Children Mental Health and Systems of Care

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					Children’s Mental Health
   and Systems of Care
          An Introduction
          and Overview

          August 2008

          Presentation to
          University of Alaska

          Robert M. Friedman, Ph.D.
          Department of Child and Family Studies
          Louis de la Parte Florida Mental Health Institute
          University of South Florida
          Tampa, Florida

On the Need for Change and
―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 today’s 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-makers—and very
 capable ones at that.‖
                                      —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
     5-9%                9-13% Youth with SED, with
                               substantial functional
                         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
        Council’s Workgroup on Child and Adolescent Mental
          Health Intervention Development and Deployment
―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
  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
  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

   ―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

                              – Florida Commission on
                           Mental Health and Substance
                                      Abuse, 2001, p.8.
Characteristics of Children with
Serious Emotional Disturbances

  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
  National Comorbidity Study shows that
  ―it’s 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
Relationship of Mental Disorders
to Negative Outcomes
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




                              White    African-    Latino           other

 Calculations based on data from the National Health Interview Study, Sturm, 2000
ACES Study
 Conducted by Kaiser Permanente and
 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          School           Child Care        Universal
                  Healthcare                                            Services

Developmenta       Special      Child        Juvenile         Special       Substance
 l Disabilities   Healthcare   Welfare       Justice         Education        Abuse

                                                         de facto Mental Health System

                               Specialty Mental Health
Mental Health Funding
Streams for Children and

MEDICAID                  MENTAL HEALTH          EDUCATION
• Medicaid Inpatient      • MH General Revenue   • ED General Revenue
• Medicaid Outpatient     • MH Medicaid Match    • ED Medicaid Match
• Medicaid Rehab. Svcs.   • MH Block Grant       • Student Services
• Medicaid EPSDT

• SA General Revenue      • CW General Revenue   • TANF
• SA Medicaid Match       • CW Medicaid Match    • Children’s Medical
• SA Block Grant          • IV-E                   Services
                          • IV-B                 • Mental
                          • Adoption and Safe      Retardation/Develop
                            Families Act           mental Disabilities
                                                 • Title XXI
• JJ General Revenue
                                                 • Local Funds
• JJ Medicaid Match
• JJ Federal Grants
Three Basic Questions
 How can we improve access to care for
 those in need?
 How can we improve quality and
 effectiveness of care?
 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 research.
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 community
What System Conditions Led
to Development of Systems of
 Inadequate range of     Lack of clear
 services and            values/principles for
 supports                system
 Failure to              Lack of clarity
 individualize           about population of
 services                concern
 Fragmentation of        Inadequate
 system when             accountability
 children and families   Lack of adequate
 had multi-system        responsiveness to
 needs                   cultural differences
 Children with special
 needs are in many
Key Principles/Values
of a System of Care
 Based on needs of        Involves provision of
 child and family         individualized supports
                          and services based on
 Promotes                 strengths and needs in
 partnerships between     multiple domains
 families and             Promotes culturally
 professionals            responsive supports
                          and services
 Involves collaboration
 between multiple         Includes system of
 agencies and service     ongoing evaluation and
 sectors                  accountability
What Should a System
of Care be Based Upon?
 A vision, and set of        Best available evidence
 values, and principles      on effectiveness of
 developed and agreed        system mechanisms,
 upon by community           and services
 stakeholders;               A theory of change that
 A clear definition of the   makes explicit the link
 population to be served     between interventions
 and a thorough              (at the system,
 understanding of the        organization, program,
 population to be served;    provider, and
 A set of goals and          child/family levels) and
 desired outcomes, also      desired outcomes
 developed and agreed
 upon by community
Findings and Recommendations
from the President’s Commission
Six Goal Areas
1. Understand that mental health is essential to
   overall health
2. Mental health care is consumer & family driven
3. Disparities in mental health services are
4. Early mental health screening, assessment, and
   referral to services in multiple settings across the
   life-span are common practice
5. Excellent mental health care is delivered and
   research is accelerated
6. 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 providers—not oriented to the
  requirements of bureaucracies.
  Second, care must focus on increasing
  consumers’ ability to successfully cope with life’s
  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 accountability…when a
 serious mental illness or a serious emotional
 disturbance is first diagnosed, the health care
 provider–in full partnership with consumers and
 families–will 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 expanded…segregating 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 Children’s 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 funding
  Prevention, early identification, and early
  Early childhood intervention
  Mental health services in schools
                           —Huang et al., 2005
Translating the Vision into
  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
 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

                                    – Friedman, 2002
Survey of Random Sample of
 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 Reality


   VISION                    REALITY
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

                  – William Sloane Coffin,
                    Social activist and clergyman
 ―The solution is not to abandon our current
  work but to do it better, with more
  sophistication and from a more strategic
  vantage point…we 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             Transformational
Happen…         Governance          Provider
               Choice                  Collaboration

        Pathways                                 Provider
         to Care               Quality           Network
            Range of

                             Theory of

                    Values               Description of
                  Stakeholders Coming Together
Core Implementation

                      —Fixsen et al., 2005
Differentiation and Integration
  Differentiation – learning new concepts
  and being able to distinguish between
  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 directions…Complexity science has moved
 science away from a linear mechanistic view of the
 world to one based on nonlinear dynamics,
 evolutionary development and systems thinking. It’s a
 dramatic new way of looking at things; it’s 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
                     Westley, Zimmerman, & Patton, 2006
Three Levels of Problems
 Simple – baking a cake
 Complicated – sending a rocket to the
 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. Don’t 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
 ―We’re in a knowledge economy but our
 managerial and governance systems are
 stuck in the Industrial era. It’s time for a
 whole new model‖ (Manville & Ober,
 Complexity leadership theory focuses on
 identifying and exploring the strategies
 and behaviors that foster organizational
 and subunit creativity, learning, and
 adaptability, when appropriate.
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 people’s 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 disabilities.‖
                                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 essential
  mechanisms between agents and
  components are critical
Alternative Model (cont.)
  Responsiveness to context issues is a
  Values, principles, culture, and goals are
  the key foundations
  Causal relationships are primarily non-
  linear and complex
  The ―system‖ exists in the eye of the
  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 jurisdictions.‖
                          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
 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 system
 Referral back to values and principles
 New ways of thinking – new mental
 models, new frameworks!!!
One General Theory
 Meaningful and ambitious goal
 Strong family voice
 Effective individualized treatment
 Strong and transparent performance
 measurement system with feedback
                                  I. Burnim
The Quality Chasm: Three
Central Themes
 Use the science we know –including the
 science of ―improvement‖
 Center care on the patient -- put patients
 in the lead on care design communities
 and develop and use care plans that
 incorporate the patients’ goals
 Cooperate as a system – a culture of
From Hodges et al.
1. 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.
2. 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.
3. Recognize that opportunities for action are not
   linear. Take advantage of opportunities to
   leverage system change when and where they
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
 Utilization and improvement-focused
 Combination of in-depth and aggregate
 Use of both qualitative and quantitative
 Focus on a few key measures
 Feedback loop to all participants
 An intervention itself…not just a
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
  one’s own community for purposes of
  assessing how the system is performing
  and identifying areas in need of
  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
Individualized Care
  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
  Based on strengths, needs, culture, and
  choices of child and family, in partnership
  with team
Individualized Care
  Enhanced by creative and participatory
  team process, and facilitated by
  availability of flexible funding, broad
  range of services, and extensive provider
  The application of system of care
  principles and values at the child and
  family level
Active Agents of
Change/Components of
Service Effectiveness
 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 interventions
Change/Components of
Service Effectiveness
 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
Change/Components of
Service Effectiveness
 ―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
                         Thomlison, 2003
Change/Components of
Service Effectiveness
 Operated by people with a commitment
 and intensity to their work and a clear
 sense of mission
 Based upon quality staff with effective
 models of training and ongoing technical
Change/Components of
Service Effectiveness
―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
Change/Components of
Service Effectiveness
―…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 care…it 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
Change/Components of
Service Effectiveness
 Comprehensive, flexible, and responsive
 to the needs of participants
 View children in the context of broader
 ecologies—families, schools,
 neighborhoods, churches, and
 Link with other systems of support and
 intervention to ensure they can produce
 and sustain their impacts over time
                          Greenberg, 2002
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 intervention
 Family choice of services and providers
 may create a more effective, efficient,
 market-driven, customer-oriented and
 accountable system
    Subcommittee on Family Choice, 2005
 The right thing to do but often
 a neglected thing
 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 ―effectiveness‖
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 families.
                                 Weisz & Sandler, 2005
―The President’s 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
  Populations served
  Attitudes and interests
Successful Models
 Westchester County
 Central Nebraska
 Travis County
 Placer County
 Erie County
 System of care values and principles as
 the foundation
 Evidence-based practices and active
 agents of change
 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 studies)
 Quantitative only
 Non-representative participants
 High on internal validity – much lower on
 external validity
 Limited voice of participants
 Outcome-oriented and not also
 implementation/process oriented
Research/Evaluation Model
 The ―system of care‖ is the independent
 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-
 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 paradigm—a 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 pattern-focused
                             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
  Ongoing – multiple streams
  Action and change-oriented
Conditions that Challenge
  High innovation
  High uncertainty
  System change
                     Patton, 2008
Newer Approaches to
 Multi-method, multi-source
 Participatory and collaborative
 Continuous rather than discrete
 Extensive use of multiple streams of
 ongoing data collection
―We need to place less emphasis on
 discovering the one objective truth about a
 program’s worth and more attention to the
 multiple perspectives that diverse interests
 bring to judgment and understanding‖

                                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 Modeling—One
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
                              Sanders & McCabe, 2003
Leadership and Organizational
 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
1. Leaders communicate a shared vision
2. Leaders centralized by mission and
   decentralized by operations
3. Leaders create an organizational culture
   that identifies and tries to live by key
4. Leaders create an organizational
   structure and culture that empowers
   their employees and themselves
Eight Principles of Leadership
5. Leaders ensure that staff are trained in a
   human technology that can translate
   vision into reality
6. Leaders relate constructively to
7. Leaders access and use information to
   make change a constant ingredient of
   their organization
8. Leaders build their organization around
   exemplary performers
Transformational Leaders
 Externalize strongly      Develop others to higher
 held values to shape      levels of ability and
 and articulate a          potential
 unifying vision for       Encourage collective
 the future                decision making
 Inspire others to see     Create energizing
 their place in that       environments that
 future                    incubate ideas, actions
 Motivate others to        and other leaders
 look beyond their         Think and plan backward
 own interests to          from an envisioned future
 achieve goals             to take action
 Act as role models      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
Identifies six major types of change:
   Reframe core cultural values;
   Create improvement capability;
   Collaborate across competitive
   Create a business environment that
   simultaneously drives business results
   and community benefit;
   Drive system-level rather than project-
   level results;
   Maintain constancy of purpose of the
   long-term transformational journey.
Eight Steps to Transforming
Your Organization
1. Establishing a sense of urgency;
2. Forming a powerful guiding coalition;
3. Creating a vision;
4. Communicating the vision;
5. Empowering others to act on the vision;
6. Planning for and creating short-term wins;
7. Consolidating improvements and producing still
   more change;
8. 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 hasn’t 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.‖
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
  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 Can’t Predict What Will Happen
In Systems, At Least We Can Learn
How to Dance with Them!
  Get the beat               Pay attention to what is
  Listen to the wisdom of    important, not just what is
  the system                 quantifiable

  Expose your mental         Go for the good of the
  models to the open air     whole

  Stay humble. Stay a        Expand time horizons.
  learner.                   Expand thought horizons.
  Honor and protect          Expand the boundary of
  information                caring
  Locate responsibility in   Celebrate complexity
  the system                 Hold fast to the goal of
  Make feedback policies     goodness.
  for feedback systems
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