Exploring Learning and Change in a Community Mental Health Setting
This four-year study explored the experiences of community mental health workers as they integrated evidence-based substance abuse services into their day-to-day practice with persons with co-occurring serious mental illness and substance-use disorders. The current policy and practice consensus has called for community mental health services to use evidence-based practices that focus on helping people overcome the interrelated challenges posed by mental illness, substance use and chronic health problems. The implementation of these practices fundamentally repositions the roles and actions of providers and users of community mental health services, requiring them to think and act in new and complex ways. Despite the existence of these practices, it has been demonstrated that persons with co-occurring disorders are not receiving these treatments consistently, and that practitioners struggle to implement evidence-based practices due to a number of barriers at the system, organizational and practitioner levels. The following sections outline a project that used qualitative methods to understand the complexities of the implementation process from the practitioner perspective.
Ethnographic field methods were used at a single community mental health setting made up of 9 community support teams serving approximately 300 persons with serious mental illness and co-occurring substance use disorders over a continuous four year period. This time period overlapped with an agency-wide initiative to integrate evidence-based substance use disorder services into the treatment milieu. A total of 36 group and personal interviews were conducted with 40 community mental health case managers. Field observations of approximately 150 team meetings and agency documents including meeting minutes, policies, procedures, treatment plan and assessment forms and case notes were also analyzed. Analysis methods included a constant-comparative method in which commonly identified codes that emerged from the various data sources were collapsed into broader categories. Major categories were then compared with each other to determine the nature of their relationship. Relationships sufficiently grounded in the data were then included in the final thematic model.
The analyses revealed four broad themes describing the conditions that both facilitate and hinder learning and change and the effective implementation of evidence-based practices at the organizational, team and individual level. First, when implementing evidence-based practices, it is important that practitioners participate in the design and evaluation processes at all levels. Second, development of organizational leaders and champions is vital to sustained implementation in an era of restricted resources. Third, it is important to have the agency’s values, mission, policies and procedures align with the practices being implemented. And fourth, effective learning of evidence-based practices is significantly influenced by organizational culture and climate.
Practitioners have largely been excluded from the design of implementation efforts leading to a sense of alienation toward academic researchers, outside experts and the practices themselves. Future research should continue to develop ways organizations can design and sustain organic learning environments that can expand to include networks of other learners across organizations and systems. In addition, research should continue to explore ways that agencies can adapt evidence-based practices in ways that accommodate organizational constraints without sacrificing effectiveness.