TEACHING MENTAL HEALTH A D M I N I S T R A T I O N TO PSYCHIATRIC RESIDENTS by E. Mansell Pattison
While there is a growing recognition of the administrative role for many psychiatrists, there has been little formalized training of psychiatrists for administration. Various training methods have been offered: special s h o r t t e r m p o s t g r a d u a t e c o u r s e s in administration, post-residency feIlowships in administrative psychiatry, an administrative preceptorship during residency, and lectures or seminars on administration in the residency curriculum (Pattison 1972). The role of the psychiatrist in the total picture of mental health manpower resources is changing, so that he is more likely to assume some administrative roles during his career (Pattison and Elpers 1972). Yet, a recent study presented data indicating that the psychiatrist is unfamiliar with and often ill-equipped to function in an administrative role (Pattison 1974). Therefore, in the department of psychiatry and human behavior, we have made social and community psychiatry a mandatory part of the basic residency curriculum. And we have built a major curriculum emphasis on mental health administration into the program. This
E. Mansell Pattison is Associate Professor and ViceChairman, Department of Psychiatry and Human Behavior, University of California, Irvine.
54
educational policy is based on the assumption that a modest introduction to the skills and knowledge of mental health administration should be part of the educational repertoire of every psychiatric resident. Those with special skills or interests may then elect more extensive administrative education on an individual elective basis.
Setting Second year psychiatric residents are assigned to social and community psychiatry for a one-half time block of six months. Six residents participate in this program at a time. The training is located within the Orange County Department of Mental Health, which has the responsibility for mental health services to a county of 1.6 million people. The county is divided into six regional catchment areas of approximately 250,000 population, with services provided by six regional teams. There are approximately 500 staff in the department with services that range from ambulatory care to transitional domicile care. Specialized services i n c l u d e c h i l d r e n , alcoholism, and drug abuse.
Assignment Each of the six psychiatric residents is
assigned to one of the six regional teams. The resident works in the regional team two days a week. Four hours a week are devoted to the didactic curriculum conducted at the central training offices. Participation in the activities of the regional team offers several different learning opportunities for the resident and his time is allocated proportionately to three major learning activities. Six hours per week are devoted to clinical experiences in the community setting. These include emergency calls, crisis intervention, brief therapy with individuals, couples, families, and groups, medication clinics, and diagnostic evaluations. The immediate openaccess services located in the community expose the resident to the actual impact of service capabilities, client demand, and community need. Four hours per week are devoted to the second major learning activity, mental health consultation to community agencies. The resident is exposed to the interactions between the mental health program and other community systems and programs as they actually operate. In addition, he is learning consultation skills. The resident also serves as psychiatric consultant to non-medical and paraprofessional staffon the regional team. He is thus exposed to staff interaction and the operational issues of a multidisciplinary mental health program. Six hours per week are devoted to activities relating to a d m i n i s t r a t i v e skills and knowledge. The resident has the opportunity to accompany and observe the mental health professional who is the team administrator. Often this administrator assumes a preceptor role with the resident. In addition, the resident attends staff meetings, program planning sessions, budget sessions, and staff training and staff development seminars. This time is also used to conduct the various interviews and data collection necessary for his didactic reports. In summary, we place the resident in a field experience where he not only has a clinical
experience but can observe and participate in the activities of mental health administration. This field experience also provides the data base for the more formal didactic teaching of mental health administration.
A Systems Orientation to Education The orientation of our program is based on social system theory. Sometimes called general systems theory, in the field of human behavior it is often termed "social system theory" to differentiate it from the related mathematical cybernetic formulations used in engineering. Social systems theory is more than an interdisciplinary orientation. Rather, it is a general view of human behavior. It views human behavior as t h e r e s u l t o f interdependent factors, biological, psychological, social, and cultural, interacting to produce observable behavior. This view avoids reductionism to one variable. Further, each v a r i a b l e is i n t e r d e p e n d e n t and interactive. Behavior is seen as "open-ended" and dependent upon the given state of the social system at a specific time. This view can be taken of an individual, a small group, an organization, a community, a culture. Furthermore, according to the principle of "isomorphism," the interdependent and reciprocal interaction of each variable is represented in the behavior of an individual or of an organization. Thus, the study of an individual will reflect the behavior of the group, organization, community, and vice-versa. We have adopted this theoretical orientation because it provides a framework within which the psychiatric resident can study individual behavior and construct linkages to group, community, and society. In this way, we avoid compartmentalizing the study of individual, group, community, and society as separate and distinct entities. Rather, they are seen as interdependent sub-systems of the larger social system. 55
Didactic Assignments The didactic curriculum is interdigitated with the field experience so that the formal teaching provides a framework for the resident to conceptualize what he observes in the field. His field data in turn is used to illustrate general principles. The didactic program is composed of seven elements including lectures, consultation, seminars, and field trips. It utilizes several approaches to teaching with strong emphasis on resident participation. Only one-third of the time is devoted to formal lectures, while the majority of the teaching sessions consist of student presentations. The didactic curriculum is organized around social systems theroy and concepts. Thus "system thinking" is reflected in the total organization of the curriculum and in each s u b - c o m p o n e n t . We begin with an introduction to the history of social psychiatry and the development of systems concepts. Then systems analysis methods are introduced and the students conduct a series of systems analysis studies. Finally we conduct separate studies of various community sub-systems. In each instance, we use several different teaching methods to examine a sub-system. For example, in our study of the welfare system, there is a lecture on this system, then a field trip to welfare agencies, and than a student symposium. There is a two week orientation in which there is a program of introduction to the mental health system. The resident thus learns about the concept of systems by looking at the mental health system in which he will work. The basic theories and concepts are also presented during the orientation. Then each subsequent topic is introduced when the resident is ready to use that knowledge in his field work. The topics include concepts of social psychiatry and social systems, social systems methodology, and sub-systems of human services. 56
The consultation seminar is the second aspect of the didactic curriculum. Basic supervision of consultation is provided in the field with a preceptor. The principles of consultation are introduced at the beginning of the course. In subsequent seminars, the residents review the principles and issues involved in consultation from the standpoint of organizational structure, organizational intervention, and the social system locus of the specific consultee organizations. Thus the consultation experience is used to provide case studies of the relationships between organizations and different social sub-systems of the community. Field trips, the third component in the didactic curriculum, serve as a method for gaining observational data on a specific subsystem. Emphasis is placed on student c o m p r e h e n s i o n of the organizational structure, function, philosophy, and ideology of each agency visited. In the systems symposia, each resident is responsible for the organization of a symposium around a specific community subsystem. These symposia usually include a panel of four to six representatives from the community representing different points of view. The student is responsible for the following: I. A review of the pertinent sub-system literature. 2. Making contacts in the community to locate resource persons in the subsystem. 3. Formulating specific issues in regard to the operation of the sub-system. 4. Conducting the symposium. This exercise is aimed at teaching the resident how to identify key resource people, to evaluate the functions of sub-systems, to elicit operational information from resource persons that can be compared with theoretical information, and to learn how to assess the information gained from resource persons. The student systems analyses, the final phase
of the curriculum, consists of three major analytic reports that each student must prepare and present during the course. Each report is based on actual field data collected by the student in his own mental health catchment area. The first report, Analysis of Community Organization, is an exercise in mental health demography and epidemiology. The student learns how to gather and analyze data as well as use it for planning mental health services. This report is submitted at the end of two months. The second report, Analysis of Service Organization, is an exercise in organizational analysis. Both the manifest and latent aspects of organizational structure are examined, based on actual observation of the regional mental health team. The quality of the delivery system is also examined in terms of the population needs defined in the first report. This is due the third month. The third report, Program Planning Analysis, is an exercise in synthetic thinking and program conceptualization, using a systems approach to planning strategies, It includes the selection of a target population, evaluating its unmet needs, and proposing a model community mental health program. Examples of target areas on which reports have been written include teen age pregnant women, retirement colonies, men with temporary work disability, ex-felons released from jail, rape victims, a d o l e s c e n t d r u g abusers, the maltreated child, and the Viet Nam veteran. Thus the residents demonstrate ingenuity in applying the principles of social psychiatry to many target populations that might not receive attention from traditional community psychiatry services.
Discussion We attempt to provide the psychiatric resident with appropriate experience, role models, theoretical concepts, and actual practical learning exercises so that he has an
awareness of the concepts and procedures involved in mental health administration. We do not aim to achieve technical proficiency in administrative skills. Our hope is to achieve familiarity and recognition of the role tasks, skills, and knowledge associated with effective mental health administration. From our point of view, mental health administration is not a narrow activity of business management. Rather, we see it as an exercise in social systems analysis and social systems management. Therefore, we cast our training in mental health administration within a larger conceptual framework of social systems thought. We attempt to consistently interweave the field observations and work of the resident with the theoretical and didactic instruction. First, we aim to teach mental health delivery where he can observe the administrative process in action. Second, the resident is presented with a social systems conceptual framework within which to interpret his field observations and work experience. Third, he is prepared for and conducts his own systems analysis of the community served by his regional mental health team. Fourth, he is prepared for and conducts his own analysis of the mental health services organization in which he is working. Fifth, the resident participates in the analysis of each major subsystem of the community human services complex as related to mental health services. Sixth, the resident concludes his curriculum experience with an intensive report on a model program plan for mental health services to a specific target population. The curriculum is organized in a sequential pattern as indicated in Table 1. Thus, the resident moves from familiar clinical terrain, to the application of systems concepts to his own system, and finally to the generalization of systems concepts to the analysis and development of systems plans. Little stress is placed on the technical details of management and administration. These vary with time and circumstance. Likewise we place little 57,
Table 1 CURRICULUM SEQUENCE Learning Activity
Week 1-2 3-8
9 10-12 13 14-24
24-26
Orientation Concepts of social psychiatry Begin consultation Begin field clinical work Concepts of social systems Collect data for community analysis Consultation seminar Present analysis of community organization Social systems methodology Collect data for organizational analysis Consultation seminar Present analysis of service organization Examination of community sub-systems (lectures, field trips, symposia) Collect data for program analysis Consultation seminar Presentation of program planning analyses
emphasis on the formal theoretical aspects of organizational and managerial theory. Such material is too abstract for the young clinician psychiatrist to rapidly assimilate and apply. In the process of the several report preparations, the resident must conduct a review of the pertinent literature. He is provided with a bibliography on mental health administration. In addition, he must review the clinical literature. In this way, he juxtaposes the clinical and the administrative. We also provide specific reprint reading assignments pertinent to understanding the application of administrative principles. We do capitalize on the actual working processes of administration by exposing the resident to staff meetings, planning and budget sessions, policy sessions, etc. He also engages in the process of community consultation and 58
gains experience in assessing the ac organizational and service delivery syster both mental health and other human serv How effective is this educational progr Unfortunately we do not have any pr~ answers at this point although longituc research is underway. A few prelimit comments can be made. We find that tw, three residents each year elect to take fur work in the administrative aspects psychiatry during their third year. In addit the regular evaluations submitted by residents indicate high satisfaction with learning process and the quality of rep developed and presented in the course has b generally high. A number of them have b actually used for administrative purposes b within the department of mental health other community programs.
Summary Methods for teaching mental health administration within the framework of the regular psychiatric residency are described. The basic principles of social systems analysis and social systems management are the framework for both the field experience and the didactic curriculum. Emphasis is placed on student participation in the teaching process. The student engages in multiple exercises within the actual working processes of mental health administration. In essence, we attempt to teach mental health administration by providing learning experiences where the student performs the tasks and engages in the conceptual work that form the basis for social systems management.
REFERENCES Pattison, E.M. Residency training issues in community psychiatry. American Journal of Psychiatry, 128: 1097-1102, 1972. Pattison, E.M. and Elpers, J.R. A developmental view of mental health manpower trends. Hospital and Community Psychiatry, 23: 325328, 1972. Pattison, E.M. Young psychiatrist administrators. American Journal of Psychiatry, 131: 154-159, 1974.
ADMINISTRATION IN MENTAL HEALTH
59
While there is a growing recognition of the administrative role for many psychiatrists, there has been little formalized training of psychiatrists for administration. Various training methods have been offered: special s h o r t t e r m p o s t g r a d u a t e c o u r s e s in administration, post-residency feIlowships in administrative psychiatry, an administrative preceptorship during residency, and lectures or seminars on administration in the residency curriculum (Pattison 1972). The role of the psychiatrist in the total picture of mental health manpower resources is changing, so that he is more likely to assume some administrative roles during his career (Pattison and Elpers 1972). Yet, a recent study presented data indicating that the psychiatrist is unfamiliar with and often ill-equipped to function in an administrative role (Pattison 1974). Therefore, in the department of psychiatry and human behavior, we have made social and community psychiatry a mandatory part of the basic residency curriculum. And we have built a major curriculum emphasis on mental health administration into the program. This
E. Mansell Pattison is Associate Professor and ViceChairman, Department of Psychiatry and Human Behavior, University of California, Irvine.
54
educational policy is based on the assumption that a modest introduction to the skills and knowledge of mental health administration should be part of the educational repertoire of every psychiatric resident. Those with special skills or interests may then elect more extensive administrative education on an individual elective basis.
Setting Second year psychiatric residents are assigned to social and community psychiatry for a one-half time block of six months. Six residents participate in this program at a time. The training is located within the Orange County Department of Mental Health, which has the responsibility for mental health services to a county of 1.6 million people. The county is divided into six regional catchment areas of approximately 250,000 population, with services provided by six regional teams. There are approximately 500 staff in the department with services that range from ambulatory care to transitional domicile care. Specialized services i n c l u d e c h i l d r e n , alcoholism, and drug abuse.
Assignment Each of the six psychiatric residents is
assigned to one of the six regional teams. The resident works in the regional team two days a week. Four hours a week are devoted to the didactic curriculum conducted at the central training offices. Participation in the activities of the regional team offers several different learning opportunities for the resident and his time is allocated proportionately to three major learning activities. Six hours per week are devoted to clinical experiences in the community setting. These include emergency calls, crisis intervention, brief therapy with individuals, couples, families, and groups, medication clinics, and diagnostic evaluations. The immediate openaccess services located in the community expose the resident to the actual impact of service capabilities, client demand, and community need. Four hours per week are devoted to the second major learning activity, mental health consultation to community agencies. The resident is exposed to the interactions between the mental health program and other community systems and programs as they actually operate. In addition, he is learning consultation skills. The resident also serves as psychiatric consultant to non-medical and paraprofessional staffon the regional team. He is thus exposed to staff interaction and the operational issues of a multidisciplinary mental health program. Six hours per week are devoted to activities relating to a d m i n i s t r a t i v e skills and knowledge. The resident has the opportunity to accompany and observe the mental health professional who is the team administrator. Often this administrator assumes a preceptor role with the resident. In addition, the resident attends staff meetings, program planning sessions, budget sessions, and staff training and staff development seminars. This time is also used to conduct the various interviews and data collection necessary for his didactic reports. In summary, we place the resident in a field experience where he not only has a clinical
experience but can observe and participate in the activities of mental health administration. This field experience also provides the data base for the more formal didactic teaching of mental health administration.
A Systems Orientation to Education The orientation of our program is based on social system theory. Sometimes called general systems theory, in the field of human behavior it is often termed "social system theory" to differentiate it from the related mathematical cybernetic formulations used in engineering. Social systems theory is more than an interdisciplinary orientation. Rather, it is a general view of human behavior. It views human behavior as t h e r e s u l t o f interdependent factors, biological, psychological, social, and cultural, interacting to produce observable behavior. This view avoids reductionism to one variable. Further, each v a r i a b l e is i n t e r d e p e n d e n t and interactive. Behavior is seen as "open-ended" and dependent upon the given state of the social system at a specific time. This view can be taken of an individual, a small group, an organization, a community, a culture. Furthermore, according to the principle of "isomorphism," the interdependent and reciprocal interaction of each variable is represented in the behavior of an individual or of an organization. Thus, the study of an individual will reflect the behavior of the group, organization, community, and vice-versa. We have adopted this theoretical orientation because it provides a framework within which the psychiatric resident can study individual behavior and construct linkages to group, community, and society. In this way, we avoid compartmentalizing the study of individual, group, community, and society as separate and distinct entities. Rather, they are seen as interdependent sub-systems of the larger social system. 55
Didactic Assignments The didactic curriculum is interdigitated with the field experience so that the formal teaching provides a framework for the resident to conceptualize what he observes in the field. His field data in turn is used to illustrate general principles. The didactic program is composed of seven elements including lectures, consultation, seminars, and field trips. It utilizes several approaches to teaching with strong emphasis on resident participation. Only one-third of the time is devoted to formal lectures, while the majority of the teaching sessions consist of student presentations. The didactic curriculum is organized around social systems theroy and concepts. Thus "system thinking" is reflected in the total organization of the curriculum and in each s u b - c o m p o n e n t . We begin with an introduction to the history of social psychiatry and the development of systems concepts. Then systems analysis methods are introduced and the students conduct a series of systems analysis studies. Finally we conduct separate studies of various community sub-systems. In each instance, we use several different teaching methods to examine a sub-system. For example, in our study of the welfare system, there is a lecture on this system, then a field trip to welfare agencies, and than a student symposium. There is a two week orientation in which there is a program of introduction to the mental health system. The resident thus learns about the concept of systems by looking at the mental health system in which he will work. The basic theories and concepts are also presented during the orientation. Then each subsequent topic is introduced when the resident is ready to use that knowledge in his field work. The topics include concepts of social psychiatry and social systems, social systems methodology, and sub-systems of human services. 56
The consultation seminar is the second aspect of the didactic curriculum. Basic supervision of consultation is provided in the field with a preceptor. The principles of consultation are introduced at the beginning of the course. In subsequent seminars, the residents review the principles and issues involved in consultation from the standpoint of organizational structure, organizational intervention, and the social system locus of the specific consultee organizations. Thus the consultation experience is used to provide case studies of the relationships between organizations and different social sub-systems of the community. Field trips, the third component in the didactic curriculum, serve as a method for gaining observational data on a specific subsystem. Emphasis is placed on student c o m p r e h e n s i o n of the organizational structure, function, philosophy, and ideology of each agency visited. In the systems symposia, each resident is responsible for the organization of a symposium around a specific community subsystem. These symposia usually include a panel of four to six representatives from the community representing different points of view. The student is responsible for the following: I. A review of the pertinent sub-system literature. 2. Making contacts in the community to locate resource persons in the subsystem. 3. Formulating specific issues in regard to the operation of the sub-system. 4. Conducting the symposium. This exercise is aimed at teaching the resident how to identify key resource people, to evaluate the functions of sub-systems, to elicit operational information from resource persons that can be compared with theoretical information, and to learn how to assess the information gained from resource persons. The student systems analyses, the final phase
of the curriculum, consists of three major analytic reports that each student must prepare and present during the course. Each report is based on actual field data collected by the student in his own mental health catchment area. The first report, Analysis of Community Organization, is an exercise in mental health demography and epidemiology. The student learns how to gather and analyze data as well as use it for planning mental health services. This report is submitted at the end of two months. The second report, Analysis of Service Organization, is an exercise in organizational analysis. Both the manifest and latent aspects of organizational structure are examined, based on actual observation of the regional mental health team. The quality of the delivery system is also examined in terms of the population needs defined in the first report. This is due the third month. The third report, Program Planning Analysis, is an exercise in synthetic thinking and program conceptualization, using a systems approach to planning strategies, It includes the selection of a target population, evaluating its unmet needs, and proposing a model community mental health program. Examples of target areas on which reports have been written include teen age pregnant women, retirement colonies, men with temporary work disability, ex-felons released from jail, rape victims, a d o l e s c e n t d r u g abusers, the maltreated child, and the Viet Nam veteran. Thus the residents demonstrate ingenuity in applying the principles of social psychiatry to many target populations that might not receive attention from traditional community psychiatry services.
Discussion We attempt to provide the psychiatric resident with appropriate experience, role models, theoretical concepts, and actual practical learning exercises so that he has an
awareness of the concepts and procedures involved in mental health administration. We do not aim to achieve technical proficiency in administrative skills. Our hope is to achieve familiarity and recognition of the role tasks, skills, and knowledge associated with effective mental health administration. From our point of view, mental health administration is not a narrow activity of business management. Rather, we see it as an exercise in social systems analysis and social systems management. Therefore, we cast our training in mental health administration within a larger conceptual framework of social systems thought. We attempt to consistently interweave the field observations and work of the resident with the theoretical and didactic instruction. First, we aim to teach mental health delivery where he can observe the administrative process in action. Second, the resident is presented with a social systems conceptual framework within which to interpret his field observations and work experience. Third, he is prepared for and conducts his own systems analysis of the community served by his regional mental health team. Fourth, he is prepared for and conducts his own analysis of the mental health services organization in which he is working. Fifth, the resident participates in the analysis of each major subsystem of the community human services complex as related to mental health services. Sixth, the resident concludes his curriculum experience with an intensive report on a model program plan for mental health services to a specific target population. The curriculum is organized in a sequential pattern as indicated in Table 1. Thus, the resident moves from familiar clinical terrain, to the application of systems concepts to his own system, and finally to the generalization of systems concepts to the analysis and development of systems plans. Little stress is placed on the technical details of management and administration. These vary with time and circumstance. Likewise we place little 57,
Table 1 CURRICULUM SEQUENCE Learning Activity
Week 1-2 3-8
9 10-12 13 14-24
24-26
Orientation Concepts of social psychiatry Begin consultation Begin field clinical work Concepts of social systems Collect data for community analysis Consultation seminar Present analysis of community organization Social systems methodology Collect data for organizational analysis Consultation seminar Present analysis of service organization Examination of community sub-systems (lectures, field trips, symposia) Collect data for program analysis Consultation seminar Presentation of program planning analyses
emphasis on the formal theoretical aspects of organizational and managerial theory. Such material is too abstract for the young clinician psychiatrist to rapidly assimilate and apply. In the process of the several report preparations, the resident must conduct a review of the pertinent literature. He is provided with a bibliography on mental health administration. In addition, he must review the clinical literature. In this way, he juxtaposes the clinical and the administrative. We also provide specific reprint reading assignments pertinent to understanding the application of administrative principles. We do capitalize on the actual working processes of administration by exposing the resident to staff meetings, planning and budget sessions, policy sessions, etc. He also engages in the process of community consultation and 58
gains experience in assessing the ac organizational and service delivery syster both mental health and other human serv How effective is this educational progr Unfortunately we do not have any pr~ answers at this point although longituc research is underway. A few prelimit comments can be made. We find that tw, three residents each year elect to take fur work in the administrative aspects psychiatry during their third year. In addit the regular evaluations submitted by residents indicate high satisfaction with learning process and the quality of rep developed and presented in the course has b generally high. A number of them have b actually used for administrative purposes b within the department of mental health other community programs.
Summary Methods for teaching mental health administration within the framework of the regular psychiatric residency are described. The basic principles of social systems analysis and social systems management are the framework for both the field experience and the didactic curriculum. Emphasis is placed on student participation in the teaching process. The student engages in multiple exercises within the actual working processes of mental health administration. In essence, we attempt to teach mental health administration by providing learning experiences where the student performs the tasks and engages in the conceptual work that form the basis for social systems management.
REFERENCES Pattison, E.M. Residency training issues in community psychiatry. American Journal of Psychiatry, 128: 1097-1102, 1972. Pattison, E.M. and Elpers, J.R. A developmental view of mental health manpower trends. Hospital and Community Psychiatry, 23: 325328, 1972. Pattison, E.M. Young psychiatrist administrators. American Journal of Psychiatry, 131: 154-159, 1974.
ADMINISTRATION IN MENTAL HEALTH
59
