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O n t h e R o a d to C o l l ab o r a t iv eT r e a t m e n t P l an n in g : C o n s u m e ra n d P r o v i d e r P e r s p e c t i ve sM atthew J . Ch inman, Ph.D.M arge Al lende, M.S.N. , A.P.R.N.R ichard Weingarten , M .A.Jean ne Steiner, D.O .Soph ie Tworkowski, L.C.S.W ., M .P.H.Larry D avidson, Ph.D.

Abs t r a c tA l t h o u g h c o n s u m e r s h a v e m a d e s i g n i fi c a n t g a i n s i n h a v i n g t h e i r v o i c e s h e a r d i n s e v e r a l a r e a s

w i t h i n m e n t a l h e a l th , t h e y h a v e m a d e l e s s p r o g r e s s i n b e i n g a b l e t o c o l la b o r a t e w i t h t h e i r o w n t r ea t -e r s in s e t ti n g t r e a t m e n t g o al s. O n t h e b a s i s o f s e v e r a l y e a r s o f g r o u n d w o r k b y s t a f f a t t h e C o n n e c t i c u tM e n t a l H e a l t h C e n t e r ( C M H C ) , t he P a t ie n t C a r e C o m m i t te e c o n d u c t e d a n e e d s a s s e s s m e n t o f p r o -v i d e r s a n d c o n s u m e r s t o a s s e s s b o t h g r o u p s ' c u r r e n t i n v o lv e m e n t , i n t e r es t in , a n d a t t i t u d e s t o w a r dc o l la b o r a t i v e t r e a t m e n t p l a n n i n g . T h e r e s u l t s in d i c a te t h a t p r o v i d e r s t e n d t o p l a c e m u c h o f t h e r e -s p o n s i b i li t y f o r t h e d if fi c u lt ie s i n i m p l e m e n t i n g c o l l a b o r a ti v e t r e a t m e n t p l a n n i n g o n c o n s u m e r s .A l s o , p r o v i d e r s t e n d t o u n d e r e s ti m a t e c o n s u m e r s ' in t e r e s t i n p a r t i c i p a t in g i n t h is p r o c e s s . I m p l i c a -t io n s o f th e s e f i n d i n g s f o r t h e d e v e l o p m e n t o f a n a g e n c y - w i d e t r a in i n g t o e n h a n c e t h e c o l l a b o r a t i v en a t u r e o f t r e a t m e n t p l a n n i n g a r e d i s c u ss e d .

S i g n i f i c a n t p r o g r e s s h a s b e e n m a d e d u r i n g t h e p a s t 1 0 to 1 5 y e a r s i n in c r e a s i n g t h e i n v o l v e m e n t o fm e n t a l h e a l t h c o n s u m e r s i n n u m e r o u s f a c e ts o f t h e d e s ig n , d e l iv e r y , a n d e v a l u a t i o n o f m e n t a l h e a l t hs e r v i ce s . C o n s u m e r s h a v e c o n t i n u e d t o b e i n v o l v e d i n a d v o c a c y 1-3 b u t a l s o h a v e b e c o m e a c t i v e i np r o v i d i n g a n d m a n a g i n g m u t u a l s u p p o r t a n d m e n t a l h e a l t h s e rv i c e s ;413 c o n d u c t i n g r e s e a r c h a n de v a l u a t i o n p r o j e c t s ; 14q7 a n d i n f l u e n c i n g p u b l i c p o l i c y a n d p r o g r a m d e v e l o p m e n t t h r o u g h d e s i g n i n g ,c o n d u c t i n g , a n d p a r t i c i p a t i n g in c o n s u m e r s a t i s fa c t i o n su r v e y s r e l a t e d to c l i n i c a l a n d r e h a b i l i t a t i v es e rv i ce s .l ~ 24 A s a n e x a m p l e o f t h i s la s t a re a , s e v e r a l v e r s i o n s o f c o n s u m e r " r e p o r t c a r d s " h a v e b e e n d e -v e l o p e d t o a s s e ss t h e s e r v i ce s p r o v i d e d b o t h b y p u b l i c se c t o r a n d b y m a n a g e d c a r e p r o v i d e r s o n d i m e n -s i o n s o f i n t e r e s t to c o n s u m e r s s u c h a s d i g n i t y , r e s p e c t , c u l t u r a l s e n s i t i v i t y , a n d e m p o w e r m e n t . 25-27

Address correspondence o M atthew J. Chinman, Ph.D., AssociateR e s e a r c h S c i e n t i s t, YaleSchool of Medicine, the C on-sultation Center, 389 W hitney Avenue, New Haven, CT 06511; e-mall: tcc@yale.edu.Marge Allende, M.S.N., A.P.R.N., s an ACT team clinical c o o r d i n a t o r a t th e C o n n e c t i c u t Mental H ealth Center.Richard W eingarten, M.A ., is director of peer support a t t h e C o n n e c t i c u t Mental Health C e n t e r .Jeanne Steiner, D.O., is a deputy medical director at the C onnecticut Men tal Health Center and an associate professor a tthe Yale School of Medicine.Sophie Tw orkowski,L.C.S.W., M.P.H., is director of so cial work at the Connecticut Mental Health Center.Larry Dav idson, Ph.D., is director of clinicals e r v i c e s a t t h e C o n n e c t i c u t Men tal Health Center and an assistant professorat the Y ale School of M edicine.

Treatment Planning CHINM AN et al . 211

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I n ad d i t i o n t o t h e s e s i g n s o f p r o g r e s s a t p r o g r am m at i c an d s y s t em i c l ev e l s , e f f o r t s h av e a l s o b eenm ad e t o i n c r ea s e d i r ec t l y t h e co l l ab o r a t i v e n a t u r e o f t h e p l an n i n g an d d e l i v e r y o f s e r v i ce s t h a t o ccu rb e t w een i n d i v i d u a l co n s u m er s an d p r o v i d e r s .2629 A l tho ugh increas ing the a c t ive par t i c ipa t ion o fi n d i v i d u a l co n s u m e r s i n t h e p l an n i n g an d ca r r y i n g o u t o f th e i r o w n t r e a tm en t , r eh ab i l i ta t i o n , an dr e c o v e r y m a y b e o n e o f t h e m o s t i m p o r t a n t ag e n d a s o f t h e c o n s u m e r m o v e m e n t , t h is a r e a i s a l so o n eof the m os t cha l l en g ing and l eas t dev e lop ed a t th is t ime. 2s'3 Prese n t ing a subs tan t i a l de par tu re f romco n v e n t i o n a l m o d e l s o f t r e a t m en t i n w h i ch c o n s u m er s a r e re l a t iv e l y p a s s i v e an d r e l y o n t h e ex p e r t i s eo f p r o v i d e r s t o s e t t r e a t m en t g o a l s , im p l em en t i n g a co l l ab o r a t i v e m o d e l o f tr e a t m en t f a ce s an ad d i -t i o n a l co m p l ex i t y a r i si n g f r o m t h e p o t en t i a l ly co n f l i c t in g ag en d a o f s o c i a l co n t r o l .2s'3 T ha t is , tw ot r ad i ti o n a l t a s k s o f m en t a l h ea l t h p r o f e s s i o n a l s h av e b ee n co n t r o l l i n g s o c i a l d ev i an ce an d t ak i n g ca r eo f i n d i v id u a l s w h o a r e j u d g e d t o b e u n a b l e t o t ak e c a r e o f th e m s e l v e s .3~ Th ese ag enda s h av e cont r ib -u t ed t o t h e i n eq u a l i t y b e t w een d o c t o r ( t h e m o r e p o w er f u l h e l p e r ) an d p a t i en t ( t h e l e s s p o w er f u lh e l p ee ) , w h i ch a t b e s t m i g h t l i m i t t h e i n p u t co n s u m er s c an h av e i n t o t h e t re a t m en t p r o ce s s an d a tw o r s t c an l e av e co n s u m er s f e e l i n g h e l p l e ss t o co n t r o l t h e i r il ln e s s . 3

C o l l ab o r a t i v e t r e a t m en t p l an n in g , t o t h e co n t r a r y , i s a i m ed a t r ev e r s in g s u ch a p r o c e s s b y em p o w -e r i n g c l i en t s to t ak e r e s p o n s i b i l i ty f o r t h e i r o w n r eco v e r y . A s d e s c r i b ed b y R i d g w ay ,

W hen the client chooses among alternatives and uses his or her ow n skills and resources to achieve goals,this enhances his or h er m otivation, investment, self-esteem, and sense of achievement, leading to greaterindependenceand self-mastery,and also contributessignificantly o the positiveoutcomeof services.(p. 5)30A ch a l l en g e f o r t h e co n s u m er m o v em en t , t h e r e fo r e , i s to c r ea t e a m o r e co l l ab o r a t i v e r e l a t io n s h i pb e t w een p r o v i d e r an d co n s u m er th a t w o u l d en ab l e t h is p r o ce s s to o ccu r .

T h i s a r t i c le d e s c r i b e s o n e p h as e o f a l a r g e r i n it i at i v e in d ev e l o p i n g a m o d e l o f co l l ab o r a t i v e t r e at -m en t p l an n i n g a t a l a rg e , a cad em i ca l l y af f il ia t ed , u r b an co m m u n i t y m en t a l h ea l t h c en t e r in N ewH av en , C o n n ec t i cu t . T h i s p h as e i n v o l v ed co n d u c t i n g a n eed s a s s e s s m en t w i t h b o t h p r o v i d e r s an dco n s u m er s t o a s s e ss r e l a ti v e l ev e ls o f i n t e r e s t in , an d ab i l it y t o p a r t i c ip a t e i n , co l l ab o r a t i v e t r e a t m en tp l an n i n g .

T h e C o l l ab o r a t iv e T r e a t m e n t - P l a n n i n gI n it ia t iv e a t t h e C M H C

T h e C o n n e c t i c u t M e n t a l H e a l t h C e n t e r ( C M H C ) , a s t a t e- f u nd e d c o m m u n i t y m e n t a l h e a l th c e n t e rr u n b y t h e Y a l e U n i v e r s i t y S ch o o l s o f M ed i c i n e an d N u r s i n g i n d o w n t o w n N ew H av en , i s th e l o ca lco n t ex t f o r th i s n eed s a s s e s s m en t . I n ad d i t i o n t o p r o v i d i n g a co m p r eh en s i v e a r ray o f in p a t i en t, p a r -t i a l h o s p i ta l , i n t en s i v e o u t p a t ien t , a s s e r ti v e co m m u n i t y t r e a t m en t , h o m e l e s s o u t r each , s p ec i a l t y H i s -p an i c , an d co n v en t i o n a l o u t p a t ien t c li n i ca l an d ca s e m an ag em en t s e r v i ce s, th e C M H C s e r v e s a s t h eL o c a l M e n t a l H e a l t h A u t h o r i t y f o r th e G r e a t e r N e w H a v e n a r e a , m a n a g i n g a n i n t e g r a te dco m m u n i t y - b a s ed n e t w o r k co n s i s t i n g o f r e s i d en t i a l , p s y ch o s o c i a l , an d v o ca t i o n a l r eh ab i l i t a t i v eserv ices .I n 1 9 9 2 , th e C M H C co n d u c t ed a co n s u m er s a ti s fac t i o n s u rv ey to ev a l u a t e t h e s e r v i ce s p r o v i d edb y t h e C M H C an d i t s n e t w o r k ag en c i e s . A m a j o r f in d i n g o f t h e f i rs t ad m i n i s t r a t io n o f th i s s u r v ey w ast h a t t h e l ev e l o f s a t i s f ac t i o n w as p o s i t i v e l y a s s o c i a t ed w i t h t h e d eg r ee t o w h i ch co n s u m er s f e l ta c t i v e l y i n v o l v ed i n d e s i g n i n g an d ca r r y i n g o u t t h e i r o w n ca r e . 21 T h e r ep o r t o f t h is f i n d i n g i n 1 9 9 3i n i t ia t ed an o n g o i n g p r o ce s s o f co l l ab o r a t i o n in v o l v i n g co n s u m er , f am i l y , an d p r o v i d e r r ep r e s en t a -t iv e s i n t h e d ev e l o p m en t o f a n ew m o d e l o f tr e a t m en t th a t a i m ed t o i n c r ea s e t h e in v o l v e m e n t b o t h o fco n s u m er s an d o f f am i l y m em b er s i n t h e t r e a t m en t - p l an n i n g p r o ce s s . A s a r e s u l t o f th i s p r o ce s s , t h eP a t i en t C a r e C o m m i t t e e a t t h e C M H C , w h i ch i s r e s p o n s i b l e f o r m o n i t o r i n g an d i m p r o v i n g t h e q u a l -i ty o f the s e rv ices de l ivered , began fou r m ajor in i t ia t ives : (1 ) c r ea t ing w r i t t en mater i a l s to as s i s t con-s u m er s , p r o v i d e r s , f am i l y m em b er s , o t h e r s e rv i ce p r o v i d e r s , an d co n s u m er ad v o ca t e s in m ak i n g t h et r ea t m en t - p l an n i n g p r o ce s s m o r e co l l ab o r a ti v e an d i n c l u s iv e o f a l l s tak eh o l d e r s ; ( 2 ) c r ea t i n g a n ew212 The Journal of Behavioral Health Services & Research 26:2 May 1999

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Table 1Barriers to Treatment Planning: Providers' R esp on sesP e r c e n t a g e E n d o r s e d

B a r r i e r b y P r o v i d e r s nC o n s u m e r ' s d i s a b il it yC o n s u m e r ' s n o n c o m p l i an c eC o n s u m e r ' s l a c k o f i n te r e stIns t i t u t i ona l c u l t u re ( i . e ., us i ng j a rgo n , foc u s i ng

o n d e f i c i t s a n d p r o b l e m s )L i a b i l i t y c o n c e r n sL a c k o f ti m eP r e s s u r e t o e s t a b l is h c e r t a i n g o a l s ( i .e ., s u b s t a n c e a b u s e

m u s t b e a d d r e s s e d b e f o r e p u r s u in g a n e d u c a t io n )L a n g u a g e b a r ri erO w n l a c k o f tr a in i n g

6 6 7 56 2 7 06 0 6 93 0 3 42 5 2 82 5 2 82 2 2 514 16

5 6

t r e a tm e n t - p l a n n i n g f o r m t h a t w o u l d b e a c c e p t a b l e to m a n a g e d c a r e c o m p a n i e s w h i l e a l s o e m p h a s i z -i n g c o n s u m e r s t re n g t h s , h o p e s , d r e a m s , a n d p r a c ti c a l n e e d s as w e l l as d i a g n o s e s a n d p r o b l e m s t o b ea d d r e ss e d ; ( 3 ) c o n d u c t in g a n e ed s a s s e s s m e n t o f C M H C p r o v i d e r s ' a n d c o n s u m e r s ' a tt it u d es t o w a r d ,a n d i n t e re s t in , c o l l a b o r a t i v e t r e a t m e n t p l a n n i n g a n d t h e d e g r e e t o w h i c h t h e y p e r c e i v e i t t o b e o c c u r -r in g ; a n d ( 4 ) c o n d u c t i n g a C M H C - w i d e t r a in i n g f o r p r o v id e r s a n d c o n s u m e r s t o e n h a n c e t h e ir w i l l-i n g n e s s a n d a b i l i t y to c o l l a b o r a t e in t h e t r e a t m e n t - p l a n n i n g p r o c e s s .

T h i s a r t i c le r e p o r t s o n t h e f in d i n g s o f th e n e e d s a s s e s s m e n t . T h e n e e d s a s s e s s m e n t s u r v e y f o c u s e so n w h a t b o t h p r o v i d e r s a n d c o n s u m e r s i n d e p e n d e n t l y r e p o r t is th e i r c u r r e n t in v o l v e m e n t i n , in t e r e s ti n , a n d a b i l i ty t o p a r t ic i p a t e in , c o l l a b o r a t iv e t re a t m e n t p la n n i n g . A l s o , b o t h g r o u p s w e r e a s k e d t oa d d r e s s s e v e r a l p o t e n t ia l b a r r i e r s to c o l l a b o r a t i v e tr e a t m e n t p l a n n i n g ( e .g . , l a c k o f t i m e , l a c k o f t r a i n -i n g , a n d l a c k o f in t e r es t ). G a t h e r i n g t h i s i n f o r m a t i o n w a s s e e n a s a n i m p o r t a n t f i r s t s t e p i n u n d e r -s t a n d i n g t h e i s s u e s t h a t n e e d t o b e a d d r e s s e d i n f u t u r e t r a in i n g s e s s io n s .

M e ~ o dM e a s u r e s

T h e P a t ie n t C a r e C o m m i t t e e - - w h i c h i n c lu d e s c o n s u m e r s , p s y c h o l o g i s t s , p s y c h i a tr i s ts , n u r s es ,s o c i a l w o r k e r s , a n d r e h a b i l i t at i o n t h e r a p is t s- - - -c r e a te d a o n e - p a g e s u r v e y t o b e a d m i n i s t e r e d t o p r o -v i d e r s . F ir s t, t h i s s u r v e y a s k e d b a s i c q u e s t io n s t o h e l p c h a r a c t e r i z e th e s a m p l e o f p r o v i d e r s w h or e s p o n d e d : p r o g r a m a n d p o s i t io n , e m p l o y e e v e r s u s tr a i n e e s ta t u s, y e a r s o f d i r e c t s e r v i c e e x p e r i e n c e ,y e a r s a t t he C M H C , a n d d i sc ip l in e . S e c o n d , t h e s u r v e y a s k e d p r o v i d e rs w h a t p e r c e n t a g e o f t h e c o n -s u m e r s o n t h e i r c a s e l o a d s w e r e i n v o l v e d i n t h e t r e a tm e n t - p l a n n i n g p r o c e s s ( 1 = none at all t o 5 = veryactive role), w e r e a b l e t o p a r t i c i p a t e i n t h e t r e a t m e n t - p l a n n i n g p r o c e s s ( 1 = none at all t o 5 =extreme), a n d w e r e i n t e r e s te d i n p a r t ic i p a t i n g i n th e t r e a t m e n t - p l a n n i n g p r o c e s s ( 1 = none at all to 5 =extreme). T h i r d , p r o v i d e r s w e r e a s k e d h o w i n te r e st e d t h e y w e r e i n l e ar n i n g m o r e a b o u t c o l l a b o r a t iv et r e a t m e n t p l a n n i n g ( 1 = none at all t o 5 = extreme). F i n a ll y , p r o v i d e r s r e s p o n d e d t o n i n e p o t e n t i a lb a r r i e r s ( y e s = 1 , n o = 0 ) , w h i c h m a y h a v e h i n d e r e d t h e i r a b il i ty t o c o n d u c t t r e a t m e n t p l a n n i n g i n ac o l l a b o r a t i v e w a y ( f o r a l i st o f p r o v i d e r b a r r i e r s, s e e T a b l e 1 ). a

a. Copies of the providerand consumersurveys are available rom he authors on request.Treatment Planning CHINMAN et al. 213

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T h e c o n s u m e r s u r v e y w a s c r e a t e d t o m i r r o r th e p r o v i d e r s u r v e y , f a c i li t at i n g c o m p a r i s o n s b e t w e e nt h e t w o g r o u p s . T h e c o n s u m e r s u r v e y a s k e d f o r d e m o g r a p h i c i n f o r m a t i o n ( a g e , g e n d er , e d u c a ti o n ,r a c e / e t h n i c i t y ) a n d f o r s e r v i c e i n f o r m a t i o n ( n u m b e r o f y e a r s r e c e iv i n g s e r v i c e s a t t h e C M H C , t e a ma s s i g n m e n t ) . T h e r e s t o f th e q u e s t io n s w e r e s i m i l a r t o th e p r o v i d e r s u r v e y ) C o n s u m e r s w e r e a s k e dh o w i n v o l v e d t h e y a r e i n t h e ir t r e a tm e n t p l a n n i n g , a n d h o w a b l e , h o w i n t e r e s t e d th e y a r e , a n d h o wi n t e r e s te d t h e y b e l i e v e t h e i r p r o v i d e r i s, in t h e t r e a t m e n t - p l a n n i n g p r o c e s s ( u s i n g t h e s a m e L i k e r t -t y p e s c a l e s a s d e s c r i b e d a b o v e ) . T h e c o n s u m e r s u r v e y a l s o p r e s e n t e d n i n e p o t e n t ia l b a r r i e r s th a t c o n -s u m e r s m a y e x p e r i e n c e a s h i n d e r i n g t h e ir a b i l it y t o b e i n v o l v e d in c o l l a b o r a t i v e tr e a t m e n t p la n n i n g .T h r e e ( l a c k o f t im e , t r a in i n g , a n d i n t er e s t) w e r e t h e s a m e b a r r i e r s p r e s e n t e d t o t h e p r o v i d e r s . T h eP a t i e n t C a r e C o m m i t t e e m e m b e r s c o n s t r u c t e d t h e q u e s ti o n s a n d t h e b a r r i e rs f o r b o t h s u r v e y s o n th eb a s i s o f t h e ir e x p e r i e n c e s a s p r o v i d e r s a n d c o n s u m e r s a n d t h e k n o w l e d g e g a i n e d f r o m t h e i r s e v e r a ly e a r s o f c o l l a b o r a ti o n w i th o t h e r c o n s u m e r s , p r o v id e r s , an d f a m i l y m e m b e r s i n d e v e l o p i n g a m o d e lo f c o l l a b o r a t i v e c a r e .P r o c e d u r e

T h e s u r v e y s w e r e a d m i n i st e r e d to a c o n v e n i e n c e s a m p l e o f p r o v i d er s a n d c o n s u m e r s . P r o v i d e rs u r v e y s w e r e g i v e n t o s t a f f a t a ll 1 6 c l in i c a l a n d r e h a b i li t at i v e p r o g r a m s a t th e C M H C . F o r m o s tt e a m s , t h e t e a m l e a d e r d i s tr i b u t ed t h e s u r v e y s t o t h e p r o v i d e r s a t a t e a m m e e t i n g , t h e p r o v i d e r s c o m -p l e t e d t h e m , a n d t h e n t h e t e a m l e a d e r c o l l ec t e d th e m . T h i s p r o c e s s t o o k a b o u t a m o n t h f r o m J u n e t oJ u l y 1 9 9 8. T h e c o n s u m e r s u r v e y s w e r e d i s tr ib u t ed t o c o n s u m e r s b y a tr a in e d c o n s u m e r i n t er v i e w e ri n t h e w a i t i n g a r e a s o f t h e m a i n C M H C a n d a t t h e w a i t i n g a r e as o f t h e s a te l li t e c l in i c s . T h e c o n s u m e rs u r v e y a l s o w a s a v a i l a b le in S p a n i s h . T h e c o n s u m e r i n t er v i e w e r r e p o r te d t h a t e v e r y o n e w h o w a sa s k e d t o p a r t i c i p a t e a g r e e d t o c o m p l e t e t h e s u r v e y . T h e c o n s u m e r i n t e r v i e w e r w a s a v a i l a b l e t oa n s w e r a n y q u e s t i o n s t h a t p a r ti c i p a n t s h a d a b o u t t h e s u r v e y a n d w a s a c c o m p a n i e d b y a t r a n s la t o rw h e n i n t e rv i e w i n g c o n s u m e r s w h o s p o k e o n l y S p a n i s h . I n s o m e c a s e s, t h e c o n s u m e r a d m i n i s te r e dt h e s u r v e y t o g r o u p s o f c o n s u m e r s ( e .g . , t h e r a p y g r o u p s ) . C o l l e c t i n g th e c o n s u m e r s u r v e y s t o o ka b o u t t h r e e m o n t h s a n d t h i s p r o c e s s o v e r l a p p e d w i t h t h e c o l l e c t i o n o f t h e p r o v i d e r d a t a ( J u n et h r o u g h A u g u s t 1 9 9 8 ). A c o n s u m e r in t e r v i e w e r w a s u s e d t o r e d u c e b i a s e s th a t te n d t o a r is e w h e na s k i n g c o n s u m e r s a b o u t t h e s e r v i c e s t h e y a r e c u r r e n t l y r e c e i v i n g 32 a n d b e c a u s e i t is c o n s i s t e n t w i t ht h e p h i l o s o p h y o f i n v o l v i n g r e le v a n t s t a k e h o l d e r s i n t h e r e s e a r c h p r o c e s s .

R e s u l t s

S a m p l e C h a r a c t e r i s t i c sS u r v e y s f r o m 1 1 3 p r o v i d e r s w e r e r e tu r n e d . T h e p r o v i d e r s h a d a n a v e r a g e o f 1 2 .7 -+ 8 . 4 y e a r s o f

d i r e c t s e r v i c e e x p e r i e n c e a n d 7 .2 - 6 . 8 y e a r s e x p e r i e n c e a t t h e C M H C . A l t h o u g h t h e r e w e r e n o sp e -c i f i c a p r i o r i q u o t a s , i t w a s d e s i r e d t o h a v e b r o a d r e p r e s e n t a t i o n f r o m s e v e r a l d i s c ip l i n e s . T h i s g o a lw a s a c h i e v e d a s th e s a m p l e i n c lu d e d s o c i a l w o r k ( 3 2 % ) , n u r s i n g ( 2 7 % ) , re h a b i l i t a ti o n ( 2 5 % ) , p s y -c h i a tr y ( 1 4 % ) , a n d p s y c h o l o g y ( 1 0 % ) . T h e r e w e r e 1 0 6 c o n s u m e r s s u r v e y e d . A b o u t h a l f w e r e m a l ea n d m o r e t h a n t w o - t h i r d s h a d a t le a s t a h ig h s c h o o l e d u c a t i o n . A b o u t 1 0 % w e r e N a t i v e A m e r i c a n ,1 7 % w e r e A f r i c a n A m e r i c an , 4 % w e r e A s i a n A m e r i c a n , an d 6 2 % w e r e w h i te . A b o u t 1 5 % r e p o r te dh a v i n g s o m e L a t i n o o r H i s p a n i c o r ig i n s. T h e a v e r a g e a g e w a s 4 4 .3 ( r a n g in g f r o m 2 2 t o 7 5 ) a n d th ea v e r a g e le n g t h o f t re a t m e n t a t t h e C M H C w a s 6 .2 y e a r s - 7 .9 y e a r s . T h e s a m p l e s o f b o t h p r o v i d e rsa n d c o n s u m e r s h a d d i v e r se r ep r e s e n ta t io n f r o m a l l th e v a r i o u s p r o g r a m s a t th e C M H C i n c lu d i n g o u t -p a t i e n t s e r v i c e s ( 4 6 % f o r p r o v i d e r s , 4 0 % f o r c o n s u m e r s ) , i n p a t ie n t s e r v i c e s ( 1 0 % , 9 % ) , s u b s t a n c ea b u s e s e r v i c e s ( 1 1 % , 3 1 % ) , i n t e n s i v e c a s e m a n a g e m e n t s e r v i c e s ( 1 7 % , 9 % ) , p a r t i a l h o s p i t a l s e r -v i c e s ( 4 % , 2 % ) , a n d a c l i n ic s p e c i f ic a l l y f o r m o n o l i n g u a l S p a n i s h - s p e a k i n g c o n s u m e r s ( 8 % , 5 % ) .T h e n u m b e r s f o r b o t h g r o u p s o n l y s u m t o 9 6 % d u e t o m i s s in g d a t a.

214 The Journal of Behavioral Health Services & Research 26:2 May 1999

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T a b l e 2B a rri er s t o T rea tm en t P lan n in g : C o n s u m ers ' R es p o n s esP e r c e n t a g e E n d o r s e d

B a r r i er b y C o n s u m e r s nL a c k o f ti m eU n s u r e o f h o w t o d o t re a t m e n t p la n n i n gN o t s u r e t h a t s et t in g t r e a t m e n t g o a l s w o u l d h e l pT r i e d i n t h e p a s t b u t h a v e g i v e n u pO w n l a c k o f i n te r e stD i s a g r e e w i th p r o v i d e r a b o u t la n g u a g eP r o v i d e r ' s l a c k o f in t e r e s tD i s a g r e e w i t h p r o v i d e r a b o u t t r ea t m e n t g o a l sA f r a i d t o d i s a g r e e w i t h p r o v i d e r

3 0 3 22 8 3 02 6 2 815 1615 1612 1311 1211 1211 12

Co l la b o r a t iv e Tr e a t m e n t - P la n n in g Co m p a r i s o n sI n d e p e n d e n t s a m p l e t -t e s ts w e r e u s e d t o a s s e s s t h e d i f f e r e n c e s b e t w e e n t h e p r o v i d e r s a n d t h e c o n -

s u m e r s o n f o u r a s p e c t s o f c o ll a b o r a ti v e tr e a t m e n t p l an n i n g : c o n s u m e r i n v o l v e m e n t , p r o v i d e r i n t e re s t ,c o n s u m e r i n te r e st , a n d c o n s u m e r a b ility . R e g a r d i n g c o n s u m e r i n v o l v e m e n t , p r o v i d e r s ( M = 3 . 4 5 , S D =1 .2 2 ) a n d c o n s u m e r s ( M = 3 . 4 9 , S D = 1 .2 2 ) d i d n o t d i f f e r i n th e i r a s s e s s m e n t s . B o t h g r o u p s r e p o r t e dt h a t c o n s u m e r s a r e s l ig h t l y m o r e t h a n m o d e r a t e l y i n v o l v e d in c o l l a b o r a t iv e t r e a t m e n t p l a n n i n g . F o rp r o v i d e r i n t er e s t in c o l l a b o r a t i v e t r e a t m e n t p l a n n i n g , t h e r e w a s a t r e n d t o w a r d c o n s u m e r s ( M = 4 . 0 2 ,S D = 1 .0 8 ) r e p o r t in g m o r e t h a n p r o v i d e r s t h e m s e l v e s r e p o r t ( M = 3 . 7 6, S D = 0 .9 3 ) , t( 2 0 2 ) = - 1 . 8 2 , p =.070 , w i t h bo t h g rou ps re por t i ng t ha t p rov i de rs a re c ons i de ra b l y i n t e re st e d . C onsu me rs (M = 3 .99, S D =1 .03) ha d s i gn if i ca n t ly m ore i n t e re st i n c o l l a bora ti ve tr e a t me nt p l a nn i ng t ha n prov i de rs t hough t t he y d i d(M = 2 .86 , S D = 1.13) , t(212) = -7.91 , p = .000. Fina lly , there w as a t rend tow ard cons um ers (M = 3.63,S D = 1 .04) r a t ing t he m se l ve s a s ha v i ng mo re a b i l it y t o do c o l l a bora t ive t r e a tme n t p l a nn i ng t ha n prov i de rsbe l i e ve d t he y ha d (M = 3 .31 , S D = 1.09) , t (211) = -1.94, p = .053.Co l la b o r a t iv e Tr e a t m e n t - P la n n in g Ba r r ie r s

T h e p r o v i d e r s ' r e s p o n s e s t o th e n i n e p o t e n t i a l b a r r i e r s to c o l l a b o r a t i v e t r e a t m e n t p l a n n i n g a r el i s te d i n T a b l e 1 a n d t h e c o n s u m e r s ' r e s p o n s e s a r e l i s te d i n T a b l e 2 . T h r e e b a r r i e r s t h a t p r o v i d e r se n d o r s e d t h e m o s t ( a n d m u c h m o r e t h a n a n y o f t h e o th e r s ) w e r e c o n s u m e r s ' d i sa b i li ty ( 6 6 % ) , c o n -s u m e r s ' n o n c o m p l i a n c e ( 6 2 % ) , a n d c o n s u m e r s ' l a c k o f i n te r e st ( 6 0 % ) . T h e b a r r ie r s th e c o n s u m e r se n d o r s e d t h e m o s t w e r e l a c k o f ti m e ( 3 0 % ) , u n s u r e t h a t tr e a tm e n t g o a l s w o u l d h e l p ( 2 8 % ) , a n du n s u r e h o w t o d o t r e a t m e n t p l a n n i n g ( 2 6 % ) . H e r e a g a i n , t h e p r o v i d e r s a n d c o n s u m e r s d i f f e r e dg r e a t l y o n t h e i r p e r c e p t io n s o f c o n s u m e r i n te r e s t. W h e r e a s m a n y p r o v i d e r s b e l i e v e d t h a t th e i r c l i-e n t s ' l a c k o f i n t e re s t is a b a r r i e r to c o l l a b o r a t i v e t r e a t m e n t p l a n n i n g ( 6 0 % ) , o n l y 1 5 % o f c o n s u m e r sb e l i e v e d t h i s w a s s o . T h e r e w a s a l s o a d i f f e r e n c e in t h e p e r c e p t i o n o f w h e t h e r o r n o t a b i l i t y to d o c o l -l a b o r a t i v e tr e a t m e n t p l a n n i n g w a s a b a r r i e r t o t h is p r o c e s s . M o s t p r o v i d e r s d i d n o t b e l i e v e t h a t t h e i ro w n l a c k o f tr a in i n g o n h o w t o d o t hi s ty p e o f t r e at m e n t p l an n i n g w a s a b a r r ie r ( 5 % ) , w h e r e a s 2 8 % o fc o n s u m e r s r e p o r t e d b e i n g u n s u r e h o w t o d o i t.

D i s c u s s i o nT h e s e d a t a s u g g e s t th a t a p r i m a r y o b s t a c l e th a t n e e d s t o b e a d d r e s s e d i n p r o m o t i n g a c o l l a b o r a t i v e

m o d e l o f t re a t m e n t p l a n n i n g i s th a t p ro v i d e r s o f t e n u n d e r e s ti m a t e c o n s u m e r s ' w i l l in g n e s s t o e n g a g e

T r e a t m e n t P l a n n i n g C H I N M A N e t a l. 215

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i n co l l ab o r a t i v e t r e a t m en t p l an n i n g . P r o v i d e r s m a y b e l e s s i n c l in ed t o p u t e f f o r t i n to t h i s p r o ce s s i ft h ey b e l i ev e t h a t t h e i r c l ien t s a r e n o t m o t i v a ted .

O n e p o s s i b i l it y t h a t m a y ex p l a i n p r o v i d e r s ' u n d e r e s t im a t i o n o f co n s u m er s ' i n t e r e s t is t h a t p e r -h a p s c o n s u m e r s h a v e l o w e x p e c t a t io n s a b o u t t h e d e g r e e t o w h i c h t r e a t m e n t p la n n i n g c a n b e h e l p f u li n t h e i r l iv e s . A b o u t h a l f o f t h e co n s u m er s r ep o r t ed e i t h e r g iv i n g u p o n co l l ab o r a t i v e tr e a t m en t p l an -n i n g , t h a t i t w o u l d n o t m ak e a d i f f e r en ce i n t h e i r li v e s, o r t h ey w e r e u n s u r e o f h o w t o d o i t. A s a r e s u lt ,p r o v i d e r s m ay t h en p e r ce i v e co n s u m er s ' l o w ex p ec t a t i o n s o r sk i ll a s a la ck o f m o t i v a t i o n o r co m p l i -an ce . T h e r e f o r e , f o r co l l ab o r a t i v e t r e a t m en t p l an n i n g t o b e s u cce s s f u l, p r o v i d e r s m ay n eed t o r e co n -cep t u a l i z e co n s u m er s ' b eh av i o r s i n l ig h t o f th e d a t a t h a t d em o n s t r a t e h i g h co n s u m e r in t e r e s t an d t ak eex t r a s t ep s t o p r o v i d e g en u i n e o p p o r t u n i t i e s f o r p a r t ic i p a t io n i n t h e t r e a t m en t - p l an n i n g p r o ce s s .H o w ev e r , i t m ay b e d i f f i cu l t f o r p r o v i d e r s t o s h a r e t h e p o w er t h ey h o l d i n t h e t h e r ap eu t i c r e l a t io n s h i pw i t h co n s u m er s . W h e t h e r it i s t h e d e s ir e to h e l p t h o s e w h o a r e th o u g h t n o t t o b e ab l e t o h e l p t h em -s e l v e s , t o co n t r o l s o c i a l d ev i an ce , o r t h e r e l u c t an ce t o g i v e u p t h e i r au th o r i ty , m en t a l h ea l t h p r o f e s -s i o n a l s h av e b een s l o w t o accep t t h e i d ea t h a t co n s u m er s c an ac t i v e l y p a r t i c ip a t e i n d e t e r m i n i n g t h ec o u r s e o f t h e i r o w n t r e a tm e n t .

A t t h e s am e t i m e , i t m ay b e d i f f icu l t t o co n v i n ce co n s u m er s t h a t t h is n ew i n i ti a t iv e i s, i n f a c t , ag en u i n e o p p o r t u n i t y f o r co l l ab o r a t i o n in w h i ch t h e i r o p i n i o n s w i l l h av e i n f l u en ce g i v en t h e t rad i -t i o n a l d i f f e r en ce i n p o w er . I n p a r t t o co u n t e r p r o v i d e r s ' n eg a t i v e b ia s e s , co n s u m er s w i l l n eed t ob e c o m e m o r e a s s e rt iv e , m a k i n g s u re t o v o c a l i z e th e i r o w n n e e d s o r p e r h a p s b y w o r k i n g w i t h a c o n -s u m er ad v o ca t e t o b eco m e a p a r tn e r i n th e t r e a t m en t - p l an n i n g p r o ce ss .

T h e f ac t t h a t d i f f e r en ces ex i st b e t w een t h e s e t w o s t ak eh o l d e rs i s n o t n ew. A l a r g e b o d y o f r e s ea r cht ak en f r o m q u a l i t a ti v e i n t e r v iew s , co n s u m er s a t is f ac ti o n s s u r v ey s , e t h n o g r ap h i c s t u d ie s , f i r s t- p e r s o nco n s u m er acco u n t s , an d s u r v ey s o f m en t a l h ea l th p r o v i d e r s s u g g es t t h a t w h i l e p r o v i d e r s co n cep t u a l -i z e co n s u m er s ' n eed s i n m en t a l h ea l t h t e r m s ( co m p l i an ce , m ed i ca t io n s , an d i n s i g h t) , t y p i ca l l y co n -s u m er s t en d t o v i ew t h e i r o w n n eed s i n t e r m s o f r e s o u r ce s s u ch a s f o o d , h o u s i n g , em p l o y m e n t , s a f e tyan d p e r s o n a l f e e l i n g s s u ch a s s e l f - r e s p ec t an d d i g n i t y .T M T h e f i n d in g s o f t h e cu r r en t s tu d y a r ean o t h e r ex am p l e o f t h e d i f f e r en t p e r s p ec t i v e s th a t ex i s t b e t w e en p r o v i d e r s an d u s e r s o f m en t a l h ea l t hs e r v ic e s d o c u m e n t e d i n p r i o r w o rk .T h e n e x t s t ep t o en h an ce t h e co l l ab o r a t iv e n a t u r e o f t r e a t m en t p l an n i n g i s to u s e t h e i n f o r m a t i o nco l l e c t ed h e r e t o b eg i n t o ad d r e s s s o m e o f t h e s e d i ff e r en ces . A t w o - p a r t p i l o t w o r k s h o p h a s a l r e ad yb een h e l d t h a t w i l l le ad t o s ev e r al tr a i n in g s e s s i o n s f o r a ll C M H C p r o v i d e r s . T o b e t r u l y co l lab o r a -t iv e , t h e p i l o t w o r k s h o p i n c l u d ed s i x p r o v i d e r s an d s i x co n s u m er s ( t h e co n s u m er s d o n o t r e ce i v et r ea t m e n t f r o m t h e s e s i x p r o v i d e r s ) an d w as d ev e l o p e d w i th i n p u t f r o m p r o v i d e r s , co n s u m er s , f am i l ym e m b er s , an d ad m i n i s tr a to r s . P a r t 1 o f t h e w o r k s h o p f o cu s ed o n t h e co l l ab o r a t i v e ap p r o ach i n g en -e r a l . T o f ac il i ta t e d i a l o g u e b e t w een p r o v i d e r s an d co n s u m er s ab o u t h o w t o b e t t e r co l l ab o r a t e w h i l ep l an n i n g t r e a tm en t , t h e w o r k s h o p en co u r ag ed p a r ti c i p an ts t o co n s en s u a l l y d e f i n e co l l ab o r a t io n an dt o p r o b l e m s o l v e a b o u t h o w t o c r e a te a n e n v i r o n m e n t th a t p r o m o t e s t h e d e v e l o p m e n t o f c o l la b o r a ti v er e l a t io n s h i p s . T o h e l p b o t h g r o u p s b e t t e r u n d e r s tan d e ach o t h e r ' s p e r s p ec t iv e s , t h e w o r k s h o p s en s i-t i z ed a l l p a r t i c ip an t s t o b e i n g i n t h e " h e l p e e" p o si t io n . T h e s e p r o g r am co m p o n e n t s w e r e i n c l u d ed t oh e l p b r i d g e t h e g ap b e t w een p r o v i d e r s an d co n s u m er s i d en t if i ed b y t h e n eed s a s s e s s m en t . P a r t 2 o ft h i s w o r k s h o p f o c u s ed o n t h e ap p l i c at i o n o f th e i n f o r m a t i o n d i s cu s s ed i n p a r t 1 to t h e ac t u a l u s e o ft r e a t m en t - p l an n i n g f o r m s cu r r en t l y i n u s e a t t h e C M H C .

T h i s s t u d y h a s s ev e r a l l i m i ta t i o n s t h a t d e s e r v e co m m e n t , m o s t l y r e su l t in g f r o m i ts d e s i g n a s an o n r an d o m i zed , q u a l i t y a s s u ran ce s t u d y an d i ts u s e o f a co n v en i en ce s am p l e o f co n s u m er s an d p r o -v i d e r s . T h e d a t a co l l e c t i o n m e t h o d s w e r e n o t s tan d a r d i zed . M o s t s u r v ey s w e r e c o m p l e t ed i n d iv i d u -a ll y, b u t s o m e w e r e c o m p l e t e d b y g r o u p s o f c o n s u m e r s f o r e a s e o f a d m i n is tr a ti o n . T h e r e w e r e a l m o s tt ri p le t h e o v e r a ll n u m b e r o f p r o v id e r re s p o n s e s ( 3 4 6) c o m p a r e d w i th t h e n u m b e r o f c o n s u m e rr e s p o n s e s ( 1 2 9 ) o n t h e b a r r i e r s to co l l ab o r a t i v e t r e a t m en t p l an n i n g , an d i t is p o s s i b l e t h a t t h e p r o v i d -e r s s aw m o r e b a r r ie r s t o co l l ab o r a t iv e tr e a t m en t p lan n i n g . I t co u l d a l s o b e t h a t t h e p r o v i d e r s w e r em o r e co m f o r t ab l e i n en d o r s in g b a r r i e rs t h an t h e co n s u m er s . H o w ev e r , w i t h o u t a s t an d a r d i zed s e t o f

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d a t a c o l l e c t i o n p r o c e d u r e s , t h e r e a s o n s f o r t h e d i f f e re n c e i n t h e n u m b e r o f r e s p o n s e s r e m a i nu n c e r t a i n .

Imp l ica t ions for Beh av iora l H ea l th ServicesI n a d d i t io n t o b e i n g i m p o r t a n t f o r t h e d e v e l o p m e n t o f t h e t r a i n i n g s e ss i o n s a t t h e C M H C , t h e s e

f i n d i n g s a l s o h a v e i m p l i c a t i o n s f o r o t h e r s e n g a g e d i n t h i s p r o c e s s . P r o v i d e r u n d e r e s t i m a t i o n o f c o n -s u m e r i n t e r e s t a n d t h e n e e d f o r c o n s u m e r s t o b e c o m e m o r e a s s e r t iv e i n p l a n n i n g t h e i r t r e a t m e n t a r ei s s u e s t h a t m a y n e e d t o b e a d d r e s s e d i n o t h e r m e n t a l h e a l t h s y s t e m s t a c k l i n g t h e is s u e o f c o l l a b o r a -t i v e t r e a t m e n t p l a n n i n g . I n a d d i t io n , i t i s r e c o m m e n d e d t h a t o t h e r a g e n c i e s i n t e r e s t e d i n c o l l a b o r a -t i v e t r e a t m e n t p l a n n i n g s u r v e y c o n s u m e r s a n d p r o v i d e r s t o b e t t e r u n d e r s t a n d t h e s p e c if i c i s s u e si n v o l v e d a t th e i r f a c i l i t y a n d t h e n u s e t h o s e r e s u l ts t o i n f o r m a n y t y p e o f p l a n n i n g o r t r a i n in g . I t i s c r u -c i a l t h a t t h is p r oc e s s , f r o m a s s e s s m e n t t h r o u g h i m p l e m e n t a t i o n , i n v o l v e p r o v i d e r s , c o n s u m e r s , f a m -i ly m e m b e r s , a n d a d m i n i s t r a t o r s . T h i s t r u e c o l l a b o r a t i o n w i l l i n c r e a s e t h e s u p p o r t t h e r e s u l ts w i l lr e c e i v e f r o m a l l t h e s t a k e h o l d e r s b e c a u s e o f t h e i r r o l e i n c r e a t i n g i t. T h i s i s e s p e c i a l l y t r u e f o r t h ec o n s u m e r s , w h o a s a r e s u l t o f t h e i r i n v o l v e m e n t w i ll h a v e h e l p e d t o c r e a t e a t r e a t m e n t - p l a n n i n gp r o c e s s t h a t th e y w i l l u l t i m a t e l y f i n d m o r e r e l e v a n t t o t h e i r o w n l i v e s a n d t h a t p e r h a p s w i l l l e a d t oi m p r o v e d c l in i c a l o u tc o m e s .

A c k n o w l e d g m e n t sT h e a u t h o r s w o u l d l i k e to t h a n k R o b i n L e w i s f o r h e r a s s i s t a n c e w i t h d a t a c o l le c t i o n a n d t h e c l i -

e n t s o f th e C o n n e c t i c u t M e n t a l H e a l t h C e n t e r w i t h o u t w h o s e p a r t i c i p a t i o n t h i s a r t i c le w o u l d n o t h a v eb e e n p o s s i b l e .

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