Thomas Robinson, Carol Chesley-Harvey, Corri Sachkiw
The North Region Mental Health Support Team (NRMHST) has adopted a consultative approach for services to people with dual diagnoses in the northern interior of British Columbia. This article provides a descriptive overview of this model as applied to a geographically remote and under-resourced region. Key elements of consultation involve an application of both indirect and direct styles matched to fit the interactive needs of clients, service providers, families and their community. Empirically, the model has demonstrable value but there is need for future evaluation of relevant outcome data.
In 1992, the Ministry of Social Services for the province of British Columbia produced a community consultation report that outlined philosophy and directions for services for people with mental handicaps (Ministry of Social Services, 1992). Integral to the spirit of this document was a commitment to values that emphasized individuality and community living (p.5). The philosophical and practical shift to more community-based service delivery systems over the last fifteen years also resulted in the identification of significant gaps for some populations. Individuals with developmental disabilities and diagnosed mental illnesses comprised one population that was at particular risk for falling through the jurisdictional cracks of interministerial services. To prevent this, a Mental Health Challenging Behaviours Delivery System (Ministry of Health and Ministry of Social Services and Housing, 1991) was proposed. A key component of this new system was the creation of five specialized mental health teams which will provide direct support and treatment to individuals with challenging behaviors, and consultation and training to their caregivers (p. 9). This article focuses on one of those teams: the North Region Mental Health Support team (NRMHST) or in its more abbreviated incarnation, the Dual Diagnosis Team. This team began to evolve in its current form in 1995. The following year, the last provincially operated institution for people with mental handicaps, Woodlands, closed its doors. British Columbia became the first Canadian province to accomplish this goal.
The northern interior region of British Columbia covers 691,856 square kilometres with an overall population of approximately 360,000 people. The terrain is mountainous with a proliferation of forests, rivers, and lakes. For tourists, its scenic grandeur is enticing. For those responsible for the delivery of generic or specialized professional services, its remoteness, transportation challenges, and isolated communities can be daunting. A needs assessment (Insight Research, 1992) to determine service requirements in the north was revealing. The following patterns were evident: professionals often followed an outreach rather than community-based model; comparatively limited training, experience and knowledge among professionals; limited access to psychiatrists and psychologists (who were difficult to recruit); underdeveloped or non-existent services for people with developmental disabilities; and minimal consultative based services for families or service providers. The development of the North Region Mental Health Support Team (NRMHST) required an appreciation of existing attitudes and skepticism in most northern communities. There was a lingering perception that most professionals would rotate through their northern sojourn like Christmas shoppers through the revolving door of a big city department store. Outreach to the smaller communities was tainted by the notion that professionals would arrive only to interfere and disappear. The NRMHST determined to adopt a consultative, community-based approach to support individuals with dual diagnoses.
A consultative approach to service delivery can have multiple implications for the design of a model. Finding the best match for consultant skills, the population served whether directly or indirectly, the capabilities of the service provider or family (as consultee) and the historical, political and resource context of the communities served, merited both individual and collective consideration. Consultative strategies or models for diverse populations have been described in the literature. These have included a social-ecological orientation for the severely mentally ill (Santos, Henggeler, Burns, Arana, Meisler, 1995), school based models (Luiselli, 1997) a conjoint family-school approach (Sheridan, 1997), family support models (Clouthier, Fennema, Johnston, Veenendaal, Uldis, 1996; Lubetsky, Mueller, Madden, Walker, Len, 1995) and crisis intervention models (Beasley, Kroll, Sovner, 1992; Davidson, Cain, Sloane-Reeves, Giesow, Quijano, Van Heyningen, Shoham, 1995). Models that are not focused primarily on supporting individuals with dual diagnoses can have transferable standards. However, there are approaches and parameters for the dually diagnosed that can be integral to applying consultative models (Hurley, A.D., Hurley, F., Sovner, 1991: Luiselli, 1997; Lew, Zaslow-Creme, Lepler, 1990; Pulcini and Howard, 1997; Beasley, Kroll, Sovner, 1992; Lubetsky, Mueller, Madden, Walker, Len, 1995; Davidson, Cain, Sloane-Reeves, Giesow, Quijano, Van Heyningen, Shoham, 1995; Shoham-Vardi, Davidson, Cain, Sloane-Reves, Giesow, Quijano, Houser, 1996).
One of the major barriers to effective consultation with services for people with dual diagnoses is the reality that they are usually served in programs which were not designed to meet the needs of individuals with psychiatric disabilities (Hurley, A.M., Hurley, F., Sovner, 1991, p. 75). In northern British Columbia, this is an important consideration with critical implications for how consultants will work with services. In a survey of the perceptions of teachers needs in working with special needs children (Werts, Wolery, Snyder, Caldwell, 1996), three critical factors were identified: i) training, particularly in an individualized manner for children with severe disabilities; ii) professional team support, i.e., consultants offering child specific strategies in a collaborative fashion; and iii) classroom assistance (e.g., aides). In providing services for the dually diagnosed, insufficient training and physical isolation from professional supports are often grim realities for service providers and caregivers. The importance of education and skill training for those delivering direct service cannot be undervalued (Hurley, A.D., Hurley, F., Sovner, 1991; Beasley, Kroll, Sovner, 1992; Lubetsky, Mueller, Madden, Walker, Len, 1995; Davidson, Cain, Sloane-Reeves, Giesow, Quijano, Van Heyningen, Shoham, 1995). Other key elements to consider in a consultative approach for people who have dual diagnoses include: availability of the consultant (Hurley, A.D., Hurley, F., Sovner, 1991), team building and time management skills (Luiselli, 1997), the ability to listen and facilitate problem-solving skills (Lew, Zaslow-Creme, Lepler, 1990) and a collaborative style in bridging services (Pulcini and Howard, 1997).
In northern British Columbia, behavior management skills among service providers are not uncommonly minimal or non-existent. In a review of the intervention literature (Scotti, Ujcich, Weigle, Holland, Kirk, 1996), inconsistent implementation of best practices was notable. In communities where professionals are less conversant with basic standards, there may be opportunities to develop best practice standards, provided there are supports available to do this. Traditionally a consultant shared specialized knowledge with a program indirectly, being external to direct care and supervision (Lew, Zaslow-Creme, Lepler, 1990). Luiselli (1997) confirms this indirect approach to problem-solving for dually diagnosed children in schools. Yet there can be latitude to interface between direct and indirect approaches in some models. Sheridan (1997) advocates a conjoint or collaborative problem-solving process between school professionals and families while Gresham and Lopez (1996) urge accommodation for the influence of social validity. Noell and Witt (1996) in reviewing assumptions underlying behavioural consultation observe that approaches alternative to a direct method merit consideration in some cases. When there is significant skill lacking, Gerald Calan (1970, p. 268) noted that more direct methods may be a better match for consultative interaction. Resource allocation and time factors can justify a less didactic approach to deliver more bang for the buck (Watson and Robinson, 19967). The North Region Mental Health Support Team was faced with choices that would ultimately be determined by geographical, historical, demographic and political factors. A consultants skill and knowledge related to people who have a dual diagnoses would not be the sole determinant of service delivery.
The North Region Mental Health Support Team (NRMHST) Model
The North Region Mental Health Support Team (NRMHST) offers community-based services in specialized assessment, staff/family training, behaviour management and crisis stabilization. Individuals are referred to the Program by Ministry for Children and Families social workers and must meet the following criteria:
be age 14 or older (though exceptions have been made)
meet the DSM IV standards for mental handicap
have a diagnosed mental illness and/or challenging behaviour
In the vast geographical expanse of the north, the NRMHST is comprised of a full-time Team Coordinator, one full-time, and six part-time consultants. All consultants are based in one of the communities they serve. Their experience and professional orientation comprises nursing, psychology, addictions and behaviour management. Although there is a preventive focus, there can also be a crisis intervention aspect. Augmenting the Team are crisis stabilization funds, most often used to supplement existing service provider resources on an emergency basis and a psychologist, familiar with the Region, who can be accessed to conduct psycho-educational assessments.
The NRMHST approach to consultation involves a blend of direct and indirect intervention. There is a recognition that communities can be as variable and idiosyncratic as individuals. Assessing service provider, client, family and community needs often requires a holistic framework because it is the dynamics of their interaction that best determines what the consultant will do. Consultative goals are best viewed as part of a continuum with three interactive components (Figure 1).
1) Contact with Person who has a Dual Diagnosis
This is the level of involvement that compels either a direct or indirect consultative interaction. Determining this will often be directly relative to the skill of the service provider or family member. The data collected may be insufficient in providing an accurate clinical understanding of the individual with a dual diagnosis thus compromising an indirect approach. Observation may supplement this, but it too may be inadequate. The consultee may benefit more from having the consultant directly interact with the client to model specific techniques or strategies. At the highest level of engagement the client or advocate is truly participative with service providers and caregivers, though the consultant will phase out, becoming more indirect.
2) Consultee Interaction
In northern British Columbia, in several isolated communities, service providers may have adopted a more custodial approach to working with clients, often being very nurturing in their style but severely tested by behavioural or mental health issues. Their initial contact with the consultant may be in response to crisis. This can open a window of opportunity for later skill acquisition across a spectrum of areas. As this develops, the consultant needs to be available, building trust and offering ongoing training. It is important to set a pace that matches the consultees needs and parallels their interests. Ultimately, service providers will endeavour to be proactive in their strategies, preventing crises and relegating the consultant to a more indirect relationship.
3) Community Development
The communities served by the NRMHST vary in population and have the common perception that distance and climate can impose daunting conditions for the delivery of any service. The influence of First Nations culture is an important consideration in many locations, having significant implications in serving individuals with dual diagnoses. In Aneshenewe Machitawin (Sainnawap, Winter, and Eprile, 1993, p. 12) these converging elements were projected constructively by noting community-based community development, simply put, means people doing something about their own needs. The reality of geographical isolation and the risk of crippling dependence requires a broader outlook which has implications for any consultative approach. This is exemplified by the following: Community Development recognizes an organizational and political need to involve the interested population and move beyond consultation to participation (Ontario Prevention Clearinghouse, 1992, p. 6).
Community response to crisis in many small communities can be a heartening encounter but being able to analyze the roots of the crisis and plan in a preventive manner is a skill that needs to be learned. In the NRMHST model, the consultant may be the active facilitator of a multi-disciplinary team formed to support the individual with a dual diagnosis. This cannot be an end in itself, for the community that a person lives in cannot be viewed as static. Phares (1988, p. 501) noted, In a world short of mental health personnel, the basic advantage of consultation is that its effects are multiplied like the ripples from a stone thrown into a pond. These are the ripples that enable community development to have meaningful and lingering effect.
4) The Consultative Interaction
In utilizing the flexibility to respond to a dually diagnosed persons needs along a continuum, the NRMHST consultant must be cognizant of the convergence of multiple influences. Schwartz and Baer (1991, p. 207) presented a model that identified four consumer groups. Figure 2 is an adaptation of this view for the individual with a dual diagnosis. In this pictorial representation, indirect and direct consultation blend with community development and goals. The consultant is central to this interaction.
This article has empirically, even subjectively outlined the consultative approach of the North Region Mental Health Support Team in working with the dually diagnosed in northern British Columbia. The development of this Team remains embryonic, thus allowing much potential for future research related to outcome data in implementing this model. There is opportunity to compare approaches and outcomes with the other mental health support teams in the province, perhaps permitting a more thorough understanding of community development distinctions in more populated and resource-rich regions. Demographic comparisons within the north may also be illuminating as would comparative data in respect to crisis intervention.
The NRMHST model of consultation is an eclectic blend of direct and indirect intervention matched to the needs of its distinctive population and geography. The stereotype of the rugged individual thriving in the far north still persists. Individuality has its value but in developing effective services for the dually diagnosed through a consultative approach, interdependence has much more appeal. It is the consultant who can be instrumental in making this happen.
Beasley, J., Kroll, J., & Sovner, R. (1992). Community-based crisis mental health services for persons with developmental disabilities: The S.T.A.R.T. model. The Habilitative Mental Healthcare Newsletter, 11, 55-58.
Caplan, G. (1970). The theory and practice of mental health consultation. New York: Basic Books.
Clouthier, K., Fennema, D., Johnston, V., Veenendaal, J., & Uldis, V. (1996). Expanding the influence of a single-session consultation program. Journal of Systemic Therapies, 15, 1-11.
Davidson, P., Cain, N., Sloane-Reeves, J., Giesow, J., Quijano, L., VanHeyningen, J., & Shoham, I. (1995). Crisis intervention for community-based individuals with developmental disabilities and behavioral and psychiatric disorders. Mental Retardation, 33, 21-30.
Gresham, F. M., & Lopez, M. F. (1996). Social validation: A unifying concept for school-based consultation research and practice. School Psychology Quarterly, 11, 204-227.
Hurley, A. D., Hurley, F., & Sovner, R. (1991). Training staff to integrate educational and therapeutic approaches for the client with developmental and psychiatric disabilities. The Habilitative Mental Healthcare Newsletter, 10, 75-77.
Insight Research. (1992). A needs analysis for mentally handicapped persons who suffer from a mental illness or who exhibit challenging behaviour in the north region of BC (Issued to British Columbia Mental Health Society). Salmon Arm, BC: Author.
Lew, M., Zaslow-Creme, B., & Lepler, S. (1990). Effective consultation with community programs. The Habilitative Mental Healthcare Newsletter, 9, 65-69.
Lubetsky, M. J., Mueller, L., Madden, K., Walker, R., & Len, D. (1995). Family-centered/interdisciplinary team approach to working with families of children who have mental retardation. Mental Retardation, 33, 251-256
Luiselli, J. K. (1997). Behavioural consultation in school-based consultation for children with developmental disabilities. The Habilitative Mental Healthcare Newsletter, 16, 22-26.
Ministry of Health and Ministry of Social Services and Housing. (1991). Planning for the future: A proposal for services for people with mental handicaps. Victoria: Government of British Columbia.
Ministry of Social Services. (1992). Common themes and future directions: A community consultation report on the review of training and support services to adults with mental handicaps. Victoria: Government of British Columbia.
Noell, G. H., & Witt, J. C. (1996). A critical evaluation of five fundamental assumptions underlying behavioral consultation. School Psychology Quarterly, 11, 189-203.
Ontario Prevention Clearinghouse. (1992). Community development resource package. Toronto: Government of Ontario.
Phares, J. E. (1988). Community psychology. In J. E. Phares (Ed.), Clinical psychology: Concepts, methods and profession. CA: Brooks/Cole.
Pulcini, J., & Howard, A. M. (1997). Framework for analyzing health care models serving adults with mental retardation and other developmental disabilities. Mental Retardation, 35, 209-217
Sainnawap, B., Winter, N., & Eprile, P. (1993). Aneshenewe machitawin: Human centred community development. Toronto: Participatory Research Group.
Santos, A. B., Henggeler, S. W., Burns, B. J., Arana, G. W., & Meisler, N. (1995). Research on field-based services: Models for reform in the delivery of mental health care to populations with complex clinical problems. American Journal of Psychiatry, 152, 1111-1123.
Schwartz, I., & Baer, D. (1991). Social validity assessment: Is current practise state of the art? Journal of Applied Behaviour Analysis, 24, 189-204.
Scotti, V. R., Ujcich, K. J., Weigle, K. L., Holland, C. M., & Kirk, K. S. (1996). Interventions with challenging behavior of persons with developmental disabilities: A review of current research practices. Journal of the Association for Persons with Severe Handicaps, 21, 123-134
Sheridan, S. M. (1997). Conceptual and empirical bases of conjoint behavioral consultation. School Psychology Quarterly, 12, 119-133.
Shoham-Vardi, I., Davidson, P. W., Cain, N. N., Sloane-Reves, J. E., Giesow, J. E., Quijano, L. E., & Houser, K. D. (1996). Factors predicting re-referral following crisis intervention for community-based persons with developmental disabilities and psychiatric disorders. American Journal on Mental Retardation, 101, 109-117.
Watson, T. S., & Robinson, S. L. (1996). Direct behavioral consultation: An alternative to traditional behavioral consultation. School Psychology Quarterly, 11, 267-278.
Werts, M. G., Wolery, M., Snyder, E. D., & Caldwell, N. K. (1996). Teachers perceptions of the supports critical to the success of inclusion programs. Journal of the Association for Persons with Severe Handicaps, 21, 9-21.
For more information contact:
Thomas A. Robinson, BA
Professional Support Services
C-19 Site 6 SS#1
Houston, BC V0J 1Z0