Community Mental Health Journal, Vol. 29, No. 3, June 1993
Training Residents for Community Psychiatric Practice: Guidelines for Curriculum Development Donald B. Brown, M.D. Charles R. Goldman, M.D. Kenneth S. Thompson, M.D. David L Cutler, M.D.
ABSTRACT: There is a critical need to recruit and retain more psychiatrists with the required skills and interest to work with seriously mentally ill and/or socially disadvantaged patients within organized programs in community settings. More residency training programs having the capacity to prepare psychiatrists for community practice can help to meet this need. A consensus definition of the clinical, administrative, consultative and academic areas of contemporary community psychiatric practice developed by the American Association of Community Psychiatrists is used to determine the goals of the training curriculum described in this paper. A comprehensive list of knowledge, skill, and attitude objectives, as well as suggestions for structuring clinical training assignments are provided as guidelines for curriculum development.
I N T R OD UCTION
As the primary locus of the psychiatric care has moved from hospitals to community settings over the past 25 years, the leadership for developDonald B. Brown, M.D., is Associate Clinical Professor of Psychiatry, Columbia University College of Physicians and Surgeons and Director, Ambulatory Mental Health Services, Department of Psychiatry, St. Luke's Roosevelt Hospital Center, 428 W. 59th St., New York, NY 10019. Charles R. Goldman, M.D., is Professor of Psychiatry and Director, Public Psychiatry Training Program, Department of Psychiatry, University of South Carolina, School of Medicine. Kenneth S. Thompson, M.D., is Assistant Professor of Psychiatry, University of Pittsburgh and Medical Director, Division of Public Psychiatry, Western Psychiatric Institute and Clinic. David L. Cutler, M.D., is Professor of Psychiatry and Director, Public Psychiatry Training Program, Department of Psychiatry, Oregon Health Sciences University. 271
9 1993 Human Sciences Press, Inc.
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ing and running community based services has dramatically shifted from psychiatrists to other professional groups. As a result, the influence of psychiatrists in policy formulation, service planning, administration, and even leadership in clinical practice has declined significantly. Consequently, there is now a critical and growing need to recruit and retain competent, dedicated psychiatrists to work with seriously mentally ill and/or socially and economically disadvantaged patients within organized programs in community settings (Clark and Vaccaro, 1987; Diamond et al., 1985; Faulkner et al., 1987; Langsley and Barter, 1983; Thompson and Bass, 1984). This need, as well as the increasing dissatisfaction and demoralization of psychiatrists now practicing in community settings, were important impetuses to the formation of the American Association of Community Psychiatrists (AACP) in 1985 (first called The American Association of Community Mental Health Center Psychiatrists). Key purposes of this organization have been to develop standards for community psychiatric practice as well as to offer ongoing support to practitioners. The original Board members of the AACP felt strongly that another way to improve the recruitment and retention of psychiatrists was for trainees to be adequately taught the special knowledge and skills for effective practice while being exposed to the special challenges and rewards associated with this kind of work. A residency training committee was established and charged with recommending strategies for improving the efforts of training programs in preparing general psychiatry residents for careers in ~community psychiatry." As a first step, a national survey of residency programs was conducted in order to obtain a baseline of data regarding current practices and trends in training residents in "social, community, or public" aspects of psychiatry. An important conclusion reached in that survey was that faculty lacked a clear conceptual base and curriculum for community psychiatry (Goldman et al., 1993). Currently, there is much emphasis on curriculum design related to treating the most seriously mentally ill (Cutler et al., 1981; Faulkner et al., 1989; Lefley e~ al., 1989; Minkoff, 1987; Factor et al., 1988) an emphasis which we agree is long overdue. However, "community psychiatry" traditionally involves concepts and methods which go beyond direct clinical services to one target population. We, therefore, saw a need to develop this basic curriculum to enhance the preparation of psychiatrists for community practice.
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W H A T IS C O M M U N I T Y PS YCH IA TR Y?
There currently is no widely accepted definition of community psychiatry. Previous efforts to define and clarify community psychiatry and related terms (Goldston, 1965; Committee on Psychiatry and the Community of the Group for the Advancement of Psychiatry, 1983; Panzetta, 1985; Bachrach, 1991) emphasize the importance of distinguishing community psychiatry from the broader field of community mental health and community mental health center programs. But we found t h a t the definitions offered in these and other related publications (Borus, 1978; Caplan and Caplan, 1967; Hinsie and Campbell, 1970; Klerman, 1988; Lamb, 1988; Langsley, 1980) were not clear or consistent enough for us to use as a basis for defining the scope of a training curriculum in community psychiatry. Thus, in 1989, the authors drafted their own definition of contemporary community psychiatric practice based upon their own experience. Over the next two years, the definition underwent a series of five revisions-each change involving a process of (often vigorous) discussion and consensus editing involving the association's 12 member Board of Directors. Input from the AACP's general membership was also obtained through publication of a draft in the association's newsletter (Brown et al., 1991). The resulting definition covers a broad spectrum of roles for community psychiatric practice and provides the basis for the authors' proposed curriculum. The definition is as follows: Community Psychiatry is a branch of psychiatry which emphasizes the integration of social and environmental factors with the biological and psychological components of mental health and mental illness. Community psychiatry is also a significant component of the more inclusive field of community medicine which focuses broadly on the prevention and treatment of illness for all individuals in a given community. Specific areas of community psychiatric practice include: 1. Clinical
The foci of practice for the clinical practitioner of community psychiatry are the particular biological and psychological dimensions of each individual patient in his/her immediate socio-cultural context. In addition to using biological and psychological assessments and interventions, emphasis is placed on addressing both the competence and needs pres-
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ent in the patient's social network. Optimal adaptation and enhancemerit of functioning are the goals. The clinical community psychiatrist may practice independently or work within an organized setting, e.g. community mental health program, community health clinic or hospital. It is desirable that the psychiatrist function as an integral part of a multidisciplinary clinical team. Clinical care may require direct outreach to persons unwilling or unable to come in to an office or clinic setting. In some service systems, the psychiatrist may be required to serve in the role of public health officer with responsibility for assuring the basic health and safety of psychiatric patients living in a variety of community settings. For effective practice, the psychiatrist will need information and resources from a wide variety of individuals and organizations. This usually requires collaboration and coordination with colleagues from mental health, medical and other h u m a n service systems as well as, when appropriate, with family members, neighbors, employers, and other persons with direct knowledge of the patient. Practice will incorporate new knowledge and will include a willingness to find approaches which maximize all available resources and enhance treatment outcome. 2. Consultative
The community psychiatrist in the role of consultant provides psychiatric input to other h u m a n services, medical practitioners, community agencies and consumers groups, thereby providing an indirect service to members of the community. In this role, the psychiatrist is able to inform and educate community organizations and groups about the prevention or amelioration of mental health/illness problems. Consultation can be an essential element of preventive interventions. It is also a strategy developed to cope with the fact that there are not enough mental health professionals (and never will be) to individually attend to all people with psychiatric problems and that a community based mental health care system on its own cannot provide the full range of h u m a n services or resources that its clients require in order to sustain themselves in the community. 3. Administrative
The community psychiatrist in administration has the responsibility to plan, organize, implement, supervise and evaluate the quality of mental health programs. The understanding and use of epidemiologic and
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mental health services research data are critical to this work. The result of this activity is to provide a comprehensive, coordinated network of mental health services to meet the diverse needs of a particular community or target population. Available resources must be allocated to assure t h a t financial, cultural, legal, and/or geographic barriers to service are minimized. The services are directed to individual patients, families and groups. Indirect services (as performed by the consultant community psychiatrist) as well as direct clinical services are important components of any community mental health system. Practice is often in an agency likely to be resource poor in comparison to the problems faced, requiring special commitment and ingenuity. 4. Academic
The community psychiatrist in academia has extensive knowledge and skills in one or more of the above described roles and is based in an academic department of psychiatry. He/she has special competency as an educator and/or researcher, usually emphasizing clinical or applied systems research. This role involves collaboration with other disciplines as well as various agencies and consumer groups, and should address identified concerns of such agencies and consumers.
RESIDENCY TRAINING ISSUES
Many areas of psychiatry requiring special knowledge and experience have been delineated in recent years. Child, Consultation and Liaison, Substance Abuse, Administrative, Geriatric, are examples. Each area has its own particular history of dealing with the questions of special curricula in residency training, fellowship programs, and/or certifications. A number of fellowships in community psychiatry (also called ~social" and ~public" in various combinations in their names) exist throughout the United States. Many objectives central to the practice of community psychiatry are already a part of any good general psychiatric residency training program. The Accreditation Council for Graduate Medical Education (ACGME) guidelines for residency training in psychiatry states that "residents must be able to conceptualize all illnesses in terms of biological, psychological and socio-cultural factors which determine normal and disordered behavior" (Special requirements for residency training in
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psychiatry, 1990, p. 4) which is fundamental to our multi-systems clinical approach. While the ACGME guidelines provide little guidance about curriculum specific to community psychiatry, two of our knowledge objectives are similar. This concurrence is referenced in our text. We also refer the reader to the article by Faulkner, Cutler, et al., (1989) for suggested revision of ACGME requirements and for a discussion of training that closely relate to those presented in this article. Our curriculum recommendations are divided into essential and recommended goals. A psychiatric residency training program which chooses to develop a curriculum to prepare residents for community psychiatric practice should be able to attain all of our essential goals. They are based upon all of the clinical and some of the consultative areas of community practice delineated in our definition. The administrative and academic aspects of community practice form the basis of our recommended objectives. These are for programs able to offer enhanced training in community psychiatry or for individual residents electing additional specialized t r a i n i n g - i n c l u d i n g that available in a fellowship program.
OUTLINE OF CONTENT CURRICULUM AND GENERAL KNOWLEDGE OBJECTIVES: The content curriculum is intended to assist in the overall design of teaching programs. Many approaches are feasible as methods for teaching, ranging from lectures and seminars to case conferences, supervision of clinical work, and visits to community sites where the lives of patients and members of their social networks can be appreciated "in vivo." In all instances, it is recommended that the clinical and formal teaching activities be complemented by reading lists and topic outlines.
A. Essential Knowledge Objectives: 1. The history of the development of community mental health concepts, legislation, deinstitutionalization, and model programs both nationally and in the local region. 2. The basic concepts and research findings of psychiatric epidemiology including the influences of social class, cultural factors, gender and age, upon the etiology, presentation, course, and treatment of psychiatric disorders.
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3. The Public Health principles and strategies of primary, secondary, and tertiary prevention as applied to psychiatry. 4. "The issues of financing and regulation of psychiatric practice, including information about the structure of governmental and private organizations that influence mental health care." (Special requirements for residency training in psychiatry, 1990, p. 8) 5. The differing '~attitudes, values and social norms prevalent" among various American cultural, and ethnic groups. (Special requirements for residency training in psychiatry, 1990, p. 13) 6. A basic understanding of the service delivery strategies for a population with special needs such as, for example, impoverished and/ or homeless populations, the chronic mentally ill, a specific ethnic group, the elderly, primary care medical patients, patients with ~dual disorders," or mentally ill prisoners. 7. The basic concepts of multilevel, interacting systems and the application of systems theory to both clinical practice and psychiatric administration. 8. The principles of multidisciplinary team function and management in a program serving psychiatric patients. 9. Basic concepts of normal family process and the special family issues involved when one or more members suffer from a psychiatric disorder. 10. A working understanding of the principles and processes of support systems and social network intervention. 11. The principles of crisis work and brief treatment utilizing multisystem level clinical intervention. 12. The assessment of disabilities and the eligibility criteria for entitlements. 13. Practical knowledge about agencies in the community that provide financial, vocational, medical, legal, child care, housing and other supportive services. 14. The variety of adaptations of persons with long term mental illness living in the community, including: clinical course, selfregulation of illness, life-styles, social and vocational dimensions, issues pertaining to co-morbidity with alcohol and drug abuse, physical illnesses/injury/neglect, personality disorder, mental retardation and criminality. 15. Consumer (including family), self-help and advocacy organizations and the various roles consumers can play in mental health programs and systems.
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16. The major laws of his/her state concerning competency, grounds for and conditions of involuntary treatment, and the relationship of criminal liability to psychiatric illness.
B) Recommended Knowledge Objectives: 1. An awareness of basic skills and knowledge base needed to be a psychiatric administrator and/or leader in the mental health service arena. a. An understanding of mental health program planning and its relationship to epidemiologic, clinical outcome, and cost effectiveness data, as well as governmental/political processes. b. A knowledge of administrative theories and practices useful to the clinician executive in mental health systems and programs. c. An understanding of the complex formal and informal interactions of staff and patients within psychiatric systems and programs. 2. Health systems research methodology-including knowledge in measurement, statistics, and research design. 3. The theoretical concepts and strategies concerning the practice of mental health consultation to various agencies and programs.
OUTLINE OF GENERAL SKILL OBJECTIVES: Opportunities may be repeated throughout the training period, permitting skills and knowledge to be accrued and elaborated progressively while working in a variety of in-patient, outpatient and community based settings. Thus the following objectives are applicable throughout the residency.
A. Essential Skill Objectives: Demonstrate Competence in: 1. Working effectively as a member of an interdisciplinary team. 2. Conducting comprehensive biopsychosocial assessments which pay special attention to the following elements needed for effective community psychiatry practice: a. Both the functional strengths/capacities and deficits/disabilities of the patient. b. The nature of family and other relevant social networks, their roles in the patient's life and their needs for education, support, and other resources.
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c. Assessment of community and environmental issues including: i. Housing/residential needs ii. Entitlements and income iii. Availability of other community resources for recreation, education, vocational pursuits. iv. The possible impact of other social factors such as stigma, idleness, or the proximity of violence and/or drug use. d. Impact on assessment of differences between the resident and the patient in socio-cultural backgrounds. 3. Formulating a multidisciplinary comprehensive treatment plan and assembling the various elements of comprehensive community care to include: a. Emphasis on least restrictive setting closest to the patient's natural environment. b. Addressing patients needs for housing, income, and optimal social and vocational functioning c. Addressing the needs of the patient's family and other key persons in the patient's social network-including other service providers 4. Rapidly treating patients during a psychiatric emergency or crisis and implementing effective linkage with programs emphasizing community maintenance and functional rehabilitation. 5. Appropriately integrating a variety of roles and tasks in working with chronically mentally ill patients: doctor (for overall health concerns as well as maintenance of psychotropic medications), psychotherapist, case manager, consultant (to family and other caretakers), teacher and skills trainer 6. Explaining to patients, families, and others the characteristics, known facts and key theories regarding relevant psychiatric disorders and their treatment. 7. Providing testimony to a court of law concerning a patient's psychiatric condition and treatment under the applicable commitment and family law codes of their State.
B. Recommended Skill Objectives: Demonstrate competence in: 1. Carrying out basic leadership and/or administrative responsibilities in a health system or program, including supervision of services provided by mental health clinicians from various disciplines.
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2. Entering a community mental health delivery system or program negotiating a psychiatrist's role which includes an awareness of the direct and indirect service aspects of his/her role. 3. Using different models of consultation by: a. Negotiating a contract and carrying out a defined period of professional mental health consultation to a community agency, utilizing a client-, consultee-, or agency-centered focus. b. Participating effectively as a resource person and group process facilitator in a community group involved with planning or carrying out self-help or community mental health services. 4. Planning and implementing a community-based mental health educational activity for a non mental health professional audience. (e.g. clergy, police, school, rotary club, self-help group). 5. Evaluating the effectiveness of service delivery programs and/or systems. Attitude Objectives 1. Appropriate respect and sensitivity to racial, cultural, and ethnic values of patients, families, and interdisciplinary mental health team members. 2. Responsibility to patients, their families, and significant others, including agency people, and appropriate respect for their opinions and welfare. 3. Openness to exploring a variety of opinions and attitudes and ideas set forth by other mental health members, patients, patient advocates, and community people at large. 4. Willingness to consider and evaluate criticism and peer review of one's professional work.
S T R U C T U R E OF CLINICAL T R A I N I N G E X P E R I E N C E S Many learning objectives of Community Psychiatry training can be achieved in the traditional setting of inpatient wards, outpatient clinics, and emergency units. Patient care responsibilities and supervision can be organized so as to assure specific attention is paid to the learning objectives we have outlined. However, the experiential component of some of the objectives requires exposure to non-traditional community-based settings. A process of multi-agency collaboration with linkages between a
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residency training program and various mental health service programs in the surrounding community offers an excellent opportunity for organizing the required residency training experiences. It also models essential dimensions of effective community psychiatry p r a c t i c e - t h e use of systems theory, linkage, collaboration, resource sharing, and mutual support seen in both effective care plans for individual patients and comprehensive service systems. Based upon our own experience, and that of others, (Goldman et al., 1993; Factor et al., 1988; Bloom et al., 1989; Breakey, 1991) we consider the following aspects of the structure of community psychiatry training experiences to be most important: 1) Supervised patient care should be offered in settings which have responsibility for the care of defined populations in the community. This clinical care should be delivered in collaboration with a multidisciplinary staff. 2) Clinical rotations in one or combined settings may vary. Examples from a recent survey (Goldman et al., 1993) included, 3 months full time, 6 months half time, or from 4 to 16 hours per week for one year or more. Most formal rotations occurred in the PG 3-4 years, although some earlier exposure to community based programs is desirable. Some examples of training sites are: a psychosocial rehabilitation program, a mobile crisis outreach team, a case management/continuous treatment team, an acute partial hospital program, a homeless outreach or shelter program, an adolescent psychiatry program in a public school, a primary care medical team, a dual diagnosis program, a prison mental health program, a service program for Asian refugees, etc. 3) Students should be supervised by faculty who are enthusiastic, experienced and knowledgeable role models who, whenever possible, are clinically active in one or more of the roles defined above. In addition to individual supervision, regular supervision of a group of residents working in various program settings is desirable. Some successful training programs utilize local staff (medical and non-medical) for remote placements with central group supervision by psychiatric faculty. 4) The training should have a faculty coordinator responsible for arranging and maintaining good working relationships with the programs used for off site placements. 5) Although much of the experience should involve direct patient care, residents should also have significant experience providing indirect service. Time for such activity must often be carefully protected and closely supervised. 6) Involving residents in ongoing research and/or special projects is an
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effective way for them to meet some of the training objectives. PGY-4 electives in community psychiatry are opportunities for residents to demonstrate initiative and creativity, and can have a beneficial impact on the mental health service system. Projects which evaluate innovative mental health programs or use existing data to facilitate planning have special value. Two well established and contrasting models for organizing community psychiatry training are a) the Oregon model (Godard et al., 1989) which requires residents to negotiate contracts at one of a variety of mental health centers in the State with lh of their time being non-direct care; and b) the Madison, Wisconsin model (Factor et al., 1988) which integrates residents into a specific highly evolved mental health center which emphasizes community treatment of chronically mentally ill patients using assertive outreach and relatively high staff to patient ratios. Variations on these two themes have been implemented in other locations. CONCLUSION
We have presented these guidelines for curriculum development in the hope that they will encourage and enable residency training programs to more adequately prepare psychiatrists for community psychiatric practice. Similar to a recommendation made by Faulkner et al. (1989) concerning their curriculum for the chronically mentally ill, we encourage residency training programs to offer support for academic careers which offer faculty opportunities to integrate research in areas relevant to community psychiatry (such as epidemiology, service evaluation, etc.) with administrative and teaching roles. This will strengthen an academic department of psychiatry's ability to recruit and retain qualified faculty to teach this curriculum. Obtaining technical assistance and administrative support for implementing a community psychiatry curriculum is encouraged through contact with the American Association of Community Psychiatrists as well as through informal collaboration among faculty responsible for Community psychiatry training. REFERENCES Bachrach L.L. (1991). Community psychiatry's changing role. Hospital and Community Psychiatry, 42:573-574. Bloom, J.D., Cutler, D.L., Faulkner, L.R., Godard, S.L., Bray, J.D., Concannon, K., & Lippincott, R.C. (1989). The evolution of Oregon's Public Psychiatry Training Program. New Directions in Mental Health Services, 44:113-121.
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Borus, J.F. (1978). Issues critical to the survival of community mental health. American Journal of Psychiatry 135:1029-1035. Breakey, W. (1991). Personal Communication. Brown, D.B., Goldman, C.R., & Thompson, K.S. (1991). Residency training committee: Defining community psychiatry. Community Psychiatrist, 5(1):4. Caplan, G., & Caplan, R.B. (1967). Development of community psychiatry concepts, in A.M. Freedman and H.I. Caplan (Eds.) The Comprehensive Textbook of Psychiatry I. Baltimore, Williams & Wilkins, pp. 1499-1514. Clark, G.H., Jr., & Vaccaro J.V. (1987). Burnout among CMHC psychiatrists and the struggle to survive. Hospital and Community Psychiatry 38:843-847. Committee on Psychiatry and the Community of the Group for the Advancement of Psychiatry (1983). Community Psychiatry: A Reappraisal. New York, Group for the Advancement of Psychiatry. Cutler, D.L., Bloom, J.D., & Shore, J.H. (1981). Training psychiatrists to work with community support systems for chronically mentally ill persons. American Journal of Psychiatry 138:98101. Diamond, R.J., Cutler, D.L., Langlsey, D.G., & Barter, J.T. (1985). Training, recruitment, and retention of psychiatrists in CMHCs: Issues and answers, in B.M. Astrachan, P. Phillips, and W. Winslow Community Mental Health Centers and Psychiatrists. Washington DC, The American Psychiatric Association, pp 32-52. Factor, R.M., Stein, L.I., & Diamond, R.J. (1988). A model community psychiatry curriculum for psychiatry residents. Community Mental Health Journal 24:310-326. Faulkner, L.R., Bloom, J.D., Bray, J.D., and Maricle R. (1987). Psychiatric manpower and services in a community mental health system. Hospital and Community Psychiatry 38:287-291. Faulkner, L.R., Cutler, D.L., Krohn, D.D., Factor, R.M., Goldfinger, S.M., Goldman, C.R., Lamb, H.R., Lefley, H., Minkoff, K., Schwartz, S.R., Shore, J.H., & Tasman, A. (1989). A basic residency curriculum concerning the chronically mentally ill. American Journal of Psychiatry 146:1323-1327. Godard, S.L., Cutler, D.L., Pollack, D.A. (1989). Education and training in public psychiatry. New Directions in Mental Health Services, 44:5-16. Goldman, C.R., Brown, D.B., & Thompson, K.S. (1993). Community psychiatry training for general psychiatry residents: Results of a national survey. Community Mental Health Journal, 29(1):67-76. Goldston, S.E. (1965). Selected definitions, in Goldston, S.E., Concepts of Community Psychiatry: A Framework for Training. Washington, DC, Government Printing Office, (U.S. Public Health Service Publication No. 1319, pp. 195-203). Hinsie, L.E., & Campbell, R.J. (1970). Psychiatric Dictionary, 4th Edition. New York, Oxford University Press. Klerman, G.L. (1988). The scope of social and community psychiatry, in R. Michels, J.O. Cavenar, A.M. Cooper, S.B. Guze, J.L. Judd, G.L. Klerman, A.J. Solnit, & J.B. Lippincott, Psychiatry, Vol. 3, pp 1-14, Philadelphia. Lamb, H.R. (1988). Community psychiatry and prevention, in J.A. Talbott, R.E. Hales, & S.C. Yudofsky (eds.) The American Psychiatric Press Textbook of Psychiatry. Washington, D.C., American Psychiatric Press, pp 1141-1160. Langsley, D.G. (1980). Community psychiatry, in H.I. Kaplan & A.M. Freedman, Comprehensive Textbook of Psychiatry, Vol. 3. Baltimore, Williams & Wilkins. Langsley, D.G. & Barter, J.T. (1983). Psychiatric roles in the community mental health center. Hospital and Community Psychiatry 34:729-733. Lefley, H.P., Bernheim, K., & Goldman, C.R. (1989). National forum on training clinicians to work with seriously mentally ill persons and their families. Hospital and Community Psychiatry 40:460-470. Minkoff, K. (1987). Resistance of mental health professionals to working with the chronic mentally ill. New Directions for Mental Health Services 33:3020. Panzetta, A.F. (1985). Whatever happened to community mental health: Portents for corporate medicine. Hospital and Community Psychiatry 36:1174-1179. Special requirements for residency training in psychiatry (1990). Chicago, Accreditation Council for Graduate Medical Education. Thompson J.W., & Bass, R.D. (1984). Changing staffing patterns in community mental health centers. Hospital and Community Psychiatry 35:1107-1114.