ORGANIZATIONAL CLIMATE, DIVERSITY, AND TREATMENT OUTCOMES AT COMMUNITY MENTAL HEALTH AGENCIES: AN ATYPICAL CASE STUDY

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ORGANIZATIONAL CLIMATE, DIVERSITY, AND
TREATMENT OUTCOMES AT COMMUNITY MENTAL HEALTH
AGENCIES AN ATYPICAL CASE STUDY Christopher R.
Larrison, Ph.D., Susan L. Schoppelrey, Ph.D.,
Eric Hadley-Ives, Ph.D., Barry J. Ackerson,
Ph.D. University of Illinois at Urbana-Champaign
School of Social Work
METHODS
INTRODUCTION
COMMUNITY MENTAL HEALTH AGENCY (CMHA)
Part One ? Convenience sample consisting of
nearly 17 (n 130) of adult clients. ?
Symptoms were measured four times over a
nine-month period (initial status and three
follow-up measures) using BASIS-32 (Eisen, Dill
Grob, 1994) ? HLM (Byrk Raudenbush, 2002) was
used to determine whether differences existed
between African American and white clients in
treatment outcomes. The model consisted of
an individual growth model, modeling change in
each clients observed level of symptomatology
over time, and a between-client model that
examined the possible differences between
client-level change trajectories created by race,
diagnosis, socioeconomic status, and gender.
Part Two ? Purposeful sample of 20 African
American clients and 22 agency staff. ? Clients
completed the 28-item adult version of the Mental
Health Statistical Improvement Program
consumer survey (MHSIP) and staff completed the
Work Environment Scale (WES) to estimate
the CMHAs organizational climate. ? The client
sample was compared to a sixteen-state sample of
mental health clients receiving outpatient
services. The staff and administrators were
compared to a group of 4,879 healthcare
workers used to norm the WES (Moos, 1994). ?
Clients and staff also participated in separate
semi-structured focus groups about the
agencys organizational climate and its
relationship to treatment outcomes for African
American clients.
The two part case study began as an evaluation of
services conducted by the lead author for the
state agency overseeing the CMHA. The process of
the evaluation, which created long term
interactions with staff, clients, and
administrators of the agency led to the
observation that the climate at the agency was
strongly set by the administrative staff and
positively permeated most aspects of agency life.
This observation was confirmed by a number of
other professionals and state officials that had
knowledge of the agency. In the first part of
the case study, the existence of racial
disparities in treatment outcomes was examined by
observing the patterns in clients symptoms over
a nine-month period. In the second part of the
case study, the organizational climate of the
agency was examined using both quantitative and
qualitative descriptive data.

• ? Served six counties in the rural Southeast.
• Licensed staff agency administrators were
  entirely white.
• Unlicensed staff was approximately 60 African
  American.
• The racial distribution of clients within the
  agency was 55 African
• American and 45 white.
• Approximately 40 of the adult clients were
  diagnosed with
• depression, 30 with schizophrenia and related
  disorders and the
• remaining 30 had a range of diagnoses,
  including bipolar
• disorder, psychotic disorders, adjustment
  disorders, PTSD, and
• impulse control disorder.
• Multiple interventions were provided including
  individual counseling,
• group therapy, medication, psychiatrists
  services, day treatment,
• client run peer groups, case management, and
  supportive services.
• A variety of therapeutic models shaped
  interventions including
• cognitive behavioral, solution focused
  therapy, family therapy, and
• insight-oriented psychotherapy.

LITERATURE
? The limited research regarding predictors of
disparate treatment outcomes for African American
clients has focused on client and staff level
factors producing little consistent knowledge
about why disparities occur (USDHHS, 2001). ?
Organizational climate has a significant effect
on staff performance, their emotions and
attitudes about their workplace, and the quality
of their relationships with clients (Glisson,
2000). These factors, in turn, are likely to
influence the quality of services provided and
the outcomes of those services. ? No research
to date has systematically examined the
relationship between organizational climate and
racial or ethnic disparities in outcomes among
CMHA clients (Snowden, 2001, 2003).
THEORETICAL MODEL
FINDINGS PART ONE
Overall, clients symptomatology either decreased
or remained constant over the nine-month period
of the study, depending primarily on their
diagnosis. The average change over time was
approximately 1/3 of a point on the four-point
scale, which means that, although change over
time was statistically significant, it may not be
clinically significant.
The only variable significantly related to
variation in symptomatology patterns was
diagnosis. Given that schizophrenia and major
depression are likely to have different courses
of treatment and patterns of outcomes, the
findings make sense from an empirical standpoint
and fit with the wide range of research
concerning treatment of mental health problems.
The results of this study suggest that in this
agency client outcomes did not differ as a
function of client level factors of race, gender,
age, or method of payment (Larrison et al.,
2004).
BASIS-32 Scores
FINDINGS PART TWO
Staff
The agency was characterized by staff as having a
positive top-down administrative structure that
orient staff towards agency goals, which centered
on improving clients quality of life. African
American and white staff reported feeling
comfortable asking each other questions
pertaining to cultural issues. All staff
reported receiving cultural competency training
as part of their employment experience. There was
support for innovative and unique treatment as
long as standard treatments had been exhausted
and proven ineffective. African American staff
reported that they sometimes observed African
American clients being treated differently than
white clients - Typical incidents cited were
minor. All staff stated that there was
recognition that client treatment was varied and
individualized, and that this variation was
determined by a number of factors beyond race.
PROPOSED RESEARCH

• Hypotheses
• CMHAs that demonstrate low levels of disparities
  in treatment outcomes between African American
  and white clients will have high levels of
  involvement, task orientation, clarity,
  innovation, and physical comfort as measured from
  the perspective of agency staff.
• CMHAs that demonstrate low levels of disparities
  in treatment outcomes between African American
  and white clients will have easy access to
  services, good quality of care, and generally
  positive treatment outcomes from the perspective
  of clients.
• Methods
• ? Sample of 780 clients and 300 staff at seven
  CMHAs with 13 offices located in Upper
  Mississippi River Basin. The southern region of
  this geographical area has one of the highest
  concentrations of rural African Americans outside
  the deep South (U.S. Census Bureau, 2001).
  Assuming a fixed alpha level of 0.05, a sample
  size of 50 subjects per site, and an effect size
  of 0.40, a minimum of eleven sites are necessary
  to ensure adequate statistical power (ß0.80
  Raudenbush Liu, 2001). 
• ? A four level hierarchical linear model, which
  can partition the total variability in the
  repeated outcome measures into its constituent
  components of clients within staff (Level 2)
  among staff within agencies (Level 3) and among
  agencies (Level 4), will be used (see Analytic
  Model).

Analytic Model
Clients
Study Sample 16-State Study Median
Access 85.0 81.8
Quality appropriateness 85.0 80.1
Positive change 95.0 71.1
Consumer participation in treatment planning 70.0 72.3
General satisfaction 95.0 83.8
The African American clients consistently cited
the high quality of care, professional appearance
of the facilities, and personalized treatment
received from staff at all levels of the
organization, which is consistent with the high
levels of satisfaction reported on the MHSIP
survey. They reported that staff were able to
act in culturally appropriate ways, and also
noted that staff were sensitive to the delicate
balance between the needs of the client and the
needs of the clients family. Treatment in
general was perceived as having a significant
positive impact upon functioning and quality of
life.
Note Figures for the 16-state study come from
Hall (2002) and Lutterman et al., (2003).