becoming real: from model programs to implemented services

For mental health service provider organizations, and especially mental health systems, to thrive requires building on initial enthusiasm and energy to institutionalize services while remaining open to new challenges and opportunities.

Becoming Real: From Model Programs to Implemented Services Alan Rosen, Ronald J. Diamond, Vivienne Millel; Leonard I. Stein

Over the years, many model programs have been developed to provide effective, humane, and cost-effective treatment for persons with psychiatric disability Some of these innovative programs included a research component and demonstrated their effectiveness, but the vast majority of these programs have proven difficult to replicate and difficult to maintain over the years, and have never grown to encompass the lives of most people with a psychiatric disability in the community. A handful of programs have not only survived but have become systems of care that have taken root and flourished in their local communities. Some have also outlasted their status as model programs, during which time they had to exist on new initiative or research grants, to become enduring organizations withstanding political, organizational, and economic vicissitudes.

The mental health systems in Dane County, Wisconsin, and the Lower North Shore of Sydney, Australia, have been internationally acknowledged as having continued to provide effective care to their populations over a long period of time. These two systems have done more than just endured. Jointly, they have more than thirty-five years of experience in continuing to change and adapt. Our experience suggests that systems may have very different structures and financing schemes, different relationships to government, even different clinical approaches, and still endure. Despite all of these potential differences, effective mental health systems that survive and thrive appear to have some characteristics in common. Many new mental health programs start with a vision based on the values and commitment of a person or small group. Those that survive over a long period of time do so by changing themselves

NEW DIRECTIONS FOR MENTAL HEALTH SERVICES, no. 74, Summer 1997 Q Jossey-Bass Puhlishers 27

28 THE SUCCESSFUL DIFFUSION OF INNOVATIVE PROGRAM APPROACHES

from a system energized by the vision of a few to a continuous learning organization (Senge, 1992) that involves all participants in a new culture that is able to sustain itself.

Like the Velveteen Rabbit in the classic children’s story (Williams, [ 19221 1983), these programs were able to “become real.” By becoming real we do not mean just surviving, or institutionalizing a particular way of working. Nor do we mean becoming the dominant market force in local mental health service delivery Becoming real is a process of continuously adapting to meet the needs of the mental health service users and the needs of the local community. Systems of care that become real are like favorite old nursery toys that become real by being loved into life. They may not look shiny and new with all the latest bells and whistles, and they may become shabby with human contact, but one hopes that they end up by exuding humanity, caring, experience, and reliability

This continuous process of improvement and change requires that a successful mental health system tailor and update its processes and products to meet the perceived needs of all stakeholders, rather than just continuing to provide its usual products. Effective systems need to avoid the trap of simply wanting to fill beds or increase service hours. For example, a crisis service must go beyond reacting to each client who comes in, but must anticipate the changing needs of potential clients, the community, and all other stakeholders. Does it need to extend its hours of operation? Should it separate or merge the func- tions of crisis responsiveness and case management? In a successful and enduring system of care, innovation is not a reaction to crisis but part of a continuous process, involving both staff and clients, that balances stability with flexibility

How Does Change Begin?

In examining the complex process of change, we examine several vital elements. The Role of Vision. Innovation does not begin with a large committee

or a high-level bureaucracy. True innovation begins with a person or a very small group having a vision of how things can be different. This vision must be so compelling that others can also see it once it is pointed out to them by the original vision holder. This may require a certain amount of fervor, especially at the beginning when one is trying to build up a critical mass of people who can see the sense in working together in a new way. Idealism is important in fueling the vision, and acts as a force to help overcome inertia and tradition. The vision can point out a problem in a new way, look at a new kind of solution, or, most important, organize people to work together in new ways. The vision can be about what needs to happen, such as how to organize services to help support people with psychiatric disability to live in their own apart- ments in the community There can also be a vision of excellence, of believing in a goal that had previously been considered unobtainable.

The initial vision in both Madison and Sydney was that of a new approach to organizing comprehensive mental health services. Traditional mental health

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clinics had focused on people who best fit into existing treatment approaches. The new vision started with placing a clear priority on people with the most needs, providing what this target population needs instead of what clinicians were most comfortable providing. In this new vision, treatment needed to start with each client’s own goals and was based on individual client needs instead of fitting clients into existing programs.

Over time, the initial vision needed to change and evolve. At one point, the vision was that people with psychiatric disability could live stable lives outside of the hospital. The vision now is that these same people can run their own households, hold competitive jobs, and fulfill normal roles in the community. The next vision is likely to be one of true community integration, something that is often talked about but rarely seen as a realistic goal.

The perceived success of the innovative systems in Madison and Sydney was often explained by those defending traditional systems as due to “idealism,” “missionary zeal,” “charismatic leadership,” or merely “idealism.” Although these systems certainly exhibited zeal, leadership, and idealism, they also rested on a growing body of evidence supporting the increased effectiveness of community-centered treatment as opposed to traditional hospital- centered treatment.

Although vision is important for initiating change, it is not enough to organize and maintain a system of care. Vision can be faulty, and the zeal may run out of steam. Vision will continue to be compelling only if it is soon accompanied by good evidence to support it. Otherwise the new movement will evaporate in a puff of smoke or become increasingly irrelevant. Vision must be translated into practical strategies. These strategies must then be supported by research that demonstrates that they really lead to desirable outcomes. For example, the “deinstitutionalization movement” in many parts of the Western world floundered in a chaotic fashion until a coherent vision led to controlled studies. This vision, supported by research, helped galvanize service providers in many parts of the world into developing an organized system of community-based treatment and rehabilitation services.

Leadership: Does Your Vehicle Have Charismatic Transmission? Ini- tially the person with a new vision may be a lone voice “preaching to the intransigent,” but this can become increasingly lonely over time and does not in itself translate into an enduring system. Vision is only productive when the initial holder of the vision finds a way to share it. If innovation principally relies on charismatic transmission it will not survive after the charismatic leader moves on or the fashion passes. For a health or clinical reform movement to take hold, prevail, persist, and gather further momentum in the long term, it must attract and consolidate a broad leadership group with an agenda based on sound evidence, demonstrable skills, and experience. How does a vision expand outward from a single charismatic source to a more stable and enduring system of broad leadership? Ironically, the very person who is per- suasive and dynamic enough to precipitate change may inadvertently inter- fere with a broadening of the leadership base.


Through force of personality and centrality to the initial change process, the charismatic leader can so dominate the leadership of the project that there is little room for other potential leaders to develop and be available when needed. Some leaders are extremely effective as initial change agents, and go from one system to another starting new projects and developing new services. Other leaders have the inclination and skills to stay with one service over the long haul, growing with the service and helping to develop a broad base of future leaders. Occasionally both sets of qualities may be found in the same person. Whatever the situation, long-term determination and tenacity are required to transform innovation into a stable system of care.

Openness to Learning. The training of staff in the new vision is a critical step in the transition from model program to enduring system. Early on, a small number of staff are trained and directly supervised by the innovative leader, often carried along in large part by the force of his or her personal commitment. Over a longer period of time, as more staff need to be involved, it becomes important for staff to learn the new approach without reliance on the leader. For the system to be stable over time, there must be some way for new staff to become part of the new culture and to support the vision. Current staff must not be forgotten in the process. They must be encouraged to develop new skills required in the new system and allowed to put their own stamp on it. They must be valued, and their enthusiasm and commitment supported. Learning needs to be built into the structure of the system so that it can become self-perpetuating.

Learning consists of imparting information, developing new skills, and changing attitudes. Imparting information is often thought of as the core of new learning, but without the development of new skills by practical training and the development of attitude change by some kind of personal acceptance of the new schema, change in behavior will not occur. Of the three components, attitudes are the most difficult to change and arguably the most important in sustaining services over time.

Attitudinal change is extremely complex. It includes encouraging creativity and innovation so that staff continue to find new solutions to problems; developing and maintaining standards to guide quality improvement, and striving for excellence at every level of the organization; and encouraging self- directed inquiry in order to make what is being learned have more personal meaning and relevance, and to encourage ownership.

Creativity is required in all innovation and change (Davis, 1986). Creativity is the ability to seek novel solutions or innovative ways of approaching old problems (Miller, 1992). It involves qualities such as risk taking, spontaneity, origi- nality, inventiveness, productivity, divergence, and playfulness (Gordon, 1975).

Strivingfor excellence is an important part of system change and endurance. Excellence is a direction, not a destination. As Aldous Huxley said, “Every ceil- ing, once reached, becomes a floor, upon which one walks as a matter of course and prescriptive right” (quoted in Rosen, Miller, and Parker, 1989). We all, in our own way, try to do a good job. It is important to provide staff with

BECOMING REAL: FROM MODEL PROGRAMS TO IMPLEMENTED SERVICES 3 1

tools to actualize this striving and allow them to move toward excellence in measurable, demonstrable ways. Quality improvement refers to the set of processes and techniques that provide staff with tools to become more skilled, to be more able to produce a better product, and to move toward excellence.

One of thefirst steps in quality improvement is to define explicit standards, including criteria by which to measure performance. What is the goal of this mental health system, and how can we measure how close we come to this goal? Standards are a means of not only marking the progress that has been made but also directing where further change and development is needed. Developing explicit standards for a mental health system requires that one examine services in great detail. Each step of the system-from a client’s initial phone call, to developing a treatment plan, to providing a service-must be measured against criteria of how a good system should work (Miller, Rosen, and Parker, 1988).

For example, the Area Integrated Mental Health Services (AIMHS) standards (Rosen, Miller, and Parker, 1995) are designed to act as a checklist (for service users) or as a blueprint for service improvement (for service providers). The standards can be used to measure an existing service, directing attention to areas of improvement. They are not prescriptive of a particular service model but rather provide a detailed set of expectations of what components of care a local integrated community and hospital mental health service should be able to provide.

Enduring systems must promote seff-directed inquiq. Self-directed inquir- ers are people who have the freedom to choose their own methods and make their own decisions about the structures, processes, and outcomes of learning (Rogers, 1992). This is not the equivalent of total anarchy, but it does require a balance between freedom to choose and some overall control of standards. In other words, there are boundaries within which staff can choose their own methods and topics and set their own standards.

Openness to Opportunities. Most often, change begins with leadership that is prepared and willing to take advantage of change opportunities. These opportunities can take many forms: a chance to apply for new money, take advantage of a change in government, start a pilot program, or reorganize things in some way, however small; a court order or the threat of a court order; or even pressure following media attention to a problem.

For example, both Lower North Shore Sydney and Madison Mental Health Service systems have managed to stay alive and develop in adverse cir- cumstances during funding cutbacks by innovating their way out of trouble. The initial funding for the first twenty-four-hour team in the Lower North Shore system came out of funding for a research program; the first work coop- erative came out of a Special Initiatives state grant. The funding for the development of Assertive Community Treatment teams (following up on the research of the PACT program) initially came from temporary startup funds provided by the State of Wisconsin to decrease hospital census; funding was continued when the program demonstrated that savings from decreased hos- pitalization more than paid for the cost of continuing the program.


Program staff cannot merely wait passively for opportunities but must seek them out and exploit them whenever possible: actively looking for resources that can be used; planning and developing programs efficiently using strategic planning that is already in place; and making decisions rapidly, which might mean writing a proposal or hiring staff to get a program up and running with minimal bureaucratic inertia. Good luck helps, but creating one’s own luck is more reliable.

Limited Reliance on Transitional Objects. When in the process of change, people and systems often use transitional objects as stepping stones. There is always the risk that the transitional object will become permanent, blocking further change rather than facilitating it. For example, for some patients a hostel or group home may ease the transition from a long-stay hospital to independent living. However, if the temporary hostel becomes the permanent residence, what was initially a means of enabling a transition becomes a block to true community integration.

Hostels and group homes were a transitional step during deinstitutionalization. At the system level, they helped both clients and staff as clients adjusted to living outside of a hospital, and at the same time functioned as a repository for capital resources previously tied up in hospitals. The need for these mini-institutions decreased with the development of mobile intensive case management teams. Successful systems needed to let go of these transitional objects and put their resources into newer programs that better supported community integration (Rosen, 1982).

Good Fit Between System and Local Context. It is important to dis- tinguish between what is particular to a specific place or time and what are essential elements of an effective system of mental health care. It is simplistic in the extreme to think that the Italian or Dane County or Sydney models of community-based psychiatry could be exported elsewhere or simply be copied. Although general principles or guidelines are useful, “Each region and each country must find their own way. Only the past can be copied, the future must be created” (Tansela, 1991).

How Is Change Sustained? Becoming a Continuous Learning Organization Commonly, as organizations become involved in continuous learning, a sub- tle process in which goals and work are related is undertaken.

Work Design. To endure, mental health systems must organize around new fundamentals of work design (McNeish and Richardson, 1992). These ideas are sometimes discussed in the context of continuous learning organizations or total quality improvement or a variety of other similar terms. Although work design has been widely discussed in industry, less attention has typically been paid to the organization of work in public mental health systems. Some of these new principles, as they are applied to mental health systems, are as follows:


Every staff person, from secretary to psychiatrist, understands enough about

Every person helps to design his or her work, which includes planning and

Dependency is replaced with interdependency Problem solving is replaced with whole-system thinking. Work is redesigned so that skills become redundant rather than staff becom-

The goal of work redesign in mental health is to produce work systems capa-

the whole process to be able to influence how it works.

reviewing work as well as doing it (building quality into every step).

ing redundant.

ble of continuous learning, improvement, and adaptation to change.

For example, in both the Lower North Shore and the Dane County Men- tal Health systems, almost all staff, from secretary to team leader, can explain what they do and where their team fits into the whole mental health system. Treatment planning is the responsibility of a team rather than an individual, and a major focus of the team is to share information and broaden the expertise of all team members.

Ongoing Change and Adaptation. Like any living organism, mental health systems either evolve or atrophy and die. There is an ongoing tension between conservation and change. This tension can be expressed in a number of different ways. On one side is a reliance on fixed policies, traditional ways of doing things, and ideas that have proved successful in the past. On the other side is the need to continuously adapt to changing conditions, changing needs, and new ideas. There is a tension between the realistic concern that too much change, too fast and too unplanned, can disrupt a sense of continuity and lead to chaos, and the need to constantly innovate both to improve and to stay alive. In effective organizations, change is an ongoing process, not an episodic event (Fullan, 1982). The following list illustrates the elements in the balance between conservation and change:

Conservation Stability Endurance Playmg safe Quality control (meeting a

predetermined, defined standard)

Closed-system procedures Habitual practice Bureaucratic administration

Change Flexibility Evolution Deep (creative, adventurous) play Continuous improvement

(continually challenging or questioning your standards to ensure that they meet changing needs)

Open-system thinking Evidence-based practice Creative change management

Tolerance of Ambiguity in Professional Knowledge. Enduring programs operate in a context of ongoing ambiguities, whereas research or model projects are more time limited, clear-cut, and simplified. Donald Schon (1990)


has used the metaphor of the swamp to emphasize the need to work with the confusing ambiguity of real-world problems rather than to always restrict our- selves to the sterile purity of controlled research.

In the varied topography of professional practice, there is a high, hard ground overlooking a swamp. On the high ground, manageable problems lend themselves to solution through the application of research-based theory and tech- nique. In the swampy lowland, messy confusing problems defy technical solution. The irony of this situation is that the problems of the high ground tend to be relatively unimportant to individuals or society at large, however great their technical interest may be, while in the swamp lie the problems of greatest human concern. The practitioner must choose. Shall he remain on the high ground where he can solve relatively unimportant problems according to prevailing standards of rigor, or shall he descend to the swamp of important problems and non-rigorous inquiry? [p. 31

On the high ground of pure empirical scientific study, the research questions are clear and the method may be exacting, but such study may be limited in immediate human interest and application. Meanwhile, in the swamp the problems may appear to be murky and complex, and the methods may be inexact and value laden, but the questions and necessarily approximate solutions are likely to be rich in human interest and application.

In reality, we need both approaches. They can be complementary and mutually enriching, and they demand cooperation rather than competition between their underlymg quantitative and qualitative methodologies.

For example, a study in Sydney tracked clinical and functional outcomes for service users of the mobile intensive case management team. The study looked at three teams who operated in vastly different demographic areas but shared the real-world problems of budget constraints, organizational change, and pressure to provide service to new clients by transferring current clients back to their referring service. Despite their shortcomings, such studies of longer-term outcomes flesh out the findings of earlier, often shorter-term controlled trials which operated with special funding that protected the research programs (Hambridge and Rosen, 1994). These “real-world’’ studies support practicing clinicians in their ongoing need to make decisions in the face of inadequate information.

Developing Stability in a Context of Continuous Change

Change involves several phases. As previously discussed, the initial phase of change is the decision to adopt the innovation, made by a small, influential group. The second phase of change comprises the first experiences of attempt- ing to put the idea or program into practice. This phase can last for two to three years (Fullan, 1982). The third phase of change is the transition to an


enduring system; this phase is the most difficult to achieve. Continuation requires that the change become incorporated as an ongoing part of the system; otherwise, the new program disappears, either by decision or through attrition.

Managing for the Long Haul. Senior management must understand that systems designed to endure must be established. This includes budget strategies for long-term strategic planning, and staff hiring and training that ensures long-term skill development and staff retention. Management must operate and make decisions based on a long-term perspective. Decisions must be proactive rather than reactive and must include consideration of multiple stakeholders. Perhaps most important, managers must consider the long-term consequences of their decisions.

An important consideration of long-term management includes continually working to integrate the system of care and to prevent fragmentation. This includes explicitly defining integration at every level, then operationalizing it. For example, the leadership of all components of service must see themselves as part of an integrated service. All elements of the system must understand the core role of the case manager as the glue in the system.

A second consideration is to maintain a long-term commitment to vision, keeping goals in mind, holding on to funding, and attending to all of the tasks of keeping the system functioning. An important part of system change is out- lasting clinical or political opposition, eventually wearing down obstruction- ist bureaucracies. Clinically we have learned to follow Lamb’s idea of “gradualism,” persisting and supporting small but substantive improvements over a long time frame (Lamb and Goertzel, 1977). This same approach works in promoting system change. Established systems change slowly: small initial changes need to be supported and celebrated, while long-term goals are kept in mind as long-term guides.

Community-based services, having a long experience of being under- funded and politically impotent, run the risk of coming to accept their second- class citizenship. For example, many of the twenty-four-hour community services systems in Australia have had to strongly resist numerous attempts by hospital-based administrations to control and siphon community budgets, to remove such critical resources as their automobiles, and to evict them from offices in cottages in the community. The mental health teams can often iden- tify with the lack of permanent housing and pressure to “get by with less” faced by their long-term service users. In one case, the team was evicted from the house in which it had operated. Drawn-out and difficult negotiations finally led to permanent community-based accommodation, despite tremendous pressure to accept inadequate offices.

Developing Stability of Leadership and Staff. Stability of leadership and staff is a requirement for an enduring system. Such stability allows for a stable culture to emerge, allows working relationships to develop, and allows individuals to understand the system well enough to articulate long-term goals and push the system to realize those goals. Over time, through personal


contacts, access to information and expertise, and perceived commitment, staff gain informal power and increased influence within a system (Mechanic, 1964). The concept of stability can be subdivided into stability of (1) top leadership, so that the system stays committed to a single direction long enough for real change to occur; (2) middle management, so that teams can form and develop long enough to be effective; and (3) front-line service staff, so that a stable culture can develop.

Many innovative projects demonstrate that they are effective and can inspire significant enthusiasm, but then die once the original leader leaves. For an innovative project to become an enduring system, the leadership base must be broadened so that it is not dependent on or dominated by one person. Unfortunately, this is easier said than done.

There are a number of ways to encourage the development of a broad- based leadership. The project director can delegate decisions to other staff or to a group. Staff can get involved in hiring, policy development, and even budget decisions, to encourage the development of both better ideas and broad- based leadership. Encouraging staff to systematically collect information about their own work and to present at conferences also helps broaden the leadership cadre. Too often, this is left for the leader or the academician when it can be part of the professional development of other staff as well.

Developing a strong sense of and mechanism for partnership between service users, families, and service providers also leads to a broadening of the leadership base. These coalitions can help maintain energy and momentum, and can be very important in lobbylng for budgets or policies needed to make the system work.

Another way to build stability is to create career advancement opportunities for experienced clinician-supervisors that allow them to stay at the clinical interface and remain part of the multidisciplinary team structure. Too often, the only way a senior clinician can advance his or her career is to become a nonclinical administrator. To keep senior clinical staff doing clinical work, experienced senior staff members can be given administrative authority over their own area, their expertise can be acknowledged through special clinical promotion ladders, and seniority can be financially rewarded.

Finally, building in clinical supervision and peer support at every level of seniority is important in order to retain experienced staff in cohesive teams and to prevent avoidable burnout by dealing routinely with work-related stress. For example, the case manager maintenance system should be designed to minimize or prevent case manager burnout or work-related stress by system- atizing supervision, mentorship, quality peer review, and refresher training; encouraging the development of new skills; increasing the variety of tasks; using team support and debriefing; involving case managers in service evaluation planning and designing their own work practices and rosters, thus fos- tering a sense of control; and having regular celebrations.

Working with Governments. Although government is too cumbersome to make change happen, it can set a context that makes change more likely.


Similarly, governmental policies can either help new systems endure or hasten their demise. Political support is needed for governmental policies that support innovative programs.

For example, citizens (and advocates) can encourage governments can be encouraged to give priority to care for people with serious psychiatric disabil- ities (positive discrimination). Political pressure can be applied to get univer- sities involved in local catchment-area services rather than to focus entirely on tertiary referral and research centers. Politicians and government administrators can be encouraged to support projects that meet the special needs of people who are homeless, or who have co-morbid problems with substance abuse and mental illness, or who are from nonmainstream cultures. Local coalitions can work to educate politicians and government administrators and work to develop bipartisan support for mental health services.

Creating Funding Incentives. An important role of government is to establish funding incentives that support best clinical practices. These incentives include mechanisms to ensure that money will follow the patients to where they now live and prefer to live. Programs should not continue to receive funding just because they have been funded in the past. Desirable government activity includes funding programs Nith demonstrable outcomes. For example, in Dane County, Wisconsin, a number of private, nonprofit groups contract with the county to provide mental health services. There are increasingly stringent requirements to include outcome assessments as part of the contracting process. Specifyng how much service or what kind of services are being provided is no longer enough. There must also be ways to measure how effective services are in making real changes in clients’ lives.

Enduring systems also require budget protection. There must be ways to ensure that funds are not siphoned off to other budgets, that budgets are indexed to keep up with inflation, and that appropriate financial management supports are in place to allow budgets to be tracked and expenditures moni- tored. A government promise of stable funding is required before service users, families, staff, and the community can begin to trust that new programs can be relied on. Initial community supports for people being deinstitutionalized do little good for either the client or the family unless there are guarantees that those supports will continue to be funded.

Creating Professional Training Programs. Educators and advocates must pay attention to training the next generation of mental health professionals to fit into the new services. Unfortunately, formal academic training programs often have their own agendas, and may be controlled by a formal hierarchy that is only loosely connected with the needs of new services. This is a particular problem for psychiatrists, who are often perceived by mental health workers to be part of the problem rather than part of the solution. Psy- chiatrists, traditionally the group at the top of the hierarchical structure of traditional mental health systems, have the most to lose in any reorganization that involves more power sharing within the multidisciplinary teams. Although changes in traditional hierarchies are well underway and will inevitably


continue, it has been difficult for psychiatrists and psychiatric training institutions to embrace these changes and train new psychiatrists in how to work within these new structures (Diamond, Stein, and Schneider-Braus, 1996).

Academic collaboration with front-line, innovative programs may help a training program become more relevant; the clinical service program benefits from the input of ideas, increased status in political negotiations, the ability to influence the training of new professionals, and a decrease in the isolation of front-line clinicians.

Building In Accountability. Accountability is required to ensure that the system of care and the clinicians within that system continue to function as intended. Mechanisms are needed in every complicated system to prevent lapses in quality of service. It is important to ensure that needs for change are identified and suggested improvements are acted on at system and program levels.

Accountability involves identifyng a problem and a solution to that problem. This includes identifyng who will do it, when it will be done (explicit time frame), what the outcome measure is, and how we will get there (processes, practicality).

Accountability can be driven internally or externally We all have an inher- ent internal drive toward wanting to do well. Most of us would like to think, and have our peers think, that we go to work to do a good job. Expectations (for example, peer review) work better than rules in this respect. We can also apply externally agreed-upon standards at different levels. Thus minimal standards can be set by institutional procedures or external regulation, and opti- mal standards can be set by seeking out “best practice” benchmarks or by setting priorities for service improvements and checking the relevant AIMHS standards for process and outcome indicators. Further, we can do outcome evaluation to ensure that service-user needs are met and service goals are achieved.

Lastly, we can make an explicit public statement of commitment to cus- tomer service, specifyng exactly what types and standards of service are offered, how to access and use these services, and how to complain if they are not up to scratch.

Establishing the New System as the New Standard. There are different ways to establish a new approach as the accepted standard. Certainly conduct- ing research and presenting sound evidence of the effectiveness of alternative models are sound currency in a world where the clinical-scientific paradigm is dominant. Usually, the establishment model (for example, the hospital-centered system of care) has not seen the need to research its own effectiveness.

Generating publicity, not just for individuals but for the new approach, is often important in what is essentially a political rather than scientific decision about what treatment approaches will be accepted. Applying for awards, research and innovation grants, and the like is a hedge against de-funding or dismantling, both as an alternative source of funding but also as a method of


increasing exposure and legitimacy (Ferber and Schoohbeck, 1977; Marks and others, 1994; Stein, 1992).

Dealing with Organizational and Clinical Backlash. One should not underestimate the resistance to developing community-based systems of care that are based on twenty-four-hour availability, mobility, and the individually derived goals of service users. Resistance comes from office-based clinicians who are uncomfortable with the new approach and from hospital-based administrators wanting more control of a decentralized and at times apparently chaotic community system. Administrators may attempt to recentralize widely dispersed community services back into the hospital on the pretext of “economies of scale.” In Australia, dismantling low-profile community-based mental health services is often seen as an easier way to deal with a budget cut than reducing hospital-based services. This is partly because senior management expect less public outcry and fewer industrial problems, and partly because of the vested interests of powerful hospital clinicians and managers. There are exceptions, of course; many senior health service managers are strong in their advocacy for community services. They are also innovating “against the grain.”

There are several examples in the United States and the United Kingdom of twenty-four-hour mobile crisis services that were thoroughly studied and demonstrated to be effective yet were curtailed or discontinued as a result of political pressure, conflict with other parts of the service delivery system, or withdrawal of adequate staffing and resources (Diamond, 1995; Marks and others, 1994; Polak, personal communication, 1996).

Even if services are dismantled, it may be some consolation that their highly experienced staffs often pick themselves up, dust themselves off, and pop up like dandelions, starting and leading innovative services elsewhere (Ferber and Schoohbeck, 1977). So the wider movement based on evidence and good sense may be resilient and enduring even while particular services remain vulnerable.

Conclusion: The Balance Between Change and Conservation

The challenge for the next decade is to establish the conditions under which comprehensive community mental health services may become widespread, stable, and enduring. This challenge will be met only by integrating hospital and community, treatment and rehabilitation services under one leadership for each catchment area. In addition, a working partnership must be fostered between service users, families, providers, management, and governments. The funding strategy must ensure that the money follows the patients from large institutions to the community in which they now live. The economic hijacking of this movement must be prevented by stemming the siphoning of institu- tionalized mental health funds into the health mainstream or into govei-nment-


consolidated revenue. Multidisciplinary professional involvement must be extended in case management, service planning for the future, and continuing training and retraining. Finally, high standards of care, quality improvement, evaluation, and research must be encouraged.

As mentioned at the very beginning of this chapter, systems do not endure by rigidly resisting change but by weaving change into the fabric of the organization so that the organization is always adapting and growing. To endure, services must anticipate change (Bachrach, 199 1). Innovative programs must “cultivate the ability to think ahead senously . . . about future treatment needs,” by making “some effort to predict the effects of imminent change on the lives and needs of chronically mentally ill persons” (pp. 1205-1206).

It is important that the new approach of the model program does not ossify into another rigid system. It becomes important that mental health systems and organizations persist in “innovating against the current” (Stein, 1992) by continuing to adapt and change, by continuing to question current assump- tions and procedures. Innovating against the current entails piloting, testing, and implementing models that rationally challenge traditional health care practices, organizations, and power differentials between service users and providers. The more an innovation runs against the current, the more obsta- cles it will have to overcome before being supported and disseminated, and the longer the time frame one must adopt compared to implementing health care models congruent with established structures. We must think in terms of decades rather than months for the acceptance and implementation of a truly innovative idea. Effective systems need to find ways to continue nurturing new ideas, even (or especially) those that challenge how the new system is operat- ing. There is no absolutely reliable cookbook or bible for developing new systems of care. The emerging pattern demonstrates some consistency in the ingredients of successful comprehensive mental health services. But the recipe may vary, and the ingredients may be put together differently in different places, according to local demography, culture, government policy, and resources. There must always be encouragement to innovate, so that we may swap notes and learn from each other.

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ALAN ROSEN is director and senior psychiatrist at Royal North Shore Hospital and Community Mental Health Services in Sydney, Australia. He is also associate professor and clinical senior lecturer at the University of Wollongong and the University of Sydney.

RONALD J. DIAMOND is professor of psychiatry, University of Wisconsin, and med- ical directol; Mental Health Center of Dane County, Wisconsin.

VIVIENNE MILLER is clinical education coordinator at Royal North Shore Hospital and Community Mental Health Services.

LEONARD I. STEIN is professor emeritus of psychiatry, University of Wisconsin, and director of research and training, Mental Health Center of Dane County.

becoming real: from model programs to implemented services

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