Stepped Care 2.0: The Power of Conundrums 3031452054, 9783031452055

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Peter Cornish Gillian Berry   Editors

Stepped Care 2.0: The Power of Conundrums

Stepped Care 2.0 The Power of Conundrums

Peter Cornish  •  Gillian Berry Editors

Stepped Care 2.0: The Power of Conundrums

Editors Peter Cornish Student Mental Health University of California Berkeley Berkeley, CA, USA

Gillian Berry Vice President for Culture and Diversity Stepped Care Solutions Inc. St. John’s, NL, Canada

ISBN 978-3-031-45205-5    ISBN 978-3-031-45206-2 (eBook) https://doi.org/10.1007/978-3-031-45206-2 © Springer Nature Switzerland AG 2023 This work is subject to copyright. All rights are reserved by the Publisher, whether the whole or part of the material is concerned, specifically the rights of translation, reprinting, reuse of illustrations, recitation, broadcasting, reproduction on microfilms or in any other physical way, and transmission or information storage and retrieval, electronic adaptation, computer software, or by similar or dissimilar methodology now known or hereafter developed. The use of general descriptive names, registered names, trademarks, service marks, etc. in this publication does not imply, even in the absence of a specific statement, that such names are exempt from the relevant protective laws and regulations and therefore free for general use. The publisher, the authors, and the editors are safe to assume that the advice and information in this book are believed to be true and accurate at the date of publication. Neither the publisher nor the authors or the editors give a warranty, expressed or implied, with respect to the material contained herein or for any errors or omissions that may have been made. The publisher remains neutral with regard to jurisdictional claims in published maps and institutional affiliations. This Springer imprint is published by the registered company Springer Nature Switzerland AG The registered company address is: Gewerbestrasse 11, 6330 Cham, Switzerland Paper in this product is recyclable.

Foreword

Once upon a time, mental health services were provided almost exclusively in weekly, 50-minute individual therapy appointments by doctoral-level practitioners operating from their favored theoretical orientations, often with little regard to the research evidence or their patients’ preferences. Individual therapy and ideological singularity did not frequently result in salubrious patient outcomes, but did reduce clinical complexity and shared decision-making. And rarely, outside of public health or community circles, did one hear laments about the mountains of underserved or untreated patients. That is not a fairy tale or a clinical dystopia, but the practice paradigm 40 plus years ago when I began clinical training. To be sure, scores of practitioners and researchers in the interim urged care innovations, but those advances largely proved scattered one-trick ponies: add self-help, deliver brief therapy, hire paraprofessionals, conduct more groups, offer e-health and apps, reduce the number of sessions, provide tele-therapy, develop massive open online courses, render only evidence-based treatments, and emphasize population interventions. Meanwhile, the worldwide prevalence of mental disorders rises, wait-lists for public care climb, and people continue to suffer. Indeed, according to every reputable metric, the vast majority of people suffering from behavioral disorders do not receive any specialized mental health care at all. At all. The system is broken, in so many ways. It proves to be inaccessible, inequitable, inefficient, and ineffective (unless you are wealthy and receiving services in the private sector). Everything we have learned in the past four decades tells us that the mental health care system has shattered—depriving our patients of responsive treatments, wasting scarce resources, and still neglecting most of those in psychological torment. Nothing short of a comprehensive and ambitious overhaul is required. Stepped Care 2.0: A Paradigm Shift in Mental Health signifies and ignites that overhaul and, in its subtitle’s terms, represents a paradigm shift in mental health. You want to improve the care of individual patients and simultaneously enhance the mental health of the entire population? This book provides a strategy and a plan. SC2.0 features and incorporates so much of what we have learned in recent years about what works and what does not work. It is strength and recovery oriented, not v

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psychopathology consumed. It tailors the intensity of care to the individual, avoiding the prevailing one-size-fits-all. It encourages brief assessments of what actually guides treatment decisions, as opposed to rigid protocols or standard batteries that satisfy administrators. It demands quick and open access to services, not iatrogenic appointments months away or dreaded waiting lists. It is righteously client centric, as opposed to discredited therapist centric. It seamlessly integrates e-mental health and multiple therapy formats instead of replacing or devaluing mental health practitioners. It harnesses the resilience and self-healing of patients, not only the services of professionals. It provides ongoing objective monitoring of outcomes in place of therapist intuition or institutional guesswork. It accommodates the diversity of the population across readiness to change, not only those action-stage treatment seekers. It is population focused, not “one client at a time,” as the primary vehicle for improving mental health. It personalizes care, not primarily to diagnoses, but to transdiagnostic characteristics of patient functioning, preferences, and cultures. In short, SC2.0 is a sustainable and systemic restructuring of mental health care. Its progenitor, the visionary Dr. Peter Cornish, has walked the walk. As a seasoned director of a university counselling center (which I was privileged to visit on two occasions), he battled the growing surge of student-patients and the usual staff resistance to anything more than hiring additional staff. He came to understand that reducing the burden of mental illness necessitates improved access and efficiency in a sustainable manner. He experimented; he failed (forward); he researched; he revised; he researched (more); and eventually he co-developed SC2.0 for the entirety of the province of Newfoundland and Labrador. He and colleagues have subsequently consulted with more than 100 mental health centers in transforming their services. A friendly word of warning: if you intend minor tweaking of your mental health services, then this is decidedly not the book for you. You need not agree with every component of SC2.0 (I don’t), and you can obviously assimilate parts of the model (I will). But this is a bold, big plan for personalized population health. SC2.0 presents nothing less than innovative disruption in health care, extending the lead of the UK and others. Their plan and this book are augmented by implementation supports, including an Implementation Guide, core components, and guiding principles, which can be found on their website (https://steppedcaresolutions.com/). These will serve as potent introductions to inveterate colleagues and other stakeholders skeptical of anything that challenges their status quo or threatens their treasured proficiency. The inexorable future of any mature health system will be integrative, universal, responsive care. Using this game-changing text, join Peter Cornish and associates in creating the transformation. As we would say 40 plus years ago, be part of the solution! Department of Psychology University of Scranton, Scranton, PA, USA

John C. Norcross

Preface

Origin Story About 10 years ago, I had to admit that a research project I co-led with a colleague had failed miserably. Rural and remote regions of our province were underserved. This was particularly so for mental health care. Most treatment was provided by either physicians or nurses who admitted feeling unprepared. In an earlier study, we demonstrated some success in providing training and support via distance technology. While this was appreciated, they still did not have the time to focus on mental health treatment. We knew from a literature review that bibliotherapy was effective in treating depression. Would the prescription of an evidence-based self-help text be effective in rural and remote settings? A relatively simple randomized controlled trial would provide the answer. Unfortunately, despite high initial interest expressed by caregivers, we were unable to recruit either health care providers or patients for the study. It was a failed study. No worries. Publishing failed studies is important. But the first journal editor disagreed: “Your methodology is flawed, and you should have anticipated the problems.” After a few more tries, one editor agreed to publish the work as a commentary if we added more on lessons learned. What did we learn from this failure? The methodology was sound. But the providers told us that they were too busy to give the study full attention. And when they did find time, their patients were not interested. We wondered if the study failed due to a lack of supportive infrastructure. Most sites had only part-time support staff, and they were overworked. Both clinical and support staff were struggling to meet even the basic needs. This was not a methodology problem. It was an infrastructure problem. There were no structures in place to help coordinate or organize treatment, let alone support research. There would need to be a better system in place to support innovation. We became curious about strategies for developing such health system infrastructure. A common lament expressed in the literature is that there is rarely anything systematic about our health care system. But surely, there are some system-building success stories. First, I discovered O’Donahue and Draper’s 2011 e-book, Stepped Care and e-Health: Practical Applications to Behavioral Disorders (O’Donahue & vii

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Draper, 2011). There I was introduced to the stepped care model implemented by the National Health Service in the UK.  I was intrigued. Would stepped care for mental health provide the right kind of structure for low-intensity self-help treatments in our rural and remote regions? We offered this as an example of what we might do differently. Sitting on my back deck one morning, feeling pleased with myself as I reread the journal acceptance letter, something clicked. I am the director of a university counselling center that is struggling to meet demand. Could stepped care help? On that warm summer morning, I quickly sketched out a plan. That sketch was the first of many that eventually led to our nine-step SC2.0 model. Mental health care is poorly organized. In most places, a help-seeker would be lucky to access treatment. There are usually only two options: psychotherapy or psychiatric medication. While undoubtedly effective, demand far exceeds the supply for such specialized programming. Many people seeking to improve their mental health do not need psychiatric medication or sophisticated psychotherapy. A typical help-seeker needs basic support. For knee pain, a nurse or physician might first recommend icing and resting the knee, working to achieve a healthy weight, and introducing low impact exercise before considering specialist care. Unfortunately, there is no equivalent low-intensity option for mental wellness. As a result, a person seeking the most basic support must line up and wait for the specialist along with those who may have very complex needs. Why are there no lower intensity options? One reason is fear and stigma. A thorough assessment by a specialist is considered best practice. After all, what if we miss signs of suicide or potential harm to others? A reasonable question on the surface; however, the premise is flawed. First, the risk of suicide, or threat to others, for those already seeking care, is low. Second, our technical capacity to predict on these threats is virtually nil. Finally, assessment in our current culture of fear tends to focus more on the identification of deficits (as opposed to functional capacities), leading to overprescription of expensive remedies and lost opportunities for autonomy and self-management. Despite little evidence linking assessment to treatment outcomes, and no evidence supporting our capacity to detect the risk for harm, we persist with lengthy intakes and screens that delay care. Before providers and policy makers can feel comfortable letting go of risk assessment, however, they need to understand the forces underlying the risk paradigm that dominates our society and restricts creative solutions for supporting those in need. In this book, I supply evidence and a plan for dismissing the risk paradigm, freeing providers to extend broadened care options with less caution, thereby ensuring rapid care access for all. It is a realistic plan that can make the work of both help-­ seekers and providers more meaningful, productive, and sustainable. Stepped Care 2.0 (SC2.0) attends to peoples’ capacities, a focus often overlooked when preoccupied with risk. SC2.0 introduces a more balanced approach to assessment and care. It does so in five ways: (1) bringing awareness to the risk paradigm, thereby releasing potential for more creative trial-and-error approaches to wellness; (2) conducting only very brief focused assessment on first contact ensuring time for an intervention; (3) supporting the inclusion of more informal, natural, and community-­ based healing resources into the traditional circle of care; (4)

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organizing the increased resources systematically and in a manner that is more readily accessible to all; and (5) continuously adjusting care based on monitoring of functioning, strengths, deficits, risks, and treatment preferences in balance. SC2.0 reimagines the original UK stepped care model by integrating a range of traditional and emerging online mental health programs systematically within the context of recovery principles and practice. Like the UK approach, SC2.0 offers the lowest level of intervention intensity warranted by objective continuous outcome monitoring. However, unlike the original UK system, which was largely driven by a risk/assessment focus with an emphasis on tracking symptoms (i.e., deficits) and cognitive behavioral therapy approaches aimed at treating the symptoms, SC2.0 allows for the addition of strength-based programming, thus extending the fit to more diverse populations and contexts. This deviation also marks a shift from relying exclusively on evidence-based practices derived from controlled experimental conditions. Such a shift is possible with the introduction of practice-based evidence using validated measures collected at every encounter with a client. Programming is adjusted based in part on client response and preference rather than relying solely on symptom-based algorithms matched to one-size-fits-all manualized treatment protocols. With this ongoing progress monitoring, practice innovations are encouraged. Program matching decisions in SC2.0 are also more flexible and client centric than in the stratified models originally developed in the UK. Rather than stepping only according to diagnosis or symptom severity, one or more options of varying intensity can be jointly selected based on client need, preference, functioning, and readiness for engaging in healing work. Because monitoring is also configured to give both provider and client continuous feedback on progress, the model empowers clients and providers to collaborate more in care options, decisions, and delivery. As an upstream approach, SC2.0 prevents problems from escalating into serious conditions by systematizing shared responsibility for accessing care options at the right time, with the right people, in the right context. Not only is SC2.0 proving more efficient than traditional mental health service models, early observations suggest that it improves outcomes and access, including the elimination of service wait-­ lists. This book will set the foundation for two subsequent more detailed edited books—one on theory, research, and clinical application and the other on implementation strategies. Berkeley, CA, USA

Peter Cornish

Reference O’Donahue, W. T., & Draper, C. (2011). Stepped care and e-health: Practical applications to behavioral disorders. Springer.

Acknowledgments

Stepped Care 2.0 and this Springer book series would not exist without the support of so many—definitely too many to be named in this acknowledgment. Know we are truly appreciative of your feedback, comments, and positive encouragement. Special thanks to Silvestro Weisner, who attended a 2014 conference presentation on the model in Chicago. He was the first to recognize the transformative potential of SC2.0. To Peter Konwerski, Danielle Lico, Forrest Maltzman, Mark Levine, and Guy Nicolette, you are dedicated disruptive postsecondary trailblazers, leading by example with passion, empathy, and courage. To Amber Cargill, Kate Seldon, Sarah Harte, Chris Davis, and those who worked under our leadership, thank you for trusting the process and traveling with us down uncharted paths. Thanks to Diane DePalma for allowing us to benefit from your knowledge and lifelong experiences. We will always be indebted to colleagues at the University of Botswana—and especially Kitso Mbenge, a traditional healer who freely shared his knowledge with a curious stranger. Kitso, it is our strongest desire that our humble actions, interpretations, and presentation of an Indigenous perspective will ensure your voice is heard. To Dick Katz, an early mentor on braiding Indigenous wisdom with modern psychological practice, without your teachings, we would not have discovered or fully understood the role of synergy in system transformation rooted in social justice. To Tobirus Newby, Matt Goodman, and the Student Mental Health staff at UC Berkeley, you introduced us to the practice of decolonizing research methodologies and inspired us to support the development of equity-based organizational structures. Thank you to Health Canada, the Mental Health Commission of Canada, the Canadian Institutes of Health Research, and the Province of Newfoundland and Labrador for funding SC2.0 innovation both provincially and nationally. When the pandemic emergency prompted an urgent call to develop a Canada-wide virtual mental health program, we paused work on this second book, redirecting our energy to adapting and scaling the implementation of SC2.0 through the development of Wellness Together Canada (WTC). From broad-based stakeholder engagement, co-­ design, and implementation of WTC alongside diverse communities across the country, we discovered the power of difference, ambiguity, and conundrums. Eventually emerging from the worst of the pandemic, the passionate staff and bold xi

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leaders at Stepped Care Solutions found the capacity to offer support to this second book’s busy contributors, who otherwise would not have had the time to convey their wisdom through these pages. Special thanks to Kait Saxton and Catie Greene who dove right into the murky depths of conundrums, bringing clarity to inherently confusing material. Thanks to unsung heroes Carmine Starnino and André Forget, who, with their fresh eyes and sharp pencils, recognized the uniqueness of the model and faithfully steered our work to completion. Our appreciation also extends to the people of Newfoundland and Labrador, whose ingenuity, tenacity, and courage for demanding mental health parity and offering common sense solutions remind us that grassroots movements are crucial drivers of health reform and community resilience. To Josh Rash, thank you for your partnership, for your thoughtful, tireless, and heartfelt guidance on research design and evaluation methods. We feel grateful to our families and friends, in both this world and the next, who consistently offer us so much love and support.

A Note on the Text

It has been 3 years since the publication of Stepped Care 2.0: A Paradigm Shift in Mental Health. A lot has changed since then. The world experienced a pandemic. While interest in expanding mental health care predates COVID-19, the social and emotional turmoil from the global crisis ignited far more public investment in mental health care than ever before. I must admit I was surprised by the growing interest in Stepped Care 2.0 (SC2.0) since I published A Paradigm Shift. As I write this note on the text, so far, seven provinces and the federal government of Canada have invested in scaling the model through the health care systems they operate. There has been interest around the world in the SC2.0 model, from countries such as Finland, New Zealand, Chile, and more. While this could be seen as a measure of success for SC2.0, I see it differently. I see the opportunity to delve deeper, to question what we are doing, and to include more viewpoints in the work of transforming mental health care. Some of my colleagues ask me why I moved to California from Canada just as SC2.0 was catching on across my native country. My simple answer? There is much more to learn from other voices. SC2.0 is a work in progress. By taking a position at the University of California Berkeley, I envisioned partnerships with leading researchers, cutting-edge Silicon Valley companies, and a state government eager to fund health transformation. A perfect place to learn and grow. This is, admittedly, an unusual book. It begins with a slightly updated version of Stepped Care 2.0: A Paradigm Shift in Mental Health, then marches straight into a series of conundrums that we and others have been facing during transformation work guided by SC2.0. The usual path would have been to offer a second edition of A Paradigm Shift and a separate volume on conundrums, with contributions from colleagues who have since joined me in the work. There could have been three books at this point. That’s too much, I thought. I want just one book, one place where people curious about what we are doing can meet us where we are now, while also seeing where we came from. Context matters. The foreword and preface to A Paradigm Shift are preserved, but some of the content (i.e., where we got it wrong) has been updated and is represented in this volume as Chaps. 1, 2, 3, 4, 5, 6, 7, and 8, just as it was in the original book. A short xiii

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transition section introduces the reader to the contributors for the remainder of the book, Chaps. 9, 10, 11, 12, 13, 14, 15, 16, 17, and 18. These authors were selected not only for their experience and knowledge with implementing SC2.0, but, more importantly, for the questions, concerns, and problems they encountered on their journeys. There is power in facing challenges head on without defensiveness. We have experienced headwinds. A colleague of mine at UC Berkeley said to me, “Peter, you change your mind a lot, and it is leading to confusion.” Yes, I do. And yes, it does. I suppose we could have called this book The Power of Confusion (but, of course, that might have been confusing). I spent my early summers sailing on the Great Lakes in North America. The first thing any sailor learns is that you cannot sail directly into the wind. Instead, you must “tack” back and forth, staying as “close to the wind” as possible without luffing the sails. For some reason, I was always drawn upwind, usually to the west, toward the sun, across the expanse of Georgian Bay and beyond that, to the much larger portion of Lake Huron. So, I learned to shift back and forth, my eye to the west and the golden summer sun. Conundrums arise when you embrace headwinds at an angle. It allows you to capture the power of the force you are facing, so that you can zigzag alongside it. It transforms what appears initially as resistance into an ally. Sailors know that the wind and sea must be respected as forces greater than them. A relationship must be forged. A few years ago, I discovered the term “diplomatic disruption.” I came to see myself as a “diplomatic disruptor” much the way a sailboat can carve through the waves and, by harnessing the wind at an angle, make slow steady progress against the larger forces. The trick is respecting, and joining, the power and reality of wind and sea. But what to do about the confusion? The tacking back and forth. The myriad of different winds from all points of the compass? How would this book be any use practically? Would it not leave readers lost? Or, worse still, what if the conundrums revealed unsolvable problems? Would that mean welcoming the demise of SC2.0? Initially, I thought I could restrict the power of conundrums and tie the chapters together with commentaries. By critiquing my colleagues’ work and providing comfort in “answers” to the difficult questions posed, I could pull the focus back from tangents and uncomfortable uncertainty. But what’s the point in welcoming criticism and new perspectives only to discount and downplay them? It occurred to me initially that the second part of this book is an interrogation of SC2.0. But it is softer than this. It includes metaphors, a parable or two, and some stories. Each chapter ends with my own musings about SC2.0—my own reflections in response to the work of my colleagues. Through these reflections, I attempt to thread together their contributions without discounting their voices. My contribution is not a criticism of my colleagues’ work but a salute to what their work stimulates in me. I am curious about what their work will stimulate in you, the reader. In Chap. 10, Gillian Berry introduces the well-known Indian parable about the blind men and the elephant. The men investigate what is before them, using only their sense of touch. Their focus is narrow, on only that which is within reach. Each

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perspective is unique. Each is rich and valuable. Each contributes to the essence of the elephant. Some might say they are fools because they fail to see the big picture, the whole elephant. I disagree. Without the details discovered through their focused investigations, much would be lost. But without seeing the bigger picture something equally important is lost. This represents a central conundrum that weaves through Part II of this book. Specifically, how do we honor, respect, and value the many unique voices on healing knowledge, the many effective mental health practices, while at the same time integrate or organize these into a larger whole? We need the richness of difference, but we also need to integrate. If we focus too much on the former, we are stuck with a broken, fragmented system that is no system at all. If we focus too much on the latter, we end up with a blend that lacks taste, spice, or richness. We hope that this book allows readers to join in this dance of conundrums. We hope that it stimulates your own musings, encourages you to share your voice and your stories. Stories, including those that are narrow and nonrepresentative, are powerful expressions of authenticity. They represent rich and unique experiences. We need them to inform new and varied paths toward well-being. And we need somehow to thread these together without damaging the fabric. We hope you will join us on this collective enterprise.

Contents

Part I Stepped Care 2.0: A Paradigm Shift in Mental Health 1

 Need a Better System������������������������������������������������������������������������    3 We Peter Cornish

2

Open Access����������������������������������������������������������������������������������������������   21 Peter Cornish

3

Recovery Values and Principles��������������������������������������������������������������   37 Peter Cornish

4

 Expanding the Options Through Nine Steps����������������������������������������   55 Peter Cornish

5

Navigating the System ����������������������������������������������������������������������������   77 Peter Cornish

6

Collaboration and Co-design������������������������������������������������������������������   93 Peter Cornish

7

 Adapting for Unique Settings�����������������������������������������������������������������  109 Peter Cornish

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 Toward a Paradigm Shift������������������������������������������������������������������������  129 Peter Cornish

Part II The Power of Conundrums: Beyond Stepped Care 2.0 9

Stepped Care, a Closer Look: Reviewing Evidence and Evaluating Outcomes ����������������������������������������������������������������������  145 Amy Salmon, Mai Berger, Saranee Fernando, and M. Elizabeth Snow

10 Diversity,  Equity, and Inclusion and the Default Factor: An Indigenous Perspective����������������������������������������������������������������������  161 Gillian Berry xvii

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11 Adaptability  and Fidelity: Exploring the Relationship Between the Two When Implementing SC2.0 ��������������������������������������  173 Alexia Jaouich, Stacie Carey, Kaitlin Saxton, Joshua Rash, and Jacquie Brown 12 Oil  and Water: Why the Legal Risk Paradigm Conflicts with Good Therapy����������������������������������������������������������������������������������  193 Kami Sidman and Justin Jacques 13 Reimagining  the “Gold Standard” ��������������������������������������������������������  209 Monte Bobele, Arnold Slive, and Heather J. Hair 14 Stubborn  Hierarchies: The Challenges of Co-design ��������������������������  229 Marion Cooper 15 Leadership  and Stepped Care 2.0: A Cautionary Tale ������������������������  243 Gillian Berry and Janis Campbell 16 Integrating  Substance Use Health into Stepped Care 2.0: The Recovery Conundrum����������������������������������������������������������������������  259 Mary Bartram 17 Stepped  Care 2.0 and the Conundrums of Intensive Care������������������  269 Andrea Levinson 18 Stepped  Care 2.0: We Think We’re Missing Something—A Conversation������������������������������������������������������������������  283 Peter Cornish, AnnMarie Churchill, and Gillian Berry 19 Cultivating  and Channeling the Power of Conundrums: The Promise of Synergistic Practices ����������������������������������������������������  307 Peter Cornish and Gillian Berry Index������������������������������������������������������������������������������������������������������������������  313

Contributor Biographies

Mary Bartram, PhD, MSc  has led mental health and substance use health policy development and implementation with federal and territorial governments, Indigenous organizations, and NGOs. She is the policy director with the Mental Health Commission of Canada, with the responsibility for proactive policy analysis and research, advancing integrated approaches to substance use health and mental health, and overseeing investments in 40 research projects on the relationship between cannabis and mental health. Bartram completed her PhD at the School of Public Policy and Administration at Carleton University in 2017, where she teaches courses in public policy as an adjunct professor, and conducted postdoctoral research at McGill University and the University of Ottawa. Her research has focused on a range of issues such as mental health and substance use health workforce planning, equity in access to psychotherapy, and harm reduction and recovery in the mental health and substance use health sectors. She is a registered social worker and holds an MSc in family therapy from Purdue University. Mai Berger, MSc, PPH  is a project coordinator at the Centre for Health Evaluation and Outcome Sciences (CHÉOS) in Vancouver, BC. She has over 5 years of experience working on community-­based research and evaluation related to youth mental health and service delivery. Currently, Berger is involved in qualitative research and evaluation in the areas of youth mental health and overdose response in BC. Gillian Berry, PhD, LCSW-C, CQSW  is vice president of culture, diversity, and workforce development at Stepped Care Solutions. She has over 35 years of experience as an educator and practitioner. She has overseen the counseling and psychological services at George Washington University, leading a multidisciplinary team of mental health professionals through the implementation of the Stepped Care 2.0 approach into their service delivery. She has been a faculty member at the University of Botswana’s Department of Social Work Southern Africa and the University of Maryland School of Social Work. Her clinical interests are strongly influenced by her grandfather's Indigenous philosophy, and she  provides short-term solutionfocused services/therapy from this perspective. xix

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Monte Bobele, PhD, ABPP  is a licensed psychologist in Texas, an emeritus professor of psychology at Our Lady of the Lake University (OLLU), an American Association for Marriage and Family Therapy clinical fellow/approved supervisor, and board certified in couple and family psychology. He is a Stepped Care Solutions one-at-a-time subject matter expert. He is co-founder, with Arnie Slive, of SingleSession Solutions, for training and consulting. At OLLU, Bobele was involved in developing programs to train culturally and linguistically competent psychologists to work with Spanish-speaking populations. He was OLLU’s Moody Professor and received the Fleming Award for Teaching Excellence, as well as the Texas Psychological Association’s Outstanding Contribution to Education Award. Bobele has published dozens of papers and book chapters. He and Slive co-edited When One Hour Is All You Have; they published (with others) Single-Session Therapy by Walk-In or Appointment. Recently, he and Michael Hoyt published Creative Therapy in Challenging Situations. Bobele was awarded a series of grants to provide walkin/single-session (WI/SST) therapy in a shelter for the unhoused. He received a Garcia-­Robles Fulbright Specialist Grant to develop WI/SST services in a university clinic in Mexico City. He has taught graduate courses and workshops in WI/ SST universities in the USA, Canada, Mexico, and Australia. Recently, he has been consulting with university counseling centers about implementing WI/SST services in a Stepped Care 2.0 context. Jacquie Brown, MES, RSW  is a globally recognized international implementation consultant. She is implementation lead at School Mental Health Ontario; head of international development at Triple P International; and previous co-director for the Child and Family Evidence Based Practice Consortium. Brown is committed to bringing implementation science into practice. As an implementation practitioner, she is involved in the implementation of evidence-based practices and best practices in the education sector, health care sector, and community-based services sector, as well as the implementation of Triple P—Positive Parenting Program—in Europe, Australia, and sub-­Saharan Africa. Brown works with program developers, researchers, and implementing organizations to support the use of implementation science in their endeavors. In addition, Brown has several publications and has provided a significant number of presentations on various aspects of implementation over the last 10 years. Janis Campbell, EdD, CCC-S  currently serves as a Stepped Care 2.0 (SC2.0) consultant with Stepped Care Solutions. Prior to her current role, Campbell facilitated client and community focus groups for the SC2.0 E-Mental Health Demonstration Project and worked as a research assistant for the Canadian Institutes of Health Research project investigating the digitization of SC2.0 in three Atlantic Canadian provinces. Campbell’s research investigates recovery-oriented practice in SC2.0 postsecondary implementations. Campbell has expertise in the provision of counseling services within the SC2.0 model and has led the development and implementation of wellness and peer support programming in postsecondary and

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community settings. Campbell is a Canadian certified counselor, clinical supervisor, and educator. She is active in the Canadian Counselling and Psychotherapy Association as the Newfoundland and Labrador representative on the National Board of Directors. Stacie Carey, PhD (c)  is the lead for learning strategy and design at Stepped Care Solutions. Her work focuses on optimizing education and training opportunities for individuals, organizations, and jurisdictions implementing Stepped Care 2.0. She has spent 10 years working in both the health care and mental health sectors, with experience in health professions education, program implementation, and knowledge translation. Carey is currently completing her PhD at the University of Toronto, within the Institute for Health Policy, Management, and Evaluation. Carey’s research program investigates the learning processes and strategies health care teams engage in as they learn and work together to enhance their practice. AnnMarie  Churchill, MSW, PhD  A research fellow in the Department of Psychology at Memorial University of Newfoundland, AnnMarie Churchill holds a PhD in experimental psychology and a master’s degree in clinical social work; she is also a registered social worker in the province of Newfoundland and Labrador. Over 30 years of direct clinical practice in community, hospital, research, and postsecondary mental health systems have given Churchill a comprehensive understanding of mental health systems and the need for transformation. Interim president and executive director of Stepped Care Solutions, she has provided training and consultation on program development and clinical implementation of Stepped Care 2.0 in diverse settings, including organizations, postsecondary institutions, provincial and territorial mental health systems, and a national universal virtual mental health and wellness service. She is also the co-author of Person-­Centered Diagnosis and Treatment in Mental Health: A Model for Empowering Clients (2012). Marion Cooper, MSW  is a clinical social worker and mental health and addictions leader who has worked in the community sector in various positions for nearly 30 years. In addition to her role with Stepped Care Solutions (SCS), Cooper is the chief executive officer of the Canadian Mental Health Association (CMHA) for Manitoba and Winnipeg. Just prior to joining SCS, Cooper served as the executive lead for strategic partnerships with the CMHA National Office, supporting partnerships with Indigenous organizations and communities. She is also the past president of the Canadian Association for Suicide Prevention and was instrumental in establishing the mental health promotion and prevention team at the Winnipeg Regional Health Authority. Cooper currently serves on the Mental Health Promotion Expert Working Group for the International Union for Health Promotion and is a public health council leader with the International Institute for Mental Health Leadership. Her areas of expertise include recovery, social justice, system transformation, codesign, and innovation.

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Peter Cornish, PhD, RPsych  Since developing the Stepped Care 2.0© (SC2.0) methodology, Peter Cornish has provided mental health system consultation and on-site implementation training to over 150 organizations across North and South America. In addition to his role as faculty and senior adviser at Stepped Care Solutions, Cornish is an honorary research professor at Memorial University and co-director of Student Mental Health (Strategic) at the University of California, Berkeley, where he established the Berkeley Center for Mental Health Innovation. He is collaborating with colleagues on a three-book series expanding on the SC2.0 methodology. He is a principal investigator for a $1.14 million Canadian Institutes of Health Research transitions-in-care, 4-year research grant aimed at digitizing and evaluating SC2.0 across three Canadian provinces. Saranee Fernando, MPH  is a qualitative methodologist at the Centre for Health Evaluation and Outcome Sciences and has a master of public health degree from the University of Alberta. Her experience conducting qualitative and community-based research spans 9  years within diverse areas, including the overdose crisis, youth mental health, and chronic illness. Heather J. Hair, PhD, RMFT, RSW  has a BA and MA in psychology, an MSc in couple and family therapy, and a PhD in social work. Hair practiced for many years as an approved supervisor of the American Association of Marriage and Family Therapy. Hair’s interest in learning led to a tenured faculty appointment and administrative positions with a Canadian university. Hair worked as a registered family therapist at an Ontario city children’s mental health center, where she co-­ created and coordinated the Brief Therapy Services and developed and supervised the Brief Therapy Community Externship. For over 25 years, she has been developing and providing skills training workshops on one-at-a-time counseling conversations/single-session therapy and practice-­focused supervision, as well as program consultation to providers of mental health, social, and community services. Justin  Jacques, Ph.D., LPC, CAC II, ACS, NCC  is a licensed professional counselor, certified addiction counselor II, certified employee assistance professional, nationally certified counselor, and approved clinical supervisor. Currently, Jacques is in private practice at Human Theory Group, the counseling consulting firm he founded in 2020. In the recent past, he has been a student assistance professional at Johns Hopkins University, a counselor III at Penn State University’s medical school, and a senior staff clinician at George Washington University. He recently completed a PhD in counseling at Oregon State University. Jacques’s research interests include student athletes, veteran populations, health behavior change, corpus linguistics, and ruptures and repairs in the counseling alliance. Jacques has 18 years of mental health experience working with individuals, couples, families, and groups. Alexia Jaouich, PhD  is a strategic system change leader and psychologist with over 20 years of clinical practice and system change experience, offering expertise in implementing large-scale, evidence-based, innovative mental health programs at

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the organizational and systems level. Currently vice president of development and implementation at Stepped Care Solutions (SCS), Jaouich leads the development of SCS’ implementation process, aligned with the Stepped Care 2.0 (SC2.0) model’s principles and implementation best practices. She oversees an SCS implementation support system, including training, resources, and capacity building to support SC2.0 implementation in different contexts nationally, internationally, and across sectors. Jaouich has also authored academic and educational texts on the subject. Andrea Levinson, MD, MSc, FRCPC  is an assistant professor in the Department of Psychiatry at the University of Toronto. She is also the director of psychiatric care at Health and Wellness, University of Toronto, and is a staff psychiatrist and student mental health liaison at the Centre for Addiction and Mental Health (CAMH). Levinson is responsible for the provision and management of psychiatric services on campus and acts as a resource for the school community on mental health issues across the university. Recently, she served as the clinical lead for the University of Toronto Student Mental Health Redesign Project and supported the adoption of the Stepped Care 2.0 model at the University of Toronto. Levinson’s research interests include postsecondary student mental health, early intervention in the context of the emerging adult cohort, health professional wellness, and mood disorders. Joshua  Rash, PhD, RPsych  is an associate professor in the Department of Psychology at Memorial University of Newfoundland, director of the Memorial University of Newfoundland’s Behavioural Medicine Centre, and senior research fellow at the Duke University Center for Health Policy and Inequalities Research. He is a registered clinical, health, and rehabilitation psychologist with expertise in behavioral medicine, health behavior change, chronic disease management, and cardiovascular psychophysiology. Rash has significant experience conducting multisite, pragmatic clinical trials that involve pharmacological and behavioral interventions. His expertise extends to chronic pain management, weight management, stress management, motivating health behavior change, treatment of insomnia, and cardiovascular psychophysiology. He has worked with provincial governments, notfor-profit organizations (e.g., Salvation Army), and mentorship networks (e.g., Atlantic Mentorship Network, Pain and Addictions) to transform health care delivery. Amy Salmon, PhD  is a scientist and associate director at the Centre for Health Evaluation and Outcome Sciences and a clinical associate professor in the University of British Columbia’s School of Population and Public Health. Her research focuses on health system transformation in mental health and substance use services and on the integration of health and social care services. Kaitlin Saxton, MSc  is a mental health system transformation leader with significant experience in large-scale implementation initiatives. She has worked in university, hospital, and not-for-profit settings, collaborating with a breadth of partners

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across many different sectors. Saxton brings expertise in the areas of project management, system design, equity and engagement, and knowledge translation and dissemination. She has also contributed to mental health system research and innovation endeavors. Currently a senior project manager at the Provincial System Support Program at the Centre for Addiction and Mental Health, she works closely with funders and service delivery partners to lead the development, implementation, and scaling of evidence-based, publicly funded psychotherapy services across Ontario. She also serves as a business consultant for Stepped Care Solutions. Kami Sidman, LPC, JD  is a board-certified licensed professional counselor in Virginia, Maryland, and the District of Columbia. She is the founder of Compassionate Therapy Center, a private therapy practice specializing in helping high-achieving, perfectionistic, and creative individuals to develop a more compassionate approach to themselves and more fulfilling relationships with others. Sidman has worked at two universities as a law school director of wellness, law career adviser, and mental health counselor. She has previously contributed to books on topics of racial justice and college counseling and has presented on topics related to emotional well-being at national and regional conferences, to businesses and organizations, and to university faculty, staff, and students. Sidman has a master’s degree in counseling from Virginia Tech, a JD from Harvard Law School, and a bachelor’s degree from the University of California, Berkeley. Arnold Slive, PhD  is a licensed psychologist (Texas) and American Association for Marriage and Family Therapy clinical fellow and approved supervisor. His interests are in brief, strength-­based, systemic psychotherapy, program development, supervision, and teaching. He has worked in hospital mental health, residential treatment, children’s mental health, and private practice. In Calgary, he was a founder of the Eastside Family Centre, a walk-in single-session counseling center, and was the clinical director of Wood’s Homes. He has a career interest in developing strategies to make mental health increasingly accessible. He is a past president of the Alberta Association of Marriage and Family Therapy. He is the recipient of the Divisional Contribution Award and the Innovative Services to Families Award. He was a Fulbright specialist teaching walk-in/single-­session services in Canada. Slive has published in the areas of family therapy, residential treatment, adolescence, and single-session/walk-in therapy. He is co-editor of When One Hour Is All You Have: Effective Counseling for Walk-in Clients (2011) and One at a Time: Single-Session Therapy by Walk-In or Appointment (2018). He is a consultant to Wellness Together Canada and Stepped Care Solutions, as well as to One Stop Talk in Ontario, Canada. M.  Elizabeth  Snow, PhD, MBA, CE  is the program head of evaluation at the Centre for Health Evaluation and Outcome Sciences. Her work focuses on bridging the gap between research and evaluation evidence and health services delivery, with a strong interest in equity. She has conducted evaluations in a range of health care

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settings, including public health, acute care, and long-­term care. She co-authored the textbook Nutrition Basics: An Active Approach (2018) and led the creation of a model of engaging marginalized populations in health services planning. Snow’s previous roles include running a transdisciplinary research training program in gender, mental health, and addictions at the British Columbia Centre of Excellence for Women’s Health and acting as an evaluation specialist in public health at Fraser Health. She teaches at the University of British Columbia, Simon Fraser University, and the Justice Institute of British Columbia.

Part I

Stepped Care 2.0: A Paradigm Shift in Mental Health

Chapter 1

We Need a Better System Peter Cornish

Crisis? What Crisis? When I was first appointed as the director of our student wellness center in 2003, my boss warned me that she would never support hiring another tenure-track faculty member, even replacements, unless we increased staff productivity. She was true to her word. She disliked the faculty model, arguing that teaching and scholarly duties reduced time available to counsel students. Making matters worse, our clinician-to-­ student ratio had long been far below average for North American campuses. At the time, faculty would take 1 day per week for research and would be available another day for urgent walk-in client presentations. This was before the surge in demand now commonplace on campuses. The average number of urgent walk-ins per week at the time was no more than five, meaning we were paying the equivalent of one faculty member to see only one person per day. In 2010, to make better use of this time, all students, regardless of urgency, were welcome to walk in at any time for an initial appointment. We discovered we did not need crisis counseling as much we thought. What we needed was better access to basic care. And while this change was motivated by a need to increase productivity, it laid the foundation for our current, more client-centric, one-at-a-time approach.

1.1 System? What System? Interest in mental health has never been higher (American Psychological Association, 2019; Rhydderch et al., 2016). Stigma is decreasing, and help-seeking is on the rise (Lipson et al., 2018). We have done such a good job with our mental health awareness programs that help-seeking now exceeds the supply of services. Some say we P. Cornish (*) Counseling and Psychological Services, University of California, Berkeley, CA, USA e-mail: [email protected] © Springer Nature Switzerland AG 2023 P. Cornish, G. Berry (eds.), Stepped Care 2.0: The Power of Conundrums, https://doi.org/10.1007/978-3-031-45206-2_1

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are in the midst of a mental health crisis. This is not the case. What we are facing is a crisis of access. Essentially, there are not enough options. A one-size-fits-all approach to mental health care limits options. In Canada, the most accessible care involves consulting a family physician. Unfortunately, family physicians are not well prepared to provide mental health services. Typically, physicians will treat with medication, or if that fails, refer to a psychiatrist or psychologist. Wait-lists to see both are quite long. Psychologists and psychiatrists are specialists and therefore expensive. Some say just hire more specialists, but doing so has limited impact on wait times. Others argue that in order to have meaningful impact we must change how we organize existing programming. Like many overused words in the English language, the word “system” has become almost meaningless. Too often it is used to describe an incoherent, largely disorganized array of processes or programs. According to the Concise Oxford English Dictionary, the word system is defined as: (1) a set of things working together as parts of a mechanism or an interconnecting network and (2) an organized scheme or method (Soanes & Stevenson, 2008). Most would agree that there is little about mental health care that is interconnected or organized. There is nothing systematic about either our health or mental health care systems.

1.2 Neoliberalism in the Context of a Risk Paradigm In the absence of systems, external socio-political forces drive our care models. In recent decades, neoliberal policies have prioritized global trade, reduced government, and increased attention to external threat. The rush to globalize may be slowing, in part due to rising right-wing anti-immigrant populism. These largely unfounded fears further stoke the risk paradigm (Stanford et al., 2017) that drives news cycles and political agendas. Socio-political forces have long capitalized on fear to justify hegemonic structures. This is not new. Neither is stoking suspicion to rationalize incarceration of people from the margins of society who might pose challenges to privileged authority. Not long ago, homosexuality was considered a disease. It was also illegal. Heresy used to be punished by death. Unconventional thinking would lead to asylum confinement. In post-industrial, Eurocentric societies, the marketing of threat has shifted outward to states with emerging economies and cultural traditions that threaten the privileged old world order. And while domestic terrorism is far more destructive than that of foreign influence, massive risk-industry players continue to drive perceptions of growing external threat. As people drown in limitless, unregulated waves of online information, tribal divisions emerge in efforts to contain the overwhelming barrage. Long gone is the notion of balanced news coverage, once deemed essential for maintaining audience share. In the absence of regulation, cybercrime is on the rise. Risk and surveillance industries, previously the domain of the military–industrial complex, have become the mainstream. These industries depend on perceptions of increasing risk. Stoking risk is essential for growth. A

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wall, we are told, is needed to keep foreigners out. Cloud-based surveillance systems, we are persuaded, are necessary to protect our homes and communities. We must enable constant streaming, abandoning all rights to privacy, in order to detect all the criminal activity surrounding us. What do these geopolitical trends have to do with mental health care systems? Fear, stigma, and perceived risk have always driven repressive responses to managing mental illness. What is relatively new is the market value attached to a mental health risk paradigm. Over the last 25 years, big pharmaceutical corporations have invested billions in marketing campaigns to convince large segments of the population that normal distress is a biochemical disease. There is very little evidence supporting these claims even for severe and persistent mental illnesses (Greenberg, 2010). Public health messages incorporate this unfounded premise with campaigns urging early detection through mental health screening programs. Airports caution passengers not to leave baggage unattended. Shoes must be removed, and toiletries reduced to micro-doses in carry-on luggage. “See something, say something” signs extend surveillance of odd behavior to the role civic duty. When there is extreme and unusually bad behavior on the scale of a mass shooting, politicians cannot resist temptations to conflate these rare acts of violence with untreated or undiagnosed mental illnesses. There is not a shred of evidence to support these causal links (Varshney et al., 2016). There is also no evidence for predicting bad behavior through psychological or psychiatric assessment (Fazel et  al., 2012). If the experts can’t do it, if there is no convincing relationship between violence and mental illness, and there is really no evidence suggesting distress can evolve into a biochemical disease, how are these myths sustained? The answer: they are convenient myths. They distract attention from the real causes of distress and strife. Journalist Johann Hari suggests the real causes of depression are lost connections (Hari, 2018). He means real connections, not manufactured or commodified ones. False needs are marketed to sell contrived solutions. Forming true social connections takes work and comes with risks. Needs are sometimes stoked, subtly, with fear by creating the perception of risk. Bad breath was not considered a social problem until a mouthwash was marketed. Social anxiety used to be called shyness. Being shy wasn’t so bad, but the word “anxiety” elevates it to the level of disease ripe for social judgment. Normal distress should be prevented or eliminated rather than commodified. The medicalization of distress replaces natural, affirming connections with technical ones. Social media reward mechanisms, such as badges, alerts, and scorecards, thereby transforming social interaction into addictive games designed to lure users back to heavily advertised platforms that sell more false needs. More expensive education, the emergence of the gig economy, and continued growing aspirations for soaring lifestyles with houses and vehicles, well equipped with expensive electronics, have increased pressure for students to compete for high-earning careers that may not be personally meaningful. Without connection to purpose, mental health deteriorates. Needs are manufactured to drive addictive, ultimately unfulfilling debt-ridden consumerism. A new gadget, a new outfit, or a lottery win will supposedly bring happiness. But real people, and especially strangers,

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are dangerous. Social media feels safe because we don’t have to leave locked homes where danger lurks behind every bush and in every shadow. Foreigners are either rapists or terrorists. But your own tribe is safe. These are convenient myths that drive our economy and erode our mental health. The myth of risk is pervasive. The chances of children being abducted by strangers are about one in 14 million (Dalley & Ruscoe, 2003). Statistically, strangers are not dangerous. Neither are immigrants. Life expectancy is increasing through much of the world. Poverty, crime, and even terrorism are on the decline. Suicide rates are relatively stable with ups and downs commonplace. There is a current upward trend in the United States (Hedegaard et  al., 2018), but rates were higher in the early twentieth century, the 1930s and the 1990s (Efflin, 2019; Joint Economic Committee, 2019). There are less fatalities from war now than there have ever been (Our World in Data, 2019). For large corporations, this is an inconvenient truth. For Al Gore and the rest of us, the most serious inconvenient truth stems from climate change. Perhaps if we found more ways to connect with nature, that connection would encourage more political action. Even if it didn’t, connection to nature is crucial to mental health. It facilitates connection to something larger than us. It allows us to know our purpose, our limits, and to fully embrace our short lives. This disintegration of connections, as it relates to tightening risk management policies, can be seen clearly on university campuses. In the early 2000s, Memorial University of Newfoundland engaged a consulting firm to advise on campus safety. The consultants highlighted unacceptable potential risks associated with the long-­ standing drinking culture in campus residences. Specifically, student-run residence-­ life events were targeted for explicitly endorsing binge drinking and social activities that put students at risk, especially female students. The student governance structures were dismantled and stricter policies on consumption of alcohol and drugs were enforced through a new student code of conduct policy. Attempts were made to build identity around academic themes through the development of living learning communities. Health and safety training of residence assistants were expanded, including 2 days of mental health first aid training. The assumption was that through these deliberate well-intentioned student development programs, residence life would mature in alignment with the academic mission of the university. While risky behavior associated with substance abuse decreased on campus, it increased off campus especially in the downtown area about five kilometers from the university. In effect, the risk was higher since now students were left with the task of traveling the distance while under the influence. A set of new modern residence towers opened about 5 years later. In the third week of March of that year—the second to last week of classes of the term—tragedy struck. A female student was found dead by hanging in her residence room shower on Friday morning. In accordance with the postvention protocol of the time, emotional support was offered on site to students and student staff. The multipurpose room on the ground floor was identified as a gathering spot; counselors were asked to attend along with chaplains and other student affairs staff. Refreshments were served. A decision was made to keep the space open and staff it for 72 h over the weekend. One staff member brought in board games; another brought coloring

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books. On Saturday, therapy dogs arrived. There were, of course, a lot of tears and hugs among students. The student affairs staff, counselors, and chaplains kept the refreshments supplied, but much of the time they clustered awkwardly in the corners of the room, sometimes chatting among themselves. The students did not appear to need them. In a review of the procedures the next week, staff and management agreed that the vigil had been longer than it needed to be and that a more rapid return to normalcy would have been more appropriate. It was unclear how helpful or productive the postvention efforts had been. As the anniversary of the death in residence drew closer, memories of the previous year resurfaced. Understandably, the mental health first aid training provided over the year had focused more intensively on suicide prevention. Students were anxious about missing the signs, but told themselves that increased efforts at identifying students of concern, referring them for help, and in some cases reporting these concerns to more senior residence staff had made the residence safer. But on the third weekend of March, another female student, on the same floor of the same tower, died by suicide in her shower stall. In discussions with campus leaders following this second suicide, we wondered what else we could have done to prevent the deaths. Why had the second one occurred, exactly 1 year later, on the same floor? Did we need to adapt or improve the training protocols? On the one hand, we acknowledged that the rate of suicide on campus over the long run was much lower than in the surrounding city. On the other hand, could this be a new worrying trend? Was it a matter of contagion? We were perplexed and unsettled. I recall a conversation I had with a senior residence student leader late Saturday evening when we were winding down the postvention support program. As was the case a year earlier, it had been hosted in the multipurpose room on the ground floor of the tower. I asked this student how the room was typically used. He said that it wasn’t used much. I wondered why it couldn’t be used for something fun or entertaining. After all, games and puppies had been brought in for the postvention session. Why wasn’t support and some kind of positive community engagement the norm? I made a note to myself to consider ways to adjust or expand our clinic-based stepped care model to encourage more social engagement on campus.

1.3 The Original Stepped Care Model “Stepped care” is a term that has been used to describe the mental health system developed in the United Kingdom over the past 20 years (Clark et al., 2009). The goals of stepped care are to reduce the burden of mental illness in society and develop a program of care that is self-corrective. To reduce the burden of mental illness, outcomes, access, and efficiency need to be increased in a sustainable manner. Typically, the most effective yet least resource-intensive programming is offered first. Programming intensity is only stepped up to the next level with evidence or prediction of failure. Several assumptions drive this stepped care approach. One is

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that our current system is inefficient with its over-reliance on specialist interventions, including psychotherapy or ongoing psychopharmacological treatment. Both forms of care are expensive, typically offered only by doctoral-level psychologists or psychiatrists. While few would dispute their effectiveness, proponents of stepped care call for the addition of viable lower intensity, less costly alternatives. A second assumption pertains to fit. Traditional care models assume that either psychotherapy or drug therapy will work for everyone. We would not be satisfied with only one or two options for treating physical illnesses. The third assumption is that stepped care achieves efficiencies through a mechanism of self-correction. Care intensity can be stepped up if initial low-intensity interventions fail. Ongoing objective monitoring of outcomes informs stepping decisions in both directions. For example, care intensity can be stepped down following stabilization or after a major reduction in symptom levels. The original UK approach is referred to, variously, as a staging, stratified, or pathways design (Scott & Henry, 2017). While the evidence supporting stratified versions of stepped care is mixed, results of clinical trials tend to favor stepped care over treatment as usual (Firth et al., 2015). Extensive up-front assessment is used to stage patients at the appropriate step level. Patients are typically staged according to their symptom levels (see Fig. 1.1). They are referred through corresponding treatment pathways designed to fit symptom profiles. Higher steps of care are offered to people with more severe symptoms, whereas lower steps of care are recommended only for those with mild or moderate symptoms. Stratified models assume that symptom levels are a good predictor of treatment outcomes. More specifically, they assume those with severe symptoms would do better with intensive treatment or that people with mild or moderate symptoms will respond best to low-intensity programs. Stratified models further assume that people with severe symptoms are more vulnerable and that more vulnerable people need more intensive mental health care. As such, more effort and expense should be targeted at those with higher symptom levels. The assumptions seem logical; however, with closer scrutiny, questions arise.

Fig. 1.1  UK-based stepped care stratified model. (Adapted with permission from NICE, 2011)

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What happens when someone with high symptom levels is functioning quite well and is not interested in treatment? And if they are not ready to engage in treatment despite both low functioning and high symptoms, does it make sense to offer high-­ intensity, expensive care? Or would it be more sensible to support a person with moderate symptoms, low functioning, and high readiness to engage? Stratified models further assume that people with severe symptoms would not likely benefit from low-intensity treatment. Does this mean peer support would not be offered? Studies suggest that low-intensity e-mental health programs work for people regardless of symptom severity (Bower et al., 2013). While well-intentioned, there is little evidence to justify staging people to treatment pathways based on symptom levels alone.

1.4 What Is Different About SC2.0? SC2.0 is not a stratified model. We do not make step decisions based on symptom severity or complexity. Instead, it is better described as a flexible progressive model. Progressive models offer low intensity first, no matter the symptom severity or clinical complexity. A recent study indicated that clients are 1.5 times more likely to recover through a progressive design (Boyd et al., 2019). There is growing evidence for considering other variables in treatment planning (Wampold & Imel, 2015). For example, someone with severe symptoms might be highly functional and may not need to be under the care of a specialist. A motivated, high-functioning person with severe symptoms might wish to direct their own healing process. And even highly symptomatic people with restricted functioning in some areas of their lives might be highly productive in others. For example, a person in the midst of a psychotic break might still be highly sociable and benefit from ongoing support from a peer helper. A simplistic stratified model based on only deficit assessment could miss opportunities for supporting recovery. So, what is different about SC2.0? For one, it is a collaborative model, drawing on recovery-oriented principles to promote client responsibility, autonomy, and resilience. In short, it is more client-centric than the stratified model of stepped care. SC2.0 starts simple with a focus on people’s self-reported issues, goals, and capacities. Investigation of potential underlying deficits or pathology is considered only if this strengths-based approach fails to achieve results. SC2.0 offers a system for developing, adjusting, delivering, and monitoring recovery-oriented programs, while promoting client responsibility, autonomy, and resilience. Because the value of autonomy is culturally rooted in Eurocentric Capitalist societies, the SC2.0 model considers level of autonomy to be preference-­ based. In some circumstances, and for some people, autonomy may be healthy, and, in others, it may be unhealthy. Step levels of treatment are based in part on readiness for change. This recognizes that people seeking help are at various stages of readiness to assume responsibility for making the kinds of changes in their lives that will contribute to recovery. For example, some people with intense symptoms of social

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anxiety may not feel comfortable attending group therapy even though the exposure method is a proven highly effective method for achieving reliable stable and long-­ term improvements in social functioning. Instead, a person with social anxiety might prefer doing preparation work online, learning about the nature, causes, and varied treatment options, before considering exposure as an option. On the other hand, a highly motivated person might be ready and eager to leap right into exposure by attending a public speaking class or social anxiety therapy group. SC2.0 is more client-centric than staging models. Client centricity is different from being client-centered. Client-centered approaches adapt care to the unique needs of the help-seeker. They eschew a one-size-fits-all all approach to treatment. Client-centric care goes one step further. In addition to considering unique needs, client-centric care incorporates client preference and prioritizes client decision-­ making power. The provider is responsible for outlining the differences in the treatment options, including both what the client might expect from each option and what might be expected from the client in order to ensure success. Once this information is made available, the client decides. Consider a buffet at a restaurant. If the buffet were client-centric, a patron at the restaurant would have all they need in order to inform healthy choices. This would include adequate description of ingredients. For a commonplace food, a simple label would suffice. For an unusual offering, a more detailed description would be helpful. Foods containing meat, or those designated either gluten or dairy-free, would be labeled as such. And of course, staff would be available to address any questions or special needs. An especially spicy food would be marked accordingly. A curry label might include four pepper icons, signaling spicy heat. A patron with sensitivity to spices might recall memories of burning lips or subsequent digestive distress and avoid all of the chili icons. The buffet would include enough information to allow a patron-centric choice. How might this look at a mental health clinic? A client-centric system is driven more by informed preference than symptom severity or treatment intensity. An informed preference is one based on accurate information. This information must specify enough details to ensure informed choices. This would include what can be expected from the product or service, as well what would be expected of the person selecting it. Let’s imagine a client who presents with social anxiety. The discussion of options would include low-, mid-, and high-intensity treatments. Low-intensity treatments would require less energy and investment. Mid-intensity treatments might require a moderate amount of effort, whereas high-intensity treatment would require a high level of commitment, time, and energy. At the low end, help-seekers might simply wish to browse the options and learn more about the problem and the potential solutions. There is less urgency and considerable autonomy. At the high end, in contrast, help-seekers would feel more urgency or be perceived by others as requiring assertive care. The person might be in crisis and incapable of consenting to treatment. The cost in terms of autonomy to the person would be high, treatment might require more time commitment, and it could end up being labor-intensive for providers. Alternatively, a stabilizing client-centric treatment plan might rely mostly on

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involvement of peers or family members. Flexible assertive community treatment team members often include highly capable peer supporters and family members. The team might decide that family support, combined with peer coaching on a mid-­ intensity e-mental health program is the best option for stabilizing a client. At the mid-intensity levels, client-centric stepped care might involve a blend of self-help, guided self-help, or group programming. While many experts would consider group treatment to be the treatment of choice for someone suffering from social anxiety, such a prescription is likely to be met with resistance by someone who fears social connection. Is it fair to call this resistance? Or would it be more accurate to view it as a natural side effect of an excessive treatment dose? Within the SC2.0 context, several options would be made available to someone interested in working on social anxiety. The lowest intensity option might simply include information about social anxiety delivered online. This could be attractive for someone suffering from extreme social anxiety and not ready for exposure to either a provider or to peers. For someone who is prepared to work with a provider, a guided e-mental health treatment might be tolerable. This combination includes a little exposure in the form of coaching and support, but the e-mental health coursework— the learning—could take place in private at home. Preference in SC2.0 extends to access modality both for initial contact and ongoing support. Access is possible through a web portal (e.g., Wellness Together Canada: https://www.wellnesstogether.ca/en-­CA) which contains a directory of programming and direct access to a suite of e-mental health programming. Access is also possible through phone (audio and text). Finally, same-day access is possible through local drop-in clinics. While some assessment is conducted at the initial point of contact, the emphasis is on support and care. Many people find the initial contact helpful and seek no further support. For those looking for more, options along the nine-step care continuum can be explored. While models of stepped care vary in terms of the breakdown of steps, nine appears to be the most granular representation (Berger et al., 2020). Our SC2.0 nine-step model is outlined in Fig. 1.2. As steps increase, stakeholder investment (i.e., time, effort, and cost to both service users and funders) also increases. Service user autonomy is greatest for low steps and lowest for high steps. This video animation uses a garden metaphor to illustrate how interventions are organized and cultivated in the context of community (https:// vimeo.com/377223766). In contrast to stratified models, SC2.0 encourages clients to start with their strengths, to start strong and to start simple. It does this in two ways. First, by drawing on capacities and trusting clients to determine what they wish to focus on, initial goals are manageable. There is no need to identify all the things that may be problematic in a person’s life or a long list of what may be wrong with them. Instead, the approach is simple. What is the thing that concerns you today? What is it that you would like to have changed today as a result of this visit? We don’t have to turn over every stone and find what might be wriggling beneath. We don’t need to see all the ugly flaws, at least not initially. We start with where the help-seeker is. What interests the person in front of us? What do they want to talk about, and what kinds of

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Fig. 1.2  Stepped care 2.0 graphic representation

solutions do they envision? If no solutions are readily at hand, we can dive a bit deeper, turn over a stone or two. But only if necessary. We acknowledge that we may get it wrong the first time and are transparent about this. It is similar to a visit to a physician. The top of mind concern is briefly assessed and addressed. Follow-up is encouraged in the unlikely event the solution fails—“If you are not feeling better in three to five days, come back.” We make ourselves just as accessible for follow-ups as we do for initial contacts. Unless we are mystified, unless something doesn’t add up, the simplest solution is likely the best place to start. We start with Occam’s razor—the simple explanation, with further investigation only as needed. In order to implement this start-strong/start-simple approach safely, establishing alignment happens fast. The therapeutic relationship has long been held central to good treatment outcomes. But, of course, it is not the same as a loving marriage. Our goal is not to create a deep attachment. Instead, we work very quickly on setting

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a trusting working alignment. One way to do this is to take some therapeutic risks. We do this by saying at the outset: “I want to work really hard at developing solutions right now, right here today. I want you to walk away saying ‘this was worth my while’… I also want you to know that I may get it wrong. I need you to let me know if this is the case. At the end of our meeting today, I will give you my card with my email address on it. Let me know if you want to follow up. You can email me, make an appointment or come to the drop-in. If today’s work needs some adjustment or rethinking, I’m counting on you to let me know so we can work on it together.” This shared responsibility for trial and error, for building alignment, for taking risks, allows trust to develop quickly. In contrast, a more traditional risk-­management approach does the opposite. If all the interviewer does is ask pre-prepared questions and invests little else in a first encounter, including no attempt at providing care, eliciting collaboration, risking some vulnerability, why would a help-seeker trust the interviewer? For this approach to work, providers need to ensure structures are in place that allow for flexibility and follow-up. Policies and procedures must also support it. Requirements for lengthy screening protocols need to be abolished. Record-keeping content may need adjustments, and scheduling processes may need to be re-examined. Support for more flexible forms of communication that maintain safety and privacy will need to be in place. Risk managers will have to be convinced of its value. They will need to understand how the empowerment approach shares risk thereby reducing it. They may need help understanding how trial and error is safe. Communications experts can help reset expectations for and of all stakeholders by promoting, with the right timing and the right audience, how this system is both safer and more empowering. They can help translate the concept of fail forward using language that challenges the risk paradigm in a way that people are ready to hear. Finding a method to communicate, with sensitivity, the value of failure in both life and academic pursuits, especially for those who are vulnerable already, is no easy task. No one can learn or grow without first being confused or engaged in struggle. Without one or the other, there is no learning or growth. The absence of struggle means either growth didn’t happen or wasn’t needed. Bold, hopeful, yet sensitive messaging on the new model is an ethical imperative. Shifting expectations with an encouraging voice is crucial for facilitating access and informed consent. Based as it is in part on the person’s readiness to accept challenges, SC2.0 arranges treatments along a continuum of readiness. For example, if a person is looking for support, a listening ear, a place to vent, but is not ready to learn or to develop skills, then a course of intensive psychotherapy would not typically be offered. Instead, less-intensive options are considered. Perhaps connection to a peer support network would be most appropriate. If one-on-one support with some professional oversight is preferred, a clinical trainee could be the best option. Both peer supporters and junior trainees are expected to restrict their interventions to supportive and active listening. This is perfect for a help-seeker not ready to introspect or be challenged. In contrast, for someone who is eager to dig deep and have defenses

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challenged, a course of intensive psychotherapy with a highly skilled therapist would be appropriate. Client readiness is the third dimension on the SC2.0 continuum. Treatment intensity increases with step level. In order to fully engage with this increasing intensity, clients must be ready for the work and, in the case of the highest steps, to forgo some autonomy. The three dimensions of SC2.0 are illustrated in Fig. 1.3. Some of my psychotherapist colleagues insist that it is the responsibility of every skilled therapist to apply motivational interviewing. It is a big part of the job to nudge people to full readiness. This seems reasonable. The value of motivational interviewing is well documented (Rubak et al., 2005). However, employing a specialist to do this work is unnecessary. Furthermore, the “nudge to readiness” premise could prove false. Should we always draw them to readiness? Or are there times when we should move? Maybe we should step back to where they are at the moment. Instead of spending weeks using motivational interviewing to shift readiness, why

Fig. 1.3  from PowerPoint here

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not shift the treatment intensity and approach to meet the person right where they are? I can hear my colleagues protest: “What if a person really needs intensive therapy to recover? Shouldn’t we do our best to get them prepared for this?” Possibly, but who should decide? And if so, who should we get to do the horse whispering? Does this preparatory work need to involve our most highly trained (expensive) specialists? Not likely, but again this could be a joint client–provider discussion focused on preference and expedience. Do we as experts really know what is best for another? What if we are wrong? Why not simply identify what the person is already prepared to do and see what happens? Maybe that would be enough to allow functioning and mental health to recover. If not, the provider and help-seeker can return to the drawing board and fail forward together. SC2.0 is firmly rooted in recovery principles. Recovery-oriented care assumes that illness and functioning are largely independent dimensions. A person may be mentally ill and highly functional just as a person might not be mentally ill and functioning poorly. A recovery model considers more than a person’s symptoms or deficits. When it comes to assessment, a recovery model invites us to attend as much to a person’s capacities as to their deficits. It also invites practitioners to draw heavily on the expertise of health-seekers. This is not to say a help-seeker has all the answers. But they may be experts on where to begin. They know the top of mind concern. They also know best what they are ready to work on. With SC2.0, we start by believing in capacities and strengths. We have faith in a client’s capacity to name the issue they are most ready to work on. With the application of solution-focused interview techniques, often the client comes up with the solution. A single, simple solution co-constructed from the help-seeker’s self-identified issue may be enough to stimulate movement to recovery. If not, follow-up is easy. Simple is the default. There can be a few more tries at simple, unless it becomes obvious that simple will not be enough. My original training looked very different. It was expert-driven. The assumption was, if I was thoroughly trained on psychopathology, diagnostic processes and interventions tied to diagnoses, I would be well equipped to provide the right treatment for the presenting concern. Certainly, this approach is well intentioned, logical, and principled. However, there are a number of fundamental flaws. Diagnostic accuracy is little better than chance. And even when accurate, diagnoses do not inform successful treatment. Neither diagnosis nor technique relates much to outcome. A third problem is that quite often care is delayed by lengthy intake or screening protocols. This lag means lost opportunity. It can contribute to treatment drop out. Imagine a visit to your physician’s office for what appears to be an infection. The physician takes the patient’s complaint at face value. A full physical is not conducted. The hypothesis that there is an infection is tested in a simple fashion. If confirmed by a brief examination, an antibiotic is prescribed. There was no full physical or referral for lab tests. Unless something peculiar arises in the investigation, the simple hypothesis holds. But, of course, the diagnosis could be wrong. It doesn’t have to be right. In fact, the physician is quite transparent about failure: “If after three or four days, you are not feeling better, or if it gets worse, come back to

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see me.” This is recovery-oriented. With SC2.0, mental health professionals begin this way, too. Similar to primary care, SC2.0 begins with a targeted brief assessment. And it always identifies strengths. After a question like “What concern is top of mind today,” the focus shifts to goal setting. What would you like to be different by the end of our meeting? Or if the issue were to be resolved in the next half hour, what would be different? Have you encountered the issue before? If yes, how did you deal with it? Would that strategy work now? There is no need to reinvent the wheel if we can draw on past successes. We are transparent about the ­start-strong/startsimple approach. And we give options. Are you more interested in exploring what led to this problem or would you rather focus on finding a solution? Whatever the choice, we make clear that this requires a trial-and-error mentality. I will keep checking in with you to see if we are on track with what is most important to you, and we can change course if needed. Every encounter in SC2.0 is treated as if it may be the last. The goal is to maximize impact because, whether we like it or not, a large proportion of visits to providers for mental health concerns are one-time visits. Because the stakes are high, we work to get the most out of every encounter. One way we do this is to infuse each meeting with hope and a conviction that something positive can come out of the session. If we work hard together today on this problem, what is something positive that will come out of it—what we will see at the end of our meeting? Whether or not something concrete is named, the question itself promotes optimism. It also leaves room for failing forward should initial solutions fall flat. I often say, “We will have about 45 minutes or an hour today in which I think we can come up with something that is helpful. I believe you will leave saying that this meeting was worth my time. It is also possible that following our meeting today, or maybe tomorrow, you may find yourself concluding that we haven’t quite solved the issue yet. This is understandable since we only just met. Getting it wrong the first time is no big deal. We can always take another crack at it.” At every encounter, whether through a web portal, by text, over the phone or in person, help-seekers can see the entire buffet of options—all the programming at all the steps. Clients also see their progress reports, the patterns of growth or deterioration, and are encouraged to consider, when appropriate, the options from the menu that may support continued success or a change of course. People with lived experience with mental illness have told us formally and informally that they like this model. They are particularly pleased with the straightforward, rapid access to basic care. My colleagues and I initially underestimated the power of same-day access. We thought this might only be relevant to the worried well—those people not at risk, but who want life to be better. We were wrong, as we learned from the voices of a tiny but resilient community. Like many along the rugged coast of Newfoundland and Labrador, inhabitants are resilient. They have clung to the isolated, storm-ravaged, craggy edge of the continent for almost 500 years.

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Everybody Gets Priority Like much of the coastline in Canada’s most easterly province, the scenery on the Burin Peninsula in Newfoundland and Labrador is breathtaking. The population is sparse, strung out along coastal roads that snake along the rocky cliffs, sandy beaches, and in and out of the deep protected harbors. But over the course of 16  months in 2016 and 2017, these tiny, sleepy communities were rocked by 14 suicides. In the town of Burin alone, which has a population of just over 2000, there were six suicides. Not surprisingly, the unusually high number of deaths drew national attention. Senior officials from the Government of Newfoundland and Labrador and the Mental Health Commission of Canada visited the region to investigate and deploy resources aimed at preventing further deaths. Initially the plan was to increase resources aimed at identifying those at risk of suicide and targeting services for those who appeared most seriously ill. But members of the community had other ideas. Sisters Natalie Randall and Valerie Peach of the town of Grand Bank both lost their husbands to suicide in 2016. Racked with grief, sadness, and anger, Natalie told a reporter that “this province has to wake up.” Both sisters decided to speak publicly to raise awareness of the unmet mental health needs in their region and across the province. “A culture change is needed,” they said, because the system is broken with long wait-lists and no services at all in many communities. Natalie helped organize a local community mental health coalition in Grand Bank to advocate for change. Organizing for change was also happening in other parts of the province. The Community Coalition for Mental Health began lobbying the provincial government in 2015. This led to an unprecedented all-party report recommending dramatic changes in the structure of the system and the delivery of care. The deaths in the Burin region strengthened the resolve of advocates and the all-party committee to seek bold changes. Rather than demanding more specialist care aimed only at those already ill, community members focused on obtaining rapid access to more basic mental care for the entire population. The best suicide prevention strategy, they argued, is basic, upstream care for all. The province’s Department of Health and Community Services worked closely with members of the coalition and other persons with lived experience to redesign care. One feature of the new system was Doorways, a single-­ session walk-in clinic. The Department had been preparing to establish these clinics province-wide, but at the request of Burin community members, the launch was fast-tracked for their community. Burin community members took the Doorways walk-in concept a step further. The concept of walk-in access was so attractive that they suggested all appointment-based services be transformed immediately to walk-­ ins. Initially, clinical staff were hesitant as they could not see how all programming could be accommodated through same-day access. The coalition persisted and in a matter of months, the wait-list was eliminated, no referrals or appointments were necessary, programming became more client-centric, and no-shows and cancellations became a thing of the past. Counseling was available 9  a.m. to 3:30  p.m., Monday through Friday, at two clinic sites. As one social worker put it, “Everyone gets priority now… not just clients in crisis.”

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References American Psychological Association. (2019). Survey: Americans becoming more open about mental health. American Psychological Association. Retrieved January 2, 2020, from https://www. apa.org/news/press/releases/2019/05/mental-­health-­survey Berger, M., Fernando, S., & Salmon, A. (2020). Scoping review of stepped care interventions for mental health service delivery to youth and young adults. Centre for Health Evaluation and Outcome Sciences. Bower, P., Kontopantelis, E., Sutton, A., Kendrick, T., Richards, D. A., Gilbody, S., et al. (2013). Influence of initial severity of depression on effectiveness of low intensity interventions: Meta-­ analysis of individual patient data. BMH, 346, 1–11. Boyd, L., Baker, E., & Reilly, J. (2019). Impact of a progressive stepped care approach in an improving access to psychological therapies service: An observational study. PLoS One, 14(4). https://doi.org/10.1371/journal Clark, D.  M., Layard, R., Smithies, R., Richards, D.  A., Suckling, R., & Wright, B. (2009). Improving access to psychological therapy: Initial evaluation of two UK demonstration sites. Behaviour Research and Therapy, 47(11), 910–920. Dalley, M. L., & Ruscoe, J. (2003). The abduction of children by strangers in Canada: Nature and scope. Royal Canadian Mounted Police. Efflin, J. (2019). Death rate for suicide in the U.S. 1950–2017, by gender. Statistica. Fazel, S., Singh, J. P., Doll, H., & Grann, M. (2012). Use of risk assessment instruments to predict violence and antisocial behaviour in 73 samples involving 24,827 people: Systematic review and meta-analysis. BMJ, 345, e4692. Firth, N., Barkham, M., & Kellett, S. (2015). The clinical effectiveness of stepped care systems for depression in working age adults: A systemic review. Journal of Affective Disorders, 170, 119–130. Greenberg, G. (2010). Manufacturing depression: The secret history of a modern disease. Bloombury. Hari, J. (2018). Lost connections: Uncovering the real causes of depression—And the unexpected solutions. Bloomsbury. Hedegaard, H., Curtin, S.  C., & Warner, M. (2018). Suicide mortality in the United States, 1999–2017. CDC National Center for Health Statistics. Joint Economic Committee. (2019). Long-term trends in deaths of despair. United States Senate. Lipson, S.  K., Lattie, E.  G., & Eisenberg, D. (2018). Increased rates of mental health service utilization by U.S. college students: 10-year population-level trends (2007–2017). Psychiatric Services, 70(1), 60–63. NICE. (2011). Commissioning stepped care for people with common mental health disorders. National Health Service. Retrieved January 21, 2019, from http://www.swscn.org.uk/wp/ wp-­content/uploads/2015/03/non-­guidance-­commissioning-­stepped-­care-­for-­people-­with-­ common-­mental-­health-­disorders-­pdf.pdf Our World in Data. (2019). Global deaths in conflicts since 1400. Retrieved from Our World in Data: https://ourworldindata.org/war-­and-­peace Rhydderch, D., Krooupa, D., Goulden, R., Williams, P., Thomicroft, A., Rose, D., et al. (2016). Changes in newspaper coverage of mental illness from 2008 to 2014  in England. Acta Psychiatrica Scandinavia, 134, 45–52. Rubak, S., Sandbaek, A., Laurtzen, T., & Christensen, B. (2005). Motivational interviewing: A systematic review. British Journal of General Practice, 55(513), 305–312. Scott, J., & Henry, C. (2017). Clinical staging models: From general medicine to mental disorders. BJPsych Advances, 23(5), 292–299. Soanes, C., & Stevenson, A. (2008). Concise Oxford English dictionary (11th ed.). Oxford University Press.

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Stanford, S., Rovinelli Heller, N., & Warner, J. (2017). Beyond the risk paradigm in mental health policy and practice. Palgrave. Varshney, M., Mahapatra, A., Krishnan, V., & Sinha Deb, K. (2016). Violence and mental illness: What is the true story? BMJ, 70(3), 223–225. Wampold, B. E., & Imel, Z. E. (2015). The great psychotherapy debate: The evidence for what makes psychotherapy work. Routledge.

Chapter 2

Open Access Peter Cornish

No One Asked Me I was visiting one of my daughters last winter. She was completing a degree in geology at a university in Western Canada. We were traveling for a day of skiing at a mountain resort about an hour away from her home when she asked me about my work on stepped care. “What is it anyway?” she asked. I decided to emphasize the rapid access, start-strong/start-simple aspect. I said my approach to stepped care provides same-day care without all the questions and assessment. We start by asking people, “What is the top of mind concern for you today that you would like to address? Then we work really hard to ensure that when that person leaves in 45 or 60 minutes, they walk away with something useful. They are able to say, ‘that was worth my time.’” Without missing a beat, my daughter said, “I wish that was there when I needed it. No one ever asked me what I wanted.” The experience she described at her campus counseling center was not SC2.0. The counselor focused on her own questions and her idea of what the problem was. She applied a lengthy, rigid, predetermined assessment protocol. My daughter said that she was disappointed by a similar approach from a private practice psychologist noting, “And this was at my own expense!” Neither encounter was client-centric. Neither counselor asked what my daughter wanted or worked to ensure the first encounter was useful. Subsequent sessions seemed driven mostly by the counselor’s curiosity, agenda, and questions. My daughter felt left out.

P. Cornish (*) Counseling and Psychological Services, University of California, Berkeley, CA, USA e-mail: [email protected] © Springer Nature Switzerland AG 2023 P. Cornish, G. Berry (eds.), Stepped Care 2.0: The Power of Conundrums, https://doi.org/10.1007/978-3-031-45206-2_2

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2.1 The Professionalization of Everyday Life What went wrong with my daughter’s attempts to access care? Both counselors were licensed, well trained, and highly qualified. They were practicing as they had been taught. My guess is that each started the session with an open-ended question like, “Tell me what led you to come in today?” I imagine each listened actively and with empathy for a minute or two. But then they got down to business. There was the requirement to follow an intake protocol of some sort. These may have varied in length and degree of structure depending on the style of each provider. The focus for both was likely on identifying risks, symptoms, and formulating a conceptualization of the problem. Their questions were probably aimed at ruling out alternative diagnostic possibilities. All of them were deficit-oriented. The goal was to turn over every stone and take notice of the unpleasant material underneath. This was, of course, well intentioned. It was the best way, they thought, to identify the sources of her difficulty and then neutralize them. They truly wanted to help my daughter. Unfortunately, my daughter did not find the experience to be particularly engaging or fruitful. She left frustrated. So, as mental health professionals and help-seekers like my daughter, how did we arrive at this disconnect? For decades, we have encouraged people who struggle with anxiety or depression to seek professional help. A generation of children, including my daughter, heard that message repeatedly from teachers and guidance counselors. Public education has focused on stigma reduction in order to encourage help-seeking. There is evidence now that stigma is decreasing (Lipson et al., 2018; Quartana et  al., 2014). Not surprisingly, more people are seeking help. This is undoubtedly a positive development. More than ever before, people are becoming comfortable talking about their mental health to friends, loved ones, and colleagues. Social and emotional learning is being incorporated in school curricula. Workplace standards for supporting mental health have been developed, and large corporations and philanthropic organizations are investing in mental health campaigns and more sophisticated employee assistance programs. While promising, these efforts lack coordination or clear direction. And in many cases, a common message encourages consultation with experts. Allan Francis, one of the architects of the DSM IV, now laments his work on the project and the resulting medicalization of everyday life (Frances, 2013). Tom Insel, former director of the National Institute of Mental Health, also expresses regrets. He oversaw approximately $20 billion in spending on neurobiological research which he now admits had no impact on mental health. He now suggests we focus more on identifying social and psychological factors that contribute to well-being (Insel, 2019). When emotionally distressing events like a death or suicide occur in a school, administrators dispatch a team of counselors to console the children. Similar deployment of psychological crisis response teams is common in workplace tragedies. I have assumed the role of counselor in such situations. While in theory this strategy aims to reduce risk of trauma or—in the case of suicide—contagion, I believe this

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is misleading, signaling to people that they should turn more to experts than each other in times of trouble. I have noticed that employees, administrators, children, parents, and teachers are not especially interested in connecting with counselors at these moments. Counselors, in turn, seem to feel out of place, standing or sitting awkwardly on the periphery, wondering how or whether to engage. Are we interfering in what would otherwise be a natural and healthy process of community engagement? Are we effectively disempowering people by our presence? We learned after years of promoting critical incident debriefings following traumatic events that these actually cause greater harm than good (Bledsoe, 2003). The debriefings were based on the assumption that PTSD onset could be prevented by leading all who had endured a tragic event through intensive, professionally guided exposure exercises. While there is some evidence that peer-led debriefings can be helpful, debriefings by outsiders, even those with solid mental health training, have been shown to slow recovery. Current best practices suggest conducting informational sessions that emphasize the normal, healthy reactions to crisis and outline resources that could be helpful should recovery stall or symptoms deepen (Pack, 2012). When I am asked to offer to support to organizations in time of crisis, I prefer to limit my role to that of consultant to the leaders of the organization. In other words, I aim to support and empower the designated administrators who are already known to the community to provide the right information. I help them to trust their natural instincts and to supplement them with resources that are evidence-informed.

2.2 The Real Reasons for Surging Demand Large numbers of people, including my daughter, are now ready to work on their mental health. Our public education and anti-stigma campaigns have succeeded. But instead of supporting people to work together on building healthy communities, we tend to encourage reliance on experts. Why is this so? Offering the highest level of expert support is certainly well intentioned, especially when we are concerned about deteriorating mental health. However well intentioned, the risk is that we could be discouraging the development of community and resilience. I think there could be darker explanations for the knee-jerk call-in-the-experts reaction. While more people are comfortable with help-seeking, there is still likely reluctance to offer support to those who are emotionally troubled. It is a circular problem. We fear doing the wrong thing or fear that someone who is troubled could be dangerous. So, we call in the experts. And the more we call upon experts to manage crisis situations, the more we reinforce the stigma. I call this the “pass-the-hot-potato” syndrome. Mental illness, odd behavior, and distress are all perceived as warning signs of danger and not only is the potato too hot to hold, we think we are being caring and responsible citizens when we rely so heavily on those with the most training. Compounding this problem is the temptation for politicians to conflate violence with mental illness. Despite the fact that mentally ill people are less likely than

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healthy people to commit acts of violence, a common conservative narrative explicitly states that mental illness is the root cause of “senseless” violence. Extreme acts of violence are rarely senseless. They usually require careful planning, attention to detail, and resourcefulness. Hostility is the most common factor. And hostility is not a mental illness. Neither is anger or bad behavior. Acts of violence are most often conducted with a clear, even razor-sharp mind. Sadly, often the same people who attribute violence to mental instability are the first to suggest punishment. As such, the mental illness/violence equivalency narrative only serves to undermine efforts to invest more in mental health. Better to just lock up dangerous/crazy people and throw away the key. Large pharmaceutical firms have distorted our perspective on mental health. They have successfully marketed the “biochemical disease” model of mental illness for virtually all types of human distress and dysfunction (Kirsch, 2009; Spielmans & Parry, 2010; Whitaker, 2010). These efforts are aimed at everything from depression to social anxiety to sexual dissatisfaction. Millions of people now believe that mental well-being can be achieved with medicine. This, despite the fact that clinical trial evidence for pharmaceutical treatment is weak at best and no clear biochemical mechanisms for antidepressants have ever been identified (Moncrieff, 2009; Shorter, 2011). The fact that help-seeking is increasing suggests that stigma might be decreasing. But the picture is not so clear. Celebrating the end of stigma is premature. While there are some signs that stigma is decreasing for youth (Lipson et al., 2018), there is some evidence that stigma might actually be increasing for the general population (Mackenzie et al., 2014). Self-reports of despair and distress are increasing as is the expectation that this can be relieved either medically or professionally. But rates of mental illness have been stable for decades (Baxter et al., 2014). People are reporting greater feelings of distress but not more mental illness. While in some cases professional help is appropriate, medicalizing normal distress is not. Seeking professional help for normal distress is potentially disempowering insofar as it weakens self-reliance. In schools, on university campuses and in workplaces, authorities who observe distress are being advised to refer people for professional assessment and care. Clearly well intentioned, this rush to professionalism coincides with a pass-the-hot-potato impulse. Risk managers, fearing violence, reinforce this process. This, in turn, leads back to stigmatizing distress and mental illness. We have convinced, and sometimes frightened, people into thinking that mental health is both fragile and complex. It is best left to professionals. Adding to the problem is the limited supply of experts and mental health programming. Jurisdictions that have recruited additional mental health personnel find that the demand immediately catches up. Why is this the case? I believe the increased comfort with help-seeking combined with the medicalization of distress is contributing to a curious demand spike. The demand is soft and price-sensitive. It is soft because when professional care is either unavailable or too expensive, those experiencing only mild or moderate distress may prefer to wait and/or recover on their own. When the supply of counselors increases, those with mild or moderate distress come rushing back until capacity is reached again. This cycle is neither sustainable

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nor effective in strengthening resilience. A more viable option is to encourage natural family-, peer-, and community-based support. While there may be a need for more professional care aimed at some currently underserved populations, new investment should be aimed at health and wellness promotion, targeting families and communities directly.

2.3 Investing Upstream I do believe we need to invest more in mental health, but not a lot more. It is more important to use existing resources differently. We should shift toward health promotion and upstream programming. Figuring out how to reconfigure existing resources will not be easy. Some new money would be well spent on system-­building with close attention to the process of change. This means applying implementation science in support of innovation. Instead of hiring more people to do the same, invest new money in changing how we organize care. While there may be a need for increased investment to fill some existing gaps in mental health (e.g., low-­intensity programming including walk-in clinics and e-mental health infrastructure), we may not require the additional funds in the long run. Some additional money spent now on upstream programming will be recovered as the need for downstream programming decreases. Upstream programming involves more than public education. It requires a variety of accessible care options aimed at preventing small issues or needs from growing into more serious ones. We have some of these now for our physical wellness. Healthy food guides prepared by our departments of health are one example. Laws and policies regulate the food industry to ensure that people know the nutritional value of the foods when grocery shopping. While parks and recreation centers are often key components of urban planning, regulations on requirements are loose. How many should we have, and how should they be subsidized? Where are the policies ensuring all workspaces have windows or natural light? Why don’t building codes require all properties to have greenspace and trees? Restaurants and workplaces must abide by strict safety codes and food preparation practices. And although in Canada we have a psychological standard for health and safety in workplace, there are no laws to enforce it.

2.4 Starting Simple, Starting Strong Monte Bobele, a seasoned single-session trainer and contributor to this volume, admits that critics sometimes dismiss his method as a Band-Aid solution, implying it has no real value. But the Band-Aid, he counters, is one of the most useful and elegant medical devices ever invented. It is simple, flexible, inexpensive, portable, and widely accessible. More importantly, it saves lives by stopping bleeding and

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preventing infection. It is, therefore, ironic that critics of one-at-time therapy use it as a metaphor for inadequacy. The fact that the brand name, Band-Aid, became a generic term for this popular device heightens the irony. As with Occam’s razor, the simplest solution is typically the best solution. If the patient presents with a small cut, it would be absurd to engage in an exhaustive investigation into what else might be wrong. Just put on a Band-Aid! Likewise, if a person comes to a walk-in mental health clinic and says, “I want help to manage stress,” why not start there? Is it necessary to assess for depression, for a family history of psychosis or anxiety? Of course, if simple stress management strategies fail to work, further investigation might be called for. We argue that a trial-and-error approach only makes sense if simple is the default approach. We don’t need to turn over every stone at the first encounter. Instead begin on the surface. With mental health issues, sometimes the problem is only skin-deep. To think otherwise is discriminatory. I suspect that the fact that upending every stone is our current default approach speaks to the long-standing deep distrust we have for presentations of human psychic distress. We suspect something dark or ominous. We do not trust overt presentations or explicit requests of clients. Perhaps mental health professionals of all persuasions are still more under the influence of psychoanalytic theory than we thought. Do we always need to identify the deep seated, sometimes dark impulses lurking in our unconscious? Don’t get me wrong. This stuff is fascinating. I loved my training in psychodynamic therapy. But this deeper analysis should not be where we begin. I reserve it as a last resort. It can make the otherwise onerous work with some of our most challenging cases both fascinating and rewarding. But only if simple solutions fail. Self-correction, a core feature of stepped care, is much more welcome after a minor investment of energy than a major one. Self-correction doesn’t make much sense in traditional practice because we are under the illusion that with careful, exhaustive, deep up-front assessment we will get it right. If clients resist, this is because they are not ready. Readiness, in this context, is just a modern variation on defensive resistance. When treatment doesn’t work, it is due to client limitation. There is never any need for self-correction with such an entrenched system of confirmatory bias. In contrast, SC2.0 begins with no assumptions and no pretense on getting anything right. Assessment is not used to support our theories or justify our treatment protocols. It is used instead to tell us in a more honest, transparent, and accountable fashion when we get it right and when we get it wrong.

2.5 Capturing the Moment of Readiness Who decides what to focus on in treatment? My daughter was not asked what she wanted to talk about, nor was she asked what kind of care she wanted. Why not? Why don’t we begin with trusting the person in front of us with both questions and then bring in our expertise when needed? If we start with the perspective of the person in front of us, chances are we will connect with something that they are

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interested in working on. Even if, somehow, we do know better, chances are the person will either disagree or not be interested in our approach or in our ideas. One of the first things I was taught in graduate school is that help-seekers are not looking for advice. But is beginning treatment with an exhaustive assessment followed by a treatment plan based on diagnosis really much different from advice giving? It just comes in a fancier package. Some of my colleagues say, “People want to be heard, and they want to tell their stories—this requires lots of time.” But, I counter, that is why we are trained to be skilled listeners. A skilled listener can pull a story from someone in a matter of minutes. Listening actively and accurately is crucial for rapid alignment. It is pleasurable to be heard. And for some this may be enough. But most people would say they want more than being heard. They want a problem solved or to function and feel better. Being listened to will usually make a person feel better. But being listened to and gaining some agency and solving a problem would likely feel even better. When we target the moment of readiness, clients will feel heard. They will think or say, “Yes that’s it, that’s what I want to work on.” They will feel aligned. And then when we help the person to see they can make headway themselves, right now, today, they feel accomplished and capable. We know about the importance of readiness for change from years of research on addictions recovery (Krebs et  al., 2018). People vary in the extent that they are ready to make prescribed life changes. A prescribed change is one recommended by someone else. Stages of change research suggest that only about 20% of people are ready (Norcross et  al., 2011). But this fact is often misinterpreted. Everyone is 100% ready to change something; it just might not be what others think they should change. There is usually a fair amount of disagreement on what to change. Expert-­ driven care often prescribes a very specific change. When a therapist recommends CBT, up to 80% of people will not bite. It is not because CBT is ineffective, nor is it that people are resistant. It is more a matter of preference. Our most valued expertise is process related. But we often act like technicians. Delivering a course of CBT, without attention to process, would simply be a technical act. Identifying the issue and strategy most aligned with readiness is a process skill. Nothing is prescribed in this process. The process cannot be manualized. When someone has made the effort to reach out, and we make ourselves available right at that moment, it does not matter what we think they should do. It matters so much more what the person in front of us is ready to do. A colleague of mine is the founder of a very successful peer support network. She, as do all who work in the organization, identifies as someone with lived experience of mental illness. She is in recovery. Her symptoms and illness come and go. Her functioning moves up and down. She, like my daughter, urges providers to be more trusting of clients’ experiences and preferences. She makes impassioned pleas to mental health professionals like me to “always start with ATP!” Ask the person in front of you instead of relying on lengthy intake or screening protocols. Just ask “what is top of mind for you right now” or “what would you like to be different in your life.” My colleague reminds me not to be surprised if people with lived experience have some brilliant answers.

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A more efficient mental health system would be tailored to capturing the moment of readiness (Hoyt & Talmon, 2014). Our assessment and techniques would focus more on identifying the problem that is most relevant to the person and identifying the thing they are most motivated to try, in an effort to resolve the problem. The approach I described to my daughter while driving to the ski hill is such a method. It is in line with single-session, or one-at-a-time, therapy, the drop-in counseling approach introduced and developed by Moshe Talmon in the early 1990s (Talmon, 1990). Talmon is the first to admit that “single-session” is a misnomer and that he prefers to call it “therapy-one-at-a-time.” But his publisher insisted on “single session,” convinced it would sell more books. Monte Bobele has told me that he prefers the term “open access therapy.” All three terms mean that every session is self-­ contained, includes a simple, very brief assessment, an intervention, and some evaluation on whether the intervention was helpful. The session is meant to stand on its own, much the way a visit to your family physician is meant to achieve an outcome without any expectation of a follow-up. Of course, a follow-up is possible. Physicians often say, “If you are not feeling better in three or four days, make an appointment to see me and we consider other options.” An additional session is possible; it just isn’t the default. As Talmon and colleagues suggest, each session is treated as if it may be the last. This fits well with the fact that the modal visit in psychotherapy is one, regardless of therapeutic approach. In other words, many people only come once no matter what, so it is important to ensure that the first encounter includes a targeted intervention. In contrast, traditional “intake” sessions are never treated like they might be the last session. Indeed, the opposite is true. The word “intake” itself implies this is just the beginning. The whole purpose of the session is to convince the client that being taken into our system is a good idea. Often, like my daughter’s experience, the “taking in” is all that happens. Lots of questions are asked, and no intervention is offered.

2.6 Open Access Imagine the impact on our collective health if people were to have open access to appropriate care when and where they want it. The good news is that we already have the capability. Single-session (or therapy one-at-a-time) clinics are opening across Canada and increasingly in other parts of the world. In Newfoundland and Labrador, help-seekers can choose between three modalities of rapid access care: web, phone, and in-person. Monte Bobele suggests the term “open access care” to encompass the expansion of therapy one-at-a-time through multiple modalities. Open access in Newfoundland and Labrador includes same-day care through three modalities (see Fig. 2.1). With all three options, care begins immediately with minimal assessment. 1. The Bridge the gApp web portal: a directory listing all care options for the province and links to a suite of e-mental health tools of varying intensity designed to

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Fig. 2.1  Innovative programs accessible through the Bridge the gApp portal in Newfoundland and Labrador

accommodate different preferences and learning styles (i.e., Mood Meter self-­ assessment tool that points to appropriate resources; Wall of Hope peer forum, Breathing Room positive psychology self-managed depression program; TAO— mid-intensity blended therapist assisted self-managed treatments for depression, anxiety, relationships, and substance use; Strongest Families telephone-led professional anxiety treatment for children and youth; and Mindwell U 30-day mindfulness training program). 2. Three phone lines: the provincial 811 help line staffed by mental health professionals; the Warmline: staffed by paid, highly trained peers with lived experience of mental illness; and the Crisis Text Line. 3. Doorways one-at-a-time drop-in clinics at 60 sites across the province offers sessions at physical clinic spaces.

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We start strong, capturing the energy that motivated the help-seeking and drawing on the existing client strengths to address the top-of-mind issues. In all three modalities, the client is introduced to the idea of trying something simple with reassurance that additional options are available should the simple approach be insufficient. This suggestion sets the foundation for a “fail-forward” approach aimed at promoting resiliency. The open-access, start-strong/start-simple approach is hypnotic. It leverages hope, through the power of suggestion, that simple can be impactful. The solutionfocused interview style is rooted in Ericksonian Hypnotherapy. Hope is prescribed, and beliefs are instilled in the potential of untapped internal capacities. Clients draw on existing strengths and past successes to make many small differences that collectively have meaningful impact. Chaos theory, often exemplified by the butterfly effect, suggests that small events matter, but predicting their effect is near impossible. Economists know this, as do successful business operators. For most businesses, continual small tweaks are the most effective way to produce sustained growth. These iterations keep clients interested and engaged. If these minor alterations fail, the impact can be moderated through vigilant monitoring and nimble adjustments. But if they succeed and compound, the rewards can be spectacular. Critics of single-session therapy are correct to question whether a simple change will lead with any certainty to a specific health outcome, but chances are that with the multiple, iterative one-at-a-time micro-solutions available through an open-­ access system, collective impact will be positive.

2.7 Failing Forward Our SC2.0 approach suggests that failure is also okay. But this is only true if there is a wide range of treatment options. Availability of all the options is made clear at the outset for two reasons: 1 . Choice from the buffet is empowering and supports ownership and buy-in. 2. Clients get a sense that should their first choice fail, other viable options exist. The intent of our approach is to stimulate hope and optimism while also preparing people for persistence and flexibility when results are not optimal. With full transparency, we share the full menu with clients on a first encounter (in-person, over the phone, or on the web). One version of the menu is illustrated in the two-dimensional graphic above. For phone and in-person sessions, clients are informed that they are at the open-access point (see box in the middle of the graph) and that the open-­ access encounter is meant to be productive and targeted. We recommend that only experienced therapists lead these sessions. Conducting a brief focused assessment, as well as a successful intervention in a single encounter, requires both a generalist’s breadth of knowledge and solid solution-focused interviewing skills. Open-access sessions also demand quick, on-your-feet thinking, as well as confidence with experimenting. Therapists must be able to hone in on opportunities for capturing the

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moment of readiness. This is why the open-access sessions are at the mid-level of the graphic. While the open-access sessions do not require the most specialized (and expensive) care, the work demands a high level of therapeutic energy. Open access means that people can get care rapidly and through a variety of modalities. Having multiple modalities, such as an online portal, telephone and text options, and in-person drop-in, reduces barriers, opening up access. In line with one-at-a-time therapy principles, each open-access encounter is treated as if it could be the last. This means that the encounter begins with a focused, very brief assessment. Typically, it involves a question like this: “What concern or issue is top-­of-­ mind for you today?” While there is no proscription on the number of issues brought forward, a skilled interviewer brings focus to the issue that is most relevant at the present moment. The assumption is that motivation for working toward change will be highest for the issue that is top-of-mind. It allows the interviewer to capture the moment of opportunity for creating a solution that is of greatest relevance. Suppose a client responds by saying, “I’m feeling shock, anxiety, and extreme loneliness because my partner of six years broke up with me, and I really didn’t see it coming.” After some active listening, and a brief screening for potential suicidal risk, the interviewer might say, “Tell me what things you have done to cope so far.” By identifying even the smallest of successes with coping so far, the therapist is attempting to identify existing strengths. The interviewer might also ask the client to imagine the end of the session and to picture feeling better and having the thought, “I’m glad I came. This was worthwhile.” Then after a pause, the therapist could ask, “What is different as you imagine this? What has changed for you?” Or, “What will you be doing next as a result of the session today?” These questions, posed at the outset, are deliberately hypnotic; they invite a small measure of hopefulness. They also set up realistic goal setting. In this case, the client might answer, “I would be feeling less anxious, and maybe I would have a plan to help me become more active so that I don’t wallow in my grief.”

2.8 Informed Consent SC2.0 is preference-based and client-centric. This means that clients are supported to make informed choices and decisions about the care that best meets their needs. Informed consent within the context of SC2.0 requires communication of what the options are, what can be expected in terms of outcomes, and what investment is required on the part of the client to achieve those outcomes. The one-at-a-time approach is relatively new. Even newer is our SC2.0 system model. Expectancy is a key driver of mental health outcomes. If the treatment matches expectations, recovery is more likely. This presents us with both a challenge and an opportunity. Shifting expectations of stakeholders require careful and deliberate communication. But they also afford an opportunity to leverage the impact of mental health promotion. We take two approaches to meet this challenge—public education and informed consent at point of contact. Messaging the model happens on clinic websites,

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tear-­off sheets, and wellness plan/prescription pads in primary care clinics. For the broader population, the model is promoted through mental health literacy campaigns and program descriptions in online service directories. At first point of contact, clients receive a description of SC2.0 which includes references to the one-at-a-time approach, as well as the fail-forward trial-and-error method. SC2.0 is transparent. The provider is explicit about starting strong and simple: “I really want you to feel by the end of our meeting that this was worthwhile. To make sure this happens I will work really hard to ensure that we focus on the issue that is top-of-mind for you and, better yet, that we identify some ways to begin resolving it quickly. I will help you to identify strengths, capacities, and resources that you already have, but may have lost sight of. I will also share any ideas I have about resources that I think you may find helpful. Then by the end of our meeting you will already have begun building a solution. How does that sound?” This is informed consent for SC2.0. This care at point of need occurs either in-person, over the phone or through chat/ text interface. This start-strong/start-simple mindset shapes the interview styles of crisis and intake workers. It is woven into the practices of therapists from all theoretical orientations—cognitive behavioral, interpersonal/dynamic, and humanistic therapy. While the approach is rooted in principles of solution-focused and narrative therapy, the start-strong/start-simple attitude can be applied when disputing thought patterns, exploring relationship dynamics or developing self-worth. Upfront assessment is minimal in open-access approaches. In some cases, it begins with only the single top-of-mind question described above. In other cases, clients may complete an open-ended single sheet with seven or eight questions in the waiting room (see Fig. 2.2). These questions can be asked over the phone or when first joining a chat session. In some settings, a brief computerized monitoring assessment may be offered in the waiting room.

2.9 Early Alignment The success of open-access programs, as with any treatment, depends on process factors that contribute to the client experience. This is why care and connection are so much more important than cool, detached information gathering or assessment. Warmth, kindness, and the promise of some immediate relief must be conveyed immediately. Alignment is primary. Information is secondary. This is true for all access modalities, including self-managed programming delivered online. Brief, targeted screens are available for online mental health platforms. For example, the same start-strong/start-simple approach guides the organization of self-help resources offered through a web-portal, such as Wellness Together Canada. Narrative approaches guide journaling activities aimed at goal setting. With goals established, simple AI algorithms guide self-managed treatment decisions. Users are encouraged to consider a wide variety of available self-help options and to begin with one that has intuitive appeal. Instead of prescribing options based on symptom

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Fig. 2.2  Single-session or therapy one-at-a-time drop-in waiting room survey

profiles, our approach is driven first by user preference and then with return visits through progress tracking feedback. Guidance emphasizes the importance of both preference and experimentation. Users are encouraged to balance a trial-and-error attitude with persistence. The AI prompts are designed to motivate and engage users. Sometimes this includes emphasizing the values of recovery that are so important to users—coping, growth, resilience, social functioning, independence, and empowerment. A clinical trial indicated that the chat-based Woebot treatment for mood disorders was effective. Most intriguing, however, was the conclusion that the benefit came not from the cognitive-behavioral techniques taught by the chatbot,

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but from the relationship users developed with the cute, funny bot itself (Fitzpatrick et al., 2017). Just as psychotherapy with humans is only as successful as the alignment or bond with the therapist, online platforms will only be as successful as they are enticing or engaging.

2.10 No Wrong Door In 2018, SC2.0, including open-access care, was launched across the province of Newfoundland and Labrador. Early usage and satisfaction data indicate that the program was well received. Wait times were reduced by 65%, with some communities reporting no waiting. We collected both quantitative and qualitative satisfaction data during the initial pilot phase from a small, non-representative convenience sample. As indicated in Fig. 2.3, most people still accessed standard Step 7 individual counseling programming. However, more than half-accessed low-intensity programming. Of the low-intensity programming, the drop-in Doorways clinics were most popular. Although the response rate was low and not representative of the population, close to 80% of people surveyed said that the self-managed online mental health programs available through the Bridge the gApp portal met at least some of their needs. With open-access care, there is no wrong door. At McGill University, where Stepped Care 2.0 was implemented in the context of an integrated wellness hub, “every door is the right door” (Romano, personal communication, January 22, 2021). Some have argued for a single point of access to care. Integrated primary care clinics strive for this, and they are an improvement over disorganized, decentralized services demarcated by professional discipline and disparate funding models. A single point of access is a good idea. It erases the contrived dichotomy between

Fig. 2.3  Selected results from the Stepped Care 2.0 e-MH demonstration project. (MHHC, 2019)

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physical and mental health. A help-seeker can decide at the merged site whether to see a medical or non-medical professional. Or perhaps a more holistic option, such as enrolling in a wellness program, would involve both medical and non-­medical care. As described in Chap. 6, collaborative care is central to SC2.0. However, proponents of integrated care recognize that there are some disadvantages to co-location. Not everyone will be comfortable with the one doorway. I recall students at our newly merged Student Wellness and Counselling Centre lamenting the peaceful, old counseling waiting room. While the new space, with large windows facing a forested hillside, was modern and efficient, it was noisier and busier. Some felt too exposed. Self-conscious students, anxiously awaiting their first mental health contact, had to share space with young parents and crying babies. Open-access care introduces multiple doorways, where any door could be the right door. Through an open-access system, clients can choose between more public and private locations. For some, web access to health and mental health resources is preferred because no one would know. And the bright, noisy waiting room could be avoided. For others, human contact is essential. And still others might prefer the anonymity of a crowd: “I am just waiting here, like everyone else, alongside crying babies and people seeking refills.” Desire Paths Twenty-five years ago, when I was working as a predoctoral intern, I commuted to work by bus and then walked half-way around the central campus bowl path to get to my office. There were signs along the path prohibiting pedestrians from walking on the grass. Judging by the criss-crossing paths, these signs were largely ignored. It made sense to me that people ignored the signs, seeking the most direct route from one building to another, or in my case from the bus stop to the Student Services Building. One day, to my surprise, a temporary fence surrounded the bowl. Construction signs replaced the keep off the grass signs. I learned that the administration had allocated funding for a five-foot wrought iron fence to ensure the grass remained green. I have long had a layperson’s curiosity about architectural design. I recalled reading something about “desire pathways”—a term for delaying construction of footpaths until the natural chosen paths were observed. I wondered to myself, at the time, why the administration chose to install a wrought iron fence instead of simply paving over the routes already claimed and preferred by the community.

References Baxter, A., Scott, K.  M., Ferrari, A.  J., Norman, R.  E., Vos, T., & Whiteford, H.  A. (2014). Challenging the myth of an “epidemic” of common mental disorders: Trends in the global prevalence of anxiety and depression between 1990 and 2010. Depression and Anxiety, 31, 506–516. Bledsoe, B. E. (2003). Critical incident stress management (CISM): Benefit or risk for emergency services. Prehospital Emergency Care, 7(2), 272–279.

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Frances, A. (2013). Saving normal: An insider’s revolt against out-of-control psychiatric diagnosis, DSM-5, big pharma, and the medicalization of ordinary life. Morrow. Fitzpatrick, K.  K., Darcy, A., & Vierhile, M. (2017). Delivering cognitive behavior therapy to young adults with symptoms of depression and anxiety using a fully automated conversational agent (Woebot): A randomized controlled trial. JMIR Mental Health, 4(2), e19. Hoyt, M., & Talmon, M. (2014). Capturing the moment: Single session therapy and walk-in services. Crown House Publishing. Insel, T. (2019). Can smartphones solve the mental health crisis. In 8th annual E-mental health conference: New generations new services. Vancouver. Kirsch, I. (2009). The emperor’s new drugs: Exploding the antidepressant myth. Bodley Head. Krebs, P., Norcross, J.  C., Nicholson, J.  M., & Prochaska, J.  O. (2018). Stages of change and psychotherapy outcomes: A review and meta-analysis. Journal of Clinical Psychology, 74(11), 1964–1979. Lipson, S.  K., Lattie, E.  G., & Eisenberg, D. (2018). Increased rates of mental health service utilization by U.S. college students: 10-year population-level trends (2007–2017). Psychiatric Services, 70(1), 60–63. Mackenzie, C. S., Erickson, J., Deane, F. P., & Wright, M. (2014). Changes in attitudes toward seeking mental health services: A 40-year cross-temporal meta-analysis. Clinical Psychology Review, 34, 99–106. MHHC. (2019). Newfoundland and Labrador stepped care 2.0 E-mental health demonstration project final report. MHCC. Retrieved September 20, 2019, from https://www.mentalhealthcommission.ca/sites/default/files/2019-­09/emental_health_report_eng_0.pdf Moncrieff, J. (2009). The myth of the chemical cure: A critique of psychiatric treatment. Palgrave. Norcross, J. C., Krebs, P. M., & Prochaska, J. O. (2011). Stages of change. Journal of Clinical Psychology, 67(2), 143–154. Pack, M. J. (2012). Critical incident stress management: A review of the literature with implications for social work. International Social Work, 56(5), 608–627. Quartana, P. J., Wilk, J. E., Thomas, J. E., Bray, R. M., Rae Omsted, K. L., Brown, J. M., et al. (2014). Trends in mental health services utilization and stigma in US soldiers from 2002 to 2011. American Journal of Public Health, 104, 1671–1679. Shorter, E. (2011). How everyone became depressed: The rise and fall of the nervous breakdown. Oxford University Press. Spielmans, G. I., & Parry, P. I. (2010). From evidence-based medicine to marketing-based medicine: Evidence from internal industry documents. Journal of Bioethical Inquiry, 7, 13–29. Talmon, M. (1990). Single session therapy: Maximizing the effect of the first (and often the only) therapeutic encounter. Jossey Bass. Whitaker, R. (2010). Anatomy of an epidemic: Magic bullets, psychiatric drugs, and the astonishing rise of mental illness in America. Random House.

Chapter 3

Recovery Values and Principles Peter Cornish

The Risk-Free (and Fun-Free) Residence I had worked late one Thursday night. After a relaxing commute back home on my bicycle (mostly downhill), I received a text. There was an emergency in one of the residence buildings. Could I come to campus to advise? I hopped back on my bike and tackled the steep climb for the second time that day. There had been another student death by suicide. It was on the same floor of the same residence, during the same week in March as the one last year. The students, of course, were in shock. The residence student-staff were in particularly bad shape. Several months later, after some planning with the university administration, we held a half-day training for all the residence student-staff members. At the time, we thought it wise to move beyond suicide risk assessment and referral to focusing more on care and support. We hoped that by introducing them to some of the informal, positive psychology elements of the stepped care model, they could be relieved from the burden of risk management. As is often the case when I introduce people to SC2.0, I received several challenging questions at the workshop—nothing out of the ordinary. But then during the break, one of the resident assistants approach me and said, “They are purposefully targeting you.” “Who is?” I asked. “There are six students, at tables throughout the room, who knew you were coming to talk about stepped care and came with a plan to disrupt.” “Why?” I asked. “Because they are angry. They don’t like the model. They say it is just a way for the counseling center to offload even more work on us that we are not qualified to do.” My initial thought was that they just don’t understand the model. I can explain it and then they will get on board. Wrong. There was an important message from students that we needed to heed. They had been traumatized by the burden of preventing the next suicide. And it was our fault. Experts can’t even prevent suicide. We had inadvertently saddled students with an impossible task. P. Cornish (*) Counseling and Psychological Services, University of California, Berkeley, CA, USA e-mail: [email protected] © Springer Nature Switzerland AG 2023 P. Cornish, G. Berry (eds.), Stepped Care 2.0: The Power of Conundrums, https://doi.org/10.1007/978-3-031-45206-2_3

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3.1 People with Lived Experience There is no such thing as resistance in psychotherapy; it is only communication. This was the sentiment in the late Steve de Shazer’s article “The Death of Resistance.” Ironically, it was rejected 17 times before being published in 1984 (De Shazer, 1984). We should consider resistance to be a form of cooperation, he argued. The students in residence who were opposed to my method and what the university had been doing for years were communicating something very important. Recognizing this, we could begin to cooperate. They were telling us to stop what we were doing. We had gotten it all wrong. We had been burdening these young adults with impossible tasks. Even experts struggle to prevent suicides. There is, in fact, no evidence that even the most carefully developed suicide prevention or screening programs delivered by experts prevent any suicide fatalities (Harrod et  al., 2014; Zalsman et al., 2016). The student leaders were right to be angry with us. They felt cheated, burnt out, and traumatized. A remedy would not be found in more training. A more systemic shift was needed. People with lived experience are central to recovery principles and mental health strategy. Their voices must be represented in all mental health care research, design, and treatment. We needed their strong, angry messages to help us get SC2.0 right. System transformation efforts must embrace disruption. Practicing disruption itself can foster recovery. Meaningful recovery comes through empowerment. It can’t happen without some agency or autonomy. Quite often, this involves learning assertiveness. It might involve wresting control from others. That is what the students did at my workshop. They spoke truth to power. They disrupted me and my message. And I am thankful for this. It tripped me up so that I could fail forward with another iteration of SC2.0. SC2.0 requires constant co-design with the most crucial stakeholders—people with lived experience and their peers. Residence leaders are, by definition, peer supporters. They are expected to lead by example and serve as mentors to fellow students. The leaders serve as the voices of their peers. The voices I heard were essential to any efforts at reforming the care ecosystem at the university. With SC2.0, care practices evolve at both micro- and macro-levels. Micro-level adjustments happen as soon as students access care, when their preferences are honored, and treatment decisions are informed by outcome tracking. Micro-level care adjustment is discussed in detail in Chap. 5. Macro-adjustments occur when we welcome and attend to the kind of socio-political feedback expressed by the residence leaders attending my workshop. This macro-level monitoring includes both direct and indirect processes. Acknowledging the student protest is an example of direct monitoring. The residence leaders were participating as a captive audience in a formal setting. Their feedback was direct. Indirect socio-political monitoring is equally important. It means that those of us involved in health system transformation must be attuned to social media chatter and prepared to engage constructively. All criticism of the care ecosystem, including the new recovery-oriented programs

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we introduce, is grist for the mill. Protest affords an opportunity to invite those with passion to join us at the design table. Translation or transformation of protest, anger, criticism, or defensiveness into productive growth opportunities and processes are central roles for any skilled psychotherapist. As a psychodynamic therapist, I was taught to think of this as repairing therapeutic ruptures. I learned that it could be one of the most transformative elements in a course of psychotherapy. This openness to processing therapeutic failures is an example of micro-level recovery-oriented practice. With SC2.0, we extend such reflexive processing to a system level by welcoming complaints as opportunities for collaborative efforts in making structural adjustments. For example, in the case of the residence protest, student leaders were invited to re-evaluate the suicide prevention and postvention strategies. At these meetings, we considered options for moving beyond the risk-oriented policies that had eroded natural, hopeful, playful dynamics essential to a vibrant and healthy campus community. We acknowledged that efforts to professionalize resident assistant roles with training in risk assessment, gatekeeping, or mental health coaching had backfired. We decided collectively that the primary responsibility of student leaders was to create conditions for a socially engaged, intellectually stimulating community. We didn’t need a counselor or an e-mental health program for that. The protesters were right—counseling is a counselor’s job, not theirs. This reflexive analysis led us to ramp up plans to launch our embedded counselor program. Newly hired wellness navigators had been trained in single-session, one-­ at-­a-time, walk-in counseling. The plan was to open walk-in clinics at various sites around campus. We decided to fast-track this in residence. Other sites under consideration included the International Student Advising Office and a nearby satellite campus. Our administrative group, comprised of the directors of residences, student life, and the student wellness and counseling center spent some time reflecting on institutional policies that had taken us down the risk paradigm rabbit hole. Two of us had been there long enough to recall a decade-old consultant’s report that labeled the culture in residence at the time as a “powder keg” of institutional liability. The binge-drinking culture and fraternity-like tradition of inter-house competition and identities were recognized as both sexist and unwelcoming of diversity. None of us disagreed. The organizational structures supporting this cultural tradition were problematic and needed transformation. Unfortunately, as is often the case, more attention was paid to dismantling the old structure than creating anything to replace it. Some efforts were made to develop academically engaging “living learning communities” and, while these showed some promise, something was missing. I asked one of the leaders who had protested at the workshop for ideas. He said we need more support and investment in fun. I paused in thought and asked, “You know that multipurpose room, the one that we opened up all night after each of the suicides? How is that used most of the time?” He replied, “It isn’t used at all.” “Hmm,” I said, “Why isn’t it a games room? Do you have a games room?” “No,” he said. “We have nothing like that.”

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3.2 Disease Model So, what does the residence story have to do with recovery principles? Recovery goes beyond a disease model. In the risk-oriented residence environment, a disease model, rather than a recovery model, had been applied to detect “illness” and send it off for cure. Residence leaders had been trained to look for signs of mental deterioration and urge, even mandate, those showing some “signs” to treatment. Obviously, this failed. Why did it fail? For one, it created a tense, overly serious atmosphere that infected all with fear. Who will be the next person at risk? When might the next suicide occur? This tension meant that leaders were walking on eggshells. That tension signaled that the environment was no longer safe, relaxing, or inviting for open discourse, disclosure of struggle, or simply playfulness. A recovery philosophy, in contrast, assumes that anyone, whether ill or not, has internal strengths and capacities to recover, to improve functioning with or without professional treatment. It assumes that in most cases there is no malignant tumor and no need for surgery. Instead, simple kindness, community, and support are essential. More invasive treatment is reserved for cases that do not respond to the basic care. With the student leaders on suicide watch and the anxiety that permeated the residence halls leading up to the first anniversary, the essence of community was lost. Without that community, efforts at encouraging professional help-seeking, while well-intentioned, were likely experienced as coercive. Residence leaders had been asked to report even the mildest signs of suicidal ideation or intent to senior staff. Senior staff were expected to approach those exhibiting these signs with an air of concern that was also ripe with tension. In the absence of a safe, relaxing atmosphere, perhaps those at risk of suicide retreated into isolation for fear of being mandated to treatment.

3.3 The Recovery Movement According to the US-based Substance Abuse and Mental Health Services Administration (SAMHSA), mental health recovery is “a process of change through which individuals improve their health and wellness, live a self-directed life, and strive to reach their full potential” (SAMHSA, 2020). The Mental Health Commission of Canada (MHCC) states that “the concept of ‘recovery’ in mental health refers to living a satisfying, hopeful, and contributing life, even when a person may be experiencing ongoing symptoms of a mental health problem or illness. Recovery journeys build on individual, family, cultural, and community strengths and can be supported by many types of services, supports, and treatments” (MHCC, 2020). Recovery is not a new concept. It has been fundamental to work on addictions for over a century. It is practiced to this day in 12-step groups. As with addictions, recovery principles were a product of long-fought battles waged by people with

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lived experience of mental illness. These were battles of resistance to power. The late French philosopher Michel Foucault might warn us now that meaningful recovery for some of our most marginalized is a false promise because powerful institutions cannot be easily challenged. He asks, “Is it surprising that prisons resemble factories, schools, barracks, hospitals, which all resemble prisons?” (Foucault, 1995, p. 228). The hope lies, however, in the fact of “where there is power, there is resistance” (Foucault, 1978). The modern conceptualization of madness as an illness, according to Foucault, is no better than medieval depictions of possession by evil spirits. Illness and cure may even be worse, cloaked as they are in the guise of scientific neutrality. In this context, the possibility of recovery—being able to function despite distress and symptoms—is the possibility of freedom and autonomy. The recovery movement can be traced back the establishment of the Alleged Lunatic’s Friend Society in England in 1845 and the Anti-Insane Asylum Society in Illinois at the time of the Civil War (Frese & Davis, 1997). The movement expanded in 1907 when Clifford Beers created the National Committee for Mental Hygiene, later to become the National Mental Health Association, and known today as Mental Health America. Beers collaborated with Clarence Hincks in Canada to establish the Canadian National Committee for Mental Hygiene known today as the Canadian Mental Health Association. Both groups continue to challenge the medical establishment to adopt more collaborative models of care and most recently are working to elevate and legitimize the role of peer-led mental services offered by trained people with lived experience. The UK-based Royal College of Psychiatrists published an editorial in 2010 stating the evidence supports recovery principles. They endorsed the recovery model as “a social movement that is influencing mental health service development around the world” (Warner, 2010). Recovery is now becoming so mainstream that it may no longer classify as a social movement.

3.4 Recovery Values, Principles, and Assumptions UK psychologist, Mike Slade defines recovery as comprising “full symptom remission, full or part-time work or education, independent living without supervision by informal carers, and having friends with whom activities can be shared, all sustained for a period of two years” (Slade & Longden, 2015). A recovery model assumes that psychological and psychiatric problems either cannot or need not be cured. It is impossible to cure something that cannot be proven to exist. How can you cure a mental illness or just plain bad behavior when we can’t clearly identify the mechanism that needs curing? There is not a shred of evidence for biological mechanisms associated with mental illness (Moncrieff, 2009). Likewise, we have no inkling of an internal mechanism that might underlie deviant or anti-social behavior. How would we know if we have cured something if we don’t know what we are curing? An infected wound is cured with evidence that the skin has healed. I think of Foucault again: “People know what they do; frequently they know why they do what they do; but what they don’t know is what what they do

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does” (Foucault, 1988). If we don’t know what the what is that we are trying to cure, maybe we should stop trying. A care system based on the concept of recovery is independent of risk, personal and structural deficits, and illness. By this, I mean that recovery models assume that wellness programming benefits those who are not ill or not engaging in problematic behaviors just as much as they can help those in trouble. It provides health and wellness for all. It is upstream. It is not reactionary. The opening story in this chapter illustrates how care delivered in the context of our current risk paradigm only prepares a community to react after it is too late. The best prevention strategy comes not from risk detection or risk prohibition (e.g., amputating the campus drinking culture) but through community development. According to the Mental Health Commission of Canada, “the dignity of risk or the right to failure” is important in work with people with emotional challenges or disabilities and “it refers to the importance of respecting a person’s right to take risks as part of personal growth” (MHCC, 2015). Risk is essential to the development of resilience, which in turn, is a foundation for growth. There is tension and some disagreement among proponents of recovery on how to balance the right to risk and the obligation for practitioners to intervene when safety could be jeopardized (Davidson et al., 2006). However, a shift in the risk paradigm toward a more collaborative engagement of this tension can maximize empowerment while minimizing threats to safety. As reported in the APA Monitor, health care professionals, researchers, and persons with lived experience agree on 10 core principles underlying a recovery philosophy (APA, 2012). As illustrated in Table  3.1, all 10 of these principles are applied in SC2.0. They are, in fact, the principles of SC2.0.

3.5 Recovery in Practice As we began to implement SC2.0 across the province of Newfoundland and Labrador, we quickly discovered the power of peer support in both the treatment process and as a key driver of successful implementation. We learned that the province’s Towards Recovery strategy was adopted through a rare process of political non-partisanship (Government of Newfoundland and Labrador, 2017). It was advanced through the leadership of people with lived experience who sat on an all-­ party committee tasked with making recommendations for broad mental health system change. How did this consensus arise? Over the past two decades, persons with lived experience, including several local celebrities, found their voices heard through a variety of local mass media channels. Persons with lived experience organized around charity events spoke on “open-line radio,” a daily broadcast that just about everyone listened to, including politicians of all stripes. With government and the people aligned on the task of massive system transformation, the province attracted the attention of national and international organizations with missions to advance system reform. Newfoundland and Labrador became

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Table 3.1  Recovery principles and Stepped Care 2.0 Principle Self-direction

Description Consumers determine their own pathway to recovery There are multiple Individualized pathways to recovery and person-centered based on individual’s unique strengths, needs, preferences, experiences, and cultural backgrounds Empowerment Consumers can choose among options and participate in all decisions that affect them Holistic Recovery focuses on people’s entire lives, including mind, body, spirit, and community Nonlinear Recovery isn’t a step-by-step process, but one based on continual growth, occasional setbacks, and learning from experience Strengths-based Recovery builds on people’s strengths Peer support

Respect

Responsibility

Application in SC2.0 Consumer preference, rather than simply symptom severity or diagnosis, is central to treatment decision-making On first contact, no assumptions are made about what will work in treatment. Instead of a lengthy assessment, the focus is on the issue that is top-of-mind for the consumer, and initial solutions are informed by consumer’s previous successes or coping strategies A full range of options is outlined on first contact as well as an opportunity to consider additional options drawn from consumers’ experiences

When considering options for care, the graphic representation of the model includes consideration of community resources related to mind, body, and spirit The value of trial and error and “failing forward” is explicitly stated in first contact and throughout the care continuum

Strengths and capacities are assessed and discussed regularly through continuous, collaborative, objective therapeutic measurement Mutual support plays an The value of peer reciprocity (giving and receiving support) is emphasized at all step levels as a invaluable role in potentially empowering opportunity recovery Participation of people with lived experience in Acceptance and appreciation by society, treatment, care system design, and evaluation is considered a requirement for implementation of communities, systems of care, and consumers SC2.0 themselves are crucial to recovery Responsibility for self-care and the journey of Consumers are recovery is emphasized at every care point. For responsible for their example, consumers are informed that we need their own self-care and assistance in getting the care right: They are journeys of recovery encouraged to try other options or return for additional visits if upon reflection the approach taken proved unhelpful. The responsibility for trial and error, persistence, and self-correction is made clear as part of the informed consent process (continued)

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Table 3.1 (continued) Principle Hope

Description Recovery’s central, motivating message is a better future—that people can and do overcome obstacles

Application in SC2.0 Hope, optimism, and the belief in the capacities of consumers are infused throughout the care continuum, which draws on principles of narrative, solution-focused, and positive psychology

a focal point for the Mental Health Commission of Canada, as well as organizations in the United Kingdom, Australia, and New Zealand that been working on innovation in mental health for years. Our own development of SC2.0 was generously funded by both the provincial and federal governments through a series of development, demonstration, and research grants. Most recently, the national office of the Canadian Mental Health Association (CMHA) has taken an interest in scaling up peer support across the country. They are particularly interested in the potential for instilling recovery values across the care continuum by implementing their Recovery College program within the context of SC2.0. Recovery values can lift stigma associated with mental health and addictions. In Canada, mental health services are not funded on parity with other health care programs. And addictions programming is the poor cousin of mental health treatment. The disparity is worrisome as we witness a deepening opioid addiction crisis. Attempts at integration have been made to rectify the imbalance. But policies aimed at amalgamating through restructuring have been largely superficial, limited to name changes like Community Mental Health and Addictions. The workforce remains divided and programming disconnected despite concurrent disorder rates ranging from 20 to 80%. My colleague at McGill University, Mary Bartram, offers theoretical grounds for bridging the divide between mental health and addictions practice (Bartram, 2019, 2020). A common assumption, Bartram observes, is that addictions recovery requires abstinence, whereas mental health recovery is possible without full symptom remission. Harm reduction approaches are being embraced by some practitioners, but abstinence dominates community-based AA programs. Bartram proposes the two-continuum model advanced by Cory Keyes (Keyes, 2007) be adapted for harm reduction approaches. Just as some with serious mental illness can flourish, those with severe substance use disorders might function well and without harm. I look forward to the day when the term “mental health” includes addictions, and work like Bertram’s takes us a step closer. SC2.0 is both a recovery and harm reduction model. Innovation demands risk-­ taking as does collaborative trial-and-error treatment planning. As argued in Chap. 1, SC2.0 embraces risk and, in doing so, aims to reduce harm. By sharing risk and responsibility broadly with all stakeholders, especially help-seekers, harm is reduced and opportunity for recovery maximized. Providers risk trusting clients with a harm reduction approach. Providers believe in the capacities of people who are vulnerable, disoriented with symptoms, or managing a substance use disorder. We trust the person, their capacities, their readiness, and their story until there might be reasons to assume otherwise. This trust increases alignment and safety.

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As a long-standing advocacy organization for those with mental health and addictions, the CMHA does likewise. The CMHA is a proponent of the dual continuum model, recovery programming, peer support, and stepped care. Their version of stepped care is illustrated in Fig. 3.1. Of note are the two lowest steps that target the largest segment of the population. The CMHA recognizes the value of both formal and informal community-based supports. In both cases, these programs are owned and operated by people with lived experience. Acknowledging the potential of both trained (formal) and untrained (informal) peer systems generates respect for, and empowerment of, all people with lived experience. The CMHA offers training for mental health professionals and works to equip the general public with increased capacities to support each other. In our work with the CMHA and representatives of other peer networks and organizations, we are discovering that the distinction between steps—with or without peer support—is not as obvious as depicted in Fig. 1.2 (in Chap. 1). For example, we have learned that peers can have an important role in greeting people in clinic waiting rooms, providing information on local community resources, or they may bring value simply by sitting in a quiet nook alongside a person in distress. As indicated in Fig. 3.2, this initial contact work could involve Step 1 information sharing or Step 3 supportive listening. Peers can be trained to help people navigate self-­ help resources (at Step 2). They can be trained to co-lead or lead educational workshops at Step 4. They could also help orient people to therapist-assisted eMH programming or, with proper training, provide eMH coaching under the guidance of professionals (Step 5). Peers could even assist in co-facilitating intensive therapy groups (Step 6). They could help clients with homework assigned in individual therapy (Step 7). Likewise, peers could assist in chronic care settings. Professionals,

Fig. 3.1  CMHA version of stepped care. (CMHA, 2018)

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Fig. 3.2  Potential role for peers in Stepped Care 2.0

including physicians, psychiatrists, nurses, and social workers, at Steps 7–9 could conduct a warm handoff to a peer that might help people get started with rehabilitation work, including exercise or navigation and transition to other points of community care. The possibilities of formal peer support in collaboration with professional programs are depicted in the lower half of Fig.  3.2. Informal peersupport activities operating independently of the formal care system are illustrated in the top part of Fig. 3.2. Why is consumer participation so important for recovery-oriented mental health and addictions care? In this chapter, a central assumption is that co-designed care is better care. Experts have years of formal training and consumers have years of lived experience. Recovery models attempt to integrate these very different types of knowing. This chapter opened with a story of disruption and tension. The tension is productive. Without welcoming the tension, the suicide prevention strategy at Memorial University would not have advanced. Peer involvement not only facilitates care system self-correction—as was the case in the residence—it also enhances access and quality of care by reducing stigma, building trust, and stimulating empowerment. One of the most promising roles for peers, described in more detail in Chap. 6, is the sense of purpose and value peers experience by giving back. This includes both giving back directly to others through care programs and indirectly by participating in care system design teams. Many questions naturally arise as we bring together professionals and non-­ professionals, providers, and consumers of programs. A question of boundaries is an obvious challenge. When I was in graduate school, I recall one of my professors saying, “Boundaries are crossed all the time in our work; the key is to manage these crossings appropriately.” Without any boundary crossings, there will be limited

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connection, missed opportunities for correction, reduced creativity, and no productive tension. Growth happens when we are prepared to risk and persist through failure. Rigid boundaries prohibit risk, so it is feared and avoided. Without risk, failure does not happen, resilience does not develop, and growth is impossible.

3.6 Research on Recovery Recovery models are optimistic. One assumption is that a large portion of people with severe and persistent mental illness, including schizophrenia, can recover and function well in society. Research supports this, indicating that up to 40% of people diagnosed with schizophrenia achieve social recovery—can function socially and economically—and approximately 20% achieve full recovery—the complete absence of symptoms (Lambert et  al., 2008). Another core assumption is that empowerment is a key driver for positive mental health treatment outcomes. Empowerment is a broad concept that includes psychological insight, autonomy, internal locus of control, self-efficacy, meaningful social connectedness, shared or collaborative power, and vocational participation. All these factors lead to better coping with the symptoms of mental illness (Tew et al., 2012). Studies show that a combination of psychological insight, including acceptance of diagnosis, is associated with good outcomes, but only if internalized stigma is low (Caveti et al., 2012). In other words, the type of insight into the illness matters. Low internalized stigma means that illness does not define or restrict a person’s self-concept. While the facts of the illness are accepted, these do not interfere with a belief in one’s capacity to have a purposeful and meaningful life. Peer support has been shown to have recovery outcomes on par with professional care (Bellamy et al., 2017). But the research also indicates an added unique benefit from peer support. Self-efficacy increases through peer support, particularly for those providing the support, more than it does for people who only receive professional care (Mahlke et al., 2017). Active involvement in clinical decision-making, a core principle of recovery, has been found to increase patient satisfaction, treatment adherence, and clinical outcomes. Unfortunately, the majority of specialists tend not to encourage patient involvement, especially for those with more severe illnesses.

3.7 Neoliberal Critique While the research on recovery models is promising, some sociologists and economists question the motives (Field & Reed, 2016). Is the recovery movement simply a neoliberal ruse to offload government responsibility for mental health care onto our most vulnerable citizens? Does it aim to privatize care through the illusion of choice among low-quality care options? The argument is that commodifying mental health recovery resources along a spectrum of self-help, peer led, online programs,

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and care from least to most expensive professionals constitutes a conservative economic policy aimed at saving money and reducing public commitment to quality health care. In other words, recovery models can be used to support neoliberal policy aimed at reducing the size of government in favor of further corporatization of health care. This is valid criticism. It would be naive to think that these forces are not at play. Health care spending is one of the biggest ticket items for government. There are large global players that dominate pricing of pharmaceuticals and information management. Health care, including mental health, is profitable. With these developments, regulation has never been more important. It is increasingly important for protecting electronic health information, the use of data, and for policing pharmaceutical research and marketing. It is equally important for monitoring the development, quality, and impact of new lower intensity mental health options, including community-based recovery programs. There will continue to be entrepreneurial innovations in this space especially now that mental health has become a high priority for a broad range of stakeholders. Given the growing public interest for improving mental health, governments will need to invest more, not less, in health care budgets. However, the new investment should not be aimed at more of the same. We do not need more physicians, social workers, nurses, psychologists, or psychiatrists. We need to invest in different ways of practicing, organizing, and regulating existing services. This means investing in training and system infrastructure that support innovation while maintaining safety and improving outcomes. Our current care models have very low accountability through self-regulated professions that are not making use of data to maximize outcomes. If we do not change this, the only ones that will have and use the data are the large telecommunication corporations. Without government investment in system building, the neoliberal ruse critique will prove correct.

3.8 Stratified Versus Recovery Most stepped care models are stratified models, which involve clinical staging (Cross et al., 2014; Scott & Henry, 2017). Sometimes these are referred to as pathways models. The goal is to determine the best treatment pathway as soon as possible. Pathways are built in accordance with triage principles. Before the development of stepped care, people would be screened for symptom severity and those with the most severe symptoms would get treatment sooner, whereas those with mild or moderate symptoms would have to wait. Pathways stepped care systems triage more efficiently, reducing wait times and ensuring all help-seekers, regardless of symptom severity, get care as soon as possible. Stratified stepped care models emerged approximately 20 years ago, first in the United Kingdom, then in Europe, Australia, and New Zealand. At the same time that the stratified model was being scaled across the United Kingdom, recovery

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principles were being introduced, and a predictable tension emerged between the expert-­driven stratified approach and the more flexible patient preference-oriented practices that were being recommended. The stratified approach is premised on the assumption that assessment and diagnoses inform the choice of step level. A thorough assessment will yield a wealth of information that the clinician could interpret to recommend the correct treatment plan at the outset. Treatment decision-tree algorithms are created to signal pathways based on symptom scores. Typically, those with high symptom scores take a more direct pathway to intensive specialized care, whereas those with low or moderate symptoms will first proceed to lower steps. Stepping up or down only occurs when symptom levels change. The focus tends to be directed mostly to those actively seeking help in clinic settings. There is less attention to health promotion and illness prevention. Only treatments that have been reliably supported through independent clinical trials are considered. Close attention is paid to ensuring the fidelity of practice to the evidence-based treatment manuals. SC2.0 is not a stratified model. Nor does it determine pathways as described above. In contrast, it is a recovery model of stepped care. Unlike the stratified model, it begins with minimal assessment. Instead, the help-seeker’s concept of the issue is taken at face value, and practical, common-sense solutions are worked on immediately. This is in line with the start-strong/start-simple principle described in Chap. 2. Treatment planning is more flexible and preference-based. Care plans are developed collaboratively. The provider outlines expectations for both parties: what the help-­ seeker can expect from the provider and what the provider expects from the help-­ seeker. Care step levels are selected to match readiness for, and interest in, meeting the expectations associated with the level of care. The assessment initially is subjective and intuitive—driven by the recovery-oriented interviewing style. The interviewer attends to signs of alignment. With the full range of step levels in mind, inquiries are made of the help-seeker’s capacities, strengths, and functioning level. Evidence is conceptualized differently with recovery models. While evidence-­ based treatments supported by clinical trials are valued, the broader approach to data and evidence allows for the inclusion of innovative approaches that are less conducive to controlled research. Therapeutic measurement allows for some trial and error. The evidence for the treatment comes from the ongoing assessment reviewed by both the help-seeker and the provider. This collaborative review of the data is a powerful validation method. It requires a progress tracking system that is visible to both the provider and the help-seeker. Finally, given the openness to treatments that may not be evaluated in controlled settings, a wider range of formal and informal treatment resources are considered. Some programs may have only preliminary research support. They may also involve social prescriptions to informal community resources like AA, a yoga class, or local support groups. Stepped care features of stratified models are compared to those of recovery models in Table 3.2.

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Table 3.2  Stratified versus recovery stepped care models Stepped care practices Regions practiced Assessment

Treatment planning Target population

Stratified model UK, Europe, Australia, NZ

Recovery model Canada, UK

Screening and a thorough up-front assessment —purpose is to detect/ address risk and conduct triage

Minimal up-front assessment, solution focus + “fail forward” initially; deep assessment only when there is “a mystery” Flexible—no predetermined pathways

Outcomes measured Sources of evidence

Decision tree—predetermined pathways Clinic focus: treatment priority is for active help-seekers with severe symptoms Symptoms/deficits; treatment fidelity Independent randomized clinical trial results

Intervention settings

Medically based formal clinic and hospital settings

Whole population focus: prevention and treatment for all regardless of severity Patient readiness, therapeutic alignment/ engagement, functioning, capacities Trial-and-error programming managed through continuous therapeutic measurement Multiple sectors—medical, community-­ based, educational, and informal settings

3.9 The Ethics of SC2.0 As we began implementing SC2.0, some colleagues questioned the model on ethical grounds. A common perception is the one-at-a-time (single-session) approach oversimplifies what may be complex illnesses. Critics worry that some help-seekers may feel that their serious issues are being dismissed or minimized. The trial-and-­ error approach is risky. If we don’t get it right the first time, maybe help-seekers will become discouraged and drop out. What about people who are vulnerable? Would they be able to tolerate “fail forward?” If we are trying innovative approaches without a rock-solid evidence base, are practitioners more vulnerable to malpractice claims? Is SC2.0 ethical care, or is it a cost-saving measure that stretches resources too thin? SC2.0 aims to improve efficiencies. This includes increasing the capacity for providers to see more people. Will this increased caseload lead to burn out and poorer care? With less up-front assessment and higher caseloads, record-keeping changes. There may be less time for record-keeping and less data obtained at the outset. Does this meet the standards or guidelines for practice of my profession? I have heard this question from social workers, psychologists, and counselors. I counter with my own question: What specifically do the guidelines say about caseloads, note-taking, and quality of care? Take records for example. Most guidelines require date of treatment, name of help-seeker, and some description of the problem and intervention. They do not require a specific level of detail. Records do not have to use full sentences or tell a rich story.

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Ethical practice in the context of recovery values means balancing risk and opportunity with security and safety. SC2.0 introduces risk as an opportunity for growth and resilience. While ethical codes tend to focus more on risk management, it is possible to integrate recovery principles in a way that nudges gently beyond the dominant risk paradigm. I am most familiar with the Canadian Psychological Association’s Code of Ethics. It is organized around four high-level principles ranked by priority. The highest level principle is respect for the dignity of persons and peoples. SC2.0 supports this with its emphasis on client centricity, choice, empowerment, strengths, and capacities. SC2.0 also supports Principle 1 with emphasis on detailed informed consent specifying expectations associated with the care model. The next principle is responsible caring. SC2.0 expands care options, eliminates wait times, and enhances outcomes by up to 50% through ongoing therapeutic measurement (Miller et al., 2015). The third principle is integrity of relationships. Therapeutic alignment is managed transparently through continuous objective measurement; collaborative treatment planning; and explicitly stated goals, expectations, and responsibilities. The fourth principle, responsibility to society, is enhanced through SC2.0 with expanded upstream whole population care and interventions.

3.10 Perching and Nesting I have often wondered how spaces could be designed to support or encourage certain types of activity, or how design can be adapted to find the right combination of security, warmth, and openness. I was fortunate enough to receive an inheritance about 20  years ago that allowed me to purchase a wooded property on a rugged hillside near the ocean in Newfoundland. I had been introduced to architect Robert Mellin who specializes in resurrecting the vernacular outport fishing village architecture typical of the Fogo Island region of the province. Robert designed a tall, long, rectangular saltbox house with 64 windows for my wooded hillside property. The idea was that this bright red structure would stand tall and strong against the ferocious North Atlantic gales while also melding with the surrounding landscape. It would be both protected from and transparent to nature. Inside, the home was open, with high ceilings supported by great fir beams. The windows and skylights brought the adjacent natural landscape inside while allowing panoramic views of the cold churning ocean from every vantage point. The terra cotta tinted, heated concrete floor and massive slate clad new England fireplace brought warmth to the steely, hard surfaces that mirrored the resilient outdoor rocky landscape. While open and high, the spaces had cozy nooks. The children’s rooms reached up steep peaked ceilings with skylights. The loft beds afforded shelter below, and the hatchways at the foot of each suspended bed allowed for retreat to a cozy hidden pathway connecting the three bedrooms. All features of the home embraced a tension between the vast, wondrous, stunningly beautiful, but unrelenting forces of nature and the draw of safe, warm, protective alcoves.

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Frank Lloyd Wright’s work expressed this dialectic. All creatures, including humans, prize both protection, warmth and safety, as well as perspective on vast open spaces. We need a room with a view. A student at the School of Architecture at Taliesin in Scottsdale, Arizona, comments on the experience of living in one of Wright’s student prairie desert designs: “It’s a sense of freedom that I had never felt before. And it’s a powerful thing,”; it sits on a cantilever so that it feels like “you’re hanging, in this sort of nest, this perch … You’re protected [from nature], but you’re not separated” (Catalfamo, 2018). This balance between hanging (or perching) and nesting is a metaphor for the vibrant, dynamic, and ethically grounded SC2.0 recovery-oriented practice. There are multiple doorways for rapid, alternate routes to safety. Once safely inside, alignment and attention to care bring immediate feelings of warmth and comfort. At the same time, the visitor can view both the forest and the trees. The whole care ecosystem, both inside and out, is visible from every vantage point. There is freedom to move around, step up, down, inside, and out. The entire system is transparent. It is also adaptable. As the climate and seasons fluctuate, furniture can be moved to adjust perspectives inward or out. Curtains can be drawn or opened, fine-tuning the balance between exposure to the elements or recharging in the comfort of the fire, on heated floors or in cozy corners. Meaningful healthy architectural design need not be reserved for people like me who are privileged. In British Columbia, philanthropists, mental health innovators, and the provincial government partnered to develop integrated youth wellness hubs. Recovery principles were central to the project. Stepped care is also a key element. Foundry BC is the name chosen by youth to represent strength, resilience, and the importance of finding a place that is home. The interior design was also driven by youth values and needs. Waiting areas are modern, vast, comfortable, and colorful, but also have cozy private nooks. The space is vibrant, bright, and hopeful. Dynamic interior design is actually an inexpensive way to leverage recovery, as well as multiple determinants of health. It is a one-time cost and in this case funded by eager donors. Foundry brings health inspiring infrastructure and architecture to some of the least privileged and most vulnerable in our population—homeless, traumatized, and/or emotionally distressed youth. Don’t Talk to Strangers Don’t talk to strangers! Who hasn’t heard this warning? A recovery-oriented system would encourage more talking to strangers. I ordered a ride through Uber recently. The car arrived after about 2 min. As I was about to step into the back seat, the driver rolled down the front passenger window and exclaimed, “Get in the front! This is Uber, not a taxi.” He told me he says this to all customers and that it is almost always well-received. He described it as a gesture of kindness, one that makes a small but meaningful difference to the day of each rider. Some passengers, he continued, who might appear tense, angry, or otherwise unhappy, warm up instantly with the invitation. Once when he witnessed this softening with one passenger, he asked what her plans were for the rest of the day. She sighed and said, “Well, I’m going to visit some of my girlfriends. I got divorced a few months ago, and I have been working

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on spending more time with them since then.” I then shared with the driver that I believed more kindness among strangers is important to mental health. I added that his gesture for me to sit in the front seat that morning had boosted my mood and outlook on life. I explained that just before he arrived, I had been preoccupied with some recent bad news, but that his gesture, and our conversation, allowed me to leave the unproductive thoughts behind. Strangers, I thought with a smile on my face as I headed into the airport, are some of our best allies for mental health recovery.

References APA. (2012). Recovery principles. Monitor on Psychology, 43(1), 55. Bartram, M. (2019). Toward a shared vision for mental health and addiction recovery and well-being: An integrated two-continuum model. Journal of Recovery in Mental Health, 2, 2371–2376. Bartram, M. (2020). ‘It’s really about wellbeing’: A Canadian investigation of harm reduction as a bridge between mental health and addiction recovery. International Journal of Mental Health and Addiction, 20–43. https://doi.org/10.1007/s11469-­020-­00239-­7 Bellamy, C., Schmutte, T., & Davidson, L. (2017). An update on the growing evidence base for peer support. Mental Health and Social Inclusion, 21(3), 161–167. Catalfamo, K. (2018, April 16). The desert architecture school where students build their own sleeping quarters. Atlas Obscura. Retrieved December 20, 2019, from https://www.atlasobscura.com/articles/taliesin-­west-­desert-­shelters Caveti, M., Kvrgic, S., Beck, E., Rusch, N., & Vauth, R. (2012). Self-stigma and its relationship with insight, demoralization, and clinical outcome among people with schizophrenia spectrum disorders. Comprehensive Psychiatry, 53(5), 468–479. CMHA. (2018). Mental health in the balance: Ending the health care disparity in Canada. CMHA.  Retrieved October 18, 2019, from https://cmha.ca/wp-­content/uploads/2018/09/ CMHA-­Parity-­Paper-­Full-­Report-­EN.pdf Cross, P. M., Hermens, D. F., Scott, E. M., Ottavio, A., McGorry, P. D., & Hickie, I. B. (2014). A clinical staging model for early intervention youth mental health services. Psychiatric Services, 65(7), 939–943. Davidson, L., O’Connell, M., Tandora, J., Styron, T., & Kangas, K. (2006). The top ten concerns about recovery encountered in mental health system transformation. Psychiatric Services, 57(5), 640–645. De Shazer, S. (1984). The death of resistance. Family Process, 23, 11–17. Field, B.  I., & Reed, K. (2016). The rise and fall of the mental health recovery model. The International Journal of Psychosocial Rehabilitation, 20(2), 86–95. Foucault, M. (1978). The history of sexuality, Vol. 1: An introduction (R. Hurley, Trans.). Vintage. Foucault, M. (1988). Madness and civilization: A history in the age of reason. Vintage. Foucault, M. (1995). Discipline and punish: The birth of the prison (A. Sheridan, Trans.). Vintage. Frese, F. J., & Davis, W. W. (1997). The consumer-survivor movement, recovery, and consumer professionals. Professional Psychology: Research and Practice, 28(3), 243–245. Government of Newfoundland and Labrador. (2017). Towards recovery: A vision for a renewed mental health and addictions system for Newfoundland and Labrador. Government of Newfoundland and Labrador. Retrieved December 10, 2019, from https://www.health.gov. nl.ca/health/all_party_committe_report.pdf

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Harrod, C. S., Goss, C. W., & DiGuiseppi, C. (2014). Interventions for primary prevention of suicide in university and other post-secondary educational settings (review). Cochrane Database of Systematic Reviews, 10, 1–88. Keyes, C. L. (2007). Promoting and protecting mental health as flourishing. American Psychologist, 62(2), 95–108. Lambert, M., Nader, D., Schacht, A., Wagner, T., Hundemer, H. P., Karow, A., et al. (2008). Rates and predictors of remission and recovery during 3 years in 392 never-treated patients with schizophrenia. Acta Psychiatrica Scandinavica, 118, 220–229. Mahlke, C.  I., Priebe, S., Heumann, K., Daubmann, A., Wegscheider, K., & Bock, T. (2017). Effectiveness of one-to-one peer support for patients with severe mental illness—A randomised controlled trial. European Psychiatry, 42, 103–110. MHCC. (2015, January 2). Guidelines for recovery-oriented practice: Hope, dignity, inclusion. Retrieved from MHCC: https://www.mentalhealthcommission.ca/sites/default/files/2016-­07/ MHCC_Recovery_Guidelines_2016_ENG.PDF MHCC. (2020, January 2). What is recovery. Retrieved from Recovery: https://www.mentalhealthcommission.ca/English/what-­we-­do/recovery. Miller, S. D., Hubble, M. A., Chow, D., & Seidel, J. (2015). Beyond measures and monitoring: Realizing the potential of feedback-informed treatment. Psychotherapy, 52(4), 449–457. Moncrieff, J. (2009). The myth of the chemical cure: A critique of psychiatric treatment. Palgrave. SAMHSA. (2020, January 2). SAMHSA’s working definition of recovery. Retrieved from https:// store.samhsa.gov/system/files/pep12-­recdef.pdf Scott, J., & Henry, C. (2017). Clinical staging models: From general medicine to mental disorders. BJPsych Advances, 23(5), 292–299. Slade, M., & Longden, E. (2015). Empirical evidence about recovery and mental health. BMC Psychiatry, 15, 285. Tew, J., Ramon, S., Slade, M., Bird, V., Melton, J., & Le Boutillier, C. (2012). Social factors and recovery from mental health difficulties: A review of the evidence. The British Journal of Social Work, 42(3), 443–460. Warner, R. (2010). Does the scientific evidence support the recovery model? The Psychiatrist, 34(1), 3–5. Zalsman, G., Hawton, K., Wasserman, D., van Heeringen, K., Arensman, E., Sarchiapone, M., et  al. (2016). Suicide prevention strategies revisited: 10-year systematic review. The Lancet Psychiatry, 3(7), 646–659.

Chapter 4

Expanding the Options Through Nine Steps Peter Cornish

Amber’s Recovery Pathway I had just delivered my speech on the results of our SC2.0 Demonstration Project. The Minister of Health had opened the event by describing the province’s recently adopted “Towards Recovery” mental health strategy. The CEO of the Mental Health Commission of Canada spoke prior to me, sharing comments about how the project fits within a pan-Canadian context. Amber was invited up right after me. I had never met Amber and had no idea what she was planning to say. It turns out that I couldn’t have scripted a better testimonial to the value of our nine-step model of care. She began by saying that she was a 23-year-old recent graduate from Memorial University and that this was the first time she had ever talked publicly about her mental illness. Despite this, she showed no signs of anxiety, and the audience was soon riveted by her story. Amber recalled having severe bouts of anxiety and panic symptoms since in kindergarten. Years later, with her mental health deteriorating, she frequently cried herself to sleep. During the day, she masked her panic with lies. One time, after a teacher asked her why she was so out of breath, she replied, “Oh, I just went for a run on my lunch break.” Ashamed and embarrassed, she was afraid to tell anyone about her weakness. In grade 11, Amber called Canada’s Kids Help Phone. This was her first contact with the mental health system. The staff at Kids Help Phone were supportive. “They gave me the courage to finally tell my parents,” she said. Amber’s parents helped her connect with their family physician. Amber remembers her physician as kind, gentle, and reassuring: “Amber, we’re going to get you some help. It is really good that you decided to talk about this with me and your parents.” Amber replied sharply, “I don’t want any meds!” She wasn’t sure why at the time, she just knew that they were a no-go. Much later, after a lot of P. Cornish (*) Counseling and Psychological Services, University of California, Berkeley, CA, USA e-mail: [email protected] © Springer Nature Switzerland AG 2023 P. Cornish, G. Berry (eds.), Stepped Care 2.0: The Power of Conundrums, https://doi.org/10.1007/978-3-031-45206-2_4

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self-­reflection and support from Lifewise (a local community-based peer network), she understood that it had to do with her values and personality. “I guess I have always been a stubborn person. I wanted to tackle the problem myself. I didn’t want to change who I am or see myself as someone with a mental illness. I wanted to fight the problem myself.” But at the time, neither Amber nor her physician knew quite how to proceed. She was referred for counselling. Amber was reluctant and nervous; Amber fought through the anxiety and doubts. She went for the counselling appointment. She was asked questions about her symptoms, her experiences of panic, and the frequent night-time crying. Then, somewhat stunned, she heard the counsellor say something that threw her off: “Amber, you are being a dramatic teenager, and you will get over it.” Amber was crushed. She retreated and gave up on help-seeking. There were no other options for counselling in her small community. Depression took over. “Depression,” she said, “it was sort of like having four or five of those blackout curtains wrapped tightly around my whole body. I couldn’t see a thing. I couldn’t move. What was happening? I would feel hot and clammy, followed by chills. I couldn’t move. I was alone and trapped with my negative, despairing thoughts.” There wasn’t a dry eye in the room at this point. I heard someone crying softly behind me. Amber’s speech, I noticed, turning my head to the left, was being recorded. The young woman holding up the smartphone just behind me had tears streaming down her face. Later, while watching the recording, I could hear the suppressed sobs and a few sniffles from Amber’s younger sister. At that moment in her speech, Amber acknowledged her sister and said if it wasn’t for her, she may not be alive. Both family and peer support were essential for Amber’s recovery: “I was in my third year of university when I got placed at CNIB (Canadian Institute for the Blind) for my first work term. CNIB works out of the same building as Lifewise (the province-­wide peer support network), just upstairs. At this time in my life, I was not very open about my mental illness and was not yet diagnosed with depression— only an anxiety disorder. I had never heard of Lifewise before and was curious. My coworkers at CNIB told me it was a mental health and addictions organization. Living with mental illness myself, I was intrigued. I decided to look up Lifewise’s Facebook page and do a little research. It sounded like an amazing place, but I was not in a healthy mindset to use their services—I still had a lot of shame. I kept tabs on their Facebook page.” Amber’s mood worsened. Suicidal thoughts became more frequent and graphic. She imagined herself jumping off a familiar cliff at the top of Signal Hill. The urge became overwhelming when she and her boyfriend parked one day at the top of the hill. But, “it was the love I feel for my sister that stopped me from acting on the impulse to jump. It was the thought of my sister that led me to my Dad. Mom was away. I told Dad about my scare on Signal Hill, and then I went back to my doctor.” Again, with genuine compassion, her physician said, “Amber, we’re going to get you help,” and once more, she gently, yet firmly, recommended counselling and medication. Amber was ready now to consider a variety of options, including counselling and medication. Her physician had recently learned about some new

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resources that had been implemented through our project and suggested that Amber check out the Bridge the gApp online mental health services directory/portal. Amber valued autonomy. She speculated that, “it was probably my shyness, my shame and stubbornness, along with my do-it myself attitude, that attracted me first to the online tools on the website. I tried the mindfulness app, but I couldn’t concentrate at the time. I found the ‘Art Room’ where other kids had posted photos of drawings. There were so many other young people posting anonymously about their own feelings of panic and despair. I was shocked. I guess I’m not really alone. My confidence boosted, I explored some of the other tools. Breathing Room inspired me, building my confidence further. I tried some online therapy modules and eventually returned to the mindfulness app. With some of these skills and growing confidence, I reached out to Lifewise. I had started opening up more about my mental illness and was ready to get the help I needed and to let go of the shame I was holding.” Recovery and resilience depend on the availability of timely opportunities: “Lifewise had posted a job. I couldn’t believe the timing; it was almost like fate. I decided to apply and just give it my best shot. If I didn’t get the job, at least I took a step forward in my recovery and a step towards Lifewise. Fortunately, I got the job along with six other amazing people. I became part of a family with the 12-plus people that were already working there. The support and respect were incredible, and I knew I had found the job that was for me. I have been there for almost a year now and am so thankful for Lifewise and its role in my recovery.” Amber paused and said with a wry smile, “You know at Lifewise they try to break you!” A few knowing chuckles across the room. “The peer training is very intensive. They challenge you to do so much self-reflection.” At the news conference, Amber emerged as a valued spokesperson for the power of peer support. Her speech has since been adapted into a video explaining the importance of co-design, peer support, and lived experience for our recovery-­ oriented SC2.0 Model (you can watch it here: https://www.youtube.com/ watch?v=q9PFN4gVbbM).

4.1 Recovery Step by Step In true recovery fashion, Amber entered the care system in her own way. I wonder what would have happened to her if the province of Newfoundland and Labrador had not adopted the Towards Recovery strategy. The SC2.0 model in Newfoundland and Labrador allowed Amber to access the help she was ready for, right at the time she sought help. Unfortunately, the model was not in place the first time she went looking, and her condition had worsened. At the beginning, the anxiety she experienced had been unpleasant and restricted her social functioning. The only services available at that time were counselling and medication. Neither proved a good match for her at the time. When the counselling backfired, there was no opportunity to fail forward. Towards Recovery had not been conceived. SC2.0 did not exist.

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Amber became severely depressed and suicidal. Luckily, according to Amber herself, “having a much wider selection of options available to me the second time I went to my doctor probably saved my life!” Amber’s recovery could now proceed step by step.

4.2 How Many Steps Should There Be? A review of published studies on stepped care reveals wide variability in the number of step categories (Berger et al., 2022). We were surprised to discover that the most common number of steps was only two. Our version, SC2.0, has the greatest number of steps. This is deliberate. We were interested in breaking care down into its most basic, elemental components. To our knowledge, the categories are exhausted at nine steps. Originally, we specified eight steps, but stakeholder input from one of our co-design implementation workshops led us to break psychoeducational and family/peer support into separate categories. Psychoeducation, we were told, could be delivered by either peers or professionals, or even both at the same time, in the form of workshops. We believe that a high specificity of step levels maximizes the potential of stepped care. It encourages the discovery of ever more mental health resource options. With more options comes greater potential for accommodating help-seeker preference and maximizing treatment fit. The most basic two-step model, formerly known as “shared care,” has been around for decades. It typically involves transitioning back and forth between physician and psychiatric care. A more recent two-step model involves stepping between e-mental health and traditional face-to-face psychotherapy. Neither of these stepped care approaches would have worked for Amber. Face-to-face counselling, poorly timed for the state Amber was in at the time, was a setback for her. It was unhelpful, and Amber lacked the confidence at the time to give this feedback to her physician. She dropped out of that treatment. In the context of our SC2.0 model, Amber made use of five of the nine steps, only one of which existed several years ago. And while research suggests that individual psychotherapy and pharmacotherapy are highly effective for treating anxiety or depression (Cuijpers et al., 2013), it fails to account for barriers to access. Barriers to access for Amber included internalized stigma and lack of readiness to engage fully in the therapeutic process. Another barrier stemmed from the one-size-fits-all approach to psychotherapy referrals. The counsellor she had been referred to was not a good fit. There was no alignment or connection. Amber experienced the counsellor as dismissive. In a recovery-based SC2.0 context, Amber would have had more choice. She could have attended the same-day walk-in clinic. She would have known from the information in the waiting room that choice was paramount. She would have known that if she didn’t feel comfortable with her first experience, she could walk in another day and try someone else.

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Amber’s journey began with a Step-9 consultation. She reached out to Kids Help Phone: a crisis line staffed by professional counsellors. This worked for Amber because it removed an access barrier. It was easy for Amber to connect without anyone knowing. She made the call in the safety and privacy of her own bedroom. The help-line counsellor recommended a Step-3 resource—family support. She was nudged to open up to a loved one. Perhaps this worked because Amber made the call from a safe and relaxed place. She was ready to receive this recommendation. Family support was key to Amber’s recovery. Her parents supported her to reach out to their family physician. This is a Step-7 resource—flexible individual professional support. In Canada, physicians and psychiatrists are the only professionals that can bill directly the publicly funded Medicare system for counselling. This was the only accessible option known to Amber and her family at the time. The compassionate mental health care she received from her physician was critically important, but it was not enough. Amber needed more options. There were only two to choose from the first time—medication or “talk therapy” with the one and only counsellor in her small community. There was no system aimed at empowering help-seekers. There was no encouragement to engage in trial and error among a variety of options. There was no buffet to sample from.

4.3 Step 1: Watchful Waiting; Informational Self-Directed The second time she reached out, again through a Step-3 resource—family support—the mental health system in the province had evolved. The provincial Towards Recovery strategy had being launched (Government of Newfoundland and Labrador, 2017). There was a new mindset among providers. Help-seeker preference was now emphasized, and many more options were available. Amber’s physician told her about the new and powerful Step-1 resource Bridge the gApp. Step 1 focuses on information. It is aimed at supporting mental health literacy. Mental health literacy includes knowing the difference between distress and mental illness. Bridge the gApp is a mental health literacy site designed to educate. In order to be effective, the information at Step 1 must be evidence-informed and practical. It must include up-­ to-­date resources, including a directory of programs available locally. It also should include details on how to access evidence-informed online resources. Bridge the gApp is such a resource. It is managed by mental health professionals and meets the highest privacy standards. It includes a directory of services organized by region. The directory includes both (1) formal, professionally and peer-led, publicly funded programs and (2) informal programs available in the community. Formal programs include counselling, psychological and psychiatric services, as well as programming offered by paid, trained peer support workers. Formal programming also includes online tools funded by the government and available to all citizens free of charge. Informal programs include community-based programs and support groups, such as AA, NA, Big Sisters and Brothers, and Survivors of Suicide.

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Step 1 also includes the notion of “watchful waiting.” Amber’s physician referred her to Bridge the gApp after learning of Amber’s bad experience with counselling, and she already knew that Amber did not want medication. She wasn’t sure if Amber was ready to try the new walk-in, single-session counselling program called “Doorways.” Amber’s preference and/or readiness for engaging in intensive programming was unclear. As such, her physician simply prescribed Step 1: self-­ directed informational resources and watchful waiting. Step 1 can be a good option when readiness is low or preferences are hard to determine. Watchful waiting in the context of SC2.0 involves no specific recommendation, but instead an agreement to keep an eye on things through continued wellness monitoring. Research suggests this alone can be an effective intervention with at least 20% of help-seekers recovering after making an initial contact and receiving no specific treatment (Whiteford et al., 2012). When watchful waiting is prescribed along with access to solid, accessible mental health literacy tools, this percentage may well increase. Amber spent a lot of time at Step 1. She discovered and experimented with a variety of resources available through the Bridge the gApp portal. From that vantage point, she moved up and down from Step 2 (interactional self-directed resources) and Step 3 (peer support). Step 1 proved to be a safe harbor for Amber. It laid the foundation for her to experiment with options, to sample the buffet, to risk trial and error. Her first attempt at the Step-2 MindWell app was a failure. It required too much concentration. She was too easily distracted at that time. No matter; the Art Wall was there. Coloring calmed her. Reading what peers posted helped her to fight internal stigma. She felt less alone with her symptoms. She kept exploring and trying out the various Step-1 options, and, as her mental health literacy grew, she made progress with recovery.

4.4 Step 2: Interactive Self-Directed Step 2 requires a little more commitment and energy than Step 1. The assumption at this step is that a help-seeker will become a more active and committed learner. Programming at Step 2 moves beyond mental health literacy. It calls for sustained participation. The participation at Step 2 is private. It typically involves completing workbooks or worksheets. These can be paper-based or online. Prior to the internet, this was referred to as bibliotherapy—self-help treatment with a book or workbook. One popular example of bibliotherapy is David Burn’s book, Feeling Good: The New Mood Therapy (Burns, 1981). This is a cognitive behavioral therapy self-help manual. Ironically, this was the text we had proposed to use in our failed self-help study described in the preface to this book. We estimated that the book had been written at a grade six reading level, but we underestimated the extent to which reading books had become unpopular. In hindsight, I wonder if the study may have succeeded were Bridge the gApp and some online Step-2 programs available? After all, online reading is now the preferred medium.

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Fig. 4.1  MindWell U’s Take-5 mediation exercise (Mindwell, 2020)

Amber accessed several Step-2 resources. The first one she tried was MindWell U. This is a 30-day mindfulness course. It requires a minimum of 3 to 5 minutes of work per day. Each day, participants receive an email from MindWell with a link to the day’s unique content, along with reminders and tips on how to practice the Take-5 meditation (see Fig.  4.1 for description of the Take-5 exercise). The programming is dynamic and has a well-designed user interface. In other words, it is attractive, enticing, and easy to use. To encourage commitment, users can select a “buddy”—a friend or family member—who they can invite to register for the program. Users are encouraged to connect with their buddies to share experiences, encourage each other, or engage in some friendly competition around participation goals. With this buddy feature, MindWell has an element of a Step-3 program (peer support). Although intrigued by the program—she had set herself a goal of becoming more relaxed through mindfulness meditation—Amber decided the program was not right for her at the time. She couldn’t concentrate enough to follow the Take-5 meditation exercise, which was central to the program. Instead, she found the TAO program, with its more basic relaxation tools, a better fit with her capacities. Whereas MindWell prescribed scheduled fixed content for each of the 30 days of the program, the TAO self-managed program allowed more flexibility. Amber was able to browse the modules, picking and choosing programming corresponding with her readiness. She found that the simple relaxation training exercises in TAO required less concentration than the Take-5 mindfulness protocol. A screenshot for one of the TAO modules on relaxation is illustrated in Fig. 4.2.

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Fig. 4.2  TAO Connect’s mindfulness module screenshot

4.5 Step 3: Family and Peer Support When Amber contacted Kids Help Phone line (Step 9), the crisis counsellor listened to her concerns and encouraged her to reach out to her parents for support. This was a good example of an effective stepping down intervention. The help-line counsellor sensed Amber was not ready or able to access professional care, but had a good relationship with her parents. Reaching out to her parents was a simple, elegant option. She was ready and willing to do this. Family support was the home base for Amber’s attempts to access formal professional care. Without Step 3, Amber would not have accessed the range of resources she needed. Though she did not understand it as such, Amber had already engaged in Step-3 support. Specifically, her connection with her younger sister and her parents are examples of informal, unpaid community-based peer support. Formal peer support, in contrast, is typically paid work which requires standardized training, supervision, and certification. The type of informal family and peer support offered through organizations like AA is voluntary and includes little or no training or oversight. Both are valuable. Amber said that she probably would not be alive if it wasn’t for her love for her younger sister. After her failed attempt with professional counselling and her successful work with self-managed e-mental health tools (at Steps 1 and 2), Amber discovered the formal peer support network Lifewise. Amber certainly valued her autonomy and the informal supports extended by her family. It is perhaps no surprise then that formal peer support was a logical step up when she became ready. She needed more than informal support but found professional care (talk therapy and medication) too intense initially; the dosage of care was too high. Formal peer support was skill-­ based (the peers who supported her had received certified paraprofessional

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training). It also included access to a community of peers, as well as a welcoming physical space (like a clubhouse). This formal peer support enabled stable connection that was also empowering. Amber initially felt uncomfortable being in the passive position of simply receiving treatment. She saw herself as strong, a fighter, and someone who finds meaning and purpose through giving to others. Amber probably does not realize how much she has already given to others. By sharing her story publicly, in front of television cameras, the Minister of Health, and other local and national dignitaries, Amber has proven the untapped power and potential for peer support to empower people while also reforming our mental health system.

4.6 Step 4: Workshops Step 4 is the first point on the care continuum where professionals may enter the picture. Unlike group counselling or therapy, the focus in Step-4 workshops is mainly educational; it does not typically involve disclosure or much interaction among attendees. The format is akin to a class or presentation. While there are some similarities to Step 1, insofar as the aim is increasing mental health literacy, the commitment and energy required by both attendees and presenters are typically greater. For an attendee, there is a social commitment to stay for at least an entire session. It involves some public exposure. Others will know of the attendee’s interest, thereby compromising privacy. However, unlike group therapy, participants will not learn much more than that. There is little chance of sensitive information being revealed. This can make it feel safe. In a few of the communities where we implemented SC2.0, workshops were the most popular option. For example, on the Burin Peninsula, a region experiencing a rash of suicides a few years ago, workshops on mood and anxiety fill to capacity. This may be a logical extension of the successful community lobbying efforts that fast-tracked the provincial Towards Recovery rollout (Government of Newfoundland and Labrador, 2017). Community members had already discovered power in numbers. They had achieved much through town hall meetings following the suicides. That attending workshops together might continue to foster mental health was a no-brainer; they already knew the healing power of community.

4.7 Step 5: Guided Self-Help Guided self-help is a little like the so-called flipped classroom. A flipped classroom is a post-secondary course modality that blends human contact with web-based content. High-quality content is procured and offered asynchronously through web-­ based video and interactive programming. Presentations by some of the world’s most gifted educators can be recorded and accessed online anytime by students. Typically, weekly interaction with a tutor or instructor is scheduled. This

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face-to-­face, classroom-based interaction focuses on problem-solving, answering questions, and motivating task completion. While flipped classrooms have demonstrated proof of concept (i.e., learning does occur), widespread implementation has not happened (O’Flaherty & Phillips, 2015). They account for a very small percentage of post-secondary curriculum delivery (McPherson & Bacow, 2015). With Step-5 mental health care, the guided sessions can be in person, online, or in group format. The focus may include technology troubleshooting, motivational interviewing to maximize module engagement, or addressing gaps arising from other mental health needs. Guided self-help has demonstrated very impressive results through clinical trials—almost always matching the outcomes achieved by traditional face-to-face 50-minute weekly psychotherapy sessions but using far less professional time and expense (Andersson et al., 2014). However, much like flipped classrooms, guided self-help just hasn’t caught on. In both cases, practitioners are unmotivated, or perhaps not well enough prepared, to adopt the new practice. Very little training is available to supply educators or therapists with knowledge or skills for successfully implementing web-based learning. Rather than waiting for practitioners to adapt their practices to include technology, some clinic decision-makers are contracting out the work. A growing number of online psychotherapy platform developers have begun recruiting their own clinicians. Only those with interest in e-therapy work and grounding in recovery principles are considered for the positions. They are expected to specialize in this modality. Although there are no clear signs yet, this could mark the beginning of disruption in the mental health field akin to Uber’s influence on the taxi industry. Will therapists and their professions adapt or might they fall prey to some more massive, as of yet unforeseen, e-mental health disruption? Currently, there are two types of vendors operating in the expert-assisted e-­mental health space. Therapy-Assisted Online (known as TAO Connect) was one of the first commercially available platforms. It is a social enterprise aimed at having a significant positive impact on campus mental health. Priced aggressively, it is easily absorbed through the limited budgets of college and university counselling centers. TAO provides the platform, a video conferencing function, a wide variety of transdiagnostic modules, and practice-based therapeutic measurement tools. TAO does not provide any labor. Clinics use their own professional staff. As such, counselling centers must somehow prepare and convince existing staff to adapt practices. This is proving to be very challenging. Few psychotherapists have shown interest. As such, companies like TAO Connect are adapting their business models by reaching outside clinic settings where there are more willing coaching partners. The shift means moving away from expert clinician guidance to peer or paraprofessional coaching. On campuses, residence leaders, athletics staff, and judicial affairs officers have started to take this on. Some are prescribing the programming regularly now to the students they serve. Mind Beacon is a Canadian startup that is succeeding with the expert-assisted e-mental health model. They recruit and train both psychologists and wellness advisors to support customers using their CBT platform which is designed to treat both anxiety and depression. While easier to implement because the therapists are

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supplied by the vendor, the program is expensive. Therapists are hired and trained specifically to support clients using the platform. This model addresses the key obstacle to implementing therapist-assisted e-mental health: professional change management. However, therapist involvement is not the only challenge. Purchasers of the solution still need to establish referral pathways and market the innovation to clients. While clinician training would not be required, stakeholder buy-in is needed to facilitate appropriate referrals and stepping decisions. Unfortunately, even with a strong evidence base supporting both guided (Andersson et  al., 2014) and self-­ guided (Karyotaki et  al., 2017) e-mental health programming, providers remain largely unconvinced. That is, many believe few clients would either choose or benefit from anything other than face-to-face traditional 50-minute weekly psychotherapy. However, since the onset of COVID-19 early in 2020, interest in these programs has increased. The pandemic is accelerating the shift to digital mental health. A carefully designed change management program is needed to ensure Step-5 success. Training might include increasing provider technical proficiency, developing a coaching mindset, and encouraging treatment adherence. Some clinics have succeeded by seconding early adopters to specialized implementation roles. With release from regular duties, they are able to focus energy on championing the program and mentoring colleagues. Some of these innovators found success in delivering the e-mental health client coaching component through a group counselling format. This has worked especially well in settings that routinely deploy two facilitators to lead groups. Such cases afford an opportunity for mentoring less enthusiastic colleagues. This apprenticeship approach could be a vehicle for gently nudging buy-in from therapists otherwise reluctant to offer guided e-mental health programming on their own. Perhaps self-help should be guided by paraprofessionals or non-professionals. Family members, friends, or others in the community could be encouraged to support help-seekers engage with online mental health tools. This kind of informal guidance already happens in the context of Flexible Assertive Community Treatment programs that include peers and family members as part of the team (van Veldhuizen & Bahler, 2015). Mental health literacy or mental health first aid training could be provided in workplaces to human resources personnel and other administrators so that they might support employees by serving as navigators to the broad continuum of resources available on portals like Wellness Together Canada.

4.8 Step 6: Intensive Group Programming Group psychotherapy is a powerful and effective treatment modality; however, group has long played second fiddle to individual psychotherapy. Many mental health professionals see individual face-to-face psychotherapy as the gold standard treatment. Anything else short changes help-seekers. Like guided e-mental health programming, group psychotherapy is proven effective but underutilized. There are several explanations for this tendency to undervalue group psychotherapy. One is

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that therapists themselves say they would not opt for group therapy given a choice. Perhaps, this is because it is a high-dosage treatment largely due to the social exposure element. Opening up to peers and being challenged by both peers and therapists in a closed environment is not for the faint of heart. From a client perspective, group therapy might better be thought of as a higher-intensity treatment than individual therapy. Currently, we situate group therapy at Step 6 just below individual therapy because from a funding perspective group requires less investment. Perhaps the order of the steps should be reversed for client-facing depictions of the model. Understandably, help-seekers may feel some trepidation when offered group psychotherapy. Consider a person struggling with social anxiety. Theoretically, we might argue group therapy is the treatment of choice. The group setting affords a safe place to fully experience, understand, and develop skills for coping with anxiety. But client readiness and preference almost always trump theory. As such, it may not be the best place to start treatment. The underutilization of group psychotherapy is also related to inadequate training. Typically, training in group therapy is limited by a relatively thin curriculum and sparse practicum site opportunities. Under such conditions, we cannot expect to develop a critical mass of confident group therapists needed to raise the profile, legitimacy, and availability of this powerful modality. Nevertheless, SC2.0 training and implementation help motivated providers to develop a variety of alternatives to the Step-7 “gold standard.” An incremental approach to group program development, in the context of this larger transformation process, holds promise. Without a lot of previous experience or training in group work, it is fair to assume inexperienced practitioners would not begin by facilitating open-ended process groups. Nor would they cut their teeth working with populations likely to challenge authority. Starting with highly structured groups makes a lot more sense. The structure allows leaders to maintain control. This is important for building confidence. Lecture and workshop psychoeducational formats, like those outlined above at Step 4, are the most structured types of groups. Just as Amber needed to begin with low-intensity programming, therapists might need to begin with Step-4 practices before attempting the more intensive Step-6 work. At Step 4, communication is unidirectional, thereby precluding any need to manage interactions. In contrast, group psychotherapy at Step 6 is by nature more unpredictable. Group psychotherapy participants are often expected to display their maladaptive interpersonal patterns in vivo. Not a good experience for neophyte therapists. Quite often, the most valuable learning for clients comes from working through authority issues by challenging the leadership. Few therapists are ready for this straight out of the gate. Some may never choose it. For agencies and clinics that have decided to adopt SC2.0, not all steps are populated at once. Implementing a group therapy program in the context of SC2.0 is best done incrementally. If group work has not been a key part of the treatment continuum at a clinic, it would make sense to begin with structured educational approaches focusing on mental health literacy in Step 4. Perhaps the next step in implementation would be to move to semi-structured psychotherapy groups. These groups have well-developed curricula and are more akin to teaching a class. There is some

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interaction, but the interaction is limited to the parameters of pre-set exercises. While there may be some open-ended disclosure and unstructured interactions, these are usually restricted by returning to the pre-set agenda of the sessions. I suggest that the most highly structured therapy groups be classified as Step-4 interventions, whereas semi-structured psychotherapy groups are best categorized as either Step-6 or Step-8 interventions, depending on the client population. Groups specifically targeting clients with highly sensitive and interpersonally volatile presentations should be considered Step-8 specialist-level interventions. A basic Yalom-style interpersonal process psychotherapy group is highly unstructured, and as such, it fits the category of intensive group work. This is by design. The lack of structure creates space, a social microcosm, whereby clients’ maladaptive patterns can play out safely within the context of skilled group leadership. And depending on the volatility of the clients attending, this could be classified as either Step 6 or 8. In an outpatient clinic context, a Yalom-style group would be considered a Step 6-level intervention. Trauma groups or DBT groups in residential or inpatient settings would be classified as Step 8. Readiness for exposure and being challenged are key factors when considering referrals to groups at Steps 6 and 8. Developing group programming can be frustrating. Groups require considerable upfront planning and some risk that this time will not pay off. Why put all the work into planning when participant recruitment is so challenging? Many practitioners report attempts at planning groups only to discover few people accept referrals. Scheduling is naturally more complicated by the fact that, even if willing and eligible clients were to be identified, it is likely that a time would not be found to accommodate all. Even if these challenges are met, repeated reluctance expressed by clients can be enough to discourage all attempts. This is understandable, particularly if groups offered never fill or have to be cancelled due to low numbers. Some providers, those with high caseloads or increasing demand, may persevere. Growing frustration may lead them to a hard sell approach: “I won’t see you unless you go to group first.” I do not expect much success with this approach unless the programming is well-matched to client readiness. Offering choices might help, especially if a series of groups, with varying levels of structure or exposure intensity, are available. Some theorists have emphasized the importance of group therapy preparation sessions or workshops. There is evidence that this increases attendance and outcomes (Piper & Perrault, 2015). There is certainly room in SC2.0 to offer group preparation at a lower level within the continuum of care. After all, readiness is a core variable in stepping decisions. If a clinic setting has a long wait time for individual therapy, clients may be open to attending a workshop entitled “Everything you would like to know about group therapy.” Some may be enticed by this one-­ time information session and enroll in group therapy. Others might decide to wait. In both cases, offering the choice is empowering. While readiness is a key factor in SC2.0, the goal of preparing people for higher-­ level programming conflicts with a key principle of our model. Instead of moving people to a level that practitioners would like to practice, the goal in SC2.0 is to move the treatment to where the person is ready without any assumption that more

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is needed. Of course, a help-seeker may wish to strive for more, and this is fine. But it is more empowering and less burdensome on the care system to leave the question of “is this enough or should there be more” up to the help-seeker.

4.9 Step 7: Flexible Intensive Individual Programming Step 7 is undoubtedly where most work currently happens in mental health care. While the demand can be reduced with the implementation of SC2.0, social workers, psychologists, counsellors, physicians, nurses, and psychiatrists will continue to deliver some form of talk therapy on a routine basis. Often the style, complexity, duration, and interval of treatment are different depending on the provider or discipline. This is a good thing, as one size does not fit all. Client preference and choice are core principles of SC2.0. However, there are considerable debate among providers and uncertainty among help-seekers about what to expect from whom. In SC2.0, informed consent is especially important. This is partly because the model and approaches are new. It is also because having clear expectations improves outcomes. Equally important to informed consent is role clarity. This includes the expectations and roles of both client and provider, but increasingly, in our more collaborative care networks, we need to do more to develop interprofessional role clarity. What should a nurse do in the SC2.0 system? What about the family physician, a psychiatrist, or a psychologist? While we have not yet worked this out, the model does provide a kind of scaffolding for exploring and testing out role differentiation. This is detailed more in Chap. 6. Have you ever wondered why psychotherapists typically work in the context of the 50-minute hour? This has been the case for more than a century. An hour is a useful period of time for costing. An hourly rate is easily understood and remains the most common unit for pricing all wages in our economy. The extra 10 minutes afforded by the 50-minute hour, of course, ensures that time spent with record keeping and other administrative tasks are factored into the pricing. But what does science say about this? Is this unit of time any better than others for improving mental health? And then, what about weekly intervals? Why do we practice psychotherapy at 1-week intervals? Is there evidence to support this? Is the weekly 50-minute session in the best interest of help-seekers or is it really for providers? Of course, we do need a system that is sustainable. The needs of providers are important, but they should not preclude innovation. Very little research has addressed these questions. That in itself is interesting. Why hasn’t this been studied more? The research that has been conducted suggests that there is nothing particularly beneficial or important about intervals and session duration (Erickson et al., 2015; Turner et al., 1996). While it is true that much more study is warranted before drawing firm conclusions, proponents of SC2.0 encourage more experimentation in general, and this also applies to the use of time. In the context of continuous therapeutic measurement, client preference, and a trial and error philosophy, therapists operating at Step 7 can become much more creative

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with time. Sometimes, we ask our clients at the beginning of Step-7 sessions, “What would you prefer today, a targeted brief 15-minute skill-building session or a longer meeting to explore and dig deeper? Do you want to get something done today or delve into understanding the complexity of your life?” With a client who is exhausted due to lack of sleep, or one with low energy levels associated with depression, maybe a briefer session is in order. With what little energy there is, a shorter, more focused session could be more productive. For someone who finds the sessions highly anxiety provoking, a small dosage might be more tolerable. My colleagues who work with Indigenous peoples sometimes suggest a day-long session on the land makes far more sense than seven or eight 50-minute meetings. My life partner, Karen, is an experienced psychologist who owns and operates a small private practice. She is known in the community for her experience in treating complex cases, including clients with borderline personality disorder, bipolar disorder, and complex PTSD. She sees her clients more regularly and for longer periods than I do. As I was finishing writing this book, we were beginning preparations for an international move. This meant that Karen was considering how to terminate treatment with her clients. She received an email request for therapy from a person with a long and complex history of mental illness. She was working on a response and asked me for advice on what to say in the email. I asked what her concern was. She replied, “I am not sure how I should indicate that I will only be practicing here for the next six months.” I asked her why she thought that was necessary. She answered, “Well, if I don’t tell the client then she won’t be able to make an informed choice about whether to see me for such a short time.” I said, “But if you do tell her in advance, aren’t you subtly implying that six months might not be enough for her? How does that instill hope?” Some colleagues, including my partner Karen, say to me, “Surely there is value in a course of 10 to 20 (or more) 50-minute sessions for those people with complex needs, such as complex PTSD.” I agree that this might be helpful but suggest it need not be the default. Why not be more flexible? Why not ask the help-seeker? “But,” say my colleagues, “It can take a long time for someone who has been abused for years to build up trust in a therapist. Having briefer and fewer sessions would further delay this process.” This may be true for some, but then I question, “Aren’t there many ways to build trust?” Colleagues sometimes counter with, “You can’t rush the development of the therapeutic bond. This happens very slowly.” While there is a large and robust body of research underscoring the value of the therapeutic alliance in driving mental health outcomes, the alliance does not necessitate a deep and lasting bond. Our goal is not to replicate friendship. Such an effort would be considered unethical for a variety of reasons—creation of dependency, profiting through the dependency, and doing more harm than good. Instead, the alliance is about alignment. Alignment can happen within a matter of seconds. A gifted health practitioner does this frequently. Think of a talented and beloved rural family physician. With kind eyes and a warm, gentle smile, such a physician aligns swiftly and smoothly with patients. I call this “flash empathy.” Unfortunately, we have not given enough attention to teaching alignment. Without adequate training, we are left

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waiting patiently with our clients for it to develop slowly and naturally over the course of many sessions. With SC2.0, we do not dawdle when it comes to connecting. Professional development on forming rapid connection is a must. The model requires swift alignment with a therapeutic success in every encounter. With SC2.0, we remind ourselves of the fact that an initial encounter is likely to be the one and only. Even if a course of sessions is contracted at Step 7, we work hard to align anew each time, just in case it may be the last. I now practice most of my psychotherapy one-session-at-a-time. I have many clients, most of whom I see infrequently. While not nearly the same number, this is akin to a typical family physician who has a large roster of patients, most of whom do not need medical attention. Some clients I see only once or twice. I believe they get what they came for. Because I have shared with them principles of the SC2.0 model, including start strong/start simple, trial and error, fail forward, and come back if/when needed, clients begin feeling empowered and reassured that care is there when they need it. This produces rapid alignment. Sometimes I say, “I will work really hard today to make sure that you walk away feeling like this was helpful, that we did something useful and that something has already been achieved. But if, tomorrow, you think we might have missed something or got it wrong today, I really would like you to come back.” This does two things related to alignment. The fact that I promise to work really hard to make sure that something therapeutic happens right away instils hope, optimism, and faith in me as a dedicated helper. Secondly, a help-seeker does not feel pressured to get everything right, to solve all their problems right now, because they know they can come back. I often invite clients to think of visiting me in the same way they visit their family physician. Come when you need to. I will be available. Because my dominant form of practice is therapy one-at-a-time, I can usually accommodate requests for sessions within a week or two. Sometimes, when there are energy and substantial momentum, we may commit to a run of weekly sessions. Regardless of the pace or frequency, we review progress using therapeutic measurement at every session to guide treatment planning. If the data indicate deterioration or flattening of progress, we might decide together to experiment with adjusting the modality, frequency, or duration of contacts. Sometimes with people whom I have followed for longer than average, I make use of the traditional assessment, diagnostic, and therapeutic techniques I was trained in. But I do this only when we are feeling both puzzled and stuck. The results can be spectacular and the outcome rewarding for both me and the client. In other cases, we discover through the use of therapeutic measurement and the successful reapplication of solution-focused interviewing that a return (or stepping down) to periodic, one-at-a-time sessions is preferred. In a case where outcomes are flat or deteriorating, we will re-examine the treatment plan and consider the many other options available along the SC2.0 continuum. Some clients do initially experience stepping down as a threat to the connection we have established. If so, I liken it to a family physician’s responsibility to find allied care options, to refer to specialists, to recommend strategies for lifestyle changes. In other words, I remind clients

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that I am still available to them, but I will not see myself as the only healer. I can be your touchpoint, your mental health go-to-consultant in the way that a family physician considers their clinic as the patients’ medical home. In a similar fashion, at Step 7, in SC2.0, the provider takes on the role of mental health treatment coordinator or their mental health-care treatment home.

4.10 Step 8: Chronic Care and Specialist Consultation Consultation is an area for growth within the context of SC2.0. There is a need for our most highly trained, expensive mental health practitioners to work to their full scope of practice. While there are decades of research supporting the efficacy of talk psychotherapy, there is very little evidence indicating that level of training, discipline, or years of practice reliably influence outcomes (Boswell et al., 2010; Stein & Lambert, 1995). In other words, a social worker with a year of post-graduate training is typically about as effective as a psychologist or psychiatrist with 6 years of post-graduate training. There is a perception that professions with more years of training provide better psychotherapy. This has led funders (insurance companies and government-funded Medicare plans) to authorize payments to providers that are the most expensive and potentially no more effective. Secondly, it allows specialists to do basic psychotherapy work that less costly providers could do. Not only is this inefficient, but it also means that specialists are not working to full scope. Both psychiatrists and psychologists working to full scope would prioritize more consultation and assessment for complex cases by either treating the complex cases themselves or advising generalist practitioners on treatment plans. If mental health specialists were working to full scope, their practices would have greater resemblance to those of medical specialists such as urologists, oncologists, and internists. For these specialty groups, the ongoing “contract” is with the general practitioner who receives their reports. The patient is only a client to the specialist for the one episode of care. The primary care physician is the specialist’s true client. Unlike other medical specialists, mental health specialists (including psychiatrists and psychologists) often carry cases for long periods of time without discharging back to their medical home—the primary care physician. Without evidence suggesting that long-term care by mental health specialists is any better than support by lower-intensity providers, this type of expensive practice is both inefficient and unethical. Some of my psychiatrist and psychologist colleagues are reluctant to move completely into consultation roles. This is understandable. They were trained to work long-term directly with help-seekers and to value the development of a therapeutic bond. Part of what makes the work rewarding is the maintenance of these bonds over time and the fact that work with patients tends to become easier as they become known to providers. Both the patients and the providers become more relaxed through familiarity. My colleagues argue that burnout could increase if they only worked with the most complex cases or lost opportunities to form more comfortable

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alliances with patients. This is possible, but only if other rewards are not in place. I can think of two possible incentives. Firstly, a consulting role should be valued more, and payments should be higher. Secondly, practices should be set up so that the relationships formed are with the other professionals benefitting from their consultation. One simple way to cultivate these relationships is through the development of integrated wellness hubs. These hubs could exist in both primary and tertiary care settings. Currently, specialists are not usually aligned with either primary or tertiary care settings. Most often, specialists work in private practice or acute care settings. Neither of these settings allow for specialists to maximize the impact of their consultation expertise. While specialist work may be essential for the treatment of complex disorders, private practice care tends to prolong care longer than is necessary. The impact of specialist care in acute care settings is limited by the restricted healing capacity of patients that are in hospital mainly to be stabilized. Complex treatments that have the potential to impact recovery do not usually begin until after stabilization.

4.11 Step 9: Acute Care, Systems Navigation, Case Management, and Advocacy In the context of SC2.0, treatment at Step 9 expands to include more meaningful partnerships with both formal and informal community-based organizations. This is needed to improve care transitions, ensure follow-up by the right provider, and reduce frustrations and inefficiencies associated with the emergency department revolving door syndrome. Many people in crisis attend emergency departments when in high distress because there are no other real or perceived options. As a result, those in high distress who are not acutely ill (i.e., do not require psychiatric stabilization) either are not admitted or are discharged quickly. This is reasonable, given that the purpose of acute care is to save lives and stabilize. It is not aimed at recovery work or complex treatment. With the development of lower step programming, including open-access modalities on first contact, inappropriate mental health presentations at the emergency department can be reduced substantially. When peer support programming is available for people in distress (but not suicidal), emergency visits are also decreased. In Newfoundland and Labrador, Lifewise operates clubhouse drop-in centers in various locations across the province. They also staff a peer-supported “Warmline.” In contrast to crisis help lines, the Warmline offers supportive, active listening to people who are not in crisis. It is staffed by persons with lived experience of mental illness who have received intensive, certified peer support training. Included in the Warmline brief assessment protocol is a question asked at the end of the phone call: “If this service were not available, what would you have done today?” In many cases, callers indicate that they would have visited the emergency department.

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Trained peer support workers are increasingly valued on hospital wards for their discharge planning and facilitation work. Not only is this work being done in psychiatric wards, but increasingly people with lived experience are facilitating social and mental health adjustment for patients discharged from oncology and cardiology wards. They are also helping with adjustment in chronic disease management, facilitating early discharge without risking rebound admissions attributed to inadequate community supports. Case management teams are becoming more common at various levels throughout the care continuum. Nurses or social workers are typically tasked with managing or coordinating the teamwork. These teams often include community stakeholders and trained peer supporters. Coordinators offer supervision and advice to team members. The coordinators likewise develop community-wide networks with counterparts operating at various levels of care. For example, almost every post-secondary institution now has a case management team. The case managers may operate within wellness clinics or independently. Team members include heads of counselling, the health clinic, accessibility services, campus police, residence life, the international students’ office, and academic advising. The coordinator’s job is twofold: (1) to support team members in making appropriate care referrals and (2), in cases where referrals are not needed, to advise on how to maintain informal community support. For example, an accessibility advisor may get direction at a team meeting on coaching a student’s supervisor in active listening techniques for moments when their student is in distress. Case managers function as both system navigators and healthy community development advisors. This dual role has the potential to reduce or reverse the hot-­ potato referral tendency that has arisen within the context of the risk paradigm dominating both our care and judicial processes. Within acute care settings, case managers coordinate care transitions required upon discharge. In the context of SC2.0, hospital-based case managers form partnerships with community-based case managers and care navigators. For example, in the city of Halifax in Nova Scotia, case managers in hospital settings have formed an alliance with the city’s ten post-secondary institutions through a program called “Stay Connected.” They rotate regular meeting locations across institutions so that case managers become familiar with the types of care offered along the stepped care continuum at the various sites. This has allowed them to develop efficient referral pathways and maintain coordinated care without duplication and while minimizing loss of continuity in care. SC2.0 can only work if all parties are familiar with the whole system of care. Given that the system is dynamic—always in a state of evolution or improvement— it is difficult to see the forest for the trees. System navigators and case managers attend to this dialectic. They have eyes on the moving parts, can help with treatment planning and life transitions on the micro-level, but are also crucial partners, at the macro-level, in system design and adjustment. They focus in and out on parts and system. Increasingly, people with lived experience with mental illness participate in this design work under the supervision of case managers. In some cases, client design teams dedicated to system adjustment are established. For example, at

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Memorial University, in 2017, we launched our first client design team. As described in the story at the end of Chap. 5, our design team was comprised of students with either lived experience of mental illness or an interest in improving care at the university. The team was led by a graduate student in educational psychology who, in turn, was supervised by our case manager. They worked over the course of a year to research, report, and recommend feasible improvements and adjustments to our stepped care model. They presented this to the wellness clinic operations manager at the end of the academic year. Almost all recommendations were implemented. This design work, involving people familiar with various levels of the care continuum and supervised by case managers who can see the forest for the trees, ensures that care coordination and innovation are one and the same. It also elevates the recovery principle of empowerment through all levels of SC2.0. Knit and Talk When we made our first SC2.0 training site visit to the small Newfoundland coastal community of Lewisporte, we invited the clinicians and mangers in attendance to populate the nine steps in our model with existing programs available in their region. Using a white board, we began by drawing the x- and y-axes to represent the two dimensions of the model: stakeholder investment on the y-axis and program intensity/client autonomy on the x-axis. We then created boxes and labelled each along the diagonal. The task for the group exercise was to “populate the steps” above and below the boxes. By this, we explained that programs existing within clinic settings should be arranged under the appropriate step boxes and resources existing external to the clinic (both formal and informal) should be listed above the boxes. Programs below the diagonal included “Doorways” walk-in appointments at Step 1, “choice appointments” at Step 7, and TAO programming at Steps 2 (self-managed TAO) and 5 (therapist assisted). Formal programs external to the clinic included Strongest Families anxiety treatment program at Step 5 (delivered through contracting out telephone counselling to therapists located in another province), the Warmline at Step 3 (operated by the province’s peer support network), and the Crisis Text Line at Step 9 (operated by a non-profit national peer support network based in Toronto). We asked if there were any informal community supports that could be included above the line. Without delay, we heard three voices in unison: “Knit and Talk.” This women’s support group had existed in the community for more than 20 years. While none of the clinicians had first-hand experience with the group, the reputation was positive. We asked if it should be included on the white board as a possible referral destination. Without hesitation, the clinicians agreed. I asked, “What about liability, what if something goes wrong at Knit and Talk and someone you refer has a negative experience?” One of the more eager participants replied, “We are so past that now, Peter. We are not so risk averse. Besides, we empower our clients to take managed risks, to fail forward when necessary, and we monitor outcomes regularly to ensure care is adjusted when necessary.”

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References Andersson, G., Cuijpers, P., Riper, H., & Heidman, E. (2014). Guided Internet-based vs. face-to-­ face cognitive behavior therapy for psychiatric and somatic disorders: A systematic review and meta-analysis. World Psychiatry, 13(3), 288–295. Berger, M., Fernando, S., Churchill, A. M., Cornish, P., Henderson, J., Shah, J., Tee, K., & Salmon, A. (2022). Scoping review of stepped care interventions for mental health and substance use service delivery to youth and young adults. Early Intervention in Psychiatry, 16(4), 327–341. https://doi.org/10.1111/eip.13180 Boswell, J. F., Castonguay, L. G., & Wasserman, R. H. (2010). Effects of psychotherapy training and intervention use on session outcome. Journal of Consulting and Clinical Psychology, 78(5), 717–723. Burns, D. D. (1981). Feeling good: The new mood therapy. Penguin Books. Cuijpers, P., Sijbrandij, M., Koole, S. L., Andersson, G., Beekman, A. T., & Reynolds, C. F. (2013). The efficacy of psychotherapy and pharmacotherapy in treating depressive and anxiety disorders: A meta-analysis of direct comparisons. World Psychiatry, 12(2), 137–148. Erickson, D. M., Lambert, M. J., & Eggett, D. L. (2015). The relationship between session frequency and psychotherapy outcome in a naturalistic setting. Journal of Consulting and Clinical Psychology, 83(6), 1097–1107. Government of Newfoundland and Labrador. (2017). Towards recovery: A vision for a renewed mental health and addictions system for Newfoundland and Labrador. Government of Newfoundland and Labrador. Retrieved December 10, 2019, from https://www.health.gov. nl.ca/health/all_party_committe_report.pdf Karyotaki, E., Riper, H., Twisk, J., Hoogendoorn, A., Kleiboer, A., Mira, A., et al. (2017). Efficacy of self-guided internet-based cognitive behavioral therapy in the treatment of depressive symptoms: A meta-analysis of individual participant data. JAMA Psychiatry, 74(4), 351–359. McPherson, M.  S., & Bacow, L.  S. (2015). Online higher education: Beyond the hype cycle. Journal of Economic Perspectives, 29(4), 135–154. Mindwell, U. (2020, January 4). Take 5. Retrieved from mindwellu.com: https://www.mindwellu. com/take-­5 O’Flaherty, J. O., & Phillips, C. (2015). The use of flipped classrooms in higher education: A scoping review. The Internet and Higher Education, 25, 85–95. Piper, W., & Perrault, E.  L. (2015). Pretherapy preparation for group members. International Journal of Group Psychotherapy, 39(1), 17–34. Stein, D. M., & Lambert, M. J. (1995). Graduate training in psychotherapy: Are therapy outcomes enhanced? Journal of Consulting and Clinical Psychology, 63(2), 182–196. Turner, P.  R., Valtierra, M., Talken, T.  R., Miller, V.  I., & DeAnda, J.  R. (1996). Effect of session length on treatment outcome for college students in brief therapy. Journal of Counseling Psychology, 43(3), 228–232. Van Veldhuizen, J., & Bahler, M. (2015). Manual Flexible Assertive Community Treatment (FACT). https://doi.org/10.13140/RG.2.1.3925.1683 Whiteford, H. A., Harris, M. G., McKeon, G., Baxter, A., Pennell, C., Barendregt, J. J., & Wang, J. (2012). Estimating remission from untreated major depression: A systematic review and meta-analysis. Psychological Medicine, 43, 1569–1585.

Chapter 5

Navigating the System Peter Cornish

Don’t Step Me Down “Don’t give me any of that stepped care crap!” Lake had indeed read the consent form in the waiting room. The form described the stepped care model and what clients might expect. In the blank space for gender, Lake wrote “queer.” I asked what pronouns Lake preferred, and the response was “they/them.” Lake explained that they had been highly suicidal and depressed throughout high school and the only thing that kept them alive was weekly 50-min sessions with a therapist. “I don’t want e-mental health apps and I don’t want to go to a group.” There was an edge to their voice, and I couldn’t quite tell if it was anger, anxiety, or both. I thanked Lake for making this clear, noting that client preference is really important to the kind of care we provide. “Tell me what was helpful about the work you did during high school,” I asked. Lake replied, “Well, it kept me going. I was able to go to my classes, keep my parents off my back, and basically survive.” “I’m glad to hear that,” I said and asked, “What kinds of things did you and the therapist do during your sessions?” “I vented a lot. My therapist listened and supported me. I was able to get things off my chest and calm down. I don’t think I would still be here if it wasn’t for the therapy.” Probing further, I said, “From the form you completed in the waiting room, I see that your symptoms of depression are still high and that you have thoughts of suicide a lot of the time.” “Yes,” Lake replied, “That’s why I’m here.” I asked Lake if they noticed any improvement in their mood or suicidal thoughts through the course of therapy. “Like I said, it kept me alive,” Lake’s patience was wearing thin. “And that is definitely a good thing. But, you know,” I said, pausing for a moment, “I’m of two minds about this. I agree that staying alive is really important, but on the other hand, I’m wanting more for you than just surviving.” Lake softened a little, looking puzzled. “What do you mean?” they asked. I said, “When I work with clients, I do my best to go beyond managing symptoms. I P. Cornish (*) Counseling and Psychological Services, University of California, Berkeley, CA, USA e-mail: [email protected] © Springer Nature Switzerland AG 2023 P. Cornish, G. Berry (eds.), Stepped Care 2.0: The Power of Conundrums, https://doi.org/10.1007/978-3-031-45206-2_5

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work for growth, for wellness, and I help clients to work hard for this too. Sometimes this doesn’t happen right away, but I feel strongly that if I ask a person to come to weekly sessions, we are both going to do our best to make use of the time. My training goes beyond helping people to survive.” Lake, frowning now, asked, “I’m not sure I understand. Not sure what that would look like to be working hard.” I said, “We are doing it right now. I am challenging you to reach for wellness. You are puzzled, you are thinking hard, wondering what that would require from you.” Lake responded, “I’m not sure I am comfortable with this. I work hard to keep alive. Isn’t that enough?” “Well it could be enough. That’s certainly an option. What I am saying is that if I were to work with you, that’s what I expect. But we have other options if that doesn’t feel right…” Lake interrupted, “I’m not doing anything online!” “No, while that is an option, there are many others,” I said. “For example, we are a training site, and the graduate students working under our supervision are actually not allowed to challenge clients. Instead, their job is to listen and be supportive. I wonder if that is the kind of thing you are looking for?” Lake hesitated a moment and said, “As long as they won’t send me to an app or a group.” I said, “Not unless that is something that would interest you.”

5.1 Desire Pathways SC2.0 is an open-access model with no predetermined pathways. It is not a staging or pathways model. We do not purport to know in advance what pathways or levels of care would be appropriate for anyone. We also do not think a strict consultation process, whether through screening tools or formal assessments, is the best way to determine initial care approaches. To me, those would be like asking the architects to design the paths on a new campus without consulting stakeholders. Instead, with SC2.0, we open up the field and point out the options and permit those who are interested to chart their course, seeking routes that make the most sense to them. Unlike other stepped care models, treatment need not be linear. There are many possible permutations and combinations of routes and reversals. We always start with preference. Then, through some gentle probing, we get a sense of what intensity level can be tolerated. This leads to a reconsideration of preference. In other words, the preference is refined. How might this have looked for my daughter? We will never know because her preference was not assessed. As described in Chap. 2, my daughter had a negative experience with counseling. This happened twice. She went first to her university counseling center and found the initial contact to be dominated by questions seemingly unrelated to her needs. She was offered an appointment 5 weeks later, but feeling discouraged by that initial disconnect, she declined. She assumed that paying out of pocket for a private practice session might ensure care more tailored to her needs with less waiting. Instead, she said the questions were the same. Neither counselor ever asked what she wanted or what she wanted to talk about. Instead, all questions were predetermined.

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My daughter admitted that she wasn’t exactly sure what she needed. That is why she was seeking help. She did, however, know what her concerns were. Being asked 30 or 40 questions about things that were not a concern was frustrating. I agreed. I said, “It’s like by turning over every stone, they will eventually discover some fascinating, deep dark mystery, and only then will you get help or relief.” She said, “I knew what the problem was, I just wasn’t sure about the solution.” I wonder how my daughter would have experienced SC2.0 programming. She is a freshly minted geologist with a passion for climate science. She, like many of her generation, was deeply distressed by the climate emergency facing our planet’s inhabitants. She loves fieldwork, the outdoors, and does everything possible to avoid a desk. With my amateur interest in architecture, I recently came across the concept of “desire pathways.” These are pathways that evolve naturally without much forethought. Some urban planners have experimented on university campuses. No sidewalks or pathways are created when the campus first opens. Instead, for a period of 6  months or so, designers observe where people naturally walk. They study the impressions left in the lawns or the gravel surrounding buildings. These are called desire pathways. If you leave space open for people to choose routes according to preference, what pathways would emerge? Once these become clear, contractors pave or otherwise reinforce the desired routes. Unfortunately, urban planners rarely consider this method. I completed my predoctoral 12-month internship in psychology at a university in central Canada. I was struck upon my arrival by the lush, open green circular lawn in the middle of the campus. An interlocking brick path neatly marked the perimeter. Every 50  ft or so, a black wrought-iron post topped with a gold letter sign warned pedestrians to “keep off the grass.” The lawn was streaked with dusty, criss-­ crossing pathways allowing for expedient links among buildings. Fall came quickly in this northern city. Adding to this annual disappointment was the sudden appearance of a garishly bright orange snow fence—a temporary cross-­ hatched flimsy barrier, familiar to northerners, designed to trap drifting snow. It was ugly, but at least only temporary. Winter in cities is often a dirty, messy affair. I was surprised to discover I was mistaken, when about a month later, construction began. The wrought-iron signs were replaced by a four-foot-high iron fence. Forget desire pathways. There would be no pathways. Now everyone would be forced to follow the circuitous route year-round. What was the lush green lawn for anyway? What was the circle for? I wonder if my daughter’s experience of counseling was a little like that forced circuitous brick path. She had no choice but to follow someone else’s ill-conceived path to get where they thought she should go. It was probably well intentioned. Following protocols is meant to keep everyone safe. There will be no causalities or property damage. The lawn will remain pristine. It will control movement and prevent anyone from falling off the prescribed course. But maybe she just needed to sit on the lawn for a while. After a while though, she would want to get going under her own steam. She thrives by finding her own path. Not only that, we need her and many others to chart new courses. The course

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prescribed by the last few generations now has the planet on suicide watch. Who are we to prescribe pathways? I think our expertise should pivot toward encouraging self-discovery and resilience, helping people find and stick to their preferred paths. They can always consult a chart or ask for help when lost. This is where our expertise with assessment can be recalibrated. Instead of a microscope or seismic drill designed to identify deep, dark structures below, our SC2.0 emphasis on therapeutic measurement is like a compass or a GPS device that can guide us to live productively on the Earth’s surface where we do best. I am a big believer in assessment. As a psychologist, I know that our tools for measuring, detecting, and understanding complex pathology are powerful and can be very useful in formulating treatment plans. However, I think sometimes our approach to assessment is overpowered. Instead of a 200-horsepower turbo-charged engine, a bicycle or a pair of sturdy walking shoes might do. Maybe we could start with the shoes. A student like my daughter is moving under her own power. We start with trusting and believing that her description of the issue is correct until proven otherwise. We don’t need to crush that self-propelled momentum that led to help-­ seeking with our turbo-charged psychometric tools. Instead, why not use our well-­ tested therapeutic measurement systems, our simple psychometric GPS, to see how well she creates her own paths. She could ask for help finding the path or she could consult a compass, map, or GPS device. If progress is too slow, the wind too strong, we can assist and coach on solutions. We might even decide together that another route or mode of transport is needed. More sophisticated investigation, using more specialized diagnostic equipment, might lead us to wonder if an e-bike kit would help or if public transit is the way to go. We might decide a full-sized vehicle or one with a turbo-charged engine is needed after all for some travel. But going full-sized, without considering less energy-hungry options, is simply wasteful.

5.2 Open Navigation If a patron samples a dish at a buffet that fails to meet expectations, they may return and try something else. Consumers decide themselves what they want with minimal direction. For a sit-down meal at an exclusive restaurant, carefully crafted menus provide some guidance. Servers then offer more tailored consultation. SC2.0 supplies both levels of direction. This may be less true in the context of pathways models. Instead, the selection is decided for them. Imagine a restaurant where dieticians decide your meals for you. Perhaps they would base these on your body type, fat levels, or pallor. Service pathways are predetermined, based on symptom cut-off scores. If your PHQ-9 score is above x, then you will receive this fortifying meal high in protein and rich with antioxidants (high-intensity programming). If it is less than x, you might receive a snack of fruit or nuts (low-intensity programming). To me, this is not much different from putting up a fence around the campus bowl. The approach curbs desire. In the context of mental health care seeking, it throttles motivation or,

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in the words of Michael Hoyt and Moshe Talmon, it fails to “capture the moment” of opportunity that presents when a help-seeker first reaches out (Hoyt & Talmon, 2014). There is an energy that drives all requests for mental health support. This is a rare, wonderful type of energy, especially given that a struggling person may not be firing on all cylinders. Stratified models are certainly well intentioned. There is a clear and simple logic to them. Give more to people who appear to suffer more. Give less to those who suffer less. After all, the risk is higher with those who suffer more. Or is it? What do we know about the relationship between symptom severity and risk? How good are we at risk assessment? According to several meta-analyses on suicide screening and suicide prevention, we are not very good at all. There is no evidence showing either approach saves lives (Harrod et al., 2014; Zalsman et al., 2016). Instead, there are some indications that deficit-oriented screening assessments without much attention to support might be harmful (Klimes-Dougan et al., 2013). In the case of Lake, outlined above, a stratified approach would have led straight to intensive therapy. At our counseling center, this would mean seeing a senior psychologist with a high level of expertise and a high salary. Lake’s care preference was for one-on-one regular support, but they were not interested in the type of specialized Step 8 programming I offer to some clients on a weekly basis. When asked to describe what worked previously, it became clear that they were looking only for support. A semester-long course of active listening is not a Step-8 speciality intervention. Lake was not ready to be challenged. I could have spent weeks attempting to nudge Lake toward therapy readiness, but in our SC2.0 approach, we do the reverse. My task was to connect Lake with something they were ready for at that very moment. To guide Lake to an option that fits their readiness, not mine. A trainee fit the bill. This does preclude some nudging. I tried some. Lake was intrigued by the possibility of accepting a greater challenge, just not quite ready. Preference is very important, but it comes with conditions. Lake may have wanted an experienced clinician, and they could have had one, but that option depended on their willingness to engage in difficult work. With this condition made clear, Lake chose to see a trainee for supportive counseling.

5.3 What Should Guide the Adjustment of Care? How and under what circumstances should we provide guidance while still honoring preference? With respect to desire paths, some features of the natural and built environments will inevitably restrict choices. A person is not likely to climb a steep hill if it is easy to walk around it. Trees will have to be skirted, and movement through buildings is limited by entrances. Consider those road signs that flash your current speed. Placed strategically near busy crosswalks or school zones, they may prompt a driver to slow down. There are no instructions. It is just feedback. Other roadway design features, while even more subtle, may have more direct influence. Traffic-calming structures influence a driver’s perception of safety. For example, a

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curb or sidewalk that juts out into the road leads most drivers to slow down because high speed on a narrow roadway feels uncomfortable. But again, it is a choice left to the driver. Given that preference, along with readiness and autonomy, is paramount in recovery models, could our mental health guidance tools somehow mirror these roadway features? But first, let us consider more precisely what we need to measure in order to guide treatment choices. Decades of research should point us in the right direction, but as is often the case with research data, interpretations vary. Over the past 30  years, much discourse has contributed to “the great psychotherapy debate,” a term coined by psychologist Bruce Wampold (Wampold & Imel, 2015). The debate involves two camps of researchers and clinicians: (1) those who believe diagnoses and specific techniques tied to these classifications are a key to good outcomes and (2) those who believe that common (or nonspecific) factors, such as therapeutic alignment, context, modality, and uncontrollable situational variables determine outcomes. While these positions are not mutually exclusive, there remains a deep divide, particularly among researchers who influence policy and ultimately programming decisions. According to Bruce Wampold, the debate has been won. The common factors are more important (see Table 5.1). Meta-analyses and studies applying multiple regression have consistently found that techniques and diagnoses account for less than 15% of outcome variability. Approximately 45% of the variance is due to unpredictable life circumstances like car accidents, an economic recession, or natural disasters (Hubble et al., 1997). The good news is that SC2.0 is well positioned to respond even to the unpredictable extra-therapeutic events. But SC2.0 is especially attentive to the 40% of outcome variance attributable to the therapeutic context variables. The debate raises questions about the nature of evidence. If diagnoses and techniques are not predictive of outcome, then how can we ensure treatments are informed by evidence? Some of the most vocal proponents of “evidence-based psychotherapies” insist that a very specific set of techniques such as cognitive behavioral therapy (CBT) merit gold-standard approval. This in itself is misleading, given that technique only accounts for 15% of outcome variance at best. Furthermore, effect sizes in clinical trials of most types of psychotherapy are moderate or high with little variation. The gold-standard stamp of approval for CBT simply cannot be Table 5.1  Estimated variance accounted for by therapeutic factors Source of therapeutic outcome Techniques and assessment Extra-therapeutic factors  Patient circumstances  Unpredictable events  Patient motivation Therapeutic context  Therapeutic alignment or engagement  Accessibility of care (e.g., immediate or wait time)  Modality of care (in person, web, text)  Expectations

Portion of variance accounted for Less than 15% Approximately 40%

Approximately 45%

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5  Navigating the System Table 5.2  Evidence-based treatments versus practice-based evidence Evidence-based treatments Evidence is derived from controlled randomized clinical trials Specific factors/techniques are manualized Fidelity to the manual is priority Contextual factors may be considered a confound Outcomes tend to focus on symptom reduction Favors techniques that can be clearly isolated and logically operationalized

Practice-based evidence Evidence is derived from continuous therapeutic progress measurement Treatment may be based more on common factors and/or may not be manualized Fidelity to the relationship is a priority; fail forward by adjusting techniques Contextual factors are key therapeutic ingredients Outcomes are more broadly defined Supports flexibility, wide range of techniques, and integration

justified. However, and it warrants repetition, specific factors, such as techniques, are not independent of the much more impactful nonspecific factors. It would be hard to develop a solid therapeutic alignment or generate hope (positive expectations) without offering a method of care. The point is that misleading claims of evidence should not dictate choice of treatment. What matters more is the fit for both therapist and client, along with tenacity to champion the choice itself with compassion, openness, and flexibility. SC2.0 endorses practice-based evidence over evidence-based treatments (see Table 5.2). Evidence-based treatments typically emphasize the importance of fidelity to a manualized protocol. Historically these were different for every diagnosis. The importance of diagnosis has decreased over the past decade. Psychologist David Barlow, who published several influential texts in the “Treatments That Work” series, each corresponding to a specific diagnosis, has since recanted. He now promotes the “transdiagnostic unified protocol” in recognition that patient distress regardless of diagnosis is all that matters in treatment planning. But SC2.0 moves even further from protocols. Instead of relying on clinical trial evidence for a specific treatment method, we simply monitor how a person’s unique chosen pathway affects their recovery and, when recovery is stalled or deteriorates, guidance is offered to carve a new path.

5.4 Therapeutic Measurement Systems designed for therapeutic measurement, also known as feedback-informed treatment (FIT), have been around for more than 20 years, but these systems are still not part of routine practice. On the one hand, this is surprising given solid research indicating that outcomes improve by up to 50% when used at every point of contact (Miller et al., 2015). For those committed to FIT, most use one of two systems: the OQ-45 or the ORS/SRS.  Both have good psychometric properties and have the

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capacity to alert clinicians when treatment is not progressing as expected. As the name implies, the OQ-45 contains 45 items, most of which target a broad range of mental health symptoms or deficits. The ORS/SRS, in contrast, is much shorter and not symptom-based. The ORS contains four broad recovery-oriented items each using a continuous scale. For example, with the first item, clients are asked to rate how they are doing “individually” by sliding a dot to the left (not doing well) or to the right (doing well). The other items capture interpersonal, social, and overall functioning. It is a simple tool to administer and has nonverbal as well as telephone versions. The SRS is a complementary four-item scale that targets alignment with the therapist. For example, the first item invites clients to rate the therapeutic “relationship” by moving the dot to the left toward “I did not feel heard, understood, and respected” or to the right toward “I felt heard, understood, and respected.” The three remaining SRS items track clients’ perception of alignment on “goals and topics,” “approach or method,” and “overall” satisfaction of the session. Although there are no symptom items, the ORS has been well validated against some of the best symptom rating scales. A popular tool for post-secondary settings is the CCAPS (Counselling Center Assessment of Psychological Symptoms). It is quite like the OQ45 in length and its focus on symptoms. Given its wide use in college and university counseling centers, it is often used for benchmarking a center’s performance. We used all three tools at Memorial University. The OQ45 and the CCAPS are longer instruments that take more time to administer. We also found them less conducive to collaborative step decision-making. Clients reported survey fatigue and counselors did not find them helpful for giving continuous feedback or initiating conversations on treatment decisions. At a conference for counseling center directors, I facilitated the Stepped Care Affinity Group meeting. There were about 100 directors in the room. When I polled the group to identify those using the CCAPS, the majority raised their hands. When I asked if anyone used it for every session (for which it was designed), no hands went up. The most common response was using it only at intake, followed by once every four sessions. This is not feedback-informed treatment. It is a periodic outcome assessment, conducted too infrequently to inform nimble stepping decisions. When we tried to use the ORS/SRS at our counseling center, clinicians felt something was missing. Specifically, while they wished to move away from simply tracking deficits, they did not appear ready to let go of some monitoring in this area. Especially for an initial encounter, counselors liked having some information on symptom patterns available on their desktops especially before greeting clients in the waiting area. We eventually landed on the BHM-20. While less well known, it does have reasonable psychometric properties and captures much of what is relevant to SC2.0 (Bryan et al., 2014). Specifically, it is brief—only 20 items and takes at most 90 seconds to complete. It includes separate symptom, wellness, functioning, readiness, and therapeutic alignment scales. In contrast to most other outcome tools but in line with recovery principles, a high score on any BHM scale implies good health. Finally, the reporting functions are user-friendly, especially for the purposes of reviewing alongside clients.

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5.5 The Case of CK A common myth associated with SC2.0 is that it oversimplifies therapy and as a result has little value for complex cases or severe and persistent mental illness. Nothing could be further from the truth. CK is a fictional client based on an amalgamation of case material from four clients with complex and severe illnesses (see Table 5.3). They all encountered SC2.0, and in one case, experienced care both prior to and following implementation. Identifying information has been disguised. The flexible nature of SC2.0 is revealed in the stops and starts and back and forth of CK’s journey. The first section is a summary of case notes on file prior to the implementation of SC2.0. Her open-access walk-in presentation is denoted as a “Step 0” intervention. This entry point is marked with the open-access box in Fig. 1.2 in Chap. 1.

5.6 The Case of TD Stepped care is also being implemented in community settings focused on treating operational stress injury. As with CK, the case of TD is based on an amalgamation of case material from several real clients at the clinic. This case was prepared by my colleague, Dr. Kyle Handley, who at the time of writing was lead psychologist at a large city police department in Canada. SC2.0 was adapted for use in the stress injury clinic. As indicated in Fig.  5.1, steps are based on the Road to Mental Readiness (R2MR) mental health continuum model developed by the Department of National Defense (Government of Canada, 2020). The journey is different for TD.  Like many first responders, TD was concerned that formal treatment might require disclosure that could compromise his employment status. These are legitimate concerns. There are indeed policies requiring disclosure of diagnoses and treatment that could affect an officer’s right to carry a badge or a firearm. Not surprisingly, TD preferred peer support and self-help options (see Table 5.4).

5.7 FIT for the Future: A Prototype Currently, on the east coast of Canada, we are working on a research project funded by the Canadian Institutes of Health Research (CIHR) to fully digitize SC2.0. One of the aims of the project is to develop a platform and portal to automate therapeutic measurement and ensure better access to these data for both help-seeker and provider. At this point, we have created a storyboard that maps the journey we envision on the Newfoundland-based platform called Bridge the gApp. A client may decide to access tools online without being connected to a provider. The portal, of course, was not available when Amber (see Chap. 4) was looking for support, but if it had been, she may have taken a path like that of Jane Doe, illustrated below in Fig. 5.2.

The case of CK—a CK is a 24-year-old female graduate student seeking a master’s of Health and Humanities degree. She first came to the Student student with complex Wellness and Counselling Centre in her third year of her undergraduate studies for treatment of symptoms of anxiety and PTSD depression. The case notes for this previous therapy indicated that initially the focus was on symptom reduction and family of origin dynamics related to the breakup of her parents’ marriage (when she was 7 years old) as well as long-standing conflict with her mother. After some initial symptom management and interpersonal focus on family dynamics, CK disclosed that she had been sexually assaulted over a period of 4 months when she was 9 years old by the son of a visiting pastor in her small community where she was living at the time with her mother. CK eventually disclosed the abuse to her mother who responded, “That’s just what boys and men are like.” The case notes revealed that CK had not disclosed the assault to her father who she said still thought of her as his “little princess” who could do no wrong. CK was estranged from her father, who had remarried shortly after the divorce. CK said that her mother had actively discouraged her from making contact with her father who she argued was a “sexist and selfish man.” CK described her mother as emotionally unstable and frequently angry. She admitted that she had a somewhat romanticized view of her father based on early childhood impressions. The previous therapist noted that although CK was quite forthcoming about “the bare facts of her life,” she seemed distant and emotionally restricted during the sessions. CK admitted that she was unsure about the potential for therapy and that she struggled to let anyone help or get close to her. She indicated that she was not comfortable talking about the childhood abuse. She stopped therapy abruptly. STEP 0—Walk-in When CK returned 5 years later, the stepped care model had been implemented. CK completed the BHM-20 in the waiting room. Consult At the walk-in visit with me, CK said that she wanted to resume therapy because her father had been diagnosed with terminal cancer. Although she appeared calm in the session, her posture was stiff, and she reported having severe anxiety and panic attacks weekly. When I queried her about a preference for a male or female therapist, CK said that she finds it extremely difficult to open-up to new people but generally felt less anxious talking to males because they are more direct and trustworthy. CK’s readiness for psychotherapy score was low. Although her suicide index scale score was in the severe range, CK said that she did not intend to kill herself, had never attempted, or developed a plan. She reported having numerous protective factors which included her husband of 3 years, two very close friends, and a passion for her studies. The new treatment model was explained and after a brief interview we developed a preliminary treatment plan to address her top priority—anxiety reduction. I demonstrated a simple technique for mindfully welcoming and “weathering” panic attacks and summarized the treatment plan on our behavioral prescription form. Included on the form was an invitation to contact me over the next few days via email should she wish to return or alter the plan. STEP 5—Therapist Three weeks later, CK attended my walk-in again. She shared her decision to engage in some ongoing work. Given CK’s low Assisted Online readiness and discomfort with face-to-face interaction, a low-intensity program plan was developed collaboratively. The program focused on developing anxiety coping skill sessions using online treatment modules and weekly 15-min face-to-face therapeutic coaching sessions. CK said that the shorter face-to-face sessions would feel less overwhelming. Session-by-­session progress monitoring revealed increasing symptoms but a strengthening therapeutic alignment.

Table 5.3  CK’s Stepped Care 2.0 journey

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STEP 9—Acute Care, System Navigation & Advocacy (includes “Creative” Case Management—e.g., Peer-led “Client Design Team”)

STEP 8—Specialist Consult STEP 7—Flexible Intensive Individual Therapy

STEP 7—Flexible Intensive Individual Therapy

As a result of the deteriorating symptoms, and in light of the strengthening alignment and readiness, care was stepped up to weekly face-to-face 50-min sessions. As the therapeutic alignment ratings gradually climbed, CK began revealing details of her troubled childhood, including the sexual abuse. We explored the impact that both the abuse and her mother’s dismissive response had on her development. CK admitted that on the one hand, she learned to be tough and independent “on the outside,” while inside she felt numb and, at times, like a “scared little girl.” Despite the growing therapeutic bond, CK’s symptoms continued to worsen as her father’s health deteriorated. In consultation with her family physician, CK was referred for a one-time consult to our psychiatrist who diagnosed her with complex PTSD and recommended antidepressant treatment. After 6 weeks, symptoms stabilized but did not improve. With the stabilization of CK’s symptoms, we began a course of prolonged exposure therapy which allowed some creative processing of the abuse experience and aftermath; however, she reported continued dissociative experiences that were easily triggered by news events or interpersonal conflict. Weekly monitoring using the BHM-20 indicated to both of us that therapy was not progressing. Furthermore, CK admitted that her interest and attention to her graduate studies were waning and that she was becoming emotionally dependent on the weekly therapy hour. We agreed that a shift in the treatment plan was needed. With CK’s interest in psychology and health, we decided that assigning her to our new “client design team” would allow her to connect with peers to research, consult on, and adjust our stepped care service model to better meet the needs of students, including herself. Given her high depression scores, low energy, and the emergence of some anhedonia, we recognized that the project would be challenging, requiring additional support. As such, while this referral involved stepping up to Step 9, weekly therapy at Step 7 continued. The work on the client design team provided her with opportunities to discover and apply strengths and capacities in a group setting by drawing on her lived experience. The occupational therapy type of support on the design team was high intensity. CK’s contributions to the design team were well received and led to the development of a new second stage “living-room like” waiting area for anxious patients. On her own initiative, CK reduced therapy session frequency. Over time, she reported increased interest in her studies, including selection of a research topic related to mental health. Although her anxiety symptoms as measured by the BHM-20 remained high, her life functioning and well-being scale scores improved to a healthy range. CK said that her dissociative episodes and panic attacks were becoming rare and attributed to healthier distractions. She explained that she was now busier with activities she finds rewarding and meaningful. She said there is “less room for those old feelings now.” CK continued with half hour, biweekly sessions which have focused increasingly on her graduate study and career interests. CK decided to end therapy and follow-up only as required.

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Fig. 5.1  Operational stress injury clinic version of Stepped Care 2.0

The use of data should remain firmly in the control of the help-seeker. In the not-­ too-­distant future, I envision a client-centric health system whereby the help-seeker is the only one with unfettered access to their own record. A provider might begin the session with, “Would you mind if I had a look at your health record?” The help-­ seeker would decide yes or no. If yes, with a few keystrokes on their phone, they could unlock the record, enabling the provider to review. If no, the encounter would be treated as a one-at-a-time single session with no need to access the full record. The same principle would apply to the use of data collected through online care. The data belong to help-seekers. This is the default and applies until help-seekers consent to release. The release would require informed consent and specify the exact purpose for the release. In the case of online program use without provider involvement, a pop-up greets Jane on her first web portal visit. The pop-up indicates that de-identified data will be collected and aggregated from Jane’s interactions with the program. It would not be tied to her personal identity or shared with anyone unless she specifically requested this. It would not even be available for her to view unless she wanted to receive the feedback to guide her choices of programming within the portal. Finally, should Jane decide to work with a clinician, she would not need to release her data pertaining to the portal use, but could do so if she wished. The provider would indicate value in collecting data on their work together moving forward, but again this would be up to Jane.

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Table 5.4  TD’s Stepped Care 2.0 journey The case of TD—a first TD is a police constable with 16 years on duty as a patrol officer. In responder with PTSD the past 8 months, his supervisors have noticed a change in his behavior while on duty, with several instances of being caught speeding in his cruiser, a sharp increase in his pay duty hours, and two public complaints regarding his abrasive interactions with the community. Recently, TD was sent home after his supervisor smelled alcohol on his breath when he arrived for his night shift. TD was referred to his service’s staff psychologist and, though he was initially reluctant, he agreed to attend voluntarily. STEP 1—The Initial TD presented as highly guarded and defensive during the intake Consult session, resisting efforts to explore his history aside from the documented behavioral concerns on the job and demonstrating a discomfort with questioning related to the emotional impact of these situations. Though he explicitly denied experiencing any suicidal ideation, he was evasive when his alcohol use was probed, insisting that his dismissal from his night shift was an overreaction and that it was only because he had a beer with dinner shortly before leaving for work. Noting his resistance, the staff psychologist explored TD’s reaction to being referred for counseling. TD was adamant that he is “not crazy” and expressed his concern that both his recent behavior on duty and his referral to counseling will erode the trust he has built with the fellow officers on his platoon and make him look “weak.” Referencing the Mental Health Continuum, the staff psychologist suspected that TD was in the orange or “injured” category and offered an intervention appropriate to his level of need. Acknowledging TD’s concerns, the staff psychologist recommended follow-up with a designated peer supporter on a separate platoon as a means of expanding his available coping resources and offering a perspective from a fellow officer with lived experience of work-related mental health concerns. TD agreed that he would be more comfortable speaking with a fellow officer at this stage and booked a follow-up with the staff psychologist to report back on his experience. STEP 4—Drop-In Peer In his second session, TD reported that he had a positive meeting with Support/Chaplaincy his peer supporter, who shared his own history with PTSD and the warning signs he missed as his symptoms escalated. TD explained that he found the peer supporter’s story mirrored his own in many ways, making note of how a slowly encroaching emotional numbness impacted his relationships at home and at work. He went on to reflect on several calls he has attended in his career that he now acknowledged contributed to the decline in his mental health, including one in which he was unable to resuscitate a 16-month-old who had fallen into a pool and drowned. Speaking with the peer supporter helped him understand why he would experience intense physical reactions when receiving calls for service related to children in danger, as well as the ways he attempted to dull his emotions by becoming withdrawn and increasing his alcohol use. After consulting the Mental Health Continuum, TD stated that he still feels as though he is in the orange category and recognized that he has more work to do to improve his psychological health. (continued)

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Table 5.4 (continued) TD agreed to participate in a course of one-to-one individual therapy STEP 7—Intensive Individual Therapy with to help him “get back to the green.” At the conclusion of TD’s course of individual psychotherapy, another Psychologist consultation session with the staff psychologist was set up to discuss his progress. TD was noticeably brighter and more engaged during the session, demonstrating greater insight into his stressors and available coping resources than seen in previous meetings. He reported significant reduction in his symptoms as a consequence of diligent work with his therapist on his cognitive processing treatment but endorsed ongoing issues with sleep that he attributed to both physical tension in his body and difficulty adjusting to the changing hours of his shifts. TD reviewed the Mental Health Continuum with the staff psychologist, and they agreed that he is likely in the yellow or “reacting” category at this time. STEP 3—Interactive With this in mind, the staff psychologist provided TD with online Online Self-Help self-directed psychoeducational materials on sleep hygiene and progressive muscle relaxation to help improve his sleep quality. TD thanked the staff psychologist for the resources and stated at the conclusion of the session that his engagement with these mental health services has helped him to become more self-aware and capable of recognizing the connection between his experiences on patrol and his psychological health.

Fig. 5.2  Jane Doe’s experience of proposed SC2.0 mental health platform

Getting It Wrong To Get It Right About 8 years ago, when stepped care was but a whisper in the back of my mind, I got a call from a woman named Susanne. She wanted care for her adult son who had been diagnosed with schizophrenia, but was receiving only pharmacological treatment. I asked her how she thought I could help. She said she was told I operated a small private practice and that I had a reputation for working well with challenging cases. I said I wasn’t confident that my type of therapy would help someone suffering from schizophrenia. She persisted, “There’s lots of research now indicating that

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CBT and other therapies can help.” I thought for a moment and said, tentatively, “Ok, go on.” She continued, “Well the thing is, we’ve tried everything in the city. You are our last resort.” My heart sank. Oh boy, I’ve heard this before, I thought to myself. “The other thing is,” Susanne continued, “He doesn’t want to see you.” Puzzled, almost hooked, I asked, “So what can be done?” She replied, “I will have to come in too.” It was becoming slightly clearer. “Okay, so maybe a family therapy consult?” “No,” she replied, not missing a beat. “Just me and him.” Reluctant but curious, I scheduled an appointment. Susanne and James arrived on time. After introductions, I asked James what he thought would be helpful. He replied, “I don’t think anything can help.” Susanne interjected, “I think James needs some support. He has no one that he can talk to. Nobody wants to listen to him or his voices. Most professionals don’t pay attention to the voices he hears. They just want to snuff them out with toxic drugs.” I started to get nervous. I think Susanne noticed me stiffening. I was feeling out of my league. What do I do with this? Does she want me to suggest he stop taking meds? And what exactly does she want me to do with his voices? Meanwhile, James was quiet but looked increasingly bored: “I don’t think this is going to help Mom. Can we leave now?” Susanne looked at me pleading. Her eyes said, “Do something Peter!” So, I pulled out the old standard and asked her what I should do. Susanne replied, “Do you know about the ‘Hearing Voices Movement’?” I said no. “It is a real thing,” she continued. “There are people and families with lived experience and a growing number of professionals organizing in Europe and the United States to work more directly with the voices, the ‘hallucinations’ (with air quotes), to support them at times, to disagree with them at times, maybe by using CBT.” James was getting more restless. “Let’s go,” he groaned. “I will email you some information on Hearing Voices,” Susanne said hopefully, packing up her things. Reluctantly, I agreed to a follow-up. But the follow-up meeting did not go well. I was unconvinced. I tried half-heartedly to engage with some CBT exercises. Not surprisingly—he was no dummy—James could see me for what I was: unconvinced and uninvested. They left the second meeting disappointed and angry. Fast forward 6  years. I am attending a regional stepped care implementation working group meeting by teleconference. There is a person with lived experience on the call. Her name is Susanne. I feel a vague yet uncomfortable sense that we may have crossed paths. But I don’t make the connection. A few months later, she says something at another meeting that piques my interest. Under the province’s Towards Recovery strategy, specialists are not adapting their practices at all “in support of people with severe and persistent mental illness.” Just before the meeting ended, I said I would like to learn more from her on this, perhaps we could have a separate call. Two months later, I receive a text from her. The text was sparse but blunt: “You wanted to talk.” It was then that it dawned on me. Was this that Susanne? We soon connected by phone. She had some suggestions about attending to the strengths of those with more serious conditions. Then there was a long pause. “We’ve met before, you know,” she said. “I know,” I replied, now with full realization. “It didn’t go well last time, did it?” I added. “No, it didn’t.” I thought for several seconds, then said, “I’m sorry. I didn’t know back then. I didn’t know anything about recovery.”

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And then several months later, I am at a recovery conference in Montreal. It is a joint conference of the “Association québécoise pour la réadaptation psychosociale” along with the “Hearing Voices Alliance.” Who should I meet in the hall? Susanne! This time she gives me a big smile and says excitedly, “I have been talking about you. I didn’t mention your name, but I have been telling everyone what you said.” Smiling too, but with a puzzled frown, I asked, “Telling them what?” “I told them how important it was that you said, ‘sorry and that you just didn’t know’.” My smile, a little bit shy now, widened: “I’m failing forward now.” She leaned forward and gave me a heartfelt hug. “Too bad it took more than six years,” I said sheepishly. After, I wondered what might have been different if SC2.0 had been in place earlier. And would therapeutic measurement have helped me to pivot quicker? Never mind, this is true co-design.

References Bryan, C. J., Blount, T., Kanzler, K. A., Morrow, C. E., Corso, M. A., & Ray-Sannerud, B. (2014). Reliability and normative data for the Behavioral Health Measure (BHM) in primary care behavioral health settings. Family, Systems, and Health, 32(1), 89–100. Government of Canada. (2020, January 12). Road to mental readiness. Retrieved from National Defence: https://strongproudready.ca/missionready/en/road-to-mental-readiness/ Harrod, C. S., Goss, C. W., & DiGuiseppi, C. (2014). Interventions for primary prevention of suicide in university and other post-secondary educational settings (review). Cochrane Database of Systematic Reviews, 10, 1–88. Hoyt, M. F., & Talmon, M. (2014). Capturing the moment: Single session therapy and walk-in services. Crown House. Hubble, M. A., Duncan, B. L., & Hubble, M. A. (1997). Escape from babel: Toward a unifying language for psychotherapy practice. Norton. Klimes-Dougan, B., Klingbell, D.  A., & Meller, S.  J. (2013). The impact of universal suicide-­ prevention programs on the help-seeking attitudes and behaviors of youths. Crisis, 34(2), 82–97. Miller, S. D., Hubble, M. A., Chow, D., & Seidel, J. (2015). Beyond measures and monitoring: Realizing the potential of feedback-informed treatment. Psychotherapy, 52(4), 449–457. Wampold, B. E., & Imel, Z. E. (2015). The great psychotherapy debate: The evidence for what makes psychotherapy work. Routledge. Zalsman, G., Hawton, K., Wasserman, D., van Heeringen, K., Arensman, E., Sarchiapone, M., et  al. (2016). Suicide prevention strategies revisited: 10-year systematic review. The Lancet Psychiatry, 3(7), 646–659.

Chapter 6

Collaboration and Co-design Peter Cornish

Client Design Team “I just wanted somebody to talk to!” I could hear the exasperation in Melanie’s voice even though it was an email she had sent to me over the weekend. Melanie was well known to our clinic. She had been given multiple diagnoses and was a frequent user of medical and mental health programming. She had a history of childhood trauma and strained relationships with her parents. She met the criteria for major depression and borderline personality disorder. Post-traumatic stress disorder was queried. She told us that she came to our university, in part, because it was 3000 kilometers away from home. Her first contact with us was a “strong referral” from residence. She could come for counselling or be kicked out of residence for failing to follow the rules. Melanie used email frequently to connect with a variety of staff she had tried working with at our center. Boundary crossings were the norm for her. We set limits, and one was that although she was free to send us messages, we would not reply to them except during office hours and only to suggest she make contact by phone or in-person when staff were available. She had signed a note promising not to send emails when in crisis and indicating her acceptance of the aforementioned conditions. On Monday morning, I replied to Melanie’s weekend message. I said, “Come on in to see me, I am free for 20 minutes this afternoon.” Melanie came in as requested and was angry from the outset, asking, “Why wouldn’t anyone see me? I came at 3 p.m. and was told the walk-in was full and no one was available to talk to me.” I said, “Melanie, you know our system. There is no guarantee that a counsellor will be available later in the day. It is best to come early. If it is urgent, you know the crisis numbers in the community.” “No, you aren’t listening to me. I just needed someone, anyone to talk to. It didn’t have to be a counsellor.” I was intrigued. “Who were you hoping to talk to?” “Anyone,” she said. “Patty or Jen on the front desk, I don’t know.” I thought for a moment. Or maybe a peer helper? P. Cornish (*) Counseling and Psychological Services, University of California, Berkeley, CA, USA e-mail: [email protected] © Springer Nature Switzerland AG 2023 P. Cornish, G. Berry (eds.), Stepped Care 2.0: The Power of Conundrums, https://doi.org/10.1007/978-3-031-45206-2_6

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6.1 What About Boundaries? Despite considerable distress, difficulty maintaining social relationships, and chronic suicidal thinking, Melanie was actually very high functioning. It puzzled me at times. How could she be getting through her pharmacy degree when her mood was chaotic and her relationships with staff in residence and our clinic were so volatile? Melanie had strengths. She had competencies. In addition to academic success, she had led in the development of a mental health advocacy alliance on campus. The group lobbied for improved mental health programming and later committed to the development of a peer support program. It was ironic that Melanie was asking for this kind of support. During our conversation, we agreed to two things: she would reach out to her peer advocacy group, and I would investigate the possibility that our administrative staff be trained to provide support (a listening ear, perhaps in the quiet room). It turns out that two of our front desk staff, Patty and Jen, had the right skillset and temperament for this. In fact, both Patty and Jen were delighted with the opportunity to provide support to students in crisis. They had already had mental health first aid training and had naturally sound listening skills. Jen said to me in passing a few months later that the invitation to provide such support in the quiet room was a turning point for her. She explained that the feelings of stress and lack of recognition she had been discussing with me for years had dissipated since she was offered this role. It was a meaningful role that complemented her clerical duties. When I shared Melanie’s story with colleagues eager to learn about our SC2.0 model, some asked about boundary crossings. “How do you handle ethical concerns associated with dual relationships with clients like Melanie who are known for their poor boundaries?” I typically give a two-part response: (1) ethical care does not prohibit boundary crossing—after all, boundary crossings are inevitable—but what is required is good boundary management, and (2) I let go of the risk paradigm and believe in my clients’ capacities despite their deficits.

6.2 Who Comes to the Table and When? Post-colonial theory reminds us of the lasting impact of oppression. People with mental illnesses have suffered oppression perhaps more than any other group. They have long held the top spot of most marginalized and disenfranchised. The “cures” at times are the epitome of barbarism. The mental health recovery movement aims to redress this. But our steps in this direction are tentative. We are still walking on eggshells. I don’t think any of us are ready for full reconciliation. We are not sure what this could look like or how to go about it. But we are making some strides. This ambivalence is evident in my own approach to co-design. We hear from those with lived experience that they must be at the table at the very beginnings of any mental health reform efforts. But I am too impatient. I envision, with some dread, the long circular conversations, a chaotic bubbling up of disparate ideas,

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grievances, and no semblance of a cohesive plan. How can we bring bold transformation in the context of anarchy? With some guilt and worry that my need for control represents a form of neo-colonialism, I propose that we must create something before we take it to the masses for input. I convince myself that the consultations will be genuine and that co-design will happen soon. But first, let me propose the idea. Let’s start with something concrete and systematic. Let me show you the forest and the trees. If you wish, you could tear it down. But I am hoping it will inspire us all to work together to cultivate the new landscape. We were thinking of this dialectic when planning our focus groups near the end of our first SC2.0 demonstration project in Newfoundland and Labrador. While piloting the questions among a few people with lived experience of mental illness, we discovered participants knew little about our project, stepped care, or e-mental health. They could tell us about their experiences with the mental health system in general, but would they know, or would we know, if this feedback pertained to our work? Surely, this is not a unique conundrum. We thought about how advertising campaigns are tested and refined before launch. Fly a trial balloon in front of a carefully selected, captive audience. We needed to fly a balloon, but we did not have one. What could it look like for SC2.0? Maybe we could draft up the elevator speech. But could we capture the complexity and the power we see in the model in a short speech? We needed a killer explainer video. So that’s what we did. Now when we visit communities and invite stakeholders to help us build a model to fit their unique culture and circumstances, we start with the video. The idea is to inspire and then let the ideas stretch out while retaining connection to the core principles.

6.3 SC2.0 Distributive Design Cycle Our design process starts from the center and works outward. It is based on a principle we call distributed co-design (see Fig. 6.1). This means that co-design is distributed progressively outward starting with thought leaders and then incrementally incorporating broader input from experts and non-experts. The first step (at the center in Fig. 6.1) is to assemble a small design leadership team comprised of clinicians and scientists who are grounded in recovery principles and theory as well as open and passionate about system transformation. This group is like a team of architects tasked with rethinking a build from the bottom-up. Like many architects, the initial designs may be somewhat fantastical with some inspiring yet ultimately unrealistic features. This becomes the ideal template for consideration at subsequent layers of the circle. We consult next at the inner circle with mental health clinicians and managers. We go here first because it is crucial to get manager and clinician buy-in and a sense of ownership of the system change process. Without some early feelings of ownership, clinicians might feel threatened especially if they think their roles and positions could be at risk through restructuring. With clinician and manager buy-in and input, we take the modified template and move mid-circle, consulting with a broad representation of people with lived experience. At both the clinician and lived

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Fig. 6.1  SC2.0 Distributive Design Cycle (two-dimensional version)

experience levels, we seek reactions to the model. What are the parts that inspire? What detracts from participants’ own visions of mental health system reform? Can the proposed model be adapted, or does it need to be torn down completely and rebuilt? Only after we have core stakeholder consensus (i.e., the first three circles) is it appropriate to expand consultation further through the larger community. These outer-level consultations include stakeholders in the broader wellness ecosystem. Formal stakeholders at this level include thought leaders and decision-makers in primary, chronic, tertiary, and acute care settings, as well as representatives of public health, education, justice, and social welfare agencies. Informal stakeholders include members of NGOs and support groups like AA. While the initial concept prepared by the SC2.0 leads is considered first by clinicians and managers, then by people with lived experience, and last by external stakeholders, the development process then reverses so that the refined model can be operationalized moving in the opposite direction. We refer to this bi-directional process more formally as the “Distributive Design Cycle.” It starts with initial ideas on why change and what might inspire (wow) us from the center. These ideas are floated through internal, and then external, consultations. Then, in reverse, we can consider how and what is needed through a narrowing needs assessment and environmental scan process. This reverse process gathers information from external stakeholders, which is then processed and refined by persons with lived experience. Then clinicians take this refined data and together with managers create feasible, adaptive programming that is well informed by all stakeholders. Further details on the Distributive Design Cycle (including the why-wow-how-what process noted in Fig. 6.1) are presented later in this chapter as well as in Chap. 7.

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6.4 Interprofessional Collaboration Client-centered and client-centric care cannot be achieved without breaking down silos. Without a formal process of interprofessional collaboration, care is fragmented. One professional ponders neurological chemistry; another contemplates social determinants of wellness; and a third might consider lifestyle or cognitive processing. In a fragmented system, help-seekers are likely to be short-changed on several levels. They may get only  a neurological perspective or maybe just some wellness prescriptions. They might leave assuming it’s just my faulty thinking. Even if the help-seeker shops around and gets other perspectives, they miss out on the whole picture. With all wearing blindfolds, no one sees the elephant. According to the ancient parable, they each “see” something through the sense of touch. They disagree on what is there and soon come to blows. Perhaps not unlike some interdisciplinary squabbles or turf wars. Pharmacists and pharmaceutical companies insist depression is a biochemical disease. No, say humanistic counsellors. It is a learned condition best resolved through discourse. You are both wrong, says the sociologist. We need to adjust housing policies, redistribute wealth better, and reform the justice system. But I wonder what the elephant experiences. Reputed to be quite intelligent, the elephant is perhaps insulted. “It’s my leg, not a tree trunk. No, it’s not a rope, it’s my tail. Although I am big and strong, that’s my stomach not a great wall!” The blindfolds come off with interprofessional care. Instead of squabbling over turf, the group of observers communicates with each other to develop a holistic assessment. Perhaps most importantly, they invite the one being observed to weigh in, to express their preferred view or focus for attention. Without blindfolds, there still might be disagreement among observers. Why not let the elephant in the room decide. And why do professionals sometimes treat humans like they can’t talk or that their preferences are not to be trusted? Interprofessional collaboration is difficult to achieve. There are many barriers. First and foremost are the structural barriers. A licensed professional is by definition a protected guild defined in part by a defined scope of practice based on unique values, assumptions, and perspectives. The various disciplines are stratified by power and authority, without much thought to rationale. Conflict and resentment are inevitable. Collaboration in this context is not very appealing. What are the incentives for collaboration? Health-care funders point to research suggesting outcomes are better and programming is more efficient (Gilbody et al., 2006; Woltmann et al., 2012). But in order to shift practice, there need to be incentive and structures for professionals to stretch beyond their siloed practices. What’s in it for professionals beyond a fear that others might encroach on their livelihood? How might collaboration enhance practice experiences of professionals? How can it allow them to improve their outcomes or to decrease workload pressure, frustration, and burnout? One place to start is with identifying and exploring the scope of practice. But without some sort of organizational structure, this process might unravel. Before

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developing our SC2.0 model, I recall attempting interprofessional team building consultations that left participants more confused at the end. One of the topics that derailed the process centered on the question of who does counselling. The answer, of course, was that everyone did counselling—physicians, psychiatrists, psychologists, counsellors, nurses, and social workers. Okay, so who does psychotherapy? “We all do.” But what kind of psychotherapy do you do? “Mine is better than yours.” “Are you saying what I do is not helpful?” And so on. Now when we consult on the topic of collaboration, we take a very different approach. Instead of beginning with who does what best, we take a similar approach to that of SC2.0 client care. We put aside our assumptions and preconceptions of who should do what, and we simply ask about interests and preferences. But as with clients, we do not begin with a blank slate. Instead, we begin with the SC2.0 graphic. More specifically, we present it as a tool for scaffolding. Interventions, roles, or competencies can be hung upon the various steps. Care providers can decide where to climb on and whether they’ll move up or down and experiment with applying their tools and skills at any level. Where do they do their best work? Which work do they prefer? It is important that this kind of exploration be conducted as part of an interprofessional group exercise or workshop. The result will look different at every collaborative care site because the interests, motivations, and skillsets will be different. In some of these scope/scaffolding discussions, participants might want a bit more guidance. What sort of role differentiation has been successful? Are roles best distinguished according to professional discipline, or is it better to consider competencies and interests? While not intended to be prescriptive, we have offered suggestions for both approaches as illustrated in Figs. 6.2 and 6.3.

6.5 Intersectoral Collaboration One of the things that differentiates SC2.0 from other stepped care models is the deliberate effort made to expand the system to include and integrate supports from other sectors (beyond physical and mental health). These sectors include educators from kindergarten to post-secondary levels, public health practitioners, child welfare, the justice system, public housing and shelters, the clergy, and Indigenous elders (see Fig. 6.4). Of growing importance are both formal and informal organizations of people with lived experience. Trained peer support is an example of the former. It usually requires training, certification, and remuneration for services provided. Informal supports include naturally occurring support networks, self-help groups, and organizations like AA. In SC2.0, these non-clinic-based programs are considered population health-­ level programs since they are available to anyone whether healthy or ill. Indeed, part of what makes these intersectoral partners so powerful is that the mental health work is mainstreamed. It is of value to everyone. There is no sorting or stigma. A professor or a teacher is empowered to be a kind listener to all students whether ill

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Fig. 6.2  SC2.0 scaffolding for disciplines

Fig. 6.3  SC2.0 scaffolding for competencies

or not. The same with clergy or Indigenous healers. A judge or a lawyer is supported to listen, communicate, and show compassion to clients no matter who they are or what state they are in.

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Fig. 6.4  SC2.0 scaffolding for intersectoral collaboration

Many professionals and non-professionals are interested in learning how to contribute to mental health. Who can help with this? As mental health practitioners develop more flexible and efficient ways of delivering care to their clients, they can pivot to provide consultation to external groups. There is synergy here. As more of this pivoting happens, intersectoral support will increase. As this external support increases, demand for clinical treatment will decrease. As a result, mental health resources expand.

6.6 Facilitating the Collaborative Aspiration Client-centric care is empowering. To be empowered, clients must be able to identify all the resources and the potential care providers available to them. They must know what to expect from the programs and what is expected of them in order to make choices. This information can only be clearly communicated if both programming and the providers involved from varied disciplines and sectors are organized and aligned in some fashion. This is a tall order especially given that not all professionals are fully committed to collaborative care, nor are there many structures in place to facilitate collaboration. SC2.0 provides a template for this structure. One way to operationalize the structure would be through the development of a therapeutic measurement platform. Such a platform, designed for ongoing progress tracking of recovery, could be embedded in electronic health record systems. But there are a lot of “ifs” related to the social and structural challenges. First, this would only work if a common version of stepped care is widely adopted.

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Second, providers and mental health program decision-makers would need to agree upon and implement a common minimal dataset for progress tracking. Third, electronic health records would need to be configured and deployed across multiple disciplines and sectors. Fourth, collaboration is an idealistic concept. It is challenging for many understandable reasons beyond system development. Collaboration involves reaching across class and cultural divides built on inflexible societal power structures. Not only does client-centric care shift the power to individuals seeking care, but it also requires some flattening of the medical hierarchy around which most health care is organized. Finally, conflict is inevitable in teamwork and needs to be attended to with care and flexibility. As such, supportive malleable structures like the SC2.0 model, with its underlying recovery principles, its commitment to co-design, and its fail forward, trial-and-error philosophy, can provide a vehicle for working toward the collaborative ideal.

6.7 The Curse of Knowledge My first attempt at writing Chaps. 6 and 7 fell flat. As I re-read this chapter, at least up to this point, it seems a bit dull. The descriptions on design processes are dry and overly technical. The variations of SC2.0 adapted and implemented by others described in my first draft of Chap. 7 seem dull and uninspiring. I recall feeling deflated and stuck with my writing. When I write, I typically start at the beginning and work my way to the end. These are crucial chapters. They must nail it. Chapter 7 is the last chapter of real substance; then Chap. 8 brings it home and links to the other two books in the planned series. Chapter 7, the penultimate chapter, could not be a sleeper. I suppose I did what anyone would do when blocked—anything except the task in front of me. Like many, I find one of my favorite distractions involves losing myself in social media. As an introvert though, all things social for me must have a purpose. It is perhaps not surprising that my medium of choice is LinkedIn where my connections are social but grounded in professional identity. As my posts on SC2.0 accumulated, my connections to others with a rebellious mindset expanded. I have been inspired by many a LinkedIn post. But with this case of writer’s block, it was a message from Facebook that broke me free. Recall Susanne from the closing in Chap. 6? The Facebook Messenger alert had lingered on my phone for about 4 days. I do not receive many of these and assumed it had something to do with a viral cat or cute toddler video. I didn’t know who it was from. Because I had read all the news, exhausted my LinkedIn feed, was bored with my mystery novel, and tired of the endless mini crosswords on my phone, I ventured to Facebook—always a last resort for me. The message was from Susanne. It read simply, “You may like this.” It included a link to an episode of NPR’s Hidden Brain You 2.0 series. The title of the episode was You 2.0: Rebel with a Cause (Gino, 2018).

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She had me with “You 2.0,” but the rebel idea piqued my curiosity. It turns out, this was just what I needed. The episode spoke directly to me—a rebel in the field of clinical psychology. Host Shankar Vedantam was interviewing Harvard’s Francesca Gino, a professor of business administration, who, among other things, studies non-conformists. The interview focused on “rebel talent,” people who defy the status quo and create breakthroughs. She talked about Captain Sully. Unlike most leaders in emergency situations who typically narrow their focus and default to protocols, Sully decided to land in the Hudson River. He was clearly breaking the rules. What was it about Captain Sully, Gino wondered, that led to success? It wasn’t because he had a lot of experience, which of course he did. Gino suggests that it was because he had overcome “the curse of knowledge.” Often, experts become set in their ways and impervious to new ideas. Sully, she argues, was a constructive rule breaker. He had what she calls “positive deviance.” He had enough good judgement to know which rules must be followed and which could be broken. This requires tremendous risk-taking balanced with good judgement. Sounds like an oxymoron. It is probably quite rare. If risk-taking leaders do not have good judgement, both tact and empathy, or a willingness to express vulnerability, no one will follow them. Without this emotional intelligence and sensitivity, they would probably be considered arrogant and reckless. So why was I stuck writing these two final chapters? The answer, thanks to Susanne, Francesca, and Captain Sully: my writing had slipped into expert mode. The first draft of Chap. 6 was too technical and dry. It described stages, processes, and recited facts. In Chap. 7, through my effort to anonymize the experiences of adaptation at various sites, the stories lost vitality. What was missing was my own vitality. The rebel that I am and my desire to throw myself completely into the tension between expertise and experimentation. I forgot to start with why. I did not ask why I was stuck until something new jolted me out of my expert mode and back into my rebel mode.

6.8 Rushing to Solutions Transforming how we provide mental health services is, of course, difficult. Just as help-seekers are often not ready to make difficult lifestyle changes or fully participate in programs offered to them, care providers, administrators, and decision-­ makers will approach change with caution. As leadership guru Simon Sinek suggests, it is important to begin with the why. Why change? What are the problems or needs that will be resolved with a change (Sinek, 2009)? Many, including me, too often start with the what. I did just that at Memorial University about a decade ago. “I’ve got this great idea—this thing called stepped care. This is what it is,” I began. I described it to my staff, and after quickly answering a few tentative questions, I said, “Let’s do it.” Some staff said, “I’m not sure how to do this,” or asked rhetorically, “Surely stepped care can’t be used to organize everything we do?” I responded, “Oh really? Give me an example of something that

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won’t fit?” Uncomfortable silence followed. I thought the question resolved and moved back to the what. Because the ideas I was talking about (this was the what) had piqued the interest of many colleagues across the country, I was encouraged to stay with the what. I was invited to deliver keynote speeches, to offer training, to consult. I spent a lot of time talking about ever more complex ideas which somehow retained their allure. Outsiders loved this. They loved the what. Organizations applied the ideas with some success, and more interest was garnered. The ideas were connecting with needs of decision-makers and administrators even if they were not spelled out all that clearly. The needs included addressing long wait-lists and finding sustainable ways to manage risk. And the changes were received well by help-seekers, who noticed access to care improving. But the why was not all that apparent to many practitioners. “Why should we change our practices? The training we have had, the research that we have studied, and our professional guidelines all say that what we are doing is appropriate. Why should we try something new that has not stood the test of time? And why should we do less assessment? What if we miss something? And, even worse, why should we shorten sessions? That will result in rushing clients and, ultimately, poorer quality service. What we really need is to hire more staff. We hear all the time that there are shortages of mental health professionals. The real solution is not change but increasing our investment in mental health to a level of parity with physical health. Problem solved.” In our consultations on implementation, we soon learned that some vocal practitioners were not convinced that the model was a step in the right direction. Initially, we simply chalked it up to the idea that “change is hard.” That was what I did. Some of my staff just didn’t have the right stuff, I thought with condescension. Or they weren’t ready yet. They needed more nudging. Or I just needed to be patient. They will eventually see the light. This is like labelling as “resistant” all help-seekers who do not want the treatment you are offering, when it just might not be the right fit or maybe the rationale for the approach had not been explained properly. How can we expect someone to embark on a challenging journey if we have not worked through to why? Like when we try preparing clients for treatment, the why must be relevant to them first and foremost. In the case of SC2.0, the why was reasonably clear and relevant to administrators and to clients, but not to many providers. While SC2.0 was born at Memorial University, and we improved efficiency, capacity, and outcomes, the implementation faltered after about 5 years. My predecessor, a seasoned clinician and former director who was a gifted mentor to trainees and new hires, had just retired. With his existential-humanistic principles and Socratic style, he had been the wise sage. While I had been urging transformation at breakneck speed, he calmed the waters, was the gentle voice of reason, reassuring all that the changes I was introducing were sensible. Several more faculty members retired. These staff were replaced with contractual hires. There was no job security. Either I hadn’t noticed the rising anxiety and the muted signs of reluctance expressed by the new cohort, or I did not want to acknowledge them. I had been buoyed by the enthusiasm my international director colleagues were showering on me at

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conferences for the bold new approach we had taken. But really, it was the new approach I had taken. I recall a conversation I had several years ago with a colleague at the Association of University and College Counselling Centre Directors conference. Over a few gin and tonics, we were musing about leadership styles and asked ourselves what kind of leaders we were. I said that I thought my colleague was an “affiliative” leader because she focused on the emotional needs versus work demands of the staff. She creates harmony and builds emotional bonds. The motto is “people come first.” While this certainly did capture the essence of her personality, she said, “Like you, Peter, I am visionary leader.” Visionary leaders mobilize people toward a vision. The motto is “come with me.” I agreed. That certainly was my style. But I said that I was not convinced this was hers. She replied, “True, I’m not really a ‘come with me’ person—I’m just going. I don’t care if anyone follows!” I laughed. But inwardly, this puzzled me. I wasn’t sure why, but I felt a little uneasy. While she is undoubtedly a bold, independent person who despises authority and even admits to being a conspiracy theorist, she is one of the most nurturing people I know. But the mischaracterization of her, it turns out, was not what troubled me. In hindsight, I learned that my discomfort was really about my own leadership, not hers. I was the real “I’m going” person. I had been the leader who failed to nurture the change in my own department. I went too quickly and expected people to follow blindly. I expected them to be as excited as some of my director colleagues, who, numbering in the hundreds by this time, had been inviting me to visit their campuses and spread the magic of SC2.0. I had left my own staff behind. I realized that I could not reverse course. I was not an affiliative leader. My department is an academic unit, and I had led for three consecutive 5-year terms. Such a long tenure is unusual for academic leadership. A sabbatical was long overdue. Luckily, my successor, serving as interim director, is a nurturer. After a pause and a few steps back to recalibrate, the SC2.0 model is being adapted. I am confident that the model will continue to evolve at Memorial University as SC2.0 should.

6.9 Starting with Why With lessons learned, our not-for-profit consulting group (i.e., SC2.0 Stepped Care Solutions Inc.) is now investing more effort in deliberate change management strategies informed by implementation science. We developed this process to ensure the right balance of leading with and focusing on bold ideas while nurturing collaboration, co-design, and stakeholder buy-in. In order to cultivate interest in transformation, consultation must initially attend closely and persistently to the question “why” change. We have applied Sinek’s “why first” strategy to our Distributive Design Cycle introduced earlier in the chapter. We start our work with institutional clients by helping them form a small SC2.0 leadership design team. This team moves gradually outward, consulting with staff, persons with lived experience, and finally external stakeholders. As we move

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outward, we ask why change might be helpful, and then, with reasons identified, we cultivate inspiring ideas. With real problems identified that are relevant to the audience at each level of consultation, they become primed to be wowed! The process then reverses, gradually returning to the center, bringing ideas of how and what will be implemented, first from external stakeholders, then from people with lived experience, and finally from staff. With the Distributive Design Cycle completed, the leadership team has a solid, well-supported mandate to implement changes. Initially, most interest in SC2.0 came from directors of college and university counselling centers who had seen me talk about it at conferences. I had successfully sold the why at these conferences, and they were wowed. Can you come and do the same with my staff? “Sure,” I said. “I would be delighted.” Over time, as I visited more and more centers, a method for why and wow emerged. It is an adaptation of a standard SWOT analysis, which I call “NOW. WOW! HOW?” (see Fig. 6.5). As a consulting team, we try to leave the what alone. “What” the model will be at the site evolves after we leave. The “why change” question is addressed through the first part of the exercise which I call “NOW.” In this exercise, both clinicians and managers are invited to list first all the things that they are doing well, the things both they and their clients treasure, and the things they are proud of (indicated by NOW(+) in Fig. 6.5). These are programs and practices to be celebrated and preserved. Then they focus on the things that they are currently doing that are not working (indicated as NOW(−) in Fig. 6.5). These are frustrating, ineffective, or both. These are things that they would like to eliminate if possible. Once this is done, participants are encouraged to shift to “blue sky” wow thinking. If you could do more of the things that you value, if you could change anything, imagine what it would look like. How would you feel delivering the adapted or SCALED-UP programs, and what impact would they make? Were there things in my presentation at the beginning of the day on innovations achieved elsewhere that piqued your interest? Finally, the last phase of the exercise shifts to focus on the first steps in their program transformation process—the “how” of design. We only take a few tentative strides with how at this Fig. 6.5  Now, wow, how SWOT exercise

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early stage. We have found that clinicians and managers are hesitant to move far with how without some further reflection and consultation with other local stakeholders. When we first started consulting, we worked only with site managers and their clinicians. The work centered mainly on the modified SWOT process described above. Since then, we have discovered the power and potential of extending the design process outward to other stakeholders. Our Distributive Design Cycle incorporates and expands on the “now, wow, how” process. After some training, reflection, and follow-up discussion with site leads and clinicians, the next step is to engage with persons with lived experience. Some implementation experts suggest that persons with lived experience should be involved at the beginning and that any delay reflects an outdated paternalistic process. We disagree. Given that there is much higher anxiety about the changes among clinicians, it would be unethical to involve persons with lived experience at the beginning. To do so would be akin to a psychologically impaired clinician treating a client. In order for consultation to be productive, professionals and managers in authority roles need to get their house in order before working with either persons with lived experience or external stakeholders. The Distributive Design Cycle method is illustrated in more detail in Fig. 6.6. Consultation broadens in stages as we move up the spiral, beginning with site staff, then with persons with lived experience, and finally with external stakeholders. At each stage, the issues are identified (WHY change), the ideas bloom and propagate (WOW possibilities), and the themes expand, evolving through the widening consultation process. Then moving from the top of the spiral back down, community-­ wide healing resources (broadly defined) are identified and configured (HOW do we implement) within the evolving SC2.0 template, integrated with more specialized informal and formal programs until the continuum of care can be clearly defined and implemented (WHAT). This process will become clearer in the next chapter, where it is applied in detail to a fictionalized case study based on an amalgamation of our experiences with institutions in both Canada and the United States. Letting It Go I came up with the name “Client Design Team” for a group of students who expressed interest in shifting how we provided care at Memorial University. I was supervising a graduate student, Brad, who was interested in developing peer support programming on campus. For at least 5 years, a mental health advocacy group called MUN Minds had been funded by the undergraduate student union to support people with lived experience to advocate for improved programming. The group held fundraisers and awareness events and sometimes lobbied the university to do more to help students struggling with mental health issues. Recently, the group indicated a desire to form a peer support network and asked the Student Wellness and Counselling Centre staff to provide training. We did so. A collaboration began that preserved the group’s autonomy. We trained students in mental health first aid, including active listening skills, but we did not supervise their work. Instead, we

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Fig. 6.6  SC2.0 Distributive Design Cycle (three-dimensional version)

made ourselves available for consultation, but only when requested by them. Brad helped with both the training and the consultation. He also mentioned to them our idea of forming a Client Design Team. There were several members of MUN Minds who were also current clients. A few volunteered to join. Two counsellors also recommended the Design Team to their clients. TK (first introduced in Chap. 5) was one of them. They worked for about 8 months, reviewing de-identified client satisfaction data and learning about stepped care theory and research. Based on this work, along with their own lived experience, they wrote a report recommending adjustments to SC2.0. With Brad’s guidance, they knew that the recommendations would have to be well-researched and feasible. They made a number of good recommendations that we implemented (e.g., plants in the waiting room, decreasing noise in the waiting room, a secondary quiet waiting area that also had more comfortable chairs and video games, the acquisition of a smartphone-based self-check-in system). But the recommendation that most surprised me was a name change for the Design Team. They did not like “Client Design Team.” Instead, they wanted to call it “Students for Stepped Care.” “That’s not right,” I thought. “You were once an advocacy group. You are disruptors and now we have co-opted you!” As with any true collaboration and client-centric system, ironically in this case, I had to let go of my “students-as-disruptors” vision.

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References Gilbody, S., Bower, P., Fletcher, J., Richards, D., & Sutton, A. J. (2006). Collaborative care for depression: A cumulative meta-analysis and review of longer-term outcomes. JAMA Internal Medicine, 166(21), 2314–2321. Gino, F. (2018, July 23). You 2.0: Rebel with a Cause (S.  Vedantam, Interviewer) NPR.  Retrieved November 30, 2019, from https://www.npr.org/2018/07/23/631524581/ you-­2-­0-­rebel-­with-­a-­cause Sinek, S. (2009). Start with why: How great leaders inspire everyone to take action. Penguin. Woltmann, E., Grogan-Kaylor, A., Perron, B., Georges, H., Kilbourne, A. H., & Bauer, M. S. (2012). Comparative effectiveness of collaborative chronic care models for mental health conditions across primary, specialty, and behavioral health care settings: Systematic review and meta-­ analysis. American Journal of Psychiatry, 169(8), 790–804.

Chapter 7

Adapting for Unique Settings Peter Cornish

Why Change “But isn’t stepped care meant for clinics with inadequate resources?” A head-hunter for an Ivy League school expressed interest in my candidacy for director of an integrated wellness and counselling center. “With a multi-billion-dollar endowment, this school is not afraid to chart bold paths through innovation. Your approach might be just what they are looking for.” I was impressed. My ego inflated. An Ivy League school might be interested in me? Not so, though, in the end. While the head-hunter was intrigued, she could not sway the committee. “We have lots of resources. We don’t need stepped care,” the committee chair reportedly said to the head-hunter. I had originally assumed as much. It had started as a model for an impoverished, remote Canadian province and our own under-resourced university counselling center. But ever since I gave that 10-minute conference presentation in Chicago in 2014, I have been inundated with requests for consultation on our model from some of the unlikeliest places. One of the first is known by many as Canada’s “Ivy league” leader. Initially, I had been invited to co-lead an administrative review of their mental health programming. I mentioned my work on stepped care during that visit and was invited back to present the model. At the time, this university had about 50 clinicians for 40,000 students. It has since increased the number of staff dramatically. Somehow, they still struggled with a long wait-list. They had an abundance of resources. The students were unhappy. The staff were unhappy. Change was necessary. While the change process was complex and not without storming and controversy, the model was adapted to the unique culture of the institution and its commitment to be the best of the best.

P. Cornish (*) Counseling and Psychological Services, University of California, Berkeley, CA, USA e-mail: [email protected] © Springer Nature Switzerland AG 2023 P. Cornish, G. Berry (eds.), Stepped Care 2.0: The Power of Conundrums, https://doi.org/10.1007/978-3-031-45206-2_7

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7.1 Adaptation Stories and Processes Our consulting team at Stepped Care Solutions has worked with over 100 colleges and universities across North America who have expressed interest in SC2.0. Recently, provincial and territorial governments in Canada have contracted with us to introduce the model more broadly through the country’s publicly funded health-­ care system. A core feature of SC2.0 is its flexibility and adaptability. Some have remarked that it is more of a recovery care design process than a treatment model. It is certainly not a manualized program. In keeping with the principles of distributed co-design, it looks different in every location. The case study presented below describes co-design stories across all six stages of the implementation cycle. These have been drawn from experiences on our own campus and work we have done with a variety of institutions in both Canada and the United States. Many details have been changed to preserve anonymity.

7.2 Case Study: Large Mid-Western Public University One of the first institutions we worked with is well known for its highly competitive admission standards and its solid reputation globally. Over the years, this university had invested more in mental health than comparable institutions, but the concerns about access had been raised by students. Was there duplication? Were there inefficiencies? Could we do better? A senior administrator asked me to serve on an external administrative review panel. We visited the campus and met with a variety of stakeholders internal and external to the department. We discovered about midway through the first day of consultations that representation from one key department responsible for addressing a large proportion of mental health programming was missing. We were surprised initially and then discovered that relationships between three student wellness service departments were strained. With a little initial resistance, we managed to arrange meetings with all parties. At the end of the first day, during a break, I described our stepped care model to my fellow administrative review panelists. They were intrigued, expressing interest in learning more. I said, “Maybe we could meet after our consultations are finished, and I could share with both of you a presentation I delivered elsewhere.” We asked one of the senior members of the department under review if we could get access to a room where I would have AV technology to present on my new model. Of course, the answer was yes. But, curious, this administrator asked if others would be welcome. We discussed privately as a panel and agreed to open it up to others. Four representatives of two of the three wellness departments attended. It was hard to read the interest of participants. The atmosphere in the room was somewhat guarded. Within a month, our report was delivered. Among the recommendations, we suggested some steps be taken to improve the collaboration among the units.

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7.2.1 Stage 1: Initial Consultation—Getting to Why and Wow I thought that was the end of my work with the university. However, about 1 year later, I was invited to present on the stepped care model to all clinical and administrative staff in the three wellness departments. I worked in advance with leaders of two wellness departments (the only two who were intrigued) to plan the agenda. The leadership teams of the two departments sat at the same table as me near the front of the room. I thought this was a good sign; the leaders were in this together. Collaboration was happening. There was both excitement and apprehension throughout the day of the workshop. Many were intrigued; however, a handful of very vocal critics held sway. These clinicians, some from each department, were skeptical. Their questions at times bordered on hostility. It was, it turned out, the beginning of a period of significant storming. Some of the clinicians filed grievances with their union. Others consulted with their professional organizations. SC2.0 was considered a potential threat to their professional autonomy, their ethical practices, and even their livelihoods. The model was perceived as prescriptive—mandating low-intensity, low-quality programming, some of which they feared would be facilitated by other professions, paraprofessionals, or peer supporters. I soon discovered that all was not well between two of the three leadership teams. One leader expressed serious concerns about SC2.0 and dropped out of the consultation process with us. Another leader, while not hostile to the SC2.0 model, did not see it as relevant at the time. Her department was not slated for amalgamation like the other two. The third leader continued to work with us, convinced that stepped care held promise. Despite the internal conflict, the university administration decided to go ahead with adapting the model. They invited me to visit again, this time to work with a smaller design team. The group on this team were enthusiastic and committed. This group knew why they were working on transformation and were wowed by SC2.0. However, one of the two departments had completely disengaged. The why did not seem clear to them. As such, collaboration between the units deteriorated. The one department that decided to go it alone received some institutional support. Lower-intensity programs were launched, including e-mental health tools and a rapid access system. The departmental leadership seemed pleased, and I was too, but the transformation process was on shaky ground. Our SC2.0 consulting team offered to help resolve some of the conflict between leaders of the two separate units that were to be merged at a future date. The unit that was more engaged with us was comprised of counsellors, psychologists, and social workers. They identified as non-medical. The disengaged unit was more medically oriented; the mental health counsellors worked alongside health clinic staff, including physicians, psychiatrists, nurses, and nurse practitioners. I was surprised initially that the medically oriented unit was not as interested in the model. Stepped care was initially developed for medical settings to improve the coordination and transfer of care between primary care physicians and psychiatrists. But the drive for change had historically come from primary care practitioners who were frustrated

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with challenges accessing psychiatric care or consultation for their patients. At this university, psychiatrists were the majority among the staff of physicians, nurses, and nurse practitioners. The unit was led by a psychiatrist. All the staff psychiatrists worked fee-for-service, which was covered by students’ insurance. It was a private practice model of care. They did not receive benefits from the university, and their allegiance was to their patients rather than the institution. First, we met with the leaders separately to gauge their interest in mediation. They agreed only if the sessions would be structured according to an agenda developed in advance with their input. Over the course of 5 months, we met four times via web conference with the two leaders. An agenda was developed collaboratively prior to the first meeting, and notes were “flip-charted” using the screen share feature. We carried forward the same agenda across all meetings, adjusting as we went along. Common goals were identified, which included developing recommendations for: 1. The relationship between the two leaders 2. More consistent revenue structures 3. Campus-wide consultations on mental health service reform and possible restructuring 4. How they envisioned their roles adapting through restructuring 5. Full implementation of an adapted version of SC2.0 While the relationship between the two leaders had been strained, we got a sense that they liked each other. They recognized how their different styles were complementary. One was thoughtful and cautious, whereas the other was passionate and eager to act. Early on, we also named “the elephant in the room”—one of them might be vulnerable. Was one of their positions at risk with restructuring? We agreed after some discussion that it would be useful to explore the kinds of roles they envisioned with restructuring. It turned out that the administration was not in a rush to complete restructuring. Instead, they were interested in what both leaders would recommend following campus-wide consultations that had begun prior to our first contact with them. The university had a reputation for consulting widely and repeatedly on many issues. The focus of the consultation was vague. It was intended to gather all and any input on mental health experiences and ideas. After 5 months of consultation, and support from our team, the two leaders completed their report. It recommended a flatter organizational structure with a variety of adjacent lead roles. To facilitate the development of the new care model (yet to be designed), the following lead roles were adopted: healthy campus lead, primary care lead, mental health lead, collaborative lead, and stepped care lead. The report also recommended that the merger would ensure that all staff would be funded by a blend of insurance and operating revenue and that all would be eligible for benefits. The new money and matching central funds would allow for this.

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7.2.2 Stage 2: Public Relations Crisis—People with Lived Experience Lash Out In hindsight, we had attempted to move too quickly to solutions. We had only gotten to the first step in the distributive design cycle—working at the inner circle with leaders. While we had made strides with the internal leadership team, we had underestimated conflict among staff. We thought we had solved some problems to their satisfaction. Low-intensity programming, including e-mental health tools, was helping to curb student demand already. Aligning revenue streams would bring clinical staff on board. And flatter leadership roles would ensure meaningful roles for existing leaders following restructuring. But the buy-in was not there. The two leaders had heard a number of complaints, but collectively we assumed we already had answers: low-intensity programming and stepped care. Yes, consultation had happened. Broad input had been obtained. But not true co-design. While all stakeholders agreed that demand for care had been exceeding supply, there was no shared perspective on why this was the case. Disregarding Sinek’s appeal to always start with “why” (Sinek, 2009), we had moved directly to “what.” And we were nowhere near a well-thought-out implementation method (how). A public relations crisis made the false start obvious. Although never proven, rumors circulated that some disaffected staff had warned the student union that the stepped care program was a threat to good service. In an effort to save money and decrease wait times, service quality would be compromised. Some clinical staff left the university. They were uncomfortable with the prospect of altering their practices in alignment with the model that was already being adopted. Highly critical articles were published in the student newspaper. The university communications team became involved. Senior administration officials had no desire to reverse the course on stepped care—after all, early indications were (contrary to the press reports) that it was working. Secondly, funders were very interested in the model. However, with input from the public relations office, a decision was made to rebrand the change. Instead of stepped care, the new approach was labelled “Cooperative Care.” This was a brilliant move because not only would there be a commitment to stepped care principles but, in addition, the issue that had derailed implementation (internal and inter-department conflict) could be addressed with a focus on relationship-building. The crisis became an opportunity to implement a formal process of working through storming at two levels: Level 1 among clinicians and leadership and Level 2 with persons with lived experience (students and the student union leadership). After the dust settled, it became clear, through deliberate engagement with clinicians, student union representatives, as well as peer helpers, what the problem areas were. The “why change” became more obvious. Students found the current organization of programming confusing. Why were there two departments offering similar services? Which one do I go to? Why do I have to wait so long when we have more funding and more staff than many other colleges and universities? Do we really have quality programming? Can’t we do better? By pausing implementation and

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asking stakeholders whether and/or why anything (whether it be programming, clinical roles, or leadership structures) should change, motivation to participate in the design process increased. Buy-in further expanded when the clinicians learned that changes would address inequities in funding between the two units and preserve their professional principles and values through horizontally organized process leadership roles and that the decisions on how and what to implement would involve them directly. Likewise, when the students learned that access to care would be streamlined and the new model would only add programming, not remove anything they valued, they were on board. Finally, both groups were reassured that future steps would include consideration of a wide range of possible solutions and that they would be involved in the process. They were invited to search for and create innovations that addressed the issues of importance to them. The fact that staff and students were supported to engage in blue-sky thinking to address their own needs indicated a shift from why to wow. We had completed Stage 2, identifying why change and inspiring some wow among the leadership team, the clinical staff, and the students (persons with lived experience).

7.2.3 Stage 3: Multi-sectoral Consultations on the Need for Change and Inspiration We could have stopped at Stage 2. The core stakeholders were engaged. Why do we need to keep moving outward? The university leaders had researched innovations and contracted with us as thought leaders for innovative practice. Students and clinicians were part of the co-design process. Should this not be enough? A wide range of expertise and experience had been tapped. But as Gino cautions, accumulated expertise and experience can be restrictive. In her NPR interview, she referred to a study she conducted on cardiac surgeons who had been notified by the Food and Drug Administration that a routine technique was no longer considered safe. The results indicated that the more experience a surgeon had, the less likely they were to change their practices in response to the FDA warning (Gino, 2018). The clinicians, managers, and students at the university we had worked with thus far had considerable experience. As a result of this experience, we wondered if they might be too deep in the forest to recognize out-of-the-box ideas. Compared to outsiders, would their collective years of experience with established practices make them less receptive to novel, experimental ideas? Outsider perspectives, according to Gino, are crucial for innovation. Following the two suicides at Memorial University (Chap. 3), it was conversations with residence leaders, not counsellors, managers, or students attending counselling, that led us to recalibrate what needed to be changed. Before these conversations, the suicide prevention strategy had created an atmosphere of high tension and fear. The risk paradigm had not been challenged. We had not even recognized its presence. The protesting residence leaders alerted me to its presence.

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And the conversations that followed inspired a vision of a more engaging, vibrant residence community that could be cultivated in the very space occupied by postvention puppies. The idea of bringing fun and games back to that multipurpose room was a wow moment. The residence leaders who helped us to see where we were going wrong with the risk paradigm would not have been invited at a Stage 2 level had the distributive design cycle method been in place at Memorial University. But they might be considered for participation as external stakeholders at Stage 3. At Memorial University, group counselling programming had been poorly attended for years. The student peer network at Memorial could not attract interest in their activities. They had helped to market the groups with us, but with no success. The experts and students with the most experience were stumped. Given the increasing demand and the full waiting rooms, why was there no uptake? We had no answers. But when a new director of the Botanical Gardens approached me expressing interest in mental health, we discovered an alternative. He had a background working in psychiatric hospitals as a horticultural therapist. He wondered if there might be opportunities for collaborating with the counselling center. He came to a staff meeting and presented on his work. One of our counsellors had expertise in mindfulness. The concept of Green Mindfulness was hatched at this meeting. Together, they launched a 90-minute weekly walk-in event in a high-traffic area of the campus. It quickly became known as a place to get a new houseplant. When students wandered in, they were invited by students from the peer network to take a cutting and plant it mindfully in a small pot. They were encouraged to feel the texture of soil, its temperature. They could take a mint leaf and absorb the aroma of fresh mint tea. An average of 100 students attended each week. It took an outsider, the director of the Botanical Gardens, to solve the problem of failed group work and the lack of uptake from peer mentors. Before his appearance, we kept offering the same kind of groups, somehow continuing to think people might start coming. The peer mentors, determined to build a successful peer counselling program, continued to host drop-in hours for 2 years despite few takers. None of us considered that we should stop doing this or try something different. While undoubtedly success stories (bringing fun back to residence and Green Mindfulness), the prompt for change was random and could easily have been missed. What would have happened if the resident assistant, the director of the Botanical Gardens, and all kinds of other outsiders had been deliberately invited to answer the question, “Why change?” Maybe innovation would have happened more smoothly and rapidly. Returning to our mid-sized public university, what might the broader community think about change? Would extending the “why change your practices” question be of interest to academic advisors, to the fitness center, to the student residences, to faculty partners? And then what about the city beyond the campus? Are there no other influential organizations asking questions about change? Could we engage in a broader conversation about change in policies with potential external partners? Who else wants change? Are others being inspired by new ideas? Can we share our “wow” blue-sky ideas?

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Not surprisingly, conflict also emerged when we got to Stage 3—external stakeholders. Campus staff and faculty invited to participate in the discussion were divided. Some said the problem was that the clinicians were not seeing students fast enough and did not have time to consult with them when they called. Others simply wanted the clinicians to take the mental health problems off their hands; they did not want to learn more about how to support students because that was not part of their job. It appeared that at least one common problem among all stakeholders (clinicians, managers, students, staff, and faculty) was the sense of being overloaded with no room to do anything new or more. What were their needs? All stakeholders needed something to make their experiences easier, more manageable, and more comfortable. How could wow be facilitated for external partners? We already learned that moving too quickly to how or what will fall flat. Resolving tensions cannot happen without some consensus on the question “why change.” Some tensions were traced to conflicting opinions about what constitutes best practices in mental health care. About a year after implementing Cooperative Care, the manager of counselling services received a complaint from a student union board member. The board member said that students were complaining about the new model. The manager called the board member to suggest they host a joint meeting with all who might have concerns. Several board members attended along with a representative from a student society group focused on mental health awareness programming. The student society representative complained about the quality of care they received at the counselling center. “What did they say about the quality? Did they have negative experiences?” asked the counselling manager. “No,” replied the student. “But they both see Dr. X at the health clinic operated by the faculty of medicine, and he said to them that they should be getting weekly CBT treatment, with hour-long sessions for up to three months. That is best practice and their symptoms warrant this.” The manager thought for a few moments and then said, “Sometimes care providers on our own teams disagree about what constitutes quality care. If you are interested, I can show you part of a presentation I give frequently which shows how we are both right. CBT is evidence-based but so is our model. Would you like to see what I have been presenting to my colleagues at conferences about our Cooperative Care model?” The students agreed. They asked pointed questions and seemed to leave the meeting both satisfied and intrigued. The counselling services manager made a note to set up a meeting with the chair of family medicine. As external consultations at Stage 3 continued, it turned out there were several philanthropic organizations interested in participating. When they joined, we learned of their concerns about current practices and, more importantly, how eager they were to fund change. For years, these organizations had been funding regional and national projects gathering data in support of innovation. They hinted that some of their funders were now ready to donate large sums of money to support change. Their raison d’etre was to fund broad systemic innovations aimed at serving all stakeholders. They were committed to well-thought-out strategies based on implementation science. A 1-day forum was hosted by one of the philanthropic groups with a focus on implementation science. An expert facilitated the workshop. Participants learned

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about the drivers of successful design and implementation. They were introduced to tools that would help focus the work at Stages 4, 5, and 6 of the multi-sectoral design cycle. They agreed to engage the implementation science expert again at later stages to support their work. Prior to the engaging stakeholders on the why and wow process at Stages 2 and 3, consultations had been reactive and unfocused. Previously, when students or other campus stakeholders complained or, worse, published scathing reports in social media or the campus newspaper, administrators and public relations staff were only able to work on putting out the fires. By the end of Stage 3, however, all parties (the SC2.0 leads, clinicians, managers, persons with lived experience, and external stakeholders) agreed on the why of change and were more inspired (wowed) by what could be.

7.2.4 Stage 4: Identify the External Partnerships, Their Resources, and How to Operationalize Them With agreement that change was needed and shared understanding of issues to be addressed, all stakeholders were ready to begin identifying solutions. They had been inspired enough by opportunities, but there was no agreed-upon process for building solutions or a clear sense of what those solutions might look like. It was time for an environmental scan. Field trips were organized. Representatives of the mental health strategy committee arranged visits to three campuses that were a little further along in their transformation process. In their visits, they asked about their process, the changes, what did and did not work, and why. Following the visits, a workshop was held to debrief. Stakeholders at all levels were asked to think about how to move forward. One of the lessons learned by an institution they had visited was to resist the allure of the “shiny object.” The manager of counselling at one campus they had visited admitted to having a reputation for saying yes to every new and exciting e-mental health program that promised to solve the challenge of increased service demands. While programs were evidence-based or evidence-informed, little attention had been paid to implementation strategy. The utilization rates had been low. The committee agreed that they did not want to fall into the shiny object trap. One of the members had recently attended a conference where a psychiatrist, now a Canadian senator, warned that “the bloom will eventually fade and fall off the rose” of e-mental health. While this committee member was not so pessimistic, she was wary of the promise of technology. The hype can be overblown. The committee struggled with a common implementation tension. One side cried for bold action now, “Mental health reform here is long overdue: we’ve been working on this forever! One more study will sit on the shelf gathering dust and nothing will change!” While perhaps less passionate, but equally pointed, another committee member countered, “Shiny-object syndrome will lead us down blind alleys. We

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should proceed carefully and cautiously.” In the end, they agreed that balance was needed. There might be some things that can be actioned immediately—initiatives that have already been researched and subjected to broad consultation. Politicians, for better or worse, are masters at balancing quick wins with carefully planned, drawn-out strategies requiring exhaustive consultation. A few carefully selected immediate actions can satisfy pent up demand and inspire others to commit to change. Was there anything in line with their Cooperative Care model that could be implemented without further delay? What needed more careful consideration? A representative from the university’s marketing and communications department spoke up, “I think what we need is a good communications strategy so that we can leverage anticipation the way Apple does, but of course within an academic values frame.” A counsellor on the committee added that managing expectations is very important in mental health treatment; expectations are key to positive outcomes. But she admitted that this was not part of her skillset and cautioned that “our licensing board actually prohibits any type of promotion of psychological services.” Due to the potential for manipulating vulnerable persons, advertising is considered unethical. Another counsellor countered this caution, “We are masters of persuasion. Our practices sell hope. Some psychotherapy schools are explicit in this respect.” Ericksonian hypnotherapy, for example, has influenced many contemporary methods, including solution-focused, narrative, and positive psychology approaches. Has the ethical code proscription on promotion been interpreted too broadly? Other committee members were intrigued. “This could work on so many levels,” one said. “The transparency about our process is in keeping with recovery principles. And a more proactive approach could stimulate feelings of anticipation and hope.” Perhaps promotion aimed at the principles underlying the system of care would be considered outside the scope of the profession, especially if it is guided by external partners and administrators and not the practitioners alone. A ripple of excitement spread through the room. The first clear action-step (an example of what) was emerging—communications. The committee would work out a full implementation strategy with input from the communications experts sitting on the panel. A communication strategy would roll in tandem with implementation steps. The committee prepared a report with recommendations organized along six guiding principles: (1) access to care needed to be streamlined—there should be a clear point of entry; (2) options for care need to be expanded since one size does not fit all; (3) the care system needs to be nimble and informed by continuous co-design by all stakeholders; (4) the care system needs to be accountable with its mission to improve outcomes; (5) implementation should follow best practices informed by implementation science; and (6) a communications strategy is needed to stimulate hopeful help-seeking.

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7.2.5 Stage 5: Identify Unmet Needs of Students and Adjust Existing Programming and Consider New Ones At Stage 5, the work was transferred back to internal stakeholders—clinic managers, clinical staff, representatives from Student Affairs, and students with lived experience. One of the first tasks was to re-engage with the implementation science consultant. This was deemed essential to ensure the “what” would not get ahead of the “how.” Implementation science has been defined as “the scientific study of methods to promote the systematic uptake of research findings and other evidence-­ based practices into routine practice, and, hence, to improve the quality and effectiveness of health services” (Eccles & Mittman, 2006). The practice has evolved to address what is referred to as “the implementation gap” that exists between research and practice. While evidence may exist to support care practices, the practices are often not adopted. If they are adopted, they may not be used with fidelity to the intervention originally tested. And even if they are used with fidelity to the originally tested intervention, the practices may not be sustained. And if they are sustained in one setting, they may not be scaled up or replicated in other settings. Multiple gaps may interfere with impactful knowledge mobilization. Our six-stage SC2.0 distributive design cycle is an example of an “active implementation framework” (Metz & Bartley, 2012). In addition to organizing the process through phases that extend across 2 to 4  years, an active implementation framework specifies useable interventions, drivers for successful implementation, processes for improvement, and composition of teams. An initial step in developing an implementation framework is to articulate a clear description of the program. Second, the essential and gold standard features of a program or model are identified. Third, core interventions are clearly operationalized in line with underlying principles. Finally, practice guidelines and standards are developed to allow for performance and fidelity assessment. Typically, few programs are implemented with attention to all these features of implementation science. While most programs are clearly described, few identify the core or essential components, and most fail to operationalize or test for fidelity in practice settings. Our team created standards for Stepped Care 2.0 in collaboration with the Mental Health Commission of Canada (MHCC, 2019). The standards have been applied through the implementation of a digital platform that extends SC2.0 to all Canadians as part of the government of Canada’s COVID-19 mental health response (Wellness Together Canada, 2020). The platform provides the technological infrastructure for not only tracking and enhancing outcomes but also treatment fidelity to the new SC2.0 standards. As indicated in Fig. 7.1, meaningful outcomes for any new program depend on the efficacy of the intervention, how it is implemented, and the context in which implementation occurs. In our six-stage implementation model, enabling contexts are nurtured first by asking why change is needed and by inspiring blue-sky wow thinking. This nurturing happens long before effective interventions are selected (the what) and before the application of implementation science (the how).

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Fig. 7.1  Implementation science outcomes. (Adapted from the National Implementation Research Network, 2019) Table 7.1  The core components of “Cooperative Care” Cooperative Care means that our health-care professionals work with students and explore various services to find the best kind of care for their needs. This means using one or multiple treatment options, both traditional and holistic. Our staff collaborates with campus colleagues, other care providers, peers, and community services to support students and meet their individual needs. Cooperative Care includes: 1. Flexible approaches that match students with the right resource at the right time to help students feel better—fast 2. Treatment that gives students choices, building on their existing strengths and autonomy 3. Community-based care that pulls together resources on-campus, off-campus, and online, depending on what best fits students’ needs 4. A holistic wellness approach that targets all of the factors that contribute to overall student wellness 5. Goal-oriented care that builds resiliency and focuses on what makes them well rather than only discussing what makes them unwell

The implementation science consultant met several times with the team. The goal was to develop “useable cooperative” interventions. The university wanted a clear description of what Cooperative Care really is. But first the team worked through another full-day workshop aimed at developing Cooperative Care practice profiles. Practice profiles were developed using a toolkit designed to operationalize care principles. The toolkit ensured that treatment protocols were based on research and information about best practices. It also ensured that competencies aligned with innovations and that the innovations would be phased in gradually. It was important that the incremental process of adoption met the expectations of all stakeholders. The facilitator began the day by asking, “What are the critical, non-negotiable components of your Cooperative Care model? To know if a component is critical, ask yourself, if it were to be missing, would you no longer be able to think of it as Cooperative Care.” The team defined Cooperative Care and came up with five critical components (see Table 7.1). Then, for each of the five components, workshop participants operationalized, in turn, what ideal implementation, acceptable variations, and unacceptable variations

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might look like. Beside each, they also specified what outcomes could be expected if acceptable variations were applied with fidelity. For example, the first component (flexible approaches) was operationalized first by deciding the number of step categories and then populating them with existing programs. The team decided on a ten-step model ranging from prevention at the lower end to psychiatric consultation at the higher end. But because of the sensitivity to hierarchy, and the long-standing discomfort with the word “stepped care,” the category list on their graphic was unnumbered. In the prevention category, four programs were specified: orientation events, outreach/distress activities, training for professors and other campus staff, and departmental talks for the various faculties. The second component (treatment that gives students choices) was operationalized in several ways. One stemmed from a mock webpage storyboard created by participants to map out the envisioned help-seeker experience. They drafted a Counselling Services webpage with the title: “What kind of support are you looking for?” Four top-level options were drafted: (1) mental health support; (2) support for a physical health condition; (3) academic support; and (4) I want to learn more about mental health and self-care. If the student were to click on the first option (mental health support), three options would appear: (a) I need to speak with someone right now; (b) It’s not a crisis but I still need to talk; and (c) I am not in immediate distress or I am open to online resources. Then if the student were to choose Option B (it’s not a crisis but I still need to talk), they would see four options: speak to a professional right now; speak to a professional in person; speak to a peer; or speak to an academic advisor. By the end of the day, practice profiles were completed for all five components of the Cooperative Care model. Participants were cautioned that none of these operationalized care components would succeed without careful attention to enabling factors. What needed to be in place to support implementation? What were the implementation drivers for their campus? These were identified at the next meeting. As indicated in Fig. 7.2, several drivers were specified on organizational, leadership, and competency dimensions. On the organizational level, support was needed to adapt policy, fund new initiatives, support the implementation process, and develop technological infrastructure. Managers had to develop new procedures for operations and strategies for anticipating and mitigating team dysfunction that might arise through the transformation process. Clinical and organizational training was needed to adapt practices and develop new competencies. A system of coaching or mentoring was needed to support ongoing adjustments to care.

7.2.6 Stage 6: Re-allocate Resources to Support Adjustments and Procure New Programs At Stage 6, the co-design process was complete. The implementation team was in full operation, useable interventions had been defined, and enabling structures were in place. Funding from donors had been received and matched by the university.

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Fig. 7.2 Implementation drivers. (Adapted from the National Implementation Research Network, 2019)

Architects and contractors were hired to redesign and renovate the space to facilitate smooth, integrated, Cooperative Care. Technological infrastructure for self-check-­ ins, shared record-keeping, therapeutic monitoring, and webpage improvements were developed. Policies and procedures were adapted or created anew. New staff with experience in walk-in, single-session counselling and e-mental health care were recruited and hired. None of these new staff were hired within the existing counsellor collective bargaining unit. This decision was made in collaboration with the union representing counsellors. Vacancies within the bargaining unit would continue to be filled for the next 3 years, and hiring outside of the bargaining unit could only be made with new funds. This agreement helped resolve some of the anxiety expressed by existing staff about the future of their roles. On the other hand, it meant that some of the existing staff no longer felt obligated to adjust their practices in line with the new Cooperative Care model, since this new way of practicing was only required by the new hires outside of the bargaining unit. We reminded the managers of the units to use the same approach to change management as counsellors use with their clients in the context of SC2.0. Rather than urging staff to become more ready for change, the job of managers was to connect with staff where they were already. This pivot to where people are ready did not mean that any staff would be isolated from the new model. Training was provided to all staff on recovery principles, stepped care decision-making, collaborative care, walk-in care interviewing techniques, case management, and e-mental health tool use. Weekly meeting agenda structures were adapted to facilitate modified operations. For example, case conferences shifted focus to sharing successes and failures with single-session care, stepping decisions, therapeutic monitoring, and using time more flexibly. Staff were supported to join community of practice webinars on stepped care, attend relevant conferences, and conduct research on topics related to the new model.

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At the time of writing, Stage 6 implementation had just begun. The renovations were complete, and a more centralized, collaborative care hub was in operation. A flatter organizational structure was in place with six leads reporting to a new assistant dean of campus wellness. The two mental health managers, as well as the manager of primary care services, had received promotions to campus lead roles. There was still a lot of work to do before the new wellness hub would be truly integrated. The physicians were still operating in isolation, and there was no unified health record. The managers were struggling with obtaining buy-in from providers. A decision was made to seek managerial training and obtain executive coaching to both inspire and direct change among staff.

7.3 Adaptations at Other Sites There are infinite ways to develop stepped care. Some of the earliest adopters of SC2.0 organize their programming in a non-hierarchical pattern. The University of British Columbia was one of the first Canadian institutions to adapt the model from our campus. As indicated in Fig. 7.3, programming is still arranged in a linear fashion, but there is no implied hierarchy. Arranged horizontally, the model gives no suggestion that one program is better than the other. In consultations following introduction to SC2.0, some stakeholders expressed discomfort with the values associated with the three dimensions (i.e., on the x-, y-, and z-axes). One worry was that help-seekers might feel cheated with lower-intensity programs or with programs requiring less investment. The arrangement along the continuums might reinforce the prevailing assumption that psychiatric care or face-to-face intensive psychotherapy is more valuable or more effective. If this were the case, help-seekers might be less inclined to consider low-intensity program offerings.

Fig. 7.3  University of British Columbia’s adaptation of SC2.0 (Cornish, 2019)

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Other non-linear versions of SC2.0 are more explicit. Instead of arranging steps perpendicularly along the x- or y-axes, interventions are positioned around a circle. The province of Newfoundland and Labrador now organizes publicly funded mental health care for adults into seven categories which are arranged in a circle around the help-seeker. This emphasizes their commitment to client-centric care, in which the help-seeker preferences are accommodated as much as possible. Following consultation with us, the George Washington University in Washington, DC, and Algonquin College in Ottawa have also developed circular versions of SC2.0. The Newfoundland and Labrador version is still under development. The two other circular versions are illustrated in Fig. 7.4. The importance of client-centricity cannot be overstated. Helen (a pseudonym) is a local hero in my mind. She was previously the CEO of Newfoundland and Labrador’s only province-wide peer network (Lifewise) and literally lives recovery principles. Helen is a person with lived experience who continues to struggle from time to time, but somehow manages to break new ground on multiple fronts. Amber’s story in Chap. 4 is a testament to Helen’s impact. Helen coined one of my favorite recovery phrases: “ATP, ask the person first!” she exclaims with the broadest of smiles. This refrain is a constant reminder to all of us working on mental health reform. Before making any prescriptions-based expert opinion, why not simply “ask the person” first? Helen says this with such good humor and so often that the acronym, ATP, is now common parlance in the province’s mental health sector. Circles are ancient features of healing practices. Sacred circles have a long tradition throughout the world. When people gather in a circle, they are practicing connection, equality, sustainability, and unity. If there is power expressed, it is not a power-over anyone or anything. Instead, it is power-with. The medicine wheel, a term coined by people of European descent, is a common structure for organizing

Fig. 7.4  Variations on SC2.0 (from left to right): Algonquin College and the George Washington University (Cornish, 2019)

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Fig. 7.5  The medicine wheel (Indigenous Corporate Training Inc., 2019)

knowledge in North American Indigenous populations. The earth’s resources and habitats, if preserved in their natural state, have healing power. The resource configuration across the four quadrants (north, east, south, and west) of the wheel represents the natural order of our planet, Mother Earth (Fig. 7.5). Order is not forced. It is what was there to begin with. Wellness and harmony are achieved by aligning with the balancing forces of nature, the elements, the four directions, and the cycle of life. While sacred circles bear some resemblance to our SC2.0 circular stepped care models, we are careful to avoid cultural appropriation. We aspire to anti-­ oppressive and anti-colonial values and avoid making firm assumptions of relevance to Indigenous peoples and their communities. If invited, however, we would welcome opportunities for co-design. Foxes and Hedgehogs Francesca Gino might consider me an aspiring rebel leader. I still have a lot to learn though. My humble attempts to lead have yielded mixed results. I broke the rules, and, while I did attract a following, I left my team behind. Good rebel leaders practice humility. They make themselves vulnerable through risk-taking. And with the right balance of positive deviance, good judgement, tact, and empathy, they manage to bring others with them. There is a tension between disruption, collaboration, and nurturing. Effective rebel leadership requires the right mix of bold action and

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patience. Perhaps a more reasonable approach is to assemble a flat rebel leadership team with complementary collegial roles. I am good at positive deviance but not so good at nurturing. Our Stepped Care Solutions not-for-profit has some of these qualities. We have systems thinkers and concrete thinkers. We have peacemakers and disruptors. We have salespeople, and we have deviants. I am reminded of a conversation many years ago with my doctoral thesis supervisor who spoke of foxes and hedgehogs. He identified with the fox and wondered if I did too. According to the ancient Greek poet, Archilochus, “The fox knows many things, but the hedgehog knows one big thing.” Hedgehogs burrow down, espousing a single, grand idea to explain everything, while foxes run around on the surface coming up with new ideas to fit every separate encounter. Isaiah Berlin popularized this distinction, but later regretted the overly simple dichotomous interpretations of his 1953 essay. I still don’t know which I am. I think it is a dialectic. I strive for the grand idea— SC2.0—but the idea itself is amorphous. It slips and slides through co-design, a built-in disruptive process. We need bold thinking. We need humility. We need risk-­ takers. We need caretakers. The fable of the fox and the cat (Aesop, 1893) is a variation on the fox/hedgehog dichotomy. The fox and the cat discuss their varied talents, namely, their tricks and dodges in the face of danger. The fox has many, whereas the cat admits to just one plan. When hunters arrive, the cat immediately flees to the safety of high tree branches. The fox can’t decide, thinks of many options, and tries a few, but none with commitment. The fox is caught by the hounds. In this perilous context, the fox fails and pays with its life. Mass media reports warn that we are in the midst of a mental health crisis. Risk managers, in efforts to maintain reputations of insurers, insist on a cat-like, focused, and rigid protocol. Professional associations for the most part follow suit. Does the cat plan save lives? While the cat survives, we can’t all hide in trees. A risk-averse approach to mental health care protects providers more than those they serve. Help-­ seekers are frustrated by this overly cautious approach. Do they want only foxes? Probably not. Isaiah Berlin wouldn’t either. Why not dispel with dichotomies. We need cats, hedgehogs, and foxes. Cats climb up to watch out for danger. Hedgehogs focus on details. Foxes run around practicing sly deviance and disruption. Let’s make room for all three.

References Aesop. (1893). The fox and the cat. In E. Grisit (Ed.), Aesop’s fables (p. 193). Cassell & Company. https://play.google.com/books/reader?id=ezkSkOjcoGkC&hl=en&pg=GBS.PR1 Cornish, P. (2019, December 13). Variants on stepped care 2.0. Retrieved from Stepped Care 2.0: Collaborating for Mental Health Innovation: https://steppedcaretwopoint0.ca/ variants-­on-­stepped-­care-­2-­0/ Eccles, M.  P., & Mittman, B.  S. (2006). Welcome to implementation science. Implementation Science, 1(1), 1–3. Gino, F. (2018, July 23). You 2.0: Rebel with a cause (S.  Vedantam, Interviewer) NPR.  Retrieved November 30, 2019, from https://www.npr.org/2018/07/23/631524581/ you-­2-­0-­rebel-­with-­a-­cause

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Indigenous Corportate Training Inc. (2019, December 4). What is an Aboriginal medicine wheel? Retrieved from Working Effectively with Indigenous Peoples Blog: https://www.ictinc.ca/blog/ what-­is-­an-­aboriginal-­medicine-­wheel Metz, A., & Bartley, L. (2012). Active implementation frameworks for program success: How to use implementation science to improve outcomes for children. Frank Porter Graham Child Development Institute, National Implementation Research Network. Retrieved January 2, 2020, from https://static1.squarespace.com/static/5279554ce4b0eea3e5bdac41/t/5bfd5e1a2b6 a28d7b076a437/1543331355258/1a_NIRN_ImpArticle.pdf MHCC. (2019). Stepped care 2.0 (revised) implementation guide. Mental Health Commission of Canada. National Implementation Research Network. (2019, December 13). Active implementation formula. Retrieved from https://nirn.fpg.unc.edu/module-­3/topic-­3/function-­3. Sinek, S. (2009). Start with why: How great leaders inspire everyone to take action. Penguin. Wellness Together Canada. (2020, May 20). Wellness together Canada: Mental health and substance use support. Retrieved from Wellness Together Canada: Mental Health and Substance Use Support: https://ca.portal.gs/

Chapter 8

Toward a Paradigm Shift Peter Cornish

You’ve Turned My World Upside-Down When we are invited to consult on mental health service or system transformation, we typically try to meet with a wide variety of stakeholder groups to explore their ideas of what works and what doesn’t. Usually, I begin by describing what I have learned in my own work and how this has evolved into the SC2.0 model. I outline what is unique about SC2.0, with an emphasis on recovery principles, moving beyond the deficit model and incorporating more open access to a broader range of supports. At a recent invited visit to a west coast campus psychiatry clinic, I noticed a wide-eyed stare from a psychiatry resident as she listened to me describe the model. There was a moment of silence before she said bluntly but without any judgement, “Everything you have said today contradicts all that I have been taught during my psychiatry residency.” While she seemed shocked, I noted an element of wonder and curiosity in her tone of voice. Something clicked. Emotion was aroused. These are the kinds of moments we need to capture to mobilize a paradigm shift. There are confusion, some conflict with what had been thought of as tried and true, and yet a glimmer of hope that a bold new approach could be refreshing.

8.1 SC2.0 Today SC2.0 is a flexible system for reforming mental health care. It supplies scaffolding for organizing and selecting from among best practices, informal supports, new and emerging illness prevention, health promotion, and treatment methods. Two meanings of the word “system” drawn from the Oxford English Dictionary (OED Online, n.d.) apply to SC2.0: P. Cornish (*) Counseling and Psychological Services, University of California, Berkeley, CA, USA e-mail: [email protected] © Springer Nature Switzerland AG 2023 P. Cornish, G. Berry (eds.), Stepped Care 2.0: The Power of Conundrums, https://doi.org/10.1007/978-3-031-45206-2_8

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1. A group or set of related or associated things perceived or thought of as a unity or complex whole 2. An organized scheme or plan of action, esp. one of a complex or comprehensive kind; an orderly or regular method of procedure, government, administration, etc. Note that the first definition is not prescriptive. It is simply a group of related things organized into a complex whole. Unlike the second definition, it is silent on application or plan of action. We have not yet decided which definition is best suited to SC2.0. While it is tempting to jump to the second plan-of-action definition, it conflicts with the post-modern plurality of values and techniques associated with recovery strategies. If no one size fits all, what is the value of prescribing? On the other hand, what use is a nicely organized group of ideas or principles without recommendations for action? I propose a dialectic. It is important to oscillate among the parts of the system. In our distributive design cycle method, we move back and forth from theory or principles to prescription. In keeping with the values of co-­ design and evolving cultural plurality, prescriptions are bound to fail. The action plan will be abandoned forcing a return to pure values. The failure might also prompt a reworking of the principles. This iterative process is like the qualitative research method of grounded theory (Charmaz, 2014). With this method, theory is continuously discovered using constant comparison of concepts and the data they represent. With every new data point observed, the capacity of the concept to represent is reviewed. Each interpretation and finding are compared with existing findings as they emerge from the data analysis. With a finite data set, the iterative process from data to theory evolves to the point at which insights from the process have been exhausted. There is no final data set for mental health practice. As such, the iterative process between application and theory is a constant. Systems are rooted in principles. A principle has been defined as “a fundamental truth or proposition on which others depend; a general statement or tenet forming the (or a) basis of a system of belief, or a primary assumption forming the basis of a chain of reasoning” (OED Online, n.d.). Here are the principles, underlying SC2.0 as we understand them today: 1. To maximize impact, a broad continuum of programming—including self-­ managed resources, family/community/peer support, and professional services—matched to readiness, preference, and need is offered, for example:

(i) Low intensity (ii) Same-day access (iii) E-mental health (iv) Multiple modalities (in person, phone, web) (v) Therapy one-at-a-time

2. Recovery principles and collaborative, co-created wellness plans are incorporated in all therapeutic encounters. 3. Therapeutic measurement is for users and must be part of every care encounter.

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4. An agile, flexible, responsive model, co-designed with persons with lived experience, must be represented graphically so that the entire system and its parts can be viewed at a glance. Representing the model graphically, as described in the fourth principle, ensures transparency. A recovery-based model is only as useful as it is visible. A graphical representation allows stakeholders to see the forest and the trees. It is equally important for stakeholders to see the many distinct relevant options as it is to see the big picture or to discern an overall pattern from this mass of detail. Preference is viable only if informed by the principles that organize the elements into a whole. Informed choice requires an understanding of how each option is distinguishable from the others and relates to the system organizing principles.

8.2 Synergy and Culture Two psychologists have influenced my work in lasting ways. John Conway was my supervisor for both my master’s and doctoral theses. Richard (Dick) Katz sat on both committees as an advisor. While both John and Dick were more foxes than hedgehogs (see Chap. 7), Dick focused on Indigenous healing, whereas John had no one true calling. John is, perhaps, what career coach Emilie Wapnick calls a multipotentialite. He has had many interests, jobs, and interlocking potentials. John, now retired, was a psychologist and, more recently, a photographer. He was interested in personality, humanism, and social activism. He was comfortable supervising students like me, whose interests were both broad and idiosyncratic. John was a generalist and as such did not believe he needed to play the expert role when supervising. Instead, he gently guided exploration and discovery. Dick started his career at Harvard at the time of Timothy Leary and Richard Alpert. Those were heady days. He spent 2  years compiling an ethnographic study of the Kalahari!Kung tribe in Botswana and has become a leading scholar in Indigenous healing psychology (Katz, 2017). He introduced me to the concept of synergy. Buckminster Fuller was another multipotentialite. He was an architect, systems theorist, designer, and inventor, most famous for his work on geodesic domes. I grew up in Montreal. I was 4  years old in 1967 when my birth city hosted the World’s Fair. The feature that most impressed me at the time (besides the punching balloons distributed for free at the gate) was the American Pavilion (named the Biosphere), a giant geodesic dome designed by Fuller. According to Fuller, synergy means “the behaviour of whole systems unpredicted by the behaviour of their parts taken separately” (Fuller, 1975). Admittedly less elegant than the structures he is famous for, this definition can be rephrased as the whole is greater than the sum of the parts. A geodesic dome is made of up of thousands of simple tubes of metal, which on their own have limited strength or potential. But arranged in the shape of a dome, they form what engineers claim is the most efficient and robust structure imaginable. Domes are lightweight but almost indestructible. Fuller’s Biosphere is

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still there despite bursting into flames during minor renovations in 1976. It is now a museum dedicated to promoting the environment and its protection. Dick Katz applies the concept of synergy to distinguish ancient Indigenous healing practices from those of modern Eurocentric medicine (Katz, 2017). In the context of Western medicine, healing resources are scarce, expensive, and difficult to access. In the context of our capitalist economy, scarce resources are highly valued, and their value can only be maintained if the supply is either naturally or intentionally limited. The cost of years of required specialized training ensures that Western medicine will retain its rare commodity status. Ancient Indigenous healing resources, Katz argues, are plentiful, and because these resources belong to everyone, their potential is virtually unlimited. Everyone in the community brings healing potential. And when those healing resources are welcomed and arranged with care, they take on the synergistic power of a geodesic dome. This is a power with others. It literally takes a village. My vision for SC2.0 has been inspired by the concept of synergy. There are almost endless parts—unlimited options for supporting mental health. If these are arranged thoughtfully, they can create a powerful and sustainable system of mental health. Each part alone is limited, but when connected, integrated, and held in balance, healing is perpetuated. If one small part, one tube, fails, the remaining pieces keep the structure intact. Failing forward is possible. If a specialist is not available for months, a peer support person can make the wait more meaningful. Waiting is no longer unproductive. The structure ensures endless support. It is easy to get lost in complex systems. By bringing together so many parts, SC2.0 can get messy and tangled. I am no stranger to this. I am the first to admit that my nine-step graphical representation of SC2.0 is a little short on elegance. True also for the distributive design cycle introduced in Chap. 6. I need a little more parsimony. Perhaps it is not surprising that we can find some of the most elegant structures featured in the longest surviving human cultural communities. The igloo is a dome made from the (once) most ubiquitous material—ice. Tragically, it is now becoming a scarce commodity. The teepee is another elegant structure. A few poles and animal skin. Both natural, sustainable materials that are used frugally and efficiently. The structure is portable allowing for movement across the land. And with that movement, the land recovers so that it may continue to sustain life. Can SC2.0 be inspired by this ancient wisdom? It is still too early to tell. I have, admittedly, appropriated this knowledge. My intent is to engage with Indigenous peoples and elders when the time is right. When I am invited to do so. Their voices are needed to further inform the transformation process.

8.3 Frugal Innovation Navi Radjou has spent years studying “jugaad” or frugal innovation. He defines it simply as “doing more with less.” Radjou puts an environmental sustainability spin on his call for “global innovation networks” to “create more business and social

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value while minimizing the use of diminishing resources such as energy, capital and time.” Ironically, while globalization has lifted many out of poverty in developing nations, including Radjou’s native India, it has also accelerated climate change and eroded the middle class in developed nations, widening the gap between rich and poor. Not surprisingly, critics smell a rat. Frugal innovation is the latest chapter in neo-liberal policies that shift the cost burden to consumers and lend support to public and private austerity measures. And somehow the rich still get richer. Radjou’s next forthcoming book, Conscious Society: Reinventing How We Consume, Work and Live, will extend frugal innovation to lifestyle (Radjou, 2020). Innovation often has both bright and dark sides. An improvement is an opportunity that can distribute benefit or withhold it. In the case of SC2.0, some critics argue that the model enables funders to divert investment in mental health by cutting expensive specialist care and shifting labor to less expensive technological or “cost-­ free” alternatives such as peer and family support. Insurance companies will retain cash that can be invested in stocks and their own bottom lines. I am under no illusions; there is no doubt that this incentive is driving corporate decision-making. However, savvy business leaders have been aware of high return on investment in mental health spending for longer than their public sector and academic counterparts. Investment in mental health will not consume scarce resources or damage the environment. Better partnerships between public and private sectors are needed to ensure that everyone wins. Social and corporate enterprise can co-exist. Vibrant social democracies in Europe have proven that partnerships between labor, industry, and government work. There does not have to be a loser. It is time to abandon the zero-sum, divisive, confrontational North American scarcity-based paradigm in favor of a more collaborative, synergistic paradigm. Mental health care has long been the purview of elites. It was this way in Victorian times and not much has changed. In his 1964 book, Psychotherapy: The Purchase of Friendship, psychologist William Schofield suggested the profession is biased toward treating only those who are young, attractive, verbal, intelligent, and successful (or YAVIS). What has changed? Cheaper psycho-pharmaceuticals with less adverse side effects have extended the reach of treatment, but psychotherapy is still only accessible to those with privilege. If anything, what has changed is that we have a greater appreciation of how psychotherapy privileges the white, heterosexual YAVIS population. While we are not there yet, one of my goals with SC2.0 is that we might finally release the power and potential of mental health innovation to benefit the whole population.

8.4 Evolution or Revolution My colleague and friend, Gillian Berry, has written a chapter to be published in the next SC2.0 book in the series. She said she wants to call it, “Why SC2.0 Won’t Work.” That’s okay, I thought. She’s a disruptor too. Gillian is of Caribbean descent. Her ancestors were enslaved people transplanted to what is now Guyana. She was

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born and raised in England and now lives in the United States. She was the first to implement SC2.0  in the United States at the George Washington University Counseling Center. Her approach was bold. On 31 August 2015, the triple-digit wait-list was eliminated. Overnight, she and her team introduced a same-day, walk­in only access system. Students at this large, private, expensive university were pleased with the model. While some staff struggled at first and there was a fair amount of turnover, the staff who remained and those who were subsequently hired could not imagine turning back. Back to Gillian’s title. As a woman of color and descendent of enslaved people, Gillian is skeptical of any promise of reform. “The entire system is broken and rigged against us!” she exclaims. “How can you even imagine this will make a difference?” True, I think. Paradigm shifts are rare. Evolution is slow. Revolutions seldom succeed. Gillian is undoubtedly a rebel leader, but she cannot afford to be as idealistic as me. Idealism is easy for a white, middle-aged, educated male. I was surprised and delighted to learn soon after I first met Gillian that she, like Dick Katz, had spent time in Botswana where she, too, learned about Indigenous healing from the Kalahari!Kung peoples. Gillian incorporates this ancient wisdom, practiced by her ancestors, into her practice with many of her marginalized clients. The practices are not privileged. They are accessible and empowering. It is a power with others. They speak truth to hegemonic power. But in the end, on their own or in the context of SC2.0, it won’t spark a revolution. Neo-liberal Ruse AnnMarie Churchill is a colleague who has been working closely with me on the implementation and evaluation of SC2.0. She has a master’s degree in social work and a doctorate in experimental psychology. Like me, she is a rebel leader and a systems thinker. It seemed like a slam dunk when she applied for a tenure-track position at Memorial University’s School of Social Work. She has decades of experience of training and social justice work with Indigenous populations; she is a fierce critic of systems and hierarchies. While she made it to the last round of interviews, the search committee did not recommend her for the position. The rumor was that her involvement with SC2.0 disqualified her. The faculty were suspicious. The model is just a neo-liberal ruse for reducing public investment in mental health by outsourcing to private industry (e-mental health vendors) and offloading care to peer supporters and informal (free) community-based networks. The assumption was that SC2.0 was a way to do less with less. I was not as surprised to see similar critiques from my colleagues on the listserv of the Association of University College and Counseling Center Directors. Most of the directors are counsellors or clinical psychologists by training. Disruption and social justice are not central to the curriculum. Some of the responses were predictable: “Stepped Care is a threat to our profession. It will erode the quality of our counselling and psychotherapy thereby short-changing students with inferior low-­ intensity care. It is the beginning of the end of our professions especially when we start to outsource to fly-by-night e-mental health vendors driven only by profits.” I was also not surprised to see critiques from colleagues in my own backyard. I

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received a copy of an email from a psychologist in Atlantic Canada who accused me of being a “shameless self-promoter.” Shameless disrupter, yes, but self-promoter? The fears expressed by colleagues in all mental health disciplines are well-­ founded. We know all too well that fear transforms into defensive anger when solutions cannot be found. The dangers are real. Neo-liberal forces are at work. Neo-conservative populism is another threat. Both work to erode investment in the public good for the benefit of elites. I don’t want to be duped by these forces. Good rebel leaders watch their backs and maintain healthy skepticism. My three grown children help me in this respect. My youngest is training to be an environmental chemist. She will save the planet. My middle child is an environmental geologist. She will fight the fossil fuel industry. My son, the eldest, is a legal aid lawyer fighting for the homeless and illegal migrants. My son said to me about this book and SC2.0: “It’s not going to do anything for my clients.” Gillian might agree. It’s still too YAVIS.

References Charmaz, K. (2014). Constructing grounded theory (2nd ed.). Sage. Fuller, B. (1975). Synergetics: Explorations in the geometry of thinking. Macmillan. Katz, R. (2017). Indigenous healing psychology: Honoring the wisdom of the first peoples. Healing Arts Press. OED Online. (n.d.). Oxford English Dictionary. Retrieved February 21, 2020, from https://www-­ oed-­com.qe2a-­proxy.mun.ca/view/Entry/196665?redirectedFrom=system#eid Radjou, N. (2020, May 20). NaviRadjou. Retrieved from NaviRadjou: Uplifter, Catalyzer, Connector. https://naviradjou.com

Part II

The Power of Conundrums: Beyond Stepped Care 2.0

1.1  Introduction Peter Cornish According to the Oxford English Dictionary, a conundrum is commonly understood as “any puzzling question or problem; an enigmatical statement” (Oxford University Press, 2022). Curiously, while the etymology is lost, early definitions, now obsolete, include “applied abusively to a person; a whim, crotchet, maggot, conceit; a pun or wordplay depending on the similarity of sound in words of different meanings” (Oxford University Press, 2022). It seems that from the beginning, “conundrum” has been a slippery word, one that can describe a frustrating problem, a person that refuses to go with the flow, or a sense of openness and play. Maybe that’s why I’m attracted to the idea of conundrums: they pose a challenge, but in a way that engages our creativity and curiosity. Since I first presented ideas on SC2.0 to colleagues at a conference in Chicago in 2014, I have been struck by two things: one, how much interest there is in this model, and two, how many questions arise. The model takes on a lot. As we learn and grow by engaging with more interested parties, SC2.0 is becoming ever more complex. It is no surprise that confusion abounds. However, the confusion seems to intrigue more than frustrate. This led me to the word “conundrum.” People are drawn to conundrums, just as they are drawn to enticing word or board games. Why not be more intentional and put together a series of essays that add fuel to the fire, drawing together those pondering the possibilities to work on the puzzles with us? This second volume is all about conundrums—the conundrums we have encountered as we have tried to continue our paradigm-shifting work. In this book, we elevate and infuse the contemporary definition of conundrum, “any puzzling question or problem,” with an energy that, we think, has the potential for driving creativity, innovation, and transformation. The word “conundrum” has a comical ring to it. But while it might not be the easiest to vocalize, eventually the word comes rolling off the tongue in a satisfying way. Like a drumroll, it prepares us for a

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much-­anticipated event. As with anything confusing or difficult, facing a problem brings tension and can intensify conflict or disagreement; we hope that the power of conundrums can help us move through that conflict and disagreement without shutting down. In this volume, you may encounter perspectives that feel alien or alienating, and some of what you read will perhaps inspire discomfort or defensiveness; after all, we are addressing difficult, longstanding problems sustained by oppression and white supremacy. But we aim to bring out the human side in these difficult conversations—a side that is variously serious, passionate, objective, subjective, confrontational, playful, alive, disheartening, and hopeful—despite the seemingly intractable challenges before us. We have not tried to present this work as if we have all the answers. On the contrary, we believe that a real paradigm shift is only possible by rigorously engaging with, and learning from, people who are as passionate as we are but who may have serious criticisms of SC2.0. To this end, each chapter explores a conundrum related to various aspects of the SC2.0 model, which I respond to in short reflections following the author’s contributions.

1.1.1 Chapter 9: Stepped Care, a Closer Look: Reviewing Evidence and Evaluating Outcomes Evidence-based practice is one of the cornerstones of mental health care, and when considering new treatments, new services, or even new systems, one of the first questions asked is often, “What is the evidence for this?” SC2.0 is no different. Administrators considering an SC2.0 approach want to know whether it will deliver what it says it will deliver, and clients want to know whether the care they are receiving will actually improve their well-being. But given that SC2.0 is a far-­ reaching and rapidly evolving system-level disruption of the mental health care system, determining whether there is evidence for SC2.0, and what evidence for SC2.0 would even look like, invites a number of conundrums. While there have been clinical studies of stepped care models, there are significant differences of opinion about what stepped care actually is, and a variety of very different models go by that name. A clinical study of “stepped care” may not reflect the unique qualities of SC2.0. This is further complicated by the fact that SC2.0 is designed to look quite different in various contexts and involves a wide demographic range of clients. Does stepped care produce better outcomes for young people or people from marginalized communities? Answering these questions would require a more targeted approach than has so far appeared in the academic research into stepped care. In this chapter, Amy Salmon, Mai Berger, Saranee Fernando, and M. Elizabeth Snow explore the conundrum involved in answering the question, “What is the evidence for stepped care?”

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1.1.2 Chapter 10: Diversity, Equity, and Inclusion and the Default Factor: An Indigenous Perspective Among the factors that make SC2.0 unique is its vision to rebuild mental health care systems using alternative philosophical foundations that incorporate Indigenous worldviews. SC2.0 seeks to leverage the unique contributions of each individual and honors the interconnections between us. The model also aims to empower clients to participate actively in their care options, decisions, and delivery. The concept of synergy embodied by SC2.0 goes beyond the standard definition of cooperation to include healing, empowerment, and justice. SC2.0 has the potential to create an environment where any person can receive appropriate and effective mental health support, no matter their race, religion, cultural background, gender identity, or sexual orientation. SC2.0 also aims to revolutionize traditional mental health treatment by recognizing that support can be offered from non-licensed professionals and unconventional sources and at customized times. However, the biggest conundrum facing SC2.0 is the Western cultural values that so thoroughly dominate corporations, academia, and social structures. SC2.0 understands that historical injustices have been embedded in mental health care systems over the past several centuries. It advocates for mental health programming to adopt a restorative approach to repair what has been done and allow healing to occur. Among the institutional practices standing in the way, however, is the tendency to compartmentalize people through labels such as clinical psychologist, clinical social worker, and professional counselor. This creates hierarchies between the experts and the communities they serve. In this chapter, Gillian Berry argues that SC2.0’s true power comes from its potential to shift the dominant culture, which requires changing approaches to mental health care that have been ingrained as “absolute truths.” Unless the supporting infrastructure is in alignment with the mission of SC2.0, Berry writes, mental health transformation will remain impossible.

1.1.3 Chapter 11: Adaptability and Fidelity: Exploring the Relationship Between the Two When Implementing SC2.0 As SC2.0 grows and expands, it is being adopted by a wide range of communities, from university mental health units to provincial mental health organizations. In implementation science, adaptability and fidelity are often viewed as being in tension, such that to adapt a model is to make it less faithful to the original vision. Because SC2.0 is designed not just to be adapted but co-designed by local communities, this creates a conundrum: How should we understand the relationship between adaptability and fidelity when fidelity requires adaptability? How can organizations seeking to adopt an SC2.0 approach be confident that they are doing SC2.0

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well, when doing SC2.0 well means that it won’t look the same as other implementations of SC2.0? These are important questions for SC2.0 to grapple with as it expands into new communities, and the authors of this chapter, Alexia Jaouich, Stacie Carey, Kaitlin Saxton, Joshua Rash, and Jacquie Brown, provide a sophisticated analysis of the problem. Does the fidelity/adaptability conundrum disappear if we understand that fidelity is adaptability? How can SC2.0 communicate this idea to organizations interested in applying SC2.0 to their own context? The SC2.0 core components and principles offer a framework in which these questions can produce generative solutions that help organizations implementing SC2.0 identify its active ingredients— and create an SC2.0 system where its uniqueness is a sign of its fidelity.

1.1.4 Chapter 12: Oil and Water: Why the Legal Risk Paradigm Conflicts with Good Therapy The existing mental health care system, like the primary care system, has been designed around the minimization of risk. In some ways, this is understandable. What clinician wants to expose their clients to risky medications, or treatments that may do more harm than good? But in a neoliberal society governed by adversarial litigation practices, natural concerns about risk can transform into an obsessive desire to reduce institutional exposure to lawsuits—even when client care is negatively impacted. Risk is an inevitable part of human life, and trying to avoid risk at all costs has contributed to the crisis in mental health care today. SC2.0 is rooted in an understanding that not all risk is bad, and embracing risk can be an important step on the journey to wellness. However, SC2.0 operates in a world where the risk paradigm continues to shape decision-making at all levels, from the clinician’s encounter with a client to the system administrator’s allocation of resources. How can SC2.0 challenge this paradigm and shift mental health care systems toward a more open approach to care when the structures in which it is being implemented continue to be profoundly risk-averse? In this chapter, Kami Sidman and Justin Jacques look at the problems inherent in the risk paradigm and how this creates a conundrum for the implementation of SC2.0.

1.1.5 Chapter 13: Reimagining the “Gold Standard” Since the foundation of modern psychotherapy, it has been widely accepted that the “gold standard” of mental health care is a regimen of regular one-on-one sessions between a licensed clinician and a client. While this is still enshrined as the norm for what good psychotherapy involves, a growing number of researchers have begun to

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question whether this is the best way to deliver mental health care, especially given the bottlenecks and wait-lists that are creating significant barriers to access for those seeking care today. Alternatives to the “gold standard” are being explored in a wide range of contexts, and these alternatives go by many names: brief therapy, single-­ session therapy, one-at-a-time, open access, walk-in therapy, and more. The proliferation of terms for this approach to therapy creates a conundrum in and of itself, but there are also disagreements about what alternatives to the “gold standard” should actually look like. Should one-at-a-time only be offered by a licensed professional or can this approach be useful for unlicensed workers providing mental health care and support in other contexts? Given that most licensed mental health care professionals make a living from ongoing one-on-one sessions with clients, does one-at-a-time represent a threat to the livelihoods of those providing mental health care? If clients expect “gold standard” treatment, will they feel shortchanged by a one-at-a-time approach? When it comes to providing alternatives to the “gold standard,” there are many conundrums that need to be unpacked. This complexity is reflected in this chapter, which consists of three perspectives on the problem from Monte Bobele, Arnie Slive, and Heather Hair.

1.1.6 Chapter 14: Stubborn Hierarchies: The Challenges of Co-Design SC2.0 consists of nine active ingredients that, taken together, provide a framework for delivering a system-wide change to mental health care. The first of these ingredients is co-design, which is meant to diplomatically disrupt decision-making by giving a wide range of stakeholders a seat at the table when it comes time to design new mental health systems and services. Co-design is predicated on the belief that there are many varieties of expertise, and people with lived and living experiences of accessing services have an essential role to play in determining what services should be offered. When co-design is done well, it radically expands the range of possibilities, democratizing systems by introducing new perspectives and new ideas into the design process. Because co-design is a direct challenge to the business-as-usual way of doing things, those seeking to engage in co-design often face structural obstacles related to existing power imbalances within the mental health care professions and society as a whole. Like other attempts to democratize and transform systems shaped by traditions of hierarchical thinking, co-design faces significant headwinds. Having a good road map for doing co-design is no guarantee that co-design will not simply become an exercise in lip service. How do we maintain the revolutionary potential of co-design in a context where so many inequalities exist? In this chapter, Marion Cooper explains the co-design process, identifying the many ways it can be compromised by a lack of resources or poor execution.

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1.1.7 Chapter 15: Leadership and Stepped Care 2.0: A Cautionary Tale SC2.0 is becoming a popular approach to delivering mental health care to postsecondary students. However, fully implementing the model requires a whole-system transformation that begins at the highest levels of leadership. In this chapter, Gillian Berry and Janis Campbell explore the conundrum of fostering transformational leadership within a dysfunctional mental health infrastructure that fails to meet the needs of clients from different backgrounds and identities. They do this by way of a cautionary tale about a Fictitious College’s counseling center. The authors liken the traditional mental health model to a classical symphony, where practices are built to exist within certain boundaries and roles. However, the fluid and evolving nature of the SC2.0 mental health model requires a leader who is able to adapt—who can invest in the workforce, promote transparency and communication, and is solution-­ focused. Berry and Campbell warn that without such adaptation, a formal, predictable, and contained “power-over” approach to SC2.0 will ultimately fail. The cautionary tale showcases the pitfalls of Fictitious College’s SC2.0 implementation, highlighting the negative effects of authoritarian leadership styles on morale and trust within the counseling center. To support the profound changes SC2.0 brings, in other words, this requires leaders who focus on the collective good, encourage constructive discussion about the integration efforts they are overseeing, and are sensitive to the growing pains involved in SC2.0 disruption. Ineffective leaders, in contrast, focus on individual interest, are defensive and impatient, and fail to provide reassurance about next steps.

1.1.8 Chapter 16: The Dilemmas of a Recovery-Oriented Practice The term “recovery” has become a controversial concept in the wellness industry, especially in the context of substance use and mental health. The harm reduction approach of recovery respects individual choice, while abstinence-oriented recovery takes that choice away, putting the two approaches at odds. This situation puts SC2.0’s recovery-oriented services, which are committed to supporting a patient’s decision to reduce the harms of substance use at their own pace, in constant danger of being mistaken for an abstinence model. The potential for confusion not only risks undermining SC2.0 core recovery principles, which are rooted in autonomy and self-determination, but can create uncertainty for potential funders. How can SC2.0 continue to use recovery as a guiding tenet while avoiding confusion about what it means? In this chapter, Mary Bartram argues that, to resolve this conundrum, SC2.0 should spell out its stance on abstinence and address the contested nature of the term “recovery” directly in its self-description. It should acknowledge that recovery is

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interpreted differently in the mental health and substance use sectors and clarify that SC2.0’s model is inclusive of both harm reduction and abstinence-based approaches.

1.1.9 Chapter 17: SC2.0 and the Conundrums of Intensive Care Many of the chapters in this book focus on the ways SC2.0 can improve the well-­ being of clients who are able to seek care on their own terms, out of their own initiative. SC2.0 holds to the conviction that the vast majority of clients do not need intensive care to see improvements in their mental health and that our mental health care systems are too focused on treating problems that have been allowed to fester rather than providing proactive preventive treatment. But what about clients who require care at higher steps? What about clients living with complex and persistent mental illness that may require more intensive care? What is the role of medication in SC2.0? Can SC2.0 make room for these clients’ experiences and address the marginalization they often face? SC2.0 is a holistic approach to care that recognizes that clients can benefit from a wide range of treatment options—including options that may not traditionally be considered mental health care. But there may be practical challenges involved in ensuring that individuals living with serious forms of mental illness are able to access care with dignity, and these challenges sometimes go beyond the mental health care system itself to include issues around housing, policing, and crisis intervention. In this chapter, Andrea Levinson explores how SC2.0 can help psychiatrists and other mental health professionals think through the conundrum that arises when clients have a reduced capacity to act on their own initiative to take care of their own well-being and the well-being of others.

1.1.10 Chapter 18: We Think We’re Missing Something—A Conversation Following the murder of George Floyd in 2020, a racial reckoning swept the United States and many other parts of the world. This passionate response to injustice galvanized many activists to challenge racist and colonialist structures and imagine a more equitable world in which such tragedies would not take place. In the world of mental health care, the response to these events was curious: a lot of emphasis was put on how traumatizing the murder of George Floyd had been, but the underlying assumption seemed to be that our job as mental health professionals was to make people feel better. Was this a form of social control? Wasn’t the anger and outrage justified? Shouldn’t we be supporting activism? Shouldn’t we be helping to channel that energy into action?

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The mental health care model put forward by SC2.0 should be much more action oriented and community development oriented. If we are committed to building a more just world, our role must go beyond simply hearing and empathizing with people’s pain. We should be actively engaged in redressing the systemic inequities that have shaped our world. Does SC2.0, as it currently exists, go far enough? Is the very fact that we describe it as a “stepped care model” confusing? Are there missing ingredients that would help us move beyond providing a model of care to providing a model for real transformation? The final chapter of this book consists of a transcript of a conversation between AnnMarie Churchill, Gillian Berry, and myself, in which we explore the question of whether SC2.0 is sufficiently up to this challenge and what it would take for SC2.0 to truly promote well-being everywhere. Conundrums open us up to new possibilities—rather than viewing them as problems to be solved or ignored before moving on, staying with these conundrums and thinking through them can help us question and reimagine current mental health system assumptions, practices, and evidence. This book is meant to encourage readers to lean into mental health transformation. This is a goal that requires wisdom and input from all of us, and so it is equally important for readers to question the work of the contributors to this volume. My hope is that readers will carry the questions further and join us on the journey to well-being everywhere! Reference Oxford University Press. (2022). Conundrum. In Oxford English dictionary online. Retrieved February 23, 2023, from www.oed.com/view/Entry/40646

Chapter 9

Stepped Care, a Closer Look: Reviewing Evidence and Evaluating Outcomes Amy Salmon, Mai Berger, Saranee Fernando, and M. Elizabeth Snow

9.1 What Is the Evidence for Stepped Care? Over the past decade, various approaches to stepped care have been touted as a potential solution for a range of challenges facing the world of mental health and substance use (MHSU) services. Stepped care models promise significant benefits both for clients and for those working to deliver MHSU services, by improving efficiency, creating a more client-centered approach to care, reducing wait times, and extending forms of care to populations that have often been excluded from more traditional ways of delivering mental health care. In particular, stepped care models have been shown to improve access to, as well as efficiency and coordination of, mental health resources and services, and they are increasingly being identified as a “best practice” in delivering mental health services (Bower & Gilbody, 2005). However, despite increasing popularity, there is little evidence available to guide health-care and social service decision-makers wishing to develop and implement stepped care models in MHSU services. The world of MHSU is in a state of flux, as service providers struggle to keep up with demand and meet mental health challenges resulting from the COVID-19 pandemic, the opioid crisis, and other factors while also responding to the longstanding need to make mental health care more accessible and responsive to people experiencing various forms of marginalization. Evidence is needed to respond to the shifting MHSU service landscape; to develop and implement stepped care models for specific populations, including youth and young adults, and diverse cultural and/or geographic communities; and to inform A. Salmon (*) · S. Fernando · M. E. Snow Centre for Advancing Health Outcomes, Vancouver, Canada e-mail: [email protected]; [email protected]; [email protected] M. Berger First Nations Health Authority, Vancouver, Canada e-mail: [email protected] © Springer Nature Switzerland AG 2023 P. Cornish, G. Berry (eds.), Stepped Care 2.0: The Power of Conundrums, https://doi.org/10.1007/978-3-031-45206-2_9

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the development and implementation of stepped care models for mental health-care systems (LaLonde et al., 2022). Both clients and service providers require evidence to make informed decisions. Clients entering a stepped care model for mental health care have a right to know whether this is an effective model for treatment, and clinicians and administrators adapting stepped care models to serve their own communities want to know whether these models have a proven track record of improving outcomes for clients. In addition, they want to know whether these models have actually been shown to reduce bottlenecks and wait times. Evidence, therefore, plays an important role in giving key clients, providers, and system leaders the confidence to move forward with a stepped care model. Evidence is also necessary to monitor the progress of existing stepped care programs to evaluate whether these programs are providing the support they are designed to deliver. There is a particularly urgent need for comprehensive evidence to support the timely and effective delivery of MHSU services for youth and young adults. Globally, MHSU concerns are the leading cause of health-related disability in young people, with an estimated 10–20% of adolescents worldwide experiencing mental health conditions (Kessler et  al., 2005; Polanczyk et  al., 2015). Timely access to MHSU supports early in life can also offer an important means of secondary prevention, with 75% of MHSU disorders emerging before the age of 25 and about 50% of those becoming apparent by the ages of 14–15 (Kessler et al., 2005, 2007; Kim-Cohen et al., 2003). In many parts of Canada, as few as 25% of youth and young adults with MHSU disorders receive timely and appropriate care while addressing their developmental needs and goals (Farris et al., 2018; Gill et al., 2017; Henderson et al., 2017; Hetrick et al., 2017). Youth, young adults, and their families are particularly likely to report “falling through the cracks” and finding mental health systems uncoordinated, adult-oriented, and difficult to both access and navigate (Farris et al., 2018; Kokanović et al., 2018; MacDonald et al., 2018). Prevention and early treatment for mental health challenges are widely recognized as being essential for young people to achieve their full potential (Anderson & Lowen, 2010; Rickwood et  al., 2007). In this context, stepped care models are emerging as a promising practice approach for delivering MHSU services to young people. But what evidence is available to guide these efforts? To answer this question, between 2018 and 2020, our team conducted a scoping review of the literature on stepped care models for MHSU service delivery to youth and young adults between the ages of 12 and 24. We selected this age range in particular because this is the age group that many MHSU services using stepped care for youth and young adults are intended to serve. From the beginning, this scoping review faced a number of challenges. Typically, our role as academic consultants is to look at the evidence and make recommendations about the best course of action, based on what the review turns up. But with stepped care, the published, peer-­ reviewed evidence needed to support decision-making is far behind existing practice. The innovation driving many stepped care models is happening at the grassroots, among people with a direct interest in making services more accessible, including clients, administrators, practitioners, academics, and activists.

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As we shall see, this has created problems when it comes to evaluating the evidence for stepped care more broadly and Stepped Care 2.0 (SC2.0) in particular. Since completing the scoping review, we have been involved in creating and implementing evaluation resources for stepped care models at various stages of implementation. This chapter summarizes some of the key findings from this work and explores one of the central conundrums facing those who advocate for stepped models for MHSU services: how should we understand the evidence for stepped care?

9.2 How Strong Is the Evidence for Stepped Care Models for Youth and Young Adults? We identified 51 relevant articles to include in the scoping review. We grouped studies that were similar enough to analyze together (i.e., studies that used the same sample of participants and/or stepped care design), which yielded a total of 43 grouped studies from 42 study teams. Because very few published studies exist of stepped care interventions for MHSU specific to the 12- to 24-year age range, we expanded our inclusion criteria to allow for any study with participants within that age range. Among the 43 grouped studies, about half (n = 20) were focused on the typically defined “adult” age ranges of 18–64, while 28% (n = 12) were actually focused on youth and young adults between the ages of 12 and 24. The remaining 26% (n = 11) were focused on children. This raises questions about whether the findings of these studies are generalizable to youth and young adults in the 12-24 year age range. The earliest studies were from the 1990s, with most being published around 2013—though some of the publications included in our review were from as late as summer 2018, suggesting that interest in stepped care is continuing. Most of the research was conducted in the USA, the Netherlands, Australia, Germany, and Canada, and close to half of the studies looked at the treatment or prevention of anxiety and depression.1 Females made up a higher proportion of the study samples than males in the literature we reviewed, and no study reported on sex and/or gender outside of the male and female binary. The search strategy we used to identify what we would include in the scoping review and the results that we built the review around are outlined in Fig. 9.1. After we completed the scoping review, we conducted a second review, applying the Cochrane Collaboration’s GRADE criteria to assess the strength of the evidence we’d found regarding the effectiveness of stepped care models for improving specific mental health conditions: depression and anxiety in youth and young adults aged 12–24 (GRADE is an approach to rating the evidence of systematic reviews  Depression and anxiety are commonly comorbid mental health disorders (Bennett et al., 2018). Rates of anxiety disorder among youth with depression have been reported to range from 15% to 75%, while depressive disorders have been shown to occur in 10% to 15% of youth with an anxiety disorder (Bennett et al., 2018; Cummings et al., 2014). 1

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Fig. 9.1  Search strategy and results

and other attempts to synthesize information). After several screening stages, studies were analyzed under the GRADE domains: risk of bias, inconsistency, indirectness, imprecision, and publication bias. This review yielded a total of 15 studies meeting the inclusion criteria,2 including outcomes related to anxiety and/or ­depression symptom severity or the elimination of related diagnoses. Using the above criteria, most studies included in our review were assigned a “very low” or “low” rating.

 For the systematic component of our review, we further refined our inclusion criteria to include only studies that reported clinical and/or functional outcomes for clients/patients/participants who received care via a stepped care model. We excluded reviews, commentaries, letters to the editor, study protocols, and editorials at this stage. Using these criteria, we identified 29 studies. To consolidate the evidence base, studies that used the same study sample were grouped by study team (i.e., if a research team conducted a randomized controlled trial (RCT) and then conducted additional analyses on the same data generated by the original RCT, these studies were represented as a single study). This yielded 24 grouped studies. Of the 24 grouped studies of interest, 14 reported on symptom severity or changes in diagnoses related to anxiety and/or depression. 2

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9.3 Assessing the Strength of the Evidence: Does Stepped Care Lead to Improved Clinical Outcomes for Young People? For this second review, we further refined our inclusion criteria to include only studies that reported clinical and/or functional outcomes for clients/patients/participants who received care via a stepped care model. Of the 26 grouped studies of interest, 15 reported on outcomes that included symptom severity or changes in diagnoses related to anxiety and/or depression. The remaining studies (excluded from this chapter) included outcomes related to alcohol abuse or risky alcohol consumption (n  =  3), eating disorders (n  =  3), obsessive-compulsive disorder (1), post-partum depression (n = 1), anti-depressant prescribing rates (n = 1), trichotillomania (n = 1), and post-traumatic stress disorder (n = 1). In general, the choice of outcomes among studies was consistent: reduction of anxiety and/or depression symptom severity and elimination of related diagnoses were common primary and secondary outcomes observed among the studies. However, while these studies focused on similar outcomes, they did not assess those outcomes in the same way; heterogeneity due to study type, type of stepped care approach, and type of control used reduced overall comparability. Across stepped care models identified in this review, the level of clinical intervention was also highly variable. This was described as a function of available resources and study design, rather than as an attempt within the studies to tailor services offered to the needs of specific clients or communities. In addition, there was considerable variability in scales used to measure depression and/or anxiety and diagnostic criteria between studies. We contend that the variability we observed between studies examining stepped care models within the context of young people with depression and/or anxiety disorders points to the lack of consensus on what “counts” as a stepped care approach. Out of the six randomized controlled trials (RCTs) addressing depression and/or anxiety outcomes, five RCTs showed no difference in symptom reduction among participants receiving stepped care compared to treatment as usual. These findings are summarized in the two tables below (Tables 9.1 and 9.2). The structure of these tables has been adapted from “Rating the Certainty in Evidence in the Absence of a Single Estimate of Effect” (Murad et al., 2017). Table 9.1  Summary of findings re: depression and anxiety symptoms Outcome Symptoms of anxiety and depression using various scales

Effect Reduction in symptom severity or elimination of anxiety and/or depression

Adapted from Murad et al. (2017)

Number of participants 37,678

Certainty in the evidence Very low, due to the presence of non-RCT studies, indirectness, risk of bias, and imprecision

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Table 9.2  Application of GRADE approach

GRADE domain Methodological limitations of studies

Indirectness

Imprecision

Inconsistency

Publication bias

Judgment Out of 15 trials, 8 presented with a risk of bias. Out of eight, four had a serious risk of bias in the items assessed (selection bias, randomization, self-reporting, sample size, and blinding). The remaining four trials with a very serious risk of bias were due to multiple potential sources of bias, including non-­ randomization and poorly controlled treatment interventions and/or participant groups. Therefore, we judged these trials to have serious methodological limitations Due to the lack of studies directed specifically at our identified youth population (12–24 years of age) or reporting of results stratified by age, the included studies do not provide direct evidence to the research question at hand. All interventions adapted are stepped care models (with some variation in the number of steps, treatment type, and/or treatment intensity). Overall, we judged the evidence to have serious indirectness largely due to the lack of youth-focused studies in the area of stepped care services for depression and/or anxiety Small sample sizes were observed in eight studies. The total number of patients included in all the trials was 37,678. This number is skewed by 1 study with 28,498 participants (Delgadillo et al., 2017). Some studies reported considerable attrition (low retention rates) and the presence of “non-­ significant results” likely because of enrolling a small number of participants, resulting in wide CIs that included meaningful benefits and no effects. We judged the evidence to have serious imprecision The direction and magnitude of effect were relatively consistent across studies. That said, the type scales used to measure outcomes were slightly variable between studies. Some variation in study setting, stepped care model, treatment as usual, and population age group was present. Overall, the results showed either small reduction in symptoms or no change There are few studies available in this area, and risk is higher among studies based on small RCTs; thus, we suspect risk of publication bias

Concerns about certainty domains Serious

Serious

Serious

Not serious

Serious

Adapted from Murad et al. (2017)

Given the low to very low ratings studies on the efficacy of stepped care models received in this review, it would seem that there is a lack of clinical literature providing solid evidence that stepped care models are an effective alternative for clients to treatment as usual. To better understand the results of the scoping review—and the conundrums around evidence facing organizations that believe a stepped care model is a better way of delivering mental health care—it is necessary to explore some of the concrete reasons why the scientific literature on stepped care models has yet to

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consistently demonstrate the clinical effectiveness of this approach to care delivery for youth and young adults.

9.4 How Applicable Are These Studies to SC2.0? Based on the evidence found in our scoping review, there would seem to be little evidence supporting the idea that stepped care models are more effective in achieving positive mental health outcomes for youth and young adult clients compared to treatment as usual. But is this actually the case? In order to understand how applicable existing literature is for SC2.0, it is necessary to consider the limitations present in these studies. One of the principles of evaluating evidence in this way is that like should be compared to like. As we will see, there are many complicating factors when it comes to determining what “stepped care” actually means and whom it can best serve.

9.5 What Is Stepped Care? A significant challenge we confront is the lack of a consistent definition of “stepped care” in the available literature. When assessing what was common to the stepped care models identified in our review, and in terms of the content or design of the stepped care interventions themselves, the most common characteristic we found was simply that they were all called “stepped care models.” Aside from that, we found considerable heterogeneity in all other aspects of the interventions that described themselves as some kind of “stepped care model.” This included important elements such as the overall number of steps, the treatment type and intensity for each step, the professionals involved in providing care or guidance, the setting in which care is provided, and the criteria for stepping up and down. In the scoping review, we identified 35 studies (81%) that specified the number of steps in their stepped care intervention, and the number of steps per model ranged from 2 to 9 steps with a median of 3 steps. The child- and youth-/young adult-­ focused studies both had a median of three steps, in comparison to the adult literature, which had a median of four steps. The youth- and young adult-focused studies had more studies, with a greater number of steps, i.e., five steps (n = 2) and nine steps (n = 1), than the other age categories. Interestingly, we found more variability at steps 1 and 2 in terms of the treatment type, intensity, and care provider, compared to steps 3 and above—but this makes sense when one considers that steps 1 and 2 are typically the prevention-based treatments that are more novel aspects of the stepped care interventions, while steps 3 and above tend to be based on established forms of mental health care. Most of the literature described specific interventions (such as cognitive behavioral therapy or bibliotherapy) delivered in the context of a stepped care

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intervention, but none described the stepped care model as being embedded in a larger system or context for service delivery. This is contrary to many high-profile efforts to advocate for stepped care service design that takes a community-level and/ or system-wide approach. For example, SC2.0 is predicated on the idea of systems transformation, rather than on specific interventions. One of its bedrock principles is that mental health care should incorporate a range of different treatment options beyond the usual scope of mental health-care treatment. Specific interventions are used to populate the SC2.0 model, but the focus is more on things like co-designing the system with all who are involved or affected using strengths-based, recovery-­ oriented, client-centric, and open-access/one-at-a-time thinking in all interventions. It also involves a focus on population health and engaging everyone in the community, not just those in the mental health sector. Because none of the studies in our scoping review were integrated stepped care models, it is hard to know how the existing literature on stepped care applies to the SC2.0 model or to any other integrated stepped care model. Stepped care is an emerging focus for research and practice, and, as we have seen, there are many different types of stepped care models. As things currently stand, there is no consensus definition in the literature for what stepped care is, beyond the idea that a stepped care model requires at least two levels of intervention—particularly in the context of MHSU service delivery for youth and young adults. That said, an overly prescriptive consensus definition may not be useful, given that approaches like SC2.0 are meant to be co-designed with local communities. What would be helpful are a set of guiding principles, a clearer understanding of the goals of a stepped care model, and an agreement about what constitutes a meaningful and effective stepped care model. This would, in turn, empower researchers to more accurately assess the implementation and effectiveness of various stepped care interventions across contexts, conditions, and communities.

9.6 Who Is Stepped Care For? In addition to the lack of a consistent definition of what constitutes a stepped care model, the literature we studied in the scoping review was also insufficiently targeted toward the populations who might benefit most from stepped care interventions for MHSU. In particular, the information around the age of participants and the demographic factors impacting inequity and marginalization did not allow for a more granular reading of the data. Furthermore, because the studies reviewed tended to focus on symptom management for those who have already met the clinical diagnostic criteria for depression and/or anxiety disorders, we do not know if stepped care models are effective in promoting better mental health among young people experiencing distress who have not yet met the threshold for diagnosis. Because many MHSU stepped care models are explicitly designed to better meet the needs of young people, people experiencing various forms of marginalization, and people who may not need intensive forms of mental health care, these gaps in the available

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literature are significant and limit the utility of the literature for guiding policy and practice change in MHSU service delivery for diverse groups of young people. Compared to the other age ranges, the youth- and young adult-focused literature had the fewest studies examining anxiety and depression, and yet these are the most common mental health diagnoses received by this cohort. A lot of the momentum around stepped care has arisen from organizations serving youth and young adults, a population that has experienced major gaps in their ability to get mental health care. The “adult” age range typically reported in the literature we assessed (which ranged from 18 to 64) is an extremely broad one. There is a growing understanding that mental health services need to be delivered differently for people at different ages and stages of life. A client in late middle age may experience very different challenges than a client just emerging into adulthood. In some cases, the experiences of an older demographic may be shared by a younger one, and vice versa, but not in all cases. Studies testing the effectiveness of stepped care models designed with younger populations in mind would benefit from greater focus on youth and young adults and the service contexts in which mental health services for this group (i.e., aged 12–24) are increasingly delivered. The literature reviewed also paid little attention to outcomes of stepped care for people experiencing inequities and marginalization. While there has been a growing commitment among mental health services researchers to look closely at currently and historically excluded and disadvantaged populations and to look at what mental health services work best for them, this dimension is not present in the current literature on stepped care models. This does not mean that the participants in the studies did not reflect the diversity of the greater population, but it was not reported on outside of the age range and the male/female binary. This makes it difficult to extrapolate from these studies whether or not stepped care models deliver better results for populations experiencing marginalization. We know that the biggest mental health disparities are experienced by communities that experience the most oppression and that experiences of marginalization and social exclusion can in and of themselves result in damage to people’s mental health, episodically and over their lifetime. We need an evidence base for stepped care models that explicitly attends to human need and human experience, but this is not currently reflected in the literature. Finally, most of the identified literature focused on symptom management of depression and/or anxiety or on preventing the progression of mild or moderate symptoms to a more severe form. Stepped care models provide a framework to treat a wide range of clients, including those who have been diagnosed with severe mental illnesses. But one of the primary features of models such as SC2.0 is a commitment to mental health promotion for people who may be experiencing distress and could benefit from supportive mental health and substance use care, but who may not meet clinical criteria for a specific mental health diagnosis and/or require intensive forms of therapy. A hallmark of open-access/one-at-a-time thinking is that a client may only attend a single session and that session might meet their needs. As much as 80% of those seeking mental health support will only attend a single session of therapy, and this population is one of the target demographics of Steps 1 and

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2 in the SC2.0 model. However, the literature we reviewed does not provide insight into the degree to which stepped care models could provide positive outcomes for this group. Taken together, this means that the literature we reviewed on MHSU stepped care models for youth and young adults is insufficiently attentive to important groups of people the SC2.0 model is designed to reach. As noted above, it is possible that the studies did, in fact, comprise diverse groups of young adults and people experiencing inequity and marginalization, but because this was not reported, we can’t know for sure. Until more focused research is undertaken on the specific outcomes of stepped care in these and other populations, it is impossible to determine the efficacy of stepped care models for these clients using the available published evidence at this time.

9.7 Where Do We Go from Here? What Evidence Is Needed for Stepped Care Models Supporting Youth and Young Adults? Since completing the scoping review, we have worked to develop evaluation resources that can help Stepped Care Solutions address some of the challenges caused by the significant gaps in the existing evidence. However, the evaluation toolkit for implementing SC2.0 is in its infancy and has not yet undergone testing. Some important questions will need to be answered: what is the best way to evaluate stepped care interventions? Are some methodologies better than others? What can we learn from attempts to evaluate stepped care in different locations? This type of evidence generation would be helpful in guiding the development of SC2.0. From our perspective as evaluators and methodologists, one of the most pressing needs faced by those advocating for stepped care models is the need for a clear, agreed-upon definition of what constitutes a stepped care model: what it is, what it does, and what values motivate it. Without a definition that can be applied consistently across a variety of stepped care models, it is difficult to gather reliable data about the effectiveness of stepped care for specific groups of clients, such as young people experiencing MHSU challenges. Stepped Care Solutions convened a steering committee to articulate the principles and core components of SC2.0 (see Chap. 12 of this volume), which may provide the foundation for such a consensus definition in the future. But the SC2.0 statement of principles and core components is distinct from other models calling themselves “stepped care,” which, for example, have fewer steps, and whether the SC2.0 definition will be widely adopted has yet to be seen. Either way, until there is an accepted definition of what stepped care is and is not, it will be hard to synthesize scholarly evidence to provide a reliable picture of its effectiveness. In addition to a consensus definition of stepped care as a whole, it is also necessary to promote consensus on components required for rigorous evaluations.

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Evidence is not only useful when it comes to determining whether stepped care models are effective, but it also makes it easier for organizations using a stepped care model to evaluate progress and enact course correction. Methodologically rigorous protocols for evaluating the performance of stepped care models would help organizations implementing them to see what is and is not working and to ensure that the active ingredients of the stepped care model are operating as they are meant to. While a consensus definition would help researchers compare apples to apples, we also need evidence specific to populations and contexts in which stepped care models are likely to be implemented, such as youth and young adults and service delivery for equity-deserving groups. For example, does a stepped care model that has a commitment to open-access/one-at-a-time thinking outperform treatment as usual when delivering MHSU services to those aged 12–24? Do mental health outcomes improve when an Indigenous community is receiving MHSU services through a stepped care model that includes traditional healing practices specific to that community? Having access to this kind of data would improve our understanding of how stepped care models impact different populations, as well as would provide greater insight into who can benefit the most from stepped care. There is a further complication in evaluating the effectiveness of a model like SC2.0: breadth. Many scientific approaches contain a bias toward studying interventions whose impact can be easily measured, and replicated, in a clinical setting. Setting up a randomized controlled trial for a specific therapy is much less complicated than determining whether a system-level transformation is having an impact on specific patient outcomes. SC2.0 is about creating a menu of options for clients to choose from, and, as such, it is greater than the sum of its individual parts. We must find ways to evaluate not just specific steps, but the overall approach to delivery. A number of the studies we reviewed for the scoping review were trying to use a model of testing and treatment similar to the kind that would be employed when testing a new medication: trying to limit confounders to figure out whether it is the treatment itself that is helping. What we miss when we do that is the more holistic, system-level understanding, which is actually how stepped care is being practiced in many cases. It’s not only about individual clinics making decisions about when specific treatments are going to be offered or not. It’s also about the system coordination piece to facilitate better access to some services and remove barriers to others. In our work as evaluators and methodologists, we take the position that we should be making decisions in the health system based on the evidence available to support those decisions. But we also acknowledge that, in order to be useful, evidence needs to be understood critically. As we have seen, the current evidence for stepped care models is incomplete, inconsistent, and fragmented. This creates a challenge for those advocating for a stepped care approach to mental health care. We are continuing to develop evaluation resources, such as an evaluation toolkit for SC2.0, for stepped care models that are still in their early stages of creation. We believe that it is possible to close the gap between practice on the ground and the scientific literature on stepped care. In the meantime, it will be necessary to develop a clear consensus on what stepped care is, even as what stepped care does continues to evolve.

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9.8 Reflection Peter Cornish What constitutes evidence? In most mental health disciplines over the past 40 years, this question has not been asked enough. Positivism was assumed to represent the truth; only results that led to the rejection of the null hypothesis were considered evidence-based. Mental health treatments and programs have been deemed either effective or ineffective through randomized controlled trials. By this standard, Stepped Care 2.0 is not evidence-based. As a counterpoint, however, one could argue that the scientific method, based on controlling extraneous variables, is not designed to evaluate something as broad and complex as SC2.0. A review of the literature is the starting point for most scientific studies. It helps distinguish knowns from unknowns. Unknowns pique our curiosity, and curiosity leads us to interesting questions. The questions are then turned into problems that can be solved. These problems lead us to hypothesize answers that can then be tested for validity with some measure of confidence. With SC2.0, we are in trouble right from the start. Salmon and her colleagues point out that there is no consensus definition of what stepped care is—so how might one fairly conduct a review of the literature? What literature is relevant? What is the phenomenon under investigation? What are we exploring? If we can’t answer these questions, the whole scientific exercise derails before leaving the station. So how is this not discouraging to those of us engaged with big ideas that can’t be broken down into testable hypotheses? I am reminded of my first existential crisis, which occurred early in my undergraduate studies. What would I major in? And what career opportunities awaited me? I recall my mother once saying I had a proclivity for business. At the age of 10, I was already innovating, finding efficiencies in managing my paper route. In those days, collecting cash from customers was an onerous weekly chore. I had 52 customers, and it sometimes took 3 to 4 hours along with return visits to obtain payment. But, I ultimately reasoned, if I saved up some money, I could pay my weekly bill from the newspaper company every week by collecting from only 12 or 13 customers. By week 4, the 12 or 13 customers would owe me for 1 month, and that would bring in enough revenue to pay the bill. So, I took business classes at university. I enjoyed the case studies, problem-­ solving, and even the accounting. But at the end of every class, the instructor asked, “What’s the bottom line; is it profitable?” He didn’t ask if the program was impactful or somehow useful to humanity. Really? Profit is the only thing that matters? Not only did this seem wrong; in the context of my white male privilege, it bored me. I started to wonder what else might be interesting to study. A young woman I was dating said she wanted to be a psychologist. In the throes of my adolescent crush, I quickly signed up for psychology classes. They turned out to be fascinating, especially social psychology. Thankfully, their appeal outlasted the crush. Why do people do such unreasonable things in certain contexts?

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In the course of my studies, I learned about the Stanford Prison Experiment, during which subjects assuming the roles of prison guards quickly became abusive to other subjects who were assuming the roles of prisoners (Haney et al., 1973). The classic diffusion of responsibility experiment also intrigued me (Darley & Latané, 1968; Latané & Nida, 1981). For a time, I was spellbound. What led to apathy among observers witnessing a horrific inner-city crime? Despite my growing interest in psychology, I remained restless. At the time, I was attending a large research university and living in an 11-story dormitory complex, famous for parties and appropriately nicknamed “The Zoo.” It was difficult for me, as an introvert, to connect with people (other students and faculty) in an institution of that size and with that culture. A friend of mine suggested I visit a smaller undergraduate university. It was nestled among hills, just north of a small Ontario city. The campus was bisected by a fast-flowing river. The architecture was eclectic and award-winning. The residences seemed designed for introverts—small clusters tucked away in irregular blocks with large windows overlooking breathtaking landscapes. I was enthralled. I applied for a transfer and set my sights on a degree in psychology. But there was a price to pay for this shift in direction. Many of the courses I had previously taken did not count toward my degree at the new school. I was advised that I would have to spend the rest of my time studying only psychology courses. Not a big deal, I thought at first. It was the early 1980s, when psychology and psychiatry were just starting to reject psychoanalysis and commit fully to behaviorism and neuroscience. I was, at first, captivated by the potential to predict and control variables for the purpose of understanding human nature. A new approach, cognitive behavioral therapy, was at the cutting edge of research and made so much sense to me at the time. But after 2 years, I felt again that something was missing. I grew tired of the reductionistic scientific method bound by endless hypothesis-testing and narrow conclusions. I was bored again. Where was the human element? I decided to take a year of broader study. I purposefully took courses in areas unfamiliar to me— philosophy, history, English literature, and political science. I failed the political science course. I’m not sure why. The instructor said my writing was appalling and lacked focus. But Eastern philosophy was fun. English literature was even more intriguing. I took a clear-writing course and attended a weekend-long essay-writing workshop. My grades in both courses were the highest I ever received. The breadth of ideas was intoxicating. I knew I was onto something. Nearly 40  years later, I think the knowledge gained through these two courses surpassed all I have acquired since. I discovered the allure of wisdom garnered from multiple diverse sources. But now, so many years later, I wonder how this sagacity might intersect, inform, or contribute to the kind of evidence deemed so crucial by policy decision-makers— the ultimate power brokers in our field. How could the force of bold ideas and the pull of deep, resonant human narratives be trusted without scientific evidence? My daughter, a young scientist, shared with me recently a book, Braiding Sweetgrass: Indigenous Wisdom, Scientific Knowledge, and the Teachings of Plants, (Kimmerer 2015), which she described as a call to integrate Indigenous wisdom and scientific knowledge. Blended epistemologies seemed to hold some promise.

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Returning to Amy Salmon and her colleagues’ chapter, I wonder how we might broaden the definition of evidence to incorporate wisdom and diverse ways of knowing. Salmon and her colleagues call for consensus—for an agreed-upon definition of stepped care and, by extension, SC2.0. Gillian Berry (Chap. 10) appeals for clarity about what is right in front of us in her reference to the fable about the elephant and the blind men. Alexia Jaouich, Stacey Carey, and Kaitlin Saxton (Chap. 11) urge us to root the SC2.0 framework in core components and principles. Monte Bobele, Arnie Slive, and Heather J. Hair (Chap. 13) debate the reach of “one-at-a-­ time thinking” in SC2.0. Disagreement is healthy in the context of SC2.0. It brings out the power of the conundrums. So, is consensus really the objective? Perhaps it is illusory. Consensus may represent less than the full reality and might be unreasonable in the context of longstanding differences. It may reveal only the portion of reality those with power wish us to see. It risks focusing on the extraction of knowledge and resources relevant to maintaining status. For example, there is currently a biased consensus among funders and decision-makers favoring evidence-based treatments established through randomized controlled trials. This serves as the gold standard, even though viable alternatives exist (see Chap. 13). This limited consensus perpetuates the dominance of a well-established elite workforce regulated by professional guilds, which exists in large part to maintain its own status. If we seek to broaden access to well-being, we must forever question hegemonic ideas. Searching for a consensus that is likely to be biased and illusory could distract us from the broader oppressive socioeconomic forces restricting our opportunities to foster widespread well-being. Clinical trials cannot capture large socioeconomic dynamics. Economic disparities have been the reality throughout human history, limiting the number of people who are able to participate in the creation of knowledge; a false consensus would obscure this important fact. It would also dilute our identification with—as well as our appreciation and understanding of—the complexity, breadth, and ubiquity of human healing resources. Perhaps the goal is coherence, rather than consensus. We need a methodology that expands to incorporate multiple ways of knowing, one that allows the kind of precision positivism offers without discounting the rich and varied alternative voices from the margins.

References Anderson, J.  E., & Lowen, C.  A. (2010). Connecting youth with health services: Systematic review. Canadian Family Physician, 56(8), 778–784. Bennett, K., Courtney, D., Duda, S., Henderson, J., & Szatmari, P. (2018). An appraisal of the trustworthiness of practice guidelines for depression and anxiety in children and youth. Depression and Anxiety, 35(6), 530–540. https://doi.org/10.1002/da.22752 Bower, P., & Gilbody, S. (2005). Stepped care in psychological therapies: Access, effectiveness and efficiency. The British Journal of Psychiatry, 186(1), 11–17. https://doi.org/10.1192/ bjp.186.1.11

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Cummings, C. M., Caporino, N. E., & Kendall, P. C. (2014). Comorbidity of anxiety and depression in children and adolescents: 20 years after. Psychological Bulletin, 140(3), 816–845. https://doi.org/10.1037/a0034733 Darley, J. M., & Latané, B. (1968). Bystander intervention in emergencies: Diffusion of responsibility. Journal of Personality and Social Psychology, 8(4, Pt.1), 377–383. https://doi. org/10.1037/h0025589 Delgadillo, J., Dawson, A., Gilbody, S., & Böhnke, J.  R. (2017). Impact of long-term medical conditions on the outcomes of psychological therapy for depression and anxiety. The British Journal of Psychiatry, 210(1), 47–53. https://doi.org/10.1192/bjp.bp.116.189027 Farris, M.  S., MacQueen, G., Goldstein, B.  I., Wang, J., Kennedy, S.  H., Bray, S., Lebel, C., & Addington, J. (2018). Treatment history of youth at-risk for serious mental illness. The Canadian Journal of Psychiatry, 64(2), 145–154. https://doi.org/10.1177/0706743718792195 Gill, P. J., Saunders, N., Gandhi, S., Gonzalez, A., Kurdyak, P., Vigod, S., & Guttmann, A. (2017). Emergency department as a first contact for mental health problems in children and youth. Journal of the American Academy of Child & Adolescent Psychiatry, 56(6), 475–482.e4. https://doi.org/10.1016/j.jaac.2017.03.012 Haney, C., Banks, C., & Zimbardo, P. (1973). Interpersonal dynamics in a simulated prison. International Journal of Criminology and Penology, 1(1), 69–97. Henderson, J. L., Cheung, A., Cleverley, K., Chaim, G., Moretti, M. E., de Oliveira, C., Hawke, L. D., Willan, A. R., O’Brien, D., Heffernan, O., Herzog, T., Courey, L., McDonald, H., Grant, E., & Szatmari, P. (2017). Integrated collaborative care teams to enhance service delivery to youth with mental health and substance use challenges: Protocol for a pragmatic randomised controlled trial. BMJ Open, 7(2) Retrieved February 22, 2023. https://doi.org/10.1136/ bmjopen-­2016-­014080 Hetrick, S. E., Bailey, A. P., Smith, K. E., Malla, A., Mathias, S., Singh, S. P., O’Reilly, A., Verma, S. K., Benoit, L., Fleming, T. M., Moro, M. R., Rickwood, D. J., Duffy, J., Eriksen, T., Illback, R., Fisher, C. A., & McGorry, P. D. (2017). Integrated (one-stop shop) youth health care: Best available evidence and future directions. The Medical Journal of Australia, 207(S10), S5–S18. https://doi.org/10.5694/mja17.00694 Kessler, R.  C., Berglund, P., Demler, O., Jin, R., Merikangas, K.  R., & Walters, E.  E. (2005). Lifetime prevalence and age-of-onset distributions of DSM-IV disorders in the National Comorbidity Survey Replication. Archives of General Psychiatry, 62(6), 593–602. https://doi. org/10.1001/archpsyc.62.6.593 Kessler, R. C., Angermeyer, M., Anthony, J. C., Graaf, D. E., Demyttenaere, K., Gasquet, I., DE Girolamo, G., Gluzman, S., Gureje, O., Haro, J. M., Kawakami, N., Karam, A., Levinson, D., Medina Mora, M. E., Oakley Browne, M. A., Posada-Villa, J., Stein, D. J., Adley Tsang, C. H., Aguilar-Gaxiola, S., Alonso, J., et al. (2007). Lifetime prevalence and age-of-onset distributions of mental disorders in the World Health Organization’s World Mental Health Survey Initiative. World Psychiatry, 6(3), 168–176. Kim-Cohen, J., Caspi, A., Moffitt, T. E., Harrington, H., Milne, B. J., & Poulton, R. (2003). Prior juvenile diagnoses in adults with mental disorder: Developmental follow-back of a prospective-­ longitudinal cohort. Archives of General Psychiatry, 60(7), 709–717. https://doi.org/10.1001/ archpsyc.60.7.709 Kimmerer, R. W. (2015). Braiding sweetgrass: Indigenous wisdom, scientific knowledge and the teachings of plants. Milkweed Editions. Kokanović, R., Brophy, L., McSherry, B., Flore, J., Moeller-Saxone, K., & Herrman, H. (2018). Supported decision-making from the perspectives of mental health service users, family members supporting them and mental health practitioners. Australian & New Zealand Journal of Psychiatry, 52(9), 826–833. https://doi.org/10.1177/0004867418784177 LaLonde, L., Good, J., Orkopoulou, E., Vriesman, M., & Maragakis, A. (2022). Tracing the missteps of stepped care: Improving the implementation of stepped care through contextual behavioral science. Journal of Contextual Behavioral Science, 23, 109–116. https://doi.org/10.1016/j. jcbs.2022.01.001

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Latané, B., & Nida, S. (1981). Ten years of research on group size and helping. Psychological Bulletin, 89(2), 308–324. https://doi.org/10.1037/0033-­2909.89.2.308 MacDonald, K., Fainman-Adelman, N., Anderson, K. K., & Iyer, S. N. (2018). Pathways to mental health services for young people: A systematic review. Social Psychiatry and Psychiatric Epidemiology, 53(10), 1005–1038. https://doi.org/10.1007/s00127-­018-­1578-­y Murad, M.  H., Mustafa, R.  A., Schünemann, H.  J., Sultan, S., & Santesso, N. (2017). Rating the certainty in evidence in the absence of a single estimate of effect. BMJ Evidence-Based Medicine, 22(3), 85–87. https://doi.org/10.1136/ebmed-­2017-­110668 Polanczyk, G. V., Salum, G. A., Sugaya, L. S., Caye, A., & Rohde, L. A. (2015). Annual research review: A meta-analysis of the worldwide prevalence of mental disorders in children and adolescents. Journal of Child Psychology and Psychiatry, 56(3), 345–365. https://doi.org/10.1111/ jcpp.12381 Rickwood, D. J., Deane, F. P., & Wilson, C. J. (2007). When and how do young people seek professional help for mental health problems? The Medical Journal of Australia, 187(S7), S35–S39. https://doi.org/10.5694/j.1326-­5377.2007.tb01334.x

Chapter 10

Diversity, Equity, and Inclusion and the Default Factor: An Indigenous Perspective Gillian Berry

Starting in the 1970s, the psychologist Richard Katz spent time with the Ju/’hoansi tribe in Southern Africa’s Kalahari Desert, an experience he chronicles in his book with Stephen Murphy-Shigematsu, Synergy, Healing and Empowerment (2012). Katz, who for decades worked closely with Indigenous elders and healers all over the world, observed that the Ju/’hoansi’s worldview was based on creating “an unexpected, new, and greater whole from disparate, apparently conflicting parts.” The tribe used this “synergy paradigm” to turn its “healing resources” into a force that could “expand and become renewable, allowing more people greater access to them.” According to Katz and Murphy-Shigematsu, members “exist in harmony with each other, maximizing each other’s potential,” leading to empowerment and community development. The co-authors believed such synergy was missing in the Western mental health system. They stressed, however, that it could only be fostered through collaboration with Indigenous practices. More specifically, they warned against assimilation—or the “therapeutic imperialism” that Western approaches typically adopt when integrating Indigenous healing methods. Building on Katz’s work, Peter Cornish envisaged a mental health system that could be organized synergistically. Cornish understood that the aim of a mental health agency is to create an environment where any person can receive appropriate and effective mental health support, no matter their race, religion, cultural background, gender identity, or sexual orientation. Yet, reality shows us that despite how hard an organization strives to meet the diverse needs of their community or student population, their efforts are never quite enough to meet the demand (Hunt et al., 2015; Lê Cook et  al., 2017). To address this gap, there have been growing calls throughout the mental health professions to deconstruct existing systems of care and build them anew (Bischoff et  al. 2016; Summerfield, 2013). According to Cornish, Stepped Care 2.0 (SC2.0) offers a promising model. With the aim of G. Berry (*) Vice President for Culture and Diversity, Stepped Care Solutions, Inc., St. John’s, NL, Canada e-mail: [email protected] © Springer Nature Switzerland AG 2023 P. Cornish, G. Berry (eds.), Stepped Care 2.0: The Power of Conundrums, https://doi.org/10.1007/978-3-031-45206-2_10

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supporting healing everywhere, it seeks to rebuild mental health-care systems using an alternative philosophical foundation. This chapter explores whether this is possible.

10.1 Indigenous Ways of Knowing SC2.0 is unusual because it is one of the few models of mental health practice derived from an Indigenous lens. Through such a lens, knowledge is not defined or determined by the consensus of a few members of a specific cultural, gendered, and gilded group at a particular time in history. The Indigenous worldview accepts and honors the fact that there are diverse ways of knowing. Each person is unique, has agency, and cannot be regarded as a member of a homogeneous group. SC2.0 thus seeks to leverage the unique contributions of each individual and honors the interconnections between us, our environments, and our systems, regardless of race, culture, religion, sexual orientation, and abilities. Diversity, equity, and inclusion (DEI) principles are therefore not siloed off, but infused into all aspects, and embedded at all levels, of the care continuum. “[C]ollaborative power,” writes Katz and Murphy-Shigematsu, “minimizes the stigmatizing, paternalistic, and sexist power-­ over tendencies witnessed in more traditional medically based mental health services.” In short, as Cornish (2012) summarizes, “synergistic power dismantles the hegemonic medical hierarchy.” SC2.0 seeks to embody the worldview of Indigenous cultures in order to realign individuals and communities for optimal well-being. The concept of synergy, embodied in SC2.0, goes beyond the term’s standard definition of cooperation to include healing, empowerment, and justice. This is the same holistic, interconnected, and multidimensional definition of synergy that we see expressed in the customs and beliefs of Indigenous groups around the world, including in New Zealand, Australia, India, and China and on the continent of Africa; Katz also saw similarities with Native Americans in the United States and First Nations in Canada. Phrases such as ubuntu (roughly defined as “person becomes human through the eyes of others”) or namaste (“the same in you as in me”) suggest the existence of core philosophical assumptions that accept as normative the condition of being in balance and harmony with nature, with each person accepting an ethical responsibility to help maintain that condition. Such a worldview regards life as the unfolding of experiences designed to bring an understanding of universal laws, and, when a person is in harmony with such laws, they can live more satisfyingly. SC2.0 attempts to transfer this understanding of Indigenous philosophy to mainstream mental health infrastructure. The model promises that, if implemented properly, it can create an environment where clinicians, support services, and administrative policies work together to facilitate positive outcomes for those using mental health services. At its most basic level, SC2.0 recognizes that there are connections throughout the mental health system—what happens at one end of the system affects what happens at the other. The reception staff at a clinic needs to

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acknowledge that their work directly impacts that of the clinicians, and leadership needs to appreciate the consequences of their policy decisions. SC2.0 is also designed to empower clients to participate actively in their care options, decisions, and delivery (see Chap. 14). SC2.0’s flexible, accessible, culturally and socially relevant approach has given early adopters reason for excitement as they report on the elimination of unacceptable wait times and the reduction in the chronicity of certain mental health conditions (Boyd et al., 2019; Cornish et al., 2019). Such reports are unusual in a medical field where “unless you are wealthy and receiving services in the private sector,” as John C.  Norcross reminded us in his preface to Stepped Care 2.0: A Paradigm Shift in Mental Health (2020), most patients now expect services to be “inaccessible, inequitable, inefficient, and ineffective.” The system is so broken, argues Norcross, that “nothing short of a comprehensive and ambitious overhaul is required.” SC2.0’s “bold, big plan,” Norcross believes, is something that can “ignite” that overhaul. That overhaul also extends to an area where the mental health field has struggled since its conception—namely, the application of DEI initiatives. Ultimately, DEI’s goal is restorative—recognizing the impact of history, naming the harms that have been done, and then repairing those harms. This means leveraging the interconnection between people to address impacts of colonialism, racism, sexism, and other forms of oppression found in mental health practices. But standard DEI gestures, such as superficial hiring practices or diversity training developed under protest or as an afterthought, have left proponents shouting even louder about injustices and how the proposals for addressing them can be as oppressive as the practices being replaced. This has left those inside the system tackling those injustices frustrated to the point of “freezing” (DiAngelo, 2021). With a diverse, equitable, and just system seeming, to many, a fast-sinking dream, SC2.0’s success in delivering a restorative practice of care will indicate whether the model and its adherents are on the right track when it comes to appropriately addressing the complexities of DEI.  To adapt the New  York anthem, if SC2.0 can make it here, it can make it anywhere.

10.2 The Harsh Reality of Social Justice But does SC2.0 have a real chance of implementing this concept of synergy, or will Cornish’s “innovative disruptions” be just another example of therapeutic imperialism? Let’s first talk about what the model seems to be getting right. Its recognition that one size does not fit all has already gone a long way toward deconstructing the assumption that weekly 50-min sessions will meet the needs of all those using its services. The traditional model of mental health treatment—in which a client meets one-on-one with a licensed therapist weekly for 50 min, for as many weeks as necessary to achieve a positive outcome—is supported by a vast mental health infrastructure. This infrastructure is often unseen and taken for granted by both client and therapist. It’s a model of practice considered so authoritative that it crosses all

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temporal, cultural, and geographical boundaries, monopolizing how people are helped. Such has been its popularity that many assume it’s the “gold standard” and the only form of help available (see Chap. 13). SC2.0 rejects that assumption and addresses the injustices in the mental health-­ care system. Long-term psychoanalysis, for example, depends on what you can afford. Not only is it often too expensive for many (in the United States, psychoanalysis can cost anywhere from $300 to $500, depending on where you live), but some health insurance carriers only allow a certain number of sessions depending on the policy. There may also be limited clinicians working for insurance carriers due to the wealth of paperwork that needs to be completed and/or difficulties with reimbursement. Clients therefore face long wait-lists. With its synergistic philosophy, SC2.0 revolutionizes mental health services by recognizing that support can be offered not only from a “trained” professional but also from a knitting group, drumming circles, or a community movie night. Counsel can also come from someone who is not licensed, such as a coach, mentor, or community elder. Counseling isn’t something that should only happen between the hours of 9 and 5  p.m. Instead, SC2.0 sees benefits in online services, with customized information or activities when the client needs it, even if it is at 2 a.m. in the morning. Of course, SC2.0 can’t stop there. The model’s true power comes from its potential to not only shift mental health service delivery but shift the dominant culture. As Tobirus Mozelle Newby, a therapist and disruptor at the University of California, Berkeley, told us in our early discussions around this book: “The goal can’t just be to change health care. Because what good is that goal if the dominant culture keeps oppressing people?” But to set off that scale of transformation, proponents of SC2.0 will need to change approaches to mental health care that have been ingrained as “absolute truths,” and in doing so—to amend advertising expert Doug Zanger’s (2020) words—they must be willing to “envision a world that doesn’t exist.” Whether that world can ever exist is the biggest conundrum facing SC2.0. Western cultural values today so thoroughly dominate corporations, academia, and social structures that an authentic and meaningful mental health transformation will remain impossible as long as only one aspect of the continuum—i.e., SC2.0— wants change. Take one area where SC2.0 has been forward-thinking: its push for mental health programing to adopt a restorative approach. SC2.0 understands that historical injustices have taken place and that many of those injustices remain undocumented, unrecognized, or unacknowledged. SC2.0 recognizes that the collective traumas of cultural supremacy have been embedded in mental health-care systems over the past several centuries (Beliso-De Jesús & Pierre, 2019). Indigenous clients in Canada, for example, should never face a therapist unaware of the horrors that took place at residential schools and of their legacy on Indigenous communities. Hence, with emphasis on co-design and outreach to community partners, SC2.0 believes in a practice of care that seeks to repair what has been done, allowing healing to occur. But for this to work, the supporting infrastructure needs to be in alignment with that mission. Unfortunately, as a society, we are very far from that.

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The need for labels is too powerful, and the institutional practice of compartmentalizing people too entrenched. Just think about the myriad of professional labels in the mental health field —from psychiatrist (MD or DO) to clinical psychologist (PhD or PsyD) to licensed clinical social worker (LCSW). You can also be a licensed professional counselor (LPC), a marriage and family therapist (MFT), a psychiatric nurse practitioner (PMHNP), or a clinical mental health counselor (CMHC). Each position identifies specific skills, qualifications, and expertise, which subsequently determines pay scale and employment opportunities. It is completely understandable that the public believes that someone who has successfully completed a rigorous training and educational program and occupies a role that is overseen by professional organizations and regulatory bodies can effectively support their unique psychological needs. Buoyed by such strong public trust and confidence, the mental health field is apt to focus on the glaring problems with its infrastructure, as previously described by Norcross (2020), rather than questioning whether the system is flawed at a foundational level. The reality is that SC2.0 can push for equitable ways to provide effective healing and support all it wants: the system will keep creating hierarchies between the “experts” and the communities they “serve,” thus generating further resource scarcity when registered clinicians are viewed as the only option for the provision of care. The problem can’t just be wished away. Constructed as a sub-branch of applied psychology or as a discipline allied to medicine, counseling has adopted restrictive methods of knowing and is still embroiled in the “on-going philosophical debate about the nature of knowledge” (McLeod, 1994, 2003). By embracing the rules and canon of the scientific method established in the eighteenth century, even SC2.0 practitioners may fail to recognize the limits of what they have been trained to appreciate as mental health. Without addressing this, we may consciously or unconsciously return to the default setting—i.e., the attempt to explain the world through a priori assumptions, in which counselors operate with “correct” or clear frameworks. For example, Western psychology generally understands human behavior as determined by sexual and aggressive instincts (psychodynamic), or conditioned responses (behaviorism), or the desire to become benevolent (humanistic). Psychologist and scholar Linda James Myers has called this a “fractured” and “suboptimal” mindset (Haggert, 2022) that, by socializing us into the idea that the world can be reduced to what our five senses can observe and control, underlies a system of dehumanization. In contrast, Myers proposes a more “optimal” level of human development, one that emerges from Indigenous deep thought, a body of wisdom which promotes healing and sustainable well-being. The ancient Africans, she argues, by teaching methods of viewing the world where human worth is intrinsic and not based on ideas that predispose people to anxiety, addictions, or violence, provide a theoretical framework for a healthy model of psychological functioning. These are universal principles that transcend culturally specific perspectives, providing a higher framework from which the world can be viewed and understood. Despite SC2.0’s ardent hope that mainstream mental health services can share the same therapeutic goal as Indigenous philosophy, the two processes and rationales are fundamentally different. Take traditional healers. With their ceremonies,

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rituals, and divinations, they are an unmistakably Indigenous practice that has survived in varying degrees, despite the lengths that colonialism, globalism, urbanization, population migration, and civil conflict have undergone to drive it to extinction. Yet such healers are not authorized, validated, or respected by Western insurance companies, professional bodies, or state boards—despite these individuals often being the first choice that their respective communities turn to for help. For a century, the mental health system has deemed millennia-old Indigenous wisdom as not scientifically proven and spurned it as “mumbo jumbo,” gibberish, or witchcraft. And what SC2.0 has helped prove is that incorporating that wisdom into the mainstream clinical environment ultimately requires the backing of professionals within that same system. Even so, SC2.0 may be trying to bridge two forces that are unbridgeable.

10.3 The Default Factor Academia has opened itself up to new and varying ways of understanding truths, with the result that directly observable phenomena are no longer regarded as the only legitimate form of reality for mental health practitioners. The objective, theory-­ laden counselor who analyzes a client’s behavior has become just one method of practice among many. However, these varying methods continue to share the notion that human biases and emotions should be controlled, reduced, or eliminated in scientific inquiry (Hamati-Ataya, 2012). Unseen or spiritual concepts are de-­ emphasized and remain sources of discomfort (Schiele, 2000). With such principles determining how counseling services are understood, it is no surprise that current mental health practices continue to have difficulties tackling such issues as the lack of cultural awareness/appropriateness and racism. For Indigenous communities, and other nondominant cultural groups, the root of the problem is the scientification of counseling per se as a universal helping tool. The scientific model, argues John McLeod (1994, 2003), “may make a lot of sense when applied to the history and evolution of exact sciences such as physics and chemistry, [but] has shown itself to be consistently problematic when applied to counselling” (p. 5). In spite of its basic assumptions being supported by a “whole apparatus or web of knowledge” (McLeod, 1994, p. 7), counseling provides only an illusion of scientific authority, one fueled by the impression strengthened by Western society’s addiction to instant gratification: namely, that happiness can be achieved from the gold standard in the field of mental health. In this case, it’s not surprising that traditional counseling is revealed as nothing more than a superficial “feel-good exercise” designed to desensitize people to the realities of living under unhealthy and oppressive conditions. This perhaps gives credence to radical views, such as those in the seminal article by psychologists Khatib et al. (1975), who interpret the perpetuation of the status quo within science as a “common agreement concerning ends” (p. 63). Western science, argue Khatib et al., builds infrastructures designed to maintain its position of

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power—i.e., in order to be a licensed therapist, you have to go to college, train, and be board certified. This ensures those in such positions continue to come from privileged ranks and are motivated to keep the practice of mental health a closed system. Khatib et  al. argue that this professional self-cosseting is the real motive of the mental health system. The ends, in this instance, serve and perpetuate Western perspectives, so that, despite the passing of time and many progressive policy changes, the lack of equal recognition of alternative worldviews ensures the outcome remains the same—the continual cultural dominance of Western philosophical thought. Because the scientific community mostly works within the realms of mainstream thought, it is no surprise that dominant scientific theories are rarely overthrown. Once an infrastructure is built, adherents are invested in ensuring its survival. This can lead scholars to become defensive when challenged by facts that do not fit the paradigm. A paradigm is a worldview that socializes its adherents into a perspective they believe is important, legitimate, and reasonable without feeling the need to question it. Adherents stoutly resist challenges to their paradigm, even at times irrationally, or may police or manipulate alternative paradigms into conforming to existing ones. The perpetuation of the dominant counseling paradigm may therefore seem inevitable, despite the continual charges against that paradigm of being discriminatory, irrelevant, and of creating widespread feelings of despair, anger, and frustration among both practitioners and clients. There is acknowledgment, for example, that researchers unconsciously promulgate racism on an epistemological level when teaching approaches like positivism and postmodernism: both can be said to implicitly promote the social history of the dominant race at the exclusion of people of color (DiAngelo, 2018; Scheurich, 1997). Our stubbornness in recognizing previous misconceptions is why creative approaches like SC2.0 can be hard to implement. Synergy requires seeing the whole person—their uniqueness, strengths, and various cultural contexts, as well as their connection to others. It means seeing all aspects of a system: the parts we welcome and those we may struggle to acknowledge or accept. Therefore, SC2.0 requires a commitment from all facets of a mental health system to work together for solutions that look, behave, and feel very different.

10.4 SC2.0 and the Promise of Synergy SC2.0 might need to overcome its own biases, too. SC2.0 is regarded as forward-­ thinking in its efforts to deconstruct established views on the existing mental health system, the regulatory bodies, training, publication, research, application, and oversight. But the model remains stranded in a set of historically rooted values and perspectives it can’t fully escape. SC2.0 is a necessary critique of a tradition of thought that reduces data to its simplest form and that regards directly observable phenomena as legitimate forms of reality, but it is also shaped by that tradition. It’s not surprising, therefore, that many interpret SC2.0 as focusing on the most tangible, objective aspects of the mental health industry—seeing SC2.0 as just tinkering

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with existing administrative processes, such as ensuring diversity in its services and staffing, or addressing risk factors by decreasing the number of consent forms. These fixes are critical, but far from the full system change Cornish is pushing for. Unfortunately, SC2.0 has no choice but to operate within the larger political and economic ecosystem, and its reactive stance means the model risks being satisfied with superficially addressing the issues giving rise to our dysfunctional system of care, thus absolving itself of the responsibility to be more aggressively proactive. How can SC2.0 change anything if it keeps defining itself by the very doctrines it wants to transform? These questions regarding how to genuinely incorporate DEI in mental health to provide effective and equitable care for all will remain a challenge without a concerted effort on individual, interpersonal, and collective responsibility levels to put synergy into action. For, despite creative approaches to transform antiquated mental health systems, an often-overlooked area is the human factor that can unknowingly derail well-intentioned restorative efforts. A lack of understanding of personal bias, perceptions, emotional intelligence, and even an unwillingness to have crucial conversations are just a few such examples. As the cautionary tale in Chap. 15 represents, we must acknowledge that it is possible for organizations to adopt the SC2.0 model either superficially or within a system made up of individuals that are so committed to the dominant cultural perspective that the essence of the SC2.0 model will be lost in favor of assimilation with the dominant paradigm. This will result in a system that may look different on the outside but is fundamentally the same. That said, Cornish (2012) quite rightly sees embracing synergy as an integral part of SC2.0. It’s not clear, however, that mainstream mental health practice, as it currently exists, is ready to admit the interconnectedness and interdependence that SC2.0 wants to infuse through the system. To be ready, it would need to ground itself in the principles of humility. And the primary tenet of that humility is lifelong learning (see Chap. 19). There is a well-known Indian parable known as “The Blind Men and an Elephant.” In this parable, a group of blind men comes across an elephant, an animal they have never encountered before. Without a frame of reference for the creature, each man begins to feel the part of the elephant directly in front of him and draws conclusions about that part based on prior information they each had (e.g., the man at the trunk of the elephant was certain he felt a snake). The vastly different descriptions they come up with for the animal mean they are unable to reach a consensus. In the parable, their disagreement ends in a physical altercation. The moral? That we should avoid drawing conclusions about absolute truth when we only have access to our limited perception or experience. Rather, if we recognize each other’s limited perceptions or experiences as part of the truth, we can better understand the whole picture or, in the case of the blind men, work together to conceptualize the elephant. In our case, the elephant that the dominant counseling paradigm has failed to recognize is a sociopolitical world infused with social injustice. What would such a recognition mean? It would mean, as Katz (2017) advocated, designing a system of care where all parts of a community, with their uniqueness, work together. A system of care that moves away from mistrust to trust; from labels to uniqueness; from

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separatism to oneness; from expert and patient to human beings; from one-size-fits-­ all to individualized care; from individual fault to shared responsibility; from feel-­ good approaches of “multicultural counseling” to honest recognition of the negative impact of oppressive practices and cultural supremacy. Whether such changes are possible is hard to say. It has taken centuries for the industry to arrive where it is. It will likely take centuries for it to change—if the system has the courage, consistency, and determination to even take such a transformational step. Misgivings aside, I believe SC2.0 might be such a step.

10.5 Reflection Peter Cornish As a young boy, I did not measure up. When it came to soccer, hockey, or baseball, I was usually picked last. My older brother, on the other hand, was popular and excelled at all sports. I adored him. I wanted to impress him, but I knew I would have to try something unusual to get his attention. The default choices in a hypermasculine culture wouldn’t work for me. Soon enough, I discovered that I did well at individual sports: bicycling, hiking, sailing, and canoeing. At the age of 12, I started kayaking. I signed up for lessons at the local pool and learned the roll. By age 15, I was paddling in white water. When I was 17, I went on my first long-­ distance cycling trip—2000 kilometers. Early in life, I learned an important lesson: I had to take a different path. SC2.0 takes a different path, but Gillian Berry’s chapter leads me to wonder how far we might get with transforming mental health systems. While it is possible for some to reject the default, what would it take for a full paradigm shift? Thomas Kuhn famously wrote that scientific revolutions result not from different interpretations of data, but from a different “gestalt” or worldview. Our default mental health system is based on a medical paradigm which assumes for the most part that mental illnesses exist within people, sometimes even become the people. I may either have depression, or I might be depressed. SC2.0 takes a trauma-informed position that mental illness exists outside of people. It is largely a consequence of many external events beyond a person’s control. Some of these are naturally occurring events such as earthquakes, fires, and accidents. Some are due to human injustices brought on by political and economic forces of oppression. A massive reversal is needed from a focus on curing or changing individuals to a sustained systematic mitigation of these external forces. Berry describes the deep well-established structures that maintain the current mental health paradigm. Economies rooted in arbitrary notions of racial supremacy are sustained by valuing what is scarce, thereby incentivizing winner-takes-all cultural norms. This is the default. What sort of crises will be needed to meaningfully disrupt the status quo? You might think the climate crisis would be enough, but there are few signs of economic reforms aimed at reducing carbon emissions.

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Our survival as a species, not to mention our collective mental health, requires massive change in how we do science, economics, and politics. But unlike previous scientific revolutions, where an old paradigm was replaced by a new one, the answer now lies in resurrecting an ancient Indigenous paradigm and then braiding or layering modern viewpoints and voices that complement the structure. Buckminster Fuller did this with his concept of the geodesic dome, integrating the Indigenous concept of synergy into contemporary engineering and structural design. Simple metal rods, inconsequential on their own, transform into the most robust, stable, and sustainable structure imaginable. More recently, Robin Wall Kimmerer called more explicitly for the resurrection of an ancient paradigm in her book Braiding Sweetgrass: Indigenous Wisdom, Scientific Knowledge, and the Teaching of Plants Kimmerer (2015). Early in my life, I was drawn to difference. I wanted to be good at something unique. And while part of this identity development valued otherness, I did not want to be apart. We all want to be different but connected. Difference is as essential to community as it is to the concept of synergy. I am not interested in a melting pot. The pieces need to be preserved and seen for themselves. It is the arrangement that creates something new. In the early 1990s, I co-created a rural community psychology practicum with my supervisor. We were focused on stress work with farm families who had been hoodwinked by government policy and large banks to industrialize through massive debt. After a rash of farmer suicides, we drove from one small town to another teaching coping skills to farmers. The job involved traveling 3 to 4 hours in a car each day, and during one of those drives, I discussed how synergy became the focus of my master’s thesis. “It’s all so abstract and philosophical,” my supervisor said, when I struggled to answer her question about the relevance of synergy. I failed to connect the ideas with the work we were doing at the time, but I knew in my heart that it was somehow relevant. The treatment paradigm then was based in cognitive behavioral theory. We were teaching farm families how to think and act differently when experiencing stress. Farm foreclosures were not their fault. It did not reflect on their skills. But neoliberal policies supporting free market capitalism were rolling across the Canadian prairies. It made sense to me that they were stressed, even suicidal. But beyond acknowledging the external cause of their distress, I felt like I was doing nothing. Clearly, I thought to myself at the time, an individualistic approach focused on coping skills would have little impact. It would not hold financial institutions accountable for pressuring farmers to take on unmanageable debt. It would not save their livelihoods or their communities. It would not reverse the industrialization of farming, the increased use of chemicals, and practices that destroy habitats and ecosystems. It was too late. The zero-sum forces of capitalism prevailed. The cooperative movements of the 1940s and 1950s, in which universal health care was born and credit unions were established, had fizzled. Commitments for health and economic equity could not withstand neoliberalism. There was no place for synergistic community.

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While the concept of synergy remains abstract, as do notions of paradigm shifts, the planet we live on is forcing a reckoning. Paradigm shifts happen when a crisis is so large that it cannot be ignored or contended with through usual practices. I have hope in crises. We have a crisis in race relations. We have a crisis of access to health and mental health resources. We have a crisis in global warming. We have a spiritual crisis. A paradigm capable of addressing all these crises exists in the concept of synergy. And the good news is that it is not a new paradigm. The SC2.0 model is a framework for operationalizing the concept of synergy. This operationalization must happen in layers. When communities first express interest in transforming their mental health systems, they are often only ready for superficial changes, like shorter intake forms, one-at-a-time therapy, the addition of mental health apps, and measurement-based care tools. It might be better than teaching coping skills to Saskatchewan families losing their farms to the banks, but it won’t result in a paradigm shift. Real impact will only come when mental health-­ care leaders connect with community organizations and policy-makers to invest together in the multiple determinants of health and well-being. This must include economic and political policy reforms that reverse the ever-escalating disparities in wealth and the distance between privileged classes and those with marginalized identities. Pilot studies have repeatedly demonstrated the positive impact of minimum income policies on strengthening the well-being of individuals, communities, and the economy as a whole (Pinto et al., 2021). The best upstream approach to promoting mental health and preventing mental illness involves supporting access to basic human needs (food, clothing, housing, health care) in the communities where people live. A holistic framework like SC2.0 could be a flash in the pan if parked within the existing mental health-care system, which is bounded by clinic and hospital walls. It’s time to break out. The framework can help us move beyond fragmented commodified treatments to fully embrace the meaning and potential of equitable and integrated approaches to mental, spiritual, physical, climate, and economic well-being. As I write these sentences, I feel like I am preaching. So be it. Maybe that is what is missing in a science-as-religion world—passion, advocacy, and vision. We need science. But we need all contributions. People want to feel better. People want connection. People want to be more involved in their communities and their care systems. People want a healthy planet. Whether conservative or liberal, people are ready for a paradigm shift—a shift in how we connect with each other and the natural.

References Beliso-De Jesús, A.  M., & Pierre, J. (2019). Anthropology of white supremacy. American Anthropologist, 122(1), 65–75. https://doi.org/10.1111/aman.13351 Bischoff, R.  J., Springer, P.  R., & Taylor, N. (2016). Global mental health in action: Reducing disparities one community at a time. Journal of Marital and Family Therapy, 43(2), 276–290. https://doi.org/10.1111/jmft.12202

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Boyd, L., Baker, E., & Reilly, J. (2019). Impact of a progressive stepped care approach in an improving access to psychological therapies service: An observational study. PLoS One, 14(4), e0214715. https://doi.org/10.1371/journal.pone.0214715 Cornish, P. (2012). The contribution of synergy to the experience of empowerment. In R. Katz & S. Murphy-Shigematsu (Eds.), Synergy, healing and empowerment: Insights from cultural diversity (pp. 241–256). Brush Education. Cornish, P. (2020). Stepped care 2.0: A paradigm shift in mental health. Springer. Cornish, P., Legge, N., Corcoran, P., Churchill, A., Fleet, L., Pegrum, S., Rash, J., Hair, H., Yetman, B., Herrell, M., Raimundo, A., Churchill, M., Boyd, B., Wells, T., Kearney, V., Watters, N., Varga, B., Impey, D., & Kora, G. (2019). Newfoundland and Labrador: Stepped care 2.0 e-mental health demonstration project final report. Mental Health Commission of Canada. DiAngelo, R. (2018). White fragility: Why it’s so hard for white people to talk about racism. Beacon Press. DiAngelo, R. (2021). Nice racism: How progressive white people perpetuate racial harm. Beacon Press. Haggert, M. (2022). Optimal psychology to address inequity: 4 questions for Linda James Myers. American Psychological Association, 53(2), 43. Retrieved February 13, 2023, from https:// www.apa.org/monitor/2022/03/conversation-­myers Hamati-Ataya, I. (2012). Beyond (post)positivism: The missed promises of systemic pragmatism. International Studies Quarterly, 56(2), 291–305. https://doi. org/10.1111/j.1468-­2478.2011.00710.x Hunt, J.  B., Eisenberg, D., Lu, L., & Gathright, M. (2015). Racial/ethnic disparities in mental health care utilization among U.S. college students: Applying the institution of medicine definition of health care disparities. Academic Psychiatry, 39(5), 520–526. https://doi.org/10.1007/ s40596-­014-­0148-­1 Katz, R. (2017). Indigenous healing psychology: Honoring the wisdom of the first peoples. Healing Arts Press. Katz, R., & Murphy-Shigematsu, S. (Eds.). (2012). Synergy, healing and empowerment: Insights from cultural diversity. Brush Education. Khatib, S.M., Akbar, N., McGee, D. P. (1975) Voodoo or IQ: An Introduction to African Psychology. Journal of Black Psychology 1(2), 61–78. Kimmerer, R. W. (2015). Braiding sweetgrass: Indigenous wisdom, scientific knowledge and the teachings of plants. Milkweed Editions. Lê Cook, B., Trinh, N. H., Li, Z., Hou, S. S., & Progovac, A. M. (2017). Trends in racial-ethnic disparities in access to mental health care, 2004–2012. Psychiatric Services, 68(1), 9–16. https:// doi.org/10.1176/appi.ps.201500453 McLeod, J. (1994). Doing counselling research. Sage. McLeod, J. (2003). Doing counselling research (2nd ed.). Sage. Norcross, J. (2020). Foreword. In P. Cornish (Ed.), Stepped care 2.0: A paradigm shift in mental health (pp. v–vi). Springer. Pinto, A.  D., Perri, M., Pedersen, C.  L., Aratangy, T., Hapsari, A.  P., & Hwang, S.  W. (2021). Exploring different methods to evaluate the impact of basic income interventions: A systematic review. International Journal for Equity in Health, 20(1), 1–20. https://doi.org/10.1186/ s12939-­021-­01479-­2 Scheurich, J. J. (1997). Research method in the postmodern. Falmer Press. Schiele, J. (2000). Human services and the Afrocentric paradigm. Haworth Press. Summerfield, D. (2013). “Global mental health” is an oxymoron and medical imperialism. British Medical Journal, 346, f3509. https://doi.org/10.1136/bmj.f3509 Zanger, D. (2020). To create racial change, advertising must ‘envision a world that doesn’t exist’. AdWeek. Retrieved February 13, 2023, from https://www.adweek.com/agencies/ racial-­change-­advertising-­glenn-­singleton-­courageous-­conversation/

Chapter 11

Adaptability and Fidelity: Exploring the Relationship Between the Two When Implementing SC2.0 Alexia Jaouich, Stacie Carey, Kaitlin Saxton, Joshua Rash, and Jacquie Brown

If you’ve made it this far into the book, you will be familiar with the idea that SC2.0 is an evolving, flexible, continuously improving model grounded in co-design. What, then, does it mean to implement SC2.0 with fidelity? What does the model look like in different regions and organizations? This brings us to our next conundrum: whether or not a model predicated on flexibility and responsiveness can actually be implemented with fidelity. How can implementers evaluate whether they are really implementing SC2.0 as it was designed and intended, given that SC2.0 should look different in each unique context? This conundrum embodies the oft-discussed tension between adaptability and fidelity within implementation science research and practice. In this chapter, we will explore how this tension applies to SC2.0. We will outline our current thinking on the matter and what this means for those interested in implementing SC2.0 in their own contexts.

11.1 Implementation Imperative: Defining SC2.0 To understand how one might implement SC2.0—this complex system transformation—with fidelity, it is imperative to first understand: what is SC2.0? Far too often, researchers, developers, funders, and policy-makers ask those implementing a given A. Jaouich · S. Carey · J. Brown Toronto, ON, Canada e-mail: [email protected]; [email protected] K. Saxton (*) Mississauga, ON, Canada e-mail: [email protected] J. Rash Memorial University of Newfoundland, St. John’s, NL, Canada e-mail: [email protected] © Springer Nature Switzerland AG 2023 P. Cornish, G. Berry (eds.), Stepped Care 2.0: The Power of Conundrums, https://doi.org/10.1007/978-3-031-45206-2_11

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innovation to do so without adequately defining the innovation—despite the fact that research has highlighted the need to have a clear understanding of the innovation and its suitability for a given context. This includes sufficient detail to enable staff and administrators to be trained to use the innovation competently, to measure whether the innovation is being implemented with fidelity, and to replicate it across different sites and contexts (Fixsen et al., 2013; Metz, 2016). As identified by the Active Implementation Framework, a good definition articulates the necessary components of the innovation or intervention, the values that guide it, and the features that comprise it (Blase et al., 2018). The concept of “usable innovations,” developed by the National Implementation Research Network (NIRN), is a practical framework to develop usable innovations that are teachable and learnable and can be actioned and assessed (Fixsen et  al., 2013; National Implementation Research Network n.d.). A pillar of good implementation practice is the development and description of “core components,” which is a key requirement of a usable innovation. Core components are the features necessary for an innovation to function as intended and to achieve the desired outcomes (National Academies of Sciences, Engineering, and Medicine, 2019). Core components are also necessary for achieving fidelity in implementation, which can be defined as the extent to which implementation aligns with the essential features and the original intervention design (Carroll et al., 2007; Dane & Schneider, 1998; Durlak & DuPre, 2008). Moreover, there is a need to consider fidelity from various perspectives: fidelity to the delivery of the innovation (i.e., how the innovation is delivered to the recipients), fidelity to the receipt of the innovation (i.e., the degree to which the intended recipients receive the innovation as intended), and fidelity to the enactment of the innovation (i.e., the degree to which the intended recipients incorporate the innovation in practice as intended) (Carroll et al., 2007). Fidelity has consistently been shown to be associated with effectiveness and successful outcomes: numerous empirical studies have demonstrated that the closer an intervention adheres to the original design, the greater the degree of behavior change (Durlak & DuPre, 2008; Mihalic, 2002). High-quality implementation is more likely when core components are defined in advance and then systematically monitored to ensure compliance. Identifying the truly essential components makes it possible to adapt nonessential elements to meet local needs and preferences (Fixsen et al., 2013). In this way, the core components are necessary to understand whether an intervention is being implemented with fidelity—that is, core components help us address the question, “What is SC2.0?” The following example, adapted from the Center for Implementation, illustrates the significance of core components in supporting implementation. Imagine you are a dental hygenist implementing an “optimal oral hygiene program” with a patient at your dental hygiene practice. What would happen if you simply instructed the person to practice “optimal oral hygiene” without additional guidance? Chances are that many people would engage in some of the same behaviors that constitute oral hygiene, such as brushing their teeth. However, other behaviors—particularly those that might be less obvious, such as flossing, certain brushing techniques, and frequent visits to the dentist—might be missed. As a hygienist, you know that these

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Fig. 11.1  Core components example

behaviors are critical to optimal oral health. So, what can you do? You can define the core components of this practice, the essentials for optimal oral hygiene which, if missed, put the outcomes at risk. Using the concept of core components, you can specify and operationalize exactly what behaviors you expect of individuals to achieve “optimal oral hygiene” (Carey et al., 2021) (Fig. 11.1). Now that we have described the importance of core components in effectively implementing a new practice, let us consider how the need for SC2.0 core components arose. SC2.0 was initially developed and implemented at Memorial University of Newfoundland and Labrador. This initial implementation was based on the vision of Peter Cornish, Director of the Student Wellness and Counselling Centre at the time and founder of Stepped Care Solutions. Cornish’s vision attracted interest from other postsecondary institutions, which led to other early iterations and implementations of the model on additional campuses. Evaluation data from these initial implementation efforts suggested that SC2.0 had the potential to reduce wait times for care, increase appointment attendance, and increase counselor productivity, all while keeping client satisfaction high (Cornish et al., 2017). These implementations were followed by a demonstration project in Newfoundland and Labrador funded and supported by the Mental Health Commission of Canada (MHCC), which showed that SC2.0 contributed to a 68% reduction in wait times across the province and was well-recieved by clients and providers (Mental Health Commission of Canada, 2019). This project generated attention from community and government partners and sparked their interest in expanding to new locations. A key challenge emerged: while there was a general understanding of SC2.0, its goals, and how services were delivered in its original context, it was difficult for those attempting to implement the model in new settings to discern exactly what the essential features were and

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how they could be translated into organizations and communities with varying policies, structures, and populations. To support scaling the innovation, the MHCC commissioned and partnered in the development of SC2.0 core components. SC2.0 is built around a commitment to co-design and is rooted in the idea that the communities in which SC2.0 is adopted should have a significant role in determining what SC2.0 will look like in their local contexts. As such, there was a need to think through how organizations and communities interested in adopting SC2.0 should understand the tension between fidelity and adaptability—between re-­ creation of the SC2.0 model as articulated by Cornish and the need to adapt SC2.0 to better serve communities in different circumstances and geographies. It was necessary to step back and articulate what defined SC2.0 before it could be implemented in other contexts.

11.2 How Were the SC2.0 Core Components Developed? We will now explore how the core components were identified and developed, which required a collaborative, committed, and unique process, given the innovative, nuanced, and complex nature of SC2.0. Our process was inspired by the practice profile methodology described by Metz (2016) and the NIRN, but adapted because of time constraints and the innovative nature of SC2.0. The core components were purposefully grounded in various forms of evidence, including empirical, experiential (including lived experience), and theoretical evidence. The role of evidence in developing the core components (and their associated practice recommendations described below) is elaborated upon further in this chapter. The first step was a material review that included the original implementation guide (Cornish et al., 2018) and various training and evaluation resources—all of which yielded rich insights and details related to the model. Reviewing them allowed the team to become familiar with the model, ascertain its essential features, and identify areas that would benefit from further refinement. The second step comprised a series of focus groups with managers and providers who had implemented SC2.0 in Newfoundland and Labrador using the original implementation guide. The purpose of these focus groups was to gather information related to the usability, content, and layout of the guide. This was followed by a 3-month period in which the facilitators held a series of discussions with representatives from the SC2.0 team, the MHCC, and a Steering Committee—all of whom were part of early implementations of SC2.0 and, thus, had invaluable perspectives based on their direct experience with the model. The purpose of these discussions was to turn their perspectives and experiences into specific and well-defined core components. The facilitation strategies included iterative cycles of discussion, reflection, and revision until consensus was achieved. It was at this point that the nine core components of SC2.0 were confirmed (Table 11.1).

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Table 11.1  SC2.0 core components • Systems are co-designed with people who bring diverse perspectives and experiences • People have same-day access to multiple levels of care • Resources and services are guided by a one-at-a-time approach • Systems reflect a variety of step levels and include both formal and informal services • The management of risk is distributed across the systems

• System and service improvement is achieved through continuous monitoring and quality improvement cycles • Recovery-oriented approaches are clearly and consistently integrated at all levels of the systems of care • Services are flexible, data-informed, and collaborative • Care is person-centric

With the identification of these core components, we now had a clear, shared, and concrete answer to the question, “What is SC2.0?”

11.3 From Discrete Core Components to a Cohesive Model: Building the Framework and Practice Recommendations As we reviewed the newly established core components, it became apparent that an organizing framework was required. An analysis of each of the nine separate core components revealed that there were two distinct levels at which they operated: the system level and the individual level. That is to say, each core component was related either to how the SC2.0 model operates as a system transformation and design tool or to how individuals receiving care through SC2.0 would experience and interact with the model. This framework organized and connected the core components and made clear their complementary nature as part of a whole (Fig. 11.2). Practice recommendations were developed after the working group reached consensus on the core components and the overarching framework. These practice recommendations are necessary to move core components from concepts to reality, as their purpose is to define how each component is operationalized. It was necessary to consider the intended change associated with each core component if we were to develop meaningful practice recommendations. The action, actor, context, target, time (AACTT) framework can be helpful in this regard (Presseau et al., 2019). In brief, it involves delineating the action (e.g., establish a group of individuals with whom to undertake co-design) that each actor (e.g., provincial government) needs to enact within a given context (e.g., province) to impact a targeted group (e.g., citizens of a province) at a specific time (e.g., during the period which the SC2.0 system of care is being designed). This methodology includes a series of interrelated steps, which can be completed iteratively and in parallel, including semi-structured interviews, a systematic scoping review, document review, vetting and consensus-building with key stakeholders, and usability testing. An example of practice recommendations for Core Component 6 is illustrated below (Table 11.2).

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CORE COMPONENT 2

The management of risk is distributed across the systems. CORE COMPONENT 4

Systems re l ect a variety ty o re lect off step levels and includes both formal f rmal and info fo informal f rmal services.

System and service improvement is achieved through continuous monitoring and quality improvement cycles.

CORE COMPONENT 1

Systems are codesigned with people who bring d iverrse p ive ersspective er ivess diverse perspectives and experiences.

CORE COMPONENT 6

People have same-day y ac access cess to multiple levels of care.

CORE COMPONENT 5 SYSTEM DESIGN & IMPROVEMENT

Recovery-oriented approaches are clearly and consistently integrated all inttegratted d att al ll levels levells of the systems of care.

CARE EXPERIENCE

CORE COMPONENT 9 Care is person-centric.

CORE COMPONENT 7

CORE COMPONENT 8

Resources and services are guided by a one-at-a-time approach.

Services are lexible, exible, data l informed, info f rmed, and collaborative.

Fig. 11.2  Core components framework

11.4 A Note on Evidence The role of evidence has been a major cause for reflection among developers and implementers of SC2.0. It is important to highlight the fact that multiple types of evidence informed the development of each core component and the associated practice recommendations, including empirical, experiential, and theoretical evidence.1 Empirical evidence is understandably important in developing a model of care, but given the innovative nature of SC2.0, and its stated intention to dramatically shift the norms in mental health care service delivery, relying on empirical evidence alone would be limiting. For this reason, experiential (including lived experience) and theoretical evidence also played an important role. To illustrate how different forms of evidence informed the core component development process, we have provided two examples to compare and contrast. First, we will consider Core Component 3—the management of risk is distributed

 Empirical evidence refers to that based on data gathered through experimentation and observation; experiential evidence refers to knowledge shared by those with relevant experience based on that experience; and theoretical evidence analyzes and makes connections across different sources of knowledge to advance a theoretical position. 1

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Table 11.2  Practice recommendations for Core Component 6 Core Component 6: People have same-day access to multiple levels of care Minimum practice recommendations Optimal practice recommendations • People have same-day access, without a • Immediate access to several options at low, referral, to resources and services, and they are moderate, and high levels of care provided a choice of at least one option of care • Providers practice effective communication at low, moderate, and high intensity and collaboration skills with one another to • People can access self-directed resources ensure efficiency in managing same-day • People can access one-to-one support in at access to services and referrals within the least one of the following modes: in-person, systems telephone, or web-based • Providers are encouraged to engage in • Services are culturally appropriate and flexible and creative thinking to address responsive and accessible to groups that are same-day needs of communities they often under-served serve. Novel issues provide opportunities • People are supported to identify their needs for creative solutions and diplomatic and preferred service options based on disruption preference and readiness to engage • Providing support is the focus of the first interaction. A full psychological assessment is only administered when more information could help inform care decisions

across the systems—which relied heavily on theoretical rationale. Second, we will consider Core Component 7—resources and services are guided by a one-at-a-time approach—which is derived primarily from empirical research (Harper-Jaques & Foucault, 2014; Hoyt et al., 2020; Hymmen et al., 2013).

11.4.1 Evidence Considered for Core Component 3: The Management of Risk Is Distributed Across the Systems Mental health care service delivery has not escaped the influence of neoliberal policies and ways of thinking. In this system, mental illness is conceptualized as a threat (Cornish, 2020). This perception of risk leads to fear and the need for “treatment” to minimize the risk of harm posed to others (Stanford et al., 2017) (refer to Chap. 13 for further exploration of the risk paradigm). In this context, SC2.0 represents a dramatic shift in thinking: in contrast to most models in which responsibility for risk is held by the one most responsible provider, “risk” in SC2.0 is shared more openly and intentionally across the spectrum of providers and partners. Unsurprisingly, this core component is not derived from empirical studies; there are no clinical trials comparing how risk is managed in SC2.0 to care as usual. Instead, this component draws from critical social theory about the impact of our neoliberal system on care and reimagines risk through a new lens (Stanford et al., 2017). Implementation of this core component provides an opportunity to generate

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new evidence that is grounded in clinical practice and advance scientific knowledge related to risk.

11.4.2 Evidence Considered for Core Component 7: Resources and Services Are Guided by a One-at-a-Time Approach A key tenet of the one-at-a-time (OAAT) approach, which is rooted in single-­session therapy (SST) methodology, is that each encounter is an opportunity for stand-alone healing or helpful experiences, with the option to reengage in additional services or resources as needed (refer to Chap. 14 for further discussion of OAAT and SST). It is both a philosophy and a practice that treats each session as potentially valuable in and of itself and leaves the decision to engage in follow-up sessions with the individual seeking services (Hoyt et al., 2020; Young, 2020). A robust body of empirical evidence supports the use of OAAT/SST. A series of investigations indicated that people are most likely to attend one session across a range of therapeutic orientations (Cannistrà et  al., 2020; Center for Collegiate Mental Health, 2020; Talmon, 1990; Young et al., 2012). Furthermore, many people who attend one session have their needs adequately met, with most recent literature showing that nearly half of people are satisfied with one session (Cannistrà et al., 2020; Harper-Jaques & Foucault, 2014). In addition to empowering clients to seek care when they need it (without having to commit to a lengthy course of treatment), this approach has the added benefit of reducing wait times and improving cost-effectiveness. These examples illustrate the complexities involved in defining what counts as evidence for SC2.0, particularly given its innovative, person-centric, and community-oriented nature, which necessitates the consideration of diverse forms of knowledge and perspectives. By expanding our definition of evidence to include experiential and theoretical knowledge in addition to empirical data, the core components and practice recommendations are reflective of the philosophical underpinnings of SC2.0.

11.5 From Theory to Practice With the articulation of core components, their organizing framework, and observable, measurable practice recommendations, the foundation for a common understanding of SC2.0 was established. Any organization or jurisdiction seeking to use the model to guide their system transformation now had a roadmap available to support their implementation with fidelity. Although SC2.0 has been implemented in more than 50 jurisdictions or settings, we are still in the early days of understanding the impact of each core component on

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a diverse array of outcomes at the system, organizational, and individual levels. Similarly, we are still in the process of learning about how implementers experience the practice recommendations. For example, early learning has led us to recently update the practice recommendations for clarity and alignment with emerging concepts of synergy. Additionally, further differentiation between the current core components may be required to ensure they are sufficiently distinct and unique while remaining complementary. The recent development of a theory of change and a common evaluation framework will support this effort and our ability to integrate learnings to inform continued development of the model—an exemplification of Core Component 4 (system and service improvement is achieved through continuous monitoring and quality improvement cycles) in practice. Although we expect the model to iterate in response to these findings, the current core components and practice recommendations are able to serve as a functional outline of what makes SC2.0 a usable innovation and to provide guidance to implementers seeking to apply the model to transform their systems of care.

11.6 Guiding Principles: Our North Star Though the core components and practice recommendations provided the functional outline of SC2.0, there still remained a critical gap in our endeavor to fulsomely describe the model. We had not yet articulated the theoretical and philosophical underpinnings that critically differentiate SC2.0 from other system transformation approaches. To address this gap, we set out to identify and document our guiding principles: the essence of SC2.0 beyond the practicalities of the core components. In doing so, we focused on the following question: in a model designed to be iterative, responsive, and ever-changing, what should ultimately guide implementers’ decisions? That is to say, how will we know we are staying true to SC2.0? To answer this question, a subset of the Stepped Care Solutions team held a collaborative working session which identified the higher-order values that serve as the foundation of SC2.0 and capture the ideals, aspirations, and ethos of the model. This initial version of the guiding principles was then shared with others familiar with SC2.0, including additional members of the Stepped Care Solutions team, those from the MHCC, and the research team working on implementing and evaluating the model at Memorial University of Newfoundland and Labrador. Once this consultation phase was finished, the team reviewed the revised guiding principles to ensure they were consistent with, and reflected in, the already established core components. The result of this process was the solidification of what we now regard as the SC2.0 guiding principles (Table 11.3). We’ve now rounded out our overview of the foundations of SC2.0: its core components, their associated practice recommendations, and guiding principles. Taken together, these comprehensively capture the essence of SC2.0. That is to say, we now

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Table 11.3  SC2.0 guiding principles • Social justice drives effective care system transformation and is an intervention in itself

• Mental health literacy is required for people to make informed decisions

• Multiple and diverse care options are required, as one approach will not work for everyone

• An effective care system ensures people have access to care when and where it is needed

• All individuals and communities have strength and capacity

• The whole is greater than the sum of the parts: the strength of the system relies on multilevel collaboration

• People engage with what they are ready to do. A • Minimal interventions can produce powerful results gold standard intervention is that which best fits the service user at any given time • Professionals do not carry all the wisdom. People often know what is best for them

• There is no ideal solution. Trial and error leads to growth and change

have the answer to the question posed at the outset of this chapter: what is SC2.0? Our work is not yet done, however, as we are still left with the conundrum: if SC2.0 should look different in each unique context, how can implementers know whether they are really implementing SC2.0 as it was designed and intended? We promise to answer this soon, but first we will dive a little deeper into the concepts of fidelity and adaptability to better understand whether a tension really exists between the two.

11.7 Fidelity and Adaptability: Tension or Harmony? Although implementation research has historically viewed fidelity to the original concept as the cornerstone to achieving expected outcomes (Fixsen et al., 2009)— and, indeed, the ability to maintain fidelity to the model served as a key rationale for the development of SC2.0 core components—the need for adaptation has emerged as a priority in implementation science. This has been prompted by the increasingly recognized significance of other factors beyond fidelity, including acceptability, adoption, appropriateness, feasibility, penetration, reach, and sustainability—all of which are improved when an intervention is adapted to a given context (Hasson et al., 2020; Leeman et al., 2017; Lewis et al., 2015; Proctor et al., 2009; Tierney et al., 2020; Varsi et al., 2019). As such, implementation research has increasingly studied the balance between implementing interventions with maximum fidelity and adapting interventions to be responsive to the needs of a local community. Adaptation has been defined as a process of intentional alteration to the design or delivery of an intervention with the goal of improving its fit, reach, appropriateness, or effectiveness in a new context (Escoffery et  al., 2018; Wiltsey Stirman et  al., 2015; Wiltsey Stirman et al., 2017). This is predicated on a growing body of research emphasizing that innovations are more effective and sustainable if they are responsive to local needs, preferences, and capacities (Horner et al., 2014; Walker et al., 2015). Of particular significance, the research highlights the importance of careful attention to the distinctive cultural characteristics when implementing interventions

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(Bernal et al., 2009), especially given the disparities in both access to care and outcomes for marginalized populations and those who live in under-resourced communities (Alegria et al., 2010, 2015; Coker et al., 2009). Clearly adaptation is an established and important aspect of implementation, but how does it interact with fidelity, another critical aspect of implementation? One might think these concepts are contradictory or in opposition based on the assumption that implementation with fidelity means that the processes and outcomes should be (close to) identical across sites; however, the concept of fidelity-adaptation “balance” reflects the recognition that implementation should involve some tailoring to context—provided that implementers adhere to an innovation’s core components (Anyon et  al., 2019; Durlak & DuPre, 2008; SAMHSA, 2022). More recently, a growing literature base has observed that some adaptations are actually a demonstration of adhering to fidelity, particularly when adaptations are consistent with, or required of, the model (Anyon et al., 2019). This goes beyond the notion of balance, which assumes that fidelity and adaptation are opposing ends of a continuum and leads to a need for more nuanced models of implementation that consider how adaptation is necessary to achieve fidelity (Aarons et al., 2017; Chambers & Norton, 2016). Innovations that require modifications (i.e., adaptations) as part of expected implementation (i.e., fidelity to a model of care) include those grounded in engagement, responsiveness, co-design, and reflexivity. For example, Anyon et al. (2019) argue that fidelity to the principles of Youth Voice Programs—power-sharing, youth ownership, and engagement in social change—requires adaptation. This can be observed with a dynamic process such as power-sharing, as it will lead to unanticipated modifications (Anyon et al., 2019). This argument can be extended to SC2.0 for much the same reasons: co-design, continuous improvement, and other essential aspects of the model require adaptation, and the processes and outcomes of SC2.0 implementation in different contexts can be different and yet have high fidelity to the model. Below, we note some approaches and strategies that support the effective implementation of adaptations: • Multiple studies have shown community partnership and consultation to be effective approaches to inform adaptations and support successful implementation (Barrera et  al., 2011; Baumann et  al., 2015; Goodkind et  al., 2010; Guttmannova et  al., 2017). Models that center partnership and consultation include the “empowerment implementation” model (van Daele et al., 2014), the CENTER-­ IT methodology grounded in the Consolidated Framework for Implementation Research (Trivedi et  al., 2022), and the ADAPT guidance (Moore et al., 2021). • Studies have shown that grounding adaptations in evidence increases the likelihood of sustainable impact (Aarons et al., 2012; Castro & Yasui, 2017; Chambers et al., 2013; Durlak & DuPre, 2008). • Implementation supports should clearly define specific activities and steps that need to be completed, but allow for enough flexibility that implementers can use co-design to develop and implement a model that works best for their own unique communities.

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• There is a need to monitor and assess outcomes at the client, service, and system levels to serve as indicators of implementation effectiveness and quality within complex health care systems (Willmeroth et al., 2019). Benchmarks are helpful for guiding implementers as they seek to implement a model with fidelity, but instruments must be sufficiently dynamic to capture processes in which adaptation is an expectation (Anyon et al., 2019). We want to highlight the point that the significance of fidelity remains unchanged—it is a critical pillar of good implementation; however, we have deepened our understanding of fidelity to include adaptation in alignment with the model. In this way, implementing SC2.0 with fidelity does not mean that the result of implementation—that is, the system of care designed and delivered—will look and be experienced the same across each setting. Rather, the gauge of fidelity is evidenced through the application of the core components and the direction of the guiding principles to co-design a system of care. Further, by virtue of adhering to the core components and guiding principles, the outputs (i.e., the system of care) should be different. That is to say, when implementing SC2.0, adaptability is fidelity.

11.8 How Do We Implement SC2.0 with Fidelity? As articulated throughout this chapter, the concept of fidelity is a complex one, and its application to the SC2.0 model is no exception. In the preceding section, we established a more nuanced conceptualization of fidelity: one in which adaptation is both necessary and expected based on the theoretical underpinnings of the model. In considering how this applies to SC2.0, we have pulled out a subset of the core components and guiding principles which highlight the need for adaptation to implement SC2.0 with fidelity (Fig. 11.3). These core components and guiding principles reflect that SC2.0 is inherently flexible, because it is designed to respond to context and data at the individual and system level. This focus on a strengths-based approach and continuous improvement means the model will evolve along with shifting needs and demands within the system and population. Moreover, the importance of co-design implies the model will be necessarily different in each community. An example of this in practice is highlighted by the implementation of SC2.0 in two different contexts: the Northwest Territories and Newfoundland and Labrador. As the needs, strengths, resources, and communities differed between these two contexts, the implementation of SC2.0 was adapted in alignment with the core components and guiding principles. In the Northwest Territories, engagement with community members revealed the importance of focusing on a holistic, person-centered approach to service delivery and system changes, which led to the inclusion of traditional and land-based care. In Newfoundland and Labrador, the initial focus, emerging from grassroots priorities, was on increasing access to a variety of

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Fig. 11.3  Principles and core components that highlight the need for adaptation

same-­day services, such as drop-in clinics and e-mental health resources aligned with a recovery approach. These examples highlight how the same model—SC2.0— can look very different in different settings, but still retain its principles (e.g., multiple and diverse care options are required, as one approach will not work for everyone) and core components (e.g., key stakeholders are engaged throughout the design process). In contrast, let us imagine what it would have looked like if SC2.0 had taken a more rigid approach to fidelity, requiring that implementation look the same across these two very different settings. Services that were deemed to be of value to local communities might have been overlooked or ignored out of a desire to achieve uniformity or “fidelity” to the original SC2.0 model first implemented at Memorial University of Newfoundland and Labrador—a very specific and unique setting. Resources and efforts would be automatically diverted toward services assumed to be required based on other contexts without engagement with, and consideration of, each community’s priorities. As such, we conclude that SC2.0 is a model which requires adaptation to achieve fidelity to its core components and guiding principles. That is, although the processes, inputs, and outcomes of implementation may look different in different ­contexts, this is acceptable as long as the design and implementation of the model is in alignment with the core components and grounded in our guiding principles.

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By embracing adaptation, SC2.0 can meet the needs of different populations, within the context of the structure and resources in its system, while recognizing the unique strengths of a community and its people. As a result, the desired outcomes of SC2.0 can be achieved: care systems will be transformed such that mental health is universally accepted as part of health and well-being, and everyone has open access to stigma-free, culturally appropriate resources, services, and supports that elevate their quality of life. Following from Anyon’s re-conceptualizing of the fidelity and adaptability debate, we understand that the essence of the SC2.0 model lies in its guiding principles and core components, which are innately responsive to context. In any given setting, implementation might look a little different, but it should follow the tenets that embody the spirit of the model. The main implication of this way of understanding SC2.0 is that adaptations that align with the core components and guiding principles are not a challenge to fidelity, but proof of it.

11.9 Reflection Peter Cornish “People don’t really like being on steps, Peter,” a colleague told me, referring to SC2.0’s nine-step model. “They are too hierarchical. There is judgment assigned to steps. Higher steps are more expensive. This leaves people either wanting the expensive option or thinking you are trying to dissuade them from using the scarce resources. The word ‘autonomy’ is also problematic. It has cultural loading. Are you saying it’s good? If so, that is not true in all cultures. And then there’s readiness. Why do you include that label as a dimension? What are you insinuating? I’m not motivated enough? Finally, you say it is a care model, but now I hear you saying it is a system transformation model. I’m confused. What is SC2.0’s?” What a mess we’ve gotten ourselves into. Alexia Jaouich and colleagues grapple with the tension between fidelity and adaptability. Their conclusion, “adaptability is fidelity,” begins to address that conundrum. But among audiences I engage with, there is still confusion on what SC2.0 is. While consensus on the key ingredients of chicken soup may involve some back-and-forth debate, it is not a complicated question. Most will arrive, at minimum, at “chicken broth.” You need that. We might assume SC2.0 is more complicated, but, nevertheless, we should still be able to capture its key ingredients in words. Complicated entities are ultimately knowable. They can be understood if studied enough and described in detail. In contrast, complex entities like SC2.0 are in essence evolving and, therefore, contain unknowables. Adaptability of SC2.0 implies continuous evolution, and, as such, a definition or clear description of what it is will remain elusive. Perhaps it is so complex that it can never be fully described or defined beyond the core components or principles. If we are to accept that the essence of SC2.0 lies in the principles or core components, we might do well to question the use of the label comprised of the words

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“stepped care” and “2.0.” Together, these imply it is something beyond the original stepped care model. At a conference recently, a presenter said their approach goes further than stepped care. She stated that collaborative mental health care is important; outcomes are better with interdisciplinary mental health care. She added that outcomes are also better with stepped care. But both of these, she argued, fall short of the next evolution, which she labeled “precision care.” She went on to describe precision care. It sounded a little bit like SC2.0. When I first coined the term “SC2.0,” I wanted to show that it was a new and improved version. As I read Chap. 11, I was reminded how different it is from most stepped care models. If our model is constantly evolving, do we have to keep changing what we call it? How will people know what it is, when it keeps moving? Maybe, like the presenter at the conference, we should find a completely new name for our method and model. Such movement presents a serious business problem for our not-for-profit consultancy, Stepped Care Solutions. How can you fund something so difficult to pin down or describe? How do you price and convince people to pay for the transformation work when the thing you are doing and the manifestations of the model are always shifting? Large system-level challenges are difficult to grasp, let alone analyze or address. This challenge is most obvious with the climate crisis. The complexity and timelines are so vast as to be beyond human comprehension. There is considerable debate about what the crisis is and how it manifests in our day-to-day lives. How will it unfold? Who will it affect and when? What do we target? Who is responsible? Who will pay for it? Thankfully, mental health systems are not that complex. So, how might we make SC2.0 more easily understandable? First, I will admit, it is a misnomer. But we will never nail it down, and that’s okay. It acknowledges that some healing resources are expensive and scarce, while others are abundant. It acknowledges a need for tension and balance between the downstream response to people in crisis and upstream population-level prevention and health promotion measures. It argues that adaptability is fidelity. It can be both a care model and a transformation tool. It can and should have many names and variations. It pays attention to our broken social structures and economic realities. It is big and complex. But in some ways—and this brings me hope—it is straightforward: care first, focus on strengths, employ democratic processes of co-design, and include formal and informal resources. Keep revamping the system to better organize options and make them accessible. While SC2.0 remains difficult to define in a sentence or two, the authors of Chap. 11 successfully represent the essence of the model in the principles and core components. This is the most accurate way to capture our method for raising the bar on mental health care and system building. Nevertheless, those unfamiliar with this work are not likely to be satisfied. Most people, including me, like clarity, simplicity, and elegance. Ten principles, nine core components, and nine steps mean that we have none of these qualities. Are we up for the challenge of engaging with communities, communicating the values, and supporting the development of implementation strategies when describing what we are doing is so cumbersome? I am.

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Lewis, C. C., Weiner, B. J., Stanick, C., & Fischer, S. M. (2015). Advancing implementation science through measure development and evaluation: A study protocol. Implementation Science, 10(1), 102. https://doi.org/10.1186/s13012-­015-­0287-­0 Mental Health Commission of Canada. (2019). Newfoundland and Labrador Stepped Care 2.0 e-mental health demonstration project. Retrieved February 10, 2023 from https://mentalhealthcommission.ca/wp-­content/uploads/2021/09/emental_health_report_eng_0.pdf Metz, A. (2016). Practice profiles: A process for capturing evidence and operationalizing innovations. National Implementation Research Network. Retrieved February 10, 2023 from http:// files.eric.ed.gov/fulltext/ED606401.pdf Mihalic, S. (2002). The importance of implementation fidelity. Retrieved February 17, 2023 from https://www.incredibleyears.com/wp-­content/uploads/fidelity-­importance.pdf. pp. 83–86. Moore, G., Campbell, M., Copeland, L., Craig, P., Movsisyan, A., Hoddinott, P., Littlecott, H., O’Cathain, A., Pfadenhauer, L., Rehfuess, E., Segrott, J., Hawe, P., Kee, F., Couturiaux, D., Hallingberg, B., & Evans, R. (2021). Adapting interventions to new contexts—The ADAPT guidance. British Medical Journal, 374, n1679. https://doi.org/10.1136/bmj.n1679 National Academies of Sciences, Engineering, and Medicine. (2019). Fostering healthy mental, emotional, and behavioral development in children and youth: A national agenda. The National Academies Press. National Implementation Research Network. (n.d.-a). Framework 1: Usable innovations. Retrieved February 10 2023, from https://nirn.fpg.unc.edu/module-­1/usable-­innovations National Implementation Research Network. (n.d.-b). Topic 1: Defining usable innovations. Retrieved February 10 2023, from https://nirn.fpg.unc.edu/module-­6/ topic-­1-­defining-­usable-­innovations Presseau, J., McCleary, N., Lorencatto, F., Patey, A. M., Grimshaw, J. M., & Francis, J. J. (2019). Action, actor, context, target, time (AACTT): A framework for specifying behaviour. Implementation Science, 14(1), 102. https://doi.org/10.1186/s13012-­019-­0951-­x Proctor, E.  K., Landsverk, J., Aarons, G., Chambers, D., Glisson, C., & Mittman, B. (2009). Implementation research in mental health services: An emerging science with conceptual, methodological, and training challenges. Administration and Policy in Mental Health and Mental Health Services Research, 36(1), 24–34. https://doi.org/10.1007/s10488-­008-­0197-­4 Stanford, S., Sharland, E., Heller, N. R., & Warner, J. (2017). Beyond the risk paradigm in mental health policy and practice. Palgrave. Substance Abuse and Mental Health Services Administration (SAMHSA). (2022). Adapting evidence-based practices for under-resourced populations. SAMHSA Publication No. PEP22-06-02-004. Retrieved February 10, 2023, from https://store.samhsa.gov/sites/default/ files/SAMHSA_Digital_Download/PEP22-­06-­02-­004.pdf Talmon, M. (1990). Single-session therapy: Maximizing the effect of the first (and often only) therapeutic encounter. Jossey-Bass. Tierney, A.  A., Haverfield, M.  C., McGovern, M.  P., & Zulman, D.  M. (2020). Advancing evidence synthesis from effectiveness to implementation: Integration of implementation measures into evidence reviews. Journal of General Internal Medicine, 35(4), 1219–1226. https://doi. org/10.1007/s11606-­019-­05586-­3 Trivedi, M., Hoque, S., Shillan, H., Seay, H., Spano, M., Gaffin, J., Phipatanakul, W., Rosal, M.  C., Garg, A., Gerald, L.  B., Broder-Fingert, S., Byatt, N., Lemon, S., & Pbert, L. (2022). CENTER-IT: A novel methodology for adapting multi-level interventions using the Consolidated Framework for Implementation Research—A case example of a school-­ supervised asthma intervention. Implementation Science Communications, 3(1), 33. https:// doi.org/10.1186/s43058-­022-­00283-­5 van Daele, T., van Audenhove, C., Hermans, D., van den Bergh, O., & van den Broucke, S. (2014). Empowerment implementation: Enhancing fidelity and adaptation in a psycho-educational intervention. Health Promotion International, 29(2), 212–222. https://doi.org/10.1093/ heapro/das070

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Varsi, C., Solberg Nes, L., Kristjansdottir, O.  B., Kelders, S.  M., Stenberg, U., Zangi, H.  A., Børøsund, E., Weiss, K. E., Stubhaug, A., Asbjørnsen, R. A., Westeng, M., Ødegaard, M., & Eide, H. (2019). Implementation strategies to enhance the implementation of eHealth programs for patients with chronic illnesses: Realist systematic review. Journal of Medical Internet Research, 21(9), e14255. https://doi.org/10.2196/14255 Walker, S. C., Bumbarger, B. K., & Phillippi, S. W., Jr. (2015). Achieving successful evidence-­ based practice implementation in juvenile justice: The importance of diagnostic and evaluative capacity. Evaluation and Program Planning, 52, 189–197. https://doi.org/10.1016/j. evalprogplan.2015.05.001 Willmeroth, T., Wesselborg, B., & Kuske, S. (2019). Implementation outcomes and indicators as a new challenge in health services research: A systematic scoping review. INQUIRY: The Journal of Health Care Organization, Provision, and Financing, 56, 004695801986125. https://doi. org/10.1177/0046958019861257 Wiltsey Stirman, S., Gutner, C.  A., Crits-Christoph, P., Edmunds, J., Evans, A.  C., & Beidas, R.  S. (2015). Relationships between clinician-level attributes and fidelity-consistent and fidelity-­ inconsistent modifications to an evidence-based psychotherapy. Implementation Science, 10(1), 115. https://doi.org/10.1186/s13012-­015-­0308-­z Wiltsey Stirman, S., Gamarra, J.  M., Bartlett, B.  A., Calloway, A., & Gutner, C.  A. (2017). Empirical examinations of modifications and adaptations to evidence-based psychotherapies: Methodologies, impact, and future directions. Clinical Psychology: Science and Practice, 24(4), 396–420. https://doi.org/10.1111/cpsp.12218 Young, J. (2020). Putting single session thinking to work: Conceptual, practical, training, and implementation ideas. Australian & New Zealand Journal of Family Therapy, 41(3), 231–248. https://doi.org/10.1002/anzf.1426 Young, J., Weir, S., & Rycroft, P. (2012). Implementing single session therapy. Australian & New Zealand Journal of Family Therapy, 33(1), 84–97. https://doi.org/10.1017/aft.2012.8

Chapter 12

Oil and Water: Why the Legal Risk Paradigm Conflicts with Good Therapy Kami Sidman and Justin Jacques

12.1 Introduction Risk is an unavoidable part of life and leads us to be in a constant state of decision-­ making, to assess whether or not the risk associated with any given action or behavior is acceptable. We live our lives by balancing and mitigating risk, for better or for worse. Risk is the currency of the legal system; lawyers are tasked with helping clients avoid legal risks, and legal structures are designed to protect power and resources for those who have them by maintaining the status quo and ensuring predictability (Bell, 1992, p. 376). This risk paradigm dominates modern institutions and is especially prevalent in institutions meant to provide primary and mental health care. While the risk paradigm supposedly exists to ensure client safety, in practice, the structures that uphold it are designed to minimize risk to institutions, even if this diminishes the care clients receive. Counselors, however, teach clients that they cannot avoid risk. Because therapeutic work is about facilitating change, helping clients take responsibility for their own choices and promoting independence means accepting the potential for exposure to danger, harm, or loss (Kottler, 2022; Rogers, 1940). In a society heavily focused on a paradigm of risk avoidance, counselors are caught between these two competing demands: the need to work within institutions that demand risk avoidance and attempting to empower clients to take responsibility and take risks. Good legal risk management inherently conflicts with good therapy, shifting counselors away from the work of building relationships, promoting self-­efficacy and autonomous decision-making, and prioritizing client needs.

K. Sidman Private Practice at Compassionate Therapy Center, Arlington, VA, USA J. Jacques (*) Private Practice at Human Theory Group, Washington, DC, USA © Springer Nature Switzerland AG 2023 P. Cornish, G. Berry (eds.), Stepped Care 2.0: The Power of Conundrums, https://doi.org/10.1007/978-3-031-45206-2_12

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Within the Stepped Care 2.0 (SC2.0) model, however, risk is understood differently. Core Component 3 stipulates that in SC2.0 “risk management is evidence-­ informed, distributed, and effectively addresses stigma inherent in the dominant risk paradigm.” Rather than seeing risk as something to be minimized and avoided at all costs, SC2.0 is attentive to the many ways, both positive and negative, that risk is present in encounters between clients and counselors. By creating a sense of shared ownership of risk, SC2.0 seeks to move toward a paradigm in which the imperative to limit legal liability doesn’t override the primary purpose of delivering therapy in the first place: improving client well-being. This raises a conundrum: given that the risk paradigm shapes every aspect of current mental health-care systems, how can SC2.0 challenge the risk paradigm while also operating within it? In this chapter, we explore how the risk paradigm operates within the context of postsecondary mental health care and why it poses such a challenge to mental health-care professionals seeking to provide good care to their clients. This chapter will mostly focus on the mental health-care provider’s experience of the risk paradigm, as they are significantly impacted by this vocational challenge in the context of SC2.0. We conclude that, while the SC2.0 model cannot resolve the fundamental conflict involved in conducting therapy within the risk paradigm, it offers a more useful approach for navigating the quagmire in which counselors find themselves.

12.2 The Background: Increased Demand and Limited Resources Drive Fear To illustrate the risk paradigm, we have chosen the context of university counseling, as it is helpful in highlighting the key challenges that university counselors and other mental health workers in a higher education setting face. The demand for mental health services has increased significantly at university counseling centers (UCCs) over the last decade. The Center for Collegiate Mental Health’s (CCMH’s) 2016 annual report found that the number of students who visit UCCs has increased by an average of 30 to 40% from 2009 to 2015. This is a growth rate five times higher than the average institutional enrollment, which is around 5% (CCMH 2016). Additionally, UCCs have shifted resources toward mental health crisis triage care, administering almost 30% more crisis service hours per student over the past 6 years and allotting almost 80% fewer hours to routine services, such as ongoing counseling (CCMH 2016). The prevalence of common mental health issues among college students may also have increased. According to a 2015 American College Health Association report, more than half of college students say they have experienced significant anxiety in the last year, and over 30% say they have felt so depressed that it was difficult to function. Although the CCMH report for 2015 found similar increases regarding student demand for mental health services, lifetime prevalence rates have

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stayed relatively the same (Institute for Health Metrics and Evaluation, 2017). This suggests that students seeking mental health services do not necessarily have a higher rate of preexisting mental health concerns. The data pointing to static prevalence rates may also indicate that students are not necessarily getting sicker over time, but are simply becoming more willing and able to seek help. This could be the result of the numerous national prevention and awareness campaigns aimed at decreasing stigma and increasing help-seeking behaviors. Whatever the cause, this significant increase in demand for mental health services has put a substantial strain on UCCs. UCCs now have to consider how to best utilize their limited resources. At the same time, UCC resources have not kept up with the increasing demand for mental health services (Coleman et  al., 2021). This inability has been highlighted by a recent report from the Association of University College Counseling Center Directors (2015). The 2015 report shows1 that colleges with enrollments of 1501 to 2500 students have an average of 8 weeks per year in which they employed wait-lists. Colleges with enrollments of 25,001 to 30,000 utilized wait-lists an average of 23 weeks a year (AUCCCD, 2015). Additionally, at universities with enrollments above 15,000, the average number of students on the wait-list at any given time was above 50, and for institutions with enrollments of 30,001 to 35,000, the average was as high as 70 students (AUCCCD, 2015). This dynamic of unmet demand has significant consequences for UCCs. With increased demand, UCCs are forced to shift from the traditional treatment paradigm to a crisis assessment and response model to address the most acute and significant needs, leaving many students with mental health issues waiting for care and possibly getting sicker. This creates a vicious cycle where students with mild to moderate mental illness, who might have been successfully treated, become students seeking crisis services, which further stresses the system. Additionally, crisis clients often present with significant risk, including suicidal ideation, adding to increased strain on already overburdened systems. When clinicians are seeing an increased number of clients with high acuity on a daily basis, they may have impaired clinical judgment and may either over-assess or under-assess the clinical risk. This has a significant negative impact on student clients. Nationally, there has been an accompanying upward trend in the number of students reporting suicidal ideation and other crisis-related issues on college campuses. Thoughts of suicide are not uncommon among college students. According to a 2018 report by the National Center for Collegiate Mental Health, among students utilizing UCC services from 2010 to 2018, there has been a significant upturn in three areas related to college student suicidality, including increases in rates of lifetime suicide attempt plans (24–35.8%), 12-month suicide plans (6.4–8.2%), and lifetime suicide attempts (8–10.3%) (CCMH, 2019).  The 2021 report does not include wait time data. Though it does include a view of 4-year trends in utilization rates, trends over this period were either stable (2017–2020) or decreased (2020–2021), largely due to the COVID-19 pandemic. For this reason, we have chosen to use the earlier data point. 1

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College students who are in crisis and eventually die by suicide have a significant impact on the university community (Andriessen & Krysinska, 2021). When a suicide becomes public knowledge on a college campus, it impacts every stakeholder— including students, faculty, staff, and administration, as well as the students’ parents and friends. This high cost on the university community, which includes life loss, emotional strain, financial consequences, and, ultimately, the fear of lawsuits, can allow legal concerns to significantly dictate what occurs in the counselor’s office (Fossey & Zirkel, 2011). One way that the delivery of services may be impacted is that a UCC counselor might refer a student with moderate-to-severe risk out to a community provider after the first session, because they do not want to take on the liability of having students with potential risk on their caseload. As a result, UCC clinicians are under intense pressure to engage in frequent risk assessment. The current reality for counselors in higher education is that they may treat students experiencing a personal crisis on a daily basis (CCMH, 2019). Therefore, clinicians must be prepared to conduct crisis evaluations, design crisis stabilization plans, and provide comprehensive treatment (Pisterello et  al. 2017). The unfortunate result of more frequent risk assessments and more nuanced suicide assessments is that counselors often experience increased stress, feel the effects of burnout, and must wrestle with the uncertainty as to whether their students of concern may attempt or possibly die by suicide. Students in need are too often left waiting for help while they are in significant psychological pain and then have to meet with counselors who are going through their own personal struggles because they are working in systems that are overburdened. Given these realities, there is an urgent need for an alternative to the current risk paradigm within mental health, particularly as it concerns the context of college counseling.

12.3 The Risk Paradigm in College Counseling The increase in serious mental health issues among college students has brought UCCs face-to-face with the impact of the risk paradigm on counseling practice, as counselors must often choose between the competing mandates of responding to the risk of harm to clients by providing lifesaving empathic client-centered practice and protecting institutions from the risk of legal liability through delivering precise, competent, evidence-based interventions that effectively moderate risk in a timely manner. Fundamentally, human concerns—the core of psychological counseling— such as honoring valid emotions, recognizing strengths, considering the whole person, and acknowledging the existential truth of life’s limits, get lost in a morass of fear and blame. Counselors and clients can become stuck in risk paradigm practices that may be more focused on limiting risk than on maximizing well-being. A 2018 case at Harvard University exposes how some therapeutic “best practices” can increase institutional liability in unexpected ways (Franklin, 2018). As reported in The Crimson, Harvard’s student paper, a 2015 student suicide resulted in a wrongful death suit against the university when it was discovered that the student

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had received mental health counseling from Harvard following a previous suicide attempt (Franklin, para. 5). After the initial attempt, the student signed a contract with the university that stipulated ongoing therapy as a condition of his remaining on campus, but he received no further therapy prior to his suicide a few months later (Franklin, para. 6). Reporting on the same case, The Boston Globe noted, in 2019, that advocates for the victim argued that representatives from Harvard should have followed up with the victim after creating the contract, citing a Massachusetts Supreme Court decision from 2018 that found that universities have a legal duty to prevent suicides if they know a student is at risk (McKim, 2019, para. 8). While the case is ongoing at the time of writing, it highlights the tensions that exist between providing therapy and taking on legal risk. In this example, the contract was likely required by counseling center policy, yet it may have only increased the UCC’s potential liability by assuming additional responsibility: following up with the student when he did not adhere to the contract. The student’s family’s lawyers will argue that Harvard failed to meet a duty of care when it failed to follow up with him after he did not take steps outlined in the contract. With overburdened and burned-out counselors in jam-packed UCCs, every additional policy requirement creates one more chance for counselors to fail to meet their standards of care. Unrealistic expectations combine with high counseling center demand to strain the limits of what counselors can do to help students. In the Harvard case, the victim was off-campus and, for periods of time, out of the country in the months between his suicide attempts. Ironically, had Harvard simply outsourced their students to off-­campus counselors, it would have assumed less risk of legal liability, even if the outside counseling services were of lower quality or harder for students to access or afford. This case offers a clear example of the risk paradigm’s chilling effect on UCCs, a reality that creates perverse incentives for universities, which might opt to close counseling centers rather than face the legal risks involved in providing care— despite the detrimental impact this could have on students. Misconceptions about counseling practice, including the belief on the part of parents or students that counselors can magically “fix” students’ significant mental health conditions, exacerbate and perpetuate the inevitable risk associated with intervening in students’ mental health. This suggests a need for mitigating alternatives to conventional UCC counseling practice.

12.4 The Risk Paradigm Continued: The Medical Model In order to make sense of a case like Harvard’s, it is helpful to understand a prevailing model of practice within the mental health profession: the medical model. Within the medical model, the goal of the mental health provider is understood to be the accurate identification, classification, and diagnosis of mental health conditions. The risk paradigm, which asks mental health providers to see clients as objects of risk (to themselves and/or others physically, as well as to the finances and reputation of the institutions in whose care they are), relies on several assumptions inherent in

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the medical model. These views guide legal attitudes toward mental health practice. They include the following: (1) mental health issues are diseases, rather than normal aspects of being human; (2) mental health problems reside in individuals; (3) mental health providers are experts capable of predicting behavior and responsible for curing clients; and (4) mental health providers appropriately hold the power and authority within the therapeutic relationship. In order to understand how the risk paradigm relates to the medical model, we must explore these four assumptions in greater detail. 1. Mental illness is a disease. Mental health issues are seen as “diseases” or “disorders.” These classifications assume that mental health issues are a pronounced variation from what is considered normal human functioning. Counselors utilizing this model diagnose these illnesses by behavioral observation, history, and client self-reporting. Specific interventions are prescribed for certain diagnosable mental health conditions. Once a disorder is classified according to the medical model, the counselor must develop a plan of treatment based on the specific cause of the illness. The idea is that the best way to cure the disorder is to isolate it from the person and develop an intervention that targets the problem at its source. This model asks counselors to endorse a treatment mentality that regards the unique perspective and values of their clients as largely irrelevant to the counseling and psychotherapy process. This has the effect of dehumanizing the client and is antithetical to effective clinical work—especially when attempting to mitigate risk which requires a significant human connection. 2. Mental health problems are individual problems. A core assumption of the medical model is that mental health problems are individual problems that can be solved between two people in a room. This idea comes from a Western emphasis on individualism and traditional psychological theories that emphasize meaning-making from an individual perspective (Hansen, 2016). This conceptual emphasis on individualism diverts attention from social and cultural influences that impact an individual’s mental health and are very important to how the client makes meaning of their condition (Hansen, 2016). This emphasis on individuality often results in the client having unhelpful beliefs regarding their mental health struggle, such as that they are choosing to feel unwell, are inherently weak, or are biologically broken. 3. Counselors are experts who can predict behavior and cure disease. In a similar fashion to doctors, counselors who adhere to the medical model control and direct the information-gathering process in a counseling session. The counselor is considered an expert, who asks empirically informed questions and then pursues a particular psychological direction to unveil the features that will lead to a mental health diagnosis. Clients are understood as having disorders, and these disorders are veiled by verbose personal narratives the client has constructed. Under this paradigm, the counselor is responsible for ascertaining the true nature of the client’s presenting issue. The counselor then employs their clinical expertise to get

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beyond the supposed distractions of irrelevant meaning systems to unveil the underlying diagnosis and provide the correct treatment technique that can resolve the mental health issue. Another common component of the medical model is the idea that the counselor, who is seen as the expert, is responsible for “curing” the client of their presenting concern or issue. The counselor may ultimately feel responsible for the mental health of their client, and the client may believe that the counselor has a magical treatment for their ills. This can be disempowering for clients, who learn to view behavioral and psychological challenges as diseases over which they have no control. This belief can be counterproductive to the work of therapy, which requires commitment and input from clients to work. 4. Counselors should hold control and authority over clients. A final defining characteristic of the medical model, though one that is often present covertly, is the role of power in the creation of meaning. Under this paradigm, the counselor controls the definition of “truth” regarding the client’s diagnosis and their mental health treatment. Ultimately, the medical model disempowers clients and can create dependency or a feeling of helplessness. It also generates an uncomfortable feeling of responsibility on the part of the counselor. This can ultimately impact the way counselors provide treatment and manage risk. These assumptions guide legal attitudes toward counseling practice and lead to beliefs about a counselor’s responsibilities. As Stanford et  al. (2017) note, the assumption that mental health issues are a form of disease leads to the belief that suicidality and other forms of harm to self or others can be diagnosed and predicted, positioning the counselor as a kind of psychic and setting the stage for increased liability. In addition to assuming the counselor’s prescience, many believe that risks associated with the diagnosis and treatment of mental illness can (and should) be managed at the institutional level. Polychronis (2018) has noted the common belief that counselors should bear responsibility for the choices of their clients, “although counselors have little control over clients’ actions outside of the therapy room” (p. 285).

12.5 Impacts of the Medical Model and Risk Paradigm Overreliance on the medical model of mental health intervention impacts the way counselors provide services to their clients, potentially undermining effective treatment and resulting in suboptimal outcomes for patients, as well as generating a host of problems for counselors and increased risk for institutions, including damage to the therapeutic relationship, the potential for increased client distress and suicidality, and suboptimal targeting of limited resources. When counselors are tasked with delivering care in a prescribed or mechanistic way, the authentic human connection is lost. When mental health providers must use standardized forms, assessments, and therapeutic tools in a one-size-fits-all manner, distance between the counselor

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and the client is established. As a result, the client does not bond with the provider, and distress is not mitigated. Of equal concern is the fact that the medical model undermines the therapeutic relationship between counselor and client, a bond defined by Flückiger et al. (2018) as “the agreement between (client and counselor) on the goals of treatment, and their collaboration on the tasks of treatment” (p. 316). The therapeutic bond plays an important role in predicting patient outcomes (Bordin, 1979), and it should be of primary importance to mental health-care providers. Essentially, it is hard for a counselor to nurture a relationship with the client when they must adhere to rigid proscriptive empirically based practices. But just as the risk paradigm traps counselors between best practices for clients and legal risk mitigation, the medicalization of mental health services positions mental health-care providers between competing mandates: to optimize patient outcomes through client-centered care and to constantly measure and mitigate potential risk to themselves and their institutions via the repeated delivery of scientifically validated and dehumanizing assessment tools. In the context of suicidality, the medical model may exacerbate risk rather than ameliorate it, especially when counselors approach their clients’ exploration of life’s meaning, values, and purpose as evidence of disorder and disease, rather than as a part of a normal—if sometimes maladaptive—attempt to make sense of difficult emotions and experiences. When clients encounter counselors who view them as broken, why wouldn’t they internalize that image of themselves? A recent study in the context of inpatient psychiatric treatment found that patients who felt coerced into hospitalization had an increased risk of a suicide attempt after discharge (Jordan & McNiel, 2020). This suggests that when a client feels saddled with a mental health diagnosis, internalizes that label, and experiences internalized stigma, risk is potentiated for that client. The demands placed on counselors by the medical model of mental health-care service can undermine the core drivers that attract counselors to the field, by interfering with client–counselor connections and even causing counselors to avoid working with high-risk clients or to advocate foregoing innovative treatments because of the potential risks involved. The documentation, extra assessments, and other rote tasks required to mitigate risk in the medical model of mental health-care services may result in increased efficiency at the institutional level, but they can also lead to burnout among counselors. The burden of administrative tasks increases with high-risk clients, who sometimes sense counselors’ fear of liability and resentment of institutional demands and understand it as ambivalence toward their treatment or toward the clients themselves. Jobes (2016) has described the adversarial relationships that sometimes develop between counselors and patients with suicidal ideation, attributing these relationships, in part, to the risks associated with the medicalization of treatment and noting that providers will sometimes refer high-risk patients to avoid potential lawsuits, possibly at the expense of effective treatment. Along with encouraging burnout and avoidance of high-risk clients, the medical model of mental health care also promotes conservative treatment approaches, which carry less risk than innovative methods that might result in better patient outcomes.

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In addition to undermining the therapeutic bond, the medicalization of mental health services also results in other undesirable outcomes that could increase institutional risk, as well as foster negative results for clients. For example, while many counselors eschew working with high-risk patients to avoid related legal exposure, counselors who do choose to work with such clients sometimes fill their schedules with frequent check-in sessions, rather than seeing patients who are not in crisis but whose mental health could decline without counseling services. Similarly, counselors might choose a more invasive level of care for high-risk clients, which limits legal risk for themselves and their counseling centers, but may ultimately be less beneficial for the client than more appropriately targeted care. Finally, as Cornish et al. (2017) have noted, mental health services are often inaccessible or undesirable for young clients who are most at risk, with providers rarely available online and with programs designed for patients who are ready to make immediate changes. Overall, the medicalization of mental health-care services undermines therapeutic outcomes and creates potential harm for clients and counselors alike. The situation in which mental health-care service providers find themselves is therefore a difficult one. A lack of resources has placed significant strains on the delivery of services, meaning that those seeking care will not be able to access it in a timely way; this, in turn, increases the likelihood that their mental health might deteriorate before they receive treatment. Because providers are worried that failing to diagnose an illness will leave them open to lawsuits, they default to rigorous testing, which exacerbates the bottlenecks in the system and potentially damages the relationship between client and therapist. Due to an overly medicalized paradigm for understanding the nature of mental health care, unrealistic expectations are placed on providers to foresee any problem that may arise, and this fosters an unhealthy power dynamic in which the client is encouraged to see themselves as lacking agency. While additional resources for clinics would lessen the strain on the system, the root problems cannot be addressed until the shortcomings of the risk paradigm are confronted.

12.6 SC2.0 as a Means of Shifting Risk The SC2.0 model offers an effective therapeutic approach that can also mitigate risk for UCCs and counselors seeking to work with high-risk clients. Bordin (1979) has noted the importance of ongoing collaboration between client and counselor, and the SC2.0 model provides for such collaboration, “as both clients and counselors monitor progress and discuss modifications when desired outcomes are not being achieved” (Bower & Gilbody, 2005). Further, as Jacques and Abel (2020) have noted, the SC2.0 model empowers students to get involved in their own therapeutic outcomes, increasing self-efficacy and self-determination. With the support of counselors, clients in the SC2.0 model become accountable to themselves, because the model works best “when clients take ownership and advocate for their personal

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care” rather than shifting responsibility to someone or something else (Jacques & Abel, 2020, p. 86). In essence, SC2.0 attempts to mitigate risk by empowering clients to take part in their own mental health intervention. It encourages clients to become their own therapists, not by gaining expertise, but by evaluating and taking advantage of available resources to participate in the creation of their treatment plans. Furthermore, SC2.0 coaxes clients to find support throughout their personal networks, breaking their dependence on counselors and positioning them as action agents in their own lives. In SC2.0, client feedback shapes the counselor’s therapeutic approach, and the client plays a role in the decision-making process. When done well, it can avoid some of the most onerous demands of the medicalization of mental health-care services because it creates a truly personalized therapeutic regimen that breaks out of the mechanized approach encouraged by the medical model. Through its focus on the client, SC2.0 offers a clear alternative to some of the destructive effects of the risk paradigm and the medical model on therapeutic outcomes. Although SC2.0 can mitigate some of the risk generated by the medicalization of mental health services among UCCs, by providing “a systematic, yet flexible structure” that can “meet the needs of students across the range of problems, personal preferences, and acuity” (Cornish et al., 2017), it cannot eliminate risk. SC2.0 can, however, help manage risk in a more client-centered, strength-based, and responsive manner. The model’s focus on rapid access to therapy does not address the large number of referrals of moderate-risk clients who express potentially high-risk behavior. Such clients are often referred out immediately, simply because they could represent a professional risk to the counselor or the institution. Similarly, some high-risk clients become “hot potatoes” who bounce from one referral to another as counselors seek to offload risk downstream. In addition to negative outcomes for high-risk patients, clients who pose less risk and would benefit from counseling intervention sometimes fall through the cracks, as counseling centers focus resources on high-risk patients instead. Finally, SC2.0 cannot eliminate risk generated by external factors. But, by taking a more holistic view of the client, it is able to consider and manage external factors more effectively.

12.7 Critiques of Stepped Care Despite support for a risk and liability paradigm shift from the counselor to the client through the implementation of the stepped care model in college counseling, renowned author Dr. Ken Pope (who has written extensively on ethics in counseling) would disagree with the risk component of the SC2.0-informed philosophy. SC2.0 contends that the client is empowered to exercise autonomy within the counseling relationship and, ultimately, to take on responsibility for their mental health (Cornish et  al., 2017). This has significant implications for clinical risk management. These implications include taking ownership of their mental health and accepting the risks involved in failing to address their psychological suffering. In

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contrast, Pope believes that when a counselor is working with a client who is in crisis, the counselor has a unique opportunity to be a part of a lifesaving process that they should honor, respect, and take seriously (Pope & Vasquez, 2016). His view aligns with traditional counseling ethics, which creates client responsibility and professional liability for the counselor (American Counseling Association, 2014). Despite the fact that SC2.0 does align with Pope’s client-centered philosophy of care and client autonomy, the model diverges significantly from Pope and traditional counseling ethics when it comes to the clinician’s responsibility for the client (Jacques & Abel, 2020). Pope sees the counselor’s obligation to the client in a nuanced way—not just as a liability, but as a duty that has potential benefits for the counselor as they see their client grow and change. SC2.0 somewhat aligns with this sentiment, but the model also recognizes the psychological stress that this obligation puts on a college counselor and proposes a shift in liability to the client. This would provide a potential way out of the risk paradigm by legally recognizing that counselors are not ultimately responsible for the choices a client makes and, thus, reorienting our understanding of the client–practitioner relationship away from the restrictions of the medical model. This would, however, mark a significant break from current practice and may be difficult to enact in the current legal climate. This important change may appear to be purely about shifting liability, but it is actually more about allowing the clinician to practice in a client-centered, strength-based way that creates autonomy in the client, as they take ownership of their mental health. Pope also recognizes that crisis assessment often brings heaviness, worry, and uncertainty related to the professional’s responsibility when making clinical decisions that may impact the client’s life or death. However, he believes that these moments can also bring satisfaction, joy, happiness, and relief when there is a positive outcome. The clinicians who embrace the SC2.0 philosophy are also joyful when a client is brought through a personal crisis with their assistance, but they disagree with Pope’s sentiment that the counselor is responsible or culpable for bringing the client through this process. Pope ultimately sees crisis assessment as the clinical responsibility of the counselor. This is in line with the view found in traditional counseling ethics that the counselor has a responsibility to protect the client if they are a danger to themselves. The counselor must assess whether or not a client is, for example, at risk of attempting suicide. This assessment should go beyond simply determining whether the client has an intention, a plan, and the means to act in a way that is harmful to self or others (Cottone et al. 2016): it should also look at a range of predictive factors, such as gender, family history, previously diagnosed mental illness, substance use patterns, and psychosocial stressors (Cottone et al. 2016). If the counselor believes the client to be at risk, they then have a responsibility to place the client under care, either in a hospital or in another context where they can be supervised (Cottone et  al. 2016). Because of these professional guidelines, a counselor who does not undertake a lengthy assessment of the client to determine whether any of these indicators are present could be deemed to have not fulfilled their duty of care. Should

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their client go on to commit an act of self-harm, the counselor could be held legally responsible. Here, we see how the good intentions embedded in the risk paradigm—protect the client from harming themselves or those around them—can inadvertently undermine the therapeutic relationship. Concern about the client’s well-being is joined with concern about how the client’s actions could potentially reflect on or materially impact the counselor, and an element of suspicion has been introduced into the therapeutic space. Before a sense of trust can be established, the counselor (or the personnel screening the client) must dedicate time to determining whether there are any signs of risk. If there are, these must be addressed before any other issues can be raised. A client who has had previous negative experiences with the mental health-care system might hold back on sharing information they believe could identify them as a “suicide risk” out of a desire to avoid hospitalization. None of this guarantees that the client will not act in a way harmful to themselves or others, but it does make it less likely that they will have a positive experience in the therapy session and could cause them to stop seeking care altogether. SC2.0 believes in clinical excellence, and assessing and managing risk, but ultimately wants the client to develop self-efficacy, insight, and awareness. This includes an understanding that the client’s mental health is their responsibility and that mental health can be managed and cultivated by their behaviors. The counselor, on the other hand, is a skilled listener, trusted expert, and available consultant to guide them through a maybe life-threatening crisis. These aspects of the model are a compelling reason why SC2.0 should be considered for implementation by mental and behavioral health organizations worldwide. SC2.0 not only delivers excellence in clinical care but can also lead to a positive organic shift in the risk paradigm.

12.8 Conclusion Ultimately, mitigating legal risk stemming from the medicalization of mental health-care services should not prevent practitioners from providing excellent care to clients. While proper application of the stepped care model can shield counselors and their institutions from some liability generated by work with high-risk students, no model can eliminate risk entirely, and too sharp a focus on legal risk mitigation can jeopardize the therapeutic process itself. Furthermore, misguided assumptions about counselors’ abilities to predict and control client behavior inherent to the medical model of mental health care can occlude the limits of individual and institutional competence, leading all stakeholders to harbor unrealistic expectations about possible outcomes. Risk avoidance all too often overshadows the fundamentals of good therapeutic practice. For all its imperfections, SC2.0 offers a way forward through the quagmire of the risk paradigm, promoting positive therapeutic values while simultaneously offering practitioners protection from unavoidable risk.

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12.9 Reflection Peter Cornish Naively, I was initially astounded by how difficult it is to implement innovative system-level change. I was perplexed by the hundreds of arbitrary regulatory processes that are designed for only one purpose—to protect institutions from litigation. Often, I hear the comment that they just don’t want their institution to appear on the front page of The New York Times. I agree that the front page is to be avoided; it’s where all the bad news goes. I’d like SC2.0 to be talked about in the commentary pieces in the back pages, by an opinion writer hailing the innovations that can be scaled through bold thinking, risk-taking, and leadership. I have lived and worked for several years in a comparatively progressive state in a litigious country rife with fear, anger, and distrust. Massive bureaucratic structures have been erected in a futile attempt to maintain order. But whose order? And who benefits from these structures? The risk paradigm fuels the capitalist engines that make this country so dominant in the world while ensuring that power remains in fewer hands. Risk management encompasses many sectors that make up the military industrial complex. Risk is a money maker. Armies of bureaucrats and vast legal teams build trenches to protect what are considered valuable assets. In US health care, the value of assets is defined by both the insurance and pharmaceutical industries and is maintained (at times reluctantly) by the professional guilds. For-­ profit insurance companies make money by obfuscating pathways to care and reinvesting premiums. The pharmaceutical industry profits by medicalizing more and more aspects of everyday life. Health-care providers must practice within the restrictive medical model, defined by the pharmaceutical industry according to rules and regulations that meet the needs of insurance companies, while also supporting the expansion of the professional guilds. The medical model itself is not the problem. We need medicine. And as Andrea Levinson points out in Chap. 17, authoritative medical care has special value when people with acute or complex needs are unable to care for themselves. The real problem stems from how approaches to care, medical and nonmedical, are organized and managed. Most health care is organized in a system that maximizes profits by minimizing expenses. There are fewer incentives for bold innovations that promise improved outcomes. This is discouraging. I have to admit that when I first read this chapter, I felt despondent and hollow. We have this problem, I thought, and our answer is, “Here, check out this Stepped Care 2.0 thing. It will help.” Really? Up against all these forces? A few minutes after finishing the chapter, I received an email from a colleague at another postsecondary institution in the state where I work. Alida, a counseling center director like me, had attended my conference presentation urging colleagues to challenge the risk paradigm that creates so many barriers to innovation.

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Alida wrote in her email that 8 months ago, she had hired a new manager to build a cutting-edge program that trains students with lived experience of marginalization, trauma, or mental illness to assume a variety of supportive roles helping other students within their newly implemented recovery-oriented care system. Although programs like this have been launched successfully in communities all over the world, senior legal counsel at the institution put the brakes on the program, citing excessive risk. Alida said that earlier that day, her risk manager had called to say that there were no job titles for hiring student peer workers, nor were there any mechanisms for credentialing them or providing clinical oversight. “Why do you even need peer support?” the risk manager had asked. “What can they offer that your clinical staff can’t?” Alida explained to the risk manager that people with lived experience, who are carefully trained to tell their stories in a way that is therapeutic, are often seen as safer to students who have experienced trauma and identify as marginalized. “Well, why don’t you simply offer more training to your clinicians in trauma-informed care with a focus on developing stronger engagement skills?” the risk manager asked. Alida admitted that she was now frustrated, disappointed, and disheartened. Her new manager had worked hard to build the program and had begun recruiting and training the peer staff. With exasperation evident in her voice, Alida asked me: “What do you think, Peter? Should we scale back our vision? I am afraid I might lose my new manager to another program that is moving forward. If that were to happen, I suppose we could offer more training to our existing staff, and we could contract out peer support through a third party that offers an app.” “I would not give up,” I replied. “Your innovation will only be possible through incremental steps. Maybe you can engage the risk management team more proactively? Could you describe the goals of your program in more detail and ask them to help you address the risk? A risk manager’s job is to say no to anything that could increase liability. But if you are assertive, you can get them to help you with the vision. Your job is to sell them on the idea and to demonstrate how, in fact, your program will reduce risk when implemented. They won’t be able to see this unless you spend time describing the program. If your pitch doesn’t work, perhaps a smaller pilot can be established as proof of concept? The hard part, I’m thinking, will be how to support your team and the stakeholders supporting your vision as you continue to work on shifting the risk paradigm.” The risk paradigm is massive. It is intertwined with the military industrial complex that underpins modern capitalism. Some, including me, might, at a low point, conclude that it is a wicked problem, one that cannot be solved. I remind myself that it can, and must, be solved. Some of the most vexing problems facing humans are the ones that can give us purpose, meaning, and a drive to persevere. Alida has a vision. This gives her purpose. She may not realize her vision anytime soon, and the journey may involve many small steps. But, as Monte Bobele, Arnie Slive, and Heather J. Hair suggest in Chap. 13, the very fact that small steps are manageable makes the work sustainable.

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References American Counseling Association. (2014). ACA code of ethics. Retrieved February 10, 2023 from https://www.counseling.org/resources/aca-­code-­of-­ethics.pdf Andriessen, K., & Krysinska, K. (2021). Suicide postvention in higher education settings (pp. 367–379). Preventing and responding to student suicide: A practical guide for FE and HE settings. Bell, D. (1992). Racial realism. Connecticut Law Review, 24(2), 363–380. Bordin, E. S. (1979). The generalizability of the psychoanalytic concept of the working alliance. Psychotherapy: Theory, Research and Practice, 16(3), 252–260. https://psycnet.apa.org/ doi/10.1037/h0085885 Bower, P., & Gilbody, S. (2005). Stepped care in psychological therapies: Access, effectiveness and efficiency. British Journal of Psychiatry, 186(01), 11–17. Center for Collegiate Mental Health. (2019, January 23). 2018 Annual Report. Retrieved February 10, 2023 from https://ccmh.psu.edu/assets/docs/2018-­Annual-­Report-­9.27.19-­FINAL.pdf Coleman, J.  J., Drinane, J.  M., Owen, J., & Kopta, S.  M. (2021). Establishing expectations: Exploring session limits in university counseling centers. Journal of College Student Psychotherapy, 35(2), 103–117. Cornish, P. A., Berry, G., Benton, S., Barros-Gomes, P., Johnson, D., Ginsburg, R., Whelan, B., Fawcett, E., & Romano, V. (2017). Meeting the mental health needs of today’s college student: Reinventing services through Stepped Care 2.0. Psychological Services, 14(4), 428–442. https://doi.org/10.1037/ser0000158 Cottone, R.  R., & Tarvydas, V. (2016). Ethics and decision making in counseling and psychotherapy (4th ed.). Springer Publishing Company. Flückiger, C., Del Re, A. C., Wampold, B. E., & Horvath, A. O. (2018). The alliance in adult psychotherapy: A meta-analytic synthesis. Psychotherapy: Theory, Research and Practice, 55(4), 316–340. https://doi.org/10.1037/pst0000172 Fossey, R., & Zirkel, P.  A. (2011). University liability for student suicides. In D.  A. Lamis & D. Lester (Eds.), Understanding and preventing college student suicide (pp. 291–303). Charles C Thomas Publisher. Franklin, D. (2018, November 30). Harvard faces wrongful death lawsuit over 2015 student suicide. The Crimson. Retrieved February 10, 2023, from https://www.thecrimson.com/ article/2018/11/30/wrongful-­death-­suit-­luke-­tang/ Hansen, J. T. (2016). Meaning systems and mental health culture: Critical perspectives on contemporary counseling and psychotherapy. Rowman & Littlefield. Institute for Health Metrics and Evaluation. (2017). Global burden of disease study 2016 (GBD 2016) results. University of Washington. Retrieved February 10, 2023, from http://ghdx. healthdata.org/gbd-­results-­tool Jacques, J. G., & Abel, N. R. (2020). Using the stepped care model to empower university students with learning disabilities. Journal of College Counseling, 23(1), 85–96. https://doi. org/10.1002/jocc.12151 Jobes, D. A. (2016). Managing suicidal risk: A collaborative approach (2nd ed.). Guilford Press. Jordan, J. T., & McNiel, D. E. (2020). Characteristics of persons who die on their first suicide attempt: Results from the National Violent Death Reporting System. Psychological Medicine, 50(8), 1390–1397. Kottler, J. A. (2022). On being a therapist (6th ed.). Oxford University Press. McKim, J. (2019, September 16). Harvard student’s suicide prompts concern about mental health care on college campuses. The Boston Globe. Retrieved February 10 2023, from https://www. bostonglobe.com/metro/2019/09/16/harvard-­student-­suicide-­prompts-­concern-­about-­mental-­ health-­care-­college-­campuses/kKJsMeSrriLeBeD2BZtu4L/story.html

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Pistorello, J., Jobes, D. A., Compton, S. N., Locey, N. S., Walloch, J. C., Gallop, R., Au, J. S., Noose, S.  K., Young, M., Johnson, J., Dickens, Y., Chatham, P., Jeffcoat, T., Dalto, G., & Goswami, S. (2017). Developing adaptive treatment strategies to address suicidal risk in ­college students: A pilot sequential, multiple assignment, randomized trial (SMART). Archives of suicide research: official journal of the International Academy for Suicide Research, 22(4), 644–664. https://doi.org/10.1080/13811118.2017.1392915 Polychronis, P. D. (2018). Unrealistic expectations for suicide prevention: Implications for counseling centers. Journal of College Student Psychotherapy, 32(4), 282–290. https://doi.org/1 0.1080/87568225.2017.1403873 Pope, K. S., & Vasquez, M. J. T. (2016). Therapist’s guide for preparing a professional will. In ethics in psychotherapy and counseling: A practical guide (5th ed.). John Wiley & Sons. Rogers, C. R. (1940). The processes of therapy. Journal of Consulting Psychology, 4(5), 161–164. Stanford, S., Sharland, E., Heller, N. R., & Warner, J. (2017). Beyond the risk paradigm in mental health policy and practice. Palgrave.

Chapter 13

Reimagining the “Gold Standard” Monte Bobele, Arnold Slive, and Heather J. Hair

13.1 Introduction It has long been taken for granted that the “gold standard” of psychotherapeutic treatment involves regularly scheduled sessions of talk therapy with a licensed or registered psychotherapist (Hoyt et  al., 2020). The assumption that this is what treatment-as-usual looks like has shaped how psychotherapists are trained, and it has also shaped client expectations. Depictions of psychotherapy in film, television, and literature have further entrenched the idea that effective therapy requires a long-­ term relationship between client and practitioner, to the extent that many clients seeking help with their mental health may believe this model of recurring, long-term treatment from a licensed professional is simply what therapy is. To suggest that regular weekly sessions may not be necessary can cause some clients to feel that they are not being offered the best possible care. From the beginning, Stepped Care 2.0 (SC2.0) has sought to challenge this assumption. It is a well-established fact that, while many clients have benefited from this treatment-as-usual model, they are a statistical minority: about half of those who seek care will only attend one therapy session (Hoyt et  al., 2020). In some cases, this may be because mental health-care systems require that clients go through a lengthy intake process, which can discourage clients who are seeking immediate help—but, in other cases, it is because a single session is enough M. Bobele (*) San Antonio, TX, USA e-mail: [email protected] A. Slive Austin, TX, USA e-mail: [email protected] H. J. Hair Memorial University, St. John’s, NL, Canada e-mail: [email protected] © Springer Nature Switzerland AG 2023 P. Cornish, G. Berry (eds.), Stepped Care 2.0: The Power of Conundrums, https://doi.org/10.1007/978-3-031-45206-2_13

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(Harper-Jaques & Foucault, 2014; Slive & Bobele, 2011). Organizing mental health care around the assumption that clients require multiple sessions over a period of months or even years has created a system that serves only a small minority of people while leaving many others—who might benefit considerably from one or two sessions during periods of heightened emotional stress, but who are not interested in a lengthy course of treatment—with few options. It also creates bottlenecks in care and reduces the efficiency of the entire system. The belief that a better way is possible is encoded in the basic principles of SC2.0, especially Principle 1 (“people engage with what they are ready to do; gold standard intervention is that which best fits the service user at any given time”) and Principle 7 (“an effective care system ensures people have access to care when and where it is needed”). In the SC2.0 model, care is organized in such a way as to empower the client to seek help with their mental health as they need it, based on their own level of readiness. While this is a significant change from treatment-as-­ usual, it is not without precedent: the idea that a single session of therapy can be of value in and of itself is not new. In Western mental health care, the literature on brief therapies goes back to the work of Don D. Jackson and Paul Watzlawick (Watzlawick et al., 1967) in the 1960s, and it has been the subject of renewed interest since the publication of Moshe Talmon’s book Single Session Therapy in 1990. And much prior to the creation of Western approaches to helping, Indigenous models of healing have traditionally reflected this thinking (Katz, 2017). In SC2.0, each session is meant to be self-contained, including a brief assessment, an intervention, and some time spent evaluating whether this intervention has been helpful (Cornish, 2020). In much the same way that a client visiting a physician receives care based on the current need they have, without the assumption that they will come back again a week later, mental health care in an SC2.0 context is meant to provide helpful treatment based on what is top of mind for the client on that given day. But what should this approach to delivering therapy be called? Some practitioners continue to use the term “single-session therapy” (SST), but terms like “open access” or “walk-in” or “one-at-a-time” (OAAT) or “one-at-a-time conversations” (OAAT-C) are used to describe similar but distinct approaches to therapy in which each session is treated as if it might be the last. SST has an established clinical literature, which means practitioners can more easily provide evidence to support its value as an intervention, but clients and clinicians alike have sometimes misunderstood it to mean that only one session of therapy will be provided, when in fact SST encourages clients to return for as many sessions as they need. “Open access” is more straightforward, but it is also a common term in other industries, including publishing. “Walk-in” has an ableist connotation and seems to suggest that care is provided in a physical space, rather than being available online or over the phone. “One-at-a-time” is a term that is used to describe the approach to therapies advocated by the SC2.0 model, but where SST refers to therapies provided by licensed mental health-care providers, there is still some disagreement around whether OAAT should refer only to services provided by licensed psychotherapists or whether it can include services provided by unlicensed care providers.

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This issue around naming isn’t just a matter of semantics: the language used to describe mental health treatments is important for many reasons. First, language tells clinicians and clients who are exploring treatment options what they can expect, and terms that contain misleading, unclear, or loaded language may unnecessarily prejudice them against a procedure or approach to treatment. Second, clinicians researching the effectiveness of an approach to treatment turn to the clinical literature to find out whether there is any evidence for it. They will find an extensive literature in books and articles on SST (see the “Further Reading” section at the end of this chapter), but there is little-to-no existing literature open access or OAAT. This raises a conundrum: there is a body of evidence showing that SST is effective, but the term “SST” causes confusion. If practitioners start using another term for similar types of service, it will make referring to the clinical literature more difficult. Furthermore, it is difficult to say whether clients will have a better response to “walk-in” or “open access” or “OAAT,” rather than “SST,” because there is little-to­no research on the favorability of these terms as used in a therapeutic context. The conundrum around naming also raises a second related conundrum around what these names describe. To name something is to place limits around it: every term, like every word, is defined in part by what it is not. Are “SST,” “OAAT,” “walk-in,” and “open access” synonyms, or do they all describe slightly different approaches to care emerging from a similar philosophy? Understanding these terms also means understanding the limits of what they describe—for example, who is qualified to provide SST or OAAT and who is not. As we shall see in this chapter, even within the SC2.0 world, there are multiple viewpoints on this question. SC2.0 is rooted in “single-session thinking,” but also uses the term “one-at-a-time” to describe its approach to care. Some practitioners see these terms as being roughly synonymous and applicable to a wide range of services provided by licensed and unlicensed care providers. Others uphold a distinction, for reasons related to training and legal risk, between types of care that can be provided by licensed psychotherapists and types of care that can be provided by unlicensed professionals. Given that SC2.0 operates in the context of legal systems, education systems, and systems of care which favor “expert”-based care over care that can be delivered by non-­ licensed professionals, the lack of clarity around what these terms describe makes it easy for them to be misunderstood. If there is no consensus within SC2.0 about what term to use or what that term describes, it will be difficult to effectively communicate the model to potential partners, clients, and organizations who are curious about SC2.0, but who don’t yet have a detailed understanding of it. As we have seen, the debate about how best to describe SC2.0’s challenge to the “gold standard” of psychotherapy is a live one, even within SC2.0 itself. This chapter reflects the dynamism of this conversation in its form: it consists of two parts, encompassing the thoughts, reflections, and arguments of three practitioners with extensive experience with SST and OAAT. The first section consists of an interview conducted with Monte Bobele and Arnie Slive in October 2022, and the second consists of an interview with Heather J. Hair conducted in August 2022. (Both interviews have been edited and expanded for the sake of clarity.) Bobele and Slive have spent decades working together at the cutting edge of SST theory and practice and

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have made multiple scholarly contributions in this area. Hair practiced for many years as an approved supervisor of the American Association of Marriage and Family Therapy and recently served as dean for Memorial University of Newfoundland’s School of Social Work. OAAT is an area of special interest for her, especially as it intersects with the role that psychotherapy plays in the lives of those experiencing various forms of marginalization. Together, these reflections explore the multiple conundrums that arise when challenging the “gold standard” and highlight the possibilities that open up when practitioners treat each therapeutic session as if it might be the last.

13.2 Interview with Monte Bobele and Arnie Slive One day a man came into the clinic where I work for a drop-in session. His daughter had died a couple of months earlier. She had moved a couple of hours away from home to attend university, and he had given her a car so that she would be able to get around more easily. She had been killed in a single car accident while driving home for a school break. The man blamed himself—he felt that she had talked him into giving her the car and that, if he hadn’t, she would still be alive. As we began the session, he told me that he was feeling very depressed and that she was on his mind continually. His immediate concern was that he was thinking about her so much that it was interfering with his work, and, when he was in his car, he worried his grief was making him a distracted driver. We talked about some ideas and coping strategies, which he thought were really going to be helpful to him. At the end of the session, I said to him—mistakenly, it turned out, but it was instructive for me— that we could talk about his depression as well. And he said: “I didn’t tell you that I wanted to talk about my depression, I’m holding on to my depression—if I didn’t do that, it would be disrespectful of my daughter.” He hadn’t come into the clinic that day with a goal of ending his depression. He came in looking for strategies for how to live with his grief. What I take away from that story is that the client knows best, and our job is to focus on what the client wants. —Arnie Slive

13.2.1 Why Did You Start Practicing Single-Session Therapy? Arnie Slive: In 1990, I was living in Calgary, and the organization I worked for, Wood’s Homes, began offering a form of SST on a walk-in basis. We had a big problem with long wait-lists, and we came up with the idea of offering the opportunity for people to just walk in to the clinic without having to go through the usual hurdles of intake processes and waiting for appointments (Slive et al., 1995). We started doing that then, and we’ve been doing it ever since—though there has been an expansion of forms of this concept over the last couple of years due to the COVID-19 pandemic. Monte and I started using the more generic term of “open

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access,” which means that someone can get access to a session with a mental health professional without having to jump through hurdles. Monte Bobele: When Arnie and the people at Wood’s Homes started their walk­in service back in 1990, the formal term “single-session therapy” had only just emerged. The first book that refers formally to this idea of SST was published at exactly the same time that Arnie was starting the walk-in service. The SST that Moshe Talmon, Michael Hoyt, and Bob Rosenbaum (Hoyt et  al., 1992; Talmon, 1990) wrote about in the late 1980s and early 1990s provided a more formal structure for those of us who were interested in extremely brief therapy, and they provided a solid research base for the application of this “one-at-a-time” idea. What Arnie really pioneered was not only the idea that somebody could walk in, but that they could walk in and have a whole therapy session in that 1 hour, without having to go through intake or a lengthy pre-assessment. They would walk in and get a service and walk out in the same way that you might walk in to a grocery store and pick up a quart of milk. The idea was to try to make things as convenient as possible for people. Slive: I should note that what we mean by “one-at-a-time” is that when we do what we’re calling “single session” … we’re not just doing a single session; we’re treating that encounter with a client as if it could be the only session. We’re not assuming there will never be other sessions; in the walk-in setting, clients are made aware that they can come back again for another session if they need it and at a time of their choosing. It’s also possible that an outcome of the session is that the client is interested in other mental health services, including the kinds of services that SC2.0 talks about or other mental health services in their community. It is important to stress that single session is not meant to replace other services—we look at it as one of the options in a continuum of services. Bobele: One of the big challenges we’ve faced, though, is overcoming this myth that if you really want to provide what our colleague Jeff Young in Australia refers to as “Rolls Royce services” (2018, p. 49), then you try to get people interested in coming to weekly therapy maybe for years. That’s the “gold standard,” and anything short of that isn’t really psychotherapy. But as Jeff likes to say, “as clinicians, we may think our clients need the ‘Rolls-Royce’ treatment, but often they are happy with the ‘Holden Ute’ (an Australian icon of automotive practicability). There is no use having a great comprehensive product if the client does not want it. Many services are built on an assumption that all people with complex problems require long-term work.” Many professional therapists, however, come to our training with the preconception that this isn’t real therapy that we’re talking about—it’s just something for people who can’t afford real therapy, for minorities and under-served populations that can’t or don’t want to become involved in the “gold standard” of treatment. In fact, in the places where we have extensive data (Canada, the USA, and Australia), we find that most people only attend one session of psychotherapy. After that, 80% only attend up to five sessions of psychotherapy, ever (Young, 2018, p. 48). If the “gold standard” is that people come for 20 to 50 visits a year, we’re

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missing out on providing service for people who will only come for 5 or fewer sessions. One of the challenges Arnie and I face is simply convincing people of what the research data shows—and it shows that we’re already doing brief therapy, whether we want to or not. Slive: There are few things we can say in our line of work that are clear facts, and one of them is that the modal number of sessions is one. If someone comes to a session, the most likely outcome is that that will be the only session they attend (Bobele & Slive, 2019). Not only that, when researchers have gone back to those folks who decided to only come to one session and ask them about that decision, the very large majority of those people say they chose to come just once because they were satisfied with what they got in that session—it’s not because they were dissatisfied. A very important focus for us is what we call the “single-session mindset.” I think that term originally came from Moshe Talmon. But the idea is this mindset helps mental health professionals,1 therapists, to develop confidence in the idea that good things can come from one session. This isn’t about a specific model of psychotherapy. There are literally hundreds of models of psychotherapy, and some people have their favorites, but we are not teaching a model of therapy: we are teaching a way of thinking, an approach. And we want clinicians to develop the confidence that good things can come from one session. The way we teach it is as a series of overarching principles for conducting a session. But we also say that if you develop that level of confidence, then you, the mental health professional, are perfectly capable of adapting your favorite ways of working to that idea.

13.2.2 Has the Term “Single-Session Therapy” Caused Confusion? Bobele: There is an interesting story behind the phrase “single-session therapy.” It was in the title of a book that Moshe Talmon published in 1990, and Arnie and I have both heard him say that this wasn’t his first choice of title for the book. The publisher thought that “single-session therapy” had a provocative sound to it that would help increase sales. If you’re a young professional, and it’s your first book contract … I imagine there was some pressure to accept it. But I know he has regretted letting that term get out into the profession, because it does have the potential for misunderstanding. There’s some debate among those of us who pioneered the idea of SST about who originated the “one-at-a-time” idea. Arnie and I talked for a while about how what we were doing wasn’t SST; it was “one session at a time.” Michael Hoyt picked up on that and talked about “one-at-a-time sessions.” That term,

 For the purposes of this interview, “mental health professionals” refers to licensed or registered psychologists, social workers, psychiatrists, professional counselors, and trainees in those professions who have at least a master’s degree and are providing services that their license covers. 1

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“one-at-a-time,” was very appealing for Stepped Care Solutions, though it has a slightly different meaning in the SC2.0 world than it has for us in the psychotherapy world, and so, for better or for worse, we continue to use the term SST. Slive: It’s also important to note that there are two major forms of what is considered to be SST.  One form is the kind that Monte and I practice, which is the open-access form, where we make it easy for people to make a same-day decision to talk to somebody. The other form is a by-appointment form of SST, and that’s the kind that Moshe Talmon and Michael Hoyt wrote about and continue to teach. And that exists in many places as well, but the form that we’re talking about in SC2.0 is that open-access, no-appointment-necessary kind. It’s tempting to fall back on the term “walk-in” because I’ve been using it so long. But we get objections to that, too, from people who are concerned about mobility issues. Though, on the other hand, in North America, “walk-in” is a widely used term. I think the term that makes the most sense now is “open access.” Bobele: There are problems with “open access,” too, though, because it’s a common term in publishing. Arnie and I are working on a book where we wanted to use “open access” as part of the title, and the editor kept insisting that people would confuse that with open-access publishing. I think we’ve won that battle, but that term has baggage associated with it, too.

13.2.3 What Is the Difference Between “Single-Session Therapy” and “One-at-a-Time?” Bobele: I still use “single-session therapy” when talking to professional psychotherapists about this idea of conducting OAAT complete sessions. I’ve moved away from OAAT partly because, in the SC2.0 world, the term OAAT has been used by Stepped Care Solutions to mean a whole host of other things besides psychotherapy. The real distinctions, or debates, about the way other people involved in SCS look at this and the way I do is that what I’m talking about when I talk about SST or OAAT therapy is a professional psychotherapeutic procedure that would be offered at Step 7 in the SC2.0 model. That’s not peer support. That’s not psychoeducation. It’s something that a licensed or registered professional provides in the context of a professional psychotherapy setting. I think that’s a really important distinction. In terms of OAAT, the way I understand SC2.0 to use that term is as a philosophy that applies across all the SC2.0 steps—the idea that people should, when they contact a mental health provider anywhere in the spectrum of services, be able to walk in and get something out of that visit that satisfies the needs they had when they walked in. They may walk in to a psychoeducational group and get something out of that one session, and that would be the OAAT philosophy operating, but it wouldn’t be SST. That’s the distinction I make. Arnie and I have spent the last 30 or so years teaching professionals how to alter their practices so they can be maximally effective in one session of psychotherapy.

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The data shows us that most people only come for psychotherapy one time. The people I offer training to will one day be licensed as psychologists or psychotherapists, which means they can take money from the general public to engage in a professional mental health activity because they’re licensed professionals. This means there are standards for training people. There are licensing requirements people have to meet in order to practice those professions, and they need to get continuing education. When I offer training to licensed professionals, they can be assured that they are getting training that is aimed at their level of expertise and practice. I’m not doing training for people doing peer support, nor am I designing education services for students who may go into other professions related to mental health care. Professionals are incentivized to pay for those registration activities because the arrangement is that they pay for continuing education, and their clients pay them because they’re paying for professionals trained to provide those services. Health insurance companies reimburse them for the same reason. This doesn’t mean that there aren’t things about the OAAT philosophy that wouldn’t be helpful for people working in intensive Step 8 operations in psychiatric facilities—but I don’t train those people to do SST in those settings any more than I would train a physical therapist to do SST with her physical therapy clients. Slive: Another way of putting this is that Monte and I are both mental health professionals who provide training to mental health professionals in this work and to professionals-in-training who are seeking a career in the mental health profession. I don’t think this diminishes the significance or importance of peer support work; we’re just saying this is what we do, this is what our focus is. And we want people attending our training sessions to be aware that all the attendees are mental health professionals or are in the process of becoming mental health professionals. You could call it a narrower group, and that’s okay, but I think it’s important that there’s a mutual understanding about that. Bobele: It has to do, maybe, with the register of the discourse. For example, in the walk-in or open-access world, the question is, “How can we possibly provide effective mental health services to people who we haven’t done an extensive psychological workup on before we even start treating them?” This is very common in the mental health world—the myth that the more we understand about a person before we start working with them, the more effective we’ll be. The research is sadly lacking to demonstrate that extensive psychological testing and assessment has any effect on treatment outcome. This was the issue that Arnie had to wrestle with in opening the walk-in at Wood’s Homes. Professional peers were saying, “How can you be so unprofessional, so unethical? How can you possibly be working with people without giving them extensive personality assessments? How can you just start talking to them without that pre-assessment?” That’s one of the differences between types of SST that Arnie alluded to early on. In some places, clinics do make an appointment where they can do some screening and where they can determine whether a single session will be appropriate for a given client. Arnie and I work in the version of SST where everyone who walks in the door can potentially be a single session, and we can operate with a lot less

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information than we thought we needed. This is why it’s important to make that distinction around who this SST training is for. We help professionals navigate these issues in the context of that professional understanding. That’s not a major concern for people running psychoeducational groups—should I screen these people ahead of time? In fact, they’re probably working in a place where that screening has happened.

13.2.4 How Does the Risk Factor Impact SST/OAAT? Slive: In our trainings, we take time to talk about the common worries and concerns that mental health professionals sometimes have. For example, how do you do OAAT or walk-in work with people who have severe mental illness? How do you handle high-risk situations? These are two questions that professionals, in particular, ask—because they’re really asking about their license and their insurance. Peer support workers may not have those same legal concerns. At a professional level, that’s something we help people understand: how they can be professional, ethical, and risk-averse when providing SST or OAAT. Bobele: For example, some therapists worry that if the client harms themselves after a single session, the therapist might be liable. In our experience, it’s rarely something they need to be worried about, though. Consider: would the therapist be liable if the client died by suicide after the tenth visit—would you be more liable because you’d seen them ten times, as opposed to seeing them once? If we’re treating every session as if it was the last, then what would you do if this person were at risk? If this was the only chance, what would you do to help them today? This is a very different mindset from thinking about how many more sessions you need to do in order to satisfy yourself that they’re not a risky client. Obviously, this is a particularly controversial example, but it’s the kind of worry that some clinicians come to OAAT/open-access training with. Slive: A single session with an at-risk client might be spent developing strategies with the client to mitigate the risk for that client. All mental health professionals learn about those strategies; we all employ them. In the collaborative relationship with the client, we want to find out from the client early on in a session what it is that is most important to this client to focus on today. And we’re going to work together around what might be a next step to take to address whatever this issue is. If it’s a risk issue, it would be about that.

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13.2.5 How Do You Respond to Clinicians Who Are Wary of SST? Bobele: When you are in private practice, you make your living by providing therapy sessions to paying clients. So, we can’t talk about challenging the “gold standard” without acknowledging that some clinicians might feel that their livelihood is being threatened. Sometimes, the concerns we hear are really just about whether professionals are going to be able to continue to make a living with this new approach. Arnie and I have done private practice, and we understand that it’s easier to keep an old client than to get a new one, just like in any business. If you have someone who is willing and able to continue to come, and you provide someone with a service that they think is worth their time and money, a private practitioner can make a good living. When practitioners in our workshops ask how they can make a living doing brief therapy, we tell them they can’t—if that’s the only thing that they do. While there are ways to use SST to augment your practice, long-term psychotherapy is the bread and butter of private practice. But that’s no reason to make it the gold standard or only option. Slive: We are in favor of people having a sense that there are options. One option is that kind of longer-term therapy Monte is talking about. We also know that what is likely to work best for a given person is what that person believes will benefit them. We’re not trying to say that people should be doing only “one-at-a-time” and not other stuff. Bobele: I usually start trainings for mental health professionals by saying that what I’m going to share is generally applicable to about 80% of people who hit your front door. The other 20% are going to be looking for long-term therapy—they’re going to be better served by long-term therapy, or by a support group, or by a psychoeducation group. But around 80% of the people you see are going to be satisfied by maybe up to three sessions or fewer. And that’s not a bad thing, because we don’t have enough mental health workers in the country to provide 50 visits a year to everyone who shows up. There’s just no way for any government-supported health-­ care system to pay for that. But here’s the other side of that: I said that 80% of people won’t come for more than five or six visits. That means that there is 20% of the population who will come for more visits, and we have some data that shows that the number of visits a person will come for drops off steadily almost to no more than 1, until we get down at the very end of the distribution, and then there is about 4 or 5% of the population that will come for 20 or more visits a year. My interpretation of that data is that those are your private practice clients. They are the people with the means or support to receive care from a private practice and engage in long-term therapy. They are the ones who believe that long-term therapy will be helpful for them. I always reassure people in private practice that I’m not coming after their business; I want to help the 80% of people that are interested in brief therapy and will come for fewer than 5 or 6 visits a year, and you can have the 5% that want to come for 30 visits a year, and there will be plenty of clients to go around. Everyone will be able to make a living.

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Slive: The other thing we stress is that it’s not just clients who benefit from SST. We’ve been talking about options for clients, what works for clients, but there’s also the question of the satisfaction of mental health professionals, of clinicians. One thing about the open-access/OAAT idea is that somebody, whoever it is, can make a decision that day to see someone. What you end up with is a highly motivated client, a client in a moment of readiness. That’s motivating and satisfying to the clinicians. Bobele: Sometimes I ask therapists, “When you sit down with a client for the first time, and you conduct the session like you normally do, how do you feel after that session?” Usually they’ll talk about some things, but they’ll mention that there’s a lot of paperwork to do, and there’s a treatment plan to write, and sometimes you’ll hear people say that they don’t like seeing people for the first time, because it means more work. And then I ask, “When you’ve had a final session with a client, and you both agree that your work is done, you’re happy with the results, how does that feel?” And they say, “I feel great, I have a high for the whole day.” And I say, “What if your first session and your last session were the same day with the same client? Then you’d be leaving the session feeling good about seeing that client that day, and the paperwork overhead would almost be cancelled out by the way you feel.” Ideally, in open-access practice, you’ve got a motivated client, you’re motivated to help them, and you’ve got a whole day filled with last sessions that turned out really well. A journey of a thousand miles begins with a single step, as Laozi said. What I take away from that aphorism is that if someone is going on a thousand-mile journey, we don’t have to walk with them every step—we just have to get them started with the first step, and then they can take the next one and the next one. And if they get stuck at a certain point, they may decide on another open-access session. The goal of SST is to get them to take that step, and after they’ve had some success with that, I have faith that success breeds success. If they have some small success, that will lead to larger success for them. That’s what keeps me in the single-session business, the experience of seeing people do that. Arnie and I can tell you stories about people we’ve done a single session with who’ve called us back for a second appointment and said, “You were so helpful, let me tell you what I’ve done in the last week.” And it’s been stuff that we never talked about in the session; it’s things they decided to do on their own. It gives me a lot of faith that this actually works for people. Several years ago, I was doing a series of ongoing brief therapy trainings for people interested in the idea. There was a woman in the audience who was in her 50s. She’d put her husband through medical school and three kids through college, and now she was going off to become a professional therapist. She lived out in the country in a far west Texas town and had grown up as a farmer’s daughter in Oklahoma. She came up to me and said, “You know, I think I have this brief therapy figured out.” I said, “Oh?” She said, “This is like if a neighbor comes to ask me for a cup of sugar to bake a cake. She’s not asking me for recommendations for how to remodel her kitchen, she just wants a cup of sugar.” I think that’s the essence of SST: they want a cup of sugar; they don’t want us to rebuild their lives or their psychological makeup. They come in because something is bothering them, and they want

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some help. We don’t remodel people’s lives. We just provide them with something they need some of. —Monte Bobele

13.3 Interview with Heather J. Hair In the early 2000s, I was providing a training workshop focused on single-session counseling. I was anticipating an audience of people who would have identified as credentialed therapists. But there was a table at the back of the room with five or six people who caught my attention early on. It turned out that they were from the local housing help center, and they told me that it was the first time they had actually seen a training opportunity with language that resonated with them: in the descriptor of the workshop, I referred to “helping conversations,” which identified with their work setting. As they pointed out, “That’s what we do! We’re not therapists, we have helping conversations with people.” After the training, they told me it was the first time in years that they’d received practice-based training that fit with what they were doing. For a while, I was puzzled by their attendance, but in time, their comments opened up a whole world for me: the world of people who were doing so much of the hard work on the streets and in the drop-in centers—who didn’t have an office or appointment books and who saw people who didn’t have phones or addresses, people who had six children under the age of 6, and people who couldn’t get on a bus to go to a therapy session without pulling them all out of school for the day. These workers often see people at the grittiest and most challenging points in their lives and have an opportunity to make a difference in one conversation. I started resonating with people in these community-based settings who were doing so much of the vital work that has traditionally been underappreciated. At the same time, I found myself wondering how they could do it. If this work was challenging for me, and I had two master’s degrees and was working on a PhD, how were they supposed to do it? The level of intellectual arrogance that I carried was complemented by the comparable privileges that came with my professional title as family therapist and my work setting: I had my own office in a multidisciplinary children’s mental health clinic, where intake filtered and streamed children and their families into “suitable” services, and I got to make appointments according to my work availability (which was daytime Monday to Friday). Nevertheless, my admiration and curiosity about community work necessitated a rather uncomfortable deconstruction of my professional arrogance. Fortunately, I had some wonderful mentors and role models who worked in the community and who helped me to see that the ideas I shared was the work that they did, but hadn’t been given the language to define. These relationships with community services that began decades ago helped to shape the way I practice and train people today. —Heather J. Hair

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13.3.1 How Did You Get Involved in SST/OAAT? I was first introduced to the idea of brief therapies in the late 1980s, when I was in training to become what was then identified as a marriage and family therapist—a postgraduate professional program recognized by the American Association of Marriage and Family Therapy. The part that intrigued me, ever since I started considering how language or conversations can be useful for people, is the separation between those who are called professionals and paraprofessionals. Those designations have irked me, quite frankly, because my career in the helping world started as a child and youth worker in 1979, when I worked at open, secure, and community-­ based treatment centers with youth. My training wasn’t just about conversations we might have, but it was also about how we might help youth develop a more structured, safe, and predictable daily life. When I worked with youth in their living environments, conversations would happen on the fly—over dishes, at bedtime. Even when they happened in a counseling session, they were very much in the moment. The training I had was pretty insufficient for preparing me to do that well. It was based in the classic medical model of mental health, which is, in turn, rooted in a positivist and empiricist philosophical outlook. There was an assumption that we needed to gather a lot of information in order to be helpful; we needed to have a complete case history; we needed to find the root cause in order to be able to effectively develop a diagnosis and treatment. I look back on my experiences as a child and youth worker as being incredibly important to how I continued to develop. I felt that there were so many more opportunities that could have been possible in the lives of those youth and the people who were working with them, but these opportunities were not taken advantage of because the people who worked there were not trained to have effective, focused conversations in the moment. I’m going to talk about my approach to what we might call “brief therapy” or “one-at-a-time,” and I’m going to explore the promise and the challenge of this approach. But before I get into how I differentiate between terms like “OAAT counseling” or “OAAT conversations” and “SST,” I believe it is important to go into a bit of detail about the conceptual framework that informs my practice. In the social sciences, there are two basic ways in which we approach meaning-making and knowledge creation: there is the modernist/empiricist/positivist approach, which is interested in categorizing and explaining the world according to a scientific and materialist logic, and the post-modern/post-structuralist/social constructionist approach, which proposes that the ideas, stories, and narratives that identify individuals and communities are flexible, relational, and co-constructed through all mediums of communication—verbal, nonverbal, and the written word. Both of these viewpoints can yield valuable insights, and both have well-established traditions in the disciplines of social science. I find the idea that knowledge and meaning develop into shared narratives through a process of social construction attractive, but I also believe that there exists

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some sort of reality “out there.” This perspective informs how I think about therapeutic or helping conversations and how I approach the question of what an effective helping conversation consists of. Accepting the social construction of knowledge and meaning liberates me to use language that comes from various sources— whether it be the words I know to be preferred by the people I am talking with or the language of the Diagnostic and Statistical Manual of Mental Disorders (American Psychiatric Association, 2022). How does this influence practice? For me, it means that a modernist/empiricist approach on its own is not enough. When I’m talking to a person, I need to keep in mind that I don’t know what “the truth” means for this person, so I need to be curious and tentative and interested in how they language their story and what words they put to it. In other words, I believe what we think informs what we say.

13.3.2 How Do You Understand the Difference Between Terms Like OAAT and SST? The acronym “OAAT,” or “OAAT-C” which I prefer, is rather new to me. As I understand, Michael Hoyt referred to single-session therapy as being “one-at-a-­ time” in his foreword to the 2011 book edited by Arnie Slive and Monte Bobele. In spite of the different wording, SST has persisted and become synonymous with people thinking that all they get is one session—a terrible misunderstanding that has circulated internationally. OAAT, on the other hand, helps to make people aware that there can be more than one session. I added “-C” to represent “conversations” or “counseling” because, for me, depending on the context, it may be preferable to use one term or the other. Whether or not I use the term “counseling,” “therapy,” “single-session therapy,” “one-at-a-time counseling,” or “effective focused conversations” is something I negotiate based on the service users I’m speaking with. After more than 20 years of providing training, both formally and informally, I’ve learned that the best way to engage with people is by using the language that’s meaningful for them. I’ve done trainings in children’s mental health centers, for youth group pastors, community leaders, community development workers, and people in housing and employment. These are not people who are usually seen as being in therapeutic relationships to the people in their care, but they have many moments of therapeutic opportunity. In those various contexts, I believe it is important to use the title for the trainings that makes most sense for the service providers. I’ve given trainings with titles that talk about SST, and I’ve given trainings with titles that talk about helpful, effective, focused conversations. Some executive directors or CEOs say that what they’re looking for is conversations, while others prefer the language of therapy—because they know what will resonate with their employees. There are people out there who would be offended if you called what they do OAAT-C, and there are people who would insist that they are not therapists and would not identify with something that was called SST. It has a lot to do with how

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they identify themselves professionally and the work that they do. For me, the identifier is not as important as the content I include under the title. (Interestingly, Hoyt et  al. (2020) offer the term “single-session work” (SSW) for non-clinical applications.) This does not mean there aren’t important differences in how these terms are often used and understood. “SST” and “brief therapy” are terms that are widely understood in the therapeutic community. It is the language that has been published, the language that resonates with professionals, and this leads to a kind of circular thinking: the language validates the profession, the profession validates the language, and it is hard to break out of that to see that there could be other ways of talking about the same thing. One of the side effects of this is that there isn’t any literature yet on OAAT-C because—as I understand—it doesn’t exist in a formalized, published, peer-reviewed journal or a chapter in a book. It’s an acronym that has developed and emerged out of what I believe service providers are looking for. Personally, I think SST approaches can be a bit too model-driven and a bit too prescriptive, at least in terms of what I have read. Whereas if we separate out the two, OAAT-C can resonate more with non-licensed service providers. But this is not a hard and fast distinction either! OAAT-C also resonates with some professionals—I have definitely used the word “conversations” when I have met with licensed or registered psychotherapists. It’s difficult to talk about the real distinctions between these terms without acknowledging that they are embedded in a professional discourse that has a lot to do with passionately held professional and philosophical positions around the problems and troubles people have and what is going to help them.

13.3.3 What Should OAAT-C Training Look Like, and Who Is It For? I began this interview by talking a bit about my own education and work experience and some of the ways that the training I have provided expanded my understanding of what therapy is and who can provide helpful conversations. During my current academic career, I have had the opportunity to contribute to the education of students in a university social work program. Social work is one of the disciplines that I believe should be embracing the assumptions and practices of OAAT-C, because of the excellent fit with the discipline’s emphasis on strengths and resiliency and the applicability of the OAAT-C approach to a wide variety of settings. Unfortunately, OAAT-C appears absent, or at best cursory, in undergraduate and graduate social work program curricula. As I understand, the situation is similar in other university degree programs for helping professionals. Yet across urban, rural, and remote communities, many service providers find that each contact with service users could be the only one. The thought that the first meeting with an individual, couple, or family may well be the last is particularly

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daunting when the mental health and relational concerns of people are woven together with experiences of poverty, racism, family violence, homelessness, and isolation. I believe that a typical university education, informed by the dominant beliefs and practices of medicine, the scientific method, psychiatric diagnoses, and the status granted to the people who claim expertise in these areas, is not sufficient for social and mental health service providers to have effective, helpful encounters with people every time they meet. Alternatively, I propose that a certificate program in one-at-a-time counseling/ conversations that is accessible for college, as well as university, graduates could provide the opportunity to educate service providers to have effective helping relationships. It could also maximize the potential value of each and every contact moment students equipped with such training might have with their communities’ most vulnerable citizens, no matter the context in which these moments of contact occur. It is my expectation that Stepped Care Solutions, along with community college and/or university partners, will co-create an education program in OAAT-C that can equip people to contribute to transformative mental health and addictions services around the world.

13.4 Conclusion: What’s in a Name? Ideas come to us through language, and this means that attending to the language we use is important if we want our ideas to resonate with others—especially if these ideas disrupt the status quo. “SST” and “OAAT” are terms used to describe therapeutic practices, but they also represent a power idea: that addressing and dismantling the barriers to access that exist in the mental health-care systems of today is possible if we understand that, sometimes, one session of therapy is enough. For decades, therapists and care providers have sought to challenge the idea that “gold standard” mental health care means regular weekly sessions with a licensed psychotherapist. But as Monte Bobele and Arnie Slive described in the case of SST, sometimes the struggle to create a new paradigm has been set back by the language used to describe it. For those who want to replace the treatment-as-usual with something that truly fosters well-being everywhere, having the right idea may not be enough if the language used to communicate this idea creates distrust and confusion or turns people against our ideas before they have a chance to fully understand them. But the conundrum involved in challenging the “gold standard” goes beyond what language gets used. In this chapter, Bobele, Slive, and Hair have each described the difficulties involved in convincing mental health-care workers who have spent years being trained to deliver therapy in a certain way to consider other alternatives. As Bobele and Slive suggest, this is all the more reason to shift the conversation so that psychotherapists are less primed to see alternatives to the “gold standard” as a threat and more able to appreciate the benefits of single-session thinking. At the same time, any attempt at dismantling entrenched professional hierarchies and challenging a system rooted in the risk paradigm will create discomfort, no matter how

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carefully it is communicated. As Hair suggests, it may be necessary for advocates of SC2.0 to expand their engagement with educational institutions and train a new generation of service providers to think differently about how therapy should be delivered. Thinking through the conundrums that arise when challenging the “gold standard” means thinking about how the terms we use have power and invoke power. The word “psychotherapist” is not simply a professional designation; it also speaks to a way of thinking about authority and expertise that many people are deeply invested in. How can we strike a balance between using language that is understandable and familiar and pushing to develop and propagate new language that can embody new ideas? As SC2.0 works to create systems of care rooted in one-at-a-­ time thinking, attending to this conundrum will be essential.

13.5 Reflection Peter Cornish When I first became licensed as a psychologist in the mid-1990s, part of my job—or so it seemed at the time—was to sell others on what I did. At the counseling center where I worked, we called this outreach. It meant finding creative ways to get in front of staff, faculty, and administrators to let them know the counseling service existed and could be a resource for any student struggling with mood concerns or mental illness. There was an assumption that more students could benefit from our care—if only they would give us a try. Nearly 30  years later, demand for counseling and psychotherapy far outstrips supply. Students arrive at college with assumptions that ongoing counseling is a necessity and should be widely available. Is this because we oversold the value and need for professional counseling or therapy? If so, was it a mistake? I don’t think Bobele, Slive, or Hair would say this. However, they do raise questions about what therapy is for, as well as how to structure it and communicate expectations. While I agree that counseling is valuable and access must be improved, questions remain in what dosage and at which venues. The OAAT approach does not ration counseling or therapy; it simply provides access to care in the moment of need. To use a pharmacological metaphor, safe low doses are available over the counter, no questions asked. These medicines require no authorization, and everyone knows which aisle to find them in. The counseling conundrums highlighted in this chapter stem from varied assumptions about dosage, questions about who should get care, differences of opinions on what constitutes effective talk therapy, and who is best equipped to offer the care. Economics underlies these questions. While Bobele and Slive imply the business model for private practice OAAT has yet to be tested, there is power and money in labels. The publisher’s choice of title for Moshe Talmon’s seminal text, Single Session Thinking, was an act of sensationalism aimed at selling more books. The

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publisher hawked the magic of a single session. To a lesser degree, the term “therapy” is also sensational. It rebrands active listening, Socratic dialogue, and helping conversations within an expensive package of medical authority. It is easier to charge more for something called “psychotherapy” than for counseling. Even though “psychotherapy” is not a protected term, a psychologist providing psychotherapy will collect a higher fee than a licensed social worker or marriage and family therapist. Naming is marketing, and marketing determines price. I find it interesting that naming focuses more on the inputs (who provides treatment and how) than on the outputs (outcomes or the impact of the treatment). Perhaps this shouldn’t be surprising given that varying the inputs has little impact on outputs. There is no evidence that the type of professional (who provides the care), or the nature and extent of training (what techniques are used), makes much difference in mental health outcomes. Marketing largely exists to differentiate products that aren’t fundamentally different. It creates the illusion of difference or exceptional quality in pursuit of market share. OAAT treatment works, but it generates less revenue. In terms of outcomes, it doesn’t matter much who delivers it—a well-trained peer counselor or a licensed psychologist. However, to members of professional guilds who earn income from treatment, it matters a great deal. This is pure supply and demand. Keep the supply low, and suppliers earn more. For private enterprise, scarcity is value. But for publicly funded care, the goal is to meet demand. Abundance is valued. The output— impact on population health—is what matters to communities and society at large. Our SC2.0 conundrums seem to boil down to politics and economics. My guess is that open access to care through SC2.0 programming, including OAAT and OAAT-C, may only scale successfully in the context of thriving social democracies where there is more shared value in balancing the interests of labor (workforce), industry (investment), and public service (management). While I worry about recent populist movements aimed at dismantling democracy, I remain hopeful that the groundswell of interest in mental health, along with early successes in implementing SC2.0  in partnership with labor, management, and policy makers (see Chap. 15), will prevail.

References Bobele, M., & Slive, A. (2019). Ideas for addressing doubts about walk-in/single-session therapy. Journal of Systemic Therapies, 38(4), 17–30. Cornish, P. (2020). Stepped Care 2.0: A paradigm shift in mental health. Springer. Harper-Jaques, S., & Foucault, D. (2014). Walk-in single-session therapy: Client satisfaction and clinical outcomes. Journal of Systemic Therapies, 33(3), 29–49. https://doi.org/10.1521/ jsyt.2014.33.3.29 Hoyt, M. F., Rosenbaum, R., & Talmon, M. (1992). Planned single-session therapy. In S. H. Budman, M. F. Hoyt, & S. Friedman (Eds.), The first session in brief therapy (pp. 59–86). Guilford Press. Hoyt, M.  F., Young, J., & Rycroft, P. (2020). Single session thinking 2020. Australian & New Zealand Journal of Family Therapy, 41(3), 218–230. https://doi.org/10.1002/anzf.1427

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Katz, R. (2017). Indigenous healing psychology: Honoring the wisdom of the first peoples. Healing Arts Press. Slive, A., & Bobele, M. (Eds.). (2011). When one hour is all you have: Effective therapy for walk­in clients. Zeig, Tucker & Theisen. Slive, A., MacLaurin, B., Oakander, M., & Amundson, J. (1995). Walk-in single sessions: A new paradigm in clinical service delivery. Journal of Systemic Therapies, 14(1), 3–11. https://doi. org/10.1521/jsyt.1995.14.1.3 Talmon, M. (1990). Single-session therapy: Maximizing the effect of the first (and often only) therapeutic encounter. Jossey-Bass. Watzlawick, P., Bavelas, J. B., & Jackson, D. D. (1967). Pragmatics of human communication: A study of interactional patterns, pathologies and paradoxes (1st ed.). Young, J. (2018). Single-session therapy: The misunderstood gift that keeps on giving. In M.  F. Hoyt, M.  Bobele, A.  Slive, J.  Young, & M.  Talmon (Eds.), Single-session therapy by walk-in or appointment: Administrative, clinical, and supervisory aspects of one-at-a-time services (pp. 40–58). Routledge.

Further Reading American Psychiatric Association. (2022). Diagnostic and statistical manual of mental disorders (5th ed., text rev.). https://doi.org/10.1176/appi.books.9780890425787 Campbell, A. (2012). Single-session approaches to therapy: Time to review. Australian & New Zealand Journal of Family Therapy, 33(1), 15–26. https://doi.org/10.1017/aft.2012.3 Cannistrà, F., Piccirilli, F., Paolo D’Alia, P., Giannetti, A., Piva, L., Gobbato, F., Guzzardi, R., Ghisoni, A., & Pietrabissa, G. (2020). Examining the incidence and clients’ experiences of single session therapy in Italy: A feasibility study. Australian & New Zealand Journal of Family Therapy, 41(3), 271–282. https://doi.org/10.1002/anzf.1421 Dryden, W. (2020). Single-session one-at-a-time therapy: A personal approach. Australian & New Zealand Journal of Family Therapy, 41(3), 283–301. https://doi.org/10.1002/anzf.1424 Duvall, J., Young, K., & Kays-Burden, A. (2012). No more, no less: Brief mental health services for children and youth. Ontario Centre of Excellence for Child and Youth Mental Health Retrieved February 8, 2023 from www.excellenceforchildandyouth.ca Hoyt, M.  F., & Talmon, M. (Eds.). (2014). Capturing the moment: Single session therapy and walk-in services. Crown House Publishing. Hoyt, M. F., Rosenbaum, R., & Talmon, M. (1992). Planned single-session therapy. In S. H. Budman, M. F. Hoyt, & S. Friedman (Eds.), The first session in brief therapy (pp. 59–86). Guilford Press. Hoyt, M. F., Bobele, M., Slive, A., Young, J., & Talmon, M. (Eds.). (2018). Single-session therapy by walk-in or appointment: Administrative, clinical, and supervisory aspects of one-at-a-time services. Routledge. Hoyt, M. F., Young, J., & Rycroft, P. (2021). Single session thinking and practice in global, cultural, and familial contexts: Expanding applications. Routledge. Hymmen, P., Stalker, C.  A., & Cait, C. (2013). The case for single-session therapy: Does the empirical evidence support the increased prevalence of this service delivery model? Journal of Mental Health, 22(1), 60–71. https://doi.org/10.3109/09638237.2012.670880 Katz, R. (2017). Indigenous healing psychology: Honoring the wisdom of the first peoples. Healing Arts Press. Miller, J. K. (2008). Walk-in single session team therapy: A study of client satisfaction. Journal of Systemic Therapies, 27(3), 78–94. https://doi.org/10.1521/jsyt.2008.27.3.78 Talmon, M. (1990). Single-session therapy: Maximizing the effect of the first (and often only) therapeutic encounter. Jossey-Bass. Young, K. (2011). When all the time you have is now: Re-visiting practices and narrative therapy in a walk-in clinic. In J. Duvall & L. Beres (Eds.), Innovations in narrative therapy: Connecting practice, training, and research (pp. 147–166). W.W. Norton & Company.

Chapter 14

Stubborn Hierarchies: The Challenges of Co-design Marion Cooper

14.1 Introduction One of the core components of Stepped Care 2.0 (SC2.0) is that “key stakeholders are engaged throughout the co-design process.” This reflects SC2.0’s intention to move away from top-down models of mental health, addictions, and substance use health services. SC2.0 is rooted in the belief that systems of care that foster greater well-being for everyone should be developed through collaboration with the communities, individuals, practitioners, and stakeholders that will be using them. A model that is implemented on behalf of a community, not in partnership with a community, will tend to reassert the hierarchical, paternalistic thinking that has created so many challenges in existing mental health-care systems. Co-design (also referred to in some academic studies as “co-production”) is meant to disrupt this business-­ as-­usual way of thinking, opening the doors to welcome a much wider range of people into the decision-making process. The co-design process invites organizations to facilitate and have dialogue with key stakeholders with a variety of different kinds of expertise. The purposes of co-­ design are threefold: 1. To bring diverse perspectives into the decision-making process 2. To amplify critical insights that can identify potential problems or blind spots in the planning and implementation of the new programs or system (e.g., language and cultural considerations, usability factors, barriers to access, etc.) 3. To give the community a sense of ownership over the programs or system being designed The ultimate goal of co-design is to inform and contribute to the development of new models—and the creation of new approaches—that support the goals and M. Cooper (*) Winnipeg, MB, Canada e-mail: [email protected] © Springer Nature Switzerland AG 2023 P. Cornish, G. Berry (eds.), Stepped Care 2.0: The Power of Conundrums, https://doi.org/10.1007/978-3-031-45206-2_14

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objectives related to system-transformation work. But implementing true co-design requires time, resources, and sensitivity, and those seeking to co-design a new system often face significant challenges. The hierarchies that structure modern institutions are deeply ingrained, and, when challenged, people in positions of power within these hierarchies may become defensive or default to a top-down decision-­ making process. Successful co-design relies on good facilitation, openness to change, patience, and a structure of discussions and activities that is simultaneously flexible and firm enough to stay on task. If co-design is to be successful, it cannot be viewed as a box to be checked or a step to be gotten out of the way—it should infuse the entire design process, creating space where real change can happen. This creates a conundrum: co-design is about redressing inequities, but it is implemented in contexts where existing structures continue to perpetuate a hierarchy of authority and power. How can SC2.0 ensure that co-design—a pillar of its approach—does not become yet another example of cosmetic diversification that leaves the underlying power imbalance intact? This chapter will explore what co-design should look like in practice, as well as address some of the practical challenges involved in co-design. It is based, in large part, on my own experiences facilitating co-design in the context of the SC2.0 model. As a powerful tool for system transformation, co-design has an important role to play in the SC2.0 approach—but if insufficient time is dedicated to co-­ design, or it is implemented in too narrow a way, its radical potential can be neutralized, rendering it little more than a focus-group exercise. As SC2.0 continues to evolve, greater attention needs to be paid to the implementation of co-design in all contexts to ensure that it becomes a central feature of the entire design process, rather than another box to be checked.

14.2 Defining the Co-design Process Before we can discuss the conundrums present in co-design, it is necessary to explain what the co-design process looks like in practice. Co-design is a way of bringing together people with lived and living experience, caregivers, families, and professionals to improve services. It creates an equal and reciprocal relationship between all stakeholders, enabling them to design and deliver services in partnership with each other. Planning, designing, and producing services with people that have experience of the problem or service means the final solution is more likely to meet the needs of those being served (Roper et al., 2018). As I use it, the term “co-design” refers to two distinct things: one, a process involving facilitated sessions in which participants share their views on building and populating a health-care model, and two, a philosophy for more democratic system design. As a process, co-design is distinct from implementation, and, ideally, there will be a separate co-design team whose sole focus is to bring together the individuals involved in the co-design process. At the same time, the co-design philosophy— the idea that the communities receiving care should have a say in how that care is

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delivered—should animate implementation as well. In the SC2.0 philosophy, a rigorous co-design process ensures that when it comes time to implement the new programs or system, potential issues have been anticipated, solutions are reflective of the unique context in a given jurisdiction, and the key stakeholders have a high degree of confidence in what is being implemented. It also provides guidance for how any difficulties that arise in the implementation process should be handled. As we have noted, the people playing a role in co-design represent the various stakeholders involved in the well-being services in a given community. This includes professionals with clinical or administrative experience, as well as individuals who have lived experience related to service delivery (which is to say, people who have been receivers of services or programs, or who have been involved in accessing services, or who have had loved ones involved in receiving services). All of these stakeholders can be brought together in a series of facilitated sessions that provide a context in which the facilitator can lead a meaningful discussion, guided by reflection tools and activities. This creates an opportunity to move away from the status quo and to engage in ideas that aren’t currently a part of how services, programs, and systems operate—thereby challenging and questioning current practices and bringing forth ideas that can be truly disruptive and reflective of local strengths and contexts. When co-design is done well, it creates a laboratory for ideas, a place where alternate visions for how a mental health-care model could work are given room to develop (Slay & Stephens, 2013). This period of openness and blue-sky thinking is one of SC2.0’s most potent active ingredients—otherwise known as core components—and the extent to which SC2.0 can help develop systems and services that are truly responsive to the needs of a community in part depends on how successful the co-design process is.

14.3 The Power of Facilitation In order for co-design to bring together and empower stakeholders to envision a system of care, there needs to be a facilitator who is able to strike the right balance between creating a space for innovation and out-of-the-box thinking and maintaining a productive and respectful conversation. Good facilitation is essential for good co-design; it is one of the points in the implementation of SC2.0 where having the right personnel in place is especially important. A facilitator is a leader, ideally well-versed in the co-design process, who is able to draw people out of themselves and build a trusting milieu in which people can brainstorm. This is essentially creative work, and it can be challenging for people who are not used to having space to explore ideas without immediately trying to find a solution, or identify potential risks, or formulate an action plan. Some people find this kind of exercise energizing and will take to it very quickly, but others may not have as easy a time sharing their views. Putting together the right co-design group means eliciting input from both those who are eager to share their ideas and those

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who might require a little more encouragement. Sometimes, the most crucial insights come from the people who may not feel immediately comfortable providing their input. It may require additional effort on the part of the facilitator to make sure these people feel able to speak honestly about their experiences and their ideas. Often, facilitators are people internal to Stepped Care Solutions who have experience facilitating change management processes and who have the necessary leadership, facilitation, and project management skills to organize effective co-design sessions. It is important, however, that the facilitator is not involved (or perceived as being involved by those participating in co-design) in implementing the end results of the co-design process. The facilitator should be someone who can be seen as an honest arbiter representing the work of the co-design participants to the team responsible for implementation. Appearances are important in co-design work, especially in situations where there are already obstacles to establishing trust between participants. If there is a perception that the facilitator is entering the process with predetermined ideas about what the end result should look like, it can be difficult to meaningfully engage the stakeholders. A good facilitator should also have a wide range of soft skills, including a sensitivity to social dynamics, a relational style of speaking, and the ability to create an atmosphere of trust and respect. Research suggests that the relationship between the facilitator and the stakeholders is especially crucial when stakeholders belong to culturally and linguistically diverse communities (O’Brien et al., 2020). Facilitators should know when to let go and let others lead the conversation, and this may involve looking beyond the qualities typically associated with “leaders,” such as extensive knowledge of the issues and a clear vision for how to proceed (Jackson, 2016). Sometimes, an outsider who is able to listen to every perspective and doesn’t have a preconceived notion of what the outcome of the co-design session should look like will be more successful in opening up the space that will allow ideas to percolate.

14.4 Consensus Decision-Making, Co-design, and Interdependence Co-design is democratic, in the sense that it is rooted in the insights and ideas of the people with lived and living experience, clinicians, administrators, and organizations who are involved in mental health-care systems. It also seeks to move toward a consensus model of decision-making in which everyone involved can feel comfortable with the final decision. This means that the tensions that arise in a co-design session need to be given space to work themselves out through the group discussions and workshops. But, at some point, decisions will need to be made—so what happens when there is passionate disagreement about one point or another? If someone is sharing an experience or identifying a perspective that is not aligned with those of the rest of the group, the facilitator has several options. They

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may start by breaking down the disagreement so as to identify which factors are creating the gap, they may encourage participants to find ways of adjusting in both directions, or they may step back from the problem and try to identify areas where agreement does exist. If none of these approaches work, it may be necessary to ask whether this means the group cannot move forward at all or whether participants are willing to move forward with the caveat that the co-design model they have landed on doesn’t have full consensus. A concrete example of this might be the following: A co-design group is exploring a new mental health-care service following the SC2.0 model, and some of the participants, including a person with lived experience accessing services, are advocating to include nonclinical approaches such as peer support in the array of services being offered. A clinician with years of experience in psychotherapy is concerned, as a professional, that this introduces an unacceptable amount of risk into the model. This clinician views peer support as being paraprofessional and outside of the formal mental health-care system; they think that some of the practices considered acceptable within the context of a peer support relationship blur professional boundaries. This introduces tension into the co-design group—not only because of the issue at hand, i.e., whether or not nonclinical approaches should be included, but also because this difference of opinion tracks onto a hierarchy of expertise that evokes strong feelings (both negative and positive) among the participants. The clinician feels that their concerns about risk are being downplayed and that their hard-earned wisdom is being ignored, while the participant with lived experience feels that the professional is disregarding the challenges people seeking care face and is being too dismissive of the value of lived experience. A brainstorming session about which services should be offered has activated strong emotions on both sides, and both parties are becoming defensive. A productive and creative disagreement is in danger of becoming a battle of egos, which neither side wants to be seen to have lost. Consensus seems increasingly difficult to achieve. This type of conflict is not uncommon in co-design, especially around the problem of risk. The risk factor shapes modern health-care systems in indelible ways (see Chap. 12), and encouraging participants to put risk to one side and focus on possibilities is not always easy. Good facilitation requires the anticipation of these sorts of conflict and that plans be made for how conflict will be de-escalated. This is also why it is essential for the co-design group, with the guidance of the facilitator and others in leadership, to determine in advance the terms for understanding how the final decision will be made and to plan for how decision-making will proceed if consensus cannot be reached. People with similar perspectives tend to gravitate toward each other, and in a situation where important decisions need to be made, these affinities can harden into inflexible factions. This kind of us-versus-them thinking is very unhelpful in a co-­ design context, and the goal of facilitation should be to move participants toward an appreciation for interdependence. All participants in the co-design process need to recognize the value of each member and a felt sense that each member’s

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contribution is needed to produce a positive outcome. Experts with experience bring valuable knowledge of, and solutions to, past user needs, and those who have expertise by role and knowledge, or decision-making responsibility, can shift the power imbalance inherent in the positional structures by exploring the interdependence between one another to co-create new solutions. It is only possible to gain access to the experiencer’s world through his or her participation in expressing that experience (Sanders & Dandavate, 1999). Recognition and an active commitment to embrace this interdependence and mutuality can eliminate the risk of tokenism and address the power imbalance, as power is then shared between members, and shared contribution and input is nurtured.

14.5 Where the Rubber Hits the Road: Four Practical Challenges of Co-design Up until this point, I have sought to provide a broad overview of how co-design works and why it can produce better outcomes when implementing SC2.0. As we have seen, co-design can be a powerful tool for challenging hierarchies and creating mental health, addictions, and substance use health systems that are more attuned to the needs of the people using them. But we have also seen that co-design relies on a wide range of human factors—from stakeholder selection to facilitation, good co-­ design relies on having the right people in the room. This is the central conundrum: given that co-design operates within systems already shaped by a number of hierarchies (including professional, gender, racial, ethnic, and economic hierarchies, as well as hierarchies of ability), who determines who gets to be in the room? Who facilitates the discussion? How is the role of facilitator filled? Who decides how much time will be dedicated to the process? What is the compensation package for those who are not participating in a professional role, but whose time and expertise is equally valuable? This problem of hierarchy can be broken down into four more specific categories: diversity, time management, power imbalances, and the process by which co-­ design is initiated. We will address each of these categories below and explore some of the ways that facilitators and others in leadership positions can proactively address these challenges.

14.5.1 Co-design Requires Diversity Some progress has been made in recent years toward opening up conversations in the world of mental health, addictions, and substance use services about the importance of diversity. In terms of participants, co-design needs to reflect the full range of people who will be accessing the services and using or staffing the programs

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being designed. But co-design also needs to include dissenting voices and people who may be skeptical of the SC2.0 approach. Embracing diversity means embracing a wide range of opinions, which, in turn, means a greater potential for conflict. Being proactive about managing this conflict is crucial if the co-design process is to yield positive outcomes. One of the challenges within any kind of system-transformation work is that the people most eager to participate are often the early adopters, who have already been convinced of a model’s value and efficacy. While it is helpful to have early adopters at the table, as they can be strategically helpful when it comes to developing new approaches, it is also important to make sure that the doubters are not written off and written out of the process for being insufficiently on board with the program. In any system, there will be people who don’t necessarily understand why change is needed, who may be resistant to changes that seem radical, and who may feel that their concerns are being ignored. Failing to include such voices will only defer conflict, making implementation more difficult down the road. The co-design team often relies on people within the organization undergoing change to identify stakeholders, and they may not always include everyone who needs to be included. An important part of the work for any facilitator of co-design is to ensure that other perspectives are brought into the discussion—perspectives of people who will ask the uncomfortable questions, who might have experiences contrary to those of the majority, or who can open up completely new ways of thinking about problems. And this is not just true of individuals. There may be community or professional groups that have a stake in the services or programs being offered and whose voices need to be included—even if they are not directly involved in accessing or delivering services. For example, a clinic in an urban setting might want to include housing advocates or frontline service providers working with unhoused people in their co-design process. Making co-design truly diverse means embracing a degree of creative tension. If the participants enter a co-design session already in full agreement about everything, this may be a sign that important voices have not been included and that the range of participants needs to be expanded. It also underlines the facilitator’s role in ensuring that this creative tension does not degenerate into unproductive conflict. Good practices for including and managing diversity within co-design include: • • • • •

Inviting the right people through strategic diversity Creating a shared goal and intention Developing group protocols that create a safe space for innovation Encouraging the process to evolve organically Summarizing progress and decisions as they are made by the group

Together, these practices can channel tensions toward the ultimate goal of consensus decision-making. Good ideas become great movement growth strategies when they are widely embraced; ideas that emerge from obligation tend to stagnate and breed conflict.

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14.5.2 Co-design Takes Time Co-design cannot be effective unless the facilitator is able to create an atmosphere of trust among the participants, and trust cannot be conjured out of thin air. It takes time to establish a sense of mutual respect and vulnerability, and this is not a process that can be rushed. A co-design session needs to have lots of different activities built into the workshop that tap into different ways people communicate ideas or connect to innovative thinking. The facilitator may want to shift between written exercises, meant to bring out thoughts and ideas, and activities that engage thinkers who work better when moving around the room and participating in conversation. Planning and resourcing realistic work plans and timelines is essential so that the co-design team can develop the trusting relationships that are central to good co-design. At the same time, bringing together a large group of stakeholders, many of whom have other obligations, for a 90-minute meeting can be a challenge in and of itself. And in the fast-paced environment in which health systems operate, time constraints can become structure that creates disparities: if not everyone can be present for every session, or if there is a sense that the sessions need to be “gotten out of the way” so the supposed real work can begin, this will have a detrimental effect on the quality of the co-design process. In some ways, the challenge is cultural. SC2.0 is operating in the context of large health-care bureaucracies where efficiency is understood in a very particular way. It is often presumed that the fastest process is the most efficient, even when the faster process does not lead to a better outcome. This is one of the reasons for the top-down decision-making model that is ubiquitous in health care, business, and politics. There is a perception that placing power in the hands of an individual or a small group of people will reduce the amount of time required to make a decision. As a health-care approach rooted in diplomatic disruption, SC2.0 sees things from a different perspective. Co-design may require a greater investment of time initially, but the decisions that are arrived at through a rigorous co-design process are far more likely to have wide acceptance among key stakeholders and will lead to a more resilient system delivering better outcomes. This represents a somewhat counter-cultural approach to efficiency and is not always well understood by organizations seeking to adopt an SC2.0 model. It is essential that these organizations understand, from the beginning, what is involved in co-design in terms of time commitments.

14.5.3 Co-design Must Acknowledge Existing Power Imbalances Every organization has people who are in positions of authority, formally and informally, and it is these individuals who are often in charge of determining the framework in which co-design will happen. This includes determining who will

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participate, as we saw above, but also things like the general process of change that already exists in the organization or the allocation of resources. Because co-design uses the expertise of clinicians, administrators, and those with lived experience of services (as service users or as family and caregivers), it creates a space in which other types of power dynamics are present as well. For example, in the mental health-care system, there is an established professional hierarchy with psychiatrists, psychologists, and administrators receiving the highest pay and often having the greatest influence, while social workers and peer support staff are lower on the hierarchy. This is perhaps the most significant obstacle to creating a space in which ideas can be freely shared. Some participants may not immediately feel comfortable sharing their views, it may not feel like a safe or neutral space to everyone present, and there may be cynicism or a deficit of trust due to previous experiences. SC2.0 approaches this challenge by recognizing that there are many different types of expertise, including expertise by experience, lived experience, family experience, and training. The goal of the facilitator should be to create a sense within the group that the co-design session is a place of equality where all perspectives and ideas are welcome, by establishing protocols that respect the different kinds of expertise needed to create a new picture of what might be possible. Other concrete steps to remove barriers to participation are also important. For example, ensuring financial compensation for those involved in the co-design work who are not employed by the health system has proved vital to moving toward addressing the power imbalance. When people with lived experience, professionals, and provocateurs work in equal partnership across the design process, it’s common to see new relationships and possibilities for different systems emerge. Often, co-design enables people to see themselves and each other in a new light. Transformational co-design can involve professionals discovering that people with lived experience do not need “empowering” or to change in any way, but rather they must be listened to (Burkett, 2012). None of this is possible, however, if facilitators and others involved in co-design are not able to acknowledge that these power imbalances exist and will be present, in one way or another, when shaping how the co-design work unfolds. The challenge can be named and anticipated, but the work of actually dismantling these hierarchies is a much longer process. This reflects the conundrum involved in co-­ design: it attempts to redress power imbalances, but it operates in the context of institutions in which those power imbalances are deeply ingrained. If co-design is poorly implemented, it may simply reinforce the existing hierarchies and further alienate the stakeholders whose voices it is meant to uplift.

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14.5.4 Co-design Cannot Be an Afterthought This chapter began by noting that co-design engages the creativity of the community and starts the process of generating new possibilities. Co-design requires a different kind of relationship between people which incorporates trust, open and active communication, and mutual learning. Within SC2.0 implementation, co-­ design is established as an approach to be threaded through the system-change model, thereby allowing co-design not to be limited to an event, but understood and practiced as a process. However, in practice, co-design teams are often initiated only after certain decisions have already been made or after the priorities have already been established. If, for example, a government organization feels pressured to provide more services, they may turn to SC2.0 because they see it as a way to expand service provision. They will begin with an exercise called “populating the model,” which helps identify which services already exist within their system: they will plot services along the nine steps to determine what is available. At this point, a gap analysis will occur to figure out what kinds of services are lacking. It is only at this point, when decisions are already being made, that co-design is introduced to brainstorm ways of filling these gaps. While co-design does have a role to play in filling these gaps, introducing co-design this late into the process runs the risk of neutralizing its radical potential, rendering it a kind of re-branded focus group. If SC2.0 is really going to invite people to think differently about what an effective mental health system could look like, it is necessary to introduce co-design into the very first stages of the process. In order to imagine and dream the kind of system that really is responsive and focused on mental health and well-being, and not simply responding to pressure points and crises, co-design needs to be present from the very beginning—dissolving hierarchical forms of decision-making and acknowledging the power and insight communities hold to improve the lives of their own members. Practical solutions to this problem may look different depending on the context. For example, it could involve including stakeholders in the “populating the model” exercise to ensure that the services community members rely on are not overlooked or to bring in new perspectives on existing services. It is crucial that, while implementing a co-design process, involvement or participation is not simply sought after an agenda has already been set. Instead, lived experience leadership should be sought from the onset, so that those with direct lived experience of the service or system are involved in defining the problem and designing the solution. The important exercise of populating the model can be strengthened by investing in building a team of individuals who use and deliver mental health care, who then support the planning of a co-design strategy that is part of the overall implementation plan.

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14.6 Conclusion SC2.0 seeks to offer a solution to mental health system design that remains adaptable to different contexts, rather than provide a cookie-cutter response—and co-­ design is meant to ensure that the systems and services produced emerge from the wisdom and local knowledge brought to the table by the communities being served. But in the context of mental health-care systems that have internalized the risk paradigm, have enshrined top-down thinking, and have been conditioned to seek quick solutions for complex problems, there is a constant danger that co-design will be hobbled by a lack of time and resources or a too narrow view of who should be engaged in decision-making. There is also the possibility that co-design enters the picture too late to open up radical possibilities for system-wide change. SC2.0 has responded to these challenges in a number of ways, including by providing workshop materials and a detailed guide to help facilitators understand what co-design looks like in practice. But at its heart, co-design is about people. This is one of its strengths. But people enter co-design with their own biases and assumptions about what good mental health care should look like, whose voices should lead the conversation, what leadership looks like, and what the end result of the process should be. These assumptions are not always fully articulated, and they may not even be fully conscious. But they will shape the conversations that are had, the work that is done, and the outcomes that are achieved. This human element means there is no magical formula that can ensure that co-design will always deliver a result everyone is happy with. At best, there are practices that can help facilitators anticipate challenges and meet them in a way that is consistent with the principles of SC2.0.

14.7 Reflection Peter Cornish Co-design, as described by Marion Cooper, is difficult to achieve. I haven’t come close in any of my own implementation work in university settings, and I have yet to work with organizations who are familiar with, or especially committed to, incorporating co-design in the transformation of mental health care. This should not be surprising. Time pressure from funders to improve access to care has seriously limited the ability to democratize the design process. As a consultant, I am invited by the people holding the power. They are hoping I can address a problem or weakness. We begin by getting to know each other. Am I the right person for them? Can I be trusted with their confidences and vulnerabilities? Prior to SC2.0’s arrival, few organizations involved people with lived experience with mental health and substance use in meaningful transformation work. The idea of working side-by-side with those who have experienced trauma or

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marginalization is usually met with only mild interest and a touch of anxiety. Sometimes, organizational leaders seeking support in implementing the model worry that inviting stakeholders from outside their professional guilds to weigh in on their dysfunctional care system would further destabilize the system. It might be premature or distracting. “How are we going to do co-design, Peter, when our own house is in such disarray? Why would we do that? We don’t even know what we need or want from you, as our consultant, let alone what the clients we are serving want. Inviting more to the table will slow us to a crawl, and we can’t afford to go slow. Work with just us now. We need to make changes fast, and opening the conversations to the whole community is beyond the scope of our budget right now. Maybe we can do it down the road when we have things more under control.” Co-design in its ideal form is both expensive and time-consuming. In the USA, where I work and live, there seems to be little appetite to fund such a process. This country is the first and last bastion of unbridled capitalism. It is a place where white supremacy thrives and the rich are getting richer. No revolution has succeeded without first accepting reality. In my opinion, true co-design as described by Cooper is not yet possible where I live. But the ideal and the conundrum do have the power to disrupt. This doesn’t mean that we reject any of Cooper’s four calls to action (foster diversity, give it time, acknowledge power imbalances, involve from the beginning). I am committed. We are making progress with fostering diversity and acknowledging power imbalances. It does mean, however, that co-design might need to be a forever project, just like dismantling racism, nurturing social democracy, or distributing wealth and power. Those efforts require persistence and patience. Is co-design largely aspirational? Not exactly, but hope does play a central role. Hope allows us to persevere while acknowledging that we are working against a system that has been designed to exclude and marginalize the very voices that we must center if we are to truly practice co-design. So, it may be true that we are not yet doing co-design optimally. We haven’t figured out exactly how yet, but by inviting more voices, we likely will. As with any conundrum, there are trade-offs. Integrating co-design requires slowing down the process. It will take longer and be more expensive. Despite this, continued calls to center co-design in all transformation work is likely to draw more funds. By democratizing the process, more people could influence policy and political decisions not only to support co-design but also to invest more in the well-being of populations. In our first large-scale implementation of SC2.0 across Newfoundland and Labrador, it was the involvement of peer supporters who were also people with lived experience of mental illness that convinced politicians to invest in the new framework. Lots of people want change. Our job is to tap into this kind of progressive populism.

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References Burkett, I. (2012). An introduction to co-design. Knode. Retrieved February 22, 2023, from https:// www.yacwa.org.au/wp-­content/uploads/2016/09/An-­Introduction-­to-­Co-­Design-­by-­Ingrid-­ Burkett.pdf Jackson, T. (2016). Paternalistic leadership: The missing link in cross-cultural leadership studies? International Journal of Cross Cultural Management, 16(1), 3–7. https://doi. org/10.1177/1470595816637701 O’Brien, J., Fossey, E., & Palmer, V. J. (2020). A scoping review of the use of co-design methods with culturally and linguistically diverse communities to improve or adapt mental health services. Health and Social Care in the Community, 29(1), 1–17. https://doi.org/10.1111/ hsc.13105 Roper, C., Grey, F., & Cadogan, E. (2018). Co-production: Putting principles into practice in mental health contexts. Retrieved February 22, 2023, from https://healthsciences.unimelb.edu. au/__data/assets/pdf_file/0007/3392215/Coproduction_putting-­principles-­into-­practice.pdf Sanders, E. B.-N., & Dandavate, U. (1999). Design for experiencing: New tools. In C. J. Overbeeke & P. Hekkert (Eds.), Proceedings of the first international conference on design and emotion. TU Delft. Retrieved February 22, 2023, from http://echo.iat.sfu.ca/library/sanders_99_newTools.pdf Slay, J., & Stephens, L. (2013). Co-production in mental health: A literature review. New economics foundation. Retrieved February 22, 2023, from https://neweconomics.org/uploads/files/ ca0975b7cd88125c3e_ywm6bp3l1.pdf

Chapter 15

Leadership and Stepped Care 2.0: A Cautionary Tale Gillian Berry and Janis Campbell

15.1 Introduction In recent years, postsecondary mental health care has faced a barrage of challenges. Eighty-seven percent of counseling directors at colleges report spiking demand for services (AUCCCD, 2021; Burt, 2022). Students face long wait-lists, limited access to clinical support, convoluted procedures for accessing that support, and a lack of diversity in staff and services (Hunt et al., 2015; Saxena et al., 2007). It’s no surprise many institutions have considered restructuring their delivery model for mental health programs. It’s also no surprise that Stepped Care 2.0 (SC2.0) is fast becoming the go-to approach for this course correction. With SC2.0, students can choose from a wide menu of treatment options: one-at-a-time sessions, e-mental health, peer support, specialist workshops, individual therapy, and crisis response. Program intensity can also be stepped up or down depending on the level of need. This approach is, in itself, a radical change from what college campuses typically offer—one-on-one individual sessions foisted on students whether or not they want, or need, the treatment. Initial feedback from test sites has been encouraging. Not only has SC2.0 led to an increase in the number of students seen by clinics, but it has also sparked an increase in the number of students who feel their needs are being met (Cornish et al., 2017). Clinicians feel better about themselves, too. They can now tailor their skills to the individual, shifting between students ready for more intensive therapy and those who would rather participate in self-guided treatment, with some minimal therapist support. This not only leaves clinicians with more time to innovate but is G. Berry (*) Vice President for Culture and Diversity, Stepped Care Solutions Inc., St. John’s, NL, Canada e-mail: [email protected] J. Campbell St. John’s, NL, Canada e-mail: [email protected] © Springer Nature Switzerland AG 2023 P. Cornish, G. Berry (eds.), Stepped Care 2.0: The Power of Conundrums, https://doi.org/10.1007/978-3-031-45206-2_15

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also a more efficient use of their time as the responsibility for what happens during a session is shared with the student. Ultimately, SC2.0 has the effect of decreasing burnout and promoting job satisfaction. Of course, SC2.0 is being implemented beyond postsecondary, too. That’s because similar disparities in quality and access to mental health treatment also exist in other settings. And having found a cost-effective approach that doesn’t strain already scarce resources, many leaders feel they can finally exhale and check off the boxes that state they have successfully met the mental health needs of their community. But SC2.0 is more than a series of checkboxes. As an exercise in systematic change, it involves risk-taking and disruption. Just as diversity training itself isn’t enough to reduce bias and alter behavior in the workplace (Dobbin & Kalev, 2018), SC2.0’s model of practice won’t be effective without measures to support the profound changes it brings. That support starts with leadership. Because SC2.0 is a whole-system transformation, implementing it requires “transformational leaders.” It demands engagement from the highest levels in order for middle management and frontline workers to join together toward a shared vision. Transformational leadership, in other words, “raises the level of motivation and morality in both the leader and the follower” (Northouse, 2018, p. 164). It supports others in reaching their fullest potential. It is important to remember that leadership is not a static position. Instead, it is a complex process. If administrators want their medical and mental health staff to work in a radically different way, a culture of innovation needs to be cultivated. Employees need to be mobilized around the new model. That means putting in place not just training but supervisory support with additional meetings for staff to share concerns about the implementation process. Administrators need to ensure this environment fosters creativity and divergent thinking and that it is a safe place to test new ideas. It should also be a space where people are appreciated and recognized for their contributions (Buller, 2015). Because SC2.0 requires that all stakeholders be engaged in the development and delivery of the model (Cornish, 2020), those leading the process need to have detailed knowledge of all the pieces of the puzzle, along with an awareness of the factors that influence the day-to-day working environment. Leaders need to understand the team they are steering and what its strengths are. They also need to communicate a clear vision with transparency. Disengaged or disconnected leadership will not succeed in replacing the current mental health-care system with a better one. It is also important to acknowledge that transformation can happen in a negative way. This has led to the development of the term “pseudo-transformational leadership” (Bass, 1998), which refers to self-interested leaders who exploit followers, have questionable morals, and chase power (Bass & Riggio, 2006). Transformational leaders, in contrast, focus on the collective good, while pseudo-transformational leaders focus on individual interest. Transformational leaders are sensitive to the growing pains involved in SC2.0 disruption, yet show a steadfast belief that solutions that benefit all can be created. Pseudo-transformational leaders are defensive and impatient, and they fail to provide reassurance about next steps. Transformational leaders encourage constructive and collaborative discussion about the integration

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efforts they are overseeing, while pseudo-transformational leaders are condescending, nonresponsive, and disrespectful. When a leader is unable to tolerate feedback, confidence and trust in them diminish—elements essential to successful systemic change. Feedback is also where new ideas come from. By making it harder for alternative voices or opinions to circulate, a leader makes it harder to design a model of care able to meet the needs of clients from different backgrounds and identities. This is more than just professional nitpicking. Beyond endangering the well-­ being of clients, bad leaders can threaten the institution itself. The adversarial dynamics generated by weak administrators can negatively impact students’ experiences and raise scrutiny from parents, campus organizations, and student newspapers. Bad leadership can also put staff in direct conflict with the professional ethics and organizational guidelines that govern their conduct. When placed in such circumstances, mental health practitioners may face the uncomfortable dilemma of choosing their professional obligations over their employment. Simply put: SC2.0 aims to change not just a problematic mental health system but the people who run that system. Just as SC2.0 urges clinicians to let go of the expectation that they have all the answers and are the “decider”—a.k.a. the all-­ knowing professional—leaders are also asked to surrender the foundational ideas that undergird the existing power-over model of care and their part in it. Think of the traditional mental health model as a classical symphony: it has a fixed repertoire. It is formal, predictable, and contained. The concerts have firm boundaries, and everyone’s role is clearly defined: performers (composers, conductors, and musicians) are active, while the audience is passive. Performers and audiences are often from a dominant tradition (white, European) and have a shared assumption of cultural superiority. Instead, SC2.0 is closer to a jazz ensemble. The repertoire is fluid and evolving. The setting is countercultural and community-based (i.e., clubs, churches, restaurants, cafes, and street corners). The music is free-flowing, improvisational, and responsive to changes in rhythm. The performer–audience divide is less passive, and there is greater multicultural representation among the two groups. Transformation from the traditional model (classical symphony) to the SC2.0 model (jazz ensemble) requires commitment from all parts of the mental health system. If leadership is not on board, implementation will ultimately fail. Yet leaders of any mental health-care system are inevitably influenced by the cultural and political climate in which they find themselves in. If leaders are unable to see the entire picture or overcome the pressures of the sociocultural context, the system, along with its clinicians and supervisors, will revert to the old ways of playing music. In line with SC2.0’s transformational approach, we’ve decided to adopt a more creative presentation for this chapter and, thus, have written a case study to visually illustrate the above discussion in action. As far as possible, the following cautionary tale seeks to offer a lived—albeit fictitious—example of the role and impact of leadership attempting to implement SC2.0 in a university counseling center. By visually demonstrating the stark realities that face any leader who hopes to introduce SC2.0 into their workplace, we hope to bring to life the question at the heart of this chapter: can transformational leadership skills eventually win out, or will pseudo-leadership always dominate?

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15.2 A Cautionary Tale 15.2.1 Seeing the Forest The 10-minute presentation at the October annual conference for college counseling directors was all it took for Director Amlap to know the Stepped Care 2.0 model was different. The workshop on innovative approaches to mental health services was well attended, and, with no available chairs, she felt lucky to find a space on the floor by the presenter’s table. Comforted that she was not the only one having sleepless nights from the challenges of overseeing a college counseling center, she valued the opportunity to hear about alternative ways of working. A recent suicide cluster at the beginning of the academic year in August had once again highlighted the need to reexamine the mental health services on her campus. The crisis also put a spotlight on her leadership abilities. She had been made to feel uncomfortable when providing senior leadership in both the Division of Student Affairs and the President’s Office with details of the unsettling events. Their barrage of questions— most of which she could not answer or diplomatically avoided answering because it would have underlined their failure to provide her with enough resources—strengthened her resolve to look outside the box for something different. The annual conference, introducing her to SC2.0, did not leave her disappointed. The business of running Fictitious College’s counseling center kept her busy until the winter break, when she finally had some concentrated time to research the SC2.0 model. By the time January rolled around, a few days from the start of the spring semester, she felt confident about responding to questions regarding its suitability. She arranged to present her proposal to her leadership team. “If we keep doing the same thing, we will get the same results,” she stated boldly, quoting Stephen Covey, as she opened the counseling center’s leadership meeting. The clinical and training directors seemed curious, while the outreach and administrative coordinators made it clear they were unhappy about the additional work that implementing SC2.0 would mean for their teams. Listening carefully and making sure her team knew she valued their contribution, Director Amlap quickly followed up this first introductory meeting with an off-campus working day for a deeper dive into what it would mean for the center if SC2.0 was adopted. The first half of the day was devoted to the practical issues of implementing the model. The model’s founder was invited to Fictitious College and happily responded to questions from the team. His enthusiasm was contagious and won over staff. The second half of the day, the team wrestled with issues related to recruitment, staff training, and managing the change. This time, Director Amlap ended the day with a quote often attributed to Gandhi— “we are the change we want to see”—and announced the provisional adoption of SC2.0. The team agreed upon an ambitious launch day: August 25th. It was the first day of the fall semester and only 8 months away. The leadership team was then charged with putting things in place for a formal presentation to senior leadership and the staff team in anticipation of SC2.0’s formal approval.

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15.2.2 Unwavering Dedication With a 25-year career in college counseling, Director Amlap had overseen many changes. She began her career as a receptionist at the newly established counseling center after completing her undergraduate degree and taking a 3-month cross-­ country trip with her friends. She had not planned to stay there for long, but decided to take advantage of the tuition benefit of free academic classes and used them to obtain her master’s and doctoral degrees. And, on reflection, in what seemed like the blink of an eye, she had progressed from her Examination for Professional Practice in Psychology to heading up a multidisciplinary team of licensed mental health professionals. When she was first appointed as the counseling center director, the primary role of the center was to prepare students for their professional careers. Then, as the stigma around mental health shifted toward acknowledgment and acceptance, she focused on supporting struggling students to find success in their academic programs. Director Amlap believed she found her niche in overseeing the counseling center, despite the stress she faced. Director Amlap was proud of her accomplishments, which included raising her family while moving the counseling center from a self-contained townhouse to an entire floor of an office building, blocks away from the main campus. She introduced Platinum, a new electronic health records system, which, after a difficult learning curve, everyone now agreed made their lives easier. Director Amlap’s real priority was to support the clinical work of her team and sought to motivate those under her leadership to find their niche in the clinical field. She aimed to create an environment of safety, where new ideas were welcomed. She was excited, for instance, when an intern suggested art therapy, which turned out to be a big hit with the campus community and became part of college tradition as a result. Director Amlap enjoyed putting out the daily fires at her center and faced, with courage, one of the most difficult aspects of her job: student deaths on campus. When the suicide cluster happened at the beginning of the academic year, she had jumped into action. She prioritized the needs of the immediate families and ensured her schedule was cleared in order to meet with them and answer their questions. It was after one of those emotional family sessions in September that she had been called into a meeting with her supervisor in the Division of Student Affairs. She was surprised to see members of the President’s Office in attendance as well. She was informed that a special task force would be formed to review the college’s mental health services, and she was not invited to participate. Although the positive comments about her work from her direct supervisor during the meeting were appreciated, she could not hide her confusion that administrators believed they were better equipped than she was to oversee such a project. She hoped that her coming presentation on SC2.0 would change their minds. Just before the end of semester exams in April, without consulting with Director Amlap about its implications, the special task force revealed their findings and announced that, beginning the following semester, all registered students would be

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offered seven free counseling sessions. They were surprised when their announcement wasn’t met by the expected fanfare. Instead, their work was dismissed by student journalists with scathing headlines insisting that only unlimited counseling sessions would be acceptable. Quickly weighing the cost of negative media exposure and the possible reduction in applications, senior leadership agreed to the student demands and announced that funds earmarked for the president’s housing initiative would instead be diverted to the provision of improved mental health services. Director Amlap, upon reading about the shift in mental health services in the student newspaper, decided to incorporate this recommendation into her PowerPoint presentation on SC2.0. Her supervisor’s office had not been able to find time on the attendees’ schedules, and so it wasn’t until the beginning of May before she was finally able to meet with the president of the college, provost, Division of Student Affairs leadership, and several members of the special task force. They all sat in the large conference room on the fifth floor of the Student Affairs building as she showed slide after slide on the model’s promise to reduce wait times and offer on-­ demand sessions. She asked for a campus outreach coordinator, four full-time clinical staff, an e-mental health platform, and an e-platform to make community resources easier for students to contact. Her presentation was persuasive enough that, before she left the room, official approval had been given for the counseling center to adopt the SC2.0 model. The next newspaper headline claimed that “something had been done” that allowed the college community to exhale. But senior leadership’s enthusiasm for SC2.0 seemed to end at the model’s ability to turn negative press to positive press, leaving the actual mental health-care system transformation and student well-being the sole responsibility of the counseling center. Despite all her efforts to persuade her bosses that the mental health of the students was shared by the entire campus community, Director Amlap was given hardly any help to implement SC2.0. Her presentation resulted in receiving just one new full-time position and a consultant who would provide specialist training in suicide prevention. This meant she faced the challenge of changing the entire infrastructure of the counseling center with no additional resources. She remained cordial, but could not hide her disappointment in the lack of support from university leadership.

15.2.3 Taking Action Director Amlap quickly moved from being concerned about the politics of the college to the politics within the counseling center. It was the middle of May and weeks before SC2.0’s launch at the end of August. The promise of SC2.0 implementation had proven to be unsettling for staff, who were unsure of what to expect in the upcoming semester. Some had found it be too much and resigned. Already underpaid, understaffed, overworked, and disrespected as licensed professionals, they found that the stress of implementing an entirely new model of practice was

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unacceptable. Undeterred, Director Amlap trusted in the process and in her belief that SC2.0’s transformational abilities would lead to better outcomes for students. Despite agreeing with many of the ex-employee’s complaints, she found solace in the clinical tools of her profession and made a point of taking a few deep breaths at the beginning of each day. She would then walk down the corridors of the counseling center, taking nearly an hour as she stopped by every office with an open door to check in with each staff member and intern. Initially, new staff found it intrusive and didn’t feel trusted to do their job, but with the counseling center’s leadership team on the same page, it would soon become clear that they were all working for the same goal, to provide an effective service for the students seeking their services. And it wasn’t long before all members of the center’s team knew how Director Amlap made decisions and, therefore, how they were expected to make them—simply by asking, “What is in the best interest of the student?” With the launch of SC2.0 set, there was no going back. But with limited resources, the counseling center staff knew they were going to be busier than ever over the summer. May began with SC2.0 training, the formation of working groups, and outreach to the wider campus community. By June, the infrastructure working group had come up with solutions to offer diverse service options for students. Thinking outside the box, the group made the traditional one-on-one session just one of the options offered by the counseling center. Brightly colored information sheets informed students they could find mental health support from social media platforms, YouTube, books, or films. Students learned to recognize that support for their mental health was all around them. The outreach working group had gone above and beyond connecting with the various student groups and academic programs on campus: they developed a calendar for the upcoming academic year that concretely laid out the weekly workshops, clinical groups, and specialized services. After the feeling of uncertainty that was generated by constant policy changes on campus and high staff turnover, the counseling center outreach schedule created a sense of stability in student services. When the Friday before the beginning of the fall semester rolled around, there was practically nothing more for Director Amlap to do other than join her team to celebrate. Over drinks, they reflected in amazement on what their teamwork had accomplished. They had onboarded and oriented new staff; supervision was in place to support the team on an ongoing basis; they had updated their website, assessments, and documentation; they had listened to campus partners and somehow completed the mandated protocol for managing students who expressed suicidal ideation. Upon implementation, the wait-list disappeared overnight, clinical sessions were available on a walk-in basis, and there was the feeling on campus that something was finally being done to improve mental health services at the college. The biggest indicator that things were going well was positive news articles in the student newspaper. The transparent leadership, high level of communication, and regular tweaking of the center’s infrastructure meant, at its 2-year anniversary, the goal of providing each student with the service they needed was a reality. No longer was the offer of seven free sessions regarded as an equitable service given to every student,

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whether it was clinically necessary or not. Instead, the counseling center was able to offer each student what they needed when they needed it—one session to process a specific issue or more sessions to address complex issues. The clinical staff, as well as the interns, agreed that this was a more equitable distribution of the clinical resources and that it had the effect of increasing their job satisfaction and clinical skills and decreasing burnout. Reveling in the new clinical confidence sparked by the high level of teamwork and cooperation, Director Amlap thought briefly about applying for the newly created leadership position that was meant to oversee the counseling, medical, and health promotion teams that made up the integrated health center. But she was happy where she was.

15.2.4 Turning Back the Clocks The Department of Student Affairs leadership was thankful when a seemingly well-­ qualified external candidate wanted the position as director of the integrated health center. Going against the recommendations from Human Resources, who had grave concerns about the chosen candidate’s personality, the senior leadership team threw all their support behind him. Once the hiring documents were signed, the successful candidate and incoming director—Associate Dean Eggliton—held his first meeting with the leadership team. “I know you’ve been running the center for the past couple of years. And by all accounts I heard you’ve all been managing quite well,” he said. “But I’m here now and want you to know we’re all in this together.” He then proceeded to spend the next 15 minutes describing himself as a transformative leader. As a transformative leader, he was going to pay particular attention to ensuring the services were diverse, equitable, and inclusive. In hindsight, it seemed like a scripted speech, one he had practiced reciting many times. At the time, however, Director Amlap decided to trust that she could lean on Associate Dean Eggliton’s support. It wasn’t long before all three directors were called to the fifth floor, where the associate dean read his required demands of the health center directors. They were to report to him in the morning for a “start of the day huddle”; they would need to text him if they were going to be late for a meeting. They also needed to make themselves available for an “end of the day huddle.” All decisions regarding the center needed his approval. He expected total loyalty, and any challenge to his leadership would be taken as a sign that they no longer wanted to work at Fictitious College. Gone was the façade of being an agent for change. On display was a leadership style that existed expressly to preserve his status and maintain the status quo. It was also a style he plainly had no interest in changing. The health center directors agreed that the last time they felt so condescended to was in high school. Director Amlap had at least 3 years of SC2.0 data to support the increased numbers of students being seen at the center, despite the staffing challenges. Her team had developed partnerships across campus, conducted mental health seminars in their areas, and had received positive parent and student feedback. But Associate Dean Eggliton seemed almost bored by the information Director

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Amlap tried to present to him during their huddles. He showed no interest in the functionality of SC2.0 and no curiosity in how the model had positively impacted the day-to-day needs of the counseling center. Director Amlap and her colleagues wondered, how was this person allowed to get past the hiring protocols? Was there a reason why the college president and provost thought this was a suitable candidate for the position? Whenever the health center directors could get together, they allowed their imaginations to run wild as they tried to make sense of their new reality. Was senior leadership aware of his leadership style? Did they think it was a good idea? Was the ultimate objective to get them to retire? Or did they want to make additional financial cuts and felt this was a strategy to get there? Whatever the case, Director Amlap felt like her years of experience as the counseling director counted for nothing. Morale in the counseling center plummeted. Staff began to hand in their notices as pressure on the remaining staff became intolerable. The professional staff of the health center, aware of the primary source of the disruption, organized a petition for his removal. Once HR had completed their investigation, Associate Dean Eggliton was unceremoniously walked off campus by an elated HR representative with an “I told you so” expression she could not hide.

15.2.5 Déjà Vu The elation following Associate Dean Eggliton’s firing did not last long. The course of Director’s Amlap’s life was changed yet again by the Board of Directors’ decision to take the college in a new direction. The directors replaced the existing college’s president and supported the new president’s decision to bring in the leadership team of his choice. The president’s representative, the vice president of Student Affairs, was Dean Smalls. With a mandate to make “radical” changes, and with a focus on being financially responsible, she announced a hiring freeze. The health center, no longer exempt from such mandates, had to report on ways to make cuts in their area along with all the other departments. The vacant positions Director Amlap had expected would be filled, the cost of living rises she wanted for her staff, and the e-mental health resources she recommended as part of the SC2.0 model—none of that was going to be funded. The stress she felt before SC2.0 was implemented returned. Vice President Smalls described her leadership style as “inspirational,” and with her daily check-in meetings, mid-semester off-campus retreats, and mandated book readings, there was little time left for Director Amlap to oversee the work at the counseling center. When she was publicly reprimanded for not completing her chapter reading of the book on how to have “crucial conversations,” the thought of resigning entered her mind for the first time. No longer was the college a place to learn, become independent, or explore interests. Under Vice President Smalls’ leadership, she felt the role of Student Affairs was being modeled after service staff in the hospitality industry, where students could expect their every whim to be catered

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to, never learning about empowerment, personal responsibility, and the development of emotional intelligence. Vice President Smalls was never available to have this crucial conversation. Director Amlap made the painful decision not to publish the annual schedule of the counseling center’s services that had once filled the team with such pride. With staff now beginning to leave in swarms, the demand on the remaining staff made it impossible to offer the wide range of mental health services characteristic of SC2.0 that they once did. When the start of the new academic year rolled around again, the only service the counseling center could offer was walk-in services between the hours of 10 a.m. and 4 p.m. Walking down the corridor of the counseling center now filled Director Amlap with dread, rather than elation. With the college’s siloed departments, and staff unable to communicate about their shared experiences, it seemed like a cloud permanently hovered over the campus threatening to rain at any moment. Most staff did their best to be present for the students while quietly making exit plans in the background. Director Amlap found herself crying most days in her office, trying her best to come up with a game plan, to motivate the remaining staff, to ensure the service was able to offer appropriate mental health care for the students on campus. And when she believed this was no longer possible, she knew she had to make the most difficult decision of her tenure. The printed resignation letter, which she had been carrying around for weeks, was delivered to a delighted Vice President Smalls. By focusing on the financial savings that could come from having one position overseeing the integrated health center, Vice President Smalls was oblivious to the long-term effects of her policy decisions. It wasn’t long before the one-on-one sessions returned to the counseling center, along with the center’s three-digit wait-list and high staff turnover. Eventually, SC2.0 became a distant memory on Fictitious College’s campus.

15.2.6 Discussion Did Fictitious College’s senior leaders do enough to rally employees around the implementation of SC2.0 on their campus? Did they provide enough supervisory support? Were they sufficiently intentional about fostering creativity, divergent thinking, and a safe place to “fail forward”? Did they adequately acknowledge the contributions of those trying to roll out the model? By not doing enough on these fronts, was the demise of SC2.0 inevitable? It’s clear that Director Amlap battled pseudo-transformational leaders, men and women who were defensive, condescending, nonresponsive, and disrespectful. But is she herself entirely blameless? She may have displayed leadership skills, such as creating an environment where her team felt appreciated and motivated under very difficult circumstances. But simply asking for approval to implement the SC2.0 model may have led her senior leadership team to conclude that nothing else was required of them to transform mental health services and support student wellness.

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Did she understand the importance of the high level of communication and transparency needed when diplomatically navigating the change management process? In our attempt to realistically capture the complexities facing leadership in the current socioeconomic climate, we believe there is a lesson for the SC2.0 model itself. SC2.0’s positive aspects—such as open access for all, diverse and multiple care options, and culturally responsive programming—may give the impression that its elements are, by themselves, revolutionary enough to fix a broken mental health system. However, the question that also needs to be asked is whether the SC2.0 model, as a set of practices, does enough to highlight the importance of transformational leadership and the risks associated with pseudo-transformational leaders. Instead, SC2.0 seems to prioritize practical transformation in the assumption that leaders are automatically equipped with skills to cultivate the environment that makes such transformation possible. True, SC2.0’s core definitions do not hide the requirement that all stakeholders be engaged in the development and delivery of the model, but do those definitions spell out strongly enough what it takes to steer through the murky waters of the current mental health system and navigate out of them?

15.2.7 Leadership Role When we use the classical symphony analogy to describe the traditional mental health model, part of what we mean is that certain practices are built to exist inside certain boundaries and defined roles. But our cautionary tale asks: could the same operating tools be applied to music or a mental health model, such as SC2.0, that is fluid and evolving? Without adaptation, we believe that using a formal, predictable, and contained power-over approach to try to lead a free-flowing, improvisational, and empowered system—SC2.0—will ultimately fail. If SC2.0 is serious about seeing leadership as a crucial component of systems transformation, then SC2.0 needs to aim big by transforming the whole system. This includes investing in the workforce and promoting transparency, along with communication. It also includes being solution-focused and paying attention to the impact of those policies. System transformation requires questioning whether the organization chart needs to be reflective not just of the chain of command but also of how positions interact with each other. This might require the adoption of a matrix or team organizational chart, which would not only raise the level of motivation but would also properly reflect a system which knows how each part connects with each other. System transformation also requires dedicated or intentional time for collaborative learning. Middle management and frontline workers should be considered in the decision-making process and not be regarded as automatons to be directed at will. For example, the delay in formally approving the adoption of SC2.0  in the cautionary tale had the unintended result of staff resignations. The scheduling delay was not communicated, leaving many to incorrectly reach their own conclusions,

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lacking trust in those in leadership. Director Amlap showed transformational leadership when she prioritized walking down the corridor and spending time with her team at a human level. It seemed to have paid off when she needed it, as the entire team was able to collaborate on a plan that was in the best interest of the center, thus avoiding burnout. However, from a macro-perspective, without a system transformation, her actions could be interpreted as honorable but ultimately ineffective.

15.3 Conclusion What is the moral of our cautionary tale? What should we take away from learning about such a mental health system in desperate need of transformation? We learn that SC2.0 can make a positive difference—not overnight, but eventually, with commitment, consensus, and effective transformational leadership. The tale of Fictitious College’s counseling center also highlights several leadership styles, each of which, at different times, wavered between ethical obligations and the college’s requirements. The authoritarian styles of some of the leaders affected morale and fueled a culture of distrust and frustrations within the center, which directly impacted the student experience. But the tale also teaches us that no leader—no matter what area of the system they oversee—is exempt from the responsibility of making their organization more responsive to the mental health needs of their clients. The decisions we make don’t simply exist in the confines of our offices. None of us live in isolation from the system we are a part of. And when we seek to change that system, we need leaders who can help us face, head on, the complex realities of the task.

15.4 Reflection Peter Cornish Transformational leadership is difficult. Change won’t happen overnight. Reflection, on the other hand, can happen continuously. Gillian Berry and Janis Campbell’s cautionary tale causes me to reflect on my experience leading at three different organizations—an academic department, a not-for-profit public sector start-up, and a large university mental  health center. Despite varying organizational structures and cultural contexts spanning two countries, my leadership bias was consistent. My tendency in all three workspaces was to cultivate a vision for resolving longstanding mental health system challenges. While my life experiences and academic training armed me with intellectual tools for solving large problems, I never received formal leadership training. Instead, I learned by trial and error, by failing forward. There was clearly a lot to learn. My first leadership role was a curious one. I was head of an academic department, which was also tasked with providing counseling to students. Like in more

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typical academic departments, I had no authority to hire, promote, or guide the faculty in my unit. Processes and decisions were collegial responsibilities of the faculty as a whole. Search committees were led by faculty, as were promotion and tenure committees. While I was responsible for managing the budget, I had little capacity to determine workloads or shape the focus of the work. The only option I saw was to inspire my colleagues with bold ideas and hope they might follow. While some were curious about what I was doing, structural barriers prevented much beyond mild interest. The right to academic freedom and the fact that faculty members are rewarded exclusively for unique, independent works took precedence over shared missions. As is typical in academia, my ideas were met with some interest, but they remained largely conceptual. My initial successes in transforming care and improving outcomes were not sustainable after I left my position. My second leadership experience as the founder of the not-for-profit start-up, Stepped Care Solutions, couldn’t have been more different. I was able to hire people who shared or complemented my vision for transforming mental health systems. But I lacked formal training in management and business operations. Receiving one-on-one coaching in leadership and organizational strategy from experts not only helped me to become a better leader, but it also equipped me to restructure the organization in ways that facilitate more effective care. I also discovered the merit of skillsets I knew little about—knowledge exchange, project management, government relations, public policy analysis, and implementation science. I learned that recruiting for the right vision and values is not enough. The organizational climate and structures needed to adapt to the emerging mission. My most recent role in a university mental health center has afforded me the opportunity to appreciate three levels of institutional leadership work: (1) clinical supervision of frontline staff, (2) leadership restructuring and change management processes, and (3) managing up with policy development and managing out through external partnership expansion. My main learning and focus, thus far, has been, at the second level, on change management and restructuring. Through trial and error, I worked on building trust among ten managers who report directly to me. I relied on external consultants to facilitate strategic planning workshops aimed at visioning and operationalizing the changes and on executive coaches to develop my skills in mentoring my managers. As a management team, we came up with the concept of leading through “DAC with heart.” This means giving Direction to achieve relevant goals, coordinating and clarifying roles to Align with the vision, and nurturing Commitment to track and recognize achievements that support the mission. The heart component serves as a pledge to lead with both compassion and care—care for each other, care for the staff we supervise, and care for those we serve through our programming. The management team also agreed to move from a vertical command structure to a matrix “team of teams” structure. The first move, as I derived through conversations with consultants, had to come from the top—in other words, from me. I decided to relinquish my role as director and assume a new co-director role. This allowed one of my direct reports to advance. It also signaled a commitment to lead

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collaboratively. The new matrix structure combined both vertical and horizontal (cross-team) decision-making. As Berry and Campbell argue, transformational leadership requires collaboration. It also demands humility. I am not yet as good as Director Amlap at “walking the corridor” each day to connect personally with staff. This is a growth area for me. I have publicly acknowledged this weakness and celebrated the skill that my new co-director colleague has in this capacity. Director Amlap may not have succeeded in managing up in her institution. This may have been due to things she had no control over (i.e., those she reported to may not have responded to any efforts on her part). Or perhaps executive coaching, if available, could have helped her to connect the needs of students and her department with the needs of those she reported to. Perhaps, like Director Amlap, I have more to learn in managing up and out. While the senior leadership to whom I report have been very supportive of me, I have not engaged with them enough to ensure synergy between our various goals and roles. I have not thought enough about what I need from them in order to support the departmental mission or what they need from me to support their larger institutional goals. Is a perfect synergy (see Chap. 10) through leadership levels possible? No. Sometimes, problematic leadership structures and dynamics will result in irreparable zero-sum, win-lose outcomes that compromise mission-related work. We live in a world that prizes power-over, not power-with (see Chap. 14) This, I think, is the source of many workplace leadership conundrums. The power of conundrums in leadership comes from our ability to step back, reflect, and become curious about dynamics and structures. But this, in itself, presents another conundrum. Who can afford to step back and reflect? Who can safely risk power sharing? As a white cisgender male, I have the privilege of doing so. Director Amlap may not be able to afford this. It could depend on the extent to which her identities influence her level of empowerment. Would she be safe enough expressing the vulnerability and transparency required to loosen structures that maintain authority? So, the conundrum here revolves around feasibility. It is one thing to reflect and become curious and quite another to take action. A realistic perspective can be disheartening. Failures, which are inevitable, must be acknowledged and grieved. I recall a pastor friend telling me, shortly after my mother died, that grief is the ultimate expression of love. Can grief, once acknowledged, give birth to hope? I hope so. Loss, grief, hope, and patience are essential ingredients for any substantive transformation. I am confident that I can continue to do my part—by reflecting and learning along the way. Effective leadership means always learning. This sets the tone for “learning organizations”—those that adapt in order to survive and thrive over time (Senge, 2006). SC2.0 is a framework for supporting mental health organizations to adapt and thrive. Leaders at all levels of mental health practice, management, policy development, and resource allocation would do well to consider and model the principles of SC2.0 to power the changes needed to repair broken mental health systems.

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References American Psychological Association. (2019). Survey: Americans becoming more open about mental health. Retrieved December 3, 2020, from https://www.apa.org/news/press/releases/2019/05/ mental-­health-­survey Association for University and College Counseling Center Directors (AUCCCD). (2021). Annual survey: 2019. Retrieved December 3, 2020, from https://www.aucccd.org/assets/documents/ Survey/2019%20AUCCCD%20Survey-­2020-­05-­31-­PUBLIC.pdf Bass, B. M. (1998). The ethics of transformational leadership. In J. Ciulla (Ed.), Ethics, the heart of leadership (pp. 169–192). Praeger. Bass, B. M., & Riggio, R. E. (2006). Transformational leadership (2nd ed.). Lawrence Erlbaum Associates. Buller, J. L. (2015). Change leadership in higher education: A practical guide to academic transformation. Jossey-Bass. Burt, C. (2022, February 2). How the mental health crisis is crushing college counseling centers. University Business. Retrieved February 2, 2022, from https://universitybusiness.com/ how-­the-­mental-­health-­crisis-­is-­crushing-­college-­counseling-­centers/ Cornish, P. (2020). Stepped care 2.0: A paradigm shift in mental health. Springer. Cornish, P. A., Berry, G., Benton, S., Barros-Gomes, P., Johnson, D., Ginsburg, R., Whelan, B., Fawcett, E., & Romano, V. (2017). Meeting the mental health needs of today’s college student: Reinventing services through Stepped Care 2.0. Psychological Services, 14(4), 428–442. https://doi.org/10.1037/ser0000158 Dobbin, F., & Kalev, A. (2018). Why doesn’t diversity training work? The challenge for industry and academia. Anthropology Now, 10, 48–55. Hunt, J.  B., Eisenberg, D., Lu, L., & Gathright, M. (2015). Racial/ethnic disparities in mental health care utilization among U.S. college students: Applying the institution of medicine definition of health care disparities. Academic Psychiatry, 39(5), 520–526. https://doi.org/10.1007/ s40596-­014-­0148-­1 Northouse, P. G. (2018). Leadership: Theory and practice (8th ed.). Sage. Saxena, S., Thornicroft, G., Knapp, M., & Whiteford, H. (2007). Resources for mental health: Scarcity, inequity, and inefficiency. The Lancet, 370(9590), 878–889. Senge, P. M. (2006). The fifth discipline: The art and practice of the learning organization (2nd ed.). Doubleday.

Chapter 16

Integrating Substance Use Health into Stepped Care 2.0: The Recovery Conundrum Mary Bartram

Against the backdrop of the opioid crisis, recovery has become one of the most contested terms in the mental health and substance use health sectors (CAPSA 2022). In many parts of Canada, recovery—largely with reference to building abstinenceoriented treatment centers—is being prioritized over harm reduction approaches, such as supervised consumption sites and safe supply, in highly politicized ways (Braat, 2023; British Columbia, 2023; Manitoba, 2022; Mussett, 2022). That reality directly affects a framework like Stepped Care 2.0 (SC2.0), which adopts the mental health sector’s definition of recovery, with a strong focus on choice and self-determination. Along with the rest of the mental health and substance use health sectors, SC2.0 finds itself in the middle of a recovery conundrum, caught between addictions and mental health recovery movements that are at once interrelated and strikingly disconnected (Bartram, 2019). While this is a topic of considerable debate within the substance use health sector, addictions recovery is generally understood to be contingent on stopping substance use. This abstinence orientation goes back to Alcoholics Anonymous (AA), a now global movement that originated in the United States in 1935 and was codified in the publication of The Big Book of AA a few years later (Bill & Dick, 2019). With its stated purpose “to stay sober and help other alcoholics to achieve sobriety,” AA has shaped how we think about addiction and, as it happens, how we conceptualize recovery. And that perspective has some important differences from the way recovery has been adopted by the mental health sector. Mental health’s notion of recovery can be traced to the 1960s patient liberation movement (Brown, 1981). It was a reaction against the psychiatric system’s long-standing message at the time, that recovery from a diagnosis of mental illness was impossible. People living with mental illness M. Bartram (*) Mental Health Commission of Canada, Ottawa, ON, Canada School of Public Policy and Administration, Carleton University, Ottawa, Canada e-mail: [email protected] © Springer Nature Switzerland AG 2023 P. Cornish, G. Berry (eds.), Stepped Care 2.0: The Power of Conundrums, https://doi.org/10.1007/978-3-031-45206-2_16

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were housed in asylums and hospitals, often in terrible conditions. Mental health recovery is shaped by the belief that people do not need to be cured to have hope of recovering fulfilling and productive lives—a belief grounded in research that has found even people with severe forms of mental illness can live well (Ellison et al., 2018). This notion of recovery isn’t opposed to medical treatment (Jacob, 2015). Rather, as set out in the Mental Health Strategy for Canada, “recovery seeks to promote people’s ability to choose and to ensure that options are available to meet the full range of people’s needs” (Mental Health Commission of Canada, 2012, p.  35). Mental health recovery prioritizes autonomy, self-determination, and informed choice. If someone living with depression has all of the information and access to all of the options and decides against medication, you support that. If someone prefers to manage their anxiety disorder through peer support, rather than psychotherapy, you support that, too. As a framework that is grounded in mental health recovery principles, SC2.0 assumes that if you put up barriers that are too high, people might be turned off from seeking help. Recovery, thus, becomes a journey unique to each individual and their experience rather than a linear process of phases and checkpoints. Harm reduction approaches apply the same principles to substance use health. Harm reduction has been defined as “interventions aimed at reducing the negative effects of health behaviors without necessarily extinguishing the problematic health behaviors completely or permanently” (Hawk et al., 2017, p. 1). Harm reduction respects choice, including the choice to continue using—that is what it has in common with mental health recovery. If you advocate for choice, then you meet people where they are at with their substance use. If a person wants to be abstinent, you support them to achieve that goal. If they don’t choose abstinence, you help them reduce the harms that may or may not be arising from their substance use at their own pace, without conditions. When it comes to substance use health and addiction work, in other words, SC2.0 has to grapple with the long association of recovery with abstinence, as well as the highly politicized debates over the benefits of abstinence-based recovery versus harm reduction. Because recovery is often associated with abstinence, there is a potential for confusion whenever SC2.0 refers to itself as recovery oriented. Put yourself in the place of a government that is deeply committed to helping people to achieve and sustain sobriety and skeptical about the value of harm reduction approaches, such as safe supply and supervised consumption sites. As you approach Stepped Care Solutions and the Mental Health Commission of Canada to learn more about the model, something that is indeed happening in many jurisdictions in Canada and internationally, it would be easy to misunderstand the recovery orientation of SC2.0. More to the point, put yourself in the shoes of someone seeking help for problematic substance use. When you hear SC2.0 is recovery oriented, it would be easy to assume, falsely, that the service will be more focused on abstinence than choice. It might even be confusing for anyone seeking help for mental health problems, who may be more familiar with recovery as it is often  used in the addiction sector.

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As SC2.0 integrates more substance use health services into its framework, the associations between harm reduction and mental health recovery, on the one hand, and abstinence and addictions recovery, on the other, are shaping up to be a fundamental conundrum. To frame it more pointedly: what can SC2.0 do to espouse a recovery orientation without appearing to be an abstinence-based model and, thus, opposed to choice, and without getting caught up in the political maelstrom over harm reduction? This conundrum isn’t unique to SC2.0. Indeed, there have been some notable attempts to build a shared vision for recovery across the mental health and substance use health sectors. In the United States, the Substance Abuse and Mental Health Services Administration (SAMHSA) led the development of a common vision that moves a few small steps toward harm reduction and choice, but retains a strong focus on abstinence: “Overcoming or managing one’s disease(s) or symptoms—for example, abstaining from use of alcohol, illicit drugs, and non-prescribed medications if one has an addiction problem—and for everyone in recovery, making informed, healthy choices that support physical and emotional well-being” (SAMHSA, 2012, p.  3). In Canada, the Mental Health Commission of Canada’s Recovery Guidelines acknowledges the tension between mental health and addictions recovery, but emphasizes that “there are multiple possible pathways to recovery in both mental health and addictions,” including harm reduction (MHCC, 2015, p. 13). When the Canadian Centre of Substance Use and Addiction (CCSA) surveyed Canadians on their personal definitions of recovery, 52% of respondents included the concept of abstinence, with only 14% including the next most commonly reported concept, quality of life (McQuaid et  al., 2017). Further, 96% of respondents agreed with a definition of recovery that introduces some flexibility but still leads with abstinence: “In addition to abstinence or stopping uncontrolled substance use, recovery implies improved health, function, and quality of life” (p. 16). While SC2.0 isn’t alone in facing this recovery conundrum, it must grapple with it in a very specific sense given how deeply choice is embedded in its recovery framework. In promoting its recovery orientation, SC2.0 puts itself forward as a disruptive force, predicated on its willingness to relinquish professional power and recognize that the person seeking help has equally valuable expertise and strengths. In the SC2.0 model, service users become active participants in decisions about their care, allowing them to engage with the system at their own pace in a culturally and personally appropriate way. SC2.0 espouses a belief that the ability to make informed decisions about one’s mental health and substance use health maximizes outcomes. To make that possible, SC2.0 prioritizes access to a wide range of supports and resources tailored to match the capacities of those seeking care. Promoting choice in substance use health services is bound to invoke harm reduction for decision-makers and everyday people alike, just as promoting recovery is bound to be associated with abstinence. SC2.0 would do well to think carefully about how to communicate its value proposition to the large part of the addiction sector that is deeply committed to abstinence as, if not a necessary starting point for substance use recovery, then a clear goal. Garnering support for a

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disruptive mental health model is bound to be hard, and clearing up misunderstandings about the terms employed to describe the model adds to the challenge. Sometimes, I think recovery has outlived its usefulness as a term, if only we could find something that could drive system transformation even better. In 2018, I interviewed about two dozen stakeholders from across Canada about their experiences in navigating the tensions between mental health recovery, addictions recovery, and harm reduction (Bartram, 2021). A number suggested that we needed to switch to well-being. (“I would use the term wellbeing because of the stigma and misunderstanding of recovery,” one participant said. “For addiction recovery, mental health recovery and harm reduction, the final goal is very much to achieve wellness at the end of the day,” said another.) In some ways, this change has already started in Canada. Provincial and territorial mental health and substance use health strategies, for example, are increasingly framed around wellness (e.g., Manitoba Pathway to Mental Health Community Wellness; Ontario Roadmap for Wellness). The Community Addictions Peer Support Association (CAPSA) changed its annual community event from Recovery Day Ottawa to the WOW festival, or Working on Wellness (CAPSA, 2022). Stepped Care Solutions itself appears to be making this shift in small ways. Its website describes its vision as “wellbeing everywhere” (Stepped Care Solutions, n.d.). And the federal government-funded portal created in response to mounting mental health and substance use concerns since the pandemic, founded in the SC2.0 framework, is called Wellness Together Canada (Wellness Together Canada, 2022). The problem with well-being, however, is that it is so broad that it can mean happiness or general physical health, at which point it loses any explicit association with mental health and substance use health. In my view, the harder task, and bigger payoff, would be to create a shared vision for mental health and substance use health. There is a great deal riding on a breakthrough that can bridge the two. We know there is a high level of co-occurrence between mental health and substance use concerns. Among Canadians and Americans with mental health or substance use disorders, an estimated 15 to 25% experience both concurrently, with a greater proportion of concurrent disorders among those with a substance use disorder (Khan, 2017; Rush et al., 2008; SAMHSA, 2021). According to polling conducted by the MHCC and CCSA, people with current substance use concerns or a history of substance use disorder have been up to three times more likely to report mental health concerns during the pandemic and vice versa (MHCC and CCSA, 2022). The interrelationship doesn’t just lie in diagnosed disorders, but shared risk factors. Trauma, poverty, stigma, racism, and other forms of discrimination can all increase the chances of both mental health and substance use concerns. During the pandemic, the top predictors of substance use were things like anxiety and suicidal ideation (Geda et al., 2022). In turn, there were high rates of suicidal ideation among people with a history of substance use disorder. This link was, in fact, more predictive than variables such as low income (Roberts et al., 2021). My understanding is that it’s precisely because of the high degree of interdependency between mental health and substance use concerns (Lai et al., 2015) that SC2.0 is working to integrate substance use health services into its framework.

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When introducing both mental health and substance use health programs into a service framework, clear definitions would go a long way toward clearing up the recovery conundrum. Right now, SC2.0 uses the term “recovery” without acknowledging its association with abstinence in the addiction sector. That association isn’t mentioned in SC2.0’s methodology, nor will you find it in its diversity, equity, and inclusion statement. SC2.0 also doesn’t clarify that abstinence is not a requirement in its model. And if it doesn't clarify that, then it further risks being misunderstood as being an abstinence-based model and being caught up in the political debates over harm reduction. SC2.0 should clearly communicate that its recovery model does not require abstinence and instead recognizes multiple pathways to recovery for both mental health and substance use health. In fact, it should go further: it should clarify that SC2.0 is inclusive of both harm reduction and abstinence-based approaches. If this isn’t sorted out, SC2.0 flirts with three unpleasant possibilities. First, it is liable to get misunderstood as an abstinence-based model, particularly in jurisdictions where this model predominates. This misunderstanding could not only affect the spread and scale of SC2.0’s implementation but also confuse the very people it aims to serve. Second, it risks being politicized in the highly contentious debates over harm reduction versus abstinence-based responses to the opioid crisis. And third, it is likely to alienate the substance use health sector by using the term “recovery” in a way that only refers to how it is used in the mental health sector, without acknowledging the deep roots and complexities in the addiction recovery movement. At the moment, Stepped Care Solutions, through the development and application of the SC2.0 framework, is holding the banner for mental health recovery high. But if it also wants to use recovery as a guiding principle in its substance use health work, it has to convince the addiction sector it is sensitive to its debates and values. There is the potential for the mental health and substance use health sectors to stand stronger together under a shared objective, and Stepped Care Solutions could make a significant contribution to that. If Stepped Care Solutions decided to play a leadership role in finding an understanding of recovery that both sectors could rally around, and if that vision recognized the distinctions between them in a meaningful way while growing the common ground, that would be truly transformative.

16.1 Reflection Peter Cornish Can SC2.0 be recovery-oriented without seeming also to be abstinence-based and therefore opposed to harm reduction? To be seen as abstinence-based might be interpreted as restricting choice or flexibility. On the other hand, abstinence for many is a viable choice and can be implemented in flexible ways that support failing forward.

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As Bartram argues, recovery is an especially problematic term because it is used to convey politically opposed values and assumptions. Continued use of the term may undermine progressive mental health policy reforms aimed at representing the needs of populations most marginalized. What happens to people who can’t or won’t abstain? An abstinence-only approach will exclude many if not most people who struggle with addictive substances or behaviors. As such, Bartram is right to ask what position SC2.0 takes on the definition of recovery. SC2.0 is founded on the principle that one size fits one. As such, while recovery could mean abstinence for one person, it would not mean that for another. All variations and sizes matter. Language is power. It has a tremendous capacity to influence, dominate, restrict, excite, expand, inspire, and heal. It can bring people together or set them apart. SC2.0 aims for the latter, using language to convey broader more inclusive meanings. From this perspective, recovery can and should not be considered synonymous with abstinence. Instead, abstinence is one of many possible paths to recovery. Our version of recovery is expansive and inclusive. We strongly oppose the use of recovery to restrict pathways to healing. That, in our view, is oppressive. At a leadership meeting recently, managers who report to me proposed that I focus more on bringing clarity to language, policies, and all communications with them and other staff across the organization. Something didn’t sit right with me about this. Clarity, if too precise, can be oppressive. Without some ambiguity, there may not be room for nuance, flexibility, alternate viable interpretations, or creativity. Other voices could end up being casualties of precision. If too general or vague, on the other hand, manipulation, and other weapons of obfuscation become possible. SC2.0 aims for flexible clarity. While on the face of it, this is an oxymoron, SC2.0 openly embraces dialectics. Our stance on the abstinence/harm reduction debate is to support choice. We need language that conveys this. SC2.0 is a “recovery-choice” model. We just might need more hyphens in our lexicon. Language, economics, and power are interrelated themes emerging in this book on conundrums. Improving mental health globally requires attention to social and economic structures that both constrain and promote well-being at scale. Successful sustainable organizations and societies manage differences, conflicts, and compromises well. People living in social democracies, such as Denmark and Finland, are reportedly the happiest in the world. In contrast, many living in free-market democracies and totalitarian societies are unhappy. My brother lived in Austria for much of his adult life. Among other things, he noted as a teacher of history, that industry, government, and labor in Europe tended to work more collaboratively than in North America. He observed less divisiveness and fewer adversarial dynamics in Western European politics and socio-economic discourse. SC2.0 encourages partnerships across sectors and among parties that may not always be fully aligned. Doing so brings the richness of diversity. An inclusive approach like this is central to the concept of synergy (see Chaps. 10 and 19). Synergy welcomes disagreement and productive tension. It recognizes that paradoxes, conundrums, and contradictions foster curiosity and creativity. Healing honors the grief, injustices, and wounds of trauma and loss while planting seeds for hope and growth. Acknowledging the value of different perspectives and

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philosophies, SC2.0 allows for work with organizations that encourage abstinence as much as those that support harm reduction. Both are on the menu. The key is to set the table with the widest variety of options possible so that people from all walks of life, wherever they are in their journeys, find something that sustains and nurtures them. SC2.0 is aligned with and committed to the World Health Organization’s definition of recovery: “The meaning of recovery can be different for each person. For many people recovery is about regaining control of their identity and life, having hope for their life, and living a life that has meaning for them, whether that be through work, relationships, community engagement, spirituality, or some or all of these. This understanding of recovery moves us away from the idea or goal of “being cured” or “being normal again”. Instead, this concept of recovery focuses more in gaining new meaning and purpose in life, being empowered and able to live a self-directed life, despite what one may have lived through and despite any emotional distress that may still be a part of one’s life” (World Health Organization, 2019).

While the lack of consensus on meaning and the use of the word recovery remains problematic, this is so for many terms, including the term Stepped Care 2.0 (see chapter 18). Clarity is important as is some tolerance for ambiguity. Language evolves. There is value in honoring the etymology of words. To do so is to learn from history. Learning is a thoughtful braiding of old with new. The recovery movement, though abstinence-based, brings the wisdom of successful social activism. One hundred years ago when incarceration was the only social remedy for those struggling with addiction, the populist AA movement emerged to offer compassion, support, and hope. SC2.0 is a continuous improvement framework. Moving forward, we will play with and work through language in ways that extend up and outward, defying restrictive solutions. For now, we support the concept of “recovery with choice.”

References Bartram, M. (2019). Toward a shared vision for mental health and addiction recovery and well-­ being: An integrated two-continuum model. Journal of Recovery in Mental Health, 2(2–3), 55–72. Retrieved March 22, 2023, from https://jps.library.utoronto.ca/index.php/rmh/article/ view/32749 Bartram, M. (2021). ‘It’s really about wellbeing’: A Canadian investigation of harm reduction as a bridge between mental health and addiction recovery. International Journal of Mental Health and Addiction, 19(5), 1497–1510. https://doi.org/10.1007/s11469-­020-­00239-­7 Bill, W., & Dick, B. (2019). Alcoholics anonymous: The big book: The original (1939th ed.). Ixia Press. Braat, T. (2023, February 22). Alberta’s recovery-based model sparks protest. City News Everywhere. Retrieved March 22, 2023, from https://calgary.citynews.ca/2023/02/22/ alberta-­recovery-­model-­protests/ British Columbia. (2023, March 2). B.C. building historic treatment, recovery services for people struggling with addiction [Press release]. Retrieved March 22, 2023, from https://news.gov. bc.ca/releases/2023MMHA0013-­000251

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Brown, P. (1981). The mental patients’ rights movement and mental health institutional change. International Journal of Social Determinants of Health and Health Services, 11(4), 523–540. https://doi.org/10.2190/CU8G-­D0RJ-­YY54-­UC3F CAPSA. (2022). Understanding substance use health: A matter of equity. https://capsa.ca/wp-content/uploads/2022/10/CAPSASubstance-Use-Health-EN-1.pdf Ellison, M. L., Belanger, L. K., Niles, B. L., Evans, L. C., & Bauer, M. S. (2018). Explication and definition of mental health recovery: A systematic review. Administration and Policy in Mental Health and Mental Health Services Research, 45(1), 91–102. https://doi.org/10.1007/ s10488-­016-­0767-­9 Geda, N., Feng, C., & Peters, B. (2022). Suicidal ideation among Canadian adults during the COVID-19 pandemic: The role of psychosocial factors and substance use behaviors. BMC Psychiatry, 22(1), 711. https://doi.org/10.1186/s12888-­022-­04353-­9 Hawk, M., Coulter, R.  W. S., Egan, J.  E., Fisk, S., Reuel Friedman, M., Tula, M., & Kinsky, S. (2017). Harm reduction principles for healthcare settings. Harm Reduction Journal, 14(1), 70. https://doi.org/10.1186/s12954-­017-­0196-­4 Jacob, K.  S. (2015). Recovery model of mental illness: A complementary approach to psychiatric care. Indian Journal of Psychological Medicine, 37(2), 117–119. https://doi. org/10.4103/0253-­7176.155605 Khan, S. (2017). Concurrent mental and substance use disorders in Canada. Statistics Canada. Retrieved March 22, 2023, from https://www150.statcan.gc.ca/n1/en/pub/82-­003-­x/2017008/ article/54853-­eng.pdf?st=Lm0Q0mYP Lai, H.  M. X., Cleary, M., Sitharthan, T., & Hunt, G.  E. (2015). Prevalence of comorbid substance use, anxiety and mood disorders in epidemiological surveys, 1990–2014: A systematic review and meta-analysis. Drug and Alcohol Dependence, 154, 1–13. https://doi.org/10.1016/j. drugalcdep.2015.05.031 Manitoba. (2022, November 9). Manitoba government commits to recovery-oriented system of addictions care [Press release]. Retrieved March 22, 2023, from https://news.gov.mb.ca/news/ index.html?item=56861&posted=2022-­11-­09 McQuaid, R. J., Malik, A., Moussouni, K., Baydack, N., Stargardter, M., & Morrisey, M. (2017). Life in recovery from addiction in Canada. Canadian Centre on Substance Use and Addiction. Retrieved March 22, 2023, from https://www.ccsa.ca/sites/default/files/2019-­04/CCSA-­Life-­ in-­Recovery-­from-­Addiction-­Report-­2017-­en.pdf Mental Health Commission of Canada. (2012). Changing directions, changing lives: The mental health strategy for Canada. Retrieved March 22, 2023, from https://mentalhealthcommission. ca/resource/mental-health-strategy-for-canada/ Mental Health Commission of Canada. (2015). Guidelines for recovery-oriented practice. Retrieved March 22, 2023, from https://mentalhealthcommission.ca/resource/ guidelines-­for-­recovery-­oriented-­practice/ Mental Health Commission of Canada & Canadian Centre on Substance Use and Addiction. (2022). Mental health and substance use during COVID-19: Regional spotlight and key factors. Retrieved March 22, 2023, from https://mentalhealthcommission.ca/resource/ mental-­health-­and-­substance-­use-­during-­covid-­19-­regional-­spotlight-­and-­key-­factors/ Mussett, B. (2022, May 12). The man behind Alberta’s pull away from harm reduction. The Tyee. Retrieved March 22, 2023, from https://thetyee.ca/Analysis/2022/05/12/ Man-­Behind-­Pull-­Away-­Harm-­Reduction-­Alberta/ Roberts, A., Rogers, J., Mason, R., Siriwardena, A.  N., Hogue, T., Whitley, G.  A., & Law, G. R. (2021). Alcohol and other substance use during the COVID-19 pandemic: A ­systematic review. Drug and Alcohol Dependence, 229(Part A), 109150. https://doi.org/10.1016/j. drugalcdep.2021.109150 Rush, B., Urbanoski, K., Bassani, D., Castel, S., Wild, T.  C., Strike, C., Kimberely, D., & Somers, J. (2008). Prevalence of co-occurring substance use and other mental disorders in the Canadian population. The Canadian Journal of Psychiatry, 53(12), 800–809. https://doi. org/10.1177/070674370805301206

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Stepped Care Solutions. (n.d.). About us. Retrieved March 22, 2023, from https://steppedcaresolutions.com/about-­us/ Substance Abuse and Mental Health Services Administration (SAMHSA). (2012). SAMHSA’s working definition of recovery. Retrieved March 22, 2023, from https://store.samhsa.gov/sites/ default/files/d7/priv/pep12-­recdef.pdf Substance Abuse and Mental Health Services Administration (SAMHSA). (2021). Key substance use and mental health indicators in the United States: Results from the 2020 national survey on drug use and health (HHS Publication No.PEP21-07-01-003, NSDUH Series H-56). Center for Behavioral Health Statistics and Quality, Substance Abuse and Mental Health Services Administration. Retrieved March 22, 2023, from https://www.samhsa.gov/data/ World Health Organization. (2019). Recovery and the right to health, WHO quality rights core training: Mental health and social services course guide. World Health Organization. Wellness Together Canada. (2022). Wellness together Canada. Retrieved March 22, 2023, from https://www.wellnesstogether.ca/en-­CA

Chapter 17

Stepped Care 2.0 and the Conundrums of Intensive Care Andrea Levinson

17.1 Introduction As a client-centric model for mental health care, Stepped Care 2.0 (SC2.0) is committed to the idea that clients should be empowered to seek the help they need. SC2.0 also seeks to dramatically expand the range of options available to clients. This can be done by incorporating community-based forms of care that have not traditionally been considered part of the mental health care system. The SC2.0 approach challenges the stigmas associated with mental illness and seeks to shift perceptions of mental illness toward a more holistic and nuanced understanding that sees each individual as an active agent in their mental health journey. This is perhaps best exemplified by the one-at-a-time thinking (see Chap. 13) that is central to the model: instead of assuming that clients will be best served by the “gold standard” of weekly one-on-one sessions with a licensed psychologist or psychiatrist, SC2.0 encourages an approach in which clients are empowered to seek out care as they need it, without having to sign on for regular ongoing sessions. But what happens when the very nature of a client’s mental illness makes it difficult for them to advocate on their own behalf? How does SC2.0 make room for people who are temporarily unable to take ownership of their treatment due to the severity or nature of their mental illness? Much of the emphasis in the SC2.0 model is placed on the less intensive treatment options outlined in the first several steps: interventions like peer support, workshops, guided self-help, and group programming. The developers of the model have placed comparatively less emphasis on Step 8, which deals with chronic care and specialist consultation, and Step 9, which includes acute care, systems navigation, case management, and advocacy. The perception that SC2.0 is not designed to deal with more persistent, chronic, or complex mental illness may create some hesitancy on the part of mental health and substance A. Levinson (*) Toronto, ON, Canada e-mail: [email protected] © Springer Nature Switzerland AG 2023 P. Cornish, G. Berry (eds.), Stepped Care 2.0: The Power of Conundrums, https://doi.org/10.1007/978-3-031-45206-2_17

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use organizations who work with clients suffering from complex addictions or mental illnesses which can, by their very nature, impair decision-making. This chapter will explore the conundrums that arise when thinking through the higher steps of the SC2.0 model. SC2.0 is an integrated model designed to provide clients with a buffet of options for care, outlined as a series of steps. On the one hand, treatment is designed to improve mental health literacy and provide clients with the resources to improve their own mental health in a more independent way; on the other hand, treatment can involve case management and intensive hospital inpatient programs. Underpinning all these steps, and perhaps more important than the steps themselves, is a commitment to ten guiding principles. For the purposes of this chapter, four of these principles are especially important: • Principle 3: All individuals and communities have strength and capacity. • Principle 4: People engage with what they are ready to do; gold standard intervention is that which best fits the user at any given time. • Principle 5: Professionals do not carry all the wisdom; people often know what is best for them. • Principle 9: Minimal interventions can produce powerful results. In the first part of this chapter, we will explore the challenges that arise when applying the SC2.0 approach to the highest steps of the model in the context of the existing mental health and substance use landscape. Mental health does not exist in a vacuum, and mental health care systems are enmeshed in a complicated series of relationships with organizations at every level of society. One cannot talk about the treatment of mental illness—especially in its more serious forms—without also talking about education, social services, housing, policing, and racial and economic marginalization. As we enter the third year of the COVID-19 pandemic, it is more important than ever to think through the intersection between mental health and the broader physical, social, and economic health of communities. Being realistic about the extent and complexity of the challenge is a precondition for understanding the limitations and potential of the SC2.0 model. In the second part of this chapter, we will consider two main conundrums involved in providing more intensive care within the SC2.0 model: the intersection between mental health and the medical model, and the challenges involved in crisis intervention. In both cases, the central principles of SC2.0 would seem to be in tension with ingrained expectations and standards for the provision of high-quality mental health care, and thinking through these tensions is necessary if the SC2.0 model is to present the strongest possible case for being an effective approach to more intensive treatment. In the final part of the chapter, we will look at how SC2.0’s open-access approach can help address the challenges in providing a higher level of treatment to clients experiencing persistent, chronic, or complex mental illnesses.

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17.2 The Impact of COVID-19 on Mental Health and Addictions Services Mental health and physical health are interrelated, and both can be negatively impacted by experiences of economic and social marginalization. Given that the COVID-19 pandemic placed a huge strain on primary physical care and mental health care, as well as created a significant amount of economic uncertainty for people already struggling to access regular employment, it is important to start by recognizing where we are today. In many places, mental and physical health care systems were already in crisis before COVID-19. The pandemic exacerbated existing problems in the delivery of mental health and addictions services, highlighting the tremendous mental health/ illness continuum needs of the global population. Prior to the pandemic, many people with more complex, persistent, or chronic mental health needs were already struggling to receive care. These problems have only gotten worse over the past 2 years (Diaz et al., 2021). Wait times are often long, and mental health care may be difficult to access in many places, due to a lack of services and geographic or administrative barriers. This is compounded by the strain on primary medical care that has worsened since the pandemic began (Frank, 2022). Because many people with chronic mental health issues also have associated problems with their physical health, this creates a very dangerous set of conditions for those experiencing serious pressures on their mental health. All of this is happening at a time when the demand for mental health and addictions services continues to grow (Terlizzi & Schiller, 2022). The global pandemic, which has left millions dead and pushed health care systems to the brink, is having a far-ranging effect on individual mental health outcomes. In places like Ontario, Canada, it has coincided with a worsening housing crisis that has left large numbers of people in insecure or temporary accommodations—which has had a disproportionate impact on people experiencing chronic mental illness (Boynton, 2022) Without an integrative solution that takes all these factors into consideration, it will be very difficult to improve mental health outcomes (Moreno et al., 2020).

17.3 The Need to Be Realistic About the Challenges of Serious Mental Illness The pandemic has created new challenges for the provision of mental health and addictions services to all clients, regardless of the intensity of care needed. But its effects are disproportionately felt by those living with addictions and/or persistent, chronic, or complex mental illnesses (Insel, 2022). It is important that we take a moment to note the unique difficulties facing these clients. In many cases, the root causes of some of the most severe mental illnesses remain unclear, and the treatment options available often come at a significant cost to quality of life. Providing care

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and support to people living with these illnesses can be extremely challenging even in the most ideal circumstances, and it is often necessary to have an entire team working with an individual to provide multiple forms of care. In my own experience as a psychiatrist who works with clients living with mental illness (e.g., bipolar disorder), I often stressed the importance of adherence to the prescribed daily medication (e.g., lithium), when speaking with young people and their families. With certain medications, there can be an “on/off” effect every time a dose of medication is skipped, which can reduce the effectiveness of the treatment. The nature of the disease is such that recovery is multifaceted and layered, with medication adherence being one factor that can aid functional recovery for the individual. Clients may express individual concerns and preferences around the prescribed medication, they may experience challenges around adherence or tolerance of the medication, and they may report challenges around acceptance of the diagnosis and its meaning for them. The client’s individual experience, cultural context, personal background, and experience of the treatment are key aspects for any practitioner providing care in a way that is empathetic and responsive to the client’s experience and journey. The health care practitioner’s ability to incorporate the key ingredient of “hope” in their work with clients is a crucial aspect to emphasize and has a significant impact on the client’s experience of their mental illness. The work of the practitioner is to engage the client as an active participant in their own recovery, with exploration of key relationships and connections to family and friends in the individual’s world. SC2.0 identifies the role of networks of care and how important these relationships are in impacting functional outcomes. One of the challenges inherent in providing care for individuals living with a complex mental illness is that it may affect the person’s ability to have fulsome insight at certain points in their illness journey. For example, when a client is in an active psychotic state, they are typically not going about their daily lives in the way they did when they weren’t experiencing psychosis. Psychosis may affect their entire way of thinking about and engaging with the world. The same is true of individuals living with severe depression, which often affects the person’s perspective and view of their individual experience. Self-advocacy, and proactively seeking out care when it is needed, becomes harder to do when one’s whole sense of personal agency is affected. There is a gravity to these challenges that needs to be named and recognized. This means that advocates for the SC2.0 approach must acknowledge the concerns that clients and practitioners with lived experience dealing with these illnesses may have when faced with a model for care that places so much emphasis on less intensive forms of treatment. Though they are currently scarce and underfunded, flexible assertive community treatment (FACT) programs are well aligned with the SC2.0 approach and could potentially bridge the gap between patient autonomy and medical authority, by involving family members and peer supports in the high-intensity work.

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17.4 The Medical Model, Medication, and Crisis Intervention: Two Conundrums The SC2.0 model is rooted in the fundamental belief that every individual—including each individual experiencing complex, persistent, or chronic mental illness— has strengths and capacities for dealing with the mental health challenges they face. It is important to bear in mind the extraordinary structural challenges many people are currently facing; however, treating people as passive victims of mental illness is unhelpful. At one point or another, everyone will struggle with mental health problems, and just as it is possible to have poor mental health without having a mental illness, it is possible to live with mental illness while having good mental health (Westerhof & Keyes, 2010). Someone with a mental illness can engage in active recovery, and their illness can go into remission; they can be fully functional, but still have a mental illness. There is a dynamic aspect to mental illness that cannot be ignored. This is especially important to acknowledge when working with clients living with more commonly stigmatized mental illnesses, like bipolar disorder or schizophrenia: these conditions cannot be viewed as labels that dismiss a person’s potential for living a dignified and meaningful life. Individuals can bring their motivation, their engagement, their curiosity, and their innate humanness to their illness/wellness journey. This doesn’t mean they don’t still live with a mental illness, nor does it mean they won’t require specialty care, psychotropic medication, or even hospitalization at some point. It simply means that no outcome is predetermined. A meaningful life lived with dignity is possible for everyone. Good mental health can be achieved and sustained when practitioners and clients work together to develop strategies for care. These principles are deeply embedded in SC2.0, but, as noted above, in the higher steps of SC2.0, a conundrum can arise when there may be a conflict between what the client thinks is best for themselves in a given moment and what the practitioner believes will be most beneficial. A second conundrum arises when we consider that mental health and addictions service providers are often required to interact with other social, legal, and governmental systems that may not operate according to these principles. Take the following example: A youth calls a crisis helpline hoping for assistance. The counselor identifies increased suicidal risk and calls 911. The caller is geo-located, and police intervene. The youth reports a triggering experience and feels like their needs were not met, saying that they are less likely to seek care in the future. How should organizations implementing SC2.0 consider their relationship with the crisis intervention systems that exist in their jurisdiction? Before we consider the ways that SC2.0 can provide better outcomes for clients requiring services at the highest levels of care in the steps of the model, it is worth exploring these two conundrums in greater detail.

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17.5 Conundrum One: Medical Treatments in the Context of SC2.0 One of the ways that the conflict between practitioners and clients can arise is around the role of medical treatments in mental health care. Biologic treatments can be an important aspect of care for some mental illnesses, and many clients feel that medication is a helpful form of treatment. But medications and medical treatments can also raise or highlight the power imbalance inherent in the client–practitioner relationship, especially when the client does not believe the medication that they have been prescribed is helping them. SC2.0 challenges the “medical model” of mental health care (see Chap. 12). This is, in part, because the medical model is embedded more heavily in the risk paradigm—and also, in part, because traditionally the medical model has been more rooted in a doctor–patient hierarchy that suggests the physician is the content expert who has more agency and the patient is the more passive recipient who can more readily defer to the physician’s expertise and guidance. But while there are good reasons to challenge both the medical model and the risk paradigm, there are intrinsic inequities in any form of health care that must be acknowledged: there is a person who is seeking help, and there is a person providing help and care. When the person seeking help has more intense, illness-driven concerns, that person is inherently more vulnerable and seeking guidance, care, expertise, and assistance. This is especially apparent when we consider that some forms of mental health care involve the prescription of medicine and that medicine can only be prescribed by a licensed professional (in this case, a physician). It is impossible to discuss the challenges of more intensive forms of mental health treatment in the SC2.0 context without also talking about the role of medication in SC2.0. How does SC2.0 think through this conundrum? What does the SC2.0 approach to medication look like? As a psychiatrist working within an SC2.0 context, I believe that medication is one of the treatment options that needs to be available to clients when indicated. Medical forms of treatment, when indicated, can have not only considerable benefit but also the potential of incurring unintended side effects. What if the client decides that these trade-offs are no longer worth it? A physician involved in the treatment journey of someone living with mental illness should be sensitive to the client’s lived experience and respond to these concerns in a way that is sensitive and attuned to the individual’s experience. In addition, the physician, with the support of an interdisciplinary team (if available), can determine the nuances and layered context when individual autonomy sometimes needs to be temporarily suspended for the safety of the client or the people around them. There is an important cultural dimension to the medical conundrum as well. For some clients, medication may be something difficult to consider or even unfathomable as a possible treatment choice. In such cases, the onus is on the practitioner to acknowledge and respect these views, while also taking seriously their responsibility to educate the client about the full buffet of treatment options available, including the potential benefits and potential negative effects, and review the evidence that

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exists to support each intervention. However, by meeting the client where they are at, there is the possibility that their illness may worsen with a delay in initiation of medical treatment. For example, there is evidence in the area of untreated psychosis, if it persists for a longer duration of time, it can lead to reduced treatment response, poorer functional outcomes, and lower likelihood of full functional recovery (Drake et al., 2020). Medical treatments are established treatments for a number of mental illnesses, and the practitioner has an ethical responsibility to educate the client about the risks they face if they refuse treatment. In the SC2.0 model, the practitioner is expected to meet the client where they are at during that point in time, especially being aware of their readiness to engage in an intervention. This is an important aspect of this more collaborative approach to care. But in some situations, the practitioner may need to take a greater leadership role in this collaboration in order to help the client understand every treatment option available to them and why some of those treatment options may have some urgency around them. There is a delicate balance between being a supportive peer, helping a client take the steps they are comfortable taking in the moment, and a medical professional who is obligated to impart knowledge and give advice based on their training and experience. One of the strengths of the SC2.0 model is that it understands the extent to which people with a mental illness can derive great benefit from a range of treatment options, including natural healers, community gatherings, peer support, and drop-in groups. Care management is not one-dimensional, favoring one form of treatment over another. Instead, it involves the idea of holistic care and ensuring the person has the range of supports they need. It means looking at the bigger picture of how the client is living and what is giving their world structure and, then, helping to integrate treatments to best meet the needs of the person. SC2.0 emphasizes the central importance of addressing the social determinants of health—for example, access to transportation, stability of housing, or case management support.

17.6 Conundrum Two: Crisis Intervention One of the thorniest challenges that organizations implementing the higher steps of the SC2.0 model face is the relationship between mental health, methods of crisis intervention, and the historical role policing has played in addressing individuals experiencing a mental health crisis. Despite the progress that has been made toward raising awareness of the importance of mental health, severe mental illness is still heavily stigmatized. While people living with persistent, chronic, or complex mental illnesses are disproportionately likely to be victims of crime, the perception is often the reverse: for decades, media and pop cultural representations of people living with mental illness have portrayed them to be dangerous, unstable, or a threat to public order, and unfortunately this has had a lasting impact on how mental illness is understood by the general population (Engel, 2015; Ghiasi et  al., 2022; Morabito & Socia, 2015). In addition to the challenges inherent in providing care to

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people with complex mental health problems, mental health care providers must also navigate the web of social prejudice and over-policing this population experiences. SC2.0 is right to emphasize a client-led, client-centric, open-access approach to mental health care for all people, including those who are living with the most stigmatized mental illnesses. It is also right to acknowledge that there may be moments of high distress when a client may need to temporarily relinquish a measure of autonomy. In such situations, it is best that there be coordinated mental health support to help the client through the crisis and to provide care afterward—which is one of the reasons SC2.0 puts so much emphasis on ensuring that a wide range of therapeutic and community supports exist to give clients agency in strengthening and maintaining their mental health. But if SC2.0 is to offer a truly holistic approach to mental health care at the higher steps, its insights need to be adopted by the wider constellation of social service providers involved in frontline mental health care and crisis intervention. This creates a conundrum: SC2.0 is capable of making changes within mental health and substance use organizations, but these organizations still exist within a larger network of systems that may not operate according to SC2.0 principles. This issue is especially noteworthy when responding to mental health crises that take place outside of a health care setting. Crisis intervention in the context of public mental health distress is a complex issue, and one that has been receiving more attention as the conversation about mental health has progressed. A recent study showed that more than 70% of fatal shootings by Canadian police involved people who were experiencing problems with their mental health (Marcoux & Nicholson, 2018). Effective, empowering frontline care for people experiencing a mental health crisis will require the decriminalization of crisis intervention, and this may, in turn, require that mental health care organizations partner with security and police in order to reduce the risks faced by those experiencing a mental health crisis. Ideally, however, the frontline work should be done by health professionals, community organizations, and peers trained in trauma-informed approaches. There is a significant body of evidence showing that most mental health crises can be safely managed without the involvement of police (Balfour et al., 2022), and establishing and resourcing alternatives to policing could help reduce the chances that clients will be re-traumatized or worse. There are already a number of global initiatives designed to create alternatives to policing in crisis situations, including four pilot projects currently underway in Toronto (Thomson, 2021). These pilot projects are being driven by communities within Toronto and take a multifaceted approach to the challenge of crisis situations, including seeking out the input of community members, community leaders, and people with lived experience. One of the goals of these projects is to screen 911 calls and identify emergencies that involve a mental health dimension, so that they can be responded to using trauma-informed de-escalation tactics. Finding ways to incorporate projects like these in Step 9 could help organizations implementing SC2.0, but, as things currently stand, SC2.0’s capacity to change how mental health

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crises are handled at the higher steps is limited by the existing crisis intervention infrastructure. Crisis management is, ultimately, about scope: understanding the limitations of a particular intervention, and knowing when it is no longer adequate. This is true at every level. If a peer has been providing support for an individual but feels that the situation is getting beyond their control, they need to know where to turn next. Finding ways to coordinate all of the available supports is one of the strengths of the SC2.0 model. One of the challenges SC2.0 faces at the higher levels—a challenge, indeed, faced by all mental health and addiction service providers—is that the supports become increasingly resource-intensive and costly. Projects designed to provide alternatives to policing require significant investments of time and resources, and coordinating between a constellation of service providers does, too. For organizations already struggling to fund their mental health care operations, the challenge of managing crisis intervention is inextricable with the more general challenge of a system that is already chronically underfunded and under-resourced.

17.7 Seeing the Big Picture The difficulties of providing quality care for clients who require more intensive interventions has been a major refrain of this chapter. These difficulties are not unique to the SC2.0 model—it requires no great insight to see that lack of funding is a significant obstacle to delivering resource-intensive care—but the question is whether SC2.0 offers any new and innovative solutions. This is where we need to step back and consider not just the highest steps of the model, but the model as an integrated whole, which is what it was designed to be. Embedded in the principles and core components of SC2.0 is a belief that access to mental health care services can have a powerful downstream effect. When people have access to mental health care, are encouraged to see themselves as agents, and given the support they need to seek help when they need it, remarkable things are possible. It isn’t necessary for clients—even those experiencing the most severe and distressing symptoms—to sign on to a years-long course of treatment just because they need help at one juncture; a single interaction can be absolutely life-changing. At the same time, a client who has undergone years-long treatment for a chronic mental illness may experience significant benefits from less intensive forms of care if they are made available. Opening up access to a buffet of options can create systemic changes by making care more dynamic. In the case of clients requiring treatments at the highest steps of the model, there are five ways increased access—a cornerstone of SC2.0, as highlighted by Core Component 6 (“people have same-day access to multiple levels of care”)—can improve outcomes.

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17.7.1 Accessible Care Is Preventive Care In primary health care, the importance of prevention is widely understood. The same is true in mental health care, even in the case of complex mental illnesses. The sooner an individual can access care, the better their outcome is likely to be. Ensuring that anyone who wants to talk about their mental health is able to quickly and easily set up a one-at-a-time session dramatically increases the chances that someone in the early stages of mental illness will be supported. Not only could this improve their prognosis, but it might also mean that lower intensity solutions have a greater impact, making it less likely they will require more costly forms of care— or if they do, they will require them with less regularity.

17.7.2 Access to Lower Steps Reduces Pressure on Higher Steps Just as increased access increases the chances that a serious illness will be caught early on, it also reduces the number of people who may need regular intensive care. Because intensive care tends to require more resources, this allows mental health and addictions services to more effectively allocate their scarce resources: spending more on prevention takes the pressure off, for example, in-hospital treatments, ensuring that when clients do require these treatments, the system has the resources to provide them with high-quality treatment.

17.7.3 Access Creates More Options Even if greater access at the early stages of an illness isn’t able to prevent the illness from progressing, the SC2.0 model makes it easier for a person to seek out the services they find helpful. The steps in the model are not stages that an individual is placed on, but options for care that a client may turn to as needed. For example, a person who requires some forms of care at Step 9 might also benefit from the care offered at Step 1. It may even be the case that a less intensive treatment option, such as a support group, provides more long-term benefits for a client than regular hospital stays. Part of the rationale behind SC2.0 Principle 5 (“professionals do not carry all the wisdom; people often know what is best for them”) is that the practitioner does not always know what will make a difference. Providing as many options as possible and empowering clients living with complex and persistent mental illnesses to be active participants in their care create space for experimentation that could lead to previously unforeseeable paths to increased well-being.

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17.7.4 Access Provides Checks and Balances A major shortcoming of the current mental health care model is the lack of checks and balances. It is easy for individuals to fall through the cracks of the system, and it can be difficult for them to reestablish contact with care providers when they feel they need help again. Ideally, the continuum of care offered by the SC2.0 model makes it easier for individuals to access the care available at each step as needed, and makes it easier for service providers to direct them to forms of care at higher or lower steps as needed. Increased accessibility in SC2.0 increases the points of access an individual has for seeking help. Implementing measurement-based care as a core component of SC2.0 helps all involved (clients and providers) to make informed clinical decisions (Lewis et al., 2019).

17.7.5 Access Isn’t Just for the Client A major emphasis of the SC2.0 model is the idea of a community of care. When someone is living with mental illness, they are usually not the only one living with it—their family, friends, and loved ones are also involved, and often it is this community of care that first notices when something is wrong. Individuals who experience, for example, psychotic episodes may not be able to seek out help in the moment of distress, but their community of care can step in on their behalf. Ensuring more options are available for peers and loved ones to access support on behalf of the client increases the chances that less intensive forms of care can be delivered and decreases the chances that more intensive forms of care will be needed.

17.8 Conclusion One of the strengths of the SC2.0 model is that it encourages a collaborative approach to care, not just between practitioners but also between practitioners and clients. At Steps 8 and 9, this collaboration may involve a large group of care providers, from primary care physicians and crisis intervention workers to psychotherapists and psychiatrists, and it may occasionally require that clients relinquish a measure of their autonomy for short periods of time. But the core principles of SC2.0 still animate the work, including the principle that “professionals do not carry all the wisdom; people often know what is best for them.” While SC2.0 is critical of some aspects of the medical model, it understands the importance of treatments that involve medication and seeks to provide practical guidance to practitioners navigating the challenges that may arise for some clients around such treatments. The SC2.0 model provides resources for thinking through the challenges facing practitioners working with clients living with persistent mental illnesses. When the

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model is operating as it was designed to operate, it enhances prevention and offers a wider range of options to those living with mental illnesses. But resolving the conundrums I have outlined in this chapter will require changes that go beyond the mental health and substance use systems. Creating a mental health care system that is truly responsive to the needs of those living with complex mental illnesses will mean pushing for long-term structural reforms that reimagine everything from policing to housing. In the meantime, organizations operating within the SC2.0 model will need to find ways to balance SC2.0’s emphasis on client-directed care with the need to operate within social, medical, economic, and political systems rooted in the risk paradigm. The SC2.0 model is not a panacea that heals all wounds, nor does it claim to be. What it can do is help mental health and substance use services respond more quickly to clients who are struggling with serious mental illness, by opening up access and creating a framework in which more options for care are more readily available to more people. This in and of itself would be a positive step toward addressing the crisis in mental health care.

17.9 Reflection Peter Cornish I recently connected with a colleague in the Netherlands on Zoom. He is a psychiatrist who is practicing differently. He described to me a more collaborative process, soon to be published, for conducting a psychiatric interview, referring to the method as a “recovery-oriented intake.” Without giving away too many details, the process he described sounded more like a two-way conversation than a typical psychiatric interview. I can’t wait to learn more. As Andrea Levinson admits, collaborative approaches are more challenging when decision-making autonomy is compromised. The conundrum of treatment as healing or social control runs deep and long through Western/European history. There is a lot of work to be done in reforming care for populations most marginalized by poverty, stigma, addiction, and racialized trauma. Levinson reminds me that compassion sometimes requires paternalism and that autonomy is not necessarily a virtue. Autonomy is lionized in societies that worship capitalism and the myths associated with freedom and individualism. Freedom and individualism work well for those with privilege. Privilege means being lucky enough to have resources. Autonomy is seen as selfish in many cultures, particularly those escaping annihilation by colonialism where power-with is valued more than power-over. I have been struck by conversations with mental health professionals from diverse backgrounds, ethnicities, races, and gender identities who will argue with me, a white heterosexual male whose success has depended on privilege, that their trauma must be addressed through workplace reforms. While  I agree  that our

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organizational structures and policies require change, what troubles me about some of these conversations is the absence of compassion for the members of our community who have far less privilege than any of us professionals. I am thinking of the unhoused population that often cross paths with my colleagues as they enter or exit buildings, walking to or from the parking lot for their commute. “It’s not safe out there, Peter. Those people are dangerous.” I feel my white fragility at times like this. Who am I to say to colleagues with less privilege than me that they should have the skills and empathy to engage safely with those further out on the margins? Do I have the right to question their demands for more security lights, fences, and police patrols? Don’t be naïve, I tell myself. There are dangers that require social control. There are times when autonomy must be restricted. But we must remind ourselves that any constraints must be limited and accompanied by extra efforts to infuse care, respect, comfort, and support. As Levinson suggests, one way to offset the negative impact of lost autonomy is to expand the range of support available to those who surrender their freedom. Where is the healing outdoor garden space for those institutionalized for mental illness stabilization and treatment? Where are the accommodations for friends and family members who might participate more actively in recovery programs with their loved ones? My hope is that by expanding highly accessible, low-cost, low-intensity programming, such as one-at-a-time drop-in clinics for anyone seeking support, there will be more funding available to develop expanded programming for those with more acute, complex, and long-term supports from highly trained, specialized high-­ cost professionals working to the top of their scope of practice. Meeting basic needs, including minimum incomes, food security, and adequate housing, is essential for building out higher-intensity programming for Stepped Care 2.0. Policy reform and community investment are crucial. One way that a community can signal commitment is to fund architecturally bold healing spaces for mental health treatment as well as long-term supportive housing. What would the message be if a community’s most spectacular buildings were designated to support healing and offer long-term affordable housing? The additional cost is a one-time expense that philanthropists would be eager to assume. The costs are miniscule compared to ongoing staffing costs, and the return on investment from healing environments would be well worth it. Investing in publicly funded, highly visible healing spaces could go a long way to erasing social stigma.

References Balfour, M. E., Stephenson, A. H., Delany-Brumsey, A., Winsky, J., & Goldman, M. L. (2022). Cops, clinicians, or both? Collaborative approaches to responding to behavioral health emergencies. Psychiatric Services, 73(6), 658–669. https://doi.org/10.1176/appi.ps.202000721 Boynton, S. (2022, May 18). Housing affordability in Ontario has eroded faster than any province amid COVID-19: Report. Global News. Retrieved February 27, 2023, from https://globalnews. ca/news/8843092/ontario-­election-­housing-­affordability-­report/

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Diaz, A., Baweja, R., Bonatakis, J. K., & Baweja, R. (2021). Global health disparities in vulnerable populations of psychiatric patients during the COVID-19 pandemic. World Journal of Psychiatry, 11(4), 94–108. https://doi.org/10.5498/wjp.v11.i4.94 Drake, R.  J., Husain, N., Marshall, M., Lewis, S.  W., Tomenson, B., Chaudhry, I.  B., Everard, L., Singh, S., Freemantle, N., Fowler, D., Jones, P. B., Amos, T., Sharma, V., Green, C. D., Fisher, H., Murray, R. M., Wykes, T., Buchan, I., & Birchwood, M. (2020). Effect of delaying treatment of first-episode psychosis on symptoms and social outcomes: A longitudinal analysis and modelling study. The Lancet: Psychiatry, 7(7), 602–610. https://doi.org/10.1016/ S2215-­0366(20)30147-­4 Engel, R.  S. (2015). Police encounters with people with mental illness: Use of force, injuries, and perceptions of dangerousness. Criminology & Public Policy, 14(2), 247–251. https://doi. org/10.1111/1745-­9133.12146 Frank, K. (2022). Difficulties accessing health care in Canada during the COVID-19 pandemic: Comparing individuals with and without chronic conditions. Health Reports. Retrieved March 6, 2023 from https://www150.statcan.gc.ca/n1/pub/82-­003-­x/2022011/article/00002-­eng.htm Ghiasi, N., Azhar, Y., & Singh, J. (2022). Psychiatric illness and criminality. StatPearls Publishing. Retrieved February 21, 2023, from https://www.ncbi.nlm.nih.gov/books/ NBK537064/?report=classic Insel, T. (2022). Healing: Our path from mental illness to mental health. Penguin. Lewis, C. C., Boyd, M., Puspitasari, A., Navarro, E., Howard, J., Kassab, H., Hoffman, M., Scott, K., Lyon, A., Douglas, S., Simon, G., & Kroenke, K. (2019). Implementing measurement-­ based care in behavioral health: A review. JAMA Psychiatry, 76(3), 324–335. https://doi. org/10.1001/jamapsychiatry.2018.3329 Marcoux, J., & Nicholson, K. (2018). Deadly force. CBC News. Retrieved February 21, 2023, from https://newsinteractives.cbc.ca/longform-­custom/deadly-­force Morabito, M. S., & Socia, K. M. (2015). Is dangerousness a myth? Injuries and police encounters with people with mental illness. Criminology & Public Policy, 14(2), 253–276. https://doi. org/10.1111/1745-­9133.12127 Moreno, C., Wykes, T., Galderisi, S., Nordentoft, M., Crossley, N., Jones, N., Cannon, M., Correll, C. U., Byrne, L., Carr, S., Chen, E. Y. H., Gorwood, P., Johnson, S., Kärkkäinen, H., Krystal, J. H., Lee, J., Lieberman, J., López-Jaramillo, C., Männikkö, M., Phillips, M. R., Uchida, H., Vieta, E., Vita, A., & Arango, C. (2020). How mental health care should change as a consequence of the COVID-19 pandemic. The Lancet: Psychiatry, 7(9), 813–824. https://doi. org/10.1016/S2215-­0366(20)30307-­2 Terlizzi, E. P., & Schiller, J. S. (2022). Mental health treatment among adults aged 18–44: United States, 2019–2021. National Center for Health Statistics Data Brief, 444, 1–8. https://doi. org/10.15620/cdc:120293 Thomson, S. (2021, June 29). “We’ve got to do better”: Toronto readies to launch non-police crisis response pilot. CBC News. Retrieved February 27, 2023, from https://www.cbc.ca/news/ canada/toronto/toronto-­policing-­alternative-­pilot-­1.6083164 Westerhof, G.  J., & Keyes, C.  L. M. (2010). Mental illness and mental health: The two continua model across the lifespan. Journal of Adult Development, 17(2), 110–119. https://doi. org/10.1007/s10804-­009-­9082-­y

Chapter 18

Stepped Care 2.0: We Think We’re Missing Something—A Conversation Peter Cornish, AnnMarie Churchill, and Gillian Berry

“I’ve got a bone to pick with you, Peter,” Alita exclaimed in a loud whisper, after springing to her feet and charging forward following what I thought was a well-­ received presentation. I was taken aback. After all, Alita represented the nonprofit organization that continued to fund much of our work. I had just shared some of my most recent thoughts on Stepped Care 2.0 (SC2.0) with an international group of mental health system leaders. Aware of my surprise, Alita added, unconvincingly, with a twinkle in her eye, “But of course it was a great presentation.” Before I could engage further, a trio of enthusiastic audience members interrupted, jockeying for a chance to connect and question. I was glad for the diversion, but made a half-hearted note to follow up with her in the future. Aware of stiffening in my chest, I remained on guard for the remainder of the post-session conversations. My responses to the eager questions posed by other audience members were wooden. I left the conference room off-kilter.—Peter Cornish

18.1 Something Is Missing Strong audience reactions like this are becoming common as we accept more opportunities to present the model’s impact. What can we make of this? Alita’s reaction wasn’t exactly hostile. She was a fan of our work and was one of our strongest allies. “I have a bone to pick” came with some warmth, but also an edge. It was both P. Cornish Berkeley, CA, USA A. Churchill St. John’s, NL, Canada G. Berry (*) Vice President for Culture and Diversity, Stepped Care Solutions, Inc., St. John’s, NL, Canada e-mail: [email protected] © Springer Nature Switzerland AG 2023 P. Cornish, G. Berry (eds.), Stepped Care 2.0: The Power of Conundrums, https://doi.org/10.1007/978-3-031-45206-2_18

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playful and a legitimate grievance. Peter never did get the chance to follow up with Alita, but we remain curious—what was the bone? Why was she the first to burst forward that day, and why had one of our trusted allies become so bold and openly critical? In June 2022, three of us (Peter Cornish, Gillian Berry, and AnnMarie Churchill) met in Washington, DC, for a deep-dive conversation about Stepped Care 2.0. We spent an afternoon reflecting on questions, criticisms, and the conundrums they reveal. We created a safe space for ourselves to think about things we are hearing people say about our work that are difficult to accept without becoming defensive. Our conversation ranged widely, and included many personal reflections on our journeys with SC2.0 and how our experiences with the limitations of the existing mental health care system inspired us to explore new approaches to delivering mental health care that put clients at the center. A few months later, in October 2022, we met again and continued our ruminations about SC2.0. The SC2.0 audience is broadening, the enthusiasm and engagement with our work is solidifying, and yet the challenges are intensifying from allies and critics alike. Could it be that the openness of the framework, the commitment to co-design, and the humility we convey when acknowledging that SC2.0 is a work-in-progress are helping to build a foundation of trust? Or was it that by emphasizing, with authenticity, that we do not have all the answers, and by inviting others to join us in iterating the model, we were making ourselves increasingly open to challenges? Ask, and ye shall receive! Being authentic about what we know and don’t know, and showing this vulnerability with intention, sets the stage for other perspectives to be welcomed. These added voices bring us discomfort, they decenter us, and they give us pause. But this is a necessary part of a process of unlearning in order to learn. A key to transformational leadership is first the willingness to hear, absorb, and reflect without too much defensiveness. By pausing and holding the tension, the conundrums are able to reveal themselves, sparking intrigue and fueling curiosity aimed at resolving the puzzle. Both discussions focused on what is missing from the existing SC2.0 model. SC2.0 is meant to disrupt business as usual. But is it bound to fail? Is there a way to ensure it doesn’t simply become a variation of the same barrier-laden system? Perhaps, most importantly, where can people who want to challenge the status quo in mental health care find hope? We are hearing many more questions. So many questions. So many critiques. So much to learn. In this chapter, we delve directly into our own conundrums. To help readers navigate the conversation, we have broken it down into three sections: 1. What We Are Hearing: Embracing Other Voices We all agree that there is a crisis in care. But how can we change to address it, and how much unlearning do we need to do? Being able to recognize and accept our own failures can help create the openness to critical voices that is necessary if we are to develop fresh approaches and new paradigms for mental health care.

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Topics discussed: the crisis in care—resistance to change—learning from failure—the importance of humility—systemic problems—one-at-a-time 2. Be Real: There Is No Magic Wand Changing the mental health care system will not be easy. The challenges are significant, the problems, especially those relating to risk, are deeply ingrained. But collective action has been a powerful tool for liberation in the past—perhaps the biggest thing missing is the will to change. Topics discussed: mental health is more than therapy—training clinicians— the importance of collective action—the risk paradigm—checks and balances 3. What We Are Wondering: How Can We Strengthen Our Leading by Learning? SC2.0 is trying to change mental health care from the inside through diplomatic disruption. But there are practical challenges involved in staying true to the SC2.0 principles, and even the name SC2.0 can be confusing. What kind of changes does SC2.0 need to make if it is to fulfill its mission? Topics discussed: diplomatic disruption—the challenges of communicating SC2.0—upgrading SC2.0—staying focused on the goal of well-being The following transcript has been condensed and edited for clarity.

18.2 What We Are Hearing: Embracing Other Voices Peter Cornish: In our conversations about the work that we’re doing to transform the system, I’ve heard you both say there might be some things we are missing in our transformational work. Some people are interested in the work we are doing, and others are pushing back. I wonder if you can share more about what you think might be missing in our model, our approach to consulting, our understanding of the challenges facing organizations that provide mental health care. I’m not quite sure what it is, which is why we are having this conversation. That’s been nagging at me, can we nail it down? SC2.0 is a buffet of options, and it includes all kinds of resources, some that we haven’t even thought of yet. But is something missing? Gillian Berry: With my practitioner hat on, I have to begin from that starting point. What is the starting point for a transformational model? It is recognizing that in the current mental health system, and I don’t think it’s an understatement to say there are some major, major issues with where we are at the moment. AnnMarie Churchill: We have a crisis in care. We’re hearing loud and clear that the care that’s available is not meeting the need for many people. So I agree, it’s missing various pieces: equity, timeliness. And that’s what the wait-lists are about.

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Berry: I accept what you just said, but many practitioners may not take well to hearing that the care that they provide is not good enough. Many can agree the system as a whole is flawed and that there is a crisis of limited resources, but when someone says that the care they do provide is actually not good, many practitioners might get defensive. Cornish:

What do you mean?

Berry: They will say, “How could it possibly be a crisis of care?” They may have spent 15 years being educated to be qualified to work in the system, and then working within a system to deliver what they believe is the very best care they can. What an insult it is for us to turn around and say, “Well, what are you doing? You’re perpetuating a system that is dysfunctional!” Cornish: So they would say that the methodology of psychotherapy is proven, it works, and so they would feel that you’re disrupting, disagreeing, dismantling—pulling the rug out from under their whole identity in the way of practice. Churchill: But I think we are doing that. We are saying to providers, “You need to shift. It’s not working.” Berry: And they may say, “Well, I’m not listening to you because who are you to tell me that what I’ve been doing for the last 15, 20 years is incorrect?” Cornish: But it’s not that it’s not valuable; it’s that we need to move away from a one-size-fits-all approach. There needs to be more than one size. Churchill: And we need to refocus on the people who are using the care, not the people who are providing it. The providers may be upset with that, may not agree with that, but we hear loud and clear from the community and from the people who are looking for care that the system is not working. Berry: But I would play devil’s advocate again and say: from the perspective of providers, we’re providing a system where clients have an opportunity to receive treatment on our terms, what we’ve been trained in, what we’ve been providing in terms of resources, of building administrative support. If they choose not to use our services, that’s not our fault. Cornish: There are also clients who do get served well by the current systems. If I’m a practitioner, and I say that in the way I’ve

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practiced, the way I was originally trained, I have clients who say, this is great—what you did was wonderful. Do we have to throw the baby out with the bath water? Because there are some things that are valuable in how we were originally trained. Churchill: So there are pieces that are valuable for some people. The question is, are we focused on providing services for a small group of people, or are we providing mental health services for entire communities, for entire populations? I mean, it’s very obvious, just by the number of people on wait-lists, that the current approach is not working and things are getting worse. The fact that some people are getting care and that care is effective—I don’t think that’s in dispute. But we also know that many people are not getting what they need. Summary First and foremost, trusting a feeling/instinct is often the start of a journey of growth. The next step is having a discussion which seeks feedback. Knowing that there will always be something missing in SC2.0 means, we start from a position of humility. It means we can learn from the environment we find ourselves in, encounters with people we meet, or reflections on the experiences we have had. Just as important is listening to the concerns of people struggling to be heard. Knowing that there is always something more to learn or unlearn, we can gain insight and be motivated to explore alternative strategies. There are no downsides to effective listening skills—for with understanding, cooperation, and communication comes respect and, hopefully, problem solving to face our current mental health crises. Therefore, what could be missing may simply be acknowledging that being humble, being open to learning, having a growth mindset, is a necessary asset—perhaps essential if we are to make the changes that are necessary.

18.2.1 Failing Fast Latisha was my first ever client. She had been living in the shelter for about 8 months and was renowned for being “difficult.” However, she enthusiastically came to all our arranged sessions, and I learned pretty quickly that she was pleased to be assigned to a Black woman counselor. I was excited to work with Latisha. It was clear she trusted me, and she made me feel like I was actually doing what I had signed up to do. I genuinely believed I was “helping” by creating an environment where she could talk about what was really going on for her. “Hi, Gill!” said Latisha excitedly when she arrived, on time as usual. “Oh, I have so much to tell you. I resisted the urge to call my ex last night.” “I am so proud of you.” I was happy that

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my strength-based perspective was being put to good use. A few weeks later, I received a frantic call from family members saying that my sister had fallen seriously ill while on vacation. I was booked on a flight scheduled to leave within hours. Within minutes, I had packed a small bag and was off to my home town to be by her side. I vaguely remember asking someone to pass the message on to the shelter that I was not sure when I would be back, and I later found out that they had forgotten. Thankfully, my sister recovered, and I returned to my internship about 4 weeks later. It was then that I learned that Latisha had been evicted soon after I had left. She had had “a breakdown,” destroying the room she had been staying in. She returned to the arms of her abusive partner, primarily because she was without financial or family support. Unfortunately, I never saw or heard from her again. My colleagues at the shelter were supportive of my developing clinical skills, and tried to cheer me up when they saw me looking sad and confused by reminding me that “you can’t change anyone, except yourself,” or that “I should not take it personally,” or “I was not responsible for my client’s actions.” They told me that it can take at least eight times before someone in an abusive relationship finally leaves, and perhaps Latisha was not yet ready to leave. They eventually seemed satisfied to conclude that Latisha was unwilling to receive the “help” I was offering. But their supportive efforts were ultimately lost on me. The cold light of reality was shining through, and I didn’t like how it felt. It had forced me to face the questions I wanted to avoid—had my “help” contributed to her breakdown and subsequently led her to return to a potentially life-­ threatening situation? Could I live with myself knowing that my “intervention” and sudden departure may have had the opposite effect? No longer could I think of “helping” as a nice, safe, or comfortable profession. It was serious, and I had so much more to learn. Did she feel abandoned because I had left so suddenly? Maybe I let her down and if so … how? Had my interactions triggered her destructive actions? Had I led her to believe I was more than just her social worker? Or was I being too hard on myself, or simply about working with the general public? Where did I go “wrong” in the use of theory? Why didn’t it “work”? How did I fail so fast? Simply put—I wanted to know—“how does the helper effectively help?” I had many sleepless nights as a result of this incident and realized pretty quickly that my conscience was forcing me to examine and question my practice. I resolved then to begin a search to find answers for my many questions.—Gillian Berry (Adapted from Helping or Hurting: A Professional’s Search for Understanding, 2023, in press). Berry: Latisha was my very first client. I will always be grateful to her, because reflecting on our work together, questioning what I was taught and trained to do at the time, changed the direction of my professional career. When I realized that what I was trained to do did not result in the helpful care I thought I was providing, I asked the same question: what was missing? Just asking that question changed the direction of my professional career. Cornish: This questioning of our own practice is so important for learning, especially when we get something horribly wrong. Gillian, your story

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about Latisha reminds me of times when I went in with the best of intentions to help, but discovered how my unconscious biases on race set me up to do the opposite. In one situation, I defended a decision I made by mentioning that a well-liked colleague agreed with me. I think I knew at some level that I was mentioning this because the decision, rejecting a proposal for an infeasible diversity, equity, and inclusion (DEI) initiative, could be justified not so much because this colleague was well liked, but because he was Black. What I did not realize was how harmful this was to both my colleague and the department as a whole. Churchill: I think also, though, it’s important to have humility. Why would I think I would know what’s best for someone? I worked in an Indigenous community for many years, and this woman came to a session. We all know that people are often ordered into therapy—she had committed a crime, and the judge told her that to stay out of prison, she had to go see a therapist. And I’ll never forget her, because she was sitting in front of me, and I introduced myself and said, “Hi, welcome, I’m glad you’re here.” And she said, “What the hell does a white woman like you have to tell me?” I looked at her and said, “Nothing. I’m just here. If I’m any use, let me know. If I’m not, that’s okay, too.” And we spent a lot of time working together after that first meeting. Cornish: So Gillian, what I take from your story is that when we think we are fully equipped and trained to care for others, we are in a precarious place. We might lose sight of what we still need to learn. We might lose sight of the power of humility. It is difficult for someone who is newly trained to be humble when they need to prove to themselves and others that they are capable. And if we layer positionality based on race, gender, or cultural identity on top of the normal imposter syndrome experienced by almost all trainees, it becomes even more challenging to admit that we haven’t learned enough, or even the right things. I’m thinking now about what we are doing today. We’ve set up a space, a safe space to share our discoveries, how we have learned from mistakes and the voices of others who often have so much less power than us. But even among ourselves, there is a power differential. I think it is less risky for me as a white male to share my mistakes, admit to defensiveness, to be vulnerable, or, as in your case AnnMarie, to say that you may have nothing of value to offer beyond being present. It was easy for me to admit my mistake and acknowledge the harm done to my department when I tried to justify my unpopular DEI decision by coopting a well-liked person of color because I am in a place of security. I wonder, though, if my colleagues who are people of color feel safe enough to admit to errors in judgment, biases, or unprofessional behavior. To do so might lead to harsh reactions from those in power who may expect people of color—even unconsciously—to lack competence.

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Berry: Learning from such experiences is necessary for personal and professional growth—the importance of humility, reflecting on what we are doing and why. These “failures,” these stories, are a necessary part of the journey of discovery. When challenged, it is easy to be defensive, deny, ignore what someone else is saying. If we go a bit deeper, though … I’m just thinking about having somebody who has, let’s say, a psychological issue, they’re coming into a counseling center, and they are going to meet with a counselor to focus on an issue. If it’s not placed in context, what are we doing? Are we just helping somebody deal with what they bring in the room? Without contextualizing it to the wider issues that client might face—issues like access to housing and dignified, well-compensated work—are we helping them make that connection, or are we coddling them, or even colluding in larger systems of oppression? Cornish: Focusing on a tiny little piece, a psychological problem taken out of context, will not be as impactful. If taken out of context, it could even be harmful. I think about the crisis in our climate right now—that’s context, that’s the biggest context. That’s bringing despair to a lot of people. If you look at just the micro, the problem immediately in front of you, and we don’t see it in that larger context, we’re missing an opportunity to build in the kind of passion and compassion, connection to our world around us that is under threat, right now. I have met people who work in environmental science, and to focus on their anxiety and despair as symptoms that could simply be reduced through Cognitive Behavioral Therapy or meditation is to miss the point. The context is what needs our attention. Churchill: Just to go back to what you were saying, Gillian, about that person in front of you coming in with a psychological issue. They say they have some anxiety, and you just focus on the anxiety—that’s the typical approach. You focus on their symptoms, and the clinical experience of anxiety, without looking at what it means to the person. Where does the anxiety come from? What’s the bigger picture? Connecting it to times when they haven’t been anxious, connecting to their strengths, their abilities, the structures of support they already have and what’s happening around them? If you don’t go out further than that little piece—the anxiety—you’re actually perpetuating the problem. We’ve talked a bit about the practice of keeping people in therapy, the idea that a person seeking help is somehow incompetent or deficient—they are their diagnosis, their anxiety. And when I do that as a mental health expert, it is an act of collusion, because I’m going along with that deficit focus. I’m not helping them link to their strengths or things outside of themselves.

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Cornish: Can you do that through one-at-a-time sessions? Because when I hear you, I hear some of the critics saying, “Well, you know, it’s going to take forever to kind of bring in all this context and go that deep.” Berry: We don’t know what’s going to happen tomorrow. Let’s just focus on what we can do in this moment and to help her be grounded in our reality. So now this is when it gets, again, simplistic but also complex. The simplicity is being able to say, “What are you excited about in real life? What do you want from your life?” Churchill: But to do that, you’ve made the assumption that there is something to be excited about in that person’s life. If you ask that question, what excites you? You’ve made an assumption in your mind this person is more than their issue. And to your point, Peter, I think maybe it’s an ethical responsibility. You say to yourself, “We’re not just going to focus on the symptom. I’m going to ask other questions—about what’s working, what’s helping. I’m going to explore other things here. Because I believe this person is more than their anxiety.” Berry:

Yes, absolutely, much more!

Cornish: Solutions, theories. These are just some ideas. What people can’t do, what I think people really struggle with, is to see what does that look like in action.

Summary “Peter insisted on my sharing an extract from the Latisha story. He felt it captured the process of unlearning—the letting go of old beliefs, habits, and ways of thinking, especially when faced with direct evidence. Without unlearning, or reflecting on what we have done and questioning what we could do differently, we may consciously or unconsciously hold on to outdated and limiting beliefs, perhaps stifling the voice within pushing us to grow. By facing the realities of our current mental health system, we can question what we are doing, rather than assuming we are on the right track. In a mental health system where control is prized, this means questioning what the opposite may look like—questioning our biases, limiting beliefs, or perhaps adapting to new information and perspectives. For example, just asking the question of whether our training has provided us with the skills to navigate the challenges of what we are seeing in the field can open up new possibilities. What may be missing in our current system is a willingness to question.”—Gillian Berry

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18.2.2 Be Real: There Is No Magic Wand Berry: My spectacular failure with my first client, Latisha, taught me a valuable lesson, but I didn’t know it at the time. I didn’t even know how much of a failure it was then. I now know how much I learned and grew from my time working with her—sometimes, much more than from the theories I’ve studied and read and been trained in. Learning from outside my red brick education—seeking knowledge from other areas, such as elders, shamans, within traditional communities in Australia, New Zealand, India, Africa, and wherever you have Indigenous communities who have held on and retained their ways of life—there’s an empowerment that comes from when you engage with a traditional healer. I feel limited if I use just one approach or understanding to assess, support, or treat my client. That does not serve a society which functions on … Cornish:

On capitalism?

Berry: Absolutely. Our current economic system may not allow for wellbeing everywhere. It might actually require many people to engage in behaviors they find oppressive—the opposite of what they need for their well-being. Cornish:

So that’s why you often tell me that SC2.0 won’t work?

Churchill: Well, what I was just thinking—SC2.0 is so much more than just oneto-one intervention. What I really appreciate about the stepped care model we’re developing, is that it’s more than one-to-one counseling or therapy. It’s community development and social justice. It’s what we talked about getting from a therapist or a healer, that you can also get from your next-door neighbor. You know, we can broaden the system and recognize that people can get help from an AA group, social gatherings, or a church group. More and more, people are starting to see mental health service delivery as more than just one-to-one therapy. And I think that that’s absolutely critical. Cornish: We can get better, and we need this hope. But I’m also … you know, Gillian, you’ve shared with me this idea for the chapter title for a long time, “Why SC2.0 Won’t Work.” We can transform to make things better, but at some point, we also have to realize that we’re in a system that will limit that. Berry: Perhaps, the title does not capture the complexities we are currently facing—by recognizing the reality, which is that in order to transform a system, those within the system need to be able to see the whole of

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the system, all parts of it, and how they all work together. If I’m only going to focus on the mental health service piece, it means that I’m missing structural trauma. I’m missing how we inadequately train our clinicians, and the importance of supervising clinicians. And then you have to say to yourself, “Well, how are they going to be employed? Who will pay for it? What systems are they going to be a part of? How are they going to operate? How will the administrators make decisions?” So, it’s the entire system. But with our focus seemingly on our “siloed” section of the mental health system, we may not realize how it may limit our understanding. Cornish: It’s more of a caution. It’s more a warning that you have to pay attention to all these other layers. It’s not telling me to give up. Berry: No, no. Because if I look at the slave trade, the genocide of Indigenous peoples, and other atrocities, I’m looking at centuries of oppressive practices. I’m sitting here today because people have come along and said that that is unacceptable. We’ve been able to change to get to a point where it has transformed practices which were clearly oppressive. We have to acknowledge that, unfortunately, it took time, but for me that represents hope. Cornish:

So, what are the reasons for hope? How do we get it?

Berry: Working within the confines of a mental health agency, you can still have hope—because the client in front of you … you don’t know what the future holds for them. But you can do something meaningful and helpful right now. Churchill: I see a lot of hope. I was just thinking when you were talking about slavery, that 40 years ago, or even 20 years ago, when I first started in mental health, no one talked about including people with lived experience in treatment delivery and planning. When we were designing programs, no one said, “We need to bring the people using the services to the table.” We didn’t hear “nothing for us, without us.” It’s only very recently that it’s become unacceptable to be designing and developing programs, doing policy on mental health, without people who use the services. So, when I think about it, there’s tremendous hope. Whenever I talk to people outside the mental health system about SC2.0, they say, “Duh, why weren’t you already doing that?” SC2.0 just makes sense. I think where we get bogged down is when we come from within the system, because as providers we go back to what we were trained to do—siloed, one-on-one care—and there’s turf, there’s expertise and familiarity with that approach, which makes change difficult.

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Summary Lessons from the past can help us navigate some of the challenges we face today. There have been innumerable situations which many deemed impossible to overcome, but they have been overcome through human action. It is through the hard work, determination, resilience of a few—which grew to be many—that created movements for liberation. What may be missing is a determination to transform a seemingly unchangeable mental health system.

18.2.3 Taking on Risk Berry: Another thing that we should perhaps talk about a little bit more is the conundrum of the risk described in Chap. 12. Cornish: What I’m sensing is that there’s a real divide in different parts of the world around how risk presents a tremendous barrier and shapes structures. There are places in the world that don’t seem to have a risk paradigm—Denmark, for example, and other places in Europe where social democracies are functioning a little bit better—where there isn’t this defensive bureaucratic structure that keeps things the way they are, as is the case in the United States. I just wonder if we need to bring some energy to that conundrum that will allow us to broaden the conversation on it. If one of the most powerful countries in the world is so tied up in knots with this, I think that’s going to really be an obstacle. Berry: I’m going to play devil’s advocate here. Don’t we need some of these regulations? There was a time in our history before those rules were in place, and it was a free-for-all. You had people who were doing some very, very unethical practices. Cornish: But then how is it that in some of these countries in Europe, they’re able to put some guardrails in, and care is good, and it isn’t out-of-bounds or unethical? It’s not that the rules aren’t there, but I think there are some structures that motivate people and inspire people to follow these guidelines—as opposed to being under threat, so you put up your defenses. I guess what I’m saying is, I think we need to learn and study more how to set conditions that support a structure that operates effectively and reasonably within the guidelines, rather than this purely defensive approach. For example, what’s happening in some communities that want to address the opioid crisis, or homelessness, is that you’re not insured to provide care to an unhoused person or person using substances; that’s out of scope for you, so guess what? The guidance from the powers that be, that have lots of money to fund this, is “don’t do it.” So nobody does anything, because you’re going to get sued, because all these rules say you’re not credentialed or approved to do that. And then what ends up happening is that the problem doesn’t get addressed.

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Churchill: My sense of the risk paradigm is that it’s being co-opted for other agendas. Most health professionals work from a practice of “do no harm.” Care professionals are guided by ethical and practice guidelines. I think those guidelines are in Denmark and all around the world, and that helps protect people and ensure that care professionals do no harm. But I think what’s happened—and Peter, you’d have a better sense of this in the United States—is the weaponizing of the practice guidelines and risk prevention—the “do no harm”—which is maintaining inequities and limiting innovative and inclusive practice. Here in Canada right now, when we hear complaints about harm reduction sites, and safe use sites, I think it’s not really about “do no harm” (because we’re doing more harm by not providing safe use sites), and it’s more about a political stand people are taking—that drugs are bad, so control of them is good. Risk is being weaponized by politics, economic structures, and capitalist greed. There are entire industries that profit from risk, real and imagined. So my question is whether this is less about the mental health care system and what we’re doing, and more about the social and economic systems? Cornish: Yes, it is absolutely about the systems. It’s policy. That’s where I think we have to lead. There has to be a strategy for engaging legislators, for engaging policy-­thinkers that inform legislators, to offer some consultation on how to get there. And also, a research network and infrastructure that studies places in the world that have actually made some headway on that. In this country, with its American exceptionalism, there is a tendency to just study everything that’s produced in the United States. No one knows that anything is going on in Denmark! Churchill: Let’s look for other models. But Peter, you know what might be helpful is actually going beyond the risk paradigm and poking at it. There is, in our profession, this whole idea of conflict of interest, that you can’t take gifts and you can’t give gifts. When I worked in an Indigenous community, I challenged that, because when I don’t accept an offering from someone who is getting something from me, that is, my ear, my compassion, then there is a power differential in that relationship. Am I going to say to someone that you can’t give me anything? Or am I going to say that I will accept what you’re offering me? When I trained social work students, I used this as an example of an ethical dilemma, and they would say it’s risky and could land me before the Ethics Board. My position was that you have to think about what you’re doing and why—if you can rationalize that your practice is based on solid interactions with the organization and the people you’re serving, and it’s not for your self-interest but rather cultural respect, then you’re in compliance with ethical standards. We need to actively poke at, challenge, and move beyond the current risk paradigm.

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Cornish: How do we do that? I think the key is that we’re going to need to think about having, in our SC2.0 model and structure for producing change, a legal team that’s going to take on some of the laws and engage with some of the people who have so much power to determine a policy and enforce it, and to threaten people that are breaking the rules. We need to power our consultation with another skill set. How do laws change? They change when they’re challenged by a legal team. We want that challenge to be a progressive challenge. Churchill: That’s the thinking through—the rationale piece. Berry: Yes. I think we have to be so careful, and Peter, the idea of having another layer of infrastructure in our system is scary. We want to be really thoughtful about whether we are empowering our community by doing this. Are we putting in a supposed safeguard, or are we bolstering this belief that we really need to be monitoring it so carefully? I do agree that if there is a layer of ethical guidelines tied in with our principles, yes, but there’s so much more work that needs to be done. I really want to talk about workforce development as well … Cornish: Which is what this ties into—because this is the upper level of the workforce, where the risk people are increasingly dominating everything that falls down into the rest of the workforce. Churchill: What was our conundrum there, what was our major concern about the workforce? I think where we were going with it was that we don’t have a scarcity, we actually have an abundance of health and well-being resources, but we have cut those off, centered risk, and told people that they’re not capable, that there’s something really mystical or complex about this work, and you need a highly specialized person to help, and therefore we need a workforce full of specialists. Perhaps, instead, we should have a workforce of people who can be helpful. Cornish: The conundrum is what Gillian was talking about, that there are many reasons why regulation came into play. Some of it is a kind of control, and some of it is very oppressive. It’s a policy that keeps the medical establishment in control, and while that might keep people who are unscrupulous from practicing, it also prevents people who have natural abilities informal supports from being part of the system. What’s the right balance between managing risk, setting up guidelines, saying what counts as care and what doesn’t, and opening up the tent for more healing practitioners, formal and informal, to participate? That’s the challenge. The risk paradigm, if it’s too restrictive, applies excessive bureaucracy to keep the gates closed to other voices. I think sometimes these systems cultivate fear to keep things the same. I have this hypoth-

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esis that people will always find a way to be unscrupulous, and there will always be a minority that breaks rules and abuses. Sometimes it’s these power structures that feed on that fear of, oh, “if we don’t have all these rules in place, the world will go to hell in a handbasket.” And I don’t know if that’s actually that true. Berry: I do agree that by setting the culture and having the expectations, all those people working in an organization may create a culture in which people are recognizing how to do this work, and if we can immediately address some of the issues that arise, using our principles to guide our actions, then I think that it’s worthwhile being able to pull back on some of the risks that we may want to pay attention to if we put strict guidelines in. Churchill: The other piece is that, ideally, we are distributing risk across communities. Because we don’t have people operating in silos by themselves, there is some accountability in the system, with co-workers and communities to ensure ethical practice. Professionals should be engaged in supervision, and we should be involved in collaborative care with other people. So how do we as a transforming organization really promote this idea of distribution of risk across a community and a system? It’s not one person, a specialist, who is responsible for care and safety, but it’s a whole community or system working together to reduce or manage risk and ensure ethical practice. Summary Taking a risk, doing something different from the norm, can vary from a small gesture to a major one. The connection is the action. The saying that a journey of a thousand miles begins with a single step is relevant in this instance. What may be missing is taking a risk, rather than doing nothing.

18.3 What We Are Wondering: How Can We Strengthen Our Leading by Learning? We’ve identified part of our role, and talked about what makes what we’re doing different at Stepped Care Solutions, but how do we engage people where they are, living in the real world that is constrained by so many structures aimed at maintaining the status quo? We need to have a conversation about how SC2.0 can continue to push for well-being everywhere without alienating those who are just learning about our model, or losing our transformational drive.

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18.3.1 Diplomatic Disruption Cornish: Because I love alliteration, the idea of “diplomatic disruption” emerged in my mind a little over a year ago. There’s a diplomatic path that’s important to me. That word “diplomacy” is often used in very difficult circumstances in the world, where people are trying to resolve conflicts. It’s a conundrum, though, because you know, if you’re too diplomatic, are you disrupting enough? It’s an oxymoron—diplomatic disruption—and what I love about the disruption part is what we are disrupting. We’re disrupting an unjust structure that restricts access to supports that people need to be well, and functioning, and living a meaningful life. So, we want to disrupt these structures—but how do we maintain that balance—or do we?—between diplomacy and disruption. Gillian and AnnMarie, in your work as leaders and as supervisors … I’m wondering how you think that would apply. Berry: I think it applies in so many different circumstances. It shouldn’t just be limited to the work between the clinician and their supervisor. I think “diplomatic disruption” is a wonderful term because I love the idea of diplomacy. Diplomacy, for me, means trying to find a win-win situation for all parties. The disruption lies in the recognition that we need to do things differently. Is it a discomfort, too? Absolutely, because we’ve got to be able to get past something very difficult. Churchill: I think that diplomacy helps with the discomfort of the disruption—I think of the diplomacy as a readiness tool. If I go in with all engines firing on the disruption, it’s not recognizing where people are at. If it’s too disruptive, people will feel it doesn’t apply to them, they’ll feel that it’s too much, they will push back, and then nothing is going to happen. But if I exercise some diplomacy, taking into consideration their state of readiness, their contextual limitations, then we can move a bit on the disruption. One of the reasons I like the diplomatic disruption is that it enables people to deal with the discomfort. It’s about that win-win, but it also recognizes the contextual limitations of people who work in mental health systems. Cornish: But I think there’s something missing, in those two words. Part of what I think is important in the disruption is an inspiration. Part of the disruption can be that you identify something that’s really important, a problem that’s really important to somebody, and then you inspire them with this hope that things can change. Churchill: Yeah, hope is important. Cornish: Disruption can be enticing and exciting, but it can also be and maybe it needs to be uncomfortable. To disrupt that system on a larger scale, I think maybe an area that SC2.0 can do well is actually engaging

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people on a problem that they might resonate with, and who have some hope that there might be a better way, then work on the execution of the idea. That’s the part where many organizations get stuck, so how do you move forward once someone tells you that you’ve caught their attention, they’re interested, they agree with you that this system is broken and they kind of like this Stepped Care framework? Churchill: We have examples where it’s been done. We’ve heard from colleagues of yours implementing SC2.0 in postsecondary settings that students can get help when they first make contact. And in very different regions across Canada, wait-lists for mental health and substance use health support have decreased substantially, and many providers are reporting satisfaction with the SC2.0 related changes. Over the last 3 years, the rise in virtual options for care has increased access and choice—so there is hope. Systemic change can happen, and I think that needs to be communicated. And we’re asked about that all the time. People will say, “Well, how have others done it? How did you do it in the postsecondary contexts you worked in? What are other people doing?” People need to know what can be done—and you’re right when you say the hard work involves how you do it. We need examples, and we need models. Summary If SC2.0 seeks to engage with health care administrators and mental health providers and to inspire them to organize their services “differently,” then it needs to do so in a manner that is considerate and appropriate. The term “diplomatic disruption” captures this—what may be missing is a recognition that we all have a part to play in the change process, and being considerate of each other will go a long way to meeting that goal.

18.3.2 What’s in a Name? Berry: In our conversations at Stepped Care Solutions, we keep coming back to the idea that we should not be outdated. Older versions of stepped care are so different from what we have in SC2.0. We should really try to be specific in what it is that we’re doing differently. When we call what we are doing “Stepped Care 2.0,” I think that it boxes us in to this concept of a “care model.” The knee-jerk reaction for many participants is that they love that, because they go right back into the stereotype of “this model is going to tell me what to do, and I don’t have to think.” I don’t want that. I want people to be able to recognize that well-being can be packaged in so many different ways.

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Cornish: I recently had a conversation with a person who watched a presentation Gillian and I did, who said he had to watch it again, because there was something about it that really clicked. He said that what we’re doing is well-being work. And it was interesting that he independently arrived at that way of conceptualizing the work that we’re doing. We’d already adopted our vision—well-being everywhere. It struck me that in this second SC2.0 book, some of the conundrums actually stem from misnomers. This person added that when he talks to people about the work we’re doing, he has found himself beginning every conversation with “it’s not what you think.” What he’s really saying is that there is a lot of baggage attached to the term “stepped care” in places where it didn’t work very well, even though what they’re doing is very different from us. So, much like the conversations that come up in Chap. 13 regarding one-at-a-time and single-session therapy, getting those names right is seen as a very important task for understanding SC2.0, because otherwise it produces unproductive confusion. In the case of the term “single-session therapy,” that title reflected a book editor’s choice to sell more books and to be dramatic, but it totally slowed the movement down—because people thought that one-at-a-time intervention was a single session, “one and done.” They thought a single session was all you get. And for 30 years, the people who were arguing for this approach had to keep doing these mental gymnastics to say that “it’s not what you think it is,” and yet all the people who wanted to dismiss the disruption, that wanted to reject one session at a time as less than, as cheap, as neoliberal … that title was ammunition for them. And I think we may be doing the same thing by hanging onto the “stepped care” part of the name. I have been a little dissatisfied with the term “Stepped Care 2.0” for a while, but I thought we needed to carry SC2.0 a little bit further, because people kind of know what it is now, and we’ll lose something if we move beyond it. But I am now starting to think of the other way around, that we continue to lose something because of the baggage. Churchill: I think from a philosophical point of view, this is all really true. I think from a practical point of view, and how we’re helping systems change … people are just coming around to the idea that a system can include informal programs, prevention, promotion, intensive intervention—it can have all of that, and it can have culturally relevant, community-based programming. People are just coming around to the idea that mental health care and service delivery is more than psychiatric care in a hospital, or even psychotherapy—that land-based programming is also “care,” and that there are different ways of knowing and doing. That is change. I tend to think that our problem with “stepped care” as a name is a communication problem: I don’t think we’ve explained it well. In my mind, the “2.0” in our name is almost like an

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indicator that this is going to change and develop. There is going to be a 3.0 or a 4.0—it’s not finished, we’re going further, expect something new. There’s more to come, continuous improvement, and of course there is, because that’s baked into the principles and core components underlying SC2.0. Berry: AnnMarie, you’ve articulated that really well. I think you’re absolutely right. We haven’t done our due diligence in communicating as effectively as we should have. But I’m still stuck on what it is we want to communicate to the public at large. We want to be proactive in the direction we want to go, and for me that really does mean that we are not afraid to set principles we stand by. Churchill: I’m not sure, Gillian. I think what often happens is people get caught up in the model. And I keep saying that the model changes wherever you are, it’s the principles, and I still think those principles are exactly what you’re talking about (see Chap. 11). Social justice is an intervention in and of itself. You can’t have well-being without justice. Berry: I absolutely can stand behind that. But what I’m saying is that the piece we have to take into account is that not everyone recognizes the principles. When we go into organizations, a lot of them are focused on “how does this meet our objectives in terms of service delivery?” They are not thinking about the importance of the principles and incorporating them into how they are operating their mental health organization. Cornish: I think you’re right, AnnMarie—right now there is some momentum. But I think we need to plant the seeds and be honest in our approach. What’s the power of the conundrum? The power of the conundrum is that we’ve got a problem, and we don’t know quite what to do with it. People want to see concrete changes, a new service, decreased wait times. They ask us what should they do. It reminds me of when therapy clients ask me to give advice. Quite often people who do so promptly reject the advice, because it doesn’t fit their unique needs. The same thing happens with people who are interested in implementing one-at-a-time therapy or a technology portal that expands the continuum of mental health services. They miss the need to build their own tailored solution based on the underlying principles rather than attempting to replicate a solution designed for another community or region. The term “Stepped Care 2.0” leads people to think there is a cookie cutter solution, a care model completely figured out. You said it’s a communication problem … well we don’t know what a better name is for SC2.0 yet, so maybe we shouldn’t race to change it. But we do say, “Hmm, let’s all think about this.” We might get all kinds of ideas bubbling up from people who engage with this question, and the answer might come a year from now.

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Churchill: And it doesn’t have to come from us. If we just plant that conundrum and that idea, the community can take it on. We have said that SC2.0 is a movement—changing the narrative, for us, isn’t just about changing mental health care, it’s changing the way we think about wellness and well-being. Maybe we don’t have an answer to what the name should be, and maybe it won’t come from us, but I think where our communications can focus is on the principles. Summary Needing to upgrade one of your apps may be perceived as an inconvenience, but it is also an opportunity to address problems and update functionality. The process of rebranding, renaming, and reformulating in the mental health field may be long in coming (“every 10  years in the case of the Diagnostic and Statistical Manual of Mental Disorders”), but with the current changes our society faces, it seems difficult at times to keep up with. SC2.0 evolved from SC—maybe it’s time for another upgrade? What may be missing is a new name that better reflects what we are trying to communicate.

18.3.3 Finding Purpose Cornish: You know, there’s a comic strip from many years ago with the punchline “Are We Having Fun Yet?” The comic strip is a little outdated in many ways, but that character’s catchphrase has stuck with me—it is a good reminder that this is supposed to be fun. When we do things that are meaningful to us, we become passionate. And this can make it enjoyable. And I’m struck by how this sometimes gets missed. When I work with trainees, they’re surprised when I ask them early into their training whether they are having fun. It won’t be enjoyable all the time; sometimes you are going to go home feeling heartbroken. I struggle with that. But what I try to get on with is that sense of purpose—sometimes this work can be really fun. Berry: Absolutely. And that connects me with what many will deem the spiritual aspect, because we’re living with, and on, purpose. And when you are living your purpose, you begin to connect with why you’re here. And there’s a real joy in being present. But to meet people who are doing something that they don’t want to do—the pain, anguish, anger, the frustration—it can be really quite toxic to be around. Cornish: Well, I think it’s been a real failing of progressive movements to not tap into the emotion. We’ve seen what’s happening with regressive movements: they tap into that emotion. And so, for our emotional well-being, and for the hope of our planet, and I think, our societies,

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we have to bring back this essence of the spirit, the emotion, and stop being so cerebral and careful. We have to start being authentic and bold, because otherwise others are going to take it away from us. Berry: But it starts with us. And as long as I know I’m having fun by doing something meaningful, if somebody doesn’t like that, that’s okay, too. Churchill: Well-being everywhere is well-being for providers, as well as for the people who are coming for services. Cornish: But it’s more than that, because I think sometimes people think wellbeing is just, “Oh, just take care of yourself. Go run a bath.” But it’s not just navel gazing. I think a question we should ask our staff is, “Why are you here? What draws you to this work?” Berry: In that onboarding process, or even before the onboarding process, we were asking that question. Because that starting point will determine whether they actually want to do this job, or they’re just thinking that they’ve got to pay their phone bill. If you’re coming here to learn the job, we don’t need to be afraid or angry or upset when somebody says, “Well, have you thought about doing it this way? How did you use your skills in this way? Did you read that article?” Because those are the things that improve what you’re doing. But some people can get really defensive—“you’re questioning me, you’re criticizing me”— rather than, “Oh, that’s interesting. You’re helping me develop my skill.” For me, that’s the exciting part of working in this way. And then what we heard from some of the service users was that we create an environment where that’s expected. So, if a student is saying, “Oh, I don’t want to do that, I can’t do that,” we can respond, “Okay, well, what about this?” “I don’t want to do that.” “Okay, what about this? What about that? What about this?” And then they get to realize, oh, my gosh, I can’t sit in this place of pain. I can actually see that there’s another way to live. Churchill: I think it’s important to be aware of the meaning of the work and not to underestimate our impact because even small steps or encounters can be significant. I’ll finish by telling a story: a while back, I was contacted by an admin person from an organization I worked with many years before. This person was delivering a message from a past client who was trying to reach me. My first thought was, oh, no! What did I do wrong? But she said: “this person wanted to thank you for your help—and for you to know that you changed his life.” She told me his name, and I had no idea who she was talking about. And I thought about it for the longest time, who is that person? So, I called the organization back and asked what part of the city he was from, and she gave me a few demographics. And for the life of me, I still couldn’t figure out who it was. And then one day it occurred to me—it was this

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kid I saw just a few times, and I did what seemed to me to be basic or minimal work. I used to … I don’t know if people know the book Dinosaurs Divorce, but I used to read that book as part of a program for kids going through parental divorce. So, I would meet this boy at school, sit on a bench, and read Dinosaurs Divorce with him. I said all the things we’re supposed to say, that anybody could say—“it’s not your fault, your parents love you, they’re still your parents.” After that call, what occurred to me was that minor interactions can have major impact and you never know. It could be someone in a grocery store, it could be a client, or it could be someone in my family. For each of us, we never know when we’re going to have this significant impact and it could be through the simplest of gestures, and that’s the value of low intensity resources and community supports. I try to live, as you said, with this mindfulness and intention to be present, to make an effort— so, for example, when I see someone at the coffee shop, I remind myself that I don’t know what they’re going through, so just give them a smile. It can have a positive impact. Cornish: Sometimes it is really easy to have impact. A simple gesture can do it. “Hello” is easy—I think of that campaign, you know, “yellow is for hello.” It was inspired by the story of a kid in middle school who had been bullied and was planning to end his life over the weekend. He didn’t want his parents to have to come back to school to retrieve his books, so he collected them, filling his backpack and carrying the rest. And some bullies came along and knocked the books out of his arms, and an athlete that was really, well, sort of popular, well regarded and respected in the institution, stepped down and said hello and helped him pick the books up. And this kind gesture made him change his mind. He did not attempt suicide. A popular fellow student said hello. That act of kindness is easy, we have to remember that sometimes that’s enough. I think that’s the SC2.0 model, the idea that the smallest intervention can have the biggest impact. We have to include all of that. We have to include saying hello.

Summary The work of our field is challenging and definitely requires more than just thinking about a paycheck. It is easy to forget that we are engaged in this work for a reason. Having a sense of direction in our lives gives a greater sense of fulfillment and satisfaction. It goes without saying that living in alignment with one’s purpose can have positive effects on a person’s well-being. What may be missing is a recognition of how important it is to stay focused on the ultimate purpose of our work.

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18.4 But Where Does This Leave Us? Last thoughts from Peter Cornish Okay. We had a long conversation. We put it in this last chapter. Maybe you read it all. I did several times. I am not sure it helped, because where does it leave us? I’m confused. The conversation is all over the place. There are no clear conclusions. We are left hanging. So much is missing. So much still to figure out. I realized, in reflecting on Gillian’s story of her first client, that I still didn’t get it. What was missing in Gillian’s clinical approach with Latisha? Gillian listened, she cared, she expressed compassion, she was supportive. So, I asked Gillian to explain. Gillian said, “Well, I hadn’t done the work.” What work? “I hadn’t learned how to be a healer. I hadn’t healed myself. I hadn’t grown. I hadn’t gone on my own journey of discovery about life. I wasn’t wise enough to heal. I had the license, I had the ‘technical skills,’ but I did not have the spirit, heart, or soul for the work yet. I hadn’t lived life enough to be a healer.” Okay, I think I’m getting closer. Wisdom comes from deep, difficult, self-reflective work. SC2.0 is not prescriptive, rather it seeks to be responsive to the environment we find ourselves in. SC2.0 is proactive and goes beyond the covers of a textbook, or regimented technical skills; it comes from humility and a willingness to face that we can do better. Expanded healing capacity comes from something deeper, broader, and longer. SC2.0 is based in discovery, lifelong learning, and making change. And that brings me hope.

Chapter 19

Cultivating and Channeling the Power of Conundrums: The Promise of Synergistic Practices Peter Cornish and Gillian Berry

There are many more questions than answers facing those interested in transforming mental health-care systems. While we promised to, in this book, go deep by exploring the conundrums arising from our Stepped Care 2.0 (SC2.0) work, it feels like we have only scratched the surface. Recognizing the complexities of transforming a mental health system can be daunting, but knowing that a journey of a thousand miles begins with a single step, we have attempted to start the conversation. In Chap. 18, we attempted to identify what we might be missing—but, of course, that is a never-ending task in an environment that is constantly changing and evolving. We acknowledge that inviting people to reflect on what remains unknown, where they went wrong, or what they might be missing requires, among many things, courage, risk-taking, and trust-building. We know the importance of creating a psychologically safe space for people to reflect on their work, as we attempted during our own conversation transcribed in Chap. 18. How might we establish the conditions where we can fully endorse harm-reduction recovery principles (Chap. 16) and invite those with less power to join in reflexive co-design conversations (Chap. 14) safely? Cultivating spaces for inclusive dialogue, debate, confrontation, co-­ production, and risk-taking is foundational to the kind of bold leadership and change management needed to transform mental health systems. Exploring conundrums is crucial for addressing what is broken in our mental health systems. For decades, science has promised to address deficiencies in mental health care. If only providers applied evidence-based practices, researchers plead, care outcomes would improve. And before expanding care options, authors of studies warn that more research is needed. Chapter 9 reviews stepped care from this P. Cornish (*) Berkeley, CA, USA e-mail: [email protected] G. Berry Hyattsville, MD, USA e-mail: [email protected] © Springer Nature Switzerland AG 2023 P. Cornish, G. Berry (eds.), Stepped Care 2.0: The Power of Conundrums, https://doi.org/10.1007/978-3-031-45206-2_19

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dominant way of knowing, otherwise known as the positivist research paradigm. We discovered, in Chap. 9, that no definitive conclusions could be drawn from that lens. Yet, this dearth of “answers” is also an invitation, a call to action. If we want to explore and discover an abundance of diverse healing opportunities, we will need to move beyond the zero-sum attitudes that consider only “evidence-based” practices as meeting the positivist standard. Perhaps more sophisticated methodologies, ones that blend multiple ways of knowing, could lead to more inclusive validation processes. Acknowledging that Eurocentric thinking, and the methodologies that flow from it, is still very much the norm and will continue to resist any attempts to break from positivist constraints, Chap. 10 questions our commitment to real transformation. Will our resolve to bring about a truly inclusive, diverse, collectivist approach to science and discovery waiver as we seek support from funders who base their decisions on the narrow slices of “truth” gleaned from the dominant research paradigm? Without more open inquiry, more voices, and more mixed-method research designs, will the changes SC2.0 proposes simply result in more of the same? If the answer to this question is yes, as Gillian Berry fears, SC2.0 could rightly be accused of being a neoliberal ruse, a commodification of disruptive energies that simply yields new “heal thyself” flavors that mask the structural fissures in the fabric of our society, all the while blaming the disaffected help-seeker for their plight. Despite the risk—and because of it—we invite readers to continue challenging us on these questions and to channel their doubt toward discovering viable alternatives. Is it then possible to have fidelity to a model of practice that recognizes the importance of flexibility? Without being able to measure, evaluate, or assess, how will we know that what we are doing is effective? Even being guided by clearly defined core components that call for flexibility and adaptation, Alexia Jaouich and colleagues in Chap. 11 recognize that the current system is constrained by manualized treatments and programs. Furthermore, the accepted positivist protocols for implementation and evaluation may not apply in this instance, and, instead, the situation requires innovation, creativity, and new ways of interpreting successes. We are at a time of racial reckoning, which involves seeking input, perspectives, wisdom, and voices from all directions. At a time when science, industry, and economics have brought us close to climate calamity, there is hope and solace in choosing paths that are varied, less trodden, and more ecologically respectful. We are hopeful that implementation science methodology will be informed by the fullest range of formal academic disciplines, some of which increasingly draw on Indigenous wisdom. Chapter 12 highlights the chokehold that risk management protocols have on change, growth, and innovation. The risk paradigm is a symptom of our society’s dysfunction; the source of the problem is economic and, therefore, political. The perception of risk escalates with widening economic disparities. Risk industries, including insurance, police, military, and justice systems, profit from those fearing the loss of what they have accumulated. We have only glancingly touched on the topic of economics in this volume, but the third volume in the series, focusing on synergy, will examine more closely how healing resources can look different when we transcend the dominant economic paradigm of scarcity. As we implement

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SC2.0  in more communities, we witness the creativity and joy that comes with breaking free from rigid risk-driven protocols. Acknowledging that therapy is a well-accepted and effective treatment, Monte Bobele, Arnie Slive, and Heather Hair (Chap. 13) question the mythical “gold standard” that restricts its application. Given evidence supporting open-access, one-at-­ a-time alternatives, we must conclude that this constraint is driven by economic and risk-related influences, including a private practice industry that often profits from unnecessary treatment offered only to those who can afford to pay, professional guilds that aim to preserve and expand their foothold, and research funding agencies that draw funds through the promise of overly rigorous and narrowly defined experimental designs. Although questions remain as to how these constraints will be overcome, there is considerable promise in the new, one-at-a-time treatment paradigm, rooted as it is across a full continuum of care options. In our next volume on SC2.0 and synergy, readers will see how differences and tensions—so unproductive in the context of scarcity care models—can be channeled to produce an abundance of sustainable healing resources. Chapter 14 (“Stubborn Hierarchies”) delves more deeply into the challenges and opportunities involved in democratizing healing work. In our class-based social structure, co-design is a lofty goal. Hierarchies are stubborn for a reason. The power of this conundrum lies in how it encourages us to tackle hierarchical tensions head­on, increasing transparency and accountability. While the mental health professions can romanticize co-design and imagine participants freely sharing their views and opinions, the reality is, for that to take place, much work is required of all who plan to participate. Over the past 2 years, Stepped Care Solutions has hired knowledge mobilization specialists, people who engage with marginalized communities, to co-­ design mental health resources and pathways. The goal is to bring more voices into the co-production of accessible, trauma-informed mental health programming. These additional voices broaden our store of expertise and our shared knowledge. This allows therapists to relinquish expert roles, assuming instead the function of expertise conduit. In his reflection, Peter Cornish recalls his most satisfying moments as a psychologist witnessing a client break free from an unproductive course of therapy to take flight through mental health activism and system-level co-­ design work. This person needed a sense of purpose through community action in order to heal, just as Peter needed evidence that the world can heal itself without him. Gillian’s memory is having a student dismissed from a social work internship by the elders in a local village while she worked in Botswana. The student had not listened to their needs and instead was promoting the strategies taken literally from her textbook that had been printed from a publishing company in downtown San Francisco. The student, visibly shaken and distraught by her exclusion, was able to use that experience to problem-solve and consider new, innovative, more culturally appropriate ways of engagement—rejecting the ones Gillian had been teaching. The learning was definitely a two-way process for all parties. Most concepts of power assume a hierarchical relationship or dominance over others. This we refer to as “power-over.” In contrast, leadership in SC2.0 transformation involves channeling “power-with” others. This notion of power is central to

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the concept of synergy, which recognizes that we can better loosen the larger structures that bind us when working collaboratively. Most of the contributors to this volume occupy leadership positions in mental health. Has this leadership been synergistic, energizing power-with, or is it still more of a top-down power-over dynamic? Perhaps we could have stepped back more as leaders to hear voices from all levels of the mental health system. From Gillian Berry and Janis Campbell’s cautionary tale (Chap. 15), we can surmise that good leadership channels the power of collaboration to steer through rough waters and that it is all about learning, even for those at the highest levels. Not only does it require mastery—and by that, we mean understanding, application, analysis, and evaluation, to allow for creativity, design, and construction to innovate on the wide-ranging subject matter (Bloom, 1956)—it also requires humility, openness to criticism, ability to change course, and the capacity to model the axiom that the more you learn, the less you know. The power of conundrums comes from the tension between opposing ideas, values, positions, and interests. A good leader steers through the rough waters, at times sailing before the wind and at others cutting through the waves, all the while respecting and riding the forces at play. Now and again, the one at the wheel is required to make difficult decisions that go against the will of others while still keeping as close to the wind as the sails will bear. Realistically, leadership will require both power-over and power-with. We suggest harnessing power-with the wind as much as possible, drawing on a diesel-powered auxiliary engine only in the absence of wind or when the gale forces risk damage to the sails. Turning to Chap. 16, Mary Bartram provides us with another example of how SC2.0 is being tested in the field. SC2.0 is challenging the longstanding link between recovery and abstinence in the realm of substance use health and addiction work. However, as a recovery-focused model, how can SC2.0 avoid the perception of being centered around abstinence and, therefore, unsupportive of harm reduction, which could potentially undermine the core recovery principle of choice? SC2.0 has room for all effective approaches to wellness and healing. Abstinence works very well for some but not for others. This is true for all interventions or resources. One size fits some. For some people, abstinence will be the best harm reduction approach. But for many others, it will not. Choice is key. Because of this value of choice, SC2.0 takes the position that the word “recovery” should not be equated with abstinence, but instead be more inclusive of the wide variety of options that not only reduce harms but promote growth and development at a rate and in a direction that fits with people’s readiness. In Chap. 17, Andrea Levinson reminds us to keep it real by focusing our therapeutic work on those most disadvantaged. Much of our early work in SC2.0 was about freeing up limited and expensive specialist providers to care only for those who needed it most. While we succeeded in reducing inappropriate referrals to specialists, our near-exclusive focus on expanding low-intensity programming, co-­ design, collaborative decision-making, and empowerment has implicitly undermined the expertise and authority of those specialists. What is the future of the expert? Just as children need parents who exercise authority, and students need teachers who evaluate their work, all healthy societies need medical experts who have the

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authority to direct care. In some cases, this may involve limiting freedom and autonomy. The conundrum in Chap. 17 arises from a tension between freedom and responsibility. We must nurture this tension because each loses its value without the other. In the original SC2.0 book, A Paradigm Shift, Peter argued that “client autonomy” was a key dimension in organizing mental health programming. The implication, many readers have since told him, was that, true to his individualistic biases, he was favoring autonomy and freedom over regard for directed care, or the kind of collaborative care that comes through community and group work. He had not been explicit enough in appreciating either directive or collaborative care. And, though this term was changed to “decision-making autonomy” in Chaps. 1 to 8 of this volume, he still doesn’t think it gets it right, either. In his workplace today, staff and managers are discussing the concept of “responsible autonomy” as something they want to achieve by channeling the conundrum. We want leaders, clinical staff, and students seeking services to have autonomy when it is productive for them, but insist this be accompanied by a measure of responsibility to self and others. There is no real freedom without transparency, responsibility, and accountability. Tools are needed to monitor the balance of power in decision-making. A measurement-based care system, thoughtfully designed to be accessed by all parties (service users, clinicians, administrators), could be one tool for tracking wellness and fine-tuning the balance of power in decision-making. In this volume, we have opened our doors wider than ever before. The goal has been to welcome diverse perspectives. We know that we have only just started this journey. There is more work to do and more voices to hear. We will be turning our focus to economic conundrums in the next volume. But there are lots of mysteries that still have to be identified, explored, debated, and played with. We look forward to hearing the reader’s voice—your voice. We envision a growing community of practice for this large-scale transformation. We encourage readers to reach out to us with criticisms, ideas, and solutions. Please contact contributors directly by email or send a message to the Stepped Care Solutions not-for-profit company website.

Reference Bloom, B.  S. (1956). Taxonomy of educational objectives, handbook: The cognitive domain. David McKay.

Index

A Access modality, 11 Acute care systems navigation & case management, see Stepped Care 2.0 (SC2.0) Allan Francis, 22 Amber’s journey, see Recovery principles Architecture desire paths, 78 foundry BC, 52 Frank Lloyd Wright, 52 perching & nesting, 52 Robert Mellin, 51

D Deficits model intake, 28 Desire paths, 35 Disruptive innovation, 37, 64, 107 Distributive design cycle, 95, 96, 104, 106, 113, 115, 119, 130, 132 dialectical design, 52, 73, 130 Dual continuum model, 44

B Bridge the gApp, see Informational self-directed

F Fail forward, 13, 15, 30, 38, 50, 57, 70, 74, 83, 101 trial and error, 49 Family and peer support, 72 CHANNAL, 62 Kids Help Phone, 62 See also Stepped Care 2.0 (SC2.0) Flexible intensive individual programming 50-min hour, 68 See also Stepped Care 2.0 (SC2.0) Flipped classroom, see Guided self-help Foxes and hedgehogs, 131 Fuller, B., 131

C Canadian Mental Health Association (CMHA), 45 Capturing the moment, 26 CHANNAL, see Family and peer support Chronic care and specialist consultation practicing to full scope, 71 See also Stepped Care 2.0 (SC2.0) Client centric, 10, 100 Client design team, 74, 87, 106 Common factors, 82

E Expert-driven, 15, 49

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314 G Great psychotherapy debate, 82 Guided self-help flipped classroom, 63 Mind Beacon, 64 TAO therapist assisted, 64 See also Stepped Care 2.0 (SC2.0) H Harm reduction, 44 I Increasing demand, 23 Indigenous healing, 98, 125, 131, 132, 134 Informational self-directed Bridge the gApp, 57, 59, 85 See also Stepped Care 2.0 (SC2.0) Informed preference & consent, 10, 31, 60, 68 Intensive group therapy, see Stepped Care 2.0 (SC2.0) Interactional self-directed Mindwell U, 61 TAO self-managed, 61 See also Stepped Care 2.0 (SC2.0) Interprofessional scaffolding, 68, 98, 129 L Lived experience, 16, 17, 27, 29, 38, 41–43, 45, 46, 57, 73, 74, 87, 89, 91, 94–96, 98, 105–107, 113, 114, 117, 119, 124, 131 Lost connections, 5 Low, mid and high intensity, 10 M Medicalization of everyday life, 5, 22 Mental Health Commission of Canada (MHCC), 42 Mental health continuum model, 85 Mind Beacon, see Guided self-help Mindwll U, see Interactional self-directed N Nature of evidence, 82 Neoliberalism, 4, 47, 48

Index O Open access, 21, 28, 30–32, 34, 72, 78, 80, 129 capturing the moment, 81 no wrong door, 34 Operational stress injury, 85 Origin story, vii–ix P Peer support, 9, 27, 38, 43, 47, 62, 72, 85, 94, 115 PTSD, 87 R Readiness, ix, 9, 13, 14, 27, 28, 31, 49, 50, 58, 60, 61, 66, 67, 81, 82, 84, 86, 87 Rebel talent, 101, 102, 107, 134 Recovery principles, ix, 15, 37, 38, 40, 41, 48–49, 51, 64, 84, 95, 101, 118, 122, 124, 129 amber’s journey, 55, 60–62 history, 40 investing upstream, 25 NL Towards Recovery strategy, 59 peer support, 27 research, 47 transparency, 30 Resistance, 11 Risk paradigm, 4, 37 crisis response teams, 22 disease model, 40 myth of risk, 6 pharmaceutical industry, 24 stranger danger, 52 violence, 23 S Self-correction, 26 Sinek, S., 102, 113 Single session open access, 28 solution focused, 3, 30, 32, 44, 70, 118 therapy one-at-a-time, 28, 70 Staging/pathways model, 8, 48 Start strong start simple, 11, 12, 25, 30, 70 Start with why, 102, 104, 113 Stepped Care 2.0 (SC2.0), viii, 9 acute care systems navigation case management, 72

Index chronic care & specialist consultation, 71 ethics, 50, 51 family and peer support, 62 flexible intensive individual programming, 68 guided self-help, 63 informational self-directed, 59 intensive group therapy, 65 interactional self-directed, 60 managing boundaries, 94 nine steps, 55, 58 not a staging model, 49 number of steps, 11 therapeutic measurement, 49 workshops, 63 Stigma, viii, 3, 5, 22–24, 44, 46, 47, 58, 60, 98 Substance use disorders, 44 Symptom severity, 8 Synergy defined, 131 System, 3, 4, 73, 77, 129

315 T TAO self-managed, see Interactional self-directed TAO therapist assisted, see Guided self-help Therapeutic alignment, 32, 69, 70 Therapeutic measurement, 83 digital platform, 85 feedback informed treatment or FIT, 83 practice-based evidence, 49, 83 Treatment for all, 17 U United Kingdom (UK) model, 7 W Watchful waiting, 59 Why? Now Wow! How? What?, 105 Workshops, see Stepped Care 2.0