What image comes to mind when you think of psychiatry?
For many, it’s a one of talk therapy — a patient sitting on a couch speaking to a psychiatrist.
In reality, that’s just a small part of the field. While psychiatry often involves listening to patients — assessing mental and physical aspects of psychological problems — that’s just the tip of the iceberg.
One innovative aspect of the field is public psychiatry, also known as community psychiatry. Public psychiatry involves caring for patients with serious mental illness in publicly funded, community mental health settings. Public psychiatry addresses social determinants of health, such as income and housing security, and often involves meeting patients where they are, like their own home, to support recovery.
Rachel Talley, MD, a clinical assistant professor of Psychiatry in the Perelman School of Medicine at the University of Pennsylvania, originally planned to pursue a career in public policy. Now, she leads Penn’s Community Psychiatry fellowship program at Penn.
In this Q&A, Talley discussed public psychiatry, the impact of COVID-19 on community mental health, and how she went from an internship at the White House to championing public health at Penn’s department of Psychiatry.
What inspired you to find a career in public psychiatry?
I’m inspired each day through my career. Working for the people in our society who have less, who for various reasons have to work with public systems of care due to limited resources, is a passion of mine. But my passion for community and pubic work sparked long before I knew I wanted to be a doctor or a psychiatrist.
Social justice has always been important to me, thanks to my parents and growing up outside of Washington, D.C. where policy and politics are a part of daily life. But it wasn’t until college that I had my first medical experience which put me on the path to public psychiatry. While an undergraduate student at Harvard University I volunteered at a community health center — a safety net outpatient clinic for primary care. There, I was introduced to the idea of innovative care for people with limited resources, and the different approaches for caring for those who are most vulnerable. But it took me a few more years to find my way to practicing medicine. After college, I pursued my interest in policy through internships in D.C. — including at the National Council for Behavioral Health, the National Association of Community Health Centers, and the White House. All those experiences empowered me to not only go to medical school, but to find ways to advocate for those who are vulnerable.
Psychiatry was a natural fit for me, particularly as a woman of color. Access to mental health care is a huge challenge for communities of color for a variety of complex reasons, largely rooted in our country’s history of racial discrimination and structural inequities that persist today. I felt strongly about being in a field to offer access to people like me and to inspire others who look like me to consider the field. With that passion, I made my way into residency and on the path I am now, which I see as the best of both worlds. I get to treat patients, but I also get to consider how public systems of care can better support those with mental health needs.
How does public psychiatry differ from traditional approaches?
Public and community psychiatry has a lot of innovative clinical programming that looks different from traditional outpatient psychiatry. Instead of a patient coming to us — sitting in an office to talk about what’s on their minds, discussing medications, and scheduling follow-up appointments — we have programs where a care team meets patients right in the community, at a patient’s home or another place outside of the clinical setting, where they are comfortable.
In addition to a psychiatrist assessing mental health needs, this team of experts helps patients navigate the health system. This team could include a case manager, a peer support specialist, or substance use support. Importantly, the patient is a member of the team as well. Together, everyone aligns on what’s best for the patient, what recovery looks like, and the path to get them there.
Horizon House, where I spend most of my week seeing patients, is a wonderful example of public and community mental health work in action. Serving more than 5,000 people in Pennsylvania and Delaware, Horizon House offers a range of recovery-oriented services, including programs in which teams meet with individuals with behavioral health challenges directly in the community to holistically address their needs.
The Hub of Hope, operated by Project HOME, is another great example here in Philadelphia. Located in SEPTA’s Suburban Station, the Hub of Hope offers a safe place for people experiencing homelessness to enjoy a warm cup of coffee, take a shower, wash laundry, and also speak with case managers about finding a permanent home. People can also connect with psychiatrists like myself who can provide mental health assessments as part of an integrated primary care and behavioral health team.
Why is it so important to have a different approach to care?
Public psychiatry takes a holistic approach to recovery. Those with serious mental illness often have a lot of challenges in their way. In order to find a road to recovery and stability, public psychiatry goes beyond the traditional medical model, and “treats” other aspects of life that can impact recovery — whether that be work, school, housing, or other goals and needs.
We often talk with people who have limited resources and heavy psycho-social needs. For example, a person who has schizophrenia but is also struggling with homelessness or having issues finding the right job. In addition to mental health, a limited income, issues with housing, or challenges with benefits are all relevant to staying healthy and well. And it can be much harder to get all the pieces together and get to a stable place if one piece of that puzzle is missing.
These programs can be incredibly powerful. Thanks to the team approach, public psychiatry is collaborative and flexible, which is what these patients need. We’re meeting them with resources where and when they need it the most.
How has the coronavirus pandemic impacted community mental health?
We’re at a time when public systems of care and mental health are more critical than ever before. So many people have economic hardships, and due to the pandemic, many are newly finding themselves struggling. It has been devastating to see how the pandemic has impacted people in Philadelphia, particularly working in homeless services. More and more people are requiring services and providing services has been a challenge, as efforts are underway to try to adjust programs that are usually provided face-to-face in the community.
However, community health is a team sport, and it has been inspiring to see how colleagues and professionals on the front lines of community mental health care — like social workers and case management — help people navigate the system during these challenging times. They are doing amazing work right now, going the extra mile to serve our most vulnerable populations.
Why are fellowship programs in public psychiatry so important?
Mental health and psychiatry can feel inaccessible for many with limited resources, but that’s exactly why I’m so passionate about public psychiatry and the fellowship program. Accessible, innovative programs exist! I want to inspire as many young people as possible to consider this path and help drive awareness and this accessibility.
Public psychiatry allows you to work with patients individually, but it also provides opportunities to make the system better. Fellows through the Penn program have a clinical placement, working part-time to provide mental health services in the public sector. In addition, they follow a curriculum to learn about public health systems, covering the criminal justice system, housing, social determinants of health, health equity, and more — all to give fellows a deeper understanding of the systems that impact our vulnerable patients, as they prepare to be a provider and leader. Additionally, fellows are tasked with coming up with and executing a project that promotes positive system change at their clinical site.
Public psychiatry is an exciting field to be in. Beyond clinical work, there are ways to be of service to those in society who truly need it the most; that is something this past year has shown is more important now than ever before.