Building Community in Mental Health
Peter J. O’Brien,
Shared Mental Health
Sheldon Chumir Health
1213 – 4th
O'Brian, PJ (2012). Building Community in Mental Health. International Journal of
Psychosocial Rehabilitation. Vol 16(1) 109-116
project focused on building a sense of community in the broader mental
health system is described. The accent is on taking the time and
creating the conditions that will facilitate members joining together
in the spirit of intentional collaboration. Participants are
collectively creating an environment conducive to the goal of an
integrated mental health system that is truly responsive to client and
Key Words: building community; integration; collaboration; mental health.
Too often, a lament in mental health
circles is that we are not a community, that particular challenges in
the delivery of service to a client or family are “not my problem,”
that, “this situation is outside our program mandate.” This article
describes the Community Rounds project that has developed in Calgary,
Alberta since 2006, amplifying our shared responsibility in the
continuum of care of clients and families in the mental health system.
Community Rounds project was stimulated by front-line staff sharing
their frustration about how to access services within the mental health
system for the Calgary region. Front-line staff were interested in
doing something constructive in response to the experience of silos and
barriers prevalent throughout the mental health system. At no time in
the initial stages of developing this project was management consulted.
Thus this project truly represents a grassroots approach to change.
main focus of the Community Rounds project is to contribute to an
integrated and collaborative mental health community by promoting
alliances across the mental health sector, inclusive of personnel in
other social service and agency settings.
Defining the terms
the outset the Community Rounds project settled on the term community
to capture the essence of the initiative. It seemed like a natural fit
and was sufficiently encompassing of the values and principles
reflected in the project. Definitions of the term community include
words and phrases such as a common or shared spirit and similarity or
agreement of interests (Hanks, 1988). From the outset the term
community has captured the spirit of the enterprise, connoting the
friendly and inclusive intentions that Community Rounds strives for.
The idea that a community is not static but will grow and evolve as the
process of the project unfolds also reflects the premise of Community
Other terms, such as partnership, coalition or
integration, can also be considered as characteristic of the project,
without suggesting a formal or sanctioned agreement between programs
and agencies. These terms will be used interchangeably throughout this
text, just as they are in Community Rounds sessions. The significance
of intentional collaboration with one another is an important premise
of the Community Rounds project.
ethos of Community Rounds - communicating respect, mutual trust and
understanding - are each identified as significant factors in
successful collaboration (Mattesssich & Monsey, 1992). The
Community Rounds project transcends individual agency mandates and
promotes collaboration as a life style “that is simultaneously flexible
and responsive to others” (London et al., 2009, p.1).
many ways to actualize the African proverb – “it takes a village to
raise a child” – and to honour the collective will to make a difference
(Tourse, et al, 2008). Further, there is increasing recognition that
partnerships among agencies and diverse organizations in the community
generate opportunities to find new and creative ways to address
complicated health care challenges (Lasker, Weiss & Miller, 2001).
Mental Health Commission of Canada proposes that organizations need to
work more closely to better coordinate and integrate programs and
services, in order to break down silos that serve as barriers to the
care of clients (Mental Health Commission Canada, 2009, p.6). Community
Rounds contributes to altering traditional cultures in the mental
health and social service systems that have fostered hierarchy, an
accent on exclusion criteria, fixed boundaries (Poole, 1997),
competition and less-than cohesive efforts to work cooperatively with
other programs and agencies. When staff of various programs and
agencies neither know one another nor understand respective
perspectives or mandates, it is easy to be sensitized to boundary
conflicts, competition for increasingly shrinking resources, tensions
between agencies and concerns about sharing information due to
confidentiality issues (Secker & Hill, 2001). Finding a forum to
energize and engage in discussion about functioning more cooperatively
Making new approaches a reality requires a major
restructuring of how mental health systems and communities behave
(Carling, 1995). It has been noted that staff from many training
disciplines in mental health tend to focus on their relationships with
clients and families, without understanding the significance of
attending to relationships with colleagues (Robinson, 2005). By
bringing people together in an informal way to discuss issues and
activities of mutual interest, misunderstanding is reduced and
relationships are fostered (Larkin & Callaghan, 2005). A culture of
individuals, agencies and institutions viewing themselves as part of
the broader mental health community is facilitated (Hall, 2005). The
Community Rounds project is also consistent with suggestions in the
Kirby Commission Report – “Out of the Shadows at Last: Transforming
Mental Health, Mental Illness and Addictions Services in Canada” -
(Kirby, 2006, p.51) that integration of services in mental health
requires local input.
Not unlike the wisdom articulated in
“The Tipping Point” (Gladwell, 2000), the Community Rounds process is
an example of a small number of people behaving differently, with the
intention of having an impact across the larger community.
The Community Rounds Process
idea of Community Rounds began from what is a familiar scenario to
many. An informal discussion, among staff from a few mental health
programs at Foothills Hospital, focused on where to refer a particular
client. The initial suggestion was disputed, on the grounds that the
recommended program had recently changed its mandate and would decline
the referral due to new exclusion criteria.
This led to a lively
discussion and assertions of considerable frustration in remaining
current with changing mandates and admission criteria for various
programs. There was agreement that an accent on exclusion criteria was
common among programs and made it difficult to access particular
programs or to take seriously the idea of collaboration or a
functioning continuum of care, or the belief that staff are all “in
this together” in sharing the care of clients in the mental health
This discussion initially focused on programs within
the Alberta Health Services (AHS) Adult Mental Health portfolio,
Calgary region. The discussion expanded to include representatives of
staff external to the health care system and produced even more
emphatic expressions of frustration about how to work in a
collaborative and integrated manner with the health care system in
providing service to clients and families.
Staff of community
agencies will despair over the fact that they offer ongoing care for a
client until that client ‘disappears’ into hospital, after which the
agency will receive no information whatsoever as to status or
treatment, until the individual is discharged from the hospital and
arrives back at the agency, with no accompanying discharge summary or
consultation about assessment and treatment. Primary care physicians
will similarly lament, with some perplexity, the complete lack of
information they are able to obtain about their office patients when
these individuals are admitted to hospital. The act of consulting
community agency personnel about treatment steps, or involving them in
the discharge process, is infrequent, though many individuals will
comment on the potential value of standardizing such a practice.
Similarly, staff of hospital programs will express the challenge in
developing a discharge plan for a client due to the paucity of programs
or outreach services available to the client in the community. In
summary, whether working in an inpatient milieu or in the wider
community, there is a recurring frustration with the lack of cohesion,
integration and basic communication in the care of clients and their
Thus, rather than simply commiserating about the
frustrations commonly shared in the mental health community, a small
group of staff created an informal Committee to address this dilemma.
The Community Rounds project, initiated in the summer of 2006, and
organizing four presentations annually, commenced in November 2006.
vision for Community Rounds was to bring together like-minded people
who share the view of having a collective responsibility to create a
more integrated and cohesive continuum of care. The Community Rounds
project makes no distinctions about which people, programs and agencies
to include in the process. The idea is to invite staff of programs,
agencies and institutions within the broader mental health and social
service systems who express an interest in Community Rounds.
the initial planning stage for this project it became clear that there
were many ways to understand the meaning of the word “community”. This
became the focal point for the first three Community Rounds sessions,
occurring over a period of six months. These first three sessions
included representatives of various programs and agencies from within
the health care system, as well as the wider community, serving as
Panel members in a discussion about “the meaning of community”.
format developed in the first year of Community Rounds has served as a
template. The designated subject being presented at the Community
Rounds session involves a presenter(s) or Panel, with a moderator,
assuming responsibility for the first half of the presentation.
Following an intermission, the moderator assumes a more active role,
typically facilitating interaction with the audience and presenter(s).
The moderator invites audience observations, comments and questions and
can choose to invite an immediate response from a presenter(s), or can
first canvass others in the audience for a response. This potentially
generates an ever-widening discussion of the presentation topic,
thereby more fully engaging the audience. This is a departure from the
more common lecture style involving a limited number of speakers that
often occurs in educational gatherings.
The Community Rounds
process is meant to facilitate a friendly and informal atmosphere, with
an emphasis on building relationships. Registration prior to the
presentation as well as a fifteen minute intermission half-way through
the session allows participants to have an additional networking
opportunity. This intermission offers a natural break in the
proceedings, complementing the shift from the more formal presentation
or Panel discussion to the audience participation in the latter portion
of the session. Also contributing to the friendly atmosphere is a
ticket draw for door prizes at the conclusion of the intermission. This
practice has been supported, as has the provision of coffee, by mental
health administration for the health region, and has added a sense of
fun to the proceedings. It is these kinds of small details that have
contributed to the success of this project.
The next phase of
the Community Rounds process arose from audience feedback in the
initial sessions, suggesting that Community Rounds serve as a forum for
discussion of the Kirby Commission Report (Kirby, 2006). The emphasis
in this document on integration of mental health services and the
importance of programs and agencies working together in a more
collaborative manner to ensure high-quality service delivery in mental
health, punctuated the collective realization that more needed to be
done to create a greater sense of community in the broader mental
health system in the Calgary area. Several points made in the Kirby
Commission Report serve as guidelines in the building of community in
mental health. For example, time, leadership and money are described as
key ingredients to the successful integration of mental health and
addictions services. In other words, you cannot dictate integration or
offer a template or timeframe for the successful merging of, and
cooperation between, services in any region. Rather, you can articulate
a vision for building community, provide leadership and then allow
people to begin the process of meaningful collaboration. Promoting
successful integration and collaboration requires attention to the
history and particular circumstances of the local area in question
(Kirby, 2006, p.51).
The early viewpoint of the Community
Rounds process was to build slowly. In some instances, it was obvious
that a particular agency or program be invited to participate in the
Community Rounds process, by virtue of their involvement with clients
and families in the mental health system. In other situations,
invitations to participate in the Community Rounds process followed
from suggestions offered in the evaluative feedback at the conclusion
of each Community Rounds session. Alternately, staff of community
groups simply expressed interest in attending Community Rounds.
Invitations are extended to any program or agency personnel expressing
such interest, based on the principle of inclusion.
Why is our specific “Community” the Focus of Community Rounds?
put, we had to start somewhere, and it seemed sensible to start with
our interactions most directly in relationship to one another in
offering services in the mental health system as our community.
Existing partnerships and working relationships in the community can
help to develop and enhance a collaborative system of care (Naidoo,
2006). This summary report states that cross-agency meetings are a
necessary component of building skills and capacities of service
providers. Further, that any process that helps staff to gain
familiarity with one another and promotes working together is to be
encouraged. The Community Rounds project offers such opportunities.
main goal of the Community Rounds project is to develop a stronger
sense of commitment and expectation for collaborative behaviour
throughout the mental health system. The idea that we all have a
responsibility to share in the provision of care and services to
consumers and their families cannot be stressed too greatly. An
illuminating study by Geoffrey Nelson and colleagues (Nelson, et. al,
2001) emphasizes that change is saturated by values and principles and
“… values provide the ‘compass’ or the ‘direction’ for all
implementation” (p.222) of desired goals. Values do matter and the more
they are lived by an organization the more meaningful they will become.
are aware that there is a robust literature about building a sense of
community and collaboration within the mental health system from a
consumer perspective. In addition to the aforementioned study by
Geoffrey Nelson and colleagues, the Canadian Mental Health Association
has been a strong and effective proponent of consumer participation and
incorporating the experiences of consumers and their families to create
a more dynamic mental health system. For example, the Frameworks for
Support (Trainor, 2004) can be accessed via the CMHA website and
includes a focus on community and how to develop partnerships with
consumers and their families, as well as engaging the wide-range of
knowledge that has emerged in contributions of consumers and their
families in the development of mental health services. The Mental
Health Commission of Canada (www.mentalhealthcommission.ca) has been an
equally strong proponent of creating a comprehensive and seamlessly
integrated system in which people living with mental illness are at its
centre and along with their families are fully engaged with the mental
The hope is that the Community Rounds project
will evolve to include the consumers and families engaged in the mental
health system. Such a vision is consistent with the dynamic literature
that can be found in consumer advocacy, self-help, community psychology
and other disciplines with an interest in building a more comprehensive
sense of community. However, in order to achieve the vision of being
genuinely inclusive in all who are part of the mental health continuum,
a collaborative system involving programs and agencies is a
Barriers & Challenges to Building Community
the earliest days of developing the Community Rounds project there was
some debate about the legitimacy of a small, volunteer group of
front-line staff creating an initiative without official sanction and
mandate. In fact, these initial and arbitrary objections to the
initiative almost derailed Community Rounds before the first session
was held. This may just reflect human nature where a negative response
to ideas can be their death-knell before they reach fruition.
Fortunately, among the small group that coalesced to form the Community
Rounds Committee there was sufficient energy and determination to
overcome this negativity. And, at a management level within the AHS
Mental Health portfolio, there was no attempt to meddle with the
An ethos that embraces inclusion of all
partners in mental health and accents collaboration – whether that
means clients, family members or personnel of agencies that have
traditionally been seen to be less sympathetic to some clients –
takes time (Backer, 2003) and encouragement to seed. In addition to
having a vision and energy to initiate the process of bringing together
the staff of disparate community programs and agencies, the value of a
core group of committed people serving as a Committee is critical. That
core group can sustain and hearten one another through the early phase
of uncertainty when maintaining confidence calls for considerable
We exist in a larger culture which frequently
emphasizes values of competition at the expense of cooperation
(O’Connor, 2001). Competition and turf (Backer, 2003) also exist in the
mental health system and in the social service sector. Further, a
culture and history of competitiveness is not easy to overcome (Norman,
2003). Worry over job security, ambitions related to career advancement
and a personal inclination to interact with potential colleagues in an
adversarial manner are rife in this culture. It is not uncommon for the
same individual who espouses principles of collaboration and
cooperation while working in a community not-for-profit agency to
suddenly become circumspect and vigilant around program boundaries when
they transfer to a “therapist” role in a program within the mental
health system for AHS, demonstrating that the concepts of collaboration
and cooperation are no longer part of their lexicon.
collaborative efforts is a challenge, as they have a tendency to be
short lived for a variety of reasons (Freeth, 2001). Maintaining energy
in the Community Rounds project, as a focal point for building
community, is required. Whether this is achieved by adding new members
to the Committee overseeing Community Rounds, or through other methods,
remains to be seen.
Some concern was expressed at the outset
of the Community Rounds project about having presentation topics that
were too general, or having a process at Community Rounds that was so
informal that it would not galvanize participants. This concern about a
too open-ended approach has been balanced with a desire to be
non-directive, and to not attempt to predict what topics and
opportunities for interaction might best suit the participants at
Community Rounds. In a similar vein, there has been occasional debate
about how widely to distribute the notices announcing Community Rounds
presentations. The larger the community representation from programs,
agencies and institutions, the greater the challenge to offer a forum
that will satisfy so disparate a gathering. Concerns that interests be
addressed in a mutually satisfying manner are a legitimate issue to
account for when planning and advertising presentations. Topics for
presentation at Community Rounds are largely drawn from the evaluative
feedback that is provided at the conclusion of each presentation. In
addition to requesting feedback about the specific presentation, the
audience is canvassed for ideas about future topics and programs or
agencies that should be invited to the Community Rounds. The Community
Rounds Committee pays careful attention to this evaluative feedback
(Francisco et al., 2003). Planning for subsequent presentations, as
well as tweaking the process of each session, is a direct result of the
audience feedback. This is also in keeping with the grassroots
objective of audience participation in the Community Rounds process and
in building the community. Although widely divergent impressions are
provided via the feedback, main themes and suggestions for future
topics do emerge.
There has been some debate within the
Community Rounds Committee concerning composition of the Committee.
This involves considering membership from the Adult Mental Health
portfolio, AHS, and programs and agencies representative of the larger
community. This can be a delicate matter, as appreciating the
importance of finding a “fit” between Committee members with sufficient
unity as to purpose and vision requires balancing with the principle of
being inclusive and representative of the wider community. Almost fifty
years ago, Robert Kennedy, as Attorney General of the United States,
insisted that there be a strong representation of black lawyers in the
Department of Justice if the administration was to promote civil rights
(Schlesinger, 1978). In building a genuine mental health community
there is a similar obligation to ensure broad representation from
across the mental health community. The Committee has an opportunity to
lead by example and to serve as a mirror for the fulfillment of the
intended vision of building a comprehensive, representative mental
Strengths & Benefits in Building Community
support from leaders and administrators in the mental health system is
important, especially so with the multiple fiscal and staffing
pressures that are being experienced throughout the health care system.
The Community Rounds project has been fortunate to have consistent and
informal support from the administrative group in the AHS Mental Health
portfolio; for example, by providing a modest budget for coffee,
muffins and door prizes at Community Rounds. As well, managers of
various programs encourage their staff to attend the Community Rounds
presentations. Such support from the formal leadership of any
institution or agency is a key component of a successful project. Aside
from offering this administrative support, the grassroots project has
evolved with no outside attempts to guide or alter the process.
topic for each presentation offers a subject for education and
discussion. The accent on networking and audience participation in the
presentations is designed to promote attention to relationships among
all who are present. Feedback has included the observation that it is
refreshing to join a forum where there is not a lot of highly critical,
sharp or intimidating verbal exchanges during presentations. There is
an emphasis on creating an atmosphere and an expectation that the
Community Rounds process offers an opportunity to participate in
friendly and informal exchange of ideas, to renew acquaintances or to
meet staff from a diverse variety of agencies and programs.
Community Rounds process provides immense opportunity to influence the
nature of relationships that evolve in the mental health community. For
example, on the basis of informal relationships formed at the Community
Rounds, discussions arise as to how two or three staff of community
agencies might collaborate with staff from an inpatient hospital
program to facilitate a discharge from hospital. Included in such a
plan are respective agency/program roles in providing follow-up care
for the client and family. This standard of collaborative practice
along the continuum of care is not necessarily as common as we might
wish, but remains a goal for working relationships among staff of
various programs, agencies and institutions in the mental health
The vision of the Community Rounds project is that it
serves as a ‘touchstone’ where individuals and agencies can attend to
renew energy and commitment to the broader goal of creating an
environment conducive (Lasker, Weiss & Miller, 2001) to an
integrated mental health system that is truly responsive to client and
family needs. This, in itself, promotes change in professional practice
(Robinson & Cottrell, 2005). The collective energy of staff
attending Community Rounds can facilitate an attitude of openness to
one another and respect for the shared enterprise, building community
in mental health.
directions are proposed as the Community Rounds project approaches its
fifth year of existence. A more systematic evaluation with the
participants to examine specific ways in which real and positive
changes are accruing is envisioned. Although it may be difficult to
evaluate whether an experience of an attitude and practice of respect
and collaboration leads to concrete results with consumers and
families, such examples can be solicited via the feedback forms that
are distributed at the conclusion of each Community Rounds
presentation. It is hoped that participants in the Community Rounds
process are experiencing a collective recognition that intentional
collaboration, shared values, respect for the mutual contributions and
learning, and a shared responsibility for participating in service
delivery enhances the well-being of consumers and families.
second proposed direction is that the Community Rounds project makes an
intentional effort to be more inclusive of consumers and families in
the presentations. This likely involves greater collaboration and
planning with some of the key agencies that advocate for consumers and
families, as well as recruitment of individual consumers and families
to be part of the planning process with Community Rounds. The more
stressful economic climate and associated pressures in the health care
system and social services network may contribute to making this step
additionally challenging. Sustained reflection and dialogue may be
imperative to address the apprehension that some staff, programs and
agencies express when contemplating including consumer groups in the
process. However, such ambitions are worthy of the Community
Rounds project and the collective energy that can be harnessed to
facilitate meaningful change in the mental health system.
is hoped that this article has reached its goal of offering a model to
create similar initiatives in systems that may be of significance to
the reader. Outreach to communities is important, and more so when
conducted with intentional collaboration. The vision of the Community
Rounds project in Calgary, Alberta is to facilitate an integrated
mental health system that is truly responsive to client and family
needs, and I hope that this blueprint may serve the needs and
aspirations of your own community.
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