The Paraprofessional as a Referral Link in The Mental Health Delivery System Katherine A. Frank Hesse, M.S.W.*
A B S T R A C T : The role of the paraprofessional in the delivery of mental health services is often ambiguously defined. Even while performing the specific task of making a referral, the activities of the paraprofessional are subject to controversy. In this study the clients, the agency board members, and the community mental health agency workers all have different expectations of the qualifications, the knowledge, and the activities of the paraprofessional referral worker. It is suggested that the disparate views the participants bring to the referral situation make it unlikely that the paraprofessional will satisfy the expectations of all of them.
In recent years there has been much discussion in the professional literature about mental health paraprofessions: What they should be doing and h o w well they are doing it. Nearly 10 years ago Reiff and Riessman (1965) emphasized the importance of the indigenous paraprofessional as an expeditor of the mental health delivery system. Since that time the roles of the mental health paraprofessionals have expanded until paraprofessionals are found in nearly every facet of mental health, from planner to therapist. In some situations the functions of the paraprofessionals are well defined and their effectiveness is unquestioned; in other situations, however, there is considerable question about the function and the effectiveness of the paraprofessional (Gottesteld, Rhee, & Parker, 1970; Loewenberg, 1968; O'Donnell, 1970; Reiff & Riessman, 1965). One such situation is the use of the paraprofessional as a referral agent as originally suggested by Reiff and Riessman (1965). This study illustrates that one reason for this inability to evaluate and accept the effectiveness of the paraprofessional may be due to their ambiguously defined, and at times, controversial roles (Loewenberg, 1968). The typical neighborhood service center, as described by Perlman and Jones (1967), provides information and referral services to assist people in using established agencies and also acts as an advocate to protect the clients' interest and rights with respect to the other agencies. The mental health paraprofessional who is employed at a neighborhood service center functions as the referral link between the population of the *Ms. Hesse is currently a medical social worker at Milford Whitinsville Regional Hospital, Milford, Massachusetts 01756. This research was partially supported by a grant from the University of Connecticut. The author wishes to express appreciation to Raymond Pichey for his assistance in developing this research. 252
Community Mental Health Journal, Vol. 12(3), 1976
Katherine A. Frank Hesse
253
community the center serves and the mental health institutions of the city (Loewenberg, 1968; Bernard, Kurtagh, & Johnson, 1968). The mental health paraprofessional at the center must act, then, as a middleman between the distributors and consumers of mental health services. The referral worker performs numerous varied roles in making successful referrals and in interpreting, negotiating, educating, counseling, and so forth (Reiff & Riessman, 1965; Grossner, 1968). The worker in this setting also functions as an advocate for his clients, becoming the client's spokesman in presenting the problem to the agency and applying whatever pressure may be necessary to ensure adequate attention. The paraprofessional worker is in a delicate position in a referral situation: He must present the community client to the social agency in the best possible light while allowing the client to take as much responsibility for the referral as possible. But he must also insist that the client be served by the other agency, while coaxing from it the best possible service for the client. Thus the activities of the paraprofessional worker are loosely defined within the referral task and can be altered to meet the needs of the situation. Because of this vague structure, it is suggested that both the referral clients and the referral agencies have different concepts of the role of the indigenous mental health paraprofessional and different expectations of the referral situation. This referral situation was explored by studying the activities of the mental health paraprofessionals of a neighborhood service center while referring Spanish-speaking clients to the mental health institutions in a N e w England city. In particular, this study explored (a) the referral activities of the paraprofessional, and (b) the differences in the way the various participants viewed the usefulness of the referral process in terms of their expectations. The agency studied is a neighborhood center serving approximately 12,000 Spanish-speaking residents of a medium-sized urban community. At the time of this study the social service section of the agency included a director of social service, a program director, three paraprofessional neighborhood workers, and a lawyer. All three neighborhood workers were Puerto Rican bilingual individuals from the community w h o were familiar with the problems and populations of the area. The workers were selected for the positions because of their ability to work well with people, although only one worker had completed high school. Each worker had had previous experience in a "helping" position, that is, family planning, drug program, or missionary work. Agency policy was originated and performance was evaluated by the agency's board of directors. The board was composed only of Spanish-speaking individuals from the community. For the purpose of this study, mental health was defined broadly as the general well-being of an individual, and a mental health institution was considered any agency that assisted the client in the improvement or main-
254
Community Mental Health Journal
tenance of his situation. Agencies ranging from the state labor department to traditional mental health clinics were considered components of the mental health delivery system of the community. RESEARCH METHODOLOGY A profile of client characteristics and clients' requests was prepared from the records of all clients who used the services of the agency during the year of this study. The three neighborhood workers were individually interviewed in English using a structured questionnaire to determine their backgrounds, qualifications for the job, and attitudes about mental health agencies. Finally, to test their skills in making referrals, three case situations were presented to the workers and they replied with the process and strategy that they would follow. To investigate the views of the various parties involved in a referral, client, board members, and mental health agency personnel were questioned. Three different, but parallel, questionnaires were used. The respondents were asked to reply to the questions giving their first impressions, their own observations, and their experiences. The clients participating in this study were selected from agency records, and individuals with problems requiring the referral worker to contact a community mental health agency were chosen. Three representative board members were chosen to be interviewed. The community mental health agencies were selected because of the frequency of their appearance in the files of the study agency. Many of the traditional private mental health agencies, such as family counseling and child guidance clinics, were not included because the study agency's clients rarely, if ever, had contact with them.
RESULTS AND DISCUSSION
Client Profile The typical client using the study agency was a young Puerto Rican man or woman less than 30 years of age (53%) who was married or separated (67%). The client had limited schooling (6.2 years average) and did not consider himself fluent in English (94%). The client rented an apartment (90%), and did not have a telephone (55%), a driver's license (90%), or a car in the family (82%). Although the client was unemployed, he or she was unlikely to be on assistance (25% received assistance payments).
Request Profile During the 1-year study period, 23% of the clients requested interpretive or transportation services. Of the requests, 34% dealt with problems connected with the state and city welfare departments. These were further broken down into three types of requests: (a) those that asked for "support" in approaching the welfare department, (b) those that asked for "help" with welfare procedures, and (c) those that asked for "action" in dealing with a complaint. Of all contacts, 43% involved clients who requested help in making a referral or in dealing with an agency other than the welfare departments. All referrals regarding schools or employment were handled separately by either the agency director or the agency employment counselor.
Katherine A. Frank Hesse
255
Paraprofessionals" Responses In performing their referral services the paraprofessionals of this agency indicated that the type of referral strategy they were likely to use was influenced by their expectations of the responses of the mental health agencies. Each worker had an opinion of the quality of services of each area agency, but one worker's opinion did not always agree with another's. Each formulated his opinions on his personal experiences. The workers had discovered that one w a y to make successful referrals was to cultivate relationships with individual staff members of the referral agencies and to try to conduct their referrals through them. The workers also assessed the ability of the clients and the seriousness of the problem. As with the agencies, the workers had generalized views about their clients, one feeling that the clients needed their services to orient themselves to the city and to work with the "system." Another worker felt some clients were often too dependent on the services of the agency. The paraprofessionals felt their role as middleman--giving information, transportation, interpretation, and what was called "expediting for d i e n t s " - - w a s important to the success of the client's referral, but they did not hesitate to use techniques of advocacy to ensure that the clients were served with all due respect and speed. When formulating a referral strategy for the hypothetical case situations, each worker suggested essentially similar approaches appropriate to resolving the problem. In some situations, however, there was a tendency immediately to become the client's advocate without complete exploration of the facts. Despite this eagerness to assume responsibility for their clients, the worker's assessment of the best strategy apparently led to many successful referrals, judging from both the results found in the files of the agency and the responses of the clients interviewed.
Qualification of Worker The three classes of respondents disagreed in their opinions about w h o m the neighborhood referral worker should be. The three board members interviewed felt that the agency should and would continue to hire indigenous paraprofessionals for the position, but they consistently expected a high quality of service and knowledge from these local individuals. They h o p e d that in the future these workers would receive special training or would have more formal education. The majority of the eight clients interviewed expected the referral worker to be a "social worker" with a great deal of knowledge. It is difficult to define exactly what the term "social worker" meant to the clients in terms of education, but it would appear they would have preferred a worker trained specifically to help them with their problems rather than a neighborhood person with limited skills. Despite the clients' high expectations of the workers, only three of the eight clients interviewed indicated
256
Community Mental Health Journal
that they would discuss personal or family problems with the workers, while four others indicated that they might, under certain circumstances. One client refused to discuss any problem with the agency worker and viewed the paraprofessional solely as an expeditor. The eight community agencies consistently concluded that the agency referral worker would be "just a Spanish-speaking neighborhood individual," hopefully one with some skills in dealing with the Spanishspeaking people. In contrast to this expected lack of education, the agencies expected the neighborhood mental health worker to have the ability to take a psycho-social history and be familiar with the clients' educational and employment experiences. They did not expect the worker to have clinical diagnostic or therapeutic skills. There was then a discrepancy between the board members', the clients', and the agencies' expectations of the abilities of the mental health paraprofessional. The clients and the board expected the workers to know a great deal about the community and to do a great deal about the clients' problems, but the clients were unwilling to share with the referral worker the significant personal information n e e d e d to make a professional referral. The mental health agencies expected the worker to be less well educated than the clients did, but they expected the worker to have acquired advanced skills in history taking in order to present fully the clients' problems. Clearly, none of the parties involved were completely confident in the abilities of the paraprofessionals, but they all hoped for a competent level of performance in completing the referral. Referral Activities During a preliminary study (Hesse, 1971) on the referral activities of the neighborhood service center, four basic referral strategies were identified that were consistently used in responding to the client's request for assistance with other agencies. Despite the distinct activities of each strategy, it must be noted that in almost all cases elements of all four types of responses are evident and it is difficult to classify strictly each referral. 1. Information referral. The worker gave the clientinformationabout where to go for assistance and called to make an appointment for him. 2. Transportation and interpretation. The worker provided transportation to the agencyor interpreted for the client at the agency. 3. Expediting referral. The worker helped the client with obtaining the required documents, completingforms, and encouragingthe clientto followup suggestions about the problem. 4. Advocacy referral. The worker became the client's spokesman presenting the situation or problem to the agency for the client and even applying pressure if the agency is slow tc help the client. The final area of research focused on these referral activities of the paraprofessionals. Each group of respondents, clients, board members, and
Katherine A. Frank Hesse
257
agencies was asked to rank the usefulness of the four identified referral strategies. All the board members felt that the paraprofessional should be free to use whatever strategy was necessary to assist the client. They showed no hesitation in approving an advocacy stance if the situation of the client justified it. Most (71%) of the clients were emphatic in their choice of the expedi, ting response as most useful and the information and telephone referral as least helpful. There was equal interest (85 %) in advocacy and transportation and interpretation referrals for second and third choices. The agencies, however, were just as definite in ranking the advocacy response as their last choice (67%), although disagreeing on the favored responses. Thus the clients and agencies had marked differences in their referral strategy preferences. The information referral received some interest as a useful response from the agencies, but the clients felt it would be the least useful method of referral. Both could see approximately equal usefulness in transportation and interpretation referrals. The clients definitely preferred having the mental health paraprofessional act as an expeditor for them, but the agencies were less convinced of the usefulness of this role. Finally, the advocacy referral was chosen as least useful by 67% of the agencies, although none of the clients rated it last. Again, it is clear that the parties involved did not have a consensus about the role the mental health paraprofessional should play in making a referral. SUMMARY The mental health paraprofessional is often called u p o n to facilitate the referral of clients to professional mental health agencies. In performing this task the paraprofessional is placed in a position about which their clients, their agency board, the mental health agencies, and they themselves frequently have different expectations. The participants in the referral process disagree about desirable qualifications of the referral worker, the knowledge the worker should have about their community and clients and the activities the worker should perform while making the referral. The disparate views the various participants bring to the referral situation make it very unlikely that the mental health paraprofessional would satisfy the expectations of all of them. Several implications for the delivery of mental health services can be drawn from these observations. In order to maximize the effectiveness of mental health services in reaching the total community, it is necessary for the mental health professional to understand the varying dimensions of the paraprofessional's role as a referral agent. Clearly the mental health agencies in this study found the variety of roles taken by the paraprofessional in performing the referral task less than fully acceptable.
258
Community Mental Health Journal
This lack of full appreciation of the neighborhood mental health worker's flexible role may contribute to the adversarylike relationship often found between the professional and the paraprofessional (Loewenberg, 1968). It should not be recommended that the paraprofessional activities become more constrained, but that, rather, the professional should become more accepting of their valuable contribution to the mental health delivery system. Finally, the uncertainties experienced by the paraprofessional in this referral role indicate that the successful worker must be a mature individual able to work within the parameters of an ambiguously defined situation (Andrade & Burstein, 1973; Reissman, 1967). The mental health paraprofessional functions as a vital link in the delivery of mental health services by acting as a referral agent, but the differing expectations imposed upon them make it doubtful that all participants in the referral process will be satisfied by their activities. REFERENCES Andrade, S., and Burstein, A. Social congruence and empathy in paraprofessional and professional mental health workers. Community Mental Health Journal, 1973, 9, 388-397. Bernard, S., Kurtagh, E., & Johnson, H. The neighborhood service organization: Specialist in social welfare innovation. Social Work, 1968, 13, 76~84. Gottesfelt, H., Rhee, C., & Parker, P. A study of the role of paraprofessionals in community mental health. Community Mental Health Journal, 1970, 6, 285-291. Grossner, G. Staff role in neighborhood organization. In J. Turner (Ed.), Neighborhood organization for community action. New York: National Association of Social Workers, 1968. Hesse, K. Client and request profile: Neighborhood service center. Unpublished manuscript, University of Connecticut, 1971. Loewenberg, F. M. Social workers and indigenous nonprofessionals: Some structural dilemmas. Social Work, 1968, 13, 65-71. O'Donnell, E. J. The professional volunteer versus the volunteer professional. Community Mental Health Journal, 1970, 6, 236-245. Perlman, R., & Jones, D. Neighborhood service centers. Washington, D.C.: U.S. Department of Health, Education, and Welfare, 1967. Reiff, R., & Riessman, F. The indigenous nonprofessional. New York: Behavioral Publications, 1965. Riessman, F. Strategies and suggestions for training nonprofessionals. Community Mental Health Journal, 1967, 3, 103-110.
A B S T R A C T : The role of the paraprofessional in the delivery of mental health services is often ambiguously defined. Even while performing the specific task of making a referral, the activities of the paraprofessional are subject to controversy. In this study the clients, the agency board members, and the community mental health agency workers all have different expectations of the qualifications, the knowledge, and the activities of the paraprofessional referral worker. It is suggested that the disparate views the participants bring to the referral situation make it unlikely that the paraprofessional will satisfy the expectations of all of them.
In recent years there has been much discussion in the professional literature about mental health paraprofessions: What they should be doing and h o w well they are doing it. Nearly 10 years ago Reiff and Riessman (1965) emphasized the importance of the indigenous paraprofessional as an expeditor of the mental health delivery system. Since that time the roles of the mental health paraprofessionals have expanded until paraprofessionals are found in nearly every facet of mental health, from planner to therapist. In some situations the functions of the paraprofessionals are well defined and their effectiveness is unquestioned; in other situations, however, there is considerable question about the function and the effectiveness of the paraprofessional (Gottesteld, Rhee, & Parker, 1970; Loewenberg, 1968; O'Donnell, 1970; Reiff & Riessman, 1965). One such situation is the use of the paraprofessional as a referral agent as originally suggested by Reiff and Riessman (1965). This study illustrates that one reason for this inability to evaluate and accept the effectiveness of the paraprofessional may be due to their ambiguously defined, and at times, controversial roles (Loewenberg, 1968). The typical neighborhood service center, as described by Perlman and Jones (1967), provides information and referral services to assist people in using established agencies and also acts as an advocate to protect the clients' interest and rights with respect to the other agencies. The mental health paraprofessional who is employed at a neighborhood service center functions as the referral link between the population of the *Ms. Hesse is currently a medical social worker at Milford Whitinsville Regional Hospital, Milford, Massachusetts 01756. This research was partially supported by a grant from the University of Connecticut. The author wishes to express appreciation to Raymond Pichey for his assistance in developing this research. 252
Community Mental Health Journal, Vol. 12(3), 1976
Katherine A. Frank Hesse
253
community the center serves and the mental health institutions of the city (Loewenberg, 1968; Bernard, Kurtagh, & Johnson, 1968). The mental health paraprofessional at the center must act, then, as a middleman between the distributors and consumers of mental health services. The referral worker performs numerous varied roles in making successful referrals and in interpreting, negotiating, educating, counseling, and so forth (Reiff & Riessman, 1965; Grossner, 1968). The worker in this setting also functions as an advocate for his clients, becoming the client's spokesman in presenting the problem to the agency and applying whatever pressure may be necessary to ensure adequate attention. The paraprofessional worker is in a delicate position in a referral situation: He must present the community client to the social agency in the best possible light while allowing the client to take as much responsibility for the referral as possible. But he must also insist that the client be served by the other agency, while coaxing from it the best possible service for the client. Thus the activities of the paraprofessional worker are loosely defined within the referral task and can be altered to meet the needs of the situation. Because of this vague structure, it is suggested that both the referral clients and the referral agencies have different concepts of the role of the indigenous mental health paraprofessional and different expectations of the referral situation. This referral situation was explored by studying the activities of the mental health paraprofessionals of a neighborhood service center while referring Spanish-speaking clients to the mental health institutions in a N e w England city. In particular, this study explored (a) the referral activities of the paraprofessional, and (b) the differences in the way the various participants viewed the usefulness of the referral process in terms of their expectations. The agency studied is a neighborhood center serving approximately 12,000 Spanish-speaking residents of a medium-sized urban community. At the time of this study the social service section of the agency included a director of social service, a program director, three paraprofessional neighborhood workers, and a lawyer. All three neighborhood workers were Puerto Rican bilingual individuals from the community w h o were familiar with the problems and populations of the area. The workers were selected for the positions because of their ability to work well with people, although only one worker had completed high school. Each worker had had previous experience in a "helping" position, that is, family planning, drug program, or missionary work. Agency policy was originated and performance was evaluated by the agency's board of directors. The board was composed only of Spanish-speaking individuals from the community. For the purpose of this study, mental health was defined broadly as the general well-being of an individual, and a mental health institution was considered any agency that assisted the client in the improvement or main-
254
Community Mental Health Journal
tenance of his situation. Agencies ranging from the state labor department to traditional mental health clinics were considered components of the mental health delivery system of the community. RESEARCH METHODOLOGY A profile of client characteristics and clients' requests was prepared from the records of all clients who used the services of the agency during the year of this study. The three neighborhood workers were individually interviewed in English using a structured questionnaire to determine their backgrounds, qualifications for the job, and attitudes about mental health agencies. Finally, to test their skills in making referrals, three case situations were presented to the workers and they replied with the process and strategy that they would follow. To investigate the views of the various parties involved in a referral, client, board members, and mental health agency personnel were questioned. Three different, but parallel, questionnaires were used. The respondents were asked to reply to the questions giving their first impressions, their own observations, and their experiences. The clients participating in this study were selected from agency records, and individuals with problems requiring the referral worker to contact a community mental health agency were chosen. Three representative board members were chosen to be interviewed. The community mental health agencies were selected because of the frequency of their appearance in the files of the study agency. Many of the traditional private mental health agencies, such as family counseling and child guidance clinics, were not included because the study agency's clients rarely, if ever, had contact with them.
RESULTS AND DISCUSSION
Client Profile The typical client using the study agency was a young Puerto Rican man or woman less than 30 years of age (53%) who was married or separated (67%). The client had limited schooling (6.2 years average) and did not consider himself fluent in English (94%). The client rented an apartment (90%), and did not have a telephone (55%), a driver's license (90%), or a car in the family (82%). Although the client was unemployed, he or she was unlikely to be on assistance (25% received assistance payments).
Request Profile During the 1-year study period, 23% of the clients requested interpretive or transportation services. Of the requests, 34% dealt with problems connected with the state and city welfare departments. These were further broken down into three types of requests: (a) those that asked for "support" in approaching the welfare department, (b) those that asked for "help" with welfare procedures, and (c) those that asked for "action" in dealing with a complaint. Of all contacts, 43% involved clients who requested help in making a referral or in dealing with an agency other than the welfare departments. All referrals regarding schools or employment were handled separately by either the agency director or the agency employment counselor.
Katherine A. Frank Hesse
255
Paraprofessionals" Responses In performing their referral services the paraprofessionals of this agency indicated that the type of referral strategy they were likely to use was influenced by their expectations of the responses of the mental health agencies. Each worker had an opinion of the quality of services of each area agency, but one worker's opinion did not always agree with another's. Each formulated his opinions on his personal experiences. The workers had discovered that one w a y to make successful referrals was to cultivate relationships with individual staff members of the referral agencies and to try to conduct their referrals through them. The workers also assessed the ability of the clients and the seriousness of the problem. As with the agencies, the workers had generalized views about their clients, one feeling that the clients needed their services to orient themselves to the city and to work with the "system." Another worker felt some clients were often too dependent on the services of the agency. The paraprofessionals felt their role as middleman--giving information, transportation, interpretation, and what was called "expediting for d i e n t s " - - w a s important to the success of the client's referral, but they did not hesitate to use techniques of advocacy to ensure that the clients were served with all due respect and speed. When formulating a referral strategy for the hypothetical case situations, each worker suggested essentially similar approaches appropriate to resolving the problem. In some situations, however, there was a tendency immediately to become the client's advocate without complete exploration of the facts. Despite this eagerness to assume responsibility for their clients, the worker's assessment of the best strategy apparently led to many successful referrals, judging from both the results found in the files of the agency and the responses of the clients interviewed.
Qualification of Worker The three classes of respondents disagreed in their opinions about w h o m the neighborhood referral worker should be. The three board members interviewed felt that the agency should and would continue to hire indigenous paraprofessionals for the position, but they consistently expected a high quality of service and knowledge from these local individuals. They h o p e d that in the future these workers would receive special training or would have more formal education. The majority of the eight clients interviewed expected the referral worker to be a "social worker" with a great deal of knowledge. It is difficult to define exactly what the term "social worker" meant to the clients in terms of education, but it would appear they would have preferred a worker trained specifically to help them with their problems rather than a neighborhood person with limited skills. Despite the clients' high expectations of the workers, only three of the eight clients interviewed indicated
256
Community Mental Health Journal
that they would discuss personal or family problems with the workers, while four others indicated that they might, under certain circumstances. One client refused to discuss any problem with the agency worker and viewed the paraprofessional solely as an expeditor. The eight community agencies consistently concluded that the agency referral worker would be "just a Spanish-speaking neighborhood individual," hopefully one with some skills in dealing with the Spanishspeaking people. In contrast to this expected lack of education, the agencies expected the neighborhood mental health worker to have the ability to take a psycho-social history and be familiar with the clients' educational and employment experiences. They did not expect the worker to have clinical diagnostic or therapeutic skills. There was then a discrepancy between the board members', the clients', and the agencies' expectations of the abilities of the mental health paraprofessional. The clients and the board expected the workers to know a great deal about the community and to do a great deal about the clients' problems, but the clients were unwilling to share with the referral worker the significant personal information n e e d e d to make a professional referral. The mental health agencies expected the worker to be less well educated than the clients did, but they expected the worker to have acquired advanced skills in history taking in order to present fully the clients' problems. Clearly, none of the parties involved were completely confident in the abilities of the paraprofessionals, but they all hoped for a competent level of performance in completing the referral. Referral Activities During a preliminary study (Hesse, 1971) on the referral activities of the neighborhood service center, four basic referral strategies were identified that were consistently used in responding to the client's request for assistance with other agencies. Despite the distinct activities of each strategy, it must be noted that in almost all cases elements of all four types of responses are evident and it is difficult to classify strictly each referral. 1. Information referral. The worker gave the clientinformationabout where to go for assistance and called to make an appointment for him. 2. Transportation and interpretation. The worker provided transportation to the agencyor interpreted for the client at the agency. 3. Expediting referral. The worker helped the client with obtaining the required documents, completingforms, and encouragingthe clientto followup suggestions about the problem. 4. Advocacy referral. The worker became the client's spokesman presenting the situation or problem to the agency for the client and even applying pressure if the agency is slow tc help the client. The final area of research focused on these referral activities of the paraprofessionals. Each group of respondents, clients, board members, and
Katherine A. Frank Hesse
257
agencies was asked to rank the usefulness of the four identified referral strategies. All the board members felt that the paraprofessional should be free to use whatever strategy was necessary to assist the client. They showed no hesitation in approving an advocacy stance if the situation of the client justified it. Most (71%) of the clients were emphatic in their choice of the expedi, ting response as most useful and the information and telephone referral as least helpful. There was equal interest (85 %) in advocacy and transportation and interpretation referrals for second and third choices. The agencies, however, were just as definite in ranking the advocacy response as their last choice (67%), although disagreeing on the favored responses. Thus the clients and agencies had marked differences in their referral strategy preferences. The information referral received some interest as a useful response from the agencies, but the clients felt it would be the least useful method of referral. Both could see approximately equal usefulness in transportation and interpretation referrals. The clients definitely preferred having the mental health paraprofessional act as an expeditor for them, but the agencies were less convinced of the usefulness of this role. Finally, the advocacy referral was chosen as least useful by 67% of the agencies, although none of the clients rated it last. Again, it is clear that the parties involved did not have a consensus about the role the mental health paraprofessional should play in making a referral. SUMMARY The mental health paraprofessional is often called u p o n to facilitate the referral of clients to professional mental health agencies. In performing this task the paraprofessional is placed in a position about which their clients, their agency board, the mental health agencies, and they themselves frequently have different expectations. The participants in the referral process disagree about desirable qualifications of the referral worker, the knowledge the worker should have about their community and clients and the activities the worker should perform while making the referral. The disparate views the various participants bring to the referral situation make it very unlikely that the mental health paraprofessional would satisfy the expectations of all of them. Several implications for the delivery of mental health services can be drawn from these observations. In order to maximize the effectiveness of mental health services in reaching the total community, it is necessary for the mental health professional to understand the varying dimensions of the paraprofessional's role as a referral agent. Clearly the mental health agencies in this study found the variety of roles taken by the paraprofessional in performing the referral task less than fully acceptable.
258
Community Mental Health Journal
This lack of full appreciation of the neighborhood mental health worker's flexible role may contribute to the adversarylike relationship often found between the professional and the paraprofessional (Loewenberg, 1968). It should not be recommended that the paraprofessional activities become more constrained, but that, rather, the professional should become more accepting of their valuable contribution to the mental health delivery system. Finally, the uncertainties experienced by the paraprofessional in this referral role indicate that the successful worker must be a mature individual able to work within the parameters of an ambiguously defined situation (Andrade & Burstein, 1973; Reissman, 1967). The mental health paraprofessional functions as a vital link in the delivery of mental health services by acting as a referral agent, but the differing expectations imposed upon them make it doubtful that all participants in the referral process will be satisfied by their activities. REFERENCES Andrade, S., and Burstein, A. Social congruence and empathy in paraprofessional and professional mental health workers. Community Mental Health Journal, 1973, 9, 388-397. Bernard, S., Kurtagh, E., & Johnson, H. The neighborhood service organization: Specialist in social welfare innovation. Social Work, 1968, 13, 76~84. Gottesfelt, H., Rhee, C., & Parker, P. A study of the role of paraprofessionals in community mental health. Community Mental Health Journal, 1970, 6, 285-291. Grossner, G. Staff role in neighborhood organization. In J. Turner (Ed.), Neighborhood organization for community action. New York: National Association of Social Workers, 1968. Hesse, K. Client and request profile: Neighborhood service center. Unpublished manuscript, University of Connecticut, 1971. Loewenberg, F. M. Social workers and indigenous nonprofessionals: Some structural dilemmas. Social Work, 1968, 13, 65-71. O'Donnell, E. J. The professional volunteer versus the volunteer professional. Community Mental Health Journal, 1970, 6, 236-245. Perlman, R., & Jones, D. Neighborhood service centers. Washington, D.C.: U.S. Department of Health, Education, and Welfare, 1967. Reiff, R., & Riessman, F. The indigenous nonprofessional. New York: Behavioral Publications, 1965. Riessman, F. Strategies and suggestions for training nonprofessionals. Community Mental Health Journal, 1967, 3, 103-110.
