Mental health center versus community perceptions of mental health services

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  • 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 impor- tance 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 Carolinas 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 com- missioners and mental health board members ( n = 13), mental health program ad- ministrators ( 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 impor- tance. 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 impor- tant. 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 psy- chotherapy at or above the criterion level. The clinicians were clinically conservative. Clerical staff identified school consultation for emotional problems and individual psy- chotherapy 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) ser- vices 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.

  • MENTAL HEALTH CENTER 207

    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 con- sultation 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 ad- ministrators. 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 ad- ministrators 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 ad- ministrators 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 ser- vices 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 con- sumers 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

    .

  • MENTAL HEALTH CENTER 209

    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 impor- tance. 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...

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