Community Ment Health J (2015) 51:383–384 DOI 10.1007/s10597-015-9878-0
OBSERVATION
Rebranding ‘‘Community Mental Health’’ Kenneth Minkoff1,2
Springer Science+Business Media New York 2015
What do we mean by ‘‘Community Mental Health’’; what does it mean to be a ‘‘Community Psychiatrist’’? One assumes these are easy questions to answer, but the responses are not as simple as they may seem. Let’s start with some simple history: Community mental health as a term originated over 50 years ago. Related to the work of seminal pioneers like Erich Lindemann, the term originally referred to addressing the mental health needs of an entire community, rather than just individual patients, and to engaging in community consultation that would leverage natural caregivers to respond to crises and promote community health. This concept was transformed by the Community Mental Health Center Act (1963), which led to the first wave of federally funded community mental health centers in the mid to late sixties and early seventies. Although many of these centers initially aspired to broad community missions, their development was heavily influenced by the de-institutionalization movement of the same time period, and the concept of community mental health evolved to include and focus on service in the community (as opposed to in the hospital or in the institution) for adults with chronic and severe mental illness and children with severe emotional served in the public sector. Finally, because the generativity of community mental health arose from several broad social movements (community focus and community organizing; publicly funded and organized mental health service delivery in catchment areas across the nation; the de-institutionalization and ‘‘liberation’’ of individuals who had & Kenneth Minkoff [email protected] 1
ZiaPartners, Inc., San Rafael, CA, USA
2
Department of Psychiatry, Harvard, Cambridge, MA, USA
been trapped in institutions for decades), community mental health and community psychiatry have long been associated with a ‘‘cutting edge’’ movement in response to the challenge of providing innovative services for those most in need and least able to pay. So what is community mental health; what does it mean to be a community psychiatrist? And perhaps the key issue: does this all mean the same thing now as it did 50 years ago? Some questions might help us determine a response: 1.
2.
3.
Is community mental health only about services in the community (location or setting)? OR Do we consider hospitals part of the community? And if so, do inpatient units constitute part of the community mental health system, and are inpatient psychiatrists actually community psychiatrists? What about jails and prisons, juvenile detention centers, and nursing homes? Are those institutions part of our community as well? Are people who work in those institutions part of the community mental health system? Is community mental health (or community psychiatry) only about services to those with serious mental illness or with serious emotional disturbances (type of patients served)? OR Are we now in an era where we are looking at the mental health needs of the entire population in any community, so that the impact of ALL mental health conditions on total population health is now a subject of great importance? Is community mental health (or community psychiatry) only about public sector services (payer source)? OR Are we now recognizing that the boundary between private and public funding is increasingly blurred (Medicaid MCOs are a major example), so that regardless of insurance type (or lack thereof), we have
123
384
4.
5.
6.
7.
Community Ment Health J (2015) 51:383–384
to think about managing limited resources to care for populations in need? Is community mental health (or community psychiatry) only about what happens in community mental health centers or related organizations (site location)? OR Are we finding those boundaries are blurring as well— as mental health services are provided in health centers, in child welfare programs, in juvenile justice programs, in schools, in brain injury programs, and so on—AND by private practitioners who are often finding a need to work, at least some of their time, in organized delivery systems? Is community mental health (or community psychiatry) only about mental health (diagnostic category)? OR Are we now addressing mental health and substance use disorders together (as ‘‘behavioral health’’) in an integrated manner, as we realize that co-occurring conditions are an expectation, not an exception? Are we increasingly addressing behavioral health and health conditions together in an integrated manner, particularly when associated with poorer outcomes and higher costs? If so, are health settings working with individuals with complex health conditions practicing community mental health? Are psychiatrists working with health centers and hospitals community psychiatrists? Is community mental health (or community psychiatry) about providing mental health and/or substance use disorder treatment services solely to seriously ill patients in need (engagement and treatment philosophy)? OR Is our whole philosophy shifting away from treating disorders to treating people who have disorders using recovery and resiliency based approaches to service delivery, from providing care to patients to working as partners, from community institutions to trauma informed care with an emphasis on equalizing power dynamics, from treatment to prevention, early intervention, and community consultation? And perhaps the most important question: Are we still on the ‘‘cutting edge’’? Are we still at the front end of the ‘‘movement’’? Are we attracting the most radical forward thinking elements in our field? (capacity for innovation) OR Are people more excited about other concepts, terms, and ideas like: primary health behavioral health integration? Triple Aim, population health, accountable care organizations? Recovery oriented systems and peer driven services? Trauma informed systems? Do present-day providers view community mental health and community psychiatry as last century ideas?
123
These are scary and challenging ideas to contemplate, but it is important that we do. For the past year or more, the American Association of Community Psychiatrists (AACP) has been facing this issue head on. As an organization, we strongly believe that the values, principles and knowledge that have informed a half century of working with very complex populations in very challenging systems are the foundation of the road that lies ahead as the entire health system and additional partner systems (e.g. criminal justice and child welfare) are coming to realize what we have known for a very long time—individuals and families with mental health and substance use needs are highly prevalent in all populations, and have significant impact on individual, family, and community health, as well as costs and outcomes in every possible domain. Behavioral health is a public health emergency with much more profound impact than almost anything else you can think of, yet it has been marginalized for years. We believe that the knowledge base of community mental health and community psychiatry can be the organizing force that takes us to the next level as a society, to address this challenge That’s all very well and good, but it doesn’t work if all we are is a legend in our own minds. That’s why we have started to take a serious look at who we are, what we do, what it means in the current world to use the terms community mental health and community psychiatrist. We are thinking that there may need to be better terms, better definitions, or possibly a complete rebranding, so that the knowledge base from the past is reconfigured into language for the future. We don’t know the answers, yet. At our last two strategic board retreats (most recently in February, 2015), however, these issues are front and center, and we are starting, slowly, to formulate our ideas. One of the key decisions we made as a Board is that we need to take the conversation wider. We want to involve all of our members (who are all journal subscribers) but also all of the other readers of the Journal as well. Let’s get all of the ideas flowing. Let’s open a dialogue…. We will be keeping this conversation and these ideas moving in each issue of the journal going forward through the course of the next few years. Please send your letters and ideas to the editor. Join AACP if you haven’t already. Attend the board meetings (which are held in conjunction with the APA Fall and Spring meetings). Contribute to discussion boards on our website and our list serve. This is an exciting time. As Eldridge Cleaver once said (and who remembers him any more?): ‘‘if you’re not part of the solution, you’re part of the problem.’’ Join the conversation.
OBSERVATION
Rebranding ‘‘Community Mental Health’’ Kenneth Minkoff1,2
Springer Science+Business Media New York 2015
What do we mean by ‘‘Community Mental Health’’; what does it mean to be a ‘‘Community Psychiatrist’’? One assumes these are easy questions to answer, but the responses are not as simple as they may seem. Let’s start with some simple history: Community mental health as a term originated over 50 years ago. Related to the work of seminal pioneers like Erich Lindemann, the term originally referred to addressing the mental health needs of an entire community, rather than just individual patients, and to engaging in community consultation that would leverage natural caregivers to respond to crises and promote community health. This concept was transformed by the Community Mental Health Center Act (1963), which led to the first wave of federally funded community mental health centers in the mid to late sixties and early seventies. Although many of these centers initially aspired to broad community missions, their development was heavily influenced by the de-institutionalization movement of the same time period, and the concept of community mental health evolved to include and focus on service in the community (as opposed to in the hospital or in the institution) for adults with chronic and severe mental illness and children with severe emotional served in the public sector. Finally, because the generativity of community mental health arose from several broad social movements (community focus and community organizing; publicly funded and organized mental health service delivery in catchment areas across the nation; the de-institutionalization and ‘‘liberation’’ of individuals who had & Kenneth Minkoff [email protected] 1
ZiaPartners, Inc., San Rafael, CA, USA
2
Department of Psychiatry, Harvard, Cambridge, MA, USA
been trapped in institutions for decades), community mental health and community psychiatry have long been associated with a ‘‘cutting edge’’ movement in response to the challenge of providing innovative services for those most in need and least able to pay. So what is community mental health; what does it mean to be a community psychiatrist? And perhaps the key issue: does this all mean the same thing now as it did 50 years ago? Some questions might help us determine a response: 1.
2.
3.
Is community mental health only about services in the community (location or setting)? OR Do we consider hospitals part of the community? And if so, do inpatient units constitute part of the community mental health system, and are inpatient psychiatrists actually community psychiatrists? What about jails and prisons, juvenile detention centers, and nursing homes? Are those institutions part of our community as well? Are people who work in those institutions part of the community mental health system? Is community mental health (or community psychiatry) only about services to those with serious mental illness or with serious emotional disturbances (type of patients served)? OR Are we now in an era where we are looking at the mental health needs of the entire population in any community, so that the impact of ALL mental health conditions on total population health is now a subject of great importance? Is community mental health (or community psychiatry) only about public sector services (payer source)? OR Are we now recognizing that the boundary between private and public funding is increasingly blurred (Medicaid MCOs are a major example), so that regardless of insurance type (or lack thereof), we have
123
384
4.
5.
6.
7.
Community Ment Health J (2015) 51:383–384
to think about managing limited resources to care for populations in need? Is community mental health (or community psychiatry) only about what happens in community mental health centers or related organizations (site location)? OR Are we finding those boundaries are blurring as well— as mental health services are provided in health centers, in child welfare programs, in juvenile justice programs, in schools, in brain injury programs, and so on—AND by private practitioners who are often finding a need to work, at least some of their time, in organized delivery systems? Is community mental health (or community psychiatry) only about mental health (diagnostic category)? OR Are we now addressing mental health and substance use disorders together (as ‘‘behavioral health’’) in an integrated manner, as we realize that co-occurring conditions are an expectation, not an exception? Are we increasingly addressing behavioral health and health conditions together in an integrated manner, particularly when associated with poorer outcomes and higher costs? If so, are health settings working with individuals with complex health conditions practicing community mental health? Are psychiatrists working with health centers and hospitals community psychiatrists? Is community mental health (or community psychiatry) about providing mental health and/or substance use disorder treatment services solely to seriously ill patients in need (engagement and treatment philosophy)? OR Is our whole philosophy shifting away from treating disorders to treating people who have disorders using recovery and resiliency based approaches to service delivery, from providing care to patients to working as partners, from community institutions to trauma informed care with an emphasis on equalizing power dynamics, from treatment to prevention, early intervention, and community consultation? And perhaps the most important question: Are we still on the ‘‘cutting edge’’? Are we still at the front end of the ‘‘movement’’? Are we attracting the most radical forward thinking elements in our field? (capacity for innovation) OR Are people more excited about other concepts, terms, and ideas like: primary health behavioral health integration? Triple Aim, population health, accountable care organizations? Recovery oriented systems and peer driven services? Trauma informed systems? Do present-day providers view community mental health and community psychiatry as last century ideas?
123
These are scary and challenging ideas to contemplate, but it is important that we do. For the past year or more, the American Association of Community Psychiatrists (AACP) has been facing this issue head on. As an organization, we strongly believe that the values, principles and knowledge that have informed a half century of working with very complex populations in very challenging systems are the foundation of the road that lies ahead as the entire health system and additional partner systems (e.g. criminal justice and child welfare) are coming to realize what we have known for a very long time—individuals and families with mental health and substance use needs are highly prevalent in all populations, and have significant impact on individual, family, and community health, as well as costs and outcomes in every possible domain. Behavioral health is a public health emergency with much more profound impact than almost anything else you can think of, yet it has been marginalized for years. We believe that the knowledge base of community mental health and community psychiatry can be the organizing force that takes us to the next level as a society, to address this challenge That’s all very well and good, but it doesn’t work if all we are is a legend in our own minds. That’s why we have started to take a serious look at who we are, what we do, what it means in the current world to use the terms community mental health and community psychiatrist. We are thinking that there may need to be better terms, better definitions, or possibly a complete rebranding, so that the knowledge base from the past is reconfigured into language for the future. We don’t know the answers, yet. At our last two strategic board retreats (most recently in February, 2015), however, these issues are front and center, and we are starting, slowly, to formulate our ideas. One of the key decisions we made as a Board is that we need to take the conversation wider. We want to involve all of our members (who are all journal subscribers) but also all of the other readers of the Journal as well. Let’s get all of the ideas flowing. Let’s open a dialogue…. We will be keeping this conversation and these ideas moving in each issue of the journal going forward through the course of the next few years. Please send your letters and ideas to the editor. Join AACP if you haven’t already. Attend the board meetings (which are held in conjunction with the APA Fall and Spring meetings). Contribute to discussion boards on our website and our list serve. This is an exciting time. As Eldridge Cleaver once said (and who remembers him any more?): ‘‘if you’re not part of the solution, you’re part of the problem.’’ Join the conversation.
