What we are like when we are at our best: Appreciative stories of staff in a community mental health center

Abstract

Appreciative Inquiry is an organizational change methodology that discovers what works well in an organization and then pursues strategies to enhance those factors. The initial discovery process itself provides data ripe for qualitative analysis. Narratives were collected from 27 community mental health staff about times when they were at their best. An emergent, consensus-based analysis was used to understand the stories and exemplary work -- with competent, caring staff and elements needed to support them. Findings are discussed in light of self-determination theory that people are at their best with a sense of mastery, connection, and autonomy.

Mental health organizations are facing ever-increasing pressures and demands to deliver more services with fewer resources. Understanding how organizations best function is important, particularly during times of economic strain. Staff perceptions of their best work have the potential to inform administrators regarding factors that facilitate effective community mental health work. Further, understanding these factors is key in light of high and increasing rates of burnout and turnover across mental health service organizations (Morse, Salyers, Rollins, Monroe-DeVita, & Pfahler, 2012; Paris & Hoge, 2010). Many have investigated staffing issues by analyzing and speculating about problems in the field; however, a strengths-based analysis of organizations has the potential to identify modifiable factors within an agency -- existing strengths at organizational and staff levels -- that can be developed even further.

Appreciative inquiry (AI) is a philosophical approach and set of linked practices designed to discover what is working well in an organization and developing strategies to build on those strengths (Cooperrider & Srivastva, 1987). As an organizational change strategy, AI involves stakeholders working together in what is often referred to as the 4D process: to discover what is going well, generally through individual “discovery” interviews, dream together about what the organization could be, design approaches to achieve the dream, and ensure the destiny of the proposed changes by implementing and sustaining changes in the organization’s day-to-day work practices (Cooperrider, Whitney, & Stavros, 2008). Evidence for the effectiveness of AI as an organizational change strategy consists primarily of case studies. A meta-case analysis of 20 such publications found evidence for transformational change (defined as shifting the identity or nature of the organization) in 35% of the cases; transformation was more likely when the process emphasized changing how people think (not just their actions) and on incorporating ways to ensure that changes endure (Bushe & Kassam, 2005).

At the heart of AI is the process of discovering what is working well, in contrast to organizational change strategies that identify problems to fix. A common approach to finding what is working well is the practice of conducting appreciative “discovery” interviews where stakeholders are asked questions about the positive potential in their organization (Ludema, Cooperrider, & Barrett, 2006). Appreciative interviewing has been used in a variety of contexts, for example, to identify and refine an organization’s core values (Taylor, Karnieli-Miller, Inui, Ivy, & Frankel, 2011), to facilitate process improvement in medical care (Helms et al., 2012), and to better understand relationships between staff and inmates in prison (Liebling, Price, & Elliot, 1999). Appreciative interviewing has also been suggested as a useful tool for conducting meaningful employee performance evaluations (Kluger & Nir, 2010).

AI and appreciative interviewing are consistent with strengths-based approaches in mental health (Rapp & Wintersteen, 1989) and with the current zeitgeist emphasizing hope and the possibility of recovery from mental illness (SAMHSA, 2011). At a time when community mental health is struggling with increased financial pressures and reduced resources, work-related stress (and distress) may be increasing (Wells, 2011). Further, as noted by the Substance Abuse and Mental Health Services Administration (SAMHSA), retaining competent staff is “a major problem for…prevention and treatment organizations and state behavioral health systems” (p.16; Hoge et al., 2007). Focusing on what is working well for staff in an organization, and identifying the factors that support these positive experiences, may help identify core factors for success. Yet, very few examples of AI in mental health have been published. We could find only two published studies that incorporated AI in community mental health settings. Goldie and colleagues (2010) used AI principles in conjunction with motivational interviewing to help mental health clinicians use effective smoking cessation strategies with clients. Fieldhouse and Onyett (2012), used AI principles with a focus group of service users and providers to identify best practices for interagency collaboration.

The purpose of the current project was to analyze narratives from appreciative “discovery” interviews (the first step in an AI process) with a sample of community mental health workers in a single multiservice agency. In the context of an AI pilot program, narratives from 27 employees were collected in a participatory action framework (Minkler & Wallerstein, 2003), partnering researchers and clinicians to collect and analyze stories. Similar to Fieldhouse and Onyett (2012), we planned to use the data collected during the discovery process to learn about effective practices. By capturing staff perceptions of their best work, we hoped to identify useful information to facilitate effective ways to engage and support staff working in community mental health.

Method

Procedures

The study took place at a Community Mental Health Center (CMHC) in a small Midwestern city. The project team attended an all-staff meeting in November 2011 to describe Appreciative Inquiry and gauge staff interest in participating in the process. Although we initially planned for about 8 interviewers, 20 staff volunteered to become AI interviewers. These individuals were required to complete training in human subjects research and additional paperwork as required by the Institutional Review Board. Interviewers participated in a half-day workshop (January, 2012) to fully develop the interview guide and receive training in interview procedures. The research team brought a sample interview guide from a prior study, and worked collaboratively with workshop participants to tailor the guide. After the workshop, interviewers were asked to recruit up to 4 employees (not supervisees) from service lines different from their own to participate in interviews. After a written informed consent process, interviews were conducted and audio recorded in a private location in the CMHC. The interviews were transcribed verbatim and checked for accuracy with all personal information removed. Neither interviewers nor participants were paid for their time. The study and procedures were approved by [the university’s] Institutional Review Board.

Setting

The CMHC is a public, non-profit organization that employs approximately 230 staff, providing community-based substance abuse and mental health services to nearly 6,000 clients annually in four predominantly rural counties. Community-based services include: case management, home-based and school services, supported employment, outpatient individual and group services, and medication management. The CMHC also operates a residential program and an acute care inpatient unit. When the study began, the agency was preparing for a leadership transition. The CEO (of 17 years) was retiring in 2012. The leadership team was concerned that this change could negatively impact morale given the long tenure of the CEO and the uncertainty that the process of recruiting and hiring a new person would bring to a relatively stable organization. The leadership team was familiar with AI, and wanted to try a pilot project to learn from and build on the organization’s strengths as well as to understand the values of the workforce.

Participants

Initially, 20 CMHC staff expressed interest in participating as interviewers. Of those, 14 completed the necessary IRB training and paperwork, and 9 interviewed at least one employee. Overall, 27 interviews were completed. Of these, 23 interviewees (85%) were female; the mean length of time employed at the CMHC was 8.3 years (ranging from 6 months to 19 years). Interviewees included receptionists, case managers, nurses, therapists, team leaders, and managers, including senior level managers.

Measures

Appreciative inquiry “discovery” interviews were conducted one time, individually, with each participant. The interviewer began by asking about the person’s role and length of time at the agency. Then, the person was asked to “think of a specific experience that stands out for you that brought out the best of who you are in your work at [agency]. Please tell the story of that time.” The interviewer then asked the person to dream into the future, where “[agency] is the ideal place to work, with happy, engaged and committed employees. What is happening at [agency] to make that happen?” Interviewers were instructed to read the questions verbatim and to probe for clarification, but to let stories emerge with minimal prompting. Interviews were audio-recorded, transcribed, de-identified, and checked for accuracy. Interviews averaged 10 minutes in length (1 was less than 5 minutes, 16 were between 6 and 10 minutes, 8 were between 11 and 15 minutes, and 2 were longer than 15 minutes).

Analysis

Transcripts were entered into Atlas-ti to facilitate coding and analysis. A team-based iterative approach was used to identify themes in the transcripts, following the tradition of immersion/crystallization (Crabtree & Miller, 1999). The team consisted of a psychologist, sociologist, doctoral student in clinical psychology, and two clinicians from the CMHC with advanced degrees in social work. Stories were read independently and team members highlighted and gave provisional labels to chunks of text that illustrated a theme for 1–2 stories at a time. The team then met to discuss constructs being identified in the data and developed a list of codes that continued to be refined as additional transcripts were read. Through iterative, consensus-building conversations, the provisional themes were discussed and finalized. The final codebook included four structural codes to identify parts of the transcripts (main story, supporting elements, future, and quotable quotes) and 14 content codes to identify the nature of the story elements (See Table 1). After the codebook was finalized, the first two authors went back to each transcript to apply codes, meeting after every third transcript to compare coding for consistency. The team summarized the content of each of the codes, examined diagrams of overlapping codes, combined codes when needed, and repeatedly went back to the transcripts to examine the presence/absence of themes.

Table 1.

Final codes for focused coding.

Structural Codes (A priori codes)
Main story	Text describing the event or time when they were at their best.
Supporting element	Factors that helped the main story take place. Often coded in response to questions about what was it about you, others, and context that allowed the story to happen.
Future	Text describing the desired future state of the organization.
Quotable quotes	Poignant text that stands out.
Content Codes (Emergent codes from the text)
Accessing Resources/Services:	Descriptions of using other services or resources in the community. [Only used 4 times, minor part of stories]
Being effective in a crisis situation	Specific issues related to working in a crisis.
Caring about consumers/believing in them	Descriptions of concerns for consumers’ well-being as well as positive attitudes about consumers.
Communicating well	Descriptions of communication. This could be between staff, and also with administration (e.g., knowing what to expect).
Feeling effective/seeing success (despite the odds)	Describing indications that staff were effective in their job.
Feeling supported by supervisor/coworkers	Instrumental and emotional supports provided by others.
Feeling valued	Feeling that people care about them. Includes other staff as well as consumers.
Flexibility/ Autonomy/ Having a flexible schedule:	Descriptions of being able to make decisions about how and/or when work is done.
Having (enough) knowledgeable, experienced, trained staff	Describing the amount of staff and/or their qualities.
Other staff characteristics	Personal characteristics staff may have mentioned, e.g., being flexible, open.
Other things	Other factors that seemed important.
Tools to do your job	Descriptions of helpful tools like phones or computers to do the job. [Only used 2 times, minor part of stories]
Trusting each other	Descriptions of trust, relying on other people.
Working as a team	Refers to working collaboratively with other people. This could refer to working across disciplines - sharing information and resources, working together, and supporting each other’s ideas.

Results

The three central elements that tended to occur in almost all main stories were: Feeling effective/seeing success; Being effective in a crisis, and Caring about consumers. In addition to the central elements, seven supporting elements emerged that participants described as helping enable the story in which they were at their best. As shown in Figure 1, at the core of positive community mental health are staff who value competence and caring. Competence is reflected in main stories describing events that allowed them to feel effective and/or see success, and for many, specifically being effective in crisis situations. Caring is reflected in main stories that describe caring about consumers and believing in them as well as many of the supporting elements related to staff caring about each other. Below, we first describe the central elements of the main stories, and then describe in more detail the supporting elements.

Figure 1.

The positive core of community mental health.

Central Elements

Feeling Effective/Seeing Success

Stories frequently included descriptions of consumers who had overcome obstacles (e.g., substance abuse, difficult relationships, legal problems, unemployment) to become successful. Some of the success stories were about transformative, and sometimes surprising, life changes that took place for consumers. One clinician described a consumer’s success in overcoming substance abuse: “I remember that case because he was so hard core. And so I think that was one case that I think of years ago that I felt brought the best out in me because he, the group members, could not even believe the change” (P14). Another person noted, “It’s interesting to see that you can make a difference in a short amount of time…in 12 months seeing like their whole world change for the better” (P23).

Staff had a sense of accomplishment seeing their efforts pay off. One case manager described seeing a previous consumer:

He wanted me to know that he is not doing any more drugs, that’s he’s going to go back and try to get his GED, that he has a girlfriend, and he’s helping his mom out, and he’s working on his relationship with his actual biological father. I was just ecstatic to not see him for a couple of years and then to run into him and (having) him tell me that 'I’m sorry for all the things I put you through. The 10 o’clock visits and whatever.' But just to hear that, I was like okay then my job is working, you know. (P1)

Seeing success feels good. For example, one person noted, “I get pleasure out of seeing them finally getting it" (P20). Others used language of “fulfilling,” an “honor,” and “the bomb” to describe the same feeling. A particularly evocative description came from one of the CMHC leaders who described a dinner to highlight consumers who were successfully employed:

The clients would get up and tell their story about their break in mental health or maybe an addictions issue and the fact that our staff worked with them, then they were able to get them a job. And they felt, I mean, they felt good about their experience. They were back on track. They were earning a living. They felt they had self-esteem, self-pride and whatever. And you know, you sit there and you say, ‘Gee this is absolutely the best, the top, zenith.’ It’s gut wrenching and heart rendering at the same time” (P10).

While most of the success stories featured consumer success, a few stories also highlighted staff success. One particularly noteworthy story came from a young case manager who experienced a transformation in her own development (that came from feeling supported by coworkers as well as helping consumers). As P12 describes:

I was scared to death to do it [run a group for adolescents] ‘cause being in front of a group of teenagers is nerve wracking. But, my co-facilitator and the other case managers were very encouraging and supportive of it and doing that over the summer completely changed how I view teenagers, how I view myself… Not only have I have been helping them, but it’s just made me become more confident in my role as a facilitator, case manager and a co-worker.

Being Effective in a Crisis

For several participants, being at their best was reflected in stories about being effective in a crisis situation. At the heart of each of these stories was a consumer in an emergency situation, and the actions a staff member (and often others) took in order to help the consumer and/or another staff member. One of the most frequent activities mentioned was coordinating services to help consumers access needed care. Coordination required working with other staff, as well as other agencies and service systems (e.g., police, detox clinic, nursing homes), which could take a great deal of time and effort, and required effective communication.

Being effective in crisis situations also involved managing one’s own and others’ emotions. For example, a supervisor described a situation in which an adolescent with autism was thought to need hospitalization, and the child's divorced parents had "heated" arguments about the best way to help the child. The supervisor and case manager worked together to effectively help the family -- "the child that was escalating because of the tension between the parents was able to calm down. The parents were able to come up with the same goal, that the child probably did need placement before he hurt himself. And they were able to coordinate who was going to be able to transport this child to the facility" (P15). The supervisor attributed the success of the mediation to his ability to stay calm, "unemotional," and be "direct but yet compassionate."

Caring about Consumers

Caring about consumers was almost ubiquitous, and was evident in 25 of the 27 transcripts. The remaining two stories revolved around staff helping other staff. Some staff explicitly made the connection between caring about consumers and their reason for working. For example, P8 described that being part of a team had, "energized the fact of why I am a therapist, and why I want to help people. And really getting to the consumers and clientele that we touch and really wanting to make a difference."

Several others highlighted the importance of caring about consumers through stories where a staff person went beyond expectations to be helpful. This frequently involved providing services at times or locations that were not part of the normal work structure. As described above, P1 "would do like 10:00 pm visits to their house just to make sure that they were where they were supposed to be" and later, "I didn’t care what time it was. You know, I was worried about him. I knew he could do it, so just that determination.” Others described taking work home, offering additional services on the weekends, or doing tasks outside the usual duties for a particular profession. As one nurse put it "I always take the time. No matter if I don’t have the time, I still take the time.” (P21)

Despite economic and political pressures, caring about consumers and effectively meeting their needs is a core value of working in community mental health. A manager alluded to finances, but emphasized that it is the care for consumers that drives the work, “But on the bottom line is we will still need to care for clients. So we’ll need care givers who are committed and dedicated to the people we serve." (P10). Another participant ended his interview describing his coworkers:

They have that passion for the people. I mean, you have those people who come in and they’re constantly, 'You got to make your billable. You got to do this. You got to do that.’ You know, it’s so company-oriented, or money-oriented that you forget the whole reason you’re doing the job. And that’s to see the changes in your clients. You know, I didn’t take the position because I thought I was going to make millions. I took it because I wanted to see people have relief and feel better and feel like they could succeed in life. And you see that time and time again when it comes to employees. (P25)

Supporting Elements

Supporting elements (that helped the main story take place) were more varied and frequently occurred together. These included Autonomy/flexibility, Trust, Communicating well, Working as a team, Feeling supported, Feeling valued, and Having knowledgeable, experienced, and trained staff.

Autonomy/Flexibility

Autonomy and flexibility were supporting elements in several stories. One staff person talked about personal flexibility and support from her mother who supported her ability to care for the consumer (with visits late at night). "I think being flexible; knowing that I could just call my mom and say, ‘Mom I’ve got to go check on a client. Come watch the kid.’ and [I] got in my car and went there.”(P1) Others also spoke about the ability to make decisions on their own about how to use their time at work to help consumers. For example, as P4 shared, "I think just yesterday when I dropped everything that I was doing and came to the (satellite office) to get a med tray for a client who forgot what day it was and came and got her med tray the wrong day. [participant crying] Sorry."

Flexibility in scheduling was also important. One person shared an example that helped the staff person (who was also a student in need of clinical hours) as well as the consumers they served: "Actually our CEO allowed me to establish this Saturday group. Not only did it benefit me because I would be able to obtain my 2000+ hours by the time I graduated, but it really did help the clients because they were able to cut the time in half that they would have to normally go which meant they could still be making income for their families." (P14). Although several people mentioned positive aspects of autonomy and having control over how their time was spent, one person did talk about initial challenges, starting his story with a low point of not having enough direction when he first started working at the agency. He went on to say that this also had some positive benefits: "So having nobody there at all was a little difficult, but it did cause me to make some connections and that was leading to some high points where I got to know some other people providing services that assisted me” (P8).

Several staff members linked autonomy directly with quality of management and trusting employees, for example, describing the importance of "allowing people to be independent in their job and not handholding and micromanaging"(P23). Autonomy support by management came up several times in the section of the interview focused on dreaming into the future. For example, P10 said, "They (staff) just need to be nurtured. They need to be guided… in some cases, management needs to get out of their way cause they can do just fine on their own. But they need to be trusted to do that."

Trust

One element of trust, closely related to autonomy, is believing that others are competent. As P15 described, this level of trust can help staff be more effective and efficient. "(My coworkers) were able to trust me enough to do my job and me trust them to do theirs. We were able to separate those duties at that time. And just get the job done." Similarly, P6 described how his supervisor trusted his judgment, "My supervisor is very supportive, trusts my judgment, allows me to make decisions. Had he not been here, I would have 911’d him anyway. And my supervisor would have been supportive of and fine with it."

Several interviewees also talked about trusting relationships. P13 talked about coworker trust; when asked about the future, she focused on relationships. "I think that having a good solid, trusting, collegial relationship with co-workers is really important…So long as you can have this open flow, have trust, do things that are trusting and helpful then it usually keeps things going really well." Similarly, P16 focused on the relationships between co-workers as being critical, "to be enjoyable and fun and we kind of let our guards down for the few hours and just enjoy each other’s company. I think that goes to relationships and a level of trust. I think those things are really important to make an organization work well."

Communicating well

From the stories that were collected, communicating well involved being open, having honest conversations, listening, and sharing information. For example, P8 described how good communication is necessary in managing conflict:

Being able to handle that conflict and keep those lines of communication open and not allowing the individuals in this situation, not allowing their feelings to get hurt or feeling tromped on and really coming together and working together. It’s really created a very safe place for this family that even though they were, you know, against services to begin with are now embracing the services and seeing that they can help them be a more productive family.

Working as a Team

Teamwork involves getting along well with other employees and being “cohesive”. Interviewees often related cohesiveness as important to communicating well and feeling supported. For example, P11 described:

It’s kind of cliché as that sense of family as far as the work environment goes. I feel there is for the most part, that they’re available, that teamwork, togetherness type of thing, communication type thing is available. And that’s something that for me personally, makes me feel good that is available. Happy and to know that I’m just not flying solo all the time, you know."

Teamwork also involves sharing information and knowledge, often across disciplines and departments. Teamwork brings “fresh” new ideas and the ability to “brainstorm” options. These additional ideas, resources, and skills work in the best interests of consumers. For example, P15 said, “I’m seeing case managers and therapists working together more and staffing cases and talking about those cases. Letting each other know what’s going on in the home or what’s in the office and sharing different skills that benefit the family”. Interviewees found working as a team enjoyable: “being there with the other activity team members and with the rest of the staff, that’s the fun part. That’s the good part.”(P16) Working as a team is efficient, and makes the work go smoothly, and one used an analogy of an orchestra “working together almost like an orchestra. I would say we orchestrate together as a team every day.”(P14)

Feeling Supported

Feeling supported often meant getting questions answered, having people to bounce ideas off, having other people being willing to help, and not feeling alone. There were also several examples of staff members helping each other during a crisis. The importance of support extended to helping consumers as well, as one clinician noted, "I can be that strong person for them because I knew I had a strong person supporting me" (P25).

Staff expressed the importance of administrators at top-levels of the organization offering support. P2 said, "The senior management care what can be done to make my job better not only for me but for the rest of the staff and for the clients as well. You know, and they think about those things. I know they do, and that’s good." Support was also evident in many of the quotes related to autonomy and trust above -- supportive leadership trusts people to make good decisions. One agency leader described the role of supporting staff to make their own decision:

If you trust people, you put them in positions where they make the decisions and then all you have to do is be informed, and so you can support them and be positive about what they have done. I think it’s important in trusting people that you have to give people the opportunity to fail. And when managers have allowed staff the opportunity to be trusted and fail and then pick them up, dust them off, and tell them that’s ok. Don’t do it again. And go back and continue doing what you’re doing, that’s when organizations function to the highest of levels. (P10)

Feeling Valued

Feeling valued was another important supporting element. One staff person mentioned feeling appreciated by consumers in particular, "I hardly have a day go by that a client doesn’t thank me very much and it means a lot to me, what I do." The same person later said, "…clients even that I used to see a long time ago on occasion will call me and say, ‘hi I miss seeing you’ and they’re still coming here but not with me. Now that’s an honor. I just feel that’s an honor."(P21) Two staff described specific instances of feeling valued by other staff, and both of these instances were also about feeling supported, highlighting the close linkage between the two concepts. For example, one staff person described working full time while pursuing graduate training: "I mean everybody was just hugely supportive, so I felt like they were vested in me and like that I was a valued employee, and they wanted me to complete that and finish that [degree]. And, you know, that helps you then become a better clinician and employee, and if you feel valued as an employee, that makes you want to do your best."(P9)

Having Knowledgeable, Experienced, Trained Staff

In order to successfully achieve any of the outcomes described above, CMHCs need sufficient numbers of staff. As P16 dreamed into the future, describing trusting relationships and working across agencies, he said "I think all those things will come, but I think we need to have the staff in place as an agency to get that done.” Staff also described the importance of having prior experience, knowledge, training, and skills that allowed them to respond most effectively to the needs of consumers. For example, specific knowledge was important in domains of medications (P13), and insurance (P2), having had experience as a job coach (P26), knowing how to remain calm in a crisis (P19). Staff indicated the importance of being flexible (P1) and being willing to respond to clients based on their individual needs. Specifically, P6 indicated that “just knowing the client” allowed her to know how to respond most effectively in a crisis situation. Staff also emphasized the importance of empathy (P11, P14) as key to successfully helping consumers. For example, P24 shared the impact of listening and being able to engage the consumer with empathy: “I think definitely listening to the clients and their family, sharing things that just help relate that you are not better than them, that you are with them and that you understand what they’re going through."

Discussion

By studying appreciative interviews among staff in one organization, a picture of critical elements supporting community mental health staff to be at their best emerged. At the positive core of this community mental health center are staff who feel at their best when they perceive themselves as competent and caring about others. The main stories highlighted situations in which staff felt effective (overall and in crises) and could see success in their work. The other predominant theme was caring about consumers (and frequently each other). A variety of other related themes supported this positive core (see Figure 1).

Staff at this agency described going above and beyond job duties in caring for consumers and helping other staff with whom they work. In a parallel process, it is notable that many staff were willing to complete extensive university training and paperwork requirements to participate in this research project, without financial compensation. Their volunteer spirit was particularly compelling given an environment of heightened accountability for (billable) time. In light of these observations, theories of human motivation may provide useful guidance to frame the findings. In particular, self-determination theory (Ryan & Deci, 2000) specifies conditions in which people are at their best -- when needs of autonomy, competence, and relatedness are met. Although analyses did not begin with this theory in mind, the emerging themes clearly support the role of all three elements in the appreciative stories that were collected, albeit in a somewhat modified configuration.

In the main stories, competence needs were evident in themes of feeling effective—overall and in times of crises. Staff frequently felt at their best in moments where they could rise to a challenge (e.g., successfully managing a crisis) or had evidence that they were effective in their jobs (e.g., seeing consumers succeed; hearing positive feedback). The importance of a sense of accomplishment has been highlighted in the work on staff burnout (Maslach, 1993), where a core symptom reflects staff no longer feeling effective in their work.

The other main story theme in staff narratives, caring about consumers, affirms relatedness needs in self-determination theory. Caring about consumers -- expressed as connecting with consumers, believing in them, and a having a desire to help make their lives better -- appeared to be a driving force, present in almost every story. Several of the supporting themes also reinforce relatedness -- feeling valued, being supported, trust, communicating well, and working as a team highlight the role that relationships with other staff can play in ensuring an environment that brings out the best in employees. Other research has highlighted similar concepts such as coworker cohesiveness (Moos & Moos, 1998) and supervisor support (Schoenwald, Sheidow, & Chapman, 2009) in maintaining quality of care. Team structures have also been effective in a variety of healthcare contexts (Gilbody, Bower, Fletcher, Richards, & Sutton, 2006), and are the basis for many evidence based practices in mental health for adults and children -- notably Assertive Community Treatment (Stein & Test, 1980) and Multisystemic Therapy (Henggeler et al., 1999). Given the widespread use of teams, and the foundational nature of the relationship with the consumer, attention to the relatedness aspect of community mental health appears critical.

Autonomy support is the third domain of self-determination theory and was also evident in participant stories, though not as the main story. Indeed, none of the stories had autonomy as the central concept. Rather, autonomy played a subordinate role, supporting staff to feel effective and to care about consumers. As Ryan and Deci (2000) note, the universality of the three components “does not imply that their relative salience and their avenues for satisfaction are unchanging” (page 75). It may be that in the work setting of providing mental health care, autonomy needs take a back seat to relatedness and competence. Autonomy supports this work by allowing staff to make decisions about how time is spent or when services would be offered (e.g., seeing consumers after hours). Autonomy was closely related to issues of trust, with senior management suggesting that managers sometimes need to “get out of the way,” and staff reporting that by trusting others to do their jobs, they were better able to do their own jobs. Other studies support the important role of autonomy for staff, predicting lower burnout and higher job satisfaction (Bakker, Demerouti, & Euwema, 2005), and well as for consumers, where autonomy support relates to better clinical outcomes (e.g., Williams, McGregor, Zeldman, Freedman, & Deci, 2004).

In this manuscript, we used AI as a data collection technique, capitalizing on the stories that were told in the discovery process, to learn more about community mental health staff at their best. This is similar to Fieldhouse and Onyett (2012), who used appreciative data collection practices to learn effective strategies from a focus group of interagency collaborators. AI as an organizational change process has even greater potential. As noted above, Goldie and colleagues (2010) described an organizational change process using AI and other techniques. While we did not study or use the full AI process, the clinical leaders noted that the appreciative interviews helped the leadership team focus on staff experiences, and communicated to staff that leadership was interested in them, which may have been particularly important as the agency was going through a leadership transition. In addition, the interviews provided a context and ideas for strategic planning that began after the interviews were completed. In a full AI process, stakeholders develop ideas to build on the positive themes and integrate them into practices (Design and Destiny; Cooperrider et al., 2008).

AI as an organizational change process, and as a research strategy, is just beginning to be used in community mental health settings (Fieldhouse & Onyett, 2012; Goldie et al., 2010). We found the rich contextual information the interviews produced helpful in understanding the critical elements necessary for community mental health staff to thrive. At the same time, there are limitations to this study. Given the single rural agency, with a small homogeneous staff who volunteered to be involved, our findings should be considered provisional. In addition, staff members were being interviewed as part of a program evaluation, and we were limited to an analysis of their stories, some of which were brief. In addition, consumers and their natural support network may also provide helpful stories to inform mental health work.

While we believe these stories are instructive, we view this as an initial foray into the field that may generate more questions than answers. For example, will similar themes emerge in other settings? How, if at all, do these themes relate to organizational effectiveness? Are all core themes and supporting elements equally important? Do all need to be present to produce success? Despite the many challenges that remain in understanding the full potential for AI, our impression is that the interviewers, participants, and researchers who took part in this project found it to be a meaningful experience while working in community mental health during uncertain times.

Implications

A number of potential implications arise from this work. The use of AI elicited domains that support community mental health staff to be at their best, and any of the factors shown in the figure could be reasonable targets for intervention. Because feeling effective is so central, one clinical implication of this work is to find or create opportunities to learn about and celebrate successes, for example, by creating opportunities for staff to hear about consumers who are being or have been successful in their recovery process. Given that staff serve consumers who are in need of treatment, healthcare providers often may not see their own and others’ successes. Some existing programs provide structure for successful consumers to tell stories of recovery; for example, NAMI’s In Our Own Voice (Corrigan et al., 2010) incorporates video and personal testimony of consumers with severe mental illness who are doing well. Given the compelling examples of seeing efforts pay off, success stories may be particularly effective when staff can hear success stories of consumers they have served. Supporting relationships, both between staff and consumers, and among staff (findings ways to increase communication, trust, teamwork, while feeling valued and supported) is also important for creating successful programs. Another possible intervention area is supporting autonomy of staff, as the recovery movement encourages for consumers of behavioral health, so that staff have flexibility and authority to be involved in decisions that affect their daily lives. Appreciative Inquiry is a feasible method that can help organizations learn from staff (as well as consumers) ideas for building on existing strengths to make such changes.