Psychiatric Annals

WHERE THE WORK IS DONE

Lawrence C Kolb, MD

No abstract available for this article.

Undoubtedly the most overlooked and least recognized and appreciated of those mental health facilities which have contributed to the last decade's enormous changes in ways of assisting the psychiatricaUy disturbed are the general hospital services of psychiatry. Their growth has come as the move has been made from custodial care in state hospitals to the front line of general hospitals and clinics and private offices. The success of that movement is enormous; a drop of over 20 per cent in a decade in the patient population of the custodial institutions, while the general population of the country increased by 20 million.

When one considers the efforts to maximize services in the area of greater need - that is, areas from which the largest numbers of seriously ill live and die- then again the inner center or ghetto medical center psychiatric service proves to be and has been the major provider as well as the major preventer and the major rehabilitator.

For those who are impressed by what they read in the daily and specialty newspapers, throw away and professional journals, the above declarations might appear the sheerest nonsense. Clearly if one accepts numbers of written references to concern over new facilities as the basis for establishing a "word fact," as Galbraith calls our national penchant for entrapment in the power of words, the community mental health center must be credited as the new and significant deliverer of service - the preventive center. But one will never discover from this kind of reporting or from those published by the Biometrics Division of the National Institute of Health who are community mental health centers or what constitutes a mental health center. Their reporting serves to support the political effort which established and maintains the Federal Community Mental Health Centers Act of 1963. That reporting makes impossible for those interested to determine where the mental health work is being done at present. It does not fulfill the goal of providing a dynamic picture of the activities in the range of facilities which constitute the modern mental health system.

What is a mental health system? The mental health system may be conceived as a subsystem of the general health system. Its major goal is the reduction of social morbidity due to personality disorder. The operation of the system depends upon the function of its various subsystems. There are those concerned with ingress (contact and case finding), diagnosis, distribution to the therapeutic subsystems, and subsystems related to information processing and decision making, maintenance and support (personnel, facilities, and support motivation through funding), internal development (manpower and research), and evaluation. Among the therapeutic facilities are those largely concerned with ingress, diagnosis and short and medium term treatment. These are the various private practice offices, free standing clinics, general hospital services, or community mental health centers. While most institutions supported by state and federal funds, as well as private institutions, offer certain of the necessities for ingress and early treatment, for the most part such facilities are given over to the care of patients who require more prolonged care ana rehabilitative procedures.

The system operates on a wide variety of illnesses (personality problems if you will), each of which makes differing demands upon the facilities of the systems as well as the available manpower within the system.

Experiences such as have occurred in the brief 10 years of existence of the Service of Psychiatry at the Harlem Hospital vividly illustrate the massive contribution made by the general hospital services nationwide. The Harlem experience particularly portrays their efforts for those living in our most deprived inner city neighborhoods.

It demonstrates the variety of therapeutic programs and the richness of staffing which constitute today the general hospital services of psychiatry. Many of these services offer the full therapeutic program to serve the full range of presently met therapeutic problems requiring short- and mediumterm care. Some even support longterm care operations through joint clinical appointments in other facilities. They contain and exceed the minimum required constituents of the federally designated community mental health centers.

How did such services come into being? Particularly, how did such a service as that at Harlem evolve? These are important questions. Many studies of the health manpower pool have shown the low ratios of skilled persons available to staff health centers in the deprived areas of both city and rural areas. There exist many commentaries on the drift away of medical and social services and the avoidance of trained persons to engage their skills in these areas. Few have suggested practical remedies for drawing the trained manpower to bear upon the populations most in need of help. The Harlem experience provides a record of one practical model of just that development. It may be useful elsewhere.

As they then existed, psychiatric services in New York City were strained to the breaking point in the late 1950s. Newspaper inspired articles provided public exposures of the plight of patients crushed into and processed through the large psychiatric receiving units of Bellevue and Kings County Hospitals. Forty per cent of the patients were routinely sent on to the state hospital system for treatment. Attempts at other than brief diagnostic studies and short-term care of the simplest sort did not occur. The select committee appointed by the then mayor, Robert Wagner, to study the delivery of mental health services in these hospitals recommended that the Department of Hospitals decentralize its psychiatric service throughout the city hospitals and upgrade the operations of the small psychiatric services in other city hospitals by arranging their direction through contracts with medical school departments of psychiatry. The first contract, arranged by the then commissioner, Dr. Ray Trussel, was made with the Department of Psychiatry of Columbia University's College of Physicians and Surgeons in the amount of $412,000. At that time there existed in the old Harlem Hospital a part-time, isolated outpatient service staffed by three overburdened part-time psychiatrists, one social worker and three secretaries.

The university contract stipulated that the university would work to develop at the Harlem Hospital a teaching service of psychiatry. Dr. Elizabeth Davis, then holding a university post in the Columbia Presbyterian Medical Center, had grown up in Harlem and had a vital interest in the growth of this city area. She was appointed to head up the new Harlem Hospital affiliate as chief of service. That post she still holds as professor of clinical psychiatry. In turn, each professional recruited to her staff who gave sufficient time to the service was nominated to the university departmental faculty. They were rewarded as well by university salaries provided through the contract monies which exceeded those paid to their counterparts teaching in other hospital services affiliated with the department. Recruitment was aided, as well, by the increasing enthusiasm of students, young psychiatrists and other mental health workers to the challenge of service in the inner city. Under the inspired leadership of Dr. Davis, the Harlem Psychiatric Service consists now of over 200 persons including 33 psychiatrists (13 are full time) and operates on an annual budget in excess of three million dollars. The example set by the development of the psychiatric service at this hospital led to the establishment of contracts for all other medical specialties in that hospital and in many others with equal success.

But what does this service do? There now exists at the Harlem Hospital Center approved residency training programs in adult and child psychiatry. The services now available to patients are: an adult inpatient; an adult day hospital; a children's psychiatric and preventive service; emergency room and hospital consultation; alcoholism program; diagnostic service for pre-school children; day treatment for school-suspended children; adolescent and geriatric programs,- and a major rehabilitation program. Treatment for drug abusers is available through general hospital programs. Several of these programs operate as outreaches of the Harlem Hospital, Department of Psychiatry, in units beyond the Center complex. At present, over 10,000 patients are served annually against a few hundred outpatients just prior to the birth of this university affiliated unit.

Can we now state where the major mental health work is being done actually? In the past decade by far the most rapidly developing segment of our delivery system has been that segment firmly planted in the general hospitals of the nation. Its growth has been dependent upon federal monies in the Hill-Burton programs and funds raised by state or local government and the voluntary hospitals. Its manpower was generated from a multitude of sources, including funds from the Manpower Division of the NIMH.

Here are some facts: the number of psychiatric inpatient units in general hospitals has risen rapidly. In 1964, there were 536; in 1967, 694; and in 1970, 766. The largest general percentage increase in these units was developed by the voluntary hospital - 71 per cent. The largest units, however, in terms of patients served were in city and county general hospitals. Inpatient units do not define the number of psychiatric services in general hospitals. General hospital psychiatric services today include not only an inpatient unit but also many other subsections (as does Harlem) including outpatient, consultation or liaison, emergency, and partial hospitalization units as well as specialized outreach programs. These number today nearly 900, according to the American Hospital Association.

The inpatient units alone discharged 454,000 patients in 1970, yet over 753,000 psychiatric patients were admitted to inpatient beds in these hospitals of which 23 per cent were in beds other than those designated as psychiatric. These services were so effective that only 10 per cent were transferred elsewhere for long-term care.

Furthermore, in 1973 there were recognized by NIMH some 254 community mental health centers. Of 140 federally supported community mental health centers in 1970, 103 were, in fact, general hospital psychiatric services. The Biometrics Division of NIMH fails in its report to clearly discriminate the modern expanded general hospital psychiatric services within the fascinating designation of community mental health center. But, indeed, of the latter, the majority are centered upon or directly relate to the general hospital system.

The general hospital psychiatric services of today offer the most desirable entry point into the mental health system. They provide the finest diagnostic services in the field. Nothing pays off more handsomely in the long run than an initial assay of the health problem - and this is best done where there exists a staff recruited with a standard of general excellence in all the specialties - a group of capable physicians recognizing and respectful of personal limitations and willing to refer to a specialist colleague when the individual competence is exceeded by the nature of the problem. I say this as, in my own present position, I am called frequently in consultation to advise as to the failure to improve of both young and middle-aged or older persons entered into treatment in our specialty without the thorough-going initial assay. All too often the problem rests upon an oversight in the original evaluation - a diagnostic failure if you will - that put the unfortunate sufferer onto a limited or misguided therapeutic track.

Far more interesting to me (but perhaps puzzling to other professions and the local community) are the different aims to which the therapeutic activities of our great new community based general hospital services are directed. The operators of this system are, to a very large extent, the expanding group of practitioners of psychiatry who are in some type of private practice. The phenomenal growth of the psychiatric units in general hospitals over the past two decades has proceeded quietly and steadily, gaining and gathering its support through the respect engendered by its evident aid to those who have sought its services. It has proceeded without the fervid and continuing public discussion which has attended the development of the community mental health centers. The general hospital services had their beginnings long before that movement and, as a matter of fact, have formed the most important nucleus for effective development of such centers. The general hospital services are the one true example of development of the much touted comprehensive health service- a growth related to other health services providing primary and secondary care to local communities. In the chain of currently active facilities of the mental health delivery system - the general hospital services are where the work is being done.

10.3928/0048-5713-19740501-03

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