April 2, 1999

By Charles Huffine, M.D.

As president of a community psychiatry organization, I am often asked how can that be considered a viable professional identity. In such comments I hear echoes of lost ideals of social activism in older colleagues or confusion over how to negotiate the hazards of managed care, government cutbacks, and antimedical bias in younger colleagues. The grand ideals of early pioneers for "treating communities" remain within the hearts of community psychiatrists, but our methods reflect a more realistic relationship to the field of community mental health and the priorities of service delivery. Methods such as assertive community treatment for adults and wraparound community care for kids have been tested and proven effective for our most ill citizens.

For those of us who are involved in the trenches, or as researchers and clinical leaders, community psychiatry could not be a more vital and exciting career. We have found that the potential of being involved in meaningful public service through expanding roles for psychiatrists in service systems excites medical students and inspires new psychiatry residents who choose our profession.

Community psychiatry is a form of psychiatric practice emphasizing the contextual issues in our patients' lives. It is an orientation that should permeate the thinking of all psychiatrists, but it is crucial for those of us who treat individuals suffering from adverse social factors such as poverty or discrimination or who are marginalized due to such adversities as severe mental illness. Because of social factors that impinge on our patients, it is inevitable that community psychiatrists embrace a public health model in understanding mental illness and are devoted to preventative and advocacy efforts on behalf of vulnerable populations. We don't define our professional identity by the populations we work with, the institutions we work in, or the funding mechanisms we are bound by. However, those who identify as community psychiatrists will usually work with those with the most severe and persistent mental illnesses or with families who deal with the most behaviorally disturbed children and adolescents. We may work in mental health centers, university clinics, V.A. programs, or jails. We may work in hospitals and see ourselves as part of a community-based continuum of care. Invariably we work in resource-poor environments that have struggled for years with shrinking budgets and a need to manage resources carefully. In this regard community psychiatrists and our colleagues in community mental health are very experienced in managing care. The American Association of Community Psychiatrists (AACP) has adopted a practical view of public-sector managed care. We embrace the concept of rational deployment of limited resources. We demand only that the system be clinically informed and accountable to the population it serves.

The AACP has asserted leadership in assuring optimal care for vulnerable populations in managed care systems. We have taken the lead, in collaboration with APA, in defining standards of practice for community psychiatrists in service-delivery systems. We produced guidelines for formulary and quality management in such systems. We have produced a methodology for determining placement in care systems, known as the Level of Care Utilization System (LOCUS), which we offer to administrators as a clinically sound management tool. In partnership with the American Academy of Child and Adolescent Psychiatry, we have produced a child/adolescent version, the CALOCUS. We are very concerned over deficits in psychiatry residencies in preparing psychiatrists for roles in community mental health systems. We have proposed model curricula for training in community psychiatry.

Individually, community psychiatrists seek close alliances with all stakeholders concerned with community mental health. We see ourselves as active participants on interdisciplinary teams. We value respectful, collaborative relationships, not only with other professionals but also with our patients and their families. We value family participation in treatment planning and join with local chapters of the Nationally Alliance for the Mentally Ill and other advocates in exploring ways families and consumers can be more involved in our systems of care. We believe that psychiatrists should exercise leadership in community programs, but recognize that we must earn that leadership. There is nothing inherent in our training that makes us automatic leaders.

Respectful collaboration, we believe, helps us to escape being relegated to limited roles as psychopharm technicians. Many of us have been successful in carving out consultative and supervisory roles and enjoy great respect among our nonmedical coworkers. Many of us have worked out clinical leadership roles that enable us to participate in policy and planning efforts in our service agencies or in government.

As one of my colleagues used to remark, a community psychiatrist may be the one individual in the system that actively relates to all involved in the community mental health drama-from the homeless individual to the governor.

So I flood my doubtful colleagues with my passion for community practice and my belief in the critical role such an orientation has for psychiatry generally. Our regard for our most vulnerable and margin-alized citizens defines us as a society. Being part of that dialogue through our voice and our deeds gives us deep satisfaction as community psychiatrists.