Patients request health care for reasons that transcend the management of medical disease. Patients seek to create an "alliance" with the physician which "compensates" for conflict or deficit in the family system. This is particularly true for "problem," "difficult," or "hateful" patients who have significant psychosocial problems. When such a compensatory alliance evolves, it may become dysfunctional, limiting the physician's ability to make necessary medical interventions. By not explicitly including other family members, the traditional dyadic model of the doctor-patient relationship predisposes towards the formation of a compensatory alliance. The nature of the dysfunctional compensatory alliance may even remain obscure because the patient presents a distorted picture of the family situation. Therefore, to manage the compensatory alliance, the physician must perform a simple family assessment, including direct communication with other family members, early in the formation of the doctor-patient relationship. The physician should be alert to the formation of a dysfunctional compensatory alliance and the need to perform a family assessment whenever a patient explicitly or implicitly makes a request that engages the doctor with another family member. Recognition that a patient is "difficult" or awareness of a sense of helplessness, and frustration in caring for a patient may also indicate formation of a dysfunctional compensatory alliance and the need for family assessment. Recognizing key aspects of the doctor-patient-family relationship will enable the clinician to manage the compensatory alliance in a productive and therapeutic fashion. When family dysfunction requiring significant change is discovered, involvement of a family therapist should be offered.

A mental health role and professional training situation was developed, spanning the child-related systems of school, pediatric, and mental health clinics. The physician intern's work in the natural setting of the school had three facets, each related to a systems intervention framework, (a) Children were seen for immediate intervention in the school or referred to the intern's pediatric or psychiatric clinic base for specialized evaluation and treatment, (b) Parents, children, and teachers met together in a problem-solving group, (c) Teachers participated in groups encouraging development of support systems. Emphasis was placed on children's pediatric, mental health, and educational needs, stressing early detection, family involvement, and lessening of transactional conflict. Acceptance by school and district personnel was extremely positive. Similar functions can be performed by other pediatric, mental health or educational staff.

One-hundred forty-nine applicants to two residency programs in psychiatry were surveyed with the Opinion About Mental Illness (OMI) scale. Stepwise regression analyses showed that the place where the applicant was raised was the best predictor. In comparison to those raised abroad, those raised in the United States tend to be less authoritarian-restrictive inclined, tend to report less adherence toward an unsophisticated benevolent approach, and less adherence toward an interpersonal-etiology approach. All subjects, whether raised in the United States or not, showed similar adherence to the concepts of the mental hygiene movement.

Leaders of national groups that have focused on issues of community and social psychiatry present their ideas about the future of psychiatry. They identify five areas: theory development; the relevance of community psychiatry in the 21st century; education and training; the relationship between community psychiatry and health maintenance organizations; and role of community psychiatry in bridging medical science with humanism. The unifying theme for these topics is that community psychiatry can be a vehicle for modifying general psychiatry's propensity towards individualism and reductionism by offering a more holistic and integrative approach to illness and well-being.