Community Psychiatry

Extract

Much confusion has resulted in recent years from the use of the word “community” to mean merely “outside hospital”. Community psychiatry is not just extramural work or a means of avoiding hospitalization. A community mental health service is a comprehensive psychiatric service of care and treatment for a defined population, including full hospital facilities (Freeman, 1963). The hospital is in fact part of the community, and provides one of its services. The size of population base that can most efficiently support a comprehensive service is probably between 150,000 and 200,000 in urban areas, judging by experience in Lancashire (Smith, 1965). This is large enough to contain all the basic services that are needed, and small enough to allow all key professional workers to remain in constant face-to-face contact. Within its defined area, the service must have continuous and final responsibility, whatever the clinical state of individual patients. It must offer a continuous spectrum of integrated services, from full-time, permanent care in an institution on the one hand, to occasional support for a patient or family at home on the other. Since the demand for services is potentially infinite, an essentially ideological choice must be made in assessing priorities for the resources that exist. I believe that if we try to act primarily on the basis of human needs within the total community, the first call on these resources must be for the three great problems of schizophrenia, subnormality and old age. Concentration on psychotherapy would make it more likely that these greater social needs remained unmet, and it may well be that any large-scale treatment of neurosis or personality problems would have to be outside psychiatric—or even medical—channels (Ryle, 1967).