METHODS OF METHODS OF INTERVENTION AND INTERVENTION AND

CHANGE IN COMMUNITY CHANGE IN COMMUNITY PSYCHOLOGYPSYCHOLOGY

Lecture 38Lecture 38

CONSULTATIONCONSULTATIONWhat is consultationWhat is consultation?? Orford (1992) offers the Orford (1992) offers the

following definition:following definition:

‘’‘’Consultation is the process whereby an Consultation is the process whereby an individual (the consultee) who has responsi individual (the consultee) who has responsi bility for providing a service to others (the bility for providing a service to others (the clients) voluntarily consults another person clients) voluntarily consults another person (the consultant) who is believed to possess (the consultant) who is believed to possess some special expertise which will help the some special expertise which will help the consultee provide a better service to his or consultee provide a better service to his or her clients’’.her clients’’.

The basic advantage of consultation is that its The basic advantage of consultation is that its effects are multiplied like the ripples from a effects are multiplied like the ripples from a stone thrown into a pond.stone thrown into a pond.

Using individual techniques of intervention, the Using individual techniques of intervention, the mental health specialist can reach only a very mental health specialist can reach only a very limited number of clients. But by consulting with limited number of clients. But by consulting with other service providers, such as teachers, other service providers, such as teachers, police, and ministers, he or she can reach police, and ministers, he or she can reach many more clients indirectly.many more clients indirectly.

Consultation can be viewed from several Consultation can be viewed from several orientations:orientations:

First, there is mental health consultation.First, there is mental health consultation. It was often practiced in rural or It was often practiced in rural or

underdeveloped areasunderdeveloped areas

A second orientation developed out of the A second orientation developed out of the behavioral tradition. In order to implement the behavioral tradition. In order to implement the technology of behavior modification that had technology of behavior modification that had been so successful in laboratory settings, it was been so successful in laboratory settings, it was necessary to move into real-life situations. To necessary to move into real-life situations. To do that, people in the patient's environment do that, people in the patient's environment (such as home or school) had to be trained to (such as home or school) had to be trained to properly dispense reinforcements for the properly dispense reinforcements for the desired behavior. Consultation became a way desired behavior. Consultation became a way of providing such training. of providing such training.

The third orientation is an organizational one The third orientation is an organizational one that emphasizes consultation to industry. that emphasizes consultation to industry. Specialists work with management or work Specialists work with management or work group leaders to improve morale, job group leaders to improve morale, job satisfaction, and productivity or to reduce satisfaction, and productivity or to reduce inefficiency, absenteeism, alcoholism, or other inefficiency, absenteeism, alcoholism, or other problems.problems.

TYPES OF MENTAL HEALTH TYPES OF MENTAL HEALTH CONSULTATIONSCONSULTATIONS

Caplan's (1970) classification. Caplan's (1970) classification.

1. 1. Client-centered case consultation.Client-centered case consultation.

2. 2. Consultee-centered case consultationConsultee-centered case consultation..

33. Program-centered administrative . Program-centered administrative consultationconsultation..

4. 4. Consultee-centered administrative Consultee-centered administrative consultation.consultation.

TECHNIQUES AND PHASES TECHNIQUES AND PHASES In most cases, the consultation process will In most cases, the consultation process will

pass through the following phases:pass through the following phases: 11. . The entry or preparatory phaseThe entry or preparatory phase.. 2. The beginning or warming-up phase2. The beginning or warming-up phase.. 3. The alternative action phase.3. The alternative action phase. 4. 4. Termination.Termination. Unfortunately, community mental health centers Unfortunately, community mental health centers

have had difficulty providing consultation have had difficulty providing consultation services, especially to schools and community services, especially to schools and community agencies; agencies;

The budgetary support has just not been there.The budgetary support has just not been there.

COMMUNITY ALTERNATIVES TO COMMUNITY ALTERNATIVES TO HOSPITALIZATIONHOSPITALIZATION

Despite the fact that there is a core of Despite the fact that there is a core of "undischargeable" patients, there are "undischargeable" patients, there are alternatives to our current hospital system-alternatives to our current hospital system-alternatives that will provide environments alternatives that will provide environments geared to the goal of enabling patients to geared to the goal of enabling patients to resume a responsible place in society.resume a responsible place in society.

Examples of alternatives include the community Examples of alternatives include the community lodge. This is akin to a halfway house where lodge. This is akin to a halfway house where formerly chronic, hospitalized patients can learn formerly chronic, hospitalized patients can learn independent living skills. independent living skills.

The Mendota Program was a pioneering The Mendota Program was a pioneering attempt to help formerly "un-dischargeable" attempt to help formerly "un-dischargeable" patients find jobs, learn cooking and shopping patients find jobs, learn cooking and shopping skills, and so on. skills, and so on.

Finally, there is the growing popularity of day Finally, there is the growing popularity of day hospitals that are often more effective and less hospitals that are often more effective and less expensive than traditional 24-hour expensive than traditional 24-hour hospitalization.hospitalization.

CRISIS INTERVENTIONCRISIS INTERVENTION The basic goal of crisis The basic goal of crisis intervention is intervention is to reach to reach

people in an acute state of stress and to people in an acute state of stress and to provide them with enough support to prevent provide them with enough support to prevent them from becoming the chronically mentally ill them from becoming the chronically mentally ill of the futureof the future

Persons in crisis are often in a uniquely Persons in crisis are often in a uniquely "reachable" state that can pave the way for "reachable" state that can pave the way for future long-term interventions.future long-term interventions.

Crisis intervention requires the relinquishing of Crisis intervention requires the relinquishing of traditional procedures and prerogatives.traditional procedures and prerogatives.

Finally, crises tend to obliterate customary Finally, crises tend to obliterate customary professional roles, pecking orders, and professional roles, pecking orders, and prerogatives.prerogatives.

Crisis intervention requires a versatility and Crisis intervention requires a versatility and flexibility that are not often found in traditional flexibility that are not often found in traditional clinics or hospitals.clinics or hospitals.

The emphasis is now on 24-hour services The emphasis is now on 24-hour services staffed by workers who personally take calls.staffed by workers who personally take calls.

Current interventions emphasize follow-up both Current interventions emphasize follow-up both to check on the well-being of the client and to to check on the well-being of the client and to assess the adequacy of the services provided assess the adequacy of the services provided by the agency to which the client was referred.by the agency to which the client was referred.

Current intervention procedures also encourage Current intervention procedures also encourage face-to-face contact rather than the earlier over face-to-face contact rather than the earlier over reliance on the telephonereliance on the telephone

Suicide prevention centers.Suicide prevention centers. Development of the Suicide and Crisis Development of the Suicide and Crisis

Intervention Service (SCIS) in Gainesville, Intervention Service (SCIS) in Gainesville, Florida.Florida.

The policy of SCIS was simply "to respond to The policy of SCIS was simply "to respond to every request to participate in the solution of every request to participate in the solution of any human problem whenever and wherever it any human problem whenever and wherever it occurs“.occurs“.

People in crisis were to be given immediate, People in crisis were to be given immediate, active, and aggressive services.active, and aggressive services.

SCIS regarded people in crisis as the SCIS regarded people in crisis as the responsibility of the community and felt that, as responsibility of the community and felt that, as citizens, they had a right to expect such a citizens, they had a right to expect such a community service.community service.

The SCIS-type crisis center is organized with The SCIS-type crisis center is organized with the idea of community Control.the idea of community Control.

Are these interventions really helpful?. Much Are these interventions really helpful?. Much

depends on the questions asked. depends on the questions asked.

For example Decker and Stubblebine (1972) For example Decker and Stubblebine (1972) found that psychiatric hospitalizations were found that psychiatric hospitalizations were reduced when crisis intervention procedures reduced when crisis intervention procedures were used. were used.

Yet when other researchers compared crisis Yet when other researchers compared crisis patients with patients who had been randomly patients with patients who had been randomly assigned to a waiting list, they could find no assigned to a waiting list, they could find no differences in several indices of psychiatric differences in several indices of psychiatric improvement. improvement.

Other reports are much more optimistic. Other reports are much more optimistic.

Not all research shows the efficacy of crisis Not all research shows the efficacy of crisis intervention. intervention.

However, others argue that additional However, others argue that additional preventive measures could well reduce the preventive measures could well reduce the number of deaths from suicide.number of deaths from suicide.

Clearly, crisis interventions can help reduce distress.Clearly, crisis interventions can help reduce distress. When a school bus collides with a train, the survivors When a school bus collides with a train, the survivors

must be helped to cope. must be helped to cope. Public health workers and mental health workers have Public health workers and mental health workers have

long been aware of the educational disadvantages long been aware of the educational disadvantages experienced by the poor. experienced by the poor.

Of great concern is the fear that early deprivation in Of great concern is the fear that early deprivation in crucial developmental periods will mark the child for crucial developmental periods will mark the child for life. life.

Impoverished preschool environments and Impoverished preschool environments and experiences may almost guarantee that the child will experiences may almost guarantee that the child will do poorly in school and thus become vulnerable to a do poorly in school and thus become vulnerable to a wide variety of mental health, legal, and social wide variety of mental health, legal, and social problems. problems.

But if successful preschool interventions can be But if successful preschool interventions can be developed, then a truly preventive course of action will developed, then a truly preventive course of action will have been taken.have been taken.

HEAD START PROGRAMSHEAD START PROGRAMS The best-known early childhood program is The best-known early childhood program is Head Head

Start.Start. Head Start was one of the programs targeted Head Start was one of the programs targeted

specifically for disadvantaged children. specifically for disadvantaged children. It was designed to prepare preschool children from It was designed to prepare preschool children from

disadvantaged back grounds for elementary school.disadvantaged back grounds for elementary school. Head Start programs are locally controlled but Head Start programs are locally controlled but

required to conform to general federal guidelines.required to conform to general federal guidelines. Local programs vary in number of hours of Local programs vary in number of hours of

attendance, number of month, background of attendance, number of month, background of teachers, and so on. teachers, and so on.

The specific techniques used also vary, but basic The specific techniques used also vary, but basic learning skills are usually stressed. learning skills are usually stressed.

Physical and medical needs are also addressed, as Physical and medical needs are also addressed, as are general school preparation and adjustment.are general school preparation and adjustment.

EVALUATION:EVALUATION: - - It was found useful to distinguish between child-It was found useful to distinguish between child-

focused programs and family-focused programs. focused programs and family-focused programs. In the former case, interventions are administered In the former case, interventions are administered

directly to the child; directly to the child; in the latter case, family members (such as parents) in the latter case, family members (such as parents)

receive the intervention or training.receive the intervention or training.

Participation in a child-focused program results in an Participation in a child-focused program results in an average IQ gain of about 8 points immediately after average IQ gain of about 8 points immediately after program completion (although these relative gains program completion (although these relative gains dissipate over time), makes it less likely that the child dissipate over time), makes it less likely that the child will be placed in special education or retained in will be placed in special education or retained in grade, and makes it more likely that the child will grade, and makes it more likely that the child will graduate from high school . graduate from high school .

Positive social outcomes resulting from Positive social outcomes resulting from program participation have also been reported, program participation have also been reported, including fewer contacts with the criminal including fewer contacts with the criminal justice system, fewer out-of-wedlock births, and justice system, fewer out-of-wedlock births, and higher average earnings than non participants.higher average earnings than non participants.

Although family-focused programs appear to Although family-focused programs appear to have more impact on parents' behaviors than have more impact on parents' behaviors than do child-focused programs, do child-focused programs,

It is not clear how much positive impact they It is not clear how much positive impact they have on children. have on children.

Not only is the focus of the intervention Not only is the focus of the intervention different, but so is its intensity and frequency. In different, but so is its intensity and frequency. In the case of family focused interventions, the case of family focused interventions, services may be rendered only once a week services may be rendered only once a week

SELF-HELPSELF-HELP Not all help comes from professionals. Not all help comes from professionals. Informal groups of helpers can provide valuable Informal groups of helpers can provide valuable

support that may stave off the need for professional support that may stave off the need for professional intervention.intervention.

What needs do self-help groups meet? Orford (1992) What needs do self-help groups meet? Orford (1992) discussed eight primary functions of self help groups:discussed eight primary functions of self help groups:

(1) They provide emotional support to members; (1) They provide emotional support to members; (2) They provide role models-indi viduals who have (2) They provide role models-indi viduals who have

faced and conquered problems that group members faced and conquered problems that group members are dealing with; are dealing with;

(3) They provide ways of understanding members' (3) They provide ways of understanding members' problems; problems;

(4) They provide important and relevant (4) They provide important and relevant information; information;

(5) They provide new ideas about how to cope (5) They provide new ideas about how to cope with existing problems; with existing problems;

(6) They give members the opportunity to help (6) They give members the opportunity to help other members; other members;

(7) They provide social companionship; and (7) They provide social companionship; and (8) They give members an increased sense of (8) They give members an increased sense of

mastery and control over their problems. mastery and control over their problems. Clearly self-help group serve several important Clearly self-help group serve several important

functions for group members. However, research functions for group members. However, research suggests that professionals should be available suggests that professionals should be available to serve as consultants to these groups in order to serve as consultants to these groups in order for the groups to be maximally effective.for the groups to be maximally effective.

PARAPROFESSIONALSPARAPROFESSIONALS One of the more visible features of the community One of the more visible features of the community

movement is its use of laypersons who have received movement is its use of laypersons who have received no formal clinical training, or no formal clinical training, or paraprofesparaprofessionals, as sionals, as therapists. therapists.

The use of paraprofessionals in the mental health field The use of paraprofessionals in the mental health field has been growing, but this trend has generated has been growing, but this trend has generated controversy. controversy.

In reviewing 42 studies, Durlak (1979) concluded that In reviewing 42 studies, Durlak (1979) concluded that professional education, training, and experience are professional education, training, and experience are not prerequisites for becoming an effective helping not prerequisites for becoming an effective helping person. person.

However, Nietzel and Fisher (1981) took issue with However, Nietzel and Fisher (1981) took issue with this conclusion and urged caution in interpreting the this conclusion and urged caution in interpreting the results of many of the studies reviewed by Durlak. results of many of the studies reviewed by Durlak.

They argued that many of the studies included They argued that many of the studies included in the Durlak review were methodologically in the Durlak review were methodologically flawed, and objected to Durlak's definitions of flawed, and objected to Durlak's definitions of "professional" and "paraprofessional." "professional" and "paraprofessional."

Results fromResults from their meta-analysis-concurred with their meta-analysis-concurred with those ofthose of Durlak. The overall results favored Durlak. The overall results favored paraprofessionals, especially those who were paraprofessionals, especially those who were more experienced and received greater more experienced and received greater amounts of training. amounts of training.

More recent summaries have also argued that More recent summaries have also argued that thethe available evidence suggests that available evidence suggests that paraprofessionalsparaprofessionals may be as effective as (and may be as effective as (and in some cases morein some cases more effective than) effective than) professionals.professionals.

Besides effectiveness, there is also the issue of Besides effectiveness, there is also the issue of access to those who can provide help. access to those who can provide help.

Like it or not, most individuals who are in need of Like it or not, most individuals who are in need of mental health services do not seek out mental health mental health services do not seek out mental health professionals. Instead, informal "therapy" takes place professionals. Instead, informal "therapy" takes place in many contexts and is provided by a variety of in many contexts and is provided by a variety of laypersons. laypersons.

For example, an interesting and provocative set of For example, an interesting and provocative set of studies, Cowen (1982) 'investigated the "helping studies, Cowen (1982) 'investigated the "helping behavior" of hairdressers and bartenders. behavior" of hairdressers and bartenders.

Many community psychologists view these and other Many community psychologists view these and other studies as evidence supporting the idea that studies as evidence supporting the idea that consultation programs might be aimed at laypersons consultation programs might be aimed at laypersons that naturally come into contact with individuals with that naturally come into contact with individuals with mental health needs. mental health needs.

Although it hardly seems wise to argue that Although it hardly seems wise to argue that professionally trained clinical psychologists are professionally trained clinical psychologists are unnecessary, it certainly appears that there is a unnecessary, it certainly appears that there is a vital role for paraprofessionals in the mental vital role for paraprofessionals in the mental health field today. health field today.

Clinical psychologists are needed, at the very Clinical psychologists are needed, at the very least, to serve as consultants. least, to serve as consultants.

Further, research may ultimately indicate that Further, research may ultimately indicate that certain types of mental health problems certain types of mental health problems respond better to services provided by a mental respond better to services provided by a mental health professional. health professional.

To date, however, the research questions To date, however, the research questions addressed (for example, are paraprofessionals addressed (for example, are paraprofessionals effective overall?) have been too broad to shed effective overall?) have been too broad to shed light on this issue.light on this issue.

THE TRAINING OF COMMUNITY THE TRAINING OF COMMUNITY PSYCHOLOGISTSPSYCHOLOGISTS

Community psychology has yet to develop an adequate Community psychology has yet to develop an adequate or identifiable theoretical frame work apart from those of or identifiable theoretical frame work apart from those of other disciplines. other disciplines.

This, at times, makes for role confusion. The community This, at times, makes for role confusion. The community psychologist is part sociologist, part political scientist, psychologist is part sociologist, part political scientist, part psychotherapist, part ombudsman, but lacks a part psychotherapist, part ombudsman, but lacks a specific identity. This ambiguity makes it difficult to specific identity. This ambiguity makes it difficult to design appropriate training programs.design appropriate training programs.

Fortunately, there are some guidelines for training.Fortunately, there are some guidelines for training. The recent IOM report (1994) recommends that future The recent IOM report (1994) recommends that future

prevention research specialists should have a solid prevention research specialists should have a solid background in a relevant discipline (such as nursing, background in a relevant discipline (such as nursing, sociology, social work, public health, epidemiology, sociology, social work, public health, epidemiology, medicine, or clinical/community psychology). medicine, or clinical/community psychology).

Training in the design of interventions and the empirical Training in the design of interventions and the empirical evaluations of interventions is essential. evaluations of interventions is essential.

Finally, practicum or internship-like training in Finally, practicum or internship-like training in prevention is also recommended. prevention is also recommended.

Educational requirements for prevention field Educational requirements for prevention field specialists (those that actually carry out the specialists (those that actually carry out the interventions) are less stringent. interventions) are less stringent.

Often, a bachelor's degree in a relevant field (such as Often, a bachelor's degree in a relevant field (such as psychology) is sufficient.psychology) is sufficient.

Given the increasing cultural and ethnic diversity in the Given the increasing cultural and ethnic diversity in the United States, it is also important for community United States, it is also important for community psychologists to receive training in how diversity psychologists to receive training in how diversity issues may impact their work. For example, issues may impact their work. For example, knowledge of and sensitivity to cultural and ethnic knowledge of and sensitivity to cultural and ethnic differences will inform the following activities and roles differences will inform the following activities and roles of a prevention researcher (IOM, 1994):of a prevention researcher (IOM, 1994):

1. Developing relationships with community 1. Developing relationships with community leaders and organizationsleaders and organizations

2. Conceptualizing and identifying potential risk 2. Conceptualizing and identifying potential risk factors, mechanisms, and antecedents of factors, mechanisms, and antecedents of problems or disordersproblems or disorders

3. Developing interventions that will have 3. Developing interventions that will have maximum effect, and deciding how these maximum effect, and deciding how these should be disseminated and delivered to the should be disseminated and delivered to the target populationtarget population

4. Determining the content and format of 4. Determining the content and format of evaluation instruments evaluation instruments