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Children’s Mental Health and Systems of Care


Children s Mental Health and Systems of Care An Introduction and Overview August 2008 Presentation to University of Alaska Robert M. Friedman, Ph.D. – PowerPoint PPT presentation

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Title: Children’s Mental Health and Systems of Care

Childrens Mental Health and Systems of Care
An Introduction and Overview
  • August 2008
  • Presentation to University of Alaska

Robert M. Friedman, Ph.D. Professor Department of
Child and Family Studies Louis de la Parte
Florida Mental Health Institute University of
South Florida Tampa, Florida friedman_at_fmhi.usf.ed
On the Need for Change and Innovation
  • We are living at a point in history when the
    need and desire for change is profound. Our
    current trajectory is no longer sustainable. We
    cannot ignore the compelling environment and
    social challenges that vex todays world because
    they will undermine us all. We cannot dismiss
    the fractures in our own communities, or the
    fissures between those of us fortunate to live in
    comfort and the massive number of our fellow
    human beings who live under the crush of poverty
    around the world. It is a pivotal time. We need
    to be change-makersand very capable ones at
  • Young, 2006

Seriousness of the Problem
Prevalence of Serious Emotional Disturbance (SED)
Population Proportions (9 to 17 year-olds)
5-9 Youth with SED extreme functional
impairment 9-13 Youth with SED, with substantial
functional impairment 20 Youth with any
diagnosable disorder
An Increase in Diagnosable Mental Disorders?
  • Four Contributing Factors
  • Need of the profession of psychiatry to
    legitimize itself as an important branch of
    medicine that deals with real disorders
  • The promotion of this by the pharmaceutical
  • The increase in funding that is available
    contingent upon there being a diagnosable mental
  • Efforts by advocacy groups to push a medical
    model to reduce stigma
  • Horwitz, A. V., 2002

  • Recent evidence compiled by the World Health
    Organization indicates that by the year 2020,
    childhood neuropsychiatric disorders will rise by
    over 50 internationally to become one of the
    five most common causes of morbidity, mortality,
    and disability among other
    illnesses damage so many children so seriously.

Report of the National Advisory Mental Health
Councils Workgroup on Child and Adolescent
Mental Health Intervention Development and
  • Growing numbers of children are suffering
    needlessly because their emotional, behavioral,
    and developmental needs are not being met by
    those very institutions which were explicitly
    created to take care of them. It is time that we
    as a Nation took seriously the task of preventing
    mental health problems and treating mental
    illnesses in youth.

Surgeon General David Satcher, 2000
Age on Onset
  • Recent research from the National Comorbidity
    Study indicates that 50 of adult disorders had
    an age of onset by 14, and 75 by 24
  • Kessler et al., 2004

  • 3rd leading cause of death in young people
    between the age of 15 and 24 (11/100000)

Characteristics of Children with Serious
Emotional Disturbances
  • Frequently served in multiple systems
  • Variety of diagnoses but most common are ADHD,
    Oppositional Disorder, and Conduct Disorder
  • High rate of co-occurring disorders
  • Deficits in intellectual and educational

Characteristics of Children with Serious
Emotional Disturbances (continued)
  • Deficits in social and adaptive behavior
  • Frequently from low income families
  • Have often been exposed to violence, and to
    losses of major people in their life

Characteristics of Children with Serious
Emotional Disturbances (continued)
  • The major barrier to school readiness for
    children is often not the lack of appropriate
    cognitive skills but rather the absence of needed
    social and emotional skills.

Florida Commission on Mental Health and
Substance Abuse, 2001, p.8.
Characteristics of Children with Serious
Emotional Disturbances (continued)
  • Emotional disturbance is part of an inter-related
    set of problems that Lisbeth Schorr has called
    rotten adolescent outcomes including poor
    school performance, delinquency, early pregnancy,
    substance abuse, and violence.

Characteristics of Children with Serious
Emotional Disturbances (continued)
  • National Comorbidity Study shows that its clear
    a substantial part of the drug problem, and the
    more severe and prolonged drug problem, is in
    people starting out with emotional problems.
  • Median age of onset for mental health disorder
    was 11 years old and for substance abuse was five
    to 10 years later.

Relationship of Mental Disorders to Negative
Impact in Adulthood
  • Early-onset psychiatric disorders have been
    associated with subsequent truncated educational
    attainment, higher risk of teenage childbearing,
    higher risk of early marriage, lower probability
    of later marriage, and lower family income.

 National Comorbidity Study
Lasting Impact
  • 60 of adult substance abuse dependence can be
    prevented by early and effective treatment of
    child an adolescent mental disorders. We know
    that child and adolescent mental disorders are
    much more powerful predictors of a wide array of
    later adverse outcomes that virtually any other
    potential target, e.g., more strongly related to
    early child-bearing than family poverty, and more
    strongly related to educational attainment than
    low parental education.
  • Kendall Kessler, 2002

A Productive Adulthood
  • The National Research Council and Institute of
    Medicine estimates at at least 25 of
    adolescents are at risk on not achieving a
    productive adulthood.
  • NRC and IOM, 2002

Many Children in Need are Not Receiving Services
Unmet Need for Mental Health Services
with unmet need
Calculations based on data from the National
Health Interview Study, Sturm, 2000
ACES Study
  • Conducted by Kaiser Permanente and CDC
  • Studied relationship between childhood trauma and
    health risk behaviors and diseases in adulthood
  • Sample of 9,508 adults

ACES (cont.) Categories of Childhood Trauma
  • Recurrent physical abuse
  • Recurrent emotional abuse
  • Contact sexual abuse
  • A alcoholic or drug abuser in home
  • An incarcerated family member
  • Someone who is chronically depressed, mentally
    ill, institutionalized or suicidal
  • Mother is treated violently
  • One or no parents
  • Emotional or physical neglect

ACES (cont.) Results
  • Graded relationship between number of categories
    of childhood exposures and each of the adult
    health risk behaviors and diseases including
    ischemic heart disease, cancer, chronic lung
    disease, skeletal fractures and liver disease

de facto Mental Health System
All Children
Primary Healthcare
Child Care
Universal Services
Special Healthcare
Juvenile Justice
Special Education
Substance Abuse
Child Welfare
Developmental Disabilities
de facto Mental Health System
Specialty Mental Health
Mental Health Funding Streams for Children and
  • Medicaid Inpatient
  • Medicaid Outpatient
  • Medicaid Rehab. Svcs.
  • Medicaid EPSDT
  • MH General Revenue
  • MH Medicaid Match
  • MH Block Grant
  • ED General Revenue
  • ED Medicaid Match
  • Student Services
  • SA General Revenue
  • SA Medicaid Match
  • SA Block Grant
  • CW General Revenue
  • CW Medicaid Match
  • IV-E
  • IV-B
  • Adoption and Safe Families Act
  • TANF
  • Childrens Medical Services
  • Mental Retardation/Developmental Disabilities
  • Title XXI
  • Local Funds
  • JJ General Revenue
  • JJ Medicaid Match
  • JJ Federal Grants

Three Basic Questions
  • How can we improve access to care for those in
  • How can we improve quality and effectiveness of
  • How can we improve the mental health status and
    well-being of all children?

Improving Quality and Effectiveness of Care
  • Major approach since the mid 1980s has been
    through the development and implementation of
    community-based systems of care based on a set of
    principles and values, and the best available

What is a System of Care?
  • A system of care is a comprehensive spectrum of
    mental health and other necessary services which
    are organized into a coordinated network to meet
    the multiple and changing needs of children and
    adolescents with severe emotional disturbances
    and their families.

Role of System of Care
  • To provide access to effective services for a
    large and diverse population within a specified

What System Conditions Led to Development of
Systems of Care?
  • Inadequate range of services and supports
  • Failure to individualize services
  • Fragmentation of system when children and
    families had multi-system needs
  • Children with special needs are in many systems
  • Lack of clear values/principles for system
  • Lack of clarity about population of concern
  • Inadequate accountability
  • Lack of adequate responsiveness to cultural

Key Principles/Values of a System of Care
  • Based on needs of child and family
  • Promotes partnerships between families and
  • Involves collaboration between multiple agencies
    and service sectors
  • Involves provision of individualized supports and
    services based on strengths and needs in multiple
  • Promotes culturally responsive supports and
  • Includes system of ongoing evaluation and

What Should a System of Care be Based Upon?
  • A vision, and set of values, and principles
    developed and agreed upon by community
  • A clear definition of the population to be served
    and a thorough understanding of the population to
    be served
  • A set of goals and desired outcomes, also
    developed and agreed upon by community
  • Best available evidence on effectiveness of
    system mechanisms, and services
  • A theory of change that makes explicit the link
    between interventions (at the system,
    organization, program, provider, and child/family
    levels) and desired outcomes

Findings and Recommendations from the
Presidents Commission
Six Goal Areas
  • Understand that mental health is essential to
    overall health
  • Mental health care is consumer family driven
  • Disparities in mental health services are
  • Early mental health screening, assessment, and
    referral to services in multiple settings across
    the life-span are common practice
  • Excellent mental health care is delivered and
    research is accelerated
  • Technology is used to access mental health care
    and information

Successfully transforming the mental health
service delivery system rests on two principles
  • First, services and treatments must be consumer
    and family centered, geared to give consumers
    real and meaningful choices about treatment
    options and providersnot oriented to the
    requirements of bureaucracies.
  • Second, care must focus on increasing consumers
    ability to successfully cope with lifes
    challenges, on facilitating recovery, and on
    building resilience, not just on managing

p. 5
  • Consumers and family members will have access to
    timely and accurate information that promotes
    learning, self-monitoring and accountabilitywhen
    a serious mental illness or a serious emotional
    disturbance is first diagnosed, the health care
    providerin full partnership with consumers and
    familieswill develop an individualized plan of
    care for managing the illness. This partnership
    of personalized care means basically choosing
    who, what, and how appropriate health care will
    be provided
  • Choosing which mental health care professionals
    are on the team,
  • Sharing in decision making, and
  • Having the option to agree or disagree with the
    treatment plan.

p. 4
Goal 2
  • Consumers and families told the Commission that
    having hope and the opportunity to regain control
    of their lives was vital to their recovery.
    Indeed, emerging research has validated that hope
    and self-determination are important factors
    contributing to recovery.

p. 27
  • In particular, community-based treatment options
    for children and youth with serious emotional
    disorders must be expandedsegregating these
    children from their families and communities can
    impede effective treatment. Emerging evidence
    shows that a major Federal program to establish
    comprehensive, community-based systems of care
    for children with serious emotional disturbances
    has successfully reduced costly out-of-state
    placements and generated positive clinical and
    functional outcomes.

p. 29
Vision for Childrens Mental Health Services
  • Comprehensive home and community-based services
    and supports
  • Family partnerships and supports
  • Culturally competent care
  • Individualized care
  • Evidence-based practices

Vision (cont.)
  • Coordination of services, responsibility and
  • Prevention, early identification, and early
  • Early childhood intervention
  • Mental health services in schools
  • Accountability
  • Huang et al., 2005

Translating the Vision into Reality
  • How are we doing?
  • What have we learned?
  • How can we apply our lessons learned in the next
    stage of system transformation?

From State Mental Health Commissions
  • Areas of progress in every state
  • But overall dissatisfaction with efforts to
    address the mental health needs of children and
    their families
  • Consistent emphasis on the importance of the
    values and principles of systems of care
  • Increased emphasis on prevention, based on models
    of risk and protective factors
  • Greater attention to planning, accountability,
    and responsibility

Friedman, 2002
Survey of Random Sample of Counties
  • 8 of respondents indicate that a system of care
    exists very substantially in their community
  • 31 of respondents indicate that a system of care
    substantially exists in their community
  • Several areas of relative strength and also some
    major deficiencies in areas like workforce
    development, accountability, financing, and
    performance measurement

  • Since the vision of system of care was created,
    there is an increased recognition of complexity
    and difficulty of implementing values and
    principles, and achieving change both at the
    service level and at the system level.

The Bridge Between Vision, Implementation and
  • It is one thing to say with the prophet Amos,
    Let justice roll down like mighty waters, and
    quite another to work out the irrigation system.

William Sloane Coffin, Social activist and
  • The solution is not to abandon our current work
    but to do it better, with more sophistication and
    from a more strategic vantage pointwe need to be
    sure to invest in a continuous cycle of tracking
    our work, distilling lessons, applying new
    information, and learning as we go.

Kubisch et al., 2002
Making it Happen
Theory of Change
Core Implementation Components
Fixsen et al., 2005
Differentiation and Integration
  • Differentiation learning new concepts and being
    able to distinguish between them
  • Integration now that they have been learned,
    being able to see the relationship between them

Systems of Care
  • From differentiation to integration from focus
    on one aspect of a system to a focus on all
    aspects and their alignment and inter-relationship

Systems Thinking
  • Systems are composed of numerous parts or
    components that interact in complex and
    non-linear ways that result in collective
    behavior that cannot be inferred from or
    explained by studying the components in isolation
    of each other.
  • Friedman, 2005

Complexity Science
  • The challenges of the 21st century will require
    new ways of thinking about and understanding the
    complex, interconnected, and rapidly change world
    in which we live and work. And the new field of
    complexity science is providing the insights we
    need to push our thinking in new
    directionsComplexity science has moved science
    away from a linear mechanistic view of the world
    to one based on nonlinear dynamics, evolutionary
    development and systems thinking. Its a
    dramatic new way of looking at things its not
    just looking at more things at once.
  • Westley, Zimmerman, Patton, 2006

Complex Systems
  • All complex systems, from human beings to stock
    markets to global organizations, share behaviors
    that cannot be explained by their parts. The
    whole is different than the sum of the parts. You
    cannot fully understand a human body by
    describing it as a list of its parts, just as an
    organization chart barely scratches the surface
    in describing an organization. In complex
    systems, relationships are key. Connections or
    relationships define how complex systems work an
    organization is its relationships, not its flow
    chart. And this perception is crucial in
    understanding how complex systems differ from
    simple or complicated systems.
  • Westley, Zimmerman, Patton, 2006

Three Levels of Problems
  • Simple baking a cake
  • Complicated sending a rocket to the moon
  • Complex raising a child
  • Disasters can occur when complex issues are
    managed or measured as if they are merely
    complicated or simple
  • From Getting to Maybe, Westley, Zimmerman,
    Patton, 2007

The Nature of Expertise
  • Situation Recognition

Producing Change in Complex Systems
  • Develop your capacity to see and understand
    complex systems, and learn to draw action
    implications from what you see and understand
    cultivate the discipline of reflective practice.
    Learn to value standing still long enough to see
    what is around you, to understand the flow of
    events and the context of the moment. As you
    act, evaluate the consequences of your actions
    and make adjustments accordingly. Dont expect
    to get it right the first or second or third or
    fourth time. Indeed, keep questioning what it
    even means to get it right
  • Westley, Zimmerman, Patton, 2006

Leadership and Complexity Science
  • Were in a knowledge economy but our managerial
    and governance systems are stuck in the
    Industrial era. Its time for a whole new model
    (Manville Ober, 2003)
  • Complexity leadership theory focuses on
    identifying and exploring the strategies and
    behaviors that foster organizational and subunit
    creativity, learning, and adaptability, when

Does Your Organization Have a Learning Disability?
  • It is no accident that most organizations learn
    poorly. The way they are designed and managed,
    the way peoples jobs are defined, and, most
    importantly, the way we have all been taught to
    think and interact (not only in organizations but
    more broadly) create fundamental learning
  • Senge, 1995

Alternative Model
  • Based on research/theory from fields of
    organizational development, systems theory, and
    complexity theory
  • Systems are iterative, evolving, changing,
    dynamic, always emerging
  • Frequent reflective processes, based on multiple
    sources of data and multiple perspectives, is
  • Relationships/connections/integrative mechanisms
    between agents and components are critical

Alternative Model (cont.)
  • Responsiveness to context issues is a key
  • Values, principles, culture, and goals are the
    key foundations
  • Causal relationships are primarily non-linear and
  • The system exists in the eye of the beholder
  • Key to understanding systems is relationships,
    recurring patterns, and implicit as well as
    explicit rules

Revised Definition of Systems of Care
  • A system of care is an adaptive network of
    structures, processes, and relationships grounded
    in system of care values and principles that
    provides children and youth with serious
    emotional disturbances and their families with
    access to and availability of necessary services
    and supports across administrative and funding
  • Hodges et al., 2006

Theory of Change
  • The underlying assumptions that guide a service
    delivery strategy and are believed to be critical
    to producing the desired outcomes for a
    particular population of concern
  • Requires a clear statement of population of
    concern, goals for that population, and methods
    for attaining the goals

Theory of Change
  • When complete, a theory of change logic model can
    serve as a guide for implementation, ensuring
    that community plans for service delivery remain
    true to their intent
  • Hernandez Hodges, 2005

How do we Believe we can Best Achieve Those Goals?
  • Review of knowledge in field
  • Use of consultants
  • Input from key stakeholders
  • Identification of strengths of community and
  • Referral back to values and principles
  • New ways of thinking new mental models, new

One General Theory
  • Meaningful and ambitious goal
  • Strong family voice
  • Effective individualized treatment planning
  • Strong and transparent performance measurement
    system with feedback loops
  • I. Burnim

The Quality Chasm Three Central Themes
  • Use the science we know including the science of
  • Center care on the patient -- put patients in the
    lead on care design communities and develop and
    use care plans that incorporate the patients
  • Cooperate as a system a culture of teamwork

From Hodges et al.
  • Create an early and consistent focus on values
    and beliefs. The emphasis on Values and Beliefs
    factors provides a significant anchor for system
    development regardless of the challenges faced.
  • Translate shared beliefs into shared
    responsibility and shared action. Most
    importantly, share a commitment that things
    really can be done differently and that local
    stakeholders can be empowered to make change.
  • Recognize that opportunities for action are not
    linear. Take advantage of opportunities to
    leverage system change when and where they occur.

From Hodges et al. (continued)
  • 4. Know that being concrete does not mean being
    static. Being concrete about values and strategic
    about action allows stakeholders to be flexible
    in system response and proactive in system
  • 5. Be aware that structural change, without a
    solid anchor in values and beliefs, rarely has
    the sustained positive impact that system of care
    implementers seek.
  • 6. Remember that the system emerges from the
    choices and actions of stakeholders throughout
    the system, including family members, front-line
    staff, and community partners.

Data-Based and Value-Based Systems of Care
  • Involves the systematic collection of data on
    system performance and outcome for purposes of
    improving system functioning
  • Involves creating a culture that promotes
    data-based accountability

Data-Based Systems of Care (Continued)
  • Utilization and improvement-focused
  • Combination of in-depth and aggregate information
  • Use of both qualitative and quantitative
  • Focus on a few key measures
  • Feedback loop to all participants
  • An intervention itselfnot just a measurement

Differentiating Between Data-Based Systems of
Care and Evidence-Based Practices
  • Data-based systems of care involve collecting
    data in the present time, and in ones own
    community for purposes of assessing how the
    system is performing and identifying areas in
    need of improvement
  • Evidence-based practice refers to interventions
    that have met a specific criteria of
    effectiveness at some other time and in some
    other place

Relationship Between Data-Based Systems of Care
and Evidence-Based Practices
  • Data on system performance helps guide system
    stakeholders to determine if they need to make
    changes. It should come before efforts to make
    change. If the need for change is identified,
    then stakeholders should examine alternative
    approaches to making change.

Individualized Care
  • Based on a belief in the uniqueness of each
    individual and family
  • Research findings show tremendous diversity in
    the strengths and needs of children with mental
    health challenges and their families
  • A long-held belief carried to previously
    unimaginable levels during the past 20 years

Individualized Care (Continued)
  • Developed through a team-process, often called
    wraparound, involving child and parents,
    important other individuals in natural support
    system, care coordinator, and other key
    representatives of service system
  • Based on strengths, needs, culture, and choices
    of child and family, in partnership with team

Individualized Care (Continued)
  • Enhanced by creative and participatory team
    process, and facilitated by availability of
    flexible funding, broad range of services, and
    extensive provider network
  • The application of system of care principles and
    values at the child and family level

Active Agents of Change/Components of Service
  • Those elements or components of interventions
    which contribute to positive outcomes the same
    active agents of change may be present in
    different forms or structures within different

Active Agents of Change/Components of Service
Effectiveness (Continued)
  • The very characteristics that are likely to make
    services effective they are comprehensive,
    individualized and flexible make them more
    difficult to describe and to evaluate.
  • Schorr, 1995

Active Agents of Change/Components of Service
Effectiveness (Continued)
  • Not all the studies show that the improvements
    resulted from the intervention specifically.
    Family engagement may play a stronger role in
    outcomes than the actual intervention program.
  • Thomlison, 2003

Active Agents of Change/Components of Service
Effectiveness (Continued)
  • Operated by people with a commitment and
    intensity to their work and a clear sense of
  • Based upon quality staff with effective models of
    training and ongoing technical assistance

Active Agents of Change/Components of Service
Effectiveness (Continued)
  • Strong bonds between families and providers
    appeared to be critical, whether the providers
    were case managers, therapists, parent advocates,
    or other staff. These bonds had their beginning
    in the engagement process providers built trust
    and confidence by listening carefully to what
    families identified as their primary needs and
    treated family members as full partners in the
    treatment process, focusing on their strengths
    rather than on their deficits
  • Worthington, Hernandez, Friedman, Uzzell, 2001

Active Agents of Change/Components of Service
Effectiveness (Continued)
  • the effectiveness of services, no matter what
    they are, may hinge less on the particular type
    of service than on how, when, and why families or
    caregivers are engaged in the delivery of careit
    is becoming increasingly clear that family
    engagement is a key component not only of
    participation in care, but also in the effective
    implementation of it.
  • Burns, Hoagwood, Mrazek, 1999

Active Agents of Change/Components of Service
Effectiveness (Continued)
  • Comprehensive, flexible, and responsive to the
    needs of participants
  • View children in the context of broader
    ecologiesfamilies, schools, neighborhoods,
    churches, and communities
  • Link with other systems of support and
    intervention to ensure they can produce and
    sustain their impacts over time
  • Greenberg, 2002

Community-Based Interventions with an
  • Function as service components in a system of
    care and adhere to system of care values
  • Are provided in the community, homes, schools,
    and neighborhoods, not in an office
  • With exception of multisystemic therapy and
    sometimes case management, direct care providers
    are not formally clinically trained
  • Their external validity is greatly enhanced
    because they were developed and studied in the
    field with real-world child and family clients
  • Burns, 2000

Why Family Choice?
  • The right thing to do
  • Providing choice may improve the outcomes of
  • Family choice of services and providers may
    create a more effective, efficient,
    market-driven, customer-oriented and accountable
  • Subcommittee on Family Choice, 2005

  • The right thing to do but often a neglected
  • An evidence-based process in and of itself

  • Integration of Systems of Care, Individualized
    Care, Evidence-Based Practices, Family Choice,
    and Performance Measurement

Evidence-Based Practices
  • Provide an important focus on outcomes and
    accountability however, often times studies
    have focused more on efficacy rather than

Effective Interventions
  • The evidence points to an array of beneficial and
    richly complementary programs for promoting
    adaptive behavior and positive mental health,
    preventing dysfunction, and ameliorating distress
    and disorder. Despite the scientific support for
    such programs, most youths in the world outside
    university trials still have little access to the
    programs in part because of gaps in the evidence
    base and in part because a marked divide between
    research and practice persists. We have proposed
    several steps toward filling these gaps and
    breaking down this divide. In our view, treatment
    will be good for science, good for practice, and
    good for children, adolescents, and their
  • Weisz Sandler, 2005

  • The Presidents New Freedom Commission on Mental
    Health emphasizes both the importance of
    individualized plans of care, and the application
    of evidence-based practice. This is very
    significant because long-term meaningful
    improvements in outcomes for children with
    serious mental health challenges and their
    families will depend on a coming together of
    these two important approaches.
  • Friedman and Drews

  • There were relatively few instances identified
    where there had been a systematic effort to
    integrate evidence-based practices with
    individualized care. In most cases, the policy
    emphasis in a local community was either on
    promoting the development of systems of care and
    individualized care, or on promoting the use of
    evidence-based practices. The good news is,
    however, that there were some very positive
    examples of such an integrated approach.
  • Friedman and Drews, 2005

Barriers to Integration of Systems of Care,
Individualized Care, and Evidence-Based Practices
  • Research requirements for description of
    intervention vs. system requirements for
  • Accountability
  • Populations served
  • Attitudes and interests

Successful Models
  • Hawaii
  • Milwaukee
  • Indianapolis
  • Westchester County
  • Central Nebraska
  • Travis County
  • Placer County
  • Erie County

  • System of care values and principles as the
  • Team-based
  • Family-driven
  • Performance-measurement
  • Evidence-based practices and active agents of
  • Culturally competent
  • Transparent system of accountability

  • Blended funding
  • Extensive provider network
  • Extensive range of services
  • Family choice
  • Provider accountability
  • Continuous quality improvement
  • Care management organization

Dominant Research Paradigm in Mental Health
  • Randomized clinical trials (or quasi-experimental
  • Quantitative only
  • Non-representative participants
  • High on internal validity much lower on
    external validity
  • Limited voice of participants
  • Outcome-oriented and not also implementation/proce
    ss oriented

Traditional Research/Evaluation Model
  • The system of care is the independent variable
  • It should be static
  • It should be easily measureable
  • It should be replicable
  • Measures should be objective
  • Causal relationships are primarily linear
  • Researchers/evaluators should be non-participants
  • Researchers/evaluators are the experts who
    determine how to study the system

Research Methods
  • The issue of selecting methods is no longer one
    of the dominant paradigm versus the alternative
    paradigm, or experimental designs with
    quantitative measurement versus
    holistic-inductive designs based on qualitative
    measurement. The debate and competition between
    paradigms is being replaced by a new paradigma
    paradigm of choices. The paradigm of choices
    recognizes that different methods are appropriate
    for different situations.
  • Patton, 1980

Continuum of Research
  • From particularistic and specific to holistic and
  • Langhout, 2003

Research/Evaluation on Systems of Care
Implications of Complexity Theory
  • Longitudinal, holistic with a specific focus on
    inter-relationships, non-linear effects, and
    rich points
  • Contextual and in-depth
  • Multi-method and multi-source
  • Participatory and collaborative
  • Iterative
  • Ongoing multiple streams
  • Action and change-oriented

Conditions that Challenge Evaluation
  • High innovation
  • Development
  • High uncertainty
  • Dynamic
  • Emergent
  • System change
  • Patton, 2008

Newer Approaches to Evaluation
  • Developmental
  • Multi-method, multi-source
  • Contextual
  • Participatory and collaborative
  • Continuous rather than discrete
  • Extensive use of multiple streams of ongoing data

  • We need to place less emphasis on discovering
    the one objective truth about a programs worth
    and more attention to the multiple perspectives
    that diverse interests bring to judgment and
  • Brown, 1995

  • The earmark of a quality program or organization
    is that it has the capacity to get and use
    information for continuous improvement and
    accountability. No program, no matter what it
    does, is a good program unless it is getting and
    using data of a variety of sorts, from a variety
    of places, and in an ongoing way, to see if there
    are ways it can do better
  • H. Weiss, 2003

Agent-Based ModelingOne Approach to Research
from a Complexity Science Perspective
  • Agent-based modeling using computer technology
    the simulate the likely real-life behavior of the
    system being studied now being viewed as the
    third way of doing science with traditional
    experimentation and observation/description being
    the other two
  • Agent-based models require knowledge of the
    agents or components of the system as well as
    the written and unwritten rules by which they
    operate after the model is built, it is
    possible to run simulations on many different
    aspects of the system to see how anay given
    change will affect the interdependencies and
    overall dynamics of the whole system
  • Sanders McCabe, 2003

Leadership and Organizational Development
  • Implications for systems of care

The Need for Leadership
  • The need for leadership in serving persons with
    severe mental illnesses has never been greater.
    As we begin the twenty-first century, change
    seems to be the only constant in the mental
    health system. We need leaders to take advantage
    of the opportunities that accompany environments
    characterized by a change so constant and
    dramatic that the very foundation of the mental
    health system is being built anew.
  • Anthony, 2008

Learning Organizations (from Senge)
  • Personal mastery
  • Shared vision
  • Systems thinking
  • Mental models
  • Team learning

Eight Principles of Leadership
  • Leaders communicate a shared vision
  • Leaders centralized by mission and decentralized
    by operations
  • Leaders create an organizational culture that
    identifies and tries to live by key values
  • Leaders create an organizational structure and
    culture that empowers their employees and

Eight Principles of Leadership (Continued)
  • 5. Leaders ensure that staff are trained in a
    human technology that can translate vision into
  • 6. Leaders relate constructively to employees
  • 7. Leaders access and use information to make
    change a constant ingredient of their
  • 8. Leaders build their organization around
    exemplary performers

Transformational Leaders
  • Externalize strongly held values to shape and
    articulate a unifying vision for the future
  • Inspire others to see their place in that future
  • Motivate others to look beyond their own
    interests to achieve goals
  • Act as role models
  • Develop others to higher levels of ability and
  • Encourage collective decision making
  • Create energizing environments that incubate
    ideas, actions and other leaders
  • Think and plan backward from an envisioned future
    to take action
  • A. Kathryn Power, Director, Center for Mental
    Health Services

Transformation Leadership Competencies Wheel
  • With transformation leadership competencies in
    the middle, the spokes are
  • Individual leader attributes
  • Knowledge and information management
  • Transformation management
  • Business acumen
  • Process toolkit
  • Future trends in mental health

Leadership Challenges of Transformation
  • Identifies six major types of change
  • Reframe core cultural values
  • Create improvement capability
  • Collaborate across competitive boundaries
  • Create a business environment that simultaneously
    drives business results and community benefit
  • Drive system-level rather than project-level
  • Maintain constancy of purpose of the long-term
    transformational journey.

Eight Steps to Transforming Your Organization
  • Establishing a sense of urgency
  • Forming a powerful guiding coalition
  • Creating a vision
  • Communicating the vision
  • Empowering others to act on the vision
  • Planning for and creating short-term wins
  • Consolidating improvements and producing still
    more change
  • Institutionalizing new approaches
  • Kotter, 2007

On Transformation of Organizations and Systems
  • Transformation of entire organizations and
    systems is a leadership task requiring an
    extraordinary depth and breadth of change. Since
    it hasnt been done before, no one can claim to
    have a recipe for how to achieve it. But for
    those leaders who want to take on this daunting
    task, it would be better to proceed with some
    theory of what it would take to lead such a
    transformation than to simply muddle along. This
    paper is written to provide such a theory, in the
    hopes that it will be helpful to health care
    leaders as they plan their transformational work,
    and to the advisors who coach them. And it is
    clearly offered in the spirit of All theories
    are wrong, but some are useful.
  • Reinertsen

Implications for Academia
  • Can we/should we continue to operate as we have,
    given the scope of need, the new models that have
    developed, and the incomplete fit between our
    existing models and the issues we need to study?
  • If we are to change, what type of change is
    needed in our research, our teaching and student
    training, and our relationship with communities?
  • What change may be needed in our mental models?

Transdisciplinary Approaches
  • Seek to develop new hypotheses for research,
    integrative theoretical frameworks for analyzing
    particular problems, novel methodological and
    empirical analyses of those problems, and
    ultimately, evidence-based recommendations for
    public policy
  • Stokols, Fuqua Gress, 2003

National Mental Health Advisory Council Report
  • A major impediment to progress in the insularity
    of many of the disciplines involved in clinical
    practice and research

Enhancing the Influence of Psychologists/Social
Workers and Others on Mental Health Policy
  • Students should study the research on policy
    development and implementation, including a focus
    on strategies for achieving system change
  • Students should study policy analysis and
    evaluation techniques
  • Students should be knowledgeable about the
    policies that serve as the foundation for the
    mental health and related fields
  • Students should study complexity theory and how
    complex systems operate
  • Graduate education should include a strong
    multi-disciplinary focus.

If We Cant Predict What Will Happen In Systems,
At Least We Can Learn How to Dance with Them!
  • Get the beat
  • Listen to the wisdom of the system
  • Expose your mental models to the open air
  • Stay humble. Stay a learner.
  • Honor and protect information
  • Locate responsibility in the system
  • Make feedback policies for feedback systems
  • Pay attention to what is important, not just what
    is quantifiable
  • Go for the good of the whole
  • Expand time horizons.
  • Expand thought horizons.
  • Expand the boundary of caring
  • Celebrate complexity
  • Hold fast to the goal of goodness.

Where Does This Leave Us?
  • A serious and complex problem to deal with but
    one in which progress is being made
  • Systems of care as one important part of the
  • Importance of focusing on implementation and
  • Openness to new mental models, and their
    implications for system development,
    collaborations within academic disciplines and
    between academics and community change agents,
    research and evaluation, and leadership and
    organizational development

Where Does This Leave Us? (cont.)
  • Importance of our role in preparing and being
    role models for the next generation of leaders,
    of innovators, of change agents