Fwd: [oacaf] Homeless Services Symposium, KDA etc. (Part 2)

Morgan Brown (morganbrown@hotmail.com)
Mon, 02 Nov 1998 08:43:52 EST


Hello,

Below is a forward which may be of interest to you and others you may 
know.

Note: CSX = Mental Health Consumer/Psychiatric Survivor/Ex-patient

Morgan <morganbrown@hotmail.com>
Morgan W. Brown  
Montpelier Vermont USA
Norsehorse's Home Turf: http://members.tripod.com/~Norsehorse/

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On: Sunday, November 1, 1998 at 21:58:35 -0600
Vicki Fox Wieselthier <vickifw@stlouis.missouri.org> sent:
[oacaf] Homeless Services Symposium, KDA etc.  (Part 2)

Symposium 2


I ended part one by saying, " There is a direct relationship between our 
not being included in this kind of process and our not getting money for 
CSX delivered services or CSX directed research."


My particular concern is that the research that is disseminated does not 
look at our preferences for services, what we find acceptable, or the 
role that coercion plays in service delivery and system design.  This is 
especially important now, when the mood of the country has shifted to 
the right and social justice issues are no longer automatically taken 
into consideration in the development of public policy.


One of the other pieces that is operative here is that CMHS (part of
SAMHSA, which is a part of HHS) has to go to Congress each year to have 
its budget approved and its programs funded.  The annual budgetary 
process is arduous.  Each year perfectly good programs have their 
budgets reduced or cut entirely because of the political climate.  When 
CMHS has to turn to the advocacy community to expand its funding, then 
it is always with strings attached, and the folks that get the money for 
expansion are the same folks who benefit directly from the additional 
funding.  It has led to a "flavor of the month" kind of pressure being 
applied to the various Federal Departments seeking allocations.


CMHS has had 124 FTE positions within its allocation for the last few
years.  In addition to supporting the people who work for CMHS directly, 
the budget allocation also supports the people who it contracts with.  
This includes the study sites and coordinating centers for individual 
KDA initiatives, the 16 technical assistance centers, the state block 
grants, and a whole slew of other projects.


In 1996, CMHS stopped funding demonstration projects and developed the
Knowledge Development and Application (KDA) model.  This was done, 
largely, because of increased opposition to the funding of demonstration 
projects which, even when shown to include effective services, were 
seldom implemented on a state, local, or national level.  The Congress 
had made it very clear that funding demonstration projects was not high 
on the list of priorities.   A very interesting discussion of what KDA 
was and how it should be presented as well as the dangers in its being 
"field driven" (the formal name for flavor of the month) appeared in the 
minutes of the September, 1966 minutes of the CMHS National Advisory 
Council.  Mike English, Director of KDA, and others talk about the 
packaging of KDA, the political pressures on the process, and the very 
small amount of commentary on the role of CSX in all of this.


See: http://www.mentalhealth.org/whatsnew/min0996.htm


"Council Member Discussion-Focusing on the Future-The Knowledge 
Development and Application (KDA) Agenda for 1997"


>From the 9/96 notes:


"Dr. Martinez stated that the fundamental issue is marketing. In the
guidelines, the guiding principle is a field-driven agenda. He asked the 
question, "What is the field?"


Mr. English defined the field as a combination of consumers, families,
associations, providers, State and local government, and people with 
very diverse interests.


Dr. Kiesler stressed that if a program becomes completely field-driven, 
it becomes a mere political process. Independent judgment is needed. He 
explained it is essential to develop best practices, document them, and 
then distribute the material. He asked whether any efforts had been made 
to create partnerships with the private sector. "


The meeting held six months later also discussed KDA at length and the
embracing of formal measures of outcomes that is part of that way of 
doing business:


<http://www.mentalhealth.org/whatsnew/min0497.htm>


"Marshall Forstein, M.D., expressed his apprehension that with the push 
to develop outcome measures, resources will be restricted to what can be 
defined as a biological disorder. Such a limited definition would 
prevent people who could benefit from mental health services, such as 
emotional support or counseling, from accessing them and have long-range 
implications for future generations. He added that when the parity issue 
returns to the House floor, "We will see a dramatic polarization within 
the mental health community."


Floyd H. Martinez, Ph.D., noted that because the capacity to conduct
outcome measures is in its infancy, there is the risk of focusing only 
on things that can be measured, which may not necessarily be important. 
He cautioned against a universal set of measures, which would not 
capture the diversity of the mental health field in its clinical, 
cultural, and political environments.

Daniel H. Gottlieb, Ph.D., remarked that it is important to focus on 
mental health, rather than mental illness. A focus on mental illness, he 
stated, considers only symptom change - not the entire person.


Dr. Horvath expressed his concerns about any proposed outcome measures. 
He indicated that measures should be brought to the Council for 
discussion.


Dr. Martinez reiterated his concern that the capacity to measure in this 
broad, diverse field is still in its infancy. He pointed out that many 
systems may not be ready to use the information captured by what is 
measured. What will we do with the outcomes? Do elected officials listen 
to outcome data? Will a reasonably rational measurement process affect 
irrational decision making machinery? "


So even the professional laden CMHS Board (only one CSX representative) 
realizes the danger of the system as it is currently constructed.  That 
is:


* Field driven (flavor of the month) funding


* Outcome driven evaluation in the absence of good ways
to design, describe, and measure effectiveness.


The flavor of the month business is especially scary right now.  The
campaign that NAMI and TAC have undertaken to make CSX appear to be
violent, unpredictable, chronically lacking in insight and other 
headline producing scary things has led to a widespread call to increase 
the amount of force in the system.  Don't be surprised if we see an 
increase in funding for service provision that addresses the headline 
fears through coercion or if joint HUD and CMHS funding is used to study 
coercive approaches to service delivery.


At the Homeless Symposium on October 29 and 30th, the PACT researchers 
were out in force--and they smell dollars.  Gary Morse, a well known 
researcher and fellow St. Louisan delivered a paper on case management 
that focused heavily on PACT and the related Continuous Treatment Team 
model of service delivery.  After reading all (or at least most of) the 
right things about the service principles (see below) he looked up from 
his notes and had the temerity to say that there was an opportunity to 
partner with NAMI to spread the PACT model.  This from a person who is 
absolutely aware that PACT as envisioned by NAMI is paired with Out 
Patient Commitment and FORCE.


Service Principals
(from "A Review of Case Management for People Whoa re Homeless:
Implications for Practice, Policy, and Research" by Gary Morse, Ph.D., 
in press)


* Assertive and persistent outreach to meet homeless people
on their own turf (as well as their own terms)


* Active assistance to help clients access needed resources


* Following the client's own self-directed priorities and
timing for services


* Respecting client autonomy


* Nurturing trust and a therapeutic working alliance


* Small caseloads for case management staff


The paper is 34 pages long (including citations).  This is the entire
portion that mentions service users as case management staff.  Note that 
it does not state that this has been found to be effective (although it 
has).


"Also appearing within the literature are approaches which are 
noteworthy for their use of consumers as case management staff.  The use 
of consumers and peers has been incorporated within various models of 
case management, including homeless ACT teams that include a consumer 
advocate (Dixon et al, 1994) and ACT teams which are almost exclusively 
comprised of consumer staff (see Herinckx, Clarke, and Paulson, 1997)."


The portion of the paper that deals with exemplary practices or the need 
for additional research does not mention peer case management at all.  I 
have asked Jean Campbell to send Gary Morse the 54 page annotated 
bibliography she has recently developed on peer delivered services. 
Perhaps he can be motivated into giving our work the prominence in 
deserves and incorporating our findings into both the best practices 
section and the suggestions for future research.


Jean has the bibliography in draft form at this point.  As soon as it is 
ready for publication I will be sure to link to it (I assume it will be 
on PIE) and publicize its availability.


There are other threats to our civil rights and to social justice that
could come out of the acceptance of the Symposium papers as they are
currently written.  I will write more about that in part three.


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