Psychodynamic psychiatry, psychotherapy, and community psychiatry.

Community psychiatry is defined by mixed systems of care for patients with severe and persistent mental disorders, many of whom are indigent. Much of it dates back to the community mental health movement 50 years ago. The emphasis at that time was on deinstitutionalization, prevention, least restrictive options for care, and transformation of large public hospitals into multiservice regional centers. The current focus, in contrast, is on economy, local control and accountability, emphasizing, for example, manualized behavioral health techniques, pharmacotherapy, and case management by allied professionals. Psychodynamic psychiatry, particularly a psychodynamic orientation is uniquely helpful in complex, community-based clinical situations. Applicable psychodynamics include unconscious mental processes, psychological defenses, emotional relationships, a developmental perspective, disciplined use of the self for healing, transference, and communications in all forms as material for therapy. Literature and case reports illustrate the approach taken. These include examples of active listening, interprofessional collaboration, clinical continuity, appropriate boundaries, and thoughtful timing. Psychodynamic applications in community settings have passed the test of time and because of their validity could again become prevalent. Competence depends upon experience with well-supervised psychodynamic psychotherapy and interdisciplinary collaboration, in a variety of cultures and settings.