Founding the AACP – One Community Psychiatrist’s Tale
(Presented as part of a panel discussion entitled “Five Decades of Community Mental Health” at the APA’s Institute on Psychiatric Services. Philadelphia, October 13, 2013.)
My mother was what my father called a “steeple chaser” because she was very involved in the church and YWCA. Two of my uncles were ministers, one of whom accompanied Hubert Humphrey daily for a week to the White House to encourage President Johnson to sign the Civil Rights Act. Having been involved, myself, as an undergraduate at Yale in anti-war and civil rights marches, demonstrations, and a student strike, I went to divinity school in Berkeley as a way of continuing to pursue the anti-war and civil rights movements. I thought of serving a pastorate in Vermont over the summer between my first and second years, but was sorely challenged by the prospect of trying to help others with the issue of faith when I was so confused about it myself. I happened to visit my 82 year-old great uncle, a devoted family doctor who had continued to do 40 miles a day in house calls up until the time he went into the hospital dying of cancer. He told me that when he was younger, he had thought of going into the ministry, but decided that, for him, the best way he could minister was through medicine. Well, that hit me like a revelation, and being a romantic at heart (I had been an English major). I was inspired to carry on from where Uncle Seaver was leaving off. So, during my last two years of divinity school, where I focused on medical ethics, I took the requisite pre-med courses.
Prior to going to medical school, I had planned on becoming a family doctor like my great uncle. But, when I did my clinical rotations, psychiatry came naturally to me because of my prior pastoral counseling training. Each of the medical students at George Washington was paired up with a faculty member. My mentor, the head of the intensive care unit, who subsequently treated Ronald Reagan when he was shot, couldn’t believe that I was going to waste my medical training on psychiatry. Similarly, at Dartmouth, where I did my internship, residency, and community psychiatry fellowship, one of the faculty members couldn’t believe I was going to waste my psychiatry training on community mental health!
I had the good fortune of being selected Chief Resident of Dartmouth’s psychiatry department and a Falk Fellow of the APA. The Falk Fellowship was designed to expose residents who showed promise of leadership to the inner workings of the APA. While I hadn’t planned on becoming a “crusader rabbit” when I entered the trenches of community mental health, it was fortuitous that I had girded myself with a basic knowledge of medical ethics, solid clinical training, and some leadership experience. Leona Bachrach and I coauthored the first chapter in the book coedited by Jerry Vaccaro and me entitled Practicing Psychiatry in the Community: A Manual. Leona, a social psychologist, eloquently described the challenge facing me and other community psychiatrists at the time:
Even though President Kennedy’s message in 1963 had actually charged physicians with leadership in the new CMHCs, and even though it had stated specifically that physicians would be assisted in their efforts by “auxiliary treatment staff,” community mental health became characterized by widely disparate viewpoints over who should be “in charge” of service delivery. Many nonpsychiatric service providers, understanding the call for multidisciplinary treatment to be a mandate to eradicate line authority in the care of mental patients, sought to eliminate invidious professional distinctions through “teamwork.”…Psychiatrists often found their clinical responsibilities assumed by others as their duties were increasingly limited to signing prescriptions, completing medical records, and verifying insurance forms.
Dramatically reflecting this downward trend in psychiatric leadership within CMHCs, Knox noted in a 1985 article in “National Council News” that between 1971 and 1985 the percentage of CMHCs headed by psychiatrists fell from 55% to 8%. I suspect this percentage is now close to 0.
In 1981, I took my first job as a staff psychiatrist in a freestanding CMHC. The medical director who hired me left within a year due to conflict with the executive director who was a social worker. Under the illusion that my more collaborative style would afford me a greater chance of success, I accepted the position of medical director. Within a year, the executive director proposed eliminating our crisis service as a way of addressing a $100,000 budget shortfall. Because this would constitute abandonment of patients, my staff psychiatrist colleague and I submitted letters of resignation. Rather than accept our letters, the board fired the executive director. Nevertheless, the chief of police, a board member, felt that I had held a gun to the board’s head – an appropriate metaphor for the chief! It was evident to me that, while our board members were upstanding, well-intentioned individuals, they simply did not understand what is involved in the Hippocratic Oath.
Around this time, another one of my uncles was stricken with cancer. He had played a major role in the founding of the National Peace Institute, which was constructed after his death on the Washington Mall’s last buildable site. Once again, I was inspired by one of my uncles, this time to create a national group that would 1) provide collegial support to CMHC psychiatrists who commonly found themselves isolated and beleaguered, and 2) develop a model job description for CMHC medical directors that would tie medical-legal responsibility to commensurate authority.
Don Hammersley, a Deputy Medical Director of the APA whom I had gotten to know through my involvement with the Falk Fellowship, advised me that rather than form a group within the APA with its cumbersome, time-consuming processes and uncertain outcomes, I should form a separate organization that could impact upon the APA from the outside,
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which could act more quickly and with more assured results. His office assisted me in distributing a national survey to CMHC psychiatrists regarding their perceived need for a national association. Given the level of expressed interest, an organizational meeting was held at the 1984 Denver meeting of the Institute on Hospital and Community Psychiatry (now the Institute on Psychiatric Services). With various individuals volunteering to fill officer and board positions, what was initially known as the American Association of Community Mental Health Center Psychiatrists was born.
I managed to secure various pharmaceutical company grants to fund our board meetings, newsletter, and a manifesto-like monograph I authored entitled “Community Psychiatry: Problems and Possibilities”. Frankly, without this pharmaceutical funding, I doubt that the AACP could have been successfully launched.
I also sought to arm myself with administrative and management expertise by reading Walter Barton’s and John Talbott’s administrative psychiatry books, getting certified in Administrative Psychiatry through the APA, and becoming a Certified Physician Executive through the American College of Physician Executives.
In 1986, the AACP Board developed “Standards of Psychiatric Practice in CMHCs”. Five years later, the APA, after consulting with the AACP and the National Council of CMHCs (now the National Council for Behavioral Health), formally issued the “Guidelines for Psychiatric Practice in CMHCs”. These guidelines include sections that likely continue to be relevant today. The following is also from the aforementioned “Manual”, this from the chapter coauthored by Alexander Young and me entitled “Guidelines for Community Psychiatric Practice”:
This document clearly describes the appropriate role of the psychiatrist at CMHCs and offers model job descriptions for the medical director and staff psychiatrist positions. These descriptions address the role of the psychiatrist in ensuring quality of care, performing clinical supervision, and directing clinical policy. Authority and responsibility are clearly linked. Guidelines were also issued for emergency services, multidisciplinary team work, psychiatric signatures, and psychiatric staffing. Every psychiatrist practicing at a CMHC should be familiar with these Guidelines. The guidelines describe a minimum expected level of quality and provide the basis for negotiating a position description and for refusing to collude with a harmful system.
The subsequent executive director at my CMHC, who also happened to be a social worker, demoted me from medical
director to staff psychiatrist largely because of my activism at the state and national levels. Subsequently, I took a position as Medical Director for Behavioral Services at a large health center that included a hospital-based CMHC. I had assumed that such a hospital system, with its keen focus on morbidity and mortality issues, would assure that its medical directors had authority commensurate with their medical-legal responsibility. I was wrong. All went well for a number of years until, once again in the midst of a fiscal crisis, there was a restructuring with my report changing to a different vice-president, and with nursing management for behavioral services being consolidated under the OB/GYN nurse manager. It was her view, a view unfortunately shared by my new boss, that 90% of what occurred on the psychiatric and addiction treatment units was nursing and only 10% was medical, and that therefore I, as Medical Director, did not have approval authority over the policies and procedures for those units. When I told my new boss that I thought the way behavioral services was being managed needed to be reviewed at the highest level of the organization, i.e., by the Board of Trustees, she fired me. Feeling like a lightening rod, I decided to develop my own interdisciplinary, private practice group so that only I could fire me, and, in that unlikely event, have only myself to blame!
When I was actively involved in the AACP, other community psychiatrists who experienced challenges similar to mine occasionally reached out to me for advice and support. In thinking about what may have made some of us more vulnerable in our jobs than others, there may be a couple of protective factors which we lacked: 1) having a solid relationship with an unusually enlightened, non-psychiatrist boss, and/or 2) working in a CMHC closely tied to an academic institution. I suspect that the challenges a number of us experienced back then continue to be encountered by community psychiatrists today. I wouldn’t be surprised if the perceived need for the AACP continues to be as strong today as it was when I conducted that first survey. I worry, however, that many community psychiatrists, who find themselves marginalized and underutilized, may not know of this remarkable organization, comprised of idealistic movers and shakers who do so much for community psychiatrists and, thereby, the populations they serve. I heartily commend all of you who continue to carry the AACP torch, which hopefully will come to light the way for those who don’t yet know it even exists!
Gordon Clark, MD, MDiv gclark@selectpsych.com