Building A Culture Of Excellence

In 1989, after years of taking every course offered at a community college without deciding what I wanted to do when I grew up, I began a four-year program in social work at the University of Missouri–St. Louis. Needing a job to make ends meet (other than playing gigs with my band at local clubs), I managed to get hired as a residential counselor at the Youth in Need (YIN) agency. Begun on a small scale in 1974 as an emergency shelter for displaced, runaway, and homeless youth, by the time I got there, YIN was seeing more than 400 kids a year at three sites, but still had a staff of fewer than 30 full- and part-time employees.

The job of a residential counselor or “RC” at the shelter was based on a 58-hour work week, which sounds terrible, but the agency allowed me to work a schedule that accommodated my schooling and even my music gigs. It was a tough grind, particularly the 24-hour shifts from Sunday at 7 a.m. to Monday at 7 a.m., but I was grateful for the $12,500 salary (not bad at the time). Besides, to my surprise, I found I was growing to enjoy the job and the milieu more and more.

The shelter was the hub of the agency. There were regular schedules to follow, but because the program was for youth and families in crisis, much of what happened on a daily basis was unpredictable. We’d be preparing dinner when the 24-hour crisis line would ring with a call from a suicidal kid. I’d spend time calming that kid, and then immediately after have to intervene between two arguing residents on the verge of coming to blows, then go back to getting dinner ready while my coworker did an emergency intake assessment.

At that time, YIN was small enough for everyone to know one another, which helped foster a sense of community and common purpose among staff and administrators. We had to rely on each other, especially in the shelter. But between 1989 and 1998, YIN grew tenfold—to more than 30 programs, operating at 25 sites. We served six counties and had a total staff of nearly 300. More than 10,000 families a year received services that included out-client counseling, emergency and crisis-placement services, long-term residential care, transitional living for teens and young adults, and Head Start and Early Head Start programs, to name a few.

Not surprisingly, with all this rapid growth, organizational problems began to emerge. Like all community-based agencies, ours was largely dependent on external funding, which waxed and waned (mostly waned) according to the state of the economy. Funding cuts meant cuts in programs and staff, and increased workloads for others, often including new assignments to unfamiliar roles and programs. Mostly the staff understood that this uncertainty came with the territory. What kept us engaged and committed was the fact that most of us truly loved the kids we worked with, each other, and our work, and would, therefore, to the best of our ability, put up with what couldn’t be controlled.

But it’s usually not external pressures, like budget shortfalls, that threaten the well-being of an agency most—it’s what happens inside, between and among the people who work there. The strength of YIN, or any agency for that matter, was its sense of community: the feeling we all had of mutual respect and support, and that we were working toward a common goal. When YIN was small, it wasn’t difficult to maintain a well-articulated mission, a sense of staff support, and mutually respectful communication between administrators and program staffers. But as YIN expanded in physical size, something else was growing as well: the agency was developing a “staff infection.” Agencies with robust immune systems—based on a clear mission, staff support, open communication—are better equipped to identify problem areas, scan and monitor for trouble spots, so that small complaints and misunderstandings don’t metastasize and infect the entire organization. Staff infections are sneaky and can do great damage if not detected early, and they’re hard to identify when people are stretched thin and stressed.

Growth and greater program diversity also meant increased administration and oversight. Soon conflicts at the administrative level came into the picture. Two program directors, both smart, committed people, got into an ongoing conflict that brought out the worst in each and also created turbulence for any staff people who fell afoul of either one. Over time, the atmosphere at the agency became increasingly toxic and staff began showing their discontent by leaving, and many of those left behind were mostly just waiting for the opportunity to leave. Frustrated at work and discouraged by the sight of so many good people exiting, I wasn’t sleeping, put on weight, and felt my own motivation waning. It appeared to me—and to most of my colleagues—that the agency was in the middle of a crisis of management and morale.

Then one day, my supervisor announced to me, without warning or discussion, that I was being reassigned to another county—a shocking and devastating blow. Just married and with a new baby, I had purchased a home near my current office. More than this, I’d been a devoted, productive employee for 10 years, and was now being summarily ordered to accept reassignment or leave. I decided it was time to move on.

A few weeks later, I began a good job with a school district where the hours, vacation, and pay were, in fact, much better than at YIN. I settled in and began my new career as a school crisis-intervention counselor. It wasn’t the path I’d hoped for, but it was an opportunity for which I was grateful. Barely eight months into my new job, however, I ran into one of the administrators of the Early Childhood Programs at YIN, who’d hired me for my first job there. She wasted no time with chit-chat. “You need to come back—we need you,” she said bluntly, saying she wanted me to start up a mental health component in the Early Childhood Programs. At first, I said no, but she wouldn’t take that for an answer. She said, “You’re the only person to do this. I know you’ll do a knockout job.”

Learning to Listen

By the time I returned to YIN in November 1999, Jim, the president and CEO, had taken charge of transforming the agency and addressing the sinking morale among staff, the low confidence in leadership, and the general feeling that the people running the place didn’t value the staff. Jim responded to the staff discontent in several ways. First, he brought me and other staff members into the Executive Management Team (EMT), comprised of the President/CEO, CFO, program VPs, and a few administrators. This gave staff a genuine voice in management and broadened the agency’s leadership base. Responsible for providing organizational direction and oversight, the EMT began by evaluating staff morale, communication between program staff and personnel, and the agency’s management structure.

Next, Jim began to elicit feedback from everyone—administrators to frontline staff. He brought in an outside consulting firm and required all directors to be part of an interview process in which staff voiced their perception of both supervisors and peers. We were encouraged to report freely and openly without fear of consequences; the results would be confidential. The staff was specifically asked to rate their supervisors’ leadership abilities, problem-solving skills, and degree of empathy. In addition, administrators went through psychological testing and an extensive interview session with the consulting firm. We were told that after the data were compiled, each of us would be given detailed feedback about our strengths and weaknesses.

Jim then focused on the Early Childhood Programs, the division where I worked, to discover why its staff was more content and had less turnover. In the years we’d worked together, a consensus had emerged on my team that we’d engage in open, honest, mutually respectful discussion, even when we disagreed, and that we wouldn’t resort to imperious fiats. Therefore, in the feedback from my staff, there were numerous variations on the theme, “My supervisor values and supports me.”

But what seemed just as important as the sense of being seen and supported to respondents from the Early Childhood Programs was the worldview that flowed from it. We’d based the program on what we called a strengths-based philosophy, applied to both clients and staff members. This meant focusing on each person’s abilities and resources, strengthening relationships, emphasizing factors that enhance change, and working to instill a sense of hope in every client, whatever the problem or nature of the intervention. This perspective focused squarely on what could be accomplished when we worked together with clients toward mutually agreeable goals, and seemed to make a difference both in working with clients and in staff members’ personal lives. I remember a home visitor coming up to me after a training and saying, “I know we’re supposed to be the ones empowering others, but I feel empowered when I talk with my families. It’s a thrill to talk about what children can do, rather than constantly trying to undo something from the past.”

We stressed three main points: (1) everyone needs to feel heard, understood, and valued—really listen to the families you see and get to know them before deciding what’s wrong or what they need to do; (2) change requires that you focus on the future and on what people most want to have happen in their lives; and (3) the primary vehicle to future change is through clients’ strengths, resiliencies, and support systems.

Meanwhile, Jim asked me to take on the role of putting in place a strengths-based philosophy throughout the entire agency. Not only would this philosophy serve as a practical and theoretical foundation for the agency, it would become a kind of flag around which the agency and all its employees could unite. We didn’t know it at the time, but what we were really doing by clarifying the purpose of the agency, improving day-to-day communication, and creating better connections among all agency personnel was developing at YIN what social learning theorist Etienne Wenger refers to as “communities of practice.” In his lexicon, these are “groups of people who share a concern or a passion for something they do, and who interact regularly to learn how to do it better.”

Communities of practice have a common interest, work together, and share information and resources. More than a group of friends or network of personal connections, a community of practice is formed, often spontaneously and informally, by practitioners of a “domain of interest”—a profession, a hobby, a field of expertise, an art or craft, even a common concern. Such communities, Wenger writes, “Engage in a process of collective learning in a shared domain of human endeavor: a tribe learning to survive, a band of artists seeking new forms of expression, a group of engineers working on similar problems, a clique of pupils defining their identity in the school,” or, he might have added, the members of a community agency working with kids and families. The central insight to this intuitively simple idea is that learning is primarily a social phenomenon, rather than—as we so often think—a purely individualistic activity. In fact, as we were discovering at YIN, people learn, acquire competency and expertise, and gain genuine knowledge and understanding through practice in community.

By creating a community of practice around the common theme of a strengths-based philosophy, we were trying to capture the elusive passion and deep commitment of each individual at YIN and funnel this energy into a collective effort to achieve excellence as an agency. We believed we could do this by shifting the prevailing culture from one reflecting division, mistrust, and resentment to one reflecting a collective vision, a shared body of knowledge, a general pattern of open, undefensive communication, and a common purpose: to make this the best agency possible.

Of course, high hopes often go hand-in-hand with nitty-gritty struggle. All cultures fight to survive, and the old culture at YIN was no exception. The overall atmosphere at the agency had been toxic for some time, but as strange as it seems, some staff had grown accustomed to the prevailing climate, and remained loyal to the old ways. For many, changing was harder than just allowing things to remain as they’d been—familiar bad conditions seemed safer than untried good ones.

So, paradoxically, to establish an atmosphere of mutual trust and work more effectively as a team, we had to go through a crucible of emotional and professional upheaval. There were disagreements and hurt feelings—mostly due to the perfectly natural human inclination to protect ourselves, our programs, our staffs, and our turf. Trying to set the tone for the whole agency, the Executive Management Team members still had to learn to behave better and accept each other, even if we didn’t always accept each other’s ideas. We were guided by the idea that we could see our differences as assets, not liabilities; and to move forward, we’d have to use our divergent views for something other than bickering.

Crucially, Jim, as the leader, set the right tone. He began to actively model what he expected of us. He’d sit back and listen, and only step in as mediator when a situation became heated. It worked, but slowly, because many of the most challenging issues involved ongoing conversations. We had to agree on a new agency-wide salary structure, for example. This meant market-pricing all jobs within the organization. Tricia, head of Human Resources, had to confront VPs and directors who were advocating for their individual staff, as opposed to thinking about the viability of the entire organization. In time, our collective mindset shifted, and it became common, in the midst of a disagreement, for one EMT member to say, “I’m on your side.” As our trust with each other grew, consensus followed.

Change was difficult, even for those of us leading it. Once EMT members were more or less in the same book, if not exactly always on the same page, it was time to figure out how to help the whole staff—CEO to maintenance worker and all stations in between—take their parts in making the vision of a renewed YIN a reality.

Spreading the Word

In an agency of more than 300 people, establishing networks of personal connections throughout the organization is a challenge. For YIN to get stronger as an agency and a community of practice, everybody had to get out of their cozy cubbyholes and do their best to get to know everybody else, whether via team meetings, over lunch, or just a brief chat at the end of the day. If we wanted to be a strengths-based and relationship-oriented agency, we needed to demonstrate that we took our philosophy seriously and personally. We decided that, to forge more “togetherness” around our emerging theme, all staff would participate in a training that came to be called “Strengths-Based 101.” Since I taught it, the name later became “Bob’s Brainwash 101.”

The training began with questions to help staff explore their personal thoughts and biases about clients, treatment, and clinical philosophy. “What are the core beliefs and ideas you have about children, youth, and families?” “Do you believe that change is possible even with the most ‘difficult’ and ‘challenging’ children, youth, and families?” “How do you believe that change occurs?”

Through body language and verbal responses, it was quickly obvious among staff, as it had been among EMT members, who was on board with a strengths-based approach, and who wasn’t. Some smiled at the tenor of the conversation and said they felt they were “working at the right place.” A few others folded their arms across their chests and said, “If you help them with one problem, five others pop up; what are we supposed to do about that?” or “Some people can’t change, no matter what you do.”

We followed up with more questions, such as: “Where does that idea come from?” “How does it help you to think about it that way?” and “What difference might it make if you were to revise your perspective?” These questions remained largely unanswered by those who disagreed, but their lack of participation in discussion, deep sighs, and slumped postures spoke volumes. One youth-care worker, however, was quite outspoken in her skepticism of the new agency philosophy and voiced an attitude shared by others. “It’s harmful to think these kids can change after coming from broken homes,” she said, to which an employee from a completely different program quickly replied, “Actually, I think it’s harmful to think that way. I believe the fact that the kids who come here are alive and resilient to the core—in our programs, they can show their strengths.” The response of the second employee prompted agreement from others—it was, in effect, an antibiotic against the staff infection, administered by the group itself in the form of collective self-monitoring. If any kind of sustained change in the culture of YIN was going to take place, it was going to have to be through staff’s taking responsibility for themselves, their programs, and their attitudes.

The purpose of our questions wasn’t to search for the answers—we wanted to get people to connect emotionally with the questions and to think, which now seemed to be happening. We could then provide support and help them to figure out which path to take. We were also unabashedly trying to create a common culture among everybody in the agency. At the end of this process of what might be called “Bob’s Socratic Questioning 101,” we hoped that staff members would be better prepared to answer the fundamental question: Should I stay or should I go?

The training delved into specific strategies for finding out about client strengths, resiliencies, and coping skills. We explored how to better involve clients in services, collaborate in meetings inside and outside the agency, and have conversations with clients or each other that focused on how to help people move forward in their lives. We asked attendees how they might bring a more strengths-based philosophy into their settings. A home visitor providing child development activities in our Early Childhood Programs said she could begin her visits by asking clients not what had gone wrong over the week (which needed no prompting) but what had gone well. A person from human resources remarked that she could be more active pursuing new ways to improve outdated, time-consuming practices.

What made these trainings increasingly uplifting was the spirit of optimism and enthusiasm such lines of questions evoked: just hearing each other talk in positive terms about what was good about their work and what they could do to make it even better provided an infectious high. Because the impact of “Strengths-Based 101” was so positive, EMT decided to make it a requirement for all new employees—administration, clinical, human resources, maintenance, secretarial—everyone, no matter their role. Even members of the agency’s board of directors have been trained in 101. If you work at YIN, you will get the training.

Real-Life Tests

Once the philosophy had been communicated to the collective YIN community, we wondered how it would work in practice. We soon got a fairly severe test of the new system.

During the mid-1990s, YIN had established an after-hours and weekend on-call system for the three residential programs and out-client counseling, comprising a therapist or case manager and a back-up supervisor, drawn from the staff on a weekly, rotating basis. In a given week, a designated on-call therapist could receive anywhere from 4 to 30 calls—any time of day or night. On-call workers also had the responsibility of doing on-site, face-to-face assessments, if needed, which meant traveling to the site, no matter how far away. Even more onerous, when a regularly scheduled staff person called in sick or had to cancel a shift, it was the responsibility of those who were on-call to either find a relief worker for that shift or to do it themselves—even if they’d already been up all night. It wasn’t uncommon to come in on Monday and find a therapist seeing clients who’d been the on-call person on the overnight shift or the weekend. Since YIN, like most other agencies, was dependent on fee-for-service billing, we simply couldn’t afford to send therapists home to bed and forgo billing. But something had to give—those on call were exhausted and their morale was declining.

The on-call system had been a point of debate for many months. A decision was finally made to move to a voluntary system: staff who volunteered would be paid extra to be on call. Unfortunately, few were enticed by this offer—the extra pay didn’t compensate for the stress. The system continued in crisis, with no solution in sight. We met again and regrouped. We focused on the escalating number of residential staff calling in and canceling their night and weekend shifts, which put clinical staff on the spot.

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.

Therapist Accountability

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.

Illustration © Paul Vismara / Images.com / Corbis