Table of Contents
INTRODUCTION... 3
PHILOSOPHY........ 3
PROGRAM DESCRIPTION 4
VCMHS
Community Experience..... 4
Supervision..... 5
Didactic
Sessions..... 5
Psychotherapy..... 5
EDUCATIONAL OBJECTIVES 6
Knowledge..... 6
Values
and Attitudes..... 6
Skills..... 7
GUIDELINES 9
GUIDE to COMMUNITY PSYCHIATRY TRAINING PROGRAM. 10
LOG BOOK...... 11
COMMUNITY AGENCIES. 15
CHRONIC CARE TRAINING PROGRAM
FACULTY
Administration
Dr.
Nicholas Sladen-Dew Medical Director, VCMHS
Dr.
Peter Gibson Site
Training Director, VCMHS
Dr.
Siemion Altman Site
Training Director, Riverview
Primary
Resident Supervisors
Dr.
Robin Friedlander West Coast Mental Health Support
Team
Dr.
Siemion Altman West
End MHT
Dr.
Mike Cook Kitsilano
/ Fairview MHT
Dr.
Kurban Madhani South
MHT
Dr.
Craig Emes Strathcona
MHT
Dr.
Kitty Perry Northeast
MHT
Dr.
Peter Gibson Grandview-Woodlands
MHT
Dr.
Ron Gibson WestSide
MHT
Dr.
Elena Lisiak Mid-Town
MHT
Secondary
Resident Supervisors
Dr.
Deborah Schwartz Grandview-Woodlands MHT
Dr.
Laura Chapman South
MHT
Dr.
David Yaxley South
MHT
Dr.
Peter Liddle Kitsilano
/ Fairview MHT
Dr.
Taki Caldis West
End MHT
Dr.
Grant Chernick WestSide
MHT
Dr.
David Hutnyk Strathcona
MHT
The specialty training
requirement in psychiatry includes a mandatory period of at least six months
entirely to the study, comprehensive care, and rehabilitation of persons with
serious mental illness and long-term disability.
In the 1994 oral examination
report, the Examination Board made the following general recommendations:
“... the Examination Board
was concerned that some candidates did not display adequate familiarity with
[clients] with chronic psychotic illness.
The impression was that some candidates did not have adequate exposure
to an appropriate number of severely mentally ill [clients] over a sufficient
period of time to understand the course of the illness, the quality of life
issues, and the principles of psychosocial rehabilitation. The Board would like to ensure that training
programs are providing trainees with adequate exposure to the severely mentally
ill population. This is necessary in
order to equip graduating psychiatrists with the experience they will need to
lead the current trend towards community-focused treatment of the seriously
mentally ill, that is, [clients] with schizophrenia and bipolar mood
disorders. It is the view of the Board
that trainees should demonstrate at the examination that they have had adequate
experience with this psychiatric population.”
Despite the trend towards
community psychiatry and the priority being given to the severely mentally ill,
residents continue to receive most of their training in hospital-based settings
and following graduation give low priority to psychiatric service in community
mental health centers and a high priority to private practice.
The care and rehabilitation
of the seriously ill is a complex enterprise that calls upon the skills of
several disciplines. High quality care
to these individuals is usually best provided by a multi-disciplinary team. The role of the psychiatrist in a community
mental health team requires a set of skills and attitudes quite different to
those employed in private practice or in a hospital setting. There is a need to develop what might be best
thought of as an “anthropological approach” which conceptualizes the mentally
ill person in terms of their understanding and beliefs about their world. This requires a shift in focus from a
predominantly biological and intra-psychic understanding of mental illness to
include a social dimension that embodies ecological concepts quite different
from the social psychiatry of the past.
In our view this is a true biopsychosocial approach. One which recognizes the real meaning of
community psychiatry in the ‘90s.
The most important ingredient
in training residents to adopt this approach is to immerse the resident in the
culture of the mentally ill person under the supervision of experienced
community psychiatrists and community mental health workers. The resident is based in a neighborhood
clinic but goes out on the street to see their clients and their support
network in their homes, in their place of work, and wherever else the client
spends time. The resident in addition
to defining their medical contribution to the total care of the client, is
encouraged to take part in arranging housing, financial support, and other case
management duties. The resident learns
at first hand the resources available to the mentally ill in the community but
more important learns the barriers that exist for our clients in accessing
those resources and how so often they fall short of what the client really
wants.
It is our view that the
psychiatrist of the future will need to be conversant with many different forms
of practice. We believe that greater
emphasis will be placed on the psychiatrist working as a team-player moving
flexibly between direct service, client-based consultation, agency-based
consultation, service planning and administration - and that most of the work
will be in a community setting.
Since 1989, the Department of
Psychiatry, UBC, in partnership with Greater Vancouver Mental Health Service
(now Vancouver Community Mental Health Services) has provided residents with a
true community-based experience working with the mentally ill as part of their
Chronic Care experience. In January of
1999, as part of their rotation, residents began working with Dr. Robin
Friedlander at West Coast Mental Health Support Team. This experience exposes the resident to clients with a Dual
Diagnosis of Psychiatric and Developmental Disorders. Prior to July 2000, residents were assigned to either Riverview
or VCMHS for their rotation in Chronic Care.
The Department felt that exposure to both Riverview and VCMHS was
important for Residents thus the current variant of the rotation was born.
Residents spend Monday
morning, Wednesday morning and Fridays at Riverview, while Monday afternoon,
Wednesday afternoon and Tuesdays are with VCMHS. Occasional Tuesday and Friday afternoons will be spent with Dr.
Friedlander at the West Coast Mental Health Support team.
|
|
Monday |
Tuesday |
Wednesday |
Thursday |
Friday |
|
AM |
Riverview |
VCMHS |
Riverview |
UBC |
Riverview |
|
PM |
VCMHS |
VCMHS |
VCMHS |
UBC |
Riverview |
VCMHS provides a range of
community services to over 7,000 seriously mentally ill individuals through
eight community mental health teams, and eighteen additional programs that
include Mental Health Emergency Service, Mental Health Residential Service,
crisis houses, outreach teams and vocational services.
The VCMHS portion emphasizes
community-based psychiatric treatment and rehabilitation, and thus compliments
the experience gained by the resident in a hospital setting. Residents are expected to have a variety of
community experiences, which instill a set of attitudes and skills preparing
them to work with the severely disabled.
These experiences include the following:
·
emergency assessments in the community setting
·
case management
·
medication assessments and monitoring
·
psycho-education
·
case consultation
·
site visits of various agencies
·
liaison with family members, other agencies and other
supports
Supervision is provided at
each team with a degree and content negotiated between the supervisor and the
resident. In addition to a Primary
Supervisor, residents may obtain supervision from any number of Secondary
Supervisors. There is also opportunity
for discussion about the rotation with the Site Training Director on a regular
basis.
Residents, as part of their
training are required to follow long-term psychotherapy cases and traditionally
time has been taken from the assigned rotation. With the changes in this rotation, Residents are expected to follow
their psychotherapy cases on Thursdays (except for special circumstances).
The
resident will become familiar with:
1)
The principles underlying:
· Community
Psychiatry
· Psychosocial
Rehabilitation/Recovery
· Mental
Health Legislation
· Case
Management Models
2)
The components of a comprehensive community mental
health system.
3)
The respective roles of inpatient, outpatient, partial
hospitalization, and rehabilitation services for the serious and persistently
mentally ill.
4)
The range of community and social agencies that serve
the serious and persistently mentally ill.
5)
The contribution of clients/consumers and families in
the care of and in the planning and delivery of mental health services
6)
The major psychiatric disorders associated with serious
and persistent mental illness from a biopsychosocial context (DSM-IV) in which
the client is seen in relationship with his or her community
7)
The psycho-dynamic aspects of serious and persistent
mental illness
8)
The social, political, and economic context in which
services to the seriously mentally ill are established.
9)
Current issues in the Mental Health field, including:
·
Substance abuse and serious persistent mental illness
·
the multi-problem client
·
medico-legal
issues including the B.C. Mental Health Act and competency
·
AIDS and
serious and persistent mental illness.
·
Developmental Disabilities and Psychiatric Illness
10)
The present and future role of the psychiatrist in
community mental health and particularly in the areas of consultation, education,
and planning.
11)
Become familiar
with common genetic/congenital syndromes (e.g. down, fragile X, Fetal Alcohol
Syndrome) associated with Mental Retardation (MR), and the concept of
behavioral phenotypes.
12)
Recognize the
behavioral and psychiatric problems associated with autism (pervasive
developmental disorders).
13)
Recognition
that individuals with MR are subject to the full range of mental disorders, but
usually presents with
maladaptive behavior.
14)
Knowledge of
age appropriate behavioral norms in individuals with developmental
disabilities. ( e.g. imaginary friends,
concrete thinking).
The
Resident will demonstrate:
1)
sensitivity to issues of social class and stigmas as
they affect the mentally ill and their families.
2)
awareness of passivity, dependency, and autonomy, as
they apply to both the client and the therapist/case manager.
3)
Awareness of and willingness to cope with biases or
preconceptions that might affect their work with the serious and persistently
mentally ill.
4)
The primacy of the clients’ needs and those of their
support systems over those of the mental health system.
5)
Ability to relate in a multi-disciplinary setting
6)
Ability to relate to other mental health professionals
as co-workers, recognizing the special contribution of each to the welfare of
the client.
7)
The ability to view clients in the community as people
rather that disorders and relate to them with genuineness and empathy.
8)
The ability to understand their client within the
entire context of their lives in which their psychiatric disorder is but one
part.
9)
Sensitivity to culturally specific factors and issues
10)
Sensitivity to issues of sexuality and gender identity
11)
Openness and flexibility in treatment planning
12)
Evidence-based psychiatric practice
13)
Sensitivity to semantics (e.g. DSM IV term of Mental
Retardation viewed as a pejorative term by Developmental Disability advocates
and families).
14)
Understand the values of normalization and community
inclusion in Developmental disability world.
15)
Appropriate use of psychopharmacology to aid community
living and integration, while recognizing historic overuse of neuroleptics in
this population.
The
resident will be able to:
1)
Function in a variety of different capabilities,
including consultant, supervisor, educator, case manager, and advocate
2)
Interview consistent with level of training
3)
Carry out a comprehensive functional assessment that is
tailored to the individual; is problem and goal oriented; reviews social,
leisure, vocational and life skills; takes into consideration the person’s
living environment including accommodation, social supports, and family
functioning; identify strengths and assess predisposing and precipitating
events.
4)
Identify medical problems and link clients with the
health care system and liase with clients’ primary health providers
5)
Assess psycho-tropic medications and monitor their
effects and interactions
6)
Use a problem-based approach that leads to a range of
potential interventions, working collaboratively with a client in developing a
management plan and in setting realistic individual goals that challenge them
without exceeding their capabilities, recognizing their vulnerability to
certain day-to-day stresses.
7)
Maintain mentally ill clients with long-term
disabilities in the community and to encourage their clients to become citizens
in the full sense of the word.
8)
Identify, assess and manage psychiatric emergencies in
the community
9) Use a
variety of psychosocial intervention strategies with individuals, families,
groups and other social units (i.e. boarding homes).
10) Work
with families providing education, counseling, support and treatment.
11)
Provide consultation to agencies, schools, and social
services from a variety of perspectives including a systems approach with an
emphasis on effective communication.
12)
Promote a positive view of mental illness by providing
education to members of the public.
13)
Manage time and clinical tasks such as documentation
efficiently
14)
Self-evaluate strengths and weaknesses
15)
Adapt standard psychiatric interview to individual's
language abilities.
16)
Learn to use symptom inventories and other skills
adapted from child psychiatry.
17)
Differentiate symptoms of mental illness (on Axis I)
from behaviors which are due to the developmental disability (Axis II) (e.g.
hallucinations vs. self talk).
1) Residents
coming to the Chronic Care Training Program are generally not in their first
year and are therefore able to take
responsibility commensurate with their experience and training. Residents should be able to call upon a
supervisor to assist them in managing a case and should not be left unsupported
at the Mental Health Team. Residents
are to be encouraged to assume as much responsibility as they are able and
willing to take.
2) The majority of Residents have an educational medical license, which limits their practice. The College of Physicians and Surgeons of BC
has ruled that Residents may sign prescriptions on supervised clients without
the co-signature of a fully licensed physician. Because certifications under the Mental Health Act are a major
withdrawal of a basic human right of individuals, physicians with an
educational license do not have this
privilege and therefore cannot sign
the required forms.
3) Residents are required to be insured for the purposes of malpractice through the CMPA or other carrier.
4) It is recommended that each week
some time be made available to meet directly with the Resident to discuss
issues that come up during the rotation and cases that the Resident is
carrying. It works best when a specific time is set aside each week
to do this.
5) The primary supervisor at each team
is responsible for arranging Resident supervision when he or she is not
available. This should be done in
consultation with the Team Director, the Area Clinician, and the other medical
staff at the team.
6) Whenever possible, if a client is
admitted from the team to hospital the Resident should follow the client in the
hospital to facilitate continuity of care.
Each
year VCMHS is asked to conduct Royal College Mock Oral Examinations. This takes place in the Spring and
assignments will be made at that time.
The
Resident and Supervisor are responsible for ensuring that a number of Royal
College type interviews take place during the six-month rotation. This is particularly important for Residents
in their final year as they approach the Royal College examination. Attached is a copy of a rating form used by
McMaster University, which may be helpful in evaluating the interviews.
LOG BOOK
This guide accompanies the Log Book, and helps
the Resident to choose the most useful site visits.
It is the Resident’s responsibility to organize
the site visits, and the supervisor’s responsibility to discuss what has been
learned in the site visits with the Resident at three months and six months
into the rotation.
The Log Book is designed to help a Resident keep
track of the variety of experiences gained on the Community Rotation. It is for the personal use of the Residents,
and will not be examined by supervisors. Three months into the rotation, however, supervisors will expect
Residents to be able to identify the experiences they have gained, and those
that still need to be completed.
Residents should ensure that they have the
opportunity to gain the necessary experiences.
For example, you will note that at least six supervised interviews are
required of the Resident in this rotation.
A Resident is responsible for setting these interviews up with the
supervisor. The Resident will find it
helpful to record in the Log the dates on which experiences were gained.
Although most of the experiences in the Log Book
are thought to be helpful in gaining a well-rounded experience in the Community
Rotation, some of the site visit locations are more important than others. The information below has been compiled over
previous years in discussion with Residents, and provides a more detailed guide
to community agencies. The information
is thought to be correct but if a Resident finds a discrepancy, please make a
note and bring it to my attention at the end of the rotation. The Resident should take the opportunity to
record his/her thoughts and ideas about the various aspects of the Community
Rotation, and bring these to my attention as well.
|
Activity |
Date |
Remarks |
|
Team
Director |
|
|
|
Clinical
Supervisor |
|
|
|
Area
Clinician |
|
|
|
Office
Manager |
|
|
|
Occupational
Therapist |
|
|
|
Home
Visit (routine) |
|
|
|
Home
Visit (routine) |
|
|
|
Home
Visit (emergent) |
|
|
|
Home
Visit (emergent) |
|
|
|
Supervised
Interview |
|
|
|
Supervised
Interview |
|
|
|
Supervised
Interview |
|
|
|
Supervised
Interview |
|
|
|
Supervised
Interview |
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|
Supervised
Interview |
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