We've been listening in on a lot of conversations lately where the term “integration” has been center stage. While the discussions cover a wide range of topics, the two most common are the integration of peers into a traditional workforce, and the integration of physical health services into behavioral health services.
As you may know, employing peers (people with a lived/recovery experience) in traditional behavioral health services has been a popular trend over the past few years. The research shows them to be a very effective addition given their skills at engaging people and building relationships based on strengths. But in spite of their popularity, the resistance to integration continues, thwarting the potential impact. In terms of integrating physical health, the actual inclusion of health services is very slow in coming, despite concerns raised by the disparity in life spans for people diagnosed with a mental illness (average of 25 years shorter).
In both cases there's a lot of agreement on the merits of integration, but no one seems to have the recipe for doing it. We don't have a recipe either. However, we can share a list of ingredients with you, give you a few tips about when to turn up the heat, and give you some clues for knowing when things are cooked.
The main ingredient for success
So how can you bake a deliciously synergistic dish of “integration?” Well, let's begin by taking a close look at the main ingredient-the staff. The values and beliefs held by staff are the bedrock of the culture of an organization. Some think that culture is held in the policies and procedures manuals. Sorry, but that would be too easy, and no one reads them anyway. The culture is actually held in the hearts and minds of the staff, the managers, the customers, and, yes, the bosses and the Board of Directors.
Preparing this main ingredient for integration is much more of a challenge than simply changing the rule books and telling everyone to read them. We're talking about preparing the hearts and minds of people for an experience they have a built-in resistance to: change. Preparing hearts and minds for change takes imagination, creativity, and a commitment to inviting everyone to the table, even those you wish would swing into a fast food joint instead.
So how do we approach this “hearts and minds” thing? Very carefully! It's a balancing act between respecting the existing beliefs and values, yet at the same time moving at a strong pace in the direction of change. You may grow weary of “balancing” early on and resort to bossing, blaming, and shaming. Try to resist this urge.
The process of change can be very aggravating due to the undercurrent of resistance. The root cause of resisting integration, whether it's related to integrating peers into the workforce or health into mental health, is simply fear; fear of change; fear of losing control; fear of losing status; fear of sharing power and responsibility. People don't ask themselves, “Am I afraid?” They ask, “What will I have to give up? How much autonomy will I lose? Will my values be compromised? Will my actions be questioned? Who's going to call the shots?”
Phases of fear
Fear of integration usually emerges in three different phases. Recognizing the phases and knowing that they are a natural part of the process may help you cope with it more gracefully.
Phase one: Meeting and talking. Early in the process this fear is usually masked with polite intellectualizing about how nice it would be to integrate, but how impossible it is due to the many barriers. After all, it's not politically correct to resist the obvious merits of integration. No one wants to admit that they really don't want to try it. So the most effective way to keep integration at bay is to just keep meeting, meeting, meeting and talking, talking, talking. Subcommittees may be appointed to identify even more reasons why it can't be done. Extensions are requested so more studies can be completed because, after all, there just isn't enough information to make a sound decision.
Phase two: Pushing back. When even the strongest resisters can't stand another meeting, they are left with a desperate option: Get mad. The reasonable excuses have been used up, and now we're down to finger pointing and blaming. Don't get us wrong-these are good people. They are just trying to avoid change and survive. Integration, by its very nature, requires significant changes that put a lot at stake, not the least of which are control and turf. These are big items in any organization. Anger is a way of trying to scare change away. Sometimes it works.
Phase three: Malicious obedience. We have probably all been guilty of using this tactic. It follows promptly on the heels of surrender: “OK, you win. We'll integrate.” On the surface there appears to be cooperation and half-hearted good will. But it doesn't take long to realize that while people are going through the motions, they have not bought into the goal of integration. Their theme song is “I told you this was a bad idea and it won't work,” and they make sure it doesn't by carefully interfering with the successes integration can bring about.
So how do we move beyond the resistance and create integrated services that are cost effective and provide improved and more comprehensive services to those we serve? Next month we'll get into the details of moving through this process with as little fall out as possible. For now, here are some things to keep in mind:
Leadership. If the leaders can stay in a positive frame of mind and reflect enthusiasm and excitement, this will help keep all the cooks in the kitchen-even the resistant ones. Keep summarizing the progress that has been made and stay focused on the goal. Most importantly, listen. There is no point in meeting if staff believes the leader is not listening. Listening to staff's objections and concerns does not mean you are agreeing with them; it means you are hearing them.
Ownership. The more ownership everyone has, the better, even though ownership creates other issues-like everyone wanting “their way.” This is a good sign, even though it may feel frustrating. Keep looking for common ground and places where compromises produce a better outcome.
Customer input. It's always tempting to leave the customers out of the conversation in the beginning. We think things are already complicated and we want to get them ironed out before we bring in the customers. We don't want to expose them to our chaos, and we don't want them adding another layer of confusion to the process. Sounds reasonable, but it's not a good idea. Bring them in right from the beginning. They will indeed add another layer, but they will also provide the bottom-line guidance needed to keep you focused on what they need instead of what's convenient for us. After all, that's one of the main reasons for integration.
Passion holders. Find the people who are the most passionate about integration. These are often the customers-the ones who will benefit from integration the most. Give them leading assignments so they can pull the rest of you along.
Accountability. Keep track of your progress and your benchmarks. Stay on course. This will help you establish momentum which is a very important ingredient in reaching your goal.
Keeping the above points in mind will help you get off to a good start on your move toward integration. With so many things up in the air and so much happening with funding cuts, this is an excellent time to look at integration. It can produce huge cost savings while improving the outcomes of services. We are all more open to finding new and better ways of doing our work. The pressure is on to be creative and innovative, and integration gives us a great place to start.
Next month we will give you more ingredients and some baking tips. If any of you want to “chime in” on the second installment of this topic, please send us a note. We are trying to listen! The more voices we can hear and include, the better.
Lori Ashcraft, PhD, directs the Recovery Opportunity Center at Recovery Innovations, Inc. in Phoenix. She is also a member of Behavioral Healthcare's editorial board. William A. Anthony, PhD, is director of the Center for Psychiatric Rehabilitation at Boston University. Behavioral Healthcare 2010 March;30(3):8-9