November 20, 1998

The philosopher Henry James once said that three things in human life are important: "The first is to be kind, the second is to be kind, and the third is to be kind," quoted Joel Feiner, M.D., in a lecture on the evolution of community psychiatry at APA's 1998 Institute for Psychiatric Services last month in Los Angeles.

Those involved in community psychiatry must never lose site of the James axiom, asserted Feiner, the clinical and training director of Mental Health Connections of Dallas. Mental Health Connections consists of four programs: a 24-bed inpatient unit, an 80-patient Assertive Community Treatment (ACT) team (a comprehensive outpatient program for people requiring the most service, commonly called a "hospital without walls," not unique to Mental Health Connections), an outpatient psychosocial rehabilitation program with 130 dual-diagnosis patients, and a supported housing program with 100 patients. About 25 people are in supported employment.

Using a neurological metaphor, Feiner likened community psychiatry to "the larger set of synapses" that function to "enhance the social transmitters so they are in balance."

Limited resources and the setting in which community psychiatry is practiced create a dilemma for psychiatrist and patient, according to Feiner. The dilemma is that the psychiatrist works to gain the patient's trust, and then, in essence, must say, "Now that you trust [me], go away and don't come back, and if you need help, go to the outpatient clinic."

Relationships-between psychiatrist and patient, and between patient and other significant people-are critical to long-term rehabilitation in the community, and yet are largely ignored in the community psychiatry setting, Feiner contended.

"Perhaps the most important thing that happens on an inpatient unit is that relationships form," observed Feiner. Despite the primacy of relationships in determining therapeutic outcome, relationships are often seen as "a side effect" of treatment, he noted. But in the Mental Health Connections program, Feiner and the multicultural staff make relationships the cornerstone of the therapeutic alliance.

More than 60 percent of the patients in Mental Health Connections are involuntarily admitted. A similar percentage have a dual diagnosis, and more than 40 percent need housing, according to Feiner.

"Dual diagnosis is an expectation, not an exception," he noted. Chemical dependency counselors are part of the treatment team. Mental illness is seen as continuous, not episodic, because, said Feiner, "short-term treatments have short-term results." The staff is taught to regard multiple admissions as a continuous incident for clinical purposes. Families are seen as integral to the treatment process.

Rather than placing the blame on the patient when there is relapse, said Feiner, treatment team members ask themselves, "What did we do or not do? Relapse prevention is key," he added. "It's really relapse interruption. We call it `relapsus interruptus.' "

When a patient sees more than one clinician, as is often the case, the patient takes his or her medical record to each clinician so the patient does not have to retell his or her story repeatedly.

The underlying philosophy is that patients are "a group of normal people who happen to have a mental illness." Further, the staff tells patients, "You may have a mental illness, but you don't have to look like a mental patient." Although there are case managers, the expectation is that the patient believes that he or she is not "a case" and does not want to be "managed." So-called "resistant behaviors are [seen as] appropriate responses to ineffective therapists or ineffective techniques," said Feiner.

Through the use of discretionary funds solicited from private donors, the program is able to provide benefits, particularly dental care, that are not normally part of a psychiatric program. Staff make a habit of saying good night to patients, another reflection of Feiner's belief that proper attachments in rehabilitation are critical to recovery from psychiatric illness.

The therapist's positive view of the patient allows the patient to feel valued. "When a person feels valued, he is willing to risk new things and try new behaviors," Feiner said.

The interaction between case manager and patient is critical, but high turnover means that case managers often leave, severing the patient's link to the psychiatric clinic. It is therefore risky to let patients invest a great deal emotionally in their relationship with the case manager, he added.

The relationship between the clinician and the patient should take precedence over the relationship between the caseworker and the patient, since in most cases, the clinician is far more likely to remain accessible than is the caseworker, observed Feiner. When a good relationship between clinician and patient is not established, compliance is undermined. Mental Health Connections has a high level of compliance, although noncompliance in most mental health programs is a huge problem, said Feiner. About half the patients in most other programs are medication noncompliant in the first year after discharge, he observed. Noncompliance is costly in both human and economic terms, resulting in unnecessary hospitalization, lost productivity, additional treatment, and death, Feiner noted. Another cost of noncompliance is "compassion fatigue," sometimes called "burnout," among overworked psychiatrists.

Despite the humane philosophy and evidence of success in helping people get their lives together, the program is not without problems, Feiner acknowledged.

The program is somewhat expensive for the numbers of people served, noted Feiner. In addition, outpatient programs are reaching capacity. The "fundamental problem is how do you keep taking patients without increasing capacity?," remarked Feiner.

Average length of stay (17 days) is relatively high, which is attributable to the "complex problems of the patient population," Feiner noted.

The four programs that make up Mental Health Connections are geographically separated, which "makes it hard to maintain the close collaboration we've always had," Feiner said. Also, "we feel that the culture we have is a different treatment culture than the larger organization that we are a part of," which is the University of Texas Southwestern Medical Center and the Dallas County Mental Health and Mental Retardation Center.

Finally, "corporate ethics are threatening to infiltrate our values," he added. Other larger organizations are "becoming businesses because financial issues are driving the system these days. The issue is efficiency and effectiveness, but I'm not sure anybody has achieved" those two goals simultaneously yet. "These are the storm clouds that are approaching us."

For example, the entire county (Dallas) was informed by the state legislature recently that "there was no money for atypical antipsychotics." At present, a patient in need of an atypical antipsychotic must be referred to the state hospital if the patient is not covered by Medicaid.

When faced with ethical dilemmas, said Feiner, he falls back on the Oath of Maimonides, a Jewish philosopher and physician who said in part: "May the love for my art actuate me at all times; may neither avarice nor miserliness, nor thirst for glory, or for a great reputation engage my mind; for the enemies of truth and philanthropy could easily deceive me and make me forgetful of my lofty aim of doing good to Thy children. May I never see in the patient anything but a fellow creature in pain. . . ."