The outpatient service of the Department of Psychiatry at Harlem Hospital Center developed as a successor service to a relatively small, undermanned and overburdened mental hygiene clinic which, prior to 1962, provided the only psychiatric services for adult outpatients in the community of 400,000.
The most immediate needs at that time were to increase the available range and volume of clinic services, to separate children's from adult services, to provide for the first time psychiatric consultation and treatment in the hospital emergency room, and to upgrade ward consultation services from simple facilitation of transfers to provision of diagnostic and management consultation, with some treatment, for general ward patients.
A core staff of well-trained psychiatrists, social workers and psychologists was recruited, a residency training program was instituted, and the above services, organized along traditional lines, were brought into being with a minimum of wasted time. The clinics were run on an appointment basis. A significant requirement, however, was that no patient be kept waiting more than one week for a work-up. No waiting list was tolerated. The usual modalities of outpatient treatment were offered: supportive and insightoriented individual psychotherapy and group therapy for specific and nonspecific types of patients with medication as indicated; 24-hour emergency psychiatric care was instituted; general ward patients received prompt, complete psychiatric consultation on request of their physicians. And then, we were discovered- by the community, by our colleagues in the hospital, by other agencies, by the state hospital, by the schools- and what had been a gradually increasing demand for services in this previously "anti-psychiatric" community became a veritable tidal wave of people requesting and requiring psychiatric help. Staff was rapidly expanded and redeployed, new kinds of staff were recruited and trained, newer methods were tried and, if useful, adopted, and new services were developed. We managed, though just, to keep up with demands. Then, in the summer of 1970, failing to obtain an adequate response to their needs from various city agencies, a group of heroin addicts and their community supporters occupied two-thirds of our clinical space, making it almost impossible to function throughout a twomonth period, and resulting in major losses from the staff which had been built up over several years. The remaining, mainly senior (and certainly superior) staff members reorganized as the Psychiatric Ambulatory Care Service, under the leadership of Dr. Austin Moore.
In the following sections of this paper the various outpatient services offered by the Department, something of how they have developed, and the use or determinants of that development will be described by the clinicians responsible for them.