Donald G. Langsley

Deinstitutionalization—The Sacramento story

Abstract Sacramento Countys approach to deinstitutionalization was to devise a system of care for those persons in need of ongoing support so as to enable them to develop their own resources and achieve their potential. Community based treatment programs enhance the persons independence because they permit the development of supportive relationships with family and friends. Provision of a continuum of services and a variety of residential options creates a maximum flexibility toward meeting the needs a person may have at any given time. The success of our programs has been directly related to our ability to apply the principles of good community mental health planning. It is important, however, to remember that changes in human services are not accomplished simply by scientific fact. They also depend upon the economy and the political scene. New and innovative human service programs are easier to adopt in times of inflation and easy money when liberal politics hold sway. They suffer during periods of economic depression and conservative politics. An example of this is the early 20th century health center movement. It grew out of the effort of those who operated settlement houses and was based on the principles of: (1) district location or accessibility, (2) preventive goals rather than direct care, (3) community participation, and (4) bureaucratic organization rather than solo practice. It was surprisingly similar to the Community Mental Health movement. It held promise and was achieving support, but came to an early demise with the shift to conservative politics and economic depression that followed World War I. Those of us committed to community-based treatment of the mentally ill need to be able to demonstrate that we have more than optimism and hope to offer and that deinstitutionalization of the chronically mentally ill can be accomplished.

Some thoughts on the training of the psychiatrist

E DUCATION in the professions is usually more responsive to practice than to theory. The psychiatrist is an example of a practitioner whose role has seen a number of changes over the past half century. His education is more likely to be related to empirically derived changes in practice than to new discoveries in the chemistry laboratory. A setting like the one in which his practice will occur is likely to be the locus of his education. The psychiatrist originally was a caretaker of the insane in an asylum. With the development of treatment for mental illness, he became a medically oriented specialist-often a neuropsychiatrist-hoping to find an explanation for mental illness in organic changes in the central nervous system. Later, when dynamic psychology opened new vistas, the psychiatrist became an office practitioner treating patients from a behavioral-science point of view. The newest phase in American psychiatric practice is represented by the community mental-health movement. Here the psychiatrist has become more responsive to social problems and works as a member of a multidisciplinary team dealing in prevention of mental disease as well as in direct treatment. In this role, the locus of his education has shifted from hospital to clinic and finally to a multiservice center in the community itself. The psychiatrist of the nineteenth century was a diagnostician, influenced by schools that classified mental disorder and then consigned the patient to long-term custodial care in a hospital usually far removed from population centers. Out of the medical orientation that functional change must be related to altered structure, the psychiatrist was often a physician who examined his patient for neurological disease and, not infrequently, a neuropathologist who examined the brain postmortem. The turn of the century saw the development of psychoanalysis and a concomitant growing interest in psychotherapy. Psychoanalytic education generally took place in institutes not associated with medical schools. Only after World War II did psychoanalysis begin to make a real impact on the practice of psychiatry and consequently upon the training of the psychiatrist. The Flexnerian reforms in the second decade of the twentieth century moved medical education out of its trade-school orientation into university settings. At the same time, the rapid expansion of knowledge and research in the health sciences resulted in the growth of the specialization movement. One school of psychiatrists identified with other medical specialists who treated their patients on specialized wards in general hospitals. They saw only the most seriously ill, followed them briefly after hospital treatment, and were inclined to use somatic therapy and biological explanations. The psychodynamic psychiatrists, on the other hand, viewed mental disorder as resulting from intrapsychic conflict; their approach was usually

Interdisciplinary Training of Mental Health Professionals

Interdisciplinary mental health teams are expected to staff the mental health centers of today and tomorrow. Existing training programs do not prepare staff to work in such settings. Instead of being trained separately and then learning to work as a team, mental health professionals should be trained by interdisciplinary programs. Task analysis suggests that such training should develop knowledge and skill in diagnosis-assessment, treatment, consultation, research, teaching, administration, prevention, and professional identity. A one-year training program for first-year psychiatric residents, psychology interns, and Master’s level students in social work and mental health nursing is described. Didactic teaching and clinical experience would be carried on by university faculty who are also members of a mental health team serving a catchment area in Sacramento County.

The Education of Psychiatrists

often called the listening professionis now engaged in a massive self -analysis. Psychiatrists are talking more publicly these days, and what they say reveals a professional identity crisis of considerable magnitude. They are struggling with questions that profoundly concern how they are or ought to be educated. They are asking: What is mental health and what is a psychiatrist? Writing at least 50 years ago, Sigmund Freud addressed himself to the question of what constitutes mental health. His two simple criteria are well known: the ability to work and the ability to love. Judgments based on these criteria are under serious attack today, and so is the nature of the doctor who presumes to make such judgments. The world has grown away from Vienna at the turn of the century. The concept of freeing a patient from psychic conflicts and allowing him or her to develop a capacity for work and love was useful for the largely middle-class intellectuals who were Freuds patients. But many psychiatrists today have become impatient with psychoanalysis. They feel that they should work to satisfy the fundamental needs of whole populations. Such doctors see at least three groups today whose problems are so severe that their plight removes them completely from the context of traditional individual psychotherapy. These groups include adolescents in conflict, ethnic minorities, and the poorand they seem to require new ways of perceiving their emotional fate. The lives of these people are radically different from those who bare their souls to paid friends in darkened rooms on New Yorks Park Avenue, Chicagos Michigan Boulevard, or Roxbury Drive in Beverly Hills. And ways of treatment that neglect those who turn on and tune out, who riot, burn, and pillage in our cities, or who have been unemployed for years, overlook many people who live in America today. Such facts have allowed a stark confrontation to