Collaboration for training

Administration and Policy in Mental Health Vol. 20, No. 6, July 1993

COLLABORATION FOR TRAINING

David L. Cutler, M.D., William H. Wilson, M.D., Sally L. Godard, M.D., and David A. Pollack, M.D.

A B S T R A C T : Tra in ing has been a longstanding and fruitful area of collaboration between the public and academic sectors. Gradua te medical education for psychiatry residents is one example. This paper reviews the history of Oregon's public psychiatry t ra in ing program and highlights factors contr ibut ing to its success.

A major problem in the American mental health system is finding appro- priately trained psychiatrists to do the work. (Vaccaro & Clark, 1987). Psychi- atrists have slowly but progressively left both community mental health centers and state hospitals, particularly in the last 10 years, creating a serious leadership vacuum to be filled by less trained and less expensive individuals (Fink & Weinstein, 1979; Minkoff, 1987; Peterson, 1981; Pollack & Cutler, 1992; Talbott, 1979). Nevertheless, the poor and the severely mentally ill are still there and even more desperately need the support of quality interdisciplinary care that cannot be provided without the participation of psychiatrists (Comer, 1977). Recently, emphasis has been placed on developing a strong linkage between state and community mental health authorities and psychiatry departments in academic institutions (Talbott & Rabinowitz, 1986). The advantages to all parties have been seen as the raison d'etre that allows these collaborations

David Cutler is Professor of Psychiatry at Oregon Health Sciences University and Director of the Oregon Public Psychiatry Training Program. William Wilson is Adjunct Associate Professor of Psychiatry at Oregon Health Sciences University; Assistant Director of the Oregon Public Psychiatry Training Program; and Director of the Professional Education Unit at Dammasch State Hospital. Sally Godard is Adjunct Assistant Professor of Psychiatry at Oregon Health Sciences University; Associate Director of the Oregon Public Psychiatry Training Program; Director of Psychiatric Education at the Oregon Mental Health Developmental Disability Services Division. David Pollack is Adjunct Associate Professor of Psychiatry at Oregon Health Sciences University; Assistant Director of the Oregon Public Psychiatry Training Program; Medical Director of Mental Health Services West, Inc. Address correspondence to David Cutler, Dept. of Psychiatry, Mail Code OP-02, Oregon Health Sciences University, Portland, OR 97201.

449 �9 1993 Human Sciences Press, Inc.

450 Administration and Policy in Mental Health

to succeed (Beigel, Sharfstein, & Wolfe, 1979; Faulkner, Eaton, & Rankin, 1979; Talbott, Jeffries, & Anana, 1987).

The Oregon Public Psychiatry Training Program has been a highly successful model for nearly 20 years in meeting the needs of the state's mental health system for community and state hospital psychiatrists (Faulkner et al, 1987). The Program was established in 1973 to provide a specialized education for residents in the unique knowledge, skills, and attitudes essential for practice in public sector psychiatry in Oregon (Shore, Kinzie, & Bloom, 1979). At that time representatives from the state senate, the dean of the medical school, the director of the state mental health agency, the state hospitals, the chair of psychiatry, and the community mental health directors association joined forces to develop funding and establish a board that would select a director and oversee the program in conjunction with the chair of psychiatry. That board is still meeting two or three times a year to monitor the progress of the program. The function of the board is to assure that psychiatrists trained in Oregon are able to meet the needs of public patients both in state hospitals and in community mental health centers. The board shares authority with the department chair to hire the director and the associate director.

The associate director position was formerly the training director of the Oregon state hospital program, but now is the director of Human Resource Development and psychiatric training and education for the Oregon Mental Health and Developmental Disability Services Division. As such, this individual is the lead psychiatrist for training, retention and recruitment of psychiatrists and other mental health workers within the state system (Godard et al., 1988). The program also maintains a close working relationship with the local community mental health program in west Portland. The medical director of that program is an assistant director of the Public Psychiatry Training Pro- gram. The program has increased its affiliation with the state hospital system by development of a training unit. The unit director is also an assistant director of the Public Psychiatry Training Program. These four individuals supervise and manage the training program.

Meetings of the board provide an opportunity for the several participants in the program to review progress and express concerns. The board includes representatives from the state mental health authority, the state hospitals, the community mental health program directors' association, and the dean of the medical school. Typically the board will hear presentations about the training program with vignettes about individual trainees. In the last few years, the director of the Western Mental Health Research Center has attended board meetings and has provided summaries of local mental health services research.

Although the board has been a great source of stability for all these years the program has not stood still. In concert with the evolution of theory and practice in the field of mental health, the orientation of the curriculum has gone from primary prevention/mental health consultation and crisis intervention (Cap-

David L. Cutler, et al. 451

lan, 1963) to tertiary prevention and the care of the chronically mentally ill (Cutler et al. 1981; Faulkner, Cutler, & Krohn, 1989; Minkoff 1987a & b; Nielsen et al., 1981).

While building an emphasis on treating persons with severe and chronic mental illness, the program has offered educational activities of broader scope and greater depth. It is integrated into the general psychiatric residency and involves three major blocks of time in the second, third, and fourth years of training. The inclusion of both state hospital and community training within its mission has strengthened the continuity of its training within the residency program.

This paper explores this education and training in public psychiatry that is a result of the successful collaboration between the state and the university. We present the various perspectives that characterize the points of view of the hospital, the community, the university, and the mental health authority.

STATE HOSPITAL TRAINING

In ideal service systems, state hospitals provide tertiary backup for compre- hensive community care (Diamond, 1979; Minkoff, 1987a). The development of state hospitals as high quality, tertiary neuropsychiatric/rehabilitation insti- tutes, as opposed to custodial institutions, requires professionals who are knowledgeable and skilled regarding service systems and special needs of the severely ill individuals that they serve (Faulkner, Cutler, & Krohn, 1989; Faulkner, Rankin, & Eaton, 1983; Stein, Factor, & Diamond, 1987). To address these issues, the Public Psychiatry Training Program, the Oregon Mental Health and Developmental Disability Services Division, and Dam- masch State Hospital have recently agreed to collaborate in upgrading previ- ously existing state hospital training to a "Professional Education Unit" (Bloom, Cutler, & Faulkner, 1989).

Setting

Dammasch State Hospital is a 375-bed facility in a suburban setting 30 minutes from the university. It offers acute and intermediate treatment as well as long term care.

The unit used for training is a 36-bed, co-educational, inpatient ward, which is staffed by the hospital at the same level as other wards, with the exception of having three additional leadership positions: Unit Director, Clinical Nurse Specialist, and Research Associate. The Unit Director is employed by the hospital and has a faculty appointment at the university. He spends one day per week at the university, teaching and supervising residents in the community psychiatry program and engaging in academic endeavors. Two second year (i.e., two years after receiving the M.D. degree) psychiatry residents are


assigned to a rotation on the unit every three months. Fourth year residents may take an elective on the Unit and focus on clinical, research, or administrative activities.

Educational Program

The Unit has both formal and informal educational activities. The formal activities center around psychiatric residency education, the hospital's psychol- ogy internship, an undergraduate nursing rotation, and new programs in graduate nursing and graduate social work. The approach of these programs is illustrated by the residency curriculum. The three month rotation for second year psychiatric residents is designed to develop the clinical and cognitive skills required to provide competent treatment and rehabilitation to severely ill individuals in a public inpatient setting. An individualized learning contract is developed collaboratively by the resident and Unit Director in the first weeks of the rotation that structures the resident's experience and provides a reference for evaluation. Activities that are required of all residents are listed in the first section of the contract, and residents then select specific areas, which they choose for enrichment activities. Required activities consist of serving as the psychiatrist on an interdisciplinary treatment team caring for 12 patients.

COMMUNITY MENTAL HEALTH TRAINING

In their third year all psychiatry residents select a placement in a community mental health center anywhere in the state of Oregon. Residents browse through an agency profile notebook (that contains information on all of the mental health agencies in the state) and then discuss their observations with the director or associate director of the Public Psychiatry Training Program. They then visit two or three of these programs prior to beginning their rotation, and select the program they wish to be placed in and begin a six-month, half time rotation in community psychiatry. During the first six to eight weeks the residents try to observe as many activities within the program as possible. They also visit collaborative community agencies and begin to discuss consultation activities. They then negotiate under supervision a contract with the community mental health center, which defines the range of activities they both can agree on. Since the training program pays the salaries, the residents have considerable leverage to do things that interest them and develop individualized roles (Langsley & Barter, 1983). Residents are not permitted to spend more than 50% of their time seeing patients, so that they have adequate time to become involved in other processes at the mental health center, such as administrative activities, quality assurance activities, supervision and training, and mental health consultation outside the agency.

By the end of this rotation residents are expected to have the following skills and attitudes.


Abili t ies to."

a) Enter a community mental health delivery system with a clear understanding of the psychiatrist's role;

b) Distinguish between levels of intervention and prevention; c) Perform case management (assessment, planning, linking, monitor-

ing, and advocacy); d) Plan, work, and relate on an interdisciplinary team for the provision

of direct or indirect services for long-term mentally disabled persons; e) Negotiate a consultation contract; f) Conduct a mental health consultation with a community agency; g) Initiate basic mental health program planning strategies; h) Work through a process of consultation termination; i) Conduct pre-commitment evaluation and court examinations under

Oregon's commitment statute; and j) Demonstrate a thorough understanding of the use of medications in

collaboration with non-medical staff around issues of compliance and informed consent.

Demonstrate."

a) Appropriate respect and sensitivity to racial, cultural, and ethnic values of patients, families, and interdisciplinary mental health team members;

b) Responsibility to patients, their families, and significant others, including agency people, and appropriate respect for their opinions and welfare;

c) Willingness to consider and evaluate criticism and peer review of one's professional work;

d) Commitment to evaluation of treatment results as scientifically as possible;

e) Comfort in dealing with highly personal and emotionally charged situations; and

f) Sensitivity and willingness to explore a variety of opinions, attitudes, and ideas set forth by patients, patient advocates, and community members at large.

Perhaps the key to our model is the written contract that residents are required to develop with the community program for their six-month rotation. This process occurs in the first month of the placement and is carefully supervised to assure that residents do not focus only on clinical responsibilities and miss the overview of community mental health service. Indirect services, including those mentioned above, must comprise at least 50% of their activities. Residents are encouraged to provide consultation not only within their program but also with other community agencies that may provide services to the same target populations of the mental health program. Direct services of


individual, family, or group therapy, medication management, and court commitment evaluations are part of the resident's activities as long as they do not undermine the goal of assuring that the resident understands the "big picture."

The knowledge base that supports this rotation is provided through a two- hour weekly seminar. The curriculum covers the history and structure of community mental health, basic concepts of social and transcultural psychiatry, psychiatric epidemiology, principles of administration, interdisciplinary treatment, and mental health needs of the chronically mentally ill as well as special populations such as minorities, developmentally disabled, and the homeless. The seminar is interdisciplinary (Cutler, 1987), attended also by social work students and nursing students in the master's level mental health nursing program. The trainees have opportunities within this seminar to discuss their placement experiences and relate them to the principles that have been presented. Guest speakers, audiovisual programs, and field trips to community programs contribute to the broad educational perspective.

During the community rotation, each psychiatric resident has two super- visors. The supervisor at the placement site is usually an administrator who may or may not be a psychiatrist. The second supervisor is a psychiatrist on faculty in the Public Psychiatry Training Program. The resident meets for one hour weekly with each supervisor. An evaluation is completed by each supervisor at the end of the rotation.

Another evaluation unique to this rotation is the oral examination. At the end of the six-month rotation, each psychiatric resident participates in a 40 minute oral exam, which is conducted by an interdisciplinary team of exam- iners with experience in public mental health programs. Residents are given hypothetical situations that relate to community mental health. They are expected to formulate a response in a problem-solving manner that draws upon the experience and knowledge gained during the rotation. They are also asked to describe specific consultation problems within their own community rotation and to discuss possible strategies that could be utilized to solve the problem. This examination evaluates abilities and knowledge in a manner that emphasizes the uniqueness of public psychiatry.

The six month rotation is very popular with psychiatric residents, as indi- cated by the frequent choice of a community placement during the elective year. The strong priority of community psychiatry in the department has been a helpful factor in the recruitment of residents from other parts of the country. It has also been successful in its goal of providing well-trained psychiatrists for the community mental health programs in Oregon. Currently, 25 of Oregon's 36 counties are served by 30 graduates of this program.

This rotation exposes residents to the realities of community mental health, which often means less than ideal circumstances for psychiatrist participation. The weekly seminars, however, provide a consistent framework for teaching

David L. Cutler, el al. 455

basic knowledge to every resident. Weekly supervision assures that the system dynamics, whether strengths or weaknesses, can be thoroughly explored. Although ideal role models are preferred, residents also learn from the struggle to establish an identity that may differ markedly from the role of the psychiatrist in their particular placement. Active public psychiatric role models within our academic department and in other parts of our system assist the residents in achieving an understanding of the behavior of strong psychiatric leaders as well as a clear sense of how to negotiate a role for themselves in the public sector.

ADMINISTRATIVE TRAINING ACTIVITIES

Some psychiatry residents choose to do an elective community rotation during the last few months of their fourth year in a location where they are considering post-residency employment. These fourth year electives have been a valuable bridge from residency to career choice, helping to ensure a good match between psychiatrist and agency.

In the fourth year residents also have an opportunity to spend a full year working in an intensive specialty clinic with long-term mentally ill patients and/or to take an elective within the state mental health authority. These activities could include electives in either administrative psychiatry focusing on the chronically mentally ill, in forensic psychiatry, or in state hospital psychiatry on any of the specialty units at Oregon State Hospital or Dammasch State Hospital. Clinical electives in psychiatric rehabilitation are available, and are based at one of three rehabilitation oriented day treatment programs in various parts of the state (Anthony, Cohen, & Cohen, 1983).

The University Hospital Outpatient Clinic includes two specialty clinics that focus on chronic mental illness. One is a Southeast Asian clinic, which recently received a gold award from Hospital and Communi ty Psychiatry. The other is a clinic for young adult schizophrenics. These are full one-year assignments where residents observe expert clinicians involved in long-term care.

Fourth year administrative residents are supervised by the director of the Public Psychiatry Training Program and by the administrator of the Oregon Mental Health and Developmental Disability Services Division. This intensive supervision allows residents to be in contact with psychiatrists who play major administrative and program planning roles. The trainees are imbedded first hand in a context where public mental health is the first goal (Gaver, Norman, & Greenblatt, 1984). The Mental Health and Developmental Disability Ser- vices Division in the state of Oregon by law must focus most of its energy on the chronically mentally ill. The residents have the opportunity to see how the planning process works within a value system that is dedicated to the public patient. Trainees work side by side with staff of the Division and consultants


from the Public Psychiatry Training Program who spend a day a week in the agency doing research, planning, and site visits throughout the state. We believe this situation is a fairly optimal one, since the residency program at the university is the only one in the state, and the relationship between the state mental health authority and the residency program has operated for 20 years smoothly and uninterrupted.

DISCUSSION

Of course, it is not always easy to establish similar programs in other places. Through a Pew Memorial Trust initiative, and independently, we have provided consultation to colleagues in other parts of the country but to date have not seen profound changes (Talbott, Bray, Flaherty, Robinowitz, & Taintor, 1991). Where there are territorial disputes between departments of psychiatry, it is sometimes difficult for state mental health agencies to establish close working relationships. In addition, many departments of psychiatry are sus- picious of the motivations of state authorities and often are not even interested in their money. Thus, a department's program focus depends on the orientation and beliefs of the department head.

Nowadays few academic psychiatrists are focused on the public sector or are connected to their 19th century moral treatment roots. Some departments have suffered by overextending themselves in direct service in community mental health centers (Barter & Langsley, 1986). Programs, for example, that are more focused on biological or psychodynamic psychiatry might be reluctant to commit themselves to a close working relationship with a mental health authority having a mission of serving large numbers of severely mentally ill persons. Most residency training directors are careful about the degree of direct services they allow their trainees to participate in for fear of burn-out.

Our program, however, appears to possess burn-out-proof checks and bal- ances which, taken as a whole, make the public sector look quite attractive. The program has been highly successful in recruiting 70 to 80 % of its graduates for the public sector over the past 20 years, particularly for community mental health and in recent years for the state hospitals as well.

In summary, public psychiatry education and training in Oregon has had a long and successful record. The program has evolved from community psychiatry training with a prevention and consultative model to public psychiatry training that recognizes the broader continuum of care in working primarily with the population of chronically mentally ill persons. Principles specific to this population have been identified and incorporated into the program, which has affiliated with other areas of training within the department to encompass all four years of psychiatric residency. More recently the collaboration between the state and academic sectors has led to joint research projects in mental health services research.


The dynamics of university and state systems require training programs to maintain an openness to new ideas. The changes that have come about in the Oregon program have enhanced, rather than diminished, the training opportunities for psychiatry residents. Though the process is time-consuming and sometimes difficult, this collaborative effort between educator and policymaker is valuable for education and system improvement.

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Collaboration for training