Peter Chien, MD, MA

FROM THE AMERICAN ASSOCIATION OF COMMUNITY PSYCHIATRISTS 

He walked in 2 hours late for his appointment. Gary, a 34-year-old man, rarely came to outpatient mental health appointments. He was suffering from a psychotic illness. He interpreted numbers as foretelling his death and had self-deprecating thoughts, sometimes heard externally as voices from the spirits around him. Many other things in his life needed to be addressed as well.

Working was very important to him, but he hadn’t held a job for more than a few months because he was either too fearful or depressed. He wanted to be a responsible adult, but he lived with his parents, argued with them over money, and felt guilty for not contributing to family finances. He valued his relationship with his girlfriend but had difficulty trusting her despite recognizing that her actions were completely supportive. He considered himself an honest person but had a pending court case for theft that had occurred during a 4-hour period he did not remember. He had adult-onset diabetes mellitus and found it difficult to afford medications. He came to the appointment looking for a way to get his life back on track-most importantly, to stay out of jail and get back to consistent work.

[[{"type":"media","view_mode":"media_crop","fid":"52326","attributes":{"alt":"","class":"media-image media-image-right","id":"media_crop_2245669668765","media_crop_h":"229","media_crop_image_style":"-1","media_crop_instance":"6640","media_crop_rotate":"0","media_crop_scale_h":"206","media_crop_scale_w":"200","media_crop_w":"222","media_crop_x":"128","media_crop_y":"0","style":"float: right;","title":"The Len/Shutterstock.com","typeof":"foaf:Image"}}]]Medications only seemed like they would do so much. Addressing real-life issues-work, legal matters, health, relationships (the social determinants of mental health)-and providing him with treatment and resources “outside the pill box” were important in meeting his needs. His case provides an introduction to the value of systems-based practice.

Systems-based practice and community psychiatry

Systems-based practice, an ACGME (Accreditation Council for Graduate Medical Education) core competency, is defined as an “awareness of and responsiveness to the larger context and system of health care, as well as the ability to call effectively on other resources in the system to provide optimal health care.”

 Both of these criteria are integral to the key principles of community psychiatry, rooted in patient-centered, recovery-oriented, collaborative, systems-based practice.

Excellent psychiatric care always includes consideration of all aspects of a person’s life and surroundings. Within community psychiatry, there is a deliberate effort to engage individuals and families who have the most serious illnesses and disabilities, and who also have the most complex array of comorbidities and life challenges, including health, substance, and legal issues as well as problems with employment, education, family, relationships, and housing. Community psychiatrists seek to help patients and their families make progress toward mental health recovery-to live hopeful and meaningful lives. To do this, it is essential that we see-and help-the person, not just the illness. It is also important to see the person in his or her “system,” which includes all the issues and relationships that are relevant to his or her most meaningful goals.

Community psychiatry understands that the psychiatrist and psychiatric programs operate within a larger system. At the most basic level, psychiatrists are most effective as valuable partners on teams of other professionals, paraprofessionals, and peer supporters who all contribute to helping patients, families, communities, and populations. Flexibly collaborating and providing key leadership skills-including being a source for particularly effective patient advocacy-is an attribute expected of us and our nonmedical colleagues too.

Community psychiatrists are most effective when they know how to connect their relationships with patients with an understanding of the broader system issues that affect the patients. To be effective, psychiatrists must also be able to access resources that can help individuals and families address the multiplicity of issues and needs that affect their progress.

Anyone who has ever integrated practical case management into his or her medication sessions, worked with family members to understand how to properly support a loved one, partnered with other services on an interdisciplinary team, dealt with entitlements and third-party payers, argued for more time to spend with individual patients in need, asked for non-formulary medication to save long-term cost, worked collaboratively with a primary care physician, interacted with the criminal justice system on behalf of a patient, or integrated attention to co-occurring medical and substance use issues into their work with patients has been doing community psychiatric practice from a systems-based perspective.

An increasing number of psychiatrists today work on teams or are part of larger organizations and deal with multiple systems of care and payment.

 And many clinical psychiatrists have, through experience, trained themselves to readily apply these precepts of systems-based practice without wholly realizing that they are actually practicing community psychiatry.

Psychiatrists play 4 key roles in systems-based practice, which are defined in the 

The first step in becoming a “systems-based practitioner” is to understand all of the different systems of care that patients need to navigate: psychiatric, medical, housing, employment, criminal justice, and social/family systems.

As a patient-care advocate, it is important to help patients prioritize goals and understand which systems to navigate first. This includes building a trusting relationship and understanding the impact that symptoms and spiritual beliefs have on the patient’s understanding of his life. For example, although some of the spirits Gary was hearing were distressing, they also symbolized a future eternally happy spiritual existence for him. Their presence was part of Gary’s protective factors against self-harm. Advocating for a patient’s needs helps the team remain patient-focused.

As part of team-based treatment, Gary’s perspective was synthesized with that of his family, girlfriend, and treatment team members. Each team member-supervising psychiatrist, case manager, psychotherapist, and supportive employment specialist-brought a unique expertise to Gary’s care. His family and friends offered insight into his well-being and learned ways they could support their loved one.

As an information integrator, the team leader (often the supervising psychiatrist) gathers information from the patient and other team members. The information is analyzed and shared with the patient to develop a collaborative treatment plan that connects him to evidence-supported interventions, including patient engagement, family psychoeducation, case management, supportive employment, cognitive-behavioral therapy (CBT) for mood and psychosis, coordination with the primary care physician, and mental health treatment court.

In being a resource manager, the team’s goal is to understand patient needs and provide interventions that are clinically effective and fiscally available. Additional outpatient resources can be used to give patients their best chance of being self-sufficient and fiscally independent in the long run. Supportive employment, for example, increases long-term employment opportunities and also increases the patient’s self-worth. Time-limited individual psychotherapy, mental health treatment courts, and injectable medications are investments in patients’ long-term self-sufficient functioning in the community.

Over the course of working with the team, Gary gained trust in them. He worked with a psychotherapist for CBT for mood and psychosis. He also used mindfulness-based approaches for his thoughts and experiences. The voices continued to give dates for his impending death, but their predictions did not come true, no matter how the voices tried to rationalize it later. His distress of hearing voices reduced with time, and he agreed to see a primary care physician to manage his diabetes.

The case manager helped Gary get patient assistance for prescriptions, including injectable medications, and helped transfer his court case to mental health court, which allowed him to continue outpatient mental health treatment without being incarcerated. He secured employment in his previous field and was able to work through occasional absences with his supported employment specialist.

Gary’s case illustrates the importance of practicing psychiatry within a broader system. Although not all patients are as complex as Gary, they are served best when we treat them within the context of the people, communities, and systems most important to them.

The authors acknowledge the American Association of Community Psychiatrists (AACP) for helping to bring this article to fruition. The mission of the AACP is to promote health, recovery, and resilience in people, families, and communities by inspiring and supporting psychiatrists and transforming psychiatry.

Dr. Chien is Medical Director, Acute Recovery Center, Edward Hines, Jr. VA Hospital, Hines, IL. Dr. Frye is Director of Psychiatry and Street Medicine, Mercy Care, Inc, Atlanta, GA. Dr. McQuistion is Director, Department of Behavioral Health, Gouverneur Health, NYC Health+Hospitals, and Clinical Professor of Psychiatry, New York University School of Medicine, New York, NY. Dr. Le Melle is Co-Director of Public Psychiatry Education and Associate Professor of Psychiatry, Columbia University Department of Psychiatry, New York State Psychiatric Institute, New York, NY. The authors report no conflicts of interest concerning the subject matter of this article.

 ACGME Common Program Requirements, July 1, 2016. 

https://www.acgme.org/Portals/0/PFAssets/ProgramRequirements/CPRs_07012016.pdf

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Meet "Gary," whose case provides an introduction to the value of systems-based practice.

Peter Chien, MD, MA

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Outside the Pill Box: The Systems-Based Practice of Psychiatry