Toward In creased Psych iatri c Presence in Community Mental Health Centers ALLAN Director Southern Tucson,
BEIGEL, Arizona Arizona
STEVEN Director Division National Rockville,
JOHN Executive National Washington,
M.D. Mental
Health
SHARFSTEIN, of Mental Institute Maryland
C.
WOLFE,
Center
M.D.
Health Service Programs of Mental Health
PH.D.
Director Council of Community D.C.
Mental
Health
Centers
The presence of psychiatrists in community mental health centers has diminished in recent years, especially in centers that are non-hospital-based and that are located in rural or disadvantaged urban settings. The decrease in psychiatric leadership in the centers is particularly notable. Factors contributing to the trend include lower salaries than in the private sector, a decrease in the number of patients with severe mental disorders coming to the centers, and the impact of a decrease in specialized training programs in community psychiatry. The authors suggest several incentives to increase psychiatric presence in the centers, including developing staffing standards as a condition offunding giving psychiatrists time to do research and evaluation and to teach, and increasing the medical involvement of centers through links with general hospitals, private psychiattic hospitals, and medical schools. #{149} Recently considerable attention has been given to the diminishing presence of psychiatrists in communitybased mental health centers. That development requires careful analysis, since it can have important ramifications for the future viability of public mental Dr. Beigel also is professor of psychiatry at the University of Arizona College of Medicine. His mailing address is 1930 East 6th Street, Tucson, Arizona 85719. The opinions expressed here are the authors’ and do not reflect the official policy of the National Institute of Mental Health or the National Council of Community Mental Health Centers.
health care (1-7). Specifically, as progress is made toward including coverage for mental illness in national health insurance, it is likely that the nature of the psychiatrist’s role will be important in determining whether payment for services will be available. The initiatives recommended by the President’s Commission on Mental Health suggest that publicly sponsored community-based mental health programs will remain an important component of our mental health service delivery system (8). The commission’s intent that programs initiated with new resources should be directed toward addressing the treatment of seriously mentally ill persons, and not toward social change, will require psychiatrists’ involvement. Further, the considerable conflict that has existed between psychiatrists and other mental health professionals about the definition of their roles has created a climate in which the multidisciplinary orientation of many CMHCs is seriously threatened (9,10). For all of these reasons, it is important to assess objectively the current role of psychiatrists in CMHCs and to define clearly how their status has changed in recent years. After specifying the nature of the changes, we will discuss the factors that have contributed to the trends and will describe strategies that could ensure an appropriate, well-defined, and central role for psychiatry in community mental health service delivery.
DESCRIPTION
OF
THE
PROBLEM
The presence of full-time-equivalent psychiatrists in CMHCs has decreased during this decade. (A full-timeequivalent position equals 35 or more hours a week in a CMHC. Figures in this section represent both full-time and part-time psychiatrists.) The nature of this change is complex, however, and requires analysis. For example, while the number of full-time-equivalent psychiatrists in CMHCs dropped from 6.8 to 4.3 between 1970 and 1977, the principal portion of the decrease occurred between 1970 and 1973, when the number went from 6.8 to 4.5. Furthermore, the centers program has been expanding since 1973, and there has been an increase of 45 per cent in the absolute number of fulltime-equivalent psychiatrists (11). Since 1973 the decrease has been relatively in-
VOLUME
30 NUMBER
11 NOVEMBER
1979
763
nent, significant-4.5 to 4.3-but there has been a corollary increase in the total number of patient care staff, from 62.5 to 75.3. Therefore, while the decrease in the absolute number of full-time-equivalent psychiatrists has been small, the difference is more significant when compared with the 20-per-cent increase in total patient care staff during this same time period (1 1). The decrease in psychiatric presence has not been uniform throughout all centers; it has been greater in centers started since 1973 than in those started before 1970. Centers that are hospital-based have almost twice as many psychiatrists as centers that are hospital-affiliated, and they are above the national norm. Rural centers have fewer full-time-equivalent psychiatrists than urban centers and contribute significantly to the decreased presence of full-time-equivalent psychiatrists in CMHCs (11). Further evidence for the decreasing impact of psychiatrists in CMHCs can be found in comparisons of their presence with that of other mental health professionals. While there has been an increase in the percentage of psychiatrists who work in CMHCs, from 12.2 per cent in 1972 to 14.9 per cent in 1976, the increase is small compared with the percentage of all mental health professionals who work in CMHCs. During the same time period, this percentage increased from 6.6 to 1 1.5 per cent (1 1). The decrease in the average number of full-timeequivalent psychiatrists in all CMHCs has been predominantly a result of a significant decrease in the average number of full-time psychiatrists per center. That decrease would have been significantly greater were it not for a corresponding increase in the number of parttime psychiatrists (those working less than 35 hours per week in the center). In addition to the 1227 psychiatrists who were working full time in CMHCs in 1976, there were 251 1 psychiatrists employed on a part-time basis (1 1). The increasing participation of the part-time psychiatrist contrasts with a diminished use of parttime psychologists, social workers, and registered nurses in CMHCs. While the data regarding the presence of psychiatrists in CMHCs are somewhat ambiguous because of the differences in comparing absolute numbers with relative numbers and averages, there is no question that there has been a major decrease in the role of psychiatrists in providing leadership in CMHCs. In 1971 about 55 per cent of center directors were psychiatrists. By 1977 the percentage had decreased to 26. The decrease has been offset by sharp increases during the same time period in center directors with backgrounds in social work, from 17 to 33 per cent, and administration, from 3 to 12 per cent (12). Furthermore, those psychiatrists who served in a CMHC leadership capacity in 1977 were overly concentrated in metropolitan and high-income catchment areas. The increasing number of centers in nonmetropolitan and low-income catchment areas since 1971, where nonpsychiatric leadership has been promi-
764
HOSPITAL
& COMMUNITY
PSYCHIATRY
has
percentage
SOME
contributed of center
UNDERLYING
to
this
directors
marked who
are
decrease
in
the
psychiatrists.
ISSUES
The decreased participation of psychiatrists in community mental health centers is the result of several factors, including economics, changing patterns of centers, and changing patient characteristics. Economics. Economic issues have played an important role in the relative decrease of psychiatric participation in CMHCs. On the average, psychiatrists who work in CMHCs make lower salaries than those in the private sector. In contrast to other mental health professionals, psychiatrists are more accustomed to working on a fee-for-service basis and possibly less willing to accept the salaried conditions that accompany CMHC employment. From the perspective of the CMHC, psychiatrists are the “most expensive” professionals. As CMHCs find themselves pressured by increased service demands and fiscal constraints, they move toward the employment of “less expensive” professionals to serve their catchment area in order to stay within the budget. Role definition. The specific role of the psychiatrist as the only mental health professional capable of assessing medication need and writing prescriptions, when viewed in the context of the relative decrease in the average number of full-time-equivalent psychiatrists, has led to a narrower focus of the role. For many psychiatrists, that focus has been a dissatisfying experience and has been counter to the expectations of the role of a community psychiatrist received during training. Psychiatrists interested in working in the community anticipated that their role would embrace a wider area of responsibility than medication prescription, and would include diagnostic assessment, leadership in treatment planning, supervision, and consultation. The necessary reliance of the CMHC on psychiatrists for medication prescription, when coupled with the economic constraints described above, has led to a decrease in their responsibilities in other areas of community psychiatry. Disenchanted and dismayed by this turn of events, many psychiatrists chose to leave CMHCs. Changing pattern of CMHCs. In some respects, the relative decrease in the presence of psychiatrists in CMHCs is a statistical artifact created by the trends in governance and administrative organization of new CMHCs. During the past eight years, fewer hospitalbased CMHCs have been funded, and that has led to an over-all decreased medical presence in CMHCs. Rules and regulations of the federal program, including community board requirements, have made it difficult for hospitals to maintain administrative control over CMHCs they have sponsored and have discouraged other hospitals from applying to enter the CMHC program. Changing patient characteristics. Recent data suggest that fewer patients with severe mental disorders are
being seen in CMHCs (13,14). It is not clear whether this phenomenon is a consequence or a cause of the decreasing psychiatric presence in CMHCs, or whether it is a statistical artifact. It is also possible that the relative lack of psychiatrists and the increasing social orientation of other mental health professionals results in a reluctance to assign diagnoses of more severe mental illness to patients. Also, it may be that patients, perceiving the relative lack of psychiatric involvement in CMHCs, are going elsewhere, principally to general hospitals with psychiatric programs. Training. During the early years of the CMHC program, considerable financial support for training in community psychiatry was available from the federal government. Numerous postgraduate fellowships were created, and many psychiatrists benefited from the training and entered CMHCs. In recent years, decreased federal training funds and changing priorities have led to the closing of some of these specialized training programs. The availability of psychiatric trainees to CMHCs has decreased in proportion to the availability of trainees in other mental health professions. In such a climate psychiatrists, concerned about role definition, become uncertain of their status and may choose not to work in centers (13). SHARPENING
THE
DEBATE
In our view, it is important to devise and implement strategies to increase the psychiatric presence in community mental health centers. However, there are those who argue for minimal psychiatric presence and who do not view the diminishing psychiatric participation with alarm. Their position must be taken into account in any future planning for increasing psychiatric presence. Those arguing for minimal psychiatric presence point out that increasing psychiatric involvement will require economic incentives, particularly to attract psychiatrists into disadvantaged urban areas and rural settings. Such economic incentives will increase the over-all cost of CMHCs, thereby diminishing one of their major advantages in the competitive marketplace, which is their relatively “cheaper” costs for services compared with the private sector. (We are aware of studies that have purported to show that the cost of services within CMHCs is more expensive than in the private sector. However, proponents of this viewpoint usually fail to take into account the comprehensive range of services provided by CMHCs and the administrative overhead that is necessary to deliver these diversified programs. When these costs are then shared among all services, the cost for individual services escalates, making it appear that the unit cost of some services-for example, outpatient treatment-is comparable to or more than the private sector. The costs per episode of care are less, however, since the average number of visits to CMHCs are far fewer than in the private sector [15].)
Data indicate that the diminishing psychiatric presence within CMHCs is most notable in areas of low socioeconomic conditions and high minority concentration. Since psychiatric residency programs are graduating relatively few minority psychiatrists, those who argue for a limited psychiatric presence point out that, even if more psychiatrists were available, their interest in working in areas of high socioeconomic status and their low minority representation would not fit with programs in these areas of greatest need. The employment of minority psychiatrists by these CMHCs would decrease the accessibility, acceptability, and appropriateness of care for the target population served. Finally, those arguing for minimal psychiatric presence point out that psychiatrists generally receive training oriented toward individual therapy, and that they lack interest in and preparation for other treatment modalities that cost less and are vitally needed within CMHCs. Consequently, an increase in their presence would lead to higher costs of programs because psychiatrists will rely on traditional, more costly treatment modalities rather than on the more innovative and less costly modalities initiated by CMHCs. We do not feel these reasons are sufficient justification for the continuation of a diminishing psychiatric presence within CMHCs. Rather, they point out problems within the system and within psychiatry that need to be addressed. Furthermore, there are important reasons that argue for increasing psychiatric presence within CMHCs and that outweigh any arguments to the contrary. First, recent data seem to suggest that many CMHCs have increased their emphasis on providing care to individuals with less severe mental disorders rather than to those with more severe disorders (14). It is immaterial whether that is a result of the diminishing psychiatnc involvement or other factors, such as increased acceptability of community mental health programs and mental health care. It is important to recognize that if community-based programs are to fulfill their current mandate to offer less restrictive alternatives for more seriously mentally ill persons, quality psychiatric care must be available within CMHCs. The availability of an increased number of psychiatrists will improve utilization by and quality of care for the severely mentally disabled because the psychiatrist is uniquely qualified to provide comprehensive evaluation of individuals with mental disorders, including assessment of the relationship between their physical state and their mental state. The psychiatrist also ensures comprehensive treatment planning, which takes into account biological as well as psychological and social considerations (16). A strong medical presence is also necessary if CMHCs are to be accepted by third-party reimbursers as components of the health care delivery system. Despite arguments by other groups of mental health professionals that third-party reimbursement should be geared toward the nature of the illness rather than the
VOLUME
30 NUMBER
11 NOVEMBER
1979
765
provider of care, both public and private fiscal intermediaries continue to recognize the critical role of the physician, including the psychiatrist, in any health care delivery, and they require that that presence be central to the delivery of care if third-party reimbursement is to be provided. Finally, there is considerable emphasis on increasing the linkage of mental health programs to components of the health care delivery systems (17). Although many emotionally disturbed individuals receive specialized care within mental health programs, the majority of those with emotional disturbance continue to seek and receive care within the general health care delivery systern (8). Consequently, if CMHCs are to have an impact on over-all mental health care, they must increase linkages with the general health care system. The psychiatrist is necessary in achieving this linkage. For these reasons, we feel that increasing the psychiatric presence in CMHCs and ensuring an appropriate role for psychiatrists in the delivery of services is critical to the future success of CMHCs. However, this goal cannot be achieved without some significant redirections in current programs and strategies.
REDIRECTING
PROGRAMS
AND
STRATEGIES
Requirements and incentives that will encourage an increased psychiatric involvement must be built into the CMHC program. The incentives could include the development of staffing standards for CMHCs as a condition of funding. The standards could include appropriate ratios of psychiatrists to the other clinical staff members. Increased targeting of federal payback programs toward service within centers also could provide an important incentive to CMHCs to include psychiatrists within their staffing pattern, since it would decrease the over-all cost of employing psychiatrists. Finally, community mental health programs long have argued for recognition as organized providers of care within third-party reimbursement mechanisms. While we agree that this recognition is appropriate, we see the potential it would have as a vehicle for increasing psychiatric presence by setting an appropriate staffing standard of psychiatrists within the over-all staffing pattern as a condition for eligibility as an organized care provider. CMHC recruitment efforts to attract competent psychiatrists have often failed to take advantage of incentives other than economic that are meaningful to psychiatrists. If clinical responsibilities were properly combined with other attractive roles, psychiatrists might be more inclined to work in CMHCs. The incentives could include time to do clinical and service delivery research and evaluation as well as clinical sopervision and teaching of other mental health professionals. Faculty appointments in medical schools that are affiliated with CMHCs or that are close by could be an additional incentive (18). Significant redirections are also required within training programs if psychiatrists’ interest in working in
766
HOSPITAL
& COMMUNITY
PSYCHIATRY
CMHCs is to be increased. While all residency programs generally have aimed at training “community psychiatrists,” the nature of the training and the expectations that are fostered often have not been in the best interest of the psychiatric resident and have not been conducive to increasing psychiatric presence within CMHCs. Specifically, most training programs fail to make the distinction between training psychiatric residents for “work in the community” (the public sector) and training “community psychiatrists.” While there are significant needs within CMHCs for both kinds of psychiatrists, the principal direction of most training programs often creates false expectations. One of two situations is likely to occur. Either the psychiatrist is inadequately trained for his role as a community psychiatrist or he enters a CMHC expecting to be treated like a community psychiatrist and then finds himself viewed primarily as a psychiatrist who has chosen to work in the community. In the latter role, the psychiatrist is often assigned to see patients for medication assessment and prescription-writing. That orientation is contrary to what he anticipated when he chose to work in a CMHC. While there is a great need within many centers for community psychiatrists, one should recognize that the principal need of most CMHCs is for psychiatrists who are willing to assume the medical functions of proper treatment planning. Residency programs need to be reoriented to convey to the trainee that working within a CMHC in a medical role, primarily seeing patients for assessment of medication, is not a demeaning task. (Conversely, some nonpsychiatric mental health professionals must recognize how their behavior often contributes to the conception that these medical tasks are relatively meaningless in the total treatment picture.) It is ironic that many psychiatrists who work in CMHCs view this specific skill, which they have in contrast to other mental health professionals, as unimportant, while many programs recognize its importance and seek it. The early days of CMHCs saw the development of significant federal programs that encouraged many psychiatrists to enter community psychiatry after they completed their core training. A cadre of psychiatrists with specialized training in community psychiatry graduated in the 1960s and early 1970s, entered CMHCs, and assumed positions of leadership (2). Many of these psychiatrists burned out, and others have not replaced them. That phenomenon has led to a lower proportion of psychiatrists among CMHC directors (12). If the trend is to be reversed, programs that prepare psychiatric residents for roles as community psychiatrists must be reinitiated. Those programs, discontinued in the early 1970s, must be started again by the federal government, in cooperation with medical schools. Recently NIMH has started in this direction (17). These two steps-a recognition that most psychiatrists should be prepared to work in the community as a
part of their total professional activities and that selected psychiatrists should be directed toward postgraduate programs that prepare them for specialization in community psychiatry-could be important in reversing the decreasing psychiatric presence within
CMHCs. As discussed earlier, psychiatric presence is higher in when they are hospital-based or affiliated with medical schools. At the same time certain developments, such as the burdens that principles of community involvement and community governance have imposed on the CMHC program, may have discouraged hospitals from inaugurating centers. Recent revisions in the Community Mental Health Centers Act (Public Law 95-622) have aimed at decreasing the requirements for community involvement while at the same time maintaining appropriate community participation in the planning and delivery of mental health services. Further steps need to be taken to balance those two objectives so that hospitals and medical schools can increase their participation in the development, support, and delivery of community mental health services. Incentives for general hospitals, private psychiatric hospitals, and medical schools to get involved with CMHCs, as well as rules and regulations that encourage public-private cooperation, can contribute to increasing psychiatric presence. When CMHCs recognize their essential role as part of the health care delivery system, they will be able to recruit more psychiatrists. Linkages between mental health programs and other health care delivery settings will underline the importance of mental health in health care delivery and will let psychiatrists know that CMHCs view themselves as principal components of a health care delivery system, not a social service delivery system. The perception that community mental health programs are moving toward a human services or social services focus has discouraged many psychiatrists from working in the programs. A reversal of that perception through linkages with general health care settings that employ nonpsychiatric physicians will encourage psychiatrists to participate in CMHCs. Since diminished psychiatric presence is most clearly associated with CMHCs located in disadvantaged urban and in rural settings, efforts should be made to increase the availability of minority psychiatrists and psychiatrists who are willing to practice in those settings. Federal manpower development funds should be allocated to support these objectives (8). In addition, more psychiatrists should be encouraged and prepared to enter CMHC administration. There is little within general or specialized psychiatric training that prepares the psychiatrist for an administrative role. Programs and training grants to prepare psychiatrists for roles in CMHC administration are a necessary part of any strategy to increase psychiatric presence. Because the role of psychiatry in CMHCs has become devalued within the profession (6,7), many psychiatrists are reluctant to work in these programs for
CMHCs
fear that their peers will view their commitment negatively. There must be a greater esprit de corps among psychiatrists who choose to work within CMHCs. Currently no organizational entity or specialized educational programs exist for psychiatrists who work within CMHCs except for the limited role of the American Psychiatric Association’s Institute on Hospital & Community Psychiatry, held each fall. The American Psychiatric Association and the National Council of Community Mental Health Centers must assume leadership in developing organizational components for psychiatrists who work in CMHCs and must promote the development of specialized educational programs in order to reverse the devaluation of psychiatric participation in CMHCs.#{149} REFERENCES 1) M. Sabshin, “Politics and the Stalled Revolution,” Annals, Vol. 7, October 1977, pp. 98-102. 2) J. S. Eaton and L. S. Goldstein, “Psychiatry in Crisis,” Journal ofPsychiatry, Vol. 134, June 1977, pp.642-645. 3)
Assembly
of
District
Branches,
American
Psychiatric
Psychiatric
American Associa-
Report ofthe Task Force on Community Mental Health Centers, Washington, D.C., 1978. 4) S. S. Sharfstein and J. C. Wolfe, “The Community Mental Health Centers Program: Expectations and Realities,” HOspital & Community Psychiatry, Vol. 29, January 1978, pp. 46-49. tion,
5)
S. S. Sharfstein,
“Will
Community
Mental
Health
Survive
in the
1980s?” American Journal of Psychiatry, Vol. 135, November 1978, pp. 1363-1365. 6) W. W. Winslow, “The Changing Role of Psychiatrists in Cornmunity Mental Health Centers,” American Journal of Psychiatry, Vol. 136, January 1979, pp. 24-27. 7) P. J. Fink and S. P. Weinstein, “Whatever Happened to Psychiatiy? The Deprofessionalization of Community Mental Health Centers,” American Journal ofPsychiatry, Vol. 136, April 1979, pp. 406409. 8) Report to the President From the Presidenfs Commission on Mental Health, Vol. 1, Washington, D.C., 1978. 9) C. A. Kiesler, “The Training of Psychiatrists and Psychologists,” American Psychologist, Vol. 32, February 1977, pp. 107-108. 10) L. Gurel, “Some Characteristics of Psychiatric Residency Training Programs,” American Journal ofPsychiatry, Vol. 132, April 1975, pp. 363-372. 11) R. D. Bass, CMHC Staffing: Who Minds the Store? National Institute of Mental Health, Rockville, Maryland, 1979. 12) Division of Biometry and Epidemiology, The Psychiatrist Centei’ Director: An Endangered Species, National Institute of Mental Health, Rockville, Maryland, 1978. 13) National Institute of Mental Health, Community Mental Health Centets: The Federal Investment, Rockville, Maryland, 1978. 14) H. H. Goldman, D. A. Regier, C. A. Taube, et at., “Community Mental Health Centers and the Treatment of Severe Mental Disorders,” presented at the annual meeting of the American Psychiatric Association, May 12-18, 1979, Chicago. 15) 5. S. Sharfstein, C. A. Taube, and I. D. Goldberg, “Problems in Analyzing the Comparative Costs of Private Versus Public Psychiatnc Care,” American Journal of Psychiatry, Vol. 134, January 1977, pp. 29-32. 16) G. L. Engel, “The Need for a New Medical Model: A Challenge for Biomedicine,” Science, Vol. 196, April 8, 1977, pp. 129-138. 17) Division of Manpower and Training Programs, Special initlatine to Prepare Psychiatrists for Practice In Public Mental Iealth Services Facilities, National Institute of Mental Health, Rockville, Maryland, 1979. 18) L. R. Faulkner and J. S. Eaton, “Administrative Relationships Between Community Mental Health Centers and Academic Psychiatry Departments,” American Journal of Psychiatry, Vol. 136, August 1979, pp. 1040-1044.
VOLUME
30 NUMBER
11 NOVEMBER
1979
767
BEIGEL, Arizona Arizona
STEVEN Director Division National Rockville,
JOHN Executive National Washington,
M.D. Mental
Health
SHARFSTEIN, of Mental Institute Maryland
C.
WOLFE,
Center
M.D.
Health Service Programs of Mental Health
PH.D.
Director Council of Community D.C.
Mental
Health
Centers
The presence of psychiatrists in community mental health centers has diminished in recent years, especially in centers that are non-hospital-based and that are located in rural or disadvantaged urban settings. The decrease in psychiatric leadership in the centers is particularly notable. Factors contributing to the trend include lower salaries than in the private sector, a decrease in the number of patients with severe mental disorders coming to the centers, and the impact of a decrease in specialized training programs in community psychiatry. The authors suggest several incentives to increase psychiatric presence in the centers, including developing staffing standards as a condition offunding giving psychiatrists time to do research and evaluation and to teach, and increasing the medical involvement of centers through links with general hospitals, private psychiattic hospitals, and medical schools. #{149} Recently considerable attention has been given to the diminishing presence of psychiatrists in communitybased mental health centers. That development requires careful analysis, since it can have important ramifications for the future viability of public mental Dr. Beigel also is professor of psychiatry at the University of Arizona College of Medicine. His mailing address is 1930 East 6th Street, Tucson, Arizona 85719. The opinions expressed here are the authors’ and do not reflect the official policy of the National Institute of Mental Health or the National Council of Community Mental Health Centers.
health care (1-7). Specifically, as progress is made toward including coverage for mental illness in national health insurance, it is likely that the nature of the psychiatrist’s role will be important in determining whether payment for services will be available. The initiatives recommended by the President’s Commission on Mental Health suggest that publicly sponsored community-based mental health programs will remain an important component of our mental health service delivery system (8). The commission’s intent that programs initiated with new resources should be directed toward addressing the treatment of seriously mentally ill persons, and not toward social change, will require psychiatrists’ involvement. Further, the considerable conflict that has existed between psychiatrists and other mental health professionals about the definition of their roles has created a climate in which the multidisciplinary orientation of many CMHCs is seriously threatened (9,10). For all of these reasons, it is important to assess objectively the current role of psychiatrists in CMHCs and to define clearly how their status has changed in recent years. After specifying the nature of the changes, we will discuss the factors that have contributed to the trends and will describe strategies that could ensure an appropriate, well-defined, and central role for psychiatry in community mental health service delivery.
DESCRIPTION
OF
THE
PROBLEM
The presence of full-time-equivalent psychiatrists in CMHCs has decreased during this decade. (A full-timeequivalent position equals 35 or more hours a week in a CMHC. Figures in this section represent both full-time and part-time psychiatrists.) The nature of this change is complex, however, and requires analysis. For example, while the number of full-time-equivalent psychiatrists in CMHCs dropped from 6.8 to 4.3 between 1970 and 1977, the principal portion of the decrease occurred between 1970 and 1973, when the number went from 6.8 to 4.5. Furthermore, the centers program has been expanding since 1973, and there has been an increase of 45 per cent in the absolute number of fulltime-equivalent psychiatrists (11). Since 1973 the decrease has been relatively in-
VOLUME
30 NUMBER
11 NOVEMBER
1979
763
nent, significant-4.5 to 4.3-but there has been a corollary increase in the total number of patient care staff, from 62.5 to 75.3. Therefore, while the decrease in the absolute number of full-time-equivalent psychiatrists has been small, the difference is more significant when compared with the 20-per-cent increase in total patient care staff during this same time period (1 1). The decrease in psychiatric presence has not been uniform throughout all centers; it has been greater in centers started since 1973 than in those started before 1970. Centers that are hospital-based have almost twice as many psychiatrists as centers that are hospital-affiliated, and they are above the national norm. Rural centers have fewer full-time-equivalent psychiatrists than urban centers and contribute significantly to the decreased presence of full-time-equivalent psychiatrists in CMHCs (11). Further evidence for the decreasing impact of psychiatrists in CMHCs can be found in comparisons of their presence with that of other mental health professionals. While there has been an increase in the percentage of psychiatrists who work in CMHCs, from 12.2 per cent in 1972 to 14.9 per cent in 1976, the increase is small compared with the percentage of all mental health professionals who work in CMHCs. During the same time period, this percentage increased from 6.6 to 1 1.5 per cent (1 1). The decrease in the average number of full-timeequivalent psychiatrists in all CMHCs has been predominantly a result of a significant decrease in the average number of full-time psychiatrists per center. That decrease would have been significantly greater were it not for a corresponding increase in the number of parttime psychiatrists (those working less than 35 hours per week in the center). In addition to the 1227 psychiatrists who were working full time in CMHCs in 1976, there were 251 1 psychiatrists employed on a part-time basis (1 1). The increasing participation of the part-time psychiatrist contrasts with a diminished use of parttime psychologists, social workers, and registered nurses in CMHCs. While the data regarding the presence of psychiatrists in CMHCs are somewhat ambiguous because of the differences in comparing absolute numbers with relative numbers and averages, there is no question that there has been a major decrease in the role of psychiatrists in providing leadership in CMHCs. In 1971 about 55 per cent of center directors were psychiatrists. By 1977 the percentage had decreased to 26. The decrease has been offset by sharp increases during the same time period in center directors with backgrounds in social work, from 17 to 33 per cent, and administration, from 3 to 12 per cent (12). Furthermore, those psychiatrists who served in a CMHC leadership capacity in 1977 were overly concentrated in metropolitan and high-income catchment areas. The increasing number of centers in nonmetropolitan and low-income catchment areas since 1971, where nonpsychiatric leadership has been promi-
764
HOSPITAL
& COMMUNITY
PSYCHIATRY
has
percentage
SOME
contributed of center
UNDERLYING
to
this
directors
marked who
are
decrease
in
the
psychiatrists.
ISSUES
The decreased participation of psychiatrists in community mental health centers is the result of several factors, including economics, changing patterns of centers, and changing patient characteristics. Economics. Economic issues have played an important role in the relative decrease of psychiatric participation in CMHCs. On the average, psychiatrists who work in CMHCs make lower salaries than those in the private sector. In contrast to other mental health professionals, psychiatrists are more accustomed to working on a fee-for-service basis and possibly less willing to accept the salaried conditions that accompany CMHC employment. From the perspective of the CMHC, psychiatrists are the “most expensive” professionals. As CMHCs find themselves pressured by increased service demands and fiscal constraints, they move toward the employment of “less expensive” professionals to serve their catchment area in order to stay within the budget. Role definition. The specific role of the psychiatrist as the only mental health professional capable of assessing medication need and writing prescriptions, when viewed in the context of the relative decrease in the average number of full-time-equivalent psychiatrists, has led to a narrower focus of the role. For many psychiatrists, that focus has been a dissatisfying experience and has been counter to the expectations of the role of a community psychiatrist received during training. Psychiatrists interested in working in the community anticipated that their role would embrace a wider area of responsibility than medication prescription, and would include diagnostic assessment, leadership in treatment planning, supervision, and consultation. The necessary reliance of the CMHC on psychiatrists for medication prescription, when coupled with the economic constraints described above, has led to a decrease in their responsibilities in other areas of community psychiatry. Disenchanted and dismayed by this turn of events, many psychiatrists chose to leave CMHCs. Changing pattern of CMHCs. In some respects, the relative decrease in the presence of psychiatrists in CMHCs is a statistical artifact created by the trends in governance and administrative organization of new CMHCs. During the past eight years, fewer hospitalbased CMHCs have been funded, and that has led to an over-all decreased medical presence in CMHCs. Rules and regulations of the federal program, including community board requirements, have made it difficult for hospitals to maintain administrative control over CMHCs they have sponsored and have discouraged other hospitals from applying to enter the CMHC program. Changing patient characteristics. Recent data suggest that fewer patients with severe mental disorders are
being seen in CMHCs (13,14). It is not clear whether this phenomenon is a consequence or a cause of the decreasing psychiatric presence in CMHCs, or whether it is a statistical artifact. It is also possible that the relative lack of psychiatrists and the increasing social orientation of other mental health professionals results in a reluctance to assign diagnoses of more severe mental illness to patients. Also, it may be that patients, perceiving the relative lack of psychiatric involvement in CMHCs, are going elsewhere, principally to general hospitals with psychiatric programs. Training. During the early years of the CMHC program, considerable financial support for training in community psychiatry was available from the federal government. Numerous postgraduate fellowships were created, and many psychiatrists benefited from the training and entered CMHCs. In recent years, decreased federal training funds and changing priorities have led to the closing of some of these specialized training programs. The availability of psychiatric trainees to CMHCs has decreased in proportion to the availability of trainees in other mental health professions. In such a climate psychiatrists, concerned about role definition, become uncertain of their status and may choose not to work in centers (13). SHARPENING
THE
DEBATE
In our view, it is important to devise and implement strategies to increase the psychiatric presence in community mental health centers. However, there are those who argue for minimal psychiatric presence and who do not view the diminishing psychiatric participation with alarm. Their position must be taken into account in any future planning for increasing psychiatric presence. Those arguing for minimal psychiatric presence point out that increasing psychiatric involvement will require economic incentives, particularly to attract psychiatrists into disadvantaged urban areas and rural settings. Such economic incentives will increase the over-all cost of CMHCs, thereby diminishing one of their major advantages in the competitive marketplace, which is their relatively “cheaper” costs for services compared with the private sector. (We are aware of studies that have purported to show that the cost of services within CMHCs is more expensive than in the private sector. However, proponents of this viewpoint usually fail to take into account the comprehensive range of services provided by CMHCs and the administrative overhead that is necessary to deliver these diversified programs. When these costs are then shared among all services, the cost for individual services escalates, making it appear that the unit cost of some services-for example, outpatient treatment-is comparable to or more than the private sector. The costs per episode of care are less, however, since the average number of visits to CMHCs are far fewer than in the private sector [15].)
Data indicate that the diminishing psychiatric presence within CMHCs is most notable in areas of low socioeconomic conditions and high minority concentration. Since psychiatric residency programs are graduating relatively few minority psychiatrists, those who argue for a limited psychiatric presence point out that, even if more psychiatrists were available, their interest in working in areas of high socioeconomic status and their low minority representation would not fit with programs in these areas of greatest need. The employment of minority psychiatrists by these CMHCs would decrease the accessibility, acceptability, and appropriateness of care for the target population served. Finally, those arguing for minimal psychiatric presence point out that psychiatrists generally receive training oriented toward individual therapy, and that they lack interest in and preparation for other treatment modalities that cost less and are vitally needed within CMHCs. Consequently, an increase in their presence would lead to higher costs of programs because psychiatrists will rely on traditional, more costly treatment modalities rather than on the more innovative and less costly modalities initiated by CMHCs. We do not feel these reasons are sufficient justification for the continuation of a diminishing psychiatric presence within CMHCs. Rather, they point out problems within the system and within psychiatry that need to be addressed. Furthermore, there are important reasons that argue for increasing psychiatric presence within CMHCs and that outweigh any arguments to the contrary. First, recent data seem to suggest that many CMHCs have increased their emphasis on providing care to individuals with less severe mental disorders rather than to those with more severe disorders (14). It is immaterial whether that is a result of the diminishing psychiatnc involvement or other factors, such as increased acceptability of community mental health programs and mental health care. It is important to recognize that if community-based programs are to fulfill their current mandate to offer less restrictive alternatives for more seriously mentally ill persons, quality psychiatric care must be available within CMHCs. The availability of an increased number of psychiatrists will improve utilization by and quality of care for the severely mentally disabled because the psychiatrist is uniquely qualified to provide comprehensive evaluation of individuals with mental disorders, including assessment of the relationship between their physical state and their mental state. The psychiatrist also ensures comprehensive treatment planning, which takes into account biological as well as psychological and social considerations (16). A strong medical presence is also necessary if CMHCs are to be accepted by third-party reimbursers as components of the health care delivery system. Despite arguments by other groups of mental health professionals that third-party reimbursement should be geared toward the nature of the illness rather than the
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provider of care, both public and private fiscal intermediaries continue to recognize the critical role of the physician, including the psychiatrist, in any health care delivery, and they require that that presence be central to the delivery of care if third-party reimbursement is to be provided. Finally, there is considerable emphasis on increasing the linkage of mental health programs to components of the health care delivery systems (17). Although many emotionally disturbed individuals receive specialized care within mental health programs, the majority of those with emotional disturbance continue to seek and receive care within the general health care delivery systern (8). Consequently, if CMHCs are to have an impact on over-all mental health care, they must increase linkages with the general health care system. The psychiatrist is necessary in achieving this linkage. For these reasons, we feel that increasing the psychiatric presence in CMHCs and ensuring an appropriate role for psychiatrists in the delivery of services is critical to the future success of CMHCs. However, this goal cannot be achieved without some significant redirections in current programs and strategies.
REDIRECTING
PROGRAMS
AND
STRATEGIES
Requirements and incentives that will encourage an increased psychiatric involvement must be built into the CMHC program. The incentives could include the development of staffing standards for CMHCs as a condition of funding. The standards could include appropriate ratios of psychiatrists to the other clinical staff members. Increased targeting of federal payback programs toward service within centers also could provide an important incentive to CMHCs to include psychiatrists within their staffing pattern, since it would decrease the over-all cost of employing psychiatrists. Finally, community mental health programs long have argued for recognition as organized providers of care within third-party reimbursement mechanisms. While we agree that this recognition is appropriate, we see the potential it would have as a vehicle for increasing psychiatric presence by setting an appropriate staffing standard of psychiatrists within the over-all staffing pattern as a condition for eligibility as an organized care provider. CMHC recruitment efforts to attract competent psychiatrists have often failed to take advantage of incentives other than economic that are meaningful to psychiatrists. If clinical responsibilities were properly combined with other attractive roles, psychiatrists might be more inclined to work in CMHCs. The incentives could include time to do clinical and service delivery research and evaluation as well as clinical sopervision and teaching of other mental health professionals. Faculty appointments in medical schools that are affiliated with CMHCs or that are close by could be an additional incentive (18). Significant redirections are also required within training programs if psychiatrists’ interest in working in
766
HOSPITAL
& COMMUNITY
PSYCHIATRY
CMHCs is to be increased. While all residency programs generally have aimed at training “community psychiatrists,” the nature of the training and the expectations that are fostered often have not been in the best interest of the psychiatric resident and have not been conducive to increasing psychiatric presence within CMHCs. Specifically, most training programs fail to make the distinction between training psychiatric residents for “work in the community” (the public sector) and training “community psychiatrists.” While there are significant needs within CMHCs for both kinds of psychiatrists, the principal direction of most training programs often creates false expectations. One of two situations is likely to occur. Either the psychiatrist is inadequately trained for his role as a community psychiatrist or he enters a CMHC expecting to be treated like a community psychiatrist and then finds himself viewed primarily as a psychiatrist who has chosen to work in the community. In the latter role, the psychiatrist is often assigned to see patients for medication assessment and prescription-writing. That orientation is contrary to what he anticipated when he chose to work in a CMHC. While there is a great need within many centers for community psychiatrists, one should recognize that the principal need of most CMHCs is for psychiatrists who are willing to assume the medical functions of proper treatment planning. Residency programs need to be reoriented to convey to the trainee that working within a CMHC in a medical role, primarily seeing patients for assessment of medication, is not a demeaning task. (Conversely, some nonpsychiatric mental health professionals must recognize how their behavior often contributes to the conception that these medical tasks are relatively meaningless in the total treatment picture.) It is ironic that many psychiatrists who work in CMHCs view this specific skill, which they have in contrast to other mental health professionals, as unimportant, while many programs recognize its importance and seek it. The early days of CMHCs saw the development of significant federal programs that encouraged many psychiatrists to enter community psychiatry after they completed their core training. A cadre of psychiatrists with specialized training in community psychiatry graduated in the 1960s and early 1970s, entered CMHCs, and assumed positions of leadership (2). Many of these psychiatrists burned out, and others have not replaced them. That phenomenon has led to a lower proportion of psychiatrists among CMHC directors (12). If the trend is to be reversed, programs that prepare psychiatric residents for roles as community psychiatrists must be reinitiated. Those programs, discontinued in the early 1970s, must be started again by the federal government, in cooperation with medical schools. Recently NIMH has started in this direction (17). These two steps-a recognition that most psychiatrists should be prepared to work in the community as a
part of their total professional activities and that selected psychiatrists should be directed toward postgraduate programs that prepare them for specialization in community psychiatry-could be important in reversing the decreasing psychiatric presence within
CMHCs. As discussed earlier, psychiatric presence is higher in when they are hospital-based or affiliated with medical schools. At the same time certain developments, such as the burdens that principles of community involvement and community governance have imposed on the CMHC program, may have discouraged hospitals from inaugurating centers. Recent revisions in the Community Mental Health Centers Act (Public Law 95-622) have aimed at decreasing the requirements for community involvement while at the same time maintaining appropriate community participation in the planning and delivery of mental health services. Further steps need to be taken to balance those two objectives so that hospitals and medical schools can increase their participation in the development, support, and delivery of community mental health services. Incentives for general hospitals, private psychiatric hospitals, and medical schools to get involved with CMHCs, as well as rules and regulations that encourage public-private cooperation, can contribute to increasing psychiatric presence. When CMHCs recognize their essential role as part of the health care delivery system, they will be able to recruit more psychiatrists. Linkages between mental health programs and other health care delivery settings will underline the importance of mental health in health care delivery and will let psychiatrists know that CMHCs view themselves as principal components of a health care delivery system, not a social service delivery system. The perception that community mental health programs are moving toward a human services or social services focus has discouraged many psychiatrists from working in the programs. A reversal of that perception through linkages with general health care settings that employ nonpsychiatric physicians will encourage psychiatrists to participate in CMHCs. Since diminished psychiatric presence is most clearly associated with CMHCs located in disadvantaged urban and in rural settings, efforts should be made to increase the availability of minority psychiatrists and psychiatrists who are willing to practice in those settings. Federal manpower development funds should be allocated to support these objectives (8). In addition, more psychiatrists should be encouraged and prepared to enter CMHC administration. There is little within general or specialized psychiatric training that prepares the psychiatrist for an administrative role. Programs and training grants to prepare psychiatrists for roles in CMHC administration are a necessary part of any strategy to increase psychiatric presence. Because the role of psychiatry in CMHCs has become devalued within the profession (6,7), many psychiatrists are reluctant to work in these programs for
CMHCs
fear that their peers will view their commitment negatively. There must be a greater esprit de corps among psychiatrists who choose to work within CMHCs. Currently no organizational entity or specialized educational programs exist for psychiatrists who work within CMHCs except for the limited role of the American Psychiatric Association’s Institute on Hospital & Community Psychiatry, held each fall. The American Psychiatric Association and the National Council of Community Mental Health Centers must assume leadership in developing organizational components for psychiatrists who work in CMHCs and must promote the development of specialized educational programs in order to reverse the devaluation of psychiatric participation in CMHCs.#{149} REFERENCES 1) M. Sabshin, “Politics and the Stalled Revolution,” Annals, Vol. 7, October 1977, pp. 98-102. 2) J. S. Eaton and L. S. Goldstein, “Psychiatry in Crisis,” Journal ofPsychiatry, Vol. 134, June 1977, pp.642-645. 3)
Assembly
of
District
Branches,
American
Psychiatric
Psychiatric
American Associa-
Report ofthe Task Force on Community Mental Health Centers, Washington, D.C., 1978. 4) S. S. Sharfstein and J. C. Wolfe, “The Community Mental Health Centers Program: Expectations and Realities,” HOspital & Community Psychiatry, Vol. 29, January 1978, pp. 46-49. tion,
5)
S. S. Sharfstein,
“Will
Community
Mental
Health
Survive
in the
1980s?” American Journal of Psychiatry, Vol. 135, November 1978, pp. 1363-1365. 6) W. W. Winslow, “The Changing Role of Psychiatrists in Cornmunity Mental Health Centers,” American Journal of Psychiatry, Vol. 136, January 1979, pp. 24-27. 7) P. J. Fink and S. P. Weinstein, “Whatever Happened to Psychiatiy? The Deprofessionalization of Community Mental Health Centers,” American Journal ofPsychiatry, Vol. 136, April 1979, pp. 406409. 8) Report to the President From the Presidenfs Commission on Mental Health, Vol. 1, Washington, D.C., 1978. 9) C. A. Kiesler, “The Training of Psychiatrists and Psychologists,” American Psychologist, Vol. 32, February 1977, pp. 107-108. 10) L. Gurel, “Some Characteristics of Psychiatric Residency Training Programs,” American Journal ofPsychiatry, Vol. 132, April 1975, pp. 363-372. 11) R. D. Bass, CMHC Staffing: Who Minds the Store? National Institute of Mental Health, Rockville, Maryland, 1979. 12) Division of Biometry and Epidemiology, The Psychiatrist Centei’ Director: An Endangered Species, National Institute of Mental Health, Rockville, Maryland, 1978. 13) National Institute of Mental Health, Community Mental Health Centets: The Federal Investment, Rockville, Maryland, 1978. 14) H. H. Goldman, D. A. Regier, C. A. Taube, et at., “Community Mental Health Centers and the Treatment of Severe Mental Disorders,” presented at the annual meeting of the American Psychiatric Association, May 12-18, 1979, Chicago. 15) 5. S. Sharfstein, C. A. Taube, and I. D. Goldberg, “Problems in Analyzing the Comparative Costs of Private Versus Public Psychiatnc Care,” American Journal of Psychiatry, Vol. 134, January 1977, pp. 29-32. 16) G. L. Engel, “The Need for a New Medical Model: A Challenge for Biomedicine,” Science, Vol. 196, April 8, 1977, pp. 129-138. 17) Division of Manpower and Training Programs, Special initlatine to Prepare Psychiatrists for Practice In Public Mental Iealth Services Facilities, National Institute of Mental Health, Rockville, Maryland, 1979. 18) L. R. Faulkner and J. S. Eaton, “Administrative Relationships Between Community Mental Health Centers and Academic Psychiatry Departments,” American Journal of Psychiatry, Vol. 136, August 1979, pp. 1040-1044.
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