the university, It provides longterm, expensive inpatient treatment to a very sick young adult population and provides psychoana- lytically-oriented training for advanced residents, The Yale-New Haven Hospital Psychiatric Service--a 25-bed intensive treatment unit, a consultative service to the other in- patient units, an outpatient clinic serving the other clinics of the general hospital, and psychiatric services in the emergency department, Here second- and third-year residents are trained, The Veterans' Administration Hospital Psy- chiatric Service--over 100 beds with em- phasis on inpatient services, Until this year this was the training area for all first-year residents, which role it now shares with the Connecticut Mental Health Center, There are other sections of the University, led by psychiatrists but with a secondary relationship to the Department of Psychiatry, These include the Child Study Center, the Mental Health Section of the Department of Epidemiology and Public Health, the Univer- sity Health Service and a one-man program in the Law School, The Department of Psy- chiatry also has important one-man programs of its own which Mr, O'Connor labeled "the independents," The Department of Psychiatry also main- tains close ties with the graduate departments of psychology, sociology, industrial adminis- tration and the Yale Graduate School of Nurs- ing. "Significant of major changes for the depart- ment is that in a two-year period ending in 1967, the number of residents will have gone from 42 to over 60, The number of social workers and psychology trainees will have doubled and occupational therapy students and fellows in a community psychiatry training program will arrive for the first time, De- tailed course design and recruiting begins for advanced residents for a degree of master of public health in administrative psychiatry," Mr. O'Connor told conferees, The Connecticut State Department of Mental Health is headed by a psychiatrist-commis- sioner backed by a nine-man board including 26 three psychiatrists, One of these is from Yale, There are three 2,000-bed State hospitals, one of which has a State-wide children's service and within a few years will have a State-wide maximum security treatment cen- ter. This same institution, serving Metro- politan New Haven, is the only one ona geo- graphical unit plan, Mr, O'Connor said, In addition, there is a 200-bed converted tuberculosis hospital serving a defined catch- ment area, an alcoholism division including a small inpatient facility and State-wide clinics, a small but outstanding residential treatment center for children and a plan, a planner and an assortment of regional planning bodies struggling to establish their own effectiveness, Mr. O'Connor told the conference that other than the Connecticut Mental Health Center, no other mental health center exists in the State, A large State-operated center is being planned for Bridgeport, Attempts are being made to convert a municipal hospital to a center for the capital area, he said, "There are some pertinent community factors that I feel have already influenced or soon will greatly influence the character of the Con- necticut Mental Health Center, ''Community' as I apply it to the Connecti- cut Mental Health Center is triple layered: 1, "The most immediate layer is Metro- politan New Haven, an area of almost 400,000 people, "The State-wide community with the mul- tiple and special expectations it places on its only medical school, "The community represented by my pres- ence with you--the nationwide network of educational institutions and health agencies addressing themselves to the problems of mental illness and, I hope, relating to nationwide planning for medical care," Mr. O'Connor told the conference he at- tached particular importance to the following six factors; 1, Community leaders in Metropolitan New Haven are just beginning to comprehend and desire the kind of hard work needed for effective regional health planning, Communities in Connecticut, especially New Haven, which have made major and innovative commitments toward solving a ''urban problems face sudden and drastic cutbacks with the decrease in Federal funding. 3. The reapportioned State legislature has shifted the power from rural areas to the urban centers, making way for a major attack on urban problems, 4, The opening of a new State university medical school within a few years raises such questions as; Can these two unique resources ap- proach State-wide health planning as partners? What is their appropriate re- lationship to the other urban centers in the State without medical centers? Since the two schools will be of different com- plexions, should they cut the pie on a geographical basis? 5. There is notable absence of psychiatric leadership in the approach to the prob- lems of the poor, 6. A new dean is to be appointed to the Yale Medical School in July 1967. When the Connecticut Mental Health Center begins full operation in the summer of 1967, Mr. O'Connor told the conference, approxi- mately 330 positions will be supported by the State, 50 by a contract with Yale and 270 through civil service, An additional 40-man staff from Yale not supported by the State is expected to be working in the center, They would be distributed within the major divisions as follows; 1, Clinical Division Unit I, 30-patient day hospital plus its own outpatient and aftercare load-- 31 persons Unit II, 22-inpatient beds, plus approxi- mately 10 day-slots, and its own Outpatient and aftercare load-- 41 persons Unit III, 22-inpatient beds, plus day-slots, plus neighborhood field station(s), plus own emergency, outpatient and aftercare load for defined catchment zone of approximately 80,000 population, This is the only unit for which we are requesting a staffing grant--55 persons Unit IV, 7-bed, 72-hour maximum Stay, plus 30-day maximum outpatient care, intensive treatment of acute emergencies, in almost all cases to come from the General Hos- pital's emergency department, Will also provide overnight hos- pital to Unit I patients when neces- sary. When possible, will hold late night patients scheduled to be transferred to the State Hospital from the General Hospital's emer- gency department--25 persons, Another 18 personnel are responsible for overall direction, coordination of training, coordination of consultation to community agencies, provision of vocational and recre- ational services to units above and in some instances to community agencies, 2, Full Time Research Of the 100 people contemplated, approxi- mately 25 will function in rather complex biologically oriented labs, Another 40 will staff the 22-bed residential study unit and 35 will be scattered in a host of diverse research programs, 3. Administration and Supporting Services The deployment of the 90 Administrative and Supporting Services personnel is as follows; Office of the director, including ad- ministrator, personnel officer, public information office, librarian, commu- nications, and other administrative personnel--36 persons Fiscal and data services, including clinical records and statistics--10 persons Plant operations, including mainte- nance, security, housekeeping, logis- tics and food service--40 persons Four service managers--I isolate them for emphasis "These are relatively high clerical positions working directly for my office and assigned to the chief of each of the major clinical units and to the director of research facilities, Presently they are sorting out those tasks on the units that need not be done by professionals, 27 ''They attempt to give each chief coordinating and expediting support, and serve as links to various supporting and administrative serv- ices,"' Mr, O'Connor said, According to Mr. O'Connor, the first full year of operation of the center is expected to cost the State approximately $2 million, Yale is expected to add another one-third to one-half million dollars from hard cash, grants and other funds, "We need 12 months of full operation before we have refined cost data, Our crude pro- jections to date would put our inpatient per diem cost near $45, per diem day hospital near $20, per diem intensive emergency treat- ment near $80 and an outpatient visit near $23, This eliminates most research cost factors but includes most of the training burden, Regardless of the actual dollars, the propor- tionate costs might be of some value, In the meantime, we are using a moderate sliding schedule of fees," he told the conference, Mr. O'Connor gave a brief 10-year chro- nology leading up to the first full year of operation of the center beginning in the sum- mer of 1967, He said the specific years are not so important as the sequence and type of event, Throughout the 10-year period important sister institutions were studied, Of prime in- fluence were the Massachusetts Mental Health Center, the New York State Psychiatric In- stitute, the Colorado Psychopathic Hospital, the Houston State Psychiatric Institute, the Langley Porter Clinic, the Neuropsychiatric Institute in Los Angeles, and the Western Pennsylvania Psychiatric Institute, --"Ten years before full operation, the present commissioner was appointed, He dis- cussed the desirability of a Massachusetts Mental Health Center-type facility during the interviews when he was considering accepting his position, --"Until three years before full operation, the Yale chairman of the Department of Psy- chiatry was a member of the State Board of Mental Health, --"Eight years before full operation, nego- tiations for community mental health took place between Yale and the State of Connecticut, --"Seven years before full operation, The Connecticut Association for Mental Health, influenced by the work of the Joint Commis- 28 sion on Mental Illness, issued a report urging the establishment of a university-related men- tal health center in New Haven, --"Six years before full operation, $250,000 was appropriated by the State legislature for architectural planning, These same funds were later used to hire program consultants, --"Five years before full operation, a hos- pital administrator was retained to coordinate architectural as well as fiscal planning, In a year and a half he fed preliminary archi- tectural plans through Yale, State and appro- priate Federal bodies and received approval, --''Five years before full operation Anthony J. J, Rourke, M,D,, was retained by the State to recommend the nature of the relationship between the State of Connecticut and Yale, --"Four years before full operation, I was retained by both State and Yale in time to participate in the last phases of the Rourke study and supervise the total revision of the architectural plans, --"That same year the Rourke Report was submitted with specific recommendations con- cerning the directorship, the admission and transfer of patients, the treatment of patients, research and training programs, an advisory board and the choice of two mechanisms by which key professional staff could be recruited and hired for the center, One necessitated new legislation creating positions in the unclassi- fied civil service with specific personnel prac- tices and policies agreed on by both the State and Yale, The other involved reimbursement to Yale for faculty services provided to the center. This was eventually adopted, --"Four years before full operation, three and one quarter million dollars was appro- priated by the State legislature for construc- tion of the center, --"Three years before full operation, these pertinent events took place: 1, "The now famous Kennedy Message to the 88th Congress on Mental Illness and Re- tardation provided a major spiritual, though not monetary, boost, "The University presidency passed to King- man Brewster, who is vitally interested in the life sciences in partnership with govern- ment, He viewed the University as the producer of responsible agents of social change, ''"Passage by the State General Assembly of an enabling act 'concerning the establish- ment of a mental health center in collab- oration with Yale University.' The act very briefly indicated the collaborative relation- ship, the exclusion from transfer and com- mitment statutes, and the advisory board committee composition, "Construction of the five million dollar facility started, "A memorandum of agreement was signed by the Governor of Connecticut and Presi- dent of Yale, specifying among many things that; a. The distinct responsibilities of the Medical School Dean and the Commis- sioner are vested in the Director. The nomination of the Director would be by Yale from the full-time psy- chiatry faculty with appointment by the Commissioner, The Commis- sioner would not officially participate in the choice and assignment of other faculty members, The Director has power to choose, admit, or transfer patients, The Commissioner has the ulti- mate responsibility for treatment of patients. Center patients will not be charged private fees, but if allowed by the University, the staff can charge pri- vate patients, The University has responsibility for research and training. Specific areas of the building can be used only for research, The State has a right to an appro- priate share of grant income for overhead, i, Both parties will enter into a written agreement every two years as to the total number and type of posi- tions needed to operate the center, the amount the State will pay towards each position and whether or not the position will be filled by a civil servant or a Yale faculty member. Yale will also be allowed a supplement, "Soon after, a yearly cost contract was signed specifying four positions to be covered and the amount to be paid for each, This amount was based on what the State would pay an indi- b, Cc. e 29 vidual in a comparable job in another insti- tution, plus 15 percent for fringe benefits, The State has further agreed that each year the University has fully filled a position, it would allow a 5 percent increase in the con- tract charge the following year, The fourth cost contract for the first full year of oper- ation will cover all physicians, Ph,D,'s, eight nurses, six social workers, director of occu- pational therapy, and the hospital adminis- trator, With these contracts we have had the freedom of assigning an aggregate of part- time people or one full-time person to a position, In addition, we would be able to bring an individual in on a per diem who would not be full-time until the following year. "Two years before full operation, the 14 key staff already at work prepared a position paper on programs and staffing plans for the Center, This not only helped clarify many issues among ourselves, but also served as an educational and even negotiating instrument with key segments of the University, State and community. "1966 was the intensive recruiting year. Near the end most of our multidiscipline training programs were initiated, --"One year before full operation, our se- quence has been: 1. "July, we partially occupied our building, 2. "July 5, each Clinical Unit assumed its appropriate share of the outpatient load, "Tn August, Clinical Unit I opened its day hospital, admitting an average of one patient per day until it reached a full census of 30, "In mid-September, Clinical Unit II started as a 30-patient day hospital rather than as a 22-bed inpatient unit because of our inability to recruit adequate evening and night nursing staff, "Recruiting efforts were then success- fully switched to Clinical Unit IV--the seven bed, 72-hour emergency treatment unit which will open January 3, 1967. "Clinical Unit II will convert to 24-hour care in February. "Clinical Unit III will open its neighbor- hood station in the spring and its 22-bed overnight service in the summer of 1967, "The research labs have been operating since they were turned over to the center in November 1966, 3. ''9. "The intensive care and study unit (22-bed research ward) is scheduled to open late in the summer, "December 1966 the first major cost con- tract with Yale-New Haven Hospital was signed for the provision of bulk prepared food, X-ray, EEG, EKG, anesthesiolo- gists, laboratory tests, pharmacy cov- erage, and central sterile supply services, Two additional contracts of note are: one that enables the center to buy into the medical center's chaplaincy program and the other to purchase steam from the Yale power house," Based on the experience of establishing the center at New Haven, Mr. O'Connor offered eight points of advice to conferees: I, Watch your timing on recruiting and the undertaking of major service and/or train- ing commitments without having a building in which to work, Watch the overlap between units to avoid an overload on key super- visory staff, 2, Make use of career public administration officials, Your leadership should thoroughly understand the difference between the real and the paper budgeting and appropriation process within State government, 3, Pay careful attention to the changes needed as you pass from a planning body to an op- erating organization, Make effective future projections of the organization, Involve appropriate talent at the leadership level, 5. "As you plan and seek support for your plans and staffing, make sure those sitting in judgment are encouraged to make stud- ies and comparisons with similar univer- sity-based programs." 10, 30 6, Those who represent the leadership of your department will have the respon- sibility of cushioning the reverberations set off within a university department of psychiatry with the introduction of a major community-oriented service teaching and research program, The new enterprise may be seen as the intrusion of a foreign body into a well-functioning system or the painful but natural growth of a dynamic department, 7, "Another factor that will surely strike at some stage of developing such as enter- prise is the total unpreparedness many of you have had for the tasks facing you, 8, "The university must decide what business it is in, If learning is its mission, each department must decide learning for what, and for when, Each of you must also come to understand the particular place your medical school plays in your community, "I wish some leading departments of psy- chiatry would each year take a promising recent graduate of their residency program and place him in what I would call a vest pocket program where he would be a staff assistant to the chairman of the department, working up or following through on matters of departmental cross-boundary importance, At the end of the year, he would be fed back into the normal clinical research-training enter- prises and start his way up the pecking lad- der, I feel the frame of reference he would have after this one year of special exposure would begin preparing him and others like him for the responsibilities that are facing you today, I would hope the academic departments would some day see administration as a leadership process rather than as a dirty word," Mr, O'Connor concluded, ''CHAPTER VIII What Are the Center’s Relationships? To the Rest of the University Several definitions of community psychiatry were given at the conference including one by Dr, Melvin Sabshin, professor and head of the Department of Psychiatry, University of Ili- nois College of Medicine. Dr, Sabshin spoke about the center's relationships to the uni- versity. "Tl: view community psychiatry as a major sector of social psychiatry, Community psy- chiatry involves the application of concepts from social psychiatry and other relevant behavioral and social sciences in order to investigate and meet the mental health needs of a functionally or geographically defined community, "In meeting these needs, there must be an effort to apply primary, secondary andtertiary preventive techniques, The effort must include research-oriented behavioral scientists able to discern transactions between and among the setting and those who live in a particular set- ting and the observers themselves. The feed- back from the system can be applied to the central body of social psychiatric knowledge and to other areas of behavioral science," Dr, Sabshin said, According to Dr, Sabshin, social psychiatry is an emerging body of knowledge in a cen- trally located research field in which sophis- ticated employment of social science insights as psychiatric variables is necessary to pre- dict and explain particular psychiatric prob- lems, "Community psychiatry and community men- tal health are in my opinion major sectors even closer to action models, but they are not tied to application," he said, He agreed that universities and university medical colleges must re-examine "with vigor" the social responsibility role they must play, Dr. Sabshin said the issue of community mental health andcommunity psychiatry should not be exclusively tied to practical models of social responsibility, 31 "Tl do believe quite strongly that there are additional and major roles that universities can and should play in relationship to com- munity mental health which are much more relevant to the classical research and teaching models," he said, "Unless community mental health and com- munity psychiatry move in a scholarly and scientific fashion, they are doomed to failure or, at the very best, to repeat some of the errors of the mental hygiene movement started in the 1920's, which lost momentum because it was not sufficiently university connected," Dr. Sabshin said it is important to envision the vast variety of possibilities that may link community mental health centers and uni- versities, The most obvious model, Dr, Sabshin told the conference, is one in which a medical college is located on a university campus, a community mental health center is developed and becomes part of the department of psy- chiatry to a significant degree, but also main- tains relationships with other departments in various colleges of the university, Dr, Sabshin said it is also conceivable that a university center may not have a medical school and nevertheless have ties with a community mental health center, "In Illinois we have divided the State into a number of zones, Each of the zone directors has established a host of complex ties to the university's colleges in his zone, One of the zones includes the Champaign-Urbana area, Facilities have been developed from the Department of Mental Health connected to the zones which have been integrally tied to the University of Illinois at Champaign-Urbana in the absence of a medical school, "Under these circumstances direct nego- tiations may take place between represen- tatives from the mental health fields and university administration as well as specific departments in various colleges in the uni- versity,'' Dr. Sabshin told the conference, ''He said in terms of university needs, the community mental health center serves as an excellent natural laboratory for a variety of studies and affords an opportunity for training in a number of professional areas, It not only affords special teaching oppor- tunities, but the enormous resources of the university are useful in attracting personnel and consultants and in carrying out studies of the effectiveness of the community mental health activities, Dr. Sabshin said universities can play ex- ceptionally important roles in State-wide or regional planning of community mental health, "In Illinois, the Universities Council of the Illinois State Mental Health Planning Board has held several conferences and many discussions about the over-all role of the universities in State-wide mental health programs, Univer- sities are an exceptional source of individuals who can be useful in over-all State planning, They can be helpful and practical as well as very stimulating, Beyond that the pooling of various universities to allocate special areas of manpower training, and to collaborate in research in teaching has been effective," he told the conference, Dr, Sabshin said universities themselves are | excellent natural laboratories to study com- munity process as it affects illness, They are examples of either a geographic or functional community, "It is my distinct impression that the com- munity mental health movement as it is devel- oping is becoming part of a larger movement towards community health, As one surveys curricular changes in medical schools, it is apparent that there is increasing attention to the social and behavioral sciences and to community problems as they pertain to health and illness," Dr, Sabshin said, Emphasis is being placed on over-all com- munity health problems in the newer medical schools of the United States, Dr, Sabshin told the conference, In discussions some participants pointed to various ways teaching programs in different aspects of community psychiatry can be devel- oped without a center directly affiliated with or part of a university, This feasibility was acknowledged, but it was emphasized that teaching is usually effective only where teach- ers do what they teach. 32 Various medical schools have adopted catch- ment areas in which they take responsibilities consonant with teaching and research aims, "In the Medical Center at the University of Illinois, we have received approval to develop’ a center for the study of community health and patient care, This center will involve the four colleges in our medical center, but will be tied with a new center for urban studies being developed on the University of Illinois' Chicago Circle Campus. We conceive of the center at the medical center as having its own autonomy, but also having staff who are faculty members of various colleges and departments," he explained, The wisdom of any kind of catchment area for a university program was batted around by conferees and the desirability was questioned by some participants, One solution seemed to lie in establishing a "primary" catchment area for the community mental health center and a "secondary" catchment area (i.e., the entire State) for other parts of the psychiatric service, Dr, Sabshin said the relationship of service responsibilities to research and teaching is an essential issue in this type of relationship as it is in the relationship to universities as a whole. He said he did not think the issue of service responsibility of universities is an isolated question, "IT expect there will always be some tension between those advocating greater social re- sponsibility and those advocating greater re- search needs, I am confident that the debate between purists of these two schools will be modulated by the general consensus, , , that a balance should be struck in a thoughtful, planned way, "IT also believe, however, that university activities in these areas of social respon- sibility should not be extended beyond what is possible for the other functions of the uni- versity." Dr. Sabshin said there are critics who have questioned over-extension of universities into areas of social responsibility as an aggrandiz- ing act which may be used for the uhiversity's power status, "Once again I am optimistic in this area since I believe that in a democracy balances can be struck, ,.. The same criticisms have been voiced regarding community psychiatry in which a number of persons have become ''concerned that psychiatrists utilize the roles in the community in an aggressive, almost imperialistic way to move into areas where they have no expertise and no right to enter, He said most psychiatrists and other mental health professionals moving into these roles are "keenly aware that in many areas related to community mental health needs they do not have any expert knowledge and need leadership of other professions and groups, "It should be clear, however, that in certain university cities, the university exercises a tremendous power in those communities and the power functions may be relevant to an analysis of the effectiveness of community health or community mental health activities," Dr. Sabshin told the conferees, There was a general view held by some participants that although universities are not explicitly excluded, they were not mentioned in the various publications concerned with community mental health centers and their participation was not facilitated, Representatives from one State's univer- sities expressed regret at this attitude, Their efforts to develop comprehensive programs for service and teaching purposes are handi- capped if they cannot enlarge their facilities and staffs, they said, Outside help is needed, they believe, and neither the State nor Federal government appears ready for such assistance, At the end of this discussion, the majority of the group recommended that the State mental health departments provide leadership in pro- moting, initiating and perhaps giving partial financial support to community mental health programs, including those developed by uni- versities. In the discussions of the North Carolina and South Carolina participants, the following con- clusions were reached; 1, If the medical center and/or university, public or private, is to cooperate with programs of comprehensive community mental health centers, they should be rep- resented at the policy setting level from the planning stages, 2, Planning for comprehensive health care should involve people from the university, State mental health department as well.as other agencies affected by the plans made, This referred to Title 19 of the Medicare Bill, 33 3. If the State participates in Title 19, mental illness coverage should not be excluded and should be treated equally with other health services, 4, Medical centers and/or universities should be cognizant of broad implications of the developing comprehensive mental health centers and make efforts to utilize to the best possible advantage their resources in this area through collaborative efforts among themselves and their own depart- ments as well as with outside agencies, To Other Community Agencies The teaching community mental health cen- ter is likely to work witha variety of agencies, sometimes consultating, sometimes offering direct care, sometimes participating in teach- ing, or training, and sometimes delimiting mental health concepts in the agency's work, Dr, Frank J, Nuckols, Associate Professor of Psychiatry, Department of Psychiatry, Med- ical College of Alabama, listed some of these agencies for the conference and cited certain issues which may be anticipated in a relation- ship between medical centers and community agencies, His list included; 1. Health agencies giving direct service: public health clinics, mental health clin- ics, well baby clinics, State hospitals, nursing homes, suicide prevention pro- grams and social clubs for returned State mental hospital patients, 2. Welfare agencies including Children's Aid Society, family counseling service, public assistance agencies and department of pensions and security, orphanages, and old people's homes, 3. Education, training and employment agen- cies such as schools for the blind, cerebral palsy schools, vocational training schools, teaching programs for professionals, drug and alcohol education in public schools, State and private employment agencies, programs for parolees and vocational re- habilitation service, 4, Fund-raising and promotional agencies such as the community chest, local, State and national mental health associations with their various committees, 5. Courts, law enforcement and correctional institutions, ''6, Religious and social action groups, for example, ministerial associations and civil rights groups, Government, Examples would be the mental health authority, city commissions, zoning boards, park and recreation boards, housing authority and transportation authority, Some questions likely to arise in the rela- tionships between the teaching community mental health center and the previously named agencies are: Tie "What kind of structure should be estab- lished in the teaching community mental health center for teaching psychiatric resi- dents and trainees in other disciplines use of community agencies? For teaching re- ferral techniques? For teaching consul- tation? "How far does the teaching role of the teaching community mental health center extend into the community andits agencies? Could there be a teaching responsibility to other agencies? "What sort of contract or agreement is necessary under the latter circumstances? Is there a fee for this service? "How does this teaching mission differ from the agreement to participate with other agencies in the network of services? "How is the need to serve comprehensively a geographic population meshed with the need to provide students with exposure to a variety of disorders for training purposes?" Dr. Nuckols said some agencies lend them- selves better as a training ground for per- sonnel than others, The issue may arise whether some agencies receive more attention from the center than others based on a selfish need of the center. A related issue would be the use of the teaching mandate of the community mental health center as a buffer to avoid unpleasant jobs, An appropriate way must be found for sorting out agencies and patients who can be helped in the structure of the teaching community men- tal health center. Is there something inherent in the consul- tation process which can assist in the work overload? "Shared work regarding individual patients with the agencies participating in the network is 34 of agencies is one way to deal with this over- load,'' Dr, Nuckols said, He continued: "How much initiative should the teaching community mental health center personnel take in making recognized needs, gaps or poor quality of mental health services in the community explicit when they exist in specific agencies? To what persons or groups should the center personnel make known these needs? What is proper timing with regard to such problems?"' "The teaching community mental health center is likely to have to make choices with regard to how much work is done with specific agencies, The determination of salience and feasibility is of paramount importance in this issue as well as the strategy as to the overall mission of the center," What kind of sanction does the teaching community mental health center have from its parent organization? The medical school? How well does this sanction agree with the collective mission of the personnel of the center and how well does "officialdom" outside the university setting sanction the current activities and future extensions of the center? Should the center wait to be asked for con- sultation or service or should it volunteer services? If so, under what circumstances? Dr. Nuckols also raised the question of the nature of working relationships with agencies, Should they be on a contract basis and if so which services should be purchased and which should be a part of the public service of the agency? The question of invading domains is quite likely to arise, Without negotiated super- ordinate goals, domain issues can make work difficult, Concern was expressed by some conferees as to a possible loss of contact between agen- cies participating in a comprehensive mental health center with a resulting lack of com- munication and loss of awareness of respective agencies’ problems, One suggested preventive measure is rota- tion of staff among agencies involved, In Alabama, the department of psychiatry of the medical college participates in a com- munity service agency "poly-log."' Agencies meet once a month to discuss such things as inter-agency problems and movement of patients, ''"In spite of the need for delimiting con- cepts, much is known about mental illness and mental health. Enough is known to get started in the general direction likely to produce some meaningful reductions in the incidence of new cases of mental disorder, and reduction in the prevalence of disorders in populations," Dr. Nuckols concluded, In the discussions participants expressed great reluctance to become involved with community agencies, When they did it was in a very limited way (for a limited function, time or number of cases) and in ways very much under the control of the university. They seemed to be afraid of being overwhelmed with service demands from the agencies, To the State Mental Health Authority Speaking about the community mental health center's relationships to the State mental health authority, Dr. Nat T. Winston, Jr., commis- sioner, Tennessee Department of Mental Health, said the Federal Comprehensive Com- munity Mental Health Centers Act, passed in 1963, bypasses the State mental health author- ity and goes directly to the local community, The act represents a new approach in leav- ing control of the policies and practices of the centers at the local communities and demands that they, in partnership with the Federal gov- ernment, begin to assume as much of the total care of the mentally ill as possible. "I, for one, feel that this approach is sound and correct, although many mental health authorities, at least initially, were quite dis- turbed by this State bypass,'' Dr. Winston said, The projected comprehensive centers will be the major first line of defense in mental ill- ness, according to Dr, Winston. He predicted that these complexes may care for 75 to 90 percent of the mentally ill individuals pre- viously cared for by the State, "It could mean that ultimately the present State hospital system would house only the ‘chronic’ cases requiring dramatically altered programs at such institutions, For example, the usual sorts of professional personnel needed would be no longer indicated in the nursing home-like situation that could con- ceivably develop in our present hospital plants, "It should be carefully pointed out, however, 35 that for many, many years to come, hospital systems will still be indicated and needed," Dr. Winston told conferees, One discussion group pointed out that while State hospitals will continue to exist and need to be included in planning of services, depart- ments of psychiatry can influence a change in the State hospital's function through greater involvement, If the new centers are successful in locally treating 75 to 90 percent of the mentally ill, Dr. Winston predicted that there will be great changes in the financial patterns of State departments of mental health, "T feel it will be imperative that the State departments of mental health contribute to- wards the local share of the various compre- hensive centers, Communities now furnishing outpatient clinics and raising on the average, let's say $50,000 a year, will now be expected to go $400,000 or $500,000 a year to operate a comprehensive center, This will be pro- hibitive, and I believe the State will have to make up a large portion of the operating costs," he said, In group discussions on financing, comments to the effect that the initial impetus for begin- ning a comprehensive center program may not be important, but broad community and State support was necessary for a continuing pro- gram, were made, There was some question as to whether or not a community could carry a comprehensive program alone, The consensus seemed to be that a clear State responsibility was necessary for leadership and financial assistance to communities for the establishment and con- tinuation of comprehensive mental health cen- ter programs, The point was made that in the event communities could not develop programs, a mandate might be necessary, A number of comments were made relevant to the phasing in of cost distribution and the phasing in of staff services, Some comments relevant to the roles of the mental health department of North Carolina and South Carolina were made, The clinics are under the county commissioner's office in North Carolina, but under local administrative boards with overall administration from the State Department of Mental Health in South Carolina, It was also pointed out that funds were available for assistance in construction ''costs for mental health centers in North Carolina from the State level, but in South Carolina this is not the case, Dr, Winston said most States are already looking towards this financial need and appro- priating money for both the construction and operation of these comprehensive centers, In Maryland, the Psychiatric Institute of the University of Maryland is preparing jointly with the State Department of Mental Hygiene for a large community mental health center to be built adjacent to the University Hospital complex in the inner city portion of Baltimore, The building is expected to be ready for oper- ation in 1970 and will serve a population of 200,000, It will cost close to $11 million and be financed by the State with the exception of about $1 million in Federal funds, The program was to start in January 1967 with the help of a Federal staffing grant to provide comprehensive services for about 90,000 people. This is a prelude to the larger program in the new building, Federal funds are matched by State funds, In addition, the Uni- versity (School of Nursing and School of Social Work) and the Vocational Rehabilitation agency will contribute several positions, The danger always exists that the State will gain control of the community centers, If the Federal dictates are followed, the local com- munity must maintain its autonomy, "and I believe it can," A long hard look must be taken at the present day role concepts of psychiatric personnel, Dr. Winston told the conference, He said it would be impossible to adequately staff the comprehensive centers with traditional pat- terns of professional people, "The State departments of mental health will have to champion, pioneer and initiate new personnel practices and personnel classi- fications if the comprehensive centers are to survive," he said, Dr, Winston said the psychiatrist has '"'zeal- ously guarded his role as the authority in the mental health complex, has only grudgingly and only as a last ditch defense given up any of his authority in the past... ."' Today the psychiatrist has evolved from psychotherapy on a one to one, hour to hour basis, to group therapy--"a great therapeutic advantage" which has helped resolve the time situation and demands made upon the psy- chiatrist, 36 The Ph.D, clinical psychologist, who 20 years ago was the only person qualified to administer a Rorschach, an I,Q, test or a thematic apper- ception test, has re-examined his role and admitted that some of these tests could be administered by a technician under the guidance of a fully trained psychologist, "Now the Ph.D, psychologist is finding himself being pushed more and more away from the traditional past of being the scientist on the mental health team and is finding himself involved in devising psychotherapeutic tech- niques to masses, carrying out community work and exploring other problems," Dr, Winston said, The role of the psychiatric social worker has undergone change in the past 20 years too, "Twenty years ago not even the psychiatrist or the psychologist was capable of talking to the family, Obviously someone so wrapped up in the intricacies of the patient's emotional difficulties could not have any appreciation for the problems of the family and this was relegated to the psychiatric social worker and zealously guarded by him," Dr, Winston said, Expediency saved the day again, Dr. Winston said, ''and within the past several years we have seen scattered in our hospitals and outpatient clinics intelligent, perceptive and intuitive young people out of college who were classified as psychiatric social worker trainees doing the job once traditionally done only by the master's level social worker," Even the recreational therapist, previously perceived as the former basketball star who couldn't make it in the business world, has a real therapeutic value in thetreatment team, Dr. Winston said, In a discussion session, one conferee pointed out that differentiation of roles is the real kernel of the problem, The overlapping of roles and the threat this presents for per- sonnel is a big problem, Nursing personnel are particularly con- cerned about this, another conferee said, Others are gradually taking over roles tra- ditionally filled by nurses, Psychiatrists are also concerned about this, The proper em- phasis seems to involve training of people as to their limitations as well as to their areas of competence, How to arrive at roles of individual com- petence is a big question which has not been ''answered, another conferee pointed out, In summary, Dr. Winston said the State will expect the new centers to handle the majority of the mentally ill in a region, "feeding back for long term only those individuals who fail to respond to treatment," He said the State should take the initiative in exploring new professional types and sub- professional types to fill the many potential vacancies and spots in the centers, "It will mark a dramatic change from total State care to community care keeping mental illness in the same context as physical illness 37 and treating it at home where experience shows it belongs, "It will force for the first time a meaning- ful, therapeutic relationship between the com- munity and the State, Each must depend on the other for essential parts of programs in the care of the mentally ill." An area of relationship to the State mental health authority that received little attention was the question of reporting treatment and other program data for the whole matter of program evaluation both of local and total State mental health operations, ''Roster Registrants Dr. Raymond E, Ackerman Community Mental Health Center Planning 275 Calhoun Street Charleston, South Carolina 29401 Dr. C. Wilson Anderson Dean, School of Social Work University of North Carolina Chapel Hill, North Carolina 27514 Dr. Moody C. Bettis Director of Sociological Research Houston State Psychiatric Institute 1300 Moursund Avenue Texas Medical Center Houston, Texas 77025 Dr. Robert K. Bing Director Department of Occupational and Recreational Therapy University of Texas Medical Branch Galveston, Texas 77550 Dr. Joseph Bistowish Metropolitan Health Department Vanderbilt University Hospital Nashville, Tennessee 37203 Dr. William Boardman Department of Psychiatry Emory University School of Medicine Atlanta, Georgia 30322 Dr. E, Ivan Bruce Professor of Neuropsychiatry Director of Psychiatric Services The University of Texas Medical Branch Galveston, Texas 77550 Dr. Ewald W. Busse Chairman, Department of Psychiatry Duke University Durham, North Carolina 27706 38 Dr. W. D. Buxton Department of Neurology and Psychiatry University of Virginia School of Medicine Charlottesville, Virginia 22901 Dr. Edward G. Byrne Alachua County Health Officer University of Florida Medical School Gainesville, Florida 32601 Dr. James E. Carson Assistant Commissioner Department of Mental Hygiene State of Maryland 301 West Preston Street Baltimore, Maryland 21201 Dr. J. F. Casey Georgia Mental Health Institute 2 1240 Briarcliff Road, N.E. Atlanta, Georgia 30306 Dr. Arthur Centor Chief, Psychological Services Department of Mental Hygiene and Hospitals P.O; Box 1/97 Richmond, Virginia 23214 Miss Jean A. Chambers Assistant Professor and Chairman Section of Psychiatric Social Work The University of Tennessee College of Medicine 42 North Dunlap Street Memphis, Tennessee 38103 Dr. Chester Clapp Director, Community Mental Health Center West Virginia University Medical Center School of Medicine Morgantown, West Virginia 26506 ''Dr. J. J. Cleckley Professor and Chairman Department of Psychiatry Medical College Hospital 55 Doughty Street Charleston, South Carolina 29403 Dr. C. Stanley Clifton Dean, School of Social Work University of Oklahoma Norman, Oklahoma 73069 Dr. L. Bradley Clough Chairman, Department of Psychology and Special Education Box 713 Morehead State University Morehead, Kentucky 40351 Mrs. Evelyn Cohelan Acting Dean College of Nursing University of Maryland School of Medicine Baltimore, Maryland 21201 Dr. Louis D. Cohen Professor and Chairman Department of Clinical Psychology College of Health Related Professions University of Florida Gainesville, Florida 32601 Mr. James F. Cooper P.O. Box 66 Mississippi State Hospital Whitfield, Mississippi 39193 Dr. Warren Cox Department of Psychiatry University of Louisville School of Medicine 323 East Chestnut Street Louisville, Kentucky 40202 Dr. Hiram W. Davis Commissioner Department of Mental Hygiene and Hospitals P.O. Box 1797 Richmond, Virginia 23214 39 Miss Loretta Denman, R.N. Professor of Psychiatric Nursing School of Nursing University of Kentucky Medical Center Lexington, Kentucky 40506 Mr. D, A, Davis Acting Chief of Social Work Emory University School of Medicine Atlanta, Georgia 30322 Dr. Hayden Donahue Superintendent Central State Griffin Memorial Hospital Oklahoma City, Oklahoma 73101 Dr. Alexander F. Donald Deputy Commissioner Community Mental Health Services South Carolina Department of Mental Health 2214 Bull Street Columbia, South Carolina 29201 Dr. William Dudley Educational Director Whitfield State Hospital Whitfield, Mississippi 39193 Dr. Addison M. Duvall Director, Division of Mental Health State of Georgia Department of Public Health 47 Trinity Avenue Atlanta, Georgia 30334 Dr. R. C. Eaton Director Community Mental Health Services Division of Mental Health 124 West Pensacola Street Tallahassee, Florida 32301 Dr. Wil Edgerton Assistant Director Community Psychiatry Program University of North Carolina Chapel Hill, North Carolina 27514 Dr. Robert D. Edwards Executive Director The Arkansas Association for Mental Health 1765 Towers Building Little Rock, Arkansas 72201 ''Dr. Lloyd C. Elam Chairman Department of Psychiatry Meharry Medical College Nashville, Tennessee 37208 Dr. Ilhan Ermutlu Director Community Services Branch Georgia Department of Public Health 47 Trinity Avenue Atlanta, Georgia 30334 Miss Betty Evans Head, Department of Psychiatric Nursing School of Nursing Emory University Atlanta, Georgia 30322 Dr. Dale Farabee Commissioner Department of Mental Health P.O. Box 678 Frankfort, Kentucky 40601 Dr. John R. Finch Department of Psychiatry Baylor University College of Medicine Division of Community Mental Health Research Houston State Psychiatric Institute 1300 Moursund Avenue Houston, Texas 77025 Mr. Charles L. France Chief, Division of Administration and Finance Department of Mental Hygiene State of Maryland 301 West Preston Street Baltimore, Maryland 21201 Dr. Edward Frank Department of Psychiatry University of Louisville School of Medicine 323 East Chestnut Street Louisville, Kentucky 40202 Dr. Walter G. Fries Executive Director Governor's Interagency Council on Mental Retardation Planning 1001 Main Street Columbia, South Carolina 29201 40 Dr. Tom Fulmer Clinical Associate Professor of Psychiatry and Superintendent Southeast Louisiana Hospital New Orleans, Louisiana 70150 Dr. M. David Galinsky Director Clinical Psychology Training Program Department of Psychology University of North Carolina Chapel Hill, North Carolina 27514 Dr. Eugene Gallagher Associate Professor Department of Behavioral Sciences University of Kentucky Medical Center Lexington, Kentucky 40506 Dr. Richard W. Garnett, Jr. Acting Chairman Department of Neurology and Psychiatry University of Virginia Hospital Charlottesville, Virginia 22904 Dr. Harold Goolishian Professor and Chief Division of Psychology University of Texas Medical Branch Galveston, Texas 77550 Dr. John A. Gronvall Acting Dean University of Mississippi School of Medicine Jackson, Mississippi 39216 Dr. Marcus Gulley Professor Department of Psychiatry Bowman Gray School of Medicine of Wake Forest College Winston-Salem, North Carolina 27103 Dr. Zachary Gussow Anthropologist Department of Psychiatry Louisiana State University Medical Center 1542 Tulane Avenue New Orleans, Louisiana 70112 ''Dr. Gene A. Hargrove Commissioner North Carolina State Department of Mental Health P.O. Box 10217 2100-C Hillsboro Street Raleigh, North Carolina 27605 Dr. Forrest Harris Deputy Commissioner for Mental Services Texas Department of Mental Health and Mental Retardation Box S = Capitol Station Austin, Texas 78711 Health Dr. Jesse Harris Department of Psychology University of Kentucky Medical Center Lexington, Kentucky 40506 Mr. Robert G. Harris Director Information and Public Relations Alabama Department of Mental Health Tuscaloosa, Alabama 35401 Dr. Robert Heckel Department of Psychology University of South Carolina Columbia, South Carolina 29208 Dr. C. Nash Herndon Associate Dean and Chairman Department of Preventive Medicine Bowman Gray School of Medicine at Wake Forest College Winston-Salem, North.Carolina 27103 Mr. David Hess Director of Student Educational Services West Virginia University Medical Center Morgantown, West Virginia 26506 Dr. Ralph H. Hines Meharry Medical College Nashville, Tennessee 37208 Dr. Bernard Holland Professor and Chairman Emory University School of Medicine Atlanta, Georgia 30322 41 Dr. Wolfgang Huber Clinical Director Central State Griffin Memorial Hospital Norman, Oklahoma 73069 Dr. John L. Hughes Director of Professional Services William S. Hall Psychiatric Institute Drawer 119 Columbia, South Carolina 29202 Dr. Robert L. Jones Assistant to the Vice President University of Arkansas Medical Center Little Rock, Arkansas 72201 Dr. Robert Kerns Director of Community Services West Virginia Department of Mental Health Charleston, West Virginia 25311 Dr. W. J. von Lackum Chairman, Department of Clinical Psychology The University of Tennessee College of Medicine 42 North Dunlap Street Memphis, Tennessee 38103 Dr. Ernest C. Land Director Division of Community Services Alabama Department of Mental Health 740 Madison Avenue Montgomery, Alabama 36104 Dr. Charles Laughton Associate Director School of Social Work University of Texas Austin, Texas 78712 Dr. Henry Lederer Professor and Chairman Department of Psychiatry Medical College of Virginia Richmond, Virginia 23219 Dr. Charles Llewellyn, Jr. Chairman, Committee on Community Health Adult Outpatient Clinic Duke University Medical Center Durham, North Carolina 27706 ''Dr. David Looff Division of Child Psychiatry University of Kentucky Hospital and Medical Center Lexington, Kentucky 40506 Dr. James McCranie Chairman Department of Psychiatry Medical College of Georgia Augusta, Georgia 30902 Dr. R. Layton McCurdy Coordinator of Medical Student Teaching Emory University School of Medicine Atlanta, Georgia 30322 Mrs. Selma Markowitz Director of Community Relations The Psychiatric Institute 645 West Redwood Street Baltimore, Maryland 21201 Mr. Charles F. Mitchell Acting Director Community Services Development Texas Department of Mental Health and Mental Retardation Box S = Capitol Station Austin, Texas 78711 Dr. Mildred Mitchell-Bateman Commissioner Department of Mental Health 1721 Quarrier Street Charleston, West Virginia 25311 Dr. Charles Neville Director Highland Hospital Division of the Department of Psychiatry Asheville, North Carolina 28801 Dr. Edward Norman Professor of Psychiatry and Preventive Medicine Tulane University School of Medicine Department of Psychiatry and Neurology 1430 Tulane Avenue New Orleans, Louisiana 70112 42 Dr. Garrett O'Connor Emergency Service Psychiatry The Johns Hopkins Hospital Baltimore, Maryland 21205 Dr. William F. Orr Chairman Department of Psychiatry Vanderbilt University Hospital Nashville, Tennessee 37203 Dr. Joseph B. Parker Professor and Chairman Department of Psychiatry University of Kentucky Medical Center Lexington, Kentucky 40506 Mr. Robert L. Parson Health Resources Consultant Acting Economic Consultant State of Arkansas Office of Economic Consultant 215 National Old Line Building Little Rock, Arkansas 72201 Dr. J. Morris Perkins Chief of Residency Training Emory University School of Medicine Atlanta, Georgia 30322 Dr. Seymour Perlin Professor of Psychiatry The Johns Hopkins University School Medicine The Johns Hopkins Hospital Baltimore, Maryland 21205 Dr. John E, Peters Professor, Department of Psychiatry University of Arkansas Medical Center Department of Psychiatry Little Rock, Arkansas 72201 Dr. David Pinosky The Institute Jackson Memorial Hospital Miami, Florida 33136 Dr. Max Plutzky West Virginia University Medical Center School of Medicine Morgantown, West Virginia 26506 ''Dr. Walter L. Prickett Department of Psychiatry Louisiana State University Medical Center 1542 Tulane Avenue New Orleans, Louisiana 70112 Dr. Robert M. Prince Director Richland-Lexington Mental Health Center 1845 Assembly Street Columbia, South Carolina 29201 Dr. Thomas Ray Director Training and Research Division of Mental Health 124 West Pensacola Street Tallahassee, Florida 32301 Dr. Robert Reed Director of Community Psychiatry Vanderbilt University Nashville, Tennessee 37203 Mrs. Jean Roper Supervisor, Psychiatric Services Greenville General Hospital 100 Mallard Street Greenville, South Carolina 29601 Dr. Stanley Russell University of Mississippi Medical Center 2500 North State Street Jackson, Mississippi 39216 Dr. Lindbergh S. Sata Assistant Professor Department of Psychiatry University of Maryland School of Medicine Baltimore, Maryland 21201 Mr. Harry Schnibbe Executive Director National Association of State Mental Health Program Directors Washington, D.C, 20036 Dr. Chester B. Scrignar Department of Psychiatry and Neurology Tulane University School of Medicine 1430 Tulane Avenue New Orleans, Louisiana 70112 43 Dr. Gordon Shaw Department of Sociology University of Texas Southwestern Medical School 5323 Harry Hines Boulevard Dallas, Texas 75235 Dr. William Sheppe University of Virginia School of Medicine Charlottesville, Virginia 22901 Dr. Raymond Sowell Resident Emory University School of Medicine Atlanta, Georgia 30322 Mr. David Spencer Administrator The University of Alabama Hospitals and Clinics Birmingham, Alabama 35233 Dr. Virginia Stone Head, Graduate Training School of Nursing Duke University Durham, North Carolina 27706 Dr. Trawick Stubbs Coordinator of Graduate Education State of Georgia Department of Public Health 47 Trinity Avenue Atlanta, Georgia 30334 Dr. James Sussex Chairman Department of Psychiatry University of Alabama Medical Center Birmingham, Alabama 35233 Dr. Emanuel Suter Dean The J. Hillis Miller Health Center University of Florida Gainesville, Florida 32601 Dr. C. Downing Tait, Jr. Emory University Department of Psychiatry Atlanta, Georgia 30322 ''Dr. Alice Tobler Director, Mental Health Planning Department of Mental Hygiene State of Maryland 301 West Preston Street Baltimore, Maryland 21201 Dr. Rufus Vaughn Head, Community Psychiatry Training Program The J. Hillis Miller Health Center University of Florida Gainesville, Florida 32601 Dr. Robert Vosburg Professor and Chairman Department of Psychiatry West Virginia University Medical Center Morgantown, West Virginia 26506 Dr. William W. Walker, Jr. Director of Outpatient Clinics Assistant Professor of Psychiatry The University of Tennessee College of Medicine 42 North Dunlap Street Memphis, Tennessee 38103 Dr. Jolyn West Professor of Psychiatry The University of Oklahoma Medical Center 800 Northeast Thirteenth Street Oklahoma City, Oklahoma 73104 Rev. James R. Wilburn St. Paul Presbyterian Church 5125 Robinson Road Jackson, Mississippi 39206 Dr. Robert Williams Professor and Chairman Department of Psychiatry The J. Hillis Miller Health Center University of Florida Gainesville, Florida 32601 ae ''Conference Faculty Dr. Robert H. Barnes Executive Director Greater Kansas City Mental Health Foundation Kansas City, Missouri 64108 Dr. Dan Brown National Institute of Mental Health Region IV 50 7th Street, N.E. Atlanta, Georgia 30323 Dr. Samuel L. Buker Associate Director Mental Health Services Program National Institute of Mental Health Chevy Chase, Maryland 20203 Dr. Simon Dinitz Department of Sociology Ohio State University Columbus, Ohio 43210 Dr. William Hollister Director Community Psychiatry Program University of North Carolina at Chapel Hill Chapel Hill, North Carolina 27514 Dr. Robert L. Leon Professor University of Texas Southwestern Medical School 5323 Harry Hines Boulevard Dallas, Texas 75235 Dr. Morton Miller Assistant Director of Special Programs National Institute of Mental Health Chevy Chase, Maryland 20203 Dr. Frank J. Nuckols Associate Professor of Psychiatry Head, Division of Community Psychiatry University of Alabama Medical Center Birmingham, Alabama 35233 Dr. Frank O'Connor Connecticut Mental Health Center 34 Park Street New Haven, Connecticut 06513 Dr. Frank Rafferty Director Division of Child Psychiatry University of Maryland School of Medicine Baltimore, Maryland 21201 Dr. Melvin Sabshin Professor and Head Department of Psychiatry University of Illinois Medical Center Chicago, Illinois 60612 Dr. Nat T. Winston, Jr. Commissioner Tennessee Department of Mental Health Nashville, Tennessee 37219 Dr. Israel Zwerling Director Bronx State Hospital Bronx, New York 10461 45 ''REPRESENTING NATIONAL INSTITUTE OF MENTAL HEALTH Miss Kathryn Fritz Program Director Mental Health Services Region VII 1114 Commerce Street Dallas, Texas 75202 Dr. Hugh Gabriel Psychiatry Branch National Institute of Mental Health Chevy Chase, Maryland 20203 Dr. Ross Grumet Mental Health Consultant Region IV 50 7th Street, N.E. Atlanta, Georgia 30323 46 REPRESENTING SOUTHERN REGIONAL EDUCATION BOARD Dr. Harold L. McPheeters Associate Director for Mental Health Training and Research Dr. Carl Bramlette Assistant Director for Mental Health Miss Helen Belcher Project Director Nursing Education and Research Miss Annie Laurie Crawford Project Director Psychiatric Nursing Dr. Harry B. Williams Assistant Director for Mental Health Mrs. Pauline Harrison Secretary Miss Amy Reynolds Secretary Mrs. Nadine Young Secretary U.S. GOVERNMENT PRINTING OFFICE : 1968 O—317-230 '' '' ''''Public Health Service Publication No. 1858 U.S. DEPARTMENT OF HEALTH, EDUCATION, AND WELFARE PUBLIC HEALTH SERVICE: HEALTH SERVICES AND MENTAL HEALTH ADMINISTRATION National Institute of Mental Health on ''- iin ii '' ''