Table of contents(17 chapters)
Serious and persistent mental illness has posed a significant social problem for a majority of cultures across most historical periods. Most recently in the United States, the aftermath of the deinstitutionalization policies of the 1950–1970s has resulted in many individuals who in the past might have spent the majority of their adult lives living in hospitals roaming city streets homeless, impoverished, and vulnerable to victimization or to being arrested for minor offenses. This paper reviews the changes both in the population of individuals with serious mental illness and in the systems that care for them over the last 25 years, and suggests that a “Tower of Babel” scenario has resulted inadvertently from the shift from hospital to community care. Following the dissolution of the monolithic hospitals (i.e. Towers of Babel), mental health providers have been dispersed among a myriad of community agencies, each with its own vision and standards of community care. Without a shared map to guide their work, community systems have become characterized by disarray, paralysis, and a lack of integration and coordination of care for a population of individuals who typically require more than one service from more than one provider at any given time. To address these issues, we offer a core set of “principles of care” developed by one local service system in an attempt to (re-)constitute a common map for their shared territory. We closed with a discussion of the issues that remain unresolved despite this collaborative process, and with suggestions for future directions to explore.
Community-based service providers (such as home health agencies, rehabilitation and mental health services) have found it necessary to cope with extremely uncertain and turbulent environments due to a changing regulatory environment and restructuring of the acute health care system. This paper discusses three types of survival strategies adopted by community-care service providers in a medium-sized city in the Northeast. These agencies provide long-term social and health services to the disabled and frail elderly with chronic care needs. The implications of each strategy for service provision to people with chronic care needs are discussed.
This chapter discusses the dilemmas of government using a market model for contracting health and human services to the private sector. The particular case in point is the use of Latino community-based agencies to help stem the disproportionate incidence of HIV/AIDS in the Latino community. The chapter explores the assumptions of efficiency and accountability in the contracting process and the concomitant possible loss of responsibility of government in providing optimal solutions to critical social problems. The conclusion is that to provide these programs, a more effective model is one where both government agency and non-profit organization work in partnership.
Case management is a technology for enhancing the continuity of care provided to clients in a community-based mental health service system. From among diverse case management models, the Massachusetts Department of Mental Health adopted the service broker model for statewide implementation and identified changes in the structure of inter-occupational and interorganizational relations in the agency that would be needed to accommodate this technology. This chapter analyzes the process of implementing this technology, based on interviews with administrators of mental health service areas during the implementation period. Potential obstacles to the implementation of a new technology are discussed and the resulting variation in adherence to the selected case management model is described. Sources of conflict about the case management model and effective responses to this conflict are identified. Conflict over the new model was strongest in areas where clinicians were most powerful and where boundaries around hospitals were strongest; such conflict was often resolved by subordinating case managers to clinicians and thus reversing the intended hierarchical structure. Implementation was facilitated by bridging strategies that facilitated cooperation among case managers and clinicians.
This paper examines evidence of “ritual conformity” with the Americans with Disabilities Act of 1990 (ADA), with a focus upon the employment of individuals with mental disabilities or illnesses. We view the ADA as an important “rational myth” in the institutional environment of American business which enunciates a new set of legal and normative standards for employment of individuals many believe to be unemployable. In conforming to the mandates of the ADA, businesses may display coercive isomorphism; hiring those with mental disabilities because they fear the coercive effects of the law. Evidence of coercive isomorphism is consistent with a more materialist/instrumental view of the relationship between legal mandates and organizations. However, drawing from the law and society tradition, we articulate a culturalist/constructionist alternative which posits that because the law is often ambiguous, contested and symbolic, organizational decision makers are responsive to normative appeals and cognitive framings. Ritual conformity may then take the form of normative isomorphism. Important to either form of institutional isomorphism for compliance) are the beliefs employers hold about the employability of those with mental disabilities. Consequently, we argue that the practical meaning of the ADA depends on the ways in which it is interpreted and enacted by the organizations that it supposedly governs. To capture this enactment process in mid-stream, we report early empirical evidence on the organizational response of a random sample of businesses to the ADA requirements governing the hiring of persons with mental disabilities. Extensive telephone interviews were completed with 117 employers (representing a 61.6% response rate) in one urban SMSA with a low unemployment rate. The majority of the employers surveyed had received information about the ADA, and most had a reasonably good understanding of the law. Over a third of the employers (37.3%) had indeed hired an individual with a mental disability since the ADA went into effect in 1992, and a third (33.3%) made special recruiting efforts to hire individuals with a mental disability. Receiving information about the ADA was significantly related to such proactive policies; larger companies were also more likely to exhibit compliance to the ADA by hiring, or having specific policies for the recruitment of individuals with mental disabilities. In examining the sources of such ritual conformity to the ADA, we found evidence of both coercive and normative isomorphism, and that ritual conformity was also associated with beliefs about the abilities of those with mental illnesses. Employers who were not in compliance with the ADA were more likely to be uncomfortable with potential employees with a previous mental hospitalization or employees taking anti-psychotic medication. Furthermore, we found important differences between those organizations which expressed coercive rationales for compliance and those which expressed normative rationales; specifically employers expressing normative isomorphism were more likely to have hired individuals with mental disabilities prior to the ADA and to exhibit ritual conformity to the ADA. Businesses expressing coercive rationales for compliance were more likely to hold stigmatizing attitudes and less likely to exhibit ritual conformity to the ADA. Our data suggest a potential synthesis between material and cultural models of law whereby early compliers with a new law are more likely to exhibit normative rationales and to respond more directly to the normative messages of the law, or else implement policies they would have otherwise adopted on their own. Over time, normatively driven proaction will foster mimetic isomorphism, and resistant firms (or those holding ideological constructions which run counter to the normative mandates of the law) will move toward a profit-maximizing mixture of compliance and evasion; complying largely because of the coercive threat of the law.
Over the past decade or so, there has been a significant renewed emphasis on community-based approaches to promoting social change and economic development, delivering services, and addressing the needs of people in poverty. One way in which such efforts strategically address this goal is by focusing on the organizational infrastructure of a community, seeking to change the ways that individual community-serving organizations relate to one another and to organizations and actors beyond the community. This paper focuses on one approach to this task: the establishment of broker organizations — local intermediaries responsible for fostering and convening partnerships and networks of relations among existing organizations. It briefly outlines the impetus and rationale for engaging in interorganizational relationships in this context, defines and explores the role of broker organizations as they have played out in a few illustrative cases, and distills some of the central issues that emerge regarding their promise and limitations.
In 1989 the Robert Wood Johnson (RWJ) Foundation began a $24.6 million program community-based alcohol and drug abuse elimination project, called “Fighting Back.” Along with the U.S. Dept HHS, Community Substance Abuse Program (CSAP), the Fighting Back projects were alternative approaches to the Police War on Drugs. The 15 RWJ communities were given up to $200,000 for two-year planning grants to develop community-based organizations that would focus on better coordinating existing resources and attracting new resources to address high-density alcohol sales, drug trafficking, and drug abuse in low-income middle size communities. In the first year implementation phase, each project was given up to $700,000. None were to provide direct services; each organization was a catalyst for social change.The initial theories used to begin this project were community empowerment and resource mobilization. Based upon site visits and in-depth interviews, this chapter reviews the lessons learned from organizing such projects based upon these theories. We review the strategies used to successfully address their central challenges and these theory's utility. The RWJ and CSAP projects suggested a variation of community empowerment where consensus among keys players in and outside of each community was a precondition to community mobilization. Also community empowerment and resource mobilization were not sufficient. Through trial and error, each project learned important new lessons and strategies that were already available in other theories — collaboration, exchange, and general theory of race relations. It is suggested that use of additional theories based on prior experiences in successfully mobilizing the community could have further improved the successes of the RWJ and CSAP projects.
Rebuild L.A. was the organizational response to the 1992 riots/rebellion in Los Angeles, created to promote economic development in the affected areas. This research links the initial failure of RLA to tensions in the public—private partnership concept on which it was based. While these tensions emanated from broader issues of state-market realignment, they were institutionalized within RLA by its chair. Peter Ueberroth, drawing from his previous public leadership positions with the Los Angeles Olympic Organizing Committee and the Council on California Competitiveness. Analysis explains how those tensions shaped organizational processes within RLA and limit its policy legacy. Conclusions address the lessons which RLA offer for future utilization of public—private partnerships in American cities — focusing on the minimum requisites of participatory processes, role definition, and accountability.
This paper addresses how the concepts of social learning and communities-of-practice explain the role of cultural meanings around social problems and the affect of efforts by social movement organizations to expand their membership and to retain community support. Drawing on data accumulated using an ethnographic approach; I use a close study of the Heritage Centre of the Walpole Island First Nation in southwestern Ontario as a social movement organization to trace compatible threads in organizational and social movement theory. I show how the Heritage Centre's strategies and ideology are determined through its relationship with the community of which it is a part.
The organizational effectiveness of methadone maintenance treatment is qualitatively evaluated by analyzing levels of compliance and involvement with treatment programs for clients at three types of methadone clinics in the San Francisco Bay Area. Secondary analysis is used on longitudinal data collected from a project funded by the National Institute on Drug Abuse, “Injection Drug Users, Methadone Maintenance Treatment, and AIDS” (n = 233). This analysis rests on the theoretical model of clinics types differentiated by the clinic's style of control over clients. With a focus on the interaction between individuals and their institutional environments, the analysis compares three types of clinics: reformist, medical-model and libertarian. Reformist clinics exercise the most control over their clients and libertarians the least. Compliance with clinic rules is defined as changes in levels of drug use and involvement with clinic program is comprised of patterns of retention. While affiliation at all three clinic types reduces drug use, reasons for continued use vary substantially by clinic type. Variation is explained by a control balance approach to understanding responses to organizational type.
This paper presents a theoretical framework and pilot study that examines the social context of the mental health treatment system and its impact on the spread of HIV among people with serious mental disorders. Recent epidemiological evidence indicates that mental illness clients may be at especially high risk of contracting HIV/AIDS. Mental health professionals' efforts to respond to the emerging epidemic, however, have been limited and focused primarily on individual-level interventions to change risk behavior. Virtually no consideration has been given to how treatment environments influence client risk behavior and/or the effectiveness of HIV prevention efforts. The perspective outlined in this paper builds on existing clinical research and proposes a general sociological framework for researching mental illness clients' HIV risk that emphasizes the clinical sexual culture of treatment programs. In an effort to develop preliminary measures and test key assumptions of the proposed framework, a small pilot study was conducted at a large state psychiatric hospital in the Midwest. The results suggest that clinical sexual culture does have a significant impact on the way both the patients and staff think about the management of patient sexual expression and HIV/AIDS at the hospital. More generally, the findings provide preliminary support for the theoretical framework presented.
Access to organizational resources decreases the level of violence in prison by reducing inmate alienation or “powerlessness.’ Staff and inmates constitute conflicting interest groups, competing for control over the daily routines of prisoners. Resources that increase the relative power of inmate groups increase the likelihood of violent confrontations between groups, whereas resources that increase an inmate's personal control of his or her fate reduce violence. Everyday disputes are transformed into serious matters when they represent an affront to an inmate's self-respect, particularly when disputes persist without resolution. Third-party dispute resolution reduces the level of violence by providing an alternative to the violent “recipes for action” that inmates derive from the wider culture.
In this paper, we describe a novel approach to this problem developed in Massachusetts which is based on the overlap between the missions of juvenile justice and public health in preventing violence and reducing substance abuse. Together with an academic department of psychiatry, the juvenile justice and public health agencies in this state have entered into a collaboration to develop an integrated system of psychiatric services in juvenile facilities. Before describing this program, we will present a background discussion on mental illness in juvenile offenders and the services in juvenile facilities. We will also review previous attempts to provide psychiatric services in Massachusetts' facilities and the history of the collaboration leading to the current program. In the final section, we will analyze referral patterns for the program during its first two years and present data on the types of psychiatric disorders found, and how they differed in boys and girls. We also present results on two measures of the program's effectiveness.
This chapter focuses on child abuse in the United States, how it is defined and measured, and its behavioral and social consequences. Throughout, the discussion is guided by concern with the organizations involved in confronting child abuse, from identifying its diverse forms and documenting their prevalence to policy formation and programmatic response. Major topics examined include the cycle of violence thesis, prevention and treatment, and problems and issues related to conceptual ambiguity (in particular, the absence of a generally accepted operational definition of child abuse) such as theoretical fragmentation and important knowledge gaps. Chief among the conclusions is the absence of the organizational unity and financial support necessary to facilitate the acquisition of the knowledge prerequisite to developing informed social policy and devising effective action programs.