The Community Psychiatrist of the Future

Alan Rosen

Disclosures

Curr Opin Psychiatry. 2006;19(4):380-388. 

In This Article

Abstract and Introduction

Purpose of Review: The potential contributions of the community psychiatrist are described, via the interdisciplinary team, to individuals and families dealing with mental illness, and to the communities of the future, along with the opportunities for, and barriers to, effective teamwork and community collaborations.
Recent Findings: Health and medical training systems still provide perverse incentives deterring psychiatrists from becoming adequately trained in community psychiatry and full members of interdisciplinary teams, and skilled partners in improving the mental health of the whole community. Sources of potential role conflict should be resolved, and advantages of community collaborations, interdisciplinary leadership, support of teamwork, division of labour, cross-fertilization and hybrid vigour should be realized.
Summary: Truly essential and desirable roles and the skill base of community psychiatrists in interdisciplinary teams and local communities could be developed and strengthened by changes in basic and advanced psychiatric training, and by psychiatric professional bodies and training programmes placing greater emphasis and value upon the roles of a community psychiatrist.

The role of the community psychiatrist is defined in both (a) the microsense of providing integrated community and hospital-based mental healthcare for individuals with psychiatric disorders and their families and (b) the macrosense of promoting mental health, resilience and well being within whole communities in partnership with other professionals and agencies. This includes taking a public health approach to the prevention, early detection and intervention of psychiatric disorders.

As this subject has not been squarely covered by previous issues of Current Opinion in Psychiatry, this review will provide an earlier context as well as focus on the limited relevant literature from 2003 to 2006.

The last partially related Current Opinion in Psychiatry review by Cox[1] extolled the advantages of collaborative multidisciplinary training as it encouraged medical students and those from other health disciplines to work collaboratively as colleagues in later professional life and of offsetting work-related stress and 'burn-out' by diversifying their skills with age. To this end, future multidisciplinary psychiatric training should be influenced by philosophical considerations in 'overcoming 400 years of Cartesian dualism', and ethical dimensions, including concepts of altruism.[1] Recently a workbook for values-based practice in mental healthcare has been disseminated in the UK[2] that emphasizes the 'two feet' and 'partnership' principles, which state that all decisions should be based on facts and values (evidence-based and values-based practice working together) and by the service users and providers of care working together in partnership. We are also encouraged to employ a 'multidisciplinary (service) user-centred model of delivery' by working towards a balance of different perspectives, with the first reference point for values being the perspective of the service user (and/or family) concerned. In-vivo experiential apprenticeship training should continue to be valued[1] for community psychiatrists, as for other doctors into the future, as 'the informal interstitial fabric of medical education with which the visible formal structures function'.[3]

Community psychiatrists of the future should integrate all these dimensions into an increasingly holistic approach, comprising the following:

  1. the realization that most disorders with which we deal have multifactorial etiologies demanding multimodal intervention responses[4*];

  2. a requirement to assess, intervene with and review the whole person, employing a bio-psycho-socio-cultural-spiritual paradigm, rather than treating disembodied symptoms or merely intervening on fragmentary biophysical subsystems.[5*] Explorations of the epistemological gaps between spirituality, religion and psychiatry[6] conclude that there is a strong case for intellectual and clinical pluralism;

  3. a focus on the service users' empowerment, strengths, abilities and role restoration and defocus on service-user submissiveness (which sometimes is held to equate with 'insight'), weaknesses, disabilities and role dysfunction; valuing the service users' agency and expertise rather than imposing professional control and vocational ownership ('we know what's best for you').[5*]

In research terms, this presents an intellectually stimulating interface between the social and biological sciences. In practice, psychiatrists are most effective in applying this multimodal approach when they are committed to the importance of good teamwork with other health professionals and disciplines.

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