Moving Forward, Together: Keep Change Sustainable, Step 2—Strengthen Relationships
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Moving Forward, Together:
Keep Change Sustainable: Step 2—Strengthen Relationships
“Boundary” or role conflicts are commonly cited concerns when involving people with experiences of homelessness in agency service delivery (Carlson & McDiarmid, 1999; Carlson, Rapp, & McDiarmid, 2001; “Consumer Practitioners in PATH-Funded Programs,” 2006; Fisk, Rowe, Brooks, & Gildersleeve, 2000). However, there is a lack of consensus on how to address those issues. Boundary conflicts seem to develop most often, although not exclusively, in the context of involving consumers in agencies where they currently receive services (Carlson et al., 2001).
The issues raised and strategies suggested to address “boundary conflicts” or “multiple relationships” fall into many categories: confidentiality; support and supervision; recruitment; training; and policy adaptation. The conflicts that arise are similar to those referred to in the organizational literature over the last 20 years under the concept of boundary spanning (Freidman & Podolny, 1992; Steadman, 1992). A definition of boundary spanner is people in positions, “linking two or more systems whose goals and expectations are at least partially conflicting” (Steadman, 1992). While the concept of boundary spanners has general application in the context of system integration (Noreus, 2006; Steadman, 1992), labor (Friedman & Podolny, 1992), and marketing (Stock, 2006), the parallel is also worth exploration in the context of consumer integration. Friedman and Podolny (1992) note that stress can result from role ambiguity arising from interactions with groups that do not share the same interests, values, and expectations. The stress emanates from difficulty figuring out how to meet conflicting expectations of both groups.
• Ensure that each person involved in the agency understands that work and treatment are separate. Develop clear agency policies with language addressing confidentiality protections for consumer-employees and prohibiting supervisors and treatment providers from sharing information.
• Avoid having consumers provide direct services to people with whom they have prior relationships (Fisk et al., 2000; Carlson et al., 2001).
• Openly address potential conflicts regarding multiple relationships.
• Consider recruiting consumers receiving their services from other agencies.
• Allow a certain amount of time to elapse after consumers terminate services at the agency before considering them as candidates for involvement within the same agency.
• If the agency is large enough, consider recruiting consumers from departments other than where they receive services.
• Support consumers to continue using their natural support systems.
• Provide clear guidance regarding confidentiality, boundaries, and role expectations.
• Develop written policies addressing confidentiality standards. A sample policy might read, “Private and confidential information obtained from friends in the community who are current recipients of services is confidential unless the information indicates the person meets the threshold for mandated reporting” (generally that the person poses a threat to themselves or others).A. Encourage Peer Support and Mentoring
Challenges can arise for people making the transition from a person who receives services to being a provider of services (Barrow, Tsemberis, McMullin, & Tripp, 2007; Chinman, Lam, Davidson, & Rosenheck, 2000; Fisher, 1994; Mowbray, Moxley, & Collinse, 1998; Mowbray, Robinson, & Holter, 2002; Van Tosh, 1993). This cultural shift may cause some consumers to become uneasy and question their own identities. The process of role transition may involve learning a new “language,” understanding the dress code, behaviors, expectations, and generally orienting to new ways of being within an organizational culture. One of the ways to assist people in maintaining their identities while making the transition is to encourage peer support and mentoring.
• Provide on-site, peer-led groups to allow consumers to talk about the benefits, challenges, and questions they have regarding role transition. This process encourages consumers to meet one another and offers access to peer supervision and guidance.
• Consider having consumers mentor each other. One way to achieve this mentorship is through cosupervision, defined as supervision plus peer support. One largely consumer-run agency commented on the success of the strategy to have more seasoned personnel mentor new staff members. They provided one-on-one attention for a sustained period, combining on-the-job training with peer support.
• Peers who are familiar with the agency environment and the various roles within the organization can be supportive as role coaches. Coaching can be a valuable way for consumers to get feedback and gain confidence with their roles, and augment their skills in preparation for advancement.
• Encourage consumers to hold meetings off-site on their own time. Sometimes meeting outside the agency helps define clear boundaries. Meeting in a community setting can provide opportunities to include peers from other agencies and organizations.B. Provide Recovery-Oriented Supervision for Consumer Providers
In our conversations with PATH providers, building trust and providing flexible, open, and clear lines of communication between consumer practitioners and supervisors were repeatedly mentioned protective factors. Supervisors reiterated the importance of keeping an open dialogue with consumer providers about personal limits and needs. Maintaining high levels of trust allowed consumers to be honest about difficulties they might have early in the process, and to advocate proactively for the conditions facilitating the greatest job productivity. Providers reported that allowing staff some flexibility in their work schedules if necessary to care for themselves and their families boosted morale.
It is equally important to ensure that supervisors fully embrace and endorse the principles of being trauma-informed and recovery-oriented. Since it is not possible to have every supervisor of a consumer provider be a peer, there needs to be a safe manner to monitor the relationship and support consumer providers. Dr. Dan Fisher relates a situation illustrating this point. The director of a day treatment program at one point authorized a consumer staff member (“Carla”) request to take a break during the afternoon. Carla’s immediate supervisor severely criticized her and further stated that Carla’s experiences as a consumer predisposed her to being overly sympathetic with others in the program. As the medical director, Dr. Fisher mediated and found Carla a new supervisor whose values were more recovery-oriented (D. Fisher, personal communication, August 3, 2007).
• Offer Employee Assistance Programs (EAP). For various reasons, consumer providers may not feel comfortable speaking with a supervisor about every job-related challenge. When there are problems, supervisors can offer EAP options to assure staff people they have access to support options that maintain privacy.C. Provide Opportunities for People to Build Skills and Advance
The U.S. Department of Labor found that lack of education and competitive work skills were two of the biggest barriers to employment for people who are homeless (National Coalition for the Homeless, 2006). Whether consumer roles are volunteer or paid, part-time or full-time, they should include opportunities to build skills for advancement.
• Create linkages with local colleges or universities. One agency developed a formal relationship with a university to provide a peer-specialist institute for its staff members to provide access to training opportunities. The agency hired consumers who completed the institute and other course work credentialing them for agency positions. Because they graduated from the training program, there was a higher likelihood of successful assimilation into the agency.
• Develop “stepping-stone” positions. Albuquerque Health Care for the Homeless expressed commitment to increasing consumer participation on its board of directors to 51 percent; so far, the agency achieved 21 percent, with the aim of reaching the goal over the next 5 years. One concrete strategy the agency uses is development of a “Client Board Advisory Committee” led by two consumer members to help prospective consumer board members develop the skills they need to serve on the board. One California agency’s “Occupational Trainee/Peer Navigator” program provides part-time employment for 2 years, during which consumers can learn job skills to move on to positions of greater responsibility.
• Encourage peer-to-peer mentoring. Programs and agencies can encourage skill building and sharing through the creation of peer-to-peer mentorship programs. The Albuquerque Health Care for the Homeless Art Street Program developed a rotating group of mentors who act as studio assistants and receive a stipend for their work.D. Team Building
Team development activities can provide opportunities for staff to learn from one another in formal and informal settings. There are a number of team-building strategies implemented in programs designed to unify staff, build stronger working relationships, increase staff retention, avoid burnout, and simply have fun:
• Unify staff through innovative team-building approaches.
• Hold meetings in a variety of settings (in parks, local coffee shops, etc.).
• Plan fun team-building activities (such as wilderness courses, scavenger hunts, etc.).
• Address stress management; providers suggested connecting with community resources to do mediation, yoga, and exercise in the agency.
• Take time away from service delivery to rejuvenate and meet as a team. One agency shuts down for a week each year to provide staff with in-house training and team-building activities.References
Barrow, S., Tsemberis, S., McMullin, L., & Tripp, J. (2007, March). Consumer integration and self-determination in homelessness research, policy, planning and services. Paper presented at 2007 National Symposium on Homelessness Research, Washington, DC.
Carlson, L., & McDiarmid, L. (1999). Consumers as providers of mental health services: A literature review and summary of strategies to address barriers. Lawrence, KS: University of Kansas, School of Social Welfare.
Carlson, L., Rapp, C., & McDiarmid, D. (2001). Hiring consumer-providers: Barriers and alternative solutions. Community Mental Health Journal, 37(3), 199–213.
Chinman, M. J., Lam, J. A., Davidson, L., & Rosenheck, R. (2000). Comparing the effectiveness of consumer and non-consumer provided case management services for homeless persons with serious mental illness. Journal of Nervous and Mental Disease, 188(7), 446–453.
Consumer practitioners in PATH-funded programs: Report of the Consumer Involvement Workgroup (2006). Retrieved September 5, 2007 from http://pathprogramarchive.samhsa.gov/pdf/ConsumerWorkgroupReport_706.pdf
Fisher, D. B. (1994). A new vision of healing as constructed by people with psychiatric disabilities working as mental health providers. Psychosocial Rehabilitation Journal, 17(3), 67–81.
Fisk, D., Rowe, M., Brooks, R., & Gildersleeve, D. (2000). Integrating consumer staff into a homeless outreach project: Critical issues and strategies. Psychiatric Rehabilitation Journal, 23(3), 244–252.
Friedman, R. A., & Podolny, J. (1992). Differentiation of boundary spanning roles: Labor negotiations and implications for role conflict. Administrative Science Quarterly, 37(1), 28–47.
Glasser, N. (1999). Giving voice to homeless people in policy, practice, and research. In L. B. Fosburg & D. L. Dennis (Eds.), Practical lessons: The 1998 National Symposium on Homelessness Research. Rockville, MD: U.S. Department of Housing and Urban Development and the U.S. Department of Health and Human Services.
Mowbray, C. T., Moxley, D. P., & Collinse, M. E. (1998). Consumers as mental health providers: First-person accounts of benefits and limitations. Journal of Behavioral Services and Research, 25(4), 397–411.
Mowbray, C. T., Robinson, E. A. R., & Holter, M. C. (2002). Consumer drop-in centers: Operations, services and consumer involvement. Health and Social Work, 27(4), 248–261.
National Coalition for the Homeless. (2006, June). Employment and homelessness (NCH Fact Sheet No. 4). Washington, DC: Author.
Noreus, B. (2006, January). Boundary spanners. Maine Criminal Justice /Mental Health Briefs (Brief #2). Retrieved September 5, 2007 from http://muskie.usm.maine.edu/justiceresearch
Prescott, L. (2001). Consumer/survivor/recovering women: Partnerships in collaboration. Retrieved August 20, 2007 from Policy Research Associates http://www.prainc.com/wcdvs/pdfs/CSR%20Manual%20Final.pdf
Steadman, H. J. (1992). Boundary spanners: A key component for the effective interactions of the justice and mental health systems. Law and Human Behavior, 16(1), 75–87.
Stock, R. M. (2006). Interorganizational teams as boundary spanners between supplier and customer companies. Journal of the Academy of Marketing Science, 34 (4), 588–599.
Van Tosh, L. (1993). Working for a change: Employment of consumers/survivors in the design and provision of services for persons who are homeless and mentally disabled. Rockville, MD: Center for Mental Health Services, Substance Abuse and Mental Health Services Administration.
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