The Role of Conflict Identification and Management in Sustaining Community Collaboration: Report on a Four-Year Exploratory Study Andrea K. Blanch, PhD Robyn Boustead, MPA Roger A. Boothroyd, PhD Mary E. Evans, RN, PhD, FAAN Huey-Jen Chen, PhD, MSN, APRN-BC Abstract Community collaboration has become increasingly common in behavioral health services. Conflict is likely to occur in any community coalition bringing together organizations with differing mandates, missions, and histories. However, research on how coalitions identify and handle conflict, and on the impact of conflict on sustainability is scarce. An exploratory study examined conflict in two federally funded children’s Bsystems of care^ using site visits and concept mapping to describe differences in how sites conceptualize and respond to conflict. Results suggest that unacknowledged and unaddressed conflict can negatively affect the development and sustainability of sites, and that focusing on cooperation may, paradoxically, make it more difficult to acknowledge conflict and to implement conflict transformation processes. Implications for behavioral health administrators are discussed, including potential interventions that could address these issues.
Introduction Community collaboration has become increasingly common in social services. Virtually every major federal human services policy initiative since the 1970s has emphasized the importance of Address correspondence to Roger A. Boothroyd, PhD, Louis de la Parte Florida Mental Health Institute, College of Behavioral and Community Sciences, University of South Florida, 13301 Bruce B. Downs Blvd., Tampa, FL 33612, USA. Phone: 813-974-1915; Email: [email protected]. Andrea K. Blanch, PhD, Sarasota, FL, USA. Phone: 941-312-9795; Email: [email protected] Mary E. Evans, RN, PhD, FAAN, Louis de la Parte Florida Mental Health Institute, College of Behavioral and Community Sciences, University of South Florida, Tampa, FL, USA. Phone: 813-980-2524; Email: [email protected] Huey-Jen Chen, PhD, MSN, APRN-BC, DeKalb Community Service, Decatur, GA, USA. Email: [email protected] Robyn Boustead passed away during the preparation of this study
)
Journal of Behavioral Health Services & Research, 2015. 1–9. c 2015 National Council for Behavioral Health. DOI 10.1007/s11414-015-9462-y
Conflict in Systems of Care
A. BLANCH ET AL.
interagency cooperation.1 Different forms of community collaboration have been described, including networks with or without legal agreements,2 cross-sector collaborations,3 community coalitions,4 and inter-organizational alliances.5 Cooperation between and among different agencies is increasingly assumed to be both necessary and desirable as a strategy for addressing complex social problems and funders often mandate collaboration despite little evidence of its effectiveness.3 Developing a coalition of agencies that do not have a shared destiny, that have traditionally competed for funds, or that have conflicting goals and cultures is a tremendous challenge.6–8 While it would seem obvious that conflict could derail collaboration, naturally occurring tensions are often not discussed openly. Agranoff refers to conflict as the Bmore or less hidden^ 2 side of collaboration. Research suggests that coalitions need to identify and recognize conflict among members, equalize relationships, support norms that allow conflict to be raised, and provide assistance in resolving and transforming conflict.9 Parties must clarify upfront what they bring to the table, and conflicting goals and cultures must be identified and discussed.7 Despite the importance of addressing differences, many coalitions appear to stress cooperation without developing clear guidelines for collaboration, internal communication systems that could foster problem discussion and resolution, or training in conflict management skills.4 Few organizations or coalitions are skilled at discriminating between constructive conflict that encourages creativity and destructive conflict that damages relationships. In addition, few managers know how to create a safe environment for conflict to be identified and worked with or how to support norms of conflict appreciation.10 Those organizations and coalitions that do attempt to address conflict often fail because they underestimate not only the inevitability of conflict, but its importance to the organization.11 The children’s system of care (SOC) initiative is one example of a federal policy mandating collaboration. The SOC model provides a set of core values and guiding principles for developing coordinated, collaborative systems to better serve children and youth with mental health concerns.12 The goal is to guide policymakers, practitioners, and community members through a transition from complex, discrete, monolithic, institutional (Bsilo^) approaches to a coordinated, holistic system of care.13 Sites are selected through a competitive review process and receive grants averaging US$850,000 a year for up to 6 years. The expectation is that sites will develop effective, coordinated service systems that will be sustained after the federal grant ends. One of the most fundamental premises of SOC philosophy is that effective partnerships be developed between parents and professionals, and between service sectors with different missions and mandates.12 SOC sites typically involve child-serving agencies and entities within communities, including child welfare, education, mental health, primary care, and juvenile justice. The SOC’s leadership includes a project director and a governing board, often called a policy board or committee. The goal of developing effective partnerships appears to be particularly challenging. The 2001 annual report to Congress noted that Bgrant communities consistently scored lowest on the principles of cultural competence and interagency collaboration.^14 Several researchers have reported similar results. Vinson, et al.15 noted that despite commitment to family involvement, few sites achieved partnerships that both families and agencies felt were fair and effective. While many sites appeared to have met their service goals, the interagency governance structure supporting shared decision-making was the component least likely to be sustained past federal funding. There is also anecdotal evidence that the failure to develop effective collaborative decision-making affects sustainability of SOC sites.16 Stroul and Friedman,17 in their discussion of strategies for expanding the SOC concept, note a number of significant underutilized strategies including creating or expanding the provider network and improving the cultural and linguistic competence of services. Their work indicates that the SOC concept has been successful, but could be even more successful, particularly as it expands, if attention were given to areas that could be strengthened.
The Journal of Behavioral Health Services & Research
2015
Although there has been little research on conflict in systems of care, the results of a survey of governing board members at SOC sites18 indicated that conflict in SOC sites is a common occurrence, and that some sources of conflict (incompatible goals, interpersonal relationships, and overlapping authority) were significantly more common than others. In this survey, sites reported responding to conflict with a variety of strategies, some direct and clearly constructive, such as Battempting to analyze the conflict and develop strategies to reduce it,^ and others more indirect and potentially less constructive, such as Bdealing with the conflict behind the scenes,^ Bignoring it,^ and Bconceding to the most powerful agent.^ The survey also found a complex relationship between prevalence and perceived impact of conflict and perceptions of the effectiveness of the site and the governing board, suggesting that the presence of conflict itself is less important than whether or not the organization attempts to address the issues and what particular strategies are used. In order to explore the specific ways in which SOC sites identify and manage conflict and to look for patterns that might explain these complex relationships, site visits and a concept mapping process were conducted at two SOC sites.
Method Site selection Data from a previous survey of conflict in systems of care were examined to identify potential sites for further study. Newly formed sites and those going through major transitions (such as the selection of a new director) were eliminated. A total of 17 sites were considered and 2 were selected. The first, a graduated site with over a decade of experience, had a low to moderate level of reported conflict and a high level of reported effectiveness. This site was widely known for its use of conflict management techniques and the governing board welcomed the site visit as a way to share what they had learned. The second site, which was entering its third year, had a moderate level of conflict which was serious enough to have raised the attention of state and federal administrators. This site was actively engaged in developing a conflict management strategy, and the governing board welcomed the site visit as a potentially helpful intervention. No site with a high level of unaddressed conflict agreed to participate. Site visit protocol Site visits were designed to gather qualitative data on how the governing board perceived conflict, how they responded to it, and how (or if) they had institutionalized conflict management processes into routine activities of the system of care. The site visit protocol included an initial meeting with the governing board to explain the study, structured interviews with key informants, a record review, a concept mapping process,16 and a debriefing with the SOC project director and invited board members. Site visits were conducted by a researcher trained in concept mapping technology and two co-facilitators experienced with conflict management and systems of care. Key informants were selected by each SOC site project director to represent the following major stakeholder groups: key partner agencies (administrators and line staff), SOC board members, and families. Structured interviews were designed to elicit historical information about the occurrence of conflict, how the SOC had responded to it, the site’s current view of collaboration and knowledge about conflict management, and any specific conflict management techniques that had been adopted. Extensive notes were taken, which were later coded and analyzed for references to collaboration, conflict, and conflict management. Using a standard protocol, board meeting minutes were reviewed for evidence of implicit or explicit conflict at all levels of the system (board, agency, program, and service) and any formal or informal steps taken to resolve it; and written policies and procedures were reviewed to assess procedures for handling conflict. The data collection protocols
Conflict in Systems of Care
A. BLANCH ET AL.
and coding scheme were based on the results of the needs assessment survey of conflict in systems of care previously conducted by the authors. Concept mapping Concept mapping was selected as an analytic tool because of its ability to surface and facilitate discussion about underlying belief systems and response patterns that often affect group and organizational behavior. Since little prior research had been done on how conflict in systems of care is conceptualized, it was important to allow each site to define the terms and relationships that best captured their own beliefs and patterns of response. Concept mapping is a process in which participants’ complex and diverse ideas, generated during a group brainstorming session, are translated into a coherent graphical framework.18,19 During the site visits, governing board members responded to the focus prompt: BWhen a conflict or disagreement arises among the participants in our system of care, what do we do?^ All non-duplicative statements were sorted based on similarity and rated according to importance in resolving conflicts effectively by using a standard 5-point scale with 1=not important and 5=very important. Sorted and rated data were entered into Concept Systems, a software program that performs multidimensional scaling and cluster analyses. Through these analytical processes, concept maps were generated to illustrate: (1) the array of statements expressed, (2) how the statements were related to one another, (3) how the ideas could be organized or clustered into general concepts, and (4) how concepts were rated by the group in terms of importance. Cluster names are generated by the software based on items in the cluster. The resulting maps and cluster names represent the site’s underlying beliefs about conflict and their habitual responses to it. Because maps arise from the unique responses of the group, rather than reflecting a pre-determined conceptual framework, they often look very different from site to site.
Results Site #1 Key informants at this site defined collaboration as requiring changes in individual agencies and viewed conflict as a source of energy and creativity that ultimately improves the collaborative culture. Every person interviewed was able to name at least one conflict management technique used in the SOC, and conveyed positive attitudes about its utility. In fact, one case manager defined her job as Bdealing with differences,^ noting that understanding conflict is essential to effective work with families. The record review indicated that training opportunities, written policies and procedures about conflict, and formal third-party conflict resolution processes (including mediation) were widely available. Conflict management processes had also been institutionalized in the governance structure of the system of care. Memoranda of Understanding (MOU) provided clear guidance for resolving conflicts, and a three-level decision process was used to transfer problems up or down to the appropriate level. When conflict was discussed at the governing board, the focus was on structural problems and solutions rather than on individuals. Leadership at the site attributed their effective collaboration to the successful resolution of conflict that had occurred early in the site’s development and to the use of skilled facilitators and mediators who had assisted in the resolution of these issues. This early success led them to see conflict as an important aspect of developing a collaborative culture. Figure 1 shows the concept map of the first site. Forty-three unique statements were generated during the brainstorming session and were used to create the map. There were no significant differences in importance between clusters. The five clusters that emerged in this concept map were
The Journal of Behavioral Health Services & Research
2015
Figure 1 Concept map from site #1
as follows: (1) respectful relationships between agencies, (2) a culture of collaboration, (3) structural and infrastructural supports for conflict management, (4) respectful communication, and (5) problem-solving skills. This map clearly describes a system that understands collaboration as a culture of respect and actively works to develop structural supports for managing conflicts at both the individual and agency levels. The cluster of statements considered most importance was labeled BAgency Relationships and Shared Vision^ (XImportance=4.40) and consisted of statements supporting the presence of a shared vision and the view that positive relationships among agencies was a key to managing differences effectively. A few examples of statements in this cluster were Bmutual respect about work, positions,^ Bpassion about families and children gets us through hard times,^ and Bshare same philosophy.^ Participants rated a cluster labeled BCollaborative Culture^ as the second most important (XImportance=4.32). Statements in this cluster reflected a working interagency culture that is collaborative in nature. Several examples of statements from this cluster included Bpeople see collaboration as part of job^ and Bhistory of leaders prioritizing and modeling collaboration.^ BStructure and Infrastructure^ was the label of the third most important cluster (XImportance=4.21) and consisted of statements noting that conflict was anticipated and structural accommodations were made to support its resolution. BThe Policy Council is one of many interagency forums for working things out,^ Bbringing issues to forum above or below as appropriate,^ and Bcoming together as a collective voice for policy concerns^ were examples of statements in this cluster. The fourth cluster was labeled BRespectful Communication^ and included statements associated with the importance of clear and respectful communication in preventing as well as helping to resolve inter-organizational conflicts. Participants rated this as the fourth most important (XImportance=4.16) cluster. Sample statements from this cluster included Bcommunicating directly and professionally,^ Blistening to each other,^ and Bstaying focused on issues.^ The final cluster that emerged at site #1 was labeled BProblem Solving Skills^ and included statements denoting that conflict management skills recognized, taught, modeled, and applied at policy, program, and practice levels. In terms of rank order, this was considered the least important of the five clusters (XImportance=3.89). Sample statements from this cluster included Busing data,^ Bconvening ad hoc meetings if no formal forum is available,^ and Bbeing accessible and knowing about each other’s programs.^
Conflict in Systems of Care
A. BLANCH ET AL.
Site #2 Key informants at this site were very aware of conflict and its potential negative impact, but they could not name any conflict management tools that were routinely used by the SOC, nor could they identify structural supports for addressing conflict. Collaboration was defined as Ban exchange of information^ rather than as requiring any kind of accommodation in agency behavior; sharing information was seen as a substitute for actively dealing with conflicting missions and mandates. For example, one written agreement stressed interagency communication, but noted that individual organizations are not bound to follow SOC protocols and should Bact in accordance with their own professional judgment.^ The record review showed no evidence that the site had institutionalized conflict management tools or turned techniques into governance or program structures. While mission and goal statements stressed collaboration, coordination, and integration (these concepts are mentioned eight times in a 1-page MOU), there were few specific details for implementation. Several MOUs remained in draft form, the result of failure to reach consensus. With the exception of a detailed and innovative procedure to ensure family voice, there was no written evidence of procedures for handling conflict at any level of the system. Notes from board meetings revealed that when conflicts were discussed, the board focused on personalities and motivations rather than structural solutions. Often, proposed interventions focused on improving the specific job performance of the individuals involved in the conflict (e.g., through training or supervision) rather than on improving conflict management or problem-solving skills. No example was found where a conflict was used to surface and examine existing structural conflicts. This suggests that neither the staff nor the board were skilled at differentiating between different sources of conflict, and in fact, there was no evidence of routine staff training on conflict or previous experience with conflict management professionals. Rather than seeing conflict as a creative force for collaboration, the governing board was clearly anxious about the potential negative impact of conflict, and was ambivalent about addressing it. Several key participants talked extensively about an ongoing administrative conflict that had the potential to seriously undermine SOC effectiveness. This conflict had already come to the attention of the site’s state and federal project officers, which was seen by key informants as very disturbing. The conflict resulted from a situation where one organizational partner had considerably more power than others. This partner was using intimidation to prevent key issues from being brought to the table, which in turn fostered Bparking lot^ discussions and negatively affected attendance at board meetings. When mediation had been suggested to help resolve this conflict, board members had tabled the issue, and subsequently presented a solution that had been arranged behind closed doors. The record review showed that their inability to confront this situation head-on was not an exception. In fact, the board routinely delayed, deferred, or avoided conflict. Board meeting minutes documented an average of one conflict per meeting, few of which were resolved or brought up again for additional discussion at later meetings. Figure 2 shows the concept map of this site, which was based on 72 unique statements generated during the brainstorming session. The six clusters generated in this concept map were as follows: (1) using training or workshops to increase professional (not conflict management) skills, (2) exchanging information, (3) responding to the human cost of the conflict (Bhuman resources^), (4) avoiding conflict whenever possible (Bprocrastinate^), (5) examining the motivation of the other party to the conflict, and (6) using aggressive or confrontational techniques (Bnasty^). While the first two clusters might be helpful in some circumstances, they did not address conflict in any direct manner. The remaining four clusters reflect strategies that are either neutral or actively destructive. In site #2, BProfessional Topics or Workshop^ was the label attached to the cluster of statements rated most important (Χ Importance=4.43) by participants. The cluster consisted of statements indicating that conflict was viewed as resulting from lack of knowledge or expertise in specific
The Journal of Behavioral Health Services & Research
2015
Figure 2 Concept map from site #2
2
professional area. Specific statements from this cluster included Busing training to explore conflict,^ Bdeferring to people with expertise,^ and Bkeeping families as the priority.^ The second most highly rated (Χ Importance=4.12) cluster was labeled BExchange Information.^ It included participant statements that viewed conflict as primarily resulting from poor communication and perceived the sharing of information as critical in resolution of conflict. BListening to everyone,^ Bensuring everyone is informed on an issue,^ and Bhaving a focus on communication^ were examples of statements in this cluster. BHuman resources^ constituted a third cluster of statements that viewed conflict as emotionally destructive and that having a focus on individual impact and relationships was important to its resolution. Participants rated this cluster as less important (Χ Importance=2.82) than the previous clusters. Specific statements in this cluster included Bfeeling tension but not raising it,^ Bkeeping moving forward even when conflict was destructive,^ Bsoftening the issue,^ and Bdiscussing the issue with those who are most comfortable with it.^ The fourth cluster was titled BProcrastination^ and included statements that indicated conflict was avoided whenever possible. Examples of statements in this cluster included Btabling issues,^ Bforming a committee or having a meeting,^ Bputting things off and hoping they will become easier,^ and Bavoiding, which stops everything.^ The importance rating for this cluster was Χ Importance=2.78. Cluster #5 was labeled BAttending to Other People’s Motives^ and consisted of statements that considered conflict a result of power dynamics and that solutions were achieved through political maneuvering. Examples of statements in this cluster were Bfigure out the politics and position oneself accordingly,^ Bspeculating about others’ motives,^ Bbuilding support for a position,^ and Btrying to persuade other people.^ Participants rated this cluster importance as Χ Importance=2.51. The final cluster (#6), which was the lowest rated cluster (Χ Importance=2.47) at site #2, was titled BNasty.^ This cluster reflected statements of behaviors in responses to conflict that bring out the worst in people. Examples included Bcreating rumors,^ Btaking cheap shots at others,^ Bthreatening and providing ultimatums,^ Bmaking promises that one never intends to keep,^ and Bengaging in black and white thinking.^ When presented with the concept map, governing board members unanimously agreed that it represented their system. Considerable discussion ensued about how ineffective (and even
Conflict in Systems of Care
A. BLANCH ET AL.
damaging) many of their responses were, especially the clusters labeled Battending to other people’s motives^ and Bnasty.^ The board was surprisingly open about the counterproductive ways in which they routinely responded to conflict. However, they had few ideas about how to create a more effective, collaborative culture.
Discussion This exploratory study examined conflict and its management within two SOC sites. The two sites revealed very different approaches to conflict and collaboration. At the first site, conflict was viewed as normal and even as a source of creativity. In fact, they saw conflict as an essential part of developing a collaborative culture. Conflict management skills were taught and modeled throughout the system. Staff saw themselves as actively engaged in conflict resolution as a normal part of their daily work. Conflict management techniques had been institutionalized with written protocols; staff went out of their way to identify potential conflicts early and to use them as diagnostic tools. All five of the factors identified in the concept mapping at this site were positive and reflected a sophisticated understanding of how conflict transformation can support systems change; and both the staff and the board clearly believed that conflict management techniques contributed to their site’s success and sustainability. This site could be called Bconflict-informed^ because it had integrated knowledge about conflict and skills in effectively responding to it throughout the SOC, and were routinely using conflict constructively to improve their system’s effectiveness. In contrast, the governing board at the second site clearly understood the potential destructive impact of conflict, acknowledged that conflict was a problem at their site, and was open about discussing it. However, neither the staff nor the board had skills for dealing effectively with conflict, and there was no evidence that they saw the potential for conflict to be helpful or even transformative. The concept map of this site portrayed a relatively undeveloped belief system about conflict and collaboration, and an almost complete lack of effective conflict management skills. Four of the six clusters in the concept map reflected negative impacts of conflict, use of power, avoidance, or hostility. This site could be called Bconflict-sensitive^ because they were both conscious of and reactive to conflict, without having yet developed the skills to work with it. Despite their current difficulties, the site visit team was hopeful about the future of this site because they had chosen to openly identify their current problems and were seeking outside expertise to help them construct more positive responses. Missing from this study was a site with ongoing conflict and no plans to address it. From the authors’ experience, it is not uncommon for SOC sites to have conflict simmering below the surface which is neither openly identified nor addressed.17 The authors hypothesize that sites of this kind will show a pattern of Bconflict-avoidant^ behavior—deny conflict happens, view it as a problem to be avoided, see it as antithetical to developing collaboration, and if it occurs, try immediately to tamp it down. The authors were unable to explore this hypothesis in this study because none of the potential sites that matched this profile would agree to a site visit. However, it seems likely that the serious conflict situation in site #2 might have been avoided if the board had embraced mediation when it was first suggested. The board’s conflict-avoidant tendency was exacerbated by their fear that their site might be criticized or even defunded if they were seen as having serious internal conflicts. The strong emphasis on collaboration in SOC philosophy may, paradoxically, make sites reluctant to acknowledge conflict when it occurs. In their rush to Bcollaborate,^ new coalitions may assume that conflict is something to be avoided at all costs, rather than recognizing its inevitability and planning for an effective response. The differences in how the two sites in this study responded to conflict were profound. The conflict-informed site recognized that the presence of conflict creates opportunity, and used it effectively to break through existing barriers and take the community collaboration to the next
The Journal of Behavioral Health Services & Research
2015
level. In contrast, the conflict-sensitive site vacillated between recognizing they had a problem and avoiding it completely. As they did so, the opportunities for change became limited and energies were channeled to maintaining the status quo. These differences suggest that the conscious introduction of a conflict transformation approach could make a difference in the functioning of systems of care. There are several steps that could be taken to move in this direction. Federal SOC leaders could acknowledge that recognizing and addressing conflict is a necessary—even critical—part of collaboration. They could stress that conflict provides the opportunity for transformation and is something to be welcomed rather than avoided. An organizational conflict self-assessment could be used in all new sites as a springboard for beginning the discussion. Training in conflict identification and conflict management could be a basic expectation for all parties involved in a SOC site. Many communities already have community dispute resolution centers, peer and student mediation programs, and other resources that could be brought to the table and could help SOC sites move from being conflict-avoidant to being conflict-informed.
Implications for Behavioral Health While further research is necessary to explore the long-term impact of conflict and conflict management on systems of care, these findings suggest that introducing principles and techniques of conflict transformation early in the development of systems of care may affect their success as well as their long-term sustainability. It is interesting to note that the most recent SOC Handbook20 does not include an entry on conflict and its management within SOC. Because conflict can impact the effectiveness of SOC, it may be useful to include information on this topic when The System of Care Handbook is revised. These findings also suggest that administrators and policymakers who mandate or encourage community coalition-building should include specific administrative requirements for conflict management processes. Requests for Proposals (RFP’s), guidelines, grant review protocols, and evaluation criteria that specified the inclusion of written conflict management procedures could increase the likelihood of success and sustainability of systems of care and other community coalitions by requiring them to describe how they will identify and handle conflict when it occurs.
Conflict of Interest The authors report no conflicts of interest.
References 1. Harbin G, McNulty B. Policy implementation: Perspectives on service coordination and interagency cooperation. In: SJ Meisels, JP Shonkoff (Eds). Handbook of Early Childhood Intervention. New York: Cambridge University Press, 1990, pp. 700–721. 2. Agranoff R. Inside collaborative networks: Ten lessons for public managers. Public Administration Review. 2006; 66(6): 56–65. 3. Bryson JM, Crosby BC, Stone MM. The design and implementation of cross-sector collaborations: Propositions from the literature. Public Administration Review. 2006; 66(suppl S1), 44–55. 4. Foster-Fishman PG, Berkowitz SL, Lounsbury SJ, et al. Building collaborative capacity in community coalitions: A review and integrative framework. American Journal of Community Psychology. 2001a; 29(2): 241–261. 5. Foster-Fishman PG, Salem DA, Allen N, et al. Facilitating interorganizational collaboration: The contributions of interorganizational alliances. American Journal of Community Psychology. 2001b; 29(6): 875–905. 6. Libby MK, Austin MJ. Building a coalition of non-profit agencies to collaborate with a county health and human services agency: The Napa County Behavioral Health Committee of the Napa Coalition of Non-Profits. Administration in Social Work. 2002; 26(4): 81–99. 7. Linden R. Learning to manage horizontally: The promise and challenge of collaboration. Public Management. 2003; 85(7): 8–11. 8. Wright ER, Wright DE, Kooreman HE, et al. The nature and impact of conflict within service coordination teams for children and adolescents with serious emotional and behavioral challenges. Administration and Policy in Mental Health and Mental Health Services Research. 2006; 33(3): 302–315. 9. Chavis DM. The paradoxes and promise of community coalitions. American Journal of Community Psychology. 2001; 29(2): 309–320.
Conflict in Systems of Care
A. BLANCH ET AL.
10. Caudron S. Keeping team conflict alive: Conflict can be a good thing. Here’s what you can do to make the most of this creative force. Public Management. 2000; 82(2): 5–9. 11. Weiss J, Hughes J. Want collaboration? Accept – and actively manage – conflict. Harvard Business Review. 2005; 83(3): 93–101. 12. Stroul BA, Friedman RM. The system of care concept and philosophy. In: BA Stroul (Ed). Children’s Mental Health. Creating Systems of Care in a Changing Society. Baltimore, MD: Paul H. Brookes Publishing Co, Inc., 1996, pp. 591–612. 13. Nissen LB, Merrigan DM, Kraft MK. Moving mountains together: Strategic community leadership and systems change. Child Welfare. 2005; 84(2): 123–140. 14. Center for Mental Health Services. Annual report to Congress on the evaluation of the Comprehensive Community Mental Health Services for Children and Their Families Program. Atlanta, GA: ORC Macro, 2001. 15. Vinson NB, Brannan AM, Baughman LN, et al. The system-of-care model: Implementation in twenty-seven communities. Journal of Emotional and Behavioral Disorders. 2001; 9(1): 30–42. 16. Thomlinson P, Boustead R, Blanch A. Conflict Management in Systems of Care: A Fruitful Research Agenda? Roundtable discussion presented at the Florida Mental Health Institute Annual Children’s Research Conference, Tampa, FL, March 2, 2004. 17. Stroul BA, Friedman RM. Effective strategies for expanding the system of care approach: A report on the study of strategies for expanding systems of care. Atlanta, GA: ICF Macro; 2011. 18. Boothroyd RA, Evans ME, Chen H-J, et al. An assessment of conflict and its management in systems of care for children with mental, emotional or behavioral problems. Journal of Behavioral Health Services and Research. 2015. 19. Trochim W. An introduction to concept mapping for planning and evaluation. Evaluation and Program Planning. 1989; 12(1): 1–16. 20. Stroul BA, Blau GM. The system of care handbook: Transforming mental health services for children, youth, and families. Baltimore: Paul H. Brookes Publishing Co., 2008.
The Journal of Behavioral Health Services & Research
2015
Introduction Community collaboration has become increasingly common in social services. Virtually every major federal human services policy initiative since the 1970s has emphasized the importance of Address correspondence to Roger A. Boothroyd, PhD, Louis de la Parte Florida Mental Health Institute, College of Behavioral and Community Sciences, University of South Florida, 13301 Bruce B. Downs Blvd., Tampa, FL 33612, USA. Phone: 813-974-1915; Email: [email protected]. Andrea K. Blanch, PhD, Sarasota, FL, USA. Phone: 941-312-9795; Email: [email protected] Mary E. Evans, RN, PhD, FAAN, Louis de la Parte Florida Mental Health Institute, College of Behavioral and Community Sciences, University of South Florida, Tampa, FL, USA. Phone: 813-980-2524; Email: [email protected] Huey-Jen Chen, PhD, MSN, APRN-BC, DeKalb Community Service, Decatur, GA, USA. Email: [email protected] Robyn Boustead passed away during the preparation of this study
)
Journal of Behavioral Health Services & Research, 2015. 1–9. c 2015 National Council for Behavioral Health. DOI 10.1007/s11414-015-9462-y
Conflict in Systems of Care
A. BLANCH ET AL.
interagency cooperation.1 Different forms of community collaboration have been described, including networks with or without legal agreements,2 cross-sector collaborations,3 community coalitions,4 and inter-organizational alliances.5 Cooperation between and among different agencies is increasingly assumed to be both necessary and desirable as a strategy for addressing complex social problems and funders often mandate collaboration despite little evidence of its effectiveness.3 Developing a coalition of agencies that do not have a shared destiny, that have traditionally competed for funds, or that have conflicting goals and cultures is a tremendous challenge.6–8 While it would seem obvious that conflict could derail collaboration, naturally occurring tensions are often not discussed openly. Agranoff refers to conflict as the Bmore or less hidden^ 2 side of collaboration. Research suggests that coalitions need to identify and recognize conflict among members, equalize relationships, support norms that allow conflict to be raised, and provide assistance in resolving and transforming conflict.9 Parties must clarify upfront what they bring to the table, and conflicting goals and cultures must be identified and discussed.7 Despite the importance of addressing differences, many coalitions appear to stress cooperation without developing clear guidelines for collaboration, internal communication systems that could foster problem discussion and resolution, or training in conflict management skills.4 Few organizations or coalitions are skilled at discriminating between constructive conflict that encourages creativity and destructive conflict that damages relationships. In addition, few managers know how to create a safe environment for conflict to be identified and worked with or how to support norms of conflict appreciation.10 Those organizations and coalitions that do attempt to address conflict often fail because they underestimate not only the inevitability of conflict, but its importance to the organization.11 The children’s system of care (SOC) initiative is one example of a federal policy mandating collaboration. The SOC model provides a set of core values and guiding principles for developing coordinated, collaborative systems to better serve children and youth with mental health concerns.12 The goal is to guide policymakers, practitioners, and community members through a transition from complex, discrete, monolithic, institutional (Bsilo^) approaches to a coordinated, holistic system of care.13 Sites are selected through a competitive review process and receive grants averaging US$850,000 a year for up to 6 years. The expectation is that sites will develop effective, coordinated service systems that will be sustained after the federal grant ends. One of the most fundamental premises of SOC philosophy is that effective partnerships be developed between parents and professionals, and between service sectors with different missions and mandates.12 SOC sites typically involve child-serving agencies and entities within communities, including child welfare, education, mental health, primary care, and juvenile justice. The SOC’s leadership includes a project director and a governing board, often called a policy board or committee. The goal of developing effective partnerships appears to be particularly challenging. The 2001 annual report to Congress noted that Bgrant communities consistently scored lowest on the principles of cultural competence and interagency collaboration.^14 Several researchers have reported similar results. Vinson, et al.15 noted that despite commitment to family involvement, few sites achieved partnerships that both families and agencies felt were fair and effective. While many sites appeared to have met their service goals, the interagency governance structure supporting shared decision-making was the component least likely to be sustained past federal funding. There is also anecdotal evidence that the failure to develop effective collaborative decision-making affects sustainability of SOC sites.16 Stroul and Friedman,17 in their discussion of strategies for expanding the SOC concept, note a number of significant underutilized strategies including creating or expanding the provider network and improving the cultural and linguistic competence of services. Their work indicates that the SOC concept has been successful, but could be even more successful, particularly as it expands, if attention were given to areas that could be strengthened.
The Journal of Behavioral Health Services & Research
2015
Although there has been little research on conflict in systems of care, the results of a survey of governing board members at SOC sites18 indicated that conflict in SOC sites is a common occurrence, and that some sources of conflict (incompatible goals, interpersonal relationships, and overlapping authority) were significantly more common than others. In this survey, sites reported responding to conflict with a variety of strategies, some direct and clearly constructive, such as Battempting to analyze the conflict and develop strategies to reduce it,^ and others more indirect and potentially less constructive, such as Bdealing with the conflict behind the scenes,^ Bignoring it,^ and Bconceding to the most powerful agent.^ The survey also found a complex relationship between prevalence and perceived impact of conflict and perceptions of the effectiveness of the site and the governing board, suggesting that the presence of conflict itself is less important than whether or not the organization attempts to address the issues and what particular strategies are used. In order to explore the specific ways in which SOC sites identify and manage conflict and to look for patterns that might explain these complex relationships, site visits and a concept mapping process were conducted at two SOC sites.
Method Site selection Data from a previous survey of conflict in systems of care were examined to identify potential sites for further study. Newly formed sites and those going through major transitions (such as the selection of a new director) were eliminated. A total of 17 sites were considered and 2 were selected. The first, a graduated site with over a decade of experience, had a low to moderate level of reported conflict and a high level of reported effectiveness. This site was widely known for its use of conflict management techniques and the governing board welcomed the site visit as a way to share what they had learned. The second site, which was entering its third year, had a moderate level of conflict which was serious enough to have raised the attention of state and federal administrators. This site was actively engaged in developing a conflict management strategy, and the governing board welcomed the site visit as a potentially helpful intervention. No site with a high level of unaddressed conflict agreed to participate. Site visit protocol Site visits were designed to gather qualitative data on how the governing board perceived conflict, how they responded to it, and how (or if) they had institutionalized conflict management processes into routine activities of the system of care. The site visit protocol included an initial meeting with the governing board to explain the study, structured interviews with key informants, a record review, a concept mapping process,16 and a debriefing with the SOC project director and invited board members. Site visits were conducted by a researcher trained in concept mapping technology and two co-facilitators experienced with conflict management and systems of care. Key informants were selected by each SOC site project director to represent the following major stakeholder groups: key partner agencies (administrators and line staff), SOC board members, and families. Structured interviews were designed to elicit historical information about the occurrence of conflict, how the SOC had responded to it, the site’s current view of collaboration and knowledge about conflict management, and any specific conflict management techniques that had been adopted. Extensive notes were taken, which were later coded and analyzed for references to collaboration, conflict, and conflict management. Using a standard protocol, board meeting minutes were reviewed for evidence of implicit or explicit conflict at all levels of the system (board, agency, program, and service) and any formal or informal steps taken to resolve it; and written policies and procedures were reviewed to assess procedures for handling conflict. The data collection protocols
Conflict in Systems of Care
A. BLANCH ET AL.
and coding scheme were based on the results of the needs assessment survey of conflict in systems of care previously conducted by the authors. Concept mapping Concept mapping was selected as an analytic tool because of its ability to surface and facilitate discussion about underlying belief systems and response patterns that often affect group and organizational behavior. Since little prior research had been done on how conflict in systems of care is conceptualized, it was important to allow each site to define the terms and relationships that best captured their own beliefs and patterns of response. Concept mapping is a process in which participants’ complex and diverse ideas, generated during a group brainstorming session, are translated into a coherent graphical framework.18,19 During the site visits, governing board members responded to the focus prompt: BWhen a conflict or disagreement arises among the participants in our system of care, what do we do?^ All non-duplicative statements were sorted based on similarity and rated according to importance in resolving conflicts effectively by using a standard 5-point scale with 1=not important and 5=very important. Sorted and rated data were entered into Concept Systems, a software program that performs multidimensional scaling and cluster analyses. Through these analytical processes, concept maps were generated to illustrate: (1) the array of statements expressed, (2) how the statements were related to one another, (3) how the ideas could be organized or clustered into general concepts, and (4) how concepts were rated by the group in terms of importance. Cluster names are generated by the software based on items in the cluster. The resulting maps and cluster names represent the site’s underlying beliefs about conflict and their habitual responses to it. Because maps arise from the unique responses of the group, rather than reflecting a pre-determined conceptual framework, they often look very different from site to site.
Results Site #1 Key informants at this site defined collaboration as requiring changes in individual agencies and viewed conflict as a source of energy and creativity that ultimately improves the collaborative culture. Every person interviewed was able to name at least one conflict management technique used in the SOC, and conveyed positive attitudes about its utility. In fact, one case manager defined her job as Bdealing with differences,^ noting that understanding conflict is essential to effective work with families. The record review indicated that training opportunities, written policies and procedures about conflict, and formal third-party conflict resolution processes (including mediation) were widely available. Conflict management processes had also been institutionalized in the governance structure of the system of care. Memoranda of Understanding (MOU) provided clear guidance for resolving conflicts, and a three-level decision process was used to transfer problems up or down to the appropriate level. When conflict was discussed at the governing board, the focus was on structural problems and solutions rather than on individuals. Leadership at the site attributed their effective collaboration to the successful resolution of conflict that had occurred early in the site’s development and to the use of skilled facilitators and mediators who had assisted in the resolution of these issues. This early success led them to see conflict as an important aspect of developing a collaborative culture. Figure 1 shows the concept map of the first site. Forty-three unique statements were generated during the brainstorming session and were used to create the map. There were no significant differences in importance between clusters. The five clusters that emerged in this concept map were
The Journal of Behavioral Health Services & Research
2015
Figure 1 Concept map from site #1
as follows: (1) respectful relationships between agencies, (2) a culture of collaboration, (3) structural and infrastructural supports for conflict management, (4) respectful communication, and (5) problem-solving skills. This map clearly describes a system that understands collaboration as a culture of respect and actively works to develop structural supports for managing conflicts at both the individual and agency levels. The cluster of statements considered most importance was labeled BAgency Relationships and Shared Vision^ (XImportance=4.40) and consisted of statements supporting the presence of a shared vision and the view that positive relationships among agencies was a key to managing differences effectively. A few examples of statements in this cluster were Bmutual respect about work, positions,^ Bpassion about families and children gets us through hard times,^ and Bshare same philosophy.^ Participants rated a cluster labeled BCollaborative Culture^ as the second most important (XImportance=4.32). Statements in this cluster reflected a working interagency culture that is collaborative in nature. Several examples of statements from this cluster included Bpeople see collaboration as part of job^ and Bhistory of leaders prioritizing and modeling collaboration.^ BStructure and Infrastructure^ was the label of the third most important cluster (XImportance=4.21) and consisted of statements noting that conflict was anticipated and structural accommodations were made to support its resolution. BThe Policy Council is one of many interagency forums for working things out,^ Bbringing issues to forum above or below as appropriate,^ and Bcoming together as a collective voice for policy concerns^ were examples of statements in this cluster. The fourth cluster was labeled BRespectful Communication^ and included statements associated with the importance of clear and respectful communication in preventing as well as helping to resolve inter-organizational conflicts. Participants rated this as the fourth most important (XImportance=4.16) cluster. Sample statements from this cluster included Bcommunicating directly and professionally,^ Blistening to each other,^ and Bstaying focused on issues.^ The final cluster that emerged at site #1 was labeled BProblem Solving Skills^ and included statements denoting that conflict management skills recognized, taught, modeled, and applied at policy, program, and practice levels. In terms of rank order, this was considered the least important of the five clusters (XImportance=3.89). Sample statements from this cluster included Busing data,^ Bconvening ad hoc meetings if no formal forum is available,^ and Bbeing accessible and knowing about each other’s programs.^
Conflict in Systems of Care
A. BLANCH ET AL.
Site #2 Key informants at this site were very aware of conflict and its potential negative impact, but they could not name any conflict management tools that were routinely used by the SOC, nor could they identify structural supports for addressing conflict. Collaboration was defined as Ban exchange of information^ rather than as requiring any kind of accommodation in agency behavior; sharing information was seen as a substitute for actively dealing with conflicting missions and mandates. For example, one written agreement stressed interagency communication, but noted that individual organizations are not bound to follow SOC protocols and should Bact in accordance with their own professional judgment.^ The record review showed no evidence that the site had institutionalized conflict management tools or turned techniques into governance or program structures. While mission and goal statements stressed collaboration, coordination, and integration (these concepts are mentioned eight times in a 1-page MOU), there were few specific details for implementation. Several MOUs remained in draft form, the result of failure to reach consensus. With the exception of a detailed and innovative procedure to ensure family voice, there was no written evidence of procedures for handling conflict at any level of the system. Notes from board meetings revealed that when conflicts were discussed, the board focused on personalities and motivations rather than structural solutions. Often, proposed interventions focused on improving the specific job performance of the individuals involved in the conflict (e.g., through training or supervision) rather than on improving conflict management or problem-solving skills. No example was found where a conflict was used to surface and examine existing structural conflicts. This suggests that neither the staff nor the board were skilled at differentiating between different sources of conflict, and in fact, there was no evidence of routine staff training on conflict or previous experience with conflict management professionals. Rather than seeing conflict as a creative force for collaboration, the governing board was clearly anxious about the potential negative impact of conflict, and was ambivalent about addressing it. Several key participants talked extensively about an ongoing administrative conflict that had the potential to seriously undermine SOC effectiveness. This conflict had already come to the attention of the site’s state and federal project officers, which was seen by key informants as very disturbing. The conflict resulted from a situation where one organizational partner had considerably more power than others. This partner was using intimidation to prevent key issues from being brought to the table, which in turn fostered Bparking lot^ discussions and negatively affected attendance at board meetings. When mediation had been suggested to help resolve this conflict, board members had tabled the issue, and subsequently presented a solution that had been arranged behind closed doors. The record review showed that their inability to confront this situation head-on was not an exception. In fact, the board routinely delayed, deferred, or avoided conflict. Board meeting minutes documented an average of one conflict per meeting, few of which were resolved or brought up again for additional discussion at later meetings. Figure 2 shows the concept map of this site, which was based on 72 unique statements generated during the brainstorming session. The six clusters generated in this concept map were as follows: (1) using training or workshops to increase professional (not conflict management) skills, (2) exchanging information, (3) responding to the human cost of the conflict (Bhuman resources^), (4) avoiding conflict whenever possible (Bprocrastinate^), (5) examining the motivation of the other party to the conflict, and (6) using aggressive or confrontational techniques (Bnasty^). While the first two clusters might be helpful in some circumstances, they did not address conflict in any direct manner. The remaining four clusters reflect strategies that are either neutral or actively destructive. In site #2, BProfessional Topics or Workshop^ was the label attached to the cluster of statements rated most important (Χ Importance=4.43) by participants. The cluster consisted of statements indicating that conflict was viewed as resulting from lack of knowledge or expertise in specific
The Journal of Behavioral Health Services & Research
2015
Figure 2 Concept map from site #2
2
professional area. Specific statements from this cluster included Busing training to explore conflict,^ Bdeferring to people with expertise,^ and Bkeeping families as the priority.^ The second most highly rated (Χ Importance=4.12) cluster was labeled BExchange Information.^ It included participant statements that viewed conflict as primarily resulting from poor communication and perceived the sharing of information as critical in resolution of conflict. BListening to everyone,^ Bensuring everyone is informed on an issue,^ and Bhaving a focus on communication^ were examples of statements in this cluster. BHuman resources^ constituted a third cluster of statements that viewed conflict as emotionally destructive and that having a focus on individual impact and relationships was important to its resolution. Participants rated this cluster as less important (Χ Importance=2.82) than the previous clusters. Specific statements in this cluster included Bfeeling tension but not raising it,^ Bkeeping moving forward even when conflict was destructive,^ Bsoftening the issue,^ and Bdiscussing the issue with those who are most comfortable with it.^ The fourth cluster was titled BProcrastination^ and included statements that indicated conflict was avoided whenever possible. Examples of statements in this cluster included Btabling issues,^ Bforming a committee or having a meeting,^ Bputting things off and hoping they will become easier,^ and Bavoiding, which stops everything.^ The importance rating for this cluster was Χ Importance=2.78. Cluster #5 was labeled BAttending to Other People’s Motives^ and consisted of statements that considered conflict a result of power dynamics and that solutions were achieved through political maneuvering. Examples of statements in this cluster were Bfigure out the politics and position oneself accordingly,^ Bspeculating about others’ motives,^ Bbuilding support for a position,^ and Btrying to persuade other people.^ Participants rated this cluster importance as Χ Importance=2.51. The final cluster (#6), which was the lowest rated cluster (Χ Importance=2.47) at site #2, was titled BNasty.^ This cluster reflected statements of behaviors in responses to conflict that bring out the worst in people. Examples included Bcreating rumors,^ Btaking cheap shots at others,^ Bthreatening and providing ultimatums,^ Bmaking promises that one never intends to keep,^ and Bengaging in black and white thinking.^ When presented with the concept map, governing board members unanimously agreed that it represented their system. Considerable discussion ensued about how ineffective (and even
Conflict in Systems of Care
A. BLANCH ET AL.
damaging) many of their responses were, especially the clusters labeled Battending to other people’s motives^ and Bnasty.^ The board was surprisingly open about the counterproductive ways in which they routinely responded to conflict. However, they had few ideas about how to create a more effective, collaborative culture.
Discussion This exploratory study examined conflict and its management within two SOC sites. The two sites revealed very different approaches to conflict and collaboration. At the first site, conflict was viewed as normal and even as a source of creativity. In fact, they saw conflict as an essential part of developing a collaborative culture. Conflict management skills were taught and modeled throughout the system. Staff saw themselves as actively engaged in conflict resolution as a normal part of their daily work. Conflict management techniques had been institutionalized with written protocols; staff went out of their way to identify potential conflicts early and to use them as diagnostic tools. All five of the factors identified in the concept mapping at this site were positive and reflected a sophisticated understanding of how conflict transformation can support systems change; and both the staff and the board clearly believed that conflict management techniques contributed to their site’s success and sustainability. This site could be called Bconflict-informed^ because it had integrated knowledge about conflict and skills in effectively responding to it throughout the SOC, and were routinely using conflict constructively to improve their system’s effectiveness. In contrast, the governing board at the second site clearly understood the potential destructive impact of conflict, acknowledged that conflict was a problem at their site, and was open about discussing it. However, neither the staff nor the board had skills for dealing effectively with conflict, and there was no evidence that they saw the potential for conflict to be helpful or even transformative. The concept map of this site portrayed a relatively undeveloped belief system about conflict and collaboration, and an almost complete lack of effective conflict management skills. Four of the six clusters in the concept map reflected negative impacts of conflict, use of power, avoidance, or hostility. This site could be called Bconflict-sensitive^ because they were both conscious of and reactive to conflict, without having yet developed the skills to work with it. Despite their current difficulties, the site visit team was hopeful about the future of this site because they had chosen to openly identify their current problems and were seeking outside expertise to help them construct more positive responses. Missing from this study was a site with ongoing conflict and no plans to address it. From the authors’ experience, it is not uncommon for SOC sites to have conflict simmering below the surface which is neither openly identified nor addressed.17 The authors hypothesize that sites of this kind will show a pattern of Bconflict-avoidant^ behavior—deny conflict happens, view it as a problem to be avoided, see it as antithetical to developing collaboration, and if it occurs, try immediately to tamp it down. The authors were unable to explore this hypothesis in this study because none of the potential sites that matched this profile would agree to a site visit. However, it seems likely that the serious conflict situation in site #2 might have been avoided if the board had embraced mediation when it was first suggested. The board’s conflict-avoidant tendency was exacerbated by their fear that their site might be criticized or even defunded if they were seen as having serious internal conflicts. The strong emphasis on collaboration in SOC philosophy may, paradoxically, make sites reluctant to acknowledge conflict when it occurs. In their rush to Bcollaborate,^ new coalitions may assume that conflict is something to be avoided at all costs, rather than recognizing its inevitability and planning for an effective response. The differences in how the two sites in this study responded to conflict were profound. The conflict-informed site recognized that the presence of conflict creates opportunity, and used it effectively to break through existing barriers and take the community collaboration to the next
The Journal of Behavioral Health Services & Research
2015
level. In contrast, the conflict-sensitive site vacillated between recognizing they had a problem and avoiding it completely. As they did so, the opportunities for change became limited and energies were channeled to maintaining the status quo. These differences suggest that the conscious introduction of a conflict transformation approach could make a difference in the functioning of systems of care. There are several steps that could be taken to move in this direction. Federal SOC leaders could acknowledge that recognizing and addressing conflict is a necessary—even critical—part of collaboration. They could stress that conflict provides the opportunity for transformation and is something to be welcomed rather than avoided. An organizational conflict self-assessment could be used in all new sites as a springboard for beginning the discussion. Training in conflict identification and conflict management could be a basic expectation for all parties involved in a SOC site. Many communities already have community dispute resolution centers, peer and student mediation programs, and other resources that could be brought to the table and could help SOC sites move from being conflict-avoidant to being conflict-informed.
Implications for Behavioral Health While further research is necessary to explore the long-term impact of conflict and conflict management on systems of care, these findings suggest that introducing principles and techniques of conflict transformation early in the development of systems of care may affect their success as well as their long-term sustainability. It is interesting to note that the most recent SOC Handbook20 does not include an entry on conflict and its management within SOC. Because conflict can impact the effectiveness of SOC, it may be useful to include information on this topic when The System of Care Handbook is revised. These findings also suggest that administrators and policymakers who mandate or encourage community coalition-building should include specific administrative requirements for conflict management processes. Requests for Proposals (RFP’s), guidelines, grant review protocols, and evaluation criteria that specified the inclusion of written conflict management procedures could increase the likelihood of success and sustainability of systems of care and other community coalitions by requiring them to describe how they will identify and handle conflict when it occurs.
Conflict of Interest The authors report no conflicts of interest.
References 1. Harbin G, McNulty B. Policy implementation: Perspectives on service coordination and interagency cooperation. In: SJ Meisels, JP Shonkoff (Eds). Handbook of Early Childhood Intervention. New York: Cambridge University Press, 1990, pp. 700–721. 2. Agranoff R. Inside collaborative networks: Ten lessons for public managers. Public Administration Review. 2006; 66(6): 56–65. 3. Bryson JM, Crosby BC, Stone MM. The design and implementation of cross-sector collaborations: Propositions from the literature. Public Administration Review. 2006; 66(suppl S1), 44–55. 4. Foster-Fishman PG, Berkowitz SL, Lounsbury SJ, et al. Building collaborative capacity in community coalitions: A review and integrative framework. American Journal of Community Psychology. 2001a; 29(2): 241–261. 5. Foster-Fishman PG, Salem DA, Allen N, et al. Facilitating interorganizational collaboration: The contributions of interorganizational alliances. American Journal of Community Psychology. 2001b; 29(6): 875–905. 6. Libby MK, Austin MJ. Building a coalition of non-profit agencies to collaborate with a county health and human services agency: The Napa County Behavioral Health Committee of the Napa Coalition of Non-Profits. Administration in Social Work. 2002; 26(4): 81–99. 7. Linden R. Learning to manage horizontally: The promise and challenge of collaboration. Public Management. 2003; 85(7): 8–11. 8. Wright ER, Wright DE, Kooreman HE, et al. The nature and impact of conflict within service coordination teams for children and adolescents with serious emotional and behavioral challenges. Administration and Policy in Mental Health and Mental Health Services Research. 2006; 33(3): 302–315. 9. Chavis DM. The paradoxes and promise of community coalitions. American Journal of Community Psychology. 2001; 29(2): 309–320.
Conflict in Systems of Care
A. BLANCH ET AL.
10. Caudron S. Keeping team conflict alive: Conflict can be a good thing. Here’s what you can do to make the most of this creative force. Public Management. 2000; 82(2): 5–9. 11. Weiss J, Hughes J. Want collaboration? Accept – and actively manage – conflict. Harvard Business Review. 2005; 83(3): 93–101. 12. Stroul BA, Friedman RM. The system of care concept and philosophy. In: BA Stroul (Ed). Children’s Mental Health. Creating Systems of Care in a Changing Society. Baltimore, MD: Paul H. Brookes Publishing Co, Inc., 1996, pp. 591–612. 13. Nissen LB, Merrigan DM, Kraft MK. Moving mountains together: Strategic community leadership and systems change. Child Welfare. 2005; 84(2): 123–140. 14. Center for Mental Health Services. Annual report to Congress on the evaluation of the Comprehensive Community Mental Health Services for Children and Their Families Program. Atlanta, GA: ORC Macro, 2001. 15. Vinson NB, Brannan AM, Baughman LN, et al. The system-of-care model: Implementation in twenty-seven communities. Journal of Emotional and Behavioral Disorders. 2001; 9(1): 30–42. 16. Thomlinson P, Boustead R, Blanch A. Conflict Management in Systems of Care: A Fruitful Research Agenda? Roundtable discussion presented at the Florida Mental Health Institute Annual Children’s Research Conference, Tampa, FL, March 2, 2004. 17. Stroul BA, Friedman RM. Effective strategies for expanding the system of care approach: A report on the study of strategies for expanding systems of care. Atlanta, GA: ICF Macro; 2011. 18. Boothroyd RA, Evans ME, Chen H-J, et al. An assessment of conflict and its management in systems of care for children with mental, emotional or behavioral problems. Journal of Behavioral Health Services and Research. 2015. 19. Trochim W. An introduction to concept mapping for planning and evaluation. Evaluation and Program Planning. 1989; 12(1): 1–16. 20. Stroul BA, Blau GM. The system of care handbook: Transforming mental health services for children, youth, and families. Baltimore: Paul H. Brookes Publishing Co., 2008.
The Journal of Behavioral Health Services & Research
2015
