Creating a Mental Health Consultation Package for Community Agencies A. RUSSELL Berkeley,
LEE,
M.D.
California
The
author designed a consultation package for a cornmental health center consultant to present to the relevant agencies and organizations in the community. The consultation package is designed to create a series of regularly scheduled voluntary group meetings that center on the discussion of a case or a particular topic. The package also includes a written agreement, an evaluation procedure, and a six- to eight-month free trial period. The steps for establishing a new consultative relationship and developing a consultation network are also outlined. By using those steps and the package, the author and his colleagues have successfully established consultation services with schools, with the welf are, probation, and police departments, and with organizations of physicians, nurses, and clergy. munity
community mental health center is mandated by to provide consultation and education as one of its 12 essential services. That provision is perhaps one of the most farsighted aspects of the law that established the centers. It is clearly intended to encourage the creation of indirect, or preventive, programs to supplement the centers’ traditional direct, or treatment, programs. Many centers find it difficult to establish such consultation programs, however. The centers have difficulties gaining entry into the appropriate community agencies, and they have difficulties establishing and maintaining a viable creative relationship with the agencies once they have gained entry. I will address primarily the problems of gaining entry into community agencies. My experience comes from three years of work at a community mental health center in a rural community in central California. The center had been in operation for about nine months before I arrived to develop and direct its consultation and education services. After arRThe
law
Dr. Lee’s mailing address 94709. He is a consultant Services
in
San
hancisco.
tion
services
fornia,
and
Martinez, He
is 1628 Euclid Avenue, Berkeley, California to Contra Costa County Mental Health California, and to the Pacific Medical Center in
formerly
at the Emanuel
also
was
director
HOSPITAL
was
director
Mental Health of the center.
&
of
consultation
Center
COMMUNITY
and
educa-
in Turlock,
PSYCHIATRY
Cali-
riving, I discovered that most of the staff in the agencies in the catchment area had no idea of the services a mental health consultant could offer. The few consultees who did have some experience with private psychiatric consultants reported almost unanimously that their experiences had been unproductive. Their criticisms fell into four major categories. The first was that the consultants had a passive, nondirective style. They refused to take an active role in analyzing the problem and in making concrete, practical suggestions for its solution. As one staff member said, We described a problem to our consultant, and he graciously told us we had a problem. We asked him what he suggested we do about it, and he replied, What do you think you ought to do about it?’ The second criticism was that when the consultants did comment, their comments were about theoretical psychodynamics and diagnosis, and they gave no practical advice about how to proceed. For example, the consultant diagnosed ‘latent homosexuality” or borderline schizophrenia’ but failed to suggest specific approaches to the problem. The third criticism was that when consultants did make suggestions, the suggestions were often totally impractical considering the resources available to the agency staff and to the clients. For example, one consultant suggested long-term, one-to-one psychotherapy for a resistant, acting-out adolescent from a poor family with an unemployed alcoholic father and a depressed mother. The fourth criticism was that the consultant often used a consultee-centered rather than a client-centered approach. The consultant would analyze the staff rather than the clients. That approach engendered great resentment among the consultees. Such negative experiences made it difficult to create consultative relationships with the agencies. Thus our first moves were cautious. We started by informally interviewing as many workers as possible in each of the relevant agencies in our area, in order to discover what they considered their needs to be and what kind of operating procedure they would like to establish. We quickly discovered that staff often could not clearly define their needs and that they were even more unclear when it came to suggesting a structure for a “
‘
‘
“
‘
VOLUME
28
NUMBER
10 OCTOBER
1977
745
consultative relationship. Therefore, we decided to try to intuit their needs from whatever data we could gather and to develop a flexible format to propose to them. We designed a consultation package that we could present to each agency. The agency then could accept, modify, or reject the package.
ELEMENTS
OF
THE
PACKAGE
The consultation package we designed contained several elements; primarily it was a designated series of regularly scheduled voluntary group meetings centered on the discussion of a particular case or topic. Each element of the package will be discussed separately. Regularly scheduled meetings. The consultant is often initially faced with the question of whether to establish a regular meeting time with his consultees or to develop an on-call’ relationship in which the consultee is invited to contact the consultant whenever the need arises. In our experience the on-call relationship, particularly when established early, becomes the yehide for a polite brush-off. It becomes the equivalent of Don’t call us, we’ll call you. Therefore, we feel that regularly scheduled meetings should be established as soon as possible. The meetings may vary in frequency according to the consultee’s needs and the consultant’s resources, and may range from once a month to twice a week. We feel that bimonthly meetings are effective; they can have some impact on a system without initially overburdening either the agency or the consultant. We further suggest that initially each meeting last approximately an hour and a half. Voluntary attendance. Occasionally an administrator suggests that some of his staff be required to attend the meetings. In our experience, that requirement breeds resentment and distrust, so we prefer to keep all consultation meetings on a voluntary basis. Group format. The group process, through open discussion and problem-solving, can be an important force in facilitating change in an agency. Group consultation can provide an open forum that allows consultees to meet, to express their feelings and opinions, and to learn from each other. It can help break up the isolation and polarization that often exists in an agency. We have found the group format more efficient and effective than a one-to-one consultation with individuals in an agency. In a one-to-one system new ideas are often shot down by staff members who have not been part of the consultative process, and the status quo wins out over innovation and change. The group format also allows the consultant to gather vital information from a wide organizational base, and it puts the consultant in a better position to mobilize the resources of the entire agency to cope with clients’ problems. That is particularly true in school consultation, where not only the present classroom teacher but also others in the school system can shed light on the behavior and background of the problem student. For example, the pupil’s previous teachers can pro‘ ‘
‘
‘ ‘
746
‘ ‘
HOSPITAL
& COMMUNITY
PSYCHIATRY
vide information about the development of problems in the past. The principal of the school may have further historical information about the student and about his siblings and parents. The school psychologist, who may have tested the student or met with the parents, can also make a valuable contribution. Paradoxically, we found that the school psychologist often feels isolated in the school system, and the group consultation meetings can give him a better chance to share his views and expertise with the rest of the school’s staff. Finally, the school nurse may have information about the student’s physical problems as well as his family’s situation. Often the nurse will have visited the family’s home and will be able to give first-hand information about the student’s background. In fact, once group consultation meetings have been established, specific information-gathering roles can and should be assigned. For example, we try to arrange the schedule so that the school nurse or the current teacher will have made a home visit to assess the child’s environment and to observe parent-child interaction before the consultation. Thus the pupil’s behavior can be seen as a function of both classroom and home settings. Often behavior that seems dysfunctional at school, such as pushing, kicking, or aggressiveness, is necessary for survival at home or in the neighborhood. Furthermore, parental denials such as ‘Johnny never does that at home’ can be more easily dealt with once Johnny has been observed at home. We request that the school principal, current teacher, and as many previous teachers as possible attend the conference. We also request that the school psychologist test the child before the conference and be prepared to report on his findings then. Thus the group format provides an excellent opportunity for many people within an organization to put their heads together, to share information, to search for understanding, and to arrive at a new approach to the problem. We do not limit the number of people attending group meetings. Occasionally we have had 30 or more, but usually we have between ten and 20 participants. Case-centered discussion. We have found that the best way to begin a consultative relationship is with case consultation ; administrative consultation should be undertaken only after a good relationship has been established with the agency. As Caplan has so elegantly pointed out, the consultative relationship needs to be an egalitarian one in which two or more experts in different fields meet to share information, to develop a better understanding of the client’s behavior, and to develop some plan for coping with or intervening in the behavior. It is to be distinguished from case supervision.’ The first formal meeting of the consultant and the consultee is best planned as an orientation meeting ‘
‘
‘ C. Caplan, Theory Basic Books, New York
and Practice City,
1970.
of Mental
Health
Consultation,
.
At the first formal consultation meeting with the agency the consultant reviews the rationale, process, and format of the meetings, answers questions, and arranges the case presentation for the next meeting.
where ground rules are established. At that meeting we immediately emphasize the point, which will have to be made repeatedly, that we cannot hope to arrive at any suggestions for coping with a client’s problems or behavior until we have some understanding of what prompts the problems or behavior. For example, in a school setting we point out that the mere observation of a disruptive or fidgeting student doesn’t tell the teacher or the consultant the cause of that behavior. The student may be fidgeting or disruptive because he is too bright for the class and is bored, because he is too slow for the class and cannot follow the lesson and expects to fail, or because his parents are fighting and he is upset. In each case, we emphasize that understanding must precede coping. Direct client contact. Whenever possible, it is our practice to meet and to talk with each client to be presented either before the conference or during the meeting itself. We have found that such personal contact is invaluable to the consultant. At schools, for example, we arrange for the problem student to be available 20 minutes before the consultation meeting so we can talk to him and make a preliminary evaluation. In addition, a visit to the classroom by the consultant or an assistant can be a valuable way of seeing how the teacher and pupil interact. We have an arrangement with the probation and welfare departments to interview clients and their families (with their permission) behind a one-way mirror as part of the consultative session. We can then discuss the interview as well as the reports from the agency. Recommendations and follow-up sessions. Specific recommendations made at the end of each session should be recorded, so that they can be referred to at the follow-up sessions. In this way recommendations can be reviewed at the beginning of each new consultation, and the consultant can get continuous feedback about the previous cases. For instance, were the suggestions followed? If not, why not? If so, what happened? Did the suggestions help, or did they make things worse? Was there no change at all? The consultant’s attitude has to be one of humility and openness. He must convey the idea that we cannot know for certain what will work, and so it is a matter of trying something new that seems to make sense in view of what we presently understand about the individual.
He must also convey that if something doesn’t work, that too can contribute to further understanding and the development of new strategies and interventions. At the follow-up meetings, the consultant must get specific information from the consultees about how they tried to implement the suggestions that were made. Frequently the consultees report, We tried it and it didn’t work. On further exploration it is found, however, that what the consultee tried bears little resemblance to what the consultant thought he had suggested. Topic-centered consultation. As the consultation progresses, the consultees often ask that the meeting be devoted to a particular topic rather than to a case. We have found such topic-centered consultation to be a useful alternative to a case presentation. At schools, for example, we have talked about discipline, responsibility, minimal brain damage, and hyperkinetic children. At the probation department we have discussed alcohol, drug abuse, and sexual deviancy. At the welfare department we have discussed separation, grieving, death and dying, and family counseling. The presentations should be designed to encourage group involvement and discussion. Cases should be described to illustrate the principle presented, and the discussion should be kept as lively and free-flowing as possible. Financial support and the free trial period. A cornmunity mental health center usually must charge a fee for its consultation services. We have found, however, that it is unrealistic for the center to expect to be paid before the agencies have an idea of the value of such services. Thus we developed a six- to eight-month free trial period for each new agency. In effect we say to the agency’s administrators, You and we have no way of knowing in advance whether this consultation will be of any use to you. So let’s try it for a specified period of time, and then let’s evaluate how successful we have been. If at the end of the time you have found these meetings valuable, we will negotiate a fee for the services with you for the next specifled period of time. We have found that most agencies have been willing and able to pay for consultation services after the trial period. Contract and evaluation. The consultation package should include a written contract and an evaluation procedure. After the agreement has been made to schedule consultative meetings, we draw up an informal written contract covering both the trial period and any subsequent services; it is in the form of a letter describing who will meet when, where, and how often, and what the cost will be. The contract clarifies the arrangement for the consultant and the consultee. We have also found it valuable to conduct a formal survey at the end of the trial period to get the consultees’ views of the consultation process. We developed an evaluation form that we ask each consultee to fill out. The consultee does not have to sign the form. The form asks such questions as how many consultation sessions were attended, how helpful the consultation was, ‘ ‘
“
“
‘ ‘
VOLUME
28
NUMBER
10
OCTOBER
1977
747
whether the consultation had any over-all impact on the department, and what the consultee expected from the consultation and how the actual consultation differed from the expectation.2 The data collected from the form can be tabulated, and the findings can be discussed with the consultees and administrators.
MAKING
NEW
CONTACTS
In setting up a new consultative relationship, the consultant first needs to make a preliminary investigation of the agency. He can learn about the agency’s problems and needs through informal discussions with other professionals, as well as with agency staff members he knows and with other knowledgeable people in the community. He can also review articles about the agency in the local newspaper. The consultant’s first formal contact with the agency must be with its top executive officer or his designate. The consultant must express his interest in establishing a consultative relationship with the agency and find out if such an arrangement is feasible. If it appears to be, he can then discuss the agency’s structure, functions, current problems, and needs with the administrator. He can also outline services he might offer the agency. If there is a mutual agreement to proceed, the consultant would then arrange to meet with other agency administrators and then with line staff. The consultant may want to meet with the staff members either individually or in groups. He can explore their perceptions of their needs, which are often different from those identified by administrators. These exploratory meetings can be used to resolve differences and to set priorities and goals. In general, the consultant’s role at these meetings is to survey and identify needs and problems, arrive at priorities, specify objectives, select methods of intervention, and develop methods of evaluation. Finally, an agencywide meeting can be arranged with all staff members and administrators. The consultant can then summarize his findings, and agency members can come to a final consensus about their needs and priorities. Then the consultant can present his prop()sal for a consultative program. There must be time after the consultant’s presentation for questions, answers, and discussion. It is our practice to leave the meeting after the discussion 50 that agency staff can review the issues in private and can decide about whether or not to establish a consultation program. The agency administrator is asked to contact us within a week to ten days to notify 115 of the decision. If the decision is positive, the designated agency administrator and the consultant work out the specific details of the arrangement, such as the time, frequency, and length of meetings, date of the first meeting, and
2
Copies
available
748
of
from
the the
consultation
letter
and
the
evaluation
form
author.
HOSPITAL
&
COMMUNITY
PSYCHIATRY
are
names of staff members who should attend the meetings. If the answer is negative, the consultant should try to find out why. Before the first formal consultation meeting, the consultant and the agency administrator should review and sign the consultation agreement letter that the consultant has drawn up. At the first meeting, the consultant reviews the rationale, process, and format of the meetings, answers questions, and arranges the first actual case presentation for the next meeting. If a community mental health center is to have a significant influence on its community, it must establish a network of services in many different agencies and organizations. They include schools and the probation, welfare, and police departments as well as organizations of nurses, ministers, and physicians. Once we have established a consultative relationship with a school district, we try to schedule meetings at each school level (elementary, junior high, and high school). We also schedule meetings at a different school each week, and invite teachers from the other schools in the district to attend. At the college level we have established a consultative program with the college’s counseling services. The probation department in our region is divided into an adult section and a juvenile section. We have found it best to arrange consultations with each section individually. We have observed that probation officers often do an excellent job with a minimum of counseling training. The two sections of the welfare department that we have been especially involved with are child welfare and foster placement. Staff in those sections as well as in the probation department are particularly interested in interviewing techniques and family therapy concepts and techniques. With policemen we use an existing educational framework rather than creating a separate consultative arrangement. We give lectures at the regional criminal justice training center on recognizing and coping with deeply disturbed individuals, crisis intervention, and coping with family disturbances. We present the material in open-ended, informal discussions as a part of the basic and advanced training programs for officers. Ministers advise many disturbed people and are often involved in family counseling. They are an excellent group to bring together to discuss cases. Using the ministerial association, we have created a consultation program for clergymen of many denominations. Consultation with local physicians can be difficult to arrange but is usually worthwhile. Through the local medical society we arranged a consultation program with many general practitioners and pediatricians to discuss the psychological problems of childhood and of parenting and the use of psychotropic drugs in general practice. Each community has different needs and problems, and each consultant must make his own decisions about how to allocate his time among the agencies and organizations needing his services.#{149}
LEE,
M.D.
California
The
author designed a consultation package for a cornmental health center consultant to present to the relevant agencies and organizations in the community. The consultation package is designed to create a series of regularly scheduled voluntary group meetings that center on the discussion of a case or a particular topic. The package also includes a written agreement, an evaluation procedure, and a six- to eight-month free trial period. The steps for establishing a new consultative relationship and developing a consultation network are also outlined. By using those steps and the package, the author and his colleagues have successfully established consultation services with schools, with the welf are, probation, and police departments, and with organizations of physicians, nurses, and clergy. munity
community mental health center is mandated by to provide consultation and education as one of its 12 essential services. That provision is perhaps one of the most farsighted aspects of the law that established the centers. It is clearly intended to encourage the creation of indirect, or preventive, programs to supplement the centers’ traditional direct, or treatment, programs. Many centers find it difficult to establish such consultation programs, however. The centers have difficulties gaining entry into the appropriate community agencies, and they have difficulties establishing and maintaining a viable creative relationship with the agencies once they have gained entry. I will address primarily the problems of gaining entry into community agencies. My experience comes from three years of work at a community mental health center in a rural community in central California. The center had been in operation for about nine months before I arrived to develop and direct its consultation and education services. After arRThe
law
Dr. Lee’s mailing address 94709. He is a consultant Services
in
San
hancisco.
tion
services
fornia,
and
Martinez, He
is 1628 Euclid Avenue, Berkeley, California to Contra Costa County Mental Health California, and to the Pacific Medical Center in
formerly
at the Emanuel
also
was
director
HOSPITAL
was
director
Mental Health of the center.
&
of
consultation
Center
COMMUNITY
and
educa-
in Turlock,
PSYCHIATRY
Cali-
riving, I discovered that most of the staff in the agencies in the catchment area had no idea of the services a mental health consultant could offer. The few consultees who did have some experience with private psychiatric consultants reported almost unanimously that their experiences had been unproductive. Their criticisms fell into four major categories. The first was that the consultants had a passive, nondirective style. They refused to take an active role in analyzing the problem and in making concrete, practical suggestions for its solution. As one staff member said, We described a problem to our consultant, and he graciously told us we had a problem. We asked him what he suggested we do about it, and he replied, What do you think you ought to do about it?’ The second criticism was that when the consultants did comment, their comments were about theoretical psychodynamics and diagnosis, and they gave no practical advice about how to proceed. For example, the consultant diagnosed ‘latent homosexuality” or borderline schizophrenia’ but failed to suggest specific approaches to the problem. The third criticism was that when consultants did make suggestions, the suggestions were often totally impractical considering the resources available to the agency staff and to the clients. For example, one consultant suggested long-term, one-to-one psychotherapy for a resistant, acting-out adolescent from a poor family with an unemployed alcoholic father and a depressed mother. The fourth criticism was that the consultant often used a consultee-centered rather than a client-centered approach. The consultant would analyze the staff rather than the clients. That approach engendered great resentment among the consultees. Such negative experiences made it difficult to create consultative relationships with the agencies. Thus our first moves were cautious. We started by informally interviewing as many workers as possible in each of the relevant agencies in our area, in order to discover what they considered their needs to be and what kind of operating procedure they would like to establish. We quickly discovered that staff often could not clearly define their needs and that they were even more unclear when it came to suggesting a structure for a “
‘
‘
“
‘
VOLUME
28
NUMBER
10 OCTOBER
1977
745
consultative relationship. Therefore, we decided to try to intuit their needs from whatever data we could gather and to develop a flexible format to propose to them. We designed a consultation package that we could present to each agency. The agency then could accept, modify, or reject the package.
ELEMENTS
OF
THE
PACKAGE
The consultation package we designed contained several elements; primarily it was a designated series of regularly scheduled voluntary group meetings centered on the discussion of a particular case or topic. Each element of the package will be discussed separately. Regularly scheduled meetings. The consultant is often initially faced with the question of whether to establish a regular meeting time with his consultees or to develop an on-call’ relationship in which the consultee is invited to contact the consultant whenever the need arises. In our experience the on-call relationship, particularly when established early, becomes the yehide for a polite brush-off. It becomes the equivalent of Don’t call us, we’ll call you. Therefore, we feel that regularly scheduled meetings should be established as soon as possible. The meetings may vary in frequency according to the consultee’s needs and the consultant’s resources, and may range from once a month to twice a week. We feel that bimonthly meetings are effective; they can have some impact on a system without initially overburdening either the agency or the consultant. We further suggest that initially each meeting last approximately an hour and a half. Voluntary attendance. Occasionally an administrator suggests that some of his staff be required to attend the meetings. In our experience, that requirement breeds resentment and distrust, so we prefer to keep all consultation meetings on a voluntary basis. Group format. The group process, through open discussion and problem-solving, can be an important force in facilitating change in an agency. Group consultation can provide an open forum that allows consultees to meet, to express their feelings and opinions, and to learn from each other. It can help break up the isolation and polarization that often exists in an agency. We have found the group format more efficient and effective than a one-to-one consultation with individuals in an agency. In a one-to-one system new ideas are often shot down by staff members who have not been part of the consultative process, and the status quo wins out over innovation and change. The group format also allows the consultant to gather vital information from a wide organizational base, and it puts the consultant in a better position to mobilize the resources of the entire agency to cope with clients’ problems. That is particularly true in school consultation, where not only the present classroom teacher but also others in the school system can shed light on the behavior and background of the problem student. For example, the pupil’s previous teachers can pro‘ ‘
‘
‘ ‘
746
‘ ‘
HOSPITAL
& COMMUNITY
PSYCHIATRY
vide information about the development of problems in the past. The principal of the school may have further historical information about the student and about his siblings and parents. The school psychologist, who may have tested the student or met with the parents, can also make a valuable contribution. Paradoxically, we found that the school psychologist often feels isolated in the school system, and the group consultation meetings can give him a better chance to share his views and expertise with the rest of the school’s staff. Finally, the school nurse may have information about the student’s physical problems as well as his family’s situation. Often the nurse will have visited the family’s home and will be able to give first-hand information about the student’s background. In fact, once group consultation meetings have been established, specific information-gathering roles can and should be assigned. For example, we try to arrange the schedule so that the school nurse or the current teacher will have made a home visit to assess the child’s environment and to observe parent-child interaction before the consultation. Thus the pupil’s behavior can be seen as a function of both classroom and home settings. Often behavior that seems dysfunctional at school, such as pushing, kicking, or aggressiveness, is necessary for survival at home or in the neighborhood. Furthermore, parental denials such as ‘Johnny never does that at home’ can be more easily dealt with once Johnny has been observed at home. We request that the school principal, current teacher, and as many previous teachers as possible attend the conference. We also request that the school psychologist test the child before the conference and be prepared to report on his findings then. Thus the group format provides an excellent opportunity for many people within an organization to put their heads together, to share information, to search for understanding, and to arrive at a new approach to the problem. We do not limit the number of people attending group meetings. Occasionally we have had 30 or more, but usually we have between ten and 20 participants. Case-centered discussion. We have found that the best way to begin a consultative relationship is with case consultation ; administrative consultation should be undertaken only after a good relationship has been established with the agency. As Caplan has so elegantly pointed out, the consultative relationship needs to be an egalitarian one in which two or more experts in different fields meet to share information, to develop a better understanding of the client’s behavior, and to develop some plan for coping with or intervening in the behavior. It is to be distinguished from case supervision.’ The first formal meeting of the consultant and the consultee is best planned as an orientation meeting ‘
‘
‘ C. Caplan, Theory Basic Books, New York
and Practice City,
1970.
of Mental
Health
Consultation,
.
At the first formal consultation meeting with the agency the consultant reviews the rationale, process, and format of the meetings, answers questions, and arranges the case presentation for the next meeting.
where ground rules are established. At that meeting we immediately emphasize the point, which will have to be made repeatedly, that we cannot hope to arrive at any suggestions for coping with a client’s problems or behavior until we have some understanding of what prompts the problems or behavior. For example, in a school setting we point out that the mere observation of a disruptive or fidgeting student doesn’t tell the teacher or the consultant the cause of that behavior. The student may be fidgeting or disruptive because he is too bright for the class and is bored, because he is too slow for the class and cannot follow the lesson and expects to fail, or because his parents are fighting and he is upset. In each case, we emphasize that understanding must precede coping. Direct client contact. Whenever possible, it is our practice to meet and to talk with each client to be presented either before the conference or during the meeting itself. We have found that such personal contact is invaluable to the consultant. At schools, for example, we arrange for the problem student to be available 20 minutes before the consultation meeting so we can talk to him and make a preliminary evaluation. In addition, a visit to the classroom by the consultant or an assistant can be a valuable way of seeing how the teacher and pupil interact. We have an arrangement with the probation and welfare departments to interview clients and their families (with their permission) behind a one-way mirror as part of the consultative session. We can then discuss the interview as well as the reports from the agency. Recommendations and follow-up sessions. Specific recommendations made at the end of each session should be recorded, so that they can be referred to at the follow-up sessions. In this way recommendations can be reviewed at the beginning of each new consultation, and the consultant can get continuous feedback about the previous cases. For instance, were the suggestions followed? If not, why not? If so, what happened? Did the suggestions help, or did they make things worse? Was there no change at all? The consultant’s attitude has to be one of humility and openness. He must convey the idea that we cannot know for certain what will work, and so it is a matter of trying something new that seems to make sense in view of what we presently understand about the individual.
He must also convey that if something doesn’t work, that too can contribute to further understanding and the development of new strategies and interventions. At the follow-up meetings, the consultant must get specific information from the consultees about how they tried to implement the suggestions that were made. Frequently the consultees report, We tried it and it didn’t work. On further exploration it is found, however, that what the consultee tried bears little resemblance to what the consultant thought he had suggested. Topic-centered consultation. As the consultation progresses, the consultees often ask that the meeting be devoted to a particular topic rather than to a case. We have found such topic-centered consultation to be a useful alternative to a case presentation. At schools, for example, we have talked about discipline, responsibility, minimal brain damage, and hyperkinetic children. At the probation department we have discussed alcohol, drug abuse, and sexual deviancy. At the welfare department we have discussed separation, grieving, death and dying, and family counseling. The presentations should be designed to encourage group involvement and discussion. Cases should be described to illustrate the principle presented, and the discussion should be kept as lively and free-flowing as possible. Financial support and the free trial period. A cornmunity mental health center usually must charge a fee for its consultation services. We have found, however, that it is unrealistic for the center to expect to be paid before the agencies have an idea of the value of such services. Thus we developed a six- to eight-month free trial period for each new agency. In effect we say to the agency’s administrators, You and we have no way of knowing in advance whether this consultation will be of any use to you. So let’s try it for a specified period of time, and then let’s evaluate how successful we have been. If at the end of the time you have found these meetings valuable, we will negotiate a fee for the services with you for the next specifled period of time. We have found that most agencies have been willing and able to pay for consultation services after the trial period. Contract and evaluation. The consultation package should include a written contract and an evaluation procedure. After the agreement has been made to schedule consultative meetings, we draw up an informal written contract covering both the trial period and any subsequent services; it is in the form of a letter describing who will meet when, where, and how often, and what the cost will be. The contract clarifies the arrangement for the consultant and the consultee. We have also found it valuable to conduct a formal survey at the end of the trial period to get the consultees’ views of the consultation process. We developed an evaluation form that we ask each consultee to fill out. The consultee does not have to sign the form. The form asks such questions as how many consultation sessions were attended, how helpful the consultation was, ‘ ‘
“
“
‘ ‘
VOLUME
28
NUMBER
10
OCTOBER
1977
747
whether the consultation had any over-all impact on the department, and what the consultee expected from the consultation and how the actual consultation differed from the expectation.2 The data collected from the form can be tabulated, and the findings can be discussed with the consultees and administrators.
MAKING
NEW
CONTACTS
In setting up a new consultative relationship, the consultant first needs to make a preliminary investigation of the agency. He can learn about the agency’s problems and needs through informal discussions with other professionals, as well as with agency staff members he knows and with other knowledgeable people in the community. He can also review articles about the agency in the local newspaper. The consultant’s first formal contact with the agency must be with its top executive officer or his designate. The consultant must express his interest in establishing a consultative relationship with the agency and find out if such an arrangement is feasible. If it appears to be, he can then discuss the agency’s structure, functions, current problems, and needs with the administrator. He can also outline services he might offer the agency. If there is a mutual agreement to proceed, the consultant would then arrange to meet with other agency administrators and then with line staff. The consultant may want to meet with the staff members either individually or in groups. He can explore their perceptions of their needs, which are often different from those identified by administrators. These exploratory meetings can be used to resolve differences and to set priorities and goals. In general, the consultant’s role at these meetings is to survey and identify needs and problems, arrive at priorities, specify objectives, select methods of intervention, and develop methods of evaluation. Finally, an agencywide meeting can be arranged with all staff members and administrators. The consultant can then summarize his findings, and agency members can come to a final consensus about their needs and priorities. Then the consultant can present his prop()sal for a consultative program. There must be time after the consultant’s presentation for questions, answers, and discussion. It is our practice to leave the meeting after the discussion 50 that agency staff can review the issues in private and can decide about whether or not to establish a consultation program. The agency administrator is asked to contact us within a week to ten days to notify 115 of the decision. If the decision is positive, the designated agency administrator and the consultant work out the specific details of the arrangement, such as the time, frequency, and length of meetings, date of the first meeting, and
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names of staff members who should attend the meetings. If the answer is negative, the consultant should try to find out why. Before the first formal consultation meeting, the consultant and the agency administrator should review and sign the consultation agreement letter that the consultant has drawn up. At the first meeting, the consultant reviews the rationale, process, and format of the meetings, answers questions, and arranges the first actual case presentation for the next meeting. If a community mental health center is to have a significant influence on its community, it must establish a network of services in many different agencies and organizations. They include schools and the probation, welfare, and police departments as well as organizations of nurses, ministers, and physicians. Once we have established a consultative relationship with a school district, we try to schedule meetings at each school level (elementary, junior high, and high school). We also schedule meetings at a different school each week, and invite teachers from the other schools in the district to attend. At the college level we have established a consultative program with the college’s counseling services. The probation department in our region is divided into an adult section and a juvenile section. We have found it best to arrange consultations with each section individually. We have observed that probation officers often do an excellent job with a minimum of counseling training. The two sections of the welfare department that we have been especially involved with are child welfare and foster placement. Staff in those sections as well as in the probation department are particularly interested in interviewing techniques and family therapy concepts and techniques. With policemen we use an existing educational framework rather than creating a separate consultative arrangement. We give lectures at the regional criminal justice training center on recognizing and coping with deeply disturbed individuals, crisis intervention, and coping with family disturbances. We present the material in open-ended, informal discussions as a part of the basic and advanced training programs for officers. Ministers advise many disturbed people and are often involved in family counseling. They are an excellent group to bring together to discuss cases. Using the ministerial association, we have created a consultation program for clergymen of many denominations. Consultation with local physicians can be difficult to arrange but is usually worthwhile. Through the local medical society we arranged a consultation program with many general practitioners and pediatricians to discuss the psychological problems of childhood and of parenting and the use of psychotropic drugs in general practice. Each community has different needs and problems, and each consultant must make his own decisions about how to allocate his time among the agencies and organizations needing his services.#{149}
