Edited by Lucile Bruce, Communications Officer, Connecticut Mental Health Center
In 1966, Connecticut Mental Health Center (CMHC) was founded as part of the "Great Society" program during the administration of President Lyndon B. Johnson. Prior to that, the Community Mental Health Act of 1963 signed into law by President John F. Kennedy laid the groundwork for deinstitutionalization—moving large numbers of people out of in-patient psychiatric hospitals—and for the establishment of CMHC as a community-based center for mental health treatment where these patients would receive care.
An enduring collaboration between the State of Connecticut and Yale University, CMHC embraces its tripartite mission in clinical care, education, and research. In this interview Michael J. Sernyak, MD, CMHC's Chief Executive Officer, discusses public psychiatry, heath and wellness in psychiatric care, and what inspires him as leader of a complex health care organization. Dr. Sernyak is professor of psychiatry and directs the newly established Division of Public Psychiatry.
Q: Tell us about the people who come to Connecticut Mental Health Center for services.
MS: We see about 5,000 people each year. Most of them are poor. They come to us for many reasons. Often they're having difficulty negotiating their life. They're dealing with the stress associated with psychiatric illness. They may have anxiety disorders, generalized anxiety, or panic attacks. We see a lot of people who are suffering from depression and many who are struggling with substance abuse issues. Some have a diagnosis of schizophrenia or bipolar disorder. And many of the people we serve are living in a context of urban poverty under extremely difficult circumstances, sometimes with post-traumatic stress disorder. That's usually not the main reason they come to us, but it frequently complicates whatever else they're struggling with.
Q: Why did you decide to become a psychiatrist?
MS: I'd intended to become an astronaut. I majored in physics and astronomy. But midway through college I had a summer job, the only one I could find, working as an aide on the night shift in a psychiatric hospital. It was a transformative experience for me. People came in and I couldn't tell why. They all seemed to be in distress, but I couldn't see the themes. I spent time talking to the attending psychiatrists and they explained to me that there was this book—at the time, the "DSM III" (Diagnostic and Statistical Manual of Mental Disorders)—that described the syndromes and helped you think about what people were struggling with and what you could do in response. I saw some people come in absolutely devastated and leave able to get back to living their lives the way they wanted to. For me, psychiatry combined intellectual rigor—trying to figure out what's happening in the human brain, which is the most complicated thing we know of in the universe—with the emotional immediacy of working with people in incredibly intimate situations and helping them. I decided to go to medical school to become a psychiatrist. I have never regretted that decision. I enjoy my work immensely.
Q: Under your leadership, CMHC has launched major initiatives in physical health and wellness. Why have you chosen physical health as a focus for a community mental health center?
MS: Two principal reasons. One, studies have shown that the people who come to us for services live 25 fewer years than the general population. That's a catastrophe. About one third of this number is due to tragic outcomes associated with mental health, such as suicide. But the remaining two-thirds stem from physical health issues like obesity, hypertension, diabetes, sedentary lifestyle. That's an emergency. It's something that we as healthcare providers have to do something about. As a physician I can't just ignore things that are going to shorten someone's life or tremendously decrease the quality of their life. Number two: American psychiatry has historically separated the brain from the rest of the body, and that doesn't make sense to me. Research is now revealing incredibly interesting things about the interconnectedness of the human body—for example, that transmitters in the gut go straight to the brain. We're a whole organism, and we have to be treated as such. So we are reorienting ourselves to care for the whole person. We launched a Wellness Center with Cornell Scott-Hill Health Center to take care of people's primary care needs, and we're in the process of completely overhauling our food services. It's an exciting time. I think we've made great inroads in addressing these physical health issues without losing our emphasis on the mental health issues that brought people to us in the first place.
Q: For CMHC clients, what are the obstacles to achieving better physical health?
MS: A great deal of the problem has to do with the social determinants of health. Geographically, where do people live? What are their neighborhoods like? What kind of housing (if any) do they have? Where do they purchase their food? How much money do they have and where do they keep it? Are they exposed to violence? Are they exposed to racial prejudice? What kind of access do they have to medical professionals who can treat their physical health problems? These are big, complex problems and we don't have solutions yet. The stress associated with poverty is tremendous—it has a great impact on people's mental and physical health. I'm trying to restore the balance of being concerned about people's overall health, not only their mental health.
Q: In 2012, you launched a Director's Advisory Council comprised of CMHC clients. Tell us about this group and some of the things you've learned from its members.
MS: The best way to design a program, especially one that provides services for people, is to guarantee input to the people who are receiving the services. If we believe in recovery, then a fundamental principal of recovery is literally to ask people, "What should I do?" Members of the Advisory Council have done a terrific job orienting me to the kinds of things I should be interested in. Without reservation, the best ideas we've put in place here have either come directly out of the Advisory Council, or have been seconded by them and highly modified by them. Interestingly, the issues that keep coming up in my Advisory Council are physical health issues. It's driven a lot of our decision-making. Advisory Council members have contributed to the development of our Wellness Center and to our food transformation project. Both of these initiatives now have advisory groups of their own comprised of clients and staff.
Q: You're the founding director of the Division of Public Psychiatry in the Yale Department of Psychiatry. What is public psychiatry, and what's your vision for the Division?
MS: Public psychiatry is psychiatric services funded by public entities. Public psychiatry acknowledges the historical division within healthcare that started many years ago. At that time, there were two systems of care: one for people who could pay privately, the other for people whose care was paid for by public entities, such as the state or federal government. Just before I began my training, many of the great public hospitals were closing. Philadelphia General Hospital no longer exists. Cook County in Chicago, Grady Memorial in Atlanta—these were publicly funded hospitals where anyone could go. Historically, these hospitals were associated with indigent care. Today, due to legislation passed through the decades, private general hospitals have become responsible for the care of all people, except in mental health where a parallel system continues to this day. It's concrete in the State of Connecticut through the Department of Mental Health & Addiction Services, which funds entities that deliver actual care including CMHC, Connecticut Valley Hospital, and other places. The Division of Public Psychiatry in the Yale Department of Psychiatry will be the organizing umbrella for faculty and practitioners who are interested in issues and research relating to public psychiatry. We have a superb group of people in public psychiatry at Yale, and with this Division we'll be even better equipped to delve into the questions facing the field. Over the next several years in public psychiatry, for example, I think we'll see the increased integration of mental and physical health services. I would venture to say that the places that are providing the best mental health care still have a robust public system and have not given up on the state's involvement. But this is a very interesting policy question, and it's going to demand a lot of evaluation going forward. The interest in public psychiatry has accelerated greatly across the nation, and it's providing us with tremendous opportunities for leadership, faculty development, grant funding, collaboration—all sorts of activities.
Q: Why is research so vital to the field of public psychiatry?
MS: I would define scientific research in public psychiatry as being a rigorous asking of questions. The questions take many forms and are investigated in many different ways. Within our division, people like Larry Davidson and others have shown that qualitative research can answer extraordinary questions and guide huge policy decisions. Another aspect of the quest for knowledge is basic scientific research—translational research in neuroscience that asks questions in the laboratory. We are fortunate at CMHC to have an entire floor dedicated to basic science research. A critical role for American healthcare is to take the extraordinary observations that scientists are now making about genetics, biochemistry, and circuitry in the brain, and to use that information to help us understand how we can better address the issues people face. One of the ongoing challenges for the Division of Public Psychiatry is to figure out how to incorporate the views of people receiving services into the research. I think the fundamental issue in public psychiatry is that there are huge sums of money being devoted to helping people with their struggles with mental illness and substance abuse, and so you want to get it right.
Q: Your bookshelves at CMHC are lined with history books. Tell us about one historical figure you admire.
MS: Abraham Lincoln. There are many things I admire about Abraham Lincoln, not the least of which is his incredible grace under pressure. He worked with a large group of people who were all convinced that they would be a much better president than he was. Yet he never lost sight of what he wanted to accomplish. People tried everything to derail him but he never lost his commitment to what he thought was right. Of course, I would never say that any of the pressure I've ever felt is anywhere close to what he must have felt for just one hour as President of the United States. But the maturation of his views was extraordinary. His early views on slavery were not admirable. But he came so far around to such a visionary place. I could only hope to ever come close to that kind of evolution in my thinking. I bore my kids with this story, but every time I go to Washington, I go to the Lincoln Memorial. I'm not a person who really enjoys speeches or hearing people talk. But there are two speeches in the Lincoln Memorial. One's the Gettysburg Address, and one's the Second Inaugural. The second inaugural is just extraordinary. I think it's the greatest speech he ever gave. This was a man who we now know was within months of being assassinated, who had borne the war in a very tangible way. He had aged decades. And he didn't talk about is how victorious he was. He talked about forgiveness, about healing the nation. It's beautiful. It's lyrical. I read a lot about Lincoln. If I were ever to go back to school, I would become a historian. I believe deeply in history being the interaction of great people, the times they lived in, and the systems and institutions they lived within. I try to bring those very lofty thoughts to deciding who gets to park in Lot A.
Q: Looking back on your life, what has prepared you best for the challenge of leading CMHC?
MS: Just living my life in the world. I've learned that deep down, all of us basically want the same things. If I'm suffering, I want to have that suffering alleviated. If I have an idea, I want people to listen and to be honest with me. The staff, the people receiving services here, me—we all want the same things. I couldn't have done this job twenty years ago. I didn't know enough about people. It's the experiential part. You can't read it. You've got to live it.