Administration and Policy in Mental Health, Vol. 29, Nos. 4/5, May 2002 ( 2002)

SOMETIMES A GREAT NOTION . . . A COMMONAGENDA FOR CHANGE

Neal Adams and Allen S. Daniels

ABSTRACT: In the midst of a sea of change in the behavioral health care field, there isemerging a common agenda regarding critical issues and challenges. This article brieflyexamines the implications for education and training as we pursue this common agenda.Understanding the process of social change helps to chart a course for addressing theidentified challenges.

KEY WORDS: change; common agenda; education; reform; training.

“I’d rather be a lightning rod than a seismograph.”—Ken Kesey

The recent death of writer and social innovator, Ken Kesey, is yet an-other tick of the hands on the clock of social change. Kesey was not justanother author, but rather someone who brought with him an idea ofsomething larger—a time, a possibility, an actual shift in the ways of being.Few today may recall exactly who he was, what he did or what he wrote,but history will clearly remember him as a pivotal person in a political andsocial revolution. Kesey (1962) made his mark in the early 1960s by bring-ing the humor and fear of psychiatric institutionalization into public viewwith his first book, One Flew Over the Cuckoo’s Nest. He went on to becomea somewhat mythical prophet for a whole generation.Kesey (1988) bears testimony to the notion that the right ideas, at the

Neal Adams, M.D., M.P.H., is President of the American College of Mental Health Administration.Allen S. Daniels, Ed.D., is Professor of Clinical Psychiatry at the University of Cincinnati College ofMedicine; he also serves as Chief Executive Officer of Alliance Behavioral Care in Cincinnati; and heis President of the Academic Behavioral Health Consortium in Cincinnati, Ohio.This work was supported in part by Grant No. R13 HS10965 from the Agency for Healthcare Re-

search and Quality.Address for correspondence: Neal Adams, M.D., ACMHA, 324 Freeport Road, Pittsburgh, PA

15238-3422. E-mail: nadamsmd@pacbell.net.

2002 Human Sciences Press, Inc.319

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right time, represented by the right people, can have a profound and last-ing effect. So it is with those leaders in the behavioral health care fieldwho are willing to acknowledge and call attention to a quiet but growingcrisis in the education and training of our workforce. They are joined bya host of stakeholders who share their concerns and seek a commonagenda for change.Taken together, the collection of articles in this special issue of Adminis-

tration and Policy in Mental Health makes clear the urgent need for substan-tial, if not fundamental, change in the education and training of the behav-ioral health workforce. We are at a time when the awareness of andconcerns about mental illness and its treatment are perhaps higher thanat any point in the recent past. The opportunities for the field to demon-strate the effectiveness, value, and relevance of mental health and sub-stance abuse treatment are enormous. The alternative scenario is to be-come an irrelevant and diminished footnote in the larger health caresystem if we fail to meet the current demand for effective, efficient, qualityservices. The implied question is this: Are we the lightning rod or theseismograph?Much has been written about the phenomenon of change in human

institutions and endeavors. These range from the old French adage, plusque ca change, plus c’est la meme chose (the more things change, the morethey stay the same), to more elaborate theories and analyses about change.Recently, Charles Curie (2001), Administrator of the Federal SubstanceAbuse and Mental Health Services Administration (SAMHSA), presentedanother view of the same paradox: “Everyone wants progress, no onewants change.” Watzlawick and colleagues argued that we often speak ofand wish for what they called first order change, which is fundamental orstructural in nature. More often than not, however, we are busied withsecond order change—the equivalent of the proverbial “rearranging deckchairs on the Titanic” (Watzlawick, Weakland, & Fisch, 1974).

Entirely new paradigms allow us to see our world differently—to seenew possibilities and discover new opportunities that previously couldnot be imagined.

Kuhn (1996) has argued convincingly that true and substantive changeultimately is not an orderly or incremental process. Rather, it is a revolu-tionary event in which entirely new paradigms emerge and take hold, withfar-reaching impacts and implications. It is often the very order of thingsthat may change. Such events allow us to see our world differently—to seenew possibilities and discover new opportunities that previously could notbe imagined.

321Neal Adams and Allen S. Daniels

Perhaps the greatest challenge to the success of the behavioral healthfield is the need for a competent workforce. Educating and training pro-fessionals and para-professionals to be knowledgeable, skilled, and pre-pared to meet the pressing demands of the behavioral health workplace isessential. Without this, there is a real question as to whether or not thefield can survive and realize its potential to contribute to the well-beingand health of our society. For example, there are genuine concerns thatcurrent educational and training programs remain rooted in the past andhave fallen out of step with the new demands of integrated clinical systemsof care and evidence-based practice (Liberman, Hilty, Drake, & Tsang,2001). These concerns and others drive the consensus that major reformor perhaps radical change is needed.This problem is not unique to behavioral health care, as is well docu-

mented by the Institute of Medicine’s (2001) report, Crossing the QualityChasm. The same concerns are found in other segments of the health carefield, in the general business sector, and in professional education. Per-haps it is the very nature of academe and its traditions that is at the rootof this disconnection between professional education and the demands ofthe workplace. Or, perhaps the problems result from the seemingly accel-erated pace of change in the cultures of practice, business, and teaching.How can academicians remain aware of the rapid changes to which prac-titioners must respond? How must training and education change to meetthese demands?

There appears to be emerging clarity among stakeholders regarding acommon agenda and set of priorities for change.

There appears to be emerging clarity among stakeholders regarding acommon agenda and set of priorities. Some of the priorities are generaland applicable to the entire field, while others specifically address educa-tion and training issues. Overall, this agenda focuses on the need to dothe following:

• Continue to build a science base in order to overcome stigma, removefinancial and other barriers to access, and facilitate entry into treat-ment.

• Improve public awareness of safe and effective treatments.• Ensure an adequate supply of mental health services and competentproviders.

• Ensure delivery of state-of-the art treatments.• Assure equity and tailor treatment to age, gender, race and culture.

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• Achieve appropriate clinical integration of primary care, mentalhealth, and substance abuse services.

The agenda demands a workforce of new and existing providers that isproperly educated and adequately trained to meet service and socialobjectives. But what is proper and adequate?

Accomplishing these aims requires more than simply a sufficient num-ber of behavioral health care providers. This agenda demands a workforceof new and existing providers that is properly educated and adequatelytrained to meet these service and social objectives. But what is proper andadequate? The authors of the Institute of Medicine report (2001) arguethat our clinical education and training programs must teach providers todo these things:

• Use a variety of approaches to deliver care (including non-face-to-faceand electronic approaches).

• Effectively combine evidence-based treatments with individual charac-teristics and preferences to tailor care for each person and family.

• Communicate with persons served and their families to support theirdecision-making and self-management.

• Use decision-support systems to aid clinical decisions and controlover-utilization, under-use, and waste.

• Identify and eliminate errors and hazards in care.• Understand the course of illnesses and the experiences of personsserved and their families.

• Measure the quality of care from both process and outcome perspec-tives, including the implementation of evidence-based practices.

• Work collaboratively with shared team responsibilities, incorporatingmultidisciplinary care in behavioral health and multispecialty care ingeneral health.

• Provide care in a range of locations and settings.• Find new knowledge, evaluate treatment effectiveness, and incorpo-rate the use of this new knowledge in practice.

• Understand the determinants of health and the links between care,healthy populations, personal choices, and clinical responsibilities.

• Identify and pursue opportunities for prevention.

In too many cases, today’s professional education and clinical trainingprograms are not addressing these needs (Hoge, Jacobs, Belitsky, & Mig-dole, 2002). These issues are reflected in both the existing workforce and

323Neal Adams and Allen S. Daniels

the training of new clinicians. The curriculum challenges facing both pro-fessional and continuing education span all levels of clinical training.In his recent book, The Tipping Point, Malcolm Gladwell (2000) attempts

to understand social change in terms of an epidemiological model or para-digm. His basic premise is that ideas spread like diseases and that changeoccurs when dissemination becomes epidemic. But not all contagionsspread—and even those that are distributed do not necessarily broadly in-fect all. He identifies three characteristics of an epidemic. These includecontagiousness, the observation that small changes can have big effects,and that change is not gradual but rather occurs dramatically in a moment.This is what he calls the “tipping point.” Gladwell then attempts to makesense of epidemics and change by offering three rules, which he calls 1)The Law of the Few, 2) The Stickiness Factor, and 3) The Power of Con-text. Understanding these phenomena, and learning to mange them, maywell empower us to become more effective agents of change and reach a“tipping point” in efforts to reform education and training.The Law of the Few supports the notion that a social epidemic is heavily

dependent on the involvement of a small group of people with a particularpoint of view and a unique set of social abilities. Gladwell describes theseindividuals as “connectors,” “mavens,” and “persuaders.” Being expert andknowledgeable, being well networked and influential, being passionateand committed are all characteristics of individuals who can make a bigdifference. Even just a few exceptional people with the right talents canhave a profound effect.The Stickiness Factor refers to the notion that some ideas can be pre-

sented in such a way as to become irresistible. Stickiness is a property ofthe message. When messages are memorable, they change people’s behav-ior. Oftentimes the challenge is to find the right packaging or medium forthe message in order to move ourselves and others to action.

A small group of influential and well-connected leaders has articulateda compelling vision of the need for, and possibility of, reform.

The Power of Context suggests that epidemics of change are sensitiveto the conditions and circumstances of the times and places in which theyoccur. Gladwell argues that we are exquisitely sensitive to certain changesin context, and that contextual changes are capable of tipping an epi-demic. Small changes in our external environment can have a dramaticeffect on how we behave. Underlying successful epidemics of change is thebelief that change is possible and that people can substantially alter behav-ior or beliefs given the right impetus in their environment.

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There is much to suggest that we are approaching a tipping point ofchange in behavioral health care education and training. There is a smallgroup of influential and well-connected leaders who have brought forwardand articulated a compelling vision of the need for, and possibility of, re-form in this arena. This is occurring at a time when there are both threatsand opportunities in the environment, both of which create a context forchange. The growing consensus around a common agenda is good evi-dence that needed reforms in our approach to human resource develop-ment may soon infect the field. The necessary conditions for reaching atipping point appear to be satisfied. The moment to bring attention andadded strength to our education and training systems is upon us.

REFERENCES

Curie, C. (2001, November). Opening remarks. National Dialogue on Identification of Model IntegratedService Programs for Co-Occurring Mental Health and Substance Abuse Providers. National Association ofState Mental Health Program Directors, Washington, DC.

Gladwell, M. (2000). The tipping point: How little things can make a big difference. New York, NY: Little,Brown & Company.

Hoge, M.A., Jacobs, S., Belitsky, R., & Migdole, S. (2002). Graduate education and training for contem-porary behavioral health practice. Administration and Policy in Mental Health, 29(4/5), 335–357.

Institute of Medicine, Committee on Quality Health Care in America. (2001). Crossing the quality chasm:A new health system for the 21

stcentury. Washington, DC: National Academy Press.

Kesey, K. (1962). One flew over the cuckoo’s nest. Madison, WI: Turtleback Books.Kesey, K. (1988). Sometimes a great notion. New York: Penguin USA.Kuhn, T.S. (1996). The structure of scientific revolutions (3

rded.). Chicago, IL: University of Chicago Press.

Liberman, R., Hilty, D., Drake, R., & Tsang, H. (2001). Requirements for multidisciplinary teamworkin psychiatric rehabilitation. Psychiatric Services, 52, 1331–1342.

Watzlawick, P., Weakland, J., & Fisch, R. (1974). Change: Principles of problem formation and problemresolution. New York: W.W. Norton & Company.