Mental health center versus community perceptions of mental health services

Journal of Communrry P3ycholog.v. 1981. 9, 204-209.

MENTAL HEALTH CENTER VERSUS COMMUNITY PERCEPTIONS OF MENTAL HEALTH SERVICES*

FRANCIS f. MILLER

University of North Carolina. Chapel Hill

A list of 53 mental health programs and services was presented to community samples of county commissioners and mental health board members, mental health program administrators, mental health clinicians, mental health clerical staff, clients, general public, staff of agencies related to mental health, and staff of community agencies not so related with a request to (a) indicate which programs and services were being offered by the mental health agencies of the catchment area, (b) indicate the relative importance of each offered service, and (c) indicate the relative importance for future program development of those not currently offered. Accuracy of program identifica- tion is noted and intergroup perceptions of mental health programs and services are compared.

Consensus between service providers and potential recipients regarding the importance of those services is of crucial importance to the development and maintenance of effective mental health services. In the final analysis, the degree of fit between the professional and community judgments may profoundly affect the degree of political and fiscal support for the mental health program within the local community. Mental health professionals and the citizen boards who, in concert, determine the nature and extent of services to be offered may asume that their decisions and priorities reflect the needs and priorities of their constituents. However, these groups often do not test this assumption. This paper describes one relatively inexpensive method to test the degree of consensus and reports the results of that test in one mental health catchment area.

METHOD The Community Psychiatry Division of the University of North Carolina’s Depart-

ment of Psychiatry was invited to plan and carry out an extensive program review of mental health services for a population of 77,240 persons in a two-county rural mental health catchment area. This study is part of that review.

Instrument development. In preparation for the review, a 3 X 3 X 2 human services planning model was presented to a group of 70 mental health professionals attending a consultation, education, and prevention workshop sponsored by the University of North Carolina with a request to list mental health programs and services. The dimensions of the model were: (a) service strategies (interventions into life adjustments, life crises, and life conditions), (b) orientation of service (reactive or proactive; offered in response to or in anticipation of a need), and (c) target groups (individuals, families and/or small groups, and communities). Respondents were asked to list in each of the 18 cells of the model, programs and services that met the requirements of each. A list of 45 programs and services resulted (examples are in Table I ) . These programs and services might or might not exist in a given catchment area. To that list were added eight known to exist in the catchment area under study. The final list of 53 was randomly ordered and cast into a form for rating.

*Send reprint requests lo author, Department of Psychology, School of Medicine, The University of North Carolina. Chapel Hill, N.C. 27514.

204

MENTAL HEALTH CENTER 205

Samples. It was decided to interview exhaustive community samples of county commissioners and mental health board members ( n = 13), mental health program administrators ( n = 7), clinical staff (n = IS), clerical staff ( n = lo), and either random or samples of convenience of clients (n = 1 IS), staff of community agencies directly related to mental health (director plus one other) (n = 46). staff of agencies not so related ( n = 26), and the general public (n = 66).

Procedure. The list of 53 programs and services was presented to each respondent individually. Each was asked (a) to indicate which programs existed in the catchment area; (b) to rate the importance of each that exist; and (c) to designate which should be included in future program development. Importance was rated on a four-point scale from 1 = “low” to 4 = “very.” The results of each rater group were compared to those of other groups.

RESULTS As one might expect, respondents having greatest direct contact with the programs

and services of the mental health center most accurately identified which programs and services were offered (criterion was a list generated by the Center Director). Clinical staff correctly identified 84% of the list of 53 as offered. Clerical staff correctly identified 73%. The general public sample correctly identified 45%.

Each respondent indicating the existence of a program was asked to rate its importance. Mean ratings ranged between 3 and 4 on the four-point scale. Most respondents felt that most programs were “moderately” to “very” important in meeting the mental health needs of the catchment area. Services offered to individuals were considered most important and services offered to the community-at-large were considered least important. Services offered reactively (after the development of a problem) were rated more important than those of a preventive nature offered proactively. Greatest importance was ascribed to programs and services by professional staff of agencies not directly related to mental health. Least importance was ascribed by the clinical staff of the mental health program. Community professionals having least direct contact with mental health programs and services see those programs and services as more important than clinicians delivering the services.

Programs and services with a mean rating of 3.75 or greater were considered as most important. One group or another rated 24 of the original list of 53 services at or higher than criterion (see Table I). Clinical staff rated only individual and family psychotherapy at or above the criterion level. The clinicians were clinically conservative. Clerical staff identified school consultation for emotional problems and individual psychotherapy as most important. Clinical administrators offered a broader list of nine “most important” services. Those were primarily direct services.

Clients considered eight programs and services in the most important range. They agreed with staff on the importance of individual and family psychotherapy. They also placed a high value on crisis-oriented services. A different picture is obtained when we consider the ratings of the general public sample which identified even more ( n = 9) services as most important. Four of those nine are the same as those identified by mental health staff. However, the agreement is with the ratings of administrators. There are no matches between the general public and the priority ratings of clinical and clerical staffs.

Some validation of a “public servant” concept is found in comparing the ratings of the commissioner/board group to the others. They have some agreement with their con- stituencies. They named four programs and services most important. Two of those agree

TAB

LE 1

M

enta

l H

ealth

Ser

vice

s Ra

ted

Mos

t Im

porta

nt Rat

ers

Com

mis

sion

ers

Clin

ical

C

leric

al

Gen

eral

R

elat

ed

Non

rela

ted

Serv

ices

Rat

ed

and

Boa

rd

Adm

inis

trato

rs

Staf

f St

aff

Clie

nts

Publ

ic

Age

ncie

s A

genc

ies

Mos

t Im

port

ant

(n =

13)

(n

= 7

) (n

= 1

5)

(n =

10)

(n

= 1

15)

(n =

66)

(n =

46)

(n =

28)

N

0

QI

Indi

vidu

al R

ycho

ther

apy

Afte

rcar

e H

alfw

ay House

Hos

pita

lizat

ion

for

Emot

iona

l Pro

blem

s D

rug

Abu

se C

linic

C

risis

Inte

rven

tion

Cou

nsel

ing

Fost

er H

ome

Plac

emen

t Tr

aini

ng P

rogr

am fo

r H

andi

capp

ed

M-R

Res

iden

tial P

rogr

am

Day

-car

e fo

r the

Ret

arde

d R

esoc

ializ

atio

n Pr

ogra

m

Men

tal H

ealth

Dia

gnos

tic S

cree

ning

Pe

er G

roup

Cou

nsel

ing

for T

eena

gers

C

ase

Con

sulta

tion

to R

elat

ed P

rofe

ssio

nals

H

ot L

ines

Su

icid

e Pr

even

tion

Prog

ram

Sc

hool

Con

sulta

tion

for

Emot

iona

l Pro

blem

s Sc

hool

Con

sulta

tion

for

Ret

arda

tion

and

Lear

ning

Pro

blem

s Fa

mily

Psy

chot

hera

py

Mar

riage

Cou

nsel

ing

Gro

up P

sych

othe

rapy

Pa

rtial

Hos

pita

lizat

ion

Cou

nsel

ing

for

Fam

ilies

of

Ret

arde

d G

roup

Wor

k w

ith S

cout

s, “Y,”

etc.

X

X

X

X

X

X

X

X

X

X

X

X

X

X

X

X

X

X

X

X

X

X

X

X

X

X

X

X

X

X

X

X

X

X

X

X

X

X

X

X

X

X

X

X

X

X

X

X

X

X

X

X

X

X

X

n

s 2 c! v)

-1 P r r rn s

X =

hig

her

than

3.7

5.


with the priorities of the client sample; three agree with the general public; none are the same as those rated most important by administrators or clinical staff.

Finally, it is useful to contrast the views of the governance and program staff groups to those of collateral service provider agencies in the catchment area. Only school consultation for emotional problems rated high by the commissioner/board group matched the eight so rated by staff of mental-health-related agencies. The match between ratings of mental health administrators and the ratings of people in related agencies was more congruent. For them, there was agreement on five services. Clinical and clerical staff were in agreement with them only on the importance of individual psychotherapy.

The major result of this portion of the study was that there was 46% agreement between the client and general public groups and the mental health program administrators. There was agreement only on individual psychotherapy when ratings of the consumer groups are contrasted to clinical and clerical staff ratings. Also, there seemed to be a high degree of consensus between governance and program staff. At least in this one catchment area, the degree of fit between service delivery staff and groups of signifi- cant others was not remarkably high and the degree of fit in the ratings of the administrators and front-line staff was not high. One might hypothesize either that someone was not listening or that someone was not educating or both. The clinical administrators as an interface group between the front-line providers and the community may need to reexamine that interface role.

The list of programs and services used for securing ratings of importance was presented with a request that respondents indicate which were needed for future program development and then to rate on a four-point scale the need for those so designated. Table 2 lists those rated at 3.0 or greater by one or more groups of raters. Sixteen services met that criterion. Services directed to the community at large (public education, drug information, etc.) were rated highest. As with ratings of program importance, there is congruence between the commissioner/board group and potential consumers but not between that group and center staff. Commissioner/board members and potential consumers agreed on the importance of detoxification programs and rape counseling for future development. The governance bodies did not place as high a priority on child abuse and neglect programs or on counseling programs for runaways as did potential consumer groups. Consumers wanted many more programs than the providers wanted. The voice of budgetary reality may play a part in that difference; however, data from a national survey of mental health centers suggest a low relationship between members and range of programs offered and the size of center budgets (Miller et al., 1978).

The two programs receiving highest priority by clinic staff-life milestones programs and family crisis police teams-were not so rated by consumers (clients, general public, and related agencies) and were not so rated by the governance group. Similarly, three of the four services considered most important for future development by three or more of the consumer groups were not rated at criterion level by the providers. The need for cross-education between the groups, thus, is futher underscored if consensus is to be a goal for determining program development.

D l s c u s s l o N

It was clear from this study that the mental health program under study was not in a consensus relationship with its catchment area regarding program priorities for either current or future services. In each case, there was more agreement within the public groups (commissioners/board, general public, clients, and related agencies) and within

N 0

00

TAB

LE 2

M

enta

l H

ealth

Ser

vice

s R

ated

Hig

hest

For

Nee

d Fo

r Fu

ture

Dev

elop

men

t -

__

__

__

__

__

__

__

_~

.

__

R

ater

s

Services R

ated

M

ost N

eede

d

Com

mis

sion

ers

Clin

ical

C

leric

al

Gen

eral

R

elat

ed

Non

rela

trd

and

Boa

rd

Adm

inis

trato

rs

Staf

f St

aff

Clie

nts

Publ

ic

Age

ncie

s A

genc

ies

(n =

13)

(n

= 7)

(n =

15)

(n

= 1

0)

(n =

115

) (n

= 6

6)

(11

= 4

6)

(n =

28)

~ Rem

edia

l Ed

ucat

ion

Chi

ld A

buse

and

Neg

lect

Pro

gram

Det

oxifi

catio

n Pr

ogra

m

Abo

rtio

n C

ouns

elin

g R

ape

Cou

nsel

ing

Run

away

Cou

nsel

ing

Birt

h C

ontr

ol C

ouns

elin

g

Life

Mile

ston

es P

rogr

ams

Chi

ld a

nd M

othe

r Car

e G

roup

s

Pare

nt E

ffec

tiven

ess T

rain

ing

Fam

ily L

ife W

orks

hops

Fam

ily C

risis

Pol

ice

Team

s

M.H. Ed

ucat

ion

“Kit”

Wor

ksho

ps

Prep

arat

ion

for

Pare

ntin

g

X

X

X

X

X

X

X

X

X

X

X

X

X

X

X

X

X

X

X

Dru

g In

form

atio

n G

roup

s X

X

X

Publ

ic I

nfor

mat

ion

Gro

ups

X

X

X

x =

hig

her

than

3.00

.


staff groups (administrators, clinical staff, administrative staff) than between the two sets of groups.

The programs and services identified as existing in the catchment area were generally rated as important. However, there were differences in the extent of importance. The differences were similar to those of Bentz et al. (1971, 1975) who found low citizen-professional agreement on mental health programs. The citizenry in all three studies placed their priorities differently from the mental health professionals. There is a question of who was not listening to whom. Was it that mental health professionals in the catchment area were not exerting enough effort to educate the public or was it that the professional community was not listening sufficiently to what people in the community were saying is important to them-or both?

While one cannot generalize from this single study, the mental health center described there seems typical of many others. It was a good program, its staff worked hard and there was financial support from the community for the agency. The staff was well-trained in usual mental health techniques but not well-trained in prevention, organizational, and program techniques, and community organization skills which might be required for further development of priority programs identified by community con- stituencies. There was also little investment of time and energy in assessing the needs of the community and there was little investment of time and energy in educating the community about programs and services which exist. We wonder what the long-term effects of these differences might be.

REFERENCES BENTZ, W. K.. EDGERTON, J. W., & MILLER. F. T.

ness. Menial Hygiene, 1971, 55, 324-330. BENT%, W. K. , & DAVIS, A.

and the general public. American Journal of Public Health, 1975, 67, 129-132. MILI.ER, F. T., MAZADE, N. A, , MCLI.ER, S., & ANDRLXIS, D.

American Journal of Community Psychology, 1978, 61. 191-198.

Attitudes of teachers and the public toward mental il l-

Perceptions of emotional disorder among children as viewed by leaders, teachers,

Trends in mental health programming.

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Mental health center versus community perceptions of mental health services