Greg Townley and John Sylvestre
This special issue of the Global Journal of Community Psychology Practice (GJCPP) aims to articulate a vision and provide suggestions for transformative change in community mental health. Certainly, in the contributions we have assembled here we can claim no clear or simple solutions. What we can offer are examples of the range of ideas, actions, and levels of actions that can be considered in the quest for transformed community mental health systems.
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Community mental health systems, across the globe, have always been in a continuous state of evolution. For about 50 years in North America, beginning with the first steps toward deinstitutionalization and the beginnings of the community mental health movement, there have been efforts to create systems of support for people with serious mental illnesses to thrive in community life. Community psychologists have been actively involved in these efforts, including George Fairweather’s Lodge program in the 1960s, Ed Seidman and Julian Rappaport’s work with the Grow mutual aid organization in the 1980s, and Sam Tsemberis’ development of Housing First in the 1990s. Over the past decade or so, we have observed, internationally, various calls and plans for not only improving mental health systems, but also for transforming them. The call for transformation speaks to a lingering dissatisfaction and a desire for fundamentally different kinds of systems. Still, many questions remain. What should a transformed system look like? What are the perspectives or values that should underlie it? Do we need a single or a common system, or is there a need for many systems, informed by different perspectives and values? How can we promote transformative change and how would we distinguish transformative from merely ameliorative change? This special issue of the Global Journal of Community Psychology Practice (GJCPP) aims to help further this discussion.
Certainly, in the contributions we have assembled here we can claim no clear or simple solutions. What we can offer are examples of the range of ideas, actions, and levels of actions that can be considered in the quest for transformed community mental health systems. In the following paragraphs, we sketch our initial thoughts on the historical roots, needs and the nature of transformative change.
What is Transformative Change?
Transformative change is easier to define than it is to identify or to create. According to Watzlawick, Weakland, and Fish (1974), first-order change is change that occurs within a system, but that leaves the system itself unchanged. It is change oriented toward improving how a system functions to produce outcomes, but that does not involve altering the fundamental assumptions or values of the system (Nelson & Prilleltensky, 2010). Second-order, or transformative, change involves a more radical form of change that fundamentally alters a system. It can involve altering the values or assumptions of a system, as well as how power is located, flows or operates within a system (Nelson & Prilleltensky, 2010).
Nelson (2010) provided a description of the evolution of housing approaches for people with serious mental illnesses that illustrates the critical distinction between ameliorative change and transformative change. Custodial housing (e.g., board-and-care homes) arose out of the need to quickly house individuals in the era of deinstitutionalization. This housing model focuses on care services, such as medication management and the provision of meals, but provides little in the way of active rehabilitation or support. Further, staff in custodial housing retains power over residents, thus replicating key features of psychiatric institutions and representing neither ameliorative nor transformative change.
Supportive housing (e.g., group homes, halfway houses, congregate apartments) arose in response to the limitations of custodial housing. These settings typically provide rehabilitative support focused on the promotion of independence, adaptive functioning, and social skills. While this model was certainly an improvement over custodial housing, individuals had little control over where they live and with whom. Some programs also required sobriety, compliance with treatment, or engagement with professional support programs as a condition for housing (Nelson, 2010). Thus, this model, when originally introduced, represented ameliorative change because, despite improvements in the living conditions of residents, they were still service recipients with limited control over their lives.
In contrast, supported housing is independent housing marked by principles of consumer choice, community-based housing, and the availability of flexible, individualized services with no requirements that residents be in treatment, sober, or asymptomatic; that is, individuals receive “Housing First” (Carling, 1993; Nelson, Lord, & Ochocka, 2001; Nelson, 2010; Ridgeway & Zipple, 1990). Supported housing represents transformative change because it fundamentally alters the system of care. “Patients” become tenants with rights; housing and mental health services are de-linked; housing is provided in normalized settings, thus combating stigma and isolation; and individuals are encouraged to become actively engaged in all facets of community life (Carling, 1995; Nelson, 2010).
As this example illustrates, transformative change in the community mental health field entails fundamentally altering the focus, operations, and outcomes of a system that has too often been impotent to address the poverty and exclusion that characterize the lives of many with serious mental illnesses. It would entail a shift from a focus on illness or disability to a focus on citizenship, from the acceptance of poverty to working toward sufficiency, from the experience of exclusion to norms of inclusion and participation, and ultimately from a state of oppression to emancipation. This change would come from a shift in power from service providers to consumers of services. It would also entail action on the longstanding observation that formal services are not the focus of recovery, but rather work in concert with informal support and other community resources and supports to support people in achieving the goals they hold for themselves (Trainor, Pomeroy, Pape, & Dewar, 2004).
Why Transformative Change?
A remarkable observation over the past decade or so has been the number of national strategies that have been developed across a number of countries aiming to improve mental health systems. For example, in the U.S., the President’s New Freedom Commission on Mental Health report (2003) stressed the need for services to assist persons with mental illnesses to live, work, learn, and participate fully in their communities. In Canada’s senate report on mental health, Out of the Shadows at Last, called for the creation of the Mental Health Commission of Canada (MHCC) and charged it with three strategic initiatives: 1) developing a national mental health strategy; 2) conducting a ten year anti-stigma and anti-discrimination campaign; and 3) building a national knowledge exchange center on mental health (Kirby, 2008; Piat & Polvere, in press). In 2012, the MHCC released a national strategy for mental health reform entitled Changing Directions, Changing Lives: The Mental Health Strategy for Canada (MHCC, 2012). The National Service Framework for Mental Health, published by the Department of Health in late 1999, set an ambitious ten-year agenda for improving mental health care in the UK. The recently established National Mental Health Commission of Australia (2012) aims to improve outcomes for people with a lived experience of mental illness, their families, service providers, and community supports. And, finally, the New Zealand Mental Health Commission (1998) has overseen a fundamental redirection of mental health resources away from hospitals and toward community-based services (Rosenberg & Rosen, 2012). These are but a sampling of international strategies that speak collectively to the dissatisfaction with the current systems and the programs they offer.
At the same time, there has been a general dissatisfaction with exclusively top-down approaches to mental health reform and an increasing recognition of the importance of a consumer/ survivor voice in the system. This consumer voice is significant at both individual and collective levels. The consumer movement arose as a both a compensatory response as well as a form of resistance against a professionally-dominated, inadequate and unresponsive system. Despite significant improvements within the system, power is still located in professional hands. In order to achieve true transformation, we must move beyond merely involving consumer/ survivors as collaborators in changes processes to ensuring that they provide leadership at all levels of our efforts (Piat & Polvere, in press).
The need for more transformative change is also found in the limits of the past and current perspectives that have informed the development of the Western systems. Notably, each of these perspectives has focused on individual-level intervention without a focus on broader system changes and empowerment. This is clear with older bio-medical and rehabilitative approaches, but also characterizes the more current recovery perspective. Recovery emphasizes the unique and personal process of acquiring meaningful roles in the community (Anthony, 1993). In its emphasis on personal experiences and goals it does not adequately consider that the struggles in recovery are not fully personal. Because they are shared struggles among many people, the essentially individual-level, recovery and therapeutically oriented services are inadequate for wholesale improvements in people’s lives.
How does Transformative Change Happen?
There are two broad perspectives on how transformative change happens (Sylvestre, in press). The most common perspective is that transformative change is the product of planned change processes that involve efforts to analyse how a system functions, identify system weaknesses and inefficiencies, and change the system to improve its overall functioning. More transformative change processes can involve defining new visions or goals for a system and altering the system to bring it in line with this new vision and goals (Sylvestre, in press).
In contrast, a less common perspective emphasizes unplanned changes that are the product of small incremental changes over time that collectively lead to potentially transformative change (Weick & Quinn, 1999). This perspective, built on complexity theory, is less concerned with system level analysis and more concerned with the everyday and local interactions among individuals. This perspective focuses on the importance of novelty (such as new ideas or system challenges) that requires adjustment in the interactions across numerous actors in systems. These many adjustments, in the form of reflection, communication, joint problem-solving, and conflict, have the potential to promote over time radical change that is unplanned, and unpredictable (Sylvestre, in press).
These change processes are not mutually exclusive, and within any system there can be planned and unplanned change processes underway. What is important is that processes are synchronous and ambitious, and that systems are not allowed to become paralyzed by historical antecedents, vested interests, and unsound assumptions. As we noted at the outset of this paper, Western community mental health systems have been in a continuous process of evolution, and despite improvements, there is lingering dissatisfaction and widespread hope for more. Working toward transformative change requires actions at multiple levels. From a planned change perspective it requires a bold vision that challenges systems to align in a radically new form. This type of change can occur at programmatic, local system, state or province, or national levels. This is exemplified in the national strategies we identified earlier, as well as in the many exemplars provided in this special issue. At the same time, it requires engaged, energized, creative and collaborative system players who reflect, share, discuss and debate ideas, new practices, and visions for community mental health.
What is the Role of Community Psychology in Transformative Change?
According to Kloos, Ornelas, Duarte, and Nelson (in press), there is a long historical relationship between community psychology and community mental health. In fact, deinstitutionalization and the community mental health movement can be credited with spurring the emergence of community psychology. As psychiatric institutions began to downsize, the search for new community-based models of treatment and support began (Kloos et al., in press). This new community psychology, with its concerns with how interactions between individuals and social systems produced health or illness, with its emphasis on prevention and social change, and with its dual clinical and research interests, was poised to make important contributions to the development of community mental health systems.
According to Kloos et al. (in press), the very principles and values of community psychology can help to inform a transformative change in community mental health systems. Among these, they have identified the promotion of well-being and health; social inclusion community integration; a focus on strengths, opportunities, and resources; social justice; individual and collective empowerment; a concern with multiple types and level of power; individual and collective liberation; collaboration; ecological approaches, and research and evaluation.
Community psychology is particularly well-suited for transformative change efforts due to its focus on developing linkages between systems. By working at a meso-system level of analysis, community psychology can link individuals, microsystems (e.g., families, peer groups), organizations (e.g., mental health centers, job sites), community settings (e.g., neighborhoods), and macro-systems (e.g., societal attitudes toward mental illness and national policies) to help promote both individual and collective liberation and well-being (Nelson, Kloos, & Ornelas, in press).
Recently, community psychologists and students have banded together to form The International Network for Transformative Change in Community Mental Health. Along with this network is a forthcoming edited volume by Nelson, Kloos and Ornelas that assembles examples of theory and practice testifying to the importance and achievability of transformative change. Among other topics relevant to community mental health transformation, the text includes chapters on transformative policy change, social determinants of health, community integration/ inclusion, and transformative organizational change.
The Current Special Issue
We are pleased that the GJCPP has agreed to publish this special issue on transformative change in community mental health. The current issue presents a diverse view of strategies for promoting transformative change from a diverse range of perspectives. In developing this special issue, we were sensitive to the need to identify theory, programs, and initiatives that stretch across ecological levels and that were written from the perspective of multiple stakeholders. Taken together, articles included in this issue provide a broad view of how to move forward as we strive to create transformative change in community mental health.
Our call for proposals for this special issue asked for papers that discuss strategies for transforming mental health services and systems of care; propose new goals for mental health promotion and intervention; present methods and projects focused on promoting involvement and leadership of mental health consumer/ survivors in research and practice; compare mental health approaches in different cultural/ national contexts; and specify contributions that community psychology can make to community mental health. In response to our call, we received a total of 25 submissions. We invited 12 papers and one film that we believed showed the most promise to contribute to theory and practice on the topic of transformation in community mental health. Contributors come from six different countries and represent a variety of perspectives, including individuals with lived experience of mental illness, practitioners, researchers/ academics, and students.
The first five papers have broader foci and use literature reviews, case studies, and narrative approaches to describe transformative change strategies for individuals, organizations, communities, and systems. The first paper, by Heather Bullock, Fredrik Lindencrona, Gary Belkin, Jane Vanderpyl, Nicholas Waters, and Kevin Hennessy, describes the International Knowledge Exchange Network for Mental Health (IKEN-MH) and examines the potential for enhancing systems-level change and implementation of evidence across regional and national jurisdictions. The authors present four case studies in diverse contexts to demonstrate the benefits of and mechanisms for implementing this international community of practice and knowledge exchange. Their work suggests that knowledge exchange networks must focus on evidence (e.g., effectively capturing qualitative and informal experience of systems-change initiatives), context (e.g., working with communities to address their local needs), and facilitation (e.g., facilitating the identification of interventions and methods that increase capacity of individuals and organizations to use data and methods for program improvement) when working to effect systems-level change in community mental health.
In the second paper, Allison Pinto combines key principles of infant mental health and complexity science and applies them to comprehensive community change efforts to articulate a new model for transformative change in community mental health. This new model, which incorporates community organizing, community data, programs, and policies, contrasts starkly with traditional strategies that focus primarily on developing well-coordinated formal service systems for young children. To illustrate this novel approach, Pinto describes a program in Sarasota, Florida that combines infant mental health and complexity science to help facilitate community change. This case study serves to illustrate the importance of and strategies for cultivating the capacity of community members across a variety of sectors to be continually attuned and responsive to the potential of all members to become self-organized and to thrive.
In the third article, Jessica Lee demonstrates how rhetorical theories of agency and persuasion inform community psychology approaches to support individuals in acute psychiatric distress. Lee suggests encouraging more collaborative engagement between professionals and consumer/ survivors and articulates a transformed system of mental healthcare that is based in the community upon the principles of shared power and decision-making.
In approaching transformative mental health system change, it is important that research tools align with core values held by community psychologies. The fourth paper, by Tim MacLeod, presents Amartya Sen’s (1999) capabilities approach as a promising framework for outcome measurement congruent with the aims of transformative change. Sen’s approach asserts that the freedom to achieve well-being is a moral imperative; and this freedom must be understood in terms of people’s capabilities, or opportunities, to do and be what they have reason to value. MacLeod compares Sen’s approach to therapeutic and citizenship values espoused by community psychologists and uses Housing First in the context of Canada’s At Home/ Chez Soi Project as a case study to illustrate the types of capabilities-informed outcome measurements and indicators that should be utilized when implementing and evaluating transformative change practices in community mental health.
In the fifth paper, Chanté DeLoach and Sujata Swaroop highlight the historic disconnect between systems of mental health, as traditionally defined within a Western context, and the experiences of marginalized and indigenous people around the world. The authors present case studies of traditional mechanisms of healing in Pakistan, Brazil, and Zambia to highlight potentially transformative practices employed by communities often silenced in Western-centric community psychology discourse. Results support a community-based mental health promotion model that combines prevention and health promotion approaches; partnerships between professional allopathic service providers, paraprofressionals, and traditional health practitioners; and community engagement and political literacy as transformative agents for both individuals and communities.
The next four papers present original empirical research in a variety of settings to address the importance of transformative change at the individual, community, organizational, and systems level. The sixth paper, by Benjamin Henwood, Kelly Melekis, and Ana Stefancic, discusses Housing First as a fundamental shift in thinking about how to approach chronic homelessness. The authors use a case study approach and thematic analysis of accounts from 20 key stakeholder perspectives to investigate whether and how introducing Housing First into a small, rural state within the Northeast United States can affect the dominant institutional logic of how homelessness should be addressed. The authors conclude that introducing Housing First can bring about reform to existing homeless and mental health service systems via its focus on consumer-driven care, a recovery orientation, and attention to basic human rights. Still, practitioners must strategically consider implementation issues within the context of the existing service system to increase the likelihood that Housing First approaches will become a core and sustainable feature of institutional logic.
The seventh paper, by Stephanie Farquhar, Marianne Ryder, Robert Lowe, and Ted Amann, also focuses on the role of housing in community mental health transformation. The authors utilize community-based participatory research (CBPR), a transformative practice in and of itself, to solicit information about personal experiences with housing, employment, and recovery programs among individuals utilizing a variety of service programs at Central City Concern in Portland, Oregon. Results highlight the importance of involving consumers in the development, data collection, and analysis of research. Further, findings present unique perspectives related to recovery, housing, employment, and suggestions for changes in service systems that better equip organizations to positively impact individuals and communities.
The eighth paper, by Thomas LaPorte, Mason Haber, Damie Jackson-Diop, and Brittany Holt, also utilizes participatory action research and evaluation methods to examine transformative change efforts. The authors describe how Appreciative Inquiry and Photovoice can be used to gather perspectives of transition-age youth (TAY) on needs and aspirations, current responsiveness of their mental health programs and systems, and possible targets for improvements in programs and systems. The authors also outline the process of sharing TAY perspectives with stakeholders to effect change through a video. Suggestions are provided for how community psychologists can apply these complimentary methods to benefit TAY and other populations facing challenges in their communities and health systems.
The ninth paper, by Maria Jorge-Monteiro, Rita Aguiar, Beatrice Sacchetto, Maria Vargas-Moniz, and José Ornelas, uses a case study approach with eight in-depth interviews of diverse participants from the Association for the Study of Psychosocial Integration (AEIPS), a non-profit community mental health organization in Portugal, to identify and describe empowering and community-oriented characteristics related to community mental health transformation. Based on their findings, the authors suggest that peer support, participation in the community, and a strengths-based service orientation can promote transformative change for individuals; while ongoing partnerships with community-based supports, including landlords, neighbors, educators, and others, are necessary for transformative change at organizational and programmatic levels.
The final three papers describe peer-facilitated programs and interventions situated at the individual and organizational level but positioned to profoundly affect communities and systems. In the tenth paper, Vicky Collins discusses the Leadership, Empowerment, Advocacy Project (LEAP), a supported education implemented at Wichita State University in Wichita, Kansas. Collins discusses the nature in which her own lived experience of mental illness, as well as the supportive classroom environment formed among peers in recovery, were vital program components that allowed students to gain a sense of community and cultivate skills to help them pursue advanced degrees and employment. Collins describes the goals, structure, and outcomes of LEAP and suggests ways in which the program can be implemented in other settings.
In the eleventh paper, Jonathan Delman, Deborah Delman, Brenda Vezina, and John Piselli describe the development and impact of the “Recovery Learning Community” (RLC) model, a regional network of peer support and education developed by peers in Massachusetts and operated and staffed by people with lived experience of mental illness. RLCs are different from most peer-run programs in that they provide meetings and workshops across communities rather than in a single location. This better positions them to enhance the social integration of people with lived experience at the community level and promote more collaborative approaches to mental health service delivery at the organizational and systems level.
The twelfth paper, by Meghan Caughey, presents the Cascadia Peer Wellness Program, a peer-facilitated program aimed at creating a culture of wellness within mental health organizations and systems. The program was informed by Caughey’s own experiences as a consumer/ survivor and peer mentor, as well as her commitment to deep democracy, a belief system that is predicated upon equality, self-responsibility, and mutuality. The program trains and employs Peer Wellness Specialists to partner with clinicians and other healthcare team members to assist in the recovery efforts of the people they serve. The paper outlines the creation and structure of the Cascadia Peer Wellness program and presents suggestions for how the program can facilitate transformative change in this era of healthcare reform in the United States and other countries.
Finally, we have included a film directed by Guillaume Pégon and Elodie Finel and produced by Handicap International. The film chronicles efforts to develop and support community mental health initiatives aimed at helping individuals regain a sense of self and community in the wake of the Rwandan genocide. Their work has enabled individuals and communities to recover and cultivate new opportunities for social participation and wellness in a post-genocide Rwanda.
As is evident from these brief descriptions of the articles and film included in this special issue of the GJCPP, there is energy, excitement, and momentum toward transformative change in community mental health. While in many ways, this work only starts to scratch the surface of how, why, when, and with whom change should and can occur, certain suggestions that are particularly relevant to community psychologists emerge. First and foremost, mental health consumer/ survivors should be involved in all aspects of research and practice related to transformative change. Further, involvement must be meaningful and self-directed—not tokenistic. Second, as a field espousing values of diversity and cultural relativity, we must continue to push ourselves to look beyond Western-centric approaches to community mental health and be more inclusive of global perspectives and indigenous health practices. Third, and related to this point, mental health service systems should complement rather than replace natural support systems already existing in communities. Fourth, we must be committed to developing and sustaining linkages across systems and settings rather than allowing organizational and geographic boundaries to keep our work fragmented and piecemeal. Finally, it is imperative that outcomes of transformed mental health systems are conceptualized in terms of optimal mental health, wellness, and thriving as opposed to merely focusing on psychiatric symptom reduction and health maintenance. The variety of perspectives, ideas, and actions presented in this special issue provide a starting point as we work to improve the lives, communities, and support systems of individuals who experience mental illness. We look forward to continuing this dialogue.
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Greg Townley and John Sylvestre
Greg Townley is Assistant Professor in the Department of Psychology at Portland State University. His research interests include community inclusion of individuals with psychiatric disabilities, homelessness and housing interventions, sense of community theory and measurement, and social-environmental research methods. He is also involved in research and applied work with peer-delivered mental health services and is the co-chair of the SCRA Self-Help/ Mutual Support interest-group.
John Sylvestre is Associate Professor in the School of Psychology, and Senior Researcher at the Centre for Research on Educational and Community Services, at the University of Ottawa. His research interests lie in the study and the evaluation of community mental health programs and systems. His current research focuses on the study of families using homeless shelters, and people with serious mental illness living in independent community housing. He has been a Senior Editor of the Canadian Journal of Community Mental Health since 2010.