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Thinking like a PSC: an exploratory study of the practice reasoning of personal service coordinators in a full-service partnership
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Thinking like a PSC: an exploratory study of the practice reasoning of personal service coordinators in a full-service partnership
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THINKING LIKE A PSC: AN EXPLORATORY STUDY OF THE PRACTICE
REASONING OF PERSONAL SERVICE COORDINATORS IN A FULL SERVICE
Deborah B. Pitts
A Dissertation Presented to the
FACULTY OF THE USC GRADUATE SCHOOL
UNIVERSITY OF SOUTHERN CALIFORNIA
In Partial Fulfillment of the
Requirements for the Degree
DOCTOR OF PHILOSOPHY
Copyright 2012 Deborah B. Pitts
To the Vanguard staff and members, thank you letting me watch and for being
willing to talk to me about your work.
To the students that I have worked and learned with, thank you for always
reminding me that the work I care about does matter.
To Dr. Ann Neville-Jan, thank you for welcoming me as a colleague and guiding me
through my doctoral experience.
To Dr. Mary Lawlor, Dr. Jeanne Jackson, Dr. John Brekke and Dr. Donald
Polkinghorne, thank you for supporting my scholarship.
To Dr. Florence Clark, thank you for giving me the time to write.
To Dr. Kim Wilkinson, thank you for saying yes when I asked for your support and
To the California Foundation of Occupational Therapy, thank you for the financial
support to complete my research.
Table of Contents
Acknowledgements ........................................................................................................ ii
List of Tables .................................................................................................................. v
Abstract ........................................................................................................................ vi
Chapter 1. Introduction .................................................................................................. 1
Background to the Study ..................................................................................................... 4
Research Questions ........................................................................................................... 10
Limitations of the Study .................................................................................................... 11
Chapter 2. Literature Review ........................................................................................ 13
How Practitioner’s Think-in-Action ................................................................................... 13
Recovery for Persons Labeled with Psychiatric Disabilities .............................................. 24
Assertive Community Treatment as an Evidence-Based Practice ..................................... 31
Conclusion ......................................................................................................................... 38
Chapter 3. Methodology ............................................................................................... 39
Recruiting Study Participants ............................................................................................ 43
Collecting Data .................................................................................................................. 51
Thematic Analysis .............................................................................................................. 68
Strategy to Enhance Rigor ................................................................................................. 71
Conclusion ......................................................................................................................... 72
Chapter 4: Contextual Influences on the Practitioner’s Reasoning ................................. 73
Philosophy of Practice ....................................................................................................... 73
Spaces and Places of Practice ............................................................................................ 87
Temporal Dimensions of Practice ................................................................................... 112
Summary ......................................................................................................................... 127
Chapter 5. The Practitioners Reasoning: Meeting Member Where They’re At ............. 129
Meeting the Member’s Needs and Wants ...................................................................... 131
Meeting Emotional and/or Cognitive Needs Within the Visit Itself ................................ 140
Meeting the Member’s Readiness or Motivation for Specific Activities or Goals .......... 154
Dilemmas Emergent in “Meeting Member Where They’re At” ...................................... 161
Summary ......................................................................................................................... 175
Chapter 6: The Practitioner’s Reasoning: What’s the Rehab Value? ............................. 178
Creating Experiences of Meaning ................................................................................... 180
Facilitating Opportunities for “Learning” ........................................................................ 189
Supporting Efforts of the Member “Doing it on their own” ........................................... 202
Dilemmas Emergent “What’s the Rehab Value?” ........................................................... 210
Summary ......................................................................................................................... 232
Chapter 7. Vanguard as a Community of Practice ........................................................ 235
Mutual Engagement at Vanguard ................................................................................... 236
Vanguard’s Shared Repertoire ........................................................................................ 243
Negotiation of a Joint Enterprise at Vanguard ................................................................ 249
Summary ......................................................................................................................... 254
Chapter 8: Implications for Practice and Further Study ............................................... 256
Practice Implications ....................................................................................................... 256
Implications for Further Research ................................................................................... 266
References ................................................................................................................. 271
List of Tables
Table 1. Floersch’s Level of Functioning and Level of Need Matrix 21
Table 2. Scheid’s Typology of Treatment Ideologies Utilized by
Community-based Mental Health Practitioners 23
Table 3. Study Participants Education, Lived Experience,
Work Experience and Years with Vanguard 48
Table 4. Locations and Primary Focus of Observed
Practitioner-Member Visits 62
Table 5. Sample Interview Questions 67
Table 6. Interviews Conducted 68
Table 7. Examples of Alignment of Agency’s Guiding Principles
with Davidson, et al (2009) Principles of Recovery-Oriented Practice 75
Table 8. Practitioner-Member Visits Observed within Building
Practice Spaces 90
Table 9. Community-Based Practitioner-Member Visits Observed 104
Table 10. Participant-Member Visits Observed at Member’s
Place of Residence 107
Table 11. Analysis of Vanguard’s Community of Practice (CoP) Elements 255
Table 12a. Themes that Emerged within Reasoning Frames 258
Table 12b. Dilemmas Emergent within Reasoning Frames 263
Research related to the implementation of California’s Mental Health Services Act (MHSA)
Full-Service Partnerships has focused on outcomes, cost effectiveness and more recently
system transformation. Despite Workforce Training and Education being a key
component of the MHSA, there is little understanding about the practice reasoning of
personal service coordinators as they engage in their day-to-day practices. This study
used participant-observation, document review and narratively focused post
practitioner-client visit observation and intensive interviews to explore the
practice reasoning of personal service coordinators working in three adult full-
service partnerships operated by a single agency. The interviews focused on what
the practitioners were paying attention to, thinking about and what influenced
their decisions about the actions they took. Data was analyzed through a thematic
analysis informed by phenomenological and hermeneutical perspectives. Findings
showed that practitioners drew on situated knowledge emergent in their day to
day experiences with clients, as well as the agency’s stages of recovery informed
guiding principles and philosophy to guide their actions. Dilemmas emergent in
the practitioners reasoning frames were also identified.
Chapter 1. Introduction
This qualitative study explored the practice reasoning of personal service
coordinators (PSC) working in a full-service partnership (FSP). Full-service
partnerships are a component of the California’s Mental Health Services Act
(Prop 63) Community Services and Supports. The California Code of Regulations,
Title 9, Section 3200.130 defines an FSP as “the collaborative relationship between
the County and the client, and when appropriate the client’s family, through
which the County plans for and provides the full spectrum of community services
so that the client can achieve the identified goals” (California Department of
Mental Health, Clarification on Requirements for Full Service Partnerships under
the Mental Health Act).
The philosophy and design of the FSP are informed by perspectives on
recovery for persons labeled with psychiatric disabilities that are shaping publicly
funded community-mental health services in the United States and internationally
as well as a specific community-based mental health treatment approach known
as Assertive Community Treatment (ACT)
. FSP services are delivered by a team
The Mental Health Services Act (MHSA) passed in 2004 represented a significant increase in
funding for community-based and voluntary mental health services in California. It imposed a 1%
income tax on personal income in excess of $1 million. The California Department of Mental Health
phased in the development of the various components including Community Services and
Assertive Community Treatment (ACT) is a comprehensive, community-based approach that
delivers services in-vivo to minimize psychiatric risk and hospitalization, and represents one of the
most widely disseminated and researched evidence-based interventions for persons labeled with
of mental health providers, to a specific cohort of mental health client’s, with low
provider to client ratio (i.e., 1:10, 1:15). The low provider to client ratio is critical
in order to deliver the intensive level of support that is characteristic of this
service approach. Each mental health client served by the team must have a
Personal Service Coordinator (PSC), who serves as the primary mental health
provider. The team provides an array of community services and supports
delivered from what is called a ‘strength-based’ approach. A critical element of
the service design, is a doing “whatever it takes” to help individuals on their path
to recovery and wellness, and important element of which is housing ("Adult Full
Service Partnership Toolkit," 2011). This “whatever it takes” philosophy presses
for creative and individually-tailored approaches to facilitating recovery.
I had not originally intended to study ‘full-service partnership’ practice,
rather I had intended on studying practitioners from a full-fidelity Assertive
Community Treatment team given criticisms regarding the fit of ACT approach
with the recovery perspective (Drake & Deegan, 2008; Gomory, 2005; Salyers &
Tsemberis, 2007). This approach has garnered criticism for its perceived coercive
and intrusive style of intervention, and it’s over reliance on a biomedical
perspective of mental illness (Gomory, 1999, 2001, 2002, 2005). In addition, the
psychiatric disabilities (Allness & Knoedler, 1998; Bond, Drake, Mueser, & Latimer, 2001; Stein &
degree to which ACT actually promotes full participation
integration for persons labeled with psychiatric disabilities has been questioned
(Horgan, 2007; Krupa, Radloff-Gabriel, Whippey, & Kirsh, 2002).
Although ACT teams had been implemented within California’s
community-based mental health system for several years, within the county in
which I conducted my research, many mental health agencies were transitioning
their ACT teams to FSPs. Given that the design of the full-service partnership
model was informed by the Assertive Community Treatment Team approach
("Adult Full Service Partnership Toolkit," 2011), and that the full-service
partnerships represented California’s current approach to community-based,
intensive service teams the full-service partnership met the service criteria for my
In addition, despite the rich body of research to support its value and
implementation as a key component of the public mental health delivery system,
there is limited information on how assertive community treatment practitioners
make practice judgments during care encounters with particular persons, at
particular times, and in particular contexts (Jerry Floersch, Ph.D., personal
communication, December 15, 2005). This gap in research is particularly
problematic given the criticism of the prescriptive nature of evidence-based
The World Health Organization’s International Classification of Function defines participation as
involvement in a life situation (http://www.who.int/classifications/icf/en/).
protocols in relation to what is argued as the demand for the improvisational
nature of practitioner judgment (Polkinghorne, 2004) in the “swampy lowland
where situations are confusing” (Schon, 1983, p. 42).
The ACT approach may give more room for such improvisations than other
psychological interventions (Angell, Mahoney, & Martinez,
2006). Empirically supported psychological interventions often provide session-by-
session prescriptions for practitioner actions minimizing any opportunity for
improvisation (Chambless & Ollendick, 2001). Although ACT has clearly defined
processes of care that are considered critical to fidelity implementation of the
model (Bond et al., 2001; Teague, Bond, & Drake, 1998), it does not provide
prescriptions for what the practitioner must do during each care encounter.
Rather it provides guidance on the frequency and location of service provision, as
well as expecting an orientation that “pushes” the service to the person as
opposed to having the person “pull” the service based on their own perceived
need (Stein & Santos, 1998)
Background to the Study
My interest in exploring the practice reasoning of community-based
mental health providers was influenced by my own developmental experiences as
an occupational therapy practitioner and educator. My practice as an
occupational therapist has been profoundly influenced by three synergistic forces,
Empirically supported interventions is another term for evidence-based interventions
all of which emerged as I have matured into a master practitioner. These forces
have focused my attention on occupation and recovery, with particular attention
to the characteristics of care contexts that are likely to promote participation in
occupation, particularly the importance of non-traumatizing health-care
encounters, including alternatives to bio-medical solutions to illness phenomena
that disrupt the lives of people labeled with psychiatric disabilities. These
influences have engaged me in particular bodies of literature and a specific set of
practice experiences, which when taken together with active reflection (Schon,
1983) have critically shaped my thinking and actions as a practitioner (Mattingly,
1998a; Mattingly & Fleming, 1994).
First, I entered the profession during a particularly important time for
contemporary occupational therapy, a time that Kielhofner & Burke (1977) called
the “paradigm of occupation” (p. 679 ). More recently this period has been
referred to as the “renaissance of occupation” (Whiteford, Townsend, & Hocking,
2000), and represents occupational therapy’s assertion, or re-assertion if you will,
of its’ jurisdictional claim (Abbott, 1988) on human occupation as a critical life
force for growth and development, as well as a means to healing and recovery.
As a young occupational therapist I was ravenous to understand the theoretical
perspectives that were emerging out of this renaissance, in particular the
historical perspective on occupation promoted by the founders of occupational
therapy (Breines, 1995) and later the knowledge that was being developed out of
the newly founded discipline of occupational science (Clark et al., 1991) to make
sense of my practice. The work of the founders was particularly meaningful to
me, because early occupational therapy practice is firmly situated in efforts to
reform psychiatric institutions in the early 1900’s and to counter the custodial
care practices that occurred in those settings as result of the demise of moral
treatment (Kielhofner & Burke, 1977).
Second, the care contexts in which I found a “home” to practice were a
perfect fit for the theoretical and practice understandings I acquired as a result of
the occupational renaissance, in particular what is known as the psychosocial
rehabilitation clubhouse. I took my training at Fountain House
in 1979 and recall
reflecting to Jim Schmidt, one of the key players at Fountain House, during one of
the daily debriefing sessions that this was “pure occupational therapy”, he replied
“no this is pure social work”. Thus began a career steeped in the philosophy and
practice of psychosocial rehabilitation with its focus on promoting participation in
“normalizing” roles and relationships, dealing with practical, realistic elements of
an individual’s needs, facilitating social learning and behavioral change through
Fountain House, located in New York City, was the first psychosocial rehabilitation clubhouse.
Founded in 1948 as “an intentional community to create the restorative environment within which
individuals who have been socially and vocationally disabled can be helped to achieve or regain the
confidence and skills necessary to lead vocationally productive and socially satisfying lives” (Beard,
Propst, & Malamud, 1982, p. 47). This model has been widely disseminated internationally under
the leadership of the International Center for Clubhouse Development (ICCD). Despite its place as
an early community service innovation, it has been criticized as outmoded in relation to more
recently developed service models (Drake et al., 1994).
experiential activities and the ongoing effort to minimize differences in role,
authority, and status between the participant and the provider (Rutman, 1987).
Further, psychosocial rehabilitation services had a set of core values that included
the belief that everyone has the right to self-determination, the belief in the
dignity/worth of every human being, optimism regarding improvement and
recovery, and the belief that everyone has capacity to learn and grow (Pratt, et al.,
1999). These beliefs aligned well with the view of occupational therapy that I had
taken both from my education, as well as the new paradigm of occupation that
emerged in occupational therapy as I entered practice (Kielhofner & Burke, 1977,
p. ). These are the service contexts that did and have continued to make sense to
me as the ’right’ place to do my work as an occupational therapist.
Although the focus and values of psychosocial rehabilitation may seem
evident given the nature of mental health practice today, particularly community
practice, in the late 1970’s and early 1980’s when these were being articulated by
the psychosocial rehabilitation movement, they were not central to psychiatric
practice settings. This practice perspective resonated more meaningfully with my
academic preparation as an occupational therapist, as well as my own personal
sensibilities, than did the psychodynamic perspective that focused on inner
psychological states and informed much of mental health practice at that time.
Being introduced to the psychosocial rehabilitation philosophy early in my career
was critical to my development and my ability to enter into collaborative
relationships with mental health consumers.
Finally, and of particular importance is the c/s/x
movement which has
given a space for believing that recovery is possible and an appreciation for the
lived experience of mental illness. In addition, it has turned the mental health
system’s gaze on the iatrogenic trauma experienced by persons labeled with
psychiatric disabilities from much of what is called mental health care. The work
of Patricia Deegan, Ph.D. on the experience of recovery, as well as her guidance to
mental health professionals about how to work with persons in recovery, has had
particular significance for my practice reasoning. Despite the dire prediction of
her psychiatrist that she would “suffer” a lifetime with “chronic mental illness”
following her diagnosis at the age of seventeen with schizophrenia, Dr. Deegan
has become an internationally respected mental health advocate. In her work on
recovery, she argues that what mental health practitioners call “lack of
motivation” or “negative symptoms”, is better understood as becoming “hard of
heart” (Deegan, 1996, p. 77). She suggests that this occurs both in response to the
illness experience and the nature of the care people receive. She called upon
c/s/x is a term adopted by persons labeled with psychiatric disabilities to represent the meaning
of their different experiences with the mental health delivery system (Bassman, 2001; Stricker,
2000). Specifically, ‘c’ stands for consumer, a sometimes contested term because of its
market/economic origins. The‘s’ stands for survivor, meaning surviving mental health treatment.
Finally, ‘x’ stands for ex-patient or ex-inmate depending on the author/speaker. Ex-inmate is
invoked by those who feel that they were incarcerated, not hospitalized.
mental health practitioners’ to understand the consumer/survivor’s behavior in
terms of its existential significance and to suspend their perception of people as
‘chronic mental patients’. Deegan among others have contributed to the use of
this language to describe persons labeled with psychiatric disabilities ("From
Privileges to Rights: People Labeled with Psychiatric Disabiliteis Speak for
Themselves," 2000)or persons in recovery being abandoned.
While these influences have shaped my thinking about how to practice,
my introduction to Mattingly & Fleming’s (1994) critical work on clinical reasoning
in occupational therapy, the combination of the readings and dialogue in which I
engaged as I moved through the doctoral courses, and my development as an
occupational therapy educator facilitated my interest in practice reasoning.
While clinical reasoning had been studied in occupational therapy prior to
Mattingly & Fleming’s work (Rogers, 1983), these researchers captured something
about occupational therapists clinical reasoning that had not been articulated in
previous studies. They were able to represent the complexity of occupational
therapists reasoning and make evident ways of thinking that resonated deeply
with occupational therapists. Like many occupational therapists, I felt understood
when I read and re-read this text. Through the work clinical reasoning in
occupational therapy, I was also introduced to Schon’s (1983) work on the
“reflective practitioner”, which identified two types of knowledge for practice—
technical rational (i.e. scientific theory) and reflection-in-action—and then argued
for a privileged position of reflection-in-action. This had sparked my curiosity
about how public mental health practitioners think, particularly practitioners
working in community-based services informed by the ACT model, given tensions
that have been identified for this particular service model.
Given the exploratory and descriptive nature of this study, my research
questions served as guides, rather than as hypotheses to be tested (Lofland &
1. How do personal service coordinators (PSC) in a full-service
partnership (FSP) make practice judgments?
2. How do they “name and frame” (Schon, 1983) what they see and
3. How does the personal service coordinator’s (PSC) understanding
of the full-service partnership (FSP) model emerge in their decision
4. How does the individual personal service coordinator’s (PSC) tacit
knowledge emerge in their decision making?
Limitations of the Study
A key limitation of this study is its’ focus on the practice reasoning of
personal service coordinators working on full-service partnerships within one
specific mental health organization. Given the situated nature of practice
reasoning, such a focus may limit what can be said about the practice reasoning of
practitioners working on full-service partnerships within other organizations.
Despite the guidelines for implementation of full-service partnerships, agencies
evolve particular ways of doing the work, and as a result the reasoning frames that
emerge may be different.
In addition, the focus on practitioners serving adults labeled with
psychiatric disabilities, limits what can be said about the practice reasoning of
personal service coordinators working on full-service partnerships serving
children, youth or older adults. For example, reasoning frames related to
development need may be more foregrounded than in this study.
In addition, the focus on practice within an urban setting, limits what can
be said about the practice reasoning of personal service coordinators working in
rural settings. Practice differences between urban and rural mental health settings
have been identified (Hough, Willging, Altschul, & Adelsheim, 2011).
Finally, while the study site had diversity in practitioners and members, no
attention to cultural differences related to ethnic diversity or socio-economic
status was included in the recruitment of participants. This limits what can be said
about the impact of cultural differences on reasoning frames.
Chapter 2. Literature Review
This chapter provides an overview of the background literature pertinent
to the current study. First, I review theoretical perspectives and research
approaches to the study of how healthcare practitioners think in “concrete
situations of practice” (Mattingly & Fleming, 1994, p. 5). Next, given the
qualitative approach to this study, I need to situate the work of these mental
health practitioners culturally and historically. Therefore, I begin with a review of
a major contextual frame for contemporary public mental health practice, i.e. the
recovery perspective. I then describe and review the evidence for the Assertive
Community Treatment (ACT), as a preferred model of service within the public
mental health system and model which, in addition to the recovery perspective,
informed California’s Mental Health Services Act (MHSA) Full-Service Partnership
(FSP) approach, including arguments regarding its’ fit with the recovery
How Practitioner’s Think-in-Action
Philosophical and theoretical perspectives on how healthcare practitioners
“think-in-action” (Schon, 1983) have drawn on Aristotle’s concepts of techne and
phronesis (Benner, 2004; Mattingly, 1998a; Polkinghorne, 2004); Polyani’s “tacit
knowing” or “personal knowledge” (Mattingly & Fleming, 1994; Polyani, 1958);
Schutz’s phenomenology of the social world (Schon, 1983; Schutz, 1967). In
addition, perspectives on situated cognition (Floersch, 2002; Lave, 1988; Rogoff &
Lave, 1984), the practice theories of Bourdeiu and Certeau (Floersch, 2002;
Polkinghorne, 2004) and cultural-historical activity theory (Toth-Cohen, 2008)
have been used to explicitly address the contextualized nature of practitioner’s
thinking. Further, various methodological and disciplinary traditions have been
used to investigate reasoning, including cognitive psychology’s “think aloud”
approach (Fonteyn, Kuipers, & Grobe, 1993; Unsworth, 2005) , ethnography
(Floersch, 2004b; Mattingly & Fleming, 1994; Toth-Cohen, 2008) and
phenomenology (Ward, 2003).
Practice reasoning (most commonly labeled as clinical reasoning in the
healthcare literature), also referred to as problem-solving, decision making or
judgment (Norman, 2005) is the term used to describe the various forms of
thinking (Mattingly & Fleming, 1994) that guide the actions of healthcare
practitioners during care encounters. It is understood to be complex process
requiring a contextualized integration of the practitioners personal and
professional knowledge (Leicht & Dickerson, 2001). Research on the reasoning of
healthcare practitioners has focused mostly on the diagnostic reasoning of
physicians (Norman, 2005) and nurses (Simmons, Lanuza, Fonteyn, Hicks, & Holm,
2003). Much of the research on nurses in particular grew out of Benner’s (1984)
foundational work using the Dreyfus Model of Skill Acquisition (i.e., novice,
advanced beginner, competent, proficient, expert) to understand the
development of expertise in nursing.
Investigation of the clinical reasoning of occupational therapists emerged
in the 1980’s (Rogers, 1983; Rogers & Masagatani, 1982), and a major contribution
was made by Mattingly & Fleming’s (Fleming, 1991a, 1991b; Mattingly, 1991;
Mattingly & Fleming, 1994) study in which they named and described procedural,
interactive, conditional and narrative forms of thinking used by occupational
therapists. Mattingly’s (1998b) perspective on narrative reasoning has been
particularly powerful for many practitioners, and she has continued to build a
body of research regarding the narrative structure of experience (Mattingly,
1998a). Researchers have continued to explore the nature of clinical reasoning in
occupational therapy (Gibson et al., 2000; Harries & Harries, 2001a, 2001b; Toth-
Cohen, 2008; Unsworth, 2001; Unsworth, 2005; Ward, 2003), and identified
additional types of reasoning including diagnostic (Rogers & Holm, 1991) and
pragmatic (Boyt Schell & Schell, 2008). Much of the way in which this research
has been used by the profession of occupational therapy, like that in medicine and
nursing, is to inform the design and focus of entry-level education programs and
practicum experiences (Neistadt, 1987, 1996, 1998; Neistadt, Wight, & Mulligan,
Studies of the clinical and/or practice reasoning of mental health providers
are limited. Notable exceptions are Luhrmann’s (2000) study of psychiatric
residents , Rhodes’ (1991) study of inpatient psychiatric practitioners, and
Townsend’s (1998) study of occupational therapists practicing in public mental
health settings. Luhrmann’s (2000) ethnographic study explored the experience of
resident’s during their psychiatric training. She found that these residents had to
learn to navigate within and reason from two divergent perspectives regarding the
nature of psychiatric disorders specifically the biological psychiatry and
psychoanalytic explanatory models. The need to mediate the tension between
these perspectives emerged in both diagnostic formulations and intervention
decisions. Further, Luhrmann situates her analysis within the larger contested
context of the mental health systems adoption of a managed care reimbursement
Rhodes (1991) ethnography explored the work of a university-affiliated
acute psychiatric unit in publicly funded community mental health center located
in a major metropolitan area. She argues that the units mental health providers,
including psychiatrists, social workers, nurses, and aides, experienced themselves
as “having an ‘impossible mandate’ that required that they discharge patients
quickly and yet treat them adequately” (p.1). Like Luhrmann, she makes evident
the ways in which the staff mediated this tension in their daily practices. Rhodes
situates her analysis with the larger dilemmas of publicly funded mental health
services, most particularly diminished resources and limited community/after-care
Townsend’s (1998) ethnographic study explored the practice of
occupational therapists working in public mental health settings in one of the
Canadian provinces, with particular attention to the “social organization” (p. xv) of
that work. She situated her analysis within the Canadian and provincial public
mental health systems move to promote community participation and
empowerment for persons labeled with psychiatric disabilities. She argues that
despite ‘good intentions’ there are powerful structural and systemic barriers
within the mental health service system that thwart practitioner efforts at
promoting empowerment and participation for persons labeled with psychiatric
There are few studies that have explored how front-line public mental
health workers think-in-action in their day-to-day practices.
Studies that have explored how front-line public mental health workers
think-in-action in their day-to-day practices include Schied (2004) and Floersch
(2002). Floersch (2002) explored the strengths-based
model of case
Although a strengths perspective has become a key feature of public mental health services focused on
facilitating recovery for persons labeled with psychiatric disabilities, here I am referring specifically to the
‘strengths-based case management’ approach developed by Charles Rapp and colleagues (Rapp & Goscha,
2006) at the University of Kansas. Strengths-based case management is an ecological model that was
management. He used an ethnographic approach in the tradition of other
ethnography’s of mental health practice, including Luhrmann’s (2000), Rhodes’
(1991), and Townsend’s (1998) described earlier, to understand how front-line
practitioners used their understanding and skill with the strengths-based model to
“produce apartment-dwelling consumers of mental health services” (Floersch,
2002, p. 1). Schied (Scheid, 2004) drew on sociological research, in particular the
work of Anselm Strauss and colleagues on psychiatric ideology (as cited in Scheid,
2004), to argue that the reasoning of community-based mental health
practitioners working in publicly funded mental health settings is informed by
particular “treatment ideologies”. She defined a treatment ideology as “the
complex set of beliefs providers hold about mental health, illness and treatment”
(p. 7). Such ideologies she argued are “critical referents for action” (p. 13),
develop experientially overtime and are mediated by the unique characteristics of
particular practice settings. In what follows, I provide a more thorough
description of both Scheid and Floersch’s findings given that they studied
practitioners in similar practices to my study participants.
Floersch (2002) conducted what he called a “practice ethnography” . He
explored the daily practices of mental health case managers trained in Strengths-
introduced in to social work practice specifically, and public mental health practice generally, in order to
mediate the hold that the medical model’s deficit perspective had on the clinical reasoning of mental health
professionals. The strengths-based case management model directs the practitioner to focus their attention
on the individual’s personal abilities and environmental resources. To some degree it also adopts a disability
studies perspective which argues that people are not ‘disabled, environments are disabling.
Based Case Management (Rapp & Goscha, 2006) providing such services to
persons labeled with psychiatric disabilities. Floersch (2004b) found that the
strengths perspective “suppresses a biomedical language of needs and illnesses
and shuns a clinical language that focuses on ‘internal resources’, focusing instead
on ‘external resources’” (p.80). He also argued that previous studies of social work
practice that used clinical documents as their primary text source missed critical
aspects of how practitioners make sense of their work and the people they serve.
He argued that to investigate what he called “practice gaps” (Floersch, 2004a)
between technical-rational (TR) and knowledge-in-action (KIA), research needed
to consider texts generated from participatory observation of in vivo practice
events (p.171). Further, Floersch drew on Bourdieu’s concept of social field to
situate the practice of these case managers within what he named as the evolving
social field of community support services. This social field he argued could be
distinguished from the ‘mental hospital’ social field, and was so “radically
reorganized and reconstituted that new disciplinary knowledge and practitioners
became necessary (p.9).
Floersch’s (2002) analysis of how case managers draw both on a form of
“disciplinary knowledge” and their own “situated knowledge” in their work (p. 5).
Drawing on Foucault, Floersch argued that the strengths-model of case
management represented a form of disciplinary knowledge. In addition, from
perspectives on situated learning (Lave, 1988; Lave & Wenger, 1991; Rogoff &
Lave, 1984), practice wisdom, e.g. Schon’s (1983) reflective practitioner, and
anthropology’s perspective on particular cultural knowledge, e.g. Geertz “local
knowledge”, he argued that case-managers working from a strengths-model
approach “produced local, specific, contextual, or situated knowledge in practice”
(Floersch, 2002, p. 5).
He argued that disciplinary knowledge has “scientific legitimization” (p.
63), and situated knowledge does not. Floersch supported his claim that the
strengths-model of case management is “scientific” by clarifying that although the
strengths-model of case management emerged out of the situated practices of a
particular agency, research conducted by a local university resulted in a
‘standardization’ of the practice and state-level policy decisions resulted in that
‘standardized’ practice being implemented. He found that the strengths-model
disciplinary knowledge did not provide practitioners with sufficient ways to make
sense of certain aspects of their work. They needed situated knowledge to provide
them with a more complete set of frames from which to reason.
Further, he argued that “situated knowledge often taps the helping,
enabling, teaching, parenting, and assisting sensibilities found in the life
experiences of case managers” (p.180). He found that the disciplinary knowledge
of the strengths-model did not provide meaningful frames for practitioner’s
reasoning about “meds, money, and manners” (p. 180). It was in these domains
that practitioners drew on situated knowledge and had developed a situated
language to communicate about their experiences. Specifically, he found that
practitioners framed decisions about their actions as either “doing for” or “doing
with”. For his participants, “doing for” was seen as problematic and risked
dependency, but might prevent problems from arising. On the other hand, “doing
with” meant that the practitioner was teaching necessary skills and manners. He
argued that the strengths textbooks did “not prescribe what should be done about
setting boundaries, teaching skills, modeling responsibility, preventing
dependency, and showing occasional acts of kindness” (p. 185). In addition, he
found that practitioners framed decisions about their actions in relationship to
their perception of the consumer’s
level of functioning and level of need (see
Table 1. Floersch’s Level of Functioning and Level of Need Matrix
Level of Need
Level of Functioning High Low
Low Low functioning, high need Low functioning, low need
High High functioning, high need High functioning, low need
He emphasized that state mental health policy, nor state Medicaid,
indentified such categories. Rather this was a situated knowledge frame that had
Consumer is used here because that is the language used by practitioners in Floersch’s study to
describe service recipients.
emerged out of the practitioner’s work which they used to manage their time with
consumers. Finally, Floersch found that his study participants utilized “natural
consequences” (p. 191) and “getting it” (p. 193) as situated knowledge frames to
facilitate certain decisions to take action or not. Allowing natural consequences
“to unfold was about learning failure and gaining insight” (p. 191) and meant that
the practitioner would not provide support. When members didn’t “get it” (p.
193) the practitioner had determined that learning was not likely to occur and that
the practitioner would provide support. Knowing when to act and when not to act
was grounded in the practitioner’s knowledge of that particular consumer.
Scheid used participant-observation and in-depth interviews, and a
grounded theory analytic approach, to develop a typology of treatment ideologies
from her own research with practitioners from a large mental health center in the
United States. Although she did extend her typology to include a “custodial” role
for providers and “control” as target of intervention based on her broader
understanding of the mental health system (Scheid, 1994). Scheid noted that
these treatment ideologies represent “ideal types or analytical constructs” (p.
679), and that the practitioners in her study framed their work from more than
I am referring to the initial typology (see Table 2) as it was based on her
work with community mental health practitioners. She identified four frames that
positioned the practitioner in particular ways (1) in relation to their role as a
provider, and (2) from their perspective on what counted as a meaningful
intervention outcome. She found that her study participants framed their roles as
either supportive or facilitative, and their perspective on intervention outcomes as
targeting adjustment or autonomy.
Table 2. Scheid’s Typology of Treatment Ideologies of Community Mental Health
Role of Provider
Treatment Goals Supportive Facilitative
Adjustment Care-taking Reparenting
Autonomy Normalization Empowerment
Care-takers, she argued, worked to insure “stabilization” and sought to
“provide havens” that gave clients a “sense of belonging”(Scheid, 1994, p. 679),
but risked developing dependency. Parents emphasized “learning the rules” and
“skills training” focused on socially appropriate behaviors and teaching clients “to
do more on their own” (p.680). The supportive-autonomy informed practitioner
believed that “clients are to resume normal lives in the community or establish a
normal existence which involves minimal contact with the mental health center”
(p. 682). With support from the practitioner, the client learns through
participation in a range of occupational roles and daily routines. The facilitative-
autonomy informed practitioner works from “a more existentialist concern with
self-direction and control” and works to “enable consumers to take charge of their
lives and to enlarge their range of choices and options” (p. 682). She also argued
that both care-takers and parents believed in the importance of developing a
wide-range of supportive environments. Practitioners that practiced from
normalization and empowerment perspectives, on the other hand, believed in the
importance of clients working toward independence from the mental health
system and promoted greater control of supportive environments and services by
persons labeled with psychiatric disabilities themselves.
Recovery for Persons Labeled with Psychiatric Disabilities
Recovery for persons labeled with psychiatric disabilities is being
addressed as part of this literature review for two key reasons: (1) it is the target
of the interventions delivered by the practitioners that were the focus of this
study, and (2) the specific setting in which this study was conducted grounds its
daily practices in the recovery perspective. Evidence of recovery for persons
labeled with psychiatric disabilities has been documented (Davidson et al., 2005;
Davidson & Strauss, 1997; Deegan, 1988; Harding, Brooks, Ashikaga, Strauss, &
Breier, 1987a, 1987b; Ridgeway, 2001; Smith, 2000; Young & Ensing, 1999), and
engagement in occupation is argued as both a means to and evidence of that
recovery (Davidson et al., 2005; Davidson & Strauss, 1997; Laliberte-Rudman,
2002; Young & Ensing, 1999). Rather than “cure” in the biomedical sense,
recovery here refers to the self-transformations and participatory shifts that occur
over time as the person makes sense of their illness experience, learns to manage
symptoms (Deegan, 1988), and develops a sense of self “outside” the illness
(Davidson, 2003). The recovery paradigm (Ridgeway, 2001), as it has come to be
referred to, now informs the provision of public mental health services in most
developed nations, including the United States (DHHS, 1999, 2003, 2005; Jacobson
& Curtis, 2000).
Although this perspective has taken hold at the public policy level with a
call to a recovery-oriented health care system (DHHS, 2005), Dickerson (2006)
raises concerns regarding what she calls the “disquieting aspects of the recovery
paradigm” (p.647). She asks “what exactly should providers do differently in a
transformed ‘recovery-oriented’ mental health system?” (p.647), and worries that
it may represent just another “cycle of reform…that seems to offer the solution
but is later evaluated to have been naïve and unscientific” (p.647). In addition,
she questions whether, along with Masland (2006), recovery as represented in
this paradigm is possible for everyone labeled with psychiatric disabilities.
Davidson, Schmutte, Dinseo & Anders-Hyman (2007) argue that, at least in part,
the work that the recovery paradigm does for persons labeled with psychiatric
disabilities is to “convey hope…that improvements in their condition are possible
and common” (italics added, p. 4). I would argue that it also does the same work
Modern accounts of recovery for persons labeled with mental illness in the
United States were reported by the early alienists in mid-1800’s in response to
, but later debunked as misrepresentations of the actual
recovery rates (Deutsch, 1936; Grob, 1991; Luchins, 1992). In the early 1900’s
during the period known as the mental hygiene movement
, Adolf Meyer’s
psychobiological perspective represented an approach that was also understood
as resulting in recovery outcomes (Lidz, 1966; Meyer, 1957; Rennie, 1940).
Meyer’s pragmatist-informed approach that argued for “a genetic-dynamic
understanding of mental disorders in terms of the unique biography of each
individual” was eclipsed by the Freudian intrapsychic approach (Lidz, 1966, p.
Moral treatment refers to a specific period (i.e, late 1700’s to mid 1800’s) in the history of the
institutional care of persons labeled with psychiatric disabilities. Moral in this context has been
understood to mean ‘psychological’, and represented a shift in thinking about the capacity for
reason of an individual once they are believed to be ‘insane’. Treatment during this period
consisted of efforts at engaging patients in a daily round of work activities and pleasurable
pursuits, with the expectation that the person would use their self-directed reasoning capacity to
manage their behavior. Generally, this period is described as being a time of more humane
institutional practices, with Phillipe Pinel’s ‘breaking of the chains at the Salpetriere’ as it’s
symbolic representation (Bockoven, 1963). Historians have contested this view, emphasizing that
it also represented the period when medicine intentionally assumed responsibility for institutional
care and changed our notions about ‘madness’ as a personal experience to ‘mental illness’ as a
medical phenomenon (Foucault, 1965).
The mental hygiene movement refers to a specific period (i.e., early 1900’s) in the history of
mental health care. It was a progressive era phenomenon informed by pragmatist philosophy, and
was adopted by the early mental health and social service professions of the time, including social
work and occupational therapy. It represented an early ecological model that understood that
context mattered and informed care and intervention efforts for “the insane” (p.60), “the criminal”
(p.118), and “the feebleminded” (p. 159) (White, 1923). Historians describe it as a reform
movement, significantly influenced by the publication of Clifford Beers A Mind That Found Itself,
which was a personal account of the oppressive and traumatic treatment experienced by Beers
during his hospitalization for mental illness (Dain, 1980).
326). Recently, a critical psychiatry
perspective has called upon psychiatry to
reconsider Meyer given what has been defined as the limits of a psychiatry
informed by the biomedical model (Double, 1990, 2002, 2003).
Ridgway (2001) and others (Bellack, 2006; Jacobson & Greenley, 2001)
however argue that the recent (1990’s to present) turn to recovery as a viable
outcome for persons labeled with mental illness is informed by the emergence of
first-person accounts of recovery during the 1980’s (Deegan, 1988; Fortner &
Steel, 1988; Houghton, 1982; Leete, 1989; O’Neal, 1984; Weingarten, 1989),
qualitative studies documenting the experience of recovery (Davidson & Strauss,
1997; Young & Ensing, 1999), and finally the empirical evidence beginning with the
foundational work of Harding and her colleagues (Harding et al., 1987a, 1987b)
that showed that recovery was possible. Persons labeled with psychiatric
disabilities are seen as recovering not just from the illness itself, but from the
“stigma they have incorporated into their very being, the iatrogenic effects of
Critical psychiatry “challenges the dominance of clinical neuroscience in psychiatry (but does not
exclude it); it introduces a strong ethical perspective on psychiatric knowledge and practice; it
politicizes mental health issue…[it] reject[s] the medical model in psychiatry and prefer[s] a social
model, which..[is seen as] more appropriate in a multi-cultural society characterized by deep
inequalities” Source: http://www.critpsynet.freeuk.com/healthmatters.htm.
treatment settings, the lack of recent opportunities for self-determination, the
negative side effects of unemployment and crushed dreams” (Anthony, 1993, p.
Ralph (2000) in a review of the recovery literature cited several definitions
of recovery from the consumer/survivor first-person accounts including Patricia
Deegan, who is an internationally respected consumer/survivor advocate:
Recovery is a process, a way of life, an attitude, and a way of approaching
the day’s challenges. It is not a perfectly linear process. At times our
course is erratic and we falter, slide back, regroup and start again. The
need is to meet the challenge of the disability and to reestablish a new and
valued sense of integrity and purpose within and beyond the limits of the
disability; the aspiration is to live, work, and love in a community in which
one makes a significant contribution (Deegan as cited in Ralph, 2000, p. 6).
One of the most commonly cited definitions in the mental health practice
literature has been the one put forth by Anthony (1993), a well-known and
respected psychiatric rehabilitation researcher and early advocate for a recovery-
oriented mental health service system. He conceptualizes recovery as follows:
Recovery is a deeply personal, unique process of changing one’s attitudes,
values, feelings, goals, and roles. It is a way of living a satisfying, hopeful
and contributing life even with the limitations caused by illness. It involves
the development of new meaning and purpose in one’s life as one grows
beyond the catastrophic effects of illness (p.11).
Findings from qualitative studies have also been used to propose phases of
recovery (Andresen, Oades, & Caputi, 2003; Davidson et al., 2005; Davidson &
Strauss, 1997; Ridgeway, 2001; Spaniol, Wewiorski, Gagne, & Anthony, 2002;
Young & Ensing, 1999). A critical aspect of the recovery process that seems
common to these models is an ‘awakening’ experience post being labeled and
often after experiencing profound functional disruptions. In this phase, according
to Davidson & Strauss (Davidson & Strauss, 1997) the person “discovers a more
active self “ (p. 131). This awareness of a changed sense of self separate from the
illness appears to offer the person sense of hope, and is often credited to the
caring from an important other who “believed in them” (p.28). Phase models of
recovery may provide mental health practitioners with frameworks for
understanding the nature and timing of their interventions.
As noted previously, tensions have arisen in the mental health practice and
research community regarding what truly counts as recovery. This tension has
been represented by arguments for process vs. outcome definitions of recovery
(Liberman, Kopelowicz, Ventura, & Gutkind, 2002; Ralph & Corrigan, 2005; Spaniol
et al., 2002), clinical vs. social models of recovery (Secker, Membrey, Grove, &
Sebolm, 2002) and scientific vs. consumer models of recovery (Bellack, 2006).
Scientific/clinical models of recovery are described as emerging out of
medical model perspective focus on symptom elimination/reduction. This
perspective it is argued takes the recovery as outcome view (Bellack, 2006), where
recovery is seen as the person having accomplished behavioral targets “that
includes symptom remission; full- or part-time involvement in work or school;
independent living without supervision by family or surrogate caregivers; not fully
dependent on financial support from disability insurance; and having friends with
whom activities are shared on a regular “ (Liberman, Kopelowicz, et al., 2002, p.
Consumer/social models of recovery on the other hand are argued as
emerging out of a civil rights frame and argues for recovery as process (Bellack,
2006). On this view, recovery is seen as being a continuous and ongoing, non-
linear experience that happens over time and represents the subjective
experience of self-transformation. The metaphor ‘journey’ is often used to
represent this perspective, as in Deegan’s (1996) “Recovery a Journey of the
Heart”. These dual perspectives are important for the study being proposed here
in that it is likely that they must be mediated in the field by mental health
practitioners as they go about day to day encounters with persons labeled with
Recovery then has come to be understood as a transformative experience
involving the re-emergence of one’s intentionality, the “inner force that directs us
outward into participation in the life-world” (Mattingly & Fleming, 1994, p. 198)
and the reconstruction of one’s lifestyle to include occupations infused with
meaning and purpose (Deegan, 2005).
I have also had to plan for the use of my time. When one has a chaotic
inner existence, the structure of a predictable daily schedule makes life
easier. No, obviously structured activity can be anything, but for me it is
work—a paying job, the ultimate goal. It gives me something to look
forward to every day and a skill to learn and to improve. It is my
motivation for getting up each morning. In addition, my hours are passed
therapeutically as well as productively. As I work I become increasingly
self-confident and my self-image is bolstered (Leete, 1989).
Assertive Community Treatment as an Evidence-Based Practice
The Assertive Community treatment (ACT) services model is considered in
this literature review because it is the community-based mental health services
model that informed the California’s Mental Health Services Act (MHSA) Full-
Service Partnerships, and it was the practice reasoning of FSP personal service
coordinators that was the focus of this study. Assertive community treatment
(ACT), also referred to as the Program for Assertive Community Treatment
(P/ACT), represents one of the community-based interventions that have evolved
over the last fifty years to meet the needs of persons labeled with psychiatric
disabilities. The ACT approach is distinguished from other approaches by its
provision of comprehensive, community-based treatment, rehabilitation and
support services, 24-hours per day, 365 days per year by a multidisciplinary team,
including psychiatrist and nurse(s), as well as employment, substance abuse and
consumer/peer specialists (Allness & Knoedler, 1998).
ACT teams typically meet each weekday morning to identify visits and
other actions/communications regarding specific ACT clients that need to
completed, as well as to briefly review visits/contacts from previous day. The
decision regarding which staff visits which client, is based on efforts to match staff
skill/knowledge/relationship with client need, as well as availability and other
commitments that that staff member may have. The model is based on all visits
being provided in the natural environment, so all providers including the
psychiatrist conducts home/community visits. The frequency of visits is intended
to be based on need, but given that this approach is generally targeted to those
defined as ‘high-need’ clients, 1-3 visits per week is common; and, in some
instances, multiple visits may happen in one day.
The assertive community treatment program evolved out of an early
1960’s research initiative at the Mendota State Hospital in Madison, Wisconsin,
that explored interventions to promote recovery for “previously unresponsive
patients”. A critical discovery in the research findings was that symptoms and
behavior did not necessarily relate to community tenure, rather access to “an
intensive and sustained aftercare treatment program” was found to be critical
(Stein & Test, 1985, p. 8). The Training in Community Living Program, the
prototype for the ACT approach, initially funded in 1972 was developed out of
understandings from that research. It was informed by (1) a finding that it was
primarily impoverished coping skills and lack of support services that lead to
psychiatric inpatient readmission; and (2) that it was in the community, not
inpatient psychiatric settings, where the necessary coping skills would be acquired
(Stein & Test, 1985, p. 11).
ACT’s practice principles guide the work of staff and provide funders,
persons served and their families with a means to distinguish this approach from
other community-based approaches.
Services are targeted to a specified group of individuals labeled with
severe mental illness.
Rather than brokering services, treatment, support, and rehabilitation
services are provided directly by the assertive community treatment team.
Team members share responsibility for the individual served by the team.
The staff-to-consumer ratio is small (approximately 1 to 10).
The range of treatment and services is comprehensive and flexible.
Interventions are carried out at the locations where problems occur and
support is needed rather than in hospital or clinic settings.
There is no arbitrary time limit on receiving services.
Treatment and support services are individualized.
Services are available on 24-hour basis.
The team is assertive in engaging individuals in treatment and monitoring
their progress (Phillips et al., 2001, p. 773).
Research on ACT is extensive including evidence of positive client
outcomes (Barry, Zeber, Blow, & Valenstein, 2003; Becker, Meisler, Stormer, &
Brondino, 1999; Calsyn, Morse, Klinkenberg, & Lemming, 2004; Coldwell &
Bender, 2007; Essock et al., 2006; Kirsh & Cockburn, 2007; Macias et al., 2006;
McGrew, Bond, Dietzen, McKasson, & Miller, 1995; Schonebaum, Boyd, & Dudek,
2006), client satisfaction (Ben-Porath, Peterson, & Piskur, 2004), client
experiences of receiving ACT services (Krupa, Eastabrook, Hern, & Lee, 2005;
Leiphart & Barnes, 2005; Watts & Priebe, 2002) , dissemination and
implementation strategies and success (Deci, Santos, Hiott, Schoenwald, & Dias,
1995), cost effectiveness (Chandler & Spicer, 2002; Chandler, Spicer, Wagner, &
Hargreaves, 1999), identification of critical ingredients (Bond et al., 2001;
McGrew, Pescosolido, & Wright, 2003), and development of fidelity measures
(McHugo, Drake, Teague, & Xie, 1999; Teague et al., 1998).
International studies have documented its implementation and
effectiveness as well, e.g., England (Priebe et al., 2003; Wright et al., 2003),
Canada (Joannette, Lawson, Eastabrook, & Krupa, 2005), Netherlands (Dekker et
al., 2002; Henskens, Garretsen, Mulder, Bongers, & Kroon, 2005; Sytema,
Wunderink, Bloemers, Roorda, & Wiersma, 2007), Singapore (Fam, Lee, Lim, &
Lee, 2007). Research has also addressed the implementation of ACT with
particular populations, i.e., older adults (Levin & Miya, 2008), adolescents (Ahrens,
Frey, Knoedler, & Senn-Burke, 2007), persons who are homeless (Coldwell &
Bender, 2007; Dixon, Friedman, & Lehman, 1993; Dixon, Krauss, Kernan, Lehman,
& DeForge, 1995), persons with co-occuring disorders (Drake et al., 1998), and
forensic populations (Lamberti, Weisman, & Faden, 2004; McCoy, Roberts,
Hanrahan, Clay, & Luchins, 2004). Implementation manuals have also been
developed (Allness & Knoedler, 1998; SAMHSA, 2003; Stein & Santos, 1998).
Despite this large research base, the ACT approach has not been without
controversy. Given the focus and nature of this approach, its fit with the recovery
perspective is seen as particularly challenging (Drake & Deegan, 2008; Salyers &
Tsemberis, 2007). As noted previously, criticisms focus on the perception that
ACT is a biomedically-driven intervention that frequently disrespects the
preferences and individual rights of persons they serve with intrusive and coercive
actions on the part of practitioners (Gomory, 1999, 2001, 2002, 2005; Spindel &
Nugent, 2000). These concerns have been strengthened particularly as states pair
their efforts to implement ACT programs with the passage of involuntary
outpatient commitment (IOC)
laws (Petrila, Ridgely, & Borum, 2003; Ridgely et
Consumers argue that the ACT approach is not informed by, nor has it
been modified in response to, understandings regarding the recovery experience
that has emerged out of the growing number of qualitative studies and first-
person accounts (Ahern & Fisher, 2001). In response to these concerns, the
National Empowerment Center (NEC), a consumer self-help and advocacy
organization, developed an alternative to ACT known as Personal Assistance in
Community Existence (PACE). The PACE model emphasizes peer support over
professional help, empowerment over “coercion”, and holistic health over
biomedical interventions (Ahern & Fisher, 2001). Drake & Deegan (2008) note
that the ACT program has been adapted over the years in response to new
evidence, and acknowledge that “shifting to more of a recovery orientation can be
Involuntary outpatient commitment (IOC), sometimes referred to as ‘assisted outpatient
treatment’ has emerged as a response to protect the public from the potential for violence
perpetrated by persons labeled with mental illness; and, to enhance treatment compliance of
persons labeled with mental illness as well (Allen & Smith, 2001). Several states have adopted IOC
laws, including California where it is referred to as Laura’s Law (AB 1421). As would be expected
consumer groups are critical of these laws, and research is mixed on the impact on public safety
and compliance (Ridgely, Borum, & Petrila, 2001).
seen as another helpful transition as the values and science of community-based
care evolve” (p.76).
It should also be noted, that some of these criticisms run counter to what
Stein & Santos (1998) identified as the fundamental beliefs and values held by the
researchers that innovated the P/ACT model. They emphasize that these
researchers were inspired by and part of an emerging perspective in psychiatry in
the 1960’s that believed strongly in an anti-biological perspective to the etiology
of mental illness and highly valued a “patient’s” civil liberties (Test & Stein, 2001).
Operational evidence of these criticisms at the level of an individual P/ACT team is
likely to depend on many factors, including the professional composition of the
team, the local availability of non-hospital crisis settings, state and local
regulations regarding voluntary and involuntary commitment, the length of time
the team has worked together, as well as other factors.
Despite the significant amount of research on ACT, there have been few
studies exploring ACT practitioner’s practice reasoning, beyond therapeutic limit
setting (Rosenheck & Neale, 2004; Rosenheck, 2001) and treatment adherence
(Angell et al., 2006). Angell, Mahoney & Martinez (2006) argue that limit setting
and treatment adherence have been prioritized in particular because of the above
noted criticisms of ACT as being intrusive and too narrowly focused on medication
use as a primary hospital avoidance strategy. Treatment adherence studies have
attempted to more fully describe/explain the nature and timing of the practitioner
actions. In addition, Angell & Mahoney (2007) also investigated the nature of the
helping relationship in ACT programs. They argue for the need for such studies
because working alliance studies of psychotherapy may have limited value in
understanding practitioner-client relationships in ACT, given the in-vivo,
community-based nature of how services are delivered.
Evidence for the experience of recovery for persons labeled with
psychiatric disabilities has been documented and has provided the impetus for a
transformation of the public mental health system in the US. This contemporary
perspective on recovery has come to be understood as representing primarily self
and participatory transformations. Assertive community treatment (ACT) is the
most well-articulated and widely adopted EBIs being adopted and implemented by
public mental service providers. Although a large body of research has
documented its critical ingredients and effectiveness, there is little research
regarding how practitioners working ACT or ACT-informed programs make
practice judgments. Qualitative research in particular has the potential for
explicating the ‘down on the ground’ reasoning.
Chapter 3. Methodology
This chapter will address the methods I used to collect, analyze and interpret the
data from the participants in this study. I used a qualitative approach informed by
ethnographic (Lofland & Lofland, 1995), hermeneutic phenomenological (Polkinghorne,
1983; Van Manen, 1990) and narrative (Mattingly, 1998a, 1998b; Mattingly & Lawlor,
2000; Polkinghorne, 1988) perspectives to explore the practice reasoning of personal
service coordinators working in a full-service partnership. As noted previously, full-
service partnerships (FSP) represent California’s most intensive community-based mental
health service for persons labeled with psychiatric disabilities. Personal service
coordinator (PSC) is the job title for the front-line mental health practitioners providing
case management and community integrations services as part of the full-service
partnership. A purposive selection process was utilized to secure both the site and recruit
study participants (Polkinghorne, 2005). The name of the agency where this research was
conducted and the names of all study participants have been changed to pseudonyms.
Selection of Study Site
This research was conducted at Vanguard, a publicly funded community
mental health nonprofit organization located in Los Angeles County, California.
The primary inclusion criterion for the site was that it provide community-based
mental health services to persons labeled with psychiatric disabilities utilizing the
full-service partnership model, and that it have or operate two or more such
teams. Selecting a site that had two or more teams was important to secure a
sufficient number of study participants in order to strengthen the trustworthiness
of the data. In Los Angeles County, these full-service partnerships are provided
both by mental health clinics directly-operated by the Los Angeles County
Department of Mental Health (LAC DMH) and not-for-profit or for-profit
organizations with whom the LAC DMH contracts to deliver such services.
Whether the site was directly operated or contracted, nonprofit or for-profit was
not a selection criterion. In addition, I sought to secure a site that was supportive
of research and would facilitate my access to their FSP personal service
In Los Angeles County, there are several organizations that operate full-
service partnerships. With the assistance of one of my committee members, I
initially contacted a nonprofit organization that delivered full-service partnerships
across the age-span in several areas throughout the county and had a long
tradition of supporting research. However, they were unable to support my
research at the time. Because I had worked in this county during my occupational
therapy career, I was familiar with several mental health agencies. I contacted
two other agencies who were operating full-service partnerships, and both
agencies expressed interest in my research. However, I did not select one of the
sites as it primarily served children and youth, and operated only one full-service
I was familiar with Vanguard, and its current leadership, as it was well-
known both within Los Angeles County and the State of California. In addition, I
had had occasional interactions with Vanguard leadership over the past three
decades given our mutual interest and engagement in community-based
psychiatric rehabilitation services. I contacted the CEO of the parent organization
who had previously served as the Vanguard research director. I provided him with
a brief summary of my research and he responded with interest. He, I and the
current Vanguard CEO met at the site to discuss the research. Vanguard has
three adult FSPs and one transition-age-youth (TAY) FSP. The TAY FSP operated
out of a separate physical plant site and had unique demands such that its’ ability
to support research at the time was not as strong as the three (3) adult teams.
Following that meeting, the CEO of the parent organization and the
Vanguard CEO met with their senior management team to review the viability of
and support for the research project. The outcome of this meeting was positive,
and I was invited to meet with the program managers work group, which included
team leaders from the full-service partnerships. At that meeting, I again provided
a summary of the purpose and design of the research, and clarified questions. I
reviewed the specifics of the study and like my initial meetings with the CEO of the
parent organization and the Vanguard CEO the management team was very
supportive, and expressed curiosity and interest in the study. The CEO emailed:
I talked to the management team and they are excited about working with you
and learning from your efforts exactly “how” do staff make day to day decisions
with so many conflicting forces at work (philosophical adherence, traditional
training, common sense and billing to name a few) (personal communication,
March 19, 2010).
It was my sense that my success in securing the study site was certainly
related to my long standing relationship with the CEO of the parent organization
and the Vanguard CEO, and our mutual interest in psychiatric rehabilitation
services for persons labeled with psychiatric disabilities. While we had never
worked together in the same agency, each of us had crossed paths during
professional conferences both at the state and national level. I felt welcomed and
respected when I met with them, and definitely felt that I was talking with like-
Although in our discussion, it was clear to me that our camaraderie was
not sufficient to their welcoming me as a researcher at their organization. I
needed to also be studying something that would matter to them, their members
and their practitioners. They seemed engaged by and enthusiastic about the focus
of the study. They acknowledged that having the research focus on the
practitioners, and not the experience of members or the outcomes of their
intervention, was not something that had been explored by previous research
studies conducted at the site. It was their hope that the findings from the study
could contribute to their understanding of how their practitioners worked.
Recruiting Study Participants
The inclusion criteria for the study participants were that they be full-time,
direct-care/front-line, nonsupervisory practitioners who had worked for at least
one year or more as a personal service coordinator on one of the study site’s FSP
teams. Although I was not explicitly studying how practitioners develop their
expertise, it was important that the practitioners had had a sufficient amount of
experience delivering services as a personal service coordinator on a full-service
partnership. This insured that they had a certain degree of familiarity and
experience with the philosophy and practices of this setting and the service
model, as well as experience with multiple care encounters, across multiple care
Prior to participant recruitment, human subject protection approval was
obtained from the University of Southern California’s Institutional Review Board
(IRB) (see Appendix) and the Los Angeles County Department of Mental Health’s
(LAC DMH) Human Subjects Committee (See Appendix). Given that the study
design involved my observing practitioner’s during one or more of their visits with
members, the Los Angeles County Department of Mental Health’s Human Subjects
Committee required that I obtain informed consent from both the practitioners’
and each member whose visit I would be observing (See Appendix).
Given the nature of the research and Vanguard’s team structure, the
Vanguard CEO and I agreed that it made most sense for me to spend some time
on each team, and to recruit study participants and complete the data collection
with one team before transitioning to the next. The first team I started with was
selected because it had team meetings on days that matched the days I was able
to be at the site, and the other teams did not. In addition, this team had not
experienced any recent personnel changes, unlike at least one other team who
had recently had changes in the team leadership. It was decided that it would be
better to work with that team later in order to give them time to adjust to the
For each team, I first met briefly with the team director and then attended
one of the team’s morning meetings. The Vanguard CEO introduced me to the first
team director and team, my introduction to the other two teams was facilitated
by the team director or assistant director of the team from which I was
transitioning. This seemed to work well and the team leaders helped me to get
situated with each new team. When I had successfully completed the scheduled
interviews with each study participant or was close to completing the interviews
from one team, I asked the first team leader to help me connect with the next
team leader. During my first meeting with each team, I briefly summarized the
purpose and design of the research. While I had developed a script, I found that
what I had initially written seemed too formal for the type of exchange that
transpired during team meetings. Over time I got better at providing a brief, but
what I felt was an accurate representation of the focus and design of my research
that seemed to make sense to the practitioners. Specifically:
I shared that I wanted to understand what they were thinking as they
interacted with members and made decisions about what they would do in
their role as a personal service coordinator to meet the needs of the
members. I emphasized that it wasn’t so much what they were doing, but
why they did one thing rather than something else or what influenced
them to take a particular action at a particular time.
I shared that I would join them on two or more visits with one of their
members and then interview them immediately after the visit. I
emphasized that the focus on the interview would be about their
experience and thinking during the visit. I also shared that once I had
completed the visit observations and post-visit interviews, I would meet
with them to conduct a more in-depth interview. I emphasized that this
longer interview would be scheduled at a time convenient to them and
focus on how they had come to know what they know about how to do
their work as a personal service coordinator.
I clarified that they, not I, would identify which member or members
would be willing to let me join them on a visit. Further, I clarified that the
only selection criteria was that the member be willing to let me join the
visit. I did not expect that they identify members’ with particular
characteristics or needs
I closed each presentation, thanking them for welcoming me to the team,
let them know which days I would be on-site and that if they were
interested in participating in my research to let me know.
During that introductory meeting the practitioners did have questions, and
most seemed to be about the logistics of the observations and interviews,
particularly in relation to the members. Once that first meeting had been
conducted, I would ‘hang out’ in the team area and make myself available for
practitioners to approach me about their interest in participating in the study. I
did this with each team, however as I moved from team to team the length of
time that I would hang out did lessen.
As I became more familiar with the routine, the people and the space I got
more comfortable and confident in approaching the practitioners. While on one
or two them did approach me on their own and express and interest in
participating in the study, for the most part I had to approach them and ask if they
were interested in meeting with me to discuss their participation. I met with
those practitioners that expressed an interest in participating, fully reviewed the
consent form (See Appendix for Practitioner’s Consent Form) and obtained their
signature as an indication of their willingness to participate in the study.
All eight practitioners who met the inclusion criteria on the first team
enrolled in the study. On the second team, four of the five practitioners who met
the inclusion criteria enrolled in the study. The practitioner, who did not enroll,
had expressed interest and I made multiple attempts to connect with him. I also
saw him several times during my tenure with that team, both in team meetings
and informally as I ‘hung out’ in the team area. We exchanged conversation on a
few occasions about not being able to find a time to meet, and I continued to try
to connect with him when I transitioned to the next team. Despite these efforts, I
was unsuccessful in securing a time to meet with him. I don’t have a real good
sense of what kept us from connecting, although during one of our brief
exchanges about finding time to meet he seemed to express some doubt about
the value of his being interviewed. I did try to communicate my belief that his
perspectives would be valuable, but I may not have been persuasive enough.
On the third and final team, six practitioners met the inclusion criteria, and
three enrolled in the study. One practitioner did not enroll because she felt that
she did not have a member at that time who she felt would be comfortable having
me observe one of their visits. Once I secured enrollment of three practitioners
from that team, I did not do any further recruitment given time constraints.
Fifteen practitioners from across Vanguard’s three adult FSP teams were
successfully recruited to participate in the study. Table 3 provides a summary of
each participant’s education, lived experience, previous work experience and the
number of years with Vanguard. Acknowledging lived experience as a participant
characteristic is important given the nature of the work and Vanguard’s
philosophy (See Chapter 4). Lived experience here meant that the study
participant had identified themselves having experience with mental illness,
substance abuse or homelessness themselves or as a family member.
Table 3. Study Participants Education, Lived Experience, Previous Work Experience
and Years with Vanguard
Participant Education Lived
Team One (8 participants)
for Masters in
but not thesis
First grade teacher
internships as part of
MSW, second was with
Vanguard and was hired
No previous work
experience in mental
health before starting at
Table 3. Continued
Participant Education Lived
Sharon In process of
No previous work
experience in mental
health before starting at
Patrick Masters in
internships, one in a
Casey Masters in
internships as part of
MSW, second was with
Vanguard and hired
Previous social service
work with children
Completed internship with
Vanguard and hired
Completed semester long
internship with a mental
Worked in full-service
partnership with another
mental health agency and
then was hired by
Table 3. Continued
Team Two (4 participants)
Participant Education Lived
Sandy BA in Sociology
No prior work experience
in mental health
Connie Masters in
Extensive work experience
with persons with
internships in mental
health, with second being
at Vanguard and was hired
No previous work
experience in mental
health, all prior nursing
work in medical settings.
Team Three (3 participants)
Previous extended work
experience in mental
health in residential setting
Has applied to
Extensive experience in
social services for children,
No prior work experience
in mental health
No previous work
Once the practitioner had agreed to participate in the study, they
identified members (i.e., this agency refers to its’ clients as ‘members’) who might
be comfortable or likely to agree to my joining them on a visit. The practitioners
then provided the member with a brief explanation and asked if they would be
willing to meet with me to discuss the study. If the member agreed I met with
them to explain the study and to obtain their signature on the consent form (See
Appendix for Client Consent Form). Practitioners only provided me with
information about members who had agreed to meet with me. I was not aware of
which members the practitioners may have spoken to about the study, and chose
not to meet with me. Twenty-five clients did agree to meet with me and then
consented to allow me to join them on a visit with their practitioner. One client
who had initially given consent withdrew prior to the visit taking place. No
member withdrew his or her consent during or after the visit that I observed. I
joined practitioners on a total of twenty-four visits.
The data collection process took place over approximately nine months,
mid-September 2010 to the end of June, 2011. During that time I spent
approximately two days per week at the research site, for approximately four to
five hours each day. I engaged in participant-observation with each of the three
teams, approximately four months with the first team, three months with the
second team and two months with the third and final team. Participant-
observation included ‘hanging out’ in the team area, attending team meetings,
and other agency meetings/trainings. With those practitioners that enrolled in the
study, I observed their visits with one or two members and interviewed them
immediately post the visit about that specific visit. After completing the visit
observations and interview, I also conducted a more in-depth interview with each
The “ethnographic lens” (Lawlor, 2003). Because my study participants
practiced in a particular context, I needed a way to understand that context
beyond what I would capture in interviews. I utilized ethnographic techniques of
participant-observation and key document review to accomplish that aspect of my
research. During my time with each team and consistent with an ethnographic
perspective I ‘hung out’(Mattingly & Fleming, 1994). I also attended/participated
in specific formal organization structures (e.g., team meetings, all agency
meetings, staff and visitor trainings) utilized by my research site to conduct their
work, and to communicate their philosophy and practices. I completed field notes
after participating in selected meetings noting what transpired, as well as my
impressions and analytical ideas (Lofland & Lofland, 1995). During team meetings
in particular, I tried to attend to, document and reflect on decision making
For example, there was one meeting in particular in which the one of the
teams was struggling about what to do to support one of the members. This
member was experiencing profound behavioral problems and had been asked to
leave her current residence. I was struck both with the very complicated and
challenging nature of this member’s difficulties, and the very engaged discussion
that ensued. The team reviewed what had and hadn’t worked in the past, with
each team member telling ‘short stories’ about recent encounters. The story
telling was informative, but also expressed both the concern they had for the
member as well as the frustration they were experiencing. As they considered
their options, they kept going back to what I came to call ‘experienced-based’
reasoning to evaluate these options. It was clear to me that this member was well
known by all the team members, and it was the knowledge gained from their
experiences with her that helped them to, in particular, reject certain options.
Towards the end of this extended discussion, one of the practitioners wondered
out loud, “Should we let her be homeless?” Overtime, I came to learn that this
question represented what the practitioners referred to as natural consequences
(See Chapter 5).
Each team had a designated and bounded physical space (see Chapter 4)
which afforded me both a place to sit and observe, but also to interact both with
staff and members from that team (See Chapter 4). When I wasn’t at a meeting,
or visiting a member with one of the practitioners, I was in the team area. On the
days that I was at the site, I would arrive around 9:00 AM because that was the
time that the building was unlocked and open for members. Although staff
arrived earlier, I wasn’t really sure in the beginning if I could enter before that
time. I never did ask for any clarification of that, and overtime one of the security
guards began to recognize me. He came to know that I was one of the non-
members and he would sometimes unlock and let me in.
I wasn’t always comfortable with that, since members had to wait until the
doors were unlocked. My discomfort had to with a sense of equity about access,
since like members, my role at the site did not afford me access to keys. So most
of the time, I would try to arrive right at 9:00 AM or a little after or would hang
out on street with other visitors or members who might be waiting for the
building to be unlocked. Somehow, this seemed to be the right way for me. What
I mean by that is that, while I had been given access to the space, people and
context, waiting each day to be ‘let in’ helped me to think of myself as something
other than a practitioner. (Lawlor, 2003).
When I finally entered the building, I would go immediately to the team
area, where most of the time there were already staff and members. While there
were other spaces I could go, it made sense for me to go directly to the team area
as that served as a gathering and coordinating space for everyone’s day. For the
first several weeks on the first team, I waited for the study participants to
approach me to let me know that I could join them on a visit. I would find a place
to sit, and would try to interact with anyone within talking distance. Sometimes I
would start conversations, and other times I would enter a conversation that had
already begun between others. I began to get to know members and staff by
name, as well as get a sense of the narratives that were in progress.
One day while on the first team, I actually had one of the staff put my
name up on the staff sign-in/sign-out magnetized white board. I was going with
her to visit one of the members, and she was signing out and added me to the list.
She even gave me one of her magnets. This felt like an acknowledgement of my
being a part of the team. From that day on, until I transitioned to the next team,
any day I came in I moved my magnet to the in-column and to the out-column
when I left for the day. It was on this first team that I felt the most integrated into
the life of the team. It’s my sense that this feeling was also the result of this being
the team on which I spent the most time, but also it was where I began learning
how to go about the data collection process.
During the ethnographic process of ‘hanging out’, I often felt
uncomfortable or awkward. While I knew I was supposed to try to get a sense of
the place and the people, I wasn’t always sure what was important for me to note
and reflect about even with my research questions in clear view. In fact, pretty
much throughout the entire data collection process I felt a constant and nagging
sense of incompetence. While much of what went on every day at the site was
familiar to me as a practitioner, I struggled throughout to “move from a clinical
gaze to an ethnographic lens” (Lawlor, 2003).
While on the first team, there was a point in time when I was struggling
with how to get the practitioners to follow up with me so that I could join them on
a visit. On one hand, I had a clear role, i.e. that of researcher, on the other, I was
also dependent on the practitioners to facilitate my access to a member visit.
Although I can be quite self-directed in familiar and structured situations, I also
find it difficult to initiate contact in social situations that have less structure. One
day, Kim, one of the study participants, asked me how things were going. She and
I had already completed one interview by then. She seemed to sense that I was
struggling and suggested that it really was okay for me to go directly to the
practitioner and ask to join them. It was like she was reading my mind, because in
my own reflections about how I was going about things I’d begun to think just
that. She too had done research as part of her graduate degree in social work and
had also studied anthropology, so was likely familiar with some of the challenges
in doing field work. Following that conversation, I changed my approach and
began to check in with practitioners as soon as I saw them each day I was there to
see if they had a visit scheduled with a member that day that I could join. This
helped me to feel a bit more confident and seemed to strengthen my
relationships with the practitioners as well.
Each team met two to three times per week in the early-morning to plan
and coordinate member visits for that the next few days. Any day that I was at
the site when one of these morning meetings occurred, I attended. While my
research was not focused on the group process that emerged in these meetings,
attending helped me to understand the supportive role that each practitioner had
in the work of other practitioners. It also made evident how mutual problem-
solving served as a key method for practitioners’ decision making about what to
do at particular times and for particular members (See example above). The need
for mutual problem solving seemed to be most necessary when a member was
experiencing substantial life disruptions that didn’t seem to be subsiding in
response to whatever intervention had been initiated. In addition, mutual
problem solving seemed necessary when practitioners had different views about
what should be done, especially if an organization resource (i.e., money,
transportation, or practitioner time) was perceived by one of the practitioners as
being exploited by a member. When I attended the meetings, I often found it
difficult to not participate by posing questions that might facilitate the
practitioners thinking like I would have when I supervise students or consult with
In addition to the morning meetings, each team also met one time per
week for a full-team meeting to address a variety of issues including
administration and service planning needs. During my tenure on each team, I
attended at least one of these meetings. These meetings were longer and much
more structured, although mutual problem-solving emerged here as well. For
example, it was in these meetings that the team met with other parts of
Vanguard’ services, like the employment or housing services. During one of these
meetings there seemed to be considerable tension between the team and the
employment services staff, and my sense was that this tension had been going on
for some time. The tension had to do with the way the employment services was
organized and how available it was to the team’s members. The funding and
design of the employment services program meant that it served people other
than Vanguard’s members. This meant that there were times when Vanguard’s
members wanted to get employment services, but could not because the
employment service was at capacity. An alternative employment search
assistance process had emerged amongst the teams, as a way to meet member’s
needs. Coordination between these two employment components had become
problematic. In addition, it was the teams’ perception that the employment
services team had ‘dropped the ball’ in their efforts to assist one of the teams
The agency also conducted full-agency meetings for various purposes,
including a weekly all-community meeting. I was able to attend only one of these
meeting during my tenure with the research site. These meetings have a rich and
long history at the organization and are intended to promote a sense of
community and inclusion. There is an open microphone and any member,
practitioner, or visitor who wants to say something can. On the day that I
attended, one of the visitors shared how meaningful his experience had been
visiting and learning about Vanguard, and a member thanked everyone for their
ongoing support. During this meeting all other organization activity is suspended
in order to support the expectation that all attend. Another type of full-agency
meeting occurs when to address current agency-wide development, for example
strategic planning activity. I was also able to attend one of these meetings during
my tenure with the research site. This meeting occurred early on in my research,
and while I hadn’t expected it the CEO warmly introduced me and my purpose for
being at the organization. I was given a round of applause.
Since I expected that the practitioner’s reasoning was likely situated within
the organizations’ philosophy and practice, it was important for me to build an
understanding of how it was formally communicated to practitioners by the
organization. During the first two months of my research I sought to understand
the organizations philosophy and practice through formal and explicit
communications. First, I participated in the Vanguard’s ‘ three-day intensive
training that introduced visitors, students and new hires to the organization’s
philosophy and practices. I was only able to participate in one day of this
workshop, but was able to review the written materials from the entire workshop.
Second, I reviewed written materials developed by the Vanguard medical
director that articulated key practice philosophy perspectives endorsed and
adopted by Vanguard. These writings were posted on the organizations website
and incorporated into the Immersion training. These writings were referred to by
the practitioners during my interviews as being meaningful to them.
Third, I reviewed an ethnographic study entitled “A Quality of Heart:
Continuity, Change, and Distinctiveness in Service Delivery at [Vanguard]”
(Erickson & Straceski, 2004). In my initial conversations with the CEO of the
parent organization, he had provided me with a copy of this study in his efforts to
understand how what I planned to research would be different. My review of this
study did help me to clarify for the CEO, the differences between what these
researchers had explored and what I planned to study. Since the CEO provided it
to me and the findings from the study are incorporated into the Immersion
training, I understood it to represent a perspective that resonates with the
organizations view of itself.
Interview Method. To capture the practitioners thinking, I conducted
interviews. This approach to data collection is consistent with studies of mental
health practice reasoning previously reviewed (Angell et al., 2006; Floersch, 2002;
Rhodes, 1991; Scheid, 2004). I drew on the work of Mattingly & Fleming (1994),
and others (Angell et al., 2006) in my design of the interview protocol, which
consisted of one or two interviews after an observation of a practitioner-member
visit, followed sometime later by an in-depth interview focused on how the
practitioner had come to know what they know.
Mattingly & Fleming (1994) videotaped practice sessions, and then
interviewed the occupational therapy practitioners while the researchers and the
practitioners viewed the videotape of the session together. Videotaping sessions
was not practical for this practice setting, so I observed the practice session and
then used my observations of the care encounter to probe the practitioners
thinking regarding specific actions and communications during the visit (Angell et
al., 2006). To minimize the discomfort of the member whose visit I was observing,
I took no notes during the session. This challenged my recall but in order to
mediate that and to facilitate the practitioners’ recall as well, every effort was
made to conduct the interview immediately after the observation, or as close to
the conclusion of the observation as possible. All but two of the post-observation
interviews were conducted within ten to fifteen minutes of the close of the
observation. The remaining two post-observation interviews were conducted
between two and five days of the observation. These interviews were conducted
wherever private space was available and lasted between fifteen and forty-five
The practitioners were asked to not schedule visits specifically for me to
observe, but to have me join them on a visit that had been scheduled to meet the
member’s needs. These visits occurred both at the study site and at various
locations in the community, including member’s place of residence, local retail
shops and restaurants, government offices and other community organizations.
The purpose of the visits also varied, from just checking-in with a member about
how they were doing or how things were going, to focused visits on different life
needs, i.e., working, housing, etc. Table 4 provides a summary of the specific
locations and purpose of each practitioner-member visit that I observed.
Table 4. Locations and Primary Focus of Observed Practitioner-Member Visits
Participant First Observation Second Observation
Location Focus Location Focus
Helen Small private
office at study
support re job,
going with her
Researcher conducted only one
post-visit interview with this
Sharon Large office
at study site.
sat at table
center of office
PSC to transition
to new team,
from a high-
Researcher conducted only one
post-visit interview with this
Table 4. Continued
Participant First Observation Second Observation
Location Focus Location Focus
Casey At the
desk in the
team area of
the study site
Plan to help
member is in
Café at study
research sat at
solving re work
Kim Member’s one-
sat in living
Check-in to see
how things were
going. PSC and
office at study
order to secure
‘board and care’
home and local
Check-in to see
how things were
going. PSC and
room and a
Leighton Member’s one-
coffee table and
Researcher conducted only one
post-visit interview with this
Patrick Member’s one-
she shared with
member to see
how things were
shop and local
Table 4. Continued
Participant First Observation Second Observation
Location Focus Location Focus
Check-in to see
was doing, and
to transport her
Vanguard to get
office at study
move into new
‘board and care’
transition out of
due to eviction
team area at
Met to update
Check-in to see
how things are
and other at-
driver’s test for
Researcher conducted only one
post-visit interview with this
Table 4. Continued
Participant First Observation Second Observation
Location Focus Location Focus
Anne Three brand
member re how
Researcher conducted only one
post-visit interview with this
support to assist
member in re-
Team area and
Researcher conducted only one
interview with this practitioner
with member re
were going with
desk in team
area at study
work to Social
I began each post-observation interview asking the participant to tell me
about what happened during the visit as if I hadn’t been there. I found this to be
very helpful, and my sense was that it was helpful to the practitioner as well. For
me, it helped me to somewhat re-experience the visit and reflect on things that
had come to mind as I was observing. For the practitioner, it seemed to help them
get comfortable with the interview process as we began. In response to this first
question, practitioners usually shared why they had met with the member, what
they had hoped or expected to accomplish and sometimes reflected on the
member’s responses during the visit.
While what the practitioners shared in response to this first question got
us started, I struggled and felt anxious throughout these interviews about where
to go next. What did I really want to know? What part of what they shared or
what I saw was worth asking questions about? What about what they shared had
to do with reasoning? And, when I did pose questions, I wasn’t sure if I would be
able to make any thoughtful sense of what was said. I left most of these post-
observation interviews feeling unsettled and worried that I had I not really elicited
an understanding of their reasoning. I did consistently try to continue the
interview using an approach intended to invite narrative responses (Kielhofner &
Mallinson, 1995) to elicit “what they saw as key decision points, dilemmas, and
surprises…[to] talk directly about their rationale and their theoretical assumptions
in making choices and decisions” (Mattingly & Fleming, p. 6).
Sample interview questions in response to the practitioners’ explicit
reflections about the visit, as well as my observations of their actions during the
visit are represented in Table 5.
Table 5. Sample Interview Questions
Practitioner Reflection or Action Sample Question
Practitioner reflected on a specific action
that they had taken during the visit, e.g.,
So you say that you have a “practice of
sharing yourself” How do you know when
to do that and when not to do that? Have
there been any situations in which your
sense was that your sharing a part of
yourself really helped?
Practitioner reflected on something that
they had noticed the member say or do
during the visit, especially if it represented
a change in the member’s behavior
How do you account for that behavior or
that change? When you think about why it
happened and your understanding of the
member, what comes to mind?
I observed the practitioner engage in a
particular action with a member
What are the things that come to mind as
you’re deciding I’m going to go to the
movie at this time or I’m not or I’m going to
drive him this time or not, what are the
things that come to mind?
Practitioner reflected on goals that they
and the member had been working on, e.g.
In your time of working with him, you say
you’ve been trying to promote his
independence, how have you gone about
doing that or what have been the major
issues that have come up?
Once I had completed the practice observations and interviews with the
study participant, I then scheduled a time to conduct the longer, more in-depth
interview. These interviews were most often conducted off-site over lunch at a
local restaurant, and lasted for about one and one-half hours. These interviews
were organized around two “grand tour” questions (Seidman, 1998). Specifically,
(1) tell me about how you came to be working at Vanguard, and (2) tell me about
how you’ve come to know what you are supposed to do and the way you are
supposed to do it here at Vanguard. In addition to the “grand tour” questions, I
explored how the practitioners knew what to do given the do “whatever it takes”
philosophy of the full-service partnership approach.
All interviews were digitally recorded and professionally transcribed. I
conducted a total of thirty-eight (38) interviews with my study participants.
Table 6. Interviews Conducted
Long Interview (#)
Kim 2 1
Helen 1 1
Sharon 1 1
Patrick 2 1
Casey 2 1
Belinda 2 1
Leighton 1 None
Allen 2 1
Karen 2 1
Sandy 2 1
Connie 1 1
Anne 1 1
Greg 2 1
Davina 2 1
Ida 1 1
Transcripts from interviews were read and thematically analyzed (Van
Manen, 1990). I completed an independent review of recorded interview
transcripts, and engaged in peer review sessions with a group of two current
and/or former doctoral students in occupational science, one with a background
in mental health practice and one with extended mentorship in Lawlor and
Mattingly’s narrative analytic method. I also periodically documented themes that
emerged overtime during the data collection process to guide coding.
My primary method for thematic analysis was what Van Manen (1990)
refers to as the selective or highlighting approach, in which the researcher
“listen(s) to or read(s) a text several times and ask(s), “What statement(s) or
phrase(s) seem particularly essential or revealing about the phenomenon or
experience being described? “ (p. 93). All transcripts were read and re-read, and
statements or phrases were highlighted and themes were identified using this
method. Like many novice researchers, I felt overwhelmed with the amount of
text and wondered if there was a way to organize my reading of the transcripts
that would facilitate my analytical work. Because I had conducted two different
types of interviews with each study participant, it made sense to me to utilize
interview type and each individual practitioner as supportive frames for my
(1) I read the transcripts for each interview conducted with a single study
participant in the sequence that the interviews were conducted. This
meant reading the one or two post practitioner-visit observation
interview transcripts, and then reading the transcript for the longer
interview for each particular participant. I found this helpful, as I was
able to keep each participant and my experiences with them in mind as
I read the transcripts and identified themes.
(2) I also organized the transcripts by type, and re-read all the transcripts
for each post practitioner-member visit interview, and then all the
transcripts for each intensive interview. I found this helpful, because
each type of interview captured different aspects of the study
participant’s reasoning and experiences, and captured the participant’s
reflections from different temporal-spatial perspectives. The post
practitioner-member visit interviews were more narrowly focused on
the practitioners reasoning within a particular visit, with a particular
member. The long interviews explored the practitioners reasoning and
experience with more breadth, particularly over time.
Another analytical method developed by Lawlor and Mattingly was used
on selected chunks of data. Wilkinson (2009) used this method, “inspired by
literary analysis and involves assigning an interpretive title to an interview as if it
were a book and breaking it into separately titled chapters” (p.71), in her study. I
was initially introduced to this method by Dr. Mattingly during my doctoral
courses, and subsequently had additional experience with this method while
participating in Narrative Workshops conducted by Dr. Lawlor each year for
doctoral students. For each transcript, I identified places in the text that
represented what appeared to be a practitioner’s full-accounting of a particular
experience, a place in the text where they had told a ‘story’. Each of these
portions of transcripts were chaptered and titled using this method to suggest
themes. I completed this portion of the analysis, first through the peer review
process described above with a selected number of transcripts, and then through
independent review of the remaining transcripts identified. Themes that emerged
through both analytical methods were refined overtime, as transcripts were read
Strategy to Enhance Rigor
To help establish the trustworthiness of the findings of my study I engaged
in a prolonged and varied field experiences. I was at the research site at least two
days per week for nine months. I observed informal practitioner-to-practitioner
interactions, as well as practitioner-member interactions. I observed twenty-four
individual practitioner-member visits that occurred both at the research site, as
well as in member’s homes and other community settings and had different
purposes and intended outcomes. My study participants were from three
different full-service partnership teams, and although operated within the same
agency, had unique operational processes. I also attended and observed daily
team meetings if they were held on a day I was at the research site, and also
attended at least one full-staff weekly meeting for each team. I also attended two
agency-wide meetings, and one day of a three-day intensive workshop conducted
by the agency and designed to orient visiting colleagues to the agency’s
philosophy and practices.
I used data triangulation to optimize the “holistic view” of the practices
that I was studying (Farmer, et al as cited in Curtin & Fossey, 2007, p.90). I used
participant observation, interviews and document review, as well as
interviewing/observing multiple practitioners across three teams to maximize the
range of data, and to be able to compare and cross-check consistency at different
times and by different means (Patton, 1990 as cited in Curtin & Fossey, p. 91). I
used purposive selection (Polkinghorne, 2005) for participant recruitment and
provided an accounting of the participants, the setting and the context of the
This study contributes to the understanding of how front-line, community-based
mental health practitioners, i.e., personal service coordinators, practicing in a particular
approach to community-based services, i.e., full-service partnership, reason about what
to do in their efforts to facilitate community stability and recovery for persons labeled
with psychiatric disorders. The chapters that follow address the unique practice context
within which my study participants were engaged and the themes that emerged in the
analytic process regarding how these practitioners ‘named and framed’ what they saw
and heard, and how it influenced their decisions to take particular actions.
Chapter 4: Contextual Influences on the Practitioner’s Reasoning
In this chapter, I will use data from interviews and observations to describe
aspects of Vanguard’s practice context including the philosophical, spatial and
temporal influences on the practitioner’s reasoning. This is important for this
study given views on the contextualized an situated nature of cognition (Rogoff &
Lave, 1984) and learning, meaning and social practices (Lave & Wenger, 1991;
Wenger, 1998). In Chapter 7 I will again consider context, and specifically apply
Wenger’s (Wenger, 1998) community of practice elements, i.e. mutual
engagement, shared repertoire and negotiation of a joint enterprise to Vanguard.
Philosophy of Practice
I was broadly familiar with Vanguard’s practice philosophy as my own
professional practice is grounded in similar foundations (i.e., psychosocial
rehabilitation and recovery), and would often see Vanguard leadership at national
conference that we both attended regularly. In addition, I had practiced in the
same large geographic region and was familiar with Vanguard’s development as a
model program. Despite that, I had only visited Vanguard one time prior to
beginning my research. So, while I could rely on my broad understanding of the
practice philosophy, I drew on my review of key Vanguard documents, my
participatory observations and my interviews to build an understanding of the
From an historical and systems level perspective, Vanguard is considered
an exemplar within California’s public mental health system, and has also
garnered national attention for its’ design ("Gold Award: A Comprehensive
Treatment Program Helps Persons With Severe Mental Illness Integrate Into the
Community," 2000). It was founded in a late 1980’s California mental health
funding initiative that sought to develop an integrated approach to “treatment,
case management, and community support” for persons labeled with psychiatric
disabilities. Since its founding in 1989, Vanguard has evolved and responded to
growth and funding shifts, but has sought to sustain its fundamental approach to
service delivery (Erickson & Straceski, 2004). An approach that has been
described as a “recovery community” that focuses on “its members lives” rather
than “its patients’ symptoms” (Ragins, 2010, p. 2).
Vanguard’s practice philosophy is informed by a stages of recovery
perspective defined by Vanguard’s medical director (Ragins, 2010) and outlined in
their guiding principles (see Table 7 below).
Table 7. Examples of Alignment of Vanguard’s Guiding Principles with Davidson, et
al (2009) Principles of Recovery-Oriented Practice
Vanguard’s Guiding Principles [Stages of Recovery]
Principles of Recovery-
(Davidson, et al, 2009)
Hope makes recovery possible; it facilitates healing of
the mind, body and spirit [Hope].
People thrive, grow and gain the courage to seek
change in respectful environments that promote self-
Care is oriented to
Table 7. Continued
Vanguard’s Guiding Principles [Stages of Recovery]
Principles of Recovery-
(Davidson, et al, 2009)
Focusing on the whole person includes their strengths
and weakness, abilities and barriers, wounds and gifts
A solid foundation for recovery is built by helping
people to honestly and responsibly deal with their
mental illness, substance abuse and emotional
Care is strengths-based.
The practical work of recovery takes place in the
community Meaningful Roles].
Each person has the right to fair and just treatment in
their community ensured through advocacy and social
responsibility [Meaningful Roles].
Care is community-focused.
Each person creates their path and determines the
pace of their recovery [Empowerment].
Care is person driven.
Relationships are developed through mutual respect
and reciprocity, including openness to genuine
emotional connections [Empowerment].
Care allows for reciprocity in
Focusing on the whole person includes their strengths
and weakness, abilities and barriers, wounds and gifts
Welcoming people includes creating a culture of
acceptance with easily accessible integrated supports
and services [Hope].
Care is culturally responsive.
Everyone deserves the opportunity to have a place to
call home [Meaningful Roles].
Employment and education are powerful means to
help people build lives beyond their illness [Meaningful
Care is grounded in the
Table 7. Continued
Vanguard’s Guiding Principles [Stages of Recovery]
Principles of Recovery-
(Davidson, et al, 2009)
Each person has the right to fair and just treatment in
their community ensured through advocacy and social
responsibility [Meaningful Roles].
Program success is based on achieving quality of life
outcomes and recovery outcomes [Meaningful Roles].
Care addresses the
socioeconomic context of
the person’s life.
The recovery process is a collaborative journey in
support of individuals pursuing their life goals
Care is relationally
Promoting natural supports, having fun and a sense of
belonging enhances quality of life [Meaningful Roles].
Care optimizes natural
These guiding principles are grounded in an approach known as
psychosocial rehabilitation that evolved over the last half of the 20
(Erickson & Straceski, 2004; Rutman, 1987). It has also been enriched by the
“recovery paradigm” (Ridgeway, 2001, p. 335) that currently informs public
mental health services in the US (DHHS, 1999) (see Chapter 2 for a review and
introduction to psychosocial rehabilitation and the recovery perspective). Practical
implications for how ‘down on the ground’ practitioners can enact recovery-
oriented practice have been documented in various sources (Davidson, Tondora,
Lawless, O'Connell, & Rowe, 2009). The guiding principles align well with the
practice principles outlined by Davidson, et al (2009) (see Table 7 above). For
example, Vanguard’s guiding principles about hope and respectful environments,
each of which has been identified in the literature as facilitating recovery (Deegan,
1988; Russinova, 1999) is consistent with the Davidson, et al’s first principle that
“care is oriented to promoting recovery”. The importance of reciprocity in
relationships from the Davidson, et al, principles is also evident in Vanguard’s
guiding principle that emphasizes mutual respect and openness.
Vanguard’s founding psychiatrist and medical director has played a key
role as a philosopher of this agency’s recovery-oriented practice. Sharon, one of
the study participants, described her experience of hearing him speak for the first
time and then seeking his consultation over time as she worked to support the
recovery of members:
Sharon: I remember being very inspired…I learned a lot and talked with
[Medical Director]… I was like so sparked by [him]…You know, like I want
to sit down with [him] and I want to...so I could find out how loving and
caring he is and I did get close with him…we’ve had discussions and to this
day, he amazes me at how he’s able to stop focus on me, the staff, and
focus on the member. He’ll stop talking to me in a second if there’s a
member...He’s really here for the members.
In addition to his consultative role with practitioners, his writings are
readily available to all agency practitioners, and can be found on Vanguard’s
website. Further, they are infused into Vanguard’s formal training rituals and
structures that each practitioner participates in when they begin their work with
Vanguard. In Road to Recovery (2010), he reflects on his own professional journey
from a medical and/or traditional clinical model psychiatrist to “a successful
recovery-based psychiatrist” (p. 3). He goes on to articulate his Four Stages of
Recovery: Hope, Empowerment, Self-Responsibility and A Meaningful Role in Life
(p. 10). For each recovery stage he offers the practitioner some guides that
challenge them to reflect on their own perceptions and adopt ways of working
that support members through each stage. When I read Road to Recovery, I
found that that it isn’t presented as an academic guide with solid references to
support the claims, despite their being clear evidence in the literature to do so.
Rather, it reads as a personal and very accessible framing of what Vanguard
practitioners must consider when practicing in way that differs from medical or
clinical model practices.
During one of the team meetings that I observed in which the team was
discussing a member who wanted to dis-enroll or leave Vanguard’s services. The
team seemed to be struggling with supporting that decision or not. Greg pulled
out from his day planner a copy of the guiding principles, and read a specific
principle a “People thrive, grow and gain the courage to seek change in respectful
environments that promote self-responsibility.” He seemed to be explicitly drawing the
team back to the principles to aid in their deliberation. During one of my interviews
with this same practitioner, we were talking about something that I had sensed
was happening during the visit that I observed. In response to my query he
immediately connected it to his understanding of the stages of recovery defined
by the medical director, and emphasized how it informed his work.
Deborah: It seemed like there was this assessment process that you go
through where you’re kind of going am I—is this, is—am I moving for—is
this person moving forward at this point or is this person at risk and, and
then you’re intentionally creating in that visit a process by which she’s
moving forward. So you’re planning for that.
Greg: Yeah. I, I think what you’re talking about is the stages of change.
Okay, there’s the four—
Greg: The four stages of change is the hope, empowerment, self-
responsibility, and meaningful role. And that’s totally insightful what you
just said because what was going on yesterday was [the member] and I
had been in the empowerment stage with this particular issue for a while
now. So what I was working at yesterday was transitioning to the self-
Greg: So we were making that trans—okay, I have empowered you
enough, you know, now it’s your time to take responsibility and kind of
passing the ball.
Deborah: Now where do those stages of change come from? Do you know
the or—I mean, is there—
Greg: I believe [the medical director] developed them years ago.
Deborah: Okay. So and he actually refers to them as stages?
Deborah: Okay. Yeah, so I can—I mean, I’m familiar with some of his
writings so I, I will…yeah.
Greg: And, and it’s always good to be aware of where an individual is at in,
in that process.
Deborah: Yeah, and that’s one of the things that seems that you do
particularly which is to, well, draw and run these frames that you’ve been
introduced to in your practice here.
Deborah: You really do. I mean, I remember in the meeting you, you
brought out the—
Greg: Guiding principles.
Deborah: So that—you really—and the fact that you’re drawing the
principles—so you really rely on and find value—
Deborah: In your work.
I began each of my final interviews with the practitioners asking them how
they had come to be working at Vanguard. I was profoundly struck the pattern of
responses that emerged regarding how many of these practitioners experienced a
sense of the fit between Vanguard’s philosophy and their own sensibilities. Their
experience of this fit seemed to be immediate and deeply felt. Connie, Sharon,
Casey and Belinda respectively described their experiences.
Connie: I was with this awful place. It was really strict and I had to stay
inside all the time and it was awful, you couldn’t learn there because they
basically told you, you were stupid and the guy would cuss you out, it was
ridiculous. I hated that and I kept hearing of this place called [Vanguard]
from all these other interns, they’re like oh yeah, it’s great, you do this and
I was like, oh, that place sounds like it’s for me. It’s not that structured,
kind of, is what I like, so it’s kind of you make it what you want, so then I
decided to interview for my second year and so I did that and then I stayed
on…Yeah, like I came to [Vanguard] because it was similar to how I already
think and what I’m comfortable with, so I wasn’t forcing myself like my first
internship, going into an environment which is not how I am as a person.
Sharon: So, I was riding my bike around and I was like what is this place,
you know. And I was drawn to it right away on my bicycle. And I went in
there and I happened to meet a gentleman...He used to be an ex-police
officer and he worked for the [agency]. He was like our security liaison and
everything. He showed me around. I ate in the deli and sat there for the
first time with a member and I knew immediately this is where I’m going to
work. And my heart just opened big time and I was like it’s so wonderful
Casey: I loved it; fell in love with it. I had never worked in another mental
health agency before, so actually thought well, they must all be like this. I
really like it. I think their philosophy, their recovery philosophy was in line
with the way I believe that services should be delivered in a very
humanitarian way, and that people can and do recover, and they’re not
just illness-centered. I really thought well, wow, this is kind of how I work
with my mom, and if she ever had to get services from a mental health
agency, I’d want her to come here.
Belinda: I interned and the first day, I was like, I want to be here. I love
it…and it’s like I belong there. I just felt like I belong, that I had something
to contribute. I wanted to be a part of what was going on. It was very
An element of this fit is the experience of a significant difference between
the philosophy and practice at this agency and other settings where these
practitioners have worked or completed internships. These other settings were
described as being informed by a ‘clinical’ or ‘medical model’ approach. An
approach that left these practitioners feeling constrained in their efforts to help,
as well as disempowered as individuals themselves. Helen recalled the difference
between her internship site and Vanguard, emphasizing how it seemed to thwart
client self-determination. She is also giving us a sense of her experience with the
supportive environment that she experienced at Vanguard. While she explicitly
identified the risk of speaking up during her internship, the impression seems to
be that speaking up at Vanguard is welcomed.
Helen: And definitely when I was there I remember I couldn’t believe that
they were making decisions for people. Like this one woman really needed
housing. She really, really needed housing, and I felt like they weren’t
doing anything about it. So I said something, and I remember I had to
speak to my supervisor after, because I spoke up during a meeting. And it
was like a whole big ordeal…I think I’d probably get fired in a different
This sense of difference between ‘clinical’ or ‘medical’ model settings and
Vanguard, seems particularly acute for those practitioners who have completed
professional degree programs, e.g., nursing, social work. Anne differentiates her
experiences with her previous work setting and her experience at Vanguard.
Anne: Well, because I had a patient at my previous job…who you could tell
she was homeless at times and how she had insurance, I have no idea, but
she did and she was just really rude, but then at the same time, I can tell
that she had a mental illness. I didn’t really know what she had but then in
hindsight I knew that she was schizophrenic, she had schizophrenia but
seeing that and then seeing how my coworkers treated her, it felt weird to
me because I knew she needed some help that we couldn’t provide her. I
just really felt bad, I felt guilty because I couldn’t do anything for her
besides what I was there for was wound care. Then I come in here, it’s like
seeing that person, we would take her to the point where we make sure
she’s housed, trying to get her to do her ADL’s and make sure she’s clean
and do everything that we could for her and at that other place, I was case
management, but I couldn’t do anything else but wound care, it was so
Anne: Yeah, so I kind of see it was I was doing nursing but here, I’m doing
as a whole person, not just to what’s restricted to that area, you know? So
it was kind of like I agreed more with the principles at [this agency] than I
did in a regular setting, like a possible setting or a traditional medical
setting so it kind of drew me in that way.
Anne also reflected how different her work with doctors here at Vanguard is, in
comparison to her work as a nurse with doctors in other settings. At Vanguard she
seems to experience a much more collegial, non-hierarchical, relationship with the
psychiatrists. This may be facilitated by the fact that the psychiatrists work out of
the same team area as do all the other practitioners. This means that it is just a
short walk to talk with psychiatrist, or in some instances the practitioner just has
to turn their chair around as their desk may be right next to the psychiatrists. In
addition, they may actually do community visits to see members together. I found
this to enhance the practitioners feeling of collegiality here at Vanguard. Anne
describes how the closeness she feels actually mediates her enactment of her
nursing practice in this setting.
Anne: I had to cater to the doctors, there was always that doctor/nurse
relationship but here, I’m very close, I can talk to [the psychiatrist] like
she’s a human being and I don’t have to cater to her. I mean, I do, as a
nurse I still have that instinct feeling to do it, but she’s very down to Earth
and she’s like, I’ll get it myself, you don’t have to get it for me.
While I certainly observed an experience of collegiality and non-
hierarchical relationships between practitioners and psychiatrists, I was also struck
with Vanguard’s practice of referring to the psychiatrist as Dr. Alex, for example.
I’ve always found the practice of referring to doctors in this way, i.e., using their
credential and their first name, as an odd mixture of familiarity and social rules. At
Vanguard I wondered if this didn’t represent some ambiguity about the
relationship between the psychiatrists and the practitioners, or at least about
what the correct social behavior was as practitioner interacted with the doctors.
On one hand, they were referring to the psychiatrists by their first name, which
was consistent with how all other practitioners were identified. This first name
basis supports an egalitarian, non-hierarchical frame. On the other hand, referring
to the psychiatrists by their credential, suggested a perspective that the
psychiatrists as doctors are different and that the broader social practice of
identifying them as doctors was important even in this setting.
Connie who has a background in social work, rather than nursing also
experienced this clinical or medical focus as limiting person-focused work.
Connie: Well, I was in a MSW program and my first year, I was with this
awful place…yeah, it was much more clinical so it was more focused on
diagnoses and the symptoms and that sort of...it was just really focused on
the diagnosis and that’s all that was really drilled into me and that wasn’t
for me. Because here, I honestly don’t know the members I work with,
what they necessarily have, if I thought about it their symptoms, okay they
have this, they say they do this, okay, so I could probably tell you what
they had if they asked, but for the most part, I don’t know, I’m just working
with who they are and individually, how they interact with the world.
As they reflected on the difference, study participants did acknowledge
that other settings might have very real barriers to adopting and successfully
implementing the practices of this agency. Karen put it this way:
Karen: [Vanguard] is almost like this individual world, you know, that
doesn’t exist in a lot of other agencies…I, I love the [agency] and
everything it has to bring. But I know… what [Vanguard] does can [do]—is
not necessarily a reality for other agencies even with the best advocacy,
the best everything… some don’t have that ability to be what we are or
maybe not yet.
Despite the sense of difference between this agency and others, what
often counts as clinical practices in mental health, for example Dialectical Behavior
, are provided by this agency for select members. In addition,
there is a sense from some of the practitioners that Vanguard would benefit from
strengthening such skill sets in their practitioners, and that in turn members in
certain phases of recovery would benefit from the more intentional use of such
clinical interventions. Casey, who has a master’s degree in social work and was
working towards her licensure as a clinical social worker reflected on how she had
used DBT and other interventions in her work with members. She frames her
utilization of these practices as empowering, which seems to align her reasoning
with the guiding principles.
Casey: I think the DBT, going through that, it’s been huge. I can utilize a lot
of those skills with other members, to be able, for them, to kind of process
Dialectical behavior therapy is a therapeutic approach originally developed by Marsh Linehan to
meet the therapeutic needs of persons labeled with borderline personality disorders. It has specific
therapeutic elements and can be delivered either as an individual intervention or group.
problem-solving, getting what they want, communication, a lot of the
interpersonal stuff that people struggle with, especially emotion regulation it’s
huge. And so the more I have an understanding about that, and how to
disseminate that, those skills to folks, it definitely empowers them to be
able to use something that they have in their toolbox too, cognitive
behavioral therapy, and exposure therapy I’ve used for some members
But, again, those members are in a different state of recovery, but that doesn’t
mean that you can’t still utilize the same premise of really changing perceptions
of how you receive information, and your choices and your actions has been
She identified an explicit professional dilemma as a clinical social worker about not being
able to utilize these interventions as much as she would like. In addition, it was her sense
that the practitioner skills associated to these interventions are needed by the personal
service coordinators to manage their day to day interactions with members. She
acknowledged that because they are considered ‘clinical’ interventions they may not align
well with Vanguard’s image of its practices.
Casey: So it’s kind of a struggle, and that’s why for me and my own
profession, being able to hopefully be in a position to where I can hone in
some of those more clinical interventions, even though clinical, you know, I
don’t know think our agency really likes to think themselves as anything
clinical, but I really want to try to push it as, staff needs the skills to be able
to, they need tools. They need tools to be able to teach members, you
know, how to work through some of these things that from day to day life
that we all need to use to be able to, and I think it is, it’s that day to day of
how can I just not blow up, how can I make the best decisions for me in
that time, and if I don’t, you’re not completely so downward spiral that
you’re suicidal, and you know what I mean?
There is evidence in the wider publicly-funded community mental health
field of the adoption and implementation of DBT (Herschell, Kogan, Celedonia,
Gavin, & Stein, 2009; Swenson, Torrey, & Koerner, 2002). In addition, I found that
the utilization of such interventions seemed to be driven by the practitioners
themselves and was perceived to meet a very real need for useful ways to work.
The practitioner views are supported by the literature on DBT. Swenson, Torrey &
Koerner (2002) in their study of the utilization of DBT in publicly-funded
community mental health agencies found that—
Practitioners have embraced DBT with enthusiasm, and many have
implemented programs. The foremost factor contributing to the demand
for DBT appears to be the intense need experienced by mental health
providers for a treatment that is clear, “do-able,” and effective” (p. 173).
Further, they argue that—
In its emphasis on skills development, self-care, a non-pejorative attitude,
a staged treatment leading to full recovery, and consultation with the
consumer rather than consultation with those in the consumer’s
environment about the consumer, DBT is also compatible with the
recovery and consumer empowerment movements” (p. 173).
Spaces and Places of Practice
The nature of the spaces and places where Vanguard’s practitioners do
their work in influence by both the assertive community treatment (ACT) and the
“clubhouse” models (Erickson & Straceski, 2004). Although this agency has
intentionally not fully implemented all of the “clubhouse” and ACT model
elements (Dave Pilon, personal communication, March 7, 2010), opportunities for
work and social exchange are important features of this agency’s integration of
the ACT approach of community delivered services and the “clubhouse” model
approach that emphasizes on-site space utilization for service delivery .
Practitioners with this agency deliver services to and for members on-site,
i.e., within the building and its immediate surrounding spaces, AND, offsite, i.e., in
the community at various locations and businesses in the surrounding community
where members need or want to engage in their daily round of occupations.
Although Vanguard has other service and administration locations, the
participants in my study worked out of one of two floors of a four-story building
that also included other agency activities, i.e., visiting colleague training staff;
housing, employment and education resource specialists; homeless outreach
program; step-down case team; medication room; as well as management and
administrative support staff.
The building as a practice space. The building is situated across the street
from both condominiums and a shopping area that hosts a major chain grocery
store as its anchor business, and includes a major coffee house chain and a major
fast-food sandwich chain as well. In addition, contiguous to the shopping area is a
public transportation stop that includes train and bus access. The building sits
approximately four (4) city blocks from the main downtown business corridor of a
major metropolitan area along the coast of Southern California, which includes
hotels, restaurants and other retail shops. In the opposite direction of the
business corridor, rest both small family homes, and apartment structures, where
many of the persons served by this agency live and call home.
I observed nine practitioner-member visits that took place within the
building practice spaces. Three of these visits took place in one of the available
small private offices, four took place at the practitioners desk in their team area,
one took place in work supervisor’s office, and one in one of the common areas
accessible to all members and staff.
Table 8. Practitioner-Member Visits Observed within Building Practice Spaces
Participant Location Purpose
Helen Small private office Provided member with emotional
support to sustain employment, and a
general check-in with member how
things were going with her family
Sharon Large office area with
multiple desks. PSC, member
and researcher sat at table
located in center of office
Met with member’s new PSC to
facilitate his transition to new team.
The transition was understood to
represent member’s ‘graduation’ from
high-support level of care.
Casey At the practitioner’s desk in
the team area
Update the members’ Wellness
Recovery Action Plan, which is intended
to help the member and the PSC know
what to do when the member is in crisis
Casey Small table in the Café area Provided member with emotional
support and problem solving related to
a recent incident that had happened as
member worked in agency’s clerical
Kim Small private office Review forms that the member needed
to complete in order to secure HUD
Belinda Small private office Reviewed plans for upcoming move into
new ‘supported housing’ apartment
Table 8. Continued
Participant Location Purpose
Davina Team area and Office of
Provided emotional support during on-
site job interview
Greg Practitioners desk in team
Reported member’s earnings from work
to Social Security
Karen Practitioners desk within
Met to update annual recovery plan
consistent with funding requirements
Entry and common areas. Either a steep set of stairs or wheelchair lift is
how one can enter the building. As you enter, there may be an easel with
announcements set up to catch your eye. This usually happens when there is a
special event or when Vanguard is hosting a group of visitors. Otherwise, there is
no distinct reception area, so as a new visitor, you have to ask for help or go
exploring. When I went to Vanguard for the purpose of my research, I recalled a
prior visit years earlier when I was meeting a colleague there and remember
thinking at the time that this was problematic.
Fountain House, the organization that innovated the ‘clubhouse’ approach,
had members greeting everyone as they arrived when I visited them early in my
career. I wondered then if this would work at Vanguard. Although not having a
distinct reception area can be a bit disorienting at first, there is almost always
someone around that is more experienced and familiar with the spaces that you
can ask for direction. As I reflected on this during my research, I reconsidered my
assessment of this practice. Rather than being problematic, it seemed that it
might well serve as an intentional environmental element consistent with
Vanguard’s philosophy that, as humans, we rely on the support of others.
Each floor is accessed by either stairwells or an elevator. These become
more than ways to travel between floors, as informal and serendipitous
interactions between practitioners and members can happen here. On the first
floor and at the end of the corridor you enter a large café or dining area that
serves as a central gathering point throughout the day for members, staff and
visitors. It is also one of the largest spaces in the building so is also used for large
community-wide meetings. Several square tables that seat four are distributed
around the space, as well as bar stools around the edge of the space to
accommodate additional seating. A piano is located at one side of the space and
at various days/times volunteers or members serenade anyone in the space at the
This common area also hosts a bank where members who have Vanguard
as their payee
can obtain their funds. It’s not uncommon at select times
Persons receiving Social Security Disability Income (SSDI) or Supplemental Security Income (SSI)
maybe required by the federal government or may choose to have someone or some organization
serve as their payee. When the government requires a payee, it based on a determination that the
person needs help in managing your money and meeting their current needs. The payee receives
the beneficiaries payments on their behalf and must use the money to pay for the beneficiaries
current needs, which includes housing and utilities; food; medical and dental expenses; personal
care items; clothing; and rehabilitation expenses (if you're disabled). After those expenses are
paid, the payee can use the rest of the money to pay any past-due bills, support dependents or
provide entertainment for the beneficiary. If there is money left over, the payee should save it. The
payee must keep accurate records of payments and how they are spent and regularly report that
information to Social Security. The payee also should share that information with the beneficiary.
throughout the day to see a line of members, and sometimes staff waiting to be
served by the bank staff. This space can be quite active at times, as it is the only
area within the building that is designated as an informal social gathering place.
Even when the café is not serving, this space is open and available for members,
staff and visitors. Practitioner-member contacts that occur in this space may be
intentional or serendipitous.
As noted in the guiding principles, it is expected that member’s education
and employment recovery goals be supported. Members are a key workforce
source for Vanguard’s café, clerical and maintenance functions. These are paid,
temporary positions, and considered a scare commodity to practitioners, as there
are many more members who want work opportunities than there are positions
available. Although not all member education and employment goals are met on-
site itself, these opportunities can serve as critical first engagement or re-
engagement experience in this major life domain.
The café space was described above, and includes a full-service kitchen.
Members work both in the kitchen, as well as serve food and clean tables in the
dining area during the cafés hours of operation. Members working for the
maintenance department move in and throughout the building. Members working
in clerical functions are primarily located in a designated area on the first floor.
Practitioner-member contacts may take place in these work spaces, however
there is an expectation that these contacts support and not disrupt the member’s
workday. In addition, practitioners work in these spaces may involve getting
updates from the members immediate work supervisor regarding his or her
As noted above, in addition to employment, furthering one’s education is
often an important recovery goal for some members. There is one space
dedicated for this purpose and addresses post-secondary education linkage and
support, as well as helping members to improve basic literacy skills. This is a
modest size area with study spaces, computers and other learning resources,
including staff dedicated to this recovery focus. Practitioner-member visits that
occur here are usually intentional and focused on supporting the members’
educational goal. Once connected with the education program, members can
access the space independently.
Team space. Each of the Full-Service Partnership Adult teams has a
dedicated area for their on-site work. Two teams are housed on the second floor
of the building and located next to each other with five-foot high wall separating
the two spaces. Each team area is accessed via two 4-5 foot-wide entries, has very
high ceilings and wonderful natural light that comes from ceiling to floor arched
Each team area is outfitted with file cabinets and desks for each staff
person mostly placed up against the walls around the edge of the room, leaving
the inner area with desks/file cabinet for use by members. Each desk has a
computer and phone, as well as other “stuff” nestled below or between desks that
staff may use when they meet or engage with members. In one team area, the
Team Leader required all desks to be situated so that the practitioner and/or staff
member was facing the entrance to the team area. I discovered that this was an
intentional strategy on her part, because one day I was assisting one of the
members with switching out an old desk for a newer desk, and we got to talking
about the best way to situate the desk. During our conversation I suggested
turning the desk in a particular way and the team leader overheard our
conversation. She joined the conversation immediately and directed us not to do
that because she wanted all the desks oriented towards the door.
She spoke with me later and clarified that situating the desks in this way
was important for creating a welcoming environment to members. She did not
want members to enter the team area and have a practitioner sitting with their
back to them. I remember thinking ‘of course’ when she stopped us, and chided
myself for not being more thoughtful about that. It was also my sense that
situating the desks in that way also served as a safety measure, as all the desks
were oriented so that each staff person could scan the entire space and be alert to
and able to intervene in interpersonally charged situations that might arise. This
was also especially important if only one staff member was in the team area,
which did occur at times.
Given the proximity of these spaces, the number of staff on each team and
the number of members served by each team, it can get quite busy and noisy
during hours that the building is open. I recall days, especially in the morning,
when all the staff were in and working at their desks, with more than one staff
person meeting with one or more members. There were also other members
mingling around, talking with each other or checking their email via the member
only computer that was available in each team area.
At other times, the desks might be full but at some of the desks a
member, not a practitioner, is sitting, waiting for a staff member or working on
something. Such a level of openness and freedom of movement requires a
particular tolerance or perhaps preference for shared spaces. Practitioners seem
to accept that they may arrive and find someone at the desk that they are
assigned. This included me at times, as I would often situate myself at one of the
desks. I was impressed with their flexibility with this, and do not recall observing a
situation in which the practitioner expressed irritation regarding such
Each wall in the team area has a continuous bulletin board strip about two-
feet wide placed just at eye level. This means that while sitting at one’s desk the
staff member can be easily access this to place announcements, calendars and
other personal mementos or photos of their participation in agency events. Some
practitioners had photos of family and friends, as well as photos of agency events,
while others did not. When reflecting on the openness of the environment at
Vanguard, I wondered how practitioners decided which photos they would put up
and which they would not. Much has been written about self-disclosure in mental
health contexts, and it seemed that putting personal photos was a type of
disclosure and could invite members to initiate conversations about the story the
photo was telling.
I had learned through my informal conversations with the practitioners
that the organization left much about what to share up to the practitioners. For
example, practitioners could decide for themselves what their practices were
around giving members their cell phone or giving them rides. While practitioners
needed to be accessible and help a member problem solve their transportation
needs, the organization did not require practitioners to give every member their
cell phone or to transport every member where they needed or wanted to go. This
meant that practitioners need to develop personal frameworks informed by the
Vanguard’s philosophy for making these decisions, like to put personal photos up
or not. As a result there were varied practices amongst the practitioners, and
these practitioners seemed to evolve overtime as practitioners gained experience.
The remaining Full-Service Partnership Adult team was housed on the
third floor. This particular team space is a bit smaller than those on the second
floor, but is set up similarly to the other team areas (e.g., desks around the edge
of the space), except in two particular ways. First, in this team area, one corner of
the room has been walled off to create an office space out of which the team
psychiatrist works. In the other two team areas, the psychiatrist is situated in
exactly the same way as the other staff members, with no private space. Second,
this team space has doors that can be opened or closed/locked to control access.
This seems due partly for safety reasons as the third floor is much less traveled
and populated than the second floor.
I was immediately struck with these two differences when I first
transitioned to this team. Like members, the locked doors meant that I often had
to knock or wait for one for of the practitioners to arrive before I could enter the
team space. This had not been my experience during my tenure with the other
two teams, I could enter those team spaces at any time, and on some occasions I
was one of the first in the team space for that day. While the option to lock doors
gave me a different experience with that team space, I imagine that it also gave
the practitioners in this team space a different experience as well. To some degree
they had a bit more control over their team space, at least regards when it could
be accessed, than the practitioners in the other two team spaces.
The flow of activity in these team areas varies considerably across the
course of the day and across the course of the week. Practitioners move in and
out of the space at different times, and move in and around the space to attend to
different work tasks and engage in varied social exchanges. At times you might
find each desk inhabited with a practitioner or a member, and at other times you
will find only one or two individuals. The desks are situated very close together,
so that exchanges and activity happening at one desk is easily visible from one
desk to another. The proximity of the desks also means that practitioner-member
contacts happening at one desk can be easily heard from another. This can mean
that serendipitous connections are made while working with members that could
not have happened if the practitioner-member contacts took place in a private
office space. Karen recalled:
Karen: I was talking to [member]… and he was talking about school and
how he wanted to go to school and study math and he needed this algebra
book and he didn’t have it, so I was looking on the computer to see if I
could find it at the book store or whatever it was, and our psychiatrist at
the time, was sitting there a couple of desks away, listening to the
conversation and he wanted to increase [member’s] meds. So he was
sitting there and he goes, “Hey, [member], what if I buy you this algebra
book and you increase your meds for a little while and I’ll buy you this
algebra book as an incentive for doing that, and you agree to change your
meds.” Okay, he changed his meds for a little while, that was what the
doctor was hoping he would do, and he got his algebra book, and it was
because we were sitting in the team area.
Such proximity pushes the boundaries of confidentiality that is considered a
critical dimension of healthcare practice, particularly in the mental health arena
and especially since the Health Insurance Portability and Accountability Act
(HIPAA) of 1996 (P.L.104-191) [HIPAA].
While I agree that it was a familiar and routine way of working in this
setting, I wondered how ‘comfortable’ members and staff really were. On several
occasions I saw practitioners utilize the available unassigned small offices to meet
with members privately, or engage in other strategies that seemed to afford more
privacy to conversations, i.e., talking more softly, taking a walk outside to have a
conversation, or intentionally meeting at a member’s home or in the community.
On other occasions I saw the same practitioner with the same member having
conversations in the ‘open’. This would suggest that practitioners did at times
intentionally utilize the practice spaces to support their interpersonal encounters
with members. For example, the psychiatrist on those teams that do not have an
enclosed area for them to work, did utilize the available private offices for certain
practitioner-member visits depending on the focus of the visit.
At least two of the visits I observed (See Table ? above) that took place at
the practitioner’s desk did seem to focus on something that might have benefitted
from a more private space, i.e., crisis plan and annual recovery plan. Since both of
these plans were an expected part of Vanguard’s documentation, one could
consider that the practitioner and member were just filling out forms. However,
the individualized nature and potential intervention importance of these plans
seemed in my view to require thoughtfulness and attention that might have been
well-served by meeting privately. I did not sense from the member any
discomfort about meeting at the practitioner’s desk, indeed they seemed engaged
with the practitioner in the process. Three other study participants did use one of
the available small offices to conduct the visits that I observed. For two of these
visits conducted in the small private offices, the primary focus of the visit seemed
less demanding of privacy, i.e., planning for the member’s facilitation of a group
activity focused on finding employment, and signing required forms to secure
While members could also request to meet in private, the serendipitous
and adhoc nature of some contacts seemed to place very real cognitive barriers on
both the members and practitioners for that option to come to mind in the
moment of the encounter. This seemed to be the case when a member was angry
with one of the practitioners or another member, and communicating in ways that
profoundly disrupted other activities and/or exchanges that were occurring at the
same time. On several occasions during my tenure with two of the teams, there
were brief, as well as extended, exchanges between members and practitioners
and/or members and members, in which staff appeared to clearly be working to
minimize the disruption, as well as potential safety risks, to all involved. For
example, during one of my visits a member had entered the team area and was
very agitated and angry. He was speaking loudly and cursing obscenities. As he
approached the team director, two of the male practitioners stood up and
appeared to ready themselves to intervene. However, before they moved away
from their desks the member walked out of the team area and exited on the fire
doors setting of the alarm.
Working in such an active and what might be perceived as a chaotic setting
requires a preference for such work environments, or the development of coping
and attentional strategies on the part of the practitioners and other staff so that
they can complete their work tasks. On a couple of occasions, I did observe staff
members, not practitioners, working in the team area utilize head phones as a
means to facilitate their attention on the task at hand and to distract them from
other activity happening in the space.
Outdoor space. At street level, to the right of the building is a small gated
area referred to as the garden, where members “hang-out” and smoke. When
members have been restricted from entering the building for behavioral
violations, staff may meet with the member in this area if they are not meeting
them in the community. In addition, serendipitous and adhoc practitioner-
member contacts happen here as well, as practitioners and members encounter
each other entering and exiting the building. Security guards are a key presence in
the garden and front sidewalk space, and other parts of the building as well. They
wore black jackets clearly marked with “Security Guard” so that they can be easily
Allen, who had worked as security guard before he became a PSC, recalled
with pride that the former executive director used to call them “ambassadors”.
Framing the role of the security guard as an ambassador, seems to argue for them
having a function beyond surveillance and risk management. Rather, it seems to
situate them in the role of community liaison. Indeed, my experience was that
these gentleman regularly greeted community locals as they walked by and also
welcomed and assisted new comers and visitors arriving at Vanguard for the first
The community as a practice space. Promoting community integration is
considered an important element of the work of this agency’s practitioners, and is
considered distinct from the case management responsibilities. Indeed, one of
the study participants recalled being given Paul Carling’s Return to Community:
Building Support Systems for People with Psychiatric Disabilities, considered a
hallmark text, by her supervisor when she was first hired. Carling’s text is
considered a foundational text for the work in which these practitioners are
Being able to work with members in the natural environment or the actual
spaces and places where they engaged in their daily lives is an important feature
of psychosocial rehabilitation and the do “whatever it takes” approach adopted by
Vanguard. Such a practice provides opportunities for the practitioner to develop a
rich and complex understanding of the member’s functional strengths and support
needs, as well as the environmental resources and barriers to support their
participation. I observed nine (9) community-based practitioner-member visits
that took place in a range of settings, including retail shops and restaurants, a
government office (i.e., Department of Motor Vehicles), a doctor’s office and
other community organizations (i.e., volunteer placement center).
Table 9. Community-Based Practitioner-Member Visits Observed
Participant Location Focus
Allen Member’s ‘board and care’
home and local donut shop.
Check-in to see how things were going.
PSC and member reviewed his current
concerns and goals.
Allen Member’s single-room
occupancy (SRO) motel room
and a local grocery store.
Help member complete shopping, and
to check-in with member about how
things were going
Leighton Member’s one-bedroom
apartment and two local
discount retail and furniture
Purchase couch, coffee table and TV
for member’s new apartment.
Patrick Local coffee shop and local
discount retail shops.
Check-in and do some shopping.
Table 9. Continued
Participant Location Focus
Sandy Department of Motor Vehicles
(DMV) and shopping at local
Transported and provided emotional
support to member while she took
driver’s test for second time and
Connie Property management
company and apartment
available for rent
Transported and provided decision
making support regarding apartment
Anne Three brand retail stores Transported and provided emotional
support to complete shopping,
checked-in with member re how things
Davina Volunteer center Transported and provided emotional
support to assist member in re-
scheduling court ordered volunteer
Ida Medical appointment Transported and provided emotional
support during medical appointment
The opportunity to support people in the actual spaces and places where
they engage in life, as opposed to some simulated experience within a treatment
or rehabilitation setting is one of the reasons why psychosocial rehabilitation
practice has always made such sense to me in my work as an occupational
therapist. I observed that being in the natural environment afforded practitioners
the opportunity to intervene in more timely and immediate ways. In many
instances, this meant averting potential problems and minimizing lost
opportunities that might result from a member’s actions.
For example, during one of the visits I observed, Davina was providing
support to one of the members who had to re-register for court ordered volunteer
work to avoid going to prison. She had been obligated to do this for several
months and had earlier worked with another PSC to complete this task, but the
paperwork had gone missing. It wasn’t clear to Davina what had actually
happened to the paperwork, but it wasn’t on file and the member could not find
her copy either. A part of this visit took place at the Volunteer Center where the
member needed to register. During the visit the member became quite frustrated
with the responses of the Volunteer Center representative. I was impressed with
the Volunteer Center representative, who remained calm and just kept trying to
answer the member’s question and provide information despite the member’s
clear expression of frustration. Eventually, Davina stepped in to mediate.
As I observed, I wondered what had influenced Davina’s decision to step in
at that point. Self-responsibility is one of the stages of recovery and a highly
valued stance for members at Vanguard. In addition, the notion of natural
consequences as important for learning was found to be a key reasoning frame for
Vanguard practitioners. I will discuss this more in a later chapter. It was clear that
the member was not being successful in her exchange, and was likely not going to
get her registration process completed if the conversation continued in the way
that it was going. The member didn’t seem to be able to be self-reflective in that
moment and change her approach to get her needs met. At one point during the
part of the interview in which she was reflecting on what had happened during
the visit, Davina said:
Davina: If I hadn’t been there, I’m sure they just would have asked her to
leave for the day because she’s not working. It’s not worth putting up
[with]—you’ve got eight people sitting in there, it’s not worth putting up
with that kind of behavior when you don’t have to. She’s the one that
needs the service.
As she continued to reflect on the visit, she addressed the value of in-vivo
Davina: The best teaching with [her] is to teach in the moment because in
teaching her after the moment when she’s calm, she has complete insight. In the
moment, you got to do a lot of redirect, a lot of coaching, a lot of teaching, a lot
of mirroring. So in some cases when we were talking and I would just finish for
her, it was more of a ‘this is how you can do it. I know you can do this. I’ve seen
you do it. I need you to do this.’ And sometimes she can but if I don’t show it to
her, she’s not going to get it because me explaining it that’s a bunch of fluff.”
A members’ housing as a practice space. Members housing as a practice
space was identified as a particular type of practice space, distinct from other
community practice spaces. Six (6) of the practitioner-member visits I observed
were conducted at the member’s place of residence, which included a single-room
occupancy (SRO) motel, a ‘board and care’ home, an assisted living facility, and
one-bedroom or studio apartments where the member was the lease holder (See
Table 10. Participant-Member Visits Observed at Member’s Place of Residence
Participant Location Focus
Kim Member’s one-bedroom
apartment. Member, PSC and
researcher sat in living room.
Check-in to see how things were
going. PSC and member reviewed
her current concerns and goals.
Patrick Member’s one-bedroom
apartment that she shared with
Check-in with member to see how
things were going.
Belinda Member’s assisted living
Check-in to see how member was
doing, and to transport her back
to Vanguard to get medications
Karen Member’s ‘board and care’
Reviewed with member
preference for new housing and
plans to transition out of current
housing due to eviction secondary
to problematic behavior
Sandy Member’s single room
occupancy (SRO) motel
Check-in to see how things are
going, focused on medication and
other at-risk behaviors
Greg Member’s studio apartment Checked-in with member re how
things were going with home
Assisting members to secure safe and affordable housing and providing
supports for members to sustain that housing is a critical service element of
Vanguard. Indeed, it was my sense that this agency’s high-risk, high support
approach means that they assist individuals labeled with psychiatric disabilities to
secure an independent living level of housing that few other mental health
agencies in which I have worked would. Persons served by the agency reside in a
range of housing situations, including apartments, single-room occupancy motels
(SROs), residential care homes (i.e., aka board and care homes) and the street.
Vanguard operates its own apartment units, as well as establishes and
works to sustain relationships with local property management companies. It has
access to federal and state funding to support the development of housing
opportunities. Access to such funding is important, as most of the members have
limited incomes and are most typically receiving or in the process of applying for
federal disability benefits. When they become eligible for federal housing
assistance, it means that they will not be using a majority of their disability
benefits for housing. Since their rental obligation is only around 30% of their
income, they have more funds available to meet other needs. This has the
potential to improve their quality of life. Federal housing assistance is limited, so
not all members have access to these resources.
An independent living alternative to apartments were single room
occupancy motels/hotels (SROs). Vanguard has developed working relationships
with some of the local SROs, and may temporarily fund a member’s stay in such
housing. It was my sense that this is not necessarily the optimum housing
arrangement for members from the practitioner’s point of view, but for various
reasons this may be best that is available at the time. Practitioners acknowledged
that in some instances, members choose this type of housing arrangement over
apartments as their permanent housing. On the practitioner-member visits that
took place at SROs I found that these were small spaces with the bed taking up a
major portion of the living area, and there was usually no defined space for meal
Some members resided in settings that minimized demands on the
members’ daily living routines and provided on-site support. These included
residential settings widely referred to as “board and care” homes and/or assisted
A board and care home is a state-licensed, non-nursing, residential care
facility, which is allowed to accept certain persons (depending upon its
license) for pay. In return, the home is to provide “care and supervision” to
all residents. A licensed facility is not limited by number of beds; some
have only 1 licensed bed while others can go over 100, 200, 300 or more
beds (Schwartz, 2006, p. 2).
In the US there has been a heavy reliance on the use of board and care
homes or adult homes to address the need for housing, federal policy has argued
for a shift to supported housing options (i.e., apartment level housing with
supports) (Transforming Housing for People With Psychiatric Disabilities Report,
2006). In California, “board and care” homes are licensed and regulated by Title
22 of the California Code of Regulations (CCR). Such housing arrangements are
usually for-profit, owner operated businesses. These are multi-resident settings
that provide assistance with taking medications, regularly completing grooming,
bathing, dressing, eating routines, or providing transportation to programs or
medical visits, recreational activities and so on. Such settings often operate out of
properties that have multiple housing units, or residential settings that used to
serve as convalescent hospitals, nursing homes or motels/hotels. These settings
are minimally staffed, often by family members of the owner-operators. Staff in
these settings generally have no professional education in mental health or
I found on the practitioner-member visits that took place at these types of
settings, that the physical plant included office space for residential staff, an
indoor area that may be used for multiple purposes including dining and/or
activities, a kitchen area for preparing meals, and an outdoor area that may or
may not include any activity space, but did serve as a smoking area. Vanguard
members shared rooms with at least one other resident. During the visits that I
observed, the practitioners began their visit making contact with the residential
setting staff. It did not appear to me that this was a requirement, but seemed to
emerge out the staff office being near the entrance to each of the facilities visited,
as well as being an intentional act on the part of the practitioner. In one instance
the practitioner checked in with office staff in order to follow up on recent
disruptive behaviors on the part of the member that had resulted in her being
“evicted” from the setting. In the other, the practitioner appeared to be alerting
the staff to his reason for being on the premises and also asking if the staff knew if
the member was at the residence.
The practitioners’ car as a practice space. A critical material resource
needed by most case managers practicing in public mental health settings, like this
agency, is a working automobile. Given the mobile nature of the services, having
a car is perceived as a necessity. Terms of employment for most non-government
agencies doing this work expect that the practitioner will utilize their own vehicle
to travel to off-site locations, including transporting members. I found that the
practitioner’s decision to transport a member emerged out of practitioner-
member negotiations. Negotiations that seemed influenced by the practitioner’s
sense of the member’s need for the assistance, as well as the very practical, and
one could argue, human response to take the member where they wanted to go if
the practitioner was going that direction anyway. The assessment of need will be
taken up further in Chapter 6 as an important aspect of the practitioners’ practice
reasoning. Sandy reflected on an experience she had with a member in response
to her request for a ride.
Sandy: Yeah, because I think a lot of members will be like, can I get a ride
here or can you come with me to this? It’s like, I know you get to your
dad’s house on the bus, you take four buses, why do you need me to take
you a few blocks down? So it is a lot of comparing and after I get to know
the members pretty well, they start to become aware, they’re really paying
attention to what I’m doing, you know? Like she told me pretty much
everything, she’s like, can you take me to social security? I’m like, really?
Do you need me to? She’s like, no, I’m just lazy. I’m like, okay, exactly. So
Practitioners also described the driving too and from places as creating
opportunities for particular practitioner-member exchanges, for example giving
space for a member to talk about things that they might not otherwise be
prepared to do in another context. Sandy again reflected on her experiences with
another member, for whom she did decide to give a ride and how she took
advantage of that time to address other things.
Sandy: We know he’s depressed and he keeps that hidden a lot, so is there
a benefit, if we take him grocery shopping, we bring that up and explore
other topics other than we’re just going to go buy food. So usually,
hopefully, it’s going beyond just giving him a ride, it’s engaging in
conversations about those things that he doesn’t like to talk about.
Connie too found that driving a member in the car facilitates the member’s
attention and increases the likelihood that he will be more authentic.
Connie: For me, like usually when you’re out with someone, like driving the
car, wonderful things happen because it’s focused, you’re in a close setting
and it’s a little more relaxed and then you can kind of bring stuff up. For
him, because he gets so distracted and everything, and he he’s also
someone, I think, that shows off for other people, like he’ll say things
like…so it’s just us in the car, like he can just say what he honestly is
Temporal Dimensions of Practice
“My days are never the same” (Davina).
There is a sense that there is no “typical” daily routine for the personal
service coordinators, as each day is different and dynamically emerges out of the
needs and desires of the members with whom the practitioner and the
practitioner’s team is currently working, specific organizational structures and
rituals, as well as demands and opportunities that emerge in the practitioner’s
own daily life outside of work. That said, I did find that there were temporal
rhythms to the practitioners work that emerged in the data analysis. In this
section, I will consider the temporal nature of the practitioner-member
relationships and team-work.
The temporal nature of practitioner-member relationships. Building and
sustaining relationships are seen as foundational to the work. Karen, a study
participant, emphasized the importance of the relationship over the actual tasks
or assistance that she was providing.
Karen: I think that the relationship part is much more important than the
task part. I know people really like it when they get their tasks completed
but to me that’s just an excuse for the relationship building, so I take
somebody to the doctor, I take somebody wherever, wherever I take them,
whatever we do, and if it’s just grocery shopping, it’s all about developing a
relationship and getting to a point where I can push them if I need to push
them, or that they will trust me so that I can make a suggestion and they’ll
try it based on our relationship.
I found that the practitioners identified explicit tasks and experiences related to
the beginning and ending of the relationships that they formed with members.
They also acknowledged the ebb and flow of these relationships overtime, and it
seemed that the beginning didn’t always happen upon their first meeting with the
member, nor did the end necessarily happen because a member transitioned out
of services. During the interviews, I explored with the practitioners how they got
started with members and how they knew what to do, in response to those
queries the described a process they called “engagement.”
Engagement represented a first phase in the practitioner-member
relationship. This is a process that the practitioners are explicitly introduced to in
the intensive three day training described previously, and is also identified in the
Adult FSP Toolkit that serves as a guide for the implementation of these types of
services ("Adult Full Service Partnership Toolkit," 2011). In this setting,
engagement was most often facilitated by the mutual participation of the
practitioner and the member in activities of interest, either for the member alone
or for both the practitioner and the member. Anne clarified how she identified
what to do with a particular member during the engagement phase.
Anne: Then when it comes to getting to know somebody, we usually ask
for things that they like to do for engagements, if they like to go to the
beach, we go to the beach with them. Do things that they’re interested to
do so that we can do it with them, that’s how we start building that
relationship, instead of just talking about simple things, like common
interests—how’s the weather, how long have you lived in [city], what do
you like to do, that kind of stuff—then it builds on over time and the time
factor is the big thing.
Like her colleagues, Sandy intentionally engaged with the member in activities
that were seen as opportunities for social contact. Also, by taking the member to
lunch she may also be intentionally meeting the member’s practical need for
Sandy: I do like to maybe take a member out to coffee or to lunch or find
something that they enjoy and go from there, just to build rapport and
open that discussion of what kind of support do they want from us.
Study participants described an ebbing of the engagement phase of the
relationship, when they had a sense that the connection had been made. Davina
emphasized that there was a time with “a new member, you, you find this, I won’t
call it an ‘ah-ha’ moment, but like an engagement moment where you know it’s
going to work”. She went on to describe that moment with one of her members.
Davina: [He] used to surf…but he also got bit by a shark…I remember when
he first told me that, that might have been one of our first engagement
moments because I like to swim and I like to surf. I suck at surfing. I
haven’t surfed in years because of all of my injuries that we were talking
about...Yeah, popping up on the board is not a skill set I have anymore.
But when [he] was telling me about it, I, I get online and I’m like, oh my
God. He’s like, oh yeah, there’s a couple articles about me... And sure
enough, there were… He got bit by a baby white shark…And that was our
moment…because I was thinking beach, you know, let’s go hang out at the
beach and he was like, yeah, I don’t do beaches. I got bit by a shark and I
was like, no. And so I was like, yeah, look it up on the internet. So I’m on
the internet and so I’m reading and I’m like, oh my God, I knew where it
was and the whole nine yards.
Although engagement was understood as critical to forming relationships
with members, there was a sense that there were risks inherent in the
engagement phase that may impact future work with the member. This focused
on the high practitioner availability and resource rich nature of this phase of
services. Practitioners actively sought out the member (i.e., assertive outreach)
which placed less demand on the member to be self-directed and also often
provided agency funded resources, i.e., food, transportation.
One study participant explicitly differentiated the level of support that she
would provide during the engagement versus post-engagement phase. The
practitioner was assisting the member in re-registering for court mandated
community service. The volunteer agency required a processing fee, and the
practitioner knew that the member had sufficient funds on hand to pay the fee or
at least part of the fee to get the process started. However, the member was
choosing not to do this. Davina situated her interaction with this member at this
time outside the engagement phase of service, and elected to not provide the
Davina: Now, if this had been an engagement activity, I probably would
have petty cashed the ten so that she could get this started because we do
have that option. But she had thirty. There was no reason for me to start
this for her and there was that look she gave like, you know, make it
happen. That wasn’t going to happen. I was not paying for you to do this,
especially when you don’t even want to pay for it. And that kind of
bummed her out because in the past for certain things I will and have given
her that extra just to make it through.
Anne reflected on times in the beginning of her work with the member
when she would go to the movies, but acknowledged that she doesn’t do that
now. This also introduces us to one of the decision support strategies utilized by
the practitioners to help them determine when to do something and when not to
do something. Specifically, “what’s the rehab value?”
Anne: I think a lot of it is, with him particularly, because we’ve gone to the
movies I ,think at least three times now and I feel like, okay, it’s no longer
an engagement tool, it’s just something he wants to do for fun. I can
understand he wants to do it for fun, but he needs to build the
relationships and it’s no longer building the relationship, we already have a
good established rapport and everything. So it’s just mainly him wanting to
go and have fun and at that point, I feel like there’s no rehab value in it for
me to go with him.
Once the connection was made, the practitioner’s took advantage of the
relationship that had been established as a motivational and support source to
promote recovery. Ongoing attention to sustaining the relationship during this
time seemed essential, as study participants described having “lost” relationships
even while the member was still receiving services. Casey reflected that at times
she needs to start again with members.
Casey: We kind of got to go back sometimes to rapport-building. I lost
rapport with, I mean, one member, she thought I called the cops on it, and
I didn’t. I don’t think she talked to me for a couple months. So it’s like
kind of we got to go back.
There is also an intentional process within Vanguard’s operations, referred
to as “flow” that continually oriented practitioners to questions about a member’s
readiness to “graduate” or “transition” out of the FSP level of care to either a
lower level of care or out of any level of support beyond natural supports in the
community. When reflecting on the “flow” process, one study participant noted
“that’s supposed to always be in the back of our minds…when are they going to be
able to move forward? It should always be there…because we want to move the
members forward, we don’t want them stifled.” This “flow” process
acknowledged Vanguard’s guiding principle that people can change and grow, the
recovery perspective that argues for movement out of the mental health system
(Young & Ensing, 1999), as well as the very real scarcity of public mental health
resources. Karen noted that:
Karen: Flow should be part of our everyday life, because we only have so
many spots, as does any agency, and to an extent [this member] is taking
an FSP slot that in reality, she really doesn’t need. She did at one point, but
she is doing really well right now and she doesn’t need that spot and that
could go to someone who really needs that intensive case management,
because that’s what FSP is.
Vanguard’s “flow” process included one or more representatives on each
FSP team that is charged with regularly asking the question “is this member ready
to move on?” The “flow” representatives from each team met regularly to discuss
the flow process on their teams, and in recent years, the agency had developed
additional service options that provide lower levels of member support and
provide less intense, ongoing support consistent with the FSP team.
When the decision to facilitate the members’ transition came from the
team, and not the member, there was a sense that this would take some time.
Practitioners began a “slow conversation” or “planting seeds” with the intended
outcome that the member would eventually take up the same view. Anne
described her thinking about this process with a member with whom the team
was currently working.
Anne: But yeah, it’s a team decision, usually we’ll talk about flow, how
everything is moving, if everyone is graduating or going to. Do they still
require services or can they just be graduated into the community? So
with him, we’ve started the discussion of flow, how he feels. I don’t truly
feel like he needs services anymore. Eventually, I can see him just going
into the community and that’s fine, but I think it’s a slow conversation to
start because I think he doesn’t think he’s ready but the rest of us feel like
It was my sense that the practitioner’s decision that it was time for the
member to transition seemed to emerge out of their awareness that recovery
and/or functional targets have been achieved, e.g., the member had secured and
sustained housing for some time, the member was consistently keeping scheduled
appointments, the member was managing their own funds now when they
weren’t before, the member did not appear to be in need of, nor was, making
requests for case management support, etc. Sandy reflected on her thinking
about her work with a member who she felt was ready to begin the process of
Sandy: She does most things on her own now. I’ve noticed she rarely asks
for help, she goes to the doctor and she became her own payee last year,
so I’ve told her, why are you still with us? Why do you think you still need
to be on the team? She’s like, I just like coming to talk to you guys and
blah-blah-blah. You can still come and talk, what else, what is the
purpose? Right now, she is doing job development stuff, so that is a part
of it but I am planting that seed of let’s start working on getting you moved
over. And luckily for her, she’s already familiar with the wellness center
because she’s done front desk stuff over there, clerical stuff, so I just keep
reminding her just because you’re over there doesn’t mean you can’t come
here. You can still call me, she calls me every weekend to tell me what she
did and I have to keep reminding her it’s not a separation, I think that’s
what freaks members out. It’s like once I go there, what happens with my
relationships here? Especially if they have close relationships with their
PSC’s, that can be very scary.
What’s also evident in the above study participant’s reflection is that the
relationships that the practitioners and members formed may have profound
meaning, for both, and that transitions can be experienced as a loss. These
relationships are long standing and can be experienced as very intimate given the
focus of the work in the daily lives of the member. Sandy again reflected on her
work with the same member.
Sandy: For her I was probably the first real companion that she had for a
long time and I keep telling her, I have to remind her I’m not going
anywhere. You’re still more than welcome to come by and say hi, but I
think that you’re at a point right now, there’s not much that we’re doing
for you anyways, so what’s the difference other than the socializing
aspects?... I bring it up every—not every time I see her, maybe once every
week or two, just kind of how do you feel about it? Because my hope for
her is to have her graduate by hopefully next year sometime.
Although transitions were intended to be a marker of recovery, they also
appeared to be initiated when the practitioners sensed that a functional ceiling
had been reached, or what is often referred to in the medical and rehabilitation
arenas as having reached what is referred to as ‘maximum benefit’. Allen
reflected on his and the teams process of deciding when transition makes sense in
light of this reasoning.
Allen: There was talk of him going to FCCS. I think we’re still going to move
forward with that…Because he’s pretty much stable where he’s at. He
doesn’t want to leave the board and care. He doesn’t want to go into an
apartment. He doesn’t—he’s pretty much just content with where he’s at
right now. And, I guess, you know, that’s all that we can do for him is what
we can…It was something that the—[psychiatrist] brought to the team and
I didn’t understand what, you know, what was—what the basis was for
that and it was explained to me that it was probably because that’s the
best it’s going to get for [him] right now…And, you know, he’s not
accessing any of our other services like money management or medication
management and that was pretty much it and I agree with that. I mean, I’d
like to see him socially interact more and come out of his shell and go to
shows with me maybe or the movies but it’s just—it’s not—it doesn’t seem
like it’s going to go in that direction.
Although the above study participant identified a desire for the member to be
more social, he determined that the member was “content” given that he doesn’t
want to move into an apartment, a common goal for members. The practitioner
was also persuaded by the psychiatrist’s assessment that the member had
reached maximum benefit, given that the member was not accessing services.
This speaks to the question of what counts as recovery (Bellack, 2006), as well as
the degree to which a recovery oriented setting accepts a members “choice” to
remain in a high support, communal living arrangement over the opportunity to
have one’s own apartment.
In some instances, endings aren’t really endings, but transitions to a
different kind of relationship. Sharon described this when reflecting on her work
with one of the members. This was a member who no longer received services or
had ‘graduated’. She decided to meet him on “her own time”, suggesting that
there was a change in the nature of the relationship. No longer was the support
she was providing within a practitioner-member relationship.
Sharon: He graduated… And I've been working with him with school and
everything, and I assured him; I said when you graduate, I’m still going to
be here for support for you... I said I’m going to be here for you if you need
any school questions or if you need to talk or anything, I just want you to
know to go ahead and make that move and feel confident and know that
you still have some type of support. So he did. And he transferred and he
graduated and he’s doing great. But he calls me every once in a while. So
he just called me and I said great, let’s have lunch in the community… So
we had lunch yesterday and we went to the community and I had lunch on
my time with him. So now I’m at the point where I’m willing to have
lunches on my time with these members because I have developed that
friendship with them. So that made me feel like I’m still gonna be there
for these members even if they do graduate, but I’m going to have to find
a way because we make lasting relationships here. And I think the
relationships are what anybody will tell you will guide us through
everything we do in our work. But those relationships don't end when
Although maintaining relationships beyond the formal care relationship is
generally considered unethical in most professional practice codes, the nature of
the work that these practitioners are engaged in means that they are involved in
member’s lives in intimate ways and often for long time periods. These
characteristics have been addressed in perspectives on relationship boundaries
within psychosocial rehabilitation and case management (Curtis & Hodge, 1994;
Williams & Swartz, 1998). Community-based mental health programs informed by
psychosocial rehabilitation have different frames for reasoning about such ethical
dilemmas as opposed to office-based or clinic-based practices. Sharon’s reasoning
about seeing a former member for lunch on her own time is seen as good practice,
practice that honored the quality of the relationship upon which it is based.
The temporal nature of team work. I found that in addition, to the ‘down-
on-the-ground’ work with members, the organizational structure of being a
member of a team influenced the temporal rhythm of the practitioners work. In
particular, team meetings afforded time, when taken by the practitioners for what
Schon (1983) called “reflection-on-action.” Reflection-on-action is a type of
reflection that happens outside the actual practice encounter, and is understood
to be a way for resolving practice dilemmas, identifying areas for additional
learning and strengthening one’s practice competencies. He suggested that
practices in which the work extends over long periods of time and is made of
multiple encounters, like the work of my study participants, are particularly well
suited to “reflection-on-action.” His perspective has been infused into much of
professional work and calls for reflective practitioners has emerged particularly in
the health and human service professions (Parham, 1987).
Each of my study participants worked on one of three Vanguard FSP teams
and participated in two different types of team-specific meetings, morning
meetings and weekly meetings. Each of these meetings served different purposes,
and specific purpose and structure of morning meetings was informed by the
assertive community treatment (ACT) approach. This approach identifies morning
meetings as a key structural element of the ACT (SAMHSA, 2008a). These
meetings serve a communication and coordination function in order to meet the
individualized and varied needs of members.
During my research, I attended any morning meeting that occurred on a
day that I was at Vanguard. Only the personal service coordinators regularly
attended the morning meeting on each team, along with team director and/or
assistant director. While guidance on implementation of the ACT approach
strongly recommend daily meetings, at Vanguard the frequency of the morning
meetings varied from team to team. Teams had the freedom to individually tailor
the frequency to meet their operational needs and preferences, and none of the
Vanguard adult FSP teams had adopted daily as a frequency for their morning
meeting schedule. They met at least 2-3 times per week around the middle of the
morning (i.e., 9:15 or 9:30 AM), and the meetings lasted for about 45-60 minutes
for the most part.
The flow of the morning meeting was usually facilitated by the team
director or assistant director, and most typically each practitioner reported on
their planned contacts with members for that day and/or the next few days. In
addition, on two of the teams, each members name was read out loud and
practitioners were expected to quickly report on any updated information they
had about that member. These morning meetings then served as intentional
venues for identifying what work needed to be done and often when it needed to
be done. Sandy described how this reporting and reviewing process in the team
meetings provided her cognitive support.
Sandy: Yeah and that kind of hits our memory, like what members have we
not seen for awhile, who’s kind of dropping off and we should definitely
check up on them, who’s in the hospital. So the Monday morning
meetings definitely help that and sometimes during the Monday morning
meetings, if I don’t remember, for some reason I hear their name and it
doesn’t come across to me like, okay, I’ve got to go see them.
Sandy clearly found that morning meeting helped her to stay on top of her work
with members. Each team works with over 100 members at a time, and each
practitioner can potentially interact with several members over the course of a
week. By communicating about these contacts, the likelihood that members will
go without contact is lessened.
While attending to immediate needs is clearly facilitated by this morning
meeting process, it also makes evident an aspect of the ACT approach that has
been criticized. That is that it focuses too much on crisis and not enough on
recovery (Krupa, 2002). This perspective emerged during my interview with
Belinda. I was exploring with her how she knew what to do and when to do it, and
I was considering the role of the morning meetings in that process.
Deborah: Now, to some degree, that’s sort of a way that you plan your
work is what the need is—the most immediate need is for that week?
When you’re trying to figure out what to do for somebody, is that sort of
Belinda: I still try to keep the long-term, the bigger-picture goal in mind,
Belinda: Because if I get caught up in every little thing that’s going on,
then we’re kind of just going through the motions.
Belinda: And we’re in constant-crisis mode, and you don’t want to be in
constant-crisis mode [LAUGHS] all the time. You get burnt out being in
constant-crisis mode, so—
Her response to my explicit query is to emphasize the work that she did to
counter or to balance out the experience of the morning meeting as being so
focused on immediate needs. She seems to be clear about the risks inherent in
being in “crisis-mode”, specifically “going through the motions” or getting “burnt
out.” What we see here appears to an additional temporal dimension to the
work in which these practitioners are engaged. That is, the movement back and
forth between the proximal immediate needs and the more distal long-term goal
or in other words, from the now to sometime in the future.
Although the daily morning meetings focused on more proximal concerns
and were it was in the weekly meetings that more distal, longer term, concerns or
planning were addressed. These meetings were typically held away from the
space of the daily work, unlike the morning meetings that were often held either
in the team space or in a small office next to the team space. In addition, weekly
meetings ran much longer than the morning meetings, i.e., between an hour and
½ to two hours. All team members attended the weekly meetings, including the
psychiatrist/nurse practitioner, resource specialists (i.e., employment, housing,
money management), and the personal service coordinators. During my research I
attended one full weekly meeting for each team.
This chapter identified contextual influences on the practice reasoning of
Vanguard’s personal service coordinators, specifically the philosophical, spatial
and temporal. Vanguard’s philosophy is articulated and communicated to the
practitioners through documents and explicit training opportunities. It is a
philosophy that has emerged out of historical influences in psychiatric
rehabilitation and the more contemporary recovery perspective. This philosophy
was outlined in stages of recovery informed guiding principles, that the study
participants found to be a good fit for their own sensibilities about what the work
should be about and what it should look like. The spatial aspect of the practice
context was described and specific spaces were identified as influencing the
practitioners reasoning. Specific practice locales were identified, i.e., team space,
member’s residences, the practitioner’s car, and ways in which they influenced on
the practitioners reasoning were considered. Finally, temporal influences related
to practitioner-member relationships and team work were identified and
considered. The next two chapters will focus on ways in which the study
participants framed their reasoning about their work with members.
Chapter 5. The Practitioners Reasoning: Meeting Member Where They’re At
“… but I feel like that’s kind of what it is, just that kind of figuring out
where they’re at” (Connie)
In this chapter and the one that follows, I will review my findings of how
the study participants made practice judgments, how they named and framed
what they saw and heard. Participants of this study identified a process they
referred to as “meeting the member where they’re at” to represent the initial and
ongoing work of matching their actions to their understanding of the member’s
needs and desires. Practitioners seemed to use this reasoning frame seemed to
locate or position themselves in relation to each individual member.
Overtime, as I worked my way through the text and considered this frame
as a way for the practitioners to locate and position themselves in relation to each
individual member, the image of a compass came to mind. Science tells us the
fact that a compass works by aligning with the earth’s magnetic field (Source:
United States Geographical Survey’s Core Facts Audio Series April 21, 2008) and
that no matter where you turn the needle of a compass will ALWAYS point to the
north. But, it’s in fiction that we have been able to get the lived experience of its
meaning for travelers. Novelists and film makers have told us story upon story of
travelers who can only find their way through a harrowing journey with the aid of
compass. A compass orients the traveler to ‘true’ north and allows the traveler,
when combined with additional information about the terrain, to know the best
way to get to their destination.
I found a compass to be a useful metaphor to represent the practitioner’s
reasoning for “meeting the member where they’re at.” My sense was that the
practitioners reasoning was influenced or magnetized, if you will, by their own
personal development, education and training, as well as exposure and experience
with Vanguard’s philosophy and practices. This tacit knowledge helped them to
find the ‘true’ north of each individual member’s personally relevant and unique
needs, desires, motivations, etc. Like travelers these practitioners had to combine
their locating ‘true’ north with additional information about the terrain in order to
make decisions about which direction to take. For these practitioners, the terrain
was the everyday spaces and places in which they traversed with members, and
what human and material resources were available based on each individual
In order to locate ‘true’ not for each individual member, practitioners
needed to refine their reasoning skills. Themes that represented aspects of
“meeting the member where they’re at” emerged from the data and included
understanding the members needs and wants for services and supports, the
member’s emotional and cognitive state during particular practitioner-member
visits, and the member’s readiness or motivation for specific activities and goals at
particular points in time. Each of these, as well as the dilemma’s that emerged,
will be addressed in this chapter.
Meeting the Member’s Needs and Wants
One way that practitioner’s utilized the “meeting the member where
they’re at” reasoning frame was to locate and position themselves in relation to
the member’s needs and wants. Vanguard’s philosophical perspective and
explicitly outlined guiding principles, as well as the regulatory requirements
outlined in the Mental Health Services Act (MHSA), clearly informed this practice.
Practitioners attended to member’s needs and wants as a way of getting started
with the work that they and the member would do together. Additionally, it was a
way to stay on track as the member’s circumstances changed and to facilitate
decisions that members needed to make.
Knowing where to start. In response to my efforts at trying to understand
how she knew what to do, Casey emphasized the person-centered nature of this
practice at Vanguard.
Deborah: How do you know what to do?
Casey: Like where to begin, what do you work with?
Casey: We’re client-centered; we’re member-centered. So it’s really
driven by what the member needs at that time. You look in the treatment
plan and look at their goals, and see what they’re doing, but ultimately
who knows what’s going on in their life at that particular time. It really
depends on what the member wants, and kind of what’s the need right
now. That always became like okay, let’s start here. There are plenty
members that just have a milieu of, you know, tons of things that really
need to happen, but then I kind of go back to my schooling as the
hierarchy of needs of like housing, food, clothing. Do they have some of
Sandy too reflected on this person-centered perspective and emphasized
her efforts to understand the member’s current circumstances and the changes
that they want to make.
Deborah: When you first meet someone, how do you know where to
begin, how do you know where to start the work with them?
Sandy: When I first meet a member, I usually assess where they’re at right
now, where are you living, do you work, are you in school, do you have any
family support…then from there be like, okay, how can I support you in
improving your life and what are those improvements that you’d like to
make? That’s where I start always.
Each of the practitioners above reflected on their beginning work with
members as focusing on the persons “needs and wants”, and although as Casey
clarified “[t]here’s no like document…with a checklist of okay, do members have
all this stuff”, the practitioners do utilize ‘categories’ of needs (i.e., Maslow’s
hierarchy) and/or life domains (i.e., work, school, etc.) as ways to frame how they
‘locate’ where the member is at. The specifics of these need categories and/or life
domains appear to be drawn from the practitioners past educational experiences,
and likely from their mentoring by more seasoned practitioners and their own
work with members over time.
I explored with Davina this same question about how she first got started
with the member whose visit I had just observed. Not only did she explicitly invoke
the “meeting the member where they’re at” reasoning frame, but she seemed to
take what I would argue was a moral stance regarding how best to do that. She
emphasized that she “wouldn’t read a new member’s file” before she’d spent
some time with them. This seemed to be a more “authentic” way to get to know the
member for this practitioner.
Deborah: And if you—when you think back over when you first started working
with him, how did you get started? How did you begin with him? I mean, what
did you—how did you know where to go? What to—what, what to do with him?
Davina: I kind of go with the school of thought of “meeting people where they’re
at.” So I kind of feel that out in our first or second meeting. So I don’t even start
to make plans or suggest anything until we’ve hung out a bit and they get to ask
me the questions that I would probably ask them. So it’s more of a conversation
versus a pull out your file, let me see what’s happening. Honestly, I probably
wouldn’t read a new member’s file unless I absolutely have to, until maybe a
week later after I’ve seen who they are first. Because sometimes when you read
the file, you have a preset of whether—who they’re going to be.
Deborah: Yeah, yeah.
Davina: And I’d rather let—I’d rather them show me who they are…
She reflected on her intentional practice of spending time with the
member as a way to come to know “where the member is at”, before she ever
read the member’s file. She emphasized the protection that this afforded her
from what she seemed to perceive as the risk inherent in coming to know the
member from the “file”. By not reading the file first, she allowed space to come to
know the member first from the member themselves. This was seen as important
to the development of an authentic and mutual relationship, and situated her in
alignment with the agency’s person-centered philosophy. She did acknowledge
that there may be circumstances in which viewing the file first was necessary, but
that was clearly the exception.
Davina went on to describe how she came to target a particular need, and
how her success with doing so helped her to “get started” with this member.
From the way that Davina told the story, it appeared that this member did not
explicitly say he wanted help on his social security, in fact she emphasized that “he
didn’t want anything”. However, in her first few contacts with him, she became
aware that he was working with another resource on obtaining social security.
She also came to understand that this was important to him because it meant a
source of income so that he could get a place to live. Davina had had some
success with assisting previous members in getting social security, and she was
able to parlay that into success for this member as well.
Deborah: Do you remember what his first goals were? What, what did he want?
Davina: (laughs) Nothing. No, that’s—he didn’t want—he didn’t want anything.
He just wanted to get his social security. He wanted to have a place to live and
I’m not a firm believer in doing your social security through the lawyers because I
just don’t think that they’re going to take the time to pick the points that social
security’s kind of looking for.
Deborah: Um hm.
Davina: So I made the suggestion to him…That’s how we really got on track. I
said, you’ve been working with a law firm that specializes in social security
for how long and he said 18 months. And knock on wood because it
doesn’t mean it always happens. But…I said, look, let’s you and I do the
paperwork. And he was like, no, no, no. So after the second time he got
denied, I was like, look, you’re going to give a law firm that specializes in
social security twenty-five percent of whatever you bring in. You’re not
going to give me anything. I’m still going to be your PSC and we’re still
going to be your payee. So why not just have all of it. And he, he thought
about it and like I said, that second time, then he was like, okay, let’s do
it…So that’s how we got started… Oh yeah, we got it in like the first, knock
on wood, we got it the first round.
Knowing how to stay on track. Coming to know what the member’s
“needs and wants” were was also understood to be an ongoing obligation, not just
something that happened at the beginning of the relationship. Such a view
acknowledges that changes do occur overtime in the member’s life circumstances,
and that the practitioner needs to be aware of and responsive to such changes.
and as the following conversation portrays, Greg acknowledged that knowing
what the “needs and wants” are overtime isn’t always clear.
Deborah: How do you know or maybe how do you end up moving from
one focus to another, one target to another
Greg: The focus of what we’re moving towards?
Deborah: Yeah, how does that change?
Greg: Sometimes that’s easy to determine, sometimes it’s ambiguous or
hard because there’s no clear attainment of a goal…with [one member]
her primary goal was housing, so once we helped her find suitable, stable,
affordable housing and she was settled in, it was like, okay, what next—
and I remember early on we talked about the possibility of school or
employment—where would you like to go now? And we defined
employment as her next objective and worked on that and now she’s
obtained that and we’re looking at increasing the employment, the hours
and maybe eventually out in the community. So that was an easy one,
because it was a clearly achieved goal, the housing, maintained for a
significant amount of time and it was now, let’s move on to the next goal.
But sometimes it’s not clear and then it’s just about—
Deborah: And is it not clear partially because the person’s not able to
express it or that it’s not evident in terms of how they’re handling what’s
Greg: Right, well we usually identify them together in the initial phases of
building the relationship, but sometimes it’s difficult to decide, okay, let’s
pursue something different now.
Greg acknowledged that when he and the member first started they focused on
her housing needs because that was her primary goal. Now that that goal had
been met it was time for them to transition to another goal area, he recalled that
they had talked about employment early on as well, so it made sense to begin
work on that goal now. But he also acknowledged that sometimes where to go
now or next isn’t always clear.
Facilitating a member’s decision making. Being focused and responsive to
members expressed preferences and needs also emerged when practitioners
were facilitating member’s decisions. Connie was assisting a member in relocating
from his current apartment to another. Together, the practitioner and the
member were checking out different apartments managed by property
management companies with which the agency had working relationships. On the
day that I joined them, they were visiting the second of two available apartments.
During the walk through, and in the subsequent travel back to the agency, the
practitioner and the member engaged in a conversation evaluating the merits of
each apartment in relationship to the members “needs and wants.”
During the interview I asked “So [what] are the next steps with the
housing.” Connie seemed to situate herself within Vanguard’s person-centered
philosophy in her very real desire to facilitate the process in such a way that the
member had “choices”. She wanted to facilitate a different experience for the
member, one in which resulted in him feeling more satisfied with his housing. This
is important because choice (Grant & Westhues, 2010) and satisfaction with
housing has been linked with successful residential tenure for persons labeled
with psychiatric disabilities (Tsemberis, Rogers, Rodis, Dushuttle, & Skryha, 2003).
In what follows, Connie reflects on her thinking about how to support the
member’s decision making.
Connie: He’s actually going around with someone else today because I was busy,
I have an appointment when they can show the apartment, so I’m sending him off
with someone else which is also good because then he’ll spend time with
someone other than me. So he’s going to look at that and then he’ll decide
basically if he wants to continue looking or if he wants to try and get the
apartment that he liked, but there’s the size and the bed that he couldn’t
really use, that bothered him, but I’m guessing he’s going to pick that
apartment just because he’s nervous about not having housing, which I
understand. And it’s a pretty good management company, so I think it’s an
okay choice, if that’s what he decides. I just wanted him to have choices
this time because last time he just took the first apartment he had and it
was like a slum lord and he was just so eager to get out of the hotel, so it
was kind of like a rush decision, but now he has more money and we have
a storage unit he could put his stuff in if he had too, so it’s a little more
What is also evident here is that some of the reasoning work that the
practitioner must do to meet the member’s “needs and wants” is to attend to
person-in-context (Bronfenbrenner, 1979). Connie noted that the preferred
apartment may not fit the members’ furniture, but the property management
company is good. So on balance, her evaluation of this option is that “it’s an okay
choice.” Person-in-context is understood to be a complex and dynamic
phenomenon (Letts, Rigby, & Stewart, 2003), and health and social care
professionals have incorporated this perspective into their conceptual models and
practices. Research supports Connie’s attention to this as it relates to the
member’s housing choice. Researchers have found that for persons labeled with
psychiatric disabilities, perceptions of the physical quality of their apartment and
the neighborhood social climate has a relationship with well-being outcomes
(Wright & Kloos, 2009).
Belinda attended to person-in-context as well in her efforts to help the
member transition from an apartment to an assisted living facility. This member
had been experiencing some cognitive decline and had become less able to
sustain her independent living. She begins with valuing the way that the staff
interacted with her and her sense of the other residents. She emphasizes the
importance of this for the member’s overall well-being.
Belinda: When I took her, the staff there were patient enough with her.
The environment of the peers there. I don’t want to say it like that. The
people who live there are old, but they ain’t that old. I’ve been in places
where they look like they’re going to die, and I didn’t want her to be in a
place like that, where it was just waiting to die.
Because Belinda was particularly concerned about the member’s isolation,
she found in this setting the characteristics that she perceived would meet the
member’s needs for social opportunities and activities.
Belinda: I wanted her to be in a place, [that’s] happy, activities going,
people walking around. They’re older, but they’re still engaging with each
other and doing things, and because she was by herself all the time and
isolated a lot, I wanted her to be around some people that would get her
moving. I felt like if she were to be somewhere that was very dark, you
know, like a hospital kind of convalescent home type of thing, that it would
just speed up the process of her time, to be quite honest. She needed to
be around people, because, like I said, she has no children. She does get
visits from her husband. She needed that component. What better way to
improve your quality of life than to have some friends and to be happy
Meeting the member’s “needs and wants” was one way that practitioners
engaged the reasoning frame of “meeting the member where they’re at”.
Reasoning about the member’s “needs and wants” helped the practitioners to
know where they could start their work with members, how they could stay on
track as the member’s circumstances changed, as well as how they could facilitate
their own and the member’s decision making. Their commitment and effort to
meet the member’s where they are at is informed by Vanguard’s philosophy, but
finding the match between the member’s preferences and needs requires that the
practitioner draw on knowledge developed from their experience with each
particular member and the circumstances of their life. Developing this knowledge
takes time and lots of opportunities to be with members as they engage in their
daily round of activities. The design of the full-service partnership affords the
practitioners with just such opportunities, given its in-vivo and team-based
Meeting Emotional and/or Cognitive Needs Within the Visit Itself
Another way in which the practitioners’ utilized the reasoning frame of
“meeting the member where they’re at”, was to locate and position themselves in
relation to the member’s emotional and cognitive needs within visits themselves.
Given the nature of the work, practitioners may see only one person in a day, and
work with them over the course of several hours to accomplish some specific task,
e.g., deal with social security payment concerns, or may see multiple members for
brief ‘drop offs’ of money or medications. Visits with members may be planned for
days, weeks or months, or may be planned early in the day for later in the day.
Visits may also occur by happenstance because the member was actively seeking
assistance, but did not contact the practitioner beforehand or had bumped into
the practitioner while they, meaning both the member and the practitioner, are
out and about.
As was noted in Chapter 2, unlike other evidence-based manualized
interventions (Chambless & Ollendick, 2001), practitioners in ACT-informed
services have substantial independence in deciding the when, where and how to
conduct visits. This is because unlike other EBI manualized interventions, manuals
and/or toolkits that describe the ACT approach (Allness & Knoedler, 1998;
SAMHSA, 2008a) do not provide a visit-by-visit outline of what should occur.
Neither does the toolkit describing the MHSA FSP toolkit ("Adult Full Service
Partnership Toolkit," 2011) provide explicit and specific guidance about what
should happen during each visit. The study participants seemed to intentionally
draw on their experience with the member, and the experience of other team
members, to help them reason about when, where and how to conduct visits.
Karen explicitly frames her thinking about what to do within a specific visit
as depending on the individual with whom she is interacting. The visit that I
observed took place at the member’s ‘board and care’ residence, and the purpose
of the visit was to explore the member’s preference about moving given her
recent eviction notice. When we arrived, Karen stopped by the main office to let
them know that she was onsite, and then we went directly to the member’s room.
The member was there and Karen asked her where she would like to meet today,
the member wanted to have a cigarette while she and Karen talked so we met on
one of the benches in the outdoors area of the residence. We met for just a few
minutes, while Karen checked in with the member about the upcoming plans and
verified the member’s preference for her next housing situation.
Deborah: When, uh, you visit someone like that, how do you decide where to
meet and how long you’re going to meet and how does that take shape?
Karen: I think every person is different. Some want to just sit on their bed
and talk in their room. Others like to go outside so they can smoke or they
want to be outside away from other people or on the bench. Or there,
they have a little gazebo thing in the back that I’ve sat with people
before…for how long…It just kind of depends on what the conversation is
and how much they want to talk. She isn’t a very talkative person. Um,
usually just answers the questions and that’s it. Um, other people are
much more talkative or want to talk about other things or more
information and want to have actual conversation. So I think it’s
individual. Every person is different in what they want or what they want
to get out of it. And also, it might depend on my purpose for being there.
Managing the visit and adjusting their actions to the individual was
understood as a way, in Kim’s words to “get work done.” What she seemed to
mean by this was that if the practitioner was not sensitive to the members’
emotional and/or cognitive needs during a visit then the visit could be derailed.
That is, that practitioner or the practitioner and the member would not succeed in
getting accomplishing what they had planned to do. This could result in missed or
delayed opportunities for access to resources or result in the member shutting
down communication with the practitioner. I found that practitioners drew on
their understanding that context can influence an individual’s emotional and/or
cognitive state and intentionally held visits at particular locations to optimize the
member’s capacity to successfully engage in the visit.
Being responsive to the member’s emotional needs. I found that
practitioners worked within visits to match their interpersonal or behavioral
responses to the member’s emotional needs as one way to “get work done”. And
while I identified these as emotional needs, in some instances, the needs that the
practitioners identified have also been identified by occupational therapists as
sensory processing needs (Brown, 2001). Sensory processing patterns have been
identified as being an interaction between neurological thresholds for stimulation
and self-regulation strategies and been compared to psychological temperament
(Dunn, 2001). In addition, persons labeled with psychiatric disabilities have been
found to experience particular sensory patterns (Brown, Cromwell, Filion, Dunn, &
Tollefson, 2002). These sensory processing needs can often be met through
intentional environmental strategies (Brown, 2001), similar to those described by
the study participants.
For example, during one of the visits that I observed, I noticed that Davina
had asked the member what music she wanted to listen to as we drove to the
volunteer center. The purpose of the visit was to assist the member in registering
for court-ordered volunteer work, and the practitioner transported the member
to the volunteer center and back to Vanguard. When I saw practitioners do
something very specific like this I would explore their reasoning for that action.
Deborah: Now the other thing that you did…you asked her about the
music…how did that come to mind?
Davina: With her I try to find things to kind of calm her down and
sometimes it’s food, sometimes it’s shopping, um, even if it’s to go buy
some lipstick. She, she’s a very material kind of self-soother… And that is
part of the relationship. I think over the past four or five years, I’ve
learned a few things to just kind of like, hey—sometimes it’ll just be let’s
just go get in the car and I hate driving around for no reason at all. But for
a few members the reason isn’t me; it’s how can I calm you down so that
we can get to a place where we can get some work done.
While other practitioners identified being sensitive to member’s interests
and facilitating a sense of agency as their reasoning for inviting the member to
select the music, Davina situated her reasoning within her efforts to help the
member be “calm” in order to “get work done.” While the member was not
explicitly agitated or upset as we traveled to the visit, Davina had had past
experiences were the member’s agitation had impacted the success of the visit.
Given the focus of the visit that day, helping the member to be calm seemed
intended to increase the likelihood that the visit with the volunteer center might
be successful. It was my sense that the strategy did work relatively well, as
although the member was unhappy with the outcomes of the visit, she did not
become verbally aggressive or walk off in a huff as she had in the past.
Practitioner’s knowing how to respond to and mediate each individual
member’s emotional needs emerges out of their own experiences, experiences of
other practitioners with that same member, as well as explicit mental health
practices that have been developed to address characteristic response styles of
persons labeled with specific psychiatric disorders. For example, overtime Kim
had found that she had to spend time or “be with” as a way to more likely have a
successful visit with one particular member. The visit that I observed took place in
the member’s one bedroom apartment, and the purpose of the visit was to do
some prioritizing of what the member’s goals were at this time.
During the visit I had noticed that Kim had taken some time before she
began to address the goal prioritizing that had been the basic purpose of the visit.
Rather, she had said very little beyond expressions of encouragement while the
member talked about what had been happening. When she began the process of
prioritizing the goals, there was a distinct shift in the exchange and Kim became
much more active and to some degree directive. During the interview, I queried
her about what she had done intentionally during the visit to facilitate the
Deborah: Across the time during the visit was there anything... because
clearly when you did the prioritizing you made this intentional decision to
do this. Was there anything else that you did intentionally across that
visit? That you were actually saying, this is how I want to be now; this is
what I want to do now?
Kim: No. The entire first part where she was just talking, I constantly
intentionally stopped myself from commenting, planning, problem solving.
Because it doesn't work. And sometime if you want to try it I’ll show you
what happens; when you try to do that, we can do that too. It’s not
usually a very good response.
Deborah: So you found over the time that if you move too quickly to act...
Kim: To problem solving.
Deborah: To problem solving.
Kim: It’s just terrible. It doesn't work. And the timeframe does seem to be
somewhere between 45 minutes and an hour. But you know I have to give
her. And then she was okay. And she had to be redirected, but...
I explored with Kim further how she had come to know that this was the best way
to work with this member and to insure a successful visit.
Deborah: What’s your sense of how you discovered that this is the best way to
manage? How did you come to know that this is the best way to work with her?
Kim: In the past she’d become very emotional, very upset with other PSCs,
she’d get very emotional and upset. And um, I found that if I could just sit
there and just listen to her and give her a chance to process and just talk
through everything, that she wouldn't explode, she wouldn't feel
pressured. She has a tendency when you pressure her to dissociate. So
she’ll freeze. She’ll just stand there and freeze. And it’s really awful when
you're trying to do something, and you have a limited amount of time. Or
it’s the end of the day and she’s just freezing. Or just getting really angry
and yelling and saying she needs to go to the hospital. And this is when
she gets pressured. So finally at some point I just decided I would try it
out. I would just see how it worked for me to sit. Be there with her, listen
to her. Give her the time she needed, and then try to go into saying now is
the time when we need to go to HUD and do this or you have a doctor’s
appointment or whatever it is. And just, it’s just trial and error to see how
long it takes and what I need to do to get her to the place where we can
move on and do something.
Kim also acknowledged how her own self-awareness was helpful in her
understanding that she needed to just be with the member in order to “meet her
where she’s at”. In addition, she draws on guidance from an evidence-based
intervention, i.e. dialectical behavioral therapy, developed specifically to help
practitioners facilitate recovery for persons labeled with borderline personality
disorders (See Chapter 3). This is one example of where Vanguard had
incorporated well-known evidence-based interventions into their practices. Kim
was one of the practitioners that had taken a lead in learning and implementing
this intervention at Vanguard, partly because she found that it resonated well with
her own Buddhist practices.
Kim: Just being aware of my own thought processes really helped me to
get to this place where I could realize that I needed to give her this space.
And it’s really helped with being able to get things done. If I don't pressure
her; if I, and if I have insight into my own reactions and responses to what
she’s saying, what she’s doing. So the basic mindfulness skills in DBT are
the first thing you learn is observe, describe and participate. So I try to do
a lot of just the observe part…and I also have a Buddhist practice of my
own, so that’s part of my personal practice. And especially with people
with borderline personality disorder, just being mindful of my own
reactions to things that maybe they say to me that I might get an
emotional reaction from, or my own frustration that things aren't moving
more quickly. Wanting to jump to problem solving in what I would
consider to be a reasonable time. Like sure I can listen to you for ten
minutes and then we’ll move on. You know with [her] that doesn't work
and with other folks that doesn't work so I have to be aware that that’s
where I’m coming from. That’s my reaction. And then just slow it down,
take a step back and be able to just focus on what she’s saying and what
she’s doing. What she considers to be important.
The practice of managing the pace and/or flow of the visit to match the
members’ emotional needs was also noted by Patrick. He too found that it worked
best if he intentionally planned for enough time to ‘be with’ when he met with a
particular member. The visit that I observed took place over about two hours, and
was a regularly scheduled visit in which Patrick would check in to see how things
were going. This mostly took place at one of the member’s favorite coffee places.
While at the coffee shop, the member reported having misplaced her reading
glasses again and also expressed concern about a tear in her jacket. Towards the
end of the time at the coffee shop, Patrick suggested that before they returned to
Vanguard that they stop by a local discount retail store to buy some new reading
glasses and a sewing kit that she could use to repair her jacket. The member
responded positively to this invitation. Like Kim before, I observed during the visit
that Patrick mostly listened and communicated expressions of encouragement.
There seemed to be a real sense of patience on his part.
During the post-observation interview, I asked him how he thought the
visit had gone and how similar or different it had been to other times he spent
Deborah: So how do you think it went?
Patrick: I felt that it was a pretty good time spent with her.
Deborah: Was it similar or different than other times you spent with her?
Patrick: It’s pretty similar in that the topics are usually pretty similar to
each time, but sometimes a little different. A little calmer than normal and
didn’t get caught up in any rumination as much, so we were able to talk
about more things in a quicker manner, even though it might have seemed
like it was going a little slow, that was actually a pretty quick pace as far as
topics with her.
Patrick notes that what while it may have seemed that things went slowly,
In comparison to other visits the pace was actually quicker. He suggested that this
might be due to recent changes in the member’s mood, emphasizing that when
she is anxious it takes longer to get things done because she is more likely to
ruminate and get stuck on something. I explored further what strategies he had
tried in order to mediate and respond to her emotional needs.
Deborah: Are there things that you’ve tried or strategies that you’ve tried,
because you’ve worked with her for about a year. That you’ve tried, to try to…
Patrick: Being patient really is the most useful I found, as far as trying to
rush, like moving past the subject or moving quicker to go do something,
usually actually causes more anxiety, which causes more time to elapse…I
just found that’s usually what’s going to move the pace quickest, is just
allowing her to go at her pace, versus trying to speed things up since she
just seems to slow down more, so it doesn’t really… rarely do I spend less
than an hour with her, I mean times that it’s less than an hour it’s going to
be if I dropped off money to her or her pickup or just kind of running into
her and having something else going, but if I’m going to spend time with
her, I usually mentally block off that it’s going to be a two to three hour
chunk of time to get into this meeting with her and going through where
she’s currently at.
Patrick emphasizes how important “allowing her to go at her pace” is if he
is to have a successful visit, because if he does try to move faster the visit actually
“just seems to slow down”. Both Kim and Patrick highlight the trial and error
reasoning process in which practitioners engage as they work with members.
Other practitioners spoke of this as well, that it took time to know the best
interpersonal and behavioral actions on their part to meet the emotional needs of
members. Given the nature of the setting, with long-term relationships and
multiple encounters with each member, practitioners have lots of opportunities to
learn to get it right. You also get the sense here that the practitioners actually
engage in what might be called ‘interaction experiments’ to test out different
strategies, as Kim says “so finally at some point I just decided I would try it out. I
would just see how it worked…”
Managing visits and adjusting one’s actions within specific practitioner-
member visits, also meant being responsive to changes in members emotional
needs. Being responsive means that the practitioner has to be ‘listening’ for
information that may inform them about what the members needs might be at
any given time. It also demands that the practitioner keep in mind the ongoing
issues that the member may be working on, so that they can evaluate new
information within the context of that work. For example, Casey was willing to do
something different during one of the visits that I observed rather than engage in
what she and the member usually did during the visit.
Casey: I usually meet Member once a week for the education project and
we actually work on building skills for him to obtain his GED. Sometimes,
depending on what is going on in Member’s life, working on the GED may
or may not happen. So, yesterday, we met in the education room and I
just wanted to do a check-in to see how he was doing because I had heard
from another team member that there was some type of, some kind of a
incident that happened on Monday when he was at work. I did want—I
actually wanted to prioritize that because there had been some situations
on the job and he is in supportive employment with the agency, so he
works two hours a day, possibly three, four, depending on what they want
him to do Monday through Friday. And so we had been working with
some of the kind of interpersonal conflicts that are going on between
either, you know, things that he feels that are going on and other co-
workers. And in his past, he has—he’s had similar experiences in which
he’s actually lost a job due to, you know, co-workers basically. So, I
wanted to check-in about that instance, see what happened. He does have
some low frustration tolerance. Sometimes he, you know, I’m not really
sure if he’s still upset about it, if it is affecting his work and, you know, I’d
like to kind of process with him what that’s about so that he can continue,
you know, obviously, to be employed. He stated that he didn’t feel like he
wanted to do the education project and really wanted to talk, really vent
about what had happened that week.
Over the course of the week Casey had heard something from another
practitioner the member had experienced some trouble on his job. She situated
this new information within her prior understanding of the challenges that the
member had experienced with his work. The combination of the incident and the
concerns about what he was experiencing on his job, readied the practitioner to
be responsive when the member wanted to talk, rather than do what had been
planned. While flexibility is clearly a valued stance in most health and social
practices, for Casey the impetus of the flexibility was her sensitivity to the
member’s emotional needs.
Being responsive to a member’s cognitive needs. Given cognition’s
importance to learning and communication, as well as the cognitive challenges
that may be experienced by person’s labeled with psychiatric disabilities
(Davidson, 2003; Green, Kern, Braff, & Mintz, 2000), it makes sense that in order
to “get work done”, practitioners were sensitive to the member’s attentional style
or capacity. Kim described how she intentionally conducted visits at the agency
site to facilitate the member’s attention to the task at hand. Kim had come to
“know” that certain work with a particular member was better accomplished at
the agency site, while other work was better accomplished at the member’s
home. The visit I observed was conducted at Vanguard in one of the small private
offices and the purpose of the visit was to complete paperwork for the member’s
During the visit as the member was looking in her bag for something, she
pulled some jewelry out, and with pride showed it to me [the researcher] stating
that this was jewelry that she made herself. This was a very brief exchange, and
during the post-observation interview, as Kim was reviewing what had happened
during the visit she addressed this action on the part of the member.
Kim: I know she was talking about her jewelry making and that’s a pretty
consistent thing too, that she gets distracted and wants to show her
jewelry. It can work better for me to meet with her here than at her home
because, as you noticed, she pulled out jewelry and was distracted by
showing it and talking about it. When I go to her home, which I do on
Monday afternoons generally, a good half to three quarters of the time
that I spend with her she spends showing me her jewelry, even if she’s got
something that she really needs to do, she spends that time showing me
her jewelry. So it actually can work better to be someplace away where
she doesn’t have all her jewelry there to spread out and show me...
Over multiple opportunities of interacting and trying to “get work done”, Kim had
clearly developed an understanding of this member’s contextualized attentional
capacity. With that knowledge, she now made intentional decisions to conduct
visits at particular locations to optimize the member’s ability to successfully
engage in the work that needed to get done.
Like his colleagues, Patrick had come to know that in his communication
and interaction with one of the members, he would always give her time to be
“tangential”. He emphasized that he had learned this from his own successful and
less successful interactions with the member, as well as interactions that he had
observed between this member and other practitioners. Specifically, he had
found that asking the member for clarification doesn’t result in improved
communication outcomes. As a result, when she would begin to share about an
experience that was confusing or unclear, he intentionally would give her some
time before he attempted to redirect her.
The visit that I observed took place at the member’s one-bedroom
apartment where she lived with her daughter, and the purpose of the visit was to
check in to see how things were going. There was a point during the visit when
the member began to talk about a specific past experience. I was having a difficult
time understanding the sequence of events, and I noticed that Patrick just
listened. This went on for some time and I couldn’t tell if he understood what she
was saying or not. He seemed to keep eye contact with her and nodded his head
in what seemed to be an acknowledgement of what she was saying. He did
eventually try to redirect her.
Deborah: Yeah, I noticed that what seemed to be happening was she
would be sharing and talking and I wasn’t always able to understand all of
what she was saying and then you’d acknowledge that, but eventually
you’d go back and say, okay, what about…?
Patrick: I try not to cut her off too quickly. Some people do cut her off
really quickly and say, I don’t understand what you’re saying, this doesn’t
make sense. It’s an ongoing thing. I’ve seen people say I don’t know what
you’re talking about, this doesn’t really have any effect, so I usually will let
her say what she’s going to say, as far as her dad and the tuna boat and
George Bush, which is the same story every time. I’d say it comes up
seventy-five, eighty percent of the time I meet with her. I let her go
through that and I try not to let her go too long to where it kind of gets
into that thing. I’ll acknowledge it and then try to move back to what we
were talking about before, that had tangented and then went into that
discussion. So it’s kind of how I approached it, some people have different
theories on how to approach it.
Being responsive to the member’s emotional and cognitive needs was
another way of “meeting the member where they’re at”. As with their efforts to
meet a member’s needs and wants, being responsive to the member’s emotional
and cognitive needs is informed by Vanguard’s person-centered philosophy.
Overtime, through a trial and error process, practitioners have found that by
reasoning about and adjusting their interpersonal and behavioral responses to the
member’s emotional and cognitive needs they are able to “get work done.”
Meeting the Member’s Readiness or Motivation for Specific Activities or Goals
Coming to understand the member’s readiness and/or motivation for
specific activities and goal, was another way in which the practitioners’ utilized the
reasoning frame of “meeting the member where they’re at.” Reasoning about
readiness and/or motivation facilitated the practitioners understanding of what
the member was likely to be able and willing to do. Further, it helped the
practitioner in their efforts to facilitate a match between the person and what
environmental supports were needed or would be accepted.
For example, Helen acknowledged her sense that she would often try to
move people forward towards some action or goal sooner than they were ready.
The visit that I observed took place in one of the small private offices at Vanguard
and was focused on helping the member to plan for an employment-focused
group in which she was going help with planning next week’s activities. She had
hoped that supporting the member to do that would help boost her self-esteem.
During the visit, it was my sense that Helen had been listening for and explicitly
encouraging the member to do more.
Helen: I think it takes time. It doesn’t just take a couple weeks to gain self-
confidence and self-esteem after a lifetime of not having that. But I think it’s
allowed her to feel those feelings of feeling good about herself. And I’m hoping
that she’ll get a taste of that and she’ll want to feel that more by putting herself
out there in other ways, not necessarily employment, but socially and other ways.
Deborah: Because I know, towards the end, it seemed like you were listening for
Deborah: To move her along in some way. I don’t know, to…
Helen: Yeah. That’s one thing I have to struggle with is that kind of meeting
people where they’re at. I have a tendency to encourage people to move a little
more forward than maybe they want to. But I also feel that people need that
encouragement at times…
During the long interview, as I explored how she had come to learn what to
do as a PSC, she acknowledged her own continued learning about how to
modulate her support, and to some degree situated her reasoning within
Vanguard’s person-centered philosophy.
Deborah: When you think about the PSC work, from the first time you started
doing that work, how have you learned to do it? What’s been the ways that
you’ve kind of learned to do the PSC?
Helen: I think I’m still learning that. I think ultimately it really is about working
with people where they’re at. You can’t force them to do anything they don’t
want to do. They’re just not going to do it.
Deborah: How do you figure that out? How do you figure out where someone’s
Helen: By listening, by working with them and spending time with them,
and learning about them…
What we see here is the same experienced-based reasoning that emerges
as practitioners spend time with members that has been identified previously.
Davina has also found that it takes time to know how to match her supportive
actions to the member’s volition. She referred to her process as “stick shift
Davina: And past experience has given me that, I call it, um, stick shift
pedaling… I remember when I first learned how to drive the stick, I used to
pounce on the clutch and my car would just jerk. And then I figured out
the balance which is always different in each car. I finally figured out the
balance of a little bit of clutch, a little bit of gas, and where and how to do
it when you’re trying to switch speeds and just learning the flow of that
and that’s kind of [where the member is]… It’s like sometimes if I’m going
uphill, it’s more clutch and gas and it’s just trying to just not force him but
help him get up and over that hill. Sometimes…kind of like a downhill
thing…all I had to do was just sit back and kind of watch, so hope that
Such a framing helps us to understand the ongoing adjustments that the
practitioners must make in matching their supportive actions to the member. She
also makes it clear that learning the right “balance” takes time and will be
individual to each member. Further, she acknowledges that there will be times
with each member when she needs to provide more support, and times when she
will provide less.
Practitioner’s reasoning about a member’s readiness or motivation to
engage in specific activities and/or goals in some instances appears to be informed
by phases or stages of recovery perspectives. For example, Greg reflected on his
work with one his members:
Greg: The four stages of change is the hope, empowerment, self-
responsibility, and meaningful role…because what was going on yesterday
was she and I had been in the empowerment stage with this particular
issue for a while now. So what I was working at yesterday was
transitioning to the self-responsibility stage.
This member was employed and also receiving a federal transfer payment
(i.e., Social Security Disability Income or Supplemental security Income). As a
result she had to report her income on a monthly basis. This is important in order
to avoid a precipitous reduction in benefits that might occur sometime in the
future if earnings are not reported monthly. The practitioner and the member
had been meeting monthly to complete the reporting process which involved the
use of an automated phone process.
Over the last several months, the practitioner had been making the phone
calls because the member had expressed “fear” and he had reasoned that she
didn’t feel confident to make the calls independently. The plan all along had been
for the member to eventually make the calls on her own, and in the last two
months the practitioner had explicitly begun conversations with her about his plan
to transition from him making the call to her making the call with his support. .
Greg’s decision to transition was informed by his observations of the
member’s actions which served as an indication to him that she was moving from
the “empowerment” stage of recovery to the “self-responsibility” stage of
recovery, at least as regards this particular task or activity. I explored with him
what the member was doing or saying that had led him to say “I’ve been doing it
Deborah: You said “I’ve been doing it enough.” How? What was she
doing? What was she saying?
Greg: She’s been showing up on time prepared with her, her documents.
The first couple of times she didn’t have her stubs so we had to postpone it
for a day or two until she got her paperwork together. The last two
months she’s shown up right on time—early for her appointments actually.
She’s had the documentation she needs so there’s, there’s a level of
preparedness on her part that indicates to me that she’s ready to, to start
doing this on her own.
He acknowledged the dynamic and individualized nature of trying to figure out
what stage of recovery the member is in, noting “that’s so individualized…You
can’t say, okay, we’ll do this for six months and then we’ll transition and then it’s
like—it’s more intuitive. You just have—got to have a sense.” Here again we see
Vanguard’s person-centered philosophy informing the practitioner’s reasoning.
Stages of recovery perspectives have mostly emerged from qualitative
studies of the recovery experience for persons labeled with psychiatric disabilities
(Andresen et al., 2003; Davidson & Strauss, 1997; Young & Ensing, 1999). In
addition, researchers have drawn on stages of change theories developed in other
practice areas (i.e., the Transtheoretical Model of Change) to provide a framework
for an individual’s readiness to engage in psychiatric rehabilitation interventions
targeting particular life domains (i.e., moving from homelessness to being housed,
from not working to working, etc.) (Cohen, Anthony, & Farkas, 1997; Farkas,
Soydan, & Gagne, 2000; Rogers et al., 2001). Using a stages-of-recovery
perspective is clearly situated within Vanguard’s philosophy and guiding
principles. As noted in previously (see Chapter 4), the medical director of this
agency had developed and articulated a stages of recovery model that had been
incorporated into the agencies philosophy and guiding principles—Hope,
Empowerment, Self-Responsibility, and A Meaningful Role in Life (Ragins, 2010).
Like Greg, Patrick works to understand a member’s motivations in order to
decide how to respond. The focus here however is on the motivation behind the
member’s periodic episodes of drinking alcohol to such an excess that she is often
severely incapacitated and at risk. Patrick recalled his first meeting with the
Patrick: When I first met Member, I actually went to outreach with her
with her previous worker and we went to the place she was staying and
then actually found her in the community, she was quite intoxicated, we
were trying to get her to sign the paperwork to actually be a part of the
FSP services… It literally took us about two-and-a-half hours to get her to
sign three or four papers, she was really down, she was ashamed that the
first time she was meeting her new worker, she was intoxicated.
In the following quote, he explicitly connects the ‘meeting the member where
they’re at’ reasoning frame with Vanguard’s philosophy.
Patrick: I see more of the let’s see what we need to do, let’s meet the
person where they’re at. I mean, when I tell people that I’ve met people in
an alley while they’re drinking and stayed and interacted with them, I’ve
let them get in my car when they’re heavily drunk, to try to go find
assistance, I think that really incorporates the spirit of [Vanguard].
He has tried to make sense of what motivates the member to drink, grounding his
reasoning in both actual statements that the member has made, as well as
perceptions he has developed in working with her over time.
Patrick: Motivation for the drinking is an escape from…it’s interesting
because she talks about escape and it’s good for a little bit and she doesn’t
have to think about all the problems and her self-esteem and where she
wishes she were and what she was doing, but after drinking for a little bit
she’s just as much there as when she’s not drinking and in a lot of ways is
more miserable. So I think a lot of the times it’s a temporary escape that
leads to a lot more…She doesn’t drink for, you know, go out and have
social gathering type thing. In the times that I’ve known her and she’s
been sober and then had a relapse or she’s talked about a previous
relapse, it’s usually she was feeling upset about where she was at and
wanted to be further along or she wanted more money or she wanted this
He also frames his decisions to take an action or not take an action within a
Deborah: Are there particular experiences, with members, that sort of make it
clear to you the philosophy and the guidance that you’ve been given, like how
they were dealt with, how they resolved when you interacted with them, like the
quintessential Vanguard model moment?
Patrick: What am I thinking when I encounter Member in the alley when
she’s drinking. It’s a good question, a lot of things go through my
head...how long do I sit here with this person while they’re drinking, where
are we going with this, is this going to lead to anything? She could use
help, what resources are out there, which I guess is not necessarily the
best thing to be thinking of at the moment because that person might not
be to that point and you’re kind of, at point I’m more pushing my desires
than necessarily where she may be at because she might not be at that
change point at all.
Meeting the member’s readiness or motivation for specific activities or
goals represented another way that practitioners engaged the reasoning frame of
“meeting the member where they’re at”. As with their efforts to meet a
member’s needs and wants, as well as being responsive to the member’s
emotional and cognitive needs here too we see Vanguard’s person-centered
philosophy informing this reasoning frame. In addition, we see again that this
experience-based reasoning is possible given the long-term relationship and
multiple encounter design of the full-service partnership.
Dilemmas Emergent in “Meeting Member Where They’re At”
I found that practitioners did experience reasoning dilemmas as they
worked to “meet the member where they are at”. The dilemmas that will be
considered here include (1) the challenge of understanding where the member is
at given the often cyclical nature (i.e., movement between crisis and stabilization)
of the psychiatric disorders, (2) being challenged by situations in which the
practitioner overrides their experienced-based reasoning to act on Vanguard’s
person-centered philosophy, and (3) situation in which the practitioner must act in
a way that seems counter to Vanguard’s person-centered philosophy.
The cyclical nature of psychiatric disorders. At the close of the long
interview that focused on how Casey had come to work at Vanguard and how she
had come to learn how to be a PSC, she reflected on the movement of members
between periods of crisis and stabilization.
Casey: This building rapport, stabilization, really moving on to recovery,
finding those meaningful roles, and what’s that going to look like for you.
But I think what’s so difficult about mental health is that that could go
backwards at any given time, and when is that going to happen? We don’t
know when that’s going to happen, and I think when so many people get
into that crisis, destabilization…I’m like over here trying to get people back
where they were, and maybe they do bounce back to where they were
originally. They bounce back or we got to build it back up again, which
takes a lot of time.
Casey acknowledged the very real challenge when where a member is at may be a
moving target. Other medical conditions may also result in fluctuations in the
members functioning. Belinda reflected on her work with an older member who
was experiencing cognitive decline associated with dementia Alzheimer’s type.
Deborah: Were there any surprises during that visit? Was there anything
that kind of surprised you or that worried you?
Belinda: For today’s visit, no. With her it’s, I’m always thinking how is her
memory today?, how is her health for the day?, because different days
there’s different Member. Sometimes she’s more cognitively alert,
meaning that she knows what day it is, she knows what time it is, she’s
able to remember certain things. Then, there’s other days where she can’t
see past her hand. She doesn’t know what we’re doing, why we’re doing
it, where we are, who I am, and that’s very scary, because she still goes with
me. For me, it’s like what if it wasn’t me, and it was someone else?
Davina too reflected that she would “never know which [member] I’m
going to get”. She had worked with this member for some time and the current
focus was helping him get a position with the agency’s on-site employment
program. She and the member were meeting with the janitorial services
supervisor on the day that I joined them. Davina noted that the member
experienced periodic “black outs” which the she linked to his episodes of heavy
drinking. She had wanted the visit to be successful and had done some
preparatory work with both the member and the work supervisor. During the
meeting she stayed very attentive, but intentionally tried to stay in the
background and let the member handle it.
Davina: So when [he] and I went downstairs to talk about his start date and
that—so [the work supervisor] could meet him and get a better feel, it was
kind of scary because I never know if [he’s] going to have a blackout, forget
why we’re down there. I never know which [member]I’m going to get…I
don’t want him to shoot himself in the foot so there’s a constant
engagement where I can’t not pay attention… In the past, when he’s
worked through Salvation Army, he didn’t do so well. So I was very
hesitant and concerned that he would just blow this off. So during the
meeting, I was like, oh my God, is he—is he really going to do this? Is he
going to pass on it?...today he’s willing; tomorrow, depending on where he
is with the drinking and his emotions, he could easily wake up and say,
yeah, no, I’m not feeling this. I’d rather just stay at home and figure
something else out...And so during that meeting and [he’s] talking, it’s
okay, he’s presenting well; he’s doing everything that he’s supposed to;
he’s acknowledging; he’s having conversation; if I weren’t here, if I was a
fly on the wall I would not know that there were any of the concerns that
are going through my head right now. And I was just like, oh my God, this
could go badly, this could great.
Psychiatric disorders like bipolar disorder, major depressive disorder and
schizophrenia are often characterized by episodes of more acute symptoms and
periods of remission. Such fluctuations may occur even when the person is taking
their medication as negotiated with their psychiatrist. Explanatory models for
fluctuations that occur in these circumstances include the stress-vulnerability
model (Zubin & Spring, 1977), which argues that life circumstances can overwhelm
coping resources like medication. Each of these practitioners made evident the
challenge that fluctuating functional levels may have on a member’s success.
Casey emphasized the potential unpredictability that comes when a person moves
from stabilization to crisis and back again—maybe. Belinda worried that the
member with cognitive disruptions will go off with someone and be at risk.
Davina was relieved when the member that she was working with was presenting
well this time.
Acting on principles rather than experience. Practitioners have also found
themselves in situations that may require them to go against their own
experienced-based reasoning in order to stay true to Vanguard’s guiding
principles. This seems to happen most when the practitioner has perceived that
the member is not ready for something that they have expressed a desire to do,
e.g., live on their own. The practitioner acts to support the member’s choice, even
if it’s their sense that the person is not likely to be successful, because doing so is
consistent with the Vanguard philosophy of promoting member’s choice and self-
determination. Such a dilemma challenges the perspective that a member’s
readiness is a necessary condition for support to be provided. Connie emphasizes
the importance of such a view.
Connie: I think it’s different with every person but I think you just have to
believe everything is possible for everybody and just try to work on the
steps to get to whatever their goal is, whether or not it is possible or not,
that’s another thing that you’ll figure out down the road, but you have to
start working towards it.
This view is consistent with psychosocial rehabilitation’s “belief in the
potential productivity” of all persons labeled with psychiatric disabilities, even
those for whom practitioners may perceive as experiencing the “most” functional
and motivational challenges (Beard et al., 1982, p. 47). Russinova (1999) drew on
her literature review of hope and its characteristics to argue that since the factors
that determine recovery are not completely known practitioners had to have what
she called “hope-inspiring competencies” (p. 54). These included the
practitioner’s competency to work without knowing for certain the outcome or
speed of recovery, to contain their own feelings of helplessness with slow
improvement, and to have a ‘good memory’ for small achievements. This is indeed
what Connie claims “you just have to believe everything is possible for
This same perspective was represented by Greg who reflected on his work
with a member that “surprised him” in his year-long success of maintaining his
own apartment. The practitioner noted that he had provided a high level of
support to this member off and on over the past year, and acknowledged that his
initial thought in response to the member’s request for help getting an apartment
was “no how, no way”.
Greg: He surprised me in his ability to maintain that apartment for as long
he has… Prior to moving there, he was living like at a transitional living
place with a lot of high support from the in-house manager, who kind of
took the member under his wing, kind of was like a paternal figure to him.
And personally, helped – you know, did a lot of what we do, but he was
right there living with him also at the transitional living. He would help him
with shopping, with haircuts, maintaining the apartment. But even with
that, it got to the place where he became so inconsistent and irresponsible
with maintaining his laundry, eating other people’s food because there
was a combined, shared kitchen, that the guy asked him to leave. Prior to
living there, he was at a board and care with a higher level of support.
Always meals were made and his laundry was taken care of, the room
upkeep was taken care of. And he wanted a less restrictive environment.
So from the board and care, we helped him get into this transitional living.
His previous PSC helped him get into transitional living. And then when
the manager there asked him to leave, or asked us to help him find
another place, okay…What board and care do you want to go to? And he
said, no, I’d like my own apartment. And my initial response in my head
was, yeah, okay, Member. What board and care are we going to work on,
because in my opinion, no how, no way, was he ready or equipped to live
on his own. However, our philosophy is member-driven, value-driven, high
risk, high support, and I had to go back to that. I always have to go back to
that. It goes back to principles and values of the agency and not my own
This practitioner’s experience-based knowledge with that particular member led
him to reason that he would not be successful, but his commitment to Vanguard’s
philosophy and principles meant that he acted against that understanding. And
the member had successfully maintained his apartment for a full year given the
availability of the “high support”. The outcome for this member provided the
practitioner with the experience that taking such a stance, i.e., supporting the
members expressed desires despite his misgivings, can work out.
Karen had had a similar experience when working with a member who was
in transition from one housing situation to another. The member had been
evicted from the “board and care” (see Chapter 4 for more information about
residential care settings known as “board and care homes”) where she had been
living because she had been drinking a lot, destroying property and had recently
thrown a cup of hot coffee in the face of another resident. On the day that the
practitioner and I visited the focus was to check in to see how she was doing in
response to the eviction notice, and to explore her preferences for alternative
housing options. This member had also just successfully secured an opportunity to
move into a new supported housing apartment unit.
Karen: Well, I was concerned about her housing; one, that she’s in the 30
day and, two, she has an opportunity for a low-income housing that she
and a lot of other members applied for. And I’m really concerned about
that because—like I asked her, “Do you know how to cook? Do you know
how to make meals?” And she said no, she’d have to learn. And that’s
really concerning when a board and care that has high support, that she’s
struggling so much in that situation that, when she even lost, uh, an
apartment—especially when this apartment, because of the way it’s
subsidized, that they will have no tolerance for any behaviors, that she will
be out so quickly, and that’s really concerning to me, so… I feel that, with
her, it’s worth a try. She hasn’t had an apartment in a very, very long time
and this might be her only chance to really afford an apartment because
it’s such a small percentage of your income that you pay for rent, that let’s
try. If she’s out, then she’s out and we’ll find another board and care and
she’ll be back in a similar situation that she’s lived in for a number of years.
But let’s try. We can certainly work with her on learning how to cook or
figuring out microwavable meals that—so that she can eat, she can come
to the [agency] every day to get her medicine because she—that wouldn’t
probably be a good thing for her take it on her own, um, because she
comes here often anyway. So I think it’s something to try. She would
definitely need high, high support; probably someone to see her almost
every day in an apartment. But I say let’s try it. Let’s see how it goes, even
though my gut feeling might be that it might not work out.
What seems to move this practitioner to support the members move to the
apartment, despite her “gut feeling” that the risk is high, is the dynamic
combination of the timing of having such housing available now, the knowledge
that high support is available and that there are alternatives if it doesn’t work.
Acting against a member’s choice. Although Vanguard’s philosophy and
culture clearly support each of these practitioners in taking the positions that they
did, there are also situations with members in which supporting a member’s
choice may be more difficult to act on. In these instances, it was my sense that
the practitioners were acting on their experienced-based reasoning, as opposed to
their principle-based reasoning, to take particular actions. For example,
practitioners do participate in involuntary psychiatric admissions, and some of the
practitioners who are licensed and have the authority to initiate involuntary
admissions. Anne reflects on her obligation as an LPS-designated practitioner to
support her when such decisions have to be made. What she seemed to be
emphasizing here is her understanding that that there are limits to Vanguard’s
Anne: A lot of us are also LPS-designated, I’m one of those, so when I see that
criteria I’m like, you can’t ignore it anymore, it’s like high-support will not fix this.
There is no way we can get out of this situation because it’s no longer safe.
In addition to involuntary psychiatric admissions, decisions to override a
member’s choice may occur in other situations in which practitioners determine
that the member’s behaviors place them at a serious safety risk. Such actions on
the part of practitioners have been both criticized as coercive (Gomory, 2002) and
lauded as reasonable and essential. When considered in the context of other
actions that override a person’s self-determination, it has been described as
“caring coercion”(Sharfstein, 2001).
It was my sense that decisions, what Belinda called a “supportive executive
decision”, to override a member’s choice most often happened after much
deliberation on the part of the team. Further, it seemed that it generally
happened after various high support strategies are experienced as unsuccessful in
reducing the risk. Belinda talked about her work with one of her members who
had been living on her own had experienced a cognitive decline related to
Dementia Alzheimer’s type. Over time, Belinda and the team had become
increasingly concerned about the functional and safety problems that were
occurring. The team eventually decided to move her from the apartment to an
assisted living facility. I asked Belinda about how that decision had happened.
Deborah: What happened that finally she... how did the team make the decision,
finally, about having her move from her apartment to assisted living?
Belinda: We called APS [Adult Protective Services] numerous times. They would
open a case and close it, because we were here. They would open a case and
close it, because they said she had assistance. We contacted another agency that
was more culturally-oriented to her Tagalog language, and trying to get that type
of assistance to see if she would have a connection with other people in our
agency. That didn’t really...
Deborah: And the calls to APS were about her not taking care of the apartment?
Belinda: Her not taking care of the apartment, her not taking care of herself, her
not taking care of cat, just neglect and grave disability.
Deborah: When you make a call like that, is that a decision you make on your own
or is that something you generally bring back to the team? How did it happen
that those calls would be made?
Belinda: Well, I would report to the team the things that I would see on my
visits, and we would make the decision on how to handle those things,
because they were chronic and long-term things that had been going on
before I began working with her, like the roaches that she would have in
her apartment, they would cover this entire floor. Like you would pull her
mattress back, and they’d just be crawling like horror movie. I don’t know
how she slept like that, and she told me she wouldn’t sleep. It was bad.
They would crawl out of her purse when she would come to [Vanguard]. It
was just horrible. Horrible. A horrible way to live. I would take her to the
grocery store, we’d spend $80 on food, and her IHSS worker would take all
of it…Just things that were going on that I would see, her money missing
out of the bank, you know, all because she can’t remember who she went
to the bank with. I mean, you know, she would go with me and forget that
we were even there. I was just able to see all these things and I would
bring them up to the team, and so we finally made the decision that
number one, as far as housing, she needed a more supportive
environment. The place where she lived was independent living. So
everyone there was 65 or up, but they were living independently. There
was no one coming there to care specifically for them. The manager there
took a liking to her, of course, and helped as much as she could, but it
wasn’t the ideal place for her. So it came the time where I talked with
[her] for months, at least three months, about moving, and she would get
upset. She would get upset and start cursing in Tagalog. She would be
like, “No, I’m not moving. This is my home. I’m not leaving.” And it finally
got to the point where after two or three months of talking I said, “You are
moving. That’s it. You’re moving. I’m sorry, but we have to make this
decision for you, because this is what’s going on.” And I took her [and] let
her see the property. I let her have a tour. I let her ask as many questions
as she wanted. She was in a really good state of mind that day where she
was able to ask a lot of questions, how was the food and how many people
live in a room and etc., etc., and she asked all the questions that she felt
she needed to, and she said that she liked it. I said, “Well, you’ll be moving
This member was clearly experiencing profound functional difficulties and in
Belinda’s story we get a sense of this member’s need for safety and protection. It
could be argued that Vanguard would have been derelict in its duty if they had not
initiated the actions they took. I explored with Belinda how she coped with taking
these steps in light of Vanguard’s person-centered philosophy. Her sense was that
in some way the philosophy had been honored.
Deborah: This idea of promoting self-determination, is such a high value…how do
you make sense and deal with that as being sort of not consistent in some ways
with the philosophy of the program?
Belinda: Well, in a sense, we still stuck to the philosophy, because I still,
like I said, I introduced the idea to her early on a couple of months before
we did it, and we had numerous conversations about it, and allowed her to
voice her opinion of not wanting to move, and I respected her decision of
not wanting to move for those months, but in those months we saw the
signs of the continuing pattern of deterioration, the continuing pattern of
just, you know, just her level of being able to care for herself just going
down. And I was able to say, “[Member], this is why.” Whenever I would
have to come and do things for her I’d say, “[Member], we’re going to the
grocery store right now, and it’s difficult for you to be out long periods of
time walking. This is why you should live in a board and care. They make
the meals for you.” And I would introduce that to you to kind of get her to
understand. Like I said, after a while it was like okay, you’re moving now.
Like we’ve done enough of the introducing and talking and talking and
talking and talking and talking, now we’re going to put something to
action, and if we don’t do that soon, we don’t know what may happen.
You may walk out the door and, you know...
She went on to poignantly characterize the shift that had happened in in her work
with this member from supporting the member’s self-determination to making
decisions on her behalf.
Belinda: [Before], she was able to initiate the help. She was able to kind of
drive the car. Now she’s kind of, in a sense, being chauffeured in this
assistance that I’m providing for her. Meaning, that I make the decisions,
and I guide where things go.
Other health conditions may influence the team to override a member’s
choice when they determine that the safety risk is high. Belinda also reflected on
her team’s decision to intervene despite a member’s refusal to seek medical care.
Belinda: [She had] had cirrhosis…[her] liver was in horrible shape [and]…we
literally had to do an intervention of getting her to the hospital, because
we had talked and talked and talked and talked and talked and talked with
her, and it was not getting any better, and her stomach was out to here
with fluid on it and other stuff, because of the health issues, and she would
not go. She wanted to go, but she didn’t want to go, because she knew
what was happening already. She was like, “I don’t even want to know
how bad it is. I know it’s bad. So if I’m going to die, just let me die versus I
want to hear about me dying, and then still die.” She just didn’t want to
deal with it. We were like, but there’s a chance that you are going to live,
so let’s go to the doctor, that’s what they’re designed for, to help us take
care of this human thing that we’re in, you know, take care of our body.
Money management was another life domain in which assessed risk meant
that the practitioners might override a member’s self-determination. A common
source of income for many members is Social Security Disability Insurance (SSDI)
or Supplemental Security Income (SSI). One of the early efforts that practitioners
took on was to assist the member in securing a source of income, and that often
meant helping the member apply for SSDI/SSI. The Social Security Administration
(SSA) may require an SSDI/SSI beneficiary to have a payee if there is an
assessment of that the person will need assistance to make responsible decisions
regarding expenditures. As was noted in previously (see Chapter 4), the agency
often serves as the payee for members. To facilitate the management of the
member’s money each team has one staff member whose sole responsibility is to
work with members to manage their money.
Person’s serving as social security payees have specific obligations to
responsibly and ethically manage the person’s access to and utilization of their
social security funds. When the member is mandated to have a payee, every
effort is made by the team to work towards transitioning the management of the
member’s money from Vanguard to the member. However, there had also been
instances when the team had actively sought to have the member’s self-
management of funds revoked and to return fund management to Vanguard.
Deborah: With the money management, how do you decide whether or
not you’re going to do the money management or not, how did it happen?
Leighton: When I started working with Member, she was already on
money management, we were already her payee, so that decision was
probably made by a doctor, somebody somewhere…We’re her payee and
actually you know what, for awhile, she was her own payee when she got
that first apartment, so I think somewhere after that, she had become her
own payee and it didn’t work out, so we had to go back down and petition
again and become her payee.
Deborah: You guys petitioned for that?
Leighton: Yes, that was a letter from the doctor, so we don’t think she’s
capable of properly maintaining her own funds and these are the reasons
and they allowed us to become the payee again.
I went on to explore with Leighton how the decision to petition for payeeship had
Deborah: How did that happen, what was the process by which the
decision happened, was there a team discussion?
Leighton: It was a team decision, a team meeting, this is the situation with
Member, this is where we’re at, she’s been her payee, this isn’t working,
we need to be the payee, what can we do?
Deborah: And if someone didn’t agree with you, how does that get
resolved? Do you, as the PSC, if you feel strongly about something, do you
have to advocate within the team?
Leighton: The strength of the argument, we need to be her payee, these
are the reasons why, she’s homeless, she’s on the street, she gets her
money, does absolutely nothing with it. Concerned about her safety, you
walk around out there with that kind of money, there are people that take
advantage of you. Member, she’s a drinker, occasionally she will use
drugs, and she’s said a couple times that she wanted some crack, so I don’t
think that that’s a problem with her, but she will. So these are all the
things that you know that are happening if she’s got a pocket full of
money, she’s on the streets, so this is the situation.
Leighton’s own experiences of having been homeless provided him with some clarity
about why such an action was necessary for this member.
Leighton: She’s a single female, homeless, in the streets, it’s not safe. I
think with me, safety is always a determining factor, something that I
consider. ..I’ve been on streets, so I understand what it’s like to be out in
the streets, especially for a female because I’ve seen them out there, I
know some of the things that they go through, so that’s always a concern.
When reflecting on the member’s response to the team’s decision, Leighton made
a clear effort to persuade her of his view as a way to secure her acceptance of the
action that was being taken.
Leighton: Did she fuss and fight? Yes, but overall, though, she accepted it
and I think that was her knowing for right now, this is the best thing…[we
were] expressing to her the whole time, this is just a temporary thing,
you’re going to be your own payee again, we’re just trying to get you back,
get you stable, get some things straightened out, get you more aware of
what’s going on and able to manage your own fund.
Taking actions that did not support member self-determination seemed
reserved for situations in which the member’s safety was at risk. While Vanguard’
tolerance for risk seemed much higher than most agencies, there was a point that
they too engaged in practices that may not support a member’s choice. What
seems important also was that decisions to did not seem to rest with individual
practitioners, but were negotiated amongst the team. Deliberation and reflection
seemed to be critical practices to support such actions when they were taken.
This chapter addressed “meeting the member where they’re at” as one of
ways in which study participants named and framed what they experienced in
their work with members. “Meeting the member where they’re at” seemed
grounded in both the recovery oriented, person-centered philosophy of the
agency, and the very real and practical sense that unless you met the member
where they were at, you really couldn’t get anything done. Based on my analysis,
I found that what the study participants seemed to mean by “meeting the
member where they’re at” included starting and staying focused on the member’s
expressed preferences and needs, adjusting their actions within practitioner-
member visits themselves to meet members emotional and/or cognitive needs,
and matching their actions to the member’s readiness and/motivation for
particular activities or goals.
I also identified dilemmas that emerged including struggling with the
cyclical nature of some psychiatric disorders and the impact that that had on
“where a member was at”. In addition, I found that practitioners described
situations in which their experienced-based knowledge seemed to collide with
Vanguard’s person-centered philosophy. In these instances practitioners seemed
to emphasize the importance of having hope and believing in the possible.
Sometimes things went the other way as well, as practitioners took actions that
did not support member self-determination. Member safety seemed to be key
driving force when such actions were taken. In addition, it was evident that
decisions to override choice were seldom taken by an individual practitioner.
Rather, such decisions were deliberated amongst the team members often for
some time to make sure that every effort to support the member’s autonomy had
Chapter 6: The Practitioner’s Reasoning: What’s the Rehab Value?
“Do they really need me?” (Karen)
“There’s got to be a purpose” (Casey)
In this chapter, the practitioner’s reasoning will be framed around the
query “what’s the rehab value?” This was another way in which the practitioners
worked to make sense of when and what to do. My first introduction to this as an
explicit reasoning query came on the first day with the agency. I was talking with
the assistant director for the team that I was with and he was helping me to get
situated. During our conversation, he was reflecting on his own time as a personal
service coordinator. He recalled during his first year being asked repeatedly, by his
team director and assistant director, “why did you do that?”, “what’s the rehab
value?” as a way to help him develop his reasoning for this work. I came to
understand that this was a common query posed to and by the practitioners as
they both learned the work and as they engaged in the work overtime.
Sandy and Anne both clarified that for them the “rehab value” is inherent
in the purpose or point of their interaction with the member. Sandy reflected that
“rehab value is pretty much what is the purpose for our interaction with this
member, how is this going to benefit them in reaching their goals?” and Anne
noted that “rehab value is more like, in my eyes, what’s the point? What is he
getting out of this if he goes with me as opposed to somebody else, like a friend?
There’s no point.” Practitioners of course want and are expected to make a
difference in the lives of the members with whom they are working. The query
“what’s the rehab value?” helps them to frame how their actions matter in
particular ways, specifically to have some purpose or point related to the
member’s needs or to benefit the member.
Clearly a major influence on this reasoning query is the obligation that
these practitioners have “to chart on everything that we do with members, that’s
what we’ve got to chart on is why are you with them” (Sandy). Like all healthcare
providers, these practitioners must document the services they provide in order
for the agency to get access to the funding (i.e., primarily Medicaid and MHSA)
that keeps it in operation. Vanguard found itself in a new documentation
environment in the early 2000’s, when it transitioned from specialized state
funding to Medicaid and MHSA funding. In addition, the federal level Deficit
Reduction Act of 2005
also increased the scrutiny of Medicaid-funded agencies.
The DRA has impacted the community mental health/behavioral health practice
field given that most of these services in the US are funded by Medicaid. Further,
efforts to reduce fraud, waste and abuse are also a key part of the federal
Accountable Care Act. As a result of these changes and initiatives, this agency has
been engaged in intensive efforts to insure that its providers are properly
The Deficit Reduction Act of 2005 (DRA) was signed into law on February 8, 2006 . This
legislation affects many aspects of domestic entitlement programs, including both Medicare and
Medicaid. Additional information on the specific provisions included in the DRA can be accessed
through the menu on the left. Source: https://www.cms.gov/deficitreductionact.Retrieved on
October 31, 2011.
documenting services. They have conducted in-service trainings, and also each
team as a staff person who’s sole purpose is to review the notes to insure that
they met MediCal documentation criteria.
I would argue that the on-going obligation to document why they are with
a member keeps practitioners tuned into the “what’s the rehab value” query. It
could be that the documentation process itself, like team meetings (see Chapter
4), may afford practitioner’s the time for “reflection-on-action” (Schon, 1983).
The process then of completing daily documentation that meets the rules may
actually act as a cognitive support for the practitioners “knowing-in-action”
(Schon, 1983) that emerges while in the midst of their work with individual
members. However, there’s more going on here than just protecting funding, I
found that the practitioners also framed “rehab value” as a way to (1) create
experiences of meaning for members, (2) facilitate opportunities for the member’s
“learning”, and (3) support the member’s efforts at “doing it on their own”. The
distinctions and/or boundaries between each of these frames were not exact, but
did provide me with multiple ways of understanding the providers reasoning
about their work and its “rehab value.“
Creating Experiences of Meaning
One way in which the practitioners infused the practitioner-member visit
with “rehab value” was by creating experiences of meaning for the members. I
had a real sense of this when Ida was reflecting on a recent interaction she had
had with a member that resulted in plans to “make a day of it” trying on wedding
dresses. The exchange below occurred during the long interview, when I explored
with the practitioners how they had come to know what to do as a PSC. Ida had
worked with the agency for several years and had had actually worked with the
same team members for some time. In her reflection Ida was emphasizing the
importance of “listening” and told this story as a way to explain what she meant.
What she seemed to be “listening” for was an opportunity to create an experience
Deborah: It’s been a long time, eleven years is a long time, can you recall
what was the first year like, what were the things, or maybe even over the
years, what are the things since you started, have been the learning
moments, or the experiences that have shaped how you think about the
work and how you know what to do and when to do it?
Ida: Yeah, but it’s basically just listening, it’s really just listening and picking
up on what they’re really trying to get across to you. Yeah, basically just
really listening and then repeating what they’re saying, maybe in a
different way in how you understand it and if it’s wrong, then they’ll
correct you and they’ll be more specific on what they want. So it’s really
just listening, a lot of motivational interviewing type of thing. Let me ask
you a few more questions and see if I got this right. Is this your goal here
we’re trying to work on? Yeah, this is exactly what I want. For example,
just recently I got a call from somebody, she was very sad because she’s
been in three marriages, they haven’t worked out and she was telling me
how she never got to try on wedding dresses and how to her that signified
being a part of the marriage, type of thing or beginning the marriage.
Deborah: It’s a part of the experience.
Ida: Yeah, and she didn’t feel she experienced anything, just the marriage
itself, not the pre and of course the after because there was divorce, but
she didn’t experience that. And I said so you’re telling me that you would
like to experience trying on dresses? She said yeah. I said well call [a
bridal shop], here’s the number, call them, set up an appointment, we’ll
go. She goes, but I’m not getting married. I said why not, experience it,
you’ve done it already, the marriage, what about experiencing it the other
way around. She was so excited about just—even though she knows she’s
not getting married, but trying on the dresses because that’s how she felt
she left out of the experience, was the dress trying on. So now we’re going
to schedule, she’s called, she’s scheduled, they asked her for wedding day
and I said pick one, in the summer sometime. She said August 5
. I said all
right, there you go, getting married August 5
. So we’re going to go next
week and she’s going to try on those dresses. Do you know how excited
Deborah: I can imagine.
Ida: Just so excited, so excited. I said why don’t we do the whole
experience, I said why don’t we get something to eat first, talk about what
kind of dresses you’re going to be trying on, what colors, what do you
want, what kind of veil. She goes veil, too? I said and shoes, try it on, the
full thing, why not? She couldn’t believe it and I think she told a few of her
friends and her friends are like oh, we want to go. I said see, you and I can
do it together and then next time go somewhere else and try on dresses,
why not, it could be some fun.
There is a sense in this story that Ida is not just trying to create an
opportunity for the member to do something she has never done before or to just
lift the member’s mood for that moment. Rather, she is trying to create an
experience that may do some reparative work, and hopefully have some
protective benefit as well. The experience may strengthen the members’ sense of
self, and her sense of identity as a woman, which may protect her from or lessen
her sadness when she remembers or reflects on her past experiences. The
practitioner’s suggestion and planning to do “the whole experience” is important
because it captures the practitioner’s thinking about what an experience ought to
Dewey’s notion of aesthetic experience comes to mind when making sense of
the kind of experience that the practitioner is trying to create. Such an experience
is infused with knowing from past experiences and future possibilities. It is an
active experience in which means and ends cohere in a personally meaningful and
unique way. Dewey (1934/1980) notes that when we remember such an
experience we would likely declare “that was an experience” (p. 36). Dewey
argued that there is a basic rhythm to an aesthetic experience which Mathur
(1966) described as consisting of
[the] immediate qualitative experience of “doing and undergoing” in
specific situations, giving rise to
reflective experience in which the organism not only “has” the experience
but understands its meaning, or perceives the relation between its “doing”
and “undergoing,” and as a result,
the final phase of experience, which incorporates the significance and
meaning of the reflective phase and is thereby rendered more rich and
deepened in its immediacy (p. 226).
Sharon too reflected on her effort to create an experience for a member
that she had worked with over a long period of time. The visit that I observed was
occurring because the member was transitioning from the team that Sharon was
on to another team. The transition was happening because the team felt that this
member had reached a level of functional success and independence that no
longer required the level of support that the FSP provide. Sharon acknowledged
how close she felt to this particular member. She had worked with him for a long
time, and had taken some practice risks with him, including taking him to her own
family’s Fourth of July celebration at her mothers.
During the interview, she had been reflecting whether the member felt
that he was ready to move to the new team. She embedded her reflections about
his readiness within her own readiness as well “So I think it’s probably a good, with
him I’m probably closer to him than any other members that I know. He has been to my
family’s house”. I explored that with her further.
Deborah: Tell me about that. How did you make that decision to do that?
That’s not a typical kind of interaction that would happen in most settings
and it’s one of the things that does happen here, that can happen here.
How did you decide to do that?
Sharon: With him I decided because he was just home a lot. He had talked
about his family with me. He had told me that he hadn't seen his family in
over seven years. He told me a little bit about his mom and his dad. He
was having a lot of resistance about really contacting his family or being
around his family again. So I thought if I brought him to my family and just
let him know that hey, not every family’s perfect. I got kids screaming and
yelling and my mom’s like get over here; that he would just see like back in
that family element again. And so that’s the decision I made to bring him
over to my house… And my mom and everybody knew that he was a
member that I was working with and it was for Fourth of July so he got to
eat and watch the fireworks and then I drove him back home. Just to have
him be around kids and to be around family. Then later is when he ran
into his sister. So now he’s being connected with his sister again. So my
attempt was if I put him in a situation where he sees me and my family
interacting, and we were just being ourselves, then maybe he might be
motivated and inspired to want that or miss that in his family.
Her intent was to create an experience that transformed the member’s
thoughts about where he stood in relation to his family. Her hope was that it
would move the member to connect with his family, or at least be more
responsive to his family’s attempts at making connections with him. Sharon went
on to reflect that “he is closer to his family than before.” The member had run into
his sister at some point after spending the holiday with the practitioner’s family
and did reconnect with them.
Sharon’s decision to take the member to her own family’s home also
represented an example of how this agency’s philosophy can result in practices
that differ considerably from most community mental health settings (see Chapter
4). Few settings would endorse such an action on the part of their practitioners,
and would draw on ethical perspectives about professional boundaries as frames
to prevent it. Consistent with a do “whatever it takes” philosophy, this agency
had very few rules about what practitioners should not do. As Connie put it, “they
tell you the things you cannot do and pretty much anything that’s outside of those
things, you’re pretty much allowed to”. Practitioners were clear on the ‘three
things that you can’t do’—
Deborah: One of the things that I’ve also been trying to understand… is this
kind of do-whatever-it-takes kind of view, so how do you know when—I
don’t know when not to do whatever it takes? Are there any lines in the
sand that get drawn and then how do you manage those when you
Connie: You can’t lend money to a member your own money, you can’t do
that. Then, I mean have sex with a member or do drugs with a member,
those are really the only real solid lines that can be crossed. I think it just
depends on the person and also what you’re comfortable with yourself.
Connie made evident the reasoning work that such breadth in possibilities
for action demands. The practitioner must decide for themselves, within their
community of practice (Lave & Wenger, 1991) (See Chapter 7), if this is an action
that they will take. They have Vanguard’s guiding principles, as well as their own
practice experience and the experience of other practitioners to draw on to make
those decisions. Connie situated the practitioner’s reasoning within their own
self-awareness of what makes sense for them as an individual.
Patrick identified this as Vanguard’s way, when during the long interview
he was comparing Vanguard to other settings and reflected that “there are some
things where you’ll get in a little hot water, where here it’s pretty hard to get in
too much trouble.” I explored that further.
Deborah: Can you say more about that, when you say it’s kind of hard to
get into hot water, just say why is that, what do you think is the…?
Patrick: There aren’t a whole lot of rules that say you can’t do this, you
can’t do that. You may get questioned if you go do something that you
can’t really justify, but as long as you can justify how this had any value,
such as going to a concert, you know, after hours with a member. A lot of
agencies would say that’s a definite no-no, there’s people that have been
over to my place and I’ll say I’m not going to take everybody over to my
place, especially because I’m way out of the way, but it’s just not a whole
lot of…I mean, you can really do what you want to do and I think there’s
not so much worry about liability or what’s going to happen if people do
Deborah: Why do you think that is, why is it that at the Agency the worry is
different, that they’re not worried about those kinds of things?
Patrick: I wouldn’t say that they aren’t worried, I just say they realize that
there’s a value of not having so many rules and boundaries and that the
mission and the vision is to get people into the community and develop
these meaningful roles, such a friendship and stuff like that. And I think
that having this structure allows us to really work with people and what is
a friendship, what’s expected. You don’t really get to test those things
when you put up so many roadblocks that it’s like you can’t know anything
about me and all I know about you…you know.
Patrick emphasized again the importance of what having few rules does for the
possibilities of action afforded by such a perspective on practice. On his view, it’s what
lets the practitioners “really work with people”, suggesting that without such breadth the
quality of the relationships between practitioner and member might be less likely to
facilitate recovery. As I thought about the do “whatever it takes philosophy”, the
practitioners understandings of the ‘three no’s’, and the reasoning obligation that this
places on practitioners about how do they know when they’ve gone too far. Like Connie
he situated this process within the practitioner’s comfort level.
Deborah: Given that openness, I guess, how do you know if you’ve gone
too far or not far enough?
Patrick: [LAUGHS] I don’t think there’s a ‘you haven’t gone far enough,’ I
think that’s more of a personal call. I wouldn’t expect somebody to go do
something that they’re uncomfortable with because somebody says this
might have some recovery value to it, if you’re not comfortable.
Sharon, who took the member to her mother’s home, had become aware
that such an action was possible when she observed it being done by other
Deborah: Was that something that just you and he negotiated or did you
have to bring that to the team? What is the process by which a PSC would
take that kind of action?
Sharon: I actually saw it happening with other people. I was invited to
Thanksgiving with one of the other staff that had their father there and
some relatives and all these members and my boss and everything and I
saw how cool that was, and how they really put that together. So that’s
where I started getting the ideas of possibly bringing him to my family.
Further, she went on to acknowledge her sense of comfort with this particular
member and her sense that such an action had low risk given the quality of their
relationship. She makes it clear that her decision is individualized to the member
as well, and this is not something that she would do with all members.
Sharon: He’s always been the member that I've managed to take a risk
with more than anybody...I think also I had a lot of trust. I trusted him
because I've known him for a long time. I trusted him. I already built a
relationship with him and I also knew that what he was seeking maybe I
could help with.
As she reflected on taking him to her family and other actions that she had taken,
she frames her willingness to take this risk as moral obligation. Her sense is that
since she expects him to take ‘risks’ to get more engaged, she should take risks as
Sharon: I think it just came from my own desire to be true to what I
practice. Practice what I preach. If I’m willing to tell the member these are
the things that I do in the community, and to accept them as just like
anybody else without the mental illness, am I willing to take them into my
Creating experiences of meaning served as one way that practitioners
sought to infuse practitioner member-visits with “rehab value”. It seemed that
practitioners intentions in creating such experiences were to provide
transformative or reparative opportunities for members consistent with the
recovery perspective (Davidson et al., 2009). Creating such experiences meant
that practitioners might engage in actions that in some settings would be seen as
problematic, i.e., taking a member to your home, but at Vanguard practitioners
understanding was that this was expected. Practitioners acknowledged that this
meant personally reflecting on what one was comfortable doing.
Facilitating Opportunities for “Learning”
Another way that the practitioner’s infused “rehab value” into their work
with members was to facilitate opportunities for “learning”. An important
foundation for this aspect of their reasoning is Vanguard’s principles, as well as
the practitioner’s own beliefs, that learning and growth are possible for persons
labeled with psychiatric disabilities. As Ida, a long time staff member, emphasized,
“I always imagine everybody moving forward.” A clear influence on this was the
psychosocial rehabilitation (PSR) approach adopted by this agency (see Chapter 4.
This perspective has an “emphasis on facilitating social learning and behavioral
change through experiential activities”(p.202), with a particular focus on “the
practical, realistic elements of an individual’s adjustment” to daily life (Rutman,
1987, p. 201).
Experiential learning is considered a key element of psychiatric
rehabilitation practices, but it is important to note that this agency had few of
what have been described as systematic skills training approaches of psychiatric
rehabilitation (Anthony & Liberman, 1986). These specifically include facility-
based, group delivered skills training in life skills. Rather this agency was
influenced by what is referred to as the ‘clubhouse’ model of psychosocial or
psychiatric rehabilitation (Beard et al., 1982). This is an approach that takes
advantage of the naturally occurring experiences that emerge as an individual
engages in everyday tasks and routines as opportunities for learning. Systematic
skills training approaches do include individually tailored in-vivo learning
experiences, but these come sequentially after the facility-based, group delivered
skills intervention (Liberman, Glynn, Blair, Ross, & Marder, 2002).
Given the ‘clubhouse model’ approach, Vanguard’s practitioners must be
somewhat opportunistic and take advantage of experiences as they arise in their
day to day interactions with members. They must also attend to the task and
environmental demands that may arise in the course of the member’s completing
their daily life tasks, and when possible to anticipate the nature of such demands.
Finally, they must build an understanding of what each member can and will do in
order to determine if ‘learning’ is needed. As was noted previously (see Chapter
6), these practitioners did not rely on formal or standardized assessment practices
to know what the member might need to learn. Rather, they relied on explicit
requests for learning that the members identified, as well as their naturalistic
observations, and those of other practitioners interacting with the member, to
build a sense of or a consensus about what the member’s learning needs were. As
Karen noted “it depends on how well I may know them” and “that’s why it’s good
that we have a team because there’s staff that maybe knows someone better”.
Knowledge and/or skill development as target for learning. One target for
learning identified by practitioners was when members requested or needed
explicit knowledge and/or skill development. Greg reflected on his work with a
member when that member had first moved into his own apartment. This was a
member that had been identified as having “high support” needs from the
beginning of his move into the apartment. The practitioner had understood this
from the beginning and utilized the guarantee that “high support” would be
provided when he advocated with the landlord to rent the apartment to this
Greg: And we helped him find this place, because I had a good relationship
with the manager and the property owner. They’re willing to give Member
a shot. And here’s another thing that the property owner appreciates. I
don’t try to blow smoke when I talk to him.
Deborah: Oh, right.
Greg: I said this guy is going to be challenging. This is going to be risky on
some level. It won’t be risky in terms of his rent payment. You’ll get your
rent, because where his pay that’s not going to be a problem. We will pay
you his rent every month. What might be a problem will be his ability to
live independently in his own apartment. But we will provide high support,
and he asked me, what would that look like? I said, well, I will visit him
regularly. We’ll have a life coach
. I was able to ease his concerns and he
was willing to take [him] in.
Skills training was one element of the high support that was provided. Greg
described his work with this member facilitating his learning in one specific life
skill, grocery shopping. Prior to his move into the apartment, the member had
lived in residential settings in which either there was limited demand for this skill
(i.e. board and care where meals were provided) or he had had full-support from a
care giver to perform this skill.
Greg: The shopping, the food shopping, that I did with [him]. Initially, it
was doing a list together in the office. Keeping in mind how much he had
to spend. And then going with him, and one by one, getting each item on
the list, and just crossing it off as we got it. And as things came up that
weren’t on the list that he thought he wanted and had some value, we
would pick those items up also. Then it got to the point. It was okay, now
we’re going to look about budgeting, and making cost-effective decisions.
So if this bologna is two for three dollars, and this one is one for two
dollars, which should we get? Same weight.
Deborah: And you would intentionally do this with him in the store?
Greg: Yes. And then had him kind of think, okay, well, let’s see. I’ll get the
two dollar one. Well, wait. It’s the same weight, two dollars. Two for
Life coaches are other persons labeled with psychiatric disabilities, and most often are former
members, hired by the agency to provide specific types of support. The nature of the support is
negotiated between the member needing the support, the team and the person serving as the life
three dollars. So how much would one be? A dollar fifty. Oh, I should get
this one. And that was difficult at times, but he was beginning – oh, and
looking at dates too, with the milk, especially. So we’d get –
Deborah: so shopping could be a two hour deal?
Deborah: I mean, it could be long….
What Greg is giving us a sense of here is the time it can take to do this
work, and to do it in such a way that member’s benefit. Practitioners may not
always have the time, but the nature of the full-service partnership is to have
caseloads (i.e., member to practitioner ratio) low enough so that practitioners can
plan time for such interventions.
Greg: Yeah, and we didn’t always – you know, sometimes I would just give
him the information rather than have him try to figure it out. This is
cheaper and I’ve explained why to you. And he would get it, but
sometimes I would have him try to figure it out, depending upon the
Deborah: It’s like you have to kind of make a decision about how much
time you have.
Deborah: And what can you do?
Greg: Right. Like I said, sometimes when there was nothing else on the agenda, it
was the end of the day thing, or right after lunch, or just before lunch, whatever.
Depending on what the schedule looked like, I would let him figure it out.
Sometimes I would just tell him. And with the dates also. You know, I
have him look at the dates on the milk, especially milk because he buys
milk regularly. And to see that, you know, the later the date on the
Deborah: The longer it will last…
Greg: The longer it’s going to last, yeah. And he wasn’t getting that right
away. It finally clicked.
Greg also gives us a sense of how over time he used the real experience of
shopping for grocery items that the member needed and wanted to teach. As was
noted in the previous chapter Davidson and colleagues (2010) have drawn on a
perspective regarding Vygotsky’s ‘zone of proximal development’ that provide a
language for a supportive learning process known as scaffolding to describe what
the practitioner is doing. Davidson describes scaffolding as involving “non-
intrusive instruction and demonstrations of tasks within the person’s capacity, and
carrying out the remaining parts of the task him or herself” (Davidson, July 28,
2011, p. 30). The practitioners reasoning demand then is to determine what
support is needed and when to provide that support. What we also see here is
the time that providing such support can take, and the very real challenges to
being able to consistently provide that support as the practitioner engages in his
work. The practitioner acknowledges that at times, he “would just tell him”
because other demands on his time limited the time he had to spend with this
member during some of the visits.
Habit development as a target for learning. In addition, to instrumental
activities of daily living (ADLs)
like shopping, practitioners identified basic
activities of daily living like hygiene and other self-care practices as targets for
learning. When focused on basic ADLs, the practitioners seem to really be
focusing on habit formation. That is, facilitating the member’s consistent
engagement in specific skilled actions or behaviors when the situation demands
such actions or behaviors. Such disruptions in daily living have long been
identified as hallmarks for some psychiatric disorders, particularly schizophrenia
In recent research on performance-based measures of functional skills for
use in clinical treatment studies this has been referred to as the
“competence/performance distinction” (Bromley & Brekke, 2010, p. 3; Harvey,
Velligan, & Bellack, 2007). Drawing on perspectives from varied disciplines,
occupational scientists have also recently re-engaged in an exploration of habits as
a key area of study (Clark, Sanders, Carlson, Blanche, & Jackson, 2007). Sharon
reflected on her work with one member who was experiencing profound habit
disruption. I had asked her about a member that she had worked with that she felt
had been her biggest success.
Health care practitioners distinguish between instrumental activities of daily living
(IADL) and basic activities of daily living (BADL). IADLs are refer to the complex skills
needed to successfully live independently, while BADLS or just ADLS refer to self-care
Deborah: A member that you worked with that you felt had considerable
success in their recovery that—and you were with them as they took that
Sharon: Oh, [he] is one of my biggest. He’s still a member. He’s on the [a
less intensive services team] and we’re talking a guy that had—he was a
homeless person, mentally ill, no drugs, maybe in the 60’s that led to his
mental illness but no drugs and he just was a street bum. Just poo poo in
his pockets, just not talking and, but a brilliant piano player. He played
Chopin and everything and I had to work hard with him. I had to throw in
those mommy nurturing skills. He has a problem with his mother for some
reason and dad was never around. So, he’s lacking a lot of basic nurturing
skills. So when we go to the deli he’s like eating like this with the poop on
him. I’m like, no, grabbed the fork and I’d say use the fork, you know what
I mean, and like really working with him and I had to literally—he wouldn’t
shower or bathe, and I had to go turn on the shower. I’d go, get in there,
get in there, you have to get in there, you have to take a shower, you have
to trust me on this, just trust me. I’m going to be outside right here. I’m
going to be over here when you’re done. You come out, dressed, and I
will—and uncomfortable things. I had to go through so many
uncomfortable things but I had to do it because he wasn’t going to shower,
he wasn’t going to get anywhere, you know what I mean? So, I had to put
Sharon makes it clear that the member had the competence—“he could do
it”—, but without her prompting he would not or not regularly ‘perform’ the
showering routine. This is a distinction that is often made between the need for
skills training and habit formation.
Deborah: And he was able to—he had the skills to do it. He just—he wasn’t—
Sharon: He could do it but I was like—I had to make sure, I said there is soap in
there. I had pointed everything to him. There’s your soap, there’s your razor and
there’s your hair stuff, you need to do that and I want you to use all those
products when you come out, okay. I’m going to be over here but you need to be
dressed, please. Don’t make me feel uncomfortable here or I’m going to leave.
You need to be dressed and come out, so he would. And I had to do this for a
The members behavior did change and he now maintains his own apartment,
works one hour per day in Vanguard’s café’, and manages his own money. Sharon
recalled with delight and pride the time that he told her “you know what, you’re
quite bossy”, because she “knew he was getting better”.
Self-awareness as a target for learning. Another target of ‘learning’ that
the study participants identified was a member’s self-awareness. Vanguard’s
guiding principle that “a solid foundation for recovery is built by helping people to
honestly and responsibly deal with their mental illness, substance abuse and
emotional difficulties” (Vanguard’s Guiding Principles, January 6, 2010) seems to
inform this perspective. During my research, I found that this target of learning
seemed more often to be identified by the practitioner, than by the member. This
of course makes sense, because if the member was already self-aware then they
wouldn’t have anything to ‘learn’. The guiding principle as it is framed seems
consistent with views that both substance abuse and/or mental health recovery
hinges on self-awareness. In the substance abuse recovery context this is most
evident in the widely held belief that a person may have to ‘hit rock bottom’
before they are ready to change. In the mental health recovery context one view
asserts that lack of insight (i.e., anosognosia) regarding the illness is a core
component of psychiatric disorders, in particular schizophrenia (Amador, 2000).
This view of lack of insight has been contested, and the experience of self-
awareness redefined as one involving the person coming to see themselves as
having an “active sense of self” (Davidson & Strauss, 1997).
Greg draws on a specific evidence-based intervention known as
motivational interviewing to facilitate the member’s learning or increased self-
awareness. Motivational interviewing is a counseling technique and has been
identified as an important skill set for practitioners in community mental health
settings. In addition, it has been identified as well as a valuable tool in facilitating
behavioral change (Corrigan, McCracken, & Holmes, 2001; Miller & Rollnick,
1991), particularly in facilitating increased insight and treatment adherence (Rusch
& Patrick, 2002). This method has been incorporated into various interventions
targeting persons labeled with psychiatric disabilities, e.g., an illness management
and recovery intervention (SAMHSA, 2008b) and a time-use intervention for
persons labeled with psychiatric disabilities (Krupa et al., 2010).
Greg: And that’s another piece that’s a big piece with [him]. [Vanguard]
does not insist on medications for people who don’t want to take
Greg: Don’t insist on medications as a prerequisite for employment or
housing, whatever. It’s not a big part of the [Vanguard] philosophy.
However, there are some members that we work with that it’s become
real apparent that when they take medications, they do a lot better. With
those people, we do push the medications. And one thing I’m so pleased
with [him], and working with [him], is that I’ve pushed that from day one.
And the way I’ve done that is through motivational interviewing because
when he’s on his meds, he does a lot better. He’s clearer. He’s like you
saw him today. The conversation we had at his apartment today, [he’s]
not able to engage at that level if he’s not taking meds. He’s not that clear.
He’s not that focused. So from day one, it was like, okay, you seem to be
doing real good. You dress nice, and you’re keeping eye contact and we’re
having this – you know? And everyone else has told me, and they told you,
that they see a different person. What’s going on? And he said, well, you
know, I took a shower today. I said, yeah, that probably helped. And how
were you able to take a shower? And eventually he gets it. He goes, well,
I’m going with my meds every day. Bingo. And now he can connect the
dots so much quicker. And now I’ll come in some days, and his little med
sheet, because he’s on med management, he goes to the med room, gets
the medication, gets the confirmation card. He comes and puts it on my
desk automatically, even when I’m not there.
Medication compliance is a contested area of behavioral change for
persons labeled with psychiatric disorders being served by assertive community
treatment (ACT) teams (Horgan, 2007). Critics of the ACT model have argued that
it overemphasizes medication management and engages in coercive tactics to
insure medication compliance (Gomory, 2005; Spindel & Nugent, 2000). Angell,
Mahoney & Martinez (2006) identified the use of mandated commitment options
(i.e., involuntary admissions), persuasion, confrontation, use of reinforcements,
and the selective use of natural consequences as strategies used by ACT workers
to promote treatment adherence. Floersch (2002) also found strengths-based case
managers utilized natural consequences, as did the participants of the study
summarized here and this will be taken up later in this chapter. Further, Angell,
Mahoney & Martinez concluded that the ACT practitioners situated their use of
these strategies within a “clinical lens; that is they view it as a sign of the client’s
psychiatric symptoms, lack of insight into illness, or addiction to drugs” (p. 514).
The participants of this study were not working in a full-fidelity ACT team,
however California’s FSP approach is informed by the ACT model ("Adult Full
Service Partnership Toolkit," 2011). In addition, Vanguard had been somewhat
influenced by the ACT program when it was founded (Erickson & Straceski, 2004)
and its practitioners do enact practices that define the ACT model, i.e., assertive
outreach. Vanguard’s commitment to the psychosocial rehabilitation philosophy
may mediate the practitioner’s framing the members need for learning about
medications as a facilitator of ‘function’, rather than within a clinical lens. Greg
drew on his direct observations of the member’s functional differences when
taking his medication, and engaged the member in self-reflections of those
The framing of “learning” as involving increased self-awareness was also
evident in the practitioner’s efforts to help member’s reduce and/or avoid
engagement in risk behaviors, in particular substance abuse. Substance use
disorders are often co-occurring with other psychiatric disorders, and the impact
of substance use has been identified as a target of interventions particularly for
community-dwelling persons labeled with psychiatric disorders (Drake, Mueser,
Brunette, & McHugo, 2004). Behaviors and situations related to substance use
often impacted member’s housing success, and helping members to secure and
maintain housing was a key focus of the supports and services provided by the
agency’s practitioners. The agency practices a “housing first” (Tsemberis, Gulcur,
& Nakae, 2004) approach for their members labeled with co-occurring mental
illness and substance abuse. This is a model that does not require sobriety to be
established before the member is assisted in securing housing. Rather, this
approach operates from a “harm reduction”(Marlatt, 1996) perspective that
“recognizes abstinence as an ideal outcome but accepts alternatives that reduce
harm” (p. 786) and “promotes low-threshold access to services as an alternative
to traditional high-threshold approaches” (p. 787).
Leighton reflected on his thinking during his visit with a member who had
just moved into her new apartment. Some years ago, she had lost her apartment,
and more recently, she had been homeless and spent some time in jail related to
her excessive use of alcohol.
Deborah: Any other things that came to mind when you were spending time with
her on Monday?
Leighton: Actually, just trying to get a sense of where she was.
Deborah: Is that something, anytime you’re seeing someone, that you are doing,
it’s not really a formal assessment, but you’re thinking…?
Leighton: With [her] I’m looking for signs that she, heaven forbid but
where she may start to decompensate or go back into the older behaviors.
Yeah, a lot of it from her past behaviors, look and see where she’s at now
as compared to then, if she’s still in a good spot, if there’s anything I can do
to help, if I saw it coming, what can I do to help. Always looking for
positive, I guess it’s a combination of both. Be familiar with the risks,
you’re always looking to see and she likes to drink, so I go in and see the
bottles sitting around and she’ll get to smiling and okay…are you okay, but
she still seems to be functioning well and dealing with that. Then always
looking for positive behaviors because, for instance, she understands that
her drinking was part of the reason for her losing her last place, so she
seems more aware of that and able to manage that just a little bit better
There is a sense that he is engaged in a sort of matching task, matching what he
sees now to what he has seen in the past. He clearly has a sense that some
“learning” has occurred with regards to the member’s awareness of the
connection between her drinking practices and keeping her housing. He is
actively scanning for risk indicators, but situates his understanding of those risks in
light of evidence that right now she is “functioning well” and that her
“understanding” and “being more aware” of the impact of her drinking on her
housing in the past may serve as a protective factor.
Supporting Efforts of the Member “Doing it on their own”
Another way in which the practitioners framed the “rehab value” of their
actions was the degree to which those actions supported the member’s
independence or their “doing it on their own”. Study participants marked times
when they observed or became aware of a member “doing it on their own” as an
indicator of forward movement. “Doing it on their own” is clear reference to one
of the stage’s of recovery—self-responsibility—that informs the work of this
agency and its practitioners. Vanguard’s guiding principle that states “people
thrive, grow and gain the courage to seek change in respectful environments that
promote self-responsibility” makes explicit the obligation that practitioners have
to support members efforts at “doing it on their own”.
Facilitating independence as a critical outcome of rehabilitation
interventions has been contested, partly because it over emphasizes
independence in relationship to interdependence (White, Simpson, Gonda,
Ravesloot, & Coble, 2010). Interdependence it is argued is a more real
representation of how most people make it in the world, they depend on others
to successfully engage in their daily routines. Critics of independence as a core
outcome of rehabilitation, further argue that when rehabilitation practitioners do
not attend to helping persons with disabilities build social capital, the “desired
outcome of full community participation” is less likely to be achieved (White et
al., 2010, p. 237).
Anne was reflecting on a member’s self-initiated action of getting involved
in recording his own music. He hadn’t sought any assistance from the practitioner
or other practitioners on the team for engagement in this occupation. This is a
member that loves music and the practitioners and the member often visited a
local music store, as well as regularly engaged in conversations around music.
During the visit that I observed, the practitioner asked him if he wanted to play his
CD. In her later reflections, she noted that he always carried the CD with him and
she wanted to support his engagement in this occupation. She situates her
reasoning about the stance of support, but no “involvement”, within her team
work, and their mutual understanding that they are “trying to increase his
Anne: He’s completely doing it on his own, that’s why I’m really, oh my
God! Because he usually just plays video games, so I’m proud that he’s
actually doing something and it’s something he loves. I think his goal was
to get a job, but I think part of it doesn’t seem like he wants to work, really.
Deborah: Conventional work.
Anne: Yeah, conventional work, yeah. I kind of just want him to do what
he loves to do because in the end, it’s going to give him more motivation
to do other stuff. That was his thing, because I had already heard the CD
before and he brought it, but I was so proud of him because he never does
anything like that. It’s a big accomplishment for him to hear himself on a
Deborah: How do you account for it happening, when you think about why
it happened and sort of your understanding of him, what comes to mind?
Anne: I know he had played the CD for [another PSC] before and she
mentioned it to me, so when he played it in my car, I was so proud because
I got to hear it, too, and I could tell he was proud of it. There are only two
songs on the CD, so the second one he was really proud of. So I don’t
really know how it came about, he kind of just brought it and I even knew
that he had a friend that he knew that does it, so I was just happy for him.
Deborah: Would you run with that in any way or is that something that you
decide to just listen for an provide support or would you take any action
Anne: It’s his friend, so he didn’t get it through us whatsoever, so I kind of
want that to be his thing to do on his own, because with him, we’re trying
to increase his independence, so it’s a good thing for us to not get involved
in that, but I think he wants to bring it to us, at least to hear feedback on it,
because I think it’s important for him. So I think for our part, he just wants
feedback and give him more confidence to be able to do things on his own.
Anne also reflected on a recent interaction with this same member, in
which his “doing it on his own” happened because she had failed to keep an
appointment with him. She expressed deep regret for having missed the
appointment and acknowledged the member was quite upset with her for not
being there for him. The visit that had been planned was for the practitioner go to
court with the member. He was on probation, and up until the visit that the
practitioner missed, he had never been to court on his own.
Anne: That particular day I think I was running late and I missed it and so
he went on his own and he came back and he was like, I went all by myself
because you weren’t there. I was like, at least you went. So now when I
said to him, you went on your own, now I know you can go on your own,
he was kind of upset with me, because he didn’t like that idea but I’m like,
you just showed to me that you can do it, so you don’t need us to go with
you. Because it’s in [town], he can take a bus and he’ll be fine, it’s just I
think the idea for him is having his independence or not having a PSC to go
with him is scary to him.
Although Anne acknowledged the serious error she made in not meeting
an agreement to be with the member for his court appearance, she situates her
reflective work, both for the member and for herself, within the “doing it on your
own” frame. Her understanding of his desire for support is not framed by
whether he can do it on his own, but within the members’ sense of confidence
about being able to do it on his own. Her reasoning that confidence for action is
what is involved, provides one way to account for the difference between a
person’s competence to do something and the actual likelihood that they will
enact the skill when needed (Bromley & Brekke, 2010; Harvey et al., 2007).
Building a member’s belief that they can indeed do something is clearly a critical
dimension of the work that the practitioners are engaged in, and is related directly
to the importance of hope in recovery. Davidson and Strauss’s (1997) perspective
on recovery as involving the development of a “functional sense of self”
emphasizes the importance of actually “putting the self into action” (p. 31). This
gives the person the evidence that he/she is capable of self-directed action. In
this instance, the practitioner took advantage of the serendipity of the member’s
“doing it on his own” when he had to, to further the team’s efforts at supporting
As was noted in the previous section, practitioners often assist members
with their medication practices. The medications that members take are not
always psychiatric medications, as many members have co-occurring medical
conditions. Concern regarding the health, not just mental health, of persons
labeled with psychiatric disabilities has strengthened over the last few years.
Research has shown, that the life expectancy for persons labeled with
schizophrenia is 20% shorter than the population at large, and that varied medical
conditions may emerge secondary to both psychiatric medications as well as life
style (Marder et al., 2004). As a result, community-based mental health
programs, particularly mental health services like the Full-Service Partnerships
implemented by this agency, include health and wellness as targets of
intervention (Sokal et al., 2004).
Sandy reflected on her work with a member, who was not currently taking
any psychiatric medication, but had finally been willing to go see a primary care
Sandy: She wasn’t even seeing a doctor when I first started, she still
doesn’t see the psychiatrist unless the psychiatrist goes out to assess her
once a year, but as far as her primary care physician, she was not seeing
anybody and refused, so that’s actually been a big step for her, is
consistently, every month, I take her to go see her physician.
As a result of her seeing the primary care physician, the member was now taking
medications to manage a chronic health condition, the practitioner reflected on
the members gradual movement towards “doing things on her own”.
Deborah: How did you come to decide to do the visit schedule that you
have now, how did that come to happen, that you thought that was the
best kind of plan?
Sandy: It happened when I first started taking her to the doctor. When it
was determined that she was going to need to take medications, I was
trying to figure out a way where I can assure she would take it. She
doesn’t come here so med management through our med room would not
be an option and when we first got her on medication, and I still do every
Monday go through her med tray with her so she can fill it and she’s been
starting to do that on her own more, which is good, because I’m trying to
get her to become more independent. I used to visit her every single day,
Monday through Friday, and even have co-workers who worked on the
weekends come by on Saturday and Sunday, now it’s just Monday,
Tuesday, Friday because she wanted to show that I think I’ll do okay on my
own. And for the most part she is okay, she misses a few here and there
but it doesn’t affect her a whole lot.
Deborah: When did the change happen, from the seven days to the three?
Sandy: I would say maybe about six to nine months ago.
Deborah: How did you decide to do that, at her request?
Sandy: I noticed that she was starting to take it on her own before I would
even come to visit, she’d be like oh, I took it already, I took it this morning,
and I was like okay, that’s great, I’m definitely not discouraging that. So
once I noticed she was taking more initiative I was like okay, how about we
move it to Monday, Tuesday, Friday
The initial level of support that Sandy provided was based on her
assessment of the realities of the member’s circumstances and level of
functioning. However, as she see’s shifts in self-initiation on the member’s part,
she adjusts her level of support in response. This reminds us of what was earlier
identified as “meeting the member where they are at”. Here the focus is providing
only the level of support that is needed and not more to be sure to give space for
the member’s self-initiation. She must listen well and be attentive to such changes
in the member’s level of self-initiation, as it acts as clear indicator of when to
change the level of support.
What we see here as well, is the active negotiation that the she engages in
with the member. She explicitly “names” the change both for herself and the
member, and actively collaborates with the member to make the change—“I was
like okay, how about we move it”. In initiating the collaboration Sandy seems to
be enacting Vanguard’s person-centered philosophy, and engaging in a practice
that has been identified as critical to facilitating recovery (Davidson & Strauss,
1997). The practitioner’s sense is that this particular member will always need
external supports. She experiences movement and/or change in some of the
member’s actions, but as of now is not confident that she will be able to fade
supports for certain life activities.
Deborah: How likely do you think it will be that some of these things will change
or is it your sense that there will be a need for reminders and support?
Sandy: I think she’ll need constant support, she’s a survivor, definitely, I
think if we weren’t here she wouldn’t be as healthy but I think she would
get by. She has a lot of people out there watching out for her and who
knows who she is, give her food, give her money when she needs it, but it’s
been a slow process. I feel like it’s going somewhere, I don’t feel like she’ll
ever be completely able to go to the doctor on her own, do things like that,
As practitioners begin to become aware that a member is “doing things on
their own” at a frequency and for a breadth of activities more than they were
previously, they begin to consider transition. Sandy, reflecting on her work with
another member, emphasizes the breadth of the member’s doing things on her
own. This is a member who since the practitioner began working with her is now
living in her own apartment, has expanded her social contacts including
reconnecting with her family, and is working with the agency employment team to
move from an agency employment position to community employment.
Deborah: And why did you decide to do that with her?
Sandy: She does most things on her own now. I’ve noticed she rarely asks
for help, she goes to the doctor and she became (inaudible)... last year, so
I’ve told her, why are you still with us? Why do you think you still need to
be on [this team]?
As was noted in Chapter 4, the agency has implemented a process that
they refer to as ‘flow’, as a way to influence practitioners thinking about a
member’s movement beyond the services and supports of the agency. The
perspective that a person in recovery can exit the mental health system has been
strongly influenced by recovery research conducted by persons in recovery
themselves. A staged model of recovery developed by persons in recovery
(Ridgeway, 2001; Ridgway, 1999) explicitly identified “reclaiming a life beyond the
system” as an important dimension of recovery.
Dilemmas Emergent “What’s the Rehab Value?”
As in “meeting the member where there at”, dilemmas also emerged in
the practitioners’ efforts to infuse “rehab value” into their practitioner-member
visits. The dilemmas that will be considered in this section are (1) the perceived
“rehab value” of providing or not providing financial and material resources at
particular points in time for particular members; (2) what to do when efforts at
facilitating a member’s “learning” appeared not be successful or did not appear to
be producing any “rehab value”; and (3) the practitioner’s efforts to make sense of
and respond when they found themselves “working harder than the member.”
Providing financial and/or material resources or not. That is, would
providing the financial or material resource create an experience of meaning,
facilitate learning and/or support a member’s efforts at doing things on their own.
During the engagement phase, practitioner’s often utilize Vanguard’s resources to
provide high levels of financial and material support. Member’s often entered
services with severely limited resources, providing resources at least until the
practitioner is successful in assisting the member to secure financial support (i.e.,
social security) is part of the work.
In the post engagement phase, members could also experience periods in
which they needed financial and material resources beyond what they personally
had available. This could occur both as a direct result of the member’s actions or
inactions, but could also be the result of external influences. When these
circumstances emerged, practitioners could access agency resources to meet the
member’s needs. There was a sense that there were risks in providing too much
support, including the potential for increasing the member’s dependency on the
agency and/or the member’s expectation that the support would always be
available were identified by the study participants as concerns.
For example, each practitioner had a modest budget that they could use
to buy member’s lunch or pay for activity participation during practitioner-
member visits. Early on in a relationship, practitioners often utilized these funds to
support their engagement efforts. Each practitioner has to build a set of practices
about how they as an individual practitioner will utilize their budgeted funds.
Davina reflects on how her practices changed with experience and guidance from
more experienced staff regarding how she used her budgeted funds.
Davina: In the past, people would come to me, when I first started,
people, oh, can I get five dollars? Sure, petty cash. Oh, can you get me a
duh-duh-duh? Sure. And it was always cash. And so [my former team
leader] said to me, you might want to take a better look at what that is.
I’m not saying don’t give them cash, but see what’s actually happening.
And they’d always come up with these excuses. They’d be logical. And I
don’t have any. Can you handle that? But can I get a few bucks to go get
the stuff? But when I had the stuff, and I was like, okay, hold on. Here you
go. Oh, I was hoping you’d give me the money. Oh, but this is what you
told me. Oh well, okay. And then I was like, I’ve been snowed. I’m really,
really, hungry. Literally, and that was like my holy crap. So now when
people say I’m hungry, I’m like, okay, let’s go downstairs and eat.
The practitioner represents her own learning here, and her perception that she
got better at managing her resources at the same time that she is trying to meet
the member’s needs. She appears to be both weighing the “rehab value” as well
as trying to “meet the member where they are at”. That is, she acknowledges the
members need for a particular resource and tries to meet that need, but not by
giving the member money. She also seems to frame the members’ behavior as
potentially manipulative, and the change in her resource support strategy appears
intended to protect her, Davina, from being “snowed” again.
Greg reflects on his learning around the same dilemma, and noted that it
too was driven by his own experiences with members and thoughtful guidance
received from a more experienced practitioner.
Greg: This guy was coming in, at the time we had deli script that we’d give
to members who were low-income or had no income to get food in the
deli, the same thing as money but they could only use it at the deli. This
guy was coming in every day asking for deli script, kind of hounding me and
initially it was like building a relationship, okay, go get some breakfast, let
me go with you and I’d go have breakfast with him. He’d come in the next
day, same thing, next day same thing and finally, I began to say no, we’re
going to have to monitor this a little bit more closely because I’m finding
that ninety percent of my deli scripts are going to you and I’ve got to have
them for everyone else. He’d okey-doke me and then come in the next
day and so I went and complained to [my team leader] I said [a member] is
coming in every day asking me for deli script and it’s becoming a problem, I
have none for anyone else.
Greg acknowledged the guidance that his then team leader provided and that he
enacted and found effective. He went on to reflect on his learning how to give
what he calls a “respectful no” to the immediate request, but a willingness to still
provide support to meet the members need.
Greg (continues): So she said, are you giving them to him every day? I said,
yeah. She said, why should he stop coming? It was an aha moment,
because maybe when you set a boundary and keep it, he’ll come less
frequently. So that was one that comes right to mind and the next day it
was like, I can’t do it today, she said do the broken record with him, if he
continues which she knew the guy, acknowledge what he’s saying and say,
I can’t do it and just broken record and watch what happens. And she was
so right on, I did that the next day and he persisted for awhile and then he
went away, he cursed me out but he went away.
Deborah: Did it have any lasting effect? Did you withholding that have any
lasting effect on the relationship?
Greg: No, in fact, that’s another thing I’ve learned, sometimes a respectful
no is better than a disrespectful yes. .. Because what I was doing with [him]
is I was giving him a disrespectful yes at one point it got to, okay, take
these and get out of here. Then it became, sorry, I can’t do it today. I hear
you, I hear you don’t have any food but I can’t do it today. I know it must
be awful, maybe I can give you some food bank referrals but I can’t do deli
script today. That was another powerful little trick I picked up down there.
Decisions about the “rehab value” of providing a member with resources
seem to rest on the practitioner or the team’s reasoning about whether the
members request was based on the member’s need versus want or desire. It was
my sense that the practitioners reasoned that meeting a member’s needs for a
particular type of resource at a particular point in time was different somehow
than meeting a members ‘wants’ or ‘desires’ for that same resource. In addition,
in the example above, we see the practitioner’s decision being influenced by his
efforts to equitably distribute his scare resources. For Karen, the “rehab value” of
providing supports seemed to make most sense when she perceived the member
to be engaged in their own recovery, as evidenced by efforts at self-initiation.
Deborah: So how far do you go?
Karen: I think it depends on the person. It depends on the person; it
depends on how well I may know them. And that’s why it’s good that we
have a team because there’s staff that maybe knows someone better or
maybe click with someone differently than I do or someone else does. And
I really think it’s individual. There are others that—not that you would try
harder, but that you would do so much more for because they would
benefit from it so much more—
Karen: Whereas others, that same amount of work, it wouldn’t be
beneficial to them. Whereas others, it would really make that difference
or that they would participate in their own recovery or participate in their
own life. And that’s different than someone who might just be existing—
Karen: In spite of all the staff’s efforts to—
Karen: Improve that or change that otherwise.
Deborah: Interesting. When you say that they would benefit, how do you
know when somebody’s benefiting? What are the indicators that they’re
benefiting from that support?
Karen: I think, for me, at the least the people that I’ve worked with, that
they become more proactive in their own life in whatever capacity that
might mean, whether it’s suddenly they don’t need me to go to the doctor
with them because they can advocate for themselves what’s going on
physically with them, or they don’t need me to help call their family
because they got on the Internet and looked up the phone numbers on
WhitePages.com themselves, which they had been asking me to do for a
while and I kept forgetting. But they did it their own.
Karen: So it’s little things like that that they’re starting to show more
Karen: It could be little, it could be big, but where they may not need—
they may like our support more. They may like our going with them to the
doctor or going with them to whatever, but they don’t need it and they are
capable of doing it on their own or on their own to an extent and maybe
just need a little push or a little extra help with this or that, so—
Decisions about when and how much to provide of the agency’s financial
and material resources seemed fraught with moral implications, and has been
identified in other studies of case management practices as challenging (Floersch,
2002). Patrick situates the dilemma within his questions about the agency’s
practice of providing financial supports, like giving loans.
Patrick: As far as helping out financially or with small stuff like rides or
something like that, it’s like what’s the point of this, is there some value as
far as relationship building at that point? I don’t know, anytime I give
them a loan, I always find myself in that situation and I hate doing loans
with people [here]. I don’t necessarily think that’s the business that we
should be in, yet I see some value to it.
Allen reflected on decisions that were made and actions that were taken to
withhold resources that a member who was a parent was relying on to meet the
needs of her children. Specifically, the team had been buying diapers. Over time
the practitioner came to understand that the member and her boyfriend had
sufficient resources to purchase the diapers. He determined that providing the
resources were no longer needed and withheld future assistance.
Allen: We were buying diapers like left and right and if it wasn’t me it was
another PSC that she would manipulate and there—it came to where I just
said I’m not going to buy diapers anteamymore. You’re going to have to
figure this one out. You and her boyfriend are going to have to figure
out—figure out—because it was coming to the first of the month and
usually what happens is her boyfriend gets his check first and he blows it.
On what, I don’t know. I mean, he doesn’t use drugs or anything. He
smokes a little pot but I don’t know what the hell he was using his money
on and I sort of used that window, again, because it was going to get to the
first of the month as, okay, the first of the month is coming. If you really
care about your kids maybe you would see that things get taken care of
and in the meantime, I’m not buying any diapers. So, for like two weeks, I
don’t know what they did for diapers but that following month they
actually came up with the money and bought diapers and food.
He communicated his expectation that the member and her boyfriend needed to
“figure it out”, and they did. The risk here of course is that they might not have
“figured it out”, and in addition, at least for two weeks the practitioner was not
sure how the member managed to meet the need for diapers. Allen, it seemed,
believed the risk was worth taking because he assessed that the member had both
the resources and the capacity to meet her needs without support from the
Deborah: How much support do you give and when do you stop the
support. And it sounds like you had—there was a decision point. There
was a point in which you said you’ve done too much.
Deborah: Is that what the sense was?
Deborah: Now, did you—but it sounds like you also believed that they
could handle it.
Allen: Yeah. I knew that they could handle it if they wanted to.
Deborah: Okay. And how did you know that? I mean, how did—
Allen: I just knew it because I know that her boyfriend gets a certain
amount of money.
Allen: And she gets a certain amount of money and the rent is at this
much and there’s just—it’s no way that they can’t provide for this one
child at that time.
Deborah: Got you. So, it was the resources. It was that you were
persuaded that they had the resources.
Deborah: They didn’t need the additional resources.
Allen: They didn’t. They had to go without for a couple of weeks because
they blew the money on something else.
Deborah: Got you.
Allen: But then from that point on, we haven’t had to buy diapers. So, it
kind of worked out.
The fact that children were involved intensified the moral dimensions of this
dilemma. Some team members felt strongly that the children should not suffer
because the parents were unable to manage their financial resources.
Deborah: And what—how—any, was there any sort of discussion amongst
the team about that; what if they’re not—
Allen: Yeah, there was a discussion that, well, what about the kids? Are
we going to punish the kids because, you know, these parents can’t get
their shit together.
Allen: And I was like, well, I felt like there was nothing else that we could
do. I mean, I knew they were capable of doing it but they just needed the
motivation. They just needed—we needed to stop taking care of these
kids, you know, and that came from everybody in the team.
Deborah: Got you.
Allen: And then I started to realize how long I’d been doing it, providing
the formula, providing the diapers, wondering why they can’t do it and it
was sort of just deciding when to stop, like you said, and so it did. It did—
it was—there was a big argument on the team about that—
Deborah: Oh, was there?
Allen: Yeah, there was. I mean, another PSC felt like we should continue,
you know, providing support for the kid no matter what.
Allen: And that kind of got me confused because it makes sense but it
doesn’t quite help [her], you know, become a parent. So, it was just a
matter of just doing it and seeing what happens.
He noted here that the there was a “big argument” amongst the team regarding
his decision. He acknowledged that the perspective of the other practitioner was
compelling, but believed the parent’s “needed to do it.” From his perspective, this
was particularly critical to the member’s full engagement in her role as a parent.
Floersch (2002) reviewed different perspectives on “separation or
integration of therapeutic intervention and money management” (p. 149) because
he too found that money complicated relationships between strengths-based case
managers and their clients. He argued that front-line practitioners need
theoretical frames for making sense of the psychological and social meanings
associated with money and commodities. He found that the guidance from the
strengths practice model, as well as the practitioner’s situated knowledge was
insufficient in assisting them to resolve the moral distress associated with such
decisions. For the participants of this study, most decisions to provide financial
support to a member were made within the team. Individual practitioners could
advocate for a particular direction, but a consensus decision making process
seemed to be in play for the most part. Team leaders, as more seasoned
practitioners and as the team member with administrative responsibility to
manage distribution of the team’s resources, most often facilitated the team’s
decision making and might set some minimum requirements that had to be met.
When efforts at facilitating a member’s “learning” appeared
unsuccessful. These dilemmas seemed to be particularly challenging when the
target of “learning” was the reduction or avoidance of engagement in risk
behaviors like alcohol or substance abuse. One way that practitioners made sense
of their actions when learning did not seem to be happening was to take a
standpoint that sometimes members had to experience the natural consequences
of their actions. That is, that the “rehab value” of not providing services and
supports was in the member’s experience of natural consequences. This seemed
to be situated within Vanguard’s ‘self-responsibility’ stage of recovery and the
guiding principle that states “people thrive, grow and gain the courage to seek
change in respectful environments that promote self-responsibility”. It also
resonated with Floersch’s (2002) understanding of how strengths-model case
managers utilized natural consequences as a frame for their work as well. He
argued the use of such a frame is consistent with a common sense perspective
about teaching life skills and that “deciding to allow a natural consequence to
unfold was about learning failure and gaining insight” (p. 191). In addition, Angell,
et al’s (2006) study of treatment adherence practices enacted by assertive
community treatment teams also noted the selective use of natural
Greg reflected on his work with a member who had received a series of
citations. The practitioner had agreed to go to court with the member to help him
deal with some of the citations, but he also made it clear that he would change
the nature of the support should the member get another citation.
Greg: That’s part of our job is to help [him] recognize. You know, your
behavior, good or bad, is going to have benefits or consequences. The
good behavior will have benefits, just like the whole thing with the
citations, you know? I’ve worked on that with him a lot because he came
in with like three in like a week and a half. And so now we have a date in
June to address one, a date in September to address another one. One is
so far down the road, I forget when it is. But I’ve told him. I’ve said and
we had the conversation today. I said one more citation and you’re on
your own. I said I’m going to support you with these that we have on the
table here. If it continues, you know, I will tell you where to go to make
the payment, or appear in court, but I’m not going with you. My support
ends with these there
Deborah: Now why that? Why? What-
Greg: The hope is that that will help him take more responsibility. You
know, why should I be responsible if someone else is going to clean up my
mess or help me clean up my mess? If I’ve got to do it on my own. And I
don’t even know if Member is capable of this kind of thinking, right?
Deborah: Yeah, I was just wondering –
Greg: The hope is that he is.
Deborah: Yeah. I mean, how would you know? How would you figure out if he
is? I guess, how do you discover if he’s able to make that?
Greg: Well, if avoids going to jail, that means he got it.
Greg has reasoned that providing the member full emotional and cognitive
support to deal with the three citations should provide a sufficient learning
experience. If not, he would reduce his level of support to providing information
only. During his reflection of this particular visit, Greg explicitly situated his
reasoning within Vanguard’s principles. He pulled out a copy of the principles that
he always carried with him and the recently updated principle that stated “people
thrive, grow, and gain the courage to see change in respectful environments that
promote self-responsibility”, but acknowledged that he liked the older version
better “allowing natural consequences to become opportunities through growth
Patrick reflected on his work with a member for whom he had repeatedly
been called upon to provide support during her episodes of drinking. These
episodes persisted despite the support that had been provided and the
practitioner often struggled with knowing what to do. He initially framed his
reasoning within the natural consequences for learning lens, but rejected that
view because he assessed the risk of taking that action was too high.
Patrick: there’s certain situations where I’ve not wanted to do stuff for her
but have found myself doing stuff for her, as far as moving sometimes,
where it’s like all right, do I let nature run its course, or do I step in and
basically try to figure something out. And I’ve done that quite a few times
where I’m like would it increase motivation if I just kind of went all right,
how are you going to figure out…
Deborah: Meaning she would do it on her own.
Patrick: Yeah, but I don’t know that that would lead to anything but
homelessness. I’ve jumped in a few times where I debate whether I should
Deborah: What is it about her, her situation, your understanding of her
that moves you in the direction of helping out?
Patrick: The couple times that she has gotten kicked out of a hotel and I’ve
had to move her, which it’s been three times.
Deborah: In a year?
Deborah: Yeah, two were within a week period, each time she’s not been
in a good place when it’s happened as far as she’s drinking a lot and my
worry is the combination of drinking and going to the street could be a
really bad consequence, as far as her long term health and safety, she is
taken advantage of a lot by people that she has met on the street that are
drinking, as well. That’s my concern and that’s why I have stepped in
several times, versus with some other people I would have said all right,
your behavior in doing this, this, this and this has led to this.
Patrick reframed the meaning of consequence. Using a risk management
perspective, he determined that the consequences of homelessness to the
member’s health and safety were greater than, the potential benefits for learning.
He makes evident what I would call an individualized risk/benefit analysis that he
engaged in to know when to provide support to avoid untoward consequences
and when to not provide support to facilitate learning. This type of analysis is not
explicit in Vanguard’s principles, and may represent reasoning work that the
principles can’t address. Practitioners may have to rely on other sources for this
type of reasoning work like a professional code of ethics. He acknowledged that
he “would probably do it again if she was in the same state”. He went on to clarify
that “If the issue came up and she wasn’t drinking, I might let it play out a little
more”. This continues to highlight the individualized and situated nature of his
reasoning. This assessment of risk as an influence on practitioner’s supportive
actions was also identified in the previous chapter about ‘meeting the member
where they’re at’.
Another way that practitioners framed their actions as having ‘rehab value’
when risk behaviors persisted and learning seemed to not be occurring, was to
draw on the harm reduction (Marlatt, 1996; Marlatt & Witkiewitz, 2010)
perspective identified previously. Casey draws on this perspective as she reflects
on her work with a member, who has not yet been able or ready to abandon his
Deborah: And, of course, the way you describe it is to standby. You may
or may not offer more support. How do you know when to stop, or do you
Casey: Right. I don’t know. I mean, I don’t think we ever... well, I mean, I
think in [his] case, I don’t think I ever stopped supporting... I did support
him, but I think when I knew that he was going to do this regardless, I
started supporting and really kind of focusing on the planning aspect in
keeping him safe as much as one can, and try to look at it at that, instead
of just fighting, this is a bad idea, you’re going to kill yourself, I mean,
there’s plenty of members that do a lot of things that are very high risk,
especially drug use, alcohol use.
Deborah: Sort of honoring that self-determination, people have a right to
Deborah: Right. And really looking at, okay, you know, I think then that
goes back to kind of the harm reduction, if you’re going to do this, how can
we keep you safe? How can we keep you safe as much as possible? This
happened with Member. I mean, he was hell bent, I’m going on a binge,
and he was going to do it. It was like okay, hard alcohol, bad news... any
alcohol is bad news for Member just health-wise. It’s just bad. It’s not
going to end good. But it was like okay, you’re going to do this. When
people have their mind set on something you know. You attempted
discussion after discussion of why this isn’t good, reflect on past history of
why these behaviors haven’t worked for you, and he was inebriated during
this conversation too. So really it’s like how much logic are you going to
get, so let’s start talking about is there safer ways we can do this. Can you
not buy the Jack Daniels and get some beer? Can you promise that you’re
going to stay inside and not walk outside in front of cars and drop your
wallet, and do all these other things that put you at risk.
Below, she acknowledges the inherent dilemma in having explicit conversations
about how to ‘drink safely’ with someone who is actively engaged in alcohol
abuse. This is part of the skill set that practitioners must develop in order to
effectively practice from a harm reduction perspective. As critics of the harm
reduction perspective have argued, she reflects on the line between harm
reduction and enabling (Marlatt & Witkiewitz, 2010).
Casey: It is an ongoing dilemma. You don’t want to enable. You know
what I mean? Being supportive of something there like, but I think I also
feel that there’s so many members that we do serve that never had any
support, and so they feel shame, they have judgment on themselves. Even
though they’re making bad decisions, no, we’re not going to support the
bad decision, but we’re still going to be there to say let’s look at this as a
learning opportunity, let’s weigh the pros and cons, and still be able to say
we’re still here for you, even though this didn’t work, and we’re not here
to judge why did you do that, what are you thinking, but more of if you’re
judging this as a bad choice and processing how whatever choices they
made work for them or didn’t work for them, there’s plenty opportunities
for learning too, that did work and we support that versus the, this didn’t
work, but we’re still here. We’re not going to leave, because you made a
The ‘rehab value’ then is in the support that she provides and the continued
opportunities for learning that will present themselves given that the member has
not yet abandoned the behavior. She acknowledges that she has learned that
sometimes she must “walk along side” and “watch people kind of go through
those consequences in life”.
When the practitioners finding themselves “working harder than the
member.” Study participants described this as an awareness that would emerge
slowly over the course of their work with a member. Practitioners would begin to
perceive an imbalance in their effort and/or investment in the member’s recovery
goals in comparison to the member’s investment. The perception of the
imbalance seemed to be drawn mostly from the member’s lack of follow through
on agreed actions or the lack of self-initiation. This would generally result in the
practitioner modifying the nature of the support, as it was perceived that there
was little or no “rehab value” in continuing doing what they were doing. Or
conversely, that the “rehab value” was in their reduction of the support.
Greg gave an example of when he found himself “more invested in the
member’s goals than they were”, emphasizing that “if you’re consistently working
harder than the member, you’re doing too much”. The member had been living in
his apartment for about a year. In the beginning Greg had assisted the member in
getting his electricity turned on. The member made contact with Greg to get
assistance because he had received a notice that his electricity would be turned
Greg: I’d find myself often times more invested in the member’s goals
than they were. If you’re consistently working harder than the member,
you’re doing too much. Boy, I had held on to that one.
Deborah: What would your hard work look like, in comparison?
Greg: I’ll give you a good example, so [a member] comes in the other day
this week and tells me his electricity in his apartment is going to be turned
off. I said, how did that happen, aren’t you paying your electric bills? He
goes, I don’t get electric bills. Well, let’s go look at your rental agreement,
so we look at the rental agreement and the landlord pays water only and I
clearly remember when you moved in there we helped get the electric
turned on in your name. So I check with [the financial planner] and
nothing in his budget is about electric bills, so there’s some lapse here. So
[the team’s financial planner] is going, let’s get the loan committee together, we’ll
figure out how much his bill is going to be, we’ll pay the bill, I said no we’re not
going to do that. I said to [him] why don’t you get your electric bills from
your mail? He says, I don’t have a mailbox key. I said you’ve been living in
this apartment for a year and you don’t have your mailbox key? He goes, I
lost it. I know him and this is where knowing him helps, his skills in this
area are really deficient. So I said, okay, let’s do this, this is the plan, I’m
going to call your apartment manager, we’ll make arrangements for you to
get your mailbox key, you’re going to go open your mailbox, you’re going
to take out the mail and everything that says Edison on it you’re going to
bring in. [I] called the apartment manager, made arrangements for him,
not for me to go get the key [he] will meet you at one o’clock at the apartment,
thank you for doing this, so we got [him] invested in it. So [he] came back an
hour-and-a-half later with a stack of Edison bills, twelve in all. So with
[him] present we called up Edison, found out just how much he owed and
what he needed to do to get his electricity turned back on.
He went on:
Greg: You know what’s amazing, too, is his bill was only like $98 or something. He
doesn’t use a whole lot of electricity, apparently. The key point here is instead of
me jumping through hoops and planning (inaudible)... committee, is he got
invested and so we made arrangements, we called up Edison, found out how
much the bill was, how he could pay the bill at his local place.
Greg draws on his experience with this member and begins by providing some
explicit support. The rationale for the support seemed to be that he had
determined that the member still has “skills learning” needs. He also designed the
member’s experience in such a way that he was expected to do some elements of
the task on his own. Part of the plan that he and the member had made included
the member meeting with the loan committee. The member’s follow through on
this part of the process was not the same as it had been with the other tasks he
had to complete.
Greg: Tomorrow I’m going to have the loan committee meeting at
10:30,we’ll more than likely approve the loan because it is kind of an
emergency. You need to be at the meeting at 10:30 and we’ll make
arrangements for you to go and pay the bill, we’re going to put the money
right on his account so he can get cash and go down here and pay the bills.
Ten-thirty, the loan committee was all set, and by 10:50, he hadn’t shown
up, we disbanded the loan committee meeting, he showed up at eleven. I
said, look, what’s your plan now, the loan committee has disbanded, how
are you going to pay your bill? He goes, oh, I’m sorry, I said yeah it’s okay
but you’re going to be in the dark for another day, can we do it
tomorrow—meaning today—I said, tomorrow I think everyone’s going on a
shopping trip. If you can find three other staff. So we worked out a plan, I
gave him two options, either today at eleven, no one was available or
Monday at ten, to get three people to sign on to meet with the loan
committee, so he went and got three people to sign up for Monday. But
working harder than the member, I am so in touch with that now and I
said, look, for me if my electricity was turned off and someone made a
plan to help me get it turned back on the next day, all I had to do was be
there, I don’t know, call me crazy but I would have been there. By hook or
by crook, I would have been there.
From his perspective, the perceived need and/or importance of having electricity
and the knowledge that a workable plan was in place should have been a
sufficient motivation to get the member to the meeting on time. Greg held this
view in spite of his “knowing” the member well and his assessment that there was
a continued need for skills learning.
What seems to be happening here is that the practitioner distinguishes
between his perception of the behavioral need for skills learning and the
psychological need to be “invested”, and acts differently as a result. My sense
was that for these practitioners when they were “working harder”, they did
understand the member’s lack of effort through a psychological lens, as opposed
to other possible explanations like an understanding of the impact of the
member’s psychiatric disorder. The self-responsibility stage of recovery and the
guiding principles that it informs seems to be foregrounded here. It wasn’t that
they didn’t at times draw on diagnostic reasoning to make sense of a member’s
level of engagement, because they did to some degree. But when they
“diagnosed” that they were “working harder than the member” that meant that
they had framed the member’s lack of effort from a psychological lens. And, when
that was the case it was an indicator to the practitioner that they needed to
withdraw or fade support until the member demonstrated behaviorally that they
Sharon identified an ongoing struggle in her work with one of her
members where it seemed that during the entire relationship she often found
herself “working harder than the member”. During the visit that I observed the
focus was on transitioning the member to a new team that provided less support.
This was understood to be a positive move and an indication that the member was
more engaged in “doing things on his own”. She reflected on changes she had
Sharon: Before he had the connection to the church, he really had nobody.
And he always had a particular friend for the whole time that I've known
him but now that he’s connected to the church I see more motivation in
him because he is getting out at least once or twice a week for
socialization. I do feel like he’s, you know caring for himself a lot more. So
he has found some meaning in his life. He’s got the dog, so he’s out now
walking the dog more and just getting out. So I do see motivation on that
She recalled her ongoing efforts to “motivate” him “come on, you gotta pay your
rent. You've got to go do that right now. It’s time. I’ll help you. I’ll do it for you.
Let’s go. Did you call your sister? Just constantly keeping him motivated.” She
acknowledged that there were “times when I've run into walls. And I've ran out of
ways to outreach him”, and wonders “how much I’m teaching him if I’m
constantly just like hey you need to turn in your gas bill.” She also struggles with
this in light of her learning that she is supposed to “hold the hope for them [the
members], keep them motivated.”
Sharon invoked the “working harder than the member” frame for her
understanding of what was happening overtime with this particular member. She
did draw on at least one other possible explanation that could account for lack of
effort, when she was able to see that he responded the same when he was
working with other PSCs. The other PSCs had expressed some frustration in their
work with this member as well, and she was able to get some sense that that was
“just how he is as a person.” In addition, the member acknowledged during the
visit that he was smoking cannabis daily. The practitioner did note this during our
interview as a concern, but did not connect it as a possible influence on the
member’s motivational state.
A useful framework for the practitioner’s reasoning about this dilemma is
the difference between a practitioner “doing for” and “doing with”. This is a
perspective that has gained purchase in the social work oriented case
management literature (Longhofer, Kubek, & Floersch, 2010), and is supported by
the recent arguments for drawing on Vygotsky’s zone of proximal development
and scaffolding to frame aspects of recovery oriented practice (Davidson, July 28,
2011; Davidson et al., 2010). On this view, “doing for” is considered a higher level
of support and understood as a legitimate stance, albeit more dependent, at
certain points in time or at certain stages of recovery. “Doing with” is understood
to be a desired transition state on the way from a practitioner “doing for” and
toward the person “doing it on their own”. For example, higher levels of support
may be provided when a member is embarking on a new experience, like getting
an apartment. Greg describes how he begins and shifts his level of support over
time. He explicitly takes a stance regarding the “doing for” versus “doing with”
here, at least with regarding his assistance with new housing.
Greg: For me, I have a general guideline and my general guideline is with
everyone, I’ll start off with doing a lot with you, with the person and that’s
the key piece, I’m not going to do something for you...If you’re there, I
believe that investment that you’re there.
This chapter identified and described “what’s the rehab value?” as one of
the ways in which study participants named and framed what they experienced in
their work with members. This frame helped direct the practitioner’s actions, but
also explicitly facilitated their meeting obligations associated to Vanguard’s
funding. That is, they had to document the purpose of any practitioner-member
visit, and the funding source required that a visit have “rehab value”. Ida’s
perception that “rehab value, to me, is will this benefit the member…What’s the
value of—the whole value (italics added)—of the process, is it a value to the
process?” also suggests that the practitioners also understood in the relation to
the long-term recovery outcomes of successful and satisfying engagement in
Based on my data analysis, I found that the study participants described
three “rehab value” targets.
First, I found that they worked to create experiences of meaning for
members. Such experiences seemed intended to have transformative or
reparative influences focused on the member’s sense of self or sense of
identity. This is consistent with a view that recovery is a “process”,
because this view argues that it is the impact on the self that is most
profound when one experiences a psychiatric disability. Engagement in
occupation was the key means by which experiences of meaning were
Second, I found that these practitioners would facilitate opportunities for
“learning” for members. Targets for ‘learning’ might include an
understanding that the member would benefit from explicit knowledge
and skills development, habit formation, and increased self-awareness
and use of that awareness to influence. Learning
Third, I found that these practitioners would support a members effort at
“doing things on their own”. Independence and self-initiation of
engagement in daily routines were highly valued ways of being by these
practitioners and were understood to a focus of their work.
As with the practitioners efforts to “meet the member where they were at”,
dilemmas emerged as practitioners reasoned about “what’s the rehab value?” in
particular, learning and independence did not always happen. In these instances,
practitioners identified a sense that there were times when “natural
consequences” had to unfold in order for the member to learn or become more
self-aware. At other times, practitioners found themselves “working harder” than
the member, which cued them to adjust or fade their actions in order to achieve a
more balanced level of effort between themselves and the member.
Chapter 7. Vanguard as a Community of Practice
In Chapter 4 I acknowledged the contextualized and situated nature of the
practice reasoning of Vanguard’s personal service coordinators (Lave & Wenger,
1991; Rogoff & Lave, 1984; Wenger, 1998), and addressed particular aspects of
Vanguard’s practice context. Here I will extend that discussion and specifically
argue that Vanguard can also be understood as a ‘community of practice’.
Communities of practice (CoP) are “groups of people who share a concern, a set of
problems, or a passion about a topic, and who deepen their knowledge and
expertise in this area by interacting on an ongoing basis” (p. 4). Lave & Wenger
(1991) state that CoPs provide “interpretative support” (p. 98) to CoP participants
for making sense of the practices of that community. This view is important for
this study given its focus on practice reasoning and provides further support for
applying the community of practice perspective to my analysis. Initially I did not
set out to study Vanguard as a community of practice. However, as conducted my
research, I began to reflect on Lave & Wenger’s theoretical perspective to which I
had been introduced during my doctoral courses. I found it compelling and it
seemed to make sense to me as a way to represent some of what I was seeing and
Wenger and colleagues have provided multiple conceptual frames for
understanding communities of practice. Wenger’s (1998) original three concepts
of (1) mutual engagement, (2) shared repertoire, and (3) the negotiation of a joint
enterprise provide a useful way to document the type and form of a community of
practice. Iverson & McPhee (2008) extended Wenger’s work by utilizing an
analytic approach known as template analysis (King as cited in Iverson & McPhee,
2008) to represent ways in which different CoPs enact Wenger’s three elements.
In template analysis, pre-defined codes based on a theoretical position of the
research may be used to begin data analysis, and then be refined as the analysis
proceeds. I found this analytic approach to be more accessible in comparison to
Wenger’s in my efforts to account for Vanguard as a community of practice,
because it provide me with a clearer template and application examples. I utilized
the same analytic approach with my research data. My intent in here is not to
provide a thoroughgoing analysis of Vanguard as a community of practice, but to
provide an initial representation of the community of practice that I found.
Mutual Engagement at Vanguard
Mutual engagement is understood to represent the amount and pattern of
interaction among the members of the community (Iverson & McPhee, 2008;
Wenger, 1998). I found that the explicit team structure and the spatial
dimensions of the Vanguard practice context afforded opportunities for
connections to be made and nurtured. While their work is organized into formal
teams with processes basic to that type of organizational structure, like team
meetings, I found that the work spaces at Vanguard were also designed in such a
way as to obligate practitioner’s engagement with each other. This aspect of how
mutual engagement was enabled at Vanguard was accounted for in Chapter 4,
and included different types of meetings, both at the team and organization level,
as well as open work spaces that co-located practitioners and gave members easy
access to the practitioners.
The co-location of practitioners in open work spaces meant that
practitioners were able to observe and over-hear practitioner-member
interactions in which they were not engaged. This gave them access to some of
the struggles that other practitioners may be experiencing in their efforts to
support a member’s recovery. Ida reflected on her efforts to assist her team
members in their work with a member who did not seem to be responding to the
efforts of her colleagues. First she gave suggestions, but her colleagues
experiences left them believing that her suggestions would not work. So she
offered to step in instead.
Ida: And I sort of just stepped in as to help them because I would see how she
took up time, and I would approach them. Well, you guys could…Well, we can’t
do that. We’ve tried with her, but it doesn’t work. I said, okay, well, can I help
you guys with… I don’t remember what it was. It was one thing I helped her with.
It wasn’t housing because he was helping her with housing. Oh, school. She
wanted computer classes. And I said, well, let me help.
She went on to situate her actions within her sensitivity about the emotional state of her
colleagues, as well as her understanding of what she’s supposed to do as a team member.
She emphasizes the reciprocity of this action, noting that she hoped that she would
receive the same support if other practitioners sensed her distress.
Deborah: You were concerned, and you just reached out, and thought maybe you
were the one who could make the –
Ida: Well, and I felt, being a part of a team, that’s what a team is. If they see me
stressed, I’m hoping that they reach out. Or I can say, hey, can you please help so
and so with so and so’s stuff? That’s what I see a team as. I’ll reach out to you.
You reach out to me. And let’s reach out to each other. And even if they don’t
ask for that, because they didn’t, let me step in and help.
While the teams at Vanguard are clearly bounded in some ways by formal
assignments and designated work spaces, the boundaries between teams
appeared very fluid. I found practitioners from different teams meeting informally
and connecting with each other, as well as intervening with members served by
other teams. This is likely facilitated in part by the open environment of the work
spaces (See Chapter 4), as well as the other formal processes that the organization
has implemented that include bringing members from different teams together to
problem solve broader organizational challenges or needs. For example, as part of
their efforts to promote ‘flow’ or movement of members across the continuum of
services, representatives from different teams meet to talk about how their teams
are doing this and to problem solve dilemmas that emerge.
Karen is the representative of her team to the ‘flow’ organization-wide
work group, and because of that it seems to ready her to see or hear indicators of
a member’s readiness for transition that emerge during team discussions. While
she acknowledged that everyone is supposed to think about it, it is her role as
team “flow champion” to be more vigilant to such possibilities for members. She
is supported in this role by participating in the organization-wide ‘flow’ adhoc
work group. Karen clarified for me the way in which processes to facilitate flow
was representative of this cross-team practice.
Karen: It can really be anyone. I think about it more because I am part of
that [‘flow’] component and not everyone who’s ready to move on
necessarily has that…, but because I am part of it and I’m part of different
meetings with the staff on each team and we discuss flow and discuss
moving people on or what is missing that could make someone ready to
move on, what do they need, that may be holding them back, that I think
about it more maybe than others.
She clarified how the awareness might emerge within the team meeting
and how she might engage with her other team members in a discussion about
flow for a member. She makes evident the mutual work (i.e., ‘shared repertoire’
and ‘joint enterprise’) that is going on, as various practitioners interact with
Deborah: I see, so you have to have a heightened sensitivity and lens for looking
at people’s readiness for movement.
Karen: Yes. There are some where maybe I don’t work with that person as
much but when I see them or when I read notes about them, it’s well, why
aren’t they ready? And sometimes it’s tough questions to ask, but the
time we’re spending with this person doing whatever, whether it’s me or
other people, do I really need to be spending that time with them or is it
just I’ve always helped them do this and you just get used to helping
someone do this? Or it’s just I’ve never said no to taking them grocery
shopping, when really they live right across the street and they could do it
themselves. It’s not like they live far away and need the transportation
support or whatever. So it’s sometimes identifying that and also, it’s not
someone that I work with that often, it’s let me talk to their PSC’s, because
there could be stuff I don’t know about. I just see one side of it, but I’m
not the person who really sees them all the time, maybe there’s things that
I’m not aware of. So sometimes I might just be the one asking the
questions, well, what about so-and-so? They seem to have all their stuff
together, they’re independent, the only time I see them is because they
were in here using the computer. Do they really need our support?
Some practitioners may have more interaction with particular members
than others, and as a result they have to rely on each other to formulate a full
picture of what is possible for an individual member. This is a good example of
what Wenger (1998) called “being included in what matters” (p. 75). As Karen
noted addressing the decision about transition means asking “tough questions”
that have implications for each individual practitioner’s practice reasoning, their
relationships with members, and for the team’s resource utilization. It is in the
‘stories’ that practitioners tell about their encounters with members during team
meetings that Karen and others use to listen for the evidence of movement.
An aspect of mutual engagement according to Wenger (1998) is it’s
“diversity and partiality” (p. 75). He emphasizes that differences in perspective
amongst the members of a CoP are as important as the similarities. One way that
this is represented at Vanguard is by the recruitment of practitioners with unique
personal (i.e., including lived experience with mental illness), educational and
work histories and experiences (Refer to Table 4). The participants in my study
included those with graduate education (i.e., Masters in Social Work), and those
that had not yet completed undergraduate degrees. In addition, most had had
little formal exposure to the work that they were now doing as personal service
coordinators beyond internships before coming to Vanguard. Given the nature of
the work and the expectation of California’s Mental Health Services Act (MHSA)
some of the study participants had lived experience, either their own experience
of overcoming challenges related to mental illness and/or having been a source of
support to a family member experiencing mental illness.
Practitioners are afforded opportunities to reason and take action about
their work from the vantage point of these unique histories and experiences.
During the final and long interview I conducted with Patrick, where I explored how
he had come to know what to do as a personal service coordinator, he reflected
on his appreciation for the diversity he found at Vanguard.
Patrick: I think also having the ability to work alongside people with such
varying backgrounds, you get to work right alongside a psychiatrist, you get
some interesting viewpoints. I always find that I feel like I learn so much
when I actually can sit down with [the medical director] and discuss
something with him. I don’t necessarily always go ‘that’s what I’m going to
go do’, but it always makes me think in a different way and I guess…
Patrick noted that when he does consult with other practitioners, including the
psychiatrist, he doesn’t always take the actions that are suggested. I asked if he
could give me an example of a recent conversation that he had had in particular
with the medical director.
Patrick: Recently a member came to me and said I’ve been struggling with
this opiate addiction, I’ve been taking Vicodin for the last three years and I
buy it on the street, I want to get some help. Her idea was methadone
treatment, a twenty-one day wean-off type program and I wasn’t so hot on
the idea in my mind, I was kind of like it seems kind of risky. It wasn’t like
she was taking thirty Vicodin a day, she was at six to eight, so it wasn’t
such an extreme, like if she were to quit there would be serious…
Deborah: Or substantial medical risk.
Patrick: Yeah, and he just met with her earlier, so after I’d had this
conversation with her [the member], ’m like, I’ve got some thoughts in my
mind as far as just weaning off actually by reducing your amount, just
multiple approaches. So I thought I’d go ask him [the medical director] to
see if he had any feedback and part of the conversation was how is their
life going to be different off of taking Vicodin, what does Vicodin provide
to her? She identified it as a feeling of calmness, it’s kind of an escape
from the feelings of being upset about stuff and that’s when I’m happy, is
when I take the Vicodin. He kind of framed it in well, we all do our certain
escapes, is six Vicodin even something that she would necessarily want to
wean off of, how is she going to replace that feeling that she gets with
another coping natural mechanism? I guess she identified, she was like
forty dollars a month is pretty low amount for something that provides you
some happiness. So it made me think about it, it’s like okay.
Deborah: So it was almost like he was arguing why stop.
Patrick: To a degree, what’s the replacement, is there any benefit? There
may be benefit, but what are the drawbacks, so I didn’t really think about
that, I was thinking more like do you have any other ideas for treatment
for withdrawing from Vicodin. I walked away and I was like hmm.
Patrick emphasized that the conversation opened up a new reasoning
frame for him. Where he had sought out the psychiatrist for his expertise in
treatment options, what he got was a different way to think about the member’s
situation. The diversity that Patrick represented here isn’t just one of two
different providers, i.e., one being a psychiatrist, and one being a personal service
coordinator who also had completed his Masters in Social Work and was working
on his licensure hours. He also emphasized the diversity in having a psychiatrist
who responded differently than he would have expected a psychiatrist to respond,
“yeah, and you don’t necessarily think of a doctor telling you that.”
Vanguard’s Shared Repertoire
A shared repertoire (Wenger, 1998) includes the “routines, words, tools,
ways of doing things, stories, gestures, symbols, genres, actions and concepts that
the community has produced or adopted in the course of its existence, and which
have become a part of its practice” (p. 83). Wenger emphasizes that a
community of practice’s shared repertoire emerges overtime as participants
mutually engage in the practice and serves as a “resource for the negotiation of
meaning” (p. 84). More specifically, Iverson & McPhee (2008) identified
terminology, skills, activities and stories as aspects of a shared repertoire.
In Chapter 5 & 6, I identified “meeting the member where they’re at” and
“what’s the rehab value” as explicit ways in which my study participants named
and framed what they say and heard. Additional perspectives like “natural
consequences” and “who’s working harder” were also identified. The consistency
with which these ways of describing how they decided what to do when emerged
support the argument that these represent Vanguard’s shared vocabulary or
language. This is a language that facilitated communication amongst the
practitioners because it meant something specific to them as a member of
Vanguard’s community of practice. It also connected them to the broader
context of community-based mental health and recovery-oriented services. For
example, the perspective that “natural consequences” as a reasoning frame for
deciding on when to support and when not to support a member has been
identified in other studies of community-based case management and community
integration services (Floersch, 2002).
The key tasks or activities in which practitioners were engaged included as
much as possible, in-vivo intentional and serendipitous practitioner-member
contacts and resource development (i.e., phone calls, etc.) focused on practical
needs and/or growth and learning. These activities are consistent with what is
referred to in the community-based mental health literature (Floersch, 2002), as
well as some regulatory language , as case management and community
integration. As was noted previously, early influences on Vanguard’s ways of
doing this was informed by psychosocial rehabilitation approaches, including the
clubhouse model and the assertive community treatment team approach
(Erickson & Straceski, 2004). Specifically, these approaches emphasized a focus on
an individual’s practical everyday needs, learning by doing, collaborative
relationships between practitioner and member (Rutman, 1987) and the
expectation that most practitioner-member interactions occur in the natural
environment, and not at the facility itself (SAMHSA, 2008a). Overtime additional
approaches have been explored and infused into Vanguard’s practices, including
“harm reduction” (Marlatt, 1996) and dialectical behavioral therapy (DBT)
(Herschell et al., 2009). All of these practices have influenced what has emerged as
Vanguard’s shared repertoire.
In considering this element of Vanguard’s community of practice, I would
argue that much of what I found in my research represented activities of
Vanguard’s shared repertoire. For example, in Chapter 4 I described how
Vanguard’s practitioners began their work with members by spending time with
them and by trying to address immediate needs, a process they called
“engagement”. Once they feel that they had made a connection with a member,
possibly by meeting their immediate needs, they might fade or reduce their level
of contact. This reduction was partly required because each team on which the
practitioners worked had many members, so practitioners had to manage their
time effectively. It seemed that the practitioners had come to understand
“engagement” as a specific phase of care that was not expected to be sustained
across the entire course of the practitioner-member relationship. It was
understood that once the member was engaged, that the practitioner could now
do things that they would not have been able to do without having an ‘engaged
Repertoire development is considered an important aspect to
understanding the shared repertoire of a community of practice. Lave & Wenger
(1991) argue that repertoire development in a community of practice happens
through a process of situated learning they call “legitimate peripheral
participation.” It is understood as a “way to speak about the relations between
newcomers and old-timers, and about activities, identities, artifacts, and
communities of knowledge and practice” (p.29). As I explored with each study
participant how they had come to be at Vanguard and learn how to do the work, I
found legitimate peripheral participation at work.
As was noted in Chapter 4, at Vanguard, practitioners learned the work by
doing the work. Before coming to Vanguard, practitioners often had little prior
experience with the work or the population. Even when they had professional
education in the mental health, they had little to no practice with the way that
Vanguard enacted case management and community integration (See Table 3 in
Chapter 4). Sandy shared that before coming to Vanguard, she had been working
at a manufacturing company as a supervisor while completing her bachelor’s
degree in social science.
Sandy: I didn’t really know what I wanted to do, so I just stayed there for a
year after I graduated. Then one of my best friends…worked [at
Vanguard]…so he told me there was an opening, I think you should try out
for it. I was like, okay, no idea what I was getting into, so I turned in my
resume, got an interview, that’s actually the first interaction. When I came
back from my shadowing that was the first interaction I had with people
with schizophrenia and everything was brand new to me. I don’t think I
did that great on my interview, either, so I was actually shocked that they
called me back for the shadowing and called me to tell me that I got the
job a few weeks later.
I went on to ask her what she thought had happened or that she had done that
made them decide to hire her.
Sandy: I think because I wasn’t scared of the people I was meeting, I
wasn’t nervous, I shook their hands, sat down on their couch. One of the
members I met, I remember we went to his apartment and I just sat on his
couch and we talked about music for awhile, because he collects records
and I love to buy CD’s and stuff, so that’s how we connected and even
surprising to me, it was pretty effortless that I was able to connect with our
clients, with our members.
Recruiting individuals who have little or no experience with the work, but
have the interpersonal capacity that Sandy described has been documented in the
psychosocial rehabilitation literature (Rutman, 1987). This perspective operates
on the notion that the specific tasks and activities that practitioners engage in can
be learned, but that what Sandy demonstrated was a level of humanity critical to
working with marginalized persons like those served by Vanguard. Recruiting
those who have little experience places demands or creates opportunities for
organization like Vanguard to find ways for practitioners to learn how to do the
work while they are doing the work.
At Vanguard, practitioners were introduced to their practice philosophy by
participating in classroom-based trainings, but it was in the actual practice that
practitioners felt that the really learned how to do the work and enact the
philosophy. They would watch others do the work, do the work themselves and
then reflect on their success or not both in formal meetings as well as, informal
provider-to-provider exchanges. Patrick emphasized this as he reflected on his
experience about how he learned what to do and how to do it, “there’s individual
conversations that I’ve had with people [that] have been more valuable than all of the
trainings that I’ve had, as far as how do you do what you do?” Karen provided a rich
sense of how this happened on her team.
Karen: I think just, one, working with members is a learning experience in
itself and being kind of thrown in there. That’s one thing I do like about
[my team] versus, I’m not sure how other teams may do in terms of their
new staff but [my team], we really push people out. I think that’s good
because it really forces you to stand on your own. I mean, they don’t push
you out to like an emergency situation on your own but they really force
you to engage stuff on your own, to—for a lot and it forced me to step up
whereas if you’re always shadowing someone, you always have someone
else to fall back on or someone else to talk to the member or to talk to the
SSI rep or to whoever. Whereas, if you’re on your own you got to kind of
take it and, you know, you make the mistakes or you make—maybe figure
out ways to say things better or more efficiently or whatever. But you can
only learn that by doing it, I think, or you learn it best by doing it on your
own or with minimal assistance. And I think just from other staff, I mean,
throughout the Agency learning about their experiences, seeing how they
worked with someone and how that was effective or not effective and how
I can adapt it to myself or the way I may do things or the way I may talk
with a certain person or ideas about advocacy or working with a landlord
or different things like that.
Stories seemed ever present at Vanguard and several rich accounts of the
practitioner’s dilemmas and reasoning emerged during in my data collection
process. As has been well documented, humans tell stories to make sense of their
worlds and to communicate both to themselves and others about their
experiences (Bruner, 1985). One way in which Vanguard intentionally used stories
for repertoire development in particular was to have active members and current
personal service coordinators serve as trainers for the three-day intensive training
that all new hires are expected to attend. Participants in the intensive training are
introduced to the work then through the story that these members and PSCs tell
about their experiences.
Negotiation of a Joint Enterprise at Vanguard
The joint enterprise must be “negotiated” amongst the participants and
emerge out of doing the work itself (Wenger, 1998, p. 78) and is situated within
“historical, social, cultural, institutional” contexts “with specific resources and
constraints” (p. 79). Wenger argues that “the practice evolves into the
communities own response” to such contextual influences” (p. 80). Through
negotiating the joint enterprise, “relations of mutual accountability” (p. 81) are
established. That is:
what matters and what does not, what is important and why it is
important, what to do and not to do, what to pay attention to and what to
ignore, what to talk about and what to leave unsaid, what to justify and
what to take for granted, what to display and what to withhold, when
actions and artifacts are good enough and when they need improvement
or refinement (p. 81).
It was my sense that the practitioner’s negotiation of the joint enterprise at
Vanguard was mutually informed by the organizations guiding principles (See
Table 7, p. 79), the “whatever it takes” perspective of the FSP model and the
unique needs and wants of the individual members with whom the practitioner is
The organizations guiding principles emerged out of and have been revised
overtime in response to the broader context of publicly-funded community
mental health services, in particular the psychosocial rehabilitation service models
(Erickson & Straceski, 2004). These guidelines emphasize and draw on the
recovery perspective (Davidson, 2003; Ridgway, 2001) that has evolved over the
last three decades, and that have been developed into an approach to recovery-
oriented care (Davidson et al., 2009). Greg summarized this perspective and its
influence on his work with a particular member—“Vanguard’s philosophy is
member-driven, value-driven, high risk, high support, and I had to go back to that.
I always have to go back to that.” I described several instances in previous
chapters (i.e., 4, 5 & 6) where practitioners explicitly identified the principles as
influencing how they engaged in their work as personal service coordinators.
An important element of the FSP was the expectation that personal
service coordinators do “whatever it takes”. Agency representatives actively
participated in and contributed to the framing of California’s Mental Health
Services Act, as well as the recent development of a toolkit to assist agencies in
the development and implementation of FSPs. The toolkit on this model defined
“whatever it takes” this way:
Whatever it takes means finding the methods and means to engage a
client, determine his or her needs for recovery, and create collaborative
services and support to meet those needs. This concept may include
innovative approaches to “no-fail” services in which service provision and
continuation are not dependent upon amount or timeliness of progress, or
on the client’s compliance with treatment expectations, but rather on
individual needs and individual progress and/or pace on their path to
recovery. Clients are not withdrawn from services based on pre-
determined expectations of response ("Adult Full Service Partnership
Toolkit," 2011, p. 13).
Although the toolkit provides some broad suggestions about “whatever it
takes” means, down on the ground, each individual practitioner must make daily
decisions about their actions to stay true to such expectations. Greg’s reference
to Vanguard’s “high risk, high support” approach seems to give local language to
this perspective. As we would expect, member’s present with individualized
needs and wants. While both the guiding principles and the FSP “whatever it
takes” philosophy emphasize the practitioner’s obligation to attend to these, it is
the actual needs and wants themselves that also influence what the practitioner
decides to do. In Chapter 5 “meeting the member they’re at” was identified as a
specific reasoning frame utilized by practitioners and several examples of how
that was experienced by practitioners was described.
Wenger (1998) argues that CoPs “become a very tight node of
interpersonal relationships” (p.76), within which “disagreement, challenges, and
competition” happens (p. 77). These are part of the negotiation of the joint
enterprise process. Study participants clearly described situations in which team
members did not agree on what actions should be taken, and I observed team
meetings where clearly different interpretations or understandings about what
was going on with a particular member were expressed. Given that the focus of
this study was on practice reasoning, such differences had the potential to expand
practitioners thinking and open up new possibilities for action.
Allen reflected that there have been times when he was not quite sure
what actions to take, and sought guidance from his supervisor. Like Patrick earlier,
he wasn’t always sure that that recommended action matched his own
sensibilities. I asked him to give an example.
Allen: Sometimes I get into a situation where I don’t think it’s the right
thing to do, but I might hear our Assistant Team Leader say that maybe this
is – another thing – is the right thing to do. So I’ll be in a conflict or I’ll just
pretty much go with what the boss says.
Deborah: Mm-hmm. Is there a time or example?
Allen: A member needed assistance for housing. We already spent a lot of
money on her for housing. And then when she wasn’t showing any change
in each situation, and I just felt like, we should give her another chance at
housing because I see a little light there. I see that there’s an opportunity
for her to really take advantage of the housing situation, change the
behavior so that she can get her grant back. And most of the team pretty
much disagreed. And we kind of came to a middle ground where okay,
we’ll get her into a sober living instead of paying for another hotel. And
that seemed to work. That was more effective.
What we see here is the negotiation process around Vanguard’s material
resources that was documented in early chapters, but also the space for one
practitioner to take a stand against his other team members. Allen clarified that
these deliberations often take time and require multiple interactions amongst
team members. He also acknowledged that despite his taking a stand, he still “got
Deborah: Got you. So as an individual PSC, you may be in a situation
where you believe something makes sense, but the rest of the team isn’t in
agreement. So there’s this process by which the team works that out?
Does it take several meetings, or is it several discussions?
Allen: It’s several discussions. It’s usually several discussions. It’s not just
done in one sitting. I mean, this individual had lost her housing grant
because of boundary issues, and putting people over and traffic in and out,
and screaming and yelling, all of that, etcetera, on and on. And so we
helped her get into the transitional living. And the same behaviors
repeated. And we got her to a hotel, and the same behaviors repeated.
And then I felt like… I was starting to think, okay. This is not working. She
obviously doesn’t want her grant back. So maybe we should just pull the
plug on this, on helping her with this. The team started to agree, but then
the next discussion I had with her, I felt like, well, okay. It seems like
you’re really going to take this serious this time.
Deborah: So there was something that she said, or some way that she that
Allen: Yeah. It just seemed genuine. I could be a sucker though. But it
just seemed very genuine. And I advocated for her for us to help with
housing one more time, and got shot down. Oh, no, no, no. She’s this and
that. She’s racked up phone bills. She’s done this and we’ve helped her
with so much. We ended up coming to a conclusion that if she commits to
a sober living, a structured one, one that is pretty rigid and requires that
she goes to meetings and things like that, that we would pay for that.
Vanguard practitioners were mutually engaged, had developed a shared
repertoire, and had overtime negotiated a joint enterprise that was in constant
renegotiation. Table 8 represents aspects of Vanguard’s CoP identified and
highlighted in this chapter.
Table 11: Analysis of Vanguard’s Community of Practice (CoP) Elements
CoP Element Vanguard
Mutual engagement Daily informal contact with other staff and members
Morning and weekly team meetings
Shared way of describing what they were doing, i.e.,
Daily activities to deliver case management and
community integration services
Learning by doing (i.e., legitimate peripheral
Negotiation of joint enterprise Daily decisions about what to do to enact case
management and community integration service
Problem-solving within team where diversity of
Although communities of practice are not always located within a single
organization, they can exist within a particular locale as I found at Vanguard. It
wasn’t the co-location that was sufficient to represent the presence of a CoP at
Vanguard, rather it was the way that work happened and that practitioners
participated in repertoire development. Multiple practitioners often worked
together on recovery targets for individual members and teams made decisions
together about what to do, especially when significant dilemmas emerged.
Vanguard’s practice philosophy was outlined in written documents and training
experience, and brought to bear and explored in daily practice. A shared
repertoire that included particular ways of “naming and framing” the work were
present at Vanguard. Practitioners learned the practice by practicing within the
Vanguard community of practice.
Chapter 8: Implications for Practice and Further Study
In this chapter I will consider the practice implications for the findings of
this study for front-line practice in recovery-oriented, community-based mental
health settings. I will also identify areas that would benefit from further study.
Findings from studies focused on clinical or practice reasoning in the fields
of medicine, nursing (Benner, 1984) and occupational therapy (Mattingly &
Fleming, 1994) are most typically utilized to promote “repertoire”(Wenger, 1998,
p. 82) development, that is learning what to do and how to do it. With its focus on
practice reasoning, my study can contribute to already existing efforts to
strengthen the development of practitioner readiness for and capacity to engage
in recovery-oriented, community-based practice with persons labeled with
psychiatric disabilities (Hoge et al., 2007; Hoge et al., 2005). The reasoning
frames, themes and dilemmas outlined in Tables 12a and 12b, make explicit how
my study participants “named and framed” (Schon, 1983) the work in which they
were engaged. These can be intentionally incorporated into site-based training
experiences through the development of focused learning activities. In addition,
they can be drawn on by practice supervisors and team leaders as they support
practitioner reflection during team and supervision meetings.
Reasoning about “meeting the member where they’re at” represented
more than the broad view regarding decisions about how to initially engage a
member in services. It represented a way for practitioners to locate and position
themselves in relation to each individual member. in my compass metaphor it
represented finding the ‘true north’ of each individual member’s personally
relevant and unique needs, desires, motivations, etc.
Table 12a. Themes that Emerged within Reasoning Frames
Reasoning Frame Themes within Frames
“Meeting the member where
Meeting the member’s needs and wants
Meeting the member’s needs within the visit itself
Meeting the member’s readiness or motivation for
specific activities or goals
“What’s the rehab value?”
Creating experiences of meaning
Facilitating opportunities for “learning”
Supporting member’s efforts at “doing it on their
In one way, it meant reasoning about how to meet the member’s wants
and needs. I found that practitioners more specifically considered this when they
were reasoning about knowing where to start with a member, knowing how to
stay on track once they had gotten started with a member, and helping them to
know how to facilitate a member’s decision making in certain situations. For
example, when Davina was working with one of her members who had initially
said he didn’t want anything. She kept spending time with him and discovered
that he had been working on trying to get his social security disability for a long
time. She had been successful in the past in helping other members to process
their applications successfully. He didn’t initially agree to let her work with him on
this, but eventually did and was successful in securing the disability. The explicit
practice guidance from this example is two-fold. On one hand it helps us
understand that members may not always make their needs explicit, and on the
other that by continuing to interact with the member an attentive practitioner can
identify needs that can be met.
“Meeting the member where they’re at” also meant reasoning about how
to meet the member’s needs within the practitioner-member visit itself,
particularly their emotional and/or cognitive needs. Practitioners would
intentionally adjust or modify their behaviors and response style in order to meet
those emotional and/or cognitive needs. These within visit adjustments were
seen as necessary in order for “work to get done.” For example, Kim had
developed an approach to her work with one of her members that involved
intentionally meeting at Vanguard when certain tasks needed to be completed.
She did this despite the expectation of ACT and FSP program approaches for in-
vivo practitioner-member visits. She had found that it was difficult if not
impossible to get the tasks completed if she met with at the member at her home.
When she did so, the member was distracted by the home situation, and would
not be able to attend to the task at hand. I believe this aspect of my study
participants experience is particularly important, because while manualized
toolkits that articulate how to implement ACT (SAMHSA, 2008a) and FSP ("Adult
Full Service Partnership Toolkit," 2011) approaches provide general guidance on
what to do, the specifics of within visit actions are not as clearly articulated.
Finally, I found that, “meeting the member where they’re at” also meant
reasoning about a member’s motivation and/or readiness to engage in specific
activities and/or goals. For example, Davina offered an explicit metaphor of
“stick-shift pedaling” to represent the work that she did to figure out how to
match her supportive actions to a member’s volition. She used this to represent
how she sometimes decided that she needed to engage in particular supportive
actions and sometimes she did not. Other practitioners explicitly drew on stages
of recovery perspectives to reason about motivation and/or readiness. While
perspectives on understanding motivational states are already widely available
both in the health and social care fields generally, and in psychiatric rehabilitation
in particular (Rogers et al., 2001), the findings from my study may enhance these
perspectives and provide examples of how such perspectives are intentionally
utilized by practitioners.
The second overarching theme identified in this research was reasoning
about “what’s the rehab value?” (See Table 12a) I found that it meant more than
just being sure that the visit was reimbursable. It represented the ways that
practitioners reasoned about when, what, and how to create experiences of
meaning, facilitate opportunities for ‘learning’ and supporting members to ‘do it
on their own.’ The practitioner’s reasoning about how to create experiences of
meaning is consistent with the recovery perspective that doing so can be
transformative. For example, Ida came to understand that a member she was
working with wanted to or might benefit from the experience of trying on
wedding dresses. This reasoning emerged out of a conversation that started with
the member reaching out because she was feeling sad. As Ida explored this with
the member, the member began to reflect on her previous wedding experiences
and how she had never tried on wedding dresses. The eventual outcome of this
practitioner-member interaction was that Ida and the member worked together
to planning a day of trying on wedding dresses. In her reflection Ida was
emphasizing the importance of “listening” and told this story as a way to explain
what she meant. What she seemed to be “listening” for was an opportunity to
create an experience of meaning. Practitioners need the skills to “listen” as well
as to figure out what kinds of experiences might have such transformative power
for the persons with whom they are working.
“What’s the rehab value” also represented ways in which practitioners
reasoned about how to facilitate opportunities for ‘learning.’ I found that for
these practitioners the specific targets of learning included a member’s
knowledge, skills, habits and/or self-awareness. For example, Greg worked with a
member on his grocery shopping skills and described how he had approached this
process. Greg had been a teacher prior to working in mental health, so he had a
readily available framework for teaching skills. Unlike Greg, the previous work
and/or educational experiences of most of these practitioners did not provide
them with explicit approaches to skills teaching. Greg points to the need for
practitioners need ways of understanding how people ‘learn’, and how psychiatric
disabilities may impact that learning, so that they can design learning experiences
that match the member’s needs. Sharon’s experience with one of her member
highlighted habit development as a target for reasoning. She described her
experience with a member where she began with basic ADLs of showering and
bathing. It was clear to her that “he could do it”, but needed her prompting to
regularly engage in his showering routine. This drew on recent research
regarding performance-based measures of functional skills identified as the
“competence/performance distinction” (Bromley & Brekke, 2010). Recent efforts
in the wider community mental health practice arena have begun to address this,
in particular attention to the cognitive needs related to learning for persons
labeled with psychiatric disabilities (Brown, Rempfer, Hamera, & Bothwell, 2006;
Rempfer, Hamera, Brown, & Cromwell, 2003).
For each of the overarching reasoning frames identified in my study, I
found the emergence of particular types of dilemmas (See Table 12b below). By
making these dilemmas explicit, this study contributes to other efforts at
articulating practice dilemmas experienced by health and social care providers in
general, and community-based mental health practitioners in particular, e.g.
‘burn out’ (Scheid, 2004) and/or what has been called “moral distress” (Slater &
Table 12b. Dilemmas Emergent within Reasoning Frames
Reasoning Frame Reasoning Dilemmas
“Meeting the member where
Deciding what to do given the often cyclical nature of
many psychiatric disorders
Deciding to act one’s community of practice principles
rather than one’s own practice experience
Deciding to act against a member’s choice
“What’s the rehab value?”
Deciding whether or not to provide material resources
Deciding what to do when efforts to facilitate
“learning” don’t appear successful
Deciding what to do when the practitioner senses that
they are “working harder than the member”
It was my sense that often the cyclical nature of many psychiatric
disorders, posed particular challenges to practitioners as they tried to reason
about how to “meet the member where they’re at.” For example, Davina
reflected that she “never know which [member] I’m going to get.” The member
that she was working with experienced blackouts related to alcohol use; and on
some days he seemed much more alert and organized than he did on others.
Casey as well reflected on the movement of members between periods of crisis
and stabilization. She stated “but I think what’s so difficult about mental health is
that they could go backwards at any given time, and when is that going to
happen?” Both of these practitioners highlight the importance of providing
practitioners with ways of understanding what is happening, as well as specific
strategies for responding to these changing states.
I also found that practitioners were challenged when they had to find ways
of deciding how to “meet the member where they’re at” when Vanguard’s
practice philosophy guided their actions in one direction and their own lived
experience guided them in another. This seemed to go both ways. That is, in some
instances they acted to support member choice because it was acting on the
Vanguard principles, even though in their own reasoning doing so was risky; and,
in others they had to act against member choice. For example, recall Greg’s
account of supporting a member to move into his own apartment even though his
thinking was “no how, no way.” Also, recall Belinda’s difficult decision to facilitate
the move of a member from her own apartment to an assisted living facility. The
member was experiencing cognitive decline associated with Alzheimer’s and this
was impacting her ability to maintain her apartment.
An important finding in my study, was the clear way in which difficult
decisions involved explicit and sometimes extended team deliberation. This
supports the role that teams can play in these and other practice settings where
complex situations are encountered. For example, recall Allen’s description of the
work that his team engaged in as they reviewed the decision to discontinue
providing a member with diapers and other supplies for her baby. Allen reflected
that there was a “big argument” and that the discussion about what to do and
when to do it took time, and transpired over several meetings. While there is a
well-articulated body of literature regarding team work, it reminds us that
recovery-oriented, community-based service providers must ensure that supports
for team work are present. In a previous chapter I argued that what was present
at Vanguard was a community of practice. Itprovides an additional lens for
considering the influence of teams on decision making practices.
To summarize the findings from my study can be used to support
practitioner repertoire development for recovery-oriented, community-based
practices, in the following ways:
Learning experiences can be designed and implemented to focus on the
nature of the reasoning and the dilemmas I identified my study. These
would serve to make explicit both the targets of “meeting the member
where they’re at” and “what’s the rehab value?”, as well as helping
practitioners build the confidence to do each aspect of the work. For
example, explicitly introducing the compass metaphor of finding ‘true’
north could provide an experiential image of the ever shifting process of
meeting member’s needs and wants. Metaphors can be quite powerful,
and as a result might help mediate practitioners experience with the
changing landscape of member’s needs and wants. In addition, by
introducing practitioners to additional ways of understanding what they
are seeing, they can draw on those lenses to make decisions, e.g., cognitive
models and intervention approaches.
Intentionally providing opportunities for practitioners to reflect on the
nature of the reasoning and dilemmas. Schon’s (1983) seminal work on the
reflective process in professional practices makes this clear. The team
structure that is a key component of the ACT and FSP approaches serve as
the main venue within which this reflection can take place. While these
approaches are designed to keep practitioner to member ratios low (i.e., 1
practitioner to 10 or 15 members), it will challenge organizations to give
their teams sufficient time to engage in such thoughtful deliberations.
Finally, strengthening the skills of supervisors in recovery-oriented,
community-based mental health programs is important. It is the
supervisors who need to be able to support individual providers learning
and reflection related to the reasoning and dilemmas identified here.
Efforts in this area have been growing in the field of psychiatric
rehabilitation, and should be strengthened and more widely disseminated.
Implications for Further Research
In this section I will present two areas for further research.
Practice reasoning in more ‘clinically’ oriented full-service partnerships.
The finding in my study that practitioners experienced an intense sense of fit with
the Vanguard philosophy and practices is compelling. An important dimension of
this sense of fit, was the experience of a clear distinction between Vanguard and
what they called ‘clinical’ practice settings. Such settings seemed to leave these
practitioners feeling constrained in their efforts to help, as well as disempowered
as individuals themselves. I was struck with how immediate and profound their
sense of these differences was almost upon each participants first contact with
Vanguard. My study identified ways in which Vanguard’s practitioners reasoned
about their case management and community integration work, Vanguard’s
philosophical heritage and explicit guiding principles informed my study
participants practice reasoning.
Given the contextualized and situated nature of the practice reasoning of
the personal service coordinators in my study, exploring personal service
coordinators practicing in full-service partnerships hosted by different agencies
would be fruitful. How would personal service coordinators (PSC) in a more
‘clinically’ oriented full-service partnership (FSP) make practice judgments? How
would they “name and frame” (Schon, 1983) what they see and hear? How would
their understanding of the full-service partnership (FSP) model emerge in their
decision making? How would their tacit knowledge emerge in their decision
making? These were the questions posed in my research regarding Vanguard’s
personal service coordinators.
The differences that practitioners in my identified are similar to some of
the ways in which psychosocial rehabilitation sought to position and differentiate
itself from other mental health practices in the late 1970’s and 1980’s (Rutman,
1987). In addition, they resonate with more recent discussions regarding clinical vs
social (Secker et al., 2002), and scientific vs consumer (Bellack, 2006) perspectives
on recovery. Vanguard has adopted an explicit perspective on recovery, which is
articulated both in their guiding principles and the writings of its medical director.
Vanguard introduces and supports practitioners understanding of their philosophy
and practices via its’ community of practice.
Full-service partnerships are being implemented throughout California
both by directly operated local mental health authorities and by agencies
contracted by the local mental health authority (e.g. Vanguard). Would the
practice reasoning of personal service coordinators in a full-service partnership
within a different agency generate different reasoning frames and/or dilemmas? I
would expect that there would be some nuanced differences informed by the
contextual and situational features of each organizations philosophy and the
degree to which a community of practice had emerged in that practice setting.
This might be especially present in organizations that have adopted what
Vanguard practitioners identified as a ‘clinical’ approach. For example, would
dilemmas about overriding a member’s choice be experienced in the same way in
practice context that is more ‘clinical.’ While the recovery perspective is
intentionally countering the implementation of the clinical perspective, nuanced
differences may still be present in down on the ground practices as specific
agencies implement full-service partnerships. Exploring the influence of these
differences on practice reasoning of personal service coordinators in full-service
partnerships would be helpful.
Supervision and mentoring practices in full-service partnerships. How do
practitioners frame the reasoning dilemmas they experience within the context of
supervisory and/or mentoring relationships? How do supervisors and/or mentors
facilitate the practitioners reasoning? What is the nature of the supervisory
and/or mentoring relationships, given the “high risk, high support” nature of the
practice of the Vanguard practitioners, for example? The finding that the teams
played a critical supportive role, particularly in those dilemmas where
practitioners experienced challenges to acting on Vanguard’s guiding principles,
argues for more study exploring the practice of supervision and mentoring.
Supportive spaces for reflection and learning have been identified as
critical to professional practices (Schon, 1983). This is an area that has garnered
recent attention from one of the national associations promoting psychiatric
rehabilitation services, United States Psychiatric Rehabilitation Association
(USPRA) and the Center for Psychiatric Rehabilitation. Given the varied
backgrounds and educational experiences of the PSCs in my study, supervision
and mentoring can provide critical spaces for reflection. Given that PSCs work
with members (i.e., clients) over long periods of time and that efforts to facilitate
specific recovery goals, like employment, can extend over several contacts with
the member, reflection-in-action (Schon, 1983) can be facilitated via supervisory
and/or mentoring practices.
This may be particularly important, as well, given the finding in my study
that most of the study participants had had little exposure to the nature of the
work in which they were engaged prior to coming to Vanguard. The situated
learning perspective of “legitimate peripheral participation” related to repertoire
development within a community of practice (Lave & Wenger, 1991) provides
support for this as a focus of study. It could offer organizations a better sense of
how to intentionally support practitioner’s development within the unique
characteristics of the full-service partnership as a model of recovery-oriented,
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