While the conversation at this meeting began civilly enough, it soon degenerated into outright contention between the out-client contingent on one side and residential staff on the other—the latter fearing that any change would put too much stress on them. There was mutual blaming, defensive posturing, and self-righteous anger. It seemed that the mutual support and collaboration, minimal defensiveness, and turf protecting we’d been working toward was going down the tubes. Could our strengths-based philosophy save us?
Over a six-month period, the crisis just got worse, and it became clear that the on-call system was collapsing. But, to paraphrase Samuel Johnson, the threat of impending execution concentrates the mind wonderfully. So we met again, and, this time, everybody was less guarded, less determined to win battles, more open to compromise, realizing that if we didn’t stand together to solve the problem, we’d all lose and the agency would lose. We’d already thought—perhaps too much—about what was good for staff; now we were ready to think about what we were trying to accomplish as a community.
We asked ourselves pointed, direct questions to define the scope of each program’s responsibilities: Whose responsibility was it to staff programs? Whose responsibility was it to handle crises? We got feedback from EMT. We asked program staff. Then something wonderful happened: we began to earnestly explore how we could improve our on-call system rather than repair something that was broken. When we did that, we started to get offers to help. The director of Human Services offered to help with the staffing side. A couple of therapists who’d opted out earlier in the voluntary system said they’d be happy to take crisis calls.
We hatched a new plan. The on-call system was split in two—one system for staffing and one for crisis. This meant that residential personnel would deal with staffing their programs and handling call-ins. Clinical staff would deal only with crises—what they were hired and trained to do. We agreed that all program staff would participate, and that this would offer the most effective coverage and support to clients, staff, and the agency as a whole. We said we’d evaluate the system in a few months and make further changes as needed.
So, how did it work out? The system took a month to put in place. Within two months of start-up, residential shift cancellations dropped by 60 percent. Crises were handled effectively, and at six months, staff complaints about being on call were virtually nonexistent.
YIN developed other ways to engage agency staff, share information, and encourage learning. For example, the President and CEO began leading town hall meetings to discuss the state of the agency and respond to staff feedback. Monthly strengths-based roundtables now connect staff from all programs and provide opportunities to share information across teams, sites, programs, and the agency at large, for the purposes of strengthening services, increasing productivity, and improving outcomes.
What about individual staff members? How does the agency culture help them get better at what they do—become better therapists, youth-care workers, teachers, and so on?
The centerpiece of our program—indeed, the most important reason for our existence—is the clinical effectiveness of our staff. No matter how well we get along, work out our disagreements as a team, and adhere to the general philosophy, if this community doesn’t produce effective practice, then all the mutual support and free-flowing communication doesn’t mean much. As a staff, we understand that we must continually strive to be better than average. How does any therapist meaningfully improve his or her work? How does any therapist know that he or she is doing good work and actually improving as a clinician?
There’s now a large body of clinical research demonstrating that therapy outcomes are far more dependent upon the therapist and the therapist–client alliance than on the model of therapy used. Indeed, different treatment models account for only about one percent of the overall variance in therapy outcome, while therapist effects alone account for approximately five to nine times more of the impact of therapy than do specific models.
Unfortunately, therapists by and large have no idea how they rate as therapists. Even worse, according to the research, clinicians frequently overestimate their own effectiveness and routinely fail to identify clients who aren’t progressing, are at the greatest risk for dropping out, or are likeliest to be worse off after therapy. Clearly, in an agency devoted to excellence, therapists can’t afford to rely on their own intuitive estimate of their effectiveness.
The only relatively sure way therapists have of effectively monitoring their own practice is to rigorously and systematically use session-by-session feedback and monitoring assessment tools—formalized measures that reliably track and follow client progress and outcomes. At YIN, incorporating feedback methods into practice isn’t an option for our therapists—it’s a requirement. Therapists regularly share and discuss the results of the client feedback with supervisors and other agency staff. For example, when Regina, a therapist in a drop-in center in North St. Louis, comes to supervision, she brings a file on each client and provides a brief overview, along with a graph that plots the client’s progress and how he or she rates the therapeutic alliance. She and the supervisor discuss any areas of risk and get a sense of whether the client is improving, unchanged, or deteriorating. Regina reflects on what’s discussed in supervision, taking any questions, ideas, and strategies back to her sessions.
Has this practice actually helped with outcomes? Well, after analyzing the data, we know that between 2007 and 2010, client outcomes improved by 46 percent, while dropout rates decreased from 31.4 to 13.6 percent. Furthermore, every YIN clinician knows his or her baseline effect size, as compared to a large normative sample, to all YIN clientele, and to clients within the clinician’s particular program. Through YIN’s community of practice, including supervision, team meetings, peer-to-peer discussions, and so on, practitioners engage in conversations in which they can learn from each other. Because they know where they stand, share this information with colleagues, and discuss what steps they can take to improve, every clinician at YIN is deeply involved in a community of practice that helps them learn from each other in a safe, respectful environment, while growing measurably better at what they do.
In a genuine community of practice, no single person is the sole keeper of knowledge or holds the keys to success. Excellence in community mental health requires a collective effort. We need people who are willing to step into unfamiliar territory and agencies that welcome their steps, giving them opportunities and letting them rise to the occasion. We don’t leave staff members to fend for themselves—success is never an individual feat. Where there’s one success, there are others. Communities of practice cultivate a collective consciousness that can be observed in everyday processes—how people talk, interact with, and treat each other. When I started at YIN, we had a budget of $600,000. In 2011, our budget will exceed $17,000,000. Yet today, YIN feels far more communal, democratic, and open than it did as that small agency where I began working more than two decades ago.
Bob Bertolino, Ph.D., is an associate professor of rehabilitation counseling at Maryville University in St. Louis, Missouri, and senior clinical advisor at Youth in Need, Inc., in St. Charles Missouri, He’s the author of Strengths-Based Engagement and Practice and coauthor of The Therapist’s Notebook on Strengths and Solution-Based Therapies.
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