Community Psychiatry and the Education of Psychiatrists Alexander S. Rogawski, M.D.
ABSTRACT: Opinions vary as to the place in psychiatric education of training for community psychiatry. The confusion is partly due to the assumption that community psychiatry represents a new subspecialty and that therefore training for community psychiatry should follow basic clinical education. With the exception of certain administrative and research aspects, the practices and the knowledge employed by community psychiatrists are becoming part of all effective contemporary psychiatric practice and should be part of the basic education of every psychiatrist. A three-year residency program which coordinates clinical and community psychiatric knowledge and experience is presented. The needs of participants in mental health programs, of teachers and of researchers in community psychiatry, can best be met by specific postgraduate instruction combined with simultaneous job experience. Community psychiatry is a fact of our life. In two years of operation the Federal grants program for the support of construction and initial staffing of community mental health centers distributed $I3o.I million to 256 such centers in 41 states, the District of Columbia, and Puerto Rico, to make comprehensive psychiatric services available to 4 9 million people (Yolles, i967). Last summer the Mental Health Amendments Act of I967 extended the provisions of the Community Mental Health Centers Act to the year I97o. The average mental health center will be staffed by two psychiatrists. More than 75 centers are slated to have up to five psychiatrists and the staffing ranges from less than one full-time psychiatrist to eight or more. Unless the current rate of training increases, there will be a growing professional manpower shortage even though the combined psychiatric coreprofessions increased by 44% between ~96o and 1 9 6 5 ~ a remarkable feat when compared with the i 9 % increase during the same period in the five major health professions of medicine, dentistry, nursing, environmental health, and health research. Educators of psychiatrists face a formidable chalDr. Rogawski, 416 North Bedford Drive, Beverly Hills, Calif. 90210, a training analyst of the Southern California Psychoanalytic Institute, is professor and director of the Division of Social and Community Psychiatry, Department of Psychiatry, University of Southern California School of Medicine. An earlier version of this paper was presented to the staff of the Department of Psychiatry, University of Colorado Medical Center, December 4, I967. Community Mental Health Journal, Vol. 5 (2), 1969 129
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lenge, The demands will affect the aims and the character of psychiatric practices and education. No valuable achievement must be sacrificed to expediency. Yet the historic opportunity to expand knowledge and increase professional effectiveness must be fully utilized. Psychiatric publications are flooded with papers on community psychiatry but in spite of the widespread interest the issue is far from winning universal endorsement. Some authors (Bellak, :t964) speak of community psychiatry as "the third major revolution in the history of psychiatry," "designed to guarantee and safeguard to a degree previously undreamed of, a basic right--the privilege of mental health." Others (Dunham, ~965) criticize it as "the newest therapeutic bandwagon." Whittington (2965) asks whether we delude ourselves with convictions of newness and omnipotence. He suspects we are not dealing with a revolution or even an innovation, but a "definitely conservative and perhaps even reactionary movement." He wonders, "Are we tempted to adopt and make a part of our society elements of the communistic man-and-world v i e w . . . ?" Even the exact meaning and scope of terms such as "community psychiatry," "community mental health," "social psychiatry," "public mental health," "preventive psychiatry," are controversial. Hume (~965) speaks of "a confusion about both labels and fundamentals." Goldston (~965) assembled from the literature five different and contradictory definitions of "community psychiatry." The following operations are a partial list of activities regarded as belonging in the domain of community psychiatry: :t. Establishment and maintenance of community-based psychiatric hospital services, including a day treatment center and night hospital. 2. Auxiliary services such as outpatient clinics offering emergency services and varieties of treatment modalities, crisis intervention, psychiatric home visits, using auxiliary personnel and approaches which eliminate the necessity of hospitalization or reduce its length to a therapeutic minimum. 3. Preventive and rehabilitative services, including efforts to maintain potential and actual patients in the community or enable chronic patients to return to the community; consultations to care-providing agencies and individuals; provisions for continuity of care by integration of community services. 4. Planning, organization, and administration of mental health programs. 5. Surveys to determine needs and resources, evaluation of programs, information and education of citizens and public officials about mental health problems and existing mental health needs. CONSIDERATION OF COMMUNITY PSYCHIATRY AS SUBSPECIALTY A formula which would comprise these and similar operations is difficult to arrive at. Hume (I966) suggested a definition sufficiently broad to be acceptable in its essence to most community psychiatrists: " . . . community psychiatry is a subspecialty that is simultaneously treatment oriented, prevention oriented and community oriented for the purpose of reducing to a minimum, by all discoverable means, the mental disorders
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of a given population." At the Division of Social and Community Psychiatry, University of Southern California, we disagree only with one point: we have become increasingly convinced that community psychiatry in its clinical aspects ought not to be considered a subspecialty. Hume is by no means alone in calling community psychiatry a "subspecialty." Bernard (I964), speaking for the Division of Community Psychiatry, Columbia University, states: "The term 'community psychiatry,' as used in this university refers to a subspecialty of psychiatry." The staff of the Langley Porter Neuropsychiatric Institute (Goldston, "r965) call community psychiatry "that subspecialty of psychiatry which directs its attention and efforts to community mental health problems." This is not merely a semantic problem. Whether or not community psychiatry is regarded as a subspecialty will have far-reaching influence on the ways it will be taught and practiced. As illustrated by the example of child psychiatry, training in a subspecialty is sought only by those with a special interest in the narrower field and, as a rule, it follows the completion of education in the basic specialty. The generalist is expected to have only a limited acquaintance with the subspecialty. According to this model, at the University of Southern California we used to introduce community psychiatry in the third year after the residents had become grounded in the fundamentals of traditional clinical psychiatry. It was assumed that some students would develop a special interest in the field and continue their education as fourth and fifth year fellows. This assumption proved wrong. The response to the introductory course was very positive, in fact, enthusiastic. The residents greatly enjoyed learning more about community problems and resources and collaborating and consulting with other professions in various community facilities. All of them, even those who planned to enter primarily the private practice of psychotherapy and psychoanalysis, approved of the course and felt it had broadened their professional competence and added an essential sociocultural dimension to their basic clinical training. Most students wished the course had been offered earlier in their career. Its theoretical and practical content would have enabled them to make better use of learning opportunities in other parts of their residency program. Some students did inquire about further training but the best qualified residents, in particular, did not apply for the fellowship program. Instead, they accepted readily available part- or full-time positions in community programs budding everywhere. The chiefs of these programs, eager to recruit staff, offered salaries more than twice as high as the fellowship stipend. They claimed that no special education was necessary since there would be an opportunity to train "on the job." There was little incentive for graduates to prolong their already lengthy education by an additional one or two years in our program. A subspecialty attracts trainees by its content and by its status. Status is based on the promise of certification, on the esteem of colleagues and of the public, and on the expectation of higher financial r e -
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turns. When gifted students failed to apply to our postgraduate program, we had to reexamine our premises. There is no certifcation in community psychiatry. Some training centers offer degree.s for combined training in public health or a "master of social psychiatry." The prospect of a degree does not seem to attract the most suitable applicants. Money does not seem to be a decisive factor either. Motivated psychiatrists do decide on academic or community careers, even though the earnings are less than in private practice. For a long time salaried positions were held in low esteem. This is no longer true since community psychiatry has acquired both status and glamour. The reluctance of well-qualified and motivated students to apply for the fellowship program forced us to reexamine the concept of community psychiatry as a subspecialty. The Conference on Graduate Education of the American Psychiatric Association (Report, 2963) defines "subspecialty" as "any area with well-defined theory, content and empirical practice." By these criteria child psychiatry is a subspecialty and it is so recognized by the American Board of Psychiatry and Neurology. It is, incidentally, the only officially recognized subspecialty in psychiatry. The Survey of Psychiatrists, a questionnaire which polls the activities of every member of the American Psychiatric Association, lists 24 subspecialties, including community psychiatry. Yet the APA's Conference on Graduate Education prefers to speak of "special interest areas" rather than of "subspecialties," when referring to mental retardation, geriatrics, and addiction. Other special interest areas are: forensic, correctional, military, industrial, and adolescent psychiatry and student mental health. They are all limited to populations identifiable by a shared characteristic or a common interest. Some, e.g., student mental health, and industrial and military psychiatry, are considered sectors of community psychiatry. Actually, they have both traditionally clinical and community psychiatric aspects and a psychiatrist working in these fields must be competent in both areas. Community psychiatry simply does not fit this definition of a "subspecialty." It does not merely represent "art area with well-defined theory, content and empirical practice." Though Dr. Gerald Caplan's (2964) brilliant conceptual model of primary prevention presents a step toward a comprehensive theory, no unifying system of thought has thus far evolved in community psychiatry. Insights gained in this field will be more likely to contribute toward a comprehensive theory of total human behavior, adding new dimensions to the understanding of the bio-psycho-socio-cultural nature of man. The content of community psychiatry cannot be considered "well defined." It is as broad and varied as man's involvement with family, groups, organizations, institutions, and social artd cultural systems, and it is essentially inseparable from effective clinical psychiatry. Some empirical practices have indeed developed out of the special condi-
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tions of community psychiatry: certain modifications of therapy, the use of the therapeutic community, techniques of consultation and collaborative planning. But many community psychiatric practices are merely new applications of traditional clinical knowledge. No matter how much psychiatrists become involved in community considerations, their ultimate concern must forever remain the individual's interests. Viewing the development of community psychiatry with a good deal of skepticism, Dunham (~965) states that "perhaps sociologists can garner some small satisfaction in the fact that the psychiatrist finally has discovered the community--something that the sociologist has been studying and reporting on for half a century in the United States." This grudging acknowledgment can be expanded. The psychiatrist has not only discovered the community, he is experiencing it in a new way by exposing himself and his patients to new settings and involving himself in new transactions and relationships. He emerges from this experience with a broader understanding of his patients' problems and, it is hoped, with a new concept of his own role. Dunham claims that "efforts in the direction of carving out a subspecialty of psychiatry known as community psychiatry take place in a cultural atmosphere which has seen a definite attempt to widen the definition of what constitutes mental illness." He deplores that such development may cast psychiatrists in the role of social engineers who attempt to solve all the ills of all mankind. He ascribes the widening of the definition of mental illness to the "adaptation of psychiatry to office practice following World War II" and to the "mounting frustration resulting from the failures to achieve therapeutic results with the bona fide psychotics." This has resulted in "a widening of the psychiatric net in order to include those persons with minor emotional disturbances who are responsive to existing treatment techniques." It is of course true that concepts of mental illness and of psychiatric treatment have been changing and that psychiatrists have accepted ever broader responsibilities for psychological malfunctioning. This is a reflection of cultural change and of better understanding of human behavior rather than a reaction to frustrations experienced in the treatment of "bona fide psychotics" or an attempt to garner business which brings greater satisfaction. In the course of history, locale and methods of study and treatment of the mentally ill have changed repeatedly and each change yielded new insights, new concepts, new theories, and new techniques. Patient listening to people in settings of psychoanalysis and psychotherapy has most decidedly altered our understanding of human functioning and disorder. As psychiatrists enter the arena of the community they observe patients, nonpatients, and themselves in new settings which must affect their conceptualization of mental disorder and treatment. The new conceptual tools and practices affect all of psychiatry and thus community psychiatry is rapidly becoming an
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"'integral part of all effective psychiatric practice" (GAP Report 2967). It should be part of the basic education of every psychiatrist, whether he will apply the knowledge in community psychiatric settings or not. Psychiatrists without knowledge of and some experience in community psychiatry lack currently available diagnostic and therapeutic tools. Their patients do not receive the best answers to their problems that contemporary psychiatry has to offer. PLACE OF COMMUNITY PSYCHIATRY IN THE CURRICULUM If it is agreed that every psychiatrist should be taught about community psychiatry, where should its place be in the basic curriculum? GAP Report No. 64, "Education for Community Psychiatry" (2967), describes 17 training programs. Most centers offer community psychiatry only in the advanced stages of residency or after its completion. There are two notable exceptions. Vaughn (University of Florida College of Medicine), in full agreement with our position, states: It is our bias that this kind of training must begin in the first year and continue through the third year. A separate fourth year program focusing on these kinds of issues would appear to us to come too late to be of general value to the trainee. The highly structured program in community psychiatry in Albert Einstein College of Medicine runs through all three years of the basic residency and is followed by a fellowship at the fourth and fifth year level. Several years ago the head of the Department of Psychiatry and the director of the training program in community psychiatry (Rosenbaum & Zwerling, 2964) discussed "the multiple conflicts . . . particularly with reference to student teaching and residency training" generated by the vigorous unit within a psychoanalytically oriented department. The "conflicts" were apparently engendered by the differences between "psychoanalytically trained faculty members who work mainly in traditional areas within the department" and "their colleagues who have shifted their focus of interest and field of activity to social psychiatry." The emphasis on these differences was the more surprising since both authors agreed on "the indefinite boundaries between community and individual psychiatric approaches." There are of course differences in the conceptual focus of the two approaches. For a competent performance, "a shift in values and an alteration in professional identity" (Caplan, i965) is indeed required. But this ambiguity must be permitted to co-exist within the mind of the individual psychiatrist so that he can acquire "the ability to shift attention and perspective, to balance sensitivity and empathy between individuals and groups, large and small" (Bernard i964). And just as, according to Bernard, "he, the community psychiatrist, learns
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to stretch his accustomed capacity for identifying with a single person to simultaneous maintenance of multiple identifications," the clinician who acquires the same flexibility will enhance his competence and usefulness to his patients. At our Division of Social and Community Psychiatry, the "indefiniteness" of the boundaries between community psychiatry and other functions of the psychiatric department is intentionally and carefully preserved. Students are shown that one and the same person can entertain two different conceptual systems and shift from one to the other as the situation demands. This ability resembles the automatic accommodation of vision to distant or close objects. The director of the community psychiatry program is a training analyst who teaches dynamic psychotherapy to second year residents. They observe him through a one-way screen while he treats a long-term patient in psychoanalytically oriented psychotherapy. Each session is followed by a discussion of the intrapsychic and interpersonal transactions, often illustrated by video tape. On the other hand, not all community psychiatry is taught by the faculty of the division. Full-time and clinical staff teach family process, family therapy, group dynamics, sensitivity training, use of the therapeutic milieu, psychiatric administration, legal psychiatry, crisis theory, and intervention. In the Department of Child Psychiatry, the inseparability of clinical from community psychiatric approaches is particularly pronounced. This approach has avoided a rift in the faculty and the corresponding conflict and confusion in the thinking of the residents. The basic problem, however, remains where in the psychiatric program the specifically new dimensions of community psychiatry can be introduced without damaging interference with the developing professional identity. Caplan (I965) states, "A fundamental issue in residency programs is to develop in young psychiatrists an appropriate role orientation and handle unconscious aspects of the relationships involved." He wonders whether "the introduction of two different sets of concepts and values during basic training will lead to identity confusion." He suggests that classical psychiatric training precede the arousal of interest in community dimensions. Likewise Berlin (2964) is uneasy about the conviction of some training centers that "community psychiatry can be taught as a specialty having a beginning with first year psychiatric residents." Every experienced community psychiatrist will agree with Berlin that "self-awareness and insights into one's own intrapsychic mechanisms are often essential to effective work in community psychiatry. Such insights come only from a combination of psychotherapeutic work, both as analyst and as therapist." In this respect there is no difference between community psychiatry and clinical psychiatry. It is generally agreed that the achievement of sensitivity
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and of skill in the management of intrapsychic phenomena and of interpersonal transactions in patients and therapist are the most important goals of psychiatric education. It is open to question whether our current training programs are geared toward these aims. Traditionally most residencies start on the inpatient service. Whatever the rationale, it is not the best place for study of subde psychological processes by the beginner. On a busy ward, there is too much going on. The change from the familiar medical identity to a wholly different and strange role for which he had little preparation causes the new resident great anxiety. Gaskill and Norton (z968) concur that "starting residency training with psychotic patients . . . seemed to have real disadvantages." The novice has not 'even acquired the basic tools of his new profession which could help him orient himself in the strange surroundings. He therefore falls back on external measures to reduce his discomfort. He fills the gaps in his psychological understanding with administrative manipulation and relieves his responsibility by relying on the more experienced staff. The inpatient service becomes unfortunately associated with the most trying period of training. Many residents complete their education without ever having learned how to use hospitalization imaginatively. The valuable opportunity of learning to use a therapeutic milieu would not have been lost to them had they first acquired some basic psychiatric skills. It seems preferable therefore to begin psychiatric training in the outpatient clinic where the new resident backed by ample and competent supervision is at once introduced to the basic skills of his new profession. The Department of Psychiatry of the Colorado School of Medicine so reorganized its curriculum a few years ago. The results were recently reported by Gaskill and Norton (i968). They felt that "irrespective of the resident's ultimate choice of career, the educational experience must emphasize what is uniquely core knowledge for psychiatry." Regarding "the dyadic doctor-patient relationship as being central to psychiatric residency training," they started their students in the outpatient clinics and found that the new rotation proved beneficial to both students and patients. The arrangement also permitted other changes, including a better integration of community-oriented psychiatry into their basic program. The resident who spends his first year in the outpatient clinic should be introduced early to certain aspects of community psychiatry to complement his clinical experience. He should be oriented in community organization, community resources, mental health legislation, development and concepts of community psychiatry, the significance of social, economic, and cultural factors for the definition of mental illness and for the delivery of mental health services. This primarily didactic instruction should be illustrated by field trips to community facilities, visits to the homes of patients from various socioeconomic backgrounds and subcultural areas, and interviews with psychiatrists who represent various career models. This introductory experience
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will prepare a resident for more intensive community awareness later on, yet it will not interfere with the acquisition of his basic dinical skills and the development of his professional identity. If part or all of the second year is spent on the inpatient service, the setting will now be ideal to acquaint the resident with the dynamics of small groups and their use as a treatment instrument, with principles of the therapeutic milieu, and with the concept of the hospital as an integrated phase of a continuum of care reaching into the community through aftercare, rehabilitation, and involvement of the patient's family and other significant figures of his social space. The third year is usually devoted to the child psychiatry service, to the psychosomatic or liaison service, and to elective special interests. During this year the resident may spend a half to one full day in a community placement where he can blend his clinical and community psychiatry skills in learning sophisticated techniques of mental health consultations. While he rotates through schools, public health districts, and welfare and correctional agencies, he consolidates his knowledge of the community under the guidance of preceptors. During this year residents with special interest should be given an opportunity to work on special research or service projects. This program complements the basic curriculum by adding that aspect of community psychiatry which corresponds to the resident's clinical experience and is commensurate with the degree of his professional development. It need not burden his already heavily crowded schedule. Several years ago the respected chairman of a major department of psychiatry discussing his staff's interest in family diagnosis, group process, group dynamics, and group psychotherapy, said: "Many of these things are rather strange and foreign to me because I have not had this experience or this background." Nobody can be equally knowledgeable in all areas of our extensive profession. But we owe it to our patients to be sufficiently informed so that we can direct them to the treatment modality which promises to meet their needs most specifically. Graduates of a psychiatric curriculum which integrates clinical and community dimensions will understand their patients' problems more fully and will have a richer and more specific repertory of treatment approaches to choose from. No psychiatric education can in three brief years cover all contingencies of psychiatric practice. It must achieve two fundamental aims. (2) It must leave the new psychiatrist with a permanent interest in the nature of man, in his relations to others, in what makes man fail and in what helps him to overcome his failings. (2) It must preserve and enhance the motivation for lifelong learning. There are, of course, "specialist" areas in community psychiatry where specialized knowledge is necessary. Psychiatrists who elect to participate in community programs or community research projects on a part-time or full-
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time basis may need additional specific education and/or preceptorship. A division of social and community psychiatry has the obligation to recognize such unfilled educational needs and to provide suitable postgraduate training opportunities. The content of such programs will be determined by need and local conditions. We anticipate requests for training in mental health administration, in program planning and evaluation, in research methodology, advanced courses in mental health consultation and education, in group dynamics, and in "special interest areas." Such training is most useful when it is associated with actual service experience. Agencies have a great deal to gain from special education of their employees. It would be to their advantage to make time and funds available for such purposes. FUNCTIONS OF COMMUNITY PSYCHIATRY DIVISIONS If it is agreed that community psychiatry is not a "subspecialty," what should be the functions of divisions of community psychiatry which are currently being established in growing numbers in various departments of psychiatry? In addition to monitoring the residency program in order to ascertain that community psychiatry is well represented, providing instruction where it is not given by others, and sponsoring research in the field of social and community psychiatry, a division has several other important functions. It must establish bridges between psychiatrists and behavioral scientists, as well as other professions. The mutual exchange of faculty and students between departments of psychiatry and departments of anthropology, sociology, political science, and public health will produce new generations of "bilingual" professionals able to integrate knowledge and skills of related professions while maintaining a primary identity. An excellent model of a collaborative relationship between a division of social and community psychiatry and a department of anthropology was established at the State University of Washington (Pattison & Wagner, ~967; Pattison, :t967). Finally, a division of community psychiatry must continually explore innovative approaches to mental health problems, such as programs for training of indigenous nonprofessionals in new mental health careers. Besides the immediate service value, such projects offer excellent opportunities for the involvement of students in imaginative educational and research ventures. REFERENCES Bellak, L. Community psychiatry: the third psychiatric revolution. In L. Bellak (Ed.), Handbook of community psychiatry and community mental health. New York: Grune & Stratton, ~964. Pp. x-ix. Berlin, I. Training in community psychiatry: its relation to clinical psychiatry. Community Mental Health ]ournaI, ~964, z, 357-36o. Bernard, V. W. Education for community psychiatry in a university medical center. In Handbook of community psychiatry and community mental health. New York: Grune & Stratton, 1964. Pp. 82-/.22.
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Caplan, G. Principles of preventive psychiatry. New York: Basic Books, i964 . Caplan, G. Community psychiatry--introduction and overview. In S. Goldston (Ed.), Concepts of community psychiatry: a framework for training. National Institute of Mental Health, Department of Health, Education, and Welfare. PHS Publication No. 1319. Washington, D. C., August 1965. Pp. 3-18. Dunham, W. Community psychiatry: the newest therapeutic bandwagon. Archives of General Psychiatry, 1965, I2,303-3 x3. Gaskill, H. S., & Norton, Janice E. Observations on psychiatric residency training. Community psychiatry. Archives of General Psychiatry, 2968, 18, 7-15. Goldston, S. Selected definitions. In Concepts of community psychiatry: a framework for training. Department of Health, Education and Welfare, PHS Publication No. I319. Washington, D. C., August I965. Pp. 195-2o3. Group for the Advancement of Psychiatry. Education for community psychiatry. GAP Report No. 64, New York, 1967. Hume, P. B. General principles of community psychiatry. In S. Arieti (Ed.) American handbook of psychiatry. New York: Basic Books, I966. Pp. 515-542. Hume, P. B. Searchlights on community psychiatry. Community Mental Health Journal, 1965, i, 2o9-12. Pattison, E. M., & Wagner, N. N. The relevance of psychiatry to anthropological training and research: an interdisciplinary program. University of Washington, 1967. Unpublished manuscript. Pattison, E. M. Psychiatry and anthropology: three models for a working relationship. University of Washington, I967 . Unpublished manuscript. Rogawski, A. S. Education for community psychiatry: its opportunities for personal and professional growth. Quarterly of CamarilIo, I966, 2 (2), 16-32. Rosenbaum, M., & Zwerling, I. Impact of social psychiatry. Archives of General Psychiatry, 2964, ii, 32-39 . Training the psychiatrist to meet changing needs. Report of Conference on Graduate Education, American Psychiatric Association, Washington, D. C., 1963. Whittington, H. G. The third psychiatric revolution--really? a consideration of principles and practices in community psychiatry. Community Mental Health Journal, i965 , I, 73-80. Yolles, S. F. Community mental health services: the view from i967. American Journal of Psychiatry, i967, 4, I24, supp. x-7.
ABSTRACT: Opinions vary as to the place in psychiatric education of training for community psychiatry. The confusion is partly due to the assumption that community psychiatry represents a new subspecialty and that therefore training for community psychiatry should follow basic clinical education. With the exception of certain administrative and research aspects, the practices and the knowledge employed by community psychiatrists are becoming part of all effective contemporary psychiatric practice and should be part of the basic education of every psychiatrist. A three-year residency program which coordinates clinical and community psychiatric knowledge and experience is presented. The needs of participants in mental health programs, of teachers and of researchers in community psychiatry, can best be met by specific postgraduate instruction combined with simultaneous job experience. Community psychiatry is a fact of our life. In two years of operation the Federal grants program for the support of construction and initial staffing of community mental health centers distributed $I3o.I million to 256 such centers in 41 states, the District of Columbia, and Puerto Rico, to make comprehensive psychiatric services available to 4 9 million people (Yolles, i967). Last summer the Mental Health Amendments Act of I967 extended the provisions of the Community Mental Health Centers Act to the year I97o. The average mental health center will be staffed by two psychiatrists. More than 75 centers are slated to have up to five psychiatrists and the staffing ranges from less than one full-time psychiatrist to eight or more. Unless the current rate of training increases, there will be a growing professional manpower shortage even though the combined psychiatric coreprofessions increased by 44% between ~96o and 1 9 6 5 ~ a remarkable feat when compared with the i 9 % increase during the same period in the five major health professions of medicine, dentistry, nursing, environmental health, and health research. Educators of psychiatrists face a formidable chalDr. Rogawski, 416 North Bedford Drive, Beverly Hills, Calif. 90210, a training analyst of the Southern California Psychoanalytic Institute, is professor and director of the Division of Social and Community Psychiatry, Department of Psychiatry, University of Southern California School of Medicine. An earlier version of this paper was presented to the staff of the Department of Psychiatry, University of Colorado Medical Center, December 4, I967. Community Mental Health Journal, Vol. 5 (2), 1969 129
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lenge, The demands will affect the aims and the character of psychiatric practices and education. No valuable achievement must be sacrificed to expediency. Yet the historic opportunity to expand knowledge and increase professional effectiveness must be fully utilized. Psychiatric publications are flooded with papers on community psychiatry but in spite of the widespread interest the issue is far from winning universal endorsement. Some authors (Bellak, :t964) speak of community psychiatry as "the third major revolution in the history of psychiatry," "designed to guarantee and safeguard to a degree previously undreamed of, a basic right--the privilege of mental health." Others (Dunham, ~965) criticize it as "the newest therapeutic bandwagon." Whittington (2965) asks whether we delude ourselves with convictions of newness and omnipotence. He suspects we are not dealing with a revolution or even an innovation, but a "definitely conservative and perhaps even reactionary movement." He wonders, "Are we tempted to adopt and make a part of our society elements of the communistic man-and-world v i e w . . . ?" Even the exact meaning and scope of terms such as "community psychiatry," "community mental health," "social psychiatry," "public mental health," "preventive psychiatry," are controversial. Hume (~965) speaks of "a confusion about both labels and fundamentals." Goldston (~965) assembled from the literature five different and contradictory definitions of "community psychiatry." The following operations are a partial list of activities regarded as belonging in the domain of community psychiatry: :t. Establishment and maintenance of community-based psychiatric hospital services, including a day treatment center and night hospital. 2. Auxiliary services such as outpatient clinics offering emergency services and varieties of treatment modalities, crisis intervention, psychiatric home visits, using auxiliary personnel and approaches which eliminate the necessity of hospitalization or reduce its length to a therapeutic minimum. 3. Preventive and rehabilitative services, including efforts to maintain potential and actual patients in the community or enable chronic patients to return to the community; consultations to care-providing agencies and individuals; provisions for continuity of care by integration of community services. 4. Planning, organization, and administration of mental health programs. 5. Surveys to determine needs and resources, evaluation of programs, information and education of citizens and public officials about mental health problems and existing mental health needs. CONSIDERATION OF COMMUNITY PSYCHIATRY AS SUBSPECIALTY A formula which would comprise these and similar operations is difficult to arrive at. Hume (I966) suggested a definition sufficiently broad to be acceptable in its essence to most community psychiatrists: " . . . community psychiatry is a subspecialty that is simultaneously treatment oriented, prevention oriented and community oriented for the purpose of reducing to a minimum, by all discoverable means, the mental disorders
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of a given population." At the Division of Social and Community Psychiatry, University of Southern California, we disagree only with one point: we have become increasingly convinced that community psychiatry in its clinical aspects ought not to be considered a subspecialty. Hume is by no means alone in calling community psychiatry a "subspecialty." Bernard (I964), speaking for the Division of Community Psychiatry, Columbia University, states: "The term 'community psychiatry,' as used in this university refers to a subspecialty of psychiatry." The staff of the Langley Porter Neuropsychiatric Institute (Goldston, "r965) call community psychiatry "that subspecialty of psychiatry which directs its attention and efforts to community mental health problems." This is not merely a semantic problem. Whether or not community psychiatry is regarded as a subspecialty will have far-reaching influence on the ways it will be taught and practiced. As illustrated by the example of child psychiatry, training in a subspecialty is sought only by those with a special interest in the narrower field and, as a rule, it follows the completion of education in the basic specialty. The generalist is expected to have only a limited acquaintance with the subspecialty. According to this model, at the University of Southern California we used to introduce community psychiatry in the third year after the residents had become grounded in the fundamentals of traditional clinical psychiatry. It was assumed that some students would develop a special interest in the field and continue their education as fourth and fifth year fellows. This assumption proved wrong. The response to the introductory course was very positive, in fact, enthusiastic. The residents greatly enjoyed learning more about community problems and resources and collaborating and consulting with other professions in various community facilities. All of them, even those who planned to enter primarily the private practice of psychotherapy and psychoanalysis, approved of the course and felt it had broadened their professional competence and added an essential sociocultural dimension to their basic clinical training. Most students wished the course had been offered earlier in their career. Its theoretical and practical content would have enabled them to make better use of learning opportunities in other parts of their residency program. Some students did inquire about further training but the best qualified residents, in particular, did not apply for the fellowship program. Instead, they accepted readily available part- or full-time positions in community programs budding everywhere. The chiefs of these programs, eager to recruit staff, offered salaries more than twice as high as the fellowship stipend. They claimed that no special education was necessary since there would be an opportunity to train "on the job." There was little incentive for graduates to prolong their already lengthy education by an additional one or two years in our program. A subspecialty attracts trainees by its content and by its status. Status is based on the promise of certification, on the esteem of colleagues and of the public, and on the expectation of higher financial r e -
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turns. When gifted students failed to apply to our postgraduate program, we had to reexamine our premises. There is no certifcation in community psychiatry. Some training centers offer degree.s for combined training in public health or a "master of social psychiatry." The prospect of a degree does not seem to attract the most suitable applicants. Money does not seem to be a decisive factor either. Motivated psychiatrists do decide on academic or community careers, even though the earnings are less than in private practice. For a long time salaried positions were held in low esteem. This is no longer true since community psychiatry has acquired both status and glamour. The reluctance of well-qualified and motivated students to apply for the fellowship program forced us to reexamine the concept of community psychiatry as a subspecialty. The Conference on Graduate Education of the American Psychiatric Association (Report, 2963) defines "subspecialty" as "any area with well-defined theory, content and empirical practice." By these criteria child psychiatry is a subspecialty and it is so recognized by the American Board of Psychiatry and Neurology. It is, incidentally, the only officially recognized subspecialty in psychiatry. The Survey of Psychiatrists, a questionnaire which polls the activities of every member of the American Psychiatric Association, lists 24 subspecialties, including community psychiatry. Yet the APA's Conference on Graduate Education prefers to speak of "special interest areas" rather than of "subspecialties," when referring to mental retardation, geriatrics, and addiction. Other special interest areas are: forensic, correctional, military, industrial, and adolescent psychiatry and student mental health. They are all limited to populations identifiable by a shared characteristic or a common interest. Some, e.g., student mental health, and industrial and military psychiatry, are considered sectors of community psychiatry. Actually, they have both traditionally clinical and community psychiatric aspects and a psychiatrist working in these fields must be competent in both areas. Community psychiatry simply does not fit this definition of a "subspecialty." It does not merely represent "art area with well-defined theory, content and empirical practice." Though Dr. Gerald Caplan's (2964) brilliant conceptual model of primary prevention presents a step toward a comprehensive theory, no unifying system of thought has thus far evolved in community psychiatry. Insights gained in this field will be more likely to contribute toward a comprehensive theory of total human behavior, adding new dimensions to the understanding of the bio-psycho-socio-cultural nature of man. The content of community psychiatry cannot be considered "well defined." It is as broad and varied as man's involvement with family, groups, organizations, institutions, and social artd cultural systems, and it is essentially inseparable from effective clinical psychiatry. Some empirical practices have indeed developed out of the special condi-
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tions of community psychiatry: certain modifications of therapy, the use of the therapeutic community, techniques of consultation and collaborative planning. But many community psychiatric practices are merely new applications of traditional clinical knowledge. No matter how much psychiatrists become involved in community considerations, their ultimate concern must forever remain the individual's interests. Viewing the development of community psychiatry with a good deal of skepticism, Dunham (~965) states that "perhaps sociologists can garner some small satisfaction in the fact that the psychiatrist finally has discovered the community--something that the sociologist has been studying and reporting on for half a century in the United States." This grudging acknowledgment can be expanded. The psychiatrist has not only discovered the community, he is experiencing it in a new way by exposing himself and his patients to new settings and involving himself in new transactions and relationships. He emerges from this experience with a broader understanding of his patients' problems and, it is hoped, with a new concept of his own role. Dunham claims that "efforts in the direction of carving out a subspecialty of psychiatry known as community psychiatry take place in a cultural atmosphere which has seen a definite attempt to widen the definition of what constitutes mental illness." He deplores that such development may cast psychiatrists in the role of social engineers who attempt to solve all the ills of all mankind. He ascribes the widening of the definition of mental illness to the "adaptation of psychiatry to office practice following World War II" and to the "mounting frustration resulting from the failures to achieve therapeutic results with the bona fide psychotics." This has resulted in "a widening of the psychiatric net in order to include those persons with minor emotional disturbances who are responsive to existing treatment techniques." It is of course true that concepts of mental illness and of psychiatric treatment have been changing and that psychiatrists have accepted ever broader responsibilities for psychological malfunctioning. This is a reflection of cultural change and of better understanding of human behavior rather than a reaction to frustrations experienced in the treatment of "bona fide psychotics" or an attempt to garner business which brings greater satisfaction. In the course of history, locale and methods of study and treatment of the mentally ill have changed repeatedly and each change yielded new insights, new concepts, new theories, and new techniques. Patient listening to people in settings of psychoanalysis and psychotherapy has most decidedly altered our understanding of human functioning and disorder. As psychiatrists enter the arena of the community they observe patients, nonpatients, and themselves in new settings which must affect their conceptualization of mental disorder and treatment. The new conceptual tools and practices affect all of psychiatry and thus community psychiatry is rapidly becoming an
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"'integral part of all effective psychiatric practice" (GAP Report 2967). It should be part of the basic education of every psychiatrist, whether he will apply the knowledge in community psychiatric settings or not. Psychiatrists without knowledge of and some experience in community psychiatry lack currently available diagnostic and therapeutic tools. Their patients do not receive the best answers to their problems that contemporary psychiatry has to offer. PLACE OF COMMUNITY PSYCHIATRY IN THE CURRICULUM If it is agreed that every psychiatrist should be taught about community psychiatry, where should its place be in the basic curriculum? GAP Report No. 64, "Education for Community Psychiatry" (2967), describes 17 training programs. Most centers offer community psychiatry only in the advanced stages of residency or after its completion. There are two notable exceptions. Vaughn (University of Florida College of Medicine), in full agreement with our position, states: It is our bias that this kind of training must begin in the first year and continue through the third year. A separate fourth year program focusing on these kinds of issues would appear to us to come too late to be of general value to the trainee. The highly structured program in community psychiatry in Albert Einstein College of Medicine runs through all three years of the basic residency and is followed by a fellowship at the fourth and fifth year level. Several years ago the head of the Department of Psychiatry and the director of the training program in community psychiatry (Rosenbaum & Zwerling, 2964) discussed "the multiple conflicts . . . particularly with reference to student teaching and residency training" generated by the vigorous unit within a psychoanalytically oriented department. The "conflicts" were apparently engendered by the differences between "psychoanalytically trained faculty members who work mainly in traditional areas within the department" and "their colleagues who have shifted their focus of interest and field of activity to social psychiatry." The emphasis on these differences was the more surprising since both authors agreed on "the indefinite boundaries between community and individual psychiatric approaches." There are of course differences in the conceptual focus of the two approaches. For a competent performance, "a shift in values and an alteration in professional identity" (Caplan, i965) is indeed required. But this ambiguity must be permitted to co-exist within the mind of the individual psychiatrist so that he can acquire "the ability to shift attention and perspective, to balance sensitivity and empathy between individuals and groups, large and small" (Bernard i964). And just as, according to Bernard, "he, the community psychiatrist, learns
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to stretch his accustomed capacity for identifying with a single person to simultaneous maintenance of multiple identifications," the clinician who acquires the same flexibility will enhance his competence and usefulness to his patients. At our Division of Social and Community Psychiatry, the "indefiniteness" of the boundaries between community psychiatry and other functions of the psychiatric department is intentionally and carefully preserved. Students are shown that one and the same person can entertain two different conceptual systems and shift from one to the other as the situation demands. This ability resembles the automatic accommodation of vision to distant or close objects. The director of the community psychiatry program is a training analyst who teaches dynamic psychotherapy to second year residents. They observe him through a one-way screen while he treats a long-term patient in psychoanalytically oriented psychotherapy. Each session is followed by a discussion of the intrapsychic and interpersonal transactions, often illustrated by video tape. On the other hand, not all community psychiatry is taught by the faculty of the division. Full-time and clinical staff teach family process, family therapy, group dynamics, sensitivity training, use of the therapeutic milieu, psychiatric administration, legal psychiatry, crisis theory, and intervention. In the Department of Child Psychiatry, the inseparability of clinical from community psychiatric approaches is particularly pronounced. This approach has avoided a rift in the faculty and the corresponding conflict and confusion in the thinking of the residents. The basic problem, however, remains where in the psychiatric program the specifically new dimensions of community psychiatry can be introduced without damaging interference with the developing professional identity. Caplan (I965) states, "A fundamental issue in residency programs is to develop in young psychiatrists an appropriate role orientation and handle unconscious aspects of the relationships involved." He wonders whether "the introduction of two different sets of concepts and values during basic training will lead to identity confusion." He suggests that classical psychiatric training precede the arousal of interest in community dimensions. Likewise Berlin (2964) is uneasy about the conviction of some training centers that "community psychiatry can be taught as a specialty having a beginning with first year psychiatric residents." Every experienced community psychiatrist will agree with Berlin that "self-awareness and insights into one's own intrapsychic mechanisms are often essential to effective work in community psychiatry. Such insights come only from a combination of psychotherapeutic work, both as analyst and as therapist." In this respect there is no difference between community psychiatry and clinical psychiatry. It is generally agreed that the achievement of sensitivity
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and of skill in the management of intrapsychic phenomena and of interpersonal transactions in patients and therapist are the most important goals of psychiatric education. It is open to question whether our current training programs are geared toward these aims. Traditionally most residencies start on the inpatient service. Whatever the rationale, it is not the best place for study of subde psychological processes by the beginner. On a busy ward, there is too much going on. The change from the familiar medical identity to a wholly different and strange role for which he had little preparation causes the new resident great anxiety. Gaskill and Norton (z968) concur that "starting residency training with psychotic patients . . . seemed to have real disadvantages." The novice has not 'even acquired the basic tools of his new profession which could help him orient himself in the strange surroundings. He therefore falls back on external measures to reduce his discomfort. He fills the gaps in his psychological understanding with administrative manipulation and relieves his responsibility by relying on the more experienced staff. The inpatient service becomes unfortunately associated with the most trying period of training. Many residents complete their education without ever having learned how to use hospitalization imaginatively. The valuable opportunity of learning to use a therapeutic milieu would not have been lost to them had they first acquired some basic psychiatric skills. It seems preferable therefore to begin psychiatric training in the outpatient clinic where the new resident backed by ample and competent supervision is at once introduced to the basic skills of his new profession. The Department of Psychiatry of the Colorado School of Medicine so reorganized its curriculum a few years ago. The results were recently reported by Gaskill and Norton (i968). They felt that "irrespective of the resident's ultimate choice of career, the educational experience must emphasize what is uniquely core knowledge for psychiatry." Regarding "the dyadic doctor-patient relationship as being central to psychiatric residency training," they started their students in the outpatient clinics and found that the new rotation proved beneficial to both students and patients. The arrangement also permitted other changes, including a better integration of community-oriented psychiatry into their basic program. The resident who spends his first year in the outpatient clinic should be introduced early to certain aspects of community psychiatry to complement his clinical experience. He should be oriented in community organization, community resources, mental health legislation, development and concepts of community psychiatry, the significance of social, economic, and cultural factors for the definition of mental illness and for the delivery of mental health services. This primarily didactic instruction should be illustrated by field trips to community facilities, visits to the homes of patients from various socioeconomic backgrounds and subcultural areas, and interviews with psychiatrists who represent various career models. This introductory experience
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will prepare a resident for more intensive community awareness later on, yet it will not interfere with the acquisition of his basic dinical skills and the development of his professional identity. If part or all of the second year is spent on the inpatient service, the setting will now be ideal to acquaint the resident with the dynamics of small groups and their use as a treatment instrument, with principles of the therapeutic milieu, and with the concept of the hospital as an integrated phase of a continuum of care reaching into the community through aftercare, rehabilitation, and involvement of the patient's family and other significant figures of his social space. The third year is usually devoted to the child psychiatry service, to the psychosomatic or liaison service, and to elective special interests. During this year the resident may spend a half to one full day in a community placement where he can blend his clinical and community psychiatry skills in learning sophisticated techniques of mental health consultations. While he rotates through schools, public health districts, and welfare and correctional agencies, he consolidates his knowledge of the community under the guidance of preceptors. During this year residents with special interest should be given an opportunity to work on special research or service projects. This program complements the basic curriculum by adding that aspect of community psychiatry which corresponds to the resident's clinical experience and is commensurate with the degree of his professional development. It need not burden his already heavily crowded schedule. Several years ago the respected chairman of a major department of psychiatry discussing his staff's interest in family diagnosis, group process, group dynamics, and group psychotherapy, said: "Many of these things are rather strange and foreign to me because I have not had this experience or this background." Nobody can be equally knowledgeable in all areas of our extensive profession. But we owe it to our patients to be sufficiently informed so that we can direct them to the treatment modality which promises to meet their needs most specifically. Graduates of a psychiatric curriculum which integrates clinical and community dimensions will understand their patients' problems more fully and will have a richer and more specific repertory of treatment approaches to choose from. No psychiatric education can in three brief years cover all contingencies of psychiatric practice. It must achieve two fundamental aims. (2) It must leave the new psychiatrist with a permanent interest in the nature of man, in his relations to others, in what makes man fail and in what helps him to overcome his failings. (2) It must preserve and enhance the motivation for lifelong learning. There are, of course, "specialist" areas in community psychiatry where specialized knowledge is necessary. Psychiatrists who elect to participate in community programs or community research projects on a part-time or full-
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time basis may need additional specific education and/or preceptorship. A division of social and community psychiatry has the obligation to recognize such unfilled educational needs and to provide suitable postgraduate training opportunities. The content of such programs will be determined by need and local conditions. We anticipate requests for training in mental health administration, in program planning and evaluation, in research methodology, advanced courses in mental health consultation and education, in group dynamics, and in "special interest areas." Such training is most useful when it is associated with actual service experience. Agencies have a great deal to gain from special education of their employees. It would be to their advantage to make time and funds available for such purposes. FUNCTIONS OF COMMUNITY PSYCHIATRY DIVISIONS If it is agreed that community psychiatry is not a "subspecialty," what should be the functions of divisions of community psychiatry which are currently being established in growing numbers in various departments of psychiatry? In addition to monitoring the residency program in order to ascertain that community psychiatry is well represented, providing instruction where it is not given by others, and sponsoring research in the field of social and community psychiatry, a division has several other important functions. It must establish bridges between psychiatrists and behavioral scientists, as well as other professions. The mutual exchange of faculty and students between departments of psychiatry and departments of anthropology, sociology, political science, and public health will produce new generations of "bilingual" professionals able to integrate knowledge and skills of related professions while maintaining a primary identity. An excellent model of a collaborative relationship between a division of social and community psychiatry and a department of anthropology was established at the State University of Washington (Pattison & Wagner, ~967; Pattison, :t967). Finally, a division of community psychiatry must continually explore innovative approaches to mental health problems, such as programs for training of indigenous nonprofessionals in new mental health careers. Besides the immediate service value, such projects offer excellent opportunities for the involvement of students in imaginative educational and research ventures. REFERENCES Bellak, L. Community psychiatry: the third psychiatric revolution. In L. Bellak (Ed.), Handbook of community psychiatry and community mental health. New York: Grune & Stratton, ~964. Pp. x-ix. Berlin, I. Training in community psychiatry: its relation to clinical psychiatry. Community Mental Health ]ournaI, ~964, z, 357-36o. Bernard, V. W. Education for community psychiatry in a university medical center. In Handbook of community psychiatry and community mental health. New York: Grune & Stratton, 1964. Pp. 82-/.22.
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Caplan, G. Principles of preventive psychiatry. New York: Basic Books, i964 . Caplan, G. Community psychiatry--introduction and overview. In S. Goldston (Ed.), Concepts of community psychiatry: a framework for training. National Institute of Mental Health, Department of Health, Education, and Welfare. PHS Publication No. 1319. Washington, D. C., August 1965. Pp. 3-18. Dunham, W. Community psychiatry: the newest therapeutic bandwagon. Archives of General Psychiatry, 1965, I2,303-3 x3. Gaskill, H. S., & Norton, Janice E. Observations on psychiatric residency training. Community psychiatry. Archives of General Psychiatry, 2968, 18, 7-15. Goldston, S. Selected definitions. In Concepts of community psychiatry: a framework for training. Department of Health, Education and Welfare, PHS Publication No. I319. Washington, D. C., August I965. Pp. 195-2o3. Group for the Advancement of Psychiatry. Education for community psychiatry. GAP Report No. 64, New York, 1967. Hume, P. B. General principles of community psychiatry. In S. Arieti (Ed.) American handbook of psychiatry. New York: Basic Books, I966. Pp. 515-542. Hume, P. B. Searchlights on community psychiatry. Community Mental Health Journal, 1965, i, 2o9-12. Pattison, E. M., & Wagner, N. N. The relevance of psychiatry to anthropological training and research: an interdisciplinary program. University of Washington, 1967. Unpublished manuscript. Pattison, E. M. Psychiatry and anthropology: three models for a working relationship. University of Washington, I967 . Unpublished manuscript. Rogawski, A. S. Education for community psychiatry: its opportunities for personal and professional growth. Quarterly of CamarilIo, I966, 2 (2), 16-32. Rosenbaum, M., & Zwerling, I. Impact of social psychiatry. Archives of General Psychiatry, 2964, ii, 32-39 . Training the psychiatrist to meet changing needs. Report of Conference on Graduate Education, American Psychiatric Association, Washington, D. C., 1963. Whittington, H. G. The third psychiatric revolution--really? a consideration of principles and practices in community psychiatry. Community Mental Health Journal, i965 , I, 73-80. Yolles, S. F. Community mental health services: the view from i967. American Journal of Psychiatry, i967, 4, I24, supp. x-7.
