An interactive approach to training teams and developing programs

A combination of educational and organizational strategies help rehabilitation teams develop programs that effectively address the needs of their consumers.

An Interactive Approach to Training Teams and Developing Programs

Patrick W Corrigan, Stanley G. McCracken

Various approaches to training and development help staff learn the basic elements of psychiatric rehabilitation and use these basics to implement a rehabilitation program that meets the needs of its consumers. Two training models have dominated: educational approaches, which describe how staff learn psychiatric rehabilitation, and organizational strategies, which help the team work better together to develop and implement an effective program (Corrigan and McCracken, 1995). An interactive approach to staff training and program development combines educational and organizational strategies. This approach teaches the rehabilitation team effective skills that are then employed to develop user-friendly, consumer-relevant programs.

Educational approaches incorporated into interactive staff training (IST) include a range of techniques that help members of the rehabilitation team learn fundamental principles of psychiatric rehabilitation. These fundamentals then set the framework for defining the program’s mission and goals. Educa- tional strategies also help team members master the set of interventions that assist consumers in attaining these goals. Specific examples of education strategies include didactic lecture, modeling, role play, in vivo on-the-job feedback, resource considerations, problem analysis, and homework (Kuehnel and Liber- man, 1990; Rogers and others, 1986; Wallace and others, 1992).

Organizational strategies of IST incorporate many of the basic assumptions of total quality management (Marks, Mirvis, Hackett, and Grady, 1986; Sluyter and Mukherjee, 1993). Namely, the training and development agenda should be established by frontline staff because operating the program is essentially their responsibility Program development and subsequent implementation should be driven by data that show whether the program meets consumer needs.

NEW DIRECTIONS FOR MENTAL HEALTH SERVICES, no. 79, Fall 1998 QJossey-Bass Publishers 3

4 BUILDING TEAMS FOR EFFECTIVE PSYCHIATRIC REHABILITATION

Characteristics of Interactive Staff Training for Teams

The principles of an interactive approach to training a rehabilitation team are as follows:

Train empirically supported principles and skills. Train the team that implements the rehabilitation program. Develop ownership of the program. Develop a user-friendly rehabilitation program. Develop a consumer-grounded program. Continually train and develop programs based on data-driven feedback.

The focus of education is on teaching empirically supported principles and skills that define practice guidelines for psychiatric rehabilitation. Team members learn to appreciate the importance of selecting principles and skills that have been supported by research.

Training should take place on the job and involve the entire team. Tradi- tionally, staff training often entails individual members of the rehabilitation team traveling away from the worksite to learn about a specific innovation from an expert. Unfortunately, information learned off-site seldom ylelds mean- ingful program change back at work. One reason newly learned innovations do not transfer to the program is that many of the team members expected to carry out the innovation have not participated in the training and do not understand the value of the new technique.

Education is facilitated when trainers on-site at the rehabilitation program see the resources and barriers that affect the success of the program. Frequently, however, experts are brought in from outside to set up state-of-the-art programs (Paul, Stuve, and Cross, 1997). Many experts fail to understand the resources and barriers to a new program, so they design programs that fall short of the team’s interests. Team ownership of the new program is essential to the success of the training and development process (Corrigan and McCracken, 199710). Participative decision making, involving members’ making explicit decisions about the form of their program, is the essence of program ownership.

The training efforts of the team should focus on helping staff members develop a user-friendly rehabilitation program rather than on insisting that individuals learn state-of-the-art interventions exactly as they were developed and tested by research-and-development programs. Many innovations are not regularly used by frontline staff members because strategies developed in the research setting are saturated in (and obscured by) jargon (Barlow, 1981). Moreover, strategies developed in the “ivory tower” may target behaviors of lit- tle interest to rehabilitation providers working with persons with severe mental illness. The frontline rehabilitation team is more likely to implement an intervention package that is relevant to its perceived treatment goals.

This does not mean that the rehabilitation team is given carte blanche to change programs any way they please. There are limits to changing empirically

AN INTERACTIVE APPROACH 5

derived practice guidelines; for instance, teams might adapt guidelines and unintentionally leave out the active ingredient leading to positive change. The final arbiter of a program’s impact, however, is its measured effect on consumers and staff. Empirically derived practice guidelines are just that, guidelines. Program development occurs within the breadth of possibilities suggested by the guidelines.

User-friendly programs reflect not only the team’s interest but also the consumer’s. Programs are only effective when they target goals that represent consumer concerns and incorporate services that consumers find satisfactory. IST includes consumers in all phases of training and development; consumers are encouraged to participate with team members in revising programs.

Finally, training and development constitute a continuous, data-driven process. Many team members mistakenly assume that program development is an up-front event; wind up the newly developed program and let it go. The rehabilitation team should continually collect evidence of the impact of the program on all interested stakeholders, including team members and consumers, then use this information to adjust the program to meet the ever- changing interests of participants.

Overview of Interactive Staff Training

Interactive staff training comprises the following four stages:

1. Introduction to the system, including achieving staff support and formu- lating a staff needs assessment

2. Program development, including participative decision making by the staff

3. Program implementation, including piloting and evaluation 4. Program maintenance, including maintaining a user-friendly program

through continuous quality improvement

During the first stage of IST-introduction to the system-consultants focus on being accepted by the rehabilitation team so that individual members are willing to work with them to develop and eventually implement various rehabilitation programs. The consultant may be an outside expert hired by the agency or a senior staff member with skills in staff training and organizational development. Although the focus of IST is the frontline rehabilitation team, the consultant’s efforts will only be successful with the explicit support of institutional adminis- trators. Hence, the consultant begins by educating executive directors about the components of IST and getting their public support to proceed.

Frontline team members are then engaged in IST through an assessment of staff needs. As noted above, team members are more likely to implement intervention programs that reflect their perceptions of important issues of consumer care and milieu management (Comgan and others, 1994a). Team members and consumers may be asked to complete a written questionnaire about


their views of the program. Alternatively, they may participate in focus groups where they can share views about current interventions with peers. The results of the needs assessment are fed back to the team, and subsequent discussion leads to agreement on a direction for program development. This process is further facilitated by presenting the team with a menu of rehabilitation strategies from which team members select appropriate intervention protocols to address program development goals.

Next, individuals from within the existing team, who will develop a blue- print for the elaborated rehabilitation program, are assembled as a program committee. This committee is charged with developing provisional program changes that will then be considered by the team as a whole. The efforts of the program committee are greatly facilitated when at least one staff member is identified as a program “champion” (Corrigan, 1995). The champion is an energetic and opti- mistic individual who wants to assume responsibility for convening the program committee and keeping the group focused on development tasks.

Efforts to develop a user-friendly rehabilitation strategy-the program development stage of IST-begin after the program committee and champion are seated. The IST consultant introduces the program committee to the principles and services, described in the research literature, that are relevant to the program development goals identified in the needs assessment. This information provides a useful framework that outlines the ideal rehabilitation program. The program committee then makes decisions about how the ideal program will be adapted to meet the needs of its consumers and staff. This process, called participative decision making, has been shown greatly to increase employees’ commitment to the organization and the program (Bowditch and Buono, 1994).

IST consultants use their expertise to help the committee evaluate the out- lined program after committee members make the initial decisions. Socratic questioning is a useful means for accomplishing this goal (Overholser 1993a, 1993b). Rather than asserting a weakness or limitation of a program, the purpose of Socratic questioning is to help the program committee evaluate the cost and benefits of specific program choices. Sometimes a line of questioning leads the committee to realize that they do not have enough information to make an informed decision. The IST consultant takes advantage of these learning opportunities to teach curious team members about the specific component. Traditional education strategies are used for this purpose. Classroom-based training grounded in IST, however, differs from more traditional strategies. Team members study rehabilitation strategies that they have identified as important and relevant to their plan of care. Moreover, their current need to transpose the particular strategy into a user-friendly program makes them sig- nificantly more attentive than in traditional classroom-based training.

After several months of planning, a date is set to implement the drafted program (the program-implementation stage of IST). The program committee and rehabilitation team must first pilot the program before a full-fledged trial occurs. Testing a drafted program during a pilot uncovers weaknesses in the newly developed program. Pilots are conducted by a subgroup of team mem-


bers with a subset of consumers. Do not attempt to implement a new program with all staff and consumers until some of the more obvious pitfalls have been worked out. Emphasize explicitly to the team that the purpose of the pilot is to work the “bugs” out of the program, not to see whether it will work under the most difficult situation.

The program committee should adopt a revisionist approach to changing components of the newly designed program that have been found deficient during the pilot. D’Zurilla (1986; D’Zurilla and Goldfried, 1971) developed a multistep strategy for evaluating interpersonal problems: Identify problems highlighted by the pilot, brainstorm solutions to the problem, evaluate costs and benefits of each solution, select one solution based on this evaluation, and try it out. This strategy is used to revise drafted programs. Through this process, program committees and treatment teams learn that limitations in a rehabilitation program are problems that can be fixed, rather than over- whelming difficulties that indicate that the program should be abandoned.

The last stage of IST is program maintenance; the team sets up structures that support the newly developed program over the long term. Continuous quality improvement (CQI) is an institutional effort that has been shown to help maintain efficient programs over time (Sluyter and Mukherjee, 1993; Cor- rigan, Luchins, Malan, and Harris, 1994). In many ways, CQI activities paral- lel the problem-solving steps in the pilot. Staff members are encouraged to brainstorm questions about the efficacy of a program. These questions then lead to a plan of correction. The IST consultant might share various resources that provide strategies relevant to the plan of correction. (For example, an IST consultant might refer a team developing a transitional employment program to a local clubhouse for advice.) The committee then sifts through this information to decide on the best solutions.

An Example of Interactive Staff Training

The remainder of this chapter highlights one component-participative decision making, the heart of IST. The interested reader should see Corrigan and McCracken (1997a) for a more thorough discussion of IST. Participative decision making captures the essential mission of IST: Involve the program committee and team in deciding about changes in how they do business with their consumers. The experiences of a rehabilitation team at a fictional agency called the Northside Clubhouse will serve to illustrate the fundamental principles of participative decision making.

Psychosocial clubhouses developed as a popular and effective venue for rehabilitation over the past several decades (Beard, Propst, and Malamud, 1982). Consumers participate in clubhouses to seek affiliation and support. The Northside Clubhouse, located in a large Midwestern city, is a program whose traditional mission had been to serve persons with severe mental illness. Recently, the Clubhouse observed that several of its members were unable to accomplish life goals because of problems related to substance abuse. Results


of the needs survey conducted with consumers and team members confirmed this observation. Traditional substance abuse services in the area were unable, or unprepared, to serve persons with severe mental illness, so the Northside Clubhouse decided to develop a dual diagnosis program for its membership. The program committee met with an IST consultant (who was knowledgeable about rehabilitation-based services for persons with dual diagnoses) to develop this program.

Participative Decision Making

In IST, decisions address changes in how team members behave with consumers and peers. Changing attitudes is not enough; team members must actively decide how the provision of services will change as the result of IST. For example, team members at the Northside Clubhouse started to provide specialized services to address the addiction problems of members. Decision making involves weighing various bits of evidence to guide the direction of behavior change. Evidence is obtained from the opinions of consumers, team members, and others invested in the program. Evidence is also based on direct observation of consumers participating in the program and team members implementing the services.

Participative decision making means the process rests with the individuals charged with carrymg out the program-team members-and the individuals who reap its benefits-consumers. The more decisions that the program committee and rehabilitation team make about their developing program, the more they will have a sense of ownership over it and the easier it will be to implement later. Most program committees include consumer representatives who provide input and feedback at all stages of development and implementation. Eliciting input from team members will probably make the program more fea- sible and acceptable; the feasibility of different elements of the program is ensured by involving the individuals who have responsibility for conducting that part of the program.

To facilitate participative decision making, the IST consultant poses a series of questions to the program committee that guides committee decisions about the targeted intervention program. These questions serve as a framework for building the program and are based on practice standards that have developed out of empirical research. These practice standards are abstracted from treatment manuals and programs that have been extensively researched elsewhere. For example, one standard from the substance abuse field is stages ofchange (sum- marized in Table 1.1). Motivation to give up a substance habit vanes across individuals’ readiness to give up the habit (Prochaska and DiClemente, 1986). Stages of change are useful because they suggest specific interventions that team members might implement to help the person reach sobriety goals. The Northside Clubhouse program committee learned these stages and decided to begin their efforts in program development by focusing on consumers in the first stage- precontemplation. Clubhouse staff struggled with many consumers who did not admit to a substance abuse problem, even in the face of objective evidence.


Table 1.1. Six Stages of Change and Corresponding Interventions Stage Some Matching Interventions

1.

2.

3.

4.

5.

6 .

precontemplation: Person admits to few problems with substance use and has no motivation to stop using.

Contemplation: Person is considering some of the costs of substance use, but is still unwilling to give up the habit.

Determination: Person admits to several problems with substance use and is willing to participate in services to stop use.

Action: Person is actively participating in substance abuse services.

Maintenance: Person has been sober for several months as a result of participating in substance abuse services.

Relapse: Person violates abstinence plan while participating in substance abuse services.

Motivation enhancement therapy Education Confrontation Outreach and case management

Twelve-step programs Skills training Cue extinction Community reinforcement

Relapse prevention

Source: Adapted from Prochaska and DiClemente, 1986

The list of practice standards is by no means a comprehensive review of the principles and skills that make up a particular rehabilitation strategy. Rather, it is a tool to orient rehabilitation team members to the task of developing the intervention; corresponding references are provided for interested team members who wish to read more about the intervention. In the North- side Clubhouse example, practice guidelines suggested a variety of interventions that could help individuals in the precontemplation stage of change, including education (Prochaska and DiClemente, 1986), confrontation (Clancy, 1961; Johnson, 1973), motivation enhancement therapy (Miller and Rollnick, 1991), and outreach (Carey, 1996). The IST consultant taught program committee members the components of each of these interventions as well as the costs and benefits of these interventions for various substance abuse-related problems. Committee members were then assigned as homework the task of selecting a strategy, based on these interventions, that they would integrate into their rehabilitation program.


The program committee is instructed to address homework assignments by consensus; that is, team members must agree among themselves about how issues posed by the IST consultant might be answered. Opinions about the best answers to specific guiding questions are likely to differ among committee members. Differences of opinion are useful; they provide alternative views of how to address the problem. To reach consensus, the program champion should poll committee members about their answers to the specific program question. This may be a spontaneous process in some program committees, especially among groups of staff members with close working relationships, who are at ease with each other and feel free to disagree with colleagues. Some committees, however, may not feel comfortable expressing disagreement. A more formal process is needed in this instance. The champion of the North- side Clubhouse committee, for example, obtained feedback from peers about which intervention (or combination of interventions) would best address the substance abuse problems of its members. Staff agreed that an education program would be relatively easy to develop and many materials supporting “drug classes” could be cheaply obtained.

IST Research and Future Directions

IST developed out of research on education and total quality management. Men- tal health investigators with an interest in dissemination strategies have built on this research by examining the impact of participative decision making and total quality management on program development and consumer outcomes in psychiatric settings (Hunter and Love, 1996; Sluyter and Barnette, 1995).

IST does not rest on prior research alone. The model that supports IST has been tested in several studies. Results have shown that staff identified lack of teamwork, institutional red tape, and burnout as barriers to setting up innova- tive rehabilitation programs (Corrigan, Holmes, and Luchins, 1995; Corrigan and others, 199413; Corrigan, Kwartarini, and Pramana, 1992; Corrigan and others, 1997a; Garman and others, 1997). Subsequent studies have examined components of IST. Research using a dismantling design (in which parts of IST were examined separately) showed that staff reliably identified their priorities in program development (Corrigan and others, 1994a) and that staff agreed about who would make a good champion for program development (Corrigan, Holmes, and Luchins, 1993).

Three studies have examined the direct impact of IST on team members and program participants. One study showed significant reductions in staff burnout and increments in attitudes about program development (Corrigan and others, 1997a). A second study suggested that improvement in team cohe- sion corresponded with more consumer satisfaction with the program (Corri- gan and others, 1997b). A third study had similar results; programmatic behavior of staff, and consumer response to that program, improved signifi- cantly (Corrigan and others, 1995). Like most interventions, IST is a work in progress, a program development package with a good base of empirical sup-


port. Future research should continue to examine the effects of IST on program change, the team who is charged with carrylng out these programs, and the consumers who benefit from their implementation.

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PATIUCK W CORRIGAN is associate professor of psychiatry at the University of Chicago, where he directs the Centerfor Psychiatric Rehabilitation. He is also director and prin- cipal investigator of the lllinois Staff Training Institutefor Psychiatric Rehabilitation.

STANLEY G. MCCRACKEN is associate professor of clinical psychiatry at the University of Chicago and training director at the Center for Psychiatric Rehabilitation. He is also associate director of the Illinois Staff Training Institutefor Psychiatric Rehabilitation.

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An interactive approach to training teams and developing programs