The International Journal of Psychosocial Rehabilitation

Building Community in Mental Health

 
 
Peter J. O’Brien, MSW,RSW
Shared Mental Health Care
  Calgary Zone
  Alberta Health Services
  Sheldon Chumir Health Centre
  1213 – 4th Street S.W.
  Calgary, Alberta,   T2R 0X7
 
peter.obrien@albertahealthservices.ca
 


Citation:
O'Brian, PJ (2012). Building Community in Mental Health.  International Journal of Psychosocial Rehabilitation. Vol 16(1) 109-116



Abstract
A 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 family needs.

Key Words: building community; integration; collaboration; mental health.


Introduction
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.

The 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.

The 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
From 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 Rounds.

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.

Rationale
The 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).

There are 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).

The 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 is required.

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
The 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 system.

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 families.

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.
The 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.

In 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”.

The 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?
Simply 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.

A 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.

We 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 health system.

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 foundational step.

Barriers & Challenges to Building Community
In 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 evolving project.

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 persistence.

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.

Sustaining 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 health community.

Strengths & Benefits in Building Community
Gaining 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.

The 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.

The 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 community.
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.

Future Directions
Two main 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.

The 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.

Conclusion
It 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.

 

References:

Backer, T. (2003). Evaluating community collaborations: An overview. In Thomas E. Backer (Ed.), Evaluating community collaborations (pp. 1-18). New York:Springer.

Carling, P. (1995). Return to community:Building support systems for people with psychiatric disabilities. New York:Guilford Press.

Francisco, V., Schultz, J. & Fawcett, S. (2003). Making sense of results from  collaboration evaluations. In Thomas E. Backer (Ed.), Evaluating community collaborations (pp. 113-128). New York: Springer.

Freeth, D. (2001). Sustaining interprofessional collaboration. Journal of Interprofessional Care, 15(1), 37-46.

Gladwell, M. (2000). The Tipping Point: How little things can make a big difference. New York:Little, Brown & Company.

Hall, P. (2005). Interprofessional teamwork: Professional cultures as barriers. Journal of Interprofesional Care, May 2005 Supplement 1: 188-196.

Hanks, P. (chief editor). (1988). Collins Concise Dictionar:, Second Edition. Glasgow: William Collins Sons & Co. Ltd.

Kirby, M. (2006). Out of the shadows at last: Transforming mental health, mental illness and addiction services in Canada. The Standing Committee on Social Affairs, Science and Technology, Senate of Canada.

Larkin, C. & Callaghan, P. (2005). Professioals’ perceptions of interprofessional working in community mental health teams. Journal of Interprofessional Care, 19(4), 338-346.

Lasker, R., Weiss, E. & Miller, R. (2001). Promoting collaborations that improve health. Education for Health, 14(2), 163-172.

London, S. Mexico, D., St. George, S. & Wuff, D. (2009). Guides for collaborating. International Journal of Collaborative Practice, 1(1),1-8.

Mattessich, P.W. & Monsey, B.R. (1992). Collaboration:What makes it work. St. Paul, MN: Amherst H. Wilder Foundation.

Mental Health Commission of Canada. (2009). Toward recovery and well-being(draft). Retrieved  July 13, 2009 from www.mentalhealthcommission.ca 

Naidoo, K. (2006). Building capacity:A framework for serving Albertans affected by addiction and mental health issues. Summary report of the concurrent disorders demonstration project evaluation. Alberta Alcohol and Drug Abuse Commission. Edmonton:AADAC Research Services.

Nelson, G., Lord, J. & Ochocka, J. (2001). Shifting the paradigm in community mental health:Towards empowerment and community. Toronto:University of Toronto Press.

Norman, A. (2003). Multicultural issues in collaboration:Some implications for multirater evaluation. In Thomas E. Backer (Ed.), Evaluating community collaborations (pp. 19-36). New York: Springer.

O’Connor, Richard. (2001). Active treatment of depression (pp.245-246). New York: W.W. Norton & Co. Inc.

Poole, D. (1997). The SAFE project: community-driven partnerships in health, mental health, and education to prevent early school failure. Health & Social Work, 22(4), 282-289.

Robinson, L. (2005). Promoting multidisciplinary relationships: a pragmatic framework for helping service providers to work collaboratively. Canadian Journal of Community Mental Health, 24(1), 115-127.

Robinson, M. & Cottrell, D. (2005). Health professionals in multi-disciplinary and multi-agency teams: Changing professional practice. Journal of Interprofessional Care, 19(6), 547-560.

Schlesinger, Jr. A. (1978). Robert Kennedy and his times. pp. 311-312. New York: Ballantine Books.

Secker, J. & Hill, K. (2001). Broadening the partnerships: experiences of working across community agencies. Journal of Interprofessional Care. 15(4), 341-350.

Tourse, R., Mooney, J., Shindul-Rothschild, J., Prince, J., Pulcinie, J., Platt, S. & Savransky, H. (2008). The university/community partnership: Transdisciplinary course development. Journal of Interprofessional Care, 22(5), 461-474.

Trainor, J., Pomeroy, E. & Pape, B. (2004). A framework for support (3rd ed.). www.cmha.ca retrieved 29 March 2011).



 


Copyright 2012  ADG, SA. All Rights Reserved.  
A Private Non-Profit Agency for the good of all, 
published in the UK & Honduras