a multiprofessional outpatient psychotherapy clinic: (an open letter to government)

A Multiprofessional Outpatient Psychotherapy Clinic: (An Open Letter to Government)Author(s): James HendersonSource: Canadian Journal of Public Health / Revue Canadienne de Sante'e Publique, Vol. 64, No.5 (September / October 1973), pp. 455-464Published by: Canadian Public Health AssociationStable URL: http://www.jstor.org/stable/41987196 .

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A Multiprofessional Outpatient

Psychotherapy Clinic

(An Open Letter to Government)

James Henderson, m.d., m.p.h., f.r.c.p.(c)1

This paper reviews the rationale and organization of a multi-professional outpatient and psychotherapy clinic and discusses certain administrative, legislative and political issues arising in the course of setting up such a facility.

Epidemiological studies have shown that in a metropolitan community , about half of the members are mildly to moderately in need of mental health care, and a further quarter are severely disabled with psychiatric symptoms. Only about one quarter are well. Despite this vast need , the demand for mental health care is substantially less, and indeed in the course of meeting this demand peculiar sociological phenomena arise which impede the delivery of mental health care services.

The mandate of government is to provide more and better service at less cost. This is a difficult mandate, and the danger is that it may well result in a lesser standard of care, a double standard of care, or a perpetuation of ineffectual large scale programs. However, the concept of " effective parsimony " main- tains that it is indeed possible to design a service which is both extensive in terms of number of people served and at the same time potent and effective. One practical means to " effective parsimony " is the training of non-physician therapists as " attending

1. Clinical Director, Outpatient and Community Services, Lakeshore Psychiatric Hospital. 3131 Lakeshore Boule- vard West, Toronto, Ontario and Associate, Depart- ment of Psychiatry, University of Toronto, Sunny- brook Hospital, 2075 Bayview Avenue, Toronto, On- tario.

clinicians", each with an independent outpatient caseload.

The outpatient service at the Lakeshore Psychiatric Hospital comprises in part such a venture. Each staff member is designated as an "attending clinician " and an extensive inservice program is designed to facilitate the sharing of knowledge and skills among clinicians of different professional backgrounds . The service is public health oriented and of- fers " training groups " for community mental health personnel such as public health nurses and school counsellors as well as providing direct outpatient service to a large catchment area.

Certain administrative, legislative and political issues are briefly discussed. The outpatient service is described as a pilot project of pioneer significance dedicated to the prag- matic implementation of " effective parsimony" and the principle of " role revision "

of non-physician mental health personnel.

H istorically, the principal thrust of medical advance has been directed to the

better understanding and more effective management of disease entities.

The appropriateness of this emphasis is presently questioned in government and medicine on two fronts.

First, many so called "disease entities" are

455



dubiously tenable as such, and it becomes increasingly necessary to re-examine and perhaps revise the medical style of compart- mentalizing human misery into "body systems" and "disease entities". Perhaps the current ideal, however feasible, is to formu- late the totality of human suffering, individual, group and societal, in a holistic and dynamic fashion. In psychiatry for example, the "body-mind" dichotomy rarely provokes vig- orous debate now; the concept of "mental illness" is challenged on a number of fronts; and psychiatrists are pressed by government to find more comprehensive and less costly methods of mental health care delivery.

Second, psychiatrists are increasingly pressed to justify what has been termed "prodigal service" (the provision of a high standard of excellence in care to a small selected group); in distinction from prodigality of services Hollister and Rae-Grant describe "effective parsimony", which is the "judicious distribution of resources to implement wherever is needed for effective intervention with the least expenditure of effort, activities and time of both professional and patient, but still sufficient to guarantee an intervention that is significant" (1).

It may be neither desirable nor possible for professionals to alter greatly the course of these developments (which appear to be politically and socially rather than technically and professionally determined). It is however, very germane to insist that the "community health movement" (perhaps a short- hand way of describing certain of these developments) pertains to the pattern of delivery not the technique of patient care. The responsibility of professionals in the face of these developments is to insist that whatever societal and political forces may shape with regard to the pattern of services delivery, excellence of therapeutic understanding and professional technique are not to be compromised.

In this respect mental health care is especially vulnerable - there is poor consensus about concept and technique, and there is

danger that government, whose political mandate may at times reflect the illusory expectations of an electorate, will be seduced by grandiose but technically ill defined and poorly tested methods of treatment (2).

This paper describes the concept of a multiprofessional outpatient psychotherapy clinic with a program resting on well established and well tested concepts and methods, but whose staff are committed toward the rigor- ous application of such concepts and methods to "extensive" (rather than intensive), and to community-oriented modes of service. If "effective parsimony" is our ideal, then our thesis is to insist that the methods and techniques of this ideal can be derived from a careful application of well tested and readily available concepts.

The Need and the Demand Economists have long distinguished be-

tween the need for a product or service, and the demand for that product or service. The need is a more abstract concept - it refers to the perception of a product or service being required by a designated population in the view of a detached observer. Demand, on the other hand, refers to a present market for a product or service in a designated con- sumer group, quite apart from whether that service or product is needed in some abstract sense. Corporations have learned to design and deliver their product or service with a view to demand, not need. But judicious and effective deployment of advertising skills can often create demand where there previously existed only some generalized need as perceived by a corporation.

This concept of need and demand has rele- vance for the more complicated issue of the deployment and delivery of health care services. In the past, health care has been deliv- ered in response to demand - citizens who wished medical care and could pay for it often received a high caliber of service. Cur- rently, we know that this demand reflects only a small proportion of the need; dis-

456 Canadian Journal of Public Health Vol. 64



advantaged, less sophisticated, less wealthy and other groups within society may have great need for preventive or therapeutic services, but this need may not be reflected in the form of any explicit demand, nor indeed even perceived as such by the target groups (the consumers of service) in question.

Epidemiology - The Need Psychiatric epidemiologic studies have ad-

dressed themselves to the extent of need for certain services within specified communities. While there are differences among the findings of these studies, there are remarkable areas of agreement. In the "Midtown Man- hattan Survey" Rennie and his colleagues carefully and elaborately studied a random sample of V/z per cent of 111,000 New Yorkers and found that of their sample 18.8 per cent were mildly disturbed, 41.3 per cent were moderately disturbed, and 18.3 per cent were impaired (requiring some type of cus- todial or protective care); 21.6 per cent were well. Perhaps as a rough beginning, we may propose that in many communities about a quarter of the population are severely disabled by emotional symptoms, about half are mildly to moderately disabled, and about a quarter are relatively well (3, 4). According- ly, perhaps as an ideal somewhere around 15 million Canadians could benefit from some kind of mental health care now (5, 6).

Community Transference - A Concept of Demand

Corporations faced with the discrepancy between need and demand can readily em- ploy advertising techniques to narrow the discrepancy. They perceive a need, they obtain the services of a skilled advertising service, and out of need they attempt to mobilize an economic demand and a market for sale. The delivery of health care services, however, is regrettably more complicated.

In previous papers I described community transference (7, 8 ) . The specifically paranoid quality of the community's transference re-

sponse to the mental health clinic "becomes evident when the mental health center fails, as indeed it only can fail, to fulfill the mag- ical expectations of the community which, at the outset, invests it in a illusory way with omnipotent and omniscient qualities once re- served for mothers, fathers, deities and gen- erals." "Community transference may be defined as the vector of the common community tension resulting from first, the mental health center's frustration of a communal demand for well-being now, and second, a perceived challenge to a communal flight from self-awareness and self-understanding. Com- munity transference is closely related to a community's response to a perceived stimulus for change in its attitudes, folkways and mores" (7).

Community transference complicates and sometimes confounds our efforts to close the gap between need and demand.

A failure to understand and adequately deal with this complicating variable can destroy a program. In Prairie Province for example Cumming and Cumming made a "concentrated effort to change attitudes toward mental illness and the mentally ill in a single community." Their technique was sophisticated and prudent, however, the community's response to their program of education and information evolved from one of polite and even friendly indifference at the outset to a sequence of responses described as apathy, flight and withdrawal, and finally hostility and aggression at the verbal level. "The ranks had closed against us; Blackfoot had responded as if to a threat to its integrity as a functioning community" (9).

With the delivery of mental health services, to create demand out of need somehow must involve us in a mandate of community education, but the Cumming and Cumming experiment shows that an understanding and sophisticated management of the community's transference response to the mental health center is an indispensable ingredient in community education.

September/ October 1973 Outpatient Psychotherapy Clinic 457



Past failures in this area have resulted in part from failures to realize that so-called "education" is in this instance not so much a simple imparting of information, but rather a demand upon the community for change in its attitudes, folkways, mores and climate of emotional tolerance for emotional distress. Such a demand requires that individuals and groups exercise a measure of self exam- ination and even limited personality change - programs of education whose success rests upon an undertaking so bold as this are a brave venture indeed, and demand a high level of sophistication, prudence and discre- tion among the program leaders. The community's expectations are illusory - the providers of service must find an appropriate balance between loving and frustrating - between illusion fulfilment and firm but gentle disillusionment (10).

The Dilemma of Government Baldly stated, the mandate of government

is to provide more and better service at less cost. To diminish the cost, or to maintain the cost at its present level in the face of increasing demand for service from a growing population, means following one of four broad paths.

The first is service cuts. If there are 15 million Canadians who require service (or for that matter even a quarter of that number), service cuts are a retrograde and im- probable solution. Ontario's Minister of Health, the Honourable Richard T. Potter, addressing himself to this dilemma, stated that, "Arbitrary cuts ... are not the right way to go about it . . . they don't necessarily slice off the right priorities. But since government is faced with heavy and increasing demands on its money, some kind of change is essential" (11).

The second alternative is some form of double standard of care - a danger inherent in the British solution. Highly qualified and well trained therapists will function on a fee for service basis delivering service of high

quality which is not relevant and quantitatively not available to the bulk of a community's suffering. There will be a dichotomy between costly private care available to a sophisticated wealthy few, and publicly fi- nanced programs backed by over-worked and over-burdened clinicians who in many in- stances have not had access to supervision in sophisticated techniques of personal assistance. From Hollister and Rae-Grant: "There are increasingly signs of a polarization between community mental health on the one side and the practice of individual care on the other. They are not mutually exclusive, and in fact, the movement to separate them will debilitate both" (7). Such a double standard system is schizmatic and politically dangerous.

A third approach is publicly supported, broadly based extensively distributed programs of low quality. Clearly it is not possible, given the present costs of training mental health clinicians, to deliver enough skilled psychiatrists to satisfy society's need for service. There is an ever present danger that if service is to become extensive rather than intensive, quality will be compromised and inadequately trained clinicians will be asked to do a job which is challenging and difficult in even the most skilled and experienced of hands.

The fourth approach (the one advocated here) is a total review and revision of the roles of non-physician primary health care workers, with a commitment and willingness on the part of physician, psychotherapists (the quantitatively largest repository of psychotherapeutic expertise) to impart their skills to non-physician clinicians who in turn can make such service available to the community on a much less costly basis.

I am advocating such a step as a prag- matic and program-oriented response to Hol- lister and Rae-Grant's call for effective parsi- monious services.

But to quote Potter once again, "... we must maintain our customary high standards




of service. We must insist that all personnel . . . have proper qualifications and are fully licensed to perform these services. We must be sure that all changes are made in the inter- est of the public" (11). One may reasonably question, however, whether psychotherapeutic services traditionally performed by trained psychiatrists can be handed over to less extensively trained personnel.

The Question of Lay Therapy Freud is not ordinarily noted for his con-

tribution to medical economics and field of health care services delivery; however, his paper "The Question of Lay Analysis" is very relevant to current discussion in these fields (10).

In "The Question of Lay Analysis" Freud addressed himself to a body of opinion in Viennese medical circles that psychoanalysis was a medical specialty to be practised by qualified physicians. The medical society of Freud's time had done its best to destroy Freud and psychoanalysis, his creation, but when the bastard infant showed signs of be- coming a child prodigy these same societies were quick to file for adoption. But quoting Freud, "Doctors have no historical claim to the sole possession of analysis. On the con- trary, until recently they have met it with everything possible that could damage it, from the shallowest ridicule to the gravest calumny."

Freud's thesis is that not only have physicians no particular propensity towards excellence in psychotherapy, but also they are if anything at some disadvantage as candidates for analytic training because of certain untoward attitudes and modes of thinking acquired by virtue of their medical training. "... Medical education . . . gives them a false and detrimental attitude." "... in his medical school a doctor receives a training which is more or less the opposite of what he would need as a preparation for psychoanalysis". It could be added that the very term "lay ana- lyst" is quite inappropriate, in that any clini-

cian well trained in psychoanalytic theory and practice is a skilled practitioner regardless of his previous professional background, and not in any sense "lay". Many professions refer to persons outside their own profession as "laymen" - the term is a restrictive one and has little generalizable validity.

Of course medical education has changed, and Freud was speaking of psychoanalysis not psychotherapy. However, most of Freud's arguments apply as well to the question of lay therapy as to the question of lay analysis, and one may legitimately ask whether improvements in this aspect of medical education have been as profound or as extensive as many of those of us involved in medical education would wish to achieve. Certainly there is room for much expansion in the teaching of psychological medicine in medical schools, within and especially outside of course time specifically set aside for the teaching of psychiatry.

Our own experience with training groups for community mental health personnel has led us to feel that physicians are one of the most difficult professional groups to teach. Whereas public health nurses and school counsellors are in some way interpersonal in their traditional "helping" orientation, physicians often have depersonalized their activities and find themselves hard pressed to abandon a mechanistic "signs and symptoms approach" or simple descriptive model in their attempts to alleviating human emotional distress.

The usual argument that a psychotherapist not medically trained may overlook impor- tant organic pathology seems likely to have been oversold. Patients requiring and re- questing psychotherapy uncommonly have difficulties which turn out to be organically determined; furthermore, non-physician therapists can and are receiving supplementary training to help them at least recognize if not manage aspects of their patients' conditions which are not purely psychogenic in etiology.

In the outpatient services at Lakeshore




Hospital we have an extensive program of inservice training designed to remedy the defi- cit in biological (and for that matter also psychological) medicine which non-physician therapists carry by virtue of their not having had traditional medical training or adequate case-oriented psychotherapy supervision.

We hope some day to advocate that a special qualification be established for "psychotherapy practice", a qualification which cuts across professional boundaries and indicates that the particular clinician, regardless of his profession, has received special training and supervision in psychotherapy practice and has been found to be competent in this area of professional activity.

To paraphrase Freud, no one should prac- tise psychotherapy who has not acquired the right to do so by a particular training. "Whether such a person is a doctor or not seems to me immaterial" (10).

The Lakeshore Project The outpatient service at Lakeshore Psy-

chiatric Hospital is a psychotherapy clinic staffed by two psychiatrists, three public health nurses, two psychologists, two social workers, one clergyman and one occupa- tional therapist. All staff are designated as "attending clinicians" and each has an independent outpatient case load, thus pre- serving a fundamental tool of outpatient psychotherapy (a tool which is often lost in multi-professional team approaches) the one- to-one relationship. Both as a technique of personal help, and as a research tool for professional development in more complex areas such as groups and families, the one-to-one relationship is the cornerstone of outpatient psychotherapy.

Levels of training and technical sophistication vary within the clinical group according to the experience, training and profession of the various staff members. Regrettably, a frequent failure of professional training programs is reflected in their graduates having an often impressive knowl-

edge of a variety of theoretical approaches to treatment, occasionally considerable skill in debating their relative merits, and frequently not the capacity to implement any of these varied approaches. It is hard to justify training programs which graduate clinicians who have never had a single supervised outpatient case. The inservice program at Lakeshore Psychiatric is addressed to this difficulty, and we provide an intensive program of case supervision using both individual and group modalities of supervision and studying both one-to-one and group techniques of treatment. This program has been generally suc- cessful.

The clinic's activities fall into three areas. The first and largest area of our function is general outpatient assessment and treatment where new cases are seen and assessed and appropriate decisions and arrangements made regarding treatment. The second area is intensive psychotherapy. We look to the intensive psychotherapy clinic both as a treatment modality for patients who are prepared to undertake a more fundamental review of their habitual responses to life stress, and as a repository for theoretical concepts and ideas which can be synthesized into a viable theory and provisional method of non- patient-oriented techniques of community intervention. The third area of activity is community training and education; toward this end we meet on a regular basis with groups comprising altogether some 200 public health nurses and board of education counsellors. These groups' are identified as "training groups" or "professional development semi- nars" and provide a format where mental health workers of different professional backgrounds can examine case material and re- fine their skills through the sharing of concepts and techniques of case management.

If there is to be a label for this particular style of clinic organization, we would propose the term "role revision". This term ac- curately reflects our commitment to ongoing review of the professional deployment of




non-physician therapists and clinicians with a view to their more efficient and effective uti- lization. "Role diffusion", an earlier term, is less specific and has come to be identified with a point of view which advo- cates that anyone with a measure of empathy and common sense is quite capable of helping clients in distress, and training and supervision are rather redundant. Our unit is committed to a rather opposite viewpoint, namely, that while personal factors are im- portant, counselling and psychotherapy are learned skills and techniques which must be practised, supervised, and perfected.

Supervision within the unit's inservice program employs both individual and group su- pervisory techniques. The unit's clinical director (the author) conducts a weekly psychotherapy seminar where two of the unit's staff present in rotation material from an ongoing psychotherapy case for a six- month period, at the end of which time the role of "presenter" passes to two other unit staff. In this way the staff group are able to examine and understand clinical material in a longitudinal way (viewing clinical material from the patient's therapy over a period of six months) in addition to the more com- monly encountered cross-sectional view ob- tained in ordinary clinical conferences. In addition, slightly more than half the unit's staff receive individual psychotherapy supervision on a dynamic model with the unit's clinical director, again employing individual case material in the longitudinal model. To offset some tendency for "inbreeding" which might result from the concentration of the inservice training mandate in the hands of one individual, an experienced Anglican clergyman who has had extensive training and supervision in psychotherapy skills in some of the conti- nent's finest psychotherapy centers conducts a weekly clinical conference, imparting dynamic psychotherapeutic treatment techniques through a case-oriented group teaching format. Finally, unit staff are encouraged to consult with each other and with the unit

psychiatrist when particular difficulties arise in patient treatment.

Economic Considerations The average salary of attending clinicians

in the clinic is of the order of $10,000. A privately practising psychiatrist psychotherapist in Ontario is paid $24.30 per psychotherapy-hour; based on eight patients a day and 46 weeks per year this amounts to an annual gross salary of nearly $45,000. As one somewhat experienced in the psychotherapy supervision of psychiatric residents, I believe I can state with some credibility that the skills of our non-physician therapists are very comparable to those of their medically trained colleagues. The savings to government involved in deploying non-physicians to this professional role are of the order of $30,000, per clinician per year (the differ- ence between the government funded earn- ings of a psychiatrist - psychotherapist and the salary of one of our non-physician therapists).

The population of Ontario is approxi- mately eight million. The epidemiologic studies cited previously suggest that perhaps three quarters of that number could benefit from some type of assistance with emotional difficulties. If we postulate that even one tenth of that number would be benefited by some modality of outpatient psychotherapy (prob- ably a very conservative figure) there are ap- proximately 600,000 persons presently un- treated who ought to have an opportunity to avail themselves of this modality of help. A caseload of a psychotherapist is not great, for the therapeutic process is often a lengthy one. However, if one were to rather con- servatively set the desirable ratio at one therapist per 1,000 population then the province of Ontario currently needs about 8,000 psychotherapists. Based on a saving of $30,000 per year per therapist, the potential savings to government (if the concept described here were taken as a mocjel) would be about $240,000,000 per annum.




One would hope that in view of the potential financial savings involved, government would be prepared to commit themselves in a liberal way to facility improvements as well as administrative and legislative advances necessary to establish the viability of non- psychiatrist psychotherapist pilot project clinics. For if such clinics are to meet the community's requirements for service in a comprehensive way, it will have to be demon- strated that they are able to serve upper and middle class patients as well as the lower socioeconomic groups for whom mental hospital services have traditionally been devel- oped.

Administrative Issues The traditional deployment of psychiatrists

as providers of patient care, and non-psychiatrist mental health workers (psychologists, social workers, nurses) as "ancillary personnel" has been reflected in a system of mental hospital organization wherein psychiatrists are responsible to psychiatric unit directors or medical directors, and their non- psychiatrist colleagues report to professional department heads (chief psychologist, chief social worker, director of nursing). This administrative structure may have been appropriate to previous models of treatment, however, with the revised deployment of all mental health workers as "attending clinicians" the old administrative structure has become anachronistic. In such a system, non- psychiatrist clinicians report in part to a unit director and in part to a hospital department head outside the clinical program unit. Ac- cordingly, the seeds are sown for potential conflicts of loyalties and the two-parent administrative structure so created is weak and schizmatic, with an ever-present tendency for anxious staff struggling with the host of personal and professional conflicts stirred by their revised role allocations (and sometimes painful accompanying changes in professional self concept) to play unit director and department head one against the other as

a way of externalizing and so in part alleviating intrapsychic conflicts.

In his paper, "Polarizing Factors Affecting Decision-Making in Mental Hospitals", Du- rost refers to "the power struggle which tends to characterize interactions between . . . (unit directors) . . . and department heads. Any new proposal that disturbs the uneasy balance that normally is worked out between these two key figures runs the risk of being dealt with more in the context of the current balance of power than on the merits of the proposal itself" (12).

Furthermore, since the model of role revision has been incorporated into the unit's administrative structure, differences in clinical mandate among the unit staff arise more from differences in level of skill, experience, and personality than from traditional clinical background. Professional traditions and iden- tifications are often tenaciously held, and it was not possible within the mental hospital administrative structure to free up the unit's attending clinicians from their traditional de- partmental accountability.

We have had to find some alternative way to overcome or at least minimize the poten- tially destructive effect of the mental hospital's historical two-parent administrative structure. We are currently experimenting with the following arrangement. An administrative director is administratively in charge of the unit, its program, and its interfaces with the hospital and community. A clinical director, at present myself as the unit's full- time psychiatrist, chairs the unit's inservice program and functions as clinician and psychiatric consultant. Thus the unit's dual administrative structure of administrative director and clinical director parallels the hospital's senior administrative organization with an administrator responsible for the hospital's over-all direction and administration, and a medical director whose mandate more directly relates to techniques and standards of patient care. In this way, the polarizing or splitting processes documented by Durost




tend to occur within the unit, rather than between unit and various hospital departments, and our hope is that the relationship between the unit's administrative director and clinical director may be such as to neutralize rather than reinforce these polarizing processes. At least, the number of individuals involved in the splitting process will be fewer.

The Need for Legislative Review There would appear to be two areas where

legislative review should be seriously considered if the model described here is to be maximally effective.

The first of these is the prescribing of medication. Only two of the 12 attending clinicians in the clinic are physicians able to prescribe drugs, yet all 12 clinicians see patients who appear to require one or an- other psychiatric medication as a part of their treatment program. The right to prescribe is, of course, denied them by law.

While the expertise of the qualified psychiatrist may be required to institute medication, patients who have been assessed with a view to medication prescribing, and have been taking a particular drug with good effect and without untoward side effect for some time, should be spared the necessity to consult with a psychiatrist each time their medication requires to be renewed.

Non-psychiatrist clinicians can achieve a good familiarity with and sophistication in the prescribing of psychiatric medications and legislation empowering them to do so should be carefully considered. To fail to do so creates a clinical style where psychotherapy is practised by non-psychiatrist therapists, and psychiatrists become administrative appendages legally required to treat out- patients who require medication as a part of their treatment program.

Concomitantly the total accountability of the physician for a treatment program should be reviewed. Where the primary therapist is a non-physician, he or she ought to be legally responsible and accountable for the treat-

ment's outcome. The present arrangement appears to postulate an omnipresent physician under whose supervision non-physician therapists are assumed to be working - in the event of mishap it is the physician (whose real involvement in the case may have been minimal) who is held responsible rather than the non-physician therapist who was attend-" ing the patient. If non-physician therapists are to have a broader role in patient care, that advance should be paralleled by administrative and legislative review so that organiza- tional structure, legal accountability, and professional role are complementary rather than divergent (13).

L'auteur de cet exposé considère le bien- fondé et l'organisation d'une clinique à l'in- tention de patients non-hospitalisés qui serait multi-pro fessionnelle et psychothérapique et étudie certains des problèmes administratifs , législatifs et politiques qu' entraînerait la créa- tion d'une telle institution.

Des études épidémiologiques ont indiqué que dans une collectivité métropolitaine , près de la moitié de la population avait un besoin léger à modéré de soins pour leur santé mentale et qu'un quart était sérieusement incapa- cité par des symptômes psychiatriques. Un quart seulement se portait bien mentalement. En dépit d'un besoin de soins aussi étendu , la demande de soins pour la santé mentale est sensiblement plus faible et dans la dis- pensation de soins en réponse à cette demande on se heurte à des phénomènes socio- logiques particuliers. Il y a longtemps que les économistes ont établi une distinction entre le besoin et la demande - dans le do- maine des soins pour la santé mentale , l'auteur décrit le "transfert affectif de la com- munauté" comme variable existante , variable qu'il faut bien comprendre et traiter si les dispensateurs du service désirent répondre au besoin de soins plutôt qu'à la demande.

Le mandat du gouvernement est de fournir




des services plus nombreux et meilleurs à un coût moindre. C'est un mandat difficile et qui présente un danger , c'est-à-dire des soins de moindre qualité , des normes de soins dif- férentes ou le maintien de vastes programmes inefficaces. Toutefois , ď après le concept des "économies bien comprises" , il est possible de concevoir un système vaste du point de vue des prestataires tout en étant efficace et effec- tif. Une application pratique de ces " écono- mies bien comprises " consiste à former des thérapeutes non-médecins qui feront office de " cliniciens responsables " et aura chacun une clientèle indépendante de patients non- hospitalisés.

Le service des patients non-hospitalisés de l'hôpital psychiatrique de Lakeshore a adopté partiellement un tel système. Chaque membre de son personnel est considéré " clinicien responsable " et il existe un programme exten- sif conçu pour faciliter l'échange des con- naissances et des compétences entre cliniciens de formation différente. Le service est orien-

té vers la santé publique et offre des " cours de formation par groupes" pour le personnel responsable de la santé mentale communau- taire , tel qu'infirmière de santé publique et orientateurs scolaires tout en fournissant des soins directs à un public étendu.

S'il faut un terme pour décrire le déploie- ment des ressources humaines , ce serait " ré- vision des rôles" par opposition à " diffusion des rôles" qui est une expression plus an- cienne et moins précise. La clinique s'est donnée pour tâche de déterminer des rôles plus appropriés et plus valables pour les thé- rapeutes non-médecins.

L'auteur soulève brièvement certaines ques- tions administratives , législatives et politiques. Il décrit ce service pour patients non-hospi- talisés comme étant un projet pilote d'avant- garde dans la mise en œuvre pragmatique des " économies bien comprises" et l'application du principe de la " révision des rôles" du personnel non médecin qui s'occupe de santé mentale.

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13. Lemieux, Marcel: "Community psychiatry m low demographic areas." Third Hoffman- LaRoche Lecture, Clarke Institute of Psy- chiatry, Toronto, February 28, 1969.




a multiprofessional outpatient psychotherapy clinic: (an open letter to government)

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