Psychotherapy is largely unavailable for persons with low or no income. Clinicians have a moral and fiduciary responsibility—not only to the individual or family but also to the general population—to give back, having received a unique and specialized education largely provided by the community at large. The community mental health clinic in Raleigh, North Carolina, is based on clinical and moral principles. Our hypothesis was that a high-quality clinic of volunteer staff offering high-quality psychotherapy to motivated people who cannot afford existing resources could be implemented in an environment free of monetary considerations and constraints. The clinic is beginning its seventh year of operation; data presented here are for the first five years.
We accepted an invitation to use classroom space at the Edenton Street United Methodist Church, which is conveniently and centrally located and is a sponsor of many community service projects. We contacted clinicians and started with word-of-mouth publicity. The clinic is open every Thursday evening. All staff at the clinic are volunteers. One of the authors (CB) provides telephone screening contact, informing callers of the clinic's functions and ground rules. Services are free and are provided only to persons who are unable to pay and lack Medicare, Medicaid, or other insurance. Treatment is provided by a therapist-psychiatrist team and is based on an initial evaluation. Patients are expected to keep their appointments and to be active and committed. Treatment is goal oriented and time limited. Medications are prescribed only in conjunction with active psychotherapy. The clinic cannot respond to crises and does not accept persons who are actively abusing substances or who are psychotic, suicidal, or homicidal, although a number of clients have a history of such behaviors and characteristics.
A volunteer board evolved from an initial steering committee, meeting quarterly and including a representative from the National Alliance for the Mentally Ill, two clergy, an attorney, a representative from the church board, a representative from the free medical clinic, a community advocate, the clinic coordinator, and the medical director.
During the first five years of the clinic's operation, a total of 423 patients were given appointments. For many other patients we serve a triage function, referring them elsewhere because of such problems as active psychosis, desire for medication or evaluation only, lack of motivation, availability of insurance coverage, or active substance abuse. Referrals come from throughout the community, including the local private psychiatric hospital, vocational rehabilitation programs, employee assistance programs, private and public psychiatrists, school counselors, and patient word of mouth. Presenting problems included losses, relationship conflicts, disruptive behavior, anger, anxiety, depression, joblessness, low energy levels, sleep disturbances, and traumatic memories. Diagnostic categories included mood, anxiety, adjustment, posttraumatic stress, and personality disorders, frequently comorbid with one another. Some patients had a history of psychosis, substance abuse, or suicide attempts. At any one time, 30 to 35 active patients were in therapy. The patients received high-quality, timely services, approximately 90 percent with medication, primarily antidepressants and mood stabilizers.
Volunteers currently include four administrative staff, seven psychiatrists, and 14 therapists, who together contribute 20 to 30 hours for 16 to 22 individuals, couples, or families each Thursday. In most cases we can achieve the goal of helping patients become more self-sufficient through the attainment of employment, benefits, or insurance. We can then link them to other community resources in the private or public system.
Supports and links initially included the Urban Ministries of Raleigh, which operates a free medical clinic. We had access to its pharmacy while preserving our self-determination. When this pharmacy service was withdrawn—our first crisis—we contracted with a downtown pharmacy to dispense samples or provide medications at Medicaid prices by drawing on unsolicited donations. This approach worked for two years until the pharmacy board forbade dispensing of samples by retail pharmacies. This was our second crisis and the only time that lack of money became a barrier to some of our services. By obtaining medication samples for the clinic, using pharmaceutical company patient assistance programs, and undertaking limited fundraising, we were able to obtain the needed medications.
In January 2001, Urban Ministries announced that they were discontinuing the organizational connection after our rejection of their plan to integrate our clinic into the medical clinic and to assume administrative and hiring responsibility, which we believed would jeopardize the primary psychotherapeutic purpose. Our board expanded and restructured as an autonomous not-for-profit clinic, still operating at the church with sanction and approval of its board, which has been most supportive and a true partner.
We are reevaluating and planning for the future. The original conceptualization is sound and will be continued. Issues being explored include staff recruitment, future leadership, expansion, development of the clinic as a training site for psychiatry and social work at the University of North Carolina, and any necessary fundraising.
Dr. Stratas is medical director and Mr. Boyd is clinic coordinator of the clinic described in this report. Both authors are also in private practice at Raleigh Psychiatric Associates, 3900 Browning Place, Raleigh, North Carolina 27609 (e-mail, firstname.lastname@example.org).