COMMUNITY PSYCHIATRY

A recently developed specialty defined byHume (1966) as “the maximum utilization of community resources in the identification, treatment, or rehabilitation of the mentally ill or retarded.” It is “simultaneously treatment-oriented, prevention-oriented, and community-oriented for the purpose of reducing to a minimum, by all discoverable means, the mental disorders of a given population.”Community psychiatry overlaps with both preventive psychiatry and social psychiatry. In common with preventive psychiatry (in the fullest sense of the term), it aims at primary prevention (promotion of conditions that forestall development of mental disorder), secondary prevention (early treatment to prevent further development of disorder), and tertiary prevention (application of rehabilitative measures to prevent or reduce handicaps resulting from disorder). In common with social psychiatry it is concerned with the impact of the social setting on mental health and psychiatric practice. The specialty has developed out of both of these areas, and has also been fed by the fields of school psychiatry, industrial psychiatry, military psychiatry, correctional psychiatry, and administrative psychiatry. Historically speaking, it has evolved from such sources as the mental hygiene movement originated by Beers, the child guidance clinics of the 20s and 30s, the National Mental Health Act of 1946, the creation of The National Institute for Mental Health in 1949, the report of the loint Commission on Mental Illness, the development of the public health point of view, and the community mental health centers program. The major areas and objectives of community psychiatry are: (1) the development of comprehensive clinical services in the community, with emphasis on outpatient and extramural services to keep as many people as possible out of mental institutions; (2) the development of a community program uniting the efforts of all nonpsychiatric organizations and individuals whose work has a bearing on mental health, including general hospitals, health departments, schools, welfare and family agencies, churches, industries, labor unions, legislative bodies, courts and prisons, lay leaders, and volunteers; (3) the promotion of epidemiological research focused on the natural history, distribution, and incidence of mental disorders in the population in order to isolate social and environmental factors that contribute to these disorders (as in the case of pellagra and general paresis); and (4) the development of a corps of psychiatrists to serve as mental health consultants, or community mental health specialists, working on either a client-centered or a program-centered basis. In his client-centered activities, the psychiatrist is concerned with diagnostic evaluation and recommendation of treatment. In his program-centered activities, he serves as administrator (planning, organizing, and directing programs and services); research director (developing and supervising projects); educator (developing and teaching courses for various institutions); and consultant in preventive psychiatry to various community services as well as to lay leaders, health educators, legislators, and others outside the psychiatric and welfare agencies. The field of community psychiatry is extremely complex. In her account, Hume lists a huge number of activities involved in carrying out a co-ordinated program. The following enumeration will aim only at indicating their variety: surveys and assessments of community organizations, leadership and public interest in mental health problems; collection of data on the character of the population, characteristics of the community, and specific local mental health problems; analysis of the administration of present programs; development of policies and standards for mental health jobs, staff training and development, COMPENSATION managerial and supervisory functions, interagency co-ordination, informational and educational services, and financing; promotion of research, including experimental methods, case studies, surveys, biostatistical data-collection, epidemiological studies, and program evaluation; development of clinical methods and services aimed at maximum utilization of resources, including new techniques of consultation and collaborative treatment; primary prevention aimed at eradication of specific factors causing breakdowns, including harmful social policies, as well as positive measures for maintaining mental health, such as anticipatory guidance and counseling; development of services directed to early case- finding, handling of psychiatric emergencies, inpatient and outpatient treatment, vocational training, rehabilitation, re-education, home nursing, sheltered workshops, halfway houses, etc.; and indirect mental health services through education of nonpsychiatric personnel (public health nurses, teachers, supervisors, child-care workers), and general education of the public through films, lectures, discussion groups, television, etc. Training for the field of community psychiatry is still available in only a few centers and is largely limited to psychiatrists, though it is now being broadened to include clinical psychologists, public health nurses, and psychiatric social workers. Leading institutions in the field are Johns Hopkins, Harvard, Columbia, University of California, Berkeley, and the Menninger Foundation.