METHODS OF INTERVENTION AND CHANGE IN COMMUNITY PSYCHOLOGY

clinical psychology  METHODS OF INTERVENTION AND CHANGE IN COMMUNITY PSYCHOLOGY

Here we will describe the methods of intervention and change in community psychology, our focus will be on patterns of service delivery.

1. CONSULTATION

What is consultation? Orford (1992) offers the following definition: ‘’Consultation is the process whereby an individual (the consultee) who has responsibility for providing a service to others (the clients) voluntarily consults another person (the consultant) who is believed to possess some special expertise which will help the consultee provide a better service to his or her clients’’

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. Using individual techniques of intervention, the mental health specialist can reach only a very limited number of clients. But by consulting with other service providers, such as teachers, police, and ministers, he or she can reach many more clients indirectly (Orford, 1992).

Consultation can be viewed from several orientations, each springing from a somewhat different historical perspective. First, there is mental health consultation. This grew out of the psychoanalytic and psychodynamic tradition. It was often practiced in rural or underdeveloped areas where there was a shortage of mental health personnel. Consultation became a way of using existing community personnel (such as teachers or ministers) to help solve the mental health problems of such areas. A second orientation developed out of the behavioral tradition. In order to implement the technology of behavior modification that had been so successful in laboratory settings, it was necessary to move into real-life situations. To do that, people in the patient’s environment (such as home or school) had to be trained to properly dispense reinforcements for the desired behavior. Consultation became a way of providing such training. The third orientation is an organizational one that emphasizes consultation to industry. Specialists work with management or work group leaders to improve morale, job satisfaction, and productivity or to reduce inefficiency, absenteeism, alcoholism, or other problems.

TYPES OF MENTAL HEALTH CONSULTATIONS

Approaches to mental health consultation can be classified in many ways. Perhaps the most widely accepted classification is Caplan’s (1970). It includes the following categories:

  1. Client-centered case consultation. Here the focus is on helping a specific client or patient to solve a current problem. For example, a clinician might be asked to consult with a colleague on a diagnostic problem involving a specific patient.
  2. Consul tee-centered case consultation. In this instance, the aim is to help the consultee enhance the skills that he or she needs in order to deal with future cases. For example, a teacher might be advised on how to selectively reinforce behavior in order to reduce classroom disturbances.
  3. Program-centered administrative consultation. The notion here is to assist in the administration or management of a specific program. For instance, a consultant might be hired to set up an “early warning system” in the schools to detect potential cases of maladjustment.
  4. Consultee-centered administrative consultation. Here the aim is to improve the skills of an administrator in the hope that this will enable her or him to function better in the future. For example, a sensitivity group

consisting of administrators might be monitored by a consultant in order to help enhance the administrators’ communication skills.

PHASES OF CONSULTATION

Several general techniques can enhance the effectiveness of the consulting process. In most cases, the consultation process will pass through the following phases:

  1. The entry or preparatory phase. In the initial phase, the exact nature of the consultant relationship and mutual obligations are worked out.
  2. The beginning or warming-up phase. In this phase, the working relationship is established.
  3. The alternative action phase. This phase encompasses the development of specific, alternative solutions and strategies of problem solving.
  4. Termination. When it is mutually agreed that further consultation is unnecessary, termination follows. Unfortunately, community mental health centers have had difficulty providing consultation services, especially to schools and community agencies; the budgetary support has just not been there. What is particularly troubling about this state of affair that there is empirical support for the efficacy of consultation?

2. COMMUNITY ALTERNATIVES TO HOSPITALIZATION

The nation’s mental hospitals have long been objects of criticism. Despite the fact that there is a core of “undischargeable” patients, there are alternatives to our current hospital system-alternatives that will provide environments geared to the goal of enabling patients to resume a responsible place in society.

Examples of alternatives include the community lodge. This is akin to a halfway house where formerly chronic, hospitalized patients can learn independent living skills. The Mendota Program (Marx, Test, & Stein, 1973) was a pioneering attempt to help formerly “undischargeable” patients find jobs, learn cooking and shopping skills, and so on. Finally, there is the growing popularity of day hospitals that are often more effective and less expensive than traditional 24-hour hospitalization.

3. CRISIS INTERVENTION

The basic goal of crisis intervention is to reach people in an acute state of stress and to provide them with enough support to prevent them from becoming the chronically mentally ill of the future. Persons in crisis are often in a uniquely “reachable” state that can pave the way for future long-term interventions.

Crisis intervention requires the relinquishing of traditional procedures and prerogatives. For example, crisis intervention centers must be close to the communities they serve. Clients should not have to travel 20 miles to reach an office or wade through 15 secretaries once they reach it. Obviously, there must be immediate service. Walk-in centers or phone services must be available all day and all night, and appointments should not be required. Staff members must be prepared to leave their office-to go with police or to visit homes.

Finally, crises tend to obliterate customary professional roles, pecking orders, and prerogatives. There is typically no time for discussion of whether a paraprofessional received an A or a B in abnormal psychology, or for a visit from an expert consultant. This is not to suggest that training has no place. However, crisis intervention requires a versatility and flexibility that are not often found in traditional clinics or hospitals.

Early crisis programs were often built largely around telephone answering services. However, it soon became apparent that such services were too slow. Consequently, the emphasis is now on 24-hour services staffed by workers who personally take calls. Current interventions emphasize follow-up both to check on the well-being of the client and to assess the adequacy of the services provided by the agency to which the client was referred. Current intervention procedures also encourage face-to-face contact rather than the earlier over reliance on the telephone. Emerging interventions even include temporary shelter (such as for battered women and their children), transportation, and follow-up services and consultation to survivors of suicides.

One of the earliest applications of the crisis philosophy was the establishment of suicide prevention centers. An illustrative example is McGee’s (1974) development of the Suicide and Crisis Intervention Service (SCIS) in Gainesville, Florida. The policy of SCIS was simply “to respond to every request to participate in the solution of any human problem whenever and wherever it occurs” (McGee, 1974, p. 181, italics deleted). The attitude of the SCIS was that people in crisis were neither sick nor mentally ill. Thus, the service was not necessarily either a medical one or a mental health one. People in crisis were to be given immediate, active, and aggressive services. SCIS regarded people in crisis as the responsibility of the community and felt that, as citizens, they had a right to expect such a community service. In contrast to many community health organizations that are often at least subtly immersed in intra psychic concepts, the SCIS-type crisis center is organized with the idea of community Control. It is staffed largely by neighborhood volunteers, and it is geared toward the specific characteristics of the immediate community. Are these interventions really helpful? Although studies on crisis intervention proliferated in the 1970s, we still do not have a definitive answer. Much depends on the questions asked. For example Decker and Stubblebine (1972) found that psychiatric hospitalizations were reduced when crisis intervention procedures were used. Yet when Gottschalk, Fox, and Bates (1973) compared crisis patients with patients who had been randomly assigned to a waiting list, they could find no differences in several indices of psychiatric improvement. Other reports (Getz, Fujita, & Allen, 1975; Huessy, 1972; Maris & Connor, 1973) are much more optimistic. There are obviously many problems in obtaining controls in crisis intervention research. Thus, little can be said with certainty at this point. Not all research shows the efficacy of crisis intervention. However, others argue that additional preventive measures could well reduce the number of deaths from suicide. Clearly, crisis interventions can help reduce distress. For example, when a teacher commits suicide, interventions must be undertaken to at least try to reduce students’ shock (Kneisel & Richards, 1988). When a school bus collides with a train, the survivors must be helped to cope (Klingman, 1987). Under such circumstances, the community cannot wait for the ideal study to demonstrate the utility of an intervention. Public health workers and mental health workers have long been aware of the educational disadvantages experienced by the poor. Of great concern is the fear that early deprivation in crucial developmental periods will mark the child for life. Impoverished preschool environments and experiences may almost guarantee that the child will do poorly in school and thus become vulnerable to a wide variety of mental health, legal, and social problems. But if successful preschool interventions can be developed, then a truly preventive course of action will have been taken.

HEAD START PROGRAMS

The best-known early childhood program is Head Start. In the mid-1960s, President Johnson created the Office of Economic Opportunity (OEO). Head Start was one of the programs targeted specifically for disadvantaged children. It was designed to prepare preschool children from disadvantaged backgrounds for elementary school. Head Start programs are locally controlled but required to conform to general federal guidelines. Local programs vary in number of hours of attendance, number of months (summer versus the entire year), background of teachers, and so on. The specific techniques used also vary, but basic learning skills are usually stressed. Physical and medical needs are also addressed, as are general school preparation and adjustment.

5. EVALUATION:

How effective are these early childhood programs? Gomby, Lamer, Stevenson, Lewit, and Behrman (1995) find it useful to distinguish between child-focused programs and family-focused programs. In the former case, interventions are administered directly to the child; in the latter case, family members (such as parents) receive the intervention or training.

Participation in a child-focused program results in an average IQ gain of about 8 points immediately after program completion (although these relative gains dissipate over time), makes it less likely that the child will be placed in special education or retained in grade, and makes it more likely that the child will graduate from high school (Barnett, 1995; Gomby et al., 1995). Positive social outcomes resulting from program participation have also been reported, including fewer contacts with the criminal justice system, fewer outof-wedlock births, and higher average earnings than non participants (Gomby et al., 1995; Yoshikawa, 1995).

Although family-focused programs appear to have more impact on parents’ behaviors than do child-focused programs, it is not clear how much positive impact they have on children (Gomby et al., 1995; Yoshikawa, 1995). Not only is the focus of the intervention different, but so is its intensity and frequency. In the case of family focused interventions, services may be rendered only once a week.

6. SELF-HELP

Not all help comes from professionals. Informal groups of helpers can provide valuable support that may stave off the need for professional intervention. What is more, such nonprofessional self-help groups as Alcoholics Anonymous, Parents without Partners, Le Leche League, AlAnon, and many others can be incorporated as an effective part of treatment by a referring professional. What needs do self-help groups meet? Orford (1992) discussed eight primary functions of self help groups:

(1)They provide emotional support to members;

(2)They provide role models-individuals who have faced and conquered problems that group members are dealing with;

(3)They provide ways of understanding members’ problems;

(4)They provide important and relevant information;

(5)They provide new ideas about how to cope with existing problems;

(6)They give members the opportunity to help other members;

(7)They provide social companionship; and

(8)They give members an increased sense of mastery and control over their problems. Clearly self-help group serve several important functions for group members. However, research suggests that professionals should be available to serve as consultants to these groups in order for the groups to be maximally effective. Professionals should not control the group, but a total lack of involvement on the part of a community psychologist does not appear to be helpful either (Orford, 1992). Certain organizational features appear to be correlated with the appraisal of group success, including a certain degree of order and rules to govern the group as well as the capability and knowledge of group leaders (Maton, 1988), and a community psychologist can play an invaluable indirect role by serving as a consultant to group leaders.

THE ROLE OF PARAPROFESSIONALS

One of the more visible features of the community movement is its use of laypersons who have received no formal clinical training, or paraprofessionals, as therapists. The use of paraprofessionals in the mental health field has been growing, but this trend has generated controversy. In reviewing 42 studies, Durlak (1979) concluded that professional education, training, and experience are not prerequisites for becoming an effective helping person. However, Nietzel and Fisher (1981) took issue with this conclusion and urged caution in interpreting the results of many of the studies reviewed by Durlak. They argued that many of the studies included in the Durlak review were methodologically flawed, and objected to Durlak’s definitions of “professional” and “paraprofessional.” With these and other criticisms in mind, Hattie, Sharpley, and Rogers (1984) reanalyzed the studies included in the Durlak review. Results from their meta-analysis-concurred with those of Durlak. The overall results favored paraprofessionals, especially those who were more experienced and received greater amounts of training. More recent summaries have also argued that the available evidence suggests that paraprofessionals may be as effective as (and in some cases more effective than) professionals.

Besides effectiveness, there is also the issue of access to those who can provide help. Like it or not, most individuals who are in need of mental health services do not seek out mental health professionals. Instead, informal “therapy” takes place in many contexts and is provided by a variety of laypersons. For example, in an interesting and provocative set of studies, Cowen (1982) ‘investigated the “helping behavior” of hairdressers and bartenders. Results indicated that a small but significant proportion of their customers raised moderate to serious personal problems, and both hairdressers and bartenders attempted a range of interventions (for example, just listening, trying to be supportive and sympathetic, presenting alternatives). Many community psychologists view these and other studies as evidence supporting the idea that consultation programs might be aimed at laypersons that naturally come into contact with individuals with mental health needs. These needs might not otherwise be addressed because the target individuals are not likely to seek out help from a mental health professional. Although it hardly seems wise to argue that professionally trained clinical psychologists are unnecessary, it certainly appears that there is a vital role for paraprofessionals in the mental health field today. Clinical psychologists are needed, at the very least, to serve as consultants. Further, research may ultimately indicate that certain types of mental health problems respond better to services provided by a mental health professional. To date, however, the research questions addressed (for example, are paraprofessionals effective overall?) have been too broad to shed light on this issue. In a relatively short time, the community emphasis has become a force that has led clinical psychologists to reexamine many of their old assumptions. But there are important questions that must be confronted as we conclude our discussion of this field.

THE TRAINING OF COMMUNITY PSYCHOLOGISTS

At present, many have difficulty in understanding exactly what a community psychologist is. Perhaps because of its multidisciplinary orientation, community psychology has yet to develop an adequate or identifiable theoretical framework apart from those of other disciplines. This, at times, makes for role confusion. The community psychologist is part sociologist, part political scientist, part psychotherapist, part ombudsman, but lacks a specific identity. This ambiguity makes it difficult to design appropriate training programs. Fortunately, there are some guidelines for training. The recent IOM report (1994) recommends that future prevention research specialists should have a solid background in a relevant discipline (such as nursing, sociology, social work, public health, epidemiology, medicine, or clinical/community psychology). Training in the design of interventions and the empirical evaluations of interventions is essential. Finally, practicum or internship-like training in prevention is also recommended. Educational requirements for prevention field specialists (those that actually carry out the interventions) are less stringent. Often, a bachelor’s degree in a relevant field (such as psychology) is sufficient. Given the increasing cultural and ethnic diversity in the United States, it is also important for community psychologists to receive training in how diversity issues may impact their work. For example, knowledge of and sensitivity to cultural and ethnic differences will inform the following activities and roles of a prevention researcher (IOM, 1994):

  1. Developing relationships with community leaders and organizations
  2. Conceptualizing and identifying potential risk factors, mechanisms, and antecedents of problems or disorders
  3. Developing interventions that will have maximum effect, and deciding how these should be disseminated and delivered to the target population
  4. Determining the content and format of evaluation instruments

In order to achieve “cultural competence” (Cross, Bazron, Dennis, & Isaacs, 1989; Isaacs & Benjamin, 1991), community psychologists need to garner relevant professional experience with a variety of cultural and ethnic populations and to receive supervision from those who have expertise in designing, implementing, and evaluating interventions for individuals from these cultural and ethnic groups.

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