PROFESSIONAL VERSUS PUBLIC HEALTH GOALS: PSYCHIATRY AND COMMUNITY MENTAL HEALTH CENTERS

An empirical study and an analysis of the historical record for the period 1960-1980 indicate that the Federal service program--Community Mental Health Centers--tended to produce organizational control but not control of the work process for psychiatrists. Psychiatrists, in reaction, left the CMHC program and were able to maintain autonomy as a profession in other settings, primarily in the private sector. Structural changes, hypothesized to be increasing organizational control of other professions, have not occurred in psychiatry, which may be unique among medical specialties in this regard. Psychiatrists in office practice are increasing while other specialties are decreasing. The ability of psychiatry to maintain autonomy as a profession must be understood in the context of the overall mental health and health care system. Federal programs during this period exacerbated the existing two-class system of mental health care. Federal CMHC dollars substituted for State outpatient care; Medicaid picked up the bill for the mentally ill poor, enhanced the ability to refer public patients rather than assume the unreimbursed cost of treating them in the pre-Medicare/Medicaid period, and supported the growth of the private sector. Federal reimbursement policies favored acute mental health care in settings which maximized psychiatrist autonomy among mental health professionals through the medical model, enabling the profession as a whole to resist organizational control. The two-class system of care was one of the enabling factors. The profession of psychiatry has not established the preconditions for the establishment of a professional market, however. The State has not created a monopoly for psychiatry in lieu of other mental health professions. Nor has psychiatry succeeded in establishing in the mind of the public a standardized and differentiated product. While psychiatrists have a major advantage by being physicians, they must sell their services in an increasingly competitive market. Lack of a technology exacerbates the differentiation of a distinct product. The development of professional markets for other mental health professions is more incomplete than for psychiatry, and, therefore, these other professionals are more subject to organizational control, never having gained the level of professional autonomy of psychiatry.