This article chronicles the evolution of a promising collaboration which may have value for other human service providers. It is an account of how one white, middle class agency (VCS Inc.) has partnered with a grassroots Haitian organization (HACSO) to provide some culturally relevant mental health services. Many of the concepts that informed this project were gained through years of Undoing Racism training offered by the People’s Institute for Survival and Beyond (PISAB).*
The real roots of the partnership began with relationship building. The Clinical Director of VCS and the Executive Director of HACSO had a number of opportunities to work together in community groups. Regular association generated mutual respect and opportunities to learn about the work that each was doing. VCS staff made a commitment to support HACSO, attend its events and fundraising efforts, and offered to serve on the HACSO Board of Directors. The Executive Director of HACSO provided valuable information and insight into the needs and concerns of her community, which enhanced the capacity of VCS counselors. Her agency was also an important referral source when VCS clients required assistance with concrete needs.
HACSO is an agency in Spring Valley NY, home to a large Haitian community. HACSO provides a wide range of concrete services, including assistance with immigration issues, enrollment in Health insurance programs, filling out forms, housing, employment, Cancer screenings and much more. HACSO basically functions as a walk-in agency. People come when they have a specific need and are served the same day, whether or not they have an appointment. Clients are accustomed to patiently sitting in the waiting room until it is their turn. HACSO has a very small but devoted staff. No one is turned away and the staff works hard to meet the needs of the community.
VCS is a family service agency with a unique tradition of training lay volunteers from the community to provide skillful counseling for very low fees. VCS has received many awards for its work and has come to be seen as an important part of the service delivery system in Rockland County.
VCS has an office in New City NY, the county seat, but will also meet in village libraries and houses of worship with those clients who lack transportation. Because of our low fees and willingness to see clients off-site, many grassroots agencies refer to us. Nonetheless, the ED at HACSO felt that there were mental health needs in her community that were not being well addressed. It was her experience that when clients came to her for help with concrete services, they often began to share other personal and family problems with the HACSO staff. Because clients seemed to have a pressing need to talk on a personal level, it took a longer time for staff to make referrals, fill out forms and complete other necessary tasks.
Also, HACSO staff was not trained to deal with serious depression, domestic violence, grief and loss, post traumatic stress and a host of other issues clients presented. The two agencies began a series of conversations about how VCS could be more helpful to HACSO clients. This process was energized by United Way of Rockland County which invited agencies to partner in order to address a series of identified ‘basic needs’. More accessible mental health services for uninsured consumers was one such identified need. More bilingual mental health services were also needed. The two agencies were given a grant to address this problem.
We developed a tentative working plan. It began by offering the VCS counselor training to the HACSO staff so that they would be more familiar with our work and thus feel comfortable referring their clients for counseling. HACSO staff would then identify those clients who might benefit from one to one counseling. VCS professional staff would offer intake appointments on site at HACSO. HACSO staff would assist with translation if that was necessary. Once an assessment was made, VCS would provide a volunteer counselor who could meet with the client on a weekly basis, at HACSO if that was most convenient. With the United Way grant, VCS also would increase its effort to recruit more bi-lingual counselor trainees from the Haitian community.
The HACSO ED was concerned that pre-scheduled, once-a-week counseling sessions might not prove ‘user-friendly’ to her consumers. They were accustomed to coming to HACSO when they had a pressing need. They were used to having that need attended to in a timely manner, usually on the day they walked in. The idea of having to wait several days for an ’intake’, or of coming for counseling when there was no crisis was not normative. Nonetheless, we decided to go forward with our pilot project in the spirit of the PISAB which urges us think outside of the box and to take our direction from the community we are trying to serve.
The VCS Assistant Clinical Director assumed responsibility for implementing the project in September 2007. She met regularly with HACSO staff to discuss launching the program and helped develop publicity materials. Her ensuing dialog with the case managers conformed to the ED’s comments about the expectations of HACSO client base.
The Associate Clinical Director had attended the PISAB multiple times. As a result, she was well acquainted with the need for white people to listen to the voices of people of color. In the meetings with HACSO staff and the ED, she elicited crucial information about the needs of HACSO’s clientele. The HACSO staff doubted that the traditional white middle class counseling model would work. But at the time they could not think of a viable alternative. So, while the both partners had questions about the design, they agreed to proceed and try to learn from ensuing experiences and mistakes.
In the next several months, HACSO staff made referrals for intake appointments at the HACSO office. Appointments were not kept. However, there continued to be a steady stream of HACSO clients eagerly discussing personal problems while filling out forms or arranging for other services discuss. The ED and the caseworkers continued to meet to dialogue with the VCS Associate Clinical Director about how to get these clients to utilize the available service.
The VCS Associate Clinical Director continued to reach out to the community, follow up on referrals and worry about the lack of utilization, especially since she continued to be told by HACSO workers about their clients desperate need for counseling. About 6 months into the initiative, she had an epiphany. The people were coming to HACSO, and pouring out their life concerns and stresses to the case managers. The case managers had already completed the VCS counselor training. Why not create a “paradigm shift”? Rather than spending a part of their “case work” time listening to the clients’ mental health concerns, then calling VCS with a referral for intake, the case managers themselves could counsel the clients who were already in front of them. It made perfect sense. These workers had formed a helping relationship with the clients and the clients have a trust in the organization. The ground was already fertile for a counseling alliance to grow. The VCS Associate Clinical director could provide ongoing supervision and support for the HACSO workers. This would give them the opportunity to enhance their counseling skills, provide the clients with a much-needed service and deliver what the clients already expected: i.e. when clients appeared at HACSO they would receive help with their problems within a very short period of time.
The VCS Associate Clinical Director met with the HACSO ED to discuss the idea of “shifting” the mode of service delivery. The caseworkers already were performing many different tasks to help the clients, but whether the ED would be willing to have them counsel as well remained a significant question. The HACSO ED, a very bright, committed, visionary thinker, immediately accepted the idea and was hopeful that we might be on to something. She set up a meeting for the Associate Clinical Director to speak with her two caseworkers about the new plan.
At this meeting, the workers had many questions and concerns. Implementing the plan required a shift in perspective. The workers had been viewing their job of providing concrete services and the job of counseling as two separate functions. They did casework; they referred clients to VCS for counseling. The original idea of the grant was “ save the caseworkers time” by having another agency do the counseling. This fits with certain traditional social work concepts about how to deliver services. In retrospect, it now appears to make much more sense to take care of all the clients’ needs together. However there were still challenges to overcome.
The caseworkers and the ACD continued to meet and talk, building relationships. They concretized a plan. One early obstacle was the workers concern about whether they could actually “counsel” their clients. Since the workers had taken the VCS counselor training they were aware of the differences between the role of counselor and the role of caseworker. They worried about their ability to integrate the two roles into a helpful model. A very large component of the VCS Associate Clinical Director’s job is to train and supervise lay people to provide effective counseling. Fear of lack of competence is normative for new counselors and is ameliorated by processing the counselors’ feelings in supervision. As she and the caseworkers met in supervision over time, the workers began to develop better counseling skills, experience some mastery and competence in their new role and, as a result, became more comfortable “wearing the counselor hat”. After awhile, the caseworkers and the HACSO ED began to notice that certain clients were beginning to return to the agency when they had no concrete needs but just wanted to process something with their caseworker.
Besides working through the caseworkers normative “beginner’s anxiety” another challenge was that this new way of working would omit the professional assessment part of the VCS model. ( All VCS clients have an intake with a professional social worker to determine whether or not they are appropriate for work with a trained lay person. If they need a higher level of care, they are referred to the Rockland County Mental Health Clinic.). The workers and the ACD developed a map for implementing this idea in a safe way. The caseworkers and the ED were already referring clients whom they thought were in need of professional care to the County Clinic. In essence,they were already doing an essential component of the traditional VCS intake process by making these referrals. But, what happens when someone comes to intake, seems appropriate for lay counseling, and later in the process appears to need a higher level of care? This is often manifested by the caseworkers' feelings of being overwhelmed. The solution resides in ongoing clinical supervision. If the ACD concurs with the workers assessment, the client would be referred to the clinic. If the problem isn’t the clients’ increased need ,but rather is countertransferential,it is worked through in supervision as well. Between supervision meetings with the ACD, the workers have access to the ACD and the rest of the VCS clinical staff for purposes of consulting about a particular client about whom they have concerns. So far this plan has worked well.
Rose Leandre, Executive Director of HACSO shares a number of very helpful observations about this project. The following is an adapted transcription of a conversation with Rose which took place on November 21, 2008.
Rose says that in her community people only tend to seek help when they feel like they are in a crisis, or in her words ‘feel frantic’. This program has been effective, in her view, because it works with this concept. People can drop in and talk when they need to. Rose differentiates between a ‘social crisis’ and a psychiatric crisis. People who feel overwhelmed by their lives and who have no close family or friend to whom they can vent tend to hold things inside for too long, and are at risk of making poor decisions. Poor decision making then aggravates the crisis which can lead to complete chaos. People who are first generation immigrants have many real stresses to cope with, including all of the issues related to adapting to a new country, and the serious economic and social stresses which can be part of that experience. People who can talk about their situation when it is still in the category of a social crisis can be helped to vent their feelings and to identify what is going on in their lives. They can be helped to make sound decisions before they become overwhelmed and depressed, often withdrawing as their lives descend into complete chaos. Making timely support available through the HACSO case managers offers consistency and support which Rose observes is making a huge difference in the lives of some of her clients. Without this kind of preventive intervention these clients, in Rose’s experience, can become psychiatric crises, eventually warranting serious diagnoses and professional psychiatric intervention.
Rose cites the recent example of a young immigrant couple who came for support almost every day for a period of time. He has a problem with addiction and she is pregnant. Through the almost daily support of the HACSO case manager, he has achieved three months of sobriety and has gotten a job. She has stopped smoking and is taking much better care of her self.
Rose observes that many of her clients have problems with self esteem and relationships. She says that without people to talk to, many of her clients tend to become very agitated and very loud. They have trouble getting their thoughts straight and can present in a manner that could seem bizarre to professionals unfamiliar with the language and culture. Rose says that her case managers have learned, through supervision, how to ‘talk people down’ and to help them organize their thoughts. Again, she feels that such clients initially resist the idea of coming for counseling by appointment, especially on days when they are feeling calm and when there is not an immediate crisis. However, Rose also makes the important observation that after a period of time when people have used the drop in service to deal with crisis situations, they become more open to the idea of regular weekly counseling in order to try to get to the roots of the felt emergencies. In this way, ‘Band-Aid’ counseling can eventually morph into something that looks like more traditional counseling by appointment. However, without the first level of ‘Band-Aid work’, people do not have the chance to experience the ways in which talking can help. (This ends the interview with Rose Leandre).
Based on our experiences so far, we think that this model of service may have promise for other community based organizations which are not mental health clinics per se but see many clients with a variety of issues, including personal and emotional needs. This model would need to be adapted to the specific needs of different communities and different kinds of agencies. The success to date with HACSO suggests that it is worth the effort to stretch our thinking about how to deliver mental health support to various communities and to continue to explore non-traditional ways to support people with ‘social crises’.
* The People’s Institute for Survival and Beyond (PISAB), is a national and international collective of anti-racist, multicultural community organizers and educators dedicated to building an effective movement for social transformation. The People’s Institute for Survival and Beyond, affectionately known in the community as The People’s Institute, considers racism the primary barrier preventing communities from building effective coalitions and overcoming institutionalized oppression and inequities. Through Undoing Racism™/Community Organizing Workshops, technical assistance and consultations, PISAB helps individuals, communities, organizations and institutions move beyond addressing the symptoms of racism to undoing the causes of racism so as to create a more just and equitable society.
Betsy Benjamin, LCSW, is the Associate Clinical Director of VCS Inc. , 77 South Main St. New City, NY 10956. contact: firstname.lastname@example.org
Gail K. Golden, Ed.D, LCSW is the Clinical Director of VCS Inc. contact: email@example.com
Rose Leandre is the Executive Director of HACSO ( Haitian American Cultural and Social Organization). contact: firstname.lastname@example.org
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