Shifting the Paradigm in Community Mental Health

This was a two and a half year research project funded by the Social Sciences and Humanities Research Council of Canada from 1996 to 1998. I was the Principal Investigator; John Lord was the Co-investigator; and Joanna Ochocka was the Project Manager.

The overall purpose of the research was to understand the experience of change as three community mental health organizations (one which provides support coordination services, one which provides housing and support, and one self-help/mutual aid organization) worked in one community to implement an emerging paradigm emphasizing the values of empowerment and community integration. There were five specific research objectives: (a) to describe the historical and policy context in which the change processes were initiated; (b) to understand how the leaders and founders of the three settings envisioned pathways of change; (c) to develop an understanding of changes in both processes and outcomes; (d) to understand changes at multiple levels of analysis; and (e) to understand changes as experienced by various stakeholder groups.

Operating from a critical, constructivist perspective, we employed a multi-phased, multi-level, multi-stakeholder qualitative, participatory action research approach. The study was conducted in our home community of Kitchener-Waterloo and involved three settings: (a) the Canadian Mental Health Association/Waterloo Region Branch, (b) Waterloo Regional Homes for Mental Health, Inc., and (c) Waterloo Region Self Help. A steering committee was comprised of staff and volunteers from these three settings and met on a monthly basis for the duration of the study to guide the research. Consumer/survivor researchers were hired from the each of the three settings and were trained to implement much of the research by staff from the Centre for Research and Education in Human Services.

The chart below depicts our conceptualization of changing paradigms in mental health. While services have moved from mental hospitals (the medical-institutional model) to community mental health services (community treatment-rehabilitation model), we assert that while the locus of intervention has changed, the underlying paradigm and assumptions about people who have experienced mental health problems have not. A paradigm shift requires a shift in thinking and related modes of practice. We believe that there are three core values/assumptions that indicate a paradigm shift: (a) consumer participation and empowerment, (b) community support and integration, and (c) social justice and access to valued resources. We wanted to find out if the three organizations and the community had made a shift to the emerging paradigm with an emphasis on these three values.

Overall, we found that there was a partial paradigm shift in the values and related practices within community mental health. Most changes occurred in the value of stakeholder participation and empowerment; consumer/survivors actively participated in mental health planning and policy, organization development, and the implementation of services and supports. There were fewer changes in the value of community support and integration; consumer/survivors participated more in self-help/mutual aid and formal services, but there was a great deal of variability in their participation in typical community settings. Some psychiatric consumer/survivors noted changes in the value of social justice and access to valued resources, but many saw little or no change with regard to employment, education, income, and housing.

In terms of the first research objective, we found that there was a distinct shift in the policy context between 1985 and 1994, which coincided with an emphasis on mental health reform. Consumer/survivors and other mental health claims-makers played an active role in shaping mental health policy during this time and influenced the trend of consumer/survivor and family participation and empowerment in the policy and planning process. However, since 1995, the climate has shifted back to a more conservative ideology, and this has been accompanied by the re-emergence of the traditional paradigm in mental health. In terms of the second objective, we found that while each of the three organizations followed its own unique pathways towards change that there were common elements in the journey to shift the paradigm. All of the settings emphasized building an organization based on consensually-defined values and a vision for the future. To bring the vision into being, a participatory management style and high levels of consumer/survivor and family participation were utilized in each of the organizations.

The outcomes that we found in relation to objectives three, four, and five included increased consumer/survivor and family participation and a shift from pre-packaged programs to services and supports that are individualized and consumer/survivor-driven. This was accompanied by increased personal empowerment of consumer/survivors, which included feelings of control, self-esteem, and new skills. A key factor in the personal empowerment process was the role played by peer support and professional support workers, who operate from a strengths perspective. To a lesser extent, there were instances of increased participation in typical community settings, and some consumer/survivors reported that they had obtained jobs, education, and/or better housing. However, poverty and feelings of stigmatization remained problems for many consumer/survivors. Overall, these organizational and personal changes were facilitated by a positive policy climate in the period from 1985 to 1994, as well as by specific organizational and relationship factors.

This research has implications for both policy and practice in community mental health. One of the important lessons from our study is that progress with mental health reform occurs when there is consistency between policy objectives and the perspectives of various advocates and stakeholders. This happened for a short period (1985-1994) in Ontario. In the middle of that era, our study may have been heralded as "influential." By 1996, it was clear that the policy direction in Ontario was shifting away from the emerging paradigm.

We hope that our research will be used in several ways to influence policy and practice. First, the study's positive findings in one community can be used to tell the story of "what is possible" to achieve with mental health reform. Should conditions within the province of Ontario shift back toward the emerging paradigm, our study could be very useful. Second, other communities embarking on the change process will be very interested in the outcomes of the study and can use our findings to assist with their change processes. Third, our own community has been strengthened by this study, as existing organizations used the study to confirm their own directions and to learn from each other. We have learned as a community that provincial policy need not frame all aspects of change. Organizations that want to maintain their innovative approaches will look as much to the people they support and to ideas in the field as they will to provincial policy. All three of the organizations now use the feedback reports that we prepared and key findings for training new staff members. As one of our Research Assistants told us, "if you want a job with our organization [one of the organizations participating in the study], you need to know what paradigm shift means."

During the course of the study, the Senior Researchers and the Steering Committee submitted a brief to the Ontario Health Services Restructuring Commission, which had a mandate to re-structure health services in the province, and to the Ontario Minister of Health. Although the influence of our study's results was minimal, these kind of presentations have continued. The framework of the emerging paradigm will also be of use to other disability groups who advocate for change.

Publications

Nelson, G., Lord, J., & Ochocka, J. (2001). Empowerment and mental health in community: Narratives of psychiatric consumer/survivors. Journal of Community and Applied Social Psychology, 11, 125-142.

Ochocka, J., Janzen, R., & Nelson, G. (2002). Sharing power and knowledge: Professional and mental health consumer/survivor researchers working together in a participatory action research project. Psychiatric Rehabilitation Journal, 25, 379-387.

Ochocka, J., Nelson, G., & Lord, J. (1999). Organizational change towards the empowerment-community integration paradigm in community mental health. Canadian Journal of Community Mental Health, 18(2), 59-72.

Reeve, P., Cornell, S., D'Costa, B., Janzen, R., & Ochocka, J. (2002). From our perspective: Consumer researchers speak about their experience in a community mental health research project. Psychiatric Rehabilitation Journal, 25, 403-408.