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weaknesses of individual supervisors and to thereby ensure that all residents receive adequate supervision. Drs. Matthews and Terrell correctly note that I did not discuss the opinions of the administrative supervisor who was ultimately responsible for the care of the patient under discussion. This administrative supervisor played a very passive role and supported my overall approach to the patient. The major portion of Drs. Matthews' and Terrell's letterconcerns my "underlying assumption that supervisors must agree on major, and perhaps minor, points if the supervision is to be valued." They then illustrate their concerns by offering analogies of psychotherapists with orchestra conductors and baseball pitchers . I find these analogies particularly offensive; in fact, they underscore one of the major motivations behind my original article. Psychiatrists are doctors, not conductors or pitchers (not ministers or sorcerers, either), Our goal is to evaluate, diagnose, and then treat people with debilitating diseases of the brain, diseases that devastate their lives and those of their families and exact enormous costs on our society at large. If supervisors use different techniques, then we must know that the differing techniques are equally efficacious. If two psychiatrists use different medications to treat a brain disease, they are expected-by professional organizations, the FDA, and our legal system-to be able to defend their choice of treatment. The same degree of rigor should be applied to nonpharmacological psychotherapies. I agree with Drs. Matthews and Terrell that the success of supervision should be measured by a patient's improvement (although I am not sure that is what they mean by a "patient's progress") and by the resident's improved skill as a doctor in alleviating mental symptoms and increasing the level of functioning of the patient (although I am not sure that is what they mean by a "resident's growth"). Contrary to their sug\l \1)1 \11( 1''-,'" 11I \ I R'l
i I i 1 I< "
gestion, the details of the path by which psychotherapy attenuates the symptoms of a brain disease is of fundamental importance. The role that psychotherapy can play in helping a patient improve, and therefore its role in residency education, can only be addressed by subjecting the myriad "psychotherapies" (e.g., cognitive, behavioral, crisis, dynamic, individual, group, and family) to the highest levels of scrutiny. Onlyon the basis of such information will we be able to determine the proper place of specific psychotherapeutic modalities in the treatment of brain diseases and in psychiatric residency education. Erlc]. Nestler, M.O., Ph.O. Yale University, New Haven, CT
References 1. Nestler EJ: The case of double supervision: a resident's perspective on common problems in psychotherapy supervision. Academic Psychiatry 1990; 14:129-136
Community Psychiatry Training SIR: In a well-meaning attempt to decrease the number of questionnaires we all receive (e.g., "It will only take you several minutes to provide us information on the number of grand rounds your residents have attended dealing with cognitive therapy over the past decade along with specific comments of supervisors in the 6-month period following such exposure that indicate the impact of the grand rounds on each resident's performance."), I would like to suggest instead that we utilize Academic Psychiatry as a forum to exchange ideas and data and to raise questions. My residency was at the University of Michigan in the late 19605. Community psychiatry was at its pinnacle. Ann Arbor was a hotbed of innovations, and I went on to get a Masters of Public Health degree in community mental health. We all know what has 1 -';
happened to community psychiatry, and we all have participated in the burgeoning biological movement with its emphasis on inpatient and in-hospital consultation psychiatry. The question I raise in this letter is, "What community mental health activities, if any, should be required in psychiatrie residency training?" The Accreditation Council for Graduate Medical Education (ACGME) requirements note that residents must demonstrate "competence in psychiatrie consultation in a variety of medical, surgical, and community settings" and that their clinical experience must indude "supervised responsibility in community mental health activities. This should indude consultation with at least one community agency and experience in forensie or court evaluations under the supervision of a psychiatrist." When visiting programs, I often ask residents about their community experience. Most commonly, answers have fallen into two categories. One is participation in ethnic clinics (e.g., a 1- or 2-month rotation at a dinie for Hispanies or South-East Asians). The other is a rotation at a community mental health center (CMHC). When asked about their activities at a CMHC, the residents describe inpatient and outpatient work. I then ask, ''How does this differ from the inpatient and outpatient work at your university or VA hospital?" 'Well, it takes place at a CMHC," is the reply. In my program, training that is labeled community psychiatry consists of the fol-
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lowing: all PGY-3 residents spend half a day per week for an entire year consulting at a nonpsychiatric mental health agency such as vocational rehabilitation, family counseling, and shelter for abused women. Because our campus has over 20,000 students, who form their own community, we also utilize the university's counseling service and psychology clinic. Residents primarily do case consultation but also do some formal In-service training, participate in agency workshops, and attend board meetings. Each agency pays a modest fee for the residents' services. The program has been in place for 15 years, so clinical service chiefs accept the fact that a resident may be absent for half a day per week. In my opinion, community agency consultation is the primary, significant legacy of the community mental health movement. Residents seem to enjoy and to profit from the experience; patients (oopsl I mean clients) benefit from their consultation, especially when hospitalization can be facilitated; and the department benefits by having a visible presence in the community. I invite colleagues to communicate their thoughts on community psychiatry training requirements and to describe the ways in which their programs train residents in this area. Armando R. Favazza, M.D. University of Missouri-Columbia Columbia, Missouri
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weaknesses of individual supervisors and to thereby ensure that all residents receive adequate supervision. Drs. Matthews and Terrell correctly note that I did not discuss the opinions of the administrative supervisor who was ultimately responsible for the care of the patient under discussion. This administrative supervisor played a very passive role and supported my overall approach to the patient. The major portion of Drs. Matthews' and Terrell's letterconcerns my "underlying assumption that supervisors must agree on major, and perhaps minor, points if the supervision is to be valued." They then illustrate their concerns by offering analogies of psychotherapists with orchestra conductors and baseball pitchers . I find these analogies particularly offensive; in fact, they underscore one of the major motivations behind my original article. Psychiatrists are doctors, not conductors or pitchers (not ministers or sorcerers, either), Our goal is to evaluate, diagnose, and then treat people with debilitating diseases of the brain, diseases that devastate their lives and those of their families and exact enormous costs on our society at large. If supervisors use different techniques, then we must know that the differing techniques are equally efficacious. If two psychiatrists use different medications to treat a brain disease, they are expected-by professional organizations, the FDA, and our legal system-to be able to defend their choice of treatment. The same degree of rigor should be applied to nonpharmacological psychotherapies. I agree with Drs. Matthews and Terrell that the success of supervision should be measured by a patient's improvement (although I am not sure that is what they mean by a "patient's progress") and by the resident's improved skill as a doctor in alleviating mental symptoms and increasing the level of functioning of the patient (although I am not sure that is what they mean by a "resident's growth"). Contrary to their sug\l \1)1 \11( 1''-,'" 11I \ I R'l
i I i 1 I< "
gestion, the details of the path by which psychotherapy attenuates the symptoms of a brain disease is of fundamental importance. The role that psychotherapy can play in helping a patient improve, and therefore its role in residency education, can only be addressed by subjecting the myriad "psychotherapies" (e.g., cognitive, behavioral, crisis, dynamic, individual, group, and family) to the highest levels of scrutiny. Onlyon the basis of such information will we be able to determine the proper place of specific psychotherapeutic modalities in the treatment of brain diseases and in psychiatric residency education. Erlc]. Nestler, M.O., Ph.O. Yale University, New Haven, CT
References 1. Nestler EJ: The case of double supervision: a resident's perspective on common problems in psychotherapy supervision. Academic Psychiatry 1990; 14:129-136
Community Psychiatry Training SIR: In a well-meaning attempt to decrease the number of questionnaires we all receive (e.g., "It will only take you several minutes to provide us information on the number of grand rounds your residents have attended dealing with cognitive therapy over the past decade along with specific comments of supervisors in the 6-month period following such exposure that indicate the impact of the grand rounds on each resident's performance."), I would like to suggest instead that we utilize Academic Psychiatry as a forum to exchange ideas and data and to raise questions. My residency was at the University of Michigan in the late 19605. Community psychiatry was at its pinnacle. Ann Arbor was a hotbed of innovations, and I went on to get a Masters of Public Health degree in community mental health. We all know what has 1 -';
happened to community psychiatry, and we all have participated in the burgeoning biological movement with its emphasis on inpatient and in-hospital consultation psychiatry. The question I raise in this letter is, "What community mental health activities, if any, should be required in psychiatrie residency training?" The Accreditation Council for Graduate Medical Education (ACGME) requirements note that residents must demonstrate "competence in psychiatrie consultation in a variety of medical, surgical, and community settings" and that their clinical experience must indude "supervised responsibility in community mental health activities. This should indude consultation with at least one community agency and experience in forensie or court evaluations under the supervision of a psychiatrist." When visiting programs, I often ask residents about their community experience. Most commonly, answers have fallen into two categories. One is participation in ethnic clinics (e.g., a 1- or 2-month rotation at a dinie for Hispanies or South-East Asians). The other is a rotation at a community mental health center (CMHC). When asked about their activities at a CMHC, the residents describe inpatient and outpatient work. I then ask, ''How does this differ from the inpatient and outpatient work at your university or VA hospital?" 'Well, it takes place at a CMHC," is the reply. In my program, training that is labeled community psychiatry consists of the fol-
J
"
lowing: all PGY-3 residents spend half a day per week for an entire year consulting at a nonpsychiatric mental health agency such as vocational rehabilitation, family counseling, and shelter for abused women. Because our campus has over 20,000 students, who form their own community, we also utilize the university's counseling service and psychology clinic. Residents primarily do case consultation but also do some formal In-service training, participate in agency workshops, and attend board meetings. Each agency pays a modest fee for the residents' services. The program has been in place for 15 years, so clinical service chiefs accept the fact that a resident may be absent for half a day per week. In my opinion, community agency consultation is the primary, significant legacy of the community mental health movement. Residents seem to enjoy and to profit from the experience; patients (oopsl I mean clients) benefit from their consultation, especially when hospitalization can be facilitated; and the department benefits by having a visible presence in the community. I invite colleagues to communicate their thoughts on community psychiatry training requirements and to describe the ways in which their programs train residents in this area. Armando R. Favazza, M.D. University of Missouri-Columbia Columbia, Missouri
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