The Psychoanalyst Working in a Community Mental Health Center

The continued emphasis on the biological substrata of mental illness, the explosion of the managed care system, the reduced training in psychotherapy for psychiatric residents, and the reduced number of medical students going into psychiatry have drastically altered the functional life expectancy of the analyst. One example may suffice to illustrate the problem. I recently requested a managed care organization to authorize 14 sessions of psychotherapy for a patient who was working, but who had a number of problems. The case manager questioned the need for therapy, saying, “But he is working, isn't he?” If private practice is going to be thus controlled and curtailed, where is the psychiatrist to find employment, and how can he use his skills and training? One solution is to serve a very needy population, that is, the large number of patients who are cared for by community mental health centers. Assuming that the analyst may seek to work in such a setting, what is he apt to find there?

I will take the Greater Bridgeport Community Mental Health Center as prototypical. The psychiatrist there works 37¹/₂ hours per week. He is part of a team that may work with close to 140 patients. In addition to this full-time psychiatrist, there is another half-time psychiatrist. Other members of the treating team consists of a Ph.D. psychologist who serves as team leader, a family-trained clinical nurse who is known as the Senior Clinician, and four others who are known as Case Managers. The training of these other team members is mixed. One is another clinical nurse who has had training in family therapy, the second is a Ph.D. psychologist, and the other two have had no formal training, but did acquire a great deal of experience working as psychiatric aides in state hospitals. One of these individuals is now going for his masters' degree in social work.

The psychiatrist participates with the team in evaluating the