The Public Psychiatrist as Advocate

Given the credibility many physicians possess with legislators, political leaders, and other policymakers, along with people of influence such as thought leaders and activists, community psychiatrists play an important role in patient advocacy. Contemporary professional advocacy is rooted in mental health advocacy generally, beginning with Dorothea Dix’s asylum movement in the 19th century. This chapter reviews the historical significance of mental illness and the underpinnings of modern-day mental health advocacy. It then discusses the community psychiatrist’s role in advocating for mental health care, primary prevention, community awareness, and social justice. It includes examples of the community psychiatrist effectively serving in the advocate role, and it explains the how and where to learn about public policy and advocacy skills. It concludes with a summary of key learning points.

The Public Psychiatrist as a Leader

One of the many areas in which a community psychiatrist can impact patient care is through providing clinical and administrative leadership. The actions of leaders have consequences, both good and bad. Good leadership in a public mental health organization can be felt even among staff who rarely interact with the executive team. People understand the vision of the organization, and they feel engaged in achieving the organization’s goals and are committed to the organization. Poor leadership impacts morale and leads to high turnover and poor quality of care. This chapter discusses some of the leadership roles available to the public psychiatrist. It incorporates case scenarios that one may confront as a community psychiatrist in a leadership role. This chapter fosters consideration of individual paths to public psychiatry leadership by using several successful community psychiatrist–leaders as examples. The chapter concludes by discussing various ethical issues related to leadership that may arise.

Introduction

Physicians who choose to serve in public sector mental healthcare settings and physicians-in-training assigned to public sector mental health clinics may not be fully prepared for the many roles of the public and community psychiatrist. This primer offers practical information and guidance to the psychiatrist called upon to serve in the roles of public-sector clinician, team member, advocate, administrator, and academician. Each chapter includes a concise description of these various roles and responsibilities and offers engaging examples of the public psychiatrist at work. The chapters also ask readers to thoughtfully consider case-based problems typical of those faced by the public psychiatrist. Each chapter also features works of art and literature, usually from the public domain. Medical humanities help physicians keep sight of the lived experiences of public-sector patients; this includes not only the pain and suffering endured by them due to both the medical disorders with which they live and the disparities they endure in health, educational and occupational outcomes, but also their resilience while facing so many challenges. Medical humanities also serve to reinforce the physician’s individual and collective will to address the disparities endured by our patients. There are several very comprehensive textbooks available that examine community psychiatry broadly. By contrast, this work is a concise guide for the resident and early-career psychiatrist to the many roles he or she might be asked to provide in a public-sector mental health setting. Our hope is that the primer provides a level of support to psychiatrists that fosters their desire, individually and collectively, to serve the poor and the marginalized with grit and determination, and to broadly consider their potential to improve not only patient well-being but also these patients’ incorporation into their communities.

The Public Psychiatrist as Researcher

Most psychiatrists undergo 4 years of residency training after medical school before being eligible to practice independently. Apart from basic training in biostatistics and exposure to research methodology in a few training programs, most trainees spend their training primarily taking care of patients. As attending, most psychiatrists have little time for research. However, psychiatrists in the community offer an important resource for clinical trials. Collaborating with a pharmaceutical company or university hospitals requires an understanding of basic concepts in biostatistics and interpretation of study results. This chapter is intended to empower community psychiatrists in research collaborations. In addition to a statistics refresher, the chapter elucidates the history, terminology, and methodological nuances of clinical trial design. It discusses how to address ethical concerns and fulfill ethical requirements for initiating research studies. Finally, it describes notable clinical trials in psychiatry, how community-based centers can be a valuable research resource, and how technology can complement these endeavors in the community.

The Public Psychiatrist and Integrated Health

This chapter provides a brief introduction to the role of integrated mental health care in improving access to care. It outlines some of the major models of integrated care, including the collaborative care model and the primary care behavioral health model, focusing on commonalties and differences in the models and considerations that drive the choice among models or their adaptation. It then describes ways in which integrated care psychiatrists may serve in clinics, including ways in which they can best use their expertise to expand psychiatric care access to more people. Special situations and specialty clinics are briefly described. Finally, the personal characteristics of psychiatrists considering a career in integrated care are reviewed.

Back to the Future of Community Psychiatry

The present historical moment in community psychiatry is witnessing a rebirth of the values of the founders of the field, as early career psychiatrists seek to carry their mantle into the future. Although a number of forces have colluded to make such work difficult, aspiring community psychiatrists are electing to go “Back to the Future,” tapping into the foundational wisdom of the community psychiatry movement. Through case examples, personal reflection, and discussion, two values in particular are discussed in this chapter: working with those persons who are most in need (i.e., the “difficult” patients) and working with challenging and at-risk populations. The overall aim of this chapter is to motivate future community psychiatrists to adopt and implement these values on their own journey Back to the Future.

The Public Psychiatrist as Educator

Among the many important educator roles of the public psychiatrist is that of teacher for the medical students, residents, and fellows who rotate through her public sector clinic or hospital. Using a case study as its basis, this chapter describes how a public psychiatrist can engage with an academic medical center’s department of psychiatry in order to offer training opportunities in the public sector. It also describes the process for developing medical student clerkships and resident rotations and includes examples from clerkships and resident rotations from throughout the United States.

The Public Psychiatrist as Clinician

The most common role of the community psychiatrist is as a clinical physician providing individual patient care, including psychiatric evaluation, diagnosis, and treatment planning for adult patients with severe mental illness, as well as child/adolescent patients with internalizing disorders and externalizing behaviors. This chapter describes common concerns that arise for public psychiatrists in their clinical role and offers resources for addressing them, including discussions on providing clinical care in a resource-limited system-of-care (e.g., working with and supervising nurse practitioners and physician assistants), fostering evidence-based best practices in public mental health care settings, and the special issues of clinical practice in rural settings. A case example describing community psychiatrists serving in this role is included.

The Public Psychiatrist in History

Just as the patient’s history is important to understanding his or her current situation, an understanding of the social, economic, and political forces that have shaped public psychiatry can offer insight into the public psychiatrist’s contemporary role in the United States. This chapter reviews the many historical factors that shaped the field’s development and that continue to motivate system transformation within public psychiatry today. It explores psychiatry’s shifting understanding of mental illness and treatment, alongside the rise and fall of the asylum movement and the evolution of outpatient psychiatry in the early 20th century and beyond. Then, it describes national legislation that led to the deinstitutionalization movement, the fragmentation of social services in the 1980s and 1990s, and the efforts of patient advocates that resulted in public psychiatry’s adoption of recovery-oriented services under the George W. Bush administration. Last, this chapter provides context to mental health parity laws under the Affordable Care Act.

The Public Psychiatrist and the Patient with Intellectual Disability

Individuals with intellectual and developmental disabilities are among the populations most underserved by health care systems. Following shifts toward deinstitutionalization during the past several decades, community-based services have largely assumed care for this population, which tends to experience high rates of medical and psychiatric morbidity. Providers frequently feel inadequately trained in providing care to these patients, and the system as a whole struggles to adequately meet their often complex needs. Nevertheless, working with those with intellectual or developmental disabilities can be highly rewarding for providers. There is great potential to offer a meaningful impact and improve the quality of life for these patients and their families and support systems with careful assessment and intervention. This chapter offers insights to the community psychiatrist working with patients with intellectual and developmental disabilities. Common obstacles in assessment, diagnosis, and management of mental illness and challenging behaviors in this population are discussed. Case examples exemplifying the complexities of these individuals are included.