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Ready, set, integrate!

April 01, 2010

Last month we opened a conversation about the merits of program integration. We focused on two topics: the benefits of integrating peers into a traditional workforce and the advantages of integrating physical health services into behavioral health services. In both cases, the evidence supporting integration is indisputable, yet the implementation is very slow in coming.

We ended the conversation by pointing out the urgency of beginning the integration process now. Yes, there will be resistance. But if you resolve your own resistance first, you'll be in a good place to help others move through theirs.

Your own resistance may sound like this: “Integration is obviously a good idea, but we can't get into it right now. We have too many other priorities and too many things are up in the air-funding cuts, regulations, and so on.” We pointed out that these are exactly the reasons why now is the best possible time to move integration forward. When things are up in the air, they are easier to move-it's a law of nature.

Last month we gave you several ideas on how to get started. This month we want to talk directly to you, regardless of who you are or what part you play in the program. Since the readers of this column seem to run the gamut from service users to service providers, we're going to give each of you some unique assignments on how to participate in the changes required for integration. Of course, there will be some overlap, so you can read each of the assignments and borrow ideas from each other. Then again, there are also things that you alone will be best at carrying out. But it takes all of us, a unified front, to create positive change and to make a big difference.

Organizational pyramid

We want to remind you of the importance of our mission before we hand out assignments. The integration we are talking about will bring significant improvements for those who use our services. So this isn't just another one of those reorganizations based on turf wars, ego trips, or economy. The integration of peers and physical health into behavioral health services will result in people getting significantly better services.

Research shows peers to be very effective additions to the workforce given their ability to engage people and build relationships based on strengths. And in terms of physical health, the lifespan disparity for people diagnosed with a mental illness (an average of 25 years shorter) is enough reason to integrate physical and behavioral health services immediately. Agreement abounds on both of these issues, yet not much happens.

It's time to hand out the assignments. First, here are some tasks that apply to all of us:

  • Please go back and read last month's column. This will give you some general ideas and some tips on how to proceed, regardless of your position in the program.

  • Try not to ask “What's in it for me?” when it comes to integration. There is a lot in it for all of us, but if that becomes our focus, we will be blinded by self-centeredness and unable to see the bigger picture.

  • Try not to look around and gauge the commitment of others in order to measure your own. This is about you making a difference by maximizing your own inherent abilities. It's about doing your best.

Service users

Now let's get down to the individual assignments. Start at what a traditional organization considers the bottom of the classic organizational pyramid-just below the front-line workers. Here's where we find the service users-the reason the whole organization exists in the first place. (A recovery philosophy suggests turning the pyramid upside down with the service users on top where the decisions are made, as seen in the figure-but we'll save that for next month's column.) Service users, here are your assignments:

  • Check your attitude. If you see yourself as a powerless victim with no influence over what happens in the programs offered to you, get over that right away. Owning your own personal power is one of the first steps toward recovery. So see yourself as someone who has an important contribution to make to the planning and delivery of the services you hope to receive.

  • Think about the ways a peer could support your recovery process. Think about how your health could improve if you could get physical health services combined with your behavioral health services. The concept here is that your health providers would actually talk to each other about what they are doing to improve your health. What a concept!

  • Once you have a clear idea of how these services could benefit you, start talking to people about it. Talk to other service users, your physical health doctors, your treatment team, and your legislators. Speak using language that is simple, passionate, and clear.

  • Don't get mad if you don't get your way. Be reasonable and persistent, and be willing to compromise. Don't give up; just keep chipping away at it. Service users still outnumber service providers and if you get your act together, you can change the whole system.

Front-line workers

Next up on the classic organizational pyramid are the front-line workers. Your front-line workers may feel like some of the least important parts of the system, but this is not true. You are the eyes and ears, the arms and legs, and, most importantly, the voice that communicates what you are experiencing firsthand. If you go about your job just “putting in your time,” your voice cannot convey the important information you are able to gather. Here's what you can do to move transformation forward:

  • Keep your ears and eyes wide open. Listen to what the service users are saying. Listen to their families.

  • Think about the implications of what you are hearing: What does it mean? Think about how integration could improve services to those you are listening to: Use a little “critical thinking” and consider what it means. Report this up the ladder so policymakers will have pertinent and up-to-date information to guide planning and organizational transformation.

  • You may be tempted to feel threatened by the inclusion of peer employees. This could blind you to the benefits they have to offer and cause you to resist their integration into the workforce. Take a look inside and see if this is happening with you. If it is, realize that peers are not coming to take your job, but to enhance what you do and free up your time to do things that are more rewarding.

The formidable middle

Those of you who populate the middle of the pyramid pose the greatest challenge to organizational transformation (see “The Formidable Middle,” published in the February 2008 issue of Behavioral Healthcare). You can make or break just about anything. The implementation of change-the day-to-day tasks that actually make things happen-falls heaviest on you. You are in a position to inform and influence those above you and those below you on the organizationaal pyramid. You hold the key to change; how you use that key will determine the degree to which change happens in your organization. Here are a couple tips to guide you:

  • There are a lot of insignificant things that can affect your decision, such as promotional opportunities, turf, workload, and so on. Try not to let these be the critical factors in your decision making. Instead, ask yourself, “What will promote recovery the most for those we serve?”

  • Don't accept mediocrity as a standard. Use your power to influence policy and procedures and promote recovery and integration.

Leaders, bosses, and directors

Now we've worked our way up to the top of the pyramid where the leaders, the bosses, and the directors live. You know what to do. You understand the merits of integrating peers and health services into your programs.

Here's the advice we gave you last month: “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.” Beyond this, remember how many people are counting on you to lead them into a transformed system. It may not feel like it, but you are not alone. Let others help you.

OK, team, take these assignments and run with them! We'll be here to cheer you on. Integration of peers and physical health services can make you a stronger and more effective organization and provide much better outcomes for those on the bottom. Let's make room for them at the top.

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 April;30(4):14-15

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