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What Transformation? A Qualitative Study of Empowering Settings and Community Mental Health Organizations

What Transformation? A Qualitative Study of Empowering Settings and Community Mental Health Organizations by  Maria F. Jorge-Monteiro, Rita Aguiar, Beatrice Sacchetto, Maria J. Vargas-Moniz, and José H. Ornelas

Author: Maria F. Jorge-Monteiro, Rita Aguiar, Beatrice Sacchetto, Maria J. Vargas-Moniz, and José H. Ornelas

Abstract:

Maria F. Jorge-Monteiro, Rita Aguiar, Beatrice Sacchetto, Maria J. Vargas-Moniz, and José H. Ornelas

This article is based on empowering settings research and has a two-fold objective: to  propose an adaptation of the empowering community settings framework to community mental health organizations practice to foster recovery and community integration; and to discuss how the adapted framework is a relevant tool to challenge community mental health transformation at multiple levels of analysis. The current study was anchored in a larger qualitative research project. It used a case study approach, with 8 in-depth interviews with diverse participants from one community mental health organization. The adapted model proved useful to guide transformational practice in community mental health programs and for evaluation of organizational empowerment and multilevel community-oriented interventions. Suggestions and implications for future research are also presented.


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Introduction
Presently, mental health and rehabilitation programs in the community still follow institutional-medical intervention approaches that perpetuate the separation of people who experience mental illness, from the rest of the population. Striving for the development of organizational models that facilitate improvements in community mental health programs, the present study is based on empowerment/community-oriented approaches that challenge structures and processes within mental health programs (Nelson, Lord, & Ochocka, 2001a, 2001b; Ornelas, Duarte, & Jorge-Monteiro, in press).

Research findings indicate that psychological empowerment processes tend to unfold as individuals participate in empowering community settings (Aber, Maton, & Seidman, 2011; Christens, Peterson, & Speer, 2011; Rappaport, 1981). Therefore, community mental health organizations (CMHO) may be conceptualized as mediating social structures where individuals can be exposed to empowering relational processes (Christens, 2012; Maton & Salem, 1995; Nelson, et al., 2001a).

Trickett (2011) emphasized the setting as a goal-focused community resource where people share stories, gather opportunities for personal growth, participation and access to organizational goods. In that sense, a setting is itself a resource for empowerment. Relational environments may also be considered as a process of co-empowerment characterized by mutual learning and influence (Bond & Keys, 1993; Rappaport, 1987).

The present study was informed by the empowering community settings (ECS) framework presented by Maton (2008), which encompasses organizational characteristics, psychological mediators and organizational dimensions that impact individual development and community betterment domains. The ECS model includes six organizational factors: 1) a group-based belief system that inspires changes at various levels, which is strengths-based focused and is goal-oriented;2) a set of core activities that should be engaging, with high quality and requiring active learning;3) a relational environment providing significant support and sense of community;4) an opportunity role structure highly accessible that offers challenging opportunities;5) a leadership structure that is inspirational, shared and committed; and 6) a maintenance and innovation feature, based on capacity-building, bridging and that impacts the external environments in the community. Based on a body of literature about current transformative challenges in mental health, the ECS’ framework, described above, was adapted for this study (see Appendix).

In the first section of this paper, the authors present a review, covering literature from community mental health, the empowerment movement, and core values and principles of community psychology, whose contribution may shift practices in mental health systems. This review was used to create a customized application of ECS to community mental health. In the second part, based on the adapted framework, we present the results from a case study, designed to explore both the presence of transformative characteristics through, which the setting empowers their members, and also impacts community and societal change. Finally, we discuss how the empowering setting model may lead to CMHOs transformation at various levels, particularly in fostering recovery and community integration.

Theoretical and Empirical Influences for ECS in Community Mental Health
International research and practice in mental health, as well as socio-political changes, have challenged the established aims, vision and outcomes of mental health systems. In this article, empowerment is simultaneously the means and the goal for mental health transformation. Empowerment relates to an alteration in power-relationships and in conditions of access to organizational and community resources.

Important contributions began with the patients’ liberation movement (Chamberlin, 1978, 1984) and the independent living movement (Ridgway, Simpson, Wittman, & Wheeler, 1994) advocating mental health users’ rights. Earlier published accounts by mental health advocates stated that the adoption of an empowerment orientation would represent a shift in mental health programs rendering them transformative in the lives of people with experience of mental illness (Chamberlin, 1997; Fisher, 1994). Research with consumer-run organizations (CRO) and self-help initiatives suggests that participating in strengths-based settings with challenging roles, results in greater empowerment among members(Brown, 2009; Fisher & Spiro, 2010; Nelson, Ochocka, Janzen, & Trainor, 2006; Segal, Silverman, & Temkin, 2011). This is congruent with the empowerment concept as a multilevel construct characterized by participatory processes over time, through which individuals, organizations, and communities gain greater control, efficacy and social justice(Rappaport, 1987).

Community-based research evidence suggests that psychological, social and civic empowerment increases across levels and forms of organizational and community participation (Christens, et al., 2011; Maton & Brodsky, 2011). The empowerment-related processes and outcomes within the various domains and levels that were described by Zimmerman (2000),should be addressed by community mental health interventions that intend to transform the lives of people who experience mental illnesses.

Nelson, et al. (2001b) articulated an empowerment-community paradigm to address conceptual limitations present in the traditional paradigm in mental health by delineating strategies and processes across policy, organizational and individual levels, directed to enact the involvement and participation of people who use mental health services.

The position and role that a person who experiences mental illness should play in the mental health system is also a core issue of the recovery vision in mental health change (Anthony, 1993; Brown, 2012; Fisher, 1994). Empirical evidence suggests that most people with mental health issues undergo a journey of personal recovery, challenging traditional perspectives that view persons with an experience of mental illness as being dependent on support and unable to achieve adaptive functioning and high quality of life (Davidson, Harding, & Spaniol, 2005; Davidson, Sells, Songster, & O'Connell, 2005).

The recovery perspective as a life experience, requires coordinated efforts from mental health advocates, policy makers, service providers and researchers in mental health system transformation (Davidson, Ridgway, Kidd, Topor, & Borg, 2008; Jacobson, Greenley, Breedlove, Roschke, & Koberstein, 2003; Piat et al., 2009). Because recovery is not symptom remission, but rather a process concerned with life goals, hope in the future, individualized supports and user empowerment, mental health advocates have acknowledged the community context as the best setting for it to flourish (Davidson, 2007; Deegan, 2005; Lovejoy, 1982; Ornelas, et al., in press).

The community integration principle is another relevant element to change mental health practice by creating opportunities for a “full life in the community”, and the exercise of citizenship through access to fundamental rights (Nelson, et al., 2001b; Ornelas, et al., in press). This dimension stresses the efforts of fostering connectedness with and the use of natural resources in the community (Newberry & Strong, 2009; Townley, Miller, & Kloos, 2013; Ware, Hopper, Tugenberg, Dickey, & Fisher, 2007).

Community integration has been conceived as a multidimensional concept with interrelated physical, social, and psychological components (Wong & Solomon, 2002).However, living outside the hospital or using community facilities is not enough to be considered integrated in a community(Lemaire & Mallik, 2005). It is necessary to advance a more transformative vision of community integration.Davidson, Ridgway, Wieland, and O'Connell (2009) promoted the adoption of the capabilities and human rights’ perspectives to enlarge that vision. The capability standpoint values personal agency, and the diversity of options in social contexts(Davidson, et al., 2009; Ornelas, et al., in press).

Another transformative issue to challenge mental health programs is the multilevel intervention due to the assumption of the interdependence between individuals, programs and systems involving radiating effects of one level on the others. Trickett and Schensul (2009) stated that the multilevel interventions tackle social change by developing interventions at different ecological levels in the community. Ecological interventions are therefore critical in order to sustain innovation and change in mental health interventions.

In closing, the empowering community settings’ theory, developed by Maton (2008), offered the current study a salient template to explore and to incorporate the transformative features of interventions that will challenge the practice of traditional community mental health organizations(Davidson, et al., 2009; Fisher & Spiro, 2010; Nelson, et al., 2001b; Ornelas, et al., in press).

AEIPS Organizational Setting
The Associação para o Estudo e Integração Psicossocial (AEIPS) is a private non-profit, mental health, community-based organization in Portugal, founded in 1987 by a group of users, families and professionals.  It is inspired by empowerment and community approaches, facilitating the implementation of strength-based services for people with mental health challenges. Although the setting and related socio-political context are detailed elsewhere (Ornelas, Vargas-Moniz, & Duarte, 2010), we present here a summary of its main features.
AEIPS’ programs address individuals’ needs and expectations through access to natural contexts with the general population, and to varied community resources and domains, such as education in regular schools, employment in the mainstream labor market, and the participation in regular social roles and activities as full citizens. The community integration process consists of bridging and bonding social relations and networks, fostering more inclusive, supportive and diverse communities (Ornelas, et al., in press).

This CMHO has more than two decades of experience influencing policy on de-institutionalization in Portugal, advocating for the perspective and role of people who experienced mental illness in the mental health system, (e.g., hosting the Empowerment and Mutual Help Centre and the National Network) and promoting innovative programs like the independent living and housing first approaches (Ornelas, et al., 2010). The comprehensive participatory organizational processes across the setting are also a fundamental aspect of this community mental health organization.

Due to the co-existence of both individual and collective empowerment, including community betterment and social change as described by Maton (2008), AEIPS was considered for the current qualitative analysis. Based on a previous brief review of transformative challenges, from community mental health and from community psychology based-knowledge, we address the following questions: 1) How to adapt the ECS framework to community mental health practice that is oriented towards recovery and community integration?; 2) What empowering characteristics derived from the ECS-CMHO contribute to a transformative change at the individual, program and systems levels of analysis?

Method
Participants
The participants included 4 program users, 2 staff members, and 2 program administrators. The users were randomly selected from a general list of 93 participants from a previous quantitative study. The following inclusion criteria were used: a balance of men and women; minimum 2 years of participation in the organization; not hospitalized. Service users were 2 women and 2 men, with ages ranging from 30 to49 years; and with 1 to 6 years of participation in the setting. Each of the users that participated received an incentive of 6€.
Two staff members were randomly sampled from a list provided by the organization. Inclusion criteria were a minimum 2 years of working in the organization, and a full-time contract. Two additional informants at the program administration level were selected and interviewed as well. Staff and program administrators were female, with ages between 29 and 48 years; and between 6 to 26 years of collaboration.

Research Approach
For the purpose of this study, an instrumental single case-study approach was used in order to provide in-depth answers to the research questions (Stake, 2005). The research team sought to triangulate information from semi-structured interviews with service users (U), staff members (S), and the coordinator and one board member as program administrators (A), to explore meaning through different perceptions or program stakeholders(Patton, 1990).

The construction of the interview guide involved several meetings of the research task group, composed of university-based researchers, staff and users from AEIPS. The researchers adopted the peer debriefing and support strategy proposed by Padgett (2012). The task group critically reflected on the contents of the guides and their relation with goals, logical sequence and analyzed the language adequacy and contextualization concerns (Trickett & Espino, 2004). We conducted one-on-one interviews at the organizational setting of the participants and ranged from 30 min to 1hr 30min. At the opening of the interview, the participants provided written informed consent and completed a demographic questionnaire.

Separate interview guides for staff and administrators were created for this qualitative study. The semi-structured interview guides were based on the literature review, in order to mirror the conceptual research framework on empowering characteristics (e.g., goals, shared mission, how theory relates to practice, member participation, nature of relationships, and influence) through open-ended questions. The same interview questions were also customized for program users. However, the user interview guide also added questions to capture program-related gains in housing, relationships, physical and mental health, and participation.

All interviews were audio-recorded and transcribed verbatim and personal identifying data was deleted for its use in the analysis stage. In the results section the quotes presented were translated from the original in Portuguese into English.

Data Analysis
The authors developed a coding grid, based on the literature review and logic model, to identify the fundamental empowering characteristics of transformative community mental health settings.

The coding grid was based on the four core components presented in the ECS model: group-based belief system; core activities; relational environment; and role opportunity structure. Data on Maton’s ECS components, such as leadership and setting maintenance, were not considered for this study. However, two particular themes, the external and policy influence, were included in the grid due to their relevance for the present discussion.

This approach required several team meetings for critical reflection, discussion and consensus, in order to achieve a successful adaptation. The trustworthiness of the codes and their definitions were determined by cross-checking among researchers, through an iterative process that generated the final version of the grid.

Data analysis also followed an interactive, back and forth, cycle among analysts(Braun & Clarke, 2006; Miles & Huberman, 1994). Two research analysts coded independently the eight interviews, line by line, and a third one joined for auditing process(Padgett, 2012). The empowering characteristics were highlighted and coded with the respective label. The credibility of analysis was assured by analytic triangulation, discussion of discrepancies, explaining how and why the interpretation was arrived at, until reaching a consensus was reached about the best code (Braun & Clarke, 2006).

In order to discuss results at multiple levels of analysis the authors created new codes for individual, program and system dimensions. This phase was also subjected to credibility and trustworthiness steps. Data were again transformed and condensed in new content tables, independently, and compared by research members for this aim.

Results
Highlights of key empirical findings are presented by empowering characteristic and across ecological levels of analysis according to the adapted framework to community mental health organizations (ECS-CMHO).

Group Based Belief System
The “group-based belief system” category’s findings included the presence of a recovery-oriented vision that values the access to the community’s natural resources, such as employment or housing. Challenges facing the individual level were expressed in the words of one user:

“[the organizational values] that people who experience mental illness are included in society, not living institutionalized in the hospital ... which gives hope to people with mental illness that they can achieve recovery and they can reach the same rights as the so-called normal people…” (U).

Values and goals were also shared among all members of the setting, and the locus of intervention was clearly the community/social context as these participants vividly expressed:

recovery is (…) a new life experience anchored in experiential knowledge and… that’s one of the key principles … it also relates to empowerment, as the possibility for people to identify resources, to be able to assume their responsibilities and freedoms and to search for resources that make sense (...) this has to do with employment, education, housing, political participation and with citizenship(S)

In this category, at system level, data reveals the organization external influence in the community and social contexts.  One program administrator affirmed that:

[organizational influence is] visible in policy change, (…) through the presence of the ideals of people with mental illness in public reports and legislation, like the Mental Health Plan (… ) we were also contacted by the Mental Health Department to collaborate with the closure of the Miguel Bombarda Hospital  (A)

Core Activities
Participants’ testimonies grouped in a “core activities” category revealed a transformative impact in the individuals’ lives through valued and challenging opportunities, like:

“(…) the Association’s supported employment program has given me a new comfort ... I didn’t know how the job market worked, and so I felt more supported” (U); and “[a milestone] was the constructing my portfolio in the training for employment integration, because it was an opportunity to increase awareness of my course of life ...” (U).

At the program level, transformative features were related to the ECS issue of meaningful and congruent practices when associated with the individualization of the users’ needs and objectives, because

“[through] the individual support program,(…) defining the objectives collaboratively… the goals that one person wants to achieve … which resources can be mobilized and also by  assessing the fulfillment of the project” (A).

Collaboration was noted in the discourse of interviewees by examples of individualized supports, setting governance and maintenance, and participatory evaluation processes:

“It’s ... a collaborative role (...) we have to have the notion that both knowledge and experience [from users] are as important as professional knowledge” (S); or also that “this organization has this kind of action of an ongoing self-assessment, asking families, participants, professionals, about what can be changed and what can be improved” (A).

Potential effects at the systems level were focused on situating the interventions in community environments beyond the organizational setting and in breaking barriers to mental health users’ participation and community inclusiveness:

[supported employment] has this goal of helping people return to employment or access employment ..., so we are talking about regular companies; ... we have the supported education service, with this same philosophy and principles of bringing people back to schools, to regular universities (S)

Relational Environment
The “relational environment” category provided evidence for impacts at an individual level through peer and natural social supports where life experiences are shared and valued:
“[milestones] … a person who belonged to that group [welcoming committee] … who helped me … to meet people, introducing me, showing me how this house works” (U), and also from mutual help initiatives.

Partnerships with the university also appeared to be significantly empowering at the program level:

“the academy has also a fundamental role here. This link of AEIPS with ISPA [university] improves the work methods and the building of skills (...) through that research and action endeavor...” (S).

An identified transformative theme at the system level was the ongoing connections with community resources located outside mental health system, such as schools or companies that appeared as the main sources of natural support for people in the setting. One participant stated:

“the approach is always contextual, natural, so we use natural community resources” (A). This idea was reinforced by another program level representative “community integration implies establishing constant bridging with community resources, with local companies, with schools, with local governments, with training centers, with all the sites where the participant is involved” (A).

Opportunity Role Structure
The data included in the “opportunity role structure” category, emphasized accessible and varying demands and opportunities for individuals within the setting. Both users and staff members highlighted the value of participation and accessing capacity-building opportunities:

“I’ve already done two thematic debates of my exclusive authorship ... and ... I use to present thematic debates previously scheduled” (U), or “… the continuous training, every week, for staff, student internships, and participants [users], who want to attend” (S).

In this category, the presence of transformative evidence at the program level was based on the participants’ discourse as related to members’ involvement across organizational structures and processes:

“our Association is constituted by families, professionals and by service users (...) they all are in the governing bodies (...) we always had this concern of having them as representatives in the governing bodies” (A).

Finally, themes at the system level also highlighted organizational members’ external influence, through the existence of opportunities for community participation within and beyond the setting, which informed a potential radiating process over resources and policies, as it is noted in this statement:

[CEAM] it is a users group that generated much change inside [the organization] and outside... also in terms of public policy, they are consultants in the policy reform of mental health services (...) and they continue to give their testimony, at universities, they are invited to conferences, too… (S)

Discussion
With the present study we learned that the development of empowering interventions with community mental health organizations promotes change towards recovery and community integration across multiple levels.

First, this research was guided by an adaptation of the ECS framework, which is presented in the Appendix section. Based on the literature review, it was found to be a viable tool to assess empowering processes across ecological levels in community mental health organizations. It also helps to guide service transformation towards recovery and life in the community, namely valuing a recovery and community oriented vision beyond traditional mental health systems; focusing the individualization of users’ needs and goals; participation opportunities; and entering community-valued contexts such as housing and employment (Maton, 2000, 2008; Nelson, et al., 2001b; Ornelas, et al., in press).

Second, evidence for transformation at the individual level of analysis, using the ECS-CMHO framework, highlights a shift towards a strengths-based approach rather than the “deficit approach”(Ridgway, 2005). The underlying empowerment-based and recovery-oriented vision was consistent with the transformed identity from user to citizen (Davidson, et al., 2009; Fisher & Spiro, 2010). This vision is applied through the individualization of interests and objectives, enhanced connectedness, and access to meaningful social roles and activities in community natural contexts (Ware, et al., 2007).

Additionally, peer support initiatives and availability of opportunities for people who experienced mental illness, to collaboratively participate across ecological levels, emerged as significant for personal achievement and empowerment (Bond & Keys, 1993; Maton & Salem, 1995). These findings are congruent with the process of member gains in psychological empowerment, social empowerment, and civic empowerment—essential components of empowering community settings, as suggested by Maton and Brodsky (2011).

At the program level, transformative empowering characteristics were mainly anchored in the community orientation of the intervention through ongoing partnerships with multiple resources outside the mental health system, including landlords, neighbors, school teachers, and others. In line with a contextual paradigm, rather than designing alternative and separated settings, the interventions should be community-situated and the interaction among community members should be collaborative(Trickett & Espino, 2004). Furthermore all these potentiate the access to regular community contexts and to change them.

At the program level, collaboration was found to provide a pervasive structure for every dimension and goal of the setting, where all members were considered resources(Brown, 2009). Collaboration was present in processes such as governance and maintenance, interpersonal support and external contacts, which were relevant to achieve the organizational purpose (Bond & Keys, 1993; Seidman & Tseng, 2011).

Another transformative characteristic is the continuous participatory process of evaluation and research (Fetterman & Wandersman, 2005; Suarez-Balcazar & Harper, 2003). The use of collaborative research methods such as community based participatory research, as well as the development of long-term community-university research partnerships by CMHO’s, may lead to transformative efforts and outcomes (Minkler & Wallerstein, 2003; Suarez-Balcazar et al., 2004).

Creating opportunities for direct interpersonal contacts, through the participation of people with experience of mental illness in community settings, will be effective for the promotion of user empowerment and community change (Janzen, Nelson, Trainor, & Ochocka, 2006; Trickett, 2009; Zimmerman, 2000). The promotion of capabilities and social inclusion also presents new challenges and demands new practices from professionals and CMHOs (Fisher & Chamberlin, 2005; Newberry & Strong, 2009).

Main themes for transformation at the system level were related to direct intervention outside the setting domain and in higher levels of analysis within and beyond the mental health system. Core features were related to linkages and with the radiating effect of setting members in utilizing those external resources, reflected in the clearance of barriers to community integration in those contexts(Lemaire & Mallik, 2005; Ornelas, et al., in press).

Results also revealed direct interventions at the public policy level, not only through the implementation of quality program content, but also with the users’ access to political decision levels(Fisher & Spiro, 2010; Janzen, Nelson, Hausfather, & Ochocka, 2007; Nelson, et al., 2001b). Davidson, et al. (2009)suggested that a transformative shift can only occur when people who experience mental illness are active participants in changing surrounding conditions and personal lives. Adopting such an empowering philosophy in their vision and practices, CMHOs may help promote agency, empowerment, recovery, and even community betterment.

Additionally, the present study also illuminated the presence of several contributions from the community psychology field that enhanced the ECS-CMHO by endorsing the collaborative approach in interventions as a core empowering structure across ecological levels and domains (Bond & Keys, 1993; Trickett & Espino, 2004). Collaboration was embedded in the professional-user relationship, not only in the definition of individual user interests and objectives, but also in service activity within and outside the setting.

The establishment of a continuous process of research and action appeared as another empowering feature in organizational setting. The research partnerships between community organization and university can be catalysts for a continuous cycle of reflection and practice and members’ achievements (Suarez-Balcazar, Harper, & Lewis, 2005).

Data also revealed significant evidence for multilevel interventions within but also across Maton’s domains of individual wellness and social change to enhance empowering settings at the policy arena. The dual nature of the studied setting, operating simultaneously at different levels and multiple domains, appeared to be empowering in and of itself in terms of transformative change (Schensul & Trickett, 2009). This focus is highly relevant for sensitive social themes, such as mental health challenges, helping to achieve sustainable social transformation and prevent backlash effects from the introduction of innovative efforts(Maton, 2000).

In light of our study limitations, future research should continue to develop and confirm the validity of the ECS-CMHO framework as a resource for transformation and for evaluation across different organizations in the mental health field. Also, for purposes of CMHO efficacy in promoting better lives in the community for people with lived experience of mental illness, we should find further longitudinal evidence regarding which particular features of empowering programs influence individual outcomes on psychological empowerment, mental health recovery, and community integration; and also which features determine transformative change at the social and policy level.

Acknowledgments
This article was supported by FCT PTDC/PSIPCL/113301/2009 & FCT-BD/65518/2009.

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Author

Maria F. Jorge-Monteiro, Rita Aguiar, Beatrice Sacchetto, Maria J. Vargas-Moniz, and José H. Ornelas Maria F. Jorge-Monteiro, Rita Aguiar, Beatrice Sacchetto, Maria J. Vargas-Moniz, and José H. Ornelas

Maria F. Jorge-Monteiro, MA, BSW, is PhD candidate in Community Psychology at ISPA-Instituto Universitário;

Rita Aguiar, MA, is PhD candidate in Community Psychology at ISPA-IU;

Beatrice Sacchetto, MA, is PhD candidate in Community Psychology at ISPA-IU;

Maria J. Vargas-Moniz, PhD, Assistant Professor at ISPA-IU;

José H. Ornelas, PhD, Associate Professor, Director of Community Psychology Department at ISPA-IU

Corresponding author:

Maria F. Jorge-Monteiro
Address: Rua Jardim do Tabaco, 34, 1149-041, Lisboa, Portugal
Telephone: 00351962475195
Email: maria_monteiro@ispa.pt


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Mamoona Majeed (Pakistan,Lahore) December 15, 2014

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Keywords: Empowering community settings, mental health, transformative change, case study, gjcpp, community psychology practice