Response and Critique: University and the CMHC--Mariage d'Amour ou de Raison? James M.A. Weiss, M.D., M.P.H.

The French expression "mariage de raison" means more than its English equivalent, "marriage of convenience." It implies a certain hardnosed calculation, a balancing of gains and losses to both parties. Sometimes such unions are very successful, and once in a great while even evolve into a mariage d'amour, but sometimes they end as as a m6salliance. What Drs. Faulkner, Eaton, Bloom, and Cutler have provided here is a sort of rational marriage counseling for University-CMHC nuptials. If you are involved in the most common type of relevant relationship, in which the academic department of psychiatry assigns its residents for training to the community mental health center but has no control over its operations, well, the authors suggest, count your blessings. Be ~rustworthy, loyal, helpful, friendly, courteous, and kind, and hope the other partner will be the same. Negotiate. Assume continuing good faith on both sides, but write it all down. Realize, if you are the department chairman, that you are selling your academic chastity in a socially acceptable manner, since your residents indeed may obtain a valuable educational experience and one that is certainly ~ la mode. Realize, if you are the center director, that you are buying services that can be vital for continuing potency in the community, not to mention restful nights. But it is the task--and the only really important task--of the university to seek the truth and to teach it. Service missions are grafts that do not always take, and the academic objective must be central if the university is to endure. On the other hand, it is the task of the CMHC to provide mental health services. Educational and research missions are enhancing and facilitative to the CMHC but not necessarily essential. Compromising the basic goals of either organization too far can only lead to mediocrity or disruption. Can such a marriage work, then? The answer is obvious: it does, especially if policy and procedures are worked out in the kind of administrative process the authors outline. But only recently has the stress, pain, and trauma hidden in such liaisons been documented. Many professors of psychiatry who originally offered strong support to the CMHC concept did so because they visualized a new kind Dr. Weiss is Professor and Chairman of the Department of Psychiatry and Professor of Community Health at the University of Missourf Health Sciences Center, Columbia, Misso uri 65252, and Academic Head of the Mid-Missouri Mental Health Center, the first federally-funded CMHC in the United States. Community Mental Health Journal Vol. 18 (1) Spring 1982 0010-3853/8211300-0019502.7501982Human Sciences Press

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of mental health facility, one that would deal with more patients treated in their own communities, reaching many who otherwise could find no services available (or only inadequate or inappropriate services). The CMHC would be a facility very closely tied to the general hospital and the medical school, we thought. Wrong. That planning went at least partly awry for a number of complicated and often political reasons, not the least of which was the distortion of the team concept and the blurring of professional roles and responsibilities, the hegira away from the medical model, the inability to establish effective patterns of treatment priority, the radical alteration in many of these centers toward becoming social change agencies, and finally, inadequate or inconsistent funding. Since the missions of the two kinds of organizations are often directed in different patterns with diverse priorities, there is bound to be not only some dilution of goals and efforts, but also administrative complications, lack of clear lines of authority, and occasional constraints on creative input. Even with the best will on both sides, with written contracts and careful attention to detail, some degree of inefficiency, lowered morale, miscommunication, and waste of time and money is the likely result. Relatively rapid turnover in administrative and line personnel makes mandatory a constant process of history review, reeducation, renegotiation, and re-accommo~tation. University-CMHC complexes are unique amalgamations whose means and ends can't always mesh, nor meet societal or bureaucratic demands without a good deal of Procrustean surgery. I am not at all sure that the mariage de raison that Drs. Faulkner, Eaton, Bloom, and Cutler have demonstrated to be the most common--academic assignment of residents to CMHCs without academic control over CMHC operations--is necessarily the best. Common choices often reflect common tastes, and commitment to excellence has never been popular. Other relationships, the authors found, were not that common: A good quarter involved integration of the CMHC into the academic department, and another quarter involved contracting for specific services. More telling, at least a fifth of the departments surveyed had more than one type of relationship to a CMHC, and a similar number had n o connection, suggesting that no single type of arrangement has proven universally satisfactory. It is history that several leading academic departments have simply terminated all relationships with the local CMHC. Measures of happiness and performance quality are not provided here, so it is not clear which (if any) arrangement is superior. My own bias is that the integrated model comes closest to the ideal. Nevertheless, most of these pragmatic but perhaps ego-alien marriages somehow persevere: the partners seem at least to get along. Probably the major reason for the success obtained is the overriding sense of dedication that characterizes so many in the mental health field. The spats and bickering may go on, perspectives may not be shared, but often there can be a workable degree of mutual respect, trust, and even affection, occasionally with the dream of that transcendent mariage d'amour, more frequently with the fear that divorce and dissolution might diminish us all. The authors' thoughtful outline delineates a logical format for avoiding that d~nouement.