Program Development in the 21st Century

To Gerri, Mom, Papa, and Paul—my family.

And to Denise Davenport, who would have been an incredible
program developer.
 Program Development in the 21st
Century
AN EVIDENCE-BASED APPROACH TO
DESIGN, IMPLEMENTATION, AND
EVALUATION

Nancy G. Calley
University of Detroit Mercy

Copyright © 2011 by SAGE Publications, Inc.

All rights reserved. No part of this book may be reproduced or utilized in
any form or by any means, electronic or mechanical, including
photocopying, recording, or by any information storage and retrieval
system, without permission in writing from the publisher.

For information:
SAGE Publications, Inc. SAGE Publications India Pvt. Ltd.
2455 Teller Road B 1/I 1 Mohan Cooperative Industrial
Thousand Oaks, California Area
 91320 Mathura Road, New Delhi 110 044
E-mail: [email protected] India

     
SAGE Publications Ltd. SAGE Publications Asia-Pacific Pte.
1 Oliver’s Yard Ltd.
55 City Road 33 Pekin Street #02–01
London EC1Y 1SP Far East Square
United Kingdom Singapore 048763

Printed in the United States of America

Library of Congress Cataloging-in-Publication Data
Calley, Nancy G.
Program development in the 21st century: an evidence-based approach to
design, implementation, and evaluation/Nancy G. Calley.
     p. cm.
Includes bibliographical references and index.
ISBN 978-1-4129-7449-3 (pbk.)
   1. Mental health planning. 2. Mental health services. 3. Community
mental health services. I. Title.
RA790.5.C3155 2011
362.2068—dc22
2010029518
This book is printed on acid-free paper.
10  11  12  13  14  10  9  8  7  6  5  4  3  2  1
 
Acquisitions Editor: Kassie Graves
Permissions Editor: Adele Hutchison
Production Editor: Jane Haenel
Copy Editor: Megan Speer
Typesetter: C&M Digitals (P) Ltd.
Proofreader: Sarah J. Duffy
Indexer: Maria Sosnowski
Cover Designer: Bryan Fishman
Marketing Manager: Stephanie Adams
 Contents

About the Author

Acknowledgments
Comprehensive Program Development in the Mental Health
Professions
Comprehensive Program Development
Today’s Mental Health Professionals and Program Development
Current Climate in the Mental Health Professions
Comprehensive Program Development Defined
Comprehensive Program Development Model
Step I: Establish the Need for Programming
Step II: Establish a Research Basis for Program Design
Step IIa: Address Cultural Identity Issues in Program Design
Step III: Design the Clinical Program
Step IV: Develop the Staffing Infrastructure
Step V: Identify and Engage Community Resources
Step VI: Identify and Evaluate Potential Funding Sources
Step VII: Develop the Financial Management Plan
Step VIII: Develop the Proposal
Step IX: Implement the Program
Step X: Evaluate the Program
Step XI: Build and Preserve Community Resources
Step XII: Develop an Advocacy Plan
Step XIII: Develop an Information-Sharing Plan
 Step XIV: Attain Program and Organizational Accreditation
About the Text
Terminology
Layout of the Text
Intended Users
Summary
REFLECTION ANDDISCUSSIONQUESTIONS
References
PART I: PROGRAM PLANNING AND IMPLEMENTATION
Establish the Need for Programming: Developing the Rationale
About This Chapter
Developing the Rationale
Identifying the Need Through Data Collection
Identifying a Target Region
Identifying a Target Population
Comprehensive Needs Assessment and Analysis
Specific Challenges in Conducting a Comprehensive Needs
Assessment
Strategies to Ensure a Successful Needs Assessment and Analysis
Data Collection Methods and Tools
Community Demography Assessment
Analysis of the Problem
Assessment of the Existing Market
Need Identification Process
Inventory of Assets
Summary: Pulling It All Together—Organizing the Data
Collection Plan and Engaging in Data-Driven Decision Making
CASE ILLUSTRATION
COMMUNITYDEMOGRAPHYASSESSMENTEXERCISE
REFLECTION AND DISCUSSION QUESTIONS
References
Establish a Research Basis for Program Design
About This Chapter
Research Basis for Program Design
Historical and Influential Factors Impacting Program Design
The Impact of the Federal Government
The Impact of Accrediting Bodies
Current Climate and the Adoption of a New Vocabulary
Evidence-Based Practices
Emerging Practices
Empirically Guided Practices
Best Practices
Research Basis
Conducting a Comprehensive Literature Review
Guiding the Literature Review
Sources of Research for the Literature Review
Scholarly Literature
Best Practice Literature
Governmental Publications
Conferences
Summary
CASE ILLUSTRATION
References
Address Cultural Identity Issues in Program Design
About This Chapter
Culturally Based Concepts: The Building Blocks of Our Current
Vocabulary
Diversity
Multiculturalism
Cultural Self-Identity
Cultural Competence
Cultural Competence and Clinical Program Design
Brief History
 Current Climate
Professional Associations
Scholarship
Academic Preparation
National Standards
Accreditation Standards for Mental Health and Human Service Organizations
Funding
Cultural Identity Aspects and Client Populations
Identifying Cultural Identity Aspects of Client Population
Developing Culturally Competent Treatment Interventions
Summary
CASE ILLUSTRATION
DESIGNINGCULTURALLYCOMPETENTINTERVENTIONSEXERCISE
References
Design the Clinical Program
About This Chapter
Comprehensive Program Design
Program Mission and Vision
Constructing the Mission Statement
NAMETHATORGANIZATIONEXERCISE
MISSIONANALYSISTOOL EXERCISE
Constructing the Vision Statement
Core Program Design
Philosophical Foundations of Program Design
Program Interventions
Outputs
Outcomes
Outcome Measures
Design Tools
Logic Models
Project Timelines
 Summary
CASE ILLUSTRATION
LOGICMODELEXERCISE
References
Develop the Staffing Infrastructure
About This Chapter
The Organizational Structure
Governance Structure
Executive Leadership
Management Staff
Administrative Support Staff
Supervisory Staff
Clinical Staff
Case Management Staff
Direct Care Staff
Other Program Staff
Organizational Processes
Communication
Supervision and Accountability
Culture
Staffing Options and Scheduling
Designing the Staffing Infrastructure
Revisiting the Program Design, Research Review, and Market
Analysis
Organizational Chart
Summary
CASE ILLUSTRATION
ORGANIZATIONALCHARTEXERCISE
References
Identify and Engage Community Resources
 About This Chapter
Community: Defined
Community Resources: Defined
Community Resources: Brief Review of the Literature
Community Resource Development
Objectives of Community Resource Development
Augment Service Array
Advocacy Coalition Development
Garner Additional and/or New Funding
Sustainability Planning
Strengthen Communities From Within
Identifying Community Resources: Revisiting the Asset Map,
Community Demography Assessment, Market Analysis, and
Logic Model
Engaging Community Resources
Initial Relationship Building
Initial Preservation Efforts
Summary
CASE ILLUSTRATION
COMMUNITYRESOURCEDEVELOPMENTEXERCISE
References
Identify and Evaluate Potential Funding Sources
About This Chapter
Funding the Program
Types of Funding Sources: Public, Philanthropic, Fee-for-
Service
Public/Governmental Sources of Funding
Philanthropic Sources of Funding
Fee-for-Service Sources of Funding
Types of Funding Opportunities
Governmental Funding Opportunities
Philanthropic Funding Opportunities
 Potential and Common Funding Sources in Clinical Program
Development
Short-Term Versus Long-Term Funding Sources
Diversified Funding
Identifying Potential Funding Sources
Revisiting the Market Analysis
Exploring Funding Sources
Electronic Database Subscriptions for Purchase
No-Cost Electronic Databases
Providers’ Lists and Electronic Notifications
Evaluating Potential Funding Sources
Philosophical Foundations of Funding Source
Funding Parameters
History of Funding
Direct Contact With the Funding Source
Other Pertinent Information
Funding Opportunity Evaluation Tool
Summary
CASE ILLUSTRATION
RESEARCHINGPOTENTIALFUNDINGOPPORTUNITIESEXERCISE
References
Develop the Financial Management Plan
About This Chapter
Finances and Program Development
History and Current Trends
Heightened Scrutiny and Accountability
Turnaround Planning
Changing Attitudes About Financial Knowledge
Financial Planning
Financial Management for Nonprofit Organizations Versus For-
Profit Organizations
Integrated Approach to Financial Management
 Types of Financial Data
Projected Expenditures
Determining Salary Ranges and Other Expenses
Projected Revenue
Budgets
Project-Specific Budget
Annual Operating Budget
Multiyear Operating Budgets
Financial Management
Internal Monitoring and Reporting Processes
The Role of the Board in Financial Management and Oversight
Public Reporting
Annual Report
Tax Return Documents
External Oversight
Regularly Scheduled Auditing
Tax Return Process
Revenue Diversification and Financial Stability
Developing the Budget
Revisiting the Logic Model and the Staffing Infrastructure
Summary
CASE ILLUSTRATION
PROGRAMBUDGETEXERCISE
References
. Develop the Proposal
About This Chapter
Developing the Proposal
Time Considerations in Proposal Development
Depth of the Proposal
Justifying Professional and Organizational Capability
Letters of Support
Collaboration
 Major Aspects of Proposal Development
Internal Versus External Grant Writers/Proposal Developers
Planning for the Work
Skills of Proposal Writing
Internal Reviewers
Other Considerations in Proposal Development
Summary
CASE ILLUSTRATION
References
PART II: PROGRAM IMPLEMENTATION AND SUSTAINABILITY
. Implement the Program
About This Chapter
Fully Implementing the Program
Establishing the Relationship With the Funding Source
Review of the Grant/Contract
Program Implementation Monitoring
Program Management
Leadership and Administrative Oversight
Information Systems
Quality Assurance Planning
Contract Compliance
Summary
CASE ILLUSTRATION
References
. Evaluate the Program
About This Chapter
Evaluation
Revisiting the Program Design
Types of Evaluation
Fidelity Assessment
 Process Evaluation
Outcomes Evaluation
Developing the Outcomes Evaluation Plan
Outcomes Evaluation Design
Selecting Assessment Tools
Establishing Evaluation Time Frames
Comprehensive Evaluation Planning
Considerations in Evaluation
Evaluation as a Tool for Organizational Sustainability
The Costs and Benefits of Evaluation
Creating a Culture of Evaluation
Summary
CASE ILLUSTRATION
COST-BENEFITANALYSISEXERCISE
References
. Build and Preserve Community Resources
About This Chapter
Significance of Community Resources in Program Sustainability
Coalitions
Preserving Coalitions
Partnerships
Preserving Partnerships
Support Agents
Preserving Relationships With Support Agents
The Power of Community Support
Direct and Indirect Benefits of Relationships With Community
Resources
Direct Benefits
Indirect Benefits
Summary
CASE ILLUSTRATION
REFLECTION ANDDISCUSSIONQUESTIONS
 References
. Develop an Advocacy Plan
About This Chapter
Advocacy in Clinical Program Development
History and Significance
Levels of Advocacy
Individual/Client
Community
Public
Professional
Advocacy Strategies
Individual Empowerment and Individual Advocacy Strategies
Community or System-Level Advocacy Strategies
Public Arena–Level and Legislative Advocacy Strategies
Professional Advocacy Strategies
Advocacy and Long-Term Sustainability
Advocacy Orientation
Developing an Advocacy Plan
Summary
CASE ILLUSTRATION
ADVOCACYPLANNINGEXERCISE
References
. Develop an Information-Sharing Plan
About This Chapter
Significance of Information Sharing
Direct and Indirect Benefits
Types of Data
Process Evaluation Data
Outcomes Evaluation Data
Human Resources Data
Sample of Human Resources Data
Financial Data
Compliance and Quality Improvement Data
Other Pertinent Data
Data Reporting
Responsibilities for Data Reporting
Reporting Time Frames
Methods for Data Reporting
Data Recipients
Data Protections and Safeguards
Developing the Data Reporting Plan
Summary
CASE ILLUSTRATION
DATAREPORTPLANEXERCISE
REFLECTION ANDDISCUSSIONQUESTIONS
References
. Attain Program and Organizational Accreditation
About This Chapter
History and Significance of Accreditation
Purpose of Accrediting Bodies
Accreditation Process
Major Accrediting Bodies in Mental Health and Human Services
Council on Accreditation
Commission on Accreditation of Rehabilitation Facilities
The Joint Commission
Costs and Benefits of Accreditation
Relevance to Clinical Program Development
Identifying the Right Fit
Accreditation Planning
Developing the Accreditation Plan
Summary
 CASE ILLUSTRATION
ACCREDITATIONPLANEXERCISE
References
. Putting It All Together: Comprehensive Program Development
in the 21st Century
Comprehensive Program Development
Design
Implementation
Sustainability
Required Knowledge and Skills of Program Developers
Where Do You Go From Here?
Remaining Current and Staying Relevant
Committing to Continued Professional Development
Ensuring and Advocating for Accountability-Based Practice
Summary
ppendix: Web Resources Discussed in Text
Glossary
Author Index
Subject Index
 About the Author

 
Nancy G. Calley, PhD, LPC, is associate professor and chair of the
Department of Counseling and Addiction Studies at the University of
Detroit Mercy. She is also the clinical director of Spectrum Human Services
Inc. and Affiliated Companies. She has worked in the mental health and
human services field for more than decades, primarily in the areas of
juvenile justice, child welfare, mental health, substance abuse treatment,
and traumatic brain injury. She has developed several clinically based
programs and has published numerous articles on program development and
treatment modalities for specialized client populations, including juvenile
sex offenders. As the focus of her clinical work has been on court-involved
individuals and other marginalized populations, she is specifically invested
in advocacy and social justice efforts to ensure access and equity in
treatment for these specialized groups. She has received funding from
several federal agencies and foundations to support her work and continues
to be highly active in comprehensive program development efforts today.
 Acknowledgments

First and foremost, I would like to acknowledge the individuals whom I

have had the privilege of serving during my career as a mental health
professional—each and every one of them has taught me so much. Second,
I would like to acknowledge all the colleagues whom I have worked with in
the human services field over the past decades—this is indeed the best and
most important work to be done, and I could not be more proud to be a part
of such an esteemed group. I would also like to acknowledge my graduate
students of the University of Detroit Mercy Counseling program—your
spirit, thirst for knowledge, and determination bring me endless inspiration.
I also must extend my deepest appreciation to my academic colleagues,
who have provided me with incredible support throughout this process,
most especially Lisa Hawley, Libby Blume, and John Staudemaier. I would
like to thank my colleagues across the country who served as reviewers of
the manuscript draft—your keen eyes and ears and erudite input contributed
immensely to this text. Finally, I must express gratitude to my editor at
Sage, Kassie Graves, whose strong belief in this project from the very
beginning helped make it possible, to both Kassie and Veronica Novak for
their expert editing and support, to Meg Speer for her diligent copy editing,
to Jane Haenel for her thoughtful graphics and other production-related
work, and to the rest of the team at Sage that participated in bringing this
book out.

Publisher’s Acknowledgments
SAGE gratefully acknowledges the following peer reviewers for their
editorial insight and guidance:
David T. Beach, University of Kentucky
John R. Belcher, University of Maryland
Kevin W. Borders, Spalding University
Beulah Hirschlein, Oklahoma State University
Amy Galin Shulin, Kennesaw State University
Rosalie Smiley, California University of Pennsylvania
Karen VanderVen, University of Pittsburgh
Cirecie West-Olatunji, University of Florida
 CHAPTER 1
Comprehensive Program
Development in the Mental Health
Professions

 
Learning Objectives
 

1. Define comprehensive program development

2. Increase understanding of the current climate in human services and
mental health programming
3. Increase understanding of the role of today’s mental health professional
and how it has changed over the past 20 years
 4. Identify the steps involved in comprehensive program development

 
COMPREHENSIVE PROGRAM DEVELOPMENT:
YESTERDAY VERSUS TODAY
 *Fortunately, and largely because of the incredible group of women with
whom I worked and our need to provide the best treatment to our clients,
we struggled, learned, and grew quickly.

Comprehensive Program Development

Today’s Mental Health Professionals and Program Development

Although not that long ago—1993—times have changed dramatically in
clinical program development. This is particularly evident in the
expectations and emphasis placed on clinical program design and the use of
evaluation methods—driven by rigorous and well-supported clinical design,
accountability, and outcomes evaluation. In fact, I would never be allowed
today to get away with what I did in 1993, specifically because today the
stakes have been raised considerably (and necessarily), and as they have
been raised, funding sources have continued to play an increasingly active
role in ensuring that sufficient rigor and accountability exists. This is
illustrated clearly in the requirements of my most recent program
development project (i.e., 2010).
In addition to the changes that have taken place specifically in program
development, the role of the mental health professional has become
increasingly more expansive and the practice of counseling (i.e., therapy)
has become increasingly more scientific. As such, mental health
professionals are currently employed as clinicians, program managers, and
administrators across a variety of settings (e.g., outpatient mental health
clinics, juvenile justice facilities). And they must demonstrate both
evidence-based practices and the ability to administer efficient operations.
Additionally, as society continues to evolve, mental health professionals
continue to find themselves treating an increasing number of specialized
clinical issues (e.g., gambling addiction, self-mutilation, suicide). As a result
of these significant changes, professional counselors and other mental health
professionals must possess both scientific and business knowledge in order
to develop efficient and effective specialized treatment programs that are not
only viable but sustainable. With increasing emphasis on the use of
evidence-based practices and efficient clinical program operations, mental
health professionals must be competent in comprehensive clinical program
development.
To further highlight the dramatic changes that have taken place over the
past several years, I conducted an interview with Roger Swaninger, president
and chief executive officer of Spectrum Human Services, Inc. and Affiliated
Companies. Roger has been with Spectrum for 32 years. He was hired
shortly after the company was founded, and as a result, he provides a
necessary historic perspective on the mental health and human service
industry. In addition, he leads a multifaceted nonprofit organization that has
grown from an annual operating budget of approximately $2 million to
approximately $56 million today, currently consisting of six companies
specializing in adult mental health services and treatment, child welfare,
juvenile justice, substance abuse prevention and treatment, vocational
development, and an outpatient mental health clinic. Roger has witnessed the
dramatic changes that have taken place over the past few decades and has
been able to not only successfully navigate the changes but grow and
develop exponentially despite myriad challenges. In fact, with so many
mental health and human service organizations today finding it increasingly
difficult to remain in business, the sustainability that Spectrum has
demonstrated may offer significant lessons for today’s mental health
professionals.
 
INTERVIEW WITH ROGER I. SWANINGER, PRESIDENT
& CEO
Spectrum Human Services, Inc. and Affiliated Companies (May 2010)
What are the greatest challenges or threats to human services today?
The most obvious challenge today is funding—today there are both shrinking dollars and more
competition, which make this business tougher than ever before. The other great challenge today
has to do with the talent factor—finding and keeping the most talented staff.
What are the most significant differences that you see today versus 30 years ago in human
services?
Before, I could just go up to the state capitol and pitch my idea for a new program, and often
they would go for it. Today, we have to demonstrate that a need exists, provide the research
support for the program design, and demonstrate that we can achieve successful outcomes in
order to gain and maintain funding.
How do you go about making decisions about new program development?
First we ask, is the idea related to programming that we currently do and/or will it enhance what
we currently do? If it is an area that we are already in and it will allow us to expand in that
particular area, it already has a natural lead-in. But there are also a number of due diligence
activities that we have to consider that include both fully examining the finances of the program
and the costs and benefits related to the new program, as well as considering if we have the
appropriate infrastructure to support the new program. You have to always estimate risk-reward
—you have to ask, how much can I afford to lose and what do I have to gain? You must do due
diligence and carefully assess every aspect. All of these factors and more must be considered in
every new venture.
To what do you attribute Spectrum’s staying power—how has Spectrum managed to succeed
despite the challenges that plague human services today?
Diversity of funding, talented staff, and the relationships our staff has built with contractors and
others in the field.
We have an existing pool of talented staff that form the core of the organization—staff that
have been with the agency for a number of years and that form the agency’s executive leadership
team. We have also taken calculated risk in expanding our business. I should add that we are
very aggressive in going after new business. We have lost our share of contracts over the years,
but it hasn’t devastated us because we have built up a large continuum so that we have some
 degree of protection when we do lose specific funding. I think being aggressive has always been
part of Spectrum’s philosophy. Beginning with the founder, Jim Minder, who was very
aggressive in going after new business, we had had a tremendous growth spurt in the late 70s,
early 80s, and then another in the late 90s.
The premise of this book is that today’s mental health professionals must be extremely well
rounded, having concrete knowledge and skills in comprehensive program development,
including finance and human resource management. What do you believe today’s mental health
professionals need to be equipped with?
The best of both worlds is needed—you need to have both a clinical and a business background
today. You must have business savvy and understand your budget as well as understand the
relationship between the services you provide and the finances related to the services. You have
to understand the politics of the business and develop effective relationships with funding
sources and other key groups.
What types of characteristics do you look for when hiring someone today?
First and foremost, you have to have strong interpersonal skills—you have to be able to develop
effective relationships with clients, colleagues, funders, et cetera. You also have to believe in our
mission—in what we are trying to accomplish—understanding that serving individuals in need is
the most important thing that we do.
I also look for someone who wants my job, someone who is hungry and really wants to do
this work and gets excited about it.
Why should mental health professionals want to pursue this work today?
They have an opportunity to have a long-term impact on individuals—to provide input to
program design, learn how to achieve effective outcomes, and understand the difference that they
can make in the lives of others.

Note: Interview used with permission.

Current Climate in the Mental Health Professions

Much of the significant change that the mental health professions have
experienced over the past 2 decades has been largely driven by the managed
care movement and the more recent emphasis on the use of evidence-based
practices (EBPs). Originally articulated by Sackett, Strauss, Richardson,
Rosenberg, and Haynes (2000), and adopted by the Institute of Medicine in
2001, “evidence-based practice is the integration of best research evidence
with clinical expertise and patient values” (p. 147). Applied to mental health
professions, EBPs involve placing the client first, adopting a process of
lifelong learning that involves continually posing specific questions of direct
practical importance to clients, searching effectively and efficiently for the
current best evidence relative to each question, and taking appropriate action
guided by evidence (Gibbs, 2003).
 The adoption of EBPs has been far-reaching and has had a considerable
effect on mental health practices. In fact, Sexton, Gilman, and Johnson (as
cited in Marotta & Watts, 2007) asserted that “the impact of EBPs is
dramatic in that they are fundamentally changing the way practitioners work,
the criteria from which communities choose programs to help families and
youth, the methods of clinical training, the accountability of program
developers and interventions, and the outcomes that can be expected from
such programs” (p. 492). Also referred to as empirically based practices,
EBPs are predicated on the use of scientific methods to evaluate clinical
interventions. As a result, there is greater pressure on mental health
professionals to either utilize clinical interventions that have established
efficacy or engage in rigorous evaluation of unevaluated new practices.
Addressing this movement toward greater intentionality and
accountability in the counseling profession, A. Scott McGowan, editor of the
Journal of Counseling and Development, announced a “Best Practices”
section to highlight evidence-based practices. Since then, a growing body of
best practice literature has emerged addressing assessment of violence risk
(Haggard-Grann, 2007), treatment of obsessive-compulsive disorder (Hill &
Beamish, 2007), and treatment of depression (Puterbaugh, 2006). In
addition, comprehensive clinical interventions for specialized populations of
juvenile sex offenders (Calley, 2007) and adult male survivors of trauma
(Mejia, 2005) have been articulated.
Within the broader mental health literature, specific types of research
based clinical interventions have been proposed, such as Wilderness therapy
(Hill, 2007), rape survivor treatment (Hensley, 2002), and outreach strategies
for female immigrants and refugees (Khamphakdy-Brown, Jones, & Nilsson,
2006). Finally, clinical interventions for such complex issues as dealing with
developmental transitions of young women with attention
deficit/hyperactivity (Kelley, English, Schwallie-Giddis, & Jones, 2007)
have been proposed. Best practice literature typically summarizes research
findings and, as a result, identifies etiological factors and proposes specific
interventions for use in clinical treatment. In this manner, much attention is
given to disseminating research findings for use in future clinical program
development, ensuring that current research is fully utilized to inform
practice.
 Moving beyond best practice literature and its role in the development of
clinical interventions, a very small body of work has begun to emerge
exploring other factors related to clinical program development. Cost
analyses of program development and implementation have been included
(Chatterji, Caffray, & Crowe, 2004; Wilderman, 2005), thus promoting a
practical understanding related to the financial implications in program
development. In addition, the role of interagency collaboration in
comprehensive program development has been examined (Donahue,
Lanzara, Felton, Essock, & Carpinello, 2006). Exploration of both these
areas provides another layer of comprehensive program development that is
not only complementary to clinically focused research but necessary to
forwarding our understanding of comprehensive program development.
Whereas literature related to program development in the mental health
professions has significantly increased over the past 5 years, limitations to
utilizing this literature in practice continue to exist. The growing body of
best practice literature provides necessary direction and guidance to treating
various clinical issues; however, without a sound, comprehensive clinical
program framework, these interventions may not be effectively implemented
and evaluated on a broad scale. This causes a dilemma not only because it
severely limits the use of such research but also because it creates challenges
to perpetuating EBPs, the very issue it is seeking to address. In addition,
literature examining factors such as cost and the role of collaboration in
clinical program development enhance our understanding of program
development but again fail to provide a more complete understanding of
program development. To address each of these issues, mental health
professionals need to be well versed in comprehensive program
development. Moreover, by gaining competence in program development,
mental health professionals will be able to effectively utilize existing
knowledge to ensure that the most effective clinical interventions are
provided to individuals in need.

Comprehensive Program Development Defined

Comprehensive clinical program development includes three major
phases—program design, program implementation, and program evaluation
—and reflects the entire developmental process from start to finish (see
Figure 1.1).
Moreover, clinical program development refers to a systematic process
that requires various stages of preplanning, planning, implementing, and
sustaining effective mental health programming. A wide variety of highly
focused and semisequential tasks compose comprehensive program
development, including
 
developing a program rationale,
conducting a thorough review of the research for use in
program design,
addressing multicultural considerations in program design,
designing the clinical program,
developing the organizational structure,
identifying relevant community resources,
 
Figure 1.1 Major Phases of Comprehensive Program Development
 identifying potential funding sources,
developing a proposal,
developing the initial budget,
implementing the program,
conducting the program evaluation,
engaging community resources,
developing a professional advocacy plan,
identifying methods of data reporting, and
developing plans to pursue accreditation.

 Clinical program development occurs in many venues, including

human/social service organizations; public systems specializing in mental
health, criminal justice, or child welfare; and outpatient clinics. Clinical
program development can be accomplished by mental health professionals
with medium to large-sized staffs as well as those in small nonprofit clinics
with very few staff members and other resources.
Fundamentally, program development in the mental health professions
refers to comprehensive business planning. As such, several key business
principles are used to guide the clinical program development process. These
include such principles as
 
identifying a need for services,
identifying a gap in the existing market,
utilizing research to guide product/service development,
developing the most effective product/service,
developing an effective and efficient infrastructure,
effectively managing finances,
continuously identifying customers,
developing key relationships to support and sustain your
business,
employing a development specialist and a lobbyist to continue
to promote your business interests,
ensuring that you have the best product/service to offer,
regularly sharing your success with stakeholders, and
garnering national recognition.

 Appreciating the inherent relationship or intersection of these key

business concepts with clinical program development is critical to
understanding precisely what clinical program development is in the 21st
century.
Historically, a very small group of mental health professionals has been
resistant to the notion that the mental health industry is indeed a business,
often citing in their defense that the concept of business and that of helping
individuals are diametrically opposed (Hansen, 2007). Mental health
professionals cannot afford to think this way, particularly since our ability to
continue to help individuals is significantly dependent on our business skills.
If we bear in mind that a failure to effectively operate our business (i.e.,
mental health practice) may inevitably result in our inability to continue to
help individuals, the compatibility of concepts related to both business and
mental health practice should become quite clear.

Comprehensive Program Development Model

In order to guide mental health professionals through gaining competence in
comprehensive program development, the Comprehensive Program
Development Model was developed (see Figure 1.2). As you can see, the
first eight steps comprise the components necessary for initial program
development and implementation, whereas the final six steps illustrate the
components necessary for implementation and ensuring long-term program
success and sustainability. It is important to note here that the model is
semisequential, insofar as some of the steps are purposely ordered. For
instance, establishing a need for programming must precede establishing a
research basis in program design, since without sufficient justification of
need, developing a program is futile. However, you may develop a program
proposal and initial budget before identifying a potential funding source or
vice versa, largely depending on proposal type and available funding
opportunities. This is because there are both prescribed funding
opportunities (opportunities in which the type of program needed is
identified as well as the amount of funding available) and self-initiated or
open funding opportunities (opportunities in which you propose the program
and requested budget amount). In addition, some of the steps may occur
simultaneously. A brief overview of each of the steps is provided below to
begin familiarizing you with the model.
Comprehensive Program Development Model: Design,
Figure 1.2
Implementation, and Evaluation
Step I: Establish the Need for Programming
The first step in program development is the identification of a broad
region in which the program will be implemented. Once determined, the
preplanning activities can begin. The results of this first phase result in
identifying a target population, articulating a statement of the
problem/primary needs of the population, and establishing the
philosophical/ideological foundation for the program (e.g., juvenile justice is
rehabilitation-focused).
Establishing the need for comprehensive programming in mental health
counseling involves completing several planning activities that include
conducting the following: a needs assessment, an asset map, a community
demography assessment, and a market analysis. A needs assessment is used
to identify and prioritize the clinical needs of a population. Conversely, an
asset map identifies existing strengths (e.g., community organizing and
cohesion) and resources in the target region (e.g., community organizing
practices, human service organizations). A comparison of the results of the
needs assessment to the results of the asset map can be used to address
identified needs through existing resources. Complementing the needs
assessment and asset map, the community demography assessment identifies
the various population parameters and characteristics, including cultural
identity aspects of community members (e.g., age parameters, prominent
spiritual and/or religious faiths), and provides necessary preplanning data to
ensure that program design takes into account any unique features of the
target population.
Once the primary needs of the region are defined, a market analysis is
conducted in the broader region in order to thoroughly examine providers
that are already involved in working to address the identified problem(s). A
market analysis should involve collecting detailed information about other
providers that includes the following: scope and type of services provided,
including treatment modalities, theoretical base, and use of best practices,
and other relevant business information, including program history, capacity,
staff credentialing, accreditation status, any limitations to service delivery,
and any other relevant demographic information about the program and/or
organization (e.g., other programs operated by organization). When
conducting a market analysis, it is important to not only identify those
providers that are engaged in direct interventions for the identified
problem(s) (e.g., counseling services to battered women) but also those that
may be involved indirectly (e.g., transitional housing for battered women),
as these providers may be essential community resources. Taken together,
these four activities provide comprehensive information about the target
region and allow the program developer to systematically identify the
problem(s) while becoming more informed about other relevant aspects of
the region that will be critical in the program design. As such, a well-
researched rationale is developed to provide evidence for the need for
program development.

Step II: Establish a Research Basis for Program Design

Once effective justification for the program has been established, work
can begin in developing the research basis for the program. This critical step
is necessary to establish an empirical basis for the program and requires the
completion of an extensive review of the literature. The literature review
should minimally include three primary areas: scholarly research; best
practice literature developed by professional associations, governmental
bodies (e.g., Bureau of Justice), or other such bodies with relevant
knowledge of the problem; and practice standards and other literature
compiled by relevant accrediting bodies (e.g., Council on Accreditation).
In conducting a review of the scholarly literature for the purpose of new
program development, the review should be comprehensive and include the
exploration of several key areas. These include various types of data
analyses regarding the identified problem (e.g., demographic issues related
to sexual offending behaviors among adolescent males), empirically based
studies related to the problem, research related to specific clinical
interventions to address the problem, results of relevant program
evaluations, literature reviews of research related to the problem, meta-
analyses related to the problem, and position papers and other scholarship
dedicated to examining and addressing the problem.
To complement the review of scholarly literature, best practice standards,
white papers, and other literature developed by individuals, organizations
(e.g., national task forces), and professional associations relevant to the
problem should be examined. Whereas this type of literature is not typically
published through traditional scholarly outlets, it is often the result of
research findings and emphasizes practice and application. Conducting an
exhaustive review of the current literature related to the problem that
includes both scholarly research and other literature can be used to establish
the empirical foundation for program design.

Step IIa: Address Cultural Identity Issues in Program Design

A significant subcomponent of the literature review involves specifically
focusing on multicultural aspects. Addressing multicultural considerations in
the program design does not constitute an independent step because it is
simply part of the literature review; however, because of its significance and
scope, it is specifically identified as a subset of Step II and a complete
chapter is devoted to it.
Data gleaned from initial assessment activities (i.e., community
demography assessment, community needs and assets assessment) are
reviewed to ensure that the literature review addresses all unique aspects of
the community population, thereby promoting culturally competent program
design. For instance, if much of the research on the treatment of eating
disorders focuses on white female adolescents and teens and your target
population in need of treatment of eating disorders is Latino and white
young adult males, specific attention must be given to program
modifications that can effectively address the differential needs of your
population.
Additionally, attention must constantly be given to exploring issues
related to the target population’s cultural identity throughout program
implementation to ensure that program modifications are continuously made
to support the dynamic nature of multiculturalism. For instance, whereas just
10 years ago it was more common to be married than single in adulthood,
today it is more common to be single than married. In addition, whereas
much research and literature has been devoted to African American studies
in the past, the significant number of biracial and biethnic relationships
producing bi- and multiracial and multiethnic children is again changing
how race and ethnicity are perceived. Likewise, the increasingly global
nature of our world is impacting the role that geography plays in cultural
identity, while at the same time, the growing disparities between the upper
and lower socioeconomic structures and diminishing middle class are
creating new perceptions and meaning of class in the United States. These
constantly changing patterns reflect what I mean by the dynamic nature of
multiculturalism—there are always new and different cultural identity
aspects that need to be considered and existing identity aspects that need to
be reconsidered in order to understand precisely what meaning they have at
any given time and to any given individual.
Because effective programs must be specifically designed for the
individuals being served, multiculturalism and, more important, cultural
competence (i.e., the use of specific knowledge and skills that effectively
address the unique identity of the individual being served) are an inherent
part of initial program design. In addition, cultural competence is a primary
factor related to subsequent program modifications.

Step III: Design the Clinical Program

The program design consists of a comprehensive description of the
program and utilizes specific design tools to illustrate the primary clinical
components of the program. Articulated in the program design are the
program vision and mission, clinical interventions, short- and long-term
outcomes, and outcome measures.
The initial steps in program design involve revisiting both the
philosophical/ideological foundations on which the program is built and the
primary needs to be addressed by the program in order to articulate the
program’s vision and mission. These activities provide particular meaning to
program design by allowing program developers to tie the primary needs and
the ideological basis to the long-term vision of the program and broadly
describe how and what the program attempts to achieve (i.e., mission).
These initial design activities promote cohesion and provide direction for the
more concrete steps of program design that follow.
Once the mission and vision of the program have been articulated, the
core program design components consisting of clinical interventions, short-
and long-term outcomes, and outcomes measures must be identified. The
results of the literature review (Step II) provide the basis for program design
and ensure that the identified clinical interventions have an empirical basis.
 To assist in designing the clinical components of the program, a program
planning tool such as a logic model (Alter & Egan, 1997) may be
particularly helpful. A logic model is used to organize the design structure of
the program and graphically should reflect a straightforward flow in program
design. The logic model evolves forward from the identified need to the
specific interventions to the intended outcomes of the interventions and the
methods by which those outcomes will be measured. Using such a tool
allows the program designer to effectively evaluate the coherence of the
program design.

Step IV: Develop the Staffing Infrastructure

Once the program design has been determined, attention must be given to
developing the appropriate staffing infrastructure necessary to implement
the program. Considerations in this stage include identifying the governance
structure (e.g., board of directors) if the program is being implemented as
part of a new organization, administrative support positions (e.g., human
resources, finance), program administrators (e.g., executive director,
program director), management and supervisory staff, and direct service staff
(e.g., counselors, case managers).
Several issues relative to the development of a staffing infrastructure that
have particular significance to the program’s effectiveness, efficiency, and
sustainability should be considered. First, the results of the market analysis
and logic model should be reexamined to determine the positions needed to
implement each of the program’s direct interventions. Second, the results of
the market analysis should be reexamined to determine how similar program
operations are structured. Finally, all key activities needed to fully operate
the program must be identified (e.g., advocacy, oversight, finance). Each of
these activities provides sound direction to decision making regarding each
of the positions needed based on job duties.
The organizational chart provides a graph of the staffing infrastructure
detailing reporting relationships, number of staff members employed, and
specific duties of staff, thus making the various service components
operational by identifying the responsibilities of the workforce. As a result,
the use of an organizational chart is recommended to identify the necessary
staffing infrastructure. Organizational structure provides the initial
framework for organizational functioning and organizational behavior, and
determining the appropriate structure requires consideration of
organizational theory. Because this text cannot provide the level of detail
needed for a full discussion of organizational theory, interested readers
should pursue literature specifically on organizational theory to acquire
deeper knowledge of this important topic. For the purpose of developing the
organizational staffing structure in new program design, four issues should
guide decision making: job duties of all positions, degree of need for
supervisory and administrative support and oversight, organizational
communication, and organizational decision making. Briefly, multiple layers
of supervisory and management staff may prohibit efficient decision making
and impact effective flow of communication throughout the program. Again,
by allowing perceived effectiveness and efficiency in program operations to
guide decision making regarding staffing infrastructure, the developmental
process related to the staffing infrastructure should proceed smoothly.

Step V: Identify and Engage Community Resources

Initial community resource development involves the identification of
various community resources consisting of like programs, organizations, or
professionals and the identification of the methods by which such
community resources will be utilized in program implementation. Some
community resources may augment program service components as primary
referral sources, whereas others may become part of a collective advocacy
group.
The initial work in community resource development occurs as part of the
asset map and market analysis that are conducted in the initial program
planning step (i.e., establishing a need). At this point, precisely how the
community resources will be utilized in program implementation (e.g.,
Marijuana Anonymous) or program sustainability (e.g., local juvenile courts)
must be determined. Finally, relationships with community resources must
be formalized. Formalizing relationships between the program and the
various community resources involves finalizing all details of the
relationship, minimally including the role of each party, responsibilities, and
lines of communication. Ideally, community resource development should be
guided by three key factors: utilization of current community resources to
augment service array, coalition building with competitors and other
invested stakeholders to increase advocacy strength, and development of
strategic partners and supporters for long-term program sustainability.

Step VI: Identify and Evaluate Potential Funding Sources

Identifying potential funding sources requires extensive research that
includes exploring all potential types of funding sources related to the
specific type of mental health counseling program developed, including
governmental sources at the local (e.g., county health department), state
(e.g., state department of mental health), and national levels (e.g., National
Institutes of Health) and nongovernmental sources (e.g., Annie E. Casey
Foundation). During this phase, it is again necessary to revisit the market
analysis to examine the funding sources related to all current providers and
gain more specific information related to the parameters of funding (e.g.,
term, limitations) as well as any other pertinent information (e.g.,
success/lack of success with particular funders, lessons learned, relationships
with funders).
In completing this phase, it is necessary to gather extensive information
about each potential funding source. This information should minimally
include the following: (1) primary focus of funding source (e.g., children’s
mental health), (2) amount of available funding, (3) length of funding (e.g., 1
year, unlimited), (4) terms and restrictions related to funding, (5) history of
funding source, and (6) other pertinent information. Additionally,
distinctions should be made between contractual funders and grant funders
as two discrete, often noncompeting funding sources that may be used
concurrently. Finally, all potential donors and types of potential donations
should be identified.

Step VII: Develop the Financial Management Plan

Developing a financial management plan requires projections on both
expenditures and revenues and comprehensive planning. The program
budget details total annual expenditures that include both personnel (e.g.,
salaries, fringe benefits) and nonpersonnel costs (e.g., rent, insurance,
professional development, evaluation instruments). Line-item budgets
should be used to provide detailed information on all expenditures.
Particular care must be taken to ensure a thorough examination of all real
costs and potential related costs. Conversely, the revenue report should
identify all actual and potential funding sources, amounts of funding and any
terms or restrictions related to funding (e.g., term-limited, restricted to
nonpersonnel costs), including monetary and nonmonetary donations (e.g.,
building space). It is recommended that great caution be given when
identifying donations in the financial report, particularly because this type of
funding may lack certainty and is often limited to one-time events. As a
result, donations should be considered as extraneous to other forms of
funding.
It is recommended that the financial management plan is developed for 3
to 5 years to reflect long-term planning and to promote increased
understanding of the financial implications involved in program
development. The financial management plan is intricately tied to other
aspects of program implementation and program sustainability, directly
reflecting expenditures related to organizational infrastructure and real and
potential funding sources. Whereas funding sources are initially identified as
specific to financial implications, the following step is dedicated to a broader
exploration of potential funding sources.

Step VIII: Develop the Proposal

Developing a proposal for a clinical program requires pulling together
what has been learned through the comprehensive needs assessment process
and articulating the program design, staffing structure, and budget
information. It is in the proposal development step that you are able to utilize
the sum of work completed in program planning and craft the most effective
argument for funding the program.
Because specific proposal development is extremely varied and based on
the type of funding opportunity being pursued, the chapter on this step deals
with essential considerations of proposal development. These include the use
of a grant writer versus program developer, the use of internal reviewers,
organizing the work of proposal development, and skills needed for proposal
development.
Step IX: Implement the Program
Program implementation deals specifically with putting the program into
place and the various tasks associated with initial implementation. Initially,
this requires a thorough review of the contract/award and establishing an
effective working relationship with the funding source/contract manager. On
an ongoing basis, program implementation includes ensuring that the
necessary structure exists to monitor and support the program throughout
implementation. These activities include, but are not limited to, providing
sufficient administrative and leadership support, acquiring and utilizing
effective information systems, engaging in quality assurance activities, and
ensuring contract compliance.

Step X: Evaluate the Program

Designing the evaluation program actually begins in the initial design of
the clinical program phase with the identification and/or development of the
clinical design, development of program outcomes, and the identification of
measurement tools. At this later step dedicated to finalizing the program
evaluation, three specific types of evaluation should be considered: fidelity
assessment, process evaluation, and outcomes evaluation. Whereas both
fidelity assessment and process evaluation deal with program
implementation, outcomes evaluation focuses on the program’s success or
lack thereof. The relationship between interventions and goals is
reexamined, and both short- and long-term outcome goals are finalized with
identified time frames for attainment. Additionally, outcomes measures are
reexamined to determine their appropriateness in assessing the established
outcomes.
Selection of assessment tools should focus on the relevance of the tool to
specific issues (e.g., depression inventory to screen for depression) and the
efficacy of the assessment tools (i.e., reliability and validity of the measure).
More than one method of assessment for each outcome is recommended to
increase the reliability of the evaluation results. For instance, published
standardized assessment tools (e.g., substance abuse assessment) in
conjunction with observable or other concrete forms of assessment (e.g.,
urine screen) may be used concurrently to increase the strength of the
evaluation results. Finally, data collection methods (e.g., initial intake
interview), responsibility for data collection and analysis, and time frames
(e.g., 6 months post-discharge) are determined in the evaluation design
phase.
The evaluation plan promotes accountability, directly tying interventions
to outcomes and identifying a process and time frames for outcomes to be
evaluated. Moreover, evaluation planning allows clinicians to modify the
original program design as a result of the evaluation. As such, evaluation
planning and program design are dynamic activities that are often modified
over time, contributing to the promotion of evidence-based practices.

Step XI: Build and Preserve Community Resources

Because community resource development is predicated on relationships
between two entities (program and community resource), it is necessary to
view community resource development as consisting of two essential
components: identifying and engaging community resources (Step V) and
building and preserving these relationships. By viewing community resource
development in this manner, the significance of these relationships is
reflected.
Whereas community resources were identified and the relationships were
formalized in an earlier step, Step XI focuses specifically on continuous
efforts to build and preserve these relationships. Establishing regular and
frequent times for communication and instituting regular venues for
information sharing are two examples of methods by which to continuously
attend to relationships with community resources.
This type of community resource relationship building may yield
concrete benefits of ensuring continued business partnerships when services
are being provided by the community resource; however, there are also
potential indirect benefits to such relationship building that cannot be
overlooked. By promoting strong relationships with community resources,
programs often may create new factions of support systems for use in
community advocacy efforts, program promotion, and securing new and
continued funding. As such, community resources play a pivotal role in
developing, implementing, and sustaining successful clinical programs and,
therefore, must be given focused attention throughout a program’s life cycle.
Step XII: Develop an Advocacy Plan
Advocacy planning is critical to program sustainability, and continuous
advocacy planning ensures that the program is responsive to environmental
changes, as well as that the public remains aware of specific treatment needs
being met through programming (e.g., child sexual abuse survivors).
Advocacy planning includes the identification of all governmental and
nongovernmental entities with whom the program will engage in advocacy
efforts (e.g., increase funding for adolescent mental health), identification of
community partners with whom advocacy coalitions might be formed—
drawing directly from previous community resource efforts—and the
articulation of multiple concrete methods of advocacy to be completed
annually by the program (e.g., participation in public hearings, engaging a
lobbyist). Depending on the type of program designed, advocacy efforts may
be varied and include such activities as participating in public hearings,
engaging a lobbyist, and facilitating regular forums to discuss advocacy
issues with community partners. Ideally, multiple factions of advocates
should be engaged and varied methods should be utilized to promote broad-
based advocacy and to ensure that client needs continue to be promoted
through public venues. Additionally, it is necessary to engage in advocacy
efforts at the local, state, national, and international levels. Whereas initial
advocacy begins in the program development phase, particularly in
establishing the need for the program, program sustainability is often largely
predicated on public awareness of specific treatment needs. As a result,
advocacy efforts should be embedded throughout program operations in
order to be systematically and continuously promoted.

Step XIII: Develop an Information-Sharing Plan

Once the evaluation program has been designed, it is necessary to
develop plans for data reporting. Whereas outcomes data generated from the
evaluation program are an integral part of a program data set, output data
(e.g., number of clients served) and other relevant program data (e.g., staff
credentials, operating costs) are also critical components that together
provide a comprehensive picture of the program. It is therefore essential that
this data is regularly shared with stakeholders. To accomplish this, a
comprehensive data-reporting plan should be developed.
 The data-reporting plan should minimally include types of data to be
reported (e.g., outcomes evaluation, outputs), reporting time frames (e.g.,
quarterly, annually), individuals and entities to whom data will be reported
(e.g., funding sources, community members, staff), and methods of data
reporting (e.g., written report, meeting). Whereas all relevant program data
and information should also be captured in the program’s annual report,
attention must be given to determining shorter and more frequent time
frames for reporting data to promote increased accountability in program
design. In fact, doing so may promote a culture of transparency and
continuous evaluation, both of which are integral to the program’s long-term
sustainability.

Step XIV: Attain Program and Organizational Accreditation

The final step in comprehensive clinical program development involves
accreditation planning. Whereas accreditation is a voluntary process and
may be less relevant for certain types of programs than others, attainment of
accreditation reflects the program’s commitment to best practices and
continuous evaluation. Accreditation standards are typically established as a
result of current research and best practices. As such, accreditation can be
used to guide ongoing program development as well as reinforce the
integrity of the program.
Initial accreditation planning involves identifying an appropriate
accrediting body(ies) and establishing a time frame by which to pursue
accreditation. National accrediting bodies specific to clinical programs
include but are not limited to the Council on Accreditation (COA) and the
Joint Council on Accreditation of Health Organizations (JCAHO). Pursuit of
accreditation is a lengthy process and, as such, requires long-term planning.
Additionally, accreditation creates an ongoing expense incurred by the
program and organization. As a result, thoughtful consideration must be
given to determine when to pursue accreditation. Ideally, accreditation
expenses should be reflected in the initial annual budget to prepare the
program’s stakeholders for the ongoing expenditures as well as to reflect the
program’s commitment to pursuing accreditation. Activities related to
accreditation and reaccreditation impact all stages of program development
and often strengthen the program by emphasizing the use of best practices in
design, promoting a culture of evaluation and program accountability.
Therefore, it is recommended that attention be given to accreditation
planning throughout a program’s life cycle.
Recall that at the beginning of the chapter, I raised the notion that
comprehensive program development in the mental health professions is
akin to business planning. I hope that this has become clearer from your
reading so far. And to further clarify the relationship between basic business
principles and comprehensive program development, take a moment to
compare the basic business principles that were presented earlier with the
comprehensive program development model in Figure 1.2. Table 1.1
illustrates this relationship.
Comparison of Basic Business Principles and Comprehensive
Table 1.1
Program Development Model Steps
 As you can see, comprehensive program development and traditional
business planning are not at all conflicting but, rather, are completely
synonymous. It is in this way that I hope you may develop—if you have not
already done so—a keen appreciation for the business that is the mental
health profession.

About the Text

Terminology
What is meant by the term mental health professionals? Mental health
professionals include master’s- and doctoral-level practitioners in
counseling, psychology (clinical and counseling psychology only), and
social work. The primary objectives of each of these disciplines are to help
individuals and groups through the use of various types of clinical
interventions. Whereas the disciplines differ in specific areas, they share
more commonalities than differences, and therefore, the inclusive term
mental health profession/professional is commonly used today. This is the
term most often used throughout this text. Marriage and family therapists are
also included under the umbrella of mental health professionals, as are
psychiatrists that engage in counseling.
The terms program developer, program administrator, and mental health
professional are used throughout the text, primarily to denote the various
roles that mental health professionals fulfill. Mental health professional
refers to the primary identity of the professional, whereas it is indeed mental
health professionals that serve in the roles of program developer, program
administrator, program manager or supervisor, program evaluator, and chief
executive officer in mental health and human services today.
The terms human services and mental health programs are also used
interchangeably throughout the text. These refer to programs that are
designed to address human, social, emotional, and behavioral needs. These
programs are typically funded through governmental, foundation, or other
philanthropic support and may exist as single-program organizations, part of
multifaceted organizations, or within primary, secondary, and postsecondary
educational institutions. Whereas the primary focus of this text is on
nonprofit human service and mental health organizations, with the exception
of funding and financial management, the material in the text is just as
applicable to for-profit organizations.
 Finally, the terms counseling and therapy are used interchangeably
throughout the text. Both terms refer to the therapeutic practice in which
master’s- and doctoral-level mental health professionals (e.g., counselors,
clinical/counseling psychologists, clinical social workers) engage.

Layout of the Text

The text centers on the Comprehensive Program Development Model,
with a full chapter dedicated to each of the 14 steps (with a separate chapter
devoted to multicultural considerations, which is actually a part of Step II of
the model). Each of the chapters provides specific background information
to increase understanding of each major task (i.e., step) involved in program
development, and unique tools are provided to guide program development
activities. Case vignettes are used at the beginning of each chapter to
illustrate the importance of the specific step presented in the chapter, and
case illustrations are used at the end of each chapter to highlight the material
presented in the chapter. A summary chapter is provided as a brief review of
the text and to offer significant issues for consideration in future program
development efforts. A list of key words is provided in the back of the book,
composed of key concepts presented throughout the text. A list of web-based
resources is provided in the Appendix at the end of the book, composed of
websites and specific resources discussed throughout the text.

Intended Users
The text is designed for master’s- and doctoral-level practitioners and
students in any of the major mental health professions (counseling, clinical
and counseling psychology, and social work) as well as practicing mental
health professionals and managers and leaders of mental health and human
service organizations. The purpose of the text is to provide effective
guidance and tools to current or future mental health professionals engaged
in program development efforts. Such efforts might take place in a nonprofit
human service organization, outpatient clinic, school, university, or
governmental organization dedicated to serving individuals in need (e.g.,
state child welfare system, prison). Because of the nature of the framework
provided in the text, the text has specific utility to the practical application of
comprehensive program development.
Summary
Mental health treatment has changed dramatically, particularly in the past 2
decades. With the advent of managed care and the continued development of
knowledge related to mental health treatment, the mental health industry has
increasingly become more scientific and rigorous than ever before. As a
result, the use of evidence-based practices is a standard requirement for
counselors and other mental health professionals. At the same time, mental
health professionals are increasingly responsible for the development of
comprehensive mental health programs—programs that must be research-
based. Therefore, mental health professionals must both understand and
appreciate evidence-based practices but also the manner in which evidence-
based practices are used in the development of comprehensive mental health
and human service programs.
Comprehensive program development in the mental health professions
involves design, implementation, and evaluation and, as a result, requires
broad-based planning and a tremendous amount of work. Additionally,
program development requires scientific, business, and clinical knowledge
and skills. Because mental health professionals are often responsible for
program design and program administration, it is essential that they are fully
competent in comprehensive clinical program development. Clinical
program design provides an essential component of program development;
however, without completing due diligence to determine the viability of a
clinical program (i.e., established need, funding) and possessing basic
budget and management skills, it is almost impossible to implement a
program. Moreover, without advocacy and leadership skills and program
evaluation abilities, sustaining comprehensive mental health programs can
be incredibly challenging.
The text provides a framework to guide mental health professionals in
comprehensive program development. By using the text, it is hoped that
mental health professionals will be better prepared to engage in clinical
program development and gain increased appreciation for the complexities
inherent in comprehensive program development. Furthermore, it is hoped
that the use of such a framework will support mental health professionals in
continuing to make even greater strides in the 21st century by responding
effectively to a climate influenced by evidence-based practices that is wholly
complemented by well-rounded business acumen.
 
REFLECTION AND DISCUSSION QUESTIONS

Please take a few minutes to reflect on the following questions

before moving on to the next chapter:
 

1. What barriers might exist for you in developing a mental

health/human service program?
2. Which of the steps involved in the comprehensive program
development model do you believe might be the most
challenging? Why?
3. What information provided in this chapter would be beneficial
to you in developing a program? Why?
4. What are your thoughts and reactions about the business of the
mental health professions and the notion that business skills are
an essential requirement for today’s mental health
professionals?

References
Alter, C., & Egan, M. (1997). Logic modeling: A tool for teaching critical
thinking in social work practice. Journal of Social Work Education, 33,
85–102.
Calley, N. G. (2007). Integrating theory and research: The development of a
research-based treatment program for juvenile sex offenders. Journal of
Counseling and Development, 85, 131–142.
Chatterji, P., Caffray, C. M., & Crowe, M. (2004). Cost assessment of a
school-based mental health screening and treatment program in New York
City. Mental Health Services Research, 6, 155–166.
Donahue, S. A., Lanzara, C. B., Felton, C. J., Essock, S. M., & Carpinello,
S. (2006). Project Liberty: New York’s crisis counseling program created
 in the aftermath of September 11, 2001. Psychiatric Services, 57, 1253–
1258.
Gibbs, L. (2003). Evidence-based practice for the helping professions: A
practical guide. Pacific Grove, CA: Brooks/Cole.
Haggard-Grann, U. (2007). Assessing violence risk: A review and clinical
recommendations. Journal of Counseling and Development, 85, 294–302.
Hansen, J. T. (2007). Should counseling be considered a health care
profession? Critical thoughts on the transition to a health care ideology.
Journal of Counseling and Development, 85, 286–293.
Hensley, L. G. (2002). Treatment for survivors of rape: Issues and
interventions. Journal of Mental Health Counseling, 24, 330–347.
Hill, N. R. (2007). Wilderness therapy as a treatment modality for at-risk
youth: A primer for mental health counselors. Journal of Mental Health
Counseling, 29, 338–349.
Hill, N. R., & Beamish, P. M. (2007). Treatment outcomes for obsessive-
compulsive disorder: A critical review. Journal of Counseling and
Development, 85, 504–510.
Institute of Medicine. (2001). Crossing the quality chasm: A new health
system for the 21st century. Washington, DC: National Academy Press.
Kelley, S. D. M., English, W., Schwallie-Giddis, P., & Jones, L. M. (2007).
Exemplary counseling strategies for developmental transitions of young
women with attention-deficit/hyperactivity disorder. Journal of
Counseling and Development, 85, 173–181.
Khamphakdy-Brown, S., Jones, L. N., & Nilsson, J. E. (2006). The
empowerment program: An application of an outreach program for
refugee and immigrant women. Journal of Mental Health Counseling, 28,
38–47.
Marotta, S. A., & Watts, R. E. (2007). An introduction to the best practices
section. Journal of Counseling and Development, 85, 491–503.
Mejia, X. (2005). Gender matters: Working with adult male survivors of
trauma. Journal of Counseling and Development, 83, 29–40.
Puterbaugh, D. T. (2006). Communication counseling as part of a treatment
plan for depression. Journal of Counseling and Development, 84, 373–
381.
Sackett, D. L., Strauss, S. E., Richardson, W. S., Rosenberg, W., & Haynes,
R. B. (2000). Evidence-based medicine: How to practice and teach (2nd
 ed.). London: Churchill Livingstone.
Wilderman, R. (2005). A practical and inexpensive model for outpatient
mental health evaluation. Dissertation Abstracts International, 65,
3734(B).
  PART I 

PROGRAM PLANNING AND

IMPLEMENTATION
 CHAPTER 2
Establish the Need for Programming
Developing the Rationale

 
 
Learning Objectives
 

1. Understand the significance of identifying a need in comprehensive

program development
2. Identify and explain the methods and tools used in identifying a need for
programming, including community demography assessment, asset map,
and market analysis
3. Identify four strategies for use in the development of survey and/or focus
group discussion questions
4. Explain how to effectively analyze the sum of data collected in order to
use it in decision making related to program development

 
 IF WE BUILD IT, THEY WILL COME
Tim’s agency had been providing community-based juvenile justice
services for the past 4 years, and Tim was anxious to grow the business
more. Recently, at a conference out of state, he had learned about
adventure-based interventions and had participated in a tour of a ropes
course that one of the agencies had. Thinking about this more on the plane
ride home, Tim realized that his state did not have anything like this, so he
began planning in his mind how he might develop such a program.
Energized, he drew up a basic outline of what the program might look like
and discussed it with three of his key staff members. They, too, were
excited about the possibility of new programming, so Tim scheduled an
emergency meeting with his board to present the idea to them. Tim outlined
his basic business plan, which included purchasing land and a small
building or house that could be used for office space for a small staff. The
land would be used to develop a ropes course and other outside activity
areas so that the agency could begin providing adventure-based
interventions for juvenile offenders. Tim stated that he would use a bank
loan and a small portion of the agency’s endowment to purchase the real
estate, and he quickly showed how both the loan and the endowment
monies could be repaid in less than 10 years as a result of the revenue that
the new program would bring—using the numbers that the out-of-state
program had presented. Everyone’s ears perked up when they heard about
these rates, especially in comparison with the relatively low per diem rate
that the agency’s community-based program currently generated. Tim
further stated that he had spoken to a couple of the leaders of his funding
agency—the state Department of Human Services—and they had expressed
an interest in the program; so Tim was sure they would want to use the
program as an additional treatment option for youth in the juvenile justice
system. In addition, Tim thought there might be a market for other youth
and/or adults in need of an alternative treatment to use the ropes course.
After answering more questions about the new program, Tim had
thoroughly convinced his board members and staff that this really was
something that they needed to do. In fact, he stressed that since adventure-
based interventions were very new, the agency had an opportunity to get in
on the ground level by offering the state the first program of its kind, but
they had to move quickly if they were going to do it. Without hesitation,
 Tim was given the green light, and he and his staff quickly got to work
finding the real estate and developing the program. Six months later, they
held the grand opening for the new adventure center. Tim had had several
conversations with the Department of Human Services about the possibility
of acquiring a contract for the services, but the state administrators stated
that they had just instituted a moratorium on any contracts for new
programs through the next fiscal year. As an aside, one administrator also
shared with Tim that she had not seen the research support for adventure-
based interventions and told him that the state would have to verify the
program’s evidence basis before considering it at a later date—as was
standard practice for all new contracts. Tim began talking to other potential
funding sources and assigned two of his staff members to immediately
explore philanthropic foundation funding to see if there was an interest in
supporting the program. A year later, Tim had only managed to get a
contract with an insurance company so that his ropes course could be an
option for their clients, and over the next 6 months, Tim had two clients
referred from the insurance contract. Tim was sweating—his agency was
going more in debt every day, and his great new idea was not amounting to
anything but a great loss. Tim began wondering how he had gotten himself
into this, and more importantly, he began wondering how he would get
himself out of it.
 
 
CONSIDERING TIM

1. What mistakes did Tim make, and how could they have been prevented?
2. As the agency’s leader, what is Tim’s responsibility to his staff and his
board?
3. What is the board’s responsibility?
4. If you were Tim, what would you do now?

About This Chapter

As you can see in the above case vignette, identifying if a problem constitutes a
need for new programming requires a significant amount of work. This work
involves conducting a comprehensive needs assessment, including gathering
community demography data, conducting a problem analysis and an asset
inventory, completing a market analysis, and determining if a need exists. The
comprehensive needs assessment process forms the basis of this chapter
because it is the critical ingredient in establishing a rationale for new (or
expanded) program development.
This chapter examines the initial step in comprehensive program
development—establishing the need for programming. This step is viewed as
the preplanning stage, since the outcome of this phase will determine if
movement into actual program planning is justified. At times, the results of the
comprehensive needs assessment may simply reinforce the need for
programming, while at other times, the results will not support new
programming. And sometimes, the results will not indicate a need for the type
of programming that had originally been thought to be needed, but another
need for programming may emerge that directs your program planning energies
elsewhere (such as the case that Gerri, Kari, and Jamie discovered, detailed in
the case illustration at the end of this chapter).
We will explore the significance of data collection and analysis and the
subsequent use of data-driven decision making throughout the chapter, just as
illustrated in the above example. In addition, we will examine the
comprehensive needs assessment thoroughly with specific tools provided to
guide each component of the assessment process. Finally, we will explore
methods by which to effectively summarize and report on all the data collected
and analyzed, along with specific tips on data collection tools.
 

STEP I: ESTABLISH THE NEED FOR

PROGRAMMING
Developing the Rationale
If you have worked as a mental health or social service practitioner, you have
likely thought at one time or another, “If only there were a program for
___________” or “We are in desperate need of a program for ___________.”
Perhaps the space could be filled in with substance abuse prevention for
preteens, autism, eating disorders, or traumatic brain injury, or with many of
the myriad issues that currently impact our world. Other often emphatic
statements you may have heard or shared personally might include “Violent
crime is on the rise,” “Teen pregnancy is an epidemic in urban areas,” or
“Anger management is desperately needed here.” Whereas in some cases these
statements may have some factual basis, often they are simply reactions to
specific occurrences that cause us to believe that an issue is much greater than
it actually is. For instance, during one of my most challenging times as a
professional counselor working with juvenile offenders, within a 3-week span,
one of my clients attempted to murder a woman during a carjacking, another
client was placed under suspicion of murdering his mother and soon thereafter
committed suicide, and a third was killed on his front porch by a gang just prior
to my visit to his home. In addition to extreme stress and sadness, these events
led me to believe that violent crime was indeed an epidemic. They reinforced
my thinking that there was a desperate need for additional programs to treat
young offenders and that the programs we were currently using did not seem to
be working very effectively. However, these beliefs were directly based on my
personal experience and, as such, represented only a very limited view of
reality. My view was subjective rather than objective, and objectivity is an
essential ingredient in establishing a need for programming. Without
comprehensive, objective data collection methods that provide empirical
evidence and support for new program development, new program
development cannot be—or more significantly, is not—justified. The question
then becomes, how can we be certain that comprehensive and objective data
exists that provides sound justification to support the need for new program
development?

Identifying the Need Through Data Collection

To answer this question, several activities must be accomplished, including
(1) identifying a target region, (2) identifying a target population, and (3)
conducting a comprehensive needs assessment. These activities compose the
preplanning stage of program development, focusing specifically on gathering
extensive amounts of data and analyzing the data to examine any needs that
may exist. By engaging in this type of in-depth investigation at the preplanning
stage, you are able to make sound decisions about initial program development
that are supported by data. This is referred to as data-based decision making
and may well be one of the most significant skills of a program developer.
Ultimately, the results of the comprehensive needs assessment and analysis will
provide evidence or justification as to what, if any, type of program is needed
in a particular region. In addition, the results of the comprehensive needs
assessment will tell you if new program development is a feasible pursuit when
a need does exist.

Identifying a Target Region

Before moving into a deeper discussion of the needs assessment and
analysis, it is necessary to first identify the broad region or area in which it is
anticipated a new program may be implemented. This is considered the target
region. The term target region, historically used in research efforts, today is
also widely used by funding sources as an identifying factor related to service
delivery.
When determining a target region, there are several factors that must be
taken into consideration, including geographic size, population size, and
population diversity. Each of these factors will likely have a direct impact on
data collection and, subsequently, on the results of the data collection. Because
geographic area does not necessarily impact population size, both geographic
size and population size must be assessed individually and together. For
instance, a city in rural South Dakota may be two to three times as physically
large as an urban city such as Chicago and, at the same time, may have less
than 1% of the population of Chicago. As a result, the diversity of individuals
and needs will likely be limited to the number of individuals in a given area.
This can have an impact on not only the types and range of needs and assets
noted in a particular region but also the subsequent financial implications
related to delivery of new programming (i.e., location of program, mileage
considerations for clients and/or personnel).
Consider this for instance: Schizophrenia and other serious mental health
disorders may be identified as a significant problem impacting 35% of the
population in a town in rural South Dakota; however, 35% of the population is
composed of just four individuals. As a result of this small number of
individuals in need of specialized treatment, it may be financially (i.e.,
supporting a clinician to provide treatment, mileage costs incurred from driving
to and from clients that are scattered throughout a broad region) and logistically
challenging (i.e., finding someone to hire on a contractual basis with
specialized skills and knowledge) to develop programming in the region to
address these needs.
 However, just as particular regions may prove challenging for program
developers because of the number of individuals impacted by a specific
problem and the geographic distances between individuals in need, mental
health professionals/program developers must be fundamentally guided by the
notion that all individuals have the right to access needed treatment. As such,
the concept of social justice must be considered as an underlying force in all
program development, working to ensure that equity and access to services are
provided to all individuals in need. In fact, did you not pursue this type of work
precisely because you wanted to make a difference in the lives of those in need?
Therefore, specific regions should not be discounted simply because there are
too few individuals or too few similar problems, but rather these areas must be
considered in sum with other contiguous areas, and program design should be
innovative enough to address any specific logistical challenges. So to ensure
that the needs of the four individuals in rural South Dakota with serious mental
health disorders are met, a program might be developed to include not only that
particular region but two other contiguous regions that together account for a
total of 12 individuals in need (i.e., 12 clients).
The program design may then consist of biweekly, home-based individual
therapy (alternating weeks), biweekly multifamily support in a central location,
and monthly medication monitoring (if needed). Staffing for the program may
consist solely of one full-time clinical case manager (master’s-level counselor
or other master’s-level clinician who has a blended role of therapist and case
manager/resource coordinator) and one contractual psychiatrist. By structuring
the program in this way with a minimal number of key staff, effective treatment
can be provided (i.e., family support, individual interventions, psychiatric care)
in a delivery format that consists of both home-based and center-based
services, thus sharing transportation responsibilities while promoting broader
community support (i.e., multifamily support sessions).
As I hope this example illustrates, there are indeed several innovative ways
in which regional challenges can be addressed. The goal then for determining a
target region is ensuring a broad enough area to yield various forms of diversity
(e.g., problems, individuals) while simultaneously ensuring that individual
needs are not ignored due to size constraints. Not limiting the target region by
either geographic size or population size but, rather, treating the target region as
flexible, with the ability to expand or reduce as needed, will allow for this to be
accomplished.
 Identifying a Target Population
Once a target region has been identified, a target population must be
selected. Just as a number of factors must be considered in determining the
target region, careful consideration must be given to determining the target
population. The target population refers to the primary or core group of
individuals to whom you ultimately plan to deliver services. Whereas it is
important to not limit your target population to the point that you are unable to
acknowledge significant needs of multiple groups, it is equally important to
identify any specific population characteristics that you are most interested in
treating. In making these initial decisions, the following questions may be
helpful to consider:
 
Is there a particular age group that I am targeting (e.g., teens,
adults, elderly)?
Is there a particular gender group that I am targeting (i.e., females,
males)?
Is there a special condition or circumstance that I am targeting
(e.g., displaced workers, high school dropouts)?
Is there a special need that I am targeting (e.g., mental health,
addiction)?

 As you can imagine, the degree to which a target population is identified
may vary greatly. For example, here are some possible target populations in
ascending order of specificity to illustrate the degrees to which you may
specify a population:
 
Elderly individuals (defines one age group)
Elderly individuals with mental health care needs (defines one age
group with broad clinical needs)
Elderly individuals with major depression (defines one age group
with a specific clinical need)
Elderly individuals with major depression living independently
(defines one age group with a specific clinical need in a particular
living situation)
  Whereas it is essential that both a target region and a target population be
identified in order to conduct the needs assessment, both of these areas must be
viewed as tentative since the results of the needs assessment may suggest
otherwise. For instance, as you work through the needs assessment process,
you might discover that there is a greater need for substance abuse treatment
for adult women even though you had originally targeted male adolescents.
Likewise, you may find that within your initially targeted region there is not a
need for new program development to treat gambling as you had originally
thought; however, two other nearby regions do have this need. This type of
tentative thinking is another essential skill that you need to conduct an effective
preplanning assessment since it allows you to be open to the data that is
presented and able to flexibly change directions in new program development
when warranted.

Comprehensive Needs Assessment and Analysis

Once the target region and the target population have been identified, a
comprehensive needs assessment and analysis must be conducted. “A needs
assessment describes the target population or community, including
demographic characteristics, the extent of relevant problems or issues of
concern, and current services” (Lewis, Packard, & Lewis, 2007, p. 29). A
comprehensive needs assessment consists of a methodical and comprehensive
evaluation of existing needs and assets and allows for sound initial decision
making regarding new program development. Moreover, a needs assessment
allows you to identify the gap between a target population’s needs and existing
services, providing essential information about how new programming can be
designed to most effectively respond to needs (Darboe & Ahmed, 2007).
To conduct a comprehensive needs assessment, the following assessment
and analysis activities must be completed:
 

1. Assessment of demographic characteristics of the community

2. Analysis of problem(s)
3. Analysis of existing treatment and service providers in the region
4. Identification of needs
5. An inventory of assets
  
 To accomplish these assessment and analysis activities, five tools are
needed. Table 2.1 illustrates each of these methods with its corresponding tool.
 
Table 2.1 Comprehensive Needs Assessment Methods and Tools

 
Taken alone, each of these five data sets provides important information
about a given region but not enough information to effectively act on.
However, taken together, these five data sets provide comprehensive
information to help engage in decision making about new program
development and allow a clear and accurate portrait of the region to emerge. I
liken this process to shuffling through various sequences of letters during a
visit to the optometrist. As you move up the chart, the lines become a bit more
focused until you reach the line that provides you all the information needed to
see clearly what is in front of you (see Figure 2.1).
The amount of work required to conduct a comprehensive needs assessment
is tremendous and requires a great deal of attention to detail, objectivity, and
trust in allowing the data to guide the decision-making process. In short, a
scientific approach must be adopted in order to complete an effective needs
assessment. Whereas the process may seem both tedious and challenging, the
outcomes of the assessment and analysis easily justify the amount of work
involved.
Figure 2.1 Ingredients Needed to Gain an Accurate Picture of the Region

Comprehensive Needs Assessment

Asset Map
Identification of Needs
Market Analysis
Problem Identification
Community Demography Assessment
Ndnigydgidios
Olndigkxoiwlighpwwog
Pfleoighwjgpodt

Specific Challenges in Conducting a Comprehensive Needs

Assessment
To ensure the most accurate results, you must be sure to avoid specific
challenges related to gathering comprehensive data. To aid in this, Finifter,
Jensen, Wilson, and Koenig (2005) identified three key problems with
conducting a needs assessment: (1) relying on intuition or anecdotal
information rather than empirical evidence, (2) using one measure on a specific
sector of the population that may not take into account the varying needs of
specific subgroups (e.g., males vs. females, various ethnic groups) rather than
collecting comprehensive data from various subgroups as well as the target
population, and (3) completing a comprehensive needs assessment and failing
to provide feedback to the various stakeholders and/or failing to implement
programming to address any of the identified need(s) resulting from the
assessment (stakeholders are all the various individuals, such as community
members, officials, and various levels of professionals working in the region in
schools, law enforcement, social service agencies, and other organizations, that
are either directly or indirectly involved in the target region). Put another way,
you must be careful to ensure that
 
needs assessments are based on factual data,
data collection is not limited to only the target population, and
follow-up occurs to inform the various stakeholders about the
results and next steps following completion of the needs
assessment.

Strategies to Ensure a Successful Needs Assessment and Analysis

Each of these challenges can be used to guide the development of a
comprehensive needs assessment to ensure that such common mishaps can be
avoided. In addition to avoiding these challenges, there are several specific
recommendations that should be considered when designing a needs
assessment:
 

1. Identify all the stakeholders in the target region.

2. Provide a full explanation of the needs assessment process to all
stakeholders.
3. Garner stakeholder support prior to beginning the needs
assessment.
4. Involve stakeholders in the design of the needs assessment
process to ensure comprehensive data collection.
5. Gather multiple forms of empirical data from multiple sources.
6. Gather multiple forms of stakeholder input through a variety of
tools.
7. Gather data on the broad population within the target area.
 
 Briefly, the success of a needs assessment depends on its scope and
accuracy, both of which are dependent on the involvement of a vast majority of
the population or stakeholders. It is therefore necessary to first identify all the
major stakeholders and provide a full explanation of the needs assessment
process that includes the following:
 
The reason for the needs assessment
The types of data to be collected
The types of data collection to be used
The methods for ensuring the protection of the data and the
privacy of individual participants
The manner in which the data will be used
The methods for reporting the results of the data collection
process to the stakeholders

 When conducting a comprehensive needs assessment, you must provide a

full explanation of the needs assessment process to all participants in order to
demonstrate ethical conduct; however, by fully explaining the purpose and the
process, stakeholders may also become fully engaged in the process (an added
benefit) and, as a result, may positively impact the data-collection process,
increasing the scope of data collected. For instance, residents can inform you
about the most effective methods to use to engage a broad part of the
population and may suggest a visit to specific places of worship or informal
clubs or associations as potential venues for reaching a diverse array of the
population. Because residents and other stakeholders often have inside
knowledge as to how their communities operate, they can provide significant
guidance to you to ensure that no one is overlooked. It is in this manner also
that stakeholders can be instrumental in further developing the needs
assessment by identifying other potential methods for data collection that the
program developer may not have considered and, thus, uncovering additional
data.
The effective assessment of needs is crucial to any program development
effort, and without it, effective planning is largely left to chance. In mental
health and social service practice, a need refers to an existing social or clinical
problem and an evident gap in services. Therefore, an untreated problem in a
given area establishes a need for specific services. For instance, if a particular
region has a high incidence of substance abuse among young adults and the
community lacks substance abuse treatment programming, substance abuse is
the identified problem and, subsequently, substance abuse treatment is the
identified need. It is in this sense that social or clinical problems become
translated into needs. A significant concern of program developers is ensuring
the accurate identification of a problem and the subsequent accurate
identification of a need. To accomplish this, an assessment of the region’s
problems must be conducted as well as an assessment of the existing market
that is addressing the problems. Examined together, these two data sets will
allow you to identify the existing gaps in treatment/services, thus identifying
the needs. To further enhance the needs assessment and analysis process, two
other data sets must be examined: demographic characteristics and assets of the
community. Each of the five activities (i.e., methods) that compose the
comprehensive needs assessment and analysis will be examined next, along
with a discussion of each of the tools needed to complete each activity.

Data Collection Methods and Tools

Community Demography Assessment
The initial data to be collected involves broad-based demographic data
about the target region and the target population. Demographic information
about the community is essential to developing a clear understanding of the
various population parameters and characteristics of the community. This type
of data is some of the richest data available as it helps both broadly define a
region/community as well as highlight some of the unique identity aspects of
the community. Various types of empirical data are used to provide
demographic information, often involving multiple data sources that include
large-scale governmental data (e.g., U.S. Census, abuse and neglect data), state
and regional data (e.g., local health department statistics, regional arrest rates),
and region-specific data (e.g., high school dropout rate). I refer to this process
of systematically gathering data sets, beginning with the largest data set
(national data) and moving to the smallest data set (e.g., community data), as
data layering. By collecting these various levels of data and comparing and
contrasting the data through analysis, specific data begin to come into clearer
focus and take on new meaning as it is compared with other data sets (as
illustrated in the case study at the end of the chapter). For instance, national
crime statistics may reveal a 28% drop in homicide rate over the past decade,
but local crime statistics indicate a 32% increase in homicide over the past 3
years. This dramatic difference in data trends suggests that local crime is an
area that may indeed represent a significant need and, as a result, must be
further explored through data collection and analysis to increase understanding
of the scope of the issue.
Demographic data typically is drawn from existing data sets; therefore, the
task of the program developer is not to collect existing data sets but rather to
collectively compile existing data sets in order to productively utilize the data
through analysis. In short, the program developer must
 

1. identify an exhaustive list of the various types of data to be

examined,
2. identify the corresponding data sources,
3. locate the data, and
4. conduct an in-depth examination and analysis of the data.
 
 From the results of this endeavor, various types of trend data should begin to
reveal detailed information and nuances about the region.
To gather the demographic information, a Community Demography
Assessment Tool is used (see Box 2.1).
 
BOX 2.1

COMMUNITY DEMOGRAPHY ASSESSMENT TOOL

 

1. After identifying the target region and target population, determine the
various types of empirically based demographic data needed to provide a
comprehensive and accurate understanding of the region’s population
characteristics (e.g., age, gender, financial information) from all three
levels: national, state, and local.
2. Identify the sources for each of the data sets: federal (e.g., U.S. Census
data, U.S. Department of Health and Human Services data), state (e.g.,
 state department of social services, state department of education), and
local (e.g., county/city health department, police department, schools).
3. Identify the various aspects of cultural identity (e.g., religion/spirituality,
ethnic groups, vocations, racial groups, first-generation immigrants) that
are present in the environment through population characteristics,
physical developments (e.g., places of worship, businesses), and other
venues.
4. Gather the various data sets from the sources, accessing easily available
published data electronically or in print format (e.g., governmental
statistics) and communicate with state and local agency officials to
acquire published data that is not easily accessible (e.g., schools, local
agencies).
5. Comprehensively analyze the data sets, examining the data separately and
in total, comparing the various data sets in order to note any trends (e.g.,
low socioeconomic status in region) or areas of significance (e.g., high
regional incidence of high school dropout rate).
6. Following the analysis of all the demographic data, develop a brief
community demography summary that highlights the various population
parameters of the target region.

The guiding perspective of the community demography assessment is to

collect enough data to ensure that an effective understanding of the
population’s characteristics can be achieved, especially as considered in
conjunction with the region’s unmet needs and assets/strengths.
Three types of data should be collected for the community demography
assessment:
 

1. Federal governmental and other data collected at the national

level (e.g., U.S. Census data, Centers for Disease Control data)
2. State governmental data and data collected by other organizations
at the state level
3. Local data collected by local municipalities, schools, and other
local organizations focused on the county, city, or town, including
 data related to specific physical structures relevant to various
aspects of cultural identity
 
 Whereas U.S. Census data should be gathered as part of any community
demography assessment, other types of national data (e.g., child abuse and
neglect data vs. addiction prevalence data) should be gathered as relevant to the
target population and/or broad-based special condition or problem identified
for future program development (e.g., children, addiction). The types of state
and local data to be gathered should also be based on their relevance to the
identified target population or initial target problem, with the perspective that
more data is better than less data. If, for instance, the target population is
children, demographic data from schools, state and local health departments,
child welfare organizations, juvenile law enforcement and juvenile justice
organizations, children’s mental health and substance abuse organizations,
schools, and other institutions dealing with children should be gathered.
The purpose of the Community Demography Assessment Tool is twofold,
ensuring that comprehensive data is reviewed and allowing for the data to be
organized in a meaningful manner to aid in data analysis. To ensure that the
scope of the community demography data is inclusive, a list of specific national
data sets that should be reviewed in most preplanning efforts is provided in
Table 2.2.
With these initial data sets providing a sound starting point and the
beginning foundation of demographic data, other essential data unique to the
program development project must be identified and examined. For instance, if
substance abuse has been identified as the broad-based need in a region, other
essential demographic data may include items such as the prevalence of
substance abuse in the community, primary types of illicit substances used, and
primary age range of individuals that abuse substances. In addition, issues
related to cultural identity must be explored to ensure that the various unique
factors of the population are addressed in program design.
Cultural identity refers to the various aspects or characteristics that are
assigned to us (what we have little to no control over/what we are born with or
into), such as class, ethnicity, initial religious or spiritual beliefs, initial
geography, language, class, race; the unique characteristics that we acquire on
our own (e.g., education, class, religion/spirituality, intimate partner status);
and the unique characteristics that impact us (e.g., historic events, chronic
illness, death of loved ones; Arredondo & Glauner, 1992). By thinking about
cultural identity in this manner, each of our unique cultural identities is
composed of three dimensions or layers:
Table Recommended Data Sets to Include in the Community Demography
2.2 Assessment
That which we are born with or into
That which we choose or direct
That which happens to us that influences our identity
development
 These layers may converge with one another to create specific meaning at
specific times (e.g., Arab American female in post-9/11 United States). As
such, cultural identity is contextual—with certain aspects and/or the
convergence of certain aspects giving unique meaning to us in specific places
and at specific times. In fact, in the 1990s, I paid little attention to being
Lebanese-American; however, after 9/11, I unfortunately found that much more
attention was paid to me simply because of my Arabic background.
In terms of program development, cultural identity provides a rich source of
information that often requires specific program interventions or modifications
in order to respond effectively. For instance, age is one unique cultural identity
variable that should be explored with relation to substance use, while other
cultural identity aspects that should also be explored include employment
status, marriage or intimate relationship status, ethnicity, and religion, to name
just a few. Creating a culturally competent program requires gaining the
awareness, knowledge, and skills necessary to effectively address various
issues related to the cultural identity of clients. Whereas initial efforts toward
increased understanding of multiculturalism occur in this preplanning stage of
program development as a result of examining the population characteristics,
effectively addressing these various cultural identity needs through treatment
and service delivery occurs in program design (see Chapter 4).
Utilizing a variety of data collection tools that include, but are not limited
to, telephone calls, data drawn from secondary sources (e.g., interviews with
local social service providers/community developers), and focus groups, you
must seek out specific information related to cultural identity and other
demographic characteristics. When doing this, it is important to keep in mind
that physical structures (e.g., places of worship, schools, nursing homes) and
other data indicators (e.g., number of children receiving free lunch) are often
rich sources of information about the characteristics of a region’s population.
Using the Community Demography Assessment Tool helps organize your
data-gathering process and allows you to examine the results of your efforts.
Whereas the data is reviewed throughout the process individually, once all the
relevant data has been gathered, you are able to view the sum of the community
demography data and generate a rich portrait of the community.
Geographic information systems (GIS) may also prove helpful in the
community demography assessment, as well as in other parts of the needs
assessment process. In fact, the widespread availability of GIS software has
proven useful in epidemiologic studies (Zandbergen & Green, 2007) and other
community studies. As such, technologies such as this and others may continue
to develop in the 21st century, providing us with ever more tools for use in
better understanding communities.

Analysis of the Problem

After completing the community demography assessment, it is time to move
to the next step in the needs assessment process: the analysis of problem(s) in
the region. This second step draws directly from the community demography
assessment, using the resulting data as foundational information about the
region and thus providing a starting point for further investigation. Whereas the
community demography assessment relies heavily on gathering large data sets
from empirical data sources (e.g., governmental), the process of identifying
existing problems in the region focuses on gathering more specific data sets
(e.g., schools, health department) and gathering data from stakeholders (i.e.,
stakeholder input) through a variety of means. As discussed earlier in the
chapter, stakeholders are critical to the success of the needs assessment process
and, as such, great care must be taken in engaging stakeholders in the process,
particularly during the problem analysis.
Stakeholder input can consist of various types of data such as perceived
problems and needs of the target region, perceived changes in the target region
(e.g., increase in the local homeless population), and opinions regarding
methods to resolve potential issues. Whereas stakeholder data is an integral part
of the problem analysis, a comprehensive array of both empirical and other
data must also be collected to ensure accurate analysis. In fact, multiple forms
of empirical data must be collected to enlarge the data picture and to ensure
that specific data is not overlooked. A thorough problem analysis should yield
a clear and accurate understanding of the problems and the scope of the
problems in the region in the same manner that a thorough community
demography assessment yields a complete picture of the community’s
population parameters. In order to maintain a systematic approach, the problem
analysis must focus specifically on identifying and understanding the problem,
not on generating solutions (Kettner, Moroney, & Martin, 2008).
To conduct the problem analysis, the Problem Analysis Guide can be used
(see Box 2.2). To begin the analysis, data must first be gathered from various
stakeholders. In fact, stakeholder input should be gathered from a broad faction
of the population, again to ensure a comprehensive scope. Multiple methods
should be used, including telephone, e-mail, face-to-face surveys and
interviews, focus groups, and community forums.
 
BOX 2.2

PROBLEM ANALYSIS GUIDE

The problem analysis process is used to identify and prioritize the clinical
needs of a population, allowing for a methodical and comprehensive
evaluation of these needs. Ideally, the problem analysis process occurs
immediately following completion of the community demography
assessment so that the results of the community demography assessment
are used to guide data collection in the problem analysis process.
 

1. Drawing from the community demography summary, identify any

specific areas of particular relevance that require further information (e.g.,
drug[s] of choice among substance users, school dropout rate) in order to
increase your understanding of the target population. Some of this data
may not be readily available (e.g., primary behavioral issues witnessed in
the school) and may require discussions with local officials and the
development and use of various data-collection tools by the program
developer (e.g., surveys, interview guides, focus group questions).
2. Identify the potential sources for each of the types of data needed.
3. Gather all available data from the sources.
4. Gain additional empirical/factual and informal input from agency officials
about other characteristics of the target population and any perceived
problems (e.g., increase in marijuana use among teens) and unmet needs
in the region (e.g., lack of mental counseling services). Whereas it is ideal
that this type of data be empirically based (drawn from existing records),
if empirical data is not available regarding specific issues, gather as much
informal data from credible sources (e.g., agency/institution officials,
teachers) as possible to strengthen the data analysis process.
5. In addition to information regarding perceived problems and unmet needs,
begin to gather data regarding existing assets and/or strengths within the
region (e.g., community organizing, percentage of longtime residents).
 6. Through communication with local officials (e.g., health department,
schools, police), develop a plan for gathering additional informal
information about any perceived problems, unmet needs, and
assets/strengths in the region from various community members through
focus groups, telephone or in-person interviews, surveys, or other venues.
7. Gather the informal data through the identified venues regarding
perceived problems, unmet needs, and assets/strengths from various
community members and other stakeholders (e.g., places of worship,
business owners).
8. By carefully reviewing the results of the community demography
summary with the various types of data gathered through the problem
analysis process, identify each of the problems and then prioritize the
problems, identifying two to four primary problems and the rationale for
the prioritization.
9. Synthesizing the information about data types and methods from both the
community demography assessment and the problem analysis process,
develop a brief summary of findings outlining this. This summary—the
Data Collection Report—should minimally include the following
information:
 
Types of data collected and rationale
Data results
Methods of data collection used
Sources of data
Data-collection time frames
Limitations to data-collection methods (e.g., number of respondents,
survey data vs. archival data)
Exhaustive list of identified problems
Two to four primary problems and the rationale for each

Because stakeholder input is gathered directly from individual stakeholders,

it is imperative that tools used to gather such data are both efficient and
effective—namely, that tools are able to generate the most necessary types of
information in the shortest amount of time. Achieving both efficiency and
effectiveness requires the development of specific questions that are designed
to do just that. Unfortunately, survey/interview guide construction is an area
that many struggle with, and as a result of poorly constructed surveys/interview
guides, time may be spent collecting information that may not be highly useful.
To avoid this and to promote the effective development of survey/interview
questions, the following strategies may prove helpful:
 
Limit the number of questions by ensuring that information
generated from each question is absolutely necessary.
Evaluate each question to determine if it is designed to generate
the type of information that you are seeking.
Identify the appropriate mixture of ranked question responses,
closed-ended questions, and open-ended questions to yield both
quantitative and qualitative data.
When using ranked question responses, determine the type of
scale to be used to yield the most effective data.
Ensure that all questions are clearly focused on a single issue to
reduce ambiguity in responses.
Avoid double-barreled items that focus on more than one issue
and, therefore, create challenges in interpreting results.
Use age-appropriate language relevant to your participants.
Capture any necessary demographic information about
participants at the beginning of the survey.
Provide informed consent to each of the participants and a full
explanation of the rationale for gathering the data, privacy and
confidentiality protections afforded to participants, and the
manner in which the survey results will be used.

 In addition to the strategies listed above, please refer to the Survey
Construction Tips (Figure 2.2) for additional strategies to consider specifically
when developing a survey, interview guide, or focus group questions.
Because informal data gathered through survey, focus groups, or interviews
constitutes subjective data rather than empirical data, when summarizing the
findings, it is essential that you fully explain the procedures and the findings to
ensure an accurate understanding of the results. Minimally, in discussing the
procedures, you should explain the method(s) by which the data was collected
(e.g., survey, focus group, interview), the rationale for using the method(s), the
rationale for selection of participants, the number of individuals participating
(e.g., 62), and the percentage of the population of which the participant group
is composed (e.g., 11%). In addition, you must identify the degree to which the
participant group reflects an appropriate sample of the population and/or any
limitations to this. In terms of reporting results, you should again seek to
provide as much information as possible to ensure accurate interpretation of the
results. You should provide both a brief narrative summary of the procedures
and the results of the assessment as well as the actual assessment items with the
corresponding response rates and the raw number of respondents per response
(e.g., 48% [n = 398] of the respondents were between the ages of 18 and 24).
As stated earlier, multiple forms of empirical data must be collected to
enlarge the data picture and to ensure that specific data is not overlooked.
Common types of readily available empirical data consist of U.S. Census data
for regionalized demographic information related to residents (e.g., age, race,
ethnicity, household income), various prevalence data from governmental
sources (e.g., child abuse data, crime data), school-based data (e.g., graduation
rate, student performance rates), and various forms of data collected by social
service and other relevant providers (e.g., trend data in mental and medical
health clinics)—some of which was gathered in the community demography
assessment. Therefore, the results of the community demography assessment
should be used to specifically direct other data collection needs so that you can
identify specific problems. For instance, if the results of the community
demography assessment indicate a 32% high school dropout rate, during the
problem analysis, you would want to gather more detailed information to better
understand this finding. To accomplish this, you would gather additional data
from the schools related to this, such as time frame during which kids are most
likely to drop out, demographic characteristics of kids that drop out (e.g.,
academic history, employment status at time of dropout, home situation,
ethnicity, emotional/mental/physical disability status, class status, race), and
any additional information that may be a perceived factor related to dropout
rate or that might be perceived to be related in some other way to the dropout
rate. By doing this, you are able to dig much deeper into understanding the
meaning of various data, as well as better see the link between the data
collected during the community demography assessment and data collected
during the problem analysis.
 Figure 2.2 Survey/Focus Group/Interview Guide Construction Tips

The following tips are strategies that may prove useful in ensuring effective
survey construction as part of a comprehensive needs assessment process.
1. When developing the questionnaire, identify the major categories of
inquiry and the rationale for each in order to organize the questions
accordingly.
2. Limit the number of questions to no more than 15 items, with
justification for each item, allowing for gathering the most essential
information in the shortest amount of time being the guiding force (if a
specific in-depth inquiry is warranted, the number of items may increase
but, again, only with sound justification).
3. Determine the type of Likert scale to be used-3-, 4-, or 5-point-and if
forced response should be used.
Example of 4-point scale with forced response (no option of
“undecided”):

Example of 5-point, unforced response, allows for participant to remain

neutral:

4. Ensure all questions are clearly focused on a single issue to reduce

ambiguity in responses.
Example: If I have a problem, I know there is someone that will listen to
me.
5. Avoid double-barreled items that focus on more than one issue and create
challenges in interpreting results.
 Example: If I have a problem, I know there is someone that will listen to
me, and I have talked to others before when I have had problems.

6. Use a variety of closed-ended and open-ended items to enhance results,

providing both quantitative and qualitative data.
Example of closed-ended item: I had a choice in the development of my
counseling goals.
Example of open-ended item: What activities (e.g., games, talking,
journaling) that you participated in during counseling helped you learn
the most about yourself?
7. Use age-appropriate language relevant to your participants.
8. Limit the number of questions to increase potential participation, and try to
limit the survey to one page.
9. Use shading and/or other formatting techniques to increase the utility of the
survey.
Example of shading to set off responses: If I have a problem, I know
there is someone that will listen to me.

10. Provide a rationale for the survey to provide participants with reason for
completion.
Example of rationale: Please take a few minutes to answer some
questions about your satisfaction with our clinical services. Your
responses will be confidential. Please do not put your name on the
survey, in order to keep it anonymous. The purpose of this questionnaire
is to help us improve our clinical services for our clients. Only
aggregate data will be published; no individual data will be published.
11. Provide instructions for completing the survey, including anonymity status
of participants.
Example of confidentiality and anonymity of participants: Your
responses will be confidential. Please do not put your name on the
survey, in order to keep it anonymous.
12. Include statement of informed consent on the survey.
Example of informed consent: Participation in completing this
questionnaire is completely voluntary, and you have the right to refuse
to participate. There are no known benefits or risks to you in completing
this questionnaire. Completion of the questionnaire implies your
consent. If you do wish to complete the questionnaire, please do so and
place the completed questionnaire in the envelope provided. If you do
not wish to complete the questionnaire, please place the questionnaire in
the envelope provided.
13. Capture any necessary demographic information about participants at the
beginning of the survey.
Examples of demographic information:
Gender: __ Male __ Female
Age: __ Under 13 __14–17 __ 18–24 __ 25–34 __ +34
Length of time in therapy with current counselor:
__ Less than 3 months __ 3–6 months __ 6–12 months __ More than 1
year

The end result of the problem analysis—derived from analyzing the results
of both community demography and problem analysis results—is the
identification and prioritization of two to four problems. This supplies you with
a specific direction as to how to move forward in the needs assessment process.

Assessment of the Existing Market

Whereas the problem analysis is designed to accurately identify problems in
the target region, only problems that are not being addressed constitute needs
and, thus, provide justification for new program development. Therefore, to
determine if the identified problem does indeed constitute a need, a thorough
assessment of existing providers in the region must be conducted. This type of
assessment is a market analysis.
Market analysis is the identification and study of a market to determine if a
particular good or service is needed (Emerson, 2008) and is based on the basic
premise of supply and demand. By conducting a market analysis for clinical
program development, you are able to determine (a) if the identified problem in
the region is being addressed by existing providers and (b) the extent to which
the problem is being addressed by existing providers. The results of this
analysis are then used to indicate either that there is no need for new program
development or that new program development is indeed warranted.
Whereas a market analysis is critical to providing evidence against or in
support of new program development, the results are equally significant to the
program design stage, particularly since the results of the analysis can provide
information about how providers are addressing specific needs. By gaining this
information about potential competitors, program developers may be able to
differentiate their services and, thus, offer a unique product (i.e., treatment).
Because the market analysis serves dual purposes, it is most effective as well as
expedient to complete a full market analysis as part of this preplanning stage,
gathering all the necessary data for both the needs assessment process as well
as the program design process once and simply utilizing the data during the two
different stages. This ensures that you gather data only once yet have all the
essential data available for different types of decision making. To promote full
understanding of the market analysis, I will first address the use of the market
analysis in justifying new program development and then cover the use of the
market analysis in program design (Chapter 5).
To accomplish an effective assessment of the existing market for use in
preplanning, the following areas must be examined:

The number of providers working to address the identified

problem
The scope of services of each provider
Program capacity and any trends in program capacity
Funding sources and trends in funding
Length of time provider(s) has been working to address problem
 Other issues related to the continuation of services to address the
problem

Each of these areas must be thoroughly explored to attain firm knowledge

about the degree to which identified problems are being addressed by existing
providers and to indicate if additional programming is indeed needed and is
feasible for a new organization. Whereas the results of the market analysis may
very well indicate that the existing providers are able to address only a fraction
of the population’s problems due to capacity constraints, the existing providers
may have funding locked up for the next several years, with no additional
funding available to address the problem, or there may be specific credentialing
needed to be considered for new program development. Both of these issues
speak to feasibility issues in regard to new program development. The first
indicates that new program development is, at best, not justified for several
years in the future, and the second indicates that other steps must be fully
examined and evaluated to determine specific time frames and the ability to
pursue additional credentialing.
There are four key benefits of a market analysis that should be discussed.
First, acquiring critical information related to both clinical programming and
business operations is essential to effective program design. As such, increased
understanding of the various clinical interventions and program outcomes
provides significant information for use in clinical program development (e.g.,
program capacity, clinical interventions and modalities). Likewise, increased
understanding related to staffing patterns, organizational structure, and
financial implications provides crucial information for operational issues in
program development. Second, gaining such information about providers that
have an established history of programming in the specific area promotes
increased appreciation for the program development project and all that is
involved in implementation and sustainability. Third, since other providers
have previously experienced several challenges in programming, they may
offer valuable insight into lessons learned that may be addressed in the initial
program design to avoid similar fates. It is in this sense that new program
developers should view competitors as having already piloted (i.e., tested) the
programs and, thus, having much to offer in substantial knowledge that may
help ensure early success with program implementation. Finally, providers that
have prior experience offer valuable information by which your new program
can be differentiated in design. This can be a significant factor in program
design, particularly because you wish to emerge as a competitor. For each of
these reasons and more, a market analysis is “arguably the most important
element in understanding the competition” (Krentz & Camp, 2008, p. 64).
As a brief recap then, a market analysis should be conducted because it
 

1. is needed to dispute or support new program development,

2. is needed for effective program design,
3. increases appreciation for the scope of the program development
project,
4. allows you to avoid similar mistakes in program development,
and
5. provides information needed to differentiate your program from
the competition.
 
For all these reasons, and likely several others, the market analysis is an
essential tool for the program developer. To ensure thoroughness, the market
analysis should include gathering the following information:

Length of time the provider has been delivering the specific

services
Other information related to the program’s history
Relevant demographic information about the program and/or
organization (e.g., other programs operated by the organization)
The scope and type of services provided, including the specific
service components and clinical interventions
The research basis/evidence basis of the clinical interventions and
service components (e.g., individual therapy, resource
coordination)
Any limitations to service delivery
Program outcomes and program performance related to
attainment of outcomes
The annual average number of clients and program capacity
 Program vacancy trends and related factors
The organizational structure (e.g., staffing patterns and hierarchy)
Staff credentialing
Financial information (i.e., annual budget, financial trends,
revenue sources and amounts)
Contractors, other funding sources, and related information
Accreditation status and other credentialing information
Any other information regarding program operations and/or
sustainability

The Market Analysis Checklist serves as an aid to the market analysis

process, ensuring that all necessary data has been collected (see Table 2.3).
In addition to the types of data collected, a market analysis should include
all the existing providers in the region that are addressing the identified
problem(s). If for some reason there are no existing providers in the region
addressing the identified problem(s), the market analysis should be conducted
on providers in similar regions (i.e., population characteristic and geographic
similarities) for later use in program design. In this case, a minimum of three
(3) organizations should be included in the market analysis to ensure a diverse
representation of providers and programming.
As is the rule with most, if not all, assessment activities, the outcomes are
only as good as the process. As such, a comprehensive market analysis will (a)
provide essential information to direct initial decision making about new
program development and (b) yield critical information for use in program
design only when thoroughness and sufficient attention to detail have directed
the process.
Table 2.3 Market Analysis Checklist

Data to Be Gathered Status

Length of time the provider has been delivering the specific services
Other information related to program history
Relevant demographic information
Scope and type of services provided
Specific service components and clinical interventions
Research basis/evidence basis of the clinical interventions
Research basis/evidence basis of the service components
Any limitations to service delivery
Program outcomes
Annual average number of clients
Program capacity (clients)
Program vacancy trends
Factors related to program vacancy (e.g., maximum length of time
paid by insurance company, increased competition)
Organizational structure
Staff credentialing
Budget and revenue information
Pay schedule information (e.g., capped rate, per diem)
Contractors and other funding sources
Accreditation status or other credentialing information
Any additional relevant information

Need Identification Process

Once you have completed both the problem analysis and the market
analysis, you have sufficient data to determine if new program development is
justified and the specific type of new program development that is needed. By
examining the results of the Market Analysis In Conjunction With The Results
Of The problem analysis, evidence is provided indicating that the identified
needs are currently being sufficiently addressed, and thus, new program
development is not warranted, or that the identified problem is not being
addressed/not being adequately addressed, and thus, new program development
is warranted. This latter finding indicates a gap between problems and
solutions to address the problems, thereby translating the identified problem
into an identified need.
Of all the steps involved in the comprehensive needs assessment, the needs
assessment provides specific sustenance to the process by allowing you to
immediately view the fruits of your labor: necessary evidence that determines
if new program development is justified or not. As a result, this step does not
require completing any new activities but rather involves bringing together
previously collected data to carefully examine it to

1. determine if the problem does indeed represent a need in the

region and
2. if a need does exist, thoroughly examine the feasibility of moving
forward in new program development.
 
Whereas the results of the community demography assessment and problem
analysis are critical to determining a, the results of the market analysis should
provide all the information needed to determine b. To determine if the problem
does represent a need, the following types of questions will guide you:
 

1. Are there existing providers working to address the problem in the

region?
2. Are there a sufficient number of existing providers to address the
problem?
3. Are the existing providers unable to address the problem due to
limited capacity?
4. Are the existing providers unable to address the problem due to
poor performance?
5. If the existing providers are unable to address the problem due to
limited capacity, what evidence exists that a new provider would
be justified and welcome in the region?
 6. If the existing providers are unable to address the problem due to
poor performance, what evidence exists that a new provider
would be justified and welcome in the region?
 
If a need does indeed exist, the following questions should be used to begin
fully examining the feasibility of entering into new program development to
address the need:
 

1. What are all the costs involved in new program development and
implementation?
2. What is the overall investment needed for new program
development (concrete expenditures, time, learning, etc.)?
3. What are the risks involved in new program development?
4. What are the benefits of new program development?
5. Do the costs outweigh the benefits of new program development?
 
It is in this manner that the results of a thorough market analysis are not
only critical to determining if a need actually exists but also to providing the
necessary information to decide if such new program development is feasible
and beneficial to the organization. Discovering that a need does exist does not
necessarily mean that new program development is warranted, particularly if
the costs and risks to new program development outweigh the benefits to the
organization. That is why the market analysis is so useful in allowing you to
gain a much deeper understanding of the specific programming and all that it
entails. Moreover, this is why the combined results of the community
demography assessment, Problem Identification, and market analysis will
provide you with the information required to determine if an actual need for
new programming exists.

Inventory of Assets
The identification of existing assets and strengths of the region is just as
critical to successful program development as the identification of specific
needs. In fact, without an accurate understanding of the various assets that a
region possesses, it is difficult to fully understand the needs of a particular
region. Whereas the other steps of the needs assessment allow for the
identification and prioritization of the clinical and related needs of a
population, an asset map identifies existing strengths (e.g., community
organizing and cohesion) and resources in the target region (e.g., community
organizing practices, social service organizations), thereby providing a more
balanced view of the region (Calley, 2009). In addition, because the assets of a
region interact directly with the needs of a region, thereby contextualizing a
region, assets provide an essential layer of information about the
region/population/needs. Further, the strengths and internal assets of a
community may prove particularly effective in resolving challenges and
addressing the needs of the community (Yoon, 2009). As a result, an asset map
(i.e., inventory of assets) is an essential part of the needs assessment process
that provides additional information for use in preplanning.
Broadly, assets refer to strengths and/or resources that may exist within the
target region or that may be characteristic of the target population. Examples of
a target population’s assets might include aspects related to cultural identity,
such as close extended families, specific religious or spiritual beliefs,
communication, and cohesion among community members. On the other hand,
additional types of assets in the region may consist of social service
organizations and the region’s eligibility for specific governmental or other
special funding status, among other issues. Mowbray et al. (2007) identify
three specific types of community assets thought to contribute to resilient
communities:
 

1. Social assets: community relationships built on friendships and

other relationships with individuals as well as social ties to
organizations such as schools, places of worship, and community
centers
2. Service agency assets: community service providers with an
institutional rather than social focus, such as hospitals and
employers
3. Economic and neighborhood resources: resources that
economically support families and communities, such as income
and employment opportunities
  
Assets speak to the positive aspects of a population and a region and, as
such, reflect the complexity that lies within populations and regions. By
conducting an asset map, the program developer is forced to more thoroughly
examine a population/region and, thus, gain a deeper sense of the
population/region and again, hopefully, a more balanced view that recognizes
both the challenges and strengths of a given population/region. This is of
tremendous significance, particularly if a program developer believes he or she
is very familiar with a population/region, since sometimes the closer we are to
something, the less able we are to clearly see it. At times, mental health
professionals become so entrenched in a given population/region that they see
only the issues or problems that negatively impact the population and fail to
acknowledge any existing strengths or resources.
For example, when I began working with physically and sexually abused
teenage girls in residential treatment in a large, urban area, I was immediately
struck by the degree to which these young ladies seemingly had the cards
stacked against them. More often than not, there was not a family member
interested in continuing to care for them, and few had any long-term
friendships (due to myriad problems that often related to both concrete issues
such as constant moves as a result of being in the child welfare system and
psychological issues such as the inability to trust), and most had poor academic
histories (again, often due to myriad issues, including lack of continuity in
education as a result of child welfare system involvement). For obvious
reasons, some of these young ladies felt hopeless, and after initially working
intensely with them, I began to feel hopeless as well. What I failed to see was
that these kids were survivors; they were resilient, adaptable, and typically able
to negotiate new issues and environments in their quickly changing worlds. In
essence, these girls had strengths and internal resources that few teens have yet
to develop at the same stage of adolescent development. Because I was so
entrenched in their everyday lives, I had become problem-saturated to the point
that I could not see beyond what was wrong, and as a result, I was not aware of
all the incredible assets that they each possessed. This is precisely the type of
skewed perspective that can negatively impact any program development
project, and that forces critical data to be overlooked. Moreover, this is
precisely why conducting an asset map as part of a comprehensive needs
assessment is so crucial to the preplanning process of program development.
 In conducting the asset map, it is best to be as expansive as possible, making
every effort to identify every existing asset (see Box 2.3).
 
BOX 2.3

ASSET MAP GUIDE

 

1. Gather asset data from regional stakeholders.

2. Reexamine the results of the community demography assessment to
determine which characteristics constitute assets.
3. Identify all existing community resources (e.g., services, supports,
networks).
4. Identify all existing providers of services.
5. Analyze the data by comparing the list of assets to the identified needs to
determine ways in which assets might be used to address needs through
new program development.
6. Identify the specific benefits to harnessing the various assets in new
program development.

Data should be gathered from various sources, including regional officials,

community members, and other mental health providers (some from sources
with whom you have previously collected data). In addition, data from the
community demography assessment must be reanalyzed to explore for assets
and strengths that may not have previously been perceived as such. For
instance, if the community demographic data indicated a preponderance of both
children and individuals 60 years and older in the region and your interest was
in developing a program for children, the aging population could be viewed as
a critical asset. More to the point, you might develop an elder-child mentoring
intervention/component or engage the aging population to serve as part of a
community safety network, thereby establishing the elderly population as a
critical asset in program design.
Similarly, the various cultural identity aspects of the demographic data must
be thoroughly reviewed again to identify other existing strengths. For instance,
if the majority of households in the target region are led by single females, the
traits of fortitude and strength of women in the region should be considered
obvious strengths. By using an enhanced, strengths-based lens (i.e., adopting an
asset orientation) by which to view a region, many assets may begin to appear;
however, doing so requires purposeful work, thus, the use of the asset map. In
this manner, it is essential that you explore deeply so as to not overlook any
existing strengths or resources.
In addition to identifying the various strengths of a population as assets,
existing community resources must also be identified as assets. Because
organizations within the region often can be utilized for a number of specific
purposes in program development, they should be considered resources. Such
resources should include all mental health and social service organizations,
including school-based programs, and may include businesses (this may be of
particular interest if program development is focused on vocational
development) and physical health facilities (if particular interest is focused on
health care or rehabilitation). Local organizations providing similar services or
serving the same population will, in most cases, always be viewed as resources
since they may be used in program development efforts for a number of
purposes. Minimally, these organizations have specific historic knowledge and
important data about the population and services. Such information is highly
useful in program planning. As a result, it is imperative that program
developers engage these organizations to learn and gain valuable data for use in
new program development. Moreover, these organizations may serve as
significant allies in advocacy and other collective efforts, as well as partners in
collaborative efforts. The creation of collaborative partnerships is of particular
interest as it may be critical to pursuing specific funding, and with the
increasing emphasis on collaboration in funding opportunities, this has become
increasingly important during the past decade. (The role of community
resources and partnerships is explored thoroughly in Chapters 7 and 13.)
As you have probably noticed, there are typically numerous assets in a given
region, and the challenge rests in working to identify all of them. Once an
exhaustive list of assets has been identified, it should be compared with the
identified needs. By comparing the region’s assets with the region’s needs, the
program developer is able to determine how specific needs may be addressed
through existing resources. This type of planning in program development,
involving various existing systems and resources, is crucial as it implies that
additional support is already available and simply needs to be creatively
harnessed for comprehensive program development. This philosophy resonates
with multisystemic approaches, originally developed by Henggeler and
Borduin (1990), which utilize existing resources and create links with existing
resources in treatment planning. More importantly, this type of approach has an
established record of producing positive treatment outcomes (Henggeler,
Clingempeel, Brondino, & Pickrel, 2002). It is because of these reasons and
more that completing an asset map is so critical to program development
efforts.

Summary: Pulling It All Together—Organizing the

Data Collection Plan and Engaging in Data-Driven
Decision Making
As you can see, establishing the need for programming is no small task. Rather,
it involves identifying a target region and a target population followed by
completing a five-pronged comprehensive needs assessment that includes
 

1. community demography assessment,

2. problem analysis,
3. market analysis,
4. need identification process, and
5. an asset map.
 
These activities focus on data collection and analysis for use in preliminary
decision making about program development and, as such, collectively
compose the preplanning stage of program development. The data gathered
during this stage has tremendous significance to the entire program
development process since this data provides the basis for decisions made
about new program development. In short, this stage is arguably the most
important stage in program development because every subsequent stage is
based on decisions initially made during this stage, so that mistakes made here
may have an enormous negative impact on program development efforts. In
fact, failure to conduct a comprehensive and effective needs assessment based
on all five components will likely lead to ill-conceived program development
efforts. That is, if you complete a thorough community demography assessment
but fail to conduct a comprehensive problem analysis, you may miss critical
data that has a direct impact on a specific problem. Since the community
demography assessment serves as the building block for the problem analysis,
failing to fully utilize the results of the community demography assessment to
dig deeper into specific areas during the problem analysis limits what you can
learn from the data. For example, whereas the community demography
assessment indicated an above-average rate of truancy among elementary
school children, comparing this data to the rate of children receiving free lunch
in the school, rather than investigating further, you might simply conclude a
relationship between lower socioeconomic status and school truancy. However,
by prematurely ending your investigation, you failed to learn that the majority
of children with school truancy problems have caregivers that either work
nontraditional hours or do not have transportation—two critical factors directly
impacting their children’s school attendance.
In addition, if you are successful in conducting an effective community
demography assessment and problem analysis but fail to complete a thorough
market analysis, your data may indicate a need for new program development
that is already being met by other providers. As a result, you may move
forward in new program development for a market that is already being served
and, therefore, does not provide an opportunity for you to enter.
Indeed, the preplanning stage carries a heavy burden, as its implications are
tremendous. However, nothing can substitute an effective comprehensive needs
assessment. Indeed, completing an effective and comprehensive needs
assessment yields the most significant results: evidence of new program
development, when and where it exists. From a scientific perspective, this type
of data-driven decision making is not only appropriate but required, and from a
business perspective, it is often the difference between a successful
entrepreneur and an unsuccessful one.
Moreover, solid data collection skills, effective analysis skills, and the
unwavering ability to remain objective and allow data to drive decision making
are each required ingredients of success in this stage. In addition, to effectively
plan and carry out each of the preplanning activities, great attention to detail
and effective organizational skills are needed. Effective planning must take into
account the progressive nature of the data collection and decision-making
process, appreciating that each activity provides an essential layer of
information for the next. Therefore, the data collection process must be
organized sequentially to allow for accurate data analysis and, ultimately, the
most effective data-based decision making. The data collection plan should be
organized as follows:
 

1. Identification of target region

2. Identification of target population
3. Community demography assessment
4. Problem analysis
5. Market analysis
6. Need identification process
7. Asset map
 
As a result of completing the needs assessment, you will have created a
sound basis for decision making based on the effective use of data. To
succinctly organize all the findings of the needs assessment and aid in decision
making about new program development, a summary report that includes each
of the assessment activities and findings should be developed.
 
CASE ILLUSTRATION
Gerri Scouton had been the executive director of Pyramid Social Services,
an organization specializing in residential treatment for adults with serious
mental health disorders, for the past 10 years. Although her agency was
financially stable and had developed a strong reputation for quality
services, her board of directors had been encouraging her to seek out new
business over the past couple of years to grow the organization further. At
the last board meeting, a discussion arose regarding the increasing number
of individuals with traumatic brain injury (TBI) in the region. One board
member stated that he did not feel there were enough residential facilities to
treat all these individuals. Another board member claimed that he believed
the large number of individuals with TBI in the region were involved in the
criminal justice system and that often, these individuals were released from
prison without any further treatment. As a result, he claimed, persons with
TBI often continued to commit crimes.
He argued that to address this issue, there needed to be a residential
program that could effectively treat these individuals upon their release
from prison.
As the discussion continued, two of the board members suggested that
this was an area that the agency should look to expand into (residential
treatment for individuals with TBI) and that, by doing so, the organization
would be able to expand its continuum of residential programming.
Summarizing this discussion, the board president quickly directed Gerri to
begin making plans for expansion in this area since this did indeed sound
like a very good business opportunity. However, Gerri was not yet
altogether convinced of the urgency of this directive.
Although Gerri had heard talk at monthly coalition meetings with other
human service organizations that there seemed to be an increase in the
number of individuals with TBI, it was not an area she had directly
explored and, therefore, she was not comfortable that this argument was
wholly founded. To be certain that this new program development effort
was justified, Gerri responded that she would conduct a comprehensive
needs assessment.
Gerri assigned the task of conducting a comprehensive needs assessment
to a lead counselor, Jamie, and his clinical supervisor, Kari. Since the target
region had already been identified (the region in which the organization
currently operated) as well as the target population (i.e., adults with TBI),
in order to get started with the community demography assessment, Jamie
and Kari began brainstorming a list of all the data needed. They then split
up the task of gathering the various data and made plans to meet at the end
of the week to discuss their findings. After compiling all the data from the
community demography assessment into a summary of findings, a clearer
picture of the community emerged with the following key features:

Increased prevalence of TBI in the region over the past 2 years—

4% higher than the state rate and 6% higher than the national rate
Increased prevalence of violent crime in the region over the past 2
years at 6% higher than the state level and 8% higher than the
national level
Racially diverse community: 48% black, 44% white, and 8%
American Indian
 Ethnically diverse community: 37% African American, 11%
Pacific Islander, 25% Euro-American, 19% Arab American, and
8% American Indian
Adults composing the majority age population with 78% of the
region’s population between the ages of 18 and 65
Economically impoverished area with 9% higher prevalence rate
of poverty than state level and 12% higher than national level
Population with limited postsecondary education, with 15% less
of the region holding a bachelor’s degree than the state level and
17% less than the national level

After discussing the community demography assessment summary in

depth, Kari and Jamie decided that they had enough pertinent data to
effectively move to the next preplanning step and begin a problem analysis.
Finding that the region did indeed have a disproportionately high rate of
both TBI and violent crime, they knew that they would need to investigate
each of these areas further. Kari and Jamie again began by brainstorming
the various types of data they would need to collect and then proceeded to
identify the various sources of data. In addition, because some of their data
would be coming from various stakeholders–in particular, the hospitals,
local law enforcement, and providers of TBI treatment and services–they
identified the methods of data collection that would be needed to gather the
information. They decided that they would need to develop an interview
guide and a survey to gather this specific data directly from these
stakeholders. They also decided to use three methods by which to gather
the data: telephone, electronic, and face-to-face—each based on the
particular person(s) providing input (e.g., law enforcement, hospitals,
providers). They had learned before in working with police that police
officers were much more comfortable speaking in person than on the
telephone or by e-mail, while providers typically preferred e-mail or other
electronic communication. After constructing the survey and interview
guide, Kari and Jamie split up tasks in order to maximize their time
completing this next set of data collection activities and went to work.
Once they had successfully gathered all their information, they began the
analysis process and compiled a report of the findings. The data yielded the
following findings:
Violent crime primarily consisted of homicide and male-to-female
domestic violence.
The trend in violent crime in the area appeared to be related to an
increase in prisoners returning to the community prior to
completing their full sentence as part of the state’s plan to reduce
its annual budget through the implementation of a prisoner reentry
program (52% of the violent crime committed in the region over
the past 2 years had been by repeat offenders).
The reason for the disproportionate violent crime rate in the
region may have been related to the fact that a specific location in
the region served as a primary drop-off point for prisoners
returning to the community.
There was not a significant relationship between TBI and violent
crime.
Of the region’s TBI population, 24% received their injury as a
result of an automobile accident.
Of the region’s TBI population, 72% consisted of veterans of the
recent war in the Middle East.
The remaining 4% of the region’s TBI population had received
their injury as a result of accidental and nonaccidental events that
were nonvehicular and not related to military involvement.
The reason for the disproportionate rate of TBI in the region
appeared to be a direct result of the state’s Veteran’s
Administration (VA) hospital, which was located in the immediate
region and at which the majority of TBI patients were treated for
myriad issues, including TBI and related mental and physical
health problems.
In addition to the continuum of programming available from the
VA hospital for TBI (providing residential programming only),
there were three other providers of TBI treatment, two of whom
provided both residential and community-based programming and
one that provided only community-based programming.
 There was no evidence that TBI patients were not able to receive
treatment due to a lack of available programming in the region.
Over the past 5 years, the region had expanded its TBI services,
including both residential and outpatient services, to the TBI
population, largely in response to the increased prevalence rate
related to the war in the Middle East.

After examining all the data that they had collected so far, Kari and
Jamie were able to prioritize two primary problems existing in the
community: (1) TBI and (2) violent crime among repeat offenders.
Although the results of the problem analysis did not indicate that there was
a lack of TBI treatment/services in the region, the results of the data
collection were limited since Jamie and Kari had gathered data about this
issue only from the VA hospital and from 38% of the TBI population. Kari
and Jamie compiled the information that they had gathered as part of the
problem analysis process, along with their previous findings from the
community demography assessment, into a summary report—Data
Collection Report. In their report, they explained the methods that they
used to collect the data as well as specific limitations that they encountered
in the data collection process (i.e., limited data on individuals with TBI).
Knowing that they had not examined a large enough sample of the TBI
population to fully understand the existing state of treatment needs or if any
gaps in services existed, Jamie and Kari were not concerned since this
would be fully explored in the next step, the market analysis; so they still
had work to do.
Now knowing that the region did have a significant population of
individuals with TBI, Jamie and Kari were anxious to get started with the
market analysis to determine if this problem translated into a need. To
begin the market analysis, Kari and Jamie identified all the existing TBI
treatment providers within the immediate region as well as those within 1
hour of the region. The six TBI treatment providers offered the following
treatment options:
2, residential treatment only
2, both residential and community-based programming
2, community-based programming only
 Sufficiently equipped with the Market Analysis Tool, they set about to
gather pertinent information about the existing providers. Although they
could gather only a limited amount of data from three of the providers that
did not include financial and vacancy information (providers unwilling to
disclose some specific information), they had been successful in gathering a
good deal of relevant data from the other three providers. After compiling
all the results of the market analysis, Kari and Jamie came to the following
conclusions:

Two of the providers (one with both residential and community-

based programming and one with residential programming only)
had been providing TBI treatment for more than 20 years and had
achieved significant positive treatment outcomes and developed
strong reputations in the region for their treatment.
The average vacancy rate for each of the residential providers was
35% (i.e., occupancy rate of 65%).
None of the residential providers had been at full capacity during
the past 2 years, with the exception of the VA hospital, which was
the automatic initial residential placement for veterans returning
from active duty with TBI (the VA hospital had been at full
capacity for less than 2-week time frames over the past 2 years).
Recent changes to the state’s auto insurance industry limiting
residential and outpatient treatment for TBI had decreased the
client population for all the providers by approximately 15%
during the past 2 years.

The results of the market analysis were clear: A need for additional TBI
programming did not currently exist in the region. In fact, the market
analysis indicated that there was already an excess of providers in the area.
And this excess of providers, coupled with a shrinking market (individuals
with TBI as a result of vehicular accidents for whom funding for treatment
would not be provided), had already had a serious negative impact on each
of the provider’s market share.
Whereas Kari and Jamie had clearly found evidence that TBI was a
significant problem in the region, the market analysis demonstrated that it
was not a problem that represented a need—an opportunity for new or
expanded program development. Further, because the results of the needs
assessment process were conclusive and did not justify new program
development for TBI, there was no reason to continue further in the
assessment process by conducting an asset map. Instead, Kari and Jamie
compiled their existing findings into a comprehensive needs assessment
summary report and scheduled a meeting with Gerri to discuss the results
of their comprehensive needs assessment.
After reviewing the findings with Jamie and Kari, Gerri, too, was
convinced that a more than sufficient market currently existed to address
TBI in the region and that, in fact, it appeared that the market may be
saturated since none of the providers were operating at capacity. Gerri
invited Jamie and Kari to present their findings at the upcoming board
meeting. Following the presentation, the board, too, was convinced that as
much as they were interested in growing the organization, new program
development for TBI was not justified; however, the board was intrigued
about the findings related to violent crime and an increase in the number of
prisoners returning to the community. After some discussion, the board
asked if Jamie and Kari could turn their attention to completing a needs
assessment on prisoners returning to the community and violent crime
among adults. The board members were impressed with the thoroughness
of the work that Kari and Jamie had conducted to fully examine the needs
related to TBI. As a result, they were anxious to see if their assessment and
analysis work could be duplicated to determine if this other problem did in
fact translate into a need for new program development.
Since they had already completed the community demography
assessment in which some data related to this problem had inadvertently
been gathered in the previous problem analysis, Jamie and Kari would be
able to start midpoint in the assessment process and continue to collect
more specific data related to the issue and then move to the market
analysis.They, too, were anxious to get started, and more importantly, they
were confident that by letting the data do the talking, their organization’s
future endeavors would be guided most effectively.

COMMUNITY DEMOGRAPHY ASSESSMENT EXERCISE

 Identify a target region and target population, and use the community
demography assessment tool to conduct a community demography
assessment.

 
REFLECTION AND DISCUSSION QUESTIONS

1. What experience have you had in participating in new program

development?
2. Having read this chapter, what most appeals to you about the
preplanning/establishing the rationale for program development
phase?
3. What, if anything, surprised you about the preplanning phase of
program development?
4. How could you use the results of a comprehensive needs
assessment to impact governmental or philanthropic funding for
new program development?

References
Arredondo, P., & Glauner, T. (1992). Personal dimensions of identity model.
Boston: Empowerment Workshops.
Calley, N. G. (2009). Comprehensive program development in mental health
counseling: Design, implementation, and evaluation. Journal of Mental
Health Counseling, 31, 9–21.
Darboe, K., & Ahmed, L. S. (2007). Elderly African immigrants in Minnesota:
A case study of needs assessment in eight cities. Educational Gerontology,
33, 855–866.
Emerson, D. M. (2008). Subdivision market analysis and absorption
forecasting. Appraisal Journal, 76, 377–390.
Finifter, D. H., Jensen, C. J., Wilson, C. E., & Koenig, B. L. (2005). A
comprehensive, multitiered, targeted community needs assessment model:
Methodology, dissemination, and implementation. Family and Community
Health, 28, 293–306.
Henggeler, S. W., & Borduin, C. M. (1990). Family therapy and beyond: A
multisystemic approach to treating the behavior problems of children and
adolescents. Pacific Grove, CA: Brooks/Cole.
Henggeler, S. W., Clingempeel, W. G., Brondino, M. J., & Pickrel, S. G.
(2002). Four-year follow-up of multisystemic therapy with substance
abusing and dependent juvenile offenders. Journal of the American Academy
of Child and Adolescent Psychiatry, 41, 868–874.
Kettner, P. M., Moroney, R. M., & Martin, L. L. (2008). Designing and
managing programs: An effectiveness-based approach (3rd ed.). Thousand
Oaks, CA: Sage.
Krentz, S. E., & Camp, T. (2008). Taking a good look at the competition.
Healthcare Financial Management, 62, 64–70.
Lewis, J. A., Packard, T. R., & Lewis, M. D. (2007). Management of human
service programs (4th ed.). Belmont, CA: Thomson Learning.
Mowbray, C. T., Woolley, M. E., Grogan-Kaylor, A., Gant, L. M., Gilster, M.
E., & Shanks, T. R. (2007). Neighborhood research from a spatially oriented
strengths perspective. Journal of Community Psychology, 35, 667–680.
Yoon, I. (2009). A mixed-method study of Princeville’s rebuilding from the
flood of 1999: Lessons on the importance of invisible community assets.
Social Work, 54, 19–28.
Zandbergen, P. A., & Green, J. W. (2007). Error and bias in determining
exposure potential of children at school locations using proximity-based GIS
techniques. Environmental Health Perspectives, 115, 1363–1370.
 CHAPTER 3
Establish a Research Basis for
Program Design

 
Learning Objectives
 

1. Increase understanding of historical factors that have influenced

clinical program design, including the federal government and
accrediting bodies
2. Differentiate between evidence-based, emerging, empirically guided,
and best practices
3. Identify the various areas to be explored in a literature review for use in
program design
4. Increase knowledge of the key questions to be explored in the literature
review
5. Identify key sources to be used in conducting the literature review
  
I DON’T HAVE THAT KIND OF TIME
Jack’s boss, the agency’s executive director, asked Jack to develop a
proposal in response to a Request for Proposal (RFP) for a new short-
term outpatient counseling program for individuals with substance abuse
disorders. Jack had not developed a proposal independently before, but
he thought that with his experience as the program supervisor of a long-
term substance abuse program he could do it. Reading the RFP, Jack
learned the program was to deliver treatment to adults with substance
abuse disorders and co-occurring mental health disorders. Jack knew
from working in the substance abuse field for the past 6 years that some
clients did often have a mental health issue as well, but he also knew that
substance abuse was always treated as the primary issue. He felt
confident that he knew his stuff when it came to substance abuse
treatment—after all, he was in recovery himself.
Jack moved through developing the proposal rather swiftly, and in
response to questions regarding the program design, he used his current
treatment model as the base, simply extending the length of time because
the new program was long-term and his existing program was short-
term. In response to the model and interventions that would be used to
specifically treat co-occurring disorders, Jack discussed the use of
psychiatric services and medication monitoring and even identified a
contractual psychiatrist on the organizational chart that he was required
to submit with the proposal. Jack articulated that the research basis for
using psychotropic medication in the treatment of substance abuse was
well founded and, therefore, did not require further discussion. Knowing
that treatment of co-occurring disorders simply meant treating
individuals with both substance abuse disorders and mental health
disorders, Jack was confident he had covered both of his bases—
identifying substance abuse treatment and psychiatric treatment as the
two interventions that would be used in his program. He certainly did not
need to review research to reinforce this since it was something he had
known for a long time. Besides, he had only a week before the proposal
was due.
 After finalizing the proposed budget, Jack felt good about having
finished his first proposal. Moreover, after briefly discussing it with his
boss, Jack said he was ready to send it in and thanked his boss for
trusting him to develop the proposal alone.
Six weeks later, Jack’s boss received notice that Jack’s proposal had
been rejected. Among other comments, the reviewers had written that the
proposal did not demonstrate an understanding of co-occurring disorders,
nor did it provide an evidence-based treatment.

 
CONSIDERING JACK

1. How could Jack have prevented this from happening?

2. If you were Jack, what would you do now/how might you work to
restore your boss’s trust in you?
3. What role does research play in program design today?

About This Chapter

To fully understand how to establish a research basis in program design, it is
necessary to first understand the various environmental changes that have
helped get us to this point in program design. These include historical and
influential factors impacting program design—namely, the role of the federal
government and that of accrediting bodies, which is discussed in the next
chapter. Next, we will examine the current climate of program design,
beginning with a review of key concepts that include evidence-based,
empirically based, emerging, and best practices. In addition to better
understanding the forces that have propelled us forward in program design, it
is equally essential to understand the various facets involved in developing a
research basis for program design that includes the multiple sources needed
to conduct a comprehensive literature review. These are composed of
scholarly literature, best practice literature, reports from governmental
bodies and other think tanks dedicated to research, professional conferences,
and other sources—each of which will be explored. And, finally, we will
discuss methods to identify significant findings from the research and
effectively use these findings in program design efforts.

STEP II: ESTABLISH A RESEARCH BASIS

FOR PROGRAM DESIGN
Research Basis for Program Design
As you witnessed in Chapter 2, deciding to move forward in program
development requires a tremendous amount of work, primarily focused on
comprehensive data collection. Once the rationale for new program
development has been firmly established, the program design phase is ready
to begin. Just as you had to provide a sound rationale for new program
development by identifying the need through empirical investigation, you
must now develop an equally sound rationale for program design.
Establishing a firm basis in research is the first step in program design and,
as such, must provide justification for the design. Whereas developing such
justification for program design requires a different type of comprehensive
investigation than conducted in establishing a need for the program, this
process is not necessarily less intensive.
Over the past decade, increased accountability and a focus on
effectiveness and outcomes have become guiding forces in program
development. As a result, the integrity of program design is more critical
than ever before, as program design is innately tied to program outcomes.
This new era in program development has radically impacted not only how
new programs are conceived but, more significantly, how new programs are
designed—design that begins with establishing a sound research basis.

Historical and Influential Factors Impacting Program Design

Today, you cannot engage in a discussion about program design without
being asked the basic question, “What evidence do you have that it works?”
But this has not always been the case, and several factors and conditions
have historically contributed to our current emphasis on evidence-based
practices. Prior to the 1980s, programs were designed and implemented
largely based on practices that had historical value—program models that
had been used before. It was often the case that if your program or
organization was known, did not commit any egregious acts, and could
effectively manage both your client population and your staff, you could
continue to receive funding. Whereas some form of accountability existed,
often it consisted of little more than requiring an organization to demonstrate
the ability to provide adequate, yet not rigorously evaluated services and
achieve a balanced budget.

The Impact of the Federal Government

During the late 20th century, several historical changes occurred on the
national level that had far-reaching influence on the state and local levels,
and while it is difficult to target any one condition as the change agent, it is
appropriate to conclude that a number of conditions contributed to varying
degrees to where we are today. First, significant changes in the federal
government occurred that reflected a shifting ideology about the importance
of human services. In fact, beginning in 1930 with the inception of the
National Institutes of Health and continuing through 1992 with the
establishment of the Substance Abuse and Mental Health Services
Administration, the 20th century was the era in which mental health and
human services initially came into being.
In addition to the establishment of the major federal entities dedicated to
mental health and human services, the late 20th century also witnessed a
progressive focus on more and more specialized issues related to mental
health and human services. For example, the Department of Health,
Education, and Welfare (HEW) was created in 1953 to address issues related
to each of these three major issues; however, in 1980, HEW became the
Department of Health and Human Services, and the Department of
Education was established as a separate entity (Department of Health and
Human Services, n.d.).
This change is symbolic for many reasons but largely because it reflects
increased understanding of the need for focused attention on health and
social issues. As with most things, the more attention that is given to a
particular issue, the more scrutinized it becomes, and thus, there is often a
demand for greater accountability. Whereas the reorganization of the
departments of health, education, and welfare offers one example of major
shifts in the federal government related to the expansion of and increased
focus on the human services, the timeline below (Table 3.1) provides a
broader historical view.
As you can see, the changing ideologies about the need for research,
increased funding, and attention to social issues are clearly illustrated by the
establishment of new federal agencies. Whereas noting these shifts in
government is integral to understanding the broad environmental changes
that took place last century, none of these changes would likely have come
about when they did without the emergence of the behavioral and social
sciences. As each of the helping disciplines came into being and further
developed, their collective influence on national legislation could not be
ignored—beginning with the introduction of talk therapy to the field of
psychiatry in the late 19th century (Trull & Phares, 2001) and followed by
the emergence of the fields of psychology, counseling, and social work.
Table 3.1 Establishment of Federal Agencies
 In addition, the influence of top-level politicians on the national
conversation must not be underestimated. Indeed, the effect of the First Lady
(e.g., Betty Ford) or the wife of a presidential contender (e.g., Kitty Dukakis,
Tipper Gore) personally and publically confronting substance abuse and
mental health issues was unprecedented. Obviously, we could spend a great
deal more time ferreting out the myriad historical influences that contributed
(and continue to contribute) to the changing landscape regarding mental
health services, but this task is best left to other texts so that we can focus
more specifically on what it all means today.
Whereas the development of a federal-level cabinet department or a
subagency of a cabinet-level department, such as the Substance Abuse and
Mental Health Services Administration, reflects national priorities, it also
carries with it a vast increase in funding to support treatment to address and
increase knowledge about the specific issue. Therefore, the major financial
implications that these changes carry must be fully appreciated.
Over the past 30 years, federal expenditures have largely been dedicated
to research and support direct services at the state and local levels. As with
most trends, national changes beget state and local changes and, conversely,
local and state changes are major drivers of national changes. Whereas local
and state governments and private philanthropic organizations had
previously provided funding for social service programs, when the federal
government began providing funding to support direct services, the focus on
accountability became greater. The reason behind this was no different than
those that motivate us all as consumers—an innate need and a right to know
that what we are purchasing works, and if it does not work, the right to not
continue to pay for it. As the largest consumer in the United States, the
federal government has the same need, only exponentially magnified!
Therefore, as spending for mental health and social service programming has
continuously expanded, accountability to deliver high-quality services has
also increased.
But this increased scrutiny on mental health and human services did not
evolve without conflict or without setting the stage for major political shifts
in our nation. In fact, when the Nixon administration and other conservative
politicians during the 1970s were initially instrumental in questioning the
effectiveness of an array of social service programs, including the War on
Poverty (Lewis, Packard, & Lewis, 2007), they were in part contributing to
the undoing of some of the major philosophical tenets of Roosevelt’s New
Deal—such as a country providing for its own when they are in need. In this
manner, the way was paved for the inception of managed care and the
sweeping welfare reform legislation of the early 1990s. Fast-forward to 2010
and you are hard-pressed to find a contract to provide mental health or
human services that does not specify required program outcomes and that
does not result in loss of pay, loss of contract, or both for failure to meet
such requirements.
In addition to the shifts resulting in the federal government’s increased
spending on mental health and human services, in the 1990s another trend
emerged that also has had a significant impact on accountability:
responsibilities for directly purchasing and monitoring programming at the
state, regional, and local levels. The emergence of block grants enabling
state, regional, and local governments to directly administer human service
programs and dollars has increased the responsibility of these smaller
governments. In addition to block grants, shifts in federal government
spending have also allowed for increased privatization of specific services
(e.g., juvenile justice). Both of these changes have contributed to a cultural
move within human service programming toward increased innovation and a
keener eye toward cost savings as the burden of fiscal control has increased
in smaller levels of governments. This burden has been naturally translated
into an increased need to ensure that each venture is worth the money that is
supporting it. Whereas governmental spending composes the majority of
funding for mental health and human service programming in the United
States, the amount of financial support provided by private philanthropic
organizations and foundations for such programming cannot be overlooked.
As primary contractors of human service programming, private
organizations have also been significantly influenced by governmental
shifts, and as such, accountability in programming has become a key
concern of private funders as well.
Various means have been utilized to address the issue of accountability in
mental health programming, two of which require specific discussion here—
national accreditation bodies and federal performance standards. The
emergence of national accreditation bodies for mental health and social
service programming and the promulgation of performance standards have
each had a tremendous impact on raising the proverbial bar by continuously
emphasizing standards of care and effectiveness. In short, these two areas
have largely served as catalysts for moving mental health and human
services through to an unwavering focus on the real bottom line—the client.

The Impact of Accrediting Bodies

While there are numerous national accreditation bodies dedicated to
specific issues, arguably the three major accrediting bodies in mental health
programming today include the Commission on Accreditation of
Rehabilitation Facilities (CARF), the Council on Accreditation (COA), and
The Joint Commission. Interestingly, the emergence of accreditation bodies
very much reflects the trend toward more focused attention on specialized
clinical issues noted in the development of various federal-level agencies. In
fact, in the late 1960s (less than 15 years after the emergence of the
Department of Health, Education, and Welfare), the first national accrediting
bodies were established to provide voluntary accreditation for behavioral
and human services in what are now The Joint Commission (formerly the
Joint Commission on Accreditation of Healthcare Organizations) and CARF.
Since its inception in 1966, CARF has accredited rehabilitation facilities
and has expanded to also include broader-based human services. Whereas
CARF has historically specialized in residential facilities, the organization
currently accredits programming in such diverse areas as dementia, brain
injury, foster care, and opioid treatment (CARF, 2010). Whereas The Joint
Commission was initially designed to accredit hospitals, in 1969, its scope
expanded to include accreditation of programs for the mentally ill and
developmentally disabled (The Joint Commission, 2010). Over the past
several decades, The Joint Commission has continuously expanded its scope,
while always maintaining a primary focus on health care facilities and
programs.
Less than a decade later, in 1977, COA was created to establish service
and administrative standards for an array of social service programs. Similar
to both The Joint Commission and CARF, COA has progressively expanded
its role in accreditation, accrediting a diversity of human service and mental
health programs (COA, 2008a).
 From the time that each of these three major national accrediting
organizations arrived on the scene to today, changes in both the scope of
programs eligible for accreditation and the major emphases of the standards
provide another illustration of the significant increase in attention to mental
and social issues. In fact, the trend toward more and more specialized
services continues and is well reflected in the ever-increasing number of
services/programs that COA accredits (40 as of 2010!). These programs
include such diverse and specialized types as volunteer mentoring services,
crisis response and intervention services, opioid treatment programs, and
pregnancy support services, to name just a few. Just as accreditation bodies
have continuously expanded their number of program standards to meet the
growing need of specialized services, service standards have shifted
significantly to emphasize the need for accountability in program outcomes.
Since program outcomes are predicated on program design, these changes
are clearly visible in program design standards. For example, consider this
2008 standard on psychosocial rehabilitation services:
The program is guided by a philosophy that provides a logical basis
for the services and support to be delivered to individuals, based on
program goals and the best available evidence of service effectiveness.
(COA, n.d.)
Providing evidence of a more fundamental shift toward increased rigor in
program design and outcomes, a statement from COA (2008b) regarding the
2008 standards revisions articulates that the “standards are grounded in a
long-standing, widely held belief that individuals who receive services are
the direct beneficiaries when organizations invest in strong management
practice, and can validate the impact of their services on those served.”
These most recent revisions to the COA standards clearly reflect the current
landscape of national accreditation with a keen focus on the interconnected
goals of quality, accountability, and effective outcomes.
Equally important in the move toward accountability is the promulgation
of performance standards that have increased exponentially during the past 2
decades. Performance standards typically refer to the identification and
tracking of quality indicators (e.g., client satisfaction), outputs (e.g., number
of clients served), and outcomes (e.g., impact of intervention on client).
Whereas outputs have particular significance, especially when funding is
directly tied to capacity building, the past decade has witnessed an ever-
increasing focus on outcomes and specifically measuring the impact of a
program on the individual, the region, and the system. At the federal level,
the Government Performance and Results Act (GPRA) of 1993, which
requires federal departments and agencies to report their performance to
Congress and to the president, has been a major driver of performance
accountability (Kettner, Moroney, & Martin, 2008). The Government
Accountability Office is charged with monitoring the GPRA in order to
improve the performance and accountability of the federal government for
the benefit of the American people (Government Accountability Office,
n.d.). As you would expect, this increased accountability at the federal level
has had tremendous impact on increased performance accountability at both
the public and private levels of states and municipalities. In fact, 48 states
currently have instituted performance accountability systems, and 50% of
local and county governments have done the same (Melkers & Willoughby,
2005).
As you can see, numerous events and changes have occurred in recent
history that collectively have had a tremendous influence on program
development—namely, resulting in a primary focus on accountability. As a
result, the current climate in clinical program development is predicated on
established proof that the program design is effective in reaching tangible
outcomes and that rigorous evaluation is built in to program implementation
as an essential component to monitor and ensure effectiveness.
Thinking back to a not-too-distant past when I directed a mentoring and
support program for kids with serious emotional disorders, my contractual
agreements with funders were largely lacking in any requirements to
demonstrate that the treatment and service interventions worked in any
substantive way and, in fact, did not even require us to identify specifically
what we were trying to achieve. This is not to say that since the clients were
a part of the mental health system, functional stability was not the primary
outcome, because it was. However, as a program specifically focused on the
interpersonal and social skill development of children and adolescents, not
only should we, as the provider, have been able to clearly identify and
evaluate the clinical interventions that we used to address these issues, but
moreover, our funding sources should have demanded that we do so.
Thankfully, we have come a long way since then, much to the benefit (and
respect) of those we serve, as well as the mental health profession itself.
In the 21st century, we are now fully ensconced in a mental health
treatment culture that is keenly focused on clinical efficacy and
accountability. That is to say, in terms of mental health programs supported
through governmental or foundation funding, this is largely the case.
Unfortunately, this continues to not necessarily be the case for individual
clinicians working for private pay in outpatient clinics and private practices
with individuals, families or groups, or with mental health professionals
working in K–12 education or in higher education counseling centers. With
the continued emphasis on clinical efficacy in mental health treatment, we
may soon see more change in this area, but for now, we can only continue
hoping for such change and take appropriate action to demand it.

Current Climate and the Adoption of a New Vocabulary

Now that we know how we arrived where we are today, let’s look at
exactly where “here” is. In our current climate, the focus on efficacy and
accountability begins with a program design that is built on evidence and is
evaluation-ready—able to measure performance throughout implementation
and beyond. To aid us in moving into this new era in program design, a new
vocabulary has continued to gain prominence in the behavioral and social
sciences that includes terminology such as evidence-based, empirically
guided, best practices, and emerging practices. While the terms have slightly
nuanced differences, they share a common emphasis—a foundation in
factual information. I prefer the term research basis because it is the most
inclusive term, including both empirically based research and conceptual
research that is factually based yet not fully empirically validated. Program
design that falls into this latter category is also referred to as emerging
practices to indicate that it is still under investigation; however, because of
its research foundation, it offers significant promise as a future empirically
based design. We will discuss each of these concepts briefly.

Evidence-Based Practices
 During the past decade, the emphasis on evidence-based practices has
grown at such a tremendous rate that it is now difficult to locate a funding
source that does not demand the use of an evidence-based practice as a core
part of a contractual agreement. Furthermore, each of the major scholarly
journals is currently filled with articles expounding new evidence-based
practices, detailing both the interventions and the evaluation findings.
Finally, most governmental reports dealing with clinical issues dedicate a
fair amount of space to defining evidence-based practices, as well as
outlining various evidence-based practices with which to treat the issue.
As the term suggests, evidence-based practices simply refer to practices
that have a basis in empirical evidence. Therefore, the use of evidence-based
practices emphasizes that clinical programming is based on the best
available evidence gathered from systematic research (Johnson & Austin,
2006). Concluding that an intervention has an evidence basis requires a
formalized evaluation of the intervention. Thus, as the emphasis on
evidence-based practice has continued to grow, the need for comprehensive
evaluation has likely intensified. Today, the astute program developer does
not consider program implementation without also developing a program
evaluation.
There are numerous methods that may be used to evaluate a clinical
program and/or the clinical interventions that compose a clinical program.
These include

randomized studies with random assignment of clients to either

a treatment or control group;
quasi-experimental study without random assignment of clients
to either treatment or control;
follow-up or cohort study—following an entire group of clients
over a specified period of time;
qualitative studies with statistical analyses;
post-test studies;
focus group, interview, or survey studies that draw from client
self-report; and
qualitative studies without statistical analyses.
 In addition, a meta-analysis may be conducted to compare the results of
multiple studies on a particular clinical intervention or clinical program.
Because each of these evaluation methods differs in the amount of rigor
required—with survey studies and qualitative analyses considered the least
rigorous and meta-analysis and randomized studies the most rigorous—when
identifying a particular evidence-based practice, you must carefully examine
how the evidence basis was established. This is not to suggest that you will
automatically reject a specific evidence-based model simply because an
unsophisticated evaluation tool was used in determining this basis but,
rather, that you must critically assess the type of evaluation as part of your
decision making about types of interventions that you might adopt. This is
important to note since there may be highly attractive reasons to consider the
use of a particular evidence-based practice despite its lack of rigorous
evaluation.
One example of an evidence-based treatment is multisystemic therapy
(MST)—a comprehensive treatment approach that seeks to address the
convergence of issues that impact the individual and takes into account the
various systems within which an individual interacts. By working at both the
family and community levels throughout the treatment process, successful
treatment outcomes have been gained through fairly rigorous evaluation
(Letourneau et al., 2009; Schoenbald, Heiblum, Saldana, & Henggeler, 2008;
Sheidow, Henggeler, & Schoenwald, 2003). Whereas previous studies that
had established the efficacy of MST with juvenile offenders were confronted
with some methodological challenges, Letourneau et al. set out to address
these challenges to determine if the approach was efficacious. In doing so,
they used a comparison treatment that consisted of the most common
treatment approaches provided to juvenile offenders, using a Treatment as
Usual control group. By doing this, they were able to ensure a real-world
comparison by which to effectively measure MST and, in so doing, found
MST to produce similar successful outcomes, thereby reinforcing its
evidence basis.
While still considered to be in its infancy, evidence-based practices in
mental health treatment are likely very much here to stay and will only
increase in use. To date, the use of evidence-based practices has had a
significant effect on mental health treatment. In fact, Sexton, Gilman, and
Johnson (as cited in Marotta & Watts, 2007) asserted that
the impact of evidence-based practices is dramatic in that they are
fundamentally changing the way practitioners work, the criteria from
which communities choose programs to help families and youth, the
methods of clinical training, the accountability of program developers
and interventions, and the outcomes that can be expected from such
programs. (p. 492)
Reflecting this new era of evidence-based practices, the Substance Abuse
and Mental Health Services Administration (2007) launched the National
Registry of Evidence-based Programs and Practice. Funded by the federal
government, the registry is a free searchable database of evidence-based
practices in mental health and substance abuse that is designed to support
program development efforts of community organizations and local and state
governments. With this current momentum, the new climate is very much
focused on accountability in program delivery and an evidence basis in
program design.

Emerging Practices
Emerging practices refer to interventions that have not yet had time to be
fully evaluated through rigorous means, that have a research basis, or that
utilize innovative strategies. Emerging practices may also be termed
promising practices, reflecting that there is more than just a hunch that these
practices may be effective and that some preliminary evaluation has likely
been done. In all cases, emerging practices imply the need for rigorous
evaluation to effectively determine if they are, indeed, evidence-based.
Because there are a limited number of evidence-based practices currently
available to treat an ever-growing number of clinical issues, emerging
practices are often accepted for use in new program development by funders,
given a rigorous evaluation plan has also been established to thoroughly test
the intervention. Allowing for such piloting of new interventions while
attempting to evaluate their merits is also very much in keeping with the
spirit of research—continuous focus on creating new knowledge through
application and testing.
 Consider this example of an emerging practice: A mentoring and social
support group for elderly individuals with chronic health issues was
identified as an emerging practice to address social isolation and prevent
depression. Mentoring had been successfully used to decrease social
isolation among a small group of at-risk adolescents at post-test, and social
support groups had been established as effective in expanding social
networks for individuals with limited social resources. Neither of these
interventions had yet been fully evaluated, but the merits of the interventions
were apparent in that some preliminary evaluation had been conducted and
there was some degree of knowledge that the interventions may prove
efficacious. As a result, the interventions were identified as emerging
practices, and a formal evaluation plan was designed to fully evaluate the
interventions as they were implemented.
Emerging practices may indeed become evidence-based practices since
most evidence-based practices begin as emerging practices. Thus, emerging
practices have the possibility to become evidence-based if and when the
anticipated outcomes are sufficiently proven and supported through rigorous
evaluation. Conversely, an emerging practice may not ever become an
evidence-based practice if such empirical evidence is not found.

Empirically Guided Practices

In addition to emerging practices emanating from preliminary studies,
another form of emerging practice is conceptual in nature, rooted in
empirical research yet not tested. These are typically referred to as
empirically guided practices. For instance, the use of clinical interventions
based on the core constructs of cognitive-behavioral therapy (i.e., the
interrelationships between cognition, affect, and behavior) may be
considered empirically guided because this theoretical base has been proven
effective in treating a wide range of issues (Jungquist et al., 2010; Navarrete-
Navarrete et al., 2010; Winokur, Rozen, Batchelder, & Valentine, 2006). By
conceptualizing a specific clinical issue, such as self-mutilation, from a
cognitive-behavioral perspective, you may be able to effectively argue that
the use of cognitive-behavioral interventions may lead to successful
treatment outcomes.
 Best Practices
The term best practice has been used interchangeably with evidence-
based practice, often signifying a program model with demonstrated success.
However, whereas evidence-based practices typically refer to the clinical
interventions that compose a program, best practices are more expansive and
may include such program components as staffing characteristics (e.g.,
credentials, staffing patterns), length of treatment time, treatment continuum
(e.g., residential, community-based, aftercare), and adjunctive services (e.g.,
support group, vocational support).
The identification of best practices often results from a thorough
examination of research dedicated to a specific issue or evolves from
rigorous evaluation. Often, best practice literature summarizes research
findings and, as a result, identifies etiological factors and recommends
specific interventions. Similar to evidence-based practices, today best
practice sections are standard in the major mental health journals. In
addition, best practices are often published by federal governmental (e.g.,
Substance Abuse and Mental Health Services Administration) and national
nonprofit organizations (e.g., Child Welfare League of America) as guidance
for new program development.

Research Basis
This new terminology in mental health practice (e.g., best practices,
evidence-based practices) is not only relatively new and seemingly growing,
but as a result, it can be somewhat confusing to practitioners and program
developers. Table 3.2 provides a brief synopsis of each of these concepts.
Particularly since each term is more similar than different, with only
slight nuances separating them, it is at times difficult to distinguish among
the terms. As a result, I prefer to use the broader concept of research basis,
as I believe it to be more inclusive, capturing evidence-based, emerging,
empirically guided, and best practices and allowing for utilizing both
research that has been proven and that which has been logically proposed but
not yet fully tested. Moreover, I believe it is in this manner that the essential
core of program design is captured—the utilization of empirical knowledge
in program design and the dynamic nature of program design as a fluid and
ever-changing process, constantly developing as new knowledge emerges.
After all, it is not the precise concept that is used in program design that is of
utmost importance but, rather, that programs have a firmly established
research basis that serves as the foundation by which clinical interventions
are anchored. This can be accomplished by the use of a specific evidence-
based practice, the utilization of an emerging practice with promising
preliminary research, the use of an empirically based conceptual design, or
the integration of best practices into program design.
Table 3.2 Key Concepts in Program Design

Knowing that the current climate of program design requires a firm basis
in research is of great use to beginning program developers, and gaining a
better understanding of the various factors that have led to the current focus
on accountability provides an effective context for working within the
current climate. More importantly, this knowledge alerts us to the amount of
attention to detail and work required in program design. This work begins
with utilizing our own research skills and involves conducting a
comprehensive review of the literature.

Conducting a Comprehensive Literature Review

As stated earlier, building a research-based program design requires a
tremendous amount of attention and significant work. To accomplish this, a
comprehensive literature review must be conducted that allows for a careful
examination of all current relevant literature. The literature review must
minimally include scholarly research (i.e., journals, academic texts), best
practice literature, governmental reports and bulletins, and research from
other sources such as national advocacy groups or professional associations
dedicated to a particular clinical or social issue (e.g., Child Welfare League
of America). For the majority of clinical program development efforts,
scholarly research typically provides the most wide-ranging source of
information; however, there often is overlap between traditional scholarship,
best practice literature, and governmental publications.
In conducting a review of the literature for the purpose of new program
development, what is most necessary is that the review is thorough, allowing
you to gain as much knowledge as possible about all the various aspects of
the particular issue you are seeking to address through programming (e.g.,
elderly depression, substance abuse). This is definitely a case in which more
is better, since your fundamental program design tool comes directly from
the literature review. As a result, it is essential that you explore all relevant
nooks and crannies in the literature so that you can become fully equipped
with the knowledge necessary to effectively inform your program design.
Before moving into a broader discussion about each major type of literature
to be examined, let’s first discuss strategies to focus or guide the review.

Guiding the Literature Review

The vast amount of research that must be examined in a thorough review
of the literature can be daunting, and as with all tasks that might at first blush
seem bigger than life, it is necessary to break things down so that they are
both manageable and effective. In this case, you must ensure that you
examine all relevant information while drilling down to focus on what is
most essential in the literature. To organize your review, you will need to
focus on the key issues (see Box 3.1) and the key questions (see Box 3.2).
BOX 3.1
 KEY ISSUES TO GUIDE LITERATURE REVIEW
 

1. The population and its specific needs to be addressed through program

design
2. Counseling theory
3. Clinical interventions
4. Adjunctive and nonclinical interventions and/or supports
5. Multicultural issues

 
BOX 3.2

KEY QUESTIONS TO GUIDE LITERATURE REVIEW

 

1. What are the specific risk factors of the target population?

2. What specific protective factors have been found to mitigate risk?
3. What specific theories have proven effective in addressing the need?
4. How has successful treatment been defined?
5. What major clinical interventions have proven effective in addressing
the need?
6. What types of nonclinical or adjunctive interventions have proven
effective in addressing the need?
7. What are the frequency and number of interventions that have proven
effective in addressing the need?
8. What specific delivery method or continuum of care (e.g., residential,
homebased) has proven effective in addressing the need?

Whereas there may be additional questions that can be used to further

focus your review depending on the specific topic, the objective here is to
ensure an efficient inquiry; so simply utilize guiding questions that allow for
this. With the guiding questions in hand to organize the literature review,
attention can be turned to the various types of literature for review.
Sources of Research for the Literature Review
Scholarly Literature
Scholarly literature provides the starting point for the research review;
however, because of the breadth and diversity within scholarship, it is
necessary to organize your search to ensure that specific key areas are
explored. These include, but are not limited to, various types of data
analyses regarding the identified problem, such as demographic variables,
risk and protective factors, and other compiled statistics and empirically
based studies related to the problem, including outcomes evaluations,
research related to specific clinical interventions, compiled literature reviews
of research related to the problem, meta-analyses of interventions and/or
programs, position papers, theoretical articles, and other scholarship
dedicated to examining and addressing the problem (Calley, 2009).
Published literature reviews and meta-analyses of program outcomes
related to the problem often are extremely valuable to the research review
process because they contain summaries of the scholarship published on the
topic. While I find these particularly helpful since a good part of work has
already been done for me, I also have to be careful not to overly rely on
these summaries at the neglect of reviewing equally significant single studies
that have not been included in the compilation. To ensure that you, too,
avoid this potential pitfall, published literature reviews and meta-analyses
should be used only in addition to single studies and independent articles
focusing on the issue at hand.
The other important facet to bear in mind when conducting a review of
scholarly literature is to search widely across the literature, appreciating that
relevant knowledge is often promoted across various disciplines. Therefore,
rather than focusing solely within your own particular discipline (e.g.,
counseling), make certain to conduct your literature search across disciplines
to ensure the necessary breadth of the literature review. Particularly today,
areas of specialization within professions are vast and overlapping. As a
result, it is not uncommon to find research on depression in counseling and
clinical psychology journals as well as in medical journals and criminal
justice literature.
 In addition to scholarship that is published through professional journals,
empirically based books published by scholarly presses or as academic texts
also should be examined. Often, collections of previously published articles
on a single topic may be bound in a text and/or the results of a
comprehensive study may be published in book format to include more
details than could be provided in a scholarly journal. These types of
scholarship often provide a great deal of knowledge on a particular topic and
can be as significant to the literature review as journal articles.

Best Practice Literature

To complement the review of scholarly literature, best practice literature
must also be examined. Whereas the scholarly literature does publish various
best practice literature, best practices are often published through a variety of
other venues as well. Typical venues for publishing best practice literature
include professional associations of major disciplines (e.g., American
Counseling Association, American Psychiatric Association), professional
associations of specialty areas (e.g., Association for the Treatment of Sexual
Abusers), and national task forces designed to address a specific area.
Although this type of literature is not always published through traditional
scholarly outlets, it is often the result of research findings and emphasizes
practice and application (Calley, 2009).

Governmental Publications
Because we are so fortunate in the United States to have so many
governmental agencies dedicated to a variety of mental health and social
service issues, the federal government is a tremendous resource for program
development efforts. In addition to the vast Departments of Health and
Human Services and Education, the National Institute of Mental Health, the
Substance Abuse and Mental Health Services Administration, and the Office
of Juvenile Justice and Delinquency Prevention, as specialty agencies,
provide focused attention to their respective issues. As a result, these and
similar governmental agencies house extensive archives and publish
comprehensive bibliographies as well as a variety of literature. Published
literature may be the result of national task forces established to make
recommendations regarding a specific issue or may summarize the findings
of various research efforts. In addition, compiled statistics and essential data
are housed by the federal government and can be freely organized to meet
the needs of a given project. Briefing books and bulletins are also regularly
published to provide information quickly and in simple formats that serve as
handy references, while white papers often provide executive summaries
addressing a particular issue. Finally, because so much mental health and
human service programming is funded by the federal government, a
significant number of publications are the direct result of funded programs
and projects.
I find that I rely heavily on the resources produced by the federal
government not only for my work in new program development but as an
integral and incredibly vast resource for my day-to-day work. The resources
are indeed extensive and, as such, require time to fully examine all that is
available and become familiar with the various types of existing knowledge.
However, governmental resources can also present their share of challenges,
particularly as the publishing process is largely dictated by fiscal health and
can be slow at times, sometimes limiting the amount of material available
while other times delaying the release of pertinent information and
resources. In addition, there is always the risk of politicization that can occur
with regard to the types of resources that are published.

Conferences
Conferences sponsored by professional associations or other professional
groups may provide yet another forum through which to obtain research for
use in the literature review. Unlike scholarly publishing, which is often
dogged by incredibly lengthy time periods between submission of research
findings and publication of the research findings, conference presentations
enjoy a much shorter shelf life, allowing research findings to be
disseminated fairly quickly. As a result, some cutting-edge research may be
easily accessible through conference presentations.
However, obtaining research through conference presentations may also
bring its fair share of challenges. First and foremost of these challenges is
the type of research presented at conferences, which may run the gamut in
terms of the degree of rigor involved in the original evaluation, from survey
data to experimental design. In addition, there are far more opportunities for
researchers to share their research at conferences than through scholarly
journal articles, making conference participation far less competitive.
Finally, and tied directly to both of these issues, is the type of vetting process
employed by the conference organizers, which may impact the type of
research presented. The use of a peer review or juried process to select
conference presentations may provide an increased level of scrutiny, but it in
no way guarantees that only scientifically sound research is presented.
Because of these reasons, when gathering research from conference
presentations, you must critically evaluate the degree of scientific rigor
applied in the research design.

Summary
As you can see, the era of program development in which we now live has
quite a long and multifaceted history. In fact, it is the result of more than 40
years of small yet significant changes, myriad factors, and external forces
that collectively have led to a climate in which accountability and
effectiveness are the core principles driving program development. This has
fundamentally changed the way in which we do business today, and it is
difficult, if not impossible, to survive as a program developer without an
innate commitment to accountability and effectiveness in the 21st century.
Both accountability and effectiveness in program development begin with
a program design that is based on empirical evidence. As such, the existing
body of research must be fully utilized to inform and guide program design.
By conducting a comprehensive literature review and using the various
principles and practices that have been identified in the research, a research-
based program design can be established, thus accomplishing the second
integral step in comprehensive program development.
 
CASE ILLUSTRATION
A Request for Proposals was issued by the state for a juvenile sex
offender treatment program. The human services agency that Joseph
worked for was interested in applying for the program as a result of its
experience with juvenile offenders. Joseph, a clinical supervisor in the
agency’s community-based program for juvenile offenders, was charged
with developing the program design description for the proposal. To
begin to develop the design, he headed to the local university library,
where he secured a visitor pass to utilize the library’s research database.
To organize his search, Joseph began by limiting research to peer-
reviewed scholarly journal articles published within the past 5 years and
utilized two comprehensive databases that focused on the behavioral and
social sciences and criminal justice. He then began searching for
information about the population by using juvenile sex offender as the
key words. As he became more familiar with the type of research
available, he conducted advanced searches focusing on both assessment
methods for juvenile sex offenders and treatment efficacy for juvenile
sex offenders. These advanced searches allowed him to locate specific
information regarding these two key aspects of treatment—assessment
and effectiveness. Moving further into the treatment aspect, Joseph
began to search for articles focusing on theory and the relationship
between theory and clinical programming for juvenile sex offenders.
After reading through either the abstracts or the full-text articles (when
available), he selected those articles that were relevant to his needs so
that he could either obtain copies of the articles that were not available
through interoffice library loan or save them to his jump drive for full
review later.
As Joseph was reading through some of the articles, he ran across
several references to sex offender legislation and other legal issues,
prompting him to conduct an advanced search on juvenile sex offender
legislation and legal issues related to juvenile sex offending. In addition,
Joseph expanded his search to include two legal databases.
He then expanded his search of databases to include books and other
documents dealing with juvenile sex offenders, marking those most
relevant for full examination later. After identifying three books and two
white papers on the topic, Joseph conducted a broad search using an
Internet search engine to get a better sense of who else was publishing
information about juvenile sex offenders. This resulted in Joseph
locating three credible resources: the National Criminal Justice Resource
Center, a comprehensive resource of research archives hosted by the
federal government; the Center for Sex Offender Management, a
consortium dedicated to disseminating knowledge about sexual
offending; and the Association for the Treatment of Sexual Offenders, a
professional association for individuals working with juvenile sex
offenders. Joseph visited each of the entities’ websites and was able to
locate a number of relevant documents, including white pages, fact
sheets, and specific bibliographies related to juvenile sex offenders.
After concluding his research, Joseph gathered all the documents
available to him directly from the library, including one of the books, and
then went about acquiring the other documents that were not available
from the library. With all the research in hand, Joseph set about learning
all he could about juvenile sex offenders, closely reading through
everything he had. His comprehensive review of the literature resulted in
identifying the primary clinical needs of juvenile sex offenders,
including but not limited to identification of pattern/cycle of abuse,
resolution of victimization in the juvenile sex offender’s history,
identification of cognitive distortions and thinking errors that support
sex-offending behaviors, and development of empathy (Andrade,
Vincent, & Saleh, 2006; Calley, 2007; Righthand & Welch, 2001;
Worling, 2005). In addition, Joseph learned that cognitive-behavioral
theory had established efficacy as a theoretical base for treating juvenile
sex offenders (Winokur et al., 2006) with several cognitive-behavioral
therapy techniques such as behavioral rehearsal, examining the
interrelationships between thoughts and behaviors and the affect of
changing one to impact change in another, and controlling stimuli used
in treatment. He also learned about the evidence related to the use of
various clinical modalities, including individual, group, and family
counseling for juvenile sex offenders, as well as differences in treatment
outcomes related to length of program and program types (i.e.,
residential, clinic-based, home-based). After thoroughly culling all the
research relevant to community-based programming for juvenile sex
offenders, Joseph was prepared to begin designing the treatment
program. Moreover, Joseph was confident that his design was well
justified, with a solid foundation in empirical research.

References
Andrade, J. T., Vincent, G. M., & Saleh, F. M. (2006). Juvenile sex
offenders: A complex population. Journal of Forensic Science, 51, 163–
167.
Calley, N. G. (2007). Promoting an outcomes-based treatment milieu for
juvenile sex offenders: A guided approach to assessment. Journal of
Mental Health Counseling, 29, 121–143.
Calley, N. G. (2009). Comprehensive program development in mental health
counseling: Design, implementation, and evaluation. Journal of Mental
Health Counseling, 31, 9–21.
Council on Accreditation. (2008a). About COA. Retrieved September 9,
2010, from http://www.coastandards.org/about.php
Council on Accreditation. (2008b). Introduction: Private standards.
Retrieved July 17, 2010, from http://coastandards.org/standards.php?
navView=private
Council on Accreditation. (n.d.). Standards. Retrieved September 9, 2010,
from http://www.coanet.org/front3/page.cfm?sect=55&cont=4191
Council on Accreditation of Rehabilitation Facilities. (2010). Quick facts
about CARF. Retrieved September 9, 2010, from
http://www.carf.org/About/QuickFacts
Department of Health and Human Services. (n.d.). Historical highlights.
Retrieved September 9, 2010, from
http://www.hhs.gov/about/hhshist.html
Government Accountability Office. (n.d.). Welcome to GAO. Retrieved April
28, 2010, from http://www.gao.gov/index.html
Johnson, M., & Austin, M. (2006). Evidence-based practice in the human
services: Implications for organizational change. Administration in Social
Work, 30, 75–104.
Joint Commission, The. (2010). A journey through the history of The Joint
Commission. Retrieved September 9, 2010, from
http://www.jointcommission.org/AboutUs/joint_commission_history.htm
Jungquist, C. R., O’Brien, C., Matteson-Rusby, S., Smith, M. T., Pigeon, W.
R., Xia, Y., et al. (2010). The efficacy of cognitive-behavioral therapy for
insomnia in patients with chronic pain. Sleep Medicine, 11, 302–309.
Kettner, P. M., Moroney, R. M., & Martin, L. L. (2008). Designing and
managing programs: An effectiveness-based approach (3rd ed.).
Thousand Oaks, CA: Sage.
Letourneau, E. J., Henggeler, S. W., Borduin, C. M., Schewe, P. A., McCart,
M. R., Chapman, J. E., et al. (2009). Multisystemic therapy for juvenile
sexual offenders: 1-year results from a randomized effectiveness trial.
Journal of Family Psychology, 23, 89–102.
Lewis, J. A., Packard, T. R., & Lewis, M. D. (2007). Management of human
service programs (4th ed.). Belmont, CA: Thomson Learning.
Marotta, S. A., & Watts, R. E. (2007). An introduction to the best practices
section. Journal of Counseling and Development, 85, 491–503.
Melkers, J. E., & Willoughby, K. (2005). Models of performance-
measurement use in local governments: Understanding budgeting,
communication, and lasting effects. Public Administration Review, 65,
180–190.
Navarrete-Navarrete, N., Peralta-Ramirez, M. I., Sabio-Sanchez, J. M., Coin,
M. A., Robles-Ortega, H., Hidalgo-Tenorio, C., et al. (2010). Efficacy of
cognitive behavioural therapy for the treatment of chronic stress in
patients with lupus erythematosus: A randomized controlled trial.
Psychotherapy and Psychosomatics, 79, 107–115.
Righthand, S., & Welch, C. (2001). Juveniles who have sexually offended: A
review of the professional literature. Washington, DC: Office of Juvenile
Justice and Delinquency Prevention.
Schoenbald, S. K., Heiblum, N., Saldana, L., & Henggeler, S. W. (2008).
The international implementation of Multisystemic Therapy. Evaluation
Translation of Health Behavior Research Innovations, Part l, 211–225.
Sheidow, A. J., Henggeler, S. W., & Schoenwald, S. K. (2003).
Multisystemic therapy. In T. L. Sexton, G. R. Weeks, & M. S. Robbins
(Eds.), Handbook of family therapy (pp. 348–370). New York: Brunner-
Routledge.
Substance Abuse and Mental Health Services Administration. (2007).
SAMHSA launches searchable database of evidence-based practices in
prevention and treatment of mental health and substance use disorders.
Retrieved September 9, 2010, from,
http://www.samhsa.gov/newsroom/advisories/0703013707.aspx
Trull, T. J., & Phares, E. J. (2001). Clinical psychology: Concepts, methods,
and profession (6th ed.). Belmont, CA: Wadsworth.
Winokur, M., Rozen, D., Batchelder, K., & Valentine, D. (2006). Juvenile
sex offender treatment: A systematic review of evidence-based research.
 Fort Collins: Colorado State University, College of Applied Human
Sciences.
Worling, J. R. (2005). Assessing sexual offense risk for adolescents who
have offended sexually. In B. K. Schwarz (Ed.), The sex offender: Issues
in assessment, treatment, and supervision of adult and juvenile
populations (Vol. 5, pp. 18–1–18–17). Kingston, NJ: Civic Research
Institute.
 CHAPTER 4
Address Cultural Identity Issues in
Program Design

 
Learning Objectives
 

1. Discuss the significance of cultural competence in program design

2. Identify two resources that can be used to provide guidance in
delivering culturally competent services
3. Discuss the various factors that have influenced the current climate
related to cultural competence in program design
4. Identify two methods for use in identifying aspects of an individual’s
cultural identity

 
 DETENTION IS DETENTION
Larry had been managing a shelter program for boys in the child welfare
system for a year when his contract manager informed him that the
county wanted him to begin serving girls as well. After working out the
logistics with his staff and his executive director, Larry was able to
confirm that the shelter would be ready to begin accepting female clients
in the next 30 days. Larry and his staff then moved quickly to rearrange
the building so that the living spaces would be separated between the
sexes, completing some minor renovations. More importantly, having
worked only with male clients in the past, Larry was looking forward to
the change that female clients would bring. He and others at his agency
were also excited that the county had specifically asked them to take on
this new business that would result in an increase of revenue for the
agency and further demonstrate the agency’s good standing with its
funding source.
Five months after the program began serving females, the county’s
licensing consultants came for their regular review/audit. When asked
about the new program that had been developed specifically for the
female clients, Larry looked back at the consultant, not quite
understanding what she was referring to. Larry shared with the
consultant that the program they had in place for the boys had been
successful, and so they did not make any changes to the program when
they began serving girls. The consultant further pushed Larry, inquiring
if he was aware of gender-specific treatment, to which Larry responded
that of course he was. In fact, he stated that the agency had made
significant—and costly—changes to the facility in order to separate the
living spaces between the girls and boys, and he further shared with the
consultant that he had directed the staff to purchase dolls and sewing kits
for the girls.
When the licensing review report arrived 2 weeks later, Larry had
been given a noncompliance for failing to provide gender-specific
treatment in the shelter. As a result, he was required to submit a
corrective action plan within 30 days stating how this issue would be
addressed.
  
CONSIDERING LARRY

1. What did Larry fail to do?

2. In addition to the licensing citation, what other ramifications might this
issue have caused Larry/the agency?
3. If you were Larry, how would you go about determining how to
develop a program for female children versus male children?

About This Chapter

Because cultural competence is an essential component of program design,
part of the literature review must be specifically devoted to examining
culturally competent interventions. While this does not constitute an
additional step in the program development model because of its
significance and scope, it is important that it be given particular attention in
the literature review. Thus, it is considered Step IIa—a specific
subcomponent involved in establishing a research basis in program design.
Because cultural competence is such an integral part of clinical
programming, the first part of the chapter is devoted to a review of some of
the major concepts of cultural competence. Next, we will examine historical
and influential factors related to the current climate of multiculturalism, with
a specific focus on the role of professional associations, scholarship,
academic preparation, accreditation, and funding. Finally, we will explore
methods by which to identify cultural identity aspects of client populations.
An exercise is provided at the end of the chapter to assist you in focusing the
literature review on cultural competence and in identifying culturally
competent treatment strategies for use in program design.

STEP IIA: ADDRESS CULTURAL IDENTITY

ISSUES IN PROGRAM DESIGN
Culturally Based Concepts: The Building Blocks of Our
Current Vocabulary
As you witnessed in Chapter 3, the manner in which clinical programs are
developed has changed dramatically over the past couple of decades. In
addition to the increased emphasis on program effectiveness and
accountability in program design, in more recent history, there has been an
increasing call for cultural competence in program design. Also, just as a
new vocabulary has been adopted for program design focused on enhanced
business practices and accountability (e.g., evidence-based practices, best
practices), other new concepts have come into more frequent use to reflect
an ever-increasing emphasis on cultural competence in program design.
Spurred on by the growth and development of the human service and mental
health fields and increased recognition and understanding of diversity, the
commitment to cultural competence has expanded tremendously.
To aid in our understanding of multiculturalism and its intersection on
program design and implementation, concepts such as diversity,
multiculturalism, cultural self-identity, and cultural competence have
reemerged or been introduced into our vocabulary. These concepts provide
us with a sound foundation for understanding issues related to cultural
identity, as well as illustrating the progress that has been made in this area.
In fact, I like to think of these terms as building blocks, each concept
dependent on the previous one and each one reflecting our increased
knowledge and growth in this area (see Figure 4.1). Although entire graduate
courses today focus on multiculturalism and related issues, a brief summary
of each of these major concepts is necessary to frame the discussion on
incorporating multicultural considerations into program design.

Diversity
Fundamentally, diversity refers to differences. In the mental health
professions, diversity refers to working with individuals who are different
from us. In our rather short history of identifying and understanding
diversity, we have come quite a long way, moving from a small and
exclusive definition of diversity into a broad, encompassing view. Early
forays into diversity in the mental health professions focused primarily on
race, with an underlying assumption that racial differences constituted the
primary differences between individuals. It was not until the 1970s that
empirical studies on ethnicity began to significantly increase (Baruth &
Manning, 1999). Interestingly, this expanding view of diversity occurred at
quite a slow pace, particularly given that Erikson (1950) began urging the
mental health professionals to enlarge their view of diversity by looking
beyond mainstream America as far back as 1950.
Figure 4.1 Building Blocks of Culturally Based Concepts

Regardless of how long it has taken to get here, today we understand a

much broader concept of diversity—one that goes well beyond both race and
ethnicity. Currently, we understand diversity as being highly inclusive of an
endless number of traits, encompassing an individual’s unique differences
that might be related to class, physical or mental ability, sexual orientation,
religion, gender, national origin, race, geography, ethnicity, or other aspects
(Lum, 2007). Moreover, as we have come to understand diversity as broad
and expansive, we have come to associate diversity with richness—
understanding that differences between individuals provide a unique source
of benefit to others and to humankind.
Corporate America was one of the first to pick up on the inherent value of
diversity, and thus, businesses began making strategic hiring decisions
designed to achieve a diverse workforce. As a result, diverse workforces
were often able to achieve greater success in business. It is not difficult to
understand the logic behind embracing diversity in the workplace,
particularly when considering decision-making processes. For instance,
decisions made by a group of individuals of similar backgrounds and
experiences often reflect nothing unusual or different to any of the members.
This results in business as usual decision making. However, decision
making by a group of individuals from varied backgrounds and experiences
often promotes new ways of thinking and doing business, thus enriching the
outcomes and allowing the business to try something new—a near necessity
in today’s rapidly changing business world.
Whereas the business world has long understood the benefits and
strengths that diversity offers in the workplace, the mental health professions
have continuously worked to better understand specifically how to support
individuals with diverse needs and from diverse backgrounds. At the basis of
this understanding is the notion of diversity as fundamental to all of us as
human beings. As a result, understanding and appreciating diversity requires
that in order to most effectively treat and serve individuals in need, we must
first understand what makes each individual who and what s/he is.

Multiculturalism
First identified as the fourth force in counseling by Pedersen (1990),
multiculturalism refers to an appreciation and acceptance of
differences/diversity and specific needs and strengths that exist among and
between groups. As such, multiculturalism embraces unity and diversity
(Flowers, 2009). Multiculturalism assumes that there are multiple forms of
diversity without hierarchal structures or values ascribed to any one type of
diversity over another. Multiculturalism promotes an understanding that
differences between individuals and groups are not only essential but are to
be embraced and celebrated. Further, multiculturalism—or more specifically,
cultural relativism—requires us to view differences from their unique
perspective rather than by using ourselves as the measuring stick by which to
evaluate differences. In so doing, we are forced to learn about differences
from the inside out rather than by applying a subjective or encapsulated view
of what constitutes a difference and what that difference means.
 Whereas diversity taught us to identify differences and begin to
understand the value of differences, multiculturalism taught us how to not
only acknowledge the nuances of differences but celebrate those differences.
As such, multiculturalism serves to limit egocentricity and expand our
thinking about what diversity is by forcing us to look beyond ourselves and
appreciate the richness of others.

Cultural Self-Identity
Cultural self-identity refers to the extent to which individuals perceive
themselves as included and aligned with others through various shared
aspects of diversity (e.g., gender, generation, ethnicity, class). Growing out
of multiculturalism, cultural identity picked up where multiculturalism left
off, allowing for an understanding that a variety of cultural differences exist
within each individual, collectively shaping the individual’s self-identity. It
is in this regard that cultural identity is highly complex, with identities
having varying levels of prominence, often contextually influenced. For
example, whereas the socioeconomic status of a 40-year-old cashier at a fast
food restaurant may not be something of which he is largely aware when he
is among friends in his neighborhood, it can become the most prominent
aspect of his identity when he is at a function with a group of wealthy
individuals. Similarly, the fact that one is agnostic may have little bearing on
how one feels about oneself day to day; however, when attending religiously
affiliated events, one’s agnosticism may suddenly have quite significant
meaning. These examples highlight the manner in which aspects of identity
converge to create a specific meaning to the individual as well as the
contextual nature of cultural identity wherein certain aspects achieve greater
prominence as a result of environmental factors.
Moving our understanding of cultural self-identity forward, Arredondo
and Glauner first presented their framework for understanding cultural
identity in 1992. The framework categorizes aspects of identity into three
groupings: identities that are assigned to us/that which we cannot control
(e.g., initial geography, class, ethnicity, initial religion), identities that we
have some control over (e.g., vocation, class, geography), and historical or
other issues that impact our self-identity (e.g., chronic illness, living through
a recession). Through this framework, cultural self-identity promotes an
enriched understanding of individuals in which the individual is the sum of
his or her parts and, as such, requires mental health professionals to
understand and appreciate the convergence of identity aspects. Moreover, the
framework suggests that whereas there are three major methods by which
our cultural identities can be shaped, the prominence and meaning of each is
determined by the individual. Therefore, whereas for some individuals,
initial socioeconomic class has significant meaning to how they perceive
themselves, for others, the class that they achieve later in life may have
greater influence on their self-perception.

Cultural Competence
Cultural competence (also known as multicultural competence) is defined
as the counselor’s development of awareness of her or his cultural identity
and belief systems and the knowledge and skills to work with diverse
individuals (D. W. Sue, Arredondo, & McDavis, 1992). As a means of
making the standards operational and to promote an inclusive view of
cultural identities, Arredondo et al. (1996) identified a set of competencies
for counselors to achieve in practice that built on the previous work of D. W.
Sue et al. These competencies have been endorsed by the Association for
Multicultural Counseling and Development and can be found both on its
website (www.amcdaca.org) and on the website of the American Counseling
Association (www.counseling.org).
Similarly, the National Association of Social Workers (2007) has
promulgated standards for cultural competence in practice to provide
specific guidance to social workers in this area. Indicators for the
Achievement of the NASW Standards for Cultural Competence in Social
Work Practice can be found on their website (www.socialworkers.org).
Briefly, cultural competence requires mental health professionals to fully
understand their own cultural self-identity, confront their own biases or
limitations, and effectively deal with any beliefs that may impact their
professional ability to support an individual of differing identity. Second,
cultural competence requires individuals to gain deep knowledge and
understanding of various identity aspects in order to be well informed and
achieve a general framework while at the same time learning from each
client about his/her cultural self-identity and its personal meaning. For
instance, possessing knowledge that for many African Americans, extended
family is a critical support system does not necessarily imply that each
African American client is significantly connected to his/her extended
family or that extended family has significant meaning to that particular
individual. Finally, cultural competence requires mental health professionals
to attain specific skills that are necessary to effectively work with
individuals from diverse backgrounds or with unique aspects of identity.
This includes the use of assessment instruments that have been appropriately
tested or normed on diverse groups (e.g., you would not use a self-efficacy
assessment tool with an Asian youth that has been normed on a population
of African-and Euro-American youth). In addition, this requires the use of
specific clinical interventions that are culturally sensitive or that take the
client’s cultural identity into account.
Seeking cultural competence—a primary objective of all mental health
professionals—requires working with clients in a state of constant curiosity.
By this, I mean that understanding the multifaceted layers and unique
meaning of a client’s cultural identity requires the counselor to be open to
continuous learning about how the client perceives him/herself. At the same
time, it means that the counselor must be continuously committed to learning
all there is to know about how to provide the most effective treatment to the
client as a result of his/her cultural identity.
As you can see, we have come quite a long way in how we think about
differences among persons and the impact of those differences on clinical
treatment. Whereas we had to first understand that differences among
individuals need to be acknowledged and thoughtfully considered, thus
ushering in studies of diversity, we soon shifted our focus beyond simply
looking at differences between individuals and groups to increasing our
understanding of the value of such differences. From this framework, an
emphasis on cultural self-identity emerged that then led us to our current
focus, which ties all three of these areas together in the concept of cultural
competence.

Cultural Competence and Clinical Program

Design
Brief History
The brief review of terminology related to multiculturalism provides one
level of understanding the history of cultural competence in clinical
programming and should also provide an effective map to better
understanding the developmental path that cultural competence has taken.
Whereas we witnessed significant growth in the area of diversity and
multiculturalism over the past 2 decades, it was not until much more recently
that particular shifts toward cultural competence in clinical program
development began to emerge.
Initially, this shift led to the development of programs focused on a
specific cultural identity aspect. This led to a much clearer focus on
developing programs not only that were gender-focused/gender-specific and
developmentally appropriate but also that focused on specific subgroup
populations, such as child-welfare–involved Latino youth and female
prisoners with primary substance abuse problems. These shifts toward
thinking about treatment for specific subpopulations had tremendous impact
as they challenged the status quo by demanding that treatment take into
account an individual’s unique attributes when relevant to treatment.
Prior to this, while it was common for males and females to be housed
separately in residential programs, the focus of clinical treatment was most
often the same, regardless if the treatment issue was addiction, a serious
mental health issue, or homelessness. As such, the risk factors for a female
addict, the manner in which she experienced addiction, the unique meaning
that she derived from being a female with an addiction problem, and the
methods by which she could be successful in treatment were not necessarily
considered since often the treatment approaches had been originally
developed for male addicts. This is not to say that early treatment programs
for males did a much better job integrating gender as a focus of treatment but
that because programs were largely facilitated by men, they may have had
somewhat of an innate predisposition to incorporating male gender into
treatment.
This very issue of the convergence of cultural identity with a treatment
need (e.g., Asian-American mental health treatment) continued to gain
ground as a body of research was developed addressing these issues. Studies
on topics such as treating single adults in homeless shelters (Baggerly &
Zalaquett, 2006), treating bereavement and coping among South Asian
families post-9/11 (Inman, Yeh, Maden-Bahel, & Nath, 2007), and
counseling clients that are deaf (Peters, 2007) began to appear, investigating
the significance of incorporating specific cultural identity aspects into
treatment. Not only did these studies produce significant knowledge for the
mental health professions, but they served to further reinforce the necessity
of addressing cultural identity in treatment.
All this may seem perfectly logical today, considering that the experience
of a female who is homeless is often significantly different than that of a
homeless male, particularly with regard to safety, risk factors that led to
homelessness, and resources needed to move out of a transitional state.
However, a tremendous amount of effort by many mental health
professionals was expended to get us to this current place of understanding
that for each individual, the convergence of various identities creates unique
meaning and treatment needs.

Current Climate
Knowing how far we have come always helps us better understand where
we are today, which is a place wherein cultural competence is not only an
aspirational goal of mental health professionals but both an intrinsic value
and mandatory objective of our profession. In addition to the multicultural
competencies that guide the work of professional counselors and other
mental health professionals, the stature of cultural competence in the mental
health and human service fields is widely evident through a multitude of
factors. In particular, six factors likely serve as the most effective indicators
of the current climate. These include
 

1. the number of professional associations specifically committed

to both broad and specific aspects of multiculturalism,
2. the amount of scholarship dedicated to cultural competence,
3. cultural competence as a core part of academic preparation in
mental health disciplines,
 4. the promulgation of national standards of cultural competence
by the federal government,
5. the inclusion of cultural competency-specific accreditation
standards for mental health and human service programs, and
6. the requirement of addressing cultural competence in proposals
for funding new program development.
 

Professional Associations
The number and diversity of cultural identity issues that are the focus of
divisions of both the American Counseling Association and the American
Psychological Association provide a snapshot of the current stature of
multiculturalism in the mental health professions. In fact, currently, there are
four divisions of the American Counseling Association and five divisions of
the American Psychological Association specifically dedicated to one or
more aspects of multiculturalism (see Table 4.1).
Table Professional Mental Health Associations With a Specific Focus on
4.1 Multicultural Issues
 Whereas these professional associations serve multiple purposes such as
providing scholarly and collegial outlets for professionals working with
issues of diversity, they each also serve to ensure that both specific (e.g.,
men and masculinity) and more broad-based issues of diversity (e.g.,
multicultural counseling and development) retain a central focus in the
mental health professions. The work of the associations is wide-ranging,
including the promotion of professional dialogue, conferences,
dissemination of scholarly and nonscholarly information through various
venues, and professional advocacy, to name just a few. What each
association shares, regardless of its particular focus on multiculturalism, is
an emphasis on increasing knowledge and skills of mental health
professionals to better support individuals of varying identities. Moreover,
professional associations serve as collectives of behavioral change agents to
clients nationwide and serve as national leadership forums in dialogue and
teaching about diversity issues.
In addition, the Codes of Ethics of both the American Counseling
Association (2005) and the National Association of Social Workers (2008)
provide further reinforcement of the central role that cultural competence has
in mental health treatment today. To illustrate this, Table 4.2 provides a
snapshot of the specific ethical standards related to culturally competent
practice.
Table 4.2 Ethical Standards Related to Culturally Competent Practice
 Scholarship
As a key function of professional associations, the dissemination of
knowledge through scholarship has long been served via the professional
journals published by various associations. Today, each of the major
behavioral and social science disciplines publishes journals dedicated solely
to multicultural issues. More telling a sign of the significance that
multiculturalism and cultural competence has today in the behavioral and
social sciences, though, is the number of scholarly articles pertaining to such
issues published across various journals within disciplines. For instance,
whereas all the articles in the Journal of Multicultural Counseling and
Development are directly related to issues of multiculturalism and cultural
competence and the Journal of Lesbian, Gay, Bisexual, and Transgendered
Issues in Counseling and the Journal for Social Action in Counseling and
Psychology focus on specific subareas of diversity, journals with a much
broader scope such as Professional School Counseling and the Journal of
Counseling and Development often contain multiple articles focused on
various aspects of cultural competence. Moreover, multiculturalism and
diversity cut across most if not all scholarship today. In fact, you would be
hard-pressed to find a major journal in any discipline, from accounting to
zoology, not addressing some aspect related to cultural identity.
The breadth of scholarship dedicated to multiculturalism and cultural
competence in the United States is highly indicative not only of the immense
diversity of our country but, more so, of our commitment to knowledge as
we continue to grow and expand. Likewise, the integration of multicultural
issues across a vast number of disciplines speaks to the universal regard for
cultural competence as one of our core values.

Academic Preparation
Related to both professional associations and scholarship is the current
focus of academic preparation in mental health fields specifically on cultural
competence. As a result, there is significant emphasis on the teaching of
cultural competence as part of standard pedagogical practice.
At the graduate level, academic programs are often largely influenced by
academic accreditation standards, as graduate programs often strive to attain
accreditation. Because these accrediting bodies are largely influenced by the
major activities of the field, while professional associations have evolved to
specifically focus on multiculturalism, unique academic program standards
dedicated to multiculturalism have also been promulgated. And it is in this
way that the interactions between these factors are evident.
For instance, the Council for Accreditation of Counseling and Related
Educational Programs (CACREP) guides the teaching of graduate-level
counselors. This type of discipline-specific academic program accreditation
concentrates on all aspects of academic programming, from the university
infrastructure to the program-level administration and from the admissions
process to the curricular experiences and academic objectives. Mirroring the
current values of the counseling profession, these accreditation standards
reflect the prominence of cultural competence within the broader mental
health field. As such, Social and Cultural Diversity is one of the eight core
curricular areas of CACREP accreditation standards, focusing on academic
experiences that promote understanding of the cultural context of
relationships, trends, and issues currently impacting the profession of
counseling (CACREP, 2009). Core curricular areas provide the foundation of
the counseling curriculum, serving as the underlying objectives of all
counselors rather than focusing on a specific specialty (e.g., addiction
counseling, school counseling). As such, these objectives focus on broad
aspects of cultural competence such as theories of identity development and
social justice and the counselor’s role in eliminating biases, prejudices,
discrimination, and oppression (CACREP, 2009). Whereas issues related to
multiculturalism compose one of the core standard areas, aspects of cultural
competence are also a part of other core areas such as assessment and
evaluation and research and program evaluation. Finally, standards related to
cultural competence are again evident in the standards of each specialty area
under the heading of Diversity and Advocacy. Within the specialty areas,
standards related to cultural competence are more practice-specific, taking
into account issues relevant to the specific specialty, such as recognizing the
various types of families that may be counseled by specialists in Marriage
and Family Counseling—which might include same-sex couples and/or
families in transition. Table 4.3 provides examples of these academic
program standards.
Academic program accreditation standards ensure that cultural
competence is an essential part of academic training and preparation. As a
result of the influence of academic preparation, new clinicians are fully
aware of the significance of cultural competence in mental health treatment
and human services.
Table Integration of Multiculturalism and Cultural Competence Across
4.3 CACREP Standards
 National Standards
Providing another form of guidance on a national level, the standards
promulgated by the Department of Health and Human Services’ (2007)
Office of Minority Health focus specifically on cultural and linguistic
competencies for health care providers (see Box 4.1). In addition, the
National Center for Cultural Competence at Georgetown University provides
a host of resources for integrating cultural competence in mental health
program design (http://nccc.georgetown.edu). Both of these may prove
significant resources in comprehensive program development to ensure that
cultural competence remains a central part of services and treatment.
 
BOX 4.1

NATIONAL STANDARDS ON CULTURALLY AND

LINGUISTICALLY APPROPRIATE STANDARDS (CLAS)
Health care organizations should take the following actions to meet
CLAS standards:
 

1. Ensure that patients/consumers receive from all staff members

effective, understandable, and respectful care that is provided in a
 manner compatible with their cultural health beliefs and practices and
preferred language
2. Implement strategies to recruit, retain, and promote at all levels of the
organization a diverse staff and leadership that are representative of the
demographic characteristics of the service area
3. Ensure that staff at all levels and across all disciplines receive ongoing
education and training in culturally and linguistically appropriate
service delivery
4. Offer and provide language assistance services, including bilingual
staff and interpreter services, at no cost to each patient/consumer with
limited English proficiency at all points of contact, in a timely manner
during all hours of operation
5. Provide to patients/consumers in their preferred language both verbal
offers and written notices informing them of their right to receive
language assistance services
6. Assure the competence of language assistance provided to limited
English proficient patients/consumers by interpreters and bilingual
staff; family and friends should not be used to provide interpretation
services (except on request by the patient/consumer)
7. Make available easily understood patient-related materials and post
signage in the languages of the commonly encountered group and/or
groups represented in the service area
8. Develop, implement, and promote a written strategic plan that outlines
clear goals, policies, operational plans, and management
accountability/oversight mechanisms to provide culturally and
linguistically appropriate services
9. Conduct initial and ongoing organizational self-assessments of CLAS-
related activities and, ideally, integrate cultural and linguistic
competence-related measures into internal audits, performance
improvement programs, patient satisfaction assessments, and
outcomes-based evaluations
10. Ensure that data on the individual patient’s/consumer’s race, ethnicity,
and spoken and written language are collected in health records,
integrated into the organization’s management information systems,
and periodically updated
 11. Maintain a current demographic, cultural, and epidemiological profile
of the community as well as a needs assessment to accurately plan for
and implement services that respond to the cultural and linguistic
characteristics of the service area
12. Develop participatory, collaborative partnerships with communities and
utilize a variety of formal and informal mechanisms to facilitate
community and patient/consumer involvement in designing and
implementing CLAS-related activities
13. Ensure that conflict and grievance resolution processes are culturally
and linguistically sensitive and capable of identifying, preventing, and
resolving cross-cultural conflicts or complaints by patients/consumers
14. Try to regularly make available to the public information about the
organization’s progress and successful innovations in implementing the
CLAS standards and provide public notice in their communities about
the availability of this information

Accreditation Standards for Mental Health and Human Service

Organizations
In addition to the above national standards of the Office of Minority
Health and the National Center for Cultural Competence, some of which are
mandated for subcontractors receiving federal funding, the major national
accrediting bodies for human services and mental health programs have also
promulgated specific standards addressing cultural competence in program
design and service delivery. By doing so, organizations that voluntarily seek
accreditation are required to comply with such standards, thereby effectively
addressing cultural competence as a primary aspect of programming. For
instance, Adoption Standard 2.02 of the Council on Accreditation (COA;
2008) requires that “assessments are conducted in a strengths-based,
culturally responsive manner to identify resources that can increase service
participation and support the achievement of agreed upon goals.”
Each of the specific accreditation standards for the Council on
Accreditation of Rehabilitation Facilities (CARF) and COA can be found on
their websites (www.carf.org and www.coanet.org), while the accreditation
standards of The Joint Commission are available for purchase at their
website (www.jointcommission.org). Taken collectively, these accreditation
standards that specifically address cultural competence constitute another
major influence on current mental health and human service programming in
the 21st century.

Funding
Just as scholarship has informed academic preparation programs and
national accrediting bodies as to the significance of cultural competence,
funding bodies have not ignored this call. In fact, some requests for new
program development are directed specifically toward diverse populations.
To illustrate this, consider these recent funding opportunities targeting
specific cultural identity aspects and treatment needs:

Urban and nonurban homeless veterans’ reintegration program

(Office of the Assistant Secretary for Administration and
Management, Department of Labor, 2010)
Technical assistance for national minority aging organizations
(Administration on Aging, 2010)
Women’s mental health in pregnancy and the post-partum
period (National Institute of Health, 2009)

As you can see, funders have begun to emphasize a need for programs
and research that addresses unique treatment needs of special populations. In
addition to directly targeting specific subpopulations through specialized
funding opportunities, funders may also require that applicants address
various unique needs of populations within more general grant applications.
In doing so, the funding source may provide information in the application
summary that speaks to some of the unique issues of the population in order
to provide background information to applicants. This information, based on
current research, is crucial to the applicant as it provides necessary
information that needs to be addressed in the application. For instance, take a
look at the following excerpt from a recent federal Request for Proposal
summary for projects to provide substance use services to United States
veterans:
 Younger service members with combat exposures had increased rates
of new-onset heavy weekly drinking, binge drinking, alcohol-related
problems and increases in smoking initiation and relapse (Jacobson et
al.,2008;Smith et al.,2008) …. In addition to deleterious effects of
deployment on the military member, there is emerging evidence of the
effects on the family. (Department of Health and Human Services,
n.d., “Deployment,” para.1)
By articulating this information in the Request for Proposal, the funder is
specifically emphasizing the significance of culturally competent treatment.
As such, the funder is providing critical information related to the specific
needs of (1) younger military personnel and (2) families of military
personnel and two specific types of unique treatment needs of these
populations—(1) substance use and abuse and (2) deployment-related issues.
Moreover, the funder explicitly requires that the unique needs of the
identified special populations must be addressed by applicants.
In both instances, when funding is provided for special populations and
when funding is provided for a general population with targeted
subpopulations, applicants are often required to stipulate their plans to work
with these populations and to state specific methods by which the treatment
needs of the populations will be met. The astute program developer is wise
to pay close attention to delineating the relevant aspects of cultural identity
and unique treatment needs to ensure that s/he is fully equipped to address
these critical issues through programming, thus articulating one’s cultural
competence.
As you can see, scholarship, professional associations, academic
preparation, national standards, accreditation bodies, and funding trends
have each had a significant influence on the current climate related to
cultural competence in program design. These influences have not occurred
in isolation but rather, in many ways, are highly interconnected, with a
change in one influencing a change in another. Moreover, it is because of the
collective force that has been brought to bear by the convergence of these
influential factors that today cultural competence is a central tenet of mental
health and human service programming.
However, whereas the current climate reflects this shift toward increased
knowledge related to cultural identity, research focused specifically on
treatment interventions for diverse groups is still very much in its infancy.
We must therefore be cautious not to mistake this growth in awareness and
knowledge of multiculturalism as growth in cultural competency. Rather, we
must continue to focus our energies toward increasing our knowledge and
skills to ensure that we can indeed most effectively address diverse needs
through culturally competent program design.

Cultural Identity Aspects and Client Populations

Building programs that are culturally competent begins with fully
understanding cultural identity and the vast aspects that compose cultural
identity. As stated originally by Arredondo and Glauner (1992) and as
reiterated by Lum (2007), cultural identity is both multifaceted and complex,
with various layers and dimensions that individually and collectively
influence a person’s perceptions of self and the world in which s/he lives. To
provide a sense of some of the aspects that contribute to one’s cultural
identity, see Table 4.4.
I should note that Table 4.4 provides just a sample of cultural identity
aspects and subtypes and that the aspects and subtypes are not organized
with any type of hierarchy or implied value. This is important to keep in
mind when remembering that the value that any aspect of cultural identity
has is determined by the individual, not by others (this deserves repeated
mention). Whereas this is only a sample, it illustrates just how complex
cultural identity is and, as a result, just how much we as program developers
need to understand all the various nuances that compose cultural identity.
Although the table is designed to provide a snapshot of some of the identity
aspects that belong to a particular category (e.g., Ableness: paraplegic,
visually impaired, traumatically brain-injured, physically abled), to gain a
sense of the complex identities of individuals, move across the table from
left to right, considering that one row reflects five identity aspects of an
individual. For instance, one individual is a gay Muslim from a poor, urban
area whose vocation is in mining and who views extended family members
as his/her primary family members. The complexity of this individual’s
cultural identity is easily evident, but only s/he can tell us what particular
meaning this identity holds for him/her.
Table 4.4 Cultural Identity Aspects and Subtypes
 Like understanding the various meanings that are made from cultural
identities, understanding the various aspects that fall into each category is no
easy task. This is especially true since new aspects of cultural identity are
constantly emerging and new meaning is formed by the convergence of
multiple aspects of identity. Particularly relevant in the United States, with
our continuously expanding diverse population, one of the primary
challenges in developing culturally competent interventions again lies in
one’s ability to remain constantly curious—ensuring that you are indeed
receptive to continuous learning about new needs related to cultural identity
and to designing programs that are flexible enough to accommodate needs as
they arise.

Identifying Cultural Identity Aspects of Client Population

Ensuring that you are adequately prepared to address the diverse needs of
client populations begins with comprehensive planning that has a focus
toward cultural competence. Ideally, this results in a culturally competent
program design and a treatment milieu that is conducive to ongoing
modifications to meet the needs of individual clients. There are two specific
activities that need to be conducted to accomplish these objectives, one that
is used to identify multicultural considerations needed in the initial program
design and the other that is used to identify additional issues related to
cultural identity that may require ad hoc program modifications. As such, the
first is necessary for initial program design and is considered part of the
preplanning stage, whereas the second is considered an ad hoc feature of
program design, utilized when necessary as new prominent aspects of
cultural identity emerge.
The first activity involves revisiting the results of the community
demography assessment.Because the community demography assessment
results provide broad information about the population parameters, they are
especially useful to this stage. Since this assessment was conducted
previously (in Step I), the work has already been completed; so the objective
at this stage is now twofold: (1) Review the information to use in developing
knowledge about the population’s diversity and attendant needs, and then (2)
use this new knowledge to identify multicultural considerations that will
need to be addressed in program design (Step III). To accomplish this, you
must return to the summary report compiled as part of the comprehensive
needs assessment process (Step I) in order to cull the cultural identity
information of the population. Having done this, you are effectively prepared
to research specific clinical needs that are related to cultural identity.
For instance, if the results of your needs assessment and market analysis
justify the development of a program targeting adolescent males, and there
are majority groups of Mexican and Chaldean youth among your target
population, research must be conducted to learn more about the unique
experiences and/or special needs of adolescent Mexican and Chaldean youth.
Examining the research on these two ethnic groups would likely clarify that
both groups may be characterized by strong familial ties (Nydell, 2006;
Szapocznik et al., 1997), a belief in Fatalism (Arredondo, Bordes, &
Paniagua, 2008; Hakim-Larson, Kamoo, Nassar-McMillan, & Porcerelli,
2007), the Catholic faith (Matovina & Riebe-Estrella, 2002; Nydell, 2006),
and difficulty attached to seeking outside help (Abudabbeh & Aseel, 1999;
McCabe, 2003). Whereas this knowledge should not be used to pigeonhole
any population (indeed, no characteristics can be applied to all individuals
within a subgroup), it does ensure that program designers have some level of
general knowledge about their specific target populations, and that
knowledge should be used to provide some guidance to program design. As
such, gaining this information about these groups allows you to determine
what, if any, unique features should be built into the program design in order
to address these multicultural considerations when relevant to the individuals
being served.
In order to accomplish the second objective related to making program
accommodations to address specific culturally related needs, culturally
focused assessment must guide this process, often built into the client intake
process. Unlike the first activity that involves research to gain broad
knowledge related to cultural identity, making program modifications relies
on gaining specific information through assessment directly from clients
who may indicate such a need. Assessment questions may be focused on
such areas as religious and/or spiritual traditions, family dynamics, or
communication style, to name a few. These questions of inquiry should be
designed both to promote sharing significant personal information with the
clinician and to inform the clinician about important client characteristics
that may require specific accommodation. As with all questions posed as
part of a therapeutic experience, each question must be fully justified and,
therefore, must add specific value to the treatment process. To illustrate this
type of assessment, Table 4.5 provides sample questions and how they may
be used to accommodate the client.
These questions can be easily embedded in the intake questionnaire so
that they simply become a part of the initial client assessment process—an
essential part, at that. By doing this, accommodations can easily be made for
the client, and in this way, cultural competence is demonstrated not only as a
programmatic value but as a construct that requires consistent and deliberate
attention in order to be achieved. It probably goes without saying that
program developers who appreciate cultural competence are fully attuned to
their responsibility to create flexible programs and work diligently at
program modifications as needs arise.
Table Sample of Culturally Focused Assessment Questions, Objectives,
4.5 and Potential Accommodations
 Developing Culturally Competent Treatment Interventions
Despite the fact that we have an advanced understanding of cultural
competence today and understand that cultural competence is a core
expectation for all mental health professionals, we have yet to fully
understand if and how cultural competence impacts treatment outcomes. In
fact, in a climate in which empirical evidence must guide clinical practice,
there is a dearth of research on culturally competent empirically supported
mental health interventions (Roberts, Yeager, & Regehr, 2006). While this
does not necessarily indicate that there is not a relationship between cultural
competence and treatment outcomes, it does mean that without doing more
work in this area, we can only discuss cultural competence from a best
practice perspective and not an evidence-based perspective.
The reasons for the dearth of research in this area are highly valid and
easy to understand, based directly on how an evidence basis is established in
the first place—through rigorous research with appropriate sample sizes.
And more importantly, through the use of randomized controlled studies (S.
Sue & Zane, 2006). Speaking specifically of cultural competence with
regard to ethnic and/or racial differences, Conner and Grote (2010)
summarize these challenges:
The ability to effectively develop and conduct randomized controlled
trials to test mental health interventions in racial/ethnic minority
populations has proven to be particularly challenging. Given that the
population sizes of racial/ethnic minorities in America are relatively
small when compared to Whites, it is not uncommon for racial/ethnic
minorities to be concentrated in particular geographic regions in the
United States. Thus, it may take additional resources to gain access to
these communities in order to engage them in research. (p. 590)
In order to begin to understand precisely how cultural competence can be
integrated into treatment in order to produce effective outcomes, we must
work to overcome these barriers. To provide a starting point for this, Conner
and Grote (2010) suggest incorporating culturally competent interventions
into existing evidence-based practices (e.g., cognitive-behavioral therapy)
and conducting rigorous evaluation to determine the outcomes. Applying
Bernal, Bonilla, and Bellido’s (1995) cultural framework that includes
language, persons, metaphors, content, concepts, goals, methods, and
context, the authors demonstrate how this can be done (see Conner & Grote,
2010). Whereas there may indeed be other methods by which to begin this
research, the fact remains that particularly because we have come so far in
our understanding of cultural competence, we must now examine it with
specific regard to evidence-based practices.

Summary
As you can see, cultural competence is a critical component of clinical
program development today, and one that is arguably a most essential factor
in the ongoing health and quality of human services. However, it has taken
quite a bit of time to reach this current state, and fully appreciating where we
are today requires an understanding of the various historical factors that
prompted us to arrive here. As a starting point, the basic concepts of
diversity, multiculturalism, cultural identity, and cultural competence have
both provided a framework for understanding issues related to culture and
moved us forward from transforming knowledge and understanding into
action. But the progressive use of these concepts did not occur outside the
context of other changes occurring in the field, and in fact, changes in
professional associations, scholarship, academic preparation, accreditation
standards, the promulgation of national standards, and funding requirements
were each instrumental in creating the current climate. Working
symbiotically, these factors—as well as others—have converged to increase
our understanding of cultural identity and propel us toward cultural
competence. As knowledge in this area has increased, program developers
have been more concerned with addressing cultural identity in initial
program design and in ongoing program implementation efforts.
However, whereas the current climate in program development does
indeed emphasize attention to cultural identity, we still have quite a long
way to go to achieve cultural competence in program design. This will likely
require both greater pressure from funding sources and rigorous evaluation
that includes an emphasis on the impact of cultural competence by program
developers and other evaluators. So, just as we have made significant strides
in increasing understanding of the role that culture plays in program design,
our energies must now be focused more specifically on the development of
culturally competent interventions that are empirically supported through
rigorous evaluation. By shifting our focus to an action orientation now, we
will continue to move forward in integrating cultural competence into
program design. Whereas this is the ideal objective of all efforts related to
multiculturalism, it is obviously no easy task. Just as it has taken more than
30 years to create the current climate that includes an expansive and
complex understanding of cultural identity, it will require concerted efforts
by program developers and practitioners, funding sources, and researchers to
continue to propel us toward this ideal end—an end that, when achieved,
will mark an entirely new dimension of growth in clinical program
development.
  
CASE ILLUSTRATION
Hank and Janet have received funding to implement an outreach program
for elderly persons with serious mental health issues. While working to
establish a research basis through a review of the literature, they realize
they need to reexamine the results of the community demography
assessment in order to better understand the specific cultural identity
aspects of their target population. In doing so, they find that the target
population is largely composed of elderly women and that the majority
of persons—both men and women in the region—are highly
impoverished and economically poor. In addition, the region itself is
large, urban, and highly challenged by a significant lack of resources,
high rates of both unemployment and crime, and a large population of
homeless individuals. The demographic information of the region
provides a necessary context for developing the program, and the four
most prominent aspects of cultural identity that have been identified
include

age (i.e., elderly),

gender (i.e., women),
mental health status (i.e., serious mental health issues), and
socioeconomic status (i.e., poor).

Each aspect requires specific consideration in program design, so

Janet and Hank turn to the scholarly literature to learn some of the
specific needs related to elderly women with serious mental health issues
in poor economic circumstances. Through this review, they learn that
serious mental health disorders among this population may include
depression, dementia (including Alzheimer’s), and psychosis. In
addition, they learn of other risk-related issues, such as

heightened sensitivity to psychotropic medication,

lifestyle and age-related risk factors for depression (e.g.,
loneliness, bereavement, poverty),
 nighttime restlessness,
suicide risk, and
homelessness risk.

As a result of this knowledge, Hank and Janet design specific program

features that will take into consideration the unique needs of the
population and, as such, may serve to guard their population against
further risk. As part of the program’s assessment activities that they have
built into the program design, they identify specific assessment
instruments designed to evaluate depression, psychosis, and dementia. In
addition, they decide to incorporate assessment tools that evaluate
substance use, including prescription drugs, because of the potential for
co-occurring disorders involving substance-use disorders and depression,
psychosis, or dementia. To address some of the other unique needs, they
then incorporate the following activities into the program design:

Increase of psychotropic medication monitoring from monthly

to weekly
Creation of a buddy system (elder to elder) to provide ongoing
one-to-one, inhome social support (in addition to the
Community Support Network that is part of the basic program
design)
Nighttime activity options
Enhanced case management activities to sustain housing and
basic living needs

By adding these culturally focused activities to their basic program

design, Janet and Hank are able to thoughtfully and effectively plan for
the unique needs that some of their clients may have. In keeping with
culturally competent practice, the individual needs of each client must be
continuously assessed to ensure appropriate treatment.
To address other unique needs more relevant to specific individuals
rather than reflective of the group, Janet and Hank add a series of
culturally focused initial assessment items to the intake interview guide.
These include such questions as the following:
 When you are feeling good, what types of things do you most
like to do?
What times of day, if any, are particularly difficult for you?
Whom do you most like to talk to if you have a problem?

By adding items like these to the interview, Hank and Janet believe
they will be able to focus more on some specific needs of their clients
and be better equipped to make individual modifications. For instance,
additional activities and monitoring will be added midday for clients who
report most difficulty during this time of day, and these clients may not
participate in nighttime activities (unless desiring to do so).
Adding culturally focused assessment items to the initial intake
process and incorporating additional activities into the initial program
design based on the literature pertaining to the target population allows
Hank and Janet to implement a culturally focused program that is
empirically guided. As such, their program design is enhanced at the
outset and, hopefully, has greater potential to fully engage the target
population in the treatment process. Moreover, Janet and Hank are
postured to deliver effective treatment that places unique identity factors
at its center, reflecting a commitment to culturally competent program
design. But determining if the program is culturally competent will
require rigorous evaluation, and Hank and Janet have already begun
thinking about this step (fully covered later in this book).

 
DESIGNING CULTURALLY COMPETENT
INTERVENTIONS EXERCISE

You have been awarded a federal grant to work with single adult
males who are homeless or in transition. After reviewing the
results of your community demography assessment, you note
that the target region consists of a large population of first-
generation Latino men, primarily of Mexican heritage, with a
sizeable portion who are in their early 20s.
 Identify four prominent aspects of cultural identity related to
this target population.
Review the scholarly literature and identify a minimum of six
unique characteristics related to the target population that
should be considered in program design.
Develop specific activities or interventions to address each of
the unique characteristics in the initial program design.
Develop four to five questions to be added to the initial intake
process that are designed to capture additional culturally based
information about each individual client.

References
Abudabbeh, N., & Aseel, H. A. (1999). Transcultural counseling and Arab
Americans. In J. McFadden (Ed.), Transcultural counseling (2nd ed., pp.
283–296). Alexandria, VA: American Counseling Association.
Administration on Aging. (2010). National minority aging organizations
technical assistance centers. Retrieved September 10, 2010, from
http://www.grants.gov/search/search.do?
mode=VIEW&flag2006=false&oppId=47070
American Counseling Association. (2005). ACA code of ethics. Alexandria,
VA: Author.
Arredondo, P., Bordes, V., & Paniagua, F. A. (2008). Mexicans, Mexican
Americans, Caribbean, and other Latin Americans. In A. J. Marsella, J. L.
Johnson, P. Watson, & J. Gryczynski (Eds.), Ethnocultural perspectives
on disaster and trauma (pp. 299–320). New York: Springer.
Arredondo, P., & Glauner, T. (1992). Dimensions of personal identity model.
Boston: Empowerment Workshops.
Arredondo, P., Toporek, R., Brown, S. P., Jones, J., Locke, D. C., Sanchez,
J., et al. (1996). Operationalization of the multicultural competencies.
Journal of Multicultural Counseling and Development, 21, 42–78.
Baggerly, J., & Zalaquett, C. P. (2006). A descriptive study of single adults
in homeless shelters: Increasing counselors’ knowledge and social action.
Journal of Multicultural Counseling and Development, 34, 155–167.
Baruth, L. G., & Manning, M. L. (1999). Multicultural counseling and
psychotherapy: A lifespan perspective (2nd ed.). Upper Saddle River, NJ:
Prentice-Hall/Merrill.
Bernal, G., Bonilla, J., & Bellido, C. (1995). Ecological validity and cultural
sensitivity for outcome research: Issues for cultural adaptation and
development of psychosocial treatments with Hispanics. Journal of
Abnormal Child Psychology, 23, 67–82.
Conner, K. O., & Grote, N. K. (2010). Enhancing the cultural relevance of
empirically supported mental health interventions. Families in Society, 89,
587–595.
Council for Accreditation of Counseling and Related Educational Programs.
(2009). CACREP accreditation manual. Alexandria, VA: Author.
Council on Accreditation. (2008). Private standards. Retrieved April 30,
2010, from http://www.coastandards.org/standards.php?navView-
private&core_id-912
Department of Health and Human Services. (2007). National standards for
culturally and linguistically appropriate services in health care. Retrieved
September 10, 2010, from
http://minorityhealth.hhs.gov/templates/browse.aspx?lvl=2&lvlID=15
Department of Health and Human Services. (n.d.). Substance use and abuse
among U.S. military personnel, veterans and their families. Retrieved
September 10, 2010, from http://grants.nih.gov/grants/guide/rfa-
files/RFA-Da10-001.html
Erikson, E. (1950). Childhood and society. New York: Norton.
Flowers, L. R. (2009). The ACA encyclopedia of counseling. Alexandria,
VA: American Counseling Association.
Hakim-Larson, J., Kamoo, R., Nassar-McMillan, S. C., & Porcerelli, J. H.
(2007). Counseling Arab and Chaldean-American families. Journal of
Mental Health Counseling, 29, 301–321.
Inman, A. G., Yeh, C. J., Maden-Bahel, A., & Nath, S. (2007). Bereavement
and coping of South-Asian families post-911. Journal of Multicultural
Counseling and Development, 35, 101–115.
Lum, D. (2007). Culturally competent practice: A framework for
understanding diverse groups and justice issues (3rd ed.). Belmont, CA:
Thomson Higher Education.
Matovina, T. M., & Riebe-Estrella, G. (2002). Horizons of the sacred:
Mexican traditions in U.S. Catholicism. Ithaca, NY: Cornell University
Press.
McCabe, K. M. (2003). Factors that predict premature termination among
Mexican-American children in outpatient psychotherapy. Journal of Child
and Family Studies, 11, 347–359.
National Association of Social Workers. (2007). Indicators for the
achievement of the NASW standards for cultural competence in social
work practice. Washington, DC: Author.
National Association of Social Workers. (2008). Code of ethics. Washington,
DC: Author.
National Institutes of Health. (2009). Women’s mental health in pregnancy
and the postpartum period. Washington, DC: Author.
Nydell, M. K. (2006). Understanding Arabs: A guide for modern times (4th
ed.). Boston: Intercultural Press.
Office of the Assistant Secretary for Administration and Management,
Department of Labor. (2010). Urban and nonurban homeless veterans’
reintegration program. Retrieved September 10, 2010, from
http://www.grants.gov/search/search.do?
oppId=41279&flag2006=false&mode=VIEW
Pedersen, P. (1990). The multicultural perspective as a fourth force in
counseling. Journal of Mental Health Counseling, 12, 93–95.
Peters, S. W. (2007). Cultural awareness: Enhancing cultural understanding,
sensitivity, and effectiveness with clients who are deaf. Journal of
Multicultural Counseling, 35, 182–190.
Roberts, A. R., Yeager, K. R., & Regehr, C. (2006). Bridging evidence-based
healthcare and social work. In A. R. Roberts & K. R. Yeager (Eds.),
Foundations of evidence-based social work practice (pp. 3–21). New
York: Oxford University Press.
Sue, D. W., Arredondo, P., & McDavis, R. J. (1992). Multicultural
counseling competencies and standards: A call to the profession. Journal
of Counseling and Development, 70, 477–486.
Sue, S., & Zane, N. (2006). Ethnic minority populations have been neglected
by evidence-based practices. In J. C. Norcross, L. E. Beutler, & R. F.
Levant (Eds.), Evidence-based practices in mental health: Debate and
 dialogue on the fundamental questions (pp. 329–337).Washington, DC:
American Psychological Association Press.
Szapocznik, J., Kurtines, W. M., Santisteban, D. A., Pantin, H., Scopetta, M.,
Mancilla, Y., et al. (1997). The evolution of a structural eco-systemic
theory for working with Latino families. In J. Garcia & M. Zea (Eds.),
Psychological interventions and research with Latino populations (pp.
166–190).Boston: Allyn & Bacon.
 CHAPTER 5
Design the Clinical Program

 
 
Learning Objectives
 

1. Discuss the relationships between Steps I and II and Step III

2. Discuss the objectives of a program mission and vision
3. Identify the components of the core clinical program
4. Differentiate between outputs and outcomes
5. Differentiate between short- and long-term outcomes
6. Develop a logic model

 
WHO ARE WE ANYWAY?
Donald had been the executive director of a mental health agency for the
past 5 years. The agency had been founded on the premise of serving
individuals in need and specializing in mental health treatment. Over the
years, they had built up a sizeable continuum of care that included
outpatient counseling, crisis services, and an in-home care program for
adults. After seeing some of his colleagues succeed in operating methadone
clinics in the region, Donald began talking to his staff about the possibility
of the agency opening one. After laying the groundwork, getting
authorization from his board, and putting a team together to develop the
program, Donald finally witnessed the opening of his new methadone
clinic. The program was successful financially and was now entering its
second year. Donald then was approached by one of his neighbors about
beginning a financial planning clinic for individuals in debt. Donald liked
the idea and again worked through the plans to open the clinic. While his
board had questioned how financial planning fit into the agency’s broader
mission, Donald claimed that it simply provided another mechanism by
which to help people, and therefore, it fit nicely with the agency’s mission.
Plus, Donald added that the mission was intended to change over time and
that he had to bear that in mind so that the agency could continue to grow
and adapt. And since they had named the financial planning program a
clinic, it sounded more like the agency’s other programs.
A couple of months later, after the financial planning program was up
and running, Donald had overheard some of his staff talking in the
lunchroom, saying they didn’t know what the agency was anymore. Making
her point, one of the supervisors had stated: “Who are we anyway? A meth
clinic, financial planners, or mental health professionals?” Donald
dismissed this as typical employee grumbling.
Donald and his board had to gear up and begin their next round of
fundraising activities for the agency. And during various campaigns, one of
the questions from potential funders that kept coming up was, what is your
business? Donald continued to claim that, as the agency’s mission stated,
the agency was committed to helping people in need, primarily through
mental health programming. When questioned about the two new
programs, Donald stated that he saw both as offshoots of broader mental
health programs and he stressed how the programs augmented the agency’s
service array. But most of the agency’s previous funders had a hard time
buying this, claiming they didn’t feel connected to the agency as they had
before. They further shared that they had previously provided their support
because the agency’s mission had specific meaning to them; however, this
was no longer the case, and they felt the mission had been diluted. Donald
 thought to himself, People put too much emphasis on mission—maybe we
should just change it and everything will be okay again.

 
CONSIDERING DONALD

1. What, if anything, do you believe Donald did wrong?

2. If you were Donald, what next steps would you take and why?
3. As the agency’s leader, what responsibility does Donald have to the
agency mission?
4. What relevance do organizational identity and mission have to staff and
other stakeholders?

About This Chapter

This chapter marks the beginning of the program design phase, specifically
dedicated to the development of the clinical program. The first part of the
chapter deals with the mission and the vision, with an in-depth examination of
each and an exploration of specific issues to consider in the development of
mission and vision statements. After tackling these two initial program design
tasks, the chapter moves into a discussion of the core program design elements,
including ideological foundations, interventions, outputs, short-and long-term
outcomes, and outcome measures. We will thoroughly examine each of these
core design elements, with examples provided throughout the chapter. Then,
we will discuss two essential design tools—the logic model and the project
timeline. Examples of each of these are also provided. Finally, a case study
illustrates and further reinforces the major concepts of the chapter, and an
exercise is provided to allow you the opportunity to construct your own core
program design.

STEP III: DESIGN THE CLINICAL

PROGRAM
Comprehensive Program Design
After the target population and primary needs have been identified, a thorough
review of the literature has been conducted, and the multicultural needs of the
population have been identified, the preplanning stage has been officially
completed and the planning phase is ready to begin. The planning phase begins
with program design. Program design includes

articulating the program mission and vision,

identifying the core components of the program (ideological
foundations, interventions, outputs, outcomes, and outcome
measures),
organizing the plan for program implementation, and
organizing the program evaluation.

Each of these aspects of program design is critical, and they all serve unique
yet interrelated purposes. And by bringing each of these aspects together, the
program developer is able to achieve effective coherence in program design—a
most significant necessity. More importantly, Step III is directly tied to Steps I
and II and cannot be completed without these previous steps being effectively
completed first. That is, the program’s objectives and what it seeks to achieve
(i.e., mission, vision, outcomes) are based on the needs that are identified in
Step I. At the same time, the interventions and outcomes are designed to
directly address and resolve the identified needs. In addition, the design is
based specifically on research that was identified in the literature review, and
modifications to the design are based on demographics of the target population
and research supporting such modifications—each of which is based on
achieving specific short-and long-term outcomes. As a result, at Step III, you
are able to clearly begin to see the sequential nature of these initial three steps
and how each acts as a building block to the next—providing precisely the type
of guidance needed in comprehensive program development.

Program Mission and Vision

The mission and vision of a program or organization are brief statements
that are developed to capture the essence of a program and that serve two
different purposes: The mission communicates the core purpose of the
program, while the vision communicates the aspirational goals of the program.
Because the mission and vision are vitally interconnected, they are typically
considered together. Ideally, the mission and vision are collaboratively
constructed by program leaders, staff, and other key stakeholders and,
ultimately, are approved by an organization’s governing board. Completed as
part of the initial program design, the mission and vision provide an
opportunity during this early program development phase for leaders and staff
to articulate the purpose of the program and look toward future goals, thus
further justifying the program’s existence while inspiring future growth.
The program mission and vision can be among the most powerful
programming development tools available to the program developer but only if
used effectively and to their full potential. Failing to effectively use the mission
and vision can alternatively result in creating statements that are tossed around
at meetings and other events that have little substance and limited meaning to
program personnel, clients, and the public. Used to their full potential, the
mission can effectively communicate the program’s rationale and core
objectives, while the vision can articulate the future goals of the program. As
such, the mission and the vision are essential communication tools—sending
critical messages to all stakeholders (i.e., staff, clients, public) about why the
program exists and what the program and its personnel seek to achieve in the
long term. Moreover, the mission and vision have the potential power to
engage stakeholders to invest in the program and to contribute to the success of
the program. Unfortunately, missions also are vulnerable to becoming no more
than empty words that convey little to no meaning. And because missions can
become so easily obscured in the day-to-day work, Gray and Kendzia (2009)
urge nonprofit organizations to continuously revisit and strengthen their
missions to ensure that they remain relevant.
The most significant stakeholder to any program is the client population;
therefore, the mission must reach this group. However, this may not often be
the case. In fact, a study of mission statements from 40 state-administered child
welfare agencies found that 30 of the statements required 12th-grade reading
comprehension (Busch & Folaron, 2005). As a result, a portion of the people
that the organizations were serving was unable to understand the mission of the
organization serving them. Thus, the agencies created barriers between
themselves and their clients. Conversely, and as the authors point out, effective
missions not only provide essential information to clients but also may provide
essential guidance to employees.
In addition to providing guidance and direction to the program both initially
and on an ongoing basis, there are several other objectives that can be
accomplished by the development of the mission and vision statements. These
include

improving outcomes by providing clear direction (Busch &

Folaron, 2005);
defining and communicating the meaning of the program to staff,
clients, and the public;
engaging staff, clients, and the public in the program;
directing short-term and long-term planning and operational
decision making;
providing coherence and continuity for the program;
setting the stage for long-term strategic planning;
differentiating the program from competitors while highlighting
common objectives; and
providing an initial branding opportunity to program developers
for use in marketing and future program identity development.

Again, while the potential exists for the mission and vision to have a
positive and far-reaching impact on the program, achieving maximum benefits
from a mission and vision requires strategic efforts and constant commitment
from program developers and program leaders. For instance, the mission and
vision must be actively and continuously assessed as part of ongoing program
planning and used as the foundation for branding and other marketing
activities. By actively using the mission and vision as a core part of initial and
ongoing program development, they remain not only relevant but essential to
the sustainability of the program. And it is in this manner that the mission and
vision are brought to life—not simply written words but living guides.

Constructing the Mission Statement

According to Brody (2005), an effective mission statement is concise,
inspiring, and understandable. More pointedly, Lewis, Packard, and Lewis
(2007) suggest that a good mission statement be approximately two sentences
in length or brief enough to fit on the back of a business card. Further, the
authors suggest that the mission statement should answer these key questions:
 What social needs does the program address?
What are the primary services of the program?
What makes the program unique?

In addition, the mission should also identify the type of organization (e.g.,
human service, advocacy, food service). Whereas this may be less relevant
when this information can be easily deduced from the type of services
provided, when this is not the case, the type of organization should be
identified. By answering these basic questions, the mission statement should
easily communicate the purpose of the program, operations of the program, and
unique features of the program—basically, it should communicate the
program’s identity.
In addition to being concise and providing a clear picture of the program,
there are some other key recommendations to consider in the construction of
the mission statement. These include the following:
 

1. Create a mission that is easily accessible to clients and that

clearly reflects the program objectives and practices (Busch &
Folaron, 2005). Because the primary target group that should be
reached through a mission statement is the client population, it is
imperative that the mission is accessible through both the reading
level at which it is written and through the means by which it is
provided. In addition, the mission must be able to communicate in
straightforward terms what is to be expected from the program.
2. Create a mission that is enlarged enough to grow with the
program while focused enough to clearly communicate the core
purpose of the program. This is particularly important because a
mission serves to communicate the identity of the program, and as
such, it needs to have lasting power lest it be easily forgotten.
3. Avoid language that may have specific meaning with a particular
group while alienating others. Whereas a program may be
specifically developed to address the needs of one particular
population, the mission statement must be easily understood and
have the ability to connect a broad range of individuals that
 include funding agents, donors, and the public. If a mission
includes language from a religious text, it may resonate deeply
with some while not engaging others. I should add that this
consideration must be carefully weighed, particularly in light of
programs/organizations that value connecting with a unique
primary group at the expense of losing a broader audience. For
instance, a human service organization that is specifically
designed to address the needs of a particular ethnic group, such as
Maltese Americans, should strategically include the target ethnic
group in the mission statement as it is a core part of the program’s
identity.
4. Use language that can be easily adapted for use in marketing and
branding. Because the mission statement has such potential for
various uses, it is important to fully consider its utility as a
marketing tool. For a mission statement to be easily adapted, it is
best to have key language that can serve as sound bites. For
instance, language such as “one family at a time” or “functional
independence” may be easily culled from a broader mission
statement and used in various venues to further promote the
program.
 
In order to examine a mission statement to determine if it is indeed
communicating the unique identity of the organization and articulating the
primary objectives of the organization, consider the current mission statement
of my employer:
The University of Detroit Mercy, a Catholic university in the Jesuit and
Mercy traditions, exists to provide excellent student-centered
undergraduate and graduate education in an urban context. A University
of Detroit Mercy education seeks to integrate the intellectual, spiritual,
ethical, and social development of our students.
As a highly subjective reviewer of this mission (since I am paid by the
institution), it seems to me that several key pieces of information are
communicated in this mission that together form a broad, yet focused identity.
These key terms include the following:

University
Catholic
Jesuit and Mercy
Education
Student-centered
Undergraduate and graduate
Urban context
Intellectual, spiritual, ethical, and social development

Further, the primary objective of the mission seems to be clearly

communicated—to provide excellent student-centered undergraduate and
graduate education. Whereas this particular mission has personal significance
to me since I am charged with carrying it out on a daily basis, consider the
mission of your organization and what it communicates to you.
Now, take a moment to review the mission statements from various
organizations to determine if you can link the mission with its corresponding
organization in the Name That Organization Exercise. Select from the list of
organizations below and match each with its mission statement by providing
the organization’s name in the box beside the statement.
NAME THAT ORGANIZATION EXERCISE

Mission Statement Organization

a. The mission of the ____ is to prepare young
people to make ethical and moral choices over
                  
their lifetimes by instilling in them the values of
the ____ Oath and Law.
b. Eliminating racism, empowering ___—it’s what
we are about and what we intend to do.
c. To make, distribute and sell the finest quality all
natural ice cream and euphoric concoctions with a
continued commitment to incorporating
 wholesome, natural ingredients and promoting
business practices that respect the Earth and the
Environment
d. ___ builds ____ of courage, confidence, and
character, who make the world a better place.
e. The mission of the __ is to ensure the political,
educational, social, and economic equality of
rights of all persons and to eliminate racial hatred
and racial discrimination.

Organizations (please note that there are more organizations listed than
included in the exercise):
Girl Scouts of America
Florence Crittenden Homes for Girls
Greenpeace International
Haagen Daas Young Women’s Christian Association (YWCA)
Boy Scouts of America
National Association for the Advancement of Colored People (NAACP)
Ben & Jerry’s
(The answers are located at the end of the chapter.)

How did you do? I am guessing that you may have easily been able to
match some of the organizations with their mission statements while others
may have posed a bit of a challenge for you. Did any of the mission statements
communicate a unique identity to you? Did any of the mission statements
surprise you or resonate with you for any particular reason? Whereas a product
such as ice cream is the same at its most basic level (i.e., milk, sugar, eggs), the
manner in which the company produces the ice cream and seeks to differentiate
the ice cream in design can make it unique from the products of other ice cream
makers. In the same manner, outpatient treatment programs for individuals with
gambling addiction may be fundamentally based on the same general treatment
principles but may be uniquely different than their peer programs as a result of
specific design features. It is these unique factors that should be communicated
in a mission lest the mission fail to reach its full potential.
Typically, when I do this exercise with my students, awareness levels related
to mission statements are raised a bit and sometimes a deeper understanding of
a specific organization is realized. But, whereas being able to match
organizations with their mission statements may increase awareness of mission
statements to a small degree, close examination and deconstruction of the
mission statement is needed to gain a much more thorough appreciation of the
power of a mission statement.
And just as with all activities that are part of business planning, it is
essential to learn from other organizations before you tackle your own work.
Therefore, before constructing your own mission statement, it is essential that
you gain the knowledge and experience of critically evaluating the mission
statements of other companies. The Mission Analysis Tool was developed to
assist in this process. Use the Mission Analysis Tool Exercise to critically
evaluate the mission statements from the companies listed in the exercise
above.
MISSION ANALYSIS TOOL EXERCISE
Organization: _____________________ Type of Business:
_____________________
 Use the findings of this exercise to further think about how you would go
about developing a mission. And most importantly, since a mission is innately
tied to program design, keep in mind that the ability of the mission to
communicate a program’s unique identity ultimately lies in the ability of the
program developer to design a unique program.

Constructing the Vision Statement

Whereas the mission statement should emphasize concise language that
clearly communicates the program/organization’s primary objectives, the vision
statement should look well beyond the mission to what the
program/organization aspires to in the future. As such, the vision should be
grand, lofty, idealistic, and far-reaching, yet attainable. Because of its
aspirational nature, the vision should be used to motivate and increase the
momentum of staff and other stakeholders as they collectively work toward this
ideal outcome.
Constructing the vision can serve to initially bring staff and other
stakeholders together to determine where they would ultimately like to take the
program/organization, and as a result, constructing the vision can be used to
harness the energy of program stakeholders. In addition to the benefits involved
in initially constructing the vision, the ongoing benefits of the vision should not
be overlooked. For instance, when programs/organizations are experiencing
particularly difficult times or growing pains, revisiting the vision can be used to
center stakeholders and provide renewed energy as staff work through
challenges.
Take a moment to consider the examples of vision statements below (Box
5.1).
BOX 5.1

VISION STATEMENT SAMPLES

We will be the model system for comprehensive and effective juvenile sex
offender management throughout the state and the nation (Comprehensive
Juvenile Sex Offender Management Initiative, 2009).
We envision a society characterized by a strong commitment to universal civil rights; safe
communities, workplaces, and schools; stable families; and self-reliant LGBT individuals (Triangle
Foundation, 2009).
To be the food company of choice (Kellogg Company, 2010).

Each of these vision statements reflects aspirations and goals, and each
provides a vision of a future not yet arrived at but, to some degree, one that is
clearly identified. Phrases such as “the model system” and “company of
choice” illustrate the ultimate goal of the organization; however, so does
“communities of service,” as it reflects a better place for individuals, a place in
which individuals are truly interdependent. This is the test of the vision
statement: Does it provide a picture of the future that the program/organization
is dedicated to achieving? If it does, it is likely to have been effectively written,
but if it does not, it probably requires revisiting.
One of the things you have probably realized is that the concept of the
mission and vision is well aligned with the mental health professions and the
business principles that guide our work. As an industry that is inherently
purpose-driven and outcomes-oriented, the vision and mission serve to provide
us with direction while communicating who we are and exactly how much of
an impact we are striving to make. Since the work that we do has the potential
to significantly impact lives, our mission and vision carry enormous weight and
require careful consideration and continuous attention.
Core Program Design
By far, the most important aspect of program development is the core clinical
program design. Without an effective design, mission and vision statements
really are little more than words, but with an effective program design, mission
and vision statements serve as useful and complementary tools of
communication. Simply put, the design of the program is the nuts and bolts—
the program’s essence.
Comprehensive program design comprises

philosophical foundations,
clinical interventions,
adjunctive services,
outputs,
short-and long-term outcomes, and
outcome measures.

As stated earlier—but well worth repeating—the program design is

completely dependent on the work completed in Step II (Establish a Research
Basis for Program Design). In fact, if a thorough and effective literature review
has been conducted, designing the program can be easily completed by using
the research findings to guide the design. More importantly, the research basis
provides empirical justification for the program design—a critical issue for all
stakeholders, particularly as each has a right to know that the program is
designed to reach its stated outcomes. And by incorporating evaluation into the
program design, you are able to effectively measure if the interventions are
able to achieve the outcomes previously identified in the research and, if not,
quickly make any necessary modifications and continue the evaluation process.
Program design requires specific structure and is a directional process in
which each major design aspect (e.g., philosophical foundations, interventions,
outputs, outcomes, outcome measures) is related to the others. It is in this
manner that program design has a particular flow, with each core component
directing the next.
Philosophical Foundations → Interventions → Outputs → Outcomes →
Outcome Measures
Philosophical Foundations of Program Design
Comprehensive program design must begin with establishing the
philosophical or ideological foundation that guides the program design. The
philosophical foundation is the basic premise on which the program is
developed and, as such, describes the guiding belief justifying why the program
has been developed. Because philosophical foundations are broad-based and
not necessarily specific to a particular program but more likely related to
specific types of programs, philosophical foundations may not be unique to a
program but rather to types of programs. For instance, several foster care
programs may operate on the philosophical foundation that all children deserve
to live in a family environment, thus sharing the same basic belief.
Other examples of philosophical foundations include the following:

Family-based treatment is necessary to sustain successful

treatment outcomes of juvenile offenders.
Substance abuse is a community issue that must be addressed at
the community level.
Individuals with serious mental health issues have the same rights
to community living as does everyone else.

As you can see, philosophical foundations really reflect the underlying

values of a program, further reinforcing the program’s purpose. This is an area
that must not be underestimated, particularly because articulating the
philosophical foundation of a program provides the basic rationale of why you
do what you do and, as such, can be instrumental in gaining support for the
program from all stakeholders. Moreover, the philosophical foundation reflects
a core part of the program’s identity and one that can be used to provide
ongoing direction and reinforcement to clients, staff, leaders, and other key
stakeholders—reminding them precisely why they do what they do.

Program Interventions
The program interventions are at the center of the program design and are
designed to directly address the clinical needs of the population. Clinical
interventions may consist of various types of treatment (e.g., counseling,
psycho-education, relapse prevention), treatment modalities (e.g., individual,
family, group counseling), and activities or other key components (e.g.,
structured play, simulated communication, family support networks). Typically,
clinical interventions derive directly from theory (e.g., cognitive-behavioral,
multisystemic); therefore, clinical interventions largely have a basis in theory,
providing further justification for the use of the intervention. More
significantly, though—and worth restating—determining program interventions
is not a result of brainstorming or other types of pondering but, rather, is based
on the empirical research that was reviewed in Step II.
In addition to clinical interventions, program interventions also may include
adjunctive interventions. These interventions are composed of additional
interventions and activities that complement the clinical interventions and that
are necessary to address the complex issues of the client population. Also,
unlike clinical interventions, adjunctive interventions may not require a
clinician for implementation. Adjunctive interventions may consist of such
activities as case management, monitoring, job coaching, and educational
support services. Table 5.1 provides examples of potential clinical and
adjunctive interventions that might be used to address specific treatment issues.
Each of the examples in Table 5.1 illustrates common evidence-based
interventions used to address specific issues. However, one issue to bear in
mind when determining which interventions to use in the program design is
that simply because an intervention has a research basis does not mean that you
will incorporate it into your design. This is because there may be several
different and somewhat conflicting approaches that may each have been found
to be effective in addressing a particular treatment issue. As a result, you would
not simply incorporate each intervention into the design but, rather, thoroughly
examine the research to understand precisely how each intervention has been
used and if each was used in isolation or concurrent with another intervention.
This relates to the fidelity of a clinical program—the degree to which an
intervention/program is implemented as originally constructed. In the case of
incorporating an evidence basis into the program design, fidelity refers to the
degree to which the intervention/program is implemented as it was when it was
found to be effective. (Fidelity is discussed in much greater depth in Chapter
12.)
For instance, one treatment model that has been found to be effective in
addressing the treatment needs of youth with marijuana use problems is
composed of therapeutic sessions based on motivational interviewing followed
by cognitive-behaviorally focused therapeutic sessions (Dennis et al., 2004). If
you had a similar target population and wished to base your treatment program
on this approach, you would need to ensure that you followed the instructions
provided for the model—specific therapy session topics, time frames, and other
essential details—in order to ensure treatment fidelity. In this case, which is
part of the Cannabis Youth Treatment project sponsored by the Substance
Abuse and Mental Health Services Administration, it would mean facilitating a
total of 14 therapeutic sessions as prescribed by the treatment manual outlining
the entire intervention. It would also mean ensuring that the credentials of the
individuals delivering the treatment are consistent with the guidelines of the
treatment, as well as attending to all other aspects of the model.
Table 5.1 Clinical and Adjunctive Interventions per Treatment Program

Whereas the clinical interventions form the crux of any treatment program,
adjunctive services are typically a necessary component of any comprehensive
program and serve to enhance the process. Therefore, the selection of
adjunctive interventions must also be guided by sound research and/or
empirical guidance and, equally important, must contribute to the overall
coherence of the program. For example, when implementing a substance abuse
program, the use of community-based 12-step meetings is also often essential
to ensuring long-term community support for individuals post-treatment.
Similarly, the establishment of additional community supports and an enhanced
social support network is often necessary to promote long-term success as
individuals work to overcome myriad treatment challenges (e.g., mental health,
criminal activity, homelessness).

Outputs
Outputs evolve directly from the interventions and, according to Brody
(2005), indicate the volume of work accomplished. Outputs provide important
information about the program design and may directly impact client outcomes.
However, unlike outcomes, outputs do not indicate a change in quality of life
for clients or reflect the impact of an intervention. The difference between
outputs and outcomes can be difficult to grasp, especially since, historically,
there have been times when outputs were conceptualized as outcomes (Rossi,
1997). Today, it is generally accepted that outputs and outcomes are distinctly
different and each is significant to program design.
There are two types of outputs—intermediate and final. Intermediate
outputs refer to the number and frequency of interventions, whereas final
outputs refer to measurements such as the number of clients served, client
completion rate, and average length of time for program completion. In this
way, one way to think of outputs is that they are often numeric and focused on
units or other types of measurements. Measuring outputs is critical to program
evaluation because outputs provide essential details related to the program that
may directly impact program outcomes. For instance, you may find that client
success is directly related to the number of family counseling sessions provided
or that client success is directly impacted by program completion. Moreover,
measuring outputs allows you to determine exactly how much of a specific
intervention a client actually received (Kettner, Moroney, & Martin, 2008) and
to what degree the program was implemented as originally designed. Returning
to the Cannabis Youth Treatment intervention discussed above, both the order
of the interventions and the number of sessions of each intervention are
outputs. Making a change to one or more of the outputs, such as limiting the
number of cognitive-behaviorally based (CBT) sessions from 12 to 7 or
changing the order by using CBT followed by motivational interviewing, may
impact the treatment outcomes. And such modifications to a prescribed
treatment model reflect nonadherence to fidelity—indicating that the fidelity of
the treatment model was not maintained. As a result, the treatment cannot be
evaluated in comparison with the original model, nor should similar treatment
outcomes be expected to result from the modified treatment.

Outcomes
As stated above, outcomes are the impact or effect that the interventions (or
treatment program) have had on the client. Outcomes are treatmentfocused,
referring to the efficacy and effectiveness of a given treatment (Mours,
Campbell, Gathercoal, & Peterson, 2009). Further, outcomes in the mental
health professions typically reflect changes in quality of life as a result of
treatment. In this way, it is hopefully easy to differentiate outcomes from
outputs. Identifying specifically targeted outcomes means identifying the
anticipated effects on clients resulting from treatment interventions. Outcomes
must be observable, attainable, and measureable. Outcomes should be
evidence-based, if possible, deriving from the literature review and directly
associated with previous findings from similar treatment interventions.
Additionally, outcomes should be ambitious and agreed on by all stakeholders
as important and feasible. Further, because the anticipated outcomes provide
the basis for most subsequent decision making, the development of the right
outcomes is critical (Lewis, Lewis, Daniels, & D’Andrea, 2003). Table 5.2
provides specific examples of outcomes for common treatment programs.
Table 5.2 Sample Outcomes for Common Treatment Issues
 According to Mours et al. (2009), there are several reasons for conducting
outcome assessments, including

to enhance the science behind clinical work,

to improve treatment,
to provide accountability, and
to maintain the ethical responsibility of clinicians to examine
quality.

Particularly today, in an era of clinical accountability, understanding and

evaluating outcomes is a primary responsibility of all mental health
professionals.
There are two types of outcomes—short-term and long-term. Short-term
outcomes may be targeted for achievement during active treatment or shortly
after treatment ends, while long-term outcomes may be targeted for
achievement shortly after treatment ends or within as many as 2 years
following treatment cessation. However, there are no standard rules regarding
when short-term versus long-term outcomes occur. In fact, time frames for
achievement of targeted outcomes must be program-specific since there are
several factors that may influence the attainment of outcomes, such as type of
clinical issue being addressed, type of intervention, length of intervention,
treatment milieu, and other factors (e.g., client supports, environmental risks).
Determining the length of time associated with short-and long-term
outcomes has particular ramifications for evaluation since outcomes
evaluations are conducted to examine a program’s success or lack of success. If
time frames for achieving short-and long-term outcomes have not been
thoughtfully established with both a research basis and relevance to the
program time frames, the program may not be effectively evaluated. Therefore,
again by fully utilizing the knowledge gained from the literature, establishing
outcomes can be fairly straightforward but requires rigor and careful
consideration.

Outcome Measures
Establishing outcomes is one thing, but once established, appropriate
measurement tools must be identified by which to evaluate the outcomes.
Outcome measures typically fall into one of three categories—standardized
assessment, level of functioning scales, and status evaluations/numeric counts.
In addition, as measuring client satisfaction has become standard practice, it
too has been considered an outcome. Briefly, standardized assessment refers to
assessment instruments that have been validated to measure specific issues.
Standardized assessment instruments are often used to measure more
sophisticated treatment needs such as depression and family functioning.
Because of the rigor with which standardized assessment tools have been
tested and validated, the findings generated from some of these measures are
highly reliable and, as such, particularly attractive to funders concerned with
the treatment of specific clinical issues. Some well-known assessment
instruments used in the mental health professions include

the Substance Abuse Subtle Screening Inventory (Miller, 1997);

the National Institute of Mental Health Diagnostic Interview
Schedule for Children IV (Shaffer, Fisher, Lucas, Dulcan, &
Schwab-Stone, 2000);
the Millon Adolescent Clinical Inventory (Millon, 1993);
the Beck Depression Inventory II (Beck, Steer, & Brown, 1996);
and
the Family Assessment Device (Epstein, Baldwin, & Bishop,
1981).

Interestingly, even though standardized outcome assessment has been

viewed as a standard part of clinical research for some time (Ogles, Lambert, &
Fields, 2002), its use is no longer limited to clinicians working in large systems
(e.g., human services, hospitals) but, rather, is widespread. In fact, most
recently, Hatfield and Ogles (2004) found that 37% of independent private
practice clinicians used standardized outcome assessments, while Phelps,
Eisman, and Kohout (1998) had earlier found that 40% of psychologists
working in a medical facility used standardized assessment instruments,
followed by 34% of those working in government-based programs. While there
is a lack of more recent studies related to the utilization rate of standardized
outcomes, these two studies reflect the trend that continues today: Standardized
outcome assessment is a basic requirement for all clinicians, regardless of work
setting.
 Great care should be used in the selection of standardized assessment
instruments. First and foremost, you must ensure that the instrument does
indeed possess strong psychometric properties and that the evaluation to
determine the instrument’s effectiveness has been both rigorous and
independently conducted (not simply conducted by the developer). Findings
related to an instrument’s effectiveness are most likely found in scholarly
journal articles, and so, as part of the selection process, the research literature
must be revisited. Second, in reviewing the literature about a specific
instrument, consideration must be given to the population for whom the tool
was initially developed, the population on which the tool was normed, and the
population for whom you wish to use the instrument. These issues relate to
cultural competency (as discussed in Chapter 4), and use of the tool may have
significant ramifications if the differences between the populations are too
great. Additionally, it is important to keep in mind that an instrument’s
popularity in terms of widespread use (e.g., Beck Depression Inventory) does
not necessarily imply its efficacy or relevance to your target population. This is
always a good rule of thumb in any business venture: Be as thorough as
possible and do your homework diligently to ensure that you know everything
about every aspect of your venture. Doing so will not only save time and
money in the long run but also allow you to experience tremendous
professional growth throughout the program development process.
At the core of most, if not all, mental health interventions is the objective of
improving the functional ability of individuals treated. Level of functioning
scales is based on the premise that an individual’s ability to fully engage in a
positive and fulfilling manner in the various aspects of lifestyle (e.g., home,
work/school, personal relationships) is predicated on one’s mental health.
Conversely, the degree to which stress or symptoms impact one’s ability to
function in a healthy manner in one or more areas is an indicator of some
degree of mental distress or symptoms. To measure this, level of functioning
scales have historically been widely used.
Likely the best known and most widely used level of functioning scale is the
Global Assessment of Functioning, which is a standard part of both
psychological and psychiatric evaluations and is indicated on Axis V of a
multiaxial assessment. More recently, the Child and Adolescent Functional
Assessment Scale, which was originally developed in 1991 (Hodges, 2000),
was developed to specifically evaluate children and youth ages 7 to 17 years,
whereas the Functional Assessment Rating Scale was developed to specifically
assess adults (Ward, Dow, Penner, Saunders, & Halls, 1998). Because level of
functioning scales are designed to assess a sophisticated treatment issue, any
instrument built for this objective must be standardized. As such, the same
issues identified in the above paragraphs regarding rigorous selection of
assessment tools must be applied—again, regardless of how well known an
instrument is.
Client status or numeric counts are commonly used as a type of outcome
measure. Numeric counts are nominal measures typically requiring a “yes” or
“no” response to specific questions (Kettner et al., 2008). Questions such as
“Did the client reoffend within 2 years of discharge?” or “Were there any new
reports of child abuse?” constitute nominal measures. Numeric counts require
other data collection, but they are typically easy to define and, when converted
into percentage scores, provide stakeholders with crucial outcome information
that is both tangible and straightforward. More significantly, client status
typically reflects the primary outcome of a given program (e.g., family
reunification, sobriety, employment) and, as such, is typically the most valued
by funding organizations. Measuring and collecting client status data often
requires the use of various methods such as urine screening to evaluate
continued substance abuse, but it also requires reviewing other data sets. For
instance, a review of paystubs and/or other employment verification documents
may be used to evaluate employment outcomes, whereas court records may be
used to evaluate any new criminal activity. Therefore, evaluating client status
outcomes requires that you have specific follow-up measures in place to allow
for gathering the necessary data.
Finally, client satisfaction surveys are a standard part of most mental health
and human service programs and largely reflect a client-centered philosophy
that prizes the client as the primary stakeholder. Client satisfaction surveys are
typically developed by the program developer and program staff and include
questions pertaining to both general (e.g., overall satisfaction) and unique
issues about the program (e.g., resource coordination and access to new
resources). Because of the manner in which client satisfaction surveys are
developed and their primary purpose in assessing satisfaction, these tools often
do not have tremendous rigor. This may not necessarily pose a problem since
client satisfaction is most often viewed as an additional, but not primary, aspect
of treatment. However, with all types of assessment, general rules regarding
assessment construction must be followed to ensure that the most effective
tools are used. Moreover, client satisfaction may directly impact more
significant client outcomes (e.g., sobriety) and, as a result, must be carefully
assessed with an eye toward understanding the potential impact of satisfaction
on treatment efficacy (Van der Haas & Horwood, 2006). It is worth
emphasizing here that client satisfaction surveys complement other types of
outcome measures—they do not replace them.
Each of these types of outcome measures has specific utility and contributes
to program design. Identifying precisely how a particular outcome will be
measured during the program design phase allows the program developer and
all stakeholders to better understand these critical relationships and ensure that
the evaluation program is effectively established prior to program
implementation. Moreover, the selection of outcome measures during program
design serves as a checkpoint for the program developer to ensure that
outcomes (program objectives) are written in terms that are measureable. Each
of these measures is covered more thoroughly in Chapter 12, which deals with
program evaluation.

Design Tools
As you can see from each of the components that make up the program design,
when done correctly, the process itself is very structured and quite fluid. The
challenge, I believe, is taking advantage of the directional nature of the process
and allowing the inherent structure to work for you. This can be accomplished
through the use of program design tools—most notably, the logic model.

Logic Models
A logic model is an essential tool for the program developer and has specific
utility at every major phase of program development (i.e., design,
implementation, and evaluation). The purpose of the logic model is to “depict
the sequence of events that identifies program resources, matches them to
needs, activates the service process, completes the service process, and
measures results” (Kettner et al., 2008, p. 6). As such, a logic model connects
the needs/problems to the interventions/treatment methods and anticipated
outcomes, demonstrating the necessary links between each of these major
program design components. Put another way, a logic model depicts the path
from resources to operations to outcomes (Torghele et al., 2007). A logic model
illustrates these interdependent relationships in a short, easy-to-follow
graphical format, allowing the program developer and stakeholders to quickly
examine the basic treatment program, including rationale (i.e., need/problem),
interventions, outcomes, and evaluation plan. Figure 5.1 provides a sample
logic model that illustrates a portion of a residential treatment program for
juveniles who have sexually offended. The sample contains both clinical and
adjunctive/nonclinical interventions.
Figure Sample Logic Model: Juvenile Sex Offender Residential Treatment
5.1 Program

It is the scope of information contained in the logic model that makes it a

primary tool in not only program planning but program evaluation. Because the
logic model should contain all the pertinent elements that go into a program
and the expected benefits of each, demonstrating the interactions between each
component—interventions, outputs, outcomes (Torghele et al., 2007)—the
logic model provides the crux of the evaluation and is, therefore, the first
evaluation tool that program developers have available to them. By using a
logic model, one of the historic challenges related to program evaluation can be
resolved: linking program design to program evaluation (Hernandez, 2000).
 Because logic models are simple in their design yet convey such complex
information about social and mental health problems, they not only are of great
use in guiding program design and program evaluation but also can be used in
other venues. In fact, one use of particular meaning is that of educating
policymakers regarding specific community problems and methods by which to
effectively address them (Lewis et al., 2007). Additionally, in today’s era of
accountability, logic models are often required by funding sources as part of a
proposal for program development.
To aid in the development of logic models, an excellent guide is the W. K.
Kellogg Foundation (2004) Logic Model Development Guide. The guide
provides examples of various types of logic models, providing information
regarding how best to use them, and discusses the various audiences that may
benefit from using them. (The guide can be found at
www.wkkf.org/knowledge-center/resources/2010/Logic-Model-Development-
Guide.aspx.) Additionally, the Office of Juvenile Justice and Delinquency
Prevention (OJJDP; 2009) provides useful information about the logic model, a
sample illustration of a logic model, and a template by which to develop your
own logic model. Whereas the logic model template is provided for applicants
preparing to submit a grant proposal, the information that the OJJDP provides
can also be of great help. (You can find this information at
http://ojjdp.ncjrs.org/grantees/pm/logic_models.html.) Because the information
pertaining to logic model development and use is provided freely by both the
W. K. Kellogg Foundation and the OJJDP, I encourage you to take the time to
review both of these resources.

Project Timelines
Whereas the logic model is an essential tool for program design, a project
timeline is an effective tool for organizing program implementation. This is
because thorough planning must be completed well in advance of program
implementation (ideally 6–12 months prior), and to effectively accomplish all
that’s necessary in the most efficient manner, a high degree of organization is
necessary. Without the use of strong organizational skills at this point, program
implementation may be jeopardized. And it is in this initial program design
step that the actual implementation process begins. Unfortunately, I have too
often witnessed well-designed programs quickly close down or not receive
continued funding due to ineffective implementation planning.
 Today, with the highly competitive climate of mental health and human
service programming that exists, implementation must often occur immediately
after funding has been awarded. Therefore, time is of the essence, and those
who are not prepared well in advance of award notification create not only an
unnecessary but often insurmountable challenge to the program implementation
process. As such, any reduction in the program’s operating time cycle could
negatively impact the program’s success. Unfortunately, because of the time
frames in which award notices are often given compared with the initially
outlined time frames for program implementation, time frame challenges are
often an inherent part of receiving funding.
To illustrate the tight time frames that can exist between notification of
award and program implementation, consider my past two projects (shown in
Table 5.3). Both of these projects were based on 2-year funding cycles, each of
which—ideally and as designed in the original proposals—required the projects
to operate for 2 full years in order to achieve anticipated program outcomes.
As you can see, notification of the award was provided well beyond the
project implementation dates for both of these projects. Whereas funding was
provided for one project to begin more than 3 months prior to notification of
the award and the other more than 5 months before notification, you cannot
retroactively begin a program that was not begun—unless, of course, there is a
physicist out there prepared to take on this challenge. As a result, you are
forced to move rapidly to implement the project, realizing that regardless of the
speed by which implementation occurs, a significant part of real time can
simply not be recovered.
Table Time Frames for Notification of Funding and Implementation of
5.3 Projects

Whereas these examples illustrate extreme challenges with program funding

and implementation cycles, they are not uncommon. However, there are
significant differences between state, federal, and foundation funding, and it is
unusual when state or foundation funding timelines actually have begin dates
prior to notification of the funding award. Unfortunately, though, it is not
uncommon for even these types of funding sources to make awards with as
little as a 60-day implementation time frame. As a result, you must have a plan
for implementing the plan (Lewis et al., 2007) so that you are prepared well in
advance and can efficiently implement the program.
It is because of each of these reasons that a project timeline is indeed a
necessity to the program developer. There are a range of project timeline
formats with varying levels of details that may include the time frames during
which each major activity should be implemented, the individual(s) responsible
for implementing each activity, and any associated outcomes, when relevant.
Because there are so many facets involved in program implementation—from
recruiting staff and developing marketing materials to admitting the first clients
and beginning the program evaluation—timelines should be used to map out
each of these. Two examples of timelines are provided, with Table 5.4
illustrating a timeline for program implementation that includes many of the
associated activities that occur both before and during program implementation
and Table 5.5 illustrating a specific timeline for one aspect of the program
development process—program evaluation.
As you can see from the two sample timelines provided, there are different
methods you can use in formatting timelines. Additionally, timelines can
include all program implementation activities or you may use timelines that are
limited to specific implementation activities (e.g., program evaluation). I find it
best to develop one master timeline that includes all the major program
activities and use additional timelines that focus on specific major activities
(e.g., staff training program, program evaluation). By doing this, my colleagues
and I are able to view an inclusive map to program implementation that can
straightforwardly and efficiently illustrate all the various activities that need to
occur as well as when they need to occur. In addition, by developing additional
timelines for subprojects, I gain more detailed directions to guide major
activities that are a part of the larger implementation plan. I have found this
incredibly helpful to organizing my own time as well as helping others
appreciate the concept of time involved in effectively implementing a program.
Moreover, I am a firm believer that the more we can break down major projects
into their various parts, the more tangible the whole process becomes. This is
integral to the success of program development. Because program development
requires such a tremendous amount of work and attention to so many details, it
can easily be intimidating if considered in its entirety. Therefore, by separating
each of the various components into tangible projects via timelines, a degree of
psychological relief is provided that often mitigates any sense of being
overwhelmed by the incredibly important and large-scale work inherent in
program development efforts.
Table Sample Program Implementation Timeline: Outreach Programming
5.4 for Homeless Women
Table Project Timeline: Program Evaluation of Juvenile Sex Offender
5.5 Program
Summary
The program design process is akin to putting a puzzle together—a puzzle for
which most of the pieces have already been identified and simply require
positioning, while other aspects involve a more thorough search for new pieces
to complete the whole. By allowing the previously collected data to guide the
program design (identification of need, research basis for program design that
includes a specific focus on culturally based interventions), developing the
mission simply means articulating how the research is used in your program
design and why you are working to address an identified need. Developing the
vision provides the opportunity to establish just how far you wish the program
to reach and succeed, while designing the core program design relies on data
found in all three of the previous steps (i.e., identifying the need, establishing a
research basis in program design, and identifying multicultural considerations)
and requires assembly into a coherent design.
It is precisely in this way that the initial part of the program development
process is data-driven and unidirectional, each step building from the previous
one. Moreover, it is in this way that program development is a scientific
endeavor, one that requires a great deal of rigor and research skill and, when
conducted effectively, one that results in a strong foundation for success—not
to mention a significant degree of satisfaction.
CASE ILLUSTRATION
Joan and Cynthia had volunteered to design a new program model for
adolescent substance abuse treatment that they were going to present as part
of a proposal to request funding from a philanthropic foundation. They had
already done due diligence and completed a comprehensive needs
assessment, thus justifying the need for the program, and they had also
conducted a market analysis as part of the preplanning process. In addition,
they had conducted an extensive review of the literature and had identified
an evidence-based treatment model. In order to design the program, they
developed a logic model illustrating the various components of the
program. Because the program was a community-based, family-focused
program, the clinical interventions included family therapy, family problem
solving, and individual sessions based on motivational interviewing and
cognitive-behavioral interventions. The program’s adjunctive or supportive
interventions included case management focused on identifying and linking
the family with needed community resources and academic support and
involvement in the treatment planning process. After establishing several
short-and long-term outcomes based directly on the treatment interventions
and the research, Joan had identified improved family functioning,
improved academic performance, decreased substance abuse–related risk
factors, and sobriety as four of the outcomes. Cynthia then began to
investigate appropriate assessment instruments to measure each. After
reviewing the research, Cynthia identified the Family Assessment Device
to assess family functioning, knowing that it had demonstrated strong
psychometric properties. Academic progress reports that focused on several
aspects of academic performance, including improvements in homework
submission, class participation, assignment grades, and overall
achievement, and report cards would be used to assess change in academic
performance. The Substance Abuse Subtle Screening Inventory for
Adolescents would be used to assess change in substance abuse risk factors,
and random drug screens would be used to assess sobriety. Both Joan and
Cynthia established the outcome targets after a further review of the
research on the evidence-based model and the target thresholds that its
population had achieved. A snapshot of the partial program design included
the following:
 Joan and Cynthia chose to identify the needs in need language rather than
as problems since this fit more with their philosophical thinking of helping.
They used the five categories of needs, clinical interventions, adjunctive
interventions, outcomes, and outcomes measures to diagram their program
design, knowing that there were different ways to develop logic models and
that what was most important was articulating a clear understanding of the
relationships between these five areas. After finalizing their program design
and adding it to the proposal that included the results of their
comprehensive needs assessment, Joan knew they had developed a strong
proposal. She and Cynthia had not only built a firm case establishing the
need for the program, they had used the most current research to design
what they knew was not only a comprehensive but highly cost-effective
program. The program’s evidence basis was well established, and they had
proposed the use of assessment methods that would allow them to
effectively evaluate the program. Cynthia and Joan praised each other on
their collaborative efforts, worked to put the finishing touches on the
proposal, and submitted it to the foundation the following week.

 
LOGIC MODEL EXERCISE

To reinforce your knowledge of the logic model, complete the

following exercise:
1. Consider a local human service, mental health, or school-based program
with which you are somewhat familiar.
2. Using the sample logic model that I provided, identify the following
information related to the program:

A minimum of three interventions (two clinical, one nonclinical)

One output for each intervention
One short-term outcome goal for each intervention
One long-term outcome goal for each intervention
One outcome measurement tool for each short- and long-term
goal (total of six measures)
 3. Contact a program representative to gain any missing information.
4. Once the logic model has been completed, critique it by examining the
following issues:

Are the clinical interventions evidence-based?

If not, identify a minimum of one evidence-based intervention.
Are outputs clearly defined?
If outputs are not clearly defined, identify alternative outputs.
Is there evidence that the clinical interventions may lead to the
identified outcomes?
If there is not evidence that the clinical interventions may lead to
the identified outcomes, develop alternate outcomes that are
related to the clinical interventions.

 
ANSWERS TO NAME THAT MISSION EXERCISE

1. Boy Scouts of America

2. Young Women’s Christian Association
3. Ben & Jerry’s
4. Girl Scouts of America
5. NAACP
 
 

References
Beck, A. T., Steer, R. A., & Brown, G. K. (1996). Beck Depression Inventory
II. Upper Saddle River, NJ: Pearson Assessment.
Brody, R. (2005). Effectively managing human service organizations (3rd ed.).
Thousand Oaks, CA: Sage.
Busch, M., & Folaron, G. (2005). Accessibility and clarity of state child
welfare agency mission statements. Child Welfare, LXXXIV, 415–430.
Comprehensive Juvenile Sex Offender Management Initiative. (2009). Mission
statement. Retrieved April 25, 2010, from http://www.cjsom.com
Dennis, M., Godley, S. H., Diamond, G., Tims, F. M., Babor, T., Donaldson, J.,
et al. (2004). The Cannabis Youth Treatment (CYA) Study: Main findings
from two randomized trials. Journal of Substance Abuse Treatment, 27, 197–
213.
Epstein, N. B., Baldwin, L. M., & Bishop, D. S. (1981). The McMaster Family
Assessment Device, Version 3. Providence, RI: Brown University & Butler
Hospital Family Research Program.
Gray, G. C., & Kendzia, V. B. (2009). Organizational self-censorship:
Corporate sponsorship, nonprofit funding, and the educational experience.
Canadian Review of Sociology, 46, 161–177.
Hatfield, D. R., & Ogles, B. M. (2004). The use of outcome measures by
psychologists in clinical practice. Professional Psychology: Research and
Practice, 35, 485–491.
Hernandez, M. (2000). Using logic models and program theory to build
outcome accountability. Education and Treatment of Children, 23, 24–40.
Hodges, K. (2000). Child and Adolescent Functional Assessment Scale
(CAFAS). Ann Arbor, MI: Functional Assessment Systems.
Kellogg Company. (2010). Vision and mission. Retrieved July 23, 2010, from
http://www.kelloggcompany.com/company.aspx?id=888
Kettner, P. M., Moroney, R. M., & Martin, L. L. (2008). Designing and
managing programs: An effectiveness-based approach (3rd ed.). Thousand
Oaks, CA: Sage.
Lewis, J. A., Lewis, M. D., Daniels, J. A., & D’Andrea, M. J. (2003).
Community counseling (3rd ed.). Pacific Grove, CA: Brooks/Cole.
Lewis, J. A., Packard, T. R., & Lewis, M. D. (2007). Management of human
service programs (4th ed.). Belmont, CA: Thomson Learning.
Miller, F. (1997). Substance Abuse Subtle Screening Inventory (SASSI) manual.
Bloomington, IN: SASSI Institute.
Millon, T. M. (1993). Millon Adolescent Clinical Inventory (MACI) manual.
Minneapolis, MN: National Computer Services.
Mours, J. M., Campbell, C. D., Gathercoal, K. A., & Peterson, M. (2009).
Training in the use of psychotherapy outcome assessment measures at
psychology internship sites. Training and Education in Professional
Psychology, 3, 169–176.
Office of Juvenile Justice and Delinquency Prevention. (n.d.). Performance
measures: Logic models. Retrieved September 10, 2010, from
http://ojjdp.ncjrs.org/grantees/pm/logic_models.html
Ogles, B. M., Lambert, M. J., & Fields, S. A. (2002). Essentials of outcome
assessment. New York: Wiley.
Phelps, R., Eisman, E. J., & Kohout, J. (1998). Psychological practice and
managed care: Results of the CAPP practitioner survey. Professional
Psychology: Research and Practice, 29, 31–36.
Rossi, P. (1997). Program outcomes: Conceptual and measurement issues. In E.
Mullen & J. Magnabosco (Eds.), Outcomes measurement in the human
services (pp. 20–34). Washington, DC: NASW Press.
Shaffer, D., Fisher, W. P., Lucas, C., Dulcan, M., & Schwab-Stone, M. (2000).
The NIMH Diagnostic Interview Schedule for Children (NIMH DISC-IV):
Description differences from previous versions and reliability of some
common diagnoses. Journal of the American Academy of Child and
Adolescent Psychiatry, 39, 28–38.
Torghele, K., Buyum, A., Dubruiel, N., Augustine, J., Houlihan, C., Alperin,
M., et al. (2007). Logic model use in developing a survey instrument for
program evaluation: Emergency preparedness summits for schools of
nursing in Georgia. Public Health Nursing, 5, 472–479.
Triangle Foundation. (2009). Our organization. Retrieved March 14, 2010,
from http://www.tri.org/our-organization.html
Van der Haas, M., & Horwood, C. (2006). Occupational therapy: How effective
do consumers think it is? New Zealand Journal of Occupational Therapy,
53, 10–16.
Ward, J. C., Dow, M. G., Penner, K., Saunders, T., & Halls, S. (1998). A
manual for using the Functional Assessment Rating Scale (FARS) (Rev. ed.).
Tampa, FL: Department of Mental Health Law and Policy, FMHI/USF.
W. K. Kellogg Foundation. (2004). Using logic models to bring together
evaluation and action: Logic model development guide. Battle Creek, MI:
Author.
 CHAPTER 6
Develop the Staffing Infrastructure

 
Learning Objectives
 

1. Explain the difference between process and structure in organizational

design
2. Identify three types of process factors related to organizational design
3. Discuss the purpose and role of the governing board in nonprofit
organizations
4. Explain the relationship that both the market analysis and the logic
model have with the design of the staffing infrastructure
5. Illustrate a staffing infrastructure through the use of an organizational
chart

 
BUT I NEED MORE SUPPORT
Annette had been managing two programs for batterers—one for female
batterers and one for male batterers—for the past 2 years and had
increased her client load considerably since the program’s inception. She
told her executive director that she needed more staff. In particular, she
requested two clinical managers—one for each program—an
administrative assistant, and an additional intake coordinator. And she
produced a revised program organizational chart to illustrate the new
staffing infrastructure, stressing how much the program had grown. After
briefly reviewing the program’s financial records with Annette and the
chief financial officer, the executive director agreed to the new positions,
each of which was a full-time, salaried position.
The human resources manager was told to develop new job
descriptions in accordance with Annette’s modified organizational chart.
After having each of the positions in place for 6 months, the programs
experienced a 40% reduction in referrals. Annette was not too worried,
accepting that her business often experienced peaks and valleys;
however, 4 months later, the programs were still operating at
approximately 60% of their previous capacity. Finally, with no change
occurring, Annette’s boss and she met and discussed the fact that she
would have to reduce her staffing costs by half within the next 30 days.
Annette admitted that she had not fully examined the financial
implications of the new hires nor had she thought about the program’s
future revenue—she really thought the program would continue to
operate at the same client/revenue levels as it had in the past. After
reviewing the recent financials on the program, Annette realized that the
new hires had cost the program in excess of $210,000, including salaries
and fringe benefits, and now the program would incur additional costs as
a result of severance and unemployment-related fees.
Annette was astounded at the costs but knew she now had to make
tough decisions about how she would go about downsizing. In fact, she
realized that the sooner the downsizing occurred the better, as she needed
to act quickly now to stop the bleeding lest she face losing her program
altogether.

 
 CONSIDERING ANNETTE

1. What mistakes did Annette make?

2. How could she have prevented this from happening?
3. What, if any, responsibility do Annette, the chief financial officer,
and/or the executive director have in creating this problem?
4. If you were Annette, what steps would you take now to attempt to
remedy this, and how might you go about making decisions related to
staffing and hiring in the future?

About This Chapter

Whereas the previous chapter dealt with clinical program design, this
chapter moves into a discussion of the other primary part of program design
—staffing infrastructure design or organizational structure. The chapter
begins with an examination of the two key elements of organizational design
—structure and process—and a discussion about the ingredients needed for
effective organizational design. Examining the various structural issues
related to staffing, we will discuss each of the various levels of staff—
including the executives, managers, supervisors, and line staff. In addition,
we will explore the purpose and role of the governing board. Next, we will
discuss the major process components, including communication,
supervision and accountability, work flow, types of staffing options and their
impact on organizational processes, and scheduling.
To again illustrate the sequential process of comprehensive program
design, we will revisit two previously discussed program planning tools—
the market analysis and the logic model. We will reexamine both of these
essential tools to illustrate the impact that each has on the development of
the organizational infrastructure design. Finally, we will fully explore the
organizational chart—the key tool used in organizational staffing
infrastructure design. An organizational chart exercise is provided at the end
of the chapter to further reinforce learning.
 
 STEP IV: DEVELOP THE STAFFING
INFRASTRUCTURE
The Organizational Structure
The clinical program design constitutes roughly half of the design process,
while the organizational structure constitutes the other half. Therefore, after
the comprehensive program design is complete, the organizational design
must be devised. Effective organizational design must minimally do the
following:
 

1. Address units, departments, roles, and responsibilities

2. Promote the most effective use of resources, open
communication, and expedient decision making
3. Reflect the goals, needs, size, theoretical orientation, and
philosophy of the organization/program
 
Organizational design consists of two major components—structure and
process. Structure refers to how the program/organization is organized,
primarily with regard to staffing. Structure is typically overt and visible
throughout the organization, referring to staffing hierarchies and the
grouping together of various staffing functions. Process, on the other hand, is
more subtle, existing within the structure. Organizational processes often
describe what is going on within the structure, such as communication
patterns and decision making.
Designing the organization/program begins with designing the
organizational structure—namely, the staffing infrastructure. The staffing
infrastructure refers to all the human resources that are needed to implement
the program and monitor the program’s operations. Developing the right
staffing infrastructure is directly tied to the program design since the type
and scope of interventions dictate program staffing needs. Additionally,
developing the right staffing infrastructure is equally critical to program
implementation since successful program implementation is dependent on
both effective program design and effective staffing to implement the
program design. There are several factors that O’Looney (1996) originally
proposed for consideration in organizational design, including

design must be consistent with organizational objectives (if

creativity is desired, promote autonomy and reduce
constraints);
design around outcomes;
promote freedom in design;
promote open communication;
allow easy access to resources for those in need;
link parallel activities;
capture information once (e.g., client database that is used by
all relevant staff); and
examine how you look to the client (e.g., are you accessible 24
hours a day?).

In addition, activities that may also be useful to the organizational design

process include

thoroughly exploring all the tasks needed to implement the

program,
separating activities for specific individuals and/or groups,
determining levels of responsibility needed per staff position,
determining the degree to which staff positions relate to one
another,
determining the decision-making process and structure,
determining internal and external lines of communication,
garnering top-level support for organizational/program design,
developing a steering committee to lead the process to promote
collaborative decision making in design,
involving all levels of staff in design,
 focusing on efficiency in operations—each step must be
justified and add value—and
designing for future climate and changes by orienting all staff
toward flexible thinking regarding process issues.

Because clinical program design dictates organizational staffing

infrastructure needs, staffing infrastructures vary from program to program,
with some programs composed of just two levels of staff (e.g., supervisors,
clinicians) and others composed of six or more levels (e.g., manager,
supervisors, clinicians, case managers, behavior specialists, direct care
workers). Likewise, human service organizations vary greatly, with some
organizations consisting of a singular program while others are multifaceted,
consisting of a variety of programs working across multiple systems (e.g.,
workforce development, substance abuse, children’s mental health). These
differences between programs and organizations highlight the dynamic
nature of staffing infrastructures by illustrating that there is no one model of
staffing infrastructure but rather that staffing needs are modulated based on
programming.
To illustrate the possible breadth of a human service organization’s
infrastructure, Box 6.1 provides a near-exhaustive list of potential staff
positions as well as the organizational oversight body (i.e., governance
structure).
 
BOX 6.1

SAMPLE OVERVIEW OF GOVERNANCE AND STAFFING

Governing board
Executive leadership
Executive management
Administrative support staff
Supervisory staff
Clinical staff
Case management staff
Direct care staff
 Paraprofessionals
Other program staff

Whereas each of these staff groups serves unique purposes, there is also
some degree of overlap between certain positions. For instance,
administrative support staff from the finance department and program
managers may both be involved in program accounting activities; however,
the program manager is largely responsible for managing the program
budget, while the financial coordinator is responsible for program billing and
financial record keeping. It is this type of structuring of both unique
responsibilities, as well as overlap associated with various work groups, that
reflects the symbiotic nature of work flow, in which multiple factions are
required to collaboratively produce and support the goals of the
organization.
Whereas numerous characteristics of organizational structures have been
examined throughout the literature, Pleshko and Nickerson (2008) identify
four major structural dimensions—formalization, integration, centralization,
and complexity—that have historical roots (Dalton, Todor, Spendolini,
Fielding, & Porter, 1980; Ford & Slocum, 1977; Frederickson, 1986; Fry,
1982; Miller, 1988; Miller & Droge, 1986). Pleshko and Nickerson provide a
brief synopsis of each of these organizational structures, which serves as a
good primer on the topic.
 

Formalization: Policies and procedures are widely used to prescribe the

manner in which tasks should be performed (Frederickson, 1986).
Opposed to promoting employee autonomy, formalization in
organizational structure restricts employee activities to only those
activities proscribed in advance.
Integration: Activities are coordinated so that various specialized
groups work together (Miller, 1988). Integrated organizations often
promote contact with experts across departments as well as contact with
top executives, promoting integrated work activities.
 Centralization: Decision-making power is concentrated in the hands of
a few (Frederickson, 1986), with critical decisions made only by top
executives.
Complexity: This term describes the various interrelated parts of an organization. Complexity
includes the scope of an organization, power structures, and number and geography of multiple-
site organizations.

Whereas these four organizational structures provide a schema by which

to better understand the science of structure, by examining each, you may
also begin to notice how organizational structure and processes interact in
organizational design. For instance, formalized organizations operate more
like a dictatorship, whereas integrated organizations function more like
democracies—both of which have obvious implications for employees and
how they play their roles within the organization.
Organizational designs in the human services and mental health settings
can differ enormously from one organization to the next, with flatter
organizations (i.e., fewer hierarchical levels) and more collaborative decision
making (i.e., integrated structures) much more common today than in
previous decades. However, hierarchical structures (i.e., formalized
structure) continue to be necessary, particularly to depict lines of authority
and organize the organization, and as a result, you would be hard-pressed to
find an organization today without some degree of formalization. But
probably the most important point regarding organizational structure was put
forth by the management guru Peter Drucker (1999), who argued that “the
best structure will not guarantee results and performance. But the wrong
structure is a guarantee of nonperformance” (p. 440). There are many texts
devoted specifically to organizational structure and theory, and I suggest you
look to those for a more in-depth examination of this topic. For now, our
discussion will focus on the staffing infrastructure.

Governance Structure
The board of directors comprises the governance structure of an
organization and, as such, serves to monitor the organization and represent
the organization to the public. In this sense, boards are both overseers of
business operations as well as ambassadors of the organization. Boards of
human service and public organizations may be termed board of directors,
board of trustees, or board of regents, depending on the type of institution
and its organizational structure.
For-profit boards differ in some ways from nonprofit human service
boards, particularly in the degree of public scrutiny that they receive;
however, all boards share ultimate accountability for organizational activity
and accomplishment (Carver, 2006). Because the board does hold ultimate
accountability for the organization, it is always placed at the top of the
organizational structure. Accountability in the extreme sense means that
boards are charged with fiduciary responsibility for the organization and for
dissolving the organization should it need to cease operations. Over the past
decade, with the introduction of the Sarbanes-Oxley Act of 2002, the role of
corporate governance has become even more significant, and as a result,
there is now greater responsibility and accountability for boards.
At a structural level, boards operate to set organizational objectives,
allocating necessary resources to meet objectives, monitor the organization’s
performance, and ensure that the organization acts as a responsible member
of the larger community (Kessler & Schuster, 2009). On a daily basis, boards
monitor the organization, working primarily with the organization’s leader
and top administrators, regularly receiving information and participating in
various levels of organizational decision making. Board activity varies
tremendously from organization to organization. On one end of the
spectrum, board members may participate solely in board meetings that are
no more than information dissemination forums in which they receive
information from the organization’s leadership team and are asked to do
little else for the organization. Conversely, in some organizations, board
members serve as strategic organizational representatives, engaging in
advocacy, fundraising, and other public activities to increase support for the
organization as well as participating in key decision making about the
organization. In the latter case, board members are often viewed as an
instrumental support and leadership arm of the organization.
Because it behooves every organization to have a board that enhances the
organization, the astute organizational leader works to develop the most
productive board that s/he can. Unfortunately, limited time and other scarce
resources, as well as perceived threats to executive power, may at times
prohibit organizational leaders from committing the necessary time and
energy to developing a dynamic, productive board. This truly is unfortunate
since the benefits gained from the work of an effective board can
exponentially increase the value of the organization with very little
associated cost. This is because board member time is the primary cost of
board participation, and since board members are volunteers, this cost is
incurred by the individual and not the organization. As such, an effective
board simply offers another layer of no-cost support and value to the
organization—a critically needed commodity in the current climate of
shrinking resources.

Executive Leadership
The executive of the organization is the top official, the individual
responsible for overseeing the organization’s day-to-day operations. In
human services organizations, the top official typically has the title of
executive director, president, and/or chief executive officer. This individual
reports directly to the board and is charged with the responsibility of
overseeing all aspects of the organization. Because the executive leader is
responsible for not only running the organization but also ensuring the
ongoing health of the organization, it is critical that this individual possess
highly effective leadership skills. In particular, the executive leader must
minimally be able to

engage staff in the mission of the organization,

represent the organization to the public,
effectively work within the political system and other systems
that impact the organization,
be able to produce successful organizational outcomes, and
be able to visualize well into the future and act to posture the
organization for success in years to come.

In his discussion of learning organizations, Senge (2006) characterizes

leaders as designers, stewards, and teachers responsible for building
organizations in which all individuals commit to learning by continuously
expanding their capabilities. As he asserts, in order to achieve this, leaders
must first be able to inspire. In a similar vein, Bolman and Deal (2008)
reframe leaders not as authority figures but as individuals who must work
within the context of multiple relationships within the organization and pay
attention to developing relationships in order to move organizations forward.
In particular, Bolman and Deal define leadership as a subtle process based
on mutual influence that fuses thought, feeling, and action to produce
cooperative efforts that meet the needs and are consistent with the values of
both the leader and the led. Leadership then must be viewed not as
something that is done to the staff and other stakeholders of an organization
but rather as what is accomplished collaboratively by the staff and
stakeholders of an organization.
While extremely significant and relevant to today’s climate, these
sentiments in no way represent new thoughts in leadership; however, when
discussed today, these arguments are often made in the context that a shift in
thinking must occur—that we must now conceptualize leaders not as
authority or control figures but as collaborators. This is particularly
interesting since historically leadership has indeed been viewed in much the
same manner. For example, consider these views on leadership from some
prominent historical figures (Box 6.2).
 
BOX 6.2

HISTORICAL QUOTES ON LEADERSHIP

I must follow the people. Am I not their leader?
—Benjamin Disraeli, prime minister of England (1804–1880; as cited in Bernays, 2005)
If your actions inspire others to dream more, learn more, do more, and become more, you are a
leader.
—John Quincy Adams, sixth president of the United States (1767–1848; as cited in Department of
the Interior, 2009)
A leader is best when people barely know he exists, when his work is done, his aim fulfilled, they
will say: we did it.
—Lau Tzu (600 BC-531 BC), Chinese Taoist philosopher and founder of Taoism
 When viewing the major thoughts on leadership from this much broader
historical view, it seems that whereas the emphasis on leaders as co-
constructionists—collaboratively creating a vision of the organization and
working collectively to fulfill its mission—is not a new concept, it is indeed
timeless. And to be an effective leader first and foremost requires an
unwavering commitment to the organization and all that the organization
represents. Without such commitment, no degree of inspiration, political
capital, or administrative competence will be enough to effectively lead.
Another critical aspect of leadership has to do with the ability of the
leader to motivate and influence individuals with different needs to attain the
goals of the organization. This most often requires modifying the leadership
approach. Indeed, effective leaders must adapt their style to meet the needs
of their subordinates (Hur, 2008).
In addition to the chief executive, several other employees may serve in
leadership roles, such as those who are directors, managers, or supervisors.
Therefore, several of these basic principles of leadership apply to them as
well.

Management Staff
Depending on the size and structure of the organization, there may be one
level or multiple levels of management staff. In mid- to large-sized human
service organizations, there may be three levels of management staff that
include executive-level management, divisional management, and program
management. In this context, I am referring only to operations/program
management and not to administrative support management (e.g., finance),
which will be discussed later.
Executive-level managers often carry the title of chief operating officer,
deputy director, or vice president and report directly to the chief executive of
the organization. These individuals function as part of the executive
leadership team, working closely with the organizational leader, providing
broad-based leadership, engaging in organizational development, and
overseeing the operations of the organization.
Members of the second level of management—division-level managers—
typically operate in organizations that are composed of multiple programs
that have been grouped together into divisions through similar services.
These managers are responsible for overseeing more than one program,
directly supervise program managers or directors, and report to the
executive-level manager. Because this level of manager works between the
program manager and the executive-level manager, her/his activities often
overlap with those of the other two levels. As such, division-level managers
may be directly involved in managing program operations to some extent, as
well as being involved in comprehensive organizational development. In
addition, division-level managers ideally focus their energies on division-
level development, working to ensure the quality of existing programs for
which they are responsible, representing their programs to the public,
working to ensure continued funding, and engaging in new program
development, to name just a few key activities.
Members of the third level of management—program managers, also
known as program directors—are responsible for directly overseeing the
program. These individuals report directly to the division-level manager (or
the executive-level manager in a flatter organization) and oversee program
supervisors. An all-important though heavy burden to carry, it is typically
the program manager who is directly charged with ensuring the most
effective treatment of program clients and protecting the welfare of clients
being served by the program.
These individuals are considered the program administrators because they
are charged with fulfilling all the duties associated with the operations of a
program. These duties can include

supervising program supervisors and staff;

hiring and training staff;
attending to the financial aspects of programming, including
budgeting and financial reporting;
representing the program to stakeholders and the public;
working directly with funding sources;
engaging in new program development;
managing program improvement activities, including program
monitoring and evaluation, and engaging in program advocacy
 efforts; and
working directly with program clients.

Regardless of management level (executive, division, program), all

managers must possess mastery of a wide range of skills, including short-and
long-term planning, human resource development, supervision, finance
management, and evaluation, and they must possess a keen understanding
and competency to work effectively within the context of the organization,
given its values, beliefs, and customs (Lewis, Packard, & Lewis, 2007). In
addition, managers must possess essential leadership skills and work to
continuously enhance the program/organization in a spirit of collective
engagement and productivity.

Administrative Support Staff

Administrative supports include departments such as finance, research
and program development, human resources, fund development, training,
and information systems. Administrative support staff are often as critical to
the organization as are direct care staff because administrative support staff
make it possible for direct care staff to carry out their duties. Administrative
support staff members typically work behind the scenes of the organization,
tending to all the essential duties that allow an organization to continue its
work. It is in this sense that mental health professionals and other program
staff may not be aware of the role and value of administrative support until it
does not exist. For instance, if the Internet connection in your office went
down or if the organization’s server could not be accessed and there were no
information systems support staff available, your work and the work of the
organization could temporarily cease. The same is true for finance support
and human resources support. If financial support staff did not manage and
coordinate the finances to ensure that billing was received, employees may
not be regularly paid. Likewise, if human resource department staff did not
gather proper documentation as part of the hiring process to ensure the
eligibility of all workers as well as compliance with state and federal
employment mandates, the livelihood of the organization could be in danger.
It is in this manner that a highly interdependent relationship exists between
program personnel and administrative support personnel in an organization.
Without program personnel to carry out the program operations, there is no
need for administrative support personnel, and conversely, without
administrative support personnel, program personnel may be unable to
effectively carry out program operations.
Depending on the size of the organization, each department may consist
of one individual (e.g., controller) or comprise large staffs with various
levels of internal leadership (e.g., chief financial officer, controller, finance
manager, finance coordinators). The number of staff members within each
administrative support department may also be an indicator of the
organization’s values. For instance, a one-person research and development
department and a five-person fund development department may indicate an
organization that values charitable fundraising over research and
programmatic innovation.

Supervisory Staff
Supervisory staff typically report to managers and are responsible for
directly supervising program staff. However, again, the number of layers
within any organization may vary greatly, with some programs composed of
only one level of management staff (e.g., manager) and others with both
supervisors and program managers. Because program staff consists of
individuals who actually deliver the program interventions, supervisors have
the most direct line of oversight to program implementation and, thus, carry
a tremendous responsibility It is in this manner that supervisory staff is
differentiated from managerial staff. However, supervisory staff may also be
involved in program development activities and other activities that are a
primary part of the managers’ responsibilities
Because there are different types of direct service workers, which may
include clinicians, case managers, and paraprofessionals, different types of
supervisors often oversee each group. Just as is true in big industry,
supervisors in human service organizations often are former direct service
workers. As a result, supervisors have prior experience in the work
performed by those whom they are supervising and, more often than not,
have been promoted to a supervisory position based on their performance as
direct care workers. Additionally, supervisors may have previously been
direct care workers who have achieved an advanced degree and have been
promoted to supervisor as a result of this advanced standing. This is more
unique to supervisors of case managers and paraprofessionals than clinical
supervisors, because clinical supervisors typically share the same or similar
academic credentials as those whom they supervise (i.e., master’s degree in
clinical field).

Clinical Staff
Clinical staff may be composed of mental health and/or substance abuse
therapists who possess either a master’s degree or doctorate in counseling,
clinical social work, or clinical psychology and who hold state licen-sure in
their respective discipline. In addition, clinical staff may include
psychiatrists who hold medical degrees and board certification in either child
or adult psychiatry.
Clinical staff play a unique and incredibly significant role in
programming and in the organizational operations as a whole. Because the
success of clinical programming is first and foremost based on the quality of
the clinical interventions, the work that these individuals perform is integral
to the value of the program/organization. Indeed, it is this group of
individuals that is responsible for delivering the therapeutic interventions
that lead to the program’s clinical outcomes.
The therapeutic interventions may include individual, group, and/or
family therapy, assessment, referral and resource coordination,
comprehensive treatment planning, and psychiatric care. In addition to their
primary functions, clinicians often provide direct input for program
development and participate in program evaluation and other forms of
research.
Because clinicians possess advanced knowledge about various treatment
issues, they are viewed as program leaders, responsible for teaching and
training other levels of staff in specific treatment issues. As is true for all
mental health clinicians, regardless of type of clinical practice, clinicians
also have a specific responsibility to advocacy—for clients, treatment issues,
and the public.

Case Management Staff

 Case management staff typically work very closely with both the
clinicians and the direct care workers, serving as somewhat of a binding
agent holding together the critical members of the treatment team. Case
managers are usually charged with leading the treatment planning process
and identifying and addressing all the clients’ nonclinical and support needs
while at the same time working to gain the input of clinicians regarding the
clients’ clinical needs. A large part of what case managers do is coordination
—coordinating resources, coordinating dialogue between treatment team
members, and coordinating meetings and other planning processes, to name
a few. As a result, case managers must possess effective communication and
organizational skills and be well versed in resource coordination.
Case managers are typically required to have bachelor’s degrees, and
some may have master’s degrees. Historically, case management jobs were
filled primarily by individuals holding master’s or bachelor’s degrees in
social work, but today, case managers may have degrees in human services
or another of the newer disciplines, and some may also have master’s
degrees in a traditional mental health discipline (e.g., counseling,
psychology).

Direct Care Staff

Direct care is the broad-based term given to the individuals responsible
for providing basic services to clients. Direct care staff perform different
functions depending on the type of treatment setting (e.g., residential,
school-based, home-based). For instance, in residential treatment programs,
direct care staff provide continuous supervision and support to clients,
ensuring that all primary needs are met, often cooking, cleaning, and
providing transportation to clients. In home-based programs, direct care staff
may provide mentoring or other types of social support services to the
client/family.
Because of the broad scope of work and responsibility that direct care
staff have, they have the greatest amount of direct interaction with clients.
As a result, direct care staff are particularly critical to the treatment process.
This is particularly true in residential or inpatient programs, where direct
care staff function as primary caregivers to clients. Because placement in a
residential program is often extremely challenging for clients, direct care
staff are charged with supporting and helping clients adjust to what is a
difficult and temporary living environment at best.
Typically, direct care staff are considered paraprofessionals, as their role
supports the primary work of other professionals. Often, these workers are
minimally required to have a high school diploma, with some organizations
requiring some postsecondary education, up to a bachelor’s degree.
Additionally, direct care staff are typically required to participate in
specialized training to further support their work.

Other Program Staff

There are two other types of program staff that may be a part of the
organization, both professional staff and other nonprofessional staff. In terms
of professional staff, some programs may employ behavior specialists,
nurses, or other medical professionals as well as occupational therapists.
These individuals specialize in a specific area, often holding a bachelor’s
degree and/or professional credentials.
Other nonprofessional staff may include individuals who perform specific
client support functions such as providing transportation or
monitoring/tracking client progress in the community. These staff support
the work of the direct care workers or, in some cases, are in place of direct
care workers and, as such, hold similar credentials.
As you can see, a diverse array of individuals may compose the staffing
infrastructure in a human service organization, each possessing a specific set
of skills and each playing a unique role within the organization. At the same
time, there is often overlap between positions. This is precisely why
organizations that value deep knowledge and skills as well as flexibility in
roles and responsibilities are often successful. Current mental health
organizations must promote staffing positions that are highly focused yet
adaptive to assuming new and different responsibilities, since one of the key
factors today is constant change within the broader mental health service
industry.

Organizational Processes
There are a multitude of process elements that must be considered in
designing the organizational structure. These include communication,
supervision and accountability, culture, and staffing options. Each of these
elements contributes to the organizational structure and, more specifically, to
the way that the organization functions both subtly and overtly.
Communication, supervision and accountability, and culture are
considered processes because they reflect specific aspects of the organization
that influence its underlying processes. For instance, in organizations in
which open communication is promoted, employees are more prone to
engage in critical thinking and collaborative decision making. As a result,
this type of communication pattern illustrates the way in which the
organization functions. Although staffing options and scheduling do not
reflect a specific process, they do influence other processes. For instance,
organizations with a majority of contractual staff may have a culture that is
highly competitive, with employees more concerned about their own work
and less engaged as a collective workforce.

Communication
As Moss Kantor (1983) put it in her seminal text, The Change Masters, a
communication system, depending on the kind adopted by a given
corporation, can either constrain or empower the effort to innovate.
Unfortunately, though, as fundamental and significant as that communication
is to the success of an organization, little attention is paid to communication
processes and functions, resulting in neglect of this critical process (Lewis et
al., 2007).
Whereas it is difficult to discuss communication patterns without a
broader discussion of organizational theory, few human service
organizations today operate from a strict theoretical foundation but, rather,
are hybrids of various theories. Organizational theories from which specific
aspects are most often reflected today include classical, learning
organizations, quality management, and open systems. Table 6.1 provides a
simple illustration of how aspects of specific organizational theories are
reflected in today’s human service organizations.
 
  
Table 6.1 Organizational Theories in Today’s Human Service Organizations

Theoretical Aspects Used in Today ‘s

Organizational Theory
Human/Social Service Organizations

• All employees work toward overall goals of

the organization
Classical theories • Employees are organized around specialized
(bureaucracy, scientific functions (e.g., counselors vs. case managers)
management) • Employees work toward same goal
• Hierarchical reporting; little employee
autonomy

• Shared vision among all employees

Learning organizations
• Team learning
• Employee commitment to continuous
Quality management improvement
• Client satisfaction as key objective
• Organization responds directly to its internal
Open systems and external environment

As you can see from Table 6.1, organizational theories have a strong
influence not only on communication but also on other aspects of
organizational functioning. While this snapshot provides you with only a
brief view of organizational theory, a multitude of organizational theory texts
are available to provide you with a firm foundation in this important area.
With regard to specific types of communication patterns in a
program/organization, communication patterns can range broadly from
having primary features of information hoarding and top-down
communication, directive and strategic communication, open exchange of
communication, and open exchange and productive use of communication,
among others. These communication patterns and their relationship to the
major organizational structures discussed previously are outlined in Box 6.3.
 
 BOX 6.3

POTENTIAL COMMUNICATION STYLES RELATED TO

ORGANIZATIONAL STRUCTURE
Information Hoarding and Top-Down Communication
(Formalization)

Authority is centralized at the top of the organization.

Information is viewed by authority as power and, therefore,
information sharing is limited.
Communication is one-way, from the top to the rest of the organization.

Directive and Strategic Communication (Centralization)

Communication is viewed by authority as a tool to be used strategically

with the rest of the organization.
Formal communication throughout the organization is managed by the
authority.

Open Exchange of Communication (Integration)

Whereas communication and dialogue are promoted throughout the

organization, it often may not impact decision making.

Open Exchange and Productive Use of Communication

(Integration)

Open communication and dialogue are promoted as a means of

enlarging decision-making processes and enhancing organizational
functioning.
Open communication may be facilitated for specific purposes and
result in specific outcomes.

Whereas outlining these broad categories of communication patterns

allows for broad characterizations of communication patterns, organizations
are composed of human beings. As a result, organizations are extremely
complex and often difficult to accurately characterize. More often than not,
communication patterns are nuanced and somewhat flexible, becoming
modified by other forces both within and external to the organization.
In terms of the significance of communication to the program developer,
the manner in which communication patterns support or prohibit effective
program/organizational functioning is a critical issue. More to the point, the
program developer must be concerned with ensuring that communication
processes are consistent with the goals and objectives of the program. In
addition, program developers must bear in mind that creating an effective
work environment begins with knowing and frequently communicating with
employees (Fodchuk, 2007); therefore, a great deal of attention must be
given to communication style and processes.

Supervision and Accountability

Supervision in any organization implies some degree of accountability, as
the existence of a supervisor indicates the need for specific monitoring and,
thus, some degree of responsibility for the actions of the supervisee. In
accordance with Standard F. 1.a. of the American Counseling Association
(2005),
A primary obligation of counseling supervisors is to monitor the
services provided by other counselors or counselors in training.
Counseling supervisors monitor the welfare and supervisees’ clinical
performance and professional development. To fulfill these
obligations, supervisors meet regularly with supervisees to review
case notes, samples of clinical work, or live observations. (p. 13)
Supervision is a vast area, encompassing such aspects as roles,
responsibilities, styles, legal issues, and ethical issues, to name just a few.
And because many organizations may have multiple layers of supervisors,
including first-line supervisors, program directors, middle managers, and
executive-level managers—including the chief executive—each of these
positions is accountable to some degree for the organization. It is the manner
in which supervisory roles and accountability are practiced within the
organization that relates to organizational design. This is because
supervisory roles and functions reflect the underlying processes of an
organization.
Whereas most human service/mental health organizations today have
some degree of supervisory hierarchy, this may vary quite a bit depending on
the type of organization/program. For instance, in a community-based
mental health organization consisting of programming for seniors with co-
occurring mental health and substance abuse issues, specific types of
workers may be separated by their functions (e.g., clinicians, case managers,
paraprofessionals)—each group with specific supervisors assigned to it as
well as one layer of management and executive leadership. A different
supervisory schema may exist within a school-based counseling program in
which counselors and other mental health clinicians may report directly to a
lead counselor for supervision that is largely consultative while indirectly
reporting to the school principal or other administrator for
nonclinical/administrative issues. In other types of mental health
organizations, there may not be any direct supervisors, but rather because of
the professional credentials of each employee, employees function as
accountable to the organization rather than to a specific individual. This is
most common in clinical private practice environments in which
professional counselors and other mental health clinicians function as
owner-employees or independent contractors.
Supervision and accountability are just as tied to organizational structure
and organizational theory as are communication patterns. Organizations
based on classical theories often are designed hierarchically, with managers
and supervisors at various levels providing direct monitoring and
supervision of staff below. Conversely, learning organizations may be
characterized by supervisory relationships that reflect collaboration and
mutual learning through support and teamwork. Actually, much can be
learned about an organization’s theoretical bend by observing supervisory
practices. In fact, I remember when one of the organizations that I worked
for began introducing some of the principles of quality management and
learning organizations throughout the organization, beginning with the
executive management team. This created some degree of tension within the
organization as executive-level managers began sharing meeting space and
engaging in more enhanced teamwork and decision making with subordinate
staff. Because the organization had been accustomed to relying more heavily
on classical theories in which power was largely situated in the hands of top-
level managers, sharing power and increasing the autonomy of others in the
organization presented a significant change—creating new friction as the
organization worked through the change process.
This example is not at all uncommon, particularly because most
organizations are constantly changing—expanding and reducing in size and
scope, being influenced by new and different individuals and thought, and
reacting to external and internal pressures. Further highlighting this, Bolman
and Deal (2008) contend that organizations are highly complex, constantly
changing, organic pinball machines in which decisions, actors, plans, and
issues continuously move through an ever-changing field of barriers,
supports, and traps. And, like all organisms, changes in one area most often
cause changes in another, and at times, these changes impact how
supervision and accountability are interpreted and practiced within an
organization.
With regard to program development, the developer must again pay
attention to the primary objectives of the program/organization and ensure
that attainment of objectives is supported through existing accountability and
supervisory processes. As such, lines of supervision and all aspects related to
supervision and accountability within the organization must be carefully
considered when designing the organization.

Culture
The concept of organizational culture is one that has been widely
discussed, particularly as it relates to the inner climate of an organization.
Just as the concept of culture refers to people, the culture of an organization
can be defined as the values, beliefs, and traditions of the organization.
Culture also speaks to the underlying orientation of an organization—the
ways in which employees of an organization think, act, and react and the
norms that guide behaviors within the organization. In addition, culture may
also be referred to as the work environment. Culture is difficult to quantify
and make tangible yet enormously significant to the operations of an
organization. In fact, Deal and Kennedy (1982) may have most succinctly
summed it up almost 3 decades ago as “the way we do things around here”
(p. 4).
The culture of an organization is highly influential, as it often sets the
internal tone of the organization. The culture of an organization often
dictates how change is interpreted, how success or failure is perceived, and
how engaged employees are in the organization. Whereas it is not always
highly evident to outsiders, employees are often subtly or overtly
indoctrinated into the organization’s culture. Speaking about the tremendous
power of culture, Moss Kantor (1983) discusses how one company credited
its ability to fully indoctrinate new employees to the organizational culture
with its success in working through a significant organizational change
process. Through this indoctrination process, employees became fully
integrated into the organization and completely engaged in the organization’s
ultimate goals. Seasoned employees spent much time sharing stories and
legends about the organization with new employees, and new employees
were sent through boot camp–like venues to attain the history and specific
perspectives of the organization. This example illustrates the importance that
this organization ascribed to culture and the subsequent lengths to which the
organization went to ensure that its culture was effectively transmitted to
new employees.
Along these same lines, there are other cultural or work environment
factors that may have a positive influence or promote organizational
citizenship behavior (OCB; Conlon, Meyer, & Nowakowski, 2005; Dalal,
2005). OCB basically refers to being a good citizen of the organization—
engaging in activities that are not directly rewarded but that ultimately are in
the best interest of the organization (e.g., obeying rules, efficiently
completing tasks, fully participating in processes). Historically, OCBs have
been found to be related to job satisfaction (Whitman, Van Roody,
Viswesvaran, 2010), organizational justice (Konovsky & Pugh, 1994), and
organizational commitment (O’Reilly & Chatman, 1986). While it seems
only logical that promoting OCBs should be an objective of all leaders and
managers, research has found that average levels of OCBs are linked to
overall organizational performance (Koys, 2001)—further highlighting its
significance!
 Conversely, just as OCBs exist in organizations, so too can
counterproductive work behaviors (CWBs; Marcus & Schuler, 2004). CWBs
are employee behaviors that can harm an organization either through actions
that directly impact the organization or through actions directed at
individuals. Just as specific antecedents to OCBs have been identified, so too
have factors that influence CWBs. These include sensation seeking (Marcus
& Schuler, 2004), motives (Rioux & Penner, 2001), and self-control (Marcus
& Schuler, 2004). Ideally, leaders and managers wish to eliminate
counterproductive work behaviors while promoting organizational
citizenship behaviors. And the key mediating factor to achieving this seems
to be organizational justice (Fodchuk, 2007)—the perception that employees
are treated in a just and fair manner. In order to positively increase a culture
of justice within an organization, various activities may be critical, including
the use of effective interpersonal skills when delivering bad news, ensuring
selection procedures are job-related (Truxillo, Bauer, Campion, & Paronto,
2002), and training managers in interpersonal justice (Skarlicki & Latham,
2005).
Mental health professionals might be predisposed to promoting
organizational justice since most have chosen their discipline because of an
innate need to help others and most are preternaturally disposed to working
col-laboratively. Moreover, most are not only accustomed but are
particularly oriented to contributing to overarching goals. As a result, leaders
of mental health organizations may be able to simply tap into the existing
shared values and beliefs of their employees and use them to reinforce a
positive organizational culture.

Staffing Options and Scheduling

Staffing pattern is another process-related issue in organizational design.
There are basically three types of staffing patterns in most human service
and mental health organizations: full-time, part-time, and
contingent/contractual employees. Whereas it most often stands to reason
that organizations largely composed of full-time employees may have an
easier time engaging their workforce with the organization, it is not
uncommon for human service organizations to maintain contingent
paraprofessional staff as well as contingent professional staff. In fact, hiring
contingent workers allows the organization greater flexibility and control
over its long-term financial commitments (Gibelman & Furman, 2008) and
may be used to ensure fiscal stability. Depending on the type of work being
done, the contingency plan, and how the contingent workforce fits into the
rest of the organization, contingent/contractual employees in human service
organizations may be equally engaged in the organization.
While staffing patterns can impact organizational culture, program
developers must be highly concerned with developing the most effective
staffing pattern for the work being done within the program/organization.
For example, inpatient substance abuse treatment programs have much
different staffing requirements than community-based substance abuse
prevention programs. Minimally, inpatient treatment programs require
paraprofessional staff to be available around the clock and require full-time
professional counselors/mental health professionals, full-time case
managers/social workers, and immediate access to medical personnel (e.g.,
physician, nurse). This may result in staffing patterns that include full-time,
part-time, and contingent paraprofessionals, recreational and other support
staff, full-time mental health professionals, full-time case managers, and
contingent or part-time medical personnel, as well as program supervisors,
managers, and administrators. In addition, client-staff ratios for
paraprofessional/direct care workers and caseload size for clinicians and
case managers must be considered in residential programs with regard to
best practice standards articulated by accrediting bodies, licensing bodies, or
other contractual requirements. Depending on the program capacity,
residential programs may have as few as 40 employees for a 12-bed program
and as many as 150 for an 80-bed program. Conversely, a community-based
substance abuse prevention program may consist solely of full-time staff that
may minimally include clinicians and other professional staff as well as a
program supervisor and/or manager. In this case, depending on the number
of target clients, a community-based prevention program may have as few as
three employees, including clinicians and a program administrator.
As a result of the vast differences in required staffing patterns based on
program type and program capacity, program developers must pay particular
attention to identifying the right staffing pattern for their program. Because
staffing patterns are directly tied to program outcomes and have significant
financial implications, it is essential that the right staffing pattern be put in
place at initial implementation. In fact, failure to do so may result in
treatment failure and financial loss, either of which could cause the program
to lose continued funding and, ultimately, cease operations.
As you can see, each of these organizational processes and design issues
(i.e., communication, supervision and accountability, culture, staffing, and
scheduling) require critical thinking by the program developer to ensure the
development of a sound design. The Organizational Design Process Issues
Checklist may aid you in initially working through these design issues (see
Table 6.2).
Table 6.2 Organizational Design Process Issues Checklist

Process Issue Question

What organizational theories guide the
program/organization?
What communication styles most reflect our
organizational theory?
What types of communication patterns most effectively
support our program objectives?
Communication What types of communication patterns may be
detrimental to the program’s success?
How does the program/organization need to be structured
to support the most effective communication patterns?
How is information disseminated within the organization?
How is communication accounted for within the
organization?
Supervision What types of supervision and accountability patterns are
and most effective given our type of program and staffing
accountability options?
What types of supervision and accountability patterns are
most effective to carry out the program’s objectives?
 What type of supervision and accountability patterns will
help us achieve our desired organizational culture?
What type of organizational culture will most effectively
help us achieve our program objectives?
What type of organizational culture should we expect as a
result of our organizational theory, communication
Culture patterns, supervision and accountability patterns, and
staffing?
What will need to be purposely done in order to promote
the desired organizational culture?
What type of culture is transmitted through this design?
Is every staff position justified?
What credentials and experience are needed to implement
the program?
Staffing options What are the accreditation standards and licensing and
contractual requirements for staffing this type of program?
What type of staffing structure has been found to most
effectively support the program objectives?

Each of the questions focuses on specific issues related to design and, as

such, should prompt further exploration into specific areas, generating more
information for use in decision making about design. However, this list is in
no way exhaustive, and likely you will generate new questions as you begin
thinking about each of these issues.

Designing the Staffing Infrastructure

Designing an effective organizational infrastructure is no small feat. On the
contrary, it requires a great deal of time, focused attention to detail, and an
ability to look beyond the nuts and bolts of staffing to how you wish the
organization to function well into the future. Because of the complex issues
that both influence and are influenced by organizational infrastructure, it is
imperative that extensive consideration be granted to this phase of program
design. And as with all other aspects of program design, this work must be
guided by data. In fact, when designing the organizational staffing
infrastructure, you must first revisit the program design, research review, and
market analysis, as each will provide guidance to the infrastructure
development.

Revisiting the Program Design, Research Review, and Market

Analysis
The program design provides the most relevant information needed for
designing the staffing infrastructure. This information includes

target population,
program type,
program size/capacity,
clinical and nonclinical interventions, and
length of treatment.

Each of these design aspects influences decision making related to

staffing. Whereas program type, size, and interventions provide basic
information related to the type and number of staff needed, program type
also guides thinking about staffing options (full-time, part-time, contractual).
After identifying the various types of staff positions needed based on the
program design, the results of the literature review should again be
consulted. However, the review at this juncture should be specifically
focused on program evaluation and other research related to achieving
program outcomes—identifying the type and number of staff needed to
successfully carry out the program.
In addition to learning about the effect that staffing patterns have had on
program outcomes through a focused research review, you should also
review national accreditation standards related to the program type for
guidance. Accrediting bodies often articulate best practices related to staff
credentials, number of staff members needed, client-staff ratio and caseload
size, and any specialized training needs, among other aspects. It is best to not
limit the review of accreditation standards but rather review the standards of
each of the major accreditation bodies that have promulgated standards for
your particular type of program, regardless if you are planning to pursue
accreditation with only one accrediting body. I say this because, as you
hopefully recall from Chapter 3, most accreditation bodies today provide
standards for a broad and highly diverse group of programs. By taking
advantage of this and reviewing the standards of each body related to your
type of program, you can gain more information for use in decision making
about staffing infrastructure development.
In addition, regional or state licensing rules and/or other oversight or
contractual bodies must be consulted for their specific staffing requirements.
Often, these types of oversight agencies also articulate staff credential needs,
staff-client ratio and caseload size, and specialized training needs.
Last but not least, the results of the market analysis should again be
utilized. Because the market analysis provides detailed information about
regional and national competitors, this data can be highly meaningful in
designing the staffing infrastructure. Learning from what others who have
been operating similar programs have done is often critical to successfully
designing your own program. When considering staffing design,
understanding what has worked well and what has not worked for
competitors can assist you in ensuring that you take advantage of the best of
what they have produced while avoiding similar failures. At the same time,
you must consider how your program will differentiate itself from the
competition, and the staffing infrastructure may be a likely component by
which to further make your program unique or enhanced so that it is set apart
from the competition. For instance, if your competitors use a treatment team
approach in a community-based program for adolescents with substance
abuse issues that includes a case manager and a clinician, you may add a
paraprofessional to your treatment team to work specifically with the client
and family in effectively linking them to various community supports and
providing direct support to them as they begin and/or continue these
relationships. By doing so, you may enhance your treatment approach while
differentiating your program from the competition. And if you share one
paraprofessional position between three work teams, the added cost that you
incur may be minimal, particularly if better program outcomes can be
achieved.

Organizational Chart
The organizational chart is one of the program developer’s principal tools
for use in designing the organizational infrastructure and constitutes the first
and arguably most critical step of organizational design. Organizational
charts provide an illustration of the staffing infrastructure of a
program/organization and, as such, communicate program/organization
structure to staff and other stakeholders. In addition, organizational charts
clarify the chain of command and illustrate the expected flow of
communication within an organization at a basic level (Lewis et al., 2007).
Similar to logic models, the organizational chart is an integral program
planning tool.
Although organizational charts are an effective tool for designing the
staffing infrastructure, the organizational chart is not intended to, nor does it,
overtly articulate deeper levels of organizational processes (e.g.,
communication, decision making, culture). Moreover, organizational charts
do not clearly illustrate the manner in which responsibilities are delegated,
and organizational charts alone cannot explain the functions of a position. As
a result, organizational charts must be used in conjunction with written job
descriptions (Lewis et al., 2007). Regardless of its limitations, the power of
the organizational chart must not be overlooked. Namely, organizational
charts illustrate chains of command/hierarchy within a
program/organization, and this in turn has a great deal of influence on
communication, decision making, and culture. So, whereas the
organizational chart will not provide information about specific
organizational process issues, it is an essential component underlying the
organizational processes. Moreover, developing the organizational chart aids
in the initial program planning, implementation, and evaluation of the
organizational structure and processes. For instance, when a program
experiences difficulty with communication among staff, a review of the
organizational chart may assist in ferreting out where communication may
be breaking down and how hierarchical reporting patterns may influence
communication, both negatively and positively. As such, the organizational
chart not only serves as critical to the initial organizational design but also as
the first line of defense in addressing organizational design issues that
emerge later during program implementation.
In addition to the significance that an organizational chart holds for the
organization, it is often equally significant to funders. In fact, organizational
charts are often required by state and regional funding agencies as part of the
proposal process to bid for human service programs. Because funders have
an integral stake in the success of a given program, organizational charts are
often required to demonstrate an appropriate staffing infrastructure—lending
further support to the overall proposal.
Because organizational charts reflect the type, number, and scope of a
program and/or organization, the charts vary drastically based on each of
these factors. In single-program organizations, one organizational chart may
be used that reflects the organization and includes the program. However,
single-program organizations that are highly complex may require both an
organizational chart for the program and one for the organization’s
administrative structure. This is the standard for multifaceted organizations
whereby an organizational chart should be developed for each program,
detailing all the staffing components contained in the program, as well as a
separate one for the organization that includes the administrative structure
and basic information about programs. Probably the most important issue to
remember regarding the use of an organizational chart is that it is a tool for
use by the program developer, manager, or other leaders. As a tool, it is
flexible and works with the program developer as needed. Therefore, you
must determine the most effective use of organizational charts, detailing as
much as you wish and using as many charts to illustrate various components
of the program/organization as needed. The organizational chart provided in
the case illustration at the end of the chapter (Figure 6.2) reflects a single
program structure and includes the total administrative structure (i.e.,
president, office support coordinator) and program structure. Figure 6.1
illustrates an additional type of organizational chart—a program-specific
chart.
Figure 6.1 depicts the staffing infrastructure of a community-based
psychiatric program for adults with serious psychiatric disorders—similar to
an Acute Community Treatment model. As such, the primary staff are
clinicians. This is because this is a clinically based program and, therefore,
the bulk of expenditures are used to support the primary workers. In this
program, the program director holds either a master’s degree or a doctorate
(counseling, clinical psychology, clinical social work). The same is true for
the clinicians, and the case managers may have a master’s in social work or
a bachelor’s degree in one of the helping professions with advanced training
in psychiatric treatment. Additionally, the number of positions per category
is based on the type and intensity of work performed by each position. As
such, the staffing pattern includes the following:
Figure Program-Specific Organizational Chart for a Community-Based
6.1 Psychiatric Treatment Program

One program director to oversee the program operations, with

responsibility for the direct supervision of the psychiatrist,
clinical supervisors, and administrative assistant
One psychiatrist to provide monthly medication reviews and
consultation as needed (smallest workload)
 Two clinical supervisors who each have a small supervisory
load of four clinicians because of the type of services provided
Eight clinicians to provide the key treatment and most intensive
services with weekly individual therapy and biweekly group
therapy
Four case managers to provide once-per-week home visits and
resource coordination as needed
One administrative assistant to provide office support to the 16
members of the staff

Summary
Achieving an effective organizational design is no small feat and, in fact,
requires a tremendous amount of knowledge and skill as well as a
commitment to continuous evaluation. In the helping professions in
particular, the success of our business depends on the individuals providing
the services, and therefore, finding the right people to fill the right roles is an
essential objective. However, before we can even consider the right people,
we must ensure that we have identified the right positions to implement the
various components of the program. This, like all other aspects of
comprehensive program development, involves no guesswork but, rather,
effectively using research, knowledge, and data to guide the planning
process. Namely, the results of the market analysis, literature review, and the
program logic model must be used to guide the development of the
organizational/program structure.
In addition to developing the right staffing infrastructure, the various
process issues that influence program/organizational functioning (e.g.,
scheduling, communication patterns, supervision and accountability, culture)
must be thoroughly considered. More to the point, there must be a deep
appreciation for the interdependent relationships between staffing
infrastructure and process issues and the need for the program developer to
thoughtfully and strategically influence the organizational design so that the
program can not only thrive but be sustained over time.
 
 CASE ILLUSTRATION
Allied Mental Health Services had been in operation for 9 years,
providing outpatient counseling to children, adults, and families with a
variety of presenting issues, including grief and loss, addiction, and
serious mental health disorders. This mental health agency was small,
with 11 staff members, including Marge, who served as the president
(also a full-time clinician); a full-time receptionist/bookkeeper; three
full-time clinicians; and six contractual clinicians. The agency had
successfully operated over the past several years in the community,
expanding its client population and increasing revenue as a result of
increased recognition for the quality of its work. Most recently, the
county mental health board had released a Request for Proposal for
comprehensive counseling and support services for veterans and their
families, and a representative of the mental health board had encouraged
Marge to submit a proposal on behalf of Allied.
Marge called a meeting for all the staff to discuss the possibility of
developing a proposal for this new program. The group engaged in quite
a bit of dialogue regarding how taking on such a program might alter the
current organization, both in terms of structure and in terms of process
(e.g., culture, decision making). This was particularly at issue since the
agency operated as an employee-owned organization, with therapists
responsible for generating specific levels of revenue and a cost-and
revenue-sharing plan in place. This arrangement had historically
promoted a high degree of autonomy for the clinicians and uniquely
engaged them in the organization since all were equally responsible for
the agency’s health.
After spending a good deal of time outlining the pros and cons of
pursuing this new business, the group decided that it was in their best
interest to develop a proposal. While working on the proposal, the group
began thinking about how the new program would be staffed and how
the new program structure would differ from their existing structure—
and how this might impact the organization. The existing structure was
almost flat—consisting of two levels, with Marge occupying the top
level and all the clinicians and the receptionist/bookkeeper sharing a
level directly beneath her.
 Because Marge assumed a quasi-leadership role in the organization,
she had a larger financial stake in the business and, because of this,
ultimately carried more risk and subsequent responsibility for the
business (e.g., physical space, business taxes). However, Marge’s
hierarchical standing had more to do with business-related liabilities and
expenditures than with decision-making authority since the clinicians
largely operated autonomously yet collectively. However, with the
addition of a traditional human service program with multiple levels of
staff, contractual obligations, and a need for varying levels of
accountability, the program staffing infrastructure would need to look
quite different from the existing structure. And as the organization’s
leader, Marge would likely have to assume more direct oversight of the
program—attending to program operations details that she did not
currently need to scrutinize.
The staff felt strongly that the current success of their organization
was largely based on the organizational structure that they had in place
and were fearful of letting go of some of the ownership that they
perceived they had in the business operations, and this remained in the
back of their minds as they moved forward in planning for the new
program. After charting out the various positions needed in the proposed
program based on the program design, market analysis, and literature
review, they were able to identify four levels of positions needed:
program director, clinicians, family support coordinators, and an office
support staff person (see Figure 6.2). The thinking behind this design
was that the program director would be responsible for the administrative
aspects of the program, while the clinicians would focus primarily on the
program implementation and, as such, would oversee the work of the
family/community support coordinators. Because the office support
coordinator would provide administrative support to all program staff,
this position would report directly to the program director so that the
clinicians would be able to focus solely on the program. Marge would
provide executive leadership to the program, directly supervising the
program director.
Figure Proposed Program Organizational Chart for Comprehensive
6.2 Counseling and Support Services for Veterans and Their Families
 Having completed the design of the staffing infrastructure, the work
group turned its attention to the various process issues that needed to be
addressed through design. The group most wanted to take steps to not
disrupt the current functioning of the organization through any radical
changes. So they decided that the program director and clinician
positions would be offered first to current part- and full-time clinicians,
if they were qualified and interested. It was thought that by doing this,
the organization would be less negatively impacted since existing staff
would simply take on new roles, thus ensuring some degree of continuity
for the entire organization during its time of transition. In addition, it was
also hoped that this would allow for the existing climate and culture,
which was very positive, to naturally influence the new program since
much of the culture resided within and was influenced by the existing
staff.
 In addition to planning to move existing staff into key positions in the
new program, the group also planned for decision making, supervision
and accountability, and other issues related to organizational culture. To
this end, the group decided that although a program director was in
place, team-based decision making would be practiced. This meant that
family/support coordinators and clinicians would engage in collaborative
decision making regarding programming and operational issues, with the
program director weighing in but with the majority ruling in decisions, as
relevant. In addition, peer review and team consultation practices would
be in place to promote a climate in which all staff would be accountable
to one another and to the program. By putting these two significant
process strategies in place, the work group believed that a culture of staff
empowerment, autonomy, and healthy engagement within the program
could be gained. In many ways, this schema would mirror the existing
organizational structure. This would ensure organizational coherence and
a smooth transition as the organization experienced this expansion and
change process.
After finalizing the detailed organizational design for the proposed
program, which would be maintained as a guide for program
implementation if the contract was awarded, the group completed the
proposal for the new program and submitted it to the funding agency. In
debriefing the work group activities as a follow-up, members reported
feeling even greater engagement in the organization and much more
investment in winning the proposal—another benefit of involving staff in
any type of change project. More significantly, though, group members
discussed making it a priority to regularly debrief and check in as a large
group about their organizational process issues if and when the new
program was implemented, as well as if it was not. As they had learned
throughout this initial planning process, successful organizational
structures do not simply happen but, rather, are well orchestrated and
continuously tended to. This was a lesson that they agreed could not
simply be taken for granted within the organization.

 
ORGANIZATIONAL CHART EXERCISE
To put your own organizational staffing infrastructure design
skills to work, complete the following exercise either
independently or in a small group:
 

1. Identify a program of particular interest to you that you would

like to develop to address a specific issue (e.g., elder abuse,
depression, gang violence), and review the research related to
this type of programming.
2. If the program is a clinical program, consider that the program
capacity is 40 clients (total number of clients served at a given
time), and if the program is a school-based program, consider
that the total number of students is 300. Or simply determine
another relevant capacity level based on your particular
program so that you can use this information to determine the
number of staff needed and relevant caseload sizes.
3. Develop a program-only organizational chart identifying all the
program-specific staff positions needed to operate the program
at full capacity.
4. Identify the types of minimal credentials needed for each staff
position and provide an explanation for each.
5. With the exception of program administrative assistant/office
support staff, if needed, do not include any other support
positions (e.g., finance, human resources, information systems)
in this chart.
6. Identify the hours of program operations and the scheduling
patterns for the various staff positions.
7. Identify the desired communication patterns, supervision and
accountability processes, and culture that you hope to achieve
within the program.
8. In small or large groups, present your findings, providing all
the following information:
 Justification for each position in the staffing infrastructure
The rationale for staff qualifications
The caseload size and rationale
The relationship between the organizational chart and the logic
model
The relationship between the desired communication patterns,
supervision and accountability processes, and culture and the
staffing structure
Any necessary modifications to the organizational chart as
warranted based on lack of effective justification or other issues
that emerge from your presentation

References
American Counseling Association. (2005). ACA code of ethics. Alexandria,
VA: Author.
Bernays, E. L. (2005). Propaganda. Brooklyn, NY: Ig.
Bolman, L. G., & Deal, T. E. (2008). Reframing organizations: Artistry,
choice, and leadership (4th ed.). San Francisco: Jossey-Bass.
Carver, J. (2006). Boards that make a difference: A new design for
leadership in nonprofit and public organizations. San Francisco: Jossey-
Bass.
Conlon, D. E., Meyer, C. J., & Nowakowski, J. M. (2005). How does
organizational justice affect performance, withdrawal, and
counterproductive behavior? In J. Greenberg & J. Colquitt (Eds.),
Handbook of organizational justice (pp. 301–328). Mahwah, NJ:
Lawrence Erlbaum.
Dalal, R. S. (2005). A meta-analysis of the relationship between
organizational citizenship behavior and counterproductive work behavior.
Journal of Applied Psychology, 90, 1241–1255.
Dalton, D., Todor, W, Spendolini, M., Fielding, G., & Porter, L. (1980).
Organization structure and performance: A critical review. Academy of
Management Review, 5, 49–64.
Deal, T. E., & Kennedy, A. A. (1982). Corporate cultures. Reading, MA:
Addison-Wesley.
Department of Interior. (2009). Federal outreach and leadership
development program. Retrieved May 10, 2010, from
http://www.doi.gov/febtc/files/FOLD brochure.pdf
Drucker, p. (1999). Management: Tasks, responsibilities, practices. New
York: HarperCollins.
Fodchuk, K. M. (2007). Work environments that negate counterproductive
behaviors and foster organizational citizenship: Research-based
recommendations for managers. Psychologist-Manager Journal, 10, 27–
46.
Ford, J., & Slocum, J. (1977). Environment, technology, and the structure of
organizations. Academy of Management Review, 2, 561–575.
Frederickson, J. (1986). The strategic decision-making process in
organizational structure. Academy of Management Review, 11, 280–297.
Fry, L. (1982). Technology-structure research: Three critical issues.
Academy of Management Journal, 25, 532–551.
Gibelman, M., & Furman, R. (2008). Navigating human service
organizations. Chicago: Lyceum.
Hur, M. H. (2008). Exploring differences in leadership styles: A study of
manager tasks, follower characteristics, and task environments in Korean
human service organizations. Social Behavior and Personality, 36, 359–
372.
Kessler, G., & Schuster, M. H. (2009). Design your governance model to
make the matrix work. People and Strategy, 32, 16–25.
Konovsky, M. A., & Pugh, S. D. (1994). Citizenship behavior and social
exchange. Academy of Management Journal, 37, 656–669.
Koys, D. J. (2001). The effects of employee satisfaction, organizational
citizenship behavior, and turnover on organizational effectiveness: A unit-
level, longitudinal study. Personnel Psychology, 54, 101–114.
Lewis, J. A., Packard, T. R., & Lewis, M. D. (2007). Management of human
service programs (4th ed.). Belmont, CA: Thomson Learning.
Marcus, B., & Schuler, H. (2004). Antecedents of counterproductive
behavior at work: A general perspective. Journal of Applied Psychology,
89, 647–660.
Miller, D. (1988). Relating Porter’s business strategies to environment and
structure: Analysis and performance implications. Academy of
Management Journal, 31, 280–308.
Miller, D., & Droge, C. (1986). Psychological and traditional determinants
of structure. Administrative Science Quarterly, 31, 539–560.
Moss Kantor, R. (1983). The change masters. New York: Simon & Schuster.
O’Looney, J. (1996). Redesigning the work of human services. Westport, CT:
Quorum.
O’Reilly, C., & Chatman, J. (1986). Organizational commitment and
psychological attachment: The effects of compliance, identification, and
internalization on prosocial behavior. Journal of Applied Psychology, 71,
492–499.
Pleshko, L., & Nickerson, I. (2008). Strategic orientation, organizational
structure, and the associated effects on performance in industrial firms.
Academy of Strategic Management Journal, 7, 95–110.
Rioux, S., & Penner, L. A. (2001). The causes of organizational citizenship
behavior: A motivational analysis. Journal of Applied Psychology, 86,
1303–1314.
Senge, P. M. (2006). The fifth discipline. New York: Doubleday.
Skarlicki, D. P., & Latham, D. P. (2005). How can training be used to foster
organizational justice? In J. Greenberg & J. Colquitt (Eds.), Handbook of
organizational justice (pp. 499–524). Mahwah, NJ: Lawrence Erlbaum.
Truxillo, D. M., Bauer, T. N., Campion, M. A., & Paronto, M. E. (2002).
Selection fairness information and applicant reactions: A longitudinal
field study. Journal of Applied Psychology, 87, 1020–1031.
Whitman, D. S., Van Roody, D. L., & Viswesvaran, C. (2010). Satisfaction,
citizenship behaviors, and performance in work units: A meta-analysis of
collective construct relations. Personnel Psychology, 63, 41–81.
 CHAPTER 7
Identify and Engage Community
Resources

 
Learning Objectives
 

1. Discuss the importance of community resource development in

comprehensive program development
2. Explain how community resources can be used to augment the service
array, build advocacy coalitions, and garner funding
3. Explain the relationship between community resource development and
program sustainability planning and strengthening communities
4. Discuss the relationships between the results of the asset map,
community demography assessment, market analysis, and logic model
to community resource development efforts
5. Investigate and identify relevant community resources by completing
the community resource development exercise

 
WHY ENGAGE THE COMPETITION?
Ryan and Adrienne recently celebrated the third anniversary of their
outreach and shelter program for female survivors of domestic violence.
Their shelter program had consistently remained at 95% capacity over
the past 2 years—unfortunately, reflecting the continued scope of the
domestic violence problem in the region—and they had expanded their
outreach program to include a domestic violence prevention program for
high school and college students. In addition, the programs had recently
gained accreditation through the Council of Accreditation—something
they were very proud to have attained.
While Ryan and Adrienne had become familiar with some of the staff
of the local hospital as well as an attorney’s office, they had had only
brief encounters with the other two major providers working with
domestic violence survivors in the area. Moreover, Ryan and Adrienne
had taken few steps to identify other resources that existed in the
community, believing that they would be better off trying to address the
needs of their clients directly rather than referring their clients to other
providers. Their fear, of course, was that if they referred their clients to
other providers, they might put their own program at risk of losing its
relevance and potentially going out of business. So far, this method had
served them well—their business was thriving, and they successfully
expanded their core business—demonstrating that they could be involved
not only in shelter services but also in primary prevention efforts.
However, not soon after they celebrated their 3-year milestone, their
shelter contract was up for bid. Whereas the original contract focused
primarily on the services provided on-site at the shelter, the contract had
been significantly modified with a new emphasis on the creation of
linkages to an extensive community network. The contractor’s intent was
to more effectively support the long-term needs of the client population
by assisting them in accessing various resources. As such, applicants
interested in applying for the contract were required to identify a
community network, consisting of multiple organizations that offered
adjunctive services (e.g., vocational development, housing) and extended
core services (e.g., domestic violence support). With the proposal due in
3 weeks, Adrienne and Ryan had to quickly begin speaking with various
leaders of community organizations (i.e., resources) in an attempt to get
them to participate as part of a community network. They began by
approaching their two main competitors; however, they quickly learned
that these two organizations had worked collaboratively for the past
several years, using each other as a referral source to augment their own
services as well as working together to pass new legislation on behalf of
domestic violence survivors. The competitors further shared that they
were also planning to pursue the contract and would be doing so in a
partnership with several other community organizations with whom they
had previously done business.
Without being able to establish a key partnership with one of the two
providers offering core services, Ryan and Adrienne knew their chances
of securing the contract were slim. And after spending a considerable
amount of time trying to line up potential adjunctive partners, Ryan and
Adrienne consistently received the same message: They were simply not
known to other community resources, and therefore, there was no desire
for others to partner with them, particularly given such a short time
frame in which to make a decision.
They were able to get the attorney’s office to provide a letter of
support, and they were able to secure a letter from one of the high
schools where they provided outreach services, but they knew that their
proposal was weak—not demonstrating their ability to offer an extensive
community network. Needless to say, when they received notice that
they did not win the contract, they were not surprised. Rather than
wallow in this failure for long, Adrienne and Ryan decided to put their
energies into getting to know their competitors in domestic violence
prevention, as well as developing relationships with other community
resources—having directly learned the significance of these
relationships.
  
CONSIDERING ADRIENNE AND RYAN

1. What mistakes did Ryan and Adrienne make, and how could they have
prevented them?
2. Beyond gaining a letter of support, what other benefits might you
receive from developing a relationship with your competitor?
3. Are relationships between competitors in human services different
from those between different types of for-profit businesses? Why or
why not?

About This Chapter

This chapter focuses specifically on community resource development and
the key role that community resource development can play in program
development efforts. In the comprehensive program development model,
there are two steps involving community resources—identifying and
engaging community resources and building and preserving relationships
with community resources. This chapter covers Step V of the model and
involves the initial work with community resources—resource development
and, specifically, identifying and engaging community resources.
The chapter begins with defining community resources and discussing the
role of community resource development in program development efforts.
Further highlighting the significance of community resource development,
we will examine five major purposes related to community resource
development that include augmenting the service array, developing an
advocacy coalition, garnering funding, planning for sustainability, and
strengthening communities. In order to illustrate how this step builds on
work previously completed in the preplanning and planning stages of
program development, we will revisit the results of the community
demography assessment, asset map, market analysis, and logic model for use
in identifying community resources. In addition, we will initially discuss the
need to not only engage but begin to preserve community resources,
particularly as this need links to Step XI (Build and Preserve Community
Resources). Finally, the Community Resource Snapshot tool is provided for
use in community resource development, and an exercise is provided to
further reinforce the topic.

STEP V: IDENTIFY AND ENGAGE

COMMUNITY RESOURCES
Community: Defined
A discussion about community resources must begin with a discussion about
community and exactly what is meant by the concept of community.
Providing a focused definition of community, Bookman (2005) views it as a
“real geographical community that shapes family life and work” (p. 144). In
contrast, according to Lewis, Lewis, Daniels, and D’Andrea (2003),
The word community means different things to different people. To
some it may refer to people living in a specific geographic area (e.g.,
rural versus urban community). To others it may mean a group of
people related by their unique cultural, ethnic, or racial background,
such as the Asian American community. Still others may use the term
to refer to the interdependence each has to one another as members of
a much broader “global community.” (p. 6)
Taking the concept of community a step further, Homan (2004) offers the
perspective that a community is similar to an individual, insofar as a
community may have strengths and limitations, specific challenges that it
faces (e.g., ethnic conflict, crime), feelings of powerlessness, unique skills
that come from its members, and the ability to engage in
collaboration/supportive activities. Whereas these definitions reinforce
Gareis and Barnett’s (2008) assertion that there still is not a well-established
consensus definition of community in the mental health professions, for the
sake of the discussion on community resource development, an even more
focused definition of community will be used. Community will be defined as
the geographic region in which client populations reside—consistent with
the concept of a target region discussed in Chapter 2.

Community Resources: Defined

Community resources are assets that the community possesses. Or simply,
“resources are what a community has going for itself ” (Homan, 2004, p.
55). As discussed in Chapter 2, resources can include services, other
treatment providers, knowledge, and other assets that are available within the
community. Because the strength, self-preservation, and sustainability of a
community are often based on the degree to which a community can be self-
supporting, the resources that a community has are integral to achieving this.
In fact, communities themselves often play a critical role in helping
individual community members overcome major stressors and successfully
adapt in the face of severe challenges (Yoon, 2009). However, it is not
simply the fact that a community has available resources that makes it
healthy but, rather, that the community fully utilizes its available resources
in order to achieve greater health and self-sufficiency.

Community Resources: Brief Review of the Literature

Unfortunately, research in the area of community resource development has
been scattered and noncumulative (Gareis & Barnett, 2008), with the bulk of
the literature still in its infancy. Studies that have been conducted in this area
have focused on the peripheral issue of needs assessments in identifying
service needs for specific populations, such as elderly African immigrants
(Darboe & Ahmed, 2007); the use of neighborhood mapping techniques to
identify community assets and other community characteristics, including
specific resources (Aronson, Wallis, O’Campo, & Schafer, 2007); and the
resilience of particular communities as a result of various existing
community assets (Maybery, Pope, Hodgins, Hitchenor, & Shepherd, 2009).
In addition, one recent study sought to move into new territory by
investigating perceived community resource fit compared with individual
community members’ needs and by developing a quantitative tool by which
to assess this (Gareis & Barnett, 2008). In this work, the authors examined a
residential community of employed families, exploring community
members’ satisfaction with their personal values, desires, or goals as
matched with the community’s existing resources. Their findings illustrated
the significance of effective community resource fit in school and work in
particular and its relationship to overall well-being, reinforcing previous
findings (Gareis, Barnett, & Brennan, 2003; Voydanoff, 2004). As such, the
greater the perceived satisfaction with work and school resources, the less
family conflict and psychological stress there is. This work also resulted in
the development of a standardized measure to assess community resource fit
that has promising psychometric properties (Gareis & Barnett, 2008), which
may be instrumental in future studies in this area.
Whereas research in this area is beginning to evolve, much more attention
will need to be paid to ensure that studies related to community resource
development focus on all types of communities, particularly those facing
serious challenges (e.g., working poor and impoverished, largely
unemployed, high-crime areas). It is often these types of marginalized
communities that provide the context of work in human services, and
therefore, it is precisely these types of communities in which we need to
better understand the role that community resource development plays.

Community Resource Development

Mental health professionals and individuals with chronic needs typically
know precisely what resources exist in their communities. This is because
they have an innate need to know. The former know because their success as
clinicians often rests on this knowledge, while the survival of the latter often
depends on such information. In fact, I have often thought the measure of a
truly effective clinician can be found in his/her awareness of and proximity
to an array of community resources. Clinicians today must not only know
what resources are available, but they also must be able to skillfully ensure
that access to such resources is unrestricted. More often than not, that means
that they have to have already developed strong working relationships with
the individuals managing the resources. Whereas resource coordination is a
core part of the clinicians’ job, individuals with chronic needs are motivated
by sheer survival skills to identify and access necessary resources for
themselves. As such, individuals with chronic needs are often the most
incredibly resilient people, with an enormous amount of knowledge and skill
related to available resources—not to mention inner strength and
perseverance—from which we all can learn.
The availability and array of community resources are integral to any
community’s health, required for community development, and indicative of
a community’s sustainability. Because of this, community resources are a
necessity for any clinical or human service program’s development efforts
and must be viewed as a key ingredient of comprehensive program
development.
Community resource development refers to three main issues:
 

1. The existence of resources within a community to meet specific

needs
2. The ability to access needed existing resources
3. The development of new resources designed to address existing
needs
 

The Sooke Navigator project (Box 7.1; Anderson & Larke, 2009)
provides an excellent example of the need for comprehensive community
resource development.
 
BOX 7.1

THE SOOKE NAVIGATOR PROJECT

The objective of the project was to improve mental health and addiction
services to individuals in a rural region in British Columbia. Led by a
collaborative team of mental health professionals and community
leaders, the project focused on identifying and engaging existing
community resources in order to increase access to available services in
the region.
After a thorough investigation of all the existing community resources, two Navigator
positions were developed that would function as direct links to needed community resources.
One Navigator was assigned to youth, and the other Navigator was responsible for adults.
Navigators were mental health workers that were responsible for

conducting a strengths-based assessment and initial plan,

connecting individuals to necessary resources,
providing focused support and guidance to individuals in need,
 educating community members and other professionals about the
existing community resources, and
following up with individuals to determine the outcomes related to
community resource linkages.
In addition, Navigators were required to have specialized knowledge of the primary treatment
issues, collaborate with both the individuals and participating community resources in the
development of the initial assessment plan, and provide or coordinate ongoing linking services to
ensure that the individual could indeed access any necessary resources.
By implementing the Navigator system, the region was able to increase community member
access to necessary mental health and addiction treatment.

One of the key factors that motivated the Sooke project was that even
though the region had various resources, individuals in need of the resources
often were unable to access them because they were not aware of them or
because other barriers stood in their way. Unfortunately, this problem is in
no way unique to British Columbia, but rather it is a highly common
problem that many, if not most, communities face. However, through a
coordinated planning and action process, the Sooke Navigator project
demonstrated that it was able to produce a significant impact in linking
individuals in need with existing community resources. And it is precisely
these types of linkages on which community resource development efforts
are based.

Objectives of Community Resource Development

In addition to ensuring that individuals in need are able to gain access to
necessary community resources, there are several other purposes for utilizing
community resources in comprehensive program development. These
include, but are not limited to, the following:

Augmenting the service array

Building an advocacy coalition
Garnering additional and/or new funding
Promoting long-term sustainability planning
Strengthening communities from within by recognizing and
utilizing existing resources
 Because each of these issues is of particular significance to program
development efforts, each will be discussed further below.

Augment Service Array

As you have likely already witnessed in each of the previous steps of the
program design process, a tremendous number of needs must be met when
addressing a clinical or social issue. This is because no clinical or social
problem exists in isolation, but rather each is connected to a highly complex
individual—moreover, a highly complex individual who is multifaceted and
who interacts within a broad social context. For instance, treating depression
relies only partially on treating the clinical symptoms of depression and
should address all aspects of the individual’s lifestyle (e.g., work, hobbies,
family, friends), social systems, and intra- and interpersonal aspects, among
other issues. Because some of these issues can be addressed therapeutically
and others require additional types of intervention, it is necessary to
coordinate additional services to ensure that the problem is truly addressed
in a holistic manner.
Therefore, achieving a comprehensive approach to program development
requires not only directly addressing a host of related issues and treating the
whole client but also demonstrating the ability to provide enhanced services
and treatment through the use of other available resources. This was one of
the key factors related to the Sooke project (Anderson & Larke, 2009)—the
need to ensure that residents could take advantage of the various resources
that existed within their community. From the program developer’s
perspective, the ability to tap into existing community resources allows for
augmenting the service array, thus enlarging the continuum of services for
use by the target population. In doing so, the program developer is able to
focus more specifically on the core treatment program since other providers
are able to offer enhanced treatment options.
In addition to being a smart business practice—using what already exists
rather than re-creating what is already there—this approach provides the
added benefit of strengthening the community by recognizing its existing
attributes. Doing so ensures not only an effectively encompassing treatment
approach but also greater potential for sustaining treatment gains as a result
of tapping into the community’s existing riches.
 Advocacy Coalition Development
Equally important to utilizing existing community resources in program
development efforts is engaging existing community resources as a means to
begin building an advocacy coalition. An advocacy coalition refers to a
group of individuals and organizations dedicated to a specific treatment issue
or social need that works collectively to increase awareness and knowledge
of the issue. Advocacy coalitions may become involved in lobbying efforts
—efforts designed to increase funding—and/or may engage in other
methods that seek to increase recognition of specific issues and in other
activities designed to ensure that the issues can be most effectively
addressed. In addition, advocacy coalitions may organize public forums or
campaigns to garner support for specific issues, and the work of advocacy
coalitions may result in increased pressure on elected officials (Roberts-
DeGennaro, 2001). Developing an advocacy coalition may prove essential to
sustaining a new program, as the coalition can function to ensure that
attention is continuously paid to the types of issues being addressed by the
program.
Lewis et al. (2003) outline the coalition-building process as one that
includes three stages of development:
 

1. Planning: In the planning stage, counselors must identify those

constituency groups that might link with their organization to
address an issue of common concern. This task includes making
sure that those invited to attend the first coalition-building
meeting really do have a common interest and stake in the
given issue(s).
2. Consultation: Coalition building involves more than simply
presenting an issue to each organization in a way that makes the
members appreciate its importance and value. During the
consultation stage, representatives from various organizations
must discuss the ways in which joining a coalition with other
groups will benefit each constituency.
 3. Planning and implementation: The planning and
implementation stage of the coalition-building process
determines the level of interest and commitment that
individuals genuinely have regarding the issues of common
concern to them. This is critical because individuals will likely
demonstrate an increased commitment to a coalition when they
feel they have been directly involved in the planning and
implementation of beneficial strategies. Given their training and
expertise in human relations, counselors are well equipped to
deal with the challenging task of facilitating group discussions
that involve all participants during the planning and
implementation stage. (p. 238)
 
By simply utilizing and working collaboratively with existing community
resources in initial program development efforts, you have an opportunity to
begin to develop your own advocacy coalition. And it is through this work of
getting out and ensuring that you are aware of all the existing resources that
you can begin to build your resource knowledge base. In addition, this work
allows you to meet and engage your neighbors and potential business
partners on a meaningful level. Moreover, by developing close relationships
with competitors that offer mutual benefits, you can decrease the possibility
of operating at cross purposes (Homan, 2004)—thus, keeping your
competitors with you serves to also ensure that they are not working against
you. The role and function of advocacy coalitions is further explained in
Chapter 13 as part of the broader discussion related to preserving community
resources.

Garner Additional and/or New Funding

Now more than ever before, collaborative efforts in mental health and
human service programming are demanded. In fact, rare is the call for
proposals for new programs that does not require collaboration between at
least two organizations. Two program proposals on which I recently worked
might be helpful in illustrating this current trend.
 The first Request for Proposal was for a contract to provide an array of
children’s mental health services and required that the applicant organization
identify an established panel of community providers that could provide
additional and enhanced services to the target population. The second, from
a federal funding agency, required that the applicant organization identify
two primary partners—one psychiatric care provider and one medical health
provider—that would provide necessary linkages to clients to ensure the
availability of comprehensive treatment. In addition, this particular proposal
required identifying two additional support service providers (e.g.,
employment, education) that could be used to further complement the core
services provided by the applicant organization.
Both of these sets of requirements outlined by the funding sources
accurately reflect the current climate in programming—a climate that is
highly focused on developing broad-based systems of care. This is largely
based on the notion that by developing a broad-based system of care through
collaborative efforts, communities can further develop their internal abilities
to respond to the needs of their residents, thus strengthening communities
from within.
Whereas developing such comprehensive systems is often necessary to
effectively treat individuals, without established relationships with a variety
of community resources, such systems are almost impossible to build.
Pragmatically, organizations that do not fully appreciate the need for
developing relationships with other existing community resources may find
that they have been effectively eliminated from potential new funding.
However, with appropriately developed community resource partnerships,
programs/organizations can find that they are well postured to seek
additional and/or new types of funding—thus, possibly allowing for new
opportunities and opportunities that may have a direct impact on
sustainability.

Sustainability Planning
Whereas both of the above issues have already alluded to long-term
sustainability planning, this notion also deserves mention on its own.
Sustainability planning refers to the ability of any organism (e.g., program,
organization, community) to continue its existence well into the future. This
term has come to be a critical part of our vocabulary in the 21st century,
particularly as it relates to sustaining the earth that we inhabit. However,
thoughtfully focusing on sustainability has been a primary business objective
throughout history since, arguably, all new businesses begin with the hope of
lasting well into the future and, more so, of experiencing continuous and vast
growth.
Since mental health and human services are indeed businesses, program
developers must design and implement programs with an initial focus on
long-term sustainability. Doing so is often a result of multiple factors that
will be discussed in detail in the final part of the text, specifically with
regard to the importance of evaluation, information sharing, and
accreditation. However, sustainability is another significant benefit related to
community resource development. That is, by initially engaging and
determining how community resources can be utilized in new program
development, you are in fact moving toward ensuring that your program can
be sustained over time. This is because any program that utilizes existing
and alternative resources—not drawing solely from within the program itself
—has greater staying power simply because it draws its strength and support
from multiple sources rather than relying only on its own. This is no
different than individual health and wellness—the richer one’s social support
network, the more resilient one is when dealing with hardship.

Strengthen Communities From Within

Developing relationships with community resources, further developing
community resources, and maximizing the relevance of existing resources
each have the potential benefit of strengthening the community from within,
as was previously noted. Indeed, the more available resources are at the local
level, the greater the likelihood that the needs of community members can be
addressed at the local level. This type of relationship between a community
and its resources serves to empower community members as they realize that
they have a community infrastructure within which their needs can be
effectively met. As you can imagine, this has tremendous significance to
most of us—after all, at the most basic level, we all want to know that we
have immediate access to needed resources.
 Strengthening communities from within is akin to making a community
more resilient. And in fact, there are three types of resources that are
believed to contribute to a community’s resilience:
 

1. Social assets—relationships with neighbors and/or affiliations

or ties to schools, places of worship, and other community-
based organizations
2. Service agency assets—human service organizations that have
an institutional rather than a social focus, such as child welfare
organizations, hospitals, etc.
3. Economic and neighborhood assets—includes such aspects of a
community as family income and employment opportunities
(Mowbray et al., 2007)
 
By utilizing community resources in new program development, you are
able to reinforce the value of existing community resources to community
members. In addition, you have the opportunity to develop new support
networks that can be accessed and that may more effectively serve
community members. As a result of engaging in community resource
development, you have the potential to strengthen communities from within,
thus increasing the community’s potential for resilience.

Identifying Community Resources: Revisiting the Asset Map,

Community Demography Assessment, Market Analysis, and
Logic Model
Identifying existing community resources is the obvious first step in
community resource development. But this is not necessarily an easy task,
and it really depends on the program developer’s ability to cast the widest
net in exploring existing community resources. Fortunately, if you already
completed the preplanning activities as part of the initial step in program
development—including an asset map, community demography assessment,
market analysis, and logic model—much, if not all, the work has been done
by this point. As a result, the task now becomes revisiting the results of each
previous activity to determine how to move forward in community resource
development.
This begins with reviewing the community resources listed on the asset
map to become more familiar with each of the existing resources and delve
deeper into gaining more specific information about each. As a guide to
ensure that you have captured basic standard information for each resource,
use the Community Resource Snapshot (Table 7.1). Completing the
Community Resource Snapshot may help guarantee that you have adequate
information pertaining to each resource that will be necessary in making
decisions about potential partnerships. For instance, whereas you may have
initially identified an outreach center for homeless adults as a resource, you
now will need to know about all the types of services provided there (e.g.,
warming center, breakfast and lunch served, Alcoholics Anonymous and
Narcotics Anonymous meetings held on-site, basic medical exams), as well
as any specific limitations that might exist (e.g., meals not served on
Sundays, medical exams available once per month). Possessing information
about the outreach center will be essential if you are to recommend this
center as a resource for your clients. In addition, this should help guarantee
that you have enough general and specific information about each resource
to begin making decisions about any potential partnerships that you wish to
form with community resources.
Table 7.1 Community Resource Snapshot

Program/Organization: __________________________________
Resource Aspects Details
Type of programming provided                              
Location(s) and contact person
Hours of operation/availability
Client eligibility and funding
Staff qualifications
Adjunctive services (e.g., transportation)
Length of time as a provider
Accreditation status and other organizational
credentialing information
Other information

Completing the Community Resource Snapshot requires conducting

additional research on each of the existing community resources. By doing
so, you are able to gain an in-depth understanding of the precise types of
existing community resources, thus gaining a better understanding of the
demographic makeup of existing community resources and more effectively
posturing yourself to make key decisions regarding how you might work
directly with specific community resources.
After you have thoroughly researched each of the community resources
initially identified on the asset map, you must once again take a broad look
at the community to ensure that you have captured all its existing resources.
By doing this, you are able to account for any new resources that might have
emerged following completion of the asset map, guaranteeing that your work
in this area has been exhaustive. This level of attention to detail—while at
times tedious—can make a world of difference to new program development
efforts. By fully understanding the landscape of the community with regard
to available resources and by thoughtfully identifying resources with which
to potentially partner or align prior to program implementation, you can save
yourself a tremendous amount of time during implementation. This time can
then be used to oversee all that is involved in program implementation since
you will be well equipped with a host of community partners and potential
referral sources for your client population. Moreover, this type of long-term
planning allows you to better position your program for initial
implementation. This is important to both introducing your
program/organization as a new participant in the community as well as
starting up with a support system of resources that will interact directly with
your program in some way.
Next, the results of the community demography assessment must be
reviewed again. Because this data set provides you with a rich understanding
of the characteristics of the community population, you will need to use this
to identify specific existing resources that may prove essential partners to
your program. For instance, if the majority of the community is Arab-
American—Lebanese and Syrian—with a sizeable subpopulation that does
not speak English, you will need to identify which community resources
exist that can provide translation and other support services to this
population.
Identifying exactly how you would like to interact with existing
community resources also requires revisiting the results of two other key
planning activities—the market analysis and the logic model.Because the
market analysis provides critical information about competing programs, this
information can be especially helpful in deciding how you might expand
your treatment and/or services through the use of specific community
resources. Such expansion serves to further differentiate your program from
the competition while enabling you to better serve your target population. In
addition, by utilizing existing community resources, you can play a key role
in strengthening the community from within by helping it become more self-
sufficient.
Because the logic model articulates the initial program design, it too must
be reviewed to determine if any of the identified services or interventions
can or should be provided by existing community resources. For instance,
consider that you have designed a treatment program for elderly women with
substance addiction. Included in the design is an activity-based component
to promote social connections through recreation and other types of
interpersonal activities. In order to meet this need, you may decide to
explore a partnership with a local daycare organization so that your elderly
clients can choose to participate as volunteers or as employees to facilitate a
variety of recreational (e.g., reading, play) or other types of activities (e.g.,
feeding). By partnering in this way with the local daycare, your clients are
able to take advantage of another type of treatment intervention while both
your program and the daycare receive mutual benefit. Because this type of
partnership is mutually rewarding, it can be adopted with no additional cost
to your program. More importantly, by facilitating this type of partnership
within your community, you expand the social support networks of both the
elderly population that you are treating and the children being served by the
daycare. This type of community collaboration is often essential to
community development efforts that may further strengthen a community.
The challenge then is gaining an expansive enough view of community
resources to recognize all the possible partnership opportunities currently
existing within the community.
As the above examples are meant to illustrate, there are numerous ways
in which your program may interact with existing community resources.
Possibilities include, but are not limited to,

direct partnerships wherein the community resource provides

an intervention or service to your clients through a
collaborative arrangement,
formally linking your clients with a community resource
through direct referral to provide additional treatment and/or
services that you do not provide, and
informally providing information about the community
resource to your clients as an additional resource.

Each of these allows your clients to receive enhanced treatment and/or

services as a result of an extended scope of treatment and/or services, and
this is precisely what is needed in the 21st century as we continue to fulfill
the charge of creating comprehensive treatment and service systems.

Engaging Community Resources

Initial Relationship Building
Engaging community resources means approaching the leader(s) of each
organization that holds the desired resource(s) and discussing the various
ways in which you believe your organizations may work together. As with
any potential partnership, the key lies in ensuring mutual benefit to both
organizations, thus the term partnership. Therefore, a major part of the initial
discussion should focus on potential benefits of the partnership. Because in
most cases new efforts to work specifically with a community resource
result in new business for the organization holding the resource, this is not a
difficult message to convey. In addition to the straightforward benefit of
increased business that the organization seeks to gain, other significant
benefits of such partnerships should also be illuminated.
These other benefits include three of the five issues identified at the
chapter’s beginning, which consist of building an advocacy coalition,
engaging in long-term sustainability planning, and strengthening
communities from within by recognizing and utilizing existing resources.
Whereas these were initially discussed as benefits of incorporating
community resources into new program development efforts, they apply
almost equally to benefits provided to the organizations holding the
community resources. As such, a minimum of two organizations in the
community (i.e., yours and the community resource) can gain from these
types of partnerships, while the community itself continues to be further
strengthened. In addition, while the partnership may result in financial
growth for the other organization, it may also lead to opportunities for the
partnership to garner additional funding—another of the key benefits listed
previously.
Once adequate work has been done to initially develop the partnership,
concrete methods for how the two organizations will interact should be
clearly identified. In addition, plans for maintaining regular communication
between program coordinators and other relevant staff should be established.
The frequency of meeting times should be dependent on the type of
partnership (core programming partner vs. referral source).Whereas you can
likely imagine that making time to maintain regular contact should be one of
the easier tasks to manage, it is the one most often neglected. This probably
has little to do with program leaders and staff not wanting to maintain
regular contact and more to do with prioritizing this as having similar value
to other operational activities. As a result, the significance of such contact
must be reinforced, and the program developer/leaders must take full
responsibility for ensuring that this happens.
The benefits of regular contact can be many. At the basic level, frequent
communication can promote open communication and a climate in which
any potential issues can be quickly resolved. This type of quick resolution
not only reduces stress on both organizations but often has the added effect
of strengthening the partnership. In addition, regular contact can ensure that
the partnership is proceeding as leaders initially anticipated, and it provides a
venue for discussing new opportunities or threats, need for specific
advocacy, and other potential shared goals or activities. Most significantly,
regular communication promotes preservation of the relationship/partnership
and may work to strengthen the relationship in its earliest stages, when it’s
needed most.

Initial Preservation Efforts

Efforts at preserving relationships with community resources are often
imperative to maintaining a program’s success; therefore, more work must
often be invested in preserving these relationships than was initially required
to develop them. The manner in which the partnership was initially
developed may indeed set the stage for the long-term relationship, and as
mentioned above, maintaining regular contact is often a necessity to
preserving the relationship.
However, there are many other issues that must be kept in mind to ensure
that these relationships are preserved. In addition to each of the benefits
identified earlier in the chapter, preserving relationships with community
resources allows your organization to maintain its own support network,
keeps you connected to other issues that may indirectly or directly impact
your business, and may provide you with ongoing opportunities for new
business. Each of these benefits is of significant value, particularly in a
business that is characterized by all the stress related to constantly shrinking
dollars and frequent—and often tumultuous—change. Indeed, with the
attendant challenges that often accompany this equally rewarding work,
close relationships with those that share in your community may be exactly
what sustains you, both literally and figuratively.
Because preserving relationships with community resources has specific
relevance to program implementation and sustainability, an entire chapter is
devoted to this second part of community resource work (Chapter 13). So we
will leave the discussion about preserving relationships here for now and
pick it up again later.

Summary
Community resource development is essential to program development
efforts. More to the point, engagement with community resources may prove
one of the most valuable activities in which you engage during the program
planning phase. There are various types of relationships that you may
develop with community resources. These include developing direct
partnerships wherein the community resource provides an intervention or
service to your clients through a collaborative arrangement, formally linking
your clients with the community resource through direct referral to provide
treatment and/or services that you do not provide, and providing information
about the community resource to your clients as an additional resource.
Engaging in any of these types of relationships constitutes a partnership of
some form in which both organizations benefit from the relationship. As
such, there is a good deal of significance generated from such relationships.
Moreover, there are numerous benefits that may be achieved through
engagement with community resources, including augmenting your
program’s service array, contributing to the development of an advocacy
coalition, better equipping your program/organization to garner new and/or
additional funding, contributing to the long-term sustainability of your
program, and strengthening the community from within.
Consistent with the previous steps in this model, community resource
development builds on work completed in earlier steps. Therefore,
information generated by the community demography assessment, asset
map, market analysis, and logic model is used to guide resource
development efforts. This again illustrates the program development process
as a highly structured, data-driven activity—one in which chance and
guesswork have no place but in which purposeful and methodical work
guide the process.
 
CASE ILLUSTRATION
Ranee and Paul had just completed the entire design of a program (i.e.,
program design, staffing structure) for children with serious emotional
and mental health disorders and their families. The program objectives
were to provide comprehensive family-focused treatment to these
children and their families through an integrated approach that involved
both in-office and community-based interventions. Both had worked in
the community for some time—Ranee in an outpatient clinic and Paul in
a foster care program. In addition, they had each previously worked with
the target population—not as part of their primary work but, more often,
when children’s mental health was a secondary treatment issue of a child
and/or family being treated. As a result of their past experience in the
community and their at least minimal exposure to the target population,
they felt that they were aware of several of the community’s existing
resources. More importantly, having completed the asset map earlier,
they now felt confident that they had a comprehensive view of all the
current resources that might be useful to their new program.
But they needed to consider the manner in which specific resources
might directly interact with their program, and they also needed to gain
deeper knowledge about each of the most relevant resources. To begin to
explore this much more thoroughly, Paul and Ranee sat down together to
review the initial list of resources and cull all the ones that they
considered potential candidates with whom to develop specific
relationships. Ranee found herself needing to really think broadly about
each resource and its potential interactions with their program, thus
causing her to be cautious in not simply eliminating a resource because
of the apparent differences it might have. For instance, Ranee initially
had automatically reached to eliminate an animal shelter because neither
she nor Paul could see the relevance of it to their program. However,
after allowing a moment to think it through, they both realized that the
shelter may indeed have a pivotal role to play in augmenting their
treatment program. Specifically, Paul began to explore the idea of
interpersonal skill development through caring for animals—an
emerging treatment strategy for work with at-risk children (Cole, 2005).
They realized that the animal shelter might provide the venue in which
some of their clients could engage in this type of intervention as part of
their individualized treatment plan. As a result, they identified the shelter
as a possible partner.
During this review of existing community resources, Ranee and Paul
also revisited the results of the community demography assessment and
market analysis.From this previously compiled data, they culled specific
resources that were relevant to the primary target population based on
community demographics (e.g., Jewish, Hmong-American) to ensure
that they would be able to link clients to culture-specific resources, if
needed. After again reviewing the results of the market analysis, they
reviewed the existing resources with an eye toward ensuring that their
program offered the same minimum services as the competition as well
as additional services or aspects that differentiated it from the current
providers. As a result of reviewing the list of existing community
resources with both of these data points in mind, several additional
community resources were culled and added to the list of resources for
follow-up. These included such organizations as the local Jewish
Community Center, Jewish Vocational Services, several synagogues and
Hmong churches, the local Hmong Economic and Social Services
Agency, and several other culture-specific organizations. In addition, a
few organizations dealing specifically with mentoring services were also
identified, particularly because these were part of the enhanced service
array provided by one of the main competitors. The previously
developed program logic model was also revisited to ensure that
community resources that might be used as referral sources could be
identified, as well as those that might be used to provide an enhanced
service (e.g., recreational facility). Finally, Paul and Ranee did a quick
review of the community to ensure that all existing resources had been
captured in their initial data collection work and that no new ones had
emerged since they completed their work. They were surprised to find
that two new resources had indeed emerged in the past 3 months—a
group home for developmentally disabled adults and an existing park
that had expanded with the addition of outdoor picnic areas and another
basketball court.
After compiling their list of existing community resources for follow-
up, Ranee and Paul split up the list, each agreeing to complete the
Community Resource Snapshot for their assigned resources. They then
reviewed the information and began to prioritize the resources based on
their program needs. In addition, they made preliminary decisions about
how they would likely interact with the various resources. From this
process, Ranee and Paul were able to identify 23 community resources
with whom they were interested in engaging in a more formal
relationship for the purposes of working directly in service delivery,
mutual use as a referring agent and referral source, providing
information about the resource to clients informally (not formal referral),
and as part of an initial advocacy coalition.
To maintain efficiency, Ranee and Paul split up the job of contacting
those organizations about whom they envisioned simply being able to
share basic informal information with their clients. They each discussed
this with the contact person at the other organizations and requested
brochures and other materials that they could make available to their
clients. During these conversations, Paul and Ranee also took the time to
reintroduce their own program and communicate that this initial business
relationship may open potential future opportunities. They assured the
other organization leaders that they would keep in close communication.
Because of the more partnership-oriented relationships that Ranee and
Paul wished to establish with the remaining organizations’ leaders, they
decided it was best to meet individually with each of these leaders to
discuss these plans. After meeting with leaders from each organization
and discussing potential working relationships, Ranee and Paul now had
partnerships established between their program and eight of the other
organizations. Of these eight partnerships, one had been formed with the
Hmong Economic and Social Services Agency, one had been formed
with the local animal shelter, and another with the Jewish Community
Center. As a secondary treatment intervention when warranted, the
clients in Ranee and Paul’s program would be able to spend time playing
with and caring for animals in the shelter, an activity that would be
cofacilitated by the case manager and a shelter staff person. The Jewish
Community Center personnel would work directly with Ranee and Paul
to develop a network of support families that would be available for
matching client families to provide additional support and mentoring
during the treatment program, as well as to expand the families’ existing
social support networks well beyond involvement in the program.
Throughout the course of these initial engagement meetings, Paul and
Ranee were also able to lay out their plans for holding regular forums
with the group of involved organizations. These forums would allow for
continuous monitoring of the relationships and promote open exchanges
of information and would provide the basis of an initial coalition for
advocacy and other pursuits.
 Having completed this step of identifying and engaging community
resources, Ranee and Paul felt confident not only that they had an
effective plan for utilizing a variety of existing resources but that their
program design had been significantly improved as a result. In addition,
they felt a sense of empowerment—largely due to the fact that they now
had a professional support network of their own. Equally significant,
Paul and Ranee felt that their program now was well positioned to pursue
funding as a result of this broad-based community collaboration. And
while they needed to work first toward securing initial funding for their
program, they couldn’t help but realize that as a result of their
community resource development efforts, they would likely be able to
explore other business opportunities as well.

 
COMMUNITY RESOURCE DEVELOPMENT EXERCISE

Using the Community Resource Snapshot, identify and

investigate five existing local community resources that you
might use in your own program development project.
After you have investigated each resource, answer the following
questions:
 

1. Exactly what type of relationship will you pursue with this

resource?
2. In what ways will your program benefit from this relationship?
3. Given the five resources you have identified for developing a
specific relationship, how will you maintain communication
with each?
4. In addition to your response to Question 1, in what other ways
do you envision working with these resources?

References
Anderson, J. E., & Larke, S. C. (2009). The Sooke Navigator project: Using
community resources and research to improve local service for mental
health and addictions. Mental Health in Family Medicine, 6, 21–28.
Aronson, R. E., Wallis, A. B., O’Campo, P., & Schafer, P. (2007).
Neighborhood mapping and evaluation: A methodology for participatory
community health initiatives. Maternal and Child Health Journal, 11,
373–383.
Bookman, A. (2005). Can employers be good neighbors? Redesigning the
work-place-community interface. In S. M. Bianchi, L. M. Casper, & R. B.
King (Eds.), Work, family, health, and well-being (pp. 141–156). Mahwah,
NJ: Lawrence Erlbaum.
Cole, D. L. (2005). Horse and youth: A not so typical approach to at-risk
programming. Journal of Extension, 43, 1–6.
Darboe, K., & Ahmed, L. S. (2007). Elderly immigrants in Minnesota: A
case study of needs assessment in eight cities. Educational Gerontology,
33, 855–866.
Gareis, K. C., & Barnett, R. C. (2008). The development of a new measure
for workfamily research: Community resource fit. Community, Work, &
Family, 11, 273–282.
Gareis, K. C., Barnett, R. C., & Brennan, R. T. (2003). Individual and
crossover effects of work schedule fit: A within-couple analysis. Journal
of Marriage and Family, 65, 1041–1054.
Homan, M. S. (2004). Promoting community change: Making it happen in
the real world. Belmont, CA: Brooks/Cole.
Lewis, J. A., Lewis, M. D., Daniels, J. A., & D’Andrea, M. J. (2003).
Community counseling: Empowerment strategies for a diverse society
(3rd ed.). Pacific Grove, CA: Brooks/Cole.
Maybery, D., Pope, R., Hodgins, G., Hitchenor, Y., & Shepherd, A. (2009).
Resilience and wellbeing of small inland communities: Community assets
as key determinants. Rural Society Journal, 19, 326–339.
Mowbray, C. T., Woolley, M. E., Grogan-Kaylor, A., Gant, L. M., Gilster, M.
E., & Shanks, T. R. (2007). Neighborhood research from a spatially-
oriented strengths perspective. Journal of Community Psychology, 35,
667–680.
Roberts-DeGennaro, M. (2001). Conceptual framework of coalitions in an
organizational context. In J. E. Tropman, J. L. Erlich, & J. Rothman
 (Eds.), Tactics and techniques of community intervention (pp. 130–140).
Belmont, CA: Wadsworth/Thomson Learning.
Voydanoff, P. (2004). Implications of work and community resources and
demands for marital quality. Community, Work, & Family, 7, 311–325.
Yoon, I. (2009). A mixed-method study of Princeville’s rebuilding from the
flood of 1999: Lessons on the importance of invisible community assets.
Social Work, 54, 19–28.
 CHAPTER 8
Identify and Evaluate Potential
Funding Sources

 
Learning Objectives
 

1. Identify and differentiate the three primary types of funding sources

that support mental health and human service programs
2. Explain the difference between a Request for Proposal and a Request
for Quote
3. Discuss methods by which you can learn about potential funding
opportunities
4. Identify three funding sources for clinical and/or human service
programs
5. Explain three advantages of diversified or mixed funding
6. Identify five aspects of a potential funding source that should be
evaluated
7. Apply the knowledge gained in this chapter by using the Funding
Opportunity Evaluation Tool

 
WHAT FINE PRINT?
For the past 8 years, Ivana had been managing a program for adults
returning to the community from prison, and she loved her work. But she
also was becoming more and more interested in pursuing other types of
programming. She had been searching various directories and websites
for potential funding opportunities when she came across a Request for
Quote (RFQ) from the Bureau of Prisons (BOP). Even though she was
not familiar with the BOP and had never pursued or received funding
from them, she was intrigued by the opportunity.
The RFQ was to provide prison-based counseling services at a local
prison. All the services that were to be provided were listed, including
individual, group, and family counseling; psychological evaluation;
psychiatric evaluation; and psychiatric monitoring. Because the funding
source was interested in not only an organization’s ability to provide the
services but also the cost at which the organization would provide them,
the RFQ had been issued as part of a competitive bid process driven by
the government securing the most effective services at the lowest cost.
After doing a quick review of the RFQ, Ivana felt confident that her
organization could effectively implement the program, and although she
did not currently work with a psychiatrist, she knew two who were
interested in contractual work. Knowing she had only 2 weeks to prepare
the proposal, Ivana quickly got to work, informing her executive director
that since the proposed program seemed like such a good fit to further
expand the agency’s continuum of care, she felt they should definitely go
for it. Moreover, she felt she could develop the proposal relatively
 quickly since it mostly involved working with the finance staff to
determine the proposed fee schedule.
Ivana spent most of the following week and the beginning of the next
working on the proposal and finally felt she had made a strong argument
for the organization’s ability to carry out the program. Moreover, she felt
that the fee schedule they had devised would be highly competitive while
allowing the agency to adequately support the program. After having
others review her work and going through her proposal several times
herself, Ivana felt confident that they had a good shot at acquiring this
funding.
Three months later, when the awards were announced, she was
surprised and upset to learn that her proposal had not been selected. She
immediately contacted the contract manager to inquire. The contract
manager shared with Ivana that, while her proposal had been fully
reviewed, the review team had been surprised by the submission since
the funding opportunity was limited to businesses with less than $1
million in annual revenue—Ivana had disclosed in the proposal (as
required) that the annual revenue of her business was $5.6 million.
Therefore, her agency was not eligible to apply. The contract manager
asked Ivana if she had not fully reviewed the RFQ, including the fine
print that clearly stated this limitation. Locating the RFQ, Ivana did find
the stipulation and sheepishly ended the call.

 
CONSIDERING IVANA

1. How could Ivana have prevented this from happening?

2. In addition to carefully reviewing a funding opportunity in its entirety,
what other steps might you take to ensure that you fully understand it
before investing time in developing a proposal?

About This Chapter

This chapter is specifically dedicated to bringing a program to fruition
through the acquisition of funding. The chapter focuses on identifying and
evaluating potential funding sources in order to increase your knowledge of
the various types and parameters of funding opportunities and to provide you
with additional knowledge and tools for use in rigorously evaluating
potential funding opportunities. The chapter begins with an examination of
the major types of funding sources available in mental health and human
services, which include public, philanthropic, and fee-for-service. Next, we
will explore types of funding opportunities, including governmental,
business, and philanthropic, along with the various parameters associated
with each. This is followed by a discussion of pursuing short- versus long-
term funding and mixed funding and the pros and cons related to each.
Next, the discussion will focus on methods by which to identify potential
funding sources and includes an introduction to some of the available tools
that may aid in this work. In addition, we will once again revisit the market
analysis in order to determine if its results provide additional guidance in
identifying potential funding sources. Finally, comprehensive methods for
evaluating potential funding opportunities are presented that include such
issues as the philosophical foundations of the funding source, funding
parameters, eligibility criteria of applicants, history of funding, and the
length of the funding opportunity. An evaluation tool is provided, and an
exercise provides you with the opportunity to apply your funding
opportunity evaluation skills.

STEP VI: IDENTIFY AND EVALUATE

POTENTIAL FUNDING SOURCES
Funding the Program
Moving the program development process from the planning phase to the
implementation phase is completely dependent on acquiring financial
support for the program—a process that begins with identifying and
evaluating potential funding opportunities and that successfully ends in
securing funding. While this is no easy task, this step is made much easier by
the previous work completed in the preplanning and planning stages.
Specifically, having completed due diligence in the preplanning stage (i.e.,
needs assessment, community demography assessment, market analysis,
asset map), there is strong justification for the program. This coupled with
designing a research-based program and developing a highly effective and
efficient staffing infrastructure provides the bulk of information needed to
identify potential funding options.
Because identifying funding opportunities and developing the financial
management plan are highly interrelated, the order of Steps VI and VII
should not necessarily be viewed as fixed—in some cases, Step VI may
precede Step VII, while in others, Step VII may precede Step VI. As such,
the sequence in which these steps occur may differ for each new project
depending on how you set about the program development process.
Particularly with regard to these two steps, the program development process
may be responsive or proactive—responsive meaning the program
development process is initiated in response to an announcement of available
funding (i.e., you begin to develop a program after learning about available
funding opportunities), or proactive meaning that the program was
developed in an effort to explore and subsequently secure funding. Even
though there are obvious benefits to developing a program in which concrete
funding is readily available (i.e., responsively), there are equally good
reasons for developing a program in hopes of identifying and securing
funding. Particularly for program developers working in human service
organizations, there may be an evident gap in the existing service and/or
treatment continuum that the developer wishes to fill and, thus, does so
through the development of a proposal that may be pitched to existing
contractors or new funding sources or both. Because the finance-related
steps in the comprehensive program development model may need to occur
either at the end or at the beginning of the program planning phase, simply
be aware of this and adapt this part of the model to best fit your
circumstances.
As you can well appreciate by this point, program development requires a
tremendous amount of energy, hard work, and perseverance throughout each
major phase (planning, implementation, and evaluation). Whereas
perseverance is a prerequisite at every step, it may be particularly necessary
when it comes to pursuing funding. This is because there is a limited amount
of funding available to meet the needs of a tremendous number of
individuals. As a result, securing funding is a highly competitive venture.
This is more the case today than ever before. Historically, nonprofit
organizations were competing only against one another for the same funds,
whereas today, for-profit organizations are also part of the competition. This
is most often notable in competitions for government and managed care
contracts (Gibelman & Furman, 2008)—which, unfortunately for nonprofits,
constitutes a significant portion of available funding. In addition, electronic
technology has significantly impacted access to funding opportunities.
Indeed, with the most recent developments of funding source directories and
databases, access to information about funding opportunities has increased
exponentially, thereby creating further competition for such opportunities.
Because of the incredible amount of work that goes into new program
development, coupled with the highly challenging task of identifying and
securing funding, this type of work is certainly not for those who cannot
effectively forge ahead, even in the face of defeat—or in this case, rejection
of your proposal. In fact, I would bet that anyone who has developed five or
more program proposals has had at least one proposal rejected, if not several.
It is in this manner that the program development process mirrors the
research and writing process for scholarly journals. Indeed, I also cannot
imagine any scholar claiming that s/he has never had an article rejected for
publication by a journal editor. The rejection process is not only a rite of
passage but also a feature of the competitive process—which both program
proposals and scholarship share. This rejection is so much affiliated with
scholarly writing that a professor once coined the term pre-jection, referring
to developing his own rejection letter at the time of submitting his
manuscript for review in order to mentally prepare himself for the probable
rejection letter from the editor (Montgomery, 2003). Whereas this struck me
as very funny—not to mention extraordinarily clever—it also seems to
perfectly reflect the challenging terrain that is an inherent part of developing
work for a competitive review process, and most significantly, it captures the
emotional component involved in this work.
Because of this highly competitive type of work, program developers
must be prepared for possible rejection. But more importantly, wise program
developers use the rejection process to their advantage—taking the feedback
provided by the reviewers and using it to revise and strengthen the proposal
for a subsequent submission or to refocus their energies in a different
direction. Whereas many funding sources will automatically provide written
and/or verbal feedback to the applicant, the Freedom of Information Act
allows you to access this information from governmental funding bodies via
written request.
In addition to preparing yourself for the competitive nature of the initial
proposal process, you also must understand that you will likely be involved
in this type of process over and over again—thus, this is where perseverance
is most needed. Unfortunately, simply because you are successful in securing
funding for your program, there is no guarantee that you will not have to
compete again for funding in a very short time (recall the case of Ryan and
Adrienne in the previous chapter). This is because the majority of funding
opportunities are time-limited, typically with funding cycles that are for 1, 3,
or 5 years, some with renewable clauses and others without. Whereas
maintaining funding for an existing program constitutes one way in which
the search for new funding will continue, each time there is a new funding
opportunity that you wish to pursue or a new program that you developed for
which you wish to secure funding, another need to pursue funding will be
created. And it will continue on and on so that you grow to realize that
identifying and securing funding will be an ongoing part of your work in
program sustainability and new program development.
This means that program developers/mental health professionals must be
highly proactive, always keeping an eye on the horizon, not only focused on
when funding will expire but also focused on exploring new funding
sources, new funding opportunities, and any sociopolitical or other
environmental factors that may influence existing or future funding. Indeed,
successful program developers and program administrators must possess
long-term strategic thinking, particularly with regard to the critical funding
aspect of comprehensive program development. This is arguably one of the
key reasons for the sustainability of most mental health and human service
organizations, and unfortunately, the lack of such proactive and strategic
efforts may be the cause for the demise of other such organizations.
Sustaining funding support is further covered in Chapter 13, but what is
most important to bear in mind for this discussion is that securing funding is
indeed a continuous part of comprehensive program development.
Types of Funding Sources: Public, Philanthropic, Fee-for-
Service
There are three major types of funding sources typically used in mental
health and human services: public, philanthropic, and fee-for-service. Public
funding is provided by the government at the federal, state, or local level.
Philanthropic funding is made available by charitable organizations and
foundations, often in support of various types of programming and related
aspects. Finally, fee-for-service funding is based on programming in which
individuals (or insurance or other businesses) pay the organization directly
for services provided. Whereas both public and philanthropic funding are
most associated with nonprofit human service organizations and for-profit
organizations may at times be excluded from pursuing public and
philanthropic funding, fee-for-service funding may be sought by both
nonprofit and for-profit organizations. Each of these sources of funding is
discussed below.

Public/Governmental Sources of Funding

As stated previously, the U.S. government is the largest funding source
for human services in the United States. Governmental funding is typically
made available through the legislative process in which allocations are
dedicated to support specific types of programming and/or research.
Depending on the specific focus of the funding, the funds may be offered
through various routes. At the cabinet level, agencies such as the Department
of Health and Human Services, Department of Education, Department of
Justice, and Department of Housing and Urban Development provide
funding for a variety of programming directly and through their subagencies
(e.g., Centers for Disease Control and Prevention, Office of Juvenile Justice
and Delinquency Prevention). In addition, funding may trickle down from
the federal level to be allocated directly at the state or local level. In this
case, statewide departments of human services, community mental health
organizations, and criminal justice systems provide funding for specific
areas, often at both the state and regional levels, while county and/or city
organizations, such as the health department, often provide funding at the
most local level.
 Philanthropic Sources of Funding
Whereas the number of governmental entities providing funding is
extensive, the number and diversity of philanthropic organizations is also
fairly tremendous. Philanthropic organizations typically have a specific
identity and seek to fulfill the organization’s mission through offering
funding in specific areas. While the breadth of the mission may be of
varying degrees, with some extremely focused on very specialized issues
(e.g., autism), others might be more broad-based but still focused in a single
area (e.g., children). In addition, some philanthropic organizations are
specifically dedicated to a geographic area as part of their mission (e.g.,
greater Chicago, Detroit), and therefore, funding opportunities are limited to
a particular region. To get a sense of the diversity of philanthropic funding
and the recent levels of funding available from each, see Table 8.1.
Table 8.1 Philanthropic Organizations
 As you can see in Table 8.1, philanthropic organizations differ quite a bit,
from large international, broad-based organizations to small local
organizations. The good work that is supported through these types of
philanthropic organizations often has its roots in highly energetic and
creative business people. In fact, delving into the origins of philanthropic
foundations can be a fascinating journey and one that I recommend all
program developers take. This is particularly necessary for those foundations
that you may wish to approach for future funding, but you also will find that
exploring the various histories of these organizations may prove helpful to
simply enlarging your view of the important organizations that support such
a large part of our work today.
To give you a brief illustration of what I mean, consider Jim Casey and
Robert and Rose Skillman. As illustrated in both of the brief sketches below,
the transformative business minds and the unwavering commitment to do
good that each of them possessed is reflected in the philanthropic legacies
they created.
 
JIM CASEY, UNITED PARCEL SERVICES FOUNDER
Jim Casey founded the United Parcel Service (UPS) in the first half of
the 1900s. Having amassed a fortune, in 1948, he began the Annie E.
Casey Foundation with his siblings in honor of their mother, who had
raised them as a widow. The mission of the foundation reflects Jim’s
belief that the future of children is largely determined by what their
families can provide to them emotionally, ethically, and materially.
In 2009, the Annie E. Casey Foundation, located in Baltimore, Maryland, was the 17th largest
private foundation in the United States with assets of more than $2.3 billion. The Annie E. Casey
Foundation (n.d.) ranks 24th in the nation for charitable giving and is dedicated to improving the
lives of children and families, with a specific focus on foster care.
 

 
ROBERT AND ROSE SKILLMAN

Robert Skillman was an early pioneer at the Minnesota Mining and

Manufacturing Company (3M), responsible for transforming a Detroit
facility into an adhesive plant in the 1940s. Robert worked for 3M until
his death in 1945. Remaining in Michigan, where the couple had lived
most of their married life, Rose was increasingly committed to the
welfare of vulnerable children, making charitable contributions to
organizations that served children. In 1960, Rose developed the
Skillman Foundation.
In 2009, the Skillman Foundation, located in Detroit, Michigan, budgeted more than $23
million for grants focused specifically and almost exclusively on the children of Detroit. The
Skillman Foundation (n.d.) remains committed to Rose’s mission of helping vulnerable children
by providing funding and using its clout to be a voice for children.
 

In addition to philanthropic organizations, many for-profit corporations,

such as Starbucks and Verizon, offer formal giving programs. Some of these
function similarly to the philanthropic organizations listed above, but others
function as mini-foundations—providing small amounts of funding to
support a variety of programming and projects. Because many for-profit
corporations seek to also fulfill a social mission, these giving arms work to
accomplish this. Often, some of these types of funding opportunities are
limited to local applicants to reflect the business’s commitment to the local
community through planned giving to the community. For example,
Microsoft Corporation has provided specific funding to programming and
other types of support services in King County, Washington, where many of
the company’s employees reside.

Fee-for-Service Sources of Funding

Fee-for-service funding is rooted in traditional business wherein a service
is provided to an individual and, in turn, the individual pays directly for the
service. In mental health and human services, payment may be made by the
individual or by the individual’s insurance. This type of payment schema is
most often associated with outpatient clinics and individual private practices
in which clinicians establish a fee for their service (e.g., counseling, clinical
assessment) and charge clients accordingly.
Fee-for-service programs may be funded by participating on a number of
insurance boards, gaining authorization as a payee. In addition, fee for
service programs may be paid by a public insurance company (e.g.,
Medicaid) to support counseling as well as psychiatric services. Whereas
insurance companies traditionally limit funding to mental health services,
human service organizations may offer specific services to be paid on a fee-
for-service basis, such as daycare.
Fee-for-service payment schedules are used by both nonprofit and for-
profit mental health providers. One of the challenges to using a fee-for-
service payment schedule is that of receiving varying amounts for the same
service. For instance, you may set the fee for an individual counseling
session at $65, but one of the insurance providers that you work with may
pay only $55 for a session while another reimburses $50. In this case, you
may be able to charge $65 only to individuals who are paying out-of-pocket
—which in and of itself may present a moral dilemma, since the privileged
population that has insurance will have their treatments funded while those
who do not will be penalized even further by possibly paying even more for
the same service. However, a good many mental health practitioners—
especially professional counselors—who hold social justice as a core
practice value offer sliding scales for payment. A sliding scale means that
the clinician creates a fee schedule that accommodates the individual client
by charging only what the client can afford.
Working solely with fee-for-service funders can prove quite challenging,
particularly because fee-for-service contracts are typically small in relation
to governmental or philanthropic contracts. In addition, grants or contracts
from the government and grant funding from philanthropic organizations
typically provide a specific amount of funding (e.g., $300,000, $1.2 million)
over a particular amount of time, whereas a contract with an insurance
company may be capped at $70,000 a year and any funds received from the
contract are based on the number of clients seen. As a result, a contract like
this may yield only $22,000 a year if only a small number of clients are
referred or choose to utilize your services. Equally challenging, simply being
on an insurance panel of providers does not necessarily mean that any
revenue will be generated from this particular endeavor. These types of
payment schemes have obvious implications for financial management and
also sustainability; however, depending on the specific area of mental health
and human services that you wish to pursue, fee-for-service may be the
primary means of funding, and for many mental health professionals, this
has proven highly successful.

Types of Funding Opportunities

The types of funding opportunities available to nonprofit mental health
and social service programs through the government and philanthropic
organizations have many things in common, particularly with regard to the
types of funding they each may make available. Beginning with
governmental funding opportunities, I would like to explore some of the
most common types of each.

Governmental Funding Opportunities

Governmental funding opportunities can be enormously diverse and have
changed dramatically over the past several decades, especially as
governmental agencies have increasingly elected to purchase services from
nonprofit agencies opposed to directly administering programs. In fact, in
the 21st century, purchasing services from the private sector has become a
favored means of delivering human services (Gibelman & Furman, 2008).
Governmental funding opportunities may be offered directly by the
federal government through a cabinet-level department (e.g., Department of
Health and Human Services) or through one of the subagencies of a cabinet-
level department (e.g., Bureau of Justice Programs). Typically, federal
agencies will issue a Request for Proposals (RFP) indicating that funding is
available to address specific needs. There are two primary types of RFPs for
program delivery: (1) one in which the treatment and/or service needs are
identified and applicants must articulate how they will address the needs as
part of the proposal and (2) another in which both the needs and the
treatment and/or service interventions have been identified or prescribed by
the funding source and applicants must articulate how they will implement
the interventions. In both of these types of proposals, applicants must also
stipulate the cost of implementing the proposed programming, staying within
the stated funding parameters.
The first type of RFP—in which a specific treatment need is identified by
the funding source and applicants must determine how they will address
these needs—is one of the most common types of funding opportunity. In
comparison with other types of RFPs and Requests for Quotes (RFQs), this
by far offers the most autonomy for the applicant. Examples of this type of
RFP include announcements for funding to address reentry issues among
juvenile offenders or to address the vocational needs of returning veterans.
Proposals for these types of RFP require that the applicant identify an
accessible target population and target region, justify the need, design a
treatment program and evaluation plan, and identify the requested amount of
financing to support program design and implementation.
The second type of RFP—in which the need has been identified and the
specific treatment is prescribed—is typically offered when a specific type of
program has been found to be effective and, thus, the governmental body has
a desire to implement the program in multiple regions. This type of RFP
could also be issued as part of a pilot program in which multiple applicants
implement the same program as part of a national comprehensive program
evaluation project. For instance, a family-based behavioral program may
have been developed for the treatment of children with autism, and an RFP
is issued that stipulates the minimum number of individuals that must be
treated as part of the funding award and provides training manuals detailing
the complete interventions and time frames for each. Applicants must
identify the accessible target population and region and justify the need and
then must specify how the treatment will be implemented as prescribed.
Another type of funding opportunity offered by the federal government is
an RFQ. Similar to an RFP, in which the identified needs and treatment
and/or services are stipulated by the funding source, RFQs are issued when
the competition for the funding is largely based on the cost requested by the
applicant. In these types of funding competitions, the award is again based
on the organization that can provide the best proposal for successfully
implementing the program; however, the cost of the program is also
considered. This is one aspect in which the RFQ can differ slightly from an
RFP competition, since the RFP competition may be slightly less focused on
cost than an RFQ competition.
An example of what may be involved in developing a proposal in
response to an RFQ can be found in one that was issued by the BOP in 2009.
This RFQ entailed providing mental health and substance abuse services for
adult male prisoners residing in a halfway house in a specific region (similar
to the RFQ in the case of Ivana). Each of the required services was identified
in the announcement of funding issued by the BOP and included individual,
group, and family counseling and clinical evaluation. In addition to
stipulating each type of intervention, the number of units to be provided was
also stipulated. Therefore, in order to respond to the RFQ, applicants simply
completed the application forms, included copies of organizational and
professional qualifications, and provided a cost for each service along with a
total annual cost.
In addition to governmental funding for clinical and human service
programming, the federal government also offers funding for clinical and
social science research. These types of opportunities typically stipulate a
broad-based area (e.g., mental health, violence) and allow for varying
degrees of freedom with which the applicant can propose specific research
projects. Although academics typically compete for research grants,
nonprofit organizations may be invited to bid as well.
 Whereas a variety of funding is available directly from the federal
government, federal monies also are issued to state and local governments
for disbursement at those levels. Through RFPs and RFQs issued by state
and local governments, mental health and human service organizations can
compete for funding to provide substance abuse prevention and/or treatment,
mental health treatment, mentoring, and family preservation work and
address a number of other issues. Whereas federal funding opportunities
involve geographic regions competing with one another, in-state and local
funding opportunities involve local providers competing with one another.
In addition to traditional RFPs and RFQs, state and local governments
also directly purchase services in a variety of areas from nonprofit
organizations. Child welfare programs such as foster care and semi-
independent living, juvenile justice programs such as community-based
treatment and detention, and mental health programs such as residential
programs for individuals with Alzheimer’s disease and supported living
environments for adults with developmental disabilities are just a handful of
program funding opportunities made available through purchase of service
agreements between state and local governments and nonprofit
organizations. Whereas purchase of service contracts also can be
competitive, they typically differ from RFPs and RFQs in that they are
longer-term (5 years or more) or may not be time-limited.
When interested in pursuing governmental funding, you must not only
have a firm understanding of how funds are secured, but you also must have
a clear understanding of specific current trends and be aware of what is on
the horizon. This is particularly significant since you may have only 3 to 4
weeks to prepare a proposal in response to an RFP, and without having a
sound framework from which to begin developing the proposal, the
opportunity may pass you by. To be aware of what current trends exist and
what may be on the horizon, several strategies are suggested:

Study the current research in your areas of interest.

Stay informed of any relevant legislative changes.
Attend conferences.
Remain connected to the governmental agencies that support
funding in your area(s).
 Stay connected to colleagues.

By using several methods to stay informed, you may be much better

postured to pursue governmental funding.
In terms of examining trends, take a moment to consider some of the
recent trends in governmental funding in the 21st century that have included
funding for Alzheimer’s, autism, and sexual offender treatment. Twenty
years ago, none of these three areas were even widely discussed, but today,
each has become a topic of national dialogue and funding for treatment and
research into each has increased exponentially. In fact, funding for research
grants supporting autism increased 15% from 1997 to 2006 (Singh, Illes,
Lazzeroni, & Hallmayer, 2009). To provide a sense of just how much
funding has been provided for autism, the National Institutes of Health have
increased from $22 million to $108 million during this time frame (Vitiello
& Wagner, 2007). In addition to the dramatic increase in funding to support
programming for individuals with autism, these most recent trends also
illustrate a shift from basic science to clinical and translational research—
integrating research into practice (Singh et al., 2009). This trajectory is a
common one in which research findings often prompt new funding for
programming, again reinforcing the need to keep abreast of current research.
Conversely, federal funding for aging services has declined sharply over
the past 3 decades, with funding today at about 70% of what it was in 1980,
a highly unfortunate trend (Payne & Applebaum, 2008). Interestingly, this
decrease in funding for aging support services is occurring at the same time
that the aging population is growing most rapidly—at a 44% increase from
the same time period. Fortunately, while federal funding for aging has
decreased, philanthropic funding for aging has increased (Farquhar, Lowe, &
Campbell, 2007)—possibly making up for some of the gaps left by the
government funding reductions in this area. Whereas there is much to learn
from the myriad trends in funding, what is most important is that adequate
time is taken to become fully informed of these trends.

Philanthropic Funding Opportunities

Funding opportunities that are made available by philanthropic
organizations generally fall into one of two categories: solicited and
unsolicited. Solicited funding opportunities typically include an RFP process
in which a specific area is identified; however, generally, these types of
RFPs are much less structured in their requirements than those issued by the
government and allow for even greater autonomy on the part of the applicant
to determine precisely how problems can most effectively be addressed. This
is often because philanthropic organizations are most interested in
connecting individuals and organizations with specific expertise to funding
in order to support advancements in these areas. This is not to say that the
government is not also interested in doing this, but since the government’s
responsibility as a steward may be perceived as much greater than that of a
philanthropic foundation, it stands to reason that such differences should
exist.
Governmental funding opportunities are reflective of the governmental
agencies that make the funding available. Therefore, funding for veteran
services most often derives from the Department of Veterans Affairs, just as
funding for mental health programs typically originates from the Department
of Health and Human Services and flows into the National Institutes of
Health or the Substance Abuse and Mental Health Services Administration.
Similarly, types of funding opportunities made available by philanthropic
organizations (i.e., foundations) are reflective of the mission of the
organization. As stated previously, the scope of issues targeted by
foundations may vary greatly, with some focusing on very specific issues
(e.g., foster care) in a variety of regions (e.g., nationally and internationally)
and some focusing on broad-based issues (e.g., children) in specific regions
(e.g., Detroit).
For instance, the W. K. Kellogg Foundation (2009)—administratively
housed in Battle Creek, Michigan, and founded by the maker of Kellogg
cereals—was developed in the 1930s to "serve humanity for generations to
come." Currently, the foundation is focused on early childhood development
and issues related to social divides around race and class. This broad-based
mission allows the foundation to offer funding in a variety of areas and, most
significantly, to be highly adaptive to environmental changes.
The John D. and Catherine T. MacArthur Foundation (n.d.)—possibly
one of the most universally known philanthropic organizations—provides
funding to foster the development of knowledge, nurture individual
creativity, strengthen institutions, help improve public policy, and provide
information to the public, primarily through support for public interest
media. The foundation currently supports four specific programs: the
Program on Global Security and Sustainability; the Program on Human and
Community Development; the General Program, which supports media and
related technologies; and the MacArthur Fellows Program, which awards
unrestricted, 5-year fellowships to individuals of exceptional merit in various
areas to support their continued creative work. Both the W. K. Kellogg
Foundation and the MacArthur Foundation solicit applications for funding
programming and research in specific areas and accept unsolicited proposals
for programming and research.

Potential and Common Funding Sources in Clinical Program

Development
Because there is such a vast array of funding opportunities available from
both the government and philanthropic organizations, if you are interested in
pursuing funding, you must take the time to become familiar with some of
the most common funding sources available for mental health and human
services. See Table 8.2 for a listing of common governmental funding
sources from the cabinet-level agencies, federal subagencies, and state and
local agencies. Please note that the actual names are provided for each of the
federal agencies, but state governments vary with regard to the names that
are given to agencies; therefore, general names are used to denote some of
the specific areas (e.g., corrections).
Table Governmental Funding Sources for Mental Health and Social
8.2 Services
 With regard to potential philanthropic sources of funding, in addition to
the foundations provided in Table 8.1, other foundations that provide
funding nationally and within specific states to support an array of mental
health and human service programs include the following:

Doris Duke Charitable Foundation

Ford Foundation
Kresge Foundation
McKnight Foundation (Minnesota)
Robert Wood Johnson Foundation
William Penn Foundation (Pennsylvania)
Theodore and Vada Stanley Foundation
Robert R. McCormick Tribune Foundation (Illinois)
 As stated previously, because several foundations were established to
address the needs in particular geographic regions that might include a state,
several counties within a state, or a city, it is not feasible to identify region-
specific foundations here. It is, however, in your best interest to investigate
which foundations serve the region in which you wish to work.

Short-Term Versus Long-Term Funding Sources

When moving forward to seek funding for a program or project, a critical
issue to explore is the length of the funding cycle needed for the program to
operate most effectively. Because funding awards have concrete time
limitations, you must know the length of time your program will need to
operate in order to realize the intended outcomes (as discussed in Chapter 5
on program design). In addition, the length of funding support may impact
your return on investment (ROI). ROI simply refers to the benefits of an
investment minus the cost of the investment. ROI has particular meaning
with regard to new program development in that there are typically start-up
costs associated with any new business venture, and in our profession, these
most often consist of hiring and training staff. Therefore, the length of
funding needed should be a central concern, as it relates to the amount of
time required to minimally break even on the costs and expenses incurred to
implement the program. Whereas nonprofit organizations are not designed to
create profit, breaking even is indeed a necessity, especially since engaging
in program development ventures in which more money is spent than
received is a likely recipe for a short business life.
Different funding opportunities offer different types of funding, some
very short (1 year or less), some moderate (2–3 years), and some long-term
(5 years or more). Contracted services—services that are bid on for specific
contracts with the government—typically are the longest-term type of
funding available. However, some foundations will provide long-term
funding by continuously renewing a specific project or program that the
foundation is particularly interested in and that they feel is an effective
investment. The MacArthur Fellows program (aka Genius Grants) is one of
the longest-term ongoing grant programs available, providing 5 years of
funding to individuals to spend in whatever way they deem most appropriate
to continue their work. On the other hand, most programmatic grant funding
available from the federal government is awarded for 2- to 3-year periods,
some with annual renewable clauses and some without. These moderate
cycles also mirror the majority of available foundation funding. Therefore,
you must be knowledgeable about not only the length of available funding
cycles but, more so, the length of funding needed to fully and most
effectively implement your program.

Diversified Funding
Because funds are time-limited, it is often necessary to secure funding
from multiple sources. By doing so, the continuation of programming is not
so dependent on one funding source and, therefore, not quite so vulnerable to
ceasing simply because one source’s funding cycle has expired. Diversity of
funding is therefore quite common to nonprofit mental health and human
service organizations as a means to remain viable and fiscally healthy. In
fact, diversification has been found to lead to greater stability (Carroll &
Stater, 2008).
Therefore, while it is not uncommon for both small and large
organizations to receive funds through government contracts, foundations,
individual giving campaigns and other sources (Ezell, 2000), it may be
critical to seek revenue diversification. Just as you consider the length of
available funding cycles, you will also need to give consideration to
attempting to secure funding from more than one source, thus securing
mixed funding to support your program. Figure 8.1 provides examples of
organizations with nondiversified and diversified funding.
Figure 8.1 Nondiversified Versus Diversified Funding
 Identifying Potential Funding Sources
More than anything else, identifying potential funding sources requires
simply knowing where to look. At the same time, identifying funding
sources also requires persistent energy dedicated to investigating what
funding is available and when. Fortunately, the development of databases
containing numerous funding opportunities and the ability to receive
electronic alerts when funding is available from particular sources has made
this work much easier. However, whereas technology has streamlined this
process, creating a much more efficient workflow related to funding
searches, it in no way means that your focused time and attention is no
longer needed. You still must dedicate specific time to checking the
databases to search and/or cull through alert notices of new funding
opportunities in order to identify potential funding sources.

Revisiting the Market Analysis

A first step of exploring potential funding sources requires revisiting the
results of the market analysis. This most obvious step should not be
overlooked since the market analysis results should inform you specifically
about the funding sources that are associated with existing competing
programs. Therefore, revisit the market analysis results to identify these
funding source(s), and explore these sources to determine if they may be a
potential source for your program as well. For instance, as you are seeking
funding to support a program on treating depression in postpartum women,
examining how other providers of these programs are funded will help you
gain this most essential information. By doing this, you not only save quite a
bit of time since you already know that these funding sources support
programs like the one that you wish to implement, but you are able to benefit
—once again—from work that you completed much earlier.

Exploring Funding Sources

After revisiting the results of the market analysis, you need to begin a
comprehensive search of funding opportunities. In order to do this, you need
access to all or as many funding opportunities as possible, and you have to
be able to conduct the most thorough search. There are basically four
sources of information pertaining to funding opportunities that include
methods that carry a cost and those that are provided at no cost.

Electronic Database Subscriptions for Purchase

Those that carry a cost include subscriptions to comprehensive databases
of funding sources. These databases have significantly improved over the
past decade as new and better ways to utilize technology have continued to
be discovered. In this case, one source/library provides access to information
about a number of different funding sources so that you can search for
opportunities offered by multiple funding sources in one place. This is no
different than research databases available through university libraries in
which one provider (e.g., Ebsco) provides access to numerous academic
journals. Database subscriptions such as these are available for both
governmental agencies and foundations, some that contain only one or the
other, and others that contain both. In addition to this type of subscription
database, subscriptions can also be purchased for newsletters that compile
information and send it to you on a regular basis to alert you to upcoming
and existing funding opportunities.

No-Cost Electronic Databases

In addition to the two types of subscriptions that provide extensive
information about various funding opportunities, there are also highly
effective no-cost sources for some of this information. The federal
government hosts the most extensive database of multiple funding sources
(available at www.grants.gov). The site contains information about current
and future governmental funding opportunities as well as archival
information. Likely the most popular site for those currently engaged in or
hoping to secure funding from the federal government in the future, this site
also has an effective search function so that you can conduct searches at
varying levels of detail (e.g., by agency, by keyword). In addition to being a
library of governmental funding sources, the site also houses templates and
other documents needed to apply for specific funding opportunities and
serves as a portal through which to submit applications and monitor the
progress of a submission. If you are not already familiar with grants.gov, I
encourage you to look into its features.
Public libraries are also a great source for free access to funding
directories and other resources. And as libraries are institutions wholly
dependent on public dollars, utilizing the public library helps ensure that the
extensive resources it offers remain available to us in the future.

Providers’ Lists and Electronic Notifications

Finally, there are two other no-cost sources of information for funding
opportunities. The first requires that you get on a providers’ list so that you
receive information about funding opportunities as they are released. The
state and local governments, as well as some foundations, typically compile
these lists so that information about any new funding opportunities that are
being launched can be disseminated as widely as possibly. The other, which
is similar, involves registering with potential funding sources to receive
electronic notifications—generally to your e-mail—about new funding
opportunities.
As you can see, there are multiple sources of information available
regarding funding opportunities. The trick, then, becomes ensuring that you
are able to take full advantage of this information. To accomplish this, there
are several strategies that will assist you in ensuring that you have both the
access and the tools to conduct an exhaustive search (see Box 8.1). In
addition, the Resource Directory of Funding Sources (Table 8.3) provides a
comprehensive list of all the funding sources discussed in the chapter, as
well as other databases that house multiple funding opportunities.
 
BOX 8.1

SIX STRATEGIES FOR IDENTIFYING FUNDING

OPPORTUNITIES
 

1. Register with all relevant local and state governmental and foundation
funding sources to receive notification of funding opportunities.
2. Utilize electronic settings to receive notification of funding
opportunities from web-based resources.
3. Subscribe to relevant funding databases and notification services.
4. Search the web.
5. Network with colleagues to learn about new funding opportunities or
new sources of funding information.
6. Make the process of identifying funding opportunities a work priority.

Table 8.3 Resource Directory of Funding Sources

Evaluating Potential Funding Sources
Whereas you need to know precisely what funding opportunities exist if you
are interested in pursuing funding, you also must know how to identify the
most viable fit(s)—funding opportunities that are most consistent with your
proposed program. This is of particular importance since the time
commitment for a grant application can require anywhere from 40 hours to 1
month. As a result of the tremendous amount of time required to complete
some applications, it behooves you to narrow down funding opportunities so
that you can invest your time in the opportunities that have the greatest
likelihood of being awarded. To do this, you have to evaluate the various
funding sources so that you can prioritize them as needed. There are several
criteria that I believe are quite helpful in sorting this out:

Philosophical foundations of the funding source

Funding parameters
History of funding
Other pertinent information

Each of these issues will be discussed in detail in the following section.

Philosophical Foundations of Funding Source

At first glance, you might think the philosophical foundations of the
funding source really have more to do with the history of the funding source
than with how it currently operates its business. However, this would be
wrong since the philosophy or guiding principles of a funding source
typically relate specifically to the types of projects they fund. As such, these
typically reflect the identity of the funding source and communicate to the
public who the funding source is and to whom and what it is committed. For
philanthropic foundations, the philosophy is often directly related to why the
foundation was first conceived—such as to recognize the importance of
families in children’s lives, as was the case with the Annie E. Casey
Foundation—and as such, this information not only holds tremendous
historical value but reflects the foundation’s core mission. In other cases,
foundations may modify their focus while maintaining their basic
philosophy. For instance, whereas the W. K. Kellogg Foundation was
initially established to fulfill the broad-based mission of "serving
humankind," following an examination of the results of many of the projects
it funded over the past decade, the foundation’s leaders decided to more
closely focus their energy on issues related to social class and racial divides.
Other foundations mirror Kellogg in that they retain a broad-based
mission while engaging in continuous reevaluation of their funding focus so
that they can redirect their energies as needed and as justified to address the
most critical and/or emerging issues. Examples of this are the MacArthur
Foundation and the Bill and Melinda Gates Foundation. Both of these
foundations have modified their focus to different degrees over the past
several years and, as a result, have expanded their reach into a variety of
social and other critical issues.
Likewise, governmental organizations are not very different from
philanthropic foundations, as they, too, have their own philosophical or
ideological foundations that drive funding decisions. This is even more
relevant today than ever before, particularly as subagencies have evolved to
focus on specific issues (e.g., Substance Abuse and Mental Health Services
Administration). The shifting focus of governmental organizations, however,
is typically directed by research and other external forces, and it is in this
manner that shifts in funding are viewed as responsive, changing to address
environmental needs. It is also in this manner that governmental funding
trends are informed by other factors and that these funding streams inform
key issues. For instance, the current focus on reentry issues within the
criminal justice system has been informed by research related to the need for
comprehensive transition planning for prisoners and, at the same time, has
significantly informed decision making about the broader criminal justice
system and incarceration. However, these changes have also been initiated
by economic factors and the goal of reducing corrections costs by releasing
certain groups of prisoners earlier than originally planned—and in this case,
philosophy may also be influenced as a result of tough economic challenges.
Because the philosophy of a funding source informs the type and scope of
its interests—and to a large degree, its values—it is imperative that you
understand this critical aspect of the funding source. If the values of your
proposed program are not consistent with the values of the funding source
you are pursuing, you likely should not be pursuing support from that
source. Conversely, if the values and philosophies are aligned, you may
indeed be able to put forward a project that has significant meaning to the
funding source and, as a result, receive serious consideration. Therefore, it is
highly recommended that for each funding source in which you are
interested, adequate time is taken to investigate the current philosophy and
focus of potential funding opportunities, the historic funding trends, and the
rationale for maintaining that specific philosophy. Doing so will not only
ensure that you have a firm understanding of the funding source but also that
efficiency guides your search for funding by using this information to either
rule in or rule out a potential source.

Funding Parameters
There are several funding requirements or restrictions (i.e., parameters)
that may or may not influence your decision making about pursuing a
specific funding opportunity. Some of the common features of funding
opportunities include

time limitations related to funding,

funding floors and ceilings,
eligibility criteria for applicants,
collaborative ventures that may be required,
funding match requirement,
qualifications of the required project director,
regular external monitoring of funding, and
required program evaluation.

The length of time for a funding period is often integral information,

especially with regard to the cost/investment that you may need to make in
order to implement a new program (as mentioned previously). Funding may
be limited to 1, 2, or 3 years and may also require annual renewal. Many
multi-year funding opportunities are considered 1-year awards with the
possibility of an additional year or more based on availability of funds. This
is particularly true with regard to governmental funding since future funding
is dependent on the economy and legislative activities and, therefore, subject
to change. In addition to issues related to the length of time of funding
opportunities, minimum and maximum amounts of funding may also be
stipulated. These are termed floors (minimum) and ceilings (maximum).
Whereas ceilings are common for most funding opportunities, ceilings are
most common with governmental grant opportunities, since specific amounts
of money have been allocated for specific projects. This type of financial
information is equally helpful to the length of time for funding, as it assists
in the financial planning process. If the ceiling is less than your projected
costs to operate the program, you may likely decide against pursuing a
particular funding opportunity.
The eligibility criteria for applicants is obviously a key consideration
when evaluating potential funding sources since you need to first and
foremost know that you (or your organization) are eligible to apply before
moving any further in evaluating a potential funding opportunity. Eligibility
criteria typically refer to the requirements related to who can apply for a
funding opportunity. Eligibility for most governmental funding is limited to
organizations, whereas charitable foundations may allow individuals and/or
organizations to apply. Funding from the federal government typically
includes four major types of eligibility criteria:
 

1. Funding limited to state or local governmental entities

2. Funding opportunities that are open to state and local
governmental entities, federally recognized American Indian or
Native Tribes, public or private universities, community-based
organizations, and faith-based organizations
3. Funding that is limited to academics or academic institutions
4. Contractual-type funding that is limited to small businesses
(e.g., under $1 million, under $5 million)
 
Following is an example of broad-based eligibility criteria for funding
from the federal government:
Eligible applicants are domestic public and private nonprofit entities.
For example, State and local governments, federally recognized
American Indian/Alaska Native Tribes and tribal organizations, urban
Indian organizations, public or private universities and colleges, and
community- and faith-based organizations may apply. (Substance
Abuse and Mental Health Services Administration, 2009, “Additional
Information on Eligibility,” para. 1)
The eligibility criteria are typically one of the first items listed on
documents for funding opportunities. Because this information is essential to
determining if you may or may not pursue specific funding, it behooves you
to locate this information as a first step in evaluating potential funding
sources.
Requirements pertaining to the number of applicants for a particular
funding opportunity and the issue of whether collaboration is preferred or
required must also be evaluated. Today, more than ever before, the
promotion of collaboration in mental health and social services has become
especially popular, and as a result, many funding opportunities require
particular types of collaborative work. When collaborative work is a funding
requirement, there are basically two forms:
 

1. A collaboration between two or more organizations that agree

to working together in a particular project via a Memorandum
of Agreement or through a subcontracting arrangement
2. A collaboration in which the applicant (for the funding
opportunity) stipulates that other organizations will be involved
with the project at varying levels via letters of support or other
relevant documentation
 
In both of these cases, agreement memoranda and letters of support are a
required part of the application documents that provide confirmation of the
potential collaboration. A recent funding opportunity for comprehensive
community-based substance abuse treatment requires that the applicant (i.e.,
substance abuse treatment provider) has established relationships with both a
mental health provider and a medical provider that will be able to address
other health-related needs of clients. In this case, letters of support
specifically outlining these relationships were required as part of the
application process.
Whereas collaboration may be required at different levels in a funding
opportunity, typically, there can be only one identified applicant. This means
that one organization will serve as the applicant organization, and other
collaborating organizations will be subcontracted for specific services as
relevant to the project. The reason for this is largely that there is one
identified leader of the project and, therefore, one faction to be held
accountable.
With regard to evaluating funding opportunities based on collaboration
requirements, it is wise to secure the required level of support from potential
collaborators prior to moving forward in a grant application since without
such, you will not be eligible to apply. In addition, when attempting to
engage in a collaborative effort, you must develop effective contractual
agreements that clearly spell out the expectations, requirements, financial
information, time frames for terminating the relationship, and other key
factors that are a part of standard contracts. In addition, very clear protocols
and other documentation and reporting requirements must be established
between collaborators to ensure that all parties are well prepared to engage
in the collaboration.
Some funding opportunities require that the applicant organization
dedicate a specific amount of funding to the project. This is typically termed
match funding. Although the term match implies equal contribution, this is
generally not the case. When match funding is required, it may be anywhere
from 10% to 50%. In some cases, cash matches are required; however, in
many cases, match funding can come from other expenses such as supplies,
salaries, or other basic charges that may be incurred as a result of the project.
When match funding is required, you must examine if there are any specific
restrictions, such as not being able to apply rent payments as part of a match.
Match funding is required as a method of demonstrating some degree of
sharing the financial costs of the project/program with the funding source
and, as such, demonstrating more of a partnership with the funding source.
By requiring match funding, the competition for grants will also be more
limited since some organizations will be unable to apply based on not being
able to provide a match.
Another element of a funding opportunity that should be evaluated is
related to the requirements of the project director. The project director may
be referred to as the project coordinator, leader, or principal investigator,
depending on the type of funding opportunity in question. As stated above
with regard to eligibility criteria related to types of organizations and the
need for an identified lead organization/applicant organization, most
applications also require that a project director is identified. In some cases,
there may be specific requirements for project directors, such as that the
individual has previous experience with receiving funding, has specific
experience with the population targeted in the opportunity, or has specific
expertise in the area targeted in the funding opportunity.
Because the project director is viewed as the leader, it is imperative that
you identify someone not only who meets any specific requirements but also
for whom strong justification can be made to successfully lead the project.
As such, a good deal of attention must be paid to evaluating potential
funding opportunities to determine if you do have an appropriate project
director who will allow you to most effectively compete for the funds since
this is such a critical part of how your application is evaluated.
In addition to the significance of a project director, the vast majority of
funding opportunities today require data collection and regular performance
monitoring. These requirements are often identified in the announcement of
the funding opportunity with much more specific information provided at the
time an award is made. Because collecting data requires dedication of both
individuals and time—as well as software, hardware, and/or other types of
data storage and analysis equipment—this is an area that again must be
carefully examined to ensure that you are able to fully comply with all data
collection and monitoring requirements. In addition, because there are costs
associated with data collection, storage, and analysis, these costs must be
considered in developing the budget.
Data collection can involve basic issues such as client demographic
information or aspects of program implementation, such as the number of
counseling sessions provided or the number of clients that successfully
completed the program. Because we do—thankfully, I believe—currently
live in a data-driven era, data about the project provides integral information
to the funding source, often about outputs and outcomes and other
performance-related aspects. Therefore, this information is pertinent to the
funding source as it reflects the return on its investment while promoting
accountability on the part of the funding recipient.
Similar to data collection but more sophisticated is the requirement for a
program evaluation that may be a part of some funding opportunities.
Program evaluation refers to a comprehensive evaluation of program/project
outcomes and may also include a fidelity assessment and a process
evaluation. Outcomes, though, are of particular significance to funding
sources because these speak directly to their ROI. In addition, outcomes data
is tremendously important for future decision making for funding similar
programs/projects.
If a funding opportunity requires a program evaluation, you must first
ensure that you have someone who is fully capable of carrying out a
comprehensive evaluation, including statistical analysis and follow-up. And
you must budget for all the costs related to evaluation in the proposal.
Additionally, justification regarding your ability to conduct the evaluation
will need to be provided in the proposal; so highlighting past experience
with evaluation, an established statistician, and an infrastructure conducive
to evaluation may serve you well in your application.

History of Funding
In addition to all the various funding parameters listed above and the
philosophical foundations of potential funding sources, it is also important to
review the history of funding of the potential funding sources as part of your
evaluation process. The history of funding refers to the projects and
organizations that have previously received funding. These details can
provide excellent information about the funding source in terms of what the
leaders of the organization value, what other parameters may exist in terms
of who has received what type of award, and other trend information that can
better inform you about the likelihood of securing funding from the source.
Because this information also is reflective of the philosophical foundations
of the funding source, you will need to examine if the focus of the funding
source has shifted recently to understand just how relevant this information
is to your current consideration.
This type of historical information is typically provided on websites of
philanthropic organizations. In addition, the information is often available
via the Internet for governmental sources and is listed in published
documents. Because both philanthropic and governmental funding sources
are required to create this information and publish it, it is generally fairly
easy to locate.
In reviewing the types of projects and organizations that have received
funding in the past, you may learn that the majority of funding awarded did
not exceed $100,000 even though the funding ceilings on new opportunities
are set at $150,000. You may also learn that faith-based organizations
received more funding than other nonprofit organizations and that the project
directors more often than not held doctoral degrees. Learning this about the
funding source, you may choose to pursue this funding and adjust your
application accordingly by not requesting more than $100,000, highlighting
other strengths of your organization if it is not faith-based, and considering
the involvement of an individual with a doctorate as part of the project team
if you do not have an identified project leader with a doctorate. Conversely,
like all other information that you use to evaluate the potential fit of a
funding source, the history of funding may influence your decision not to
pursue a particular source.

Direct Contact With the Funding Source

Another key activity in evaluating a potential funding source and/or
opportunity is to initiate direct contact with the funder. This may mean
calling, e-mailing, and/or meeting directly with the project
coordinator/contract manager to share your interests and abilities and learn
more about how your proposal or ideas of future proposals might fit with the
intent of the funding opportunity. Cultivating relationships with all potential
funding sources should be a top priority when you wish to seek funding from
these sources. It is in this way that you may work to prepare the funding
source to eventually receive your proposal (Homan, 2004). Indeed, the
quality of the relationship that you form with the funding source may be as
critical as the quality of the proposal that you submit (Golden, 2001).
In addition, pre-bid sessions may be offered by funders as part of the RFP
process so that specific additional information can be provided regarding an
opportunity. These can be held on-site or through a webinar or use of other
forms of electronic technology. It is essential that you attend these sessions,
as details are often provided that may significantly impact your proposal but
are not available through other venues.

Other Pertinent Information

 In addition to all the aspects identified above, there is other information
that may be pertinent to know as you move forward in determining which
specific funding opportunities to pursue. Often, other critical information
that must be evaluated has unique meaning to the applicant/applicant
organization and, therefore, what is most essential is that you fully evaluate
each potential funding source to determine which may be the best fit for you.
Failing to engage in due diligence in evaluating potential funding sources
before pursuing specific funding can result in a significant loss of time,
work, and energy—prized possessions in the mental health professions.

Funding Opportunity Evaluation Tool

In order to streamline the process of evaluating potential funding
opportunities and to aid in decision making by objectively reviewing
multiple sources, the Funding Opportunity Evaluation Tool (Figure 8.2) was
developed.

Summary
As you can see, securing funding for mental health and social service
programs is no easy task and, in fact, is a highly competitive, labor-intensive
process. Moreover, because financial support is limited, securing funding
must be considered a regular activity of work rather than a special project.
This likely ensures that sufficient time is set aside for investigating and
pursuing funding—recognizing the significance of pursuing funding
alongside managing daily operations since both are ongoing tasks requiring
specific attention.
Figure 8.2 Funding Opportunity Evaluation Tool
 Whereas an extraordinary number of funding opportunities are made
available through both philanthropic organizations and the government,
knowing where to look and how to thoroughly examine opportunities
requires both knowledge and skills. Technology has made the process of
exploring funding opportunities not only highly efficient but also highly
effective. Searching for funding opportunities, evaluating funding sources,
and completing applications for funding can largely be done electronically
now. In addition, the federal government has moved to almost exclusive use
of electronic technology for all aspects of funding, including management
and monitoring of fund awards.
A major aspect of financial planning and management, the process of
securing funding for your program can be quite rewarding, both figuratively
and literally. Just as it is imperative that program developers possess both the
knowledge and skills to competently engage in financial planning and
management, they must also be able to effectively understand how funding
operates, the climate of public and philanthropic funding, and how to most
effectively make decisions regarding which funding opportunities to pursue.
By doing so, program developers are much better postured to be successful,
not only in securing initial funding but in continuing to secure funding—a
key ingredient of sustainability.
 
CASE ILLUSTRATION
Andy and Amanda had been codirectors of a small foster care program
for the past several years and had become all too aware that the majority
of their clients were single mothers with children. As a result, their
parenting classes—one of the mandatory requirements that must be
completed for parents to be reunited with their children—were almost
solely filled with females. They were disturbed by their sense that the
child welfare system seemed to either overtly or covertly focus on
mothers at the expense of neglecting to get fathers involved with their
noncustodial children. After doing some research in the area, they found
some support for this notion, but more importantly, they came across a
specific program model that targeted nonparticipating fathers associated
with children in foster care. The model had demonstrated promise as an
emerging practice, as preliminary outcome studies showed significantly
favorable results.
Energized by this, Amanda suggested they take a stab at implementing
a program based on this model. Andy was equally excited about this
prospect, especially since, in addition to fulfilling a passion that they
shared, it could result in expanding their service array, potentially
bringing in a new funding source. And it reflected their mission. Now
they just needed to identify potential funding sources.
Through an exhaustive investigation of potential sources, they were
able to narrow their search down to four potential funding sources that
included the Janet L. Reed Foundation, the Rankovic Forum, the
Harrington Foundation, and the state Department of Health and Human
Services. Andy reviewed the funding trends over the past 3 years to get a
sense of specific projects that each had funded, while Amanda contacted
the project managers at each of the philanthropic organizations to discuss
their proposed program and determine if the foundation had any interest
in supporting it. Amanda discovered that the Rankovic Forum had
already dedicated their funding to other specific issues for the next
couple of years and, therefore, suggested she check back next year as the
upcoming agenda might be prepared by then. After speaking with a
representative from the Harrington Foundation, Amanda learned that
they were currently not accepting unsolicited proposals and were
focusing their attention on large geographic regions such as states, as
opposed to smaller regions. However, Amanda was encouraged to
continue to check their website for announcements of any new funding
competitions in the future. After pitching their program proposal to the
children’s programming manager from the Reed Foundation, the
program manager stated that parenting programs was an area that they
were actually beginning to explore and that an RFP was going to be
issued in October. She further shared that while the focus of the RFP did
not specify mother versus father, several members of the organization
had recently been discussing the role of the father in noncustodial
parenting, further indicating that proposing a father-focused program
might strengthen the proposal.
Amanda shared her news with Andy, and they decided to continue
exploring other options while learning even more about the Reed
Foundation in hopes of submitting a proposal once the RFP was released
in a couple of months. Andy also had set up an electronic notification on
a free funding database to ensure that they were notified when funding
opportunities in the area became available.
While they were not successful in identifying any other potential
funding sources, they received the RFP from the Reed Foundation in
October. Using the Funding Opportunity Evaluation Tool, Amanda and
Andy began rigorously reviewing the RFP. Their findings indicated that
the opportunity was indeed a good fit for them, but the data collection
requirements were extensive, and they were concerned about their own
abilities to effectively manage the data collection process. They currently
used the county-administered client information system for their foster
care program and used Excel spreadsheets to handle their program data
needs.
After discussing the RFP with their staff and with Hank, the executive
director, everyone agreed that the opportunity was one they should
pursue. Hank stated that the board had been urging him to use some of
the company’s technology funds to purchase a client information system,
but he had been hesitant. Hearing about this new opportunity, he realized
that regardless of the outcome of the fatherhood parenting program, it
was becoming increasingly clear that having a client information system
in place would better posture the organization to pursue other funding
opportunities, and it would allow the staff to do more with their existing
data.
After receiving the green light, Andy and Amanda got to work on
developing the proposal.

 
RESEARCHING POTENTIAL FUNDING OPPORTUNITIES
EXERCISE

In order to get more comfortable with identifying and evaluating

potential funding sources, complete the following exercise:
 
 1. Visit www.grants.gov and identify two open (current) funding
competitions that might be used to fund the program that you
developed in Chapter 6. If your program of interest is school-
based, visit the federal or state department of education
websites to search for K–12 funding. If you cannot locate
funding for your specific type of program in current
opportunities, identify two funding opportunities that are
somewhat related to your identified treatment issue or
population.
2. Explore the Internet and any other sources available to you to
identify two philanthropic organizations that provide funding
support in your area of interest.
3. Gather the applications for all four of these funding
opportunities and, using the Funding Opportunity Evaluation
Tool, evaluate each one.
4. Explain the results of your evaluation, indicating which, if any,
of the funding opportunities appear worth pursuing, which do
not, and why.
 
 

References
Annie E. Casey Foundation. (n.d.). Mission and history. Retrieved
September 10, 2010, from
http://www.aecf.org/Home/AboutUs/MissionAndHistory.aspx
Carroll, D. A., & Stater, K. J. (2008). Revenue diversification in nonprofit
organizations: Does it lead to financial stability? Journal of Public
Administration Research and Theory, 19, 947–966.
Ezell, M. (2000). Financial management. In R. J. Patti (Ed.), The handbook
of social welfare management (pp. 377–393). Thousand Oaks, CA: Sage.
Farquhar, C., Lowe, J. I., & Campbell, J. W. (2007). Trends in aging funding
and current areas of foundation interest. Philanthropy and Aging, 31, 50–
 53.
Gibelman, M., & Furman, R. (2008). Navigating human service
organizations. Chicago: Lyceum.
Golden, S. L. (2001). The grant-seeking process. In J. M. Greenfield (Ed.),
The non-profit handbook: Fundraising (3rd ed., pp. 666–691). New York:
Wiley
Homan, M. S. (2004). Promoting community change: Making it happen in
the real world. Belmont, CA: Brooks/Cole.
John D. and Katherine T. MacArthur Foundation. (n.d.). Overview. Retrieved
September 10, 2010, from
http://www.macfound.org/site/c.lkLXJ8MQKrH/b.855245/k.588/About_t
he_Foundation
Montgomery, M. (2003, September 5). Thank you for advertising, but your
needs don’t meet my interests [Electronic version]. Chronicle of Higher
Education, 50(2), B15.
Payne, M., & Applebaum, R. (2008). Local funding of senior services: Good
policy or just good politics? Aging Policy and the States, XXXII, 81–85.
Singh, J., Illes, J., Lazzeroni, L., & Hallmayer, J. (2009). Trends in U.S.
autism research funding. Journal of Autism Developmental Disorders, 39,
788–795.
Skillman Foundation. (n.d.). Always a Rose for Detroit: Rose Skillman.
Retrieved September 10, 2010, from http://www.skillman.org/about-
us/history
Substance Abuse and Mental Health Services Administration. (2009).
Offender reentry program. Retrieved September 10, 2010, from
http://www.grants.gov/search/search.do?mode=VIEW&oppId=50070
Vitiello, B., & Wagner, A. (2007). The rapidly expanding field of autism
research. Biological Psychiatry, 61, 427–428.
W K. Kellogg Foundation. (2009). Mission and vision. Retrieved December
10, 2009, from http://www.wkkf.org/default.aspx?
tabid=1163&ItemID=199&NID=344&LanguageID=0
 CHAPTER 9
Develop the Financial Management
Plan

 
Learning Objectives
 

1. Identify key historic issues in financial management that may impact

current practices
2. Identify two current trends in financial management of nonprofit social
service organizations
3. Differentiate between financial management of nonprofit organizations
and for-profit organizations
4. Identify the basic components of an annual program budget
5. Identify the major objectives of an annual report
6. Identify the major objectives of a financial audit
7. Develop a comprehensive annual operating budget

 
WHOSE JOB IS IT TO MANAGE THE FINANCES?
Bill had been operating a human service organization for the past 4
years, primarily providing an array of services for developmentally
disabled adults. The agency had grown significantly over the past 2 years
and now had annual revenue of $4.8 million. After presenting the
proposed budget that his chief financial officer (CFO) had developed,
Bill’s board of directors had unanimously approved his program
expansion into a clubhouse program (i.e., multipurpose space for clients
to gather, recreate, and participate in various structured and
nonstructured events).
However, 9 months after successfully implementing the program, Bill
learned that his agency was in the red. Even more surprising, Bill found
that his agency had been losing money for the past 8 months. Bill
immediately met with the CFO to better understand what was going on.
After meeting with his CFO, Bill realized that the projected revenue
for the clubhouse program on which the expense budget had originally
been based was nowhere near what the agency was collecting in revenue,
even though he had been spending all the money initially budgeted to
support the program. Bill had always thought of himself as a clinician
first, as well as an agency administrator, and felt that his role was to be
fully focused on operations and not finances. As a result, he had hired a
CFO and two finance staff persons to manage the agency’s finances.
However, after realizing that there had been a grave disconnect
between what was happening on the operations/expenditures side and
what was happening on the revenue side, Eric knew he had to quickly get
a handle on his budget. Bill immediately set about learning all he could
about the state of his agency’s finances and implemented weekly budget
 meetings to review their financial status. Three weeks later, he realized
that he could not afford to retain the clubhouse program given the
revenue it had produced thus far and the unlikelihood of its revenue
significantly increasing in the future.
Although this was a terribly difficult lesson to learn, Bill was
confident that he would never again find himself in this position. He had
vowed that from this day forward, he would be completely involved in
the finances of his agency, and thus, there would be no more surprises.

 
CONSIDERING BILL

1. As the organization’s leader, what is Bill’s responsibility in the

financial management of the organization?
2. What responsibility does the CFO have in the agency’s financial
management?
3. If you were Bill, what specific steps would you take to ensure this type
of problem would not occur again?

About This Chapter

This chapter is designed to examine several key financial planning and
management issues related to program development. Since it is necessary to
first gain a historical perspective and understand current trends in mental
health and human service programs related to financial management, this
will serve as a starting point. Second, in order to gain an understanding of
the distinction between nonprofit and for-profit financial management, we
will briefly explore this issue. In addition, we will discuss an integrated
approach to discussions and decision making pertaining to program
development that directly includes financial aspects and implications.
Next, we will examine types of financial data that include projected
revenue and expenditures as well as project-specific budgets and annual
program budgets. We will discuss financial reporting mechanisms and time
frames, the annual report, and auditing practices toward the end of the
chapter to promote increased understanding of the significance of regular
reporting and oversight pertaining to financial management. Finally, we will
explore the way in which financial planning directly derives from previous
steps (i.e., program design, staffing infrastructure), with an exercise at the
end of the chapter providing an opportunity for you to develop your own
initial budget.

STEP VII: DEVELOP THE FINANCIAL

MANAGEMENT PLAN
Finances and Program Development
Despite the most brilliant program design, without clients (i.e., justifiable
need), a program cannot be implemented. Similarly, without sound financial
management, a program that has been implemented cannot be effectively
sustained. Therefore, financial management must be viewed as just as
integral to program development efforts as the identification of a viable
client population. As a result, the program developer must be equally
equipped to effectively engage in comprehensive financial planning as s/he
is to engage in asset mapping, community resource development, and all
other aspects of program planning.
There are two major areas of finance that are relevant to comprehensive
program development—financial planning and management. Financial
planning must be conducted as part of initial program planning, whereas
financial management is related to program implementation and
sustainability. However, because of the interdependent nature of these issues
—finances cannot be effectively managed if they have not been effectively
planned (as Bill learned in the vignette above)—it is necessary to cover both
areas in this chapter.

History and Current Trends

One of the most unfortunate memories that will historically be associated
with the new millennium is the behemoth disasters resulting from financial
mismanagement and lack of financial oversight. Even though the depression-
like era that fully evolved in the United States in 2007 may take center stage
in our collective memory for years to come, the public fall of companies
such as Enron in the earliest days of the new millennium must not be
forgotten—especially since some could argue that what occurred with Enron
was simply a symptom of a larger culture of financial negligence in which
we so passively allowed ourselves to become entangled, thus setting the
stage for what followed.
Rather than spend too much time rehashing such unpleasantness here,
what is necessary for this discussion is what we learned from these events of
the 21st century—namely, lesson No. 1 from Enron: Failure to engage in
effective accounting and financial management practices and failure to
enforce effective oversight of financial management and accounting
practices puts everyone at risk, including clients/consumers, employees, and
the public, and such negligence can result in harm to all stakeholders and
the decimation of the business, and lesson No. 2 from the banking industry:
Failure to engage in effective accounting and financial management
practices, failure to enforce effective oversight of financial management and
accounting practices, and failure of the federal government to provide
sufficient and effective regulations can result in worldwide financial
disasters of a proportion never before witnessed.
We would likely be hard-pressed to identify any more-significant
historical events related to financial management. And the far-reaching
impact of these events may remain yet to be seen since they so recently
occurred. However, even as the conditions were being created that
eventually led to these financial disasters, trends related to financial
management in the nonprofit human service industry were beginning to
change. In fact, three major trends that have gained increasing traction over
the past several years are
 

1. heightened scrutiny and accountability of finances,

2. the use of turnaround planning, and
3. changing attitudes about financial knowledge.
 

Heightened Scrutiny and Accountability

 Myriad changes have affected the human services industry over the past 2
decades, such as changes in governmental funding patterns, greater emphasis
on more localized management of funds, and significant losses in the stock
market that have not only affected philanthropic organizations’ funding but
have had a far-reaching effect on literally all funding sources. Each of these,
in addition to the well-publicized financial catastrophes discussed above, has
led to increased scrutiny and accountability of nonprofit financial
management. In nonprofit human service organizations, “accountability is
rooted in how organizations spend the money entrusted to them” (Gibelman
& Furman, 2008, p. 49).
One of the drivers of this increased scrutiny was the new legislation that
was passed in 2002, the Sarbanes-Oxley Act. This legislation was
specifically put in place as a result of the financial negligence that came to
light during the past several years and, as such, was designed to create
increased accountability of finances. With the passage of Sarbanes-Oxley,
public attention initially focused on board members of for-profit companies;
however, public attention is now shifting to increased scrutiny of nonprofit
organizations, including human service organizations and charitable
organizations (Grunewald, 2007). As a result of increased scrutiny, the
manner in which nonprofits handle their money is a primary focus of various
constituencies (e.g., funders, board members, politicians) that now hold
management of these organizations far more accountable than ever before
(Katz, 2005).

Turnaround Planning
Related to the significant changes that the human service industry has
faced in recent years, particularly with regard to the tremendous shrinkage in
available funding, an inordinate number of organizations have been unable
to remain in business. In some instances, the reduction in the number of
human service organizations was a natural and necessary response to
shrinking funds—since the pieces of pie are limited and, therefore, can feed
only so many—and as a result, it has become an issue of survival of the
fittest. However, most organizations have not been able to survive simply by
resting on their past successes. Rather, in order to remain in business, many
have had to engage in various degrees of turnaround planning—
incorporating responsive and, at times, radical changes to their business
model in order to redefine the business and continue to compete. In many
cases, this has meant diversification. For some, diversification has meant
expanding the service array to include community-based services in
organizations that had traditionally provided only residential treatment
programs; for others, it has meant pursuing funding from new and different
sources, such as the federal government and large national foundations, in
addition to state and local governmental funding sources.
The majority of nonprofit human service organizations typically engage
in less formal types of turnaround planning, utilizing key administrators and,
in some cases, forming internal committees to think through potential
operational changes. However, with increased frequency, nonprofit human
service and mental health organization leaders have sought financial and
management advice from turnaround firms—once the bastion of the for-
profit world (Katz, 2005). This trend constitutes another recent significant
change in financial management of mental health and human service
organizations.

Changing Attitudes About Financial Knowledge

Further connected to these other trends are the changing attitudes
regarding financial knowledge within human service organizations and,
namely, ideas about who should hold such knowledge. Whereas,
traditionally, the chief financial officer and other finance staff were looked to
for their expertise in all things financial, it is now widely understood that
while there still must be those who have significant expertise within the
organization, this does not exclude the necessity for managers and
administrators to possess a strong working knowledge of finance. In fact,
because the program administrator is ultimately responsible for the program
operations, s/he must be knowledgeable about each and every aspect of
operations, including finance.
Precisely because much of the funding for mental health and human
services derives from governmental, foundational, or philanthropic funding,
program developers are stewards of the resources of others (Lewis, Packard,
& Lewis, 2007). This is a tremendous responsibility and one that requires the
ability to effectively manage these resources in a manner that allows for the
greatest amount of good to be achieved. As a result, it is now widely
accepted that effective financial management and accountability are key
responsibilities held by program developers.
Historic events and current trends have dramatically changed financial
planning and management in the mental health and human service industry
in recent years. As a result, today more than ever before, program developers
must be keenly aware, knowledgeable, and skillful regarding financial
planning and management.

Financial Planning
Financial planning refers to the financial design process that is directly
related to program design in the program development process. Initial
financial planning derives directly from the program design and is based on
the type and scope of services that will be provided and the staffing
infrastructure that will be in place. Initial financial planning is composed of
projections—projected expenditures that are expected to be incurred as a
result of implementing the program. In addition, initial financial planning is
equally based on projections of expected revenues that will be received as a
result of program implementation. Because of the significant implications
related to projections of expenses and revenues, it is imperative that these
projections be as accurate as possible in predicting actual expenses and
revenues. In addition, cost-containment practices and effective monitoring
must be in place to protect against over-expenditures, and appropriate billing
and highly effective collection practices must exist to ensure that all
revenues are received. In fact, the ongoing ability of a human service agency
to operate efficiently in a constantly changing environment is dependent on
how well the organization’s finances are managed (Kettner, Moroney, &
Martin, 2008).
With regard to financial planning for mental health and human service
programs, two key issues must be considered:
 

1. The financial management–related differences between

nonprofit and for-profit organizations
2. Utilizing an integrated approach to financial planning
  
Both of these have specific significance for comprehensive program
development, and so each will be discussed in depth.

Financial Management for Nonprofit Organizations Versus For-

Profit Organizations
Within the mental health and human services, a large portion of
organizations are nonprofit. This is not to say that for-profit corporations do
not also provide mental health and human services, but because the field is
indeed composed of a significant number of nonprofit organizations, it is
necessary to fully understand the characteristics that make these
organizations unique.
The fundamental difference between for-profit organizations and
nonprofit organizations is aptly conveyed in each title: for-profit versus
nonprofit. Simply put, for-profit organizations operate in order to make
money by selling some good or service, whereas nonprofit organizations
function to use the money provided to them by third parties (e.g.,
government, charitable organizations, individuals) to carry out specific
services to other individuals and/or groups. Although the manner in which
each acquires funds is vastly different, the amount of revenue generated may
be similarly meaningful to both for-profit and nonprofit organizations.
Indeed, for-profit companies often seek to make as much money as possible,
typically basing profit directly on what the market will bear and resulting in
increased salaries, equipment, facilities, and—for publicly traded companies
—increased value to stockholders. Similarly, nonprofit organizations are also
often concerned with increasing the amount of revenue that is generated by
the organization since this often translates into a broader organizational
staffing infrastructure, more equipment, and other items needed to directly
support operations. As a result, the key difference between for-profit and
nonprofit human service organizations is not related to the amount of
revenue produced—or desired—by the organizations but, rather, how the
revenue that is generated can be spent. Whereas leaders of for-profit
organizations typically enjoy a high degree of freedom and autonomy in
decision making about how money can be spent—albeit, with oversight from
the board of directors when applicable—leaders of nonprofit organizations
have limited autonomy in decision making about expenditures. This is
precisely because, from a financial perspective, nonprofit organizations are
primarily concerned with justifying all revenue through expenditures, thus
demonstrating that funds generated were utilized to directly and indirectly
deliver the services for which they were initially provided.
In addition to this fundamental difference between for-profit and
nonprofit organizations, there are also characteristics specifically related to
nonprofit organizations. According to Horejsi and Garthwait (2004),
attributes of a nonprofit human service organization include

operating legally under the control of a board of directors

whose members are empowered to act on behalf of the
organization and represent the interests of the clients served;
being created or chartered to serve some facet of the common
good;
being held publicly accountable for all its activities;
being specifically empowered to hire individuals that will carry
out the mission of the organization and provide and support its
services and programs;
being empowered to engage in fundraising to support the
mission of the organization and to support its services and
programs; and
being restricted by the Internal Revenue Service (IRS) and
many state statutes from participating in political activities,
including lobbying and promoting political candidates.

Additionally, Carver (2006) offers three other characteristics of nonprofit

organizations specific to financial management, which include

being exempt from certain taxes,

typically receiving a large portion of revenue from other
organizations and from donations rather than for the direct sale
of a product, and
 having no place for profit in their accounting systems.

Each of these characteristics distinguishes nonprofit organizations to

some degree from their for-profit counterparts. And as a result of these
unique features related to financial management of nonprofit organizations,
it is essential that most, if not all, stakeholders minimally possess a basic
understanding of financial management. Moreover, it is imperative that
most, if not all, employees possess a basic understanding of financial
management, while program developers, administrators, managers, and
supervisors are equipped with an even deeper knowledge of this aspect.

Integrated Approach to Financial Management

It is because of this need for program leaders and program developers to
possess an effective amount of finance-related knowledge that an integrated
approach must be used in initial financial planning and management. What I
mean by an integrated approach is that the program developer must initially
be able to demonstrate her/his strong working knowledge of finance through
leading the development of a comprehensive budget. By doing this, the
developer conveys that s/he understands the integral relationship between
finances and services, staffing, and other aspects of the program and, thus, is
able to integrate each of the various components of the program into a
whole. Integrated also then means that discussions about the program are
inclusive or integrated—addressing both operations and finances, not simply
one aspect versus the other. While it is important to have an expert (i.e.,
finance manager) both review and provide input to the initial budget, this
responsibility should never be shifted directly to the finance leader in lieu of
the program developer’s involvement. This is because mental health
professionals can fully understand the programs that they are operating only
when they understand how those programs are financially managed (Lewis
et al., 2007).
Unfortunately, some organizations continue to operate in this
compartmentalized fashion, ceding full responsibility for the initial budget
development to the finance leader. As a result, organizational leaders and
program staff often struggle to understand financial decision making simply
because they are somewhat ignorant about this crucial aspect of
programming.
By utilizing an integrated approach, the program developer is able to gain
a much greater vantage point for fully understanding the full program
operations and, thus, is better equipped to deal with any challenges that
might arise. Whereas this initially occurs at the point of program
development and development of the initial budget, the program’s financial
issues must be incorporated into all dialogue related to program
implementation and evaluation. As a result, it is necessary that all post-
implementation program review processes include review and discussion
related to the financial aspects of the program as integral to the program
operations. These discussions must be led by program leaders and staff to
ensure that an integrated approach to discussions and decision making
continues to be inculcated at all levels of the program. Indeed, this serves to
promote a keen understanding and appreciation of the interdependent
relationship between program operations and finances and, ultimately, to
increase the collective knowledge of the program/organization.

Types of Financial Data

There are two primary types of financial data used in accounting and
financial decision making in the nonprofit mental health and human service
industry—expenditures and revenue. As you know, quite an intimate
relationship exists between these two types of data, since one refers to what
goes out (expenditures) and the other to what comes in (revenue).

Projected Expenditures
Whereas expenditures will differ somewhat based on the specific type of
programming being provided, there are several basic expenditures that the
majority of programs incur:

Staff salaries
Staff benefits
Insurance
Office space
 Office equipment
Office supplies
Transportation

As you would likely imagine, staffing costs frequently constitute the

largest expense. This is particularly significant to mental health and human
service, since programs are primarily composed of interventions directly
provided by individual staff members. In fact, without individual staff,
interventions or services cannot be rendered. The various salary amounts and
the sum of expenses per salary are based on the scope of the program and the
necessary staffing infrastructure. For example, because residential (i.e.,
inpatient) programs are much more complex than most community-based
programs and because they require 24-hour staffing, the range of personnel
and associated salaries in residential programs may be quite expansive. To
highlight this, Table 9.1 illustrates a comparison of staffing for an inpatient
substance abuse treatment center for adolescents and an outpatient substance
abuse treatment center for adolescents. Both programs serve up to 24 clients
at a time.
As you can see, the staffing structures of these two programs are quite
different, although each is designed to treat adolescent substance abuse and
each serves the same number of clients. The intensity of residential
treatment, not to mention other costs associated with supporting the primary
needs of individuals (e.g., housing, food, hygiene) on a daily basis,
contributes to the vast budgetary differences inherently based on program
type.
Table Salary Structure and Range Comparison: Inpatient Versus Outpatient
9.1 Substance Abuse Treatment Programs
 In the above example of the residential program, all the staff members are
full-time salaried employees—with the exception of the medical director and
psychiatrist, both of whom are contractually paid. With salaried employees,
as well as with some part-time employees, come employee benefits. Benefits
primarily refer to employer contributions to employee health and possibly
life insurance programs and typically cost an employer approximately 30%
of the employee’s salary. Therefore, for an employee with a salary of
$32,000, the employer may pay up to $9,600 in employee benefits.
In addition to employee health insurance benefits, employers in mental
health and human service programs also must carry insurance for their
business. Typically, this includes insurance on the buildings/facilities and
professional liability insurance for any malpractice lawsuits.
Office space, equipment, and supplies compose another large group of
expenses and, again, vary depending on the type and scope of programming
provided. Minimally, one office space is needed to house the administrative
functions of the program and to provide space in which the clinicians and
other staff work. The office space itself refers to the work space that is either
purchased or rented and that houses the program operations. Whereas
outpatient or community-based programs may have one office
space/location, residential programs may have both the inpatient facility that
serves as the office space for all the direct care workers (e.g., clinicians, case
managers, treatment staff, physicians) as well as an additional administrative
office housing administrative support staff (e.g., finance, human resources).
This schema may be particularly relevant if the organization is operating
multiple residential facilities.
Office equipment generally refers to the basic furnishings and equipment
necessary to conduct business. Items such as desks, chairs, and tables
compose basic furnishings, while computers, copiers, printers, telephones,
and fax machines are some of the equipment needed. Paper, pens, calendars,
highlighters, and staplers are some such basic office supplies.
Transportation is another typical expense incurred by mental health and
social service programs. Transportation costs may result from mileage
reimbursement to employees who conduct home visits or other business
involving transportation to or from off-site meetings, conferences, and other
professional or administrative duties involving transportation. The federal
and state governments provide guidance for mileage reimbursement, as each
publishes its annual mileage rate paid to employees or subcontractors. For a
basic reference point, over the past several years, mileage rates have ranged
from $0.38 to $0.52 per mile.

Determining Salary Ranges and Other Expenses

Just like all the other components of comprehensive program
development, determining expense allocations must be guided by research
and due diligence. Salary ranges should be determined based on both
national and local market analysis data. Often, salary data is compiled by
various professional associations (e.g., Child Welfare League of America) as
well as the government, and as a result, you simply need to review all the
pertinent data and use it to guide the salary range development process. In
addition, because many human service organizations affiliate with
colleagues in local consortiums, it is not uncommon for both informal and
formal dialogue about salaries to emerge, particularly for a specific position
(e.g., therapist). Also, because salary information is often disclosed in job
postings, a review of job postings from similar organizations in your region
should also be examined. Unfortunately, some program administrators learn
about the salary ranges offered by competitors by witnessing a continuous
exodus of their own employees to their competitors’ somewhat greener
pastures.
The point here is that information about salaries is available; therefore,
the program developer/manager must simply ensure that the information is
effectively used in determining salary ranges. Salary ranges are typically
guided by competition; therefore, in order to remain competitive, you often
must ensure that you can offer a competitive wage. This is not to say that
salary is necessarily the most compelling feature of a position for potential
employees, but it is to say that, by and large, salary matters to many
individuals—particularly when there are significant differences in salary
between employers for the same work. Because salaries are collectively
influenced—by the various competing organizations—salary ranges
typically are created based on the market, and not only what the market can
bear but also what the market wishes to bear. In terms of what the market
wishes to bear, contractors of services either directly or indirectly impact
salaries. For instance, contracts and grants may be awarded based on
projected salary ranges for various positions, and conversely, contracts and
grant funding may not be awarded if the funding source deems the projected
salary ranges inappropriate. In other cases, and particularly with
governmental contracts, salary ranges may be pre-established by the
contractor.
The work of gathering and analyzing salary data can and should be done
in concert with a human resources staff person—but not solely by the human
resources person. No different than other aspects of financial management,
mental health professionals must understand the entire scope of their
programs—not simply the clinical components—and doing so requires
active involvement in all aspects. In addition, whereas the initial salary
ranges must be established prior to setting program implementation,
comprehensive review of salary ranges must be regularly conducted to
ensure that you remain competitive.
Because salary is only one form of employee compensation, determining
other aspects that together compose the total compensation package must
also be guided by market research. These aspects include, but are not limited
to, insurance, time off, mileage reimbursement, professional development,
and other benefits.
 Finally, research must also guide decision making about all other
expenses, including office space, equipment, and other supplies. By first
ensuring that all costs are justified, then regularly reviewing the markets for
each type of expenditure and conducting effective cost-benefit analyses, you
can be confident that your expenditures are not only well justified but also
cost-effective.

Projected Revenue
To reiterate, the projected revenue is the amount of money you hope to
collect as a result of service provisions. Typically, there are three types of
revenue streams in human service programming—governmental funding;
foundation funding; and individual, fee-for-service payments. In addition,
nonprofit organizations can receive funding through charitable giving. Each
of these funding sources was discussed in detail in the previous chapter.
However, for the sake of this discussion, what is important to note is the
manner in which the funding is provided. Whereas some contracts with both
governmental and nongovernmental organizations are based on providing a
lump-sum payment, others provide payment based on a per diem schema
(e.g., per client, per day). Precisely how the reimbursement occurs is
particularly significant since this information is crucial to projecting and
managing expenses. To get a sense of the differences in revenue based on
program type and funding type, see Tables 9.2a and 9.2b.
The per diem rate for residential programming is obviously much greater
than that for community-based programming, since the residential per diem
payment supports 24-hour staffing as well as housing, food, clothing, and
other necessities of daily living. In contrast, the per diem rate for
community-based treatment supports clinical staff and supervision. With
regard to Table 9.2b, both programs are residentially based and have a
capacity of 30 youth. The first is paid a per diem rate based on the days in
which the youth are physically placed in the facility. As a result of this
payment schema, the program is paid based on the number of beds filled by
clients. Conversely, any time that a bed is not filled, the program does not
receive payment. To counter this issue, contractual agreements for payment
may specify a lump sum to be paid on an annual basis (or some other regular
time period), therefore paying the program independent of the number of
clients placed in the program at a given time. Both payment schemas have
merit; both also come with their own advantages and disadvantages. In short,
per diem payment may work best when programs are able to operate at full
capacity and/or are flexible enough to regulate expenditures effectively
based on client numbers. On the other hand, a lump sum payment schema
may work best for programs that are not always able to operate at full
capacity so that the payment can be spread out based on the number of
clients in treatment at a given time. Regardless of type of program and
manner in which payment is made, how the funding is managed is by far the
most critical issue facing the financial livelihood of a program. This only
reinforces the need for program developers, leaders, and all stakeholders to
possess specific and deep knowledge of financial management.
Table Per Diem Revenue Comparisons Between Different Program
9.2a Types

Table Different Payment Type Comparisons Between Identical

9.2b Programs

Budgets
Because projected expenditures and projected revenue are the two key
ingredients needed to develop a budget, once this information is available,
the initial budget can be developed. As such, the budget allows you to view
all the projected financial data and, more significantly, provides day-to-day
guidance for financial management. Just as an effective logic model
provides a road map for program implementation, an effective budget
provides a road map for financial management. Moreover, “a budget must be
seen as the concrete documentation of the planning process, bringing ideals
into reality” (Lewis et al., 2007, p. 12). As such, budgets must never be
thought of as static documents that serve a purpose in initial planning and
are then left to be revisited in a year or more; rather, budgets should be
integrated into day-to-day operations and, as such, can be fully utilized as a
critical operational tool.
There are several types of budgets, including project-specific budgets,
annual operating budgets, and multiyear budgets. Each is discussed below.

Project-Specific Budget
Project-specific budgets are typically created for mental health or human
service projects that are time-specific. I use the term project-specific to
denote that these are contained and finite with a clear start-and-stop funding
cycle. For instance, funding may be provided to develop and implement a
prevention program to address depression in adolescents. As such, a specific
amount of funding has been made available; specific performance objectives
have been established; and specific time frames for development,
implementation, and evaluation of the project have been identified. These
types of funding opportunities are project-based since there are clear stop-
and-start time frames and it is understood that there is no plan for
continuation of funding. As such, project-based budgeting is based on
completing the agreed-to project and achieving the established outcomes.
Table 9.3 provides an illustration of a project-based budget for a depression
prevention project.
The project budget illustrates several items worth further discussion, first
of which is staffing and salaries. As you can see, the budget provides for one
full-time employee (FTE) who will be fully dedicated to the program.
Because this particular project consists of a prevention program that involves
individual assessment, a group-based psychoeducational curriculum, and 6-
month follow-up telephone contact, only one primary staff person is needed.
However, in addition to the full-time clinician, two other core components of
the program require additional staffing: data collection activities and
evaluation. Both of these jobs require limited time and will result in tangible
outcomes. It should be noted here that in this project, the data collection is
being conducted by someone other than the clinician to ensure objectivity in
the data collection process—an important ethical consideration in research.
Because the organization has an employee in another program who can
perform the duty of data collection, the project funding will be used to
support the amount of the employee’s salary dedicated to the project, which
in this case is 10%. This type of schema has benefits to both the project and
the organization. The project benefits from someone already engaged in the
organization’s larger mission and, thus, someone who is likely competent
and committed to the work. At the same time, the organization benefits from
being able to offer a different type of work to an employee—most of whom
are strongly attracted to a work life full of variety and, thus, have chosen a
career in the mental health profession. On the other hand, the organization
does not currently employ a clinician with the degree of statistical
knowledge needed to evaluate the project. To provide this service, a set
dollar amount is dedicated to supporting specific data analyses and report
development (based on market research). By budgeting in this manner, the
program developer is able to identify the specific deliverables required for
payment to which both s/he and the statistician can agree. This type of work
is particularly suited for contractual hiring because it is specialized and is
associated with concrete outcomes.
Table 9.3 Project-Specific Budget Sample
 The supplies needed to operate the program include assessment
instruments, paper, and binding, for which specific costs have been
identified. In addition to supplies, the budget includes funding for client
transportation to and from the prevention workshops. To determine this
projected cost, an analysis of the distance between the majority of clients
and the office site was calculated and an average was computed. Telephone
calls were also included in the budget, which account primarily for the
follow-up data collection process. Finally, because the organization has
existing office space that can be used for this project, the organization is
providing use of this space as an in-kind donation. Whereas some funding
opportunities specifically require a match from the applicant, others do not.
This particular project did not require a match, but because space was
needed for the project and was provided at no cost by the organization, this
was reflected in the budget without a specified cost.
The total budget is $43,036.30, which also is the total request of funding
(i.e., revenue). This is typical of project-based funding in that the requested
revenue is often for a lump sum, and then the lump sum total is used to
calculate the expenditures. Finally, because of the relatively small financial
costs associated with the project and the need for resources from an existing
program/organization (e.g., data collection staff, building), this project
budget also illustrates why projects often complement an organization’s core
business, rather than constituting the primary operations.

Annual Operating Budget

Because project-based funding is typically short-term, human service
organizations may engage in projects sporadically while focusing core
business around continuous and renewable types of programming. Often,
this means that funding is specified for a particular amount of time (typically
3 years or more), at the end of which, funding may be renewed. This type of
ongoing programming is often based on contractual agreements or awards
that have been granted by a contractor; however, it could also be based on
the development of fee-for-service programming. For instance, you could
receive a contract to provide family-focused treatment to women with HIV
and their children. Or you could operate an outpatient clinic to treat adults
with a variety of mental health challenges for which you receive third-party
reimbursement from insurance companies or accept cash from clients.
Regardless of the type of programming, from a financial perspective,
receiving long-term funding for various types of programming requires the
development of an annual operating budget. Similar to a project-based
budget, an annual operating budget allows you to identify the projected
expenditures and revenues over a 1-year time frame and provides ongoing
financial guidance to program administrators and staff. Different than most
project-based funding, funding for ongoing programs may be structured as a
per diem or lump-sum payment (as discussed earlier), and therefore, this
must be taken into consideration in the development of the budget. Table 9.4
provides an illustration of an annual operating budget.
Table 9.4 illustrates a fairly comprehensive annual operating budget for a
residential program. Several elements require further explanation to increase
understanding of the budget development process. The budget uses a line-
item format, with each line indicating one category of the budget (Raggio,
2004); however, it is based on the budget for one program—not an entire
organization. This particular example deals with a residential program that is
funded through a state contract. The pay structure is based on a per diem
cost paid per client, per day that the client is residing in the program. In
residential programs, a full per diem is typically paid only when the
individual remains in the program overnight, meaning that if a client enters
the program in the morning and is discharged in the evening before spending
the night, the organization is not eligible for full payment. Partial payment
may be made in this case, but full payment typically is not. Along these
same lines, the day that a client is discharged (exits) the program is typically
not considered a billable day, but rather the last full billable day would be
the preceding day in which the client spent the night in the home/facility.
This has significant implications for budgeting and is also why residential
programs refer to the number of beds filled in financial discussions.
The total amount of money available through the contract is $573,780
which is based on the residential program operating at full capacity (six
clients) for the entire year. In order to account for times that the program
may not be at capacity, a more conservative projection of revenue that the
program can expect to receive is used (80% or $459,024), which is based on
occupancy rates in comparable local programs that typically run between
80% to 86%. The purpose of this conservative projection is to ensure that the
expenses that are contained in the budget are realistically based on what the
program will receive in revenue. Eighty percent is determined not only to be
a more accurate financial projection but also to possibly provide an
additional protection against overspending—both of which are essential to
effective financial planning and management.
Table Annual Operating Budget Sample: Small Group Home for
9.4 Individuals With Dementia of the Alzheimer’s Type
 The budget is formatted so that revenue projections are at the top
followed by a separate area for projected expenditures. In addition to the
revenue that will come directly from the contract, it is also anticipated that
approximately $9,500 will be donated to the program through fundraising
activities. The estimate is conservative at $9,500 and is based solely on
anticipated cash donations (not donation of supplies or other tangibles).
Program leaders have a targeted first-year fundraising goal of $15,000, but
because the program is new and therefore not well known to community
members, $9,500 was projected in the budget as the minimum amount
anticipated. Whereas the revenues in this sample are solely based on one
contract and cash donations, other programs may receive revenue from
multiple sources. In addition, the payment levels may differ. What is most
critical is that in developing the annual operating budget, all potential
sources and levels of revenue are identified and sound projections of the
actual revenue anticipated for collection are made.
In the expense area of the operating budget, multiple items have been
identified. First, all the staff positions that support the program are listed. In
this section, you will see an expense, unit, and total, which each provide
more detailed information about each line item on the budget. The
administrator is listed as a half-time position (0.50 FTE), with FTE used to
denote full-time employment status. Because there is a full-time program
manager in place, this program is structured in a manner that allows for
administrative oversight at a part-time level. In addition to the full-time
program manager, there are eight other full-time employees that include one
case manager and seven treatment technicians. The case manager handles all
the resource coordination and overall case management activities, while the
treatment technicians compose the direct care staff that provides 24-hour
care and support to the clients. Because 11 of the employees assigned to the
program are either part-or full-time staff persons, payroll taxes and fringe
benefits for these employees must also be included in the expenses. Finally,
a part-time nurse is dedicated to the program (0.50 FTE), and a psychiatrist
is used by the program on a contractual basis. Because of the limited and
highly specific work performed by the psychiatrist—psychiatric evaluation,
medication monitoring, medical consultation—it is most appropriate from
both a logistical as well as financial perspective to engage the psychiatrist as
an independent contractor. A total amount of funding is specified in the
contract, which reflects an average of 4 hours per week that is paid only
upon completion of specific work. This type of employment relationship
allows for the provision of specific work and promotes increased
accountability—consistent with the specialized nature of the work. Finally,
and also related to staff expenses, professional liability insurance serves to
protect the organization against malpractice.
Each of the other expenses details the various costs associated with
operating a residential program in which you must provide for the day-to-
day support of individuals. All cost projections are annualized and include
direct care supports, such as groceries, utilities, and transportation; program-
related expenses, such as office supplies and computers; and joint expenses
(client and staff), such as the telephone.
Also highlighted in this budget, staffing expenses far outweigh
nonpersonnel-related expenses at a rate of more than five times more (as
discussed previously). Finally, the small gap between revenue and expenses
is important to note. Because the projected annual operating budget must be
based on the most accurate projections of both revenue and expenses, there
should be a very small gap between expenses and revenues, with more
revenue anticipated than expenses. This is because as a nonprofit operation,
the financial objective is to have a balanced budget that demonstrates that all
funds are dedicated directly to the program’s operations.

Multiyear Operating Budgets

Directly related to annual operating budgets, multiyear operating budgets
are generally created for long-term programming. The development of
multiyear budgets allows you to consider any financial changes that may be
planned from one year to the next (e.g., increased capacity) as well as
increases in funding that may occur from one year to the next (or conversely,
decreases in the budget). Multiyear budgets are typically developed for a 3-
year period. Multiyear budgets contain the same information as annual
operating budgets but with multiple years included, as well as all revenue
and expense projections associated with each year. In addition to the benefit
that multiyear budgets provide to long-term financial management, these
types of budgets can also be particularly helpful in spreading costs over time
for large purchases, such as a client information system or a building.
 Each of the three types of budgets is used for specific purposes, and as
such, each has unique and similar value. It is imperative that program
developers be familiar with all three and that program developers/mental
health professionals possess the necessary knowledge and skills to develop
program budgets.

Financial Management
The development of a sound initial budget sets the stage for effective
financial management to begin; however, it in no way ensures it. In fact, as
you have seen above, initial financial planning is largely based on the
identification of cost allocations that can most effectively support the
program or project while remaining within the anticipated revenue to be
received. In addition, it is based on the ability to make the most accurate
initial revenue and expense projections. Subsequently, sound financial
management is predicated on internal monitoring and reporting processes,
public reporting, and external oversight.

Internal Monitoring and Reporting Processes

Budget management (aka financial management of the program) is the
responsibility of the program administrator, and as such, the program
administrator (i.e., leader, manager, supervisor) must ensure that
mechanisms are created that enable close monitoring to occur. Whereas
individual programs and/or organizations may have either minimal standards
in place or quite elaborate systems, all program administrators should
minimally have several standards in place to aid in managing the budget.
Each of these standards is illustrated in Table 9.5, the Program
Administrator’s Financial Management Aid Checklist. The checklist can be
used as a tool to ensure that the necessary standards are in place.
Whereas at this point the importance of financial management knowledge
should be well appreciated, a bit of further elaboration on some of the items
identified in Table 9.5 might be helpful. As you can see, monitoring of
expenditures and revenues is the most critical aspect of financial
management. Program administrators must concern themselves equally with
financial management of their programs as they do with the clinical
operations, since these are interdependent activities. Ensuring that ad hoc
monitoring and review of expenditures occurs—meaning a quick review of
expenditures immediately following purchase and a comparison of the actual
with the projected expenditure—allows you to maintain an ongoing eye on
the budget, thus, allowing you to take action when necessary and avoid any
long-term buildup of financial issues that may present challenges more
difficult to overcome. This type of monitoring is simply absorbed into the
day-to-day activities of the manager and is an informal process. On a
monthly basis, all the financial activities of the previous month should be
reviewed with a comparison of actual versus projected revenues and
expenses. Any gaps that are identified between the two should require the
development and institution of a plan to resolve them during the following
month. Similar to ad hoc daily monitoring, this will help ensure that
financial issues can be quickly identified and resolved.
Table 9.5 Program Administrator’s Financial Management Aid Checklist

Financial Management Aid Status

Knowledge of financial planning and management                                 
Mechanism by which to ensure that all staff are trained
in financial management
Development of a program/organizational culture that
promotes a keen understanding of financial
management and the integral role it plays in
programming
Immediate and direct knowledge of all expenditures
and the rationale for the expenditures
Ad hoc comparisons of actual expenditures with
projected expenditures and an established plan to
compensate for any over-expenditures within the
shortest time frame possible
Monthly review of all revenues and expenses and
comparison to projections
Accounting protocols that include immediate and
complete follow-up for all uncollected revenues within
30 days of billing
Brief monthly review and reporting of expenditures
and revenues that includes plans to compensate for any
over-expenditures and/or collect any unpaid revenues
during the following month
Comprehensive formal quarterly reporting that includes
all elements of operations (e.g., program
implementation and outcomes, staffing and training,
budget and financial management)
Mechanisms in place to make any necessary
adjustments to the budget as a result of significant
changes to revenue or expenditures

On a more formal basis, quarterly reports should be developed that

provide for a comprehensive review of the program’s finances as part of a
more comprehensive program review. This type of formal and
comprehensive review allows for increased understanding of the essential
role that financial management plays in overall program implementation and
allows for broad-based discussion about the comprehensive program
operations. Whereas the development of a written report provides the
program administrator the necessary opportunity for a thorough review, how
this information is communicated both to staff and to superiors for additional
oversight and monitoring is equally important. In addition to the
dissemination of a written report, the information should be verbally
communicated and discussed with staff through staff meetings or other
communication forums. In addition, a venue should exist in which the report
can be presented to superiors for dialogue, oversight, and engagement in any
additional planning that might be needed to tackle any financial management
issues. The same format should be used on an annual basis, simply providing
for a review of the previous year rather than the previous quarter.
Each of the items identified in Table 9.5 accounts for internal practices
that together promote sound financial management. The use of these
protocols may work to create an environment in which the role of finance
remains central to program operations and that contains mechanisms by
which to effectively monitor finances and quickly resolve any issues so that
long-term program sustainability is not jeopardized.

The Role of the Board in Financial Management and Oversight

Because the board of directors plays a primary role in governance of the
organization, a key part of this oversight is related to the financial
management of the organization. Not only are boards responsible for
approving the policies of the organization, they also “share collective
responsibility for the fiscal and programmatic aspects of the organization’s
performance” (Gibelman & Furman, 2008, p. 75). As such, boards should
participate in the approval of all budgets. This may not be the case in many
organizations, but with increased scrutiny on the financial management of
organizations, board members should heed the current climate and become
much more effectively involved in financial decision making, particularly
since they can indeed be held accountable.
Since the inception of the Sarbanes-Oxley Act, board members have no
choice but to become much more involved in the ongoing oversight of their
organizations. Sarbanes-Oxley is guided by fiscal transparency. As such,
organizations that are mandated to comply with the law require that the chief
executive officer and the chief financial officer certify that the organization’s
financial statements are accurate (Grunewald, 2007), thus, this is an area that
the board is responsible for overseeing. Whereas board members may have
previously played a more minor role within certain human service
organizations, in the 21st century, such passivity is no longer possible.
Boards must ensure that the organization does indeed have the necessary
controls in place for effective financial management and that its role
provides for essential oversight that can stand the test of fiscal transparency.

Public Reporting
Whereas internal monitoring and review ensures that the program can be
effectively managed from a financial perspective, public reporting allows for
public disclosure of financial activities—a requirement for all nonprofit
organizations and publicly held companies. There are two primary methods
used for public reporting or public disclosure of finances of nonprofit social
service organizations. These include the annual report that is issued to
stakeholders and the tax return that is submitted to the IRS and is available
for public inspection. For nonprofit organizations, the tax form that must be
filed with the IRS is the 990.

Annual Report
The annual report is a written document that is published on an annual
basis to reflect financial and other relevant organizational information (e.g.,
types of programs, board of directors, donors). Whereas annual reports often
provide a venue for marketing and disseminating information about the
organization’s programs, clients, and staff, the annual report ultimately
provides a mechanism for disclosing financial information to the
organization’s stakeholders. As such, financial reporting can serve both as a
coordinating and monitoring function (Mayers, 2004). Annual reports are
typically available in both print and electronic format and often provide
straightforward yet comprehensive information about programs and
organizations.

Tax Return Documents

As stated earlier, nonprofit mental health and human service
organizations are exempted from payment of specific taxes and are thus
given the designation of tax exemption. Because of this tax-exemption
designation, these organizations are required to submit specific information
to the IRS, and the organizations must make specific information available
for public inspection. The following information from the IRS website
(www.irs.gov) further explains the rules for public disclosure:
An exempt organization must make available for public inspection and
copying its annual return…. Returns must be available for a three-year
period beginning with the due date of the return (including any
extension of time for filing). (IRS, 2010)

External Oversight
Both the annual report and the public disclosure rules related to the tax
returns of nonprofit social service organizations provide for public
disclosure of the organization’s finances. However, other mechanisms
provide for external oversight of the organization’s financial management:
regular auditing and state and federal tax filing, review, and possible audits.

Regularly Scheduled Auditing

For external oversight of financial activities, organizations hire
independent auditors for broad-based regular monitoring. Typically, auditors
review financial transactions on a regular basis (e.g., quarterly,
semiannually), requesting further information and follow-up and, ultimately,
certifying that the financial records have been independently reviewed. “The
audit is typically conducted by an independent public accounting firm that
applies appropriate industry accounting standards” (Gibelman & Furman,
2008, p. 65). The audit can be anxiety-producing for program developers,
administrators, and finance staff, but if an effective financial management
system is in place, major surprises should be greatly reduced (Lewis et al.,
2007). More significantly, external auditing protects the organization against
financial negligence or other troublesome issues while providing an added
layer of financial review that ultimately can further inform the organization’s
operations.
In addition to contributing to sound fiscal policy, regular audit reports are
also often required by funding sources both as a regulatory process and when
applying for new and/or continued funding. Also, audit reports may be
required by accrediting bodies as part of the comprehensive accreditation
review process.

Tax Return Process

Just as we all must file personal taxes on a regular basis, so must all
businesses file taxes. With regard to nonprofit mental health and human
service organizations, there are specific tax forms that must be filed. By
requiring this information, the federal government provides another layer of
oversight and review for the organization. Further, the government has the
ability to require further information or explanation, penalize the
organization, or take other action against the organization as a result of lack
of payment, falsification of information, or other problems with notification,
filing, or payment of taxes.
 As you can see, financial management is a complex process consisting of
multiple layers, each with its own attendant nuances. From internal
monitoring and reporting to public reporting and external oversight, each
aspect has its own unique yet overlapping role to play in the financial
management process of the organization.

Revenue Diversification and Financial Stability

In the previous chapter, we discussed the importance of revenue
diversification with regard to program sustainability; however, the role that
revenue diversification may play in the broader organizational stability is
even more significant. Revenue diversification simply refers to receiving
funding from multiple sources and, as such, may offer financial protection to
an organization—when diversification exists, the loss of funding from one
source does not necessarily equal a total loss of organizational funding. And
because the climate in mental health and human services in the 21st century
continues to be highly volatile, the protection organizations have may
indicate which ones will not only survive but thrive.
A modest body of research has been conducted on revenue diversification
and nonprofit organizations, with more recent findings consistently
indicating a positive relationship between diversification of revenue sources
and financial stability (Carroll & Stater, 2008; Frumkin & Keating, 2002;
Greenlee, 2002; Greenlee & Trussel, 2000; Keating, Fischer, Gordon, &
Greenlee, 2005). Frumkin and Keating identified revenue diversification as a
specific strategy to minimize financial volatility. Illustrating similar results,
Greenlee and Trussel and Greenlee found that revenue diversification
reduced the likelihood that an organization would experience a net loss over
several years or decrease its program expenses, both indicating the long-term
stability associated with revenue diversification. Keating et al. examined the
opposite of revenue diversification by evaluating the effects of revenue
concentration and found that such concentration leads to a significant decline
in revenue and much greater risk to the sustainability of the organization.
Finally, in one of the largest studies to date, Carroll and Stater (2008)
examined financial records of 294,543 public charities between 1991 and
2003 to better understand the relationship between revenue diversification
and nonprofit organizations. In short, the findings revealed that revenue
diversification promoted organizational sustainability and reduced financial
volatility and that, conversely, organizations relying primarily on
contributions experienced much greater instability. Interestingly, they also
found that larger, more growth-oriented nonprofit organizations experienced
much less volatility and that nonprofits located in urban areas had more
stable revenue over time, highlighting the notions that both size and place
matter. Therefore, there must be concerted efforts made to ensure that
financial planning and management emphasize revenue diversification and
continuous monitoring of the comprehensive revenue portfolio.

Developing the Budget

Equipped with both the knowledge and skills needed for initial financial
planning and financial management, you must take the first step and develop
the program budget. As with all other components of the comprehensive
program development model, the step involving budget development is
directly informed by previous steps. However, differing from other steps of
the planning process, developing the initial budget also requires some
knowledge of anticipated revenue, thus creating the need to be informed by
previous steps as well as subsequent steps in the planning process.
The degree of knowledge pertaining to projected revenue that can be used
to develop your initial budget will vary based on the type of program you are
proposing and the manner in which you are seeking funding. For instance, in
some program development efforts, the amount of available funding will be
known to you at the point of budget development. This is particularly true if
you are bidding on a contract offered by a local, state, or federal
governmental agency; philanthropic organization; or other contracting
agency. It may also be the case if you are applying for a project or program
through a grant process in which the amount of available funding has been
specified. Often in this case, funding parameters are provided that consist of
floors (i.e., lowest level of funding available) and ceilings (i.e., highest level
of funding available). Whereas these provide broad guidance for budget
development, it is up to you to identify the revenue target that will be used to
support expense projections. If you are proposing a new program in which a
specific call for proposals has not been issued, and you intend to pitch the
program to foundations and/or other funding organizations, you should base
your funding request on existing levels of funding supporting similar
programs. Thus, the results of the market analysis will be particularly useful
in determining costs and the subsequent funding request. So what all this
means is that in order to develop the initial budget, you must have a sound
understanding of what level of funding support may be available for your
program.
Once you have gained the necessary information regarding potential
available funding, you are able to use this information as the parameters to
develop the expense portion of the budget. Depending on the nature of
funding support that you are seeking, you will develop either a project
budget or an annual operating budget. In addition to an annual budget,
funding sources may also require that you submit a multiyear budget.

Revisiting the Logic Model and the Staffing Infrastructure

Equipped with this knowledge of potential available revenue, developing
the budget then requires specific work on the expense portion. Three specific
data sets that you previously compiled are needed to inform the expense
budget:
 

1. The logic model, outlining the program’s core components

(e.g., interventions, services)
2. The staffing infrastructure
3. The results of the market analysis
 
The staffing infrastructure is used specifically to determine costs
associated with the necessary staff positions, inform the number of each type
of position, and assign the status of each position (e.g., part-time). The
results of the market analysis should also be revisited here, particularly with
regard to staff pay. As such, it is helpful to use information regarding
potential competitor pay to inform your staffing pay structure, just as it is
necessary to fully understand the staffing qualification levels of competitors
for use in establishing your own.
 Expenses related to other aspects of the program should be informed by
the logic model to ensure that all costs associated with the program’s
implementation are effectively reflected in the expense budget. Again, this is
guided by the notion that the budget is simply an illustration of the clinical
program in financial terms. Clinical supplies such as assessment tools and
workbooks, office supplies and equipment, and accreditation fees are all
items that may be included in the “Supplies and Materials” section of the
budget, but again, each expense must be directly related to the program.
Moreover, each expense must be thoroughly justified as critical to program
implementation (e.g., intake assessment instruments) or program
sustainability (e.g., program evaluation materials, accreditation fees).
Once you have identified all necessary expenses and have computed total
expenditures, you are able to revisit and complete the revenue portion of the
budget. At this point, you will either be able to use the total expenses to
identify the total revenue needed to fully support your program, knowing
that you may need to pursue more than one funding source if your expense
needs far outweigh the available revenue, or use the gap in expense/revenue
projections to revise the expense budget. This type of interplay or back-and-
forth movement between the revenue and expense portion of the budget is
common and is an integral part of developing the initial budget. In addition
to the numerous learning benefits associated with the challenges of lining up
revenue and expense predictions, this process may result in the knowledge
that you simply cannot afford to engage in certain programming because the
gap between available revenue and the projected expenses is far too big.
It is also during this time of initial budget development that you should
work directly with a finance specialist, either through independent
consultation or through the organization, if you are part of a larger
organization with finance staff. Whereas it is essential that program
developers and administrators possess thorough knowledge of financial
planning and management, it is also necessary that individuals with
specialized financial knowledge and experience be utilized to provide input
to the initial budget. This simply ensures that you begin with the most
effective initial budget through expert review, consultation, and input.

Summary
Financial planning and financial management are indeed essential to
comprehensive program development. Engaging in initial budget
development allows for a much deeper understanding of the fundamental
relationship that exists between funding and programming and, as such,
provides the necessary context to fully appreciate not only the cost of
programming but the need for advocacy to maintain and/or increase funding
of specific treatment and/or services. This is knowledge not easily come by,
but once you are equipped, the relationship between what you do and how
you are able to do it can be significantly enhanced. Particularly in the mental
health and human services, the interdependent, at times frighteningly
tenuous relationship between funding and programming is one that is both
exciting and nail-bitingly frustrating. However, as clinicians and program
developers, it is our duty to be not only well informed but competent in all
aspects of program development, including finance, so that we can
effectively lend our voice to pivotal discussions regarding funding and
finances.
Unfortunately, I still hear clinicians stating, “This is too businesslike—I
am a clinician.” This is highly unfortunate for those speaking it, but more so,
this is unfortunate for us and for those whom we wish to serve. When
clinicians fail to recognize that mental health and human services are indeed
a business, they put our collective work in jeopardy and run the risk of
neglecting the individuals that they wish to treat and/or serve. In order for
any business to be successful, it must be well planned and effectively
managed, and financial planning and financial management are critical to
achieving this. Therefore, rather than viewing financial management as a
burden, we should view it as an essential component of our livelihood.
Moreover, the inability of any professional to successfully manage a
program and/or organization may have significant implications on the
industry as a whole, since financial support is almost solely provided by
public and/or philanthropic funding. Indeed, if we cannot prove that we can
effectively handle the funding that has been entrusted to us, future funding
may not be available to us. Knowing this, it is my hope that the last time I
heard a clinician disregard the need for business knowledge and skills was,
indeed, the last time.
 
 CASE ILLUSTRATION
Kathy and Judy recently were awarded a contract to provide vocational
assessment and employment placement services to individuals recently
displaced from the workforce. Because they had invested the necessary
amount of time and effort in the development of the budget, they were
confident that the program could be effectively implemented within the
projected cost parameters. But they wanted to ensure that they had
appropriate mechanisms in place to continuously monitor the program’s
finances. In addition, since they realized how important it was that they
had developed the budget—thus, allowing them to better understand all
the aspects of the new program—they wanted to involve the program
staff in the ongoing financial monitoring process. They knew that by
doing so, they would ensure that those most involved in the program
were able to also be engaged in this most essential aspect of the
program’s operations.
To accomplish this, they devised a plan that outlined the methods by
which the two of them, the staff, and the relevant stakeholders could
continuously examine and monitor the finances. The methods involved
the following:

A weekly report of service activity indicating all clients served,

types of services provided, and billed amounts to be compiled
by the Finance Department and distributed to all program staff
A biweekly report of outstanding payments to be compiled by
the Finance Department and distributed to all program staff
A biweekly budget report indicating all expenditures and
revenue to date to be compiled by the Finance staff and
distributed to all program staff
Weekly staff meetings facilitated by Judy and Kathy in which
all the financial reports would be discussed as part of the
overall program progress updates and ongoing program
planning efforts
 Time set aside during the staff meetings to develop strategies
for any adjustments that had to be made based on where the
program’s finances were in relation to the budget and
assignments of specific program staff to work directly with the
Finance staff to recoup any unpaid overdue bills
Purposefully integrating the program’s finances into other both
informal and formal dialogue with program staff
The adoption of a comprehensive quarterly report format that
tied finances directly to all other aspects of program operations,
compiled collaboratively by various members of the staff and
presented to the rest of the staff on a quarterly basis as well as
to the board of directors
Monthly meetings between the CFO and Kathy and Judy to
review and discuss the program’s finances
A requirement for Judy and Kathy, in concert with the CFO and
the CEO, to file a formal Financial Management Correction
Plan with the board any time the net balance of the budget fell
below 5%

By setting each of these activities in place, Kathy and Judy felt

confident that the financial management of the program would be
conducted in the most transparent manner. In addition, by involving all
program staff, they hoped that they would be taking an active step
toward improving the financial knowledge base of their staff, thus
promoting staff development while offering further protection to the
program’s operations. Finally, they believed that these activities would
promote significant accountability for the two of them, the program staff
and administrators, and the board—further ensuring fiscal integrity and
ongoing fiscal health.

 
PROGRAM BUDGET EXERCISE
 To consolidate all that you have learned about financial
planning, develop your own program budget. To do so, complete
the following steps:
 

1. Using the proposed program and organizational staffing

structure that you developed previously, develop the expense
portion of an annual operating budget.
2. Use the expense portion of the Annual Operating Budget
Sample provided in Table 9.4 as a guide to formatting your
budget.
3. In the expense budget, identify all staff positions with the
following information: number of each position, employment
status (e.g., full-time), pay, payroll taxes, fringe benefits, and
any other staff-related costs.
4. Identify all the supplies, materials, and other expenses
associated with the program.
5. Subtotal the “Staff” and “Supplies and Materials” expense
sections and provide a grand total.
6. Develop a brief summary (three pages or less) justifying each
of the costs associated with the program.

References
Carroll, D. A., & Stater, K. J. (2008). Revenue diversification in nonprofit
organizations: Does it lead to financial stability? Journal of Public
Administration Research and Theory, 19, 947–966.
Carver, J. (2006). Boards that make a difference: A new design for
leadership in nonprofit and public organizations (3rd ed.). San Francisco:
Jossey-Bass.
Frumkin, P., & Keating, E. (2002). The risks and rewards of nonprofit
revenue concentration (Working Paper).Cambridge, MA: Hauser Center
for Nonprofit Organizations.
Gibelman, M., & Furman, R. (2008). Navigating human service
organizations. Chicago: Lyceum.
Greenlee, J. (2002). Revisiting the prediction of financial vulnerability.
Nonprofit Management and Leadership, 13, 17–31.
Greenlee, J., & Trussell, J. (2000). Estimating the financial vulnerability of
charitable organizations. Nonprofit Management and Leadership, 11,
199–210.
Grunewald, D. (2007). The Sarbanes-Oxley Act will change the governance
of nonprofit organizations. Journal of Business Ethics, 80, 399–401.
Horejsi, C. R., & Garthwait, C. L. (2004). The social work practicum: A
guide and workbook for students (3rd ed.). Boston: Allyn & Bacon.
Internal Revenue Service. (2010). Exempt organizations: Documents subject
to public disclosure. Retrieved September 13, 2010, from
http://www.irs.gov/charities/article/0, id=135008,00.html
Katz, R. D. (2005). The not-for-profit sector: No longer about just raising
funds. Journal of Private Equity, 8, 110–113.
Keating, E., Fischer, M., Gordon, T., & Greenlee, J. (2005). Assessing
financial vulnerability in the nonprofit sector (Working Paper No.
27).Cambridge, MA: Hauser Center for Nonprofit Organizations.
Kettner, P. M., Moroney, R. M., & Martin, L. L. (2008). Designing and
managing programs: An effectiveness-based approach. Thousand Oaks,
CA: Sage.
Lewis, J. A., Packard, T. R., & Lewis, M. D. (2007). Management of human
service programs (4th ed.). Belmont, CA: Thomson Learning.
Mayers, R. S. (2004). Financial management for nonprofit human service
agencies (2nd ed.). Springfield, IL: Charles C. Thomas.
Raggio, D. (2004). Fostering career paths to independence: Model proposal.
Unpublished manuscript, San Diego State University.
 CHAPTER 10
Develop the Proposal

 
Learning Objectives
 

1. Discuss methods that can be used to justify professional and/or

organizational capability
2. Explain the differences between a grant writer and a program developer
3. Identify three skills of proposal writing
4. Discuss the role of collaboration with partners and or other providers in
proposal development
5. Discuss the purpose of including letters of support in proposals
6. Explain how each of the preceding steps of the comprehensive program
development model relates to proposal development

 
HOW DIFFICULT CAN THIS BE?
Dan had been the director of mental health and substance abuse
treatment at a large nonprofit outpatient clinic for the past 4 years; over
the past 2 years, revenue had declined by 10%. Because of this decline in
revenue, Dan was interested in looking for new business and possibly
branching out into a new area. With the recent legislative changes that
had created an onslaught of casinos in the area and with new state
monies allocated to gambling addiction prevention and treatment, Dan
was particularly interested in exploring funding for the treatment of
gambling addiction, even though this was not an area in which he or
anyone in his office specialized.
When a Request for Proposal (RFP) was issued by the state for a
gambling addiction treatment program, Dan was immediately interested
in pursuing it. Because Dan’s clinic worked directly with insurance
companies and individuals who privately paid, no one in the clinic had
experience developing a proposal. Dan did not think this was necessarily
a barrier, and in fact, he thought, How difficult could it be?-especially
since the proposal was not due for 3 weeks, and Joe knew he could
probably take care of it much quicker than that. Rather than make more
of it than need be, Dan decided to finish up with some other projects he
had been working on and take care of the proposal the following week.
When Dan started working on the proposal, he was surprised at the
level of detail that was required. The proposal requirements included a
review of literature on gambling addiction treatment, the use of an
evidence-based model to treat gambling addiction, and identification of
staff with appropriate credentials to provide the treatment. Although Dan
felt as though he was in over his head, he had already told his president
and staff that he was going to take care of this proposal-not to mention
the fact that he had also assured them that it would be a “piece of cake.”
Because Dan still had his own clients to see and supervision sessions
to facilitate, in addition to his other administrative duties, he spent the
next 10 days working late into the night trying to learn all he could about
gambling addiction. He was able to piece together a literature review and
a basic program design. Since he did not know anyone who specialized
in gambling addiction, he put together a basic organizational chart,
stating that clinicians with specific experience in gambling addiction
would be hired once the program received funding. The day before the
proposal was due, Dan was exhausted. Although he realized the proposal
was weak, he was determined to see it through; so he quickly read the
 submission instructions and took another glance at the proposal
requirements. Staring him in the face was the requirement for a budget
narrative report, detailing each budget item. Dan thought, How did I miss
this? Then his eyes landed on another requirement that he had missed:
three letters of support! Dan thought he could probably knock out the
budget narrative that day, but how in the world would he get three letters
of support by the next day? Plus, he questioned whether he was even
comfortable asking anyone to write a letter with such short notice. Dan
decided he would go ahead and submit the proposal without the letters of
support and claim ignorance if asked about them-after all, how much
bearing could they have on the proposal? The county needed someone to
provide the treatment, and he was willing to do it. Dan was excited when
he received a letter back from the county a week later, and he quickly
opened it. The letter indicated that his proposal would not be reviewed
since it had failed to meet the basic requirements outlined in the RFP,
which included a list of key staff persons and their credentials and three
letters of support.

 
CONSIDERING DAN

1. What mistakes did Dan make, and how could he have avoided them?
2. What did this failed project cost Joe and his clinic, both in terms of
concrete costs and other costs?
3. What advice would you give Dan about developing a proposal in the
future?

About This Chapter

This chapter is specifically dedicated to the proposal development process
and the various factors that are related to this all-important step. Just as was
the case with Steps VI and VII, the order of Steps VII and VIII should not
necessarily be viewed as fixed since in some cases, Step VII (Develop the
Financial Management Plan) may be completed after developing the
proposal. As such, the sequence in which these steps occur may differ for
each new project, depending on how you move forward in the program
development process. But this step does presume that Step VI (Identify and
Evaluate Potential Funding Sources) is complete and, therefore, picks up
from the point when a viable funding opportunity has been identified.
Since proposal writing has become a relatively big business associated
with the human services field—with numerous how-to books written on the
subject, a regular flurry of grant-writing workshops offered across the
country, and an endless number of grant writers available for hire—the intent
of this chapter is not to provide a how-to on proposal development. Rather,
this chapter is designed to investigate the proposal development process to
increase your knowledge about all that developing the proposal entails.
This investigation begins with an examination of several considerations
of proposal development, including time needed in proposal development,
the depth of material required in a proposal, the importance of justifying
professional and/or organizational capability to effectively implement the
proposed project or program, the role of collaboration in proposal
development, and the purpose of and need for letters of support.
Following this discussion, we will explore several major aspects of
proposal development, including the use of grant writers versus program
developers in proposal development, planning the work of proposal
development, skills of proposal writing, the use of internal reviewers, and
other considerations in proposal development. Finally, a case illustration will
reinforce the chapter’s key points.

STEP VIII: DEVELOP THE PROPOSAL

Developing the Proposal
Have you ever heard this? “This opportunity looks perfect for us—we can do
this!” or “If they were able to get funding for that, we certainly can.” How
about this one? “How could we not have been selected?” or “I cannot
believe they did not find our program worthy of funding.” Unfortunately,
these are all common exhortations in the world of funding for the human
services. Too often, the process of securing funding for mental health and
human service programs is underestimated, and as a result, individuals often
believe that doing so does not present too difficult a challenge. As a result of
underestimating the rigor involved in the proposal process, applicants may
become quite upset when they are not awarded funding—as Dan learned. As
Dan also learned, you must follow the guidelines of a proposal if you are
interested in having it reviewed. Indeed, one of the major reasons behind
rejection of proposals is simply failure to follow the instructions (New,
2001).
Engaging in due diligence with regard to exploring and identifying the
most appropriate funding opportunities to pursue ensures that, minimally,
you will be investing your time wisely when you do decide to apply for
funding. But these are only the initial steps, whereas actually developing the
proposal for funding is the final step toward potentially securing funding.
When you are interested in pursuing funding for program development
and/or research activities, there are several issues that require serious
consideration: the time required to develop a proposal, the depth of material
needed for the proposal, justification of professional and/or organizational
capability to effectively implement a program, the role of collaboration in
proposal development, and letters of support.

Time Considerations in Proposal Development

Developing a grant proposal for a mental health or human service
program or project is a time-consuming process that requires a tremendous
amount of work. Whereas the precise extent of a grant proposal is often
dictated by the specific funding source, I would estimate that many medium-
to large-scale proposals (i.e., awards of $100,000 per year or more) may
require anywhere from 1 to 6 months (Devine, 2009) and from 40 to 100
hours to complete. For most of us, that means that we must plan for at least 1
month of our work year to be dedicated to proposal development. And this is
typically spread over a greater amount of time, since often only a portion of
our workload can be dedicated to grant writing because of our other regular
duties. Indeed, when I have the luxury of spending 8 hours a week on a grant
proposal, I am happiest, because I know that I should be able to steadily
complete it in about 4 weeks. Having said this, please note that these are
simply broad time parameters since there is so much variation in the types of
proposals required for specific funding opportunities.
 In addition, the specific type of funding opportunity often dictates the
time frame involved in completion of a proposal. In fact, there are basically
three types of funding opportunity specific to time frames for accepting
applications:
 

1. Open application periods, which are most common to funding

opportunities from philanthropic organizations
2. Continuous funding opportunities with annual submission
deadlines, which are common in clinical research grants and
also tied to specific continuously funded areas of interest of
philanthropic organizations
3. Funding opportunities with specific submission deadlines,
which may be released one time only or on an annual basis for
more than 1 year
 
Many funding opportunities offered by the county, state, and federal
governments to mental health and human service programs fall into this third
category, with very specific submission deadlines. Unfortunately, it is not
uncommon for there to be a time frame of 6 weeks or less from the time a
funding opportunity is announced to the time applications are due. This often
means that the application must be completed quickly and also reinforces
viewing proposal development as part of one’s regular workload.
Particularly in the case of very short time frames for completion of
applications, proposal development must temporarily become the work
priority—an easier pill to swallow if these activities are already considered
part of your regular activities.
Of course, developing grant proposals often requires the input of more
than one person and, therefore, it is not only the time of the individual
leading the proposal development that is of issue but the time of everyone
who is involved in the process. And because of the complex nature of some
proposals, more than one person is needed to plan and carry out the writing
(Homan, 2004). The issue of time is probably one of the most surprising
aspects to first-time proposal developers. This may be particularly true for
those of us who have been conditioned to think, “It has a 30-page limit, so it
couldn’t possibly require too much time or be too difficult—I have written
longer papers in school for just one minor assignment.” Indeed, page limits
can seem like a positive aspect insofar as they should reflect the degree of
time required; however, the old adage about quality not quantity fits well
here. Similar to any effective research paper, in developing a sophisticated
piece of writing, the amount of words and pages is not necessarily an
accurate reflection of the depth of the material. Therefore, appreciation for
the complexity involved in most grant proposals and the need for sufficient
time to do an adequate job is crucial.

Depth of the Proposal

Another aspect that often surprises first-time proposal developers is the
fact that page limits may refer to the narrative portion of the proposal and
not to other required documents. Often, other documents may need to be
developed to be submitted with the proposal. These additional documents
may include

budgets,
biographical sketches of key program staff,
job descriptions,
organizational charts,
project timelines, and
logic models.

These documents often are attachments to the narrative, and each may
require a good deal of time to develop. In addition, existing documents about
the applicant organization and proposed project staff may need to be
gathered to be included as part of the appendix. These may include such
items as

resumes,
past financial statements,
verification of business status,
 certifications,
professional and/or program licensure,
verification of accreditation status, and
other existing documents.

Finally, documents from potential collaborators, supporters, and/or other

authorizing agents may need to be requested and provided with the proposal.
These may include

letters of support,
memoranda of understanding or agreement indicating
collaborative partners, and
approval by authorizing agencies or general support for the
program/project.

These documents can require a great deal of time and energy since they
are predicated on not only existing but supportive relationships with other
organizations. Therefore, if these relationships are not already in place, it
may prove a barrier to meeting this requirement based on the time frame in
which the proposal must be developed.
To better illustrate the amount of material that may be required in a
proposal, what follows is an example of a funding opportunity for mental
health and substance abuse services, authorized by the Department of Health
and Human Services, Substance Abuse and Mental Health Services
Administration (SAMHSA; 2009):

Application format requirements

Application face page
Table of contents
PHS 5161–1 HHS checklist
Budget
Budget justification
Staffing plan/personnel requirements
Assurances
 Certifications
Project abstract
Program narrative
Program-specific forms (e.g., logic model, organizational chart)
Attachments

As you can see, the application requires far more than a narrative of the
program, and in fact, the narrative is simply listed as one of the required
documents for this proposal.
In addition to the various documents that are needed for a comprehensive
proposal, funders may specify program-specific requirements that must be
met, some of which are very focused. For instance, see the following excerpt
from the funding opportunity discussed above:
Applicants for this funding opportunity are expected to (1) describe
the target population and its need for mental health/substance abuse
services; (2) present a service delivery plan that demonstrates
responsiveness to the identified needs of the target population; and (3)
present a sound business plan that links the goals and objectives from
the service delivery plan to the budget. … The populations served by
these programs are medically underserved populations in urban and
rural areas; migratory and seasonal agricultural workers and their
families; homeless people, including children and families; and
residents of publicly-subsidized housing. (SAMHSA, 2009)
As you can see, this snapshot of some of the requirements provides a
great deal of essential information critical to proposal development. As such,
the funding source has communicated pertinent information about the
opportunity to the applicant, including the

defined target population,

need for applicants to provide evidence of the target
population’s needs for services,
requirement that applicants produce a sound program model to
effectively address the needs of the target population, and
 requirement that applicants develop a comprehensive budget
that directly relates to program implementation.

Although this information may have been communicated very concisely,

you can see just how detailed it is. Essentially, you should usually be able to
review this type of snapshot—common to funding opportunities—and gain a
firm understanding of the specific funding opportunity.
After viewing both of the requirement sections of this funding
opportunity, you should note that all the requirements have already been
covered in this text, including identifying and justifying a target population,
providing evidence of need, designing a program model and implementation
plan, determining staffing structure and requirements, setting a budget that is
tied directly to program implementation and outcomes, and providing budget
justification. This further reinforces the effectiveness and relevance of the
comprehensive program development model presented in this text and again
reflects the need for this type of systematic approach to this work.
In their discussion of the merits of a proposal, Lewis, Packard, and Lewis
(2007) identify several questions that may be useful in evaluating a proposal:

How well does the applicant demonstrate that there is a real

need for the proposed project?
How clear and attainable are the project’s objectives?
Does the proposal spell out a plan of action that suits project
goals and objectives?
Is the program model supported by research and best practices?
Is the applying agency likely to be able to carry out the
proposed project and meet the specified goals within the
suggested time frame?
Is the budget clearly thought out and appropriate for the scope
of the project?
Are plans for evaluation and dissemination well documented,
feasible, and appropriate?
 If you understand the amount of material needed in most grant proposals,
it is much easier to appreciate the amount of time and work required to
complete this process. At this point, though, I do want to remind you that
this discussion of developing grant proposals solely pertains to
program/project-based and clinical research-based grants—consistent with
the focus of the book. Because other types of funding exist for equipment
and other non-program/project/research grants and because the process for
applying for such funds is much different (i.e., much less rigorous), it is
important to clarify the difference here so that you fully understand the type
of grant proposals to which this chapter (and book) is referring.
The development of program/project grant proposals is indeed a
tremendous undertaking, particularly with regard to time considerations and
the volume of work involved. In addition to these two key considerations,
applicants must consider if they have both the organizational and
professional/individual capability needed to justify that they are capable of
successfully implementing a proposed program.

Justifying Professional and Organizational Capability

A key requirement of most funding opportunities is that justification is
provided as to the capability of both the organization and a lead
individual/other staff to carry out the intended project. In terms of
organizational capability, this is typically provided by official documents
that verify an organization’s corporate status; board of directors; fiscal health
and banking status; administrative staffing structure; licensure and/or other
relevant credentials; accreditation status; facility; hardware, software,
Internet, and other communication and electronic capabilities; and other
relevant aspects of the business. For each of these factors, you maybe
required to provide evidence of the organization’s functional status as an
eligible entity and one that has the organizational capabilities to implement
the proposed project based on previous business experience.
Whereas official documents provide justification of organizational
capability, other types of evidence are needed to prove that the applicant has
an individual capable of carrying out the proposed project. This individual is
usually referred to as the project director or principal investigator and is an
essential requirement of most funding opportunities. While organizational
capability is a prerequisite to apply for funding, identifying an individual
who is fully capable of leading the project is equally necessary. Again,
depending on the type of funding opportunity you are pursuing, the
requirements of the project leader will vary.
Funding sources are understandably concerned that their funds are
awarded to applicants that present the least risk—or put more positively, to
applicants that seem the most likely to effectively utilize the funds. This
seems perfectly reasonable since, to a funding source, every award is a
financial investment; therefore, officials of the funding agency are most
concerned with yielding the greatest return from each investment. One of the
criteria by which the funding agency attempts to evaluate this is based on the
experience and credentials of the project leader and other key members of
the program/project staff. In fact, for specific types of clinically based and
research proposals, reviewers may look specifically at the expertise and
publication record of the applicant and any other key individuals who are a
part of the project team (Kessel, 2006), whereas for other program- and
project-based proposals, reviewers will be most interested in the relevant
work experience of the applicants. While a sound program design is a
necessity for a successful proposal, demonstrating expertise is a crucial part
of selling your proposal; therefore, having both the right project leader and
also experienced team members may greatly improve your proposal
(Zlowodzki, Jonsson, Kregor, & Bhandari, 2007).
This means that applicants must provide evidence that the project team
does indeed have sufficient knowledge and skills to effectively coordinate
and implement the proposed project. Evidence of this can be provided in
several ways, which may include any and all of the following, depending on
the funding opportunity:

The project leader’s resume documenting academic and

professional credentials and relevant experience
A biographical sketch documenting additional and more
detailed relevant knowledge, skills, and experience
A record of scholarly publishing in the relevant area
Documentation of experience with past funding opportunities
 Each of these may provide justification that the project team has specific
knowledge and skills and, possibly, expertise in the identified area—
precisely what funders wish to know.
However, in addition to establishing the capabilities of the professionals
involved in the proposed program, funders are also interested in knowing
that the organization is appropriately structured to effectively implement the
program. A number of factors typically are reviewed to establish
organizational capability, such as the length of time in business,
organizational licensure and/or certifications, accreditation, and funding
history. Recall the list of attachments provided, as many of these were
already cited, and thus, documents such as these are often required to
provide evidence that the organization is capable of carrying out the
proposed plan. One other specific and highly common requirement that
speaks to organizational capability is the letters of support from peer
organizations, other contractors, or other key officials.

Letters of Support
Often, three or more letters of support are required with submission of a
proposal. The purpose of the letters of support is to provide additional
evidence that the organization and/or the program staff are qualified for the
proposal. Therefore, letters of support should be requested from those that
are in a position to provide such information. Other contractors with whom
the organization is currently doing or has done business are often the most
relevant source to provide letters since they have firsthand knowledge of the
organization/staff performance. In addition, peer agencies with whom your
organization has worked collaboratively form a second group whose letters
of support may be particularly meaningful since they, too, are in a position to
directly attest to your organization’s past performance. When collaboration
with other organizations has not occurred, peer organizations may still prove
valuable in providing a letter of support; however, a stronger level of support
can be provided by those that have direct knowledge of your past
performance.
The letter of support is typically used to provide another level of evidence
of the program team and/or organization’s ability to successfully implement
the proposal, hence such should be the primary objective of the letter. Other
information that provides further context to the letter of support is also
helpful, such as

length of time the support writer has worked with/known you or

your organization,
existing and/or past focus of the business relationship, and
specific reasons why the writer believes you/your organization
is uniquely qualified for the project.

Whereas letters of support from colleagues at peer organizations are

especially helpful, acquiring them and letters from contractors may at times
prove challenging. This is often the case when peer organizations and/or
contractors are pursuing the same funding opportunity as you; thus, they are
competing against you and likely not interested in supporting you in the
competition. In addition, when two or more organizations that a funder
contracts are pursuing the same opportunity, the contractor may be
comfortable supporting only one or may simply decide not to support either.
As a result, obtaining letters of support can indeed come with its own set of
challenges. But being in a position to even request such a letter is primarily
based on having established effective business relationships with
contractors, peer organizations, and other key resources. This again
highlights the purpose of identifying and engaging community resources
(previously discussed in Chapter 7) and building and preserving these
relationships (Chapter 13).

Collaboration
As discussed previously, collaboration in new program development
efforts is more common in the 21st century than ever before (Donahue,
Lanzara, & Felton, 2006). In fact, foundations and government agencies look
favorably on collaborative efforts (Klein, 2000; Quick & New, 2000), and
today, some funding opportunities are specifically limited to collaborative
efforts. Engaging in collaborative efforts may strengthen a proposal—
especially when, through collaboration, essential resources can be shared,
thus increasing organizational capability and justification. However, when
developing a proposal for a collaborative effort, it is imperative that the
relationship between the two or more organizations be clearly defined during
the proposal development step, if not before. This includes but is not limited
to establishing the following:

The applicant/lead organization

Work expectations for each organization
Time frames for delivery of specific activities and specific
deliverables
Communication expectations
Payment expectations

To discuss each briefly, most funding sources require that one

organization and individual be assigned the role of applicant for the funding
opportunity, taking responsibility as both the primary contact person and the
individual and organization ultimately responsible for effectively utilizing
the funding provided. As a result, the applicant organization is the direct
payee of the funder (i.e., fiduciary), and thus, any collaborating partners
become subcontractors of the applicant organization. Therefore, because
collaborating organizations are embarking on a joint business venture, it
behooves the organizations to clearly identify the role that each will play,
specifying the work activities to be performed by each as well as the time
frames in which certain activities will be accomplished and any deliverables,
such as reports, data, and other documentation, will be completed. The role
and work expectations are directly tied to payment. In addition, expectations
about communication should be outlined to establish types (e.g., telephone,
e-mail, meetings) and frequency of communication. A formal contract
should be drafted to articulate all these expectations and to also address
issues related to dissolving the relationship. However, the contract is
typically maintained between the collaborating organizations, while a
Memorandum of Understanding/Agreement is the document that is prepared
and signed for submission with the proposal. The Memo of
Understanding/Agreement is usually required by the funding agency to
provide evidence of the collaboration and captures the basic primary aspects
of the contract. The Memo of Understanding/Agreement does not include all
the details contained in the contract that are particularly necessary to
establish the business relationship between the collaborating organizations
but, rather, includes the basic facts of the relationship.
In addition to clearly defining the roles and expectations of collaborating
organizations, collaborative organizations often wish to either jointly
develop the proposal and/or provide significant input to the proposal. Like
all collaborative development projects, working together on a grant proposal
requires negotiation of roles, consensus building, and solid interpersonal
skills in order to develop the best product that reflects shared ownership.
Fortunately, these are skills that most counselors and other mental health
professionals naturally possess.
Each of these issues—time considerations, depth of material needed,
justifying professional/organizational capability, letters of support, and
collaboration—must be given considerable thought when developing a
proposal. Each of the issues may have specific ramifications for the proposal
development process and, ultimately, for the proposal outcome; therefore, it
is essential that each is given attention before and during the proposal
development process.

Major Aspects of Proposal Development

In addition to the factors outlined above, there are also a great many aspects
of proposal development that should be examined. In particular, there are
four that I would like to specifically discuss here, because they are more
universal in nature than others. These are
 

1. the use of grant writers or program developers,

2. planning for the work of proposal development,
3. the skills needed in proposal writing, and
4. the use of internal reviewers.
 

To begin this discussion, let’s first tackle the issue of using external grant
writers versus internal program developers to develop the grant proposal.
Internal Versus External Grant Writers/Proposal Developers
Because I am using the term grant writer here, I do want to again clarify
that I am speaking solely about grant writing for program/project
development and not for fundraising or other charitable giving activities—an
important distinction to make. Particularly with the number of grant-writing
workshops and consultation services available today, organizations may
struggle with deciding whether they should hire a grant writer to develop
their proposal or write their proposals independently—with valid reasons for
doing both.
As such, reasons for hiring a grant writer may include, but are not
necessarily limited to,

not having an employee on staff that might be capable of

developing a proposal,
not being able to allow an existing staff person to take time
away from other duties in order to develop a proposal,
wishing to utilize someone with prior experience in
successfully securing funding in hopes of increasing the
organization’s chance of securing grant funding, and
utilizing a grant writer for assistance in developing initial
proposals so that existing employees can begin to learn to
develop their own proposals.

As you can see, organizations may decide to hire a grant writer for
various reasons. In addition, some organizations may choose to contract with
a grant writer for specific projects or on a part- or full-time basis.
Organizations that employ a grant writer part- or full-time may also decide
to contract a grant writer for a specific project, especially if it involves new
territory for the organization or the organization’s leaders feel that a grant
writer’s services may be especially needed for a certain proposal.
However, whereas hiring a grant writer often makes sense for an
organization, today’s program developers/mental health professionals should
know how to develop their own proposals. Just as mental health
professionals must be competent at developing their own budgets, managing
the finances of their program, developing job descriptions, and hiring staff,
proposal development skills compose another essential aspect of the 21st-
century mental health professional. This does not mean that external grant
writers cannot be used to provide additional support and guidance,
particularly as one is learning to become effective in proposal development,
but it does mean that external grant writers should not be used instead of
program developers but in addition to, as needed.
This is especially true since, unlike finance and human resource
personnel that are specially credentialed and needed to serve a core function
within an organization, there are no specific credentials for grant writers.
Rather, grant-writing skills are learned and, therefore, can be acquired by
anyone and particularly by mental health professionals. In addition,
someone’s success in securing past funding for a specific type of program
does not necessarily translate into success in securing grants in other areas or
in the future. Consider the major aspects of a proposal that were examined
earlier—depth of material, justification of personal and organizational
capability, letters of support, and collaboration. None of these major aspects
of a proposal has to do with writing skills but, rather, with having specific
structure and knowledge in place that can be utilized to make an effective
argument. Therefore, while an external grant writer may be able to provide
the narrative of a proposal, s/he can only do so based on work that has
already been done or is being accomplished by the organization and, as such,
is not creating but rather stating what the organization has done/plans to do.
In addition, hiring a grant writer may mean that an organization will miss
an opportunity for organizational engagement. This is because when
someone outside the organization is hired to perform work that will
ultimately be done within the organization, the initial opportunity to engage
staff in the project may be lost. This is no different than any time that
someone external is brought in to perform specific work or to do something
that is part of the organization. Therefore, unless organizational leaders are
purposeful in their efforts to involve key staff in the grant-writing process, it
is unlikely that the staff will feel engaged in or connected to the project.
Unfortunately, this lack of engagement at the proposal development stage
can result in a lack of engagement in the project if and when it’s funded.
 Finally, whereas for some organizations, hiring an external grant writer is
simply a question of economics—Can we afford to hire this person or not?
—for others, it is a question of hedging the bet and trying to minimize risk—
ensuring that you hire the best person for the job and achieve the right
outcome. Both of these can come with significant financial risk to the
organization since most organizations have to pay for grant-writing services
regardless of the success or lack thereof of the proposal being funded. While
this is perfectly understandable, it does raise the issue of using a pay
structure that can both reduce financial risk to the organization and reward
positive outcomes. For instance, organizations that do wish to hire a grant
writer should consider a two-tier pay structure: a minimum amount down for
proposal development and submission and a second payout if the proposal is
funded. By doing this, organizations would be in a position to negotiate their
financial risk—an issue made more critical today within the climate of
shrinking dollars.
For each of these reasons and more, it makes most sense to view grant
writing/proposal writing as simply a component of comprehensive program
development and not as an activity to be done solely by individuals external
to the organization. By doing so, mental health professionals are able to
expand their repertoire and learn to effectively articulate the reasons that
their programs should be funded—an essential part of program development.
Interestingly, just as securing funding is essential to the survival of
mental health and human service providers, it is often equally important to
researchers. As a result and in order to ensure that young researchers are
equipped with the ability to develop their own proposals, colleges (Blair,
Cline, & Bowen, 2007) and professional associations (Kessel, 2006) have
provided specific instruction in this area. In fact, Jacksonville State
University developed three new courses for its undergraduate biology
students to increase knowledge and skills related to developing effective
research designs and proposals. And Kessel, writing for the American
College of Chest Physicians, not only provides a highly useful article about
grant writing across disciplines but also includes some simple tips for grant
writers, such as

check out the websites of grant-making agencies for tips,

 have your proposal reviewed before submission, and
attempt to participate on the review panel of a funding agency
to learn more about the evaluation process.

By taking these extra steps, professions outside mental health are

reinforcing the necessity of grant-writing skills for their colleagues—a
necessity that mental health professions share. Therefore, we must have the
same expectations for ourselves and ensure that we, too, have mechanisms in
place by which to teach grant-writing skills.

Planning for the Work

Because developing a proposal is often such a tremendous undertaking,
effective planning is crucial to successful proposal development. This is
particularly necessary given the aggressive deadlines associated with many
funding opportunities. First and foremost, long before you prepare to
develop an application for funding, you must garner support from
administrators and other organizational leaders. This will ensure (1) that you
do not waste any time pursuing something that you may not be able to
complete after an initial investment of time and energy, (2) that you have the
necessary resources to effectively complete the proposal, and (3) that you are
able to devote sufficient time to completing the proposal.
Once you have received support for the project, there are several
logistical aspects of planning that must be considered. Because developing a
proposal often requires the input of other individuals—in addition to the
program developer—it is necessary to treat the proposal development
process as you would any type of time-limited project. This typically means
ensuring that everyone with a need to know understands the expectations for
the proposal development project and that concrete plans are in place to see
the process to completion. Often, this minimally involves the following
steps:

Identify all the individuals that will need to be involved in the

proposal development, including internal reviewers and
professionals from collaborating organizations.
 Hold an initial meeting to discuss the proposal, develop a plan
for completion, and clarify the roles that each individual will
have in the proposal development process.
Schedule time to complete the proposal based on the proposal
deadline.
Schedule an update (if needed) and final meeting with all the
involved individuals to review progress and finalize the
proposal.

Skills of Proposal Writing

Specific skills are needed for successful proposal writing. These include
both priority skills that are based on comprehensive program development
and secondary skills that are needed to complete the proposal. Priority skills
refer to the activities that have been previously completed in the program
development model, including the following:

Ability to develop a rationale for the program/project through

identifying a need and target population
Ability to establish a research basis for program design to
effectively address the needs
Ability to identify and incorporate multicultural aspects in
program design
Ability to design an effective clinical program
Ability to design a staffing and organizational structure to
effectively implement the program
Ability to plan an effective budget that directly ties program
interventions to outcomes
Ability to design an evaluation program that effectively
assesses the program

Each of these skills directly corresponds with a previous step already

covered in the text, with the exception of Step X (Evaluate the Program),
which is covered in Chapter 12. See Table 10.1 for an illustration of this
connection.
Table 10.1 Priority Skills and Corresponding Program Development Steps

As you can see, the priority skills are simply the basic skills that program
developers must possess. Therefore, mental health professionals who possess
these skills will find that they already have the most critical skills needed to
develop a successful grant proposal. You will note that none of these skills
refers to writing but, rather, to possessing a sophisticated level of knowledge
and skills.
 Secondary skills refer to additional skills needed for successful proposal
development. Unlike the priority skills listed above, secondary skills refer to
writing and other logistical aspects of proposal development that include
such issues as articulation, flow of ideas, organizing the proposal, and
compliance with proposal requirements (see Box 10.1).
 
BOX 10.1

SECONDARY SKILLS FOR WRITING A SUCCESSFUL

PROPOSAL

Review all application instructions thoroughly to gain a firm

understanding of content and submission requirements.
Determine if any presubmission steps are required prior to application
submission, and complete these steps.
Write in an articulate and concise manner.
Ensure that there is an effective flow of ideas that is directional,
beginning with justification for the project, then the project description,
and then the project outcomes.
Communicate a firm understanding of what the funding source is
looking for—speak the language of the funding source, as applicable.
Develop all required tools and other documents.
Collect and compile other required documents.
After completing the application, conduct a thorough review to ensure
that you have completed all required documents.
Read the entire proposal packet personally in order to critically
evaluate it, paying special attention to the following: thoroughness in
responding to all content requirements, soundness of proposal, flow of
information throughout the proposal, and justification for budget and
plan given the identified scope of problem/identified needs.
 

In addition, successful grant writing requires significant preparation and

deep knowledge about not only the proposed program but what other
research or programs have previously been funded and how to speak directly
to the grant maker’s interests (Devine, 2009). Finally, the use of a team
approach to grant writing may prove successful to the proposal development
process (Miller, 2008). In addition to scholarly articles, books, and tips from
professional associations, there are several web-based resources that may be
helpful to the proposal development process (see Box 10.2).
 
BOX 10.2

WEB RESOURCES FOR PROPOSAL WRITING

Action Without Borders: www.idealist.org
The Foundation Center: http://foundationcenter.org
The Grantsmanship Center: www.tgci.com
U.S. Environmental Protection Agency: www.epa.gov/ogd/recipient/tips.htm

However, whereas these websites may provide useful broad-based

suggestions about grant writing, they should not be used in place of all
suggestions and guidance provided by the funding agency. In fact, many
funding agencies provide both general and specific tips, suggestions, and
strategies to improve your proposal, and therefore, obtaining all the available
information and guidance from the funding agency itself is essential to the
success of a proposal.

Internal Reviewers
In addition to the overwhelming amount of work involved in developing
a proposal, there are also significant stakes involved as a result of the initial
investment of time and work and the degree of risk/potential business
outcomes at play. As a result, every attempt should be made to ensure that
you have developed the best proposal possible. Having completed due
diligence throughout the process is essential, just as is reviewing the
proposal personally and checking and double-checking that all the
requirements have been met. But another set of eyes—or two—should also
thoroughly review the entire proposal to ensure that it is strong. Reviewers
should particularly be those individuals who possess the necessary
objectivity to effectively evaluate the proposal. In fact, critiques by
colleagues can be particularly helpful in evaluating the content of the
proposal and the effectiveness of the argument (Hegyvary, 2005). These
critiques are completed by internal reviewers—individuals who did not
participate in the proposal development and who are not a part of the
funding agency’s review team and, therefore, are able to be highly objective.
Internal reviewers may be from within your organization or outside it,
depending on who is accessible to you. It is obviously ideal to utilize
someone external to your organization as a reviewer if you can; however,
this is not always possible, especially today, given the competitive
environment in which mental health and human service organizations
operate—indeed, some program developers are afraid of sharing too much
information with competitors.
Regardless of who is identified as an internal reviewer, what is most
important is that the individual(s) is familiar with grant proposals and has
reviewed the particular funding opportunity so that s/he has a firm
understanding of the purpose of the funding opportunity and the
requirements of the proposal. The review should focus on three key areas:
 

1. The content of the proposal, including the strength of the entire

argument (e.g., identified need, program design, budget)
2. The writing
3. Compliance with the funding opportunity requirements
 
Because the proposal will be reviewed by a team of reviewers upon
submission, this type of internal review may serve as a preliminary,
comprehensive review resulting in valuable feedback about the proposal and
its merits that can be used to further strengthen the proposal. Often, internal
reviews may identify thoughts or arguments that have not been articulated
clearly enough, grammatical issues, or lack of substantial evidence to
support claims—each of which, once corrected, is understandably helpful in
improving the proposal. In addition, using internal reviewers can help
prepare you for the official review process.

Other Considerations in Proposal Development

There are two other considerations in proposal development that deserve
special attention here:
 

1. Experience as a reviewer
2. Specific attention to budget requests
 
While it is critically important that you fully understand the funding
source—its history, philosophy, and major goals—prior to pursuing a
funding opportunity to ensure that you fully understand the rationale and
broader context of the funding opportunity, it is wise to also have deep
knowledge of the review process. To this end, it is recommended that you
apply to become a reviewer for grant proposals for the sources with whom
you most likely will be applying. However, if you cannot review for a
funding source that is particularly relevant to you, seek out other review
opportunities, since it is the experience of reviewing itself that is most
valuable. By participating as a reviewer, you are able to gain firsthand
knowledge of the review process, learning precisely how proposals are
evaluated, if there are particular issues that tend to resonate with the funders,
and what a successful proposal looks like. As you can imagine, this
experience can be invaluable to you as you develop your own proposal.
The findings from a study examining the personal perspectives of
scientists who served as reviewers for the National Science Foundation
further highlight some reasons why reviewing may be pivotal as a
professional endeavor (Porter, 2005). After examining the primary
motivational factors influencing reviewers to engage in the review process,
the findings included four main reasons (Porter, 2005):

A desire to learn the ropes about the review process in order to

improve their own proposal development skills
 A strong obligation to serve the professional community
A desire to remain current and relevant in their own work
through learning about the work of others
Additional opportunity for professional networking

Each of these issues can also easily be applied to explain why mental
health professionals should participate in the review process.
The second issue has to do with paying specific attention to the budget.
Aside from ensuring that the budget is commensurate with the plan and the
identified needs and that all expenditures are justified, specific attention
must be paid to ensuring that the budget accurately reflects the needs of the
proposal. To this end, budgets typically should not contain items such as
computers, office space, and other items that are regular expenses of the
organization but, rather, specialized items that are specifically needed to
implement the program/project. As Devine (2009) summarizes,
Budgets are often very specific and include salaries for personnel,
equipment, supplies, travel to the field site, travel to meetings to
present results, and educational support, as allowed. Each aspect of the
budget must be sufficiently justified to ensure accountability to the
grant makers; time frames must be included. Justifying the proportion
and duration of each individual’s time is critical. (p. 584)
In addition, projected expenditures for program evaluation and other such
specialized activities must be competitive and limited to fair pricing. In
simple terms, all expenses must be fully justified, and budgets cannot
contain any fluff—either in budgeted items or projected costs. Some funding
sources provide specific guidelines to ensure these restrictions, such as
prohibiting certain expenditures (e.g., hardware, rent) and limiting
expenditures for specific activities, such as program evaluation. In fact, it is
common today in federal grant opportunities to limit program evaluation
activities to no more than 20% of the total cost requested in the proposal.

Summary
As you well know by now, available funding for mental health and human
service programs is highly limited and, as a result, extremely competitive.
Therefore, successfully acquiring funding is no easy task but, rather, one that
is quite challenging and predicated on effective research skills, creativity,
and the ability to establish sound justification for both the proposal and the
professional skills, knowledge, and organizational infrastructure needed to
implement the proposal. In addition, grant proposals require support from
the applicant organization and input from other individuals and, therefore,
are rarely completed independently. It is precisely because of each of these
issues and the necessary unique skills that program developers are best
suited to lead the grant proposal process.
Although developing the actual proposal does require a significant
amount of skill and attention to detail, the proposal itself has already been
built for those who have completed Steps II through VII of the
comprehensive program development model. Doing so means that all the
essential building blocks of a grant proposal have been assembled, and the
job of the program developer then focuses on consolidating all the work into
the most effective proposal and presenting a clear argument for funding. It is
in this manner that the task of developing the grant application allows the
program developer to integrate all the program development steps—allowing
for the sum of work to come together into a coherent, effective, and highly
justifiable plan.
 
CASE ILLUSTRATION
Maya had been working in the schools with kids who had various types
of learning disorders and their families. The program was a collaborative
effort between the human service agency for which Maya worked and
the local school district. During the past year, Maya had become more
and more disturbed by what appeared to be an increase in youth
violence, including new gang activity. As a result of her increasing
concern, Maya had spent the past several months systematically
gathering information and designing a prevention and treatment program
to prevent and combat the issue. She began by investigating whether
what she thought was a problem/need (i.e., youth violence) really was.
To this end, she conducted a comprehensive needs assessment, asset
map, and market analysis and found that a need did exist—not only had
there been a 36% increase in youth violence over the past 2 years, but
there was no formal programming currently in place to address the issue
from either a preventive or treatment aspect.
Maya then began an exhaustive review of the research and other
literature to begin learning the most effective strategies for addressing
the issue. From this, she was able to design a community-based
prevention program as well as a treatment program that would involve
caregivers and teachers and that would be delivered in the schools and
community, with specific reinforcement provided in the home by the
caregivers. Having previously discussed this potential need for new
programming with her supervisors and administrators, Maya was able to
then work directly with her agency’s human resources and finance
departments in order to collaboratively design an effective staffing
infrastructure and an operating budget for both programs. Whereas Maya
led the development of both the staffing infrastructure and the projected
budget, she was able to gain valuable input from the finance and human
resources administrators, particularly in regard to developing job
descriptions and pay scales.
Realizing she could get more accomplished if she shared the work,
Maya spoke with Sofia, one of her colleagues, to see if she was
interested in working on the project. Sofia was interested, noting her
shared passion for this type of program. Both Sofia and Maya began
exploring funding opportunities, and each set aside 20 minutes each
week to explore two free websites dedicated to philanthropic and federal
funding opportunity notifications. In addition, the administrators at their
organization were looking out for any related funding opportunities from
the state or local government. After identifying a specific charitable
organization that had funded youth programs in the past and that
currently was focused on children and youth programs, Sofia and Maya
developed a letter of inquiry briefly outlining the program proposals.
Because this particular funding source accepted only letters of inquiry,
they followed the instructions provided and submitted such a letter in
hopes of being invited to submit a full proposal.
 A week later, Maya and Sofia received an announcement for a funding
opportunity for youth violence prevention programming. The state’s
Department of Human Services issued a Request for Proposal (RFP) for
violence prevention programs in their target community. The terms of the
RFP included $130,000 annually for a period of 3 years to fund
evidence-based programming. In addition, proposed interventions were
required to utilize a multisystemic approach and were expected to be
provided for at least 6 months.
Although Maya had viewed the RFP just 3 days after it was issued, the
application deadline was less than 3 weeks away. They quickly got to
work divvying up the assignments and scheduled an initial meeting with
a fellow clinician, case manager, administrator, and representatives from
the information technology, finance, and human resources departments to
review the RFP. Together, the group developed a plan for completing the
proposal that included the finance representative gathering all the
required corporate documentation and information, the information
technology representative developing a draft response to the application
sections regarding computer and communication technology, and the
fellow clinician gathering the required letters of support from the schools
and community organizations. Because Maya had previously developed
relationships with the local schools and two community organizations
providing youth programming, the letters simply solidified the
relationships that she had already worked to establish as part of program
implementation. Maya and Sofia would lead the development of the
application—largely using the proposal that Maya had already developed
—gaining input from others, as needed. In addition, the administrator
agreed to serve as an internal reviewer, and Sofia and Maya were also
able to get one of their former colleagues, who was practicing out of
state, to agree to be a second reviewer.
Once they sat down to complete the application, they were relieved
and happy to see that a multisystemic approach was required, since Maya
had learned from reviewing the literature that multisystemic approaches
had been proven effective in preventing youth violence. This reinforced
the thoroughness of her work on the literature review and subsequent
program design. The only aspect of the application that they struggled
with was justifying professional capability to effectively carry out the
program through an individual with expertise since there was not
someone in the organization with specific expertise in youth violence
prevention. To deal with this, Sofia and Maya decided to argue from the
point of view of organizational capability via rich experience with youth
and family treatment coupled with strong ties to the schools and specific
community organizations, one of which did specialize in violence
prevention. Because Maya had already developed a comprehensive
proposal, completing the application simply involved tailoring the
proposal to the requirements, compiling required tools and other
documents and collecting other documentation.
Maya and Sofia and the rest of their team were able to meet their self-
imposed deadline of completing the application 6 days before it was due
so that both Sofia and Maya could fully review the proposal and then
have it reviewed by both the administrator and out-of-state colleague.
Following the reviews, Maya and Sofia made final changes, and the
proposal was submitted the day before the deadline.

Postscript
Six weeks later, Sofia and Maya received notice from the charitable
organization to which they had submitted the letter of inquiry that they
would not be invited to submit a full proposal. Citing economic
challenges, the philanthropic organization informed them that they
would not be pursuing any new ventures until the following year but that
they could resubmit another letter of inquiry at that time. They were
disappointed about this, particularly because they thought they had
identified a solid match to fund one or both of their programs.
Maya and Sofia were not upset for too long, though. Two months later,
they received notification that they had been awarded the state contract
for youth violence prevention programming. Maya and Sofia were
promoted to program director and supervisor, respectively, and they
began preparing for program implementation. They—and organizational
leaders—felt that gaining this experience in violence prevention would
well position their organization to pursue youth violence treatment
programming in the future; so they decided to dedicate their energies to
the newly awarded contract and shelve the treatment program with an
eye toward possibly pursuing funding for it in the near future.
  

References
Blair, B. G., Cline, G. R., & Bowen, W R. (2007). NSF-style peer review for
teaching: Undergraduate grant-writing. American Biology Teacher, 69,
34–37.
Devine, E. B. (2009). The art of obtaining grants. American Journal of
Health-System Pharmacists, 66, 580–587.
Donahue, S. A., Lanzara, C. B., & Felton, C.J. (2006). Project Liberty: New
York’s crisis counseling program created in the aftermath of September
11, 2001. Psychiatric Services, 57, 1253–1258.
Hegyvary, S. T. (2005). Writing that matters. Journal of Nursing
Scholarship, 37, 193–194.
Homan, M. S. (2004). Promoting community change: Making it happen in
the real world. Belmont, CA: Brooks/Cole.
Kessel, D. (2006). Writing successful grant applications for preclinical
studies. Chest, 130, 296–298.
Klein, K. (2000). Fundraising for the long haul. Berkeley, CA: Chardon.
Lewis, J. A., Packard, T. R., & Lewis, M. D. (2007). Management of human
service programs (4th ed.). Belmont, CA: Thomson Learning.
Miller, I? W (2008). Grant writing: Strategies for developing winning
proposals (2nd ed.). Munster, IN: Patrick W Miller & Associates.
New, C. (2001). Grants from the government. In J. M. Greenfield (Ed.), The
non-profit handbook: Fundraising (3rd ed., pp. 692–712). New York:
Wiley
Porter, R. (2005). What do grant reviewers really want, anyway? Journal of
Research Administration, 36, 47–55.
Quick, J. A., & New, C. C. (2000). Grant winner’s toolkit: Project
management and evaluation. New York: Wiley.
Substance Abuse and Mental Health Services Administration. (2008).
Service expansion in mental health/substance abuse. Retrieved September
13, 2010, from
https://grants.hrsa.gov/webExternal/FundingOppDetails.asp?
FundingCycleId=2E31CDA0–5DE6–4AB4–8F89–
 2CFF50A4A978&ViewMode=EU&GoBack=&PrintMode=&OnlineAvail
abilityFlag=&pageNumber=&version=&NC=&Popup=
Zlowodzki, M., Jonsson, A., Kregor, P J., & Bhandari, M. (2007). How to
write a grant proposal. Indian Journal of Orthopaedics, 41, 23–26.
  PART II 

PROGRAM IMPLEMENTATION
AND SUSTAINABILITY
 CHAPTER 11
Implement the Program

 
Learning Objectives
 

1. Identify specific issues that should be addressed with the funding

source at the beginning of the relationship
2. Identify the three documents related to the proposal that must be
reviewed to ensure effective implementation
3. Discuss the roles of information systems, quality assurance, and
contract compliance in program management

 
I MUST HAVE MISSED THAT
Kyra had just received notification that the proposal she and her
colleagues had developed had been funded. Their project involved
facilitating a training curriculum for foster care and adoption workers
across the state, using an existing curriculum. Because Kyra and two of
her clinicians had developed the proposal, they felt comfortable that they
had a firm grasp on the project’s expectations; so they briefly reviewed
the contract they had just received, had it signed by the agency’s
president, and sent it back to the contractor. Then they got to work
planning for implementing the project. Knowing that they were required
to deliver the trainings across the entire state, they mapped out a 1-year
plan, identifying each of the locations to which they needed to deliver
the training. In addition, they used a Gantt chart to identify each of the
major activities needed for implementation, as well as time frames and
the individuals responsible for each activity. Feeling as though they had a
firm plan in place, they began implementation, finalizing the training
schedule by coordinating with representatives from each of the
organizations that would receive the training, preparing for training
facilitation, and getting on the road to begin training.
Kyra and her co–trainers were excited by the initial responses of the
training participants—the participants often telling them that they had
enjoyed the training and commenting on the trainers’ ability to connect
with the audience. In addition, Kyra and her team found that they really
enjoyed facilitating the training—even more than they had thought they
would—and they liked the added bonus of getting out and meeting
others across the state who worked in the child welfare field.
After training about one–third of their assigned population and
spending approximately 6 months delivering the training across the state,
Kyra received a call from the contract manager. The contract manager
stated that she had still not received any of the training evaluations from
the organizations that had been trained, although she knew from the
monthly progress reports Kyra had submitted that they had in fact trained
several organizations in multiple locations. Not quite knowing how to
respond since she did not recall any type of evaluation requirement, Kyra
asked the contract manager for more information about the evaluations.
The contract manager stated that standardized evaluation tools had been
developed for the training program and were available through the
contract manager’s office. She further stated that it was Kyra’s
responsibility as the trainer to distribute the evaluation form to all
training recipients, along with instructions regarding electronic
submission of the evaluation, following each completed training
curriculum. Since the contract manager had never heard from Kyra, she
assumed that Kyra had obtained the evaluation form from someone else
in the funder’s office.
 Kyra was aghast—she was not aware of the evaluation and had not
provided it to any of the training recipients, and she could only admit her
oversight to the contract manager. The contract manager encouraged
Kyra to review her contract so that she did fully understand all its
requirements. She then let Kyra know that she would have to speak to
her supervisor to determine how they would handle this initial failure to
comply with the contractual expectations and would get back to Kyra
within a week.
 
CONSIDERING KYRA

1. How could Kyra have avoided this?

2. If you were Kyra, what might you propose to rectify this situation?
3. If Kyra is permitted to continue the contract, what advice would you
give her to effectively move forward in her relationship with the
contract manager?

About This Chapter

This chapter focuses specifically on program implementation—the step that
follows successfully securing funding. This step in the comprehensive
program development model follows developing the proposal and precedes
program evaluation; however, as you know, implementation activities and
initial evaluation activities are originally developed in Step III (Design the
Clinical Program). As a result, this chapter is specifically connected to Step
III, as well as Steps X (Evaluate the Program) and XIII (Develop an
Information–Sharing Plan), again illustrating the interconnectedness of the
model. Therefore, specific components of the program evaluation, such as
process evaluation, fidelity assessment, and outcomes evaluation, are not
fully examined here but, rather, in the following chapter, and whereas quality
assurance methods and contract compliance issues are initially explored
here, the significance of this type of data collection is specifically discussed
in Chapter 15.
 This chapter explores two major areas—program implementation and
program management, which begins during initial implementation. In terms
of program implementation, we will explore key issues that must be attended
to during this time. These issues include establishing a relationship with the
funding source, reviewing and implementing the grant/contract, and
attending to the specific aspects of the program implementation process,
including the implementation of various evaluation and monitoring
activities. In addition, critical aspects of program management are examined,
with specific attention paid to four major areas: leadership and
administrative oversight, the use of information systems, quality assurance
planning and mechanisms, and contract compliance.

STEP IX: IMPLEMENT THE PROGRAM

Fully Implementing the Program
After investing a great deal of time, energy, and hard work into the
development of a clinical program, the greatest reward is seeing it come to
fruition—and this is possible only after funding support has been awarded.
Indeed, receiving notification that your proposal for a new program/project
has been selected for funding validates all the work that went into
developing the proposal—from the exhaustive needs assessment process to
the comprehensive literature review to putting the finishing touches on the
program design. But as validating as such an award is, it also comes with a
great deal of new work and a much longer time commitment. In fact,
whereas the preplanning and planning phases may have taken up a year or so
and possibly up to 5% of your overall time during the year, the
implementation phase most often requires 80% to 100% of your time (as
well as the time of other key staff), typically for the next 1 to 5 years.
Implementation signals a far more significant and steady commitment to
the program/project and, as such, means that the program will likely become
the primary focus of the program developer/mental health professional’s
energies. Further, there are dramatically different stakes involved in
implementation versus proposal development, since funding was awarded on
the basis of the funder’s trust and a belief in the success of the project. As a
result, the program developer is able to implement a program and effectively
use the funds provided is critical not only to the relationship between the
developer and the funder but also to the program developer’s future ability to
attract new funding.

Establishing the Relationship With the Funding Source

The first step in program implementation is formally establishing the
relationship with the funding source. In many cases, a relationship with the
fund/contract manager will already have been formed—and should have
already been formed—since cultivating relationships with potential funders
is a critical aspect of pursuing funding (as discussed in Chapter 8). However,
once funded, the relationship with the funder moves from being an informal
one without contractual expectations to a formal business relationship and,
therefore, must be treated as such.
On receipt of the notification of funding award, the program developer
should immediately contact the funding source to acknowledge the award
and personally extend gratitude. Depending on the funding source, there may
be specific requirements regarding acceptance that may be both formal and
informal. For instance, federal grants typically require formal acceptance of
funding as well as the completion of initial setup activities. State and local
governmental grants and philanthropic organizations may also require
formal acceptance of funding, whereas others may initially require only a
simple acknowledgment. In most—if not all—cases, instructions regarding
acceptance and beginning implementation are provided in the initial
notification letter, and these instructions must be followed.
Regardless of the requirements regarding acceptance of the funding
award, the issue remains that the relationship between the program
developer and the funding source is a particularly important one. Since
clinicians are in the business of building effective relationships, this should
not constitute too much of a challenge. As such, using the same skills that
make clinicians effective can allow program developers to quickly establish
a good working relationship with the contract manager. The type and scope
of the relationship between the contract manager and the program developer
will vary based on the particular funding source, just as the types of required
acceptance activities do. Some relationships will require formal regular
written reporting and frequent verbal communication and, thus, are
characterized by frequent contact and close working relationships, whereas
others may require minimal communication. Because it is the program
developer’s responsibility to comply with all the requirements and
preferences of the funding source, it is important to find out exactly the type
of relationship required and/or desired by the contract manager as part of
establishing the relationship.
Interestingly, the type of relationship and reporting requirements may not
be remotely correlated with the type of funding awarded or the amount of
funding but, rather, are typically a reflection of the funding source itself. In
fact, a $25,000 award from a corporation’s community giving program may
come with much more rigorous reporting requirements and require a greater
level of involvement than a $300,000 award from the federal government.
This again underscores why it is imperative that the program developer finds
out exactly what type of relationship is required and/or desired by the
funding source and then complies fully with this, careful to avoid attempts to
prejudge the scope of the relationship. Since any person and/or organization
that receives external funding is a steward—trusted to carry out the mission
and/or objectives of the funding source and all its constituents—the
relationship between the program developer and the contract manager forms
the basis for this type of stewardship.

Review of the Grant/Contract

Following acceptance of the award and as you are beginning to establish
the relationship with the funding source, you must thoroughly review the
grant/contract. This is of particular significance since it may have been a
year or more since the proposal was actually developed. If you are anything
like me, much of what you developed even a short time ago may not be
easily recalled today; thus, a thorough review of the original proposal and all
the accompanying documentation must occur. Failing to conduct a thorough
review may put you in Kyra’s shoes—a third of the way into the project and
overlooking a critical requirement.
There are three basic components that must be reviewed:
 

1. The initial application requirements

 2. The initial proposal
3. Any changes or modifications to the original requirements or
documents
 
I have found the initial application requirements and initial notice of the
funding competition to be among the most important documents to review,
because it is in these documents that the rationale, objectives, and other
aspects related to the intent of the funding are set forth. As such, this
information can be quite rich in outlining the priorities of the funding source
and can provide a unique window into the thinking behind the funding
source leaders. Because funding recipients are most often evaluated based on
the degree to which they can carry out the agenda of the funding source, as
well as its more subtle ideological aspects, it is imperative that the recipient
understand precisely what that agenda is so as to ensure that all aspects of
the project reflect this—not simply the interventions themselves. As such,
you must keep in mind that one of your jobs in carrying out the program is to
help the funding source be successful (Porter, 2005). For instance, a Request
for Proposals (RFP) to provide mental health treatment for returning
veterans may include a narrative about the importance of family involvement
in the treatment process and reducing isolation. Whereas the funding
recipient was successful in designing a treatment program that effectively
addressed both of these issues, as evidenced by the award, it is equally
necessary that other aspects of the program, including clinical decision
making, are guided by these priorities; thus, clinical decision making would
need to reflect family involvement. By attending to this, you are able to
fulfill both the content and the substance of the funding source’s
expectations.
Reviewing the initial proposal that was developed in response to the RFP
is also of critical importance, since this document outlines precisely what the
program developer has agreed to do in terms of implementation and delivery
of services. The proposal is a legal document insofar as it provides the initial
agreement that the program developer has stipulated with the funding
source. Moreover, funding was awarded based on what was outlined in the
proposal. As a result, any changes or diversions from the proposal must
receive preauthorization by the funding source so as to avoid a potential
breach of contract—failure to conform to the contractual requirements.
Finally, it is not uncommon for changes or modifications to be made to
the initial requirements of the funding source. These changes may occur as
part of the review process in which the funding agent may request specific
changes to your original proposal or request that you provide further
explanation for part of the proposal—both of which can result in
modifications to the proposal. As a result, any modifications to the original
proposal and/or requirements of the funding source must be reviewed
thoroughly, since these will replace parts of your initial proposal.
For each of these, a thorough reading must be conducted to ensure full
understanding of the intent and requirements of the funding source and
precisely what was promised by the applicant/funding recipient. Bear in
mind that it is solely the responsibility of the funding recipient to comply
with all requirements of the funding grant/contract. Therefore, this process
must be wholly initiated by the funding recipient/program developer with a
commitment to thoroughness, lest something of significance be missed in
implementing the program.
To ensure that all individuals who will be working in the program/project
are fully informed as to the program requirements, all relevant
documentation should be shared with all key staff. In addition, an orientation
should be held to further discuss the requirements and other aspects of the
project and to answer any questions regarding the documentation. This
should allow for all involved individuals to gain a thorough sense of the
project/program. Moreover, these initial review activities can reinforce the
significance of being awarded funding and the stewardship it brings—for
which all key staff are accountable.

Program Implementation Monitoring

Once everyone has had an opportunity to get acquainted or reacquainted
with the project/program through reviewing the official documents and
orientation, program implementation is ready to begin. At this point,
documentation from the original proposal is essential, especially with regard
to planning and design tools such as timelines, Gantt charts, and logic
models. Whereas there are multiple aspects of implementation that must be
carefully considered and coordinated, each is directed at ensuring the most
effective implementation process. Effective, in this sense, means that the
program/project is implemented as originally designed (i.e., promised).
In order to ensure this is the case, the implementation must not only be
closely guided by the program developer but also be evaluated throughout
the implementation process. This type of evaluation is considered a process
evaluation and focuses on assessing all aspects of the program by comparing
the implementation of various activities with the information stipulated in
the proposal and other requirements of the funding source. Activities
assessed include the time frames in which staff are hired, trained, and begin
work; the number and type of staff employed in each of the roles; the
recruitment of clients; orientation; and delivery of each of the interventions
and supporting activities, to name a few.
Whereas the existing planning tools are essential to effectively guide the
implementation process, depending on the scope of the project/program, you
may need to develop additional tools for use in implementation and
assessing the implementation process. Because process evaluation is one of
the types of evaluation that compose a comprehensive program evaluation, it
is discussed in depth in the following chapter. At this point, we will focus
primarily on methods by which to monitor the implementation process.
Implementation Update meetings are especially helpful in both guiding
and assessing the implementation process. For most programs/projects, I
recommend that these meetings be held weekly during the first 2 months of
implementation and then reduced to biweekly and monthly, as necessary. I
say this because the first 2 months of any program/project can be the most
challenging and harried time in a program’s life cycle. It is not difficult to
imagine why this is the case, since during this time, there are competing
pressures to finalize the development of any program manuals, policies, or
other relevant documents; finalize and coordinate the program evaluation;
train and orient new staff; orient clients; engage in public relations and/or
marketing efforts to communicate the new program to the public; and attend
to a multitude of other activities that all must be done in order to fully
implement the program. Because of the chaotic nature of this time period,
open and constant communication is a necessity to ensure that nothing is
missed, questions are answered, and continuous guidance is provided
throughout the process. By creating a venue for this type of communication
via weekly Implementation Update meetings, you are able to provide the
necessary nurturing and monitoring needed to ensure successful
implementation. And since achieving a successful program is no easy task,
by spending the time up front to guide the implementation process, you are
much better suited to attain long–term success for the project.

Program Management
Just as effective implementation is essential to the success of a program,
effective management is critical to the sustainability of a program. Sound
management begins with fully understanding and appreciating the objectives
of a program and possessing a keen understanding of the program’s meaning
that can be effectively conveyed to clients, staff, and the public—all of
which should be revealed through a review of the initial program
documentation. Because management comes with a need for leadership,
managers must be excellent communicators, able to convey not only the
program’s purpose but the reason why the purpose is so important to
multiple groups.
However, in addition to providing leadership and guidance to the
program throughout its life cycle, there are many other aspects of program
management. Indeed, management of mental health and human service
programs is also composed of the various activities of planning, designing,
staffing, budgeting, supervising, monitoring, and evaluating (Lewis,
Packard, & Lewis, 2007)—each of which is discussed throughout this text as
part of the comprehensive program development process.
Program management is big—in both size and scope, often varying
depending on the type of individuals serving as managers and the culture of
the organizational and external environment in which they manage. Whereas
individuals are needed to manage—thus, the job classification called
managers—management is not the exclusive domain of individuals with the
title of manager/supervisor/administrator. In fact, every staff person
connected to a program typically engages in some form of program
management. This is because program management includes paying
attention to all the details that compose a program, working to ensure that
everything is executed as planned, discussing issues and challenges, working
collaboratively, collecting and reporting various data, and making changes as
warranted, all with the shared goal of program success.
In this context, management refers to a series of processes that is shared
by all key stakeholders and is highly collaborative, with input and
monitoring occurring at multiple levels (Gibelman & Furman, 2008). As
such, these management processes are designed to

guide, inspire, and motivate;

monitor and assess;
correct or resolve problems and/or threats; and
improve and lead to the attainment of success.

For the sake of this discussion, there are four key areas on which I want
to focus, as each relates to program management: leadership and
administrative oversight, information systems, quality assurance planning,
and contract compliance. These four areas are integral, as each constitutes a
specific management system that can effectively guide implementation.

Leadership and Administrative Oversight

"Management is about human beings. Its task is to make people capable
of joint performance, to make their strengths effective and their weaknesses
irrelevant" (Drucker, 2001, p. 10). As only Peter F. Drucker could, he sums
up management concisely and brilliantly. I liken this characterization of
management to the aspects of leadership and administrative oversight that
are essential parts of program management. The program director/manager is
primarily responsible for the program/project, overseeing day–to–day
operations, serving as the chief program administrator, and engaging in
multiple levels of decision making pertinent to the program, among other
tasks. However, leaders of the organization and key administrators, such as
human resource and finance executives, provide another layer of oversight to
the program. As such, organizational executives are charged with broad–
based responsibility for all the company’s programs and operations and,
therefore, indirectly provide leadership and engage in various types of
oversight activities.
 Most significantly, an organizational leader directly supervises the
program director, ensuring that the director can effectively and successfully
implement and sustain her/his program—thus, highlighting the director’s
strengths while, ideally, teaching the director how to be an effective
manager. In addition, organizational leaders and administrators must closely
observe and monitor the program’s operations, reviewing various types of
data (e.g., staffing reports, finance reports, client vacancy rates) and
discussing findings and ongoing plans with the program director and/or other
program leaders, as well as requiring modifications and/or action plans to
correct any deficiencies. In this regard, the organizational leaders and
administrators provide a critical layer of management to the program,
ultimately designed to ensure the program’s success.

Information Systems
Information systems basically refer to forms and types of data collection
and storage that allow for maintaining and analyzing various types of
information. Today, it is difficult to imagine information systems without
immediately thinking of computer technology. Indeed, computers have
exponentially changed every aspect of the way that we work and live and,
for many, are simply a common part of work and life. And because of the
technological advances that have been made, funding source requirements
for data collection and data reporting have changed dramatically over the
past decade (Kettner, Moroney, & Martin, 2008). As a result, electronic
technology is the most common means today to ultimately store and analyze
data. However, the sophistication level of technology at a given agency may
vary greatly based on financial disparities between organizations that dictate
precisely what an organization can afford. Thankfully, relatively inexpensive
hardware and software are now available that allow agencies to computerize
many of their critical activities (Kettner et al., 2008). Basic spreadsheet
programs such as Microsoft Excel and database programs such as Microsoft
Access can be used with relative ease and little expense. And through
charitable giving programs that provide reduced or no–cost technology to
nonprofit organizations, acquiring technology is easier today than ever
before in the mental health and human services. For instance, consider the
impact that TechSoup Global—an essential technology resource in our field
—has made in increasing access to technology for nonprofit organizations
over just the past several years.
 
TECHSOUP GLOBAL
TechSoup Global is one of the most comprehensive technology resources for nongovernmental
organizations in the world. Working with corporate donors, including Microsoft, Adobe, Cisco,
and Symantec, TechSoup provides nongovernmental organizations, nonprofits, libraries, and
community–based organizations with the latest professional hardware, software, and services
they need. These information and communication technology donations are available alongside
educational content such as articles, webinars, and nonprofit technology community forums. As
of June 2009, TechSoup Global has served more than 101,000 organizations, distributed more
than 4.9 million technology donations, and enabled nonprofit recipients to save more than $1.4
billion in information technology expenses (TechSoup Global, 2001–2009).

Since we now have such a variety of information systems available,

program developers and managers must determine which types of data
should be collected through which types of methods. In addition, they must
specify precisely how the data will be used. In the mental health and human
services industry, multiple types of electronic information systems are
available that range in scope and degree of sophistication and functionality.
There are electronic information systems designed specifically for
accounting and other financial practices, systems designed to support human
resource functions such as staff records and benefits, and systems designed
to manage client information. Whereas these types of single–focused
electronic systems have been developed as stand–alone systems (e.g.,
accounting), there are also now a host of integrated electronic systems that
have been developed specifically for the mental health and human service
industry. These systems are integrated in the sense that each of the major
functions—accounting, human resource management, and client information
management—is contained in one electronic information system.
Since the beginning of the new millennium, a host of integrated systems
has hit the market, creating quite a wide selection from which organizations
can choose. However, the cost of both integrated and function–specific
electronic systems varies tremendously and can be cost–prohibitive for many
organizations. Because nonprofit organizations typically do not receive
specific funding to support such expenses as technology and rent/property,
agencies must utilize other funds or create other mechanisms by which to
support these critical components of the organizational infrastructure.
Further complicating the financial implications related to purchasing an
integrated or stand–alone information system is the fact that payment for
these systems is often an ongoing factor. This means that when making these
purchases, you must be able to financially plan for 10 to 20 years to ensure
the appropriate level of funding support will continue to be available for the
system that you wish to use. To give you a sense of the costs that are
involved, I recently shopped for a Client Information System (CIS) for a $50
million+ revenue nonprofit agency with approximately 400 users (revenue
and users are noted here since costs of systems may be based on one or
both). All four of the systems reviewed required both initial setup fees as
well as annual maintenance fees. After annualizing the costs of each over 10
years, these products ranged from 40,000 to $130,000—meaning each year,
the organization would have to be able to financially support this payment
level. To give you another illustration of these costs, these products were
projected to cost anywhere from $400,000 to $1.3 million over a 10–year
period. This is not to say that all CIS systems require annual maintenance
fees, but when they do, thoughtful financial planning must guide purchase
decision making. I should add that much less expensive CIS systems are
available; however, purchasing a comprehensive client information system
for most presents a considerable expense that must be appreciated and
thoroughly examined.
In order to address this, due diligence must be conducted to determine
precisely what need the organization has and examine the extent of the
financial ramifications to ensure effective decision making in this area.
Whereas the financial status of an organization will largely dictate the type
of information system an organization will be able to purchase, there are a
number of questions that should be asked to guide the purchase. First and
foremost, everyone involved in the decision–making process must
acknowledge that information systems were developed to make work more
efficient and effective. At the same time, information systems can be used by
individuals and organizations in a manner that produces wasted time and
energy and, in effect, creates unnecessary costs to organizations—precisely
what information systems are designed to combat! Indeed, I have witnessed
many an organization purchase an information system and invest more than
3 years of multiple staff persons’ time in modifying it to fit the perceived
needs of the organization, just to abandon the system without ever fully
implementing it. As a result, the organization is left where it started—only,
now with an exorbitant amount of money lost, on both technology and staff
time. Therefore, this most fundamental aspect of information systems must
be understood prior to engaging in decision making about the potential type
of system needed. There must be an understanding that if data is to be
captured in an electronic system, the capture must be justified—meaning
there must be a plan to use the data following its capture. As such, “every
form, procedure, measure, data collection task, and data summary should be
created in direct response to a particular need of the agency” (Lewis et al.,
2007, p. 197).
Simply by spending the time to evaluate each desired data element and
determine if each can be effectively justified for capture, program
administrators are able to ensure that all the data they are capturing is
necessary. This is not only essential to running an effective and efficient
operation, but it is also necessary to convincing and motivating the
individuals that are charged with collecting the data. Rare is the individual
who wishes to engage in a futile act, and staff persons that collect data are
certainly no exception. In fact, because data collection is not typically
viewed as an exciting or necessarily meaningful act, it is that much more
critical that those collecting data fully understand the rationale for their
work. In order to guide the process of determining what types of data should
be captured—and are thus justified—the Data Element Evaluation Tool was
developed (see Table 11.1).
To illustrate the use of the Data Element Evaluation Tool, Table 11.2
provides an example of a partially completed evaluation for an independent
living program for developmentally disabled adults.
Table 11.1 Data Element Evaluation Tool
Table 11.2 Sample Data Element Evaluation Tool
 By using this or a similar tool, you can identify desired data elements—
which you need to do anyway when preparing to use an information system
—justify the reason for needing to collect the data, and explain precisely
how the data will be used. While this work may seem tedious, ensuring that
all data captured has a specific purpose may result in saving staff and the
organization an inordinate amount of time and money that may otherwise
have been used to collect unnecessary data. As such, engaging in this work
up front may indeed reduce future work.

Quality Assurance Planning

Historically associated with the medical field and emphasized by
accreditation bodies, quality assurance has become a basic feature of mental
health and human service programming. Just as it sounds, quality assurance
is concerned with ensuring quality and seeks to achieve this through ongoing
assessment. By utilizing quality assurance, mental health professionals are
able to continuously assess the extent to which a program meets identified
standards (Royse, Thyer, Padgett, & Logan, 2006). However, unlike
outcomes assessment, quality assurance focuses on process issues and
activities that reflect the operations of the program. Because of this unique
emphasis on processes, quality assurance can indeed be a highly useful
component of a comprehensive program/organizational evaluation (Lewis et
al., 2007), since it complements other types of assessment.
Quality assurance processes derive from clearly defined policies and
procedures that initially guide program implementation. Therefore, planning
for quality must begin during the program design phase, with much thought
initially given to how each of the program operations will function and how
and when each activity will be implemented. Therefore, programs that have
been carefully planned and well documented with great attention to detail
are highly amenable to quality assurance monitoring. As a result, program
developers can ensure that clients receive quality service from the moment
the program begins (Hutchins, Frances, & Saggers, 2009) and throughout the
entire life of the program.
Quality assurance–related aspects may include
 the time frame in which a client received a physical
examination,
the completion of a comprehensive intake evaluation, or
the development of an initial treatment plan that reflects a
person-centered planning philosophy.

From a psychiatric perspective, quality assurance may include monitoring

such treatment aspects as drug selection, changes in drug prescriptions, and
compliance with prescription treatment guidelines (Pyrkosch, Psych, &
Linden, 2007). By monitoring these activities, program developers and other
mental health professionals are able to assess the degree to which quality is
maintained throughout implementation.
Whereas some quality assurance aspects are self–determined by the
program developer and other key mental health professionals, other aspects
may be externally established by accrediting bodies, funders, or other
governing bodies. It is because various stakeholders have an investment in
the program that clients, board members, staff, and funding sources each
should and usually do have input in determining precisely what constitutes
quality (Kettner et al., 2008). For instance, issues such as the occurrence of
an initial treatment team meeting within the first 3 days of a client’s
admission and a 6–month follow–up with clients post–discharge may be
primary program components chosen by program leaders for quality
monitoring, whereas the development of an initial treatment plan within the
first 30 days of a client’s treatment may be required by the funding agency.
Both of these may then be included in the quality assurance plan.
Quality assurance is another area in which, for obvious reasons, it is not
quantity but quality that matters. In this sense, the number of quality
assurance aspects that are monitored does not necessarily reflect the
sophistication level of a quality assurance program, but it is important that
each aspect being monitored has substance. Any activity that is being
monitored for quality assurance purposes should be deemed a quality
indicator. Quality indicators refer to the fact that the activity/aspect being
monitored is a reflection of the program’s quality. In this regard, the
occurrence of the initial treatment team meeting within the first week of a
client’s admission is indicative of a high level of program responsiveness to
client needs and, therefore, constitutes a quality indicator. Similarly, the
composition of a multidisciplinary treatment team is also reflective of
quality, in that the input of multiple professional perspectives will likely
impact the treatment planning process. However, the time of day that the
meeting occurred or the number of individuals participating in the treatment
team meeting would not constitute quality, as neither is substantive.
For the most part, quality assurance indicators are goals, since they
identify a target to be attained. As a result, they should be developed as goal
statements that specify both the desired threshold as well as the method by
which it will be assessed/measured. Box 11.1 provides a sample of quality
assurance indicators developed for a foster care program. It is important to
note that, consistent with the nature of quality management, some quality
assurance indicators are intended to change over time, illustrating continuous
improvement. For instance, once the foster care program staff have reached
and sustained the target goal of 470 days or less for permanency (Item 8),
the indicator may be revised to 450 days or less, since this type of activity
refers specifically to working more diligently on reducing the time children
are in the foster care system.
 
BOX 11.1

SAMPLE QUALITY ASSURANCE INDICATORS FOR A

FOSTER CARE PROGRAM
1. Eighty percent of all foster parents will report that staff members return their calls within 48
hours.

Measurement:Annual Foster Parent Survey item

2. A team approach to service delivery will be used 100% of the time that includes birth
parents, staff, foster parents, and other significant persons and will demonstrate evidence of
this approach in the Service Plan and/or Wraparound meeting notes.

Measurement:Quarterly supervisory case record audits

3. Visitation between birth parents and children in foster care will be arranged within the first
14 days for 100% of families unless contraindicated by the court, and evidence of visitation
arrangements will be documented in the Service Plan.

Measurement:Quarterly supervisory case record audits

 4. Foster care workers will have a private, face–to–face visit with all assigned foster children
within the first 3 days of placement, and documentation of this will be recorded in the case
file in the Initial Service Plan and/or Foster Home Visit record.

Measurement:Quarterly supervisory case record audits

5. Welcome Packs will be distributed to all birth parents during the first 5 days that their
children are in care and will contain information regarding the legal system, foster care,
foster homes, foster parents, their rights, and other relevant information in order to provide an
orientation to foster care.

Measurement:Quarterly supervisory case record audits

6. The time between intake completion and case manager assignment will be 4 days or less.

Measurement:Quarterly supervisory case record audits

7. A mean average number of days in care will be 171 days or less for family reunification
cases.

Measurement:Year–end discharge data analysis

8. Permanency (family reunification or availability for adoption) will be achieved within 470
days or less in order to reduce days in care for children and families.

Measurement:Year–end discharge data analysis

The degree to which a program/organization establishes a system of

quality assurance can vary dramatically; however, it is essential that all
programs institute some type of quality assurance program. In fact, it is
highly unlikely in this day and age that a program lacking a quality
assurance plan will be able to remain in business long, since quality
assurance has become an embedded feature in our business and part of
standard practice. Without quality assurance monitoring, program developers
and leaders have no real sense of how well they are succeeding—or not
succeeding—in regard to compliance with various standards of practice.
Because data is a primary ingredient of quality assurance, electronic
technology often plays an instrumental role in data storage, management,
and analysis. Indeed, the use of an electronic spreadsheet program or a
database is critical to maximizing the quality assurance program.
Because quality is predicated on a clear understanding by the program
staff of precisely what constitutes quality and a commitment to quality,
procedures and plans that allow for ongoing data collection, monitoring, and
reporting must be established (Gibelman & Furman, 2008). At the most
basic level, a quality assurance system may consist of a brief checklist that
captures major quality indicators and that can be easily used by program
staff to monitor quality assurance activities twice per year or in some other
specified time frame. More sophisticated efforts may involve the
development of a quality assurance committee composed of various levels of
staff that are charged with both leading and overseeing the quality assurance
program. The committee may conduct monthly monitoring, develop
quarterly update reports, and engage in annual quality assurance planning.
Regardless of the type of quality assurance program that is instituted, a
culture of quality must be created within the program/organization in order
to most effectively support quality assurance efforts. First and foremost,
creating a culture of quality requires a commitment to quality by all staff.
This means that every individual staff person has an appreciation of quality
assurance, recognizes the significance of the quality indicators, and views
quality assurance as pivotal to overall program success. This obviously
requires program leaders who can effectively communicate this to staff.
More significantly, though, this requires program leaders who view quality
assurance as an opportunity for learning and professional development and
not a cause for punishment. Therefore, failures to attain quality are viewed
as opportunities to learn more about a specific aspect, to dissect what may
have gone wrong, to review all its connected parts, and to rethink the
aspect/process and perhaps make modifications. Such a culture can exist
only when there is open and frequent communication about quality, with
constant reinforcement of its significance through regular sharing of results
and modifications to the program.

Contract Compliance
Not wholly separate from quality assurance, contract compliance refers
specifically to compliance with activities that are required by the
contractor/funder. These activities or aspects may be process–oriented and
constitute areas that are a part of a quality assurance program, or they may
be outcome–oriented and consist of a critical part of an outcomes evaluation.
Because contractors/funders are most interested in ensuring that their
investment was wisely made, the promulgation and monitoring of specific
standards promotes accountability amongst the programs that they have
funded and allows funders to be aware of exactly how successful these
programs are in this regard.
Examples of contract compliance for an outpatient gambling addiction
program may consist of items such as

a comprehensive intake interview and evaluation conducted

within 24 hours of program admission,
80% of clients successfully completing the program,
100% of clients having an identified sponsor, or
80% of clients refraining from gambling 6 months post–
discharge.

As you can see, there are both process and outcome issues that may be
part of the contractor’s compliance requirements. As you can also see,
contract compliance issues, just like quality indicators, may be directly
related to program outcomes and, therefore, may also be incorporated into
the outcomes evaluation.
Because contract compliance issues are not voluntarily selected but rather
delineated by the funder, these aspects are nonnegotiable; therefore,
continued funding may be dependent on the program’s ability to achieve
them. Moreover, these must be regularly monitored in accordance with the
time frame established by the funder. Therefore, these items should
automatically be included in the quality assurance program so that they are
embedded in the program’s quality assurance plan. Furthermore, if the
contractor’s monitoring time frames are more frequent and rigorous than
those established by program staff, the contractor’s time frames should be
adopted and used to guide the other aspects of the quality assurance
program. This is all done in the spirit of ensuring that the bar is set high
enough for us to continuously strive to reach it.

Summary
As you can see, the program implementation process requires attention to
multiple details and a great deal of planning and organization; however,
effective implementation is largely aided by the work accomplished in the
program design phase. As a result, comprehensive and thorough program
planning that took place in earlier steps can lead directly to efficient and
effective program implementation—once again reinforcing that time and
effort invested up front should never be underestimated.
There are two main aspects to program implementation that include fully
implementing the program and specific components of program
management. The initial implementation involves attention to such details as
(1)establishing the relationship with the funding source/contract manager,
(2)conducting a thorough review of the grant/contract, and (3) developing a
program implementation plan and mechanisms by which to monitor and
evaluate the implementation. In terms of program management as related to
implementation, the key issues of (1) program leadership and administrative
oversight, (2) information systems, (3) quality assurance planning, and (4)
contract compliance must each be given appropriate attention.
By attending to each of these areas, the initial program implementation
should proceed smoothly. And since so much of the work that has brought
you to this point is at stake in the initial implementation, this level of
attention to detail is precisely what is needed at this step.
 
CASE ILLUSTRATION
Lisa and Ann received notification that their proposal for a family–based
autism treatment program had been selected to receive funding. After an
ample celebration of lattés and muffins, they sat down to fully review the
award notification letter and the attached instructions. Per the
instructions, they logged into the funder’s website to officially accept the
award and to consent to following the specific guidelines outlined in the
instructions. They then contacted the contract manager who had been
assigned to their project. After personally thanking the contract manager,
Lisa asked if she would prefer that they check in by phone each month
with a verbal update to keep her abreast of their progress between the
required 6–month written reports. The contract manager agreed that
monthly telephone calls would be effective and that, other than that, Ann
and Lisa should feel free to contact her if they ran into a problem or had
a question. She also stated that if there were no problems or questions,
she did not need more frequent or alternate communication than the
monthly phone calls.
After hanging up, Ann and Lisa felt that they had successfully begun
to establish a relationship with the contract manager and that they had
established a solid plan for keeping her updated throughout the project.
Excited to move forward, Ann then coordinated a meeting for all the
staff that would be involved with the program. This meeting provided an
opportunity for Lisa and Ann to review all the major aspects of the
project, including the rationale behind the funding. Lisa highlighted the
objectives of the project from the original RFP, and Ann explained the
major aspects of the proposal. Ann also shared the award notification
letter with all the staff, emphasizing that the funders were particularly
pleased with the commitment to family and community building that had
been reflected in their proposal.
After answering questions about the program and gaining
confirmation that everyone fully understood, Lisa reviewed the
implementation plan with the group. She and Ann were glad they had
taken the extra time when writing the proposal to develop detailed
timelines and project maps to guide implementation. Assignments were
made to ensure that someone was responsible for each part of the
implementation, including such activities as finalizing staff hiring,
recruiting clients, and developing the quality assurance plan.
Because the first clients would need to be served within the next 52
days, Ann reinforced the need for diligent work to the group. And in
order to provide additional guidance to everyone during implementation,
she established a weekly Program Implementation Update Meeting
schedule. The update meetings would provide a forum to update
progress, answer any questions, and monitor the implementation process.
Ann took on the task of updating the existing client information
system to capture specific information for the autism program, some of
which was required by the funder and some of which Ann and Lisa
determined should be captured. These updates required adding new
fields to the database and establishing new linkages between certain data
fields. Ann worked directly with Gerri, the information systems
 administrator, to finalize these changes and prepare the electronic system
for the new program.
While Ann devoted time to updating the technology, Lisa worked with
Alli, one of the new program supervisors, on developing the initial
quality assurance plan. To begin this process, they culled the contract
compliance issues and performance standards that were identified in the
award documents from the funder. They then incorporated the quality
indicators that Lisa and Ann had stipulated in the proposal. Whereas
these two data sets provided comprehensive quality indicators, Lisa
wanted to ensure that they were not missing anything essential. After
reviewing national accreditation standards for children’s mental health
programs, Alli identified two more critical quality assurance aspects
related to individual educational planning and family-based decision
making. At the same time, Lisa noted the need for documenting review
of the state and federal Mental Health Codes with clients and families as
an essential quality issue. They then asked for input from the staff
regarding other specific aspects of quality that they wished to monitor.
Following several hours of work and lots of input, Alli, Lisa, and Ann
took a step back to review the initial draft of the quality assurance plan.
Having done so, they felt that they had a solid plan in place and were
anxious to present the draft to the group at the upcoming update meeting.
Once the plan was finalized with the staff, they would set up the
monitoring systems to begin tracking quality and would plan to share the
quality assurance plan with the contract manager during their first
monthly telephone call.

References
Drucker, P. F. (2001). The essential Drucker. New York: HarperCollins.
Gibelman, M., &Furman, R. (2008). Navigating human service
organizations. Chicago: Lyceum.
Hutchins, T., Frances, T., & Saggers, S. (2009). Australian indigenous
perspectives on quality assurance in children’s services. Australasian
Journal of Early Childhood, 34(1), 56–60.
Kettner, P. M., Moroney, R. M., & Martin, L. L. (2008). Designing and
managing programs: An effectiveness–based approach. Thousand Oaks,
 CA: Sage.
Lewis, J. A., Packard, T. R., & Lewis, M. D. (2007). Management of human
service programs (4th ed.). Belmont, CA: Thomson Learning.
Porter, R. (2005). What do grant reviewers really want, anyway? Journal of
Research Administration, 36, 47–55.
Pyrkosch, L., Psych, D., & Linden, M. (2007). Why do psychiatrists select
or switch an antipsychotic? Psychiatric Times, 24(4), 42–46.
Royse, D., Thyer, B., Padgett, D., & Logan, T. (2006). Program evaluation:
An introduction (4th ed.). Belmont, CA: Thomson/Brooks Cole.
TechSoup Global. (2001–2009). About TechSoup. Retrieved September 13,
2010, from http://home.techsoup.org/pages/about.aspx
 CHAPTER 12
Evaluate the Program

 
 Learning Objectives
 

1. Differentiate between treatment fidelity assessment, process evaluation,

and outcomes evaluation
2. Discuss the significance of research design in program evaluation
3. Provide an example of a quasi-experimental design used in an
outcomes evaluation
4. Explain the concept of a culture of evaluation and identify at least three
methods by which to promote this
5. Identify three costs and three benefits of evaluation

 
IMPLEMENTING THE STOP THE VIOLENCE PROGRAM
After being directly approached by one of her funders/contractors to
design a new program for female batterers, Nikki immediately began
examining the research in this area. She located a relatively new program
model, Stop the Violence, which had been implemented in a similar
geographic region and had initially achieved successful program
outcomes. The program had been evaluated twice, both times by the
program developer. Because of the rigor involved (i.e., experimental
design) in both of the reviews, the evaluations were considered highly
effective, and as such, the program had an established evidence basis.
Encouraged by what she had learned through reading about the
program, Nikki contacted the Stop the Violence program developer
directly, and they talked at length about the program and her hope for
implementing the program in her region. The program developer was
excited to hear of this interest and agreed to send Nikki additional
material about the program. Nikki then communicated back with her
funding/contracting agency to let them know that she had identified an
evidence-based model and was ready to implement it. Together, they
agreed on an implementation date.
After hiring new staff and transitioning existing staff into new
positions in the program, Nikki met with the group to review the
program. Nikki provided a thorough orientation to the group and spent a
considerable amount of time discussing the various aspects of the
program, attempting to ensure that the program model was implemented
correctly. Nikki also discussed the program evaluation that would begin
at implementation to assess the program’s success in their region and
with their specific client population.
A couple of weeks into the implementation, with 14 clients enrolled in
the program, Nikki was called away by her supervisor to address some
challenges that were occurring in the agency’s independent living
program. While Nikki tried to check in on a semiregular basis with her
Stop the Violence staff, she found this more and more difficult as she
became more absorbed in trying to resolve problems in the independent
living program.
After being away from the Stop the Violence program for 7 months,
Nikki was anxious to get back to it and examine the preliminary program
outcomes. After reviewing the program evaluation data, Nikki was
surprised to see that the program outcome rates were far below the
outcomes that the original program had achieved. Nikki met with the
program supervisor to talk more in depth about this issue. Through the
course of their conversations, the supervisor shared with Nikki that she
and the staff had made several modifications to the program that seemed
necessary given their client population. The most significant
modification involved eliminating group therapy as the primary modality
and replacing it with individual therapy. The program supervisor
explained to Nikki that this seemed a better option since staff had
complained that it was logistically too difficult to get all the clients to a
group session. Learning of this and other program modifications that had
been made, Nikki quickly called a staff meeting so that she could speak
with everyone involved in the program.
Nikki informed the staff that she had made a critical error by not fully
educating each of them on the importance of implementing the treatment
model in accordance with its original design. She further stated that she
had failed to teach the staff about the significant relationships that exist
between program design, implementation, and evaluation. She explained
that because the Stop the Violence model had not been implemented
consistent with the original design, similar successful outcomes would
likely not be achieved and the initial evaluation data had limited
relevance. Rather than wasting any further time, Nikki was able to chalk
this unfortunate incident up to an important learning experience for all,
and she and the staff quickly turned their attention to thoroughly
reviewing every aspect of the original program model, learning
specifically about treatment fidelity, process evaluation, and outcomes
evaluation—with Nikki ensuring that all her staff were well educated
about each. They then immediately set a date for another program
implementation and a new program evaluation that would begin
simultaneously.

 
CONSIDERING NIKKI

1. Identify the various steps that Nikki could have taken to prevent this
from happening in the first place.
 2. What, if any, relevance might the initial evaluation data that Nikki’s
staff collected have?
3. What is Nikki’s responsibility to the clients that received this modified
treatment—and what should she do to address this?
4. If you were Nikki, how and what would you communicate to the
funder/contract manager?

About This Chapter

This chapter is dedicated to program evaluation and the three major
components that compose a comprehensive program evaluation—fidelity
assessment, process evaluation, and outcomes evaluation. This step of the
model is directly related to Step III (Design the Clinical Program), as it is
based on the logic model that was previously developed, as well as the
outcomes assessment tools that were initially identified, and utilizes these in
finalizing and implementing the formal evaluation. In addition, because
evaluation activities—especially fidelity and process evaluation—focus
specifically on aspects related to implementation, these evaluation activities
must begin concurrently with program implementation (Step IX).
To begin this exploration of program evaluation, we must start with
revisiting the program design. Then, we will examine fidelity assessment,
process evaluation, and outcomes evaluation. Next, we will discuss the
development of the program evaluation plan, giving special attention to
measuring program outcomes, selecting outcomes tools, and establishing
time frames. This will be followed by a discussion of the various
considerations in evaluation, including the costs and benefits associated with
evaluation and the importance of creating an evaluation-friendly
environment. The chapter will conclude with an exercise to further
illuminate the costs and benefits related to evaluation and a case illustration
to highlight the major issues discussed throughout the chapter.

STEP X: EVALUATE THE PROGRAM

Evaluation
Each of the steps (i.e., components) of the comprehensive program
development model has a specific value and plays a specific role, and
without attending to each, the full benefits of the model cannot be realized.
This is because the components are interdependent—relying on one another
to build toward the overarching goal of designing, implementing, and
sustaining a program that is successful in addressing the mental health or
human service needs of its consumers. No better example of the
interdependent nature of these relationships can be found than that of the
relationship between program design and program evaluation. Measuring the
effectiveness of a program design requires a program evaluation, and an
effective program evaluation requires planning for the evaluation at the point
of program implementation. Therefore, without one, the other is severely
limited.
An emphasis on program evaluation has continued to gain strength over
the past several decades as a means by which private and public
organizations can work toward quality and efficiency (Stufflebeam, 2000).
Because evaluation allows you to measure and assess various elements of
design, process, and impact or outcomes, it is critical to sustainability. This
is truer in the 21st century than ever before, since accountability and
evidence-based practices are standard protocol in program development
today. Indeed, few funding sources will support programs and/or projects
without an established evidence basis, and in addition, programs/projects
that cannot achieve their intended outcomes may be short-lived. At the same
time, an evidence-based program design does not guarantee that the program
outcomes will be automatically attained or that the program will be
implemented in the same manner as the original design. Moreover, an
evidence-based design does not imply that the results of an evaluation are
necessarily valid, since the validity is dependent on the degree to which
evidence-based methods are replicated in subsequent implementations.
In any evaluation, it is important to address not only whether the
intervention worked but also whether the implementation of the
intervention was sufficient to permit a good test. The problem is
compounded when a weak implementation is accompanied by a weak
process evaluation. Then when the program yields null results, there is
no way to determine whether the negative findings were due to poor
 implementation of the program, poor implementation of the
evaluation, or poor program theory. (Orwin, 2000, p. 309)
Nikki was able to take her mishap in stride, not only taking responsibility
for the mistakes that were made but turning the mistakes into an opportunity
to teach her staff about the significance of such concepts as fidelity, process
evaluation, and outcomes evaluation. Few would deny that this type of
learning is often the richest kind—attained through our own actions, our own
mistakes, and allowing for a redo in order to get it right. Unfortunately,
though, this type of mistake can be extraordinarily costly—not only in staff
time and other expenses incurred in the initial and subsequent
implementations but, more significantly, in the costs to the clients who did
not receive adequate treatment. This last cost is the one that matters the
most, and it is the primary reason that mental health professionals must be
knowledgeable and fully competent in evaluation methods.

Revisiting the Program Design

Any type of program-related evaluation must begin with the program design.
This is because the program design is the essential driver needed to guide the
evaluation. For instance, you cannot assess the degree to which a program
model was implemented in accordance with the original design if you are
uncertain of the original design and have not accounted fully for the design
in the assessment procedures. The same is true for an evaluation of the
processes involved in implementation—if you do not know what steps
should be involved, you will not have anything meaningful to measure the
implementation process against. Finally, if an outcomes evaluation is not
constructed based on the program design, while you may be able to identify
outcomes, you will have limited information as to the specific interventions
that may have led to those outcomes—and failures to achieve outcomes.
To better understand this, consider the logic model discussed in Chapter
5. Recall the purpose of the logic model in providing a graphical
representation of the program that, in short, identifies

the need or problem to be addressed,

the interventions and services designed to address the need, and
 the short- and long-term outcomes of the program.

All this information is needed to guide the program evaluation process.

And as a result, the logic model is not only an essential program design tool
but also an essential evaluation tool. In fact, the logic model and other
design tools and components of program design contain information
necessary to program assessment and evaluation efforts so that all program
assessment and/or evaluation planning efforts actually begin during the
initial program design process.
There are three major types of evaluation relevant to clinical programs:
 

1. Fidelity assessment
2. Process evaluation
3. Outcomes evaluation
 
These are all highly interdependent (as Nikki illustrated in the case
vignette above)—work in one area will undoubtedly impact work in another.
In addition, each is distinct—serving a specific purpose. Therefore, program
developers and other mental health professionals must not only understand
the various types of evaluation methods, but they must be able to distinguish
between them.

Types of Evaluation
Fidelity Assessment
“Intervention fidelity means that the intervention was conducted as
planned” (Horner, Rew, & Torres, 2006, p. 80) or indicates the degree to
which the integrity of a program’s original design is maintained when the
program is being implemented. Fidelity assessment is concerned with
ensuring that the original intent of the design is maintained and that each
design component has been adhered to throughout the implementation
process. Moreover,
 treatment fidelity is defined as the strategies that monitor and enhance
the accuracy and consistency of an intervention to ensure it is
implemented as planned and that each component is delivered in a
comparable manner to all participants/clients. (Smith, Daunic, &
Taylor, 2007, p. 121)
Whereas fidelity assessment is highly useful when assessing newly
designed treatment models that have not yet been evaluated, it is imperative
in assessing treatment models that have previously been evaluated to ensure
that the treatment was implemented as designed.
Fidelity assessment is critical to determining the efficacy and
effectiveness of any treatment practice (Smith et al., 2007), and as such,
fidelity assessment can be viewed as a part of process evaluation; however,
whereas process evaluation assesses the entire implementation process and
related aspects, fidelity assessment specifically focuses on adherence to the
original treatment design.
Because fidelity assessment is a relatively new concept in mental health
and human services, the Treatment Fidelity Workgroup of the National
Institutes of Health Behavior Change Consortium was created to advance
understanding and knowledge of treatment fidelity as well as methodology
and measurement of fidelity (Bellg et al., 2004). The Workgroup developed
a conceptual framework for understanding treatment fidelity and set forth
guidelines and recommendations that cover the five major areas of fidelity:

Design
Training
Delivery
Receipt
Enactment

Each of these areas is considered pertinent to maintaining treatment

fidelity, and as such, great attention must be paid to each prior to and during
treatment implementation. Design focuses on each of the specific elements
of program design to ensure that there is complete understanding of the
design and the original design is kept intact during implementation. Training
focuses on various issues related to preparing staff for program
implementation and various characteristics that might influence fidelity, such
as competency and theoretical orientation. The recommendations that were
made in the area of training related to such issues as hiring for the
appropriate qualifications and developing training and other supports to
ensure treatment fidelity. Delivery focuses on the implementation process
itself and methods for monitoring implementation to ensure that the
interventions were delivered as intended. The Receipt category refers to the
degree to which treatment recipients understand the treatment interventions
and anticipated outcomes. Finally, Enactment refers to treatment outcomes
and the ability of recipients to enact the skills acquired from the intervention.
These categories are not mutually exclusive. Inattention to one category
could compromise the internal validity of the study despite adherence to the
other categories. For example, without assessing provider skill acquisition
and maintenance, it cannot be determined if nonsignificant results are due to
an ineffective intervention or to a lack of attention to the training issues
(Borelli et al., 2005).
To move the conceptual framework into practice, Borelli et al. (2005)
developed the Treatment Fidelity Assessment Checklist (see Box 12.1). The
assessment evaluates fidelity in each of the five categories and was derived
directly from the conceptual framework of fidelity.
 
BOX 12.1

TREATMENT FIDELITY ASSESSMENT CHECKLIST

Treatment Design
Provided information about the treatment dose in the intervention condition
Provided information about the treatment dose in the comparison condition
Mention of provider credentials
Mention of theoretical model or clinical guidelines on which the intervention is based

Training Providers
Description of how providers were trained
Standardized provider training
 Measured provider skill acquisition post-training
Described how provider skills are maintained over time

Delivery of Treatment
Included method to ensure that the content of the intervention was being delivered as specified
Included method to ensure that the dose of the intervention was being delivered as specified
Included method to assess if the provider actually adhered to the intervention plan
Assessed nonspecific treatment effects
Used treatment manual

Receipt of Treatment
Assessed subject comprehension of the intervention during the intervention period
Included a strategy to improve subject comprehension of the intervention above and beyond
what is included in the intervention
Assessed subject’s ability to perform the intervention skills during the intervention period
Included a strategy to improve subject performance of the intervention skills during the
intervention period

Enactment of Treatment Skills

Assessed subject performance of the intervention skills assessed in settings in which the
intervention might be applied
Assessed strategy to improve subject performance of the intervention in the setting in which the
intervention might be applied
 

The Treatment Fidelity Assessment Checklist may prove a useful guide to

developing a fidelity assessment for use with a broad range of treatment
interventions and, as such, is a welcome addition to an assessment toolbox.
In terms of the actual use of fidelity assessment in evaluating specific
programs, efforts have been made in an attempt to quantify and guide
fidelity assessment of different types of treatment interventions that have
included family grief therapy (Chan, O’Neill, McKenzie, Love, & Kissane,
2004), the Wraparound Model of community-focused programming for
youth and their families (Bruns, Burchard, Suter, Leverentz-Brady, & Force,
2004), serious emotional disorders in children (Epstein et al., 2003), and a
cognitive-behavioral approach to relapse prevention in individuals with
psychosis (Alvarez-Jiminez et al., 2008). Let’s take a closer look at two of
these fidelity assessments, in which two very different tools were developed
—the Wraparound Model and the cognitive-behavioral approach for relapse
prevention. In the first, attempts have been made to evaluate fidelity of the
nationally used Wraparound Model. To this end, the Wraparound Fidelity
Index was developed (Bruns et al., 2004), and initial reports found this tool
to be useful in assessing the model—a model that has been used across the
country over the past 2 decades.
The second fidelity assessment tool may be of even greater interest to
mental health professionals because it was designed to focus specifically on
the therapeutic process (Alvarez-Jiminez et al., 2008). This tool, the Relapse
Prevention Therapy-Fidelity Scale, was designed to assess the major
therapeutic components, which included assessment/engagement, agenda,
psychoeducation, early warning signs, cognitive-behavioral interventions,
and review/termination as well as the use of general therapeutic factors. The
tool allowed the evaluators to drill down to the micro level of the therapeutic
process to evaluate the degree to which treatment fidelity was maintained.
This type of micro-level tool may have specific promise as efforts toward
treatment fidelity assessment continue to grow and varying levels of fidelity
are explored.
Fidelity is critical for many reasons, chief among them being the
relationship between fidelity and the use of evidence-based practices. In our
21st-century climate that emphasizes the use of evidence-based practices and
increased accountability in mental health treatment, the concept of fidelity is
critical. This is because evidence-based practices are predicated on previous
evaluations that have found the practices to be effective and, thus, evidence-
based. Therefore, individuals wishing to adopt evidence-based practices
must do so in a manner that replicates the original implementation of the
treatment and maintains the integrity of the practices. Failure to do so would
imply that evidence-based practices have not been adopted.
The fact that we currently emphasize the use of evidence-based practices
without a parallel emphasis on fidelity assessment should cause concern,
since without assessing for fidelity, there is no evidence that the integrity of
the program/model has been maintained. In fact, only 27% of the practice
research conducted on youth with emotional and/or behavioral disorders
reported treatment fidelity data (Mooney, Epstein, Reid, & Nelson, 2003).
Interestingly, Borelli et al. (2005) used the Treatment Fidelity Assessment
Checklist to evaluate treatment fidelity in articles in five journals and found
that only 27% of the 342 studies reviewed had assessed if the treatment was
delivered as specified. So while recent discussions of treatment fidelity
assessment have gained prominence, the act of conducting treatment fidelity
assessments has yet to become part of the common protocol of program
development—much to my dismay.
However, if we continue in the future to examine treatment fidelity as a
critical issue of program development, we should hopefully begin to see an
increase in fidelity assessment as well. Moreover, the process of assessing
for treatment fidelity may draw attention to the need for clearly delineated
program design that is conducive to effective fidelity assessment. This
additional outcome may indeed move the area of program development
forward as greater attention to detail is provided in the initial program
design. In the case of multisystemic therapy, the Office of Juvenile Justice
and Delinquency Prevention has put forth funding to specifically promote
the successful dissemination of the treatment model (Schoenwald,
Henggeler, Brondino, & Rowland, 2000). This is not an uncommon
occurrence, since often, the relationship between research and funding is a
symbiotic one—with research agendas being driven by funding priorities
and vice versa. So it is hoped that with this specific funding made available
to promote treatment fidelity, there will indeed be an increased focus on the
implications of treatment fidelity in comprehensive program development.

Process Evaluation
Whereas treatment fidelity focuses intensively on adherence to program
design, process evaluation focuses on the broader aspects related to the
implementation process. I should point out that process evaluation has been
referred to by other names, such as monitoring and implementation
evaluation, and in some cases, fidelity assessment has been referred to as
process evaluation (Kettner, Moroney, & Martin, 2008). To effectively
differentiate these three constructs—fidelity, process implementation, and
outcomes evaluation—I will be referring to each independently.
Basically, a process evaluation sets out to accomplish the following:
 Describe the program’s implementation process
Assess whether the services were delivered to the intended
recipients (Orwin, 2000)
Provide descriptive information about the type and quantity of
program activities
Provide information about program outcomes relative to
program costs
Assess if programs have been implemented as expected (Lewis,
Packard, & Lewis, 2007)

Whereas fidelity assessment provides essential information specifically

related to maintaining the integrity of a clinical model, process evaluation
has a much broader scope—thus, it provides several other benefits. For one,
process evaluation allows program administrators an opportunity to critically
evaluate the number and type of resources dedicated to a particular program.
Resources such as staff, travel, training, and other such expenses attributed
to a program can be examined. As such, administrators and managers can
better understand the relationship between program interventions, resources,
and outcomes. Because of this focus, administrators may be better equipped
to think about program development efforts not only in terms of
effectiveness but also in terms of efficiency (Lewis et al., 2007).
In addition to evaluating resource allocation, process evaluations also
allow for immediate feedback, since this type of evaluation assesses
activities as they are being implemented (i.e., in process). As a result, you
are able to obtain immediate feedback about many aspects of the
implementation, some of which are crucial to ongoing planning efforts. For
instance, a process evaluation assesses such areas as client type, number of
clients served, and time frames in which clients were served. This type of
information can inform you not only if the target population is being served
(i.e., client type) but also if the intended number of clients are being served
within the expected time frames. Equipped with such information, program
staff are able to make necessary adjustments quickly, particularly if
increased recruitment activities are needed. This information also can be
used to prompt program staff to engage in more thorough planning efforts to
address any challenges detected during implementation. In addition, this
type of information is often required by funding sources, thereby reflecting
another concrete purpose of conducting a process evaluation.
Technically speaking, the types of issues examined in a process
evaluation are varied and often determined by the program design, staff, and
the evaluator/evaluation team based on specific data needs. Whereas
evaluating data related to the target population—such as the number of
clients served and the time frames in which they were served—is a typical
part of a process evaluation, the number of interventions and the scope of
services provided to each client and changes in assigned clinicians and/or
other support staff may also provide meaningful information. By collecting
this type of information, you are able to monitor specific aspects of the
program—ensuring that identified targets are met and reviewing essential
data. This type of monitoring (Lewis et al., 2007)—another feature of a
process evaluation—can provide additional benefits needed to effectively
manage the program and, as such, is often related to quality assurance.
Kettner et al. (2008, p. 256) sum up some of the major questions
answered through a process evaluation:

What proportion of the community need is the program

meeting?
Are only eligible target-group clients being served?
Are subgeographical areas and subgroups being served in
appropriate numbers?
What products and services are being provided and in what
amounts?
What results are being achieved in terms of outputs and
outcomes?

Additional questions that may be used to guide a process evaluation

include the following:

Are the expected number of staff involved in the program?

Are the expected types and levels of resources being dedicated
to the program?
 Are the services being provided in the expected location(s)?
Are the expected number of services being provided?
Is the service being provided in the expected time frames?
Were there any changes in staffing throughout the
implementation process?
What factors may have influenced the implementation process?

The answers to each of these questions can provide important information

to promote increased understanding of the implementation process.
Moreover, this information is essential to outcomes evaluation since any
nuances of program implementation may significantly impact the program
outcomes and, therefore, need to be fully considered.

Outcomes Evaluation
Unlike fidelity assessment and process evaluations, outcomes evaluations
focus on the results or the effect of the interventions on the clients.
Outcomes evaluations—also confusingly referred to as program evaluations
—provide the most important information to mental health professionals—
that is, the impact that their work has had on the individuals served. Whereas
process evaluations rely on clearly defined objectives that are activity-based
(e.g., number of sessions) in order to conduct the evaluation, outcomes
evaluation relies on impact objectives (Lewis et al., 2007). This clearly
differentiates these two types of evaluation. In addition, outcomes evaluation
is a hypothesis-testing activity (Kettner et al., 2008)—the results of which
indicate if the desired impact has been achieved.
In order to be effectively evaluated, outcomes must be observable,
measureable, and developed in behavioral terms. “If objectives are clearly
written, criteria and standards for success can be developed in relation to
them” (Lewis et al., 2007, p. 234). In the mental health and human services
industries, there are typically three major categories into which program
outcomes fall:
 

1. Knowledge-based outcomes
 2. Affectively based outcomes
3. Behaviorally based outcomes
 
Knowledge-based outcomes are used to evaluate changes in a client’s
knowledge as a result of an intervention. Alternatively, affectively based
outcomes are concerned with assessing changes in a client’s affect or
emotional state that may be impacted by treatment, while behaviorally based
outcomes focus on changes in behavior resulting from therapeutic
interventions. Table 12.1provides examples of short-term/intermediate and
program completion outcomes for each of the three categories.
As you can see in the examples provided, each of the outcomes is written
in measureable and observable terms, with the exception of the self-reported
outcome related to self-esteem. This is because of the inherent difficulty in
trying to quantify the construct of self-esteem. As a result, self-report may be
used as a means for the client to indicate change in self-esteem. Whereas this
type of evaluation method is not ideal, at times, it may prove the best of
what is available, depending on the types of outcomes being measured. In
addition to the self-report measure used, the examples also illustrate various
other types of outcome measurements that include pre/post-test scores of a
standardized instrument (e.g., Beck Depression Inventory) and concrete
measures (e.g., independent living). The selection of outcome measures
should be guided by identifying the most relevant and effective tool/activity
given the outcome. Finally, the examples illustrate outcome thresholds or
targets. This, too, is highly significant and must be based on previous rates
of success with the interventions/program—when the interventions and/or
program are not being piloted for the first time—or with success rates from
alternative interventions. As such, target areas are guided by data and
existing evidence that indicate expected results.
Table 12.1 Examples of Outcome Types
 For instance, when implementing a newly designed program for young
women with bulimia nervosa, the targeted outcome threshold should be
based on previous outcome studies so that if outcomes of full recovery at 1
year post-treatment have ranged from 76% to 92% with a mean of 85%, the
targeted outcome for the same goal should be set at 85%. By doing this, you
are able to evaluate your program outcomes in relation to other previously
reported outcomes, ensuring that you are indeed setting the bar high enough
to achieve results previously attained.
Loesch (2001) most effectively sums up outcomes evaluation as a process
that is
 

1. used for making reasonable determinations about program

efforts, efficiency, effectiveness, and adequacy;
2. based on systematic data collection and analysis;
 3. designed for uses in external accountability and internal
program management and future planning; and
4. focused on acceptability, awareness, availability,
comprehensiveness, accessibility, integration, continuity, and
cost.
 
Because outcomes evaluation has grown into a distinct field on its own,
referring to specialized skill sets and often large-scale evaluations that may
include multiple states and regions, it is important to differentiate between
the scale levels of outcomes evaluations. Depending on the work that you
do, you may be involved with large-scale program evaluation; however,
most mental health and human service practitioners engage in small-scale,
localized program development efforts. As such, these small-scale outcomes
evaluations are considered micro-evaluations—a type of action research
geared toward monitoring and improving a particular program or service
(Astramovich & Coker, 2007).
The United Way’s Outcome Measurement Resource Center contains a
broad array of books, tools, and other resources to aid in outcomes
evaluation. To review their offerings, visit www.liveunited.org/outcomes.

Developing the Outcomes Evaluation Plan

As is true of all evaluation efforts, the outcomes evaluation is a complex
process and, as such, requires significant planning. In addition to conducting
all the preparatory work needed to effectively support the evaluation
process, there are three major areas that compose the planning process:
 

1. Determining the evaluation design

2. Selecting the assessment instruments
3. Establishing the evaluation time frames
 

Outcomes Evaluation Design

 Similar to fidelity assessment and process evaluation, outcome
evaluations are highly complex and require a tremendous amount of
planning, effort, and attention to detail. Outcome evaluations are the driving
force behind the development of evidence-based practices. Indeed, without
an effective program evaluation, an evidence basis cannot be established. As
a result, the highest degree of scientific rigor is required in order to most
effectively evaluate outcomes. To this end, randomized clinical trials (RCTs)
have become the gold standard for the efficacy of outcome evaluations. This
is because of the potential of RCTs to maximize internal validity (i.e.,
attribute outcomes directly to the treatment rather than other causes; Del
Boca & Darkes, 2007). The significance of the interdependent relationship
shared by fidelity assessment, process evaluation, and outcomes evaluation
is further underlined by the requirement of RCTs, because RCTs are
dependent on treatment fidelity as well as an effective process evaluation.
Whereas RCTs are indeed the gold standard, experimental designs that
use a control group (i.e., withhold treatment) are not always feasible in
practice settings for ethical as well as logistical reasons. As a result, program
developers must be well versed in various types of program evaluation
design to ensure that the most effective and ethically sound evaluation is
used. Although there are multiple types of design that can be used, I would
like to focus briefly on quasi-experimental design, since it may account for
the most rigorous type of design, given the inherent challenges of research in
practice settings.
One of the most commonly used types of quasi-experimental design in
mental health and human services is the pre/post-test design. In the pre/post-
test design, clients can be randomly assigned or deliberately assigned to
either one of two treatments or to a treatment or control group (i.e., no
treatment is provided). But again, because of ethical reasons prohibiting the
withholding of treatment to those in need, pre/post-test design in practice
settings typically involves assigning clients to one of two treatments—an
evaluation design that is increasingly common today (Heppner, Wampold, &
Kivlighan, 2008).
A pre/post-test design allows you to examine pretest differences, a critical
aspect when comparing unequivalent groups. In comparison to a post-test-
only design, the pre/post-test design is stronger and more interpretable
because of this (Heppner et al., 2008). However, it should be noted that a
threat to this type of design is related to potential problems with external
validity that can occur as a result of pretest sensitization—the pretest itself
creates a difference between the two groups. However, most agree that this is
minor, and the benefits of the design outweigh this risk (Heppner et al.,2008;
Kazdin, 2003).
The aspect of random selection should be briefly discussed, particularly
as it can significantly impact the integrity of the pre/post-test design. In
order to maximize the strength of research findings, the two treatment
groups being evaluated should be equal. Such equality among treatment
participants is referred to as between-groups design—meaning that the
groups are equal prior to treatment. By ensuring this, you are able to more
easily attribute post-treatment differences to the treatment. Accounting for
between-groups equality requires random selection of participants to one of
the two or more groups. Random selection, or randomization, means that
participants have been assigned without bias. Random selection can be
accomplished in several ways, such as assignment to one of the two groups
based on order of program admission—Client 1 is assigned to Treatment 1,
Client 2 to Treatment 2, Client 3 to Treatment 1, Client 4 to Treatment 2, and
so on. In this type of randomization, all odd-number admissions are assigned
to Treatment 1, while all even-number admissions are assigned to Treatment
2. While quite straightforward, this type of randomization requires that
clients enter in a sequential manner and that the sequence of client admission
is tracked. This may not be feasible in some practice settings, particularly
when clients are admitted en masse. To address this issue, the old and trusted
hat trick may serve better. You can simply place the names of all clients in a
hat, and use the order in which names are pulled to assign the clients to one
of the two treatment groups (i.e., first name pulled is assigned to Treatment
1, second name to Treatment 2, third name to Treatment 1, etc.). As with
every aspect of research design, the issue of random selection must be given
adequate attention in order to further strengthen your overall design.
While basic research design composes one part of an evaluation program,
the other area that must be given thoughtful attention is that of research
methods; however, such a discussion is outside the scope of this text. A
number of quantitative and qualitative research methods may be used in
program evaluation as relevant to the study design, and a good resource for
use in designing the program evaluation is Heppner et al.’s (2008) Research
Design in Counseling.
Whereas little can replace firm knowledge of research design, attention to
specific issues related to design may provide basic guidance for planning the
research design (see Box 12.2).
BOX 12.2

BASIC GUIDE TO DETERMINING THE RESEARCH

DESIGN

Consult your profession’s ethical standards related to research.

Review each of the potential types of research design to identify the
most rigorous design that can be implemented within the practice
setting.
Seek out more and new knowledge as needed to increase your own
competency level with regard to research design and analysis.
Consult with experts in research design and statistical analysis as
needed.
Involve staff and other stakeholders in the design selection process to
promote early engagement in the research.
 

Most importantly, before embarking on any research design project,

ensure that you have a comprehensive grasp of research design and methods.
This often requires revisiting research methods coursework, pursuing new
coursework, attending training and workshops focused on research design
and methods, and utilizing the vast array of texts and tools available to you
in this area. Failure to do so will almost certainly threaten your ability to
effectively evaluate your program’s outcomes. It is often at this stage that we
get to finally put to practice in the real world what we have learned only
conceptually or through academic assignments. As a result, this should be
viewed as an exciting opportunity to grow. Therefore, regardless of any
previous struggles that you may have experienced with research design
and/or methods, applying research in practice often signifies the opening of a
window that has not been opened before. So rather than facing it with
discomfort or fear, pursue it with zest and perseverance, and once you have
thoroughly engaged in it, the stimulation and sense of accomplishment will
reinforce how truly rewarding the process of learning is.

Selecting Assessment Tools

The research design will guide the selection of assessment instruments.
This is particularly true if you have selected a pre/post-test design, since
assessment instruments that assess change over time are needed rather than
assessment instruments that have been developed to assess issues that are
static or not prone to change. For instance, there are assessment instruments
that evaluate potential risk based on events that occurred at a particular time
in a person’s life, such as the age at which an individual committed his/her
first crime or when an individual was physically abused. The results of this
type of assessment will not change over time; therefore, the assessment is
intended to be used just one time to gain specific information. However,
other assessment instruments are developed precisely to evaluate change
over time and, therefore, are designed to be given multiple times. Examples
of these types of outcomes include mental health functioning, recidivism,
sobriety, and employment. These types of outcomes lend themselves to
evaluation through a pre/post-test research design, whereas the former (i.e.,
static outcomes) do not.
Selecting both the most effective and the most relevant assessment tools
for an outcomes evaluation requires quite a bit of work and investigation;
however, much of this work should have been completed during the program
design stage (discussed in Chapter 5). At this step, then, it means revisiting
the program design in order to review previously selected assessment
instruments and determine if additional instruments are needed. There are
several guidance factors that should be considered in the selection of
assessment instruments:

Use assessment instruments only with established psychometric

properties.
Use assessment instruments only for their intended purpose and
in the manner in which they have been found to be effective.
Ensure a thorough understanding of the strengths and
limitations of assessment instruments.
Review the qualifications level needed to administer a test, and
ensure that individuals charged with test administration have
the required qualifications.
Ensure a firm understanding of the ethical standards that guide
the use of assessment instruments.
Use assessment instruments for the purpose of treatment
planning and improving treatment and services, not for denying
or limiting services that would otherwise be provided.
Ensure a firm understanding of the role that testing conditions
play in test performance, work to promote optimal testing
conditions, and include a discussion of testing conditions and
potential impact on test scores in the testing summary.
Gather and maintain assessment data, as you do all client
information, in a confidential manner, and protect it in
accordance with all relevant state and federal laws.
Practice additional compliance as required for all research
protocols, policies, and laws when using assessment data for
research purposes (e.g., outcomes/program evaluation).
Gain consent and/or authorization, when required, from the
oversight organization with indirect responsibility for the client,
in addition to gaining consent from clients and/or other
authorized individuals (in the case of minors and vulnerable
adults).
Conduct all research in accordance with laws regarding the
protection of human subjects and with authorization and
oversight by an institutional review board.
 In addition, a valuable resource regarding the use of tests is
Responsibilities of Users of Standardized Tests, promulgated by the
Association for Assessment in Counseling (2003). The publication provides
broad-based guidance in seven key areas:
 

1. Qualifications of test users

2. Technical knowledge
3. Test selection
4. Test administration
5. Test scoring
6. Administering test results
7. Communicating test results
 
The publication is available at no cost through the association’s website
(www.theaaceonline.com).

Establishing Evaluation Time Frames

Conducting any type of evaluation is always a lengthy process—and
understandably so, given all that is involved. This is why planning for the
evaluation is such a critical aspect. Part of this planning process requires the
establishment of evaluation time frames. Essentially, these are the time
frames in which the actual evaluation will be conducted. For instance, a
basic research design may include one pretest and one post-test that will be
given at program admission and then at program discharge, respectively.
However, there are multiple other time frames that may be used based on the
research design, some of which allow you to evaluate progress during the
treatment process and others that allow you to evaluate long-term treatment
gains. Table 12.2 provides examples of time frames for conducting
assessment activities based on the research design.
Table 12.2 Evaluation Time Frame Samples
 In addition to identifying time frames for conducting specific assessment
activities, “developing a timeline to facilitate the collection of data for the
development, maintenance, and revision of the program evaluation plan is
recommended” (Gard, Flannigan, & Cluskey, 2004, p. 177). Again, I cannot
stress enough the use of specific planning tools to help organize the planning
process. Whereas timelines are often essential, Gantt charts and project maps
may also prove indispensable not only in managing your time but also in
communicating plans to others.

Comprehensive Evaluation Planning

Whereas a large part of this chapter has been devoted to outcomes evaluation
and its various aspects, mental health professionals should be engaging in
comprehensive evaluation that includes all three types of evaluation
discussed above—fidelity assessment, process evaluation, and outcomes
evaluation. This is because each has specific relevance and, therefore, is
conducted for specific purposes. Indeed, comprehensive evaluation planning
should include the use of multiple types of evaluation and should be used to
guide long-term evaluation activities.
When engaging in comprehensive program evaluation, several issues
must be attended to that include, but are not limited to, the following:

Identify specifically what is being evaluated and why and how

the evaluation results will be disseminated and used to inform
treatment and services.
Engage all stakeholders in the evaluation process early in order
to sustain engagement throughout the evaluation process.
Provide orientation and training to all evaluation participants to
promote knowledge and understanding of evaluation
procedures, rationale, and methods.
Establish a comprehensive evaluation plan with identified
evaluation types and time frames as part of initial program
planning.

In addition to promoting effective program management, engaging in

comprehensive evaluation planning ensures that the evaluation processes are
well organized and are a pivotal part of program development.

Considerations in Evaluation
As mentioned earlier, evaluation can be one of the most rewarding
endeavors in which you engage, particularly as viewed from a program
management perspective. In order to fully consider all that is involved and
related to evaluation efforts, there are three key areas that I would like to
highlight:
 

1. Evaluation as a tool for organizational sustainability

2. Costs and benefits of evaluation
3. Creating a culture of evaluation
 
Evaluation as a Tool for Organizational Sustainability
Evaluation is a tool—a tool that is used by professionals in order to gain
critical information. In the case of process and outcomes evaluations, data is
collected and analyzed to determine the efficiency, effectiveness, and impact
of programs and services (Boulmetis & Dutwin, 2005). As such, evaluation
demonstrates accountability—the accountability of a provider of services to
the recipient/client, to the funder or contractor of services, to the public, to
the profession to which the provider belongs, and to the industry in which
the provider is working. It is this accountability that may allow the provider
to continue providing services—just as, conversely, a lack of accountability
may result in the discontinuation of practice.
Because the appropriate and effective use of evidence-based practices
guides the mental health and human service fields today, evaluation is no
longer an optional activity for those who are so moved but a required
activity that must be incorporated into all aspects of practice. Indeed, when
called on to provide evidence of program or intervention effectiveness,
mental health professionals can effectively draw on information gathered
from the evaluations that they have instituted (Astramovich & Coker, 2007).
As such, evaluation is a tool—a tool necessary for the long-term
sustainability of the service, program, organization, and counseling and other
mental health professions.

The Costs and Benefits of Evaluation

As any good manager knows, never embark on any new endeavor
without conducting a thorough cost-benefit analysis. Otherwise, you may
find that your investment far outweighs your return, that what you received
was far from what you originally hoped, or any number of other unfortunate
surprises. There are multiple potential costs and benefits related to engaging
in evaluation efforts. I use the term potential since, ultimately, the outcomes
will dictate actual costs and benefits.Table 12.3 provides a sample of some
of the costs and benefits typically associated with evaluation efforts.
Table Sample of Potential Costs and Benefits of Engaging in Evaluation
12.3 Efforts
 The point here, although rather obvious, is that the benefits resulting from
engaging in evaluation efforts should always greatly outweigh the costs. And
while only few costs and benefits are economic and can be easily quantified,
the benefits to the professionals involved in evaluation efforts are priceless.
This is of particular significance in a profession that does not naturally
receive immediate feedback about the impact of our work. Unlike the car
salesperson who gains immediate feedback about her/his selling ability
based on the act of completing a car sale or the senator who witnesses the
passage of a bill that s/he authored, many mental health professionals rarely
gain substantial feedback about their work unless an evaluation has been
conducted. It is in this regard, then, that evaluations provide significant and
meaningful information about our work. Even when anticipated outcomes
have not been attained, evaluation data usually provides other significant
information and is useful for service/treatment improvement efforts and, as
such, provides essential input to our work.

Creating a Culture of Evaluation

 The environment in which an evaluation is conducted plays a major role
in any evaluation process. This is due to many reasons, not least of which is
the very intent of evaluation—to assess or evaluate how one is doing. And in
this case, it means evaluating the work of mental health professionals. For
many of us—regardless of how otherwise healthy we might be—the notion
of having our work evaluated has a tendency to make us a bit uneasy. It is
because of this that the climate created within practice environments is key
to effectively supporting evaluation efforts.
Creating a culture or climate for evaluation requires close attention to
several details and adequate preparation of the work environment. Murray
(2005) identifies two of these issues:
 

1. Encouraging an atmosphere of openness and trust throughout

the evaluation process
2. Including all relevant stakeholders throughout the evaluation
process
 
In addition, all stakeholders must understand the purpose of the
evaluation and how the results will be used. Often, uncertainty about how
results will be used can cause the greatest anxiety to stakeholders in an
evaluation process. Therefore, an environment must be created in which
continuous improvement is the overarching goal—and the philosophy that
there is no failure, only room for improvement, is used to guide the process.
It is only in this type of environment that evaluation can be viewed as a
necessary and positive experience, regardless of the results. However, this
also means that evaluation results cannot be used for punitive measures,
since such measures are counterproductive to creating a healthy evaluation
environment.
The following activities should also be used to promote a culture of
evaluation:

Before starting the evaluation process, identify where you

would like it to lead and all that will result from the evaluation.
 Openly and frequently discuss the relationship between
evaluation and accountability and long-term sustainability.
Incorporate progress updates into existing forums so that
evaluation information and activities are consistently shared
among stakeholders as part of the ongoing communication
cycle.
Share various types of results with stakeholders frequently to
keep the evaluation process alive.
Explain precisely how each set of evaluation results will be
used, and then provide ongoing updates regarding their use.
Celebrate evaluation processes as a core part of work life.

Summary
Evaluation is an integral part of comprehensive program development and
one that is specifically connected to program design and program
implementation. The significance of evaluation has grown steadily over the
past several decades and today is viewed as standard practice in mental
health and human services. Moreover, the significance of the various types
of evaluation has also continued to grow as our understanding of the
influence of treatment fidelity and process implementation on evaluation has
developed. While there is still room for growth in broad-based
acknowledgment about the role that fidelity and process implementation
play in comprehensive program evaluation, today there are signs that this
knowledge will only continue to evolve. As such, fidelity and process
implementation may soon reach the same level of significance as outcomes
evaluation holds today.
The manner in which mental health professionals perceive evaluation as a
core part of program development and thereby embed evaluation activities
throughout programs and organizations is largely indicative of their
commitment not only to quality and accountability but to long-term
sustainability. Whereas there continues to be a need to bring in external
evaluation experts to handle evaluation activities on behalf of the
organization, evaluation knowledge and skills are essential skills of all
mental health professionals. As a result, there is increased understanding of
the link between program design, implementation, and evaluation and a
much more intimate relationship between the treatment provider and the
treatment. This is not only a basic right of accountability to which all
consumers are entitled but also what consumers most prefer—a closer
relationship between the product and the seller to ensure that the seller is
intrinsically aware of all that the treatment and/or service is and is not able to
provide.
 
CASE ILLUSTRATION
Alana and Ava had been cofacilitating a treatment program for adults
with panic disorder and agoraphobia for the past year and a half. Their
interventions consisted of individual and group therapy using cognitive-
behavioral interventions. Whereas cognitive-behavioral interventions had
been found to be effective in addressing panic disorder, Ava and Alana
knew that they needed to evaluate their approach to determine if it was
indeed evidence-based, and they also needed to explore existing
evidence-based models. Adding a sense of urgency to this, Alana and
Ava were increasingly being recognized as specialists in their
community for treating panic disorder, and therefore, they were anxious
to ensure that they were providing the best treatment they could to their
clients.
After reviewing the research, Ava discovered a treatment approach
that was evidence-based and shared the details with Alana. The approach
had been rigorously evaluated with strong outcomes over multiple
evaluations—reinforcing their excitement to implement the approach
with their clients. Alana got a hold of all the details of the model,
examining all the components and how each was implemented so that
she and Ava could implement it as designed, thus retaining the model’s
fidelity. At the same time, Ava designed the evaluation components,
including a fidelity assessment, process implementation, and outcomes
evaluation.
The outcomes that would be measured were determined based on the
research about expected outcomes for panic disorder and the results of
previous outcomes evaluations. The assessment tools were identified
based on the research as well as on the previous outcomes evaluations.
Because they wanted to evaluate their existing program as well, Alana
and Ava decided to use a quasi-experimental design to evaluate their
existing treatment approach against the evidence-based model. They
would do this through randomly assigning clients into one or the other of
the treatments, evaluating treatment outcomes during treatment, at
discharge, and at 6 months post-discharge. Neither Ava nor Alana had
conducted a formal evaluation before, so they consulted with an
evaluator for guidance in finalizing the evaluation design, thus learning
how to design and conduct the evaluation. They then developed
informed consent forms for their clients and obtained approval through
the agency’s human subjects committee to conduct the study.
Ava and Alana developed a timeline to guide the evaluation, including
the implementation date for the new treatment model, which was also the
date that the evaluations would begin for both the existing and the new
model. Following implementation, Alana and Ava met to review the
initial fidelity and process evaluation data and were pleased to note that
they had implemented the evidence-based model as designed. After 4
months, they had their initial outcomes data set, which did in fact
illustrate significant differences between the two treatment groups, with
clients who had received the evidence-based treatment showing greater
improvements (i.e., fewer panic symptoms and less frequent episodes)
than those clients who had received their existing treatment. Whereas
Ava and Alana realized that these short-term outcomes may not translate
into long-term outcomes, they were anxious to learn what the long-term
outcomes would be.
Soon enough, they witnessed the first four groups complete treatment
and had enough data to analyze the post-treatment outcomes. The post-
treatment outcomes also revealed significant differences between the two
treatment groups, with the clients who had received the evidence-based
treatment continuing to show even greater improvements (i.e., less panic
symptoms and less frequent episodes) than those clients who had
received the existing treatment. In addition, Ava and Alana’s existing
treatment did not produce significant positive outcomes in comparison
 with the evidence-based model, and the findings did not indicate any
significant change for this group.
Because both the fidelity assessment and process implementation
assessment results indicated that Alana and Ava had implemented the
treatments as originally designed and intended and they had effectively
conducted the evaluations, they were confident that the results of the
outcomes evaluation were valid. Unfortunately, the outcomes did not
provide evidence that the treatment approach that they had been using
was effective, and therefore, they planned to immediately stop using it.
In its place, they would continue to use the evidence-based treatment
model that they had now become comfortable using and, more
importantly, that had yielded significant positive outcomes for their
clients. Being guided in this decision making by the evaluation data, Ava
and Alana were excited about their newly adopted treatment approach,
their outcomes, and the continuation of their evaluation program—which
would continue to inform and guide their practice well into the future.

COST-BENEFIT ANALYSIS EXERCISE

Using the table below and beginning where I left off in Table 12.3, take
some time to identify additional costs and benefits of evaluation. Share
and compare results with others to gain a better sense of the varied costs
and benefits resulting from evaluation activities.
 
   Costs    Benefits
   
   
 
 

References
Alvarez-Jiminez, M., Wade, D., Cotton, S., Gee, D., Pearce, T., Crisp, K., et
al. (2008). Enhancing treatment fidelity in psychotherapy research: Novel
 approach to measure the components of cognitive behavioral therapy for
relapse prevention in first-episode psychosis. Royal Australian and New
Zealand College of Psychiatrists, 42, 1013–1020.
Association for Assessment in Counseling. (2003). Responsibilities of users
of standardized tests (3rd ed.). Alexandria, VA: Author.
Astramovich, R. L., & Coker, J. K. (2007). Program evaluation: The
accountability bridge model for counselors. Journal of Counseling and
Development, 85, 162–172.
Bellg, A. J., Borelli, B., Resnick, B., Hecht, J., Minicucci, D. S., Ory, M., et
al. (2004). Enhancing treatment fidelity in health behavior change studies:
Best practices and recommendations from the NIH Behavior Change
Consortium. Health Psychology, 23, 443–451.
Borelli, B., Sepinwall, D., Ernst, D., Bellg, A. J., Czajkowski, S., Breger, R.,
et al. (2005). A new tool to assess treatment fidelity and evaluation of
treatment across 10 years of health behavior research. Journal of
Consulting and Clinical Psychology, 73, 852–860.
Boulmetis, J., & Dutwin, P (2005). The ABCs of evaluation: Timeless
techniques for program and project managers (2nd ed.). San Francisco:
Jossey-Bass.
Bruns, E. J., Burchard, J. D., Suter, J. C., Leverentz-Brady, K., & Force, M.
M. (2004). Assessing fidelity to a community-based treatment for youth:
The Wraparound Fidelity Index. Journal of Emotional and Behavioral
Disorders, 12, 79–89.
Chan, E. K. H., O’Neill, I., McKenzie, M., Love, A., & Kissane, D. W.
(2004). What works for therapists conducting family meetings: Treatment
integrity in family-focused grief therapy during palliative care and
bereavement Journal of Pain and Symptom Management, 27, 502–512.
Del Boca, F. K., & Darkes, J. (2007). Enhancing the validity and utility of
randomized clinical trials in addictions treatment research: Treatment
implementation and research design. Addiction, 102, 1047–1056.
Epstein, M. H., Nordness, P. D., Kutash, K., Duchnowski, A., Schrepf, S.,
Benner, G. J., et al. (2003). Assessing the wraparound process during
family planning meetings. Journal of Behavioral Health Services and
Research, 30, 352–362.
Gard, C. L., Flannigan, P. N., & Cluskey, M. (2004). Program evaluation: An
ongoing systematic process. Nursing Education Perspectives, 25, 176–
 179.
Heppner, P. P., Wampold, B. E., & Kivlighan, D. M. (2008). Research design
in counseling (3rd ed.). Pacific Grove, CA: Brooks/Cole.
Horner, S., Rew, L., & Torres, R. (2006). Enhancing intervention fidelity: A
means of strengthening study impact. Journal of Specialists in Pediatric
Nursing, 11, 80–89.
Kazdin, A. E. (2003). Research design in clinical psychology (4th ed.).
Boston: Allyn & Bacon.
Kettner, P M., Moroney, R. M., & Martin, L. L. (2008). Designing and
managing programs: An effectiveness-based approach. Thousand Oaks,
CA: Sage.
Lewis, J. A., Packard, T. R., & Lewis, M. D. (2007). Management of human
service programs (4th ed.). Belmont, CA: Thomson Learning.
Loesch, L. C. (2001). Counseling program evaluation: Inside and outside the
box. In D. C. Locke, J. E. Myers, & E. L. Herr (Eds.), The handbook of
counseling (pp. 513–525). Thousand Oaks, CA: Sage.
Mooney, P., Epstein, M., Reid, R., & Nelson, J. R. (2003). Status and trends
in academic intervention research for students with emotional disturbance.
Remedial and Special Education, 24, 273–287.
Murray, V. (2005). Evaluating the effectiveness of nonprofit organizations.
In R. Herman & Associates (Eds.), The Jossey-Bass handbook of
nonprofit leadership and management (2nd ed., pp. 345–370). San
Francisco: Jossey-Bass.
Orwin, R. G. (2000). Assessing program fidelity in substance abuse health
services research. Addiction, 95, 309–327.
Schoenwald, S. K., Henggeler, S. W, Brondino, M. J., & Rowland, M. D.
(2000). Multistemic therapy: Monitoring treatment fidelity Family
Process, 39, 83–103.
Smith, S. W., Daunic, A. P., & Taylor, G. G. (2007). Treatment fidelity in
applied educational research: Expanding the adoption and application of
measures to ensure evidence-based practice. Education and Treatment of
Children, 30, 121–134.
Stufflebeam, D. L. (2000). Foundational models for 21st-century program
evaluation. In D. L. Stufflebeam, G. F. Madaus, & T. Kellaghan (Eds.),
Evaluation models: Viewpoints on educational and human services
evaluation (2nd ed., pp. 33–96). Boston: Kluwer Academic.
 CHAPTER 13
Build and Preserve Community
Resources

 
Learning Objectives
 

1. Differentiate between coalitions, partners, and support agents

2. Identify at least two direct benefits and two indirect benefits resulting
from relationships with partners and/or support agents
3. Identify four strategies to preserve relationships with community
resources
4. Explain what is meant by creating a culture of collaboration

 
WHY WON’T YOU HELP ME?
When Joe was developing a proposal for a community–based gang
violence prevention grant, he reached out to a program leader who had
been doing youth violence prevention work in the schools in a nearby
region. Joe had spent several hours with the program director, Nicole,
learning about her work, and she freely shared her experiences,
particularly emphasizing the interventions and scope of the program.
Because Nicole worked directly for the public school system, she was
not eligible to apply for the same grant, which was limited to nonprofit
human service organizations. So after having developed this initial
relationship, Joe asked if she would be willing to provide him with a
letter of support reinforcing the need for additional gang violence
prevention programs. Joe also reminded Nicole that he saw her as an
integral ally and hoped to continue and strengthen their relationship,
especially if his proposal was funded. Nicole provided Joe with a letter
of support indicating that she, as a representative of the school, did
indeed believe there was a need for more gang violence prevention in the
region and that she believed that Joe and his organization were uniquely
postured to deliver the services in the community. Joe thanked Nicole for
the letter, promising to let her know the outcome and to stay in touch.
Ten months later, Joe’s proposal was awarded funding, and he quickly
went to work finalizing the program, hiring and training staff, and
beginning the implementation process. A year later, Joe ran into Nicole
at a state conference on bullying and other forms of youth violence. Not
having spoken to her since he had received her letter of support and
submitted his proposal, Joe told Nicole that his proposal had been funded
and that he had been working on the program for more than a year.
Nicole congratulated him, and after a brief conversation, Joe promised to
stay in touch and told her that he was hoping they might be able to
collaborate on future projects.
Eight months before funding for Joe’s project was scheduled to end,
he had identified a new funding opportunity focused on broader issues of
youth violence prevention and decided it was worth going after. The
proposal required letters of support from at least two organizations.
While Joe felt a bit uncomfortable calling Nicole for another letter of
support since he had not spoken to her since the conference, he had not
developed any new relationships with professionals that might be able to
provide relevant letters of support. So Joe called Nicole, letting her know
how his program was going and then sharing with her details of the new
 proposal he was working on, emphasizing how he believed this program
could really strengthen the work that they had both been doing in
violence prevention. Before hanging up, Joe asked Nicole if she would
provide him with a letter of support that he could include in the proposal.
Nicole asked Joe how he believed she and her program might benefit
from this new funding opportunity, and Joe again stressed that he
believed that the region itself would benefit because of an expanded
service continuum of youth violence prevention programming. Nicole
agreed that the broader the continuum of available services, the greater
potential they all had to make a difference in their efforts to reduce youth
violence, but she said that she would have to check with her
superintendant to determine if the school could provide another letter of
support. Nicole called Joe back a week later to let him know that the
school administrators had decided that they would not provide a letter of
support because they did not believe they were familiar enough with
Joe’s work to do so. After a good deal of work, Joe was able to obtain
one letter of support from a local organization working in juvenile
justice; however, without the letter from the school, he did not have the
required two letters of support needed as part of the application. As a
result, Joe was unable to pursue the funding opportunity.

 
CONSIDERING JOE

1. What was Joe’s first mistake in how he handled his relationship with
Nicole and : why?
2. Should Joe now try to redevelop his relationship with Nicole? Why or
why not?
3. If you were Joe, what steps would you take to ensure that you continue
to build and preserve relationships with community resources?

About This Chapter

Because of the critical role that meaningful and long–term business
relationships play in the mental health and human services today, this
chapter is dedicated to preserving relationships with community resources.
Whereas Chapter 7 introduced the notion of identifying and engaging
community resources, this chapter focuses on preserving those relationships
once they have been established.
To fully explore the issue of preserving relationships with community
resources, we will examine several aspects. To begin, we will discuss the
different types of relationships, which include coalitions, partnerships, and
support agents. This will be followed by an examination of both direct and
indirect benefits potentially resulting from these relationships. Next, we will
review methods by which to preserve relationships. These methods include
engaging in regular communication and enhancing relationships through
specific means. The chapter concludes with a case illustration that highlights
the central concepts explored in the chapter and several questions for
reflection and discussion focusing on collaboration and its role in mental
health and human services today.

STEP XI: BUILD AND PRESERVE

COMMUNITY RESOURCES
Significance of Community Resources in Program
Sustainability
Unfortunately, the example Joe and Nicole provide is not all that uncommon
in the human services, illustrating the importance of not only engaging
community supports but, more significantly, maintaining those relationships.
Whereas Joe effectively developed an initial relationship with a highly
relevant community resource via Nicole, he failed to appreciate the
importance of preserving that relationship. As a result, the benefits that he
received from the relationship were short–lived.
Few mental health and human service organizations today can exist in
isolation but, rather, must actively engage with the larger community of
providers and other resources in order to sustain their business. This means
that the onus is on each provider to initiate and nurture a variety of
relationships with other supports. In fact, now more than ever before,
collaboration in programming is often the preferred mode of service
delivery, yet collaboration is available only to those who have established
relationships with potential collaborators. Being aware of the current
emphasis on collaboration in programming and being able to adapt your
business to it means that you are able to effectively manage the environment
in which you work. This type of environmental management results from
monitoring the trends in the environment and being critically aware of
changes that impact the way in which business is done at the local, state,
national, and at times, global levels (Lewis, Packard, & Lewis, 2007)—a key
characteristic of an effective program administrator. In this manner, program
developers and administrators must constantly be tuned in to the greater
context in which they work, lest they be unprepared to move with the rapidly
changing tide.
Collaboration is becoming increasingly the norm rather than the
exception in mental health and human services for a multitude of reasons,
including sharing resources between organizations. However, interagency
collaboration has also been viewed as a promising managerial approach and
one that not only allows for sharing resources between agencies but also for
more effective use of society’s resources (Entwistle & Martin, 2005). In
addition, collaboration may lead to improved quality and/or reduced costs,
thus enhancing the organizations that participate in collaborative efforts
(Nylen, 2007).
The types of collaborative relationships that exist among human service
and mental health providers can vary considerably. Collaboration may be
very informal, consisting of ongoing communication among individuals
around particular areas of interest (Nylen, 2007), or it can be much more
structured, with regularly scheduled communication and the development of
more concrete relationships (Gittell & Weiss, 2004; Hill & Lynn, 2003). As
a result, different types of collaboration not only have distinct features, but
they also may offer different benefits to their participants. However, each
collaboration constitutes a business relationship since each is built and
focused on the business of the organization and/or the broader field in which
the organization operates.
To begin to examine the significance of relationships with other
community providers and resources, three prominent types of business
relationships are explored: coalitions, partnerships, and support agents. Each
of these relationships represents some form of collaborative effort in varying
degrees, and thus, collaboration is what binds them; however, each is
different and, as a result, may offer a different set of benefits as well as
challenges.

Coalitions
Because of the ever–shrinking dollars available to address social and
mental health issues, coalition building has become an increasing necessity
in the human services. As discussed in Chapter 7, the term coalition refers to
“a group of organizations working together for a common purpose” (Lewis,
Lewis, Daniels, & D’Andrea, 2003, p. 238). Because of the unifying nature
involved in trying to address a specific problem, organizations may become
empowered and emboldened to work collectively toward solutions. This can
be quite pragmatic since coalitions are often created when one group realizes
that it does not have the power to effectively tackle an issue alone and,
therefore, needs to join forces with others in order to expand its power base
(Homan, 2004). However, even though initial participation in a coalition is
often highly inspiring and may propel newfound motivation in work, a
primary challenge of coalitions is related to their staying power. Like any
collective endeavor, when participants cease to perceive a benefit, they are
no longer motivated to continue in the coalition. Therefore, whereas building
a coalition often proves to be exciting work initially, preserving coalitions
can be quite challenging. As a result, preserving coalitions requires
appreciation of the inherent challenges and perseverance needed for
sustainability.
Coalitions in the mental health and human services typically emerge as
organizations coalesce around shared work and interests. Whereas coalitions
emerge for similar reasons, they may differ quite a bit in terms of the
formality of their structure, the reach of the coalition, the number and type of
participants, and other factors that can significantly impact their ability to be
sustained. Informal grassroots–level coalitions are typically initiated by one
or two community organizations. Often, motivation to develop a coalition
may be based on an interest in developing a community support network,
and the coalition may not have well–defined objectives or goals.
 Other coalitions may be initiated in a more formal manner, with financial
dues/contributions provided by participants to support a leader and other
aspects of the coalition’s work. This type of coalition often has a specific
organizational structure in place. In addition to the organizational structure
of a coalition, coalitions can be developed at various levels—local, regional,
state, national, or international. In this regard, coalitions often vary in the
type of activities they pursue and the degree of reach they desire. For
instance, local coalitions are most invested in seeking change at the local
level, motivated by the need to directly and immediately impact a locality.
For instance, a group of foster care providers in a region may come together
to address the need for foster homes for teens, or two providers working with
individuals with dementia may work together to increase local support
services for dementia. Conversely, national coalitions are most directed
toward change at the national level, motivated by a need for large–scale
change that can ultimately impact regional and local environs. For instance,
a national coalition may be formed to increase both recognition and funding
for substance abuse treatment or to demand that equal funding be provided
for the treatment of autism as is given to research on autism. Neither of these
types of coalitions is superior to the other; they each simply occur at
different levels.
The number of participating organizations that compose a coalition may
vary widely as well and may be directly related to the specific work or
geographic structure of the coalition (e.g., local, statewide). Finally, the
primary objectives of the coalitions may vary greatly, as some coalitions
may evolve to address a particular broad issue such as mental health while
others may be much more specifically focused on the treatment of an issue
such as bipolar disorder. Each of these myriad factors may significantly
impact the coalition’s sustainability, and therefore, each must be given
attention in order to preserve coalitions. I should also note here that the
exception to the issue of preserving coalitions is the rare occurrence of
coalitions that are developed to tackle a specific short–term issue. In these
cases, coalitions are initiated as temporary structures that serve a specific
purpose and, therefore, are not intended as long–term support networks.
However, even in these instances when the work of a coalition is meant to be
time–limited, it is not uncommon for the coalition to morph into new work,
thereby becoming a more permanent endeavor—especially when the
coalition has developed effective cohesion and, therefore, has a need to
continue working collaboratively.
The boxes below provide examples of three existing coalitions. The first
(Box 13.1) is based on a very new, locally developed coalition focusing on a
specific zip code in a region. This coalition reflects a grassroots effort at the
most local level. The second (Box 13.2) is a national coalition of child
welfare and mental health organizations that is much more reflective of a
business and a professional association. The third (Box 13.3) is a regional
coalition developed in a completely inclusive manner that has accomplished
significant change through local collaborative work.
 
BOX 13.1

MID–CENTER COALITION: THE 55555 ZIP CODE

The Mid–Center Coalition is a group of nine organizations providing

mental health, human services, and educational services in a 4–square–
mile radius. Mid–Center was formed at the initiation of one of the local
mental health providers in an effort to focus the collective efforts of the
organizations on exploring new ways to garner funding and ensure that
the region, a large urban area in the Midwest, had a sufficient
community support network in place. The extreme economic conditions
facing the region—one of the poorest in the nation—was another driving
force in the initial development of Mid–Center.
An administrator from the mental health organization chairs the meetings, but there is no
formal leadership in place as of this writing. Mid–Center is open to all organizations providing
mental health and human services in the region, and all are encouraged to participate. The group
has continued to hold quarterly meetings since its inception 1 year ago. To date, the meetings
have largely focused on brain–storming possible endeavors that the coalition may be interested
in pursuing. No formal action has yet been taken to pursue any new venture as a group; however,
the creation of Mid–Center marks the first forum in which community organizations have come
together voluntarily to work collaboratively.
To date, Mid–Center has established a membership directory and is examining how the group
might work with another local group that is planning to provide free services in the community.
In addition, two of the participating organizations have begun a collaborative business
relationship, and other participating members have provided letters of support to three member
organizations as they each have pursued new funding opportunities on behalf of their respective
organizations.
  
BOX 13.2

THE ALLIANCE FOR CHILDREN AND FAMILIES

The Alliance for Children and Families (2009) was formed in 1998 as a
result of a merger of Family Service America and the National
Association of Homes and Services for Children. Today, the Alliance
provides services to nonprofit child, family, and economic
empowerment organizations. In fulfillment of the Alliance’s vision of a
healthy society and strong communities, the organization is dedicated to
strengthening America’s nonprofit sector and using advocacy to assure
continued independence (Alliance for Children and Families, 2009).
The Alliance has an extensive and sophisticated organizational structure led by a chief
executive officer and consisting of seven administrative support departments, several project–
specific departments, and two administrative office locations and employing more than 60 paid
staff members. The Alliance is supported through annual membership dues of participating
organizations, donations, and other funding.
The services provided to member organizations range from public policy and advocacy at the
national level; publications, which include a journal, magazine, and newsletters; alerts regarding
funding opportunities; consultation and evaluation services; conferences and training institutes;
and a job posting board.
In 2010, more than 360 organizations in the United States and Canada were members of the
Alliance.

 
BOX 13.3

THE HAVERHILL VIOLENCE COALITION

The Haverhill Violence Coalition has been in existence since 2001 and
was developed in response to research conducted in the region on abuse
during pregnancy. : Haverhill is supported by federal funding and is
composed of more than 30 agencies and institutions that meet monthly
(Hawkins et al., 2008).
Haverhill’s mission involves bringing together individuals interested in addressing all forms
of violence and coordinating services for those experiencing or witnessing violence in the
community.
 Haverhill has a formal governance structure in place, including leadership and bylaws
designed and supported by the membership.
Since its inception, Haverhill has successfully created new programs to address violence in
homes, schools, and communities and has designed interventions for children witnessing
violence. In addition, Haverhill has garnered funding support from a variety of sources to
forward its mission.
Haverhill works collaboratively with the community, holding open meetings in which its
efforts are evaluated by community members and community members : provide input to
Haverhill’s ongoing agenda. After more than 8 years of making a significant impact in the region
and garnering widespread support, Haverhill is well positioned to continue its important work
addressing the various dimensions of violence in the community.

As you can see, these examples represent three very different types of
coalitions. The Mid–Center Coalition is quite limited in its organizational
structure and has yet to engage in any specific planning efforts that might
result in tangible action; however, the development of Mid–Center has
served to bring organizations in a local community together and, as such, has
resulted in the development of a semiformal community support network in
which community organizations work together in a variety of manners. One
collaborative partnership has been formed as a result of Mid–Center’s
existence, and organizations have lent formal support to one another as they
pursued funding for new programming. Based on the types of new
relationships that have been formed by members of some of the participating
organizations, these relationships may be well postured to become long–
term. However, without specific efforts to keep participating organizations
engaged in Mid–Center the coalition itself may not be able to continue.
Mid–Center provides an example of a coalition in its initial stages of
development; however, Mid–Center’s challenge will be for its participants to
continue to promote its growth by adopting a formalized, action–oriented
approach.
Conversely, the Alliance for Children and Families has a long history, is
well established, and operates with both an extensive staffing infrastructure
and an ambitious and comprehensive agenda. In this regard, it appears to be
a well–oiled machine designed to attract new members while continuously
acting to maintain relationships with existing members by offering new and
seemingly meaningful benefits. We cannot forget that the Alliance is a
professional membership association first and foremost; however, it is
included because it shares some of the critical features of a coalition (e.g.,
works toward collective goals, sets the stage for enhanced relationships
among professionals). In addition, the Alliance is included because it
highlights the distinct differences related to finances in coalitions. In
comparison with regional or local coalitions that have no membership fees,
the Alliance’s membership fees and other available funding further
differentiate it. Of course, the actual benefits of membership in the Alliance
may not be easily deciphered and may vary from one member agency to
another, but as long as members do perceive benefits from their relationship
with the Alliance, this coalition is likely to sustain.
Whereas the Mid–Center Coalition and the Alliance for Children and
Families highlight two very different types of coalition in terms of
organizational structure and organizational reach, the Haverhill Violence
Coalition arguably provides an ideal example of a regional, community–
based coalition. Developed in response to an evidence–based need, open to
all interested individuals possessing a shared commitment to addressing the
issue of violence, and operated fully by the membership, for the
membership, and for the community, the work of Haverhill showcases the
outcomes of orchestrated community–action planning. In addition, Haverhill
reflects all that can be accomplished when effective organization takes place
at the local level to address local needs and how sustainability can be
achieved through self–evaluation, organizational flexibility, and long–term
planning.
To illustrate the perseverance required in preserving coalitions, after
realizing that members were losing interest in Haverhill, they decided to
bring in an expert to formalize the organization and redefine the mission and
vision. As a result, Haverhill has firmly established itself as a force in the
community and, more significantly, has demonstrated the significance of
preserving community relations.

Preserving Coalitions
All the participants must share an appreciation of the many factors that
can threaten the sustainability of a coalition as a prerequisite for actively
working to preserve the coalition. By promoting a culture in which members
of the coalition can actively work to maintain it, a climate of engagement
can be inherently developed and harnessed for the survival of the coalition.
In addition, because the membership of a coalition is subject to change over
time, both in terms of organizations represented and the individuals
representing specific organizations, it is imperative that ideological
commitments be continuously renewed. In this regard, incentives may serve
a particular role in maintaining more senior members of the coalition and
may, in fact, enhance their commitment (Roberts–DeGennaro, 2001).
In an attempt to better understand what leads to a coalition’s success,
Mizrahi and Rosenthal (2001) surveyed 40 coalitions. Six of the major
factors that the coalition members reported contributing to their success are
 

1. competent leadership,
2. ownership and shared responsibility,
3. commitment to the coalition’s work and to coalition unity,
4. equal decision making,
5. achievement of short–term accomplishments, and
6. mutual respect and trust among members.
 
Whereas each of these factors represents a feature of a successful
coalition, each could easily be applied to the effectiveness of the group
therapy process (e.g., effective leadership, shared responsibility, respect,
trust, visible outcomes). This is because some of the factors that make the
group therapy process so successful are transferrable to many types of group
processes. Moreover, what is most evident here is the importance of
leadership and structure, unity, and achievement of outcomes—essential to
gaining success as a coalition.
It would stand to reason that the factors that contribute to a successful
coalition are also paramount to preserving the coalition. So in addition to the
factors identified above, seven strategies are recommended to preserve
coalitions (see Box 13.4). Whereas this list is in no way conclusive, one of
the most important lessons to take away from this is that preserving
coalitions must be well planned—it does not simply happen but, rather, is
strategically accomplished and requires ongoing determination.
 
 BOX 13.4

STRATEGIES TO PRESERVE COALITIONS

 

1. Adopt a formal leadership structure to guide the coalition’s work and

provide continuity to the coalition (Lewis et al., 2003; Roberts–
DeGennaro, 2001).
2. Engage in long–term planning (Lewis et al., 2003) and strategic
planning with ongoing reviews and assessments of the coalition’s work.
3. Work to maintain long–term strategic effectiveness (Tefft, 1987).
4. Regularly evaluate the degree to which participants benefit from the
work of the coalition, and use the findings to inform subsequent
reengagement efforts.
5. Maintain open communication.
6. Work to develop a flexible culture that allows for the coalition to
change and grow over time in order to be sustained.
7. Continue to collectively modify the mission and objectives of the
coalition.

Whereas there is no guarantee that any type of coalition can be sustained

long–term, you can be certain that without conscientious and continuous
efforts to preserve the relationships that compose the coalition, it will indeed
be short–lived. It is not uncommon for you/your organization to establish
other business relationships with coalition members outside the coalition,
and therefore, coalitions often provide opportunities for other types of
relationship building. Further, some organizations may not belong to a
coalition yet may have established formal and informal relationships with
other professionals/organizations that serve a distinct purpose. Two of the
most common types of these other business relationships in mental health
and human services are partnerships and support agents.

Partnerships
 In basic terms, partnerships imply that both organizations benefit from
the specific relationship. Partnerships often are established to serve a variety
of purposes—from large–scale partnerships in which two or more
organizations merge, creating a new collective organization, to a schema in
which two organizations come together to jointly administer a specific
program/project. In addition, a partnership may result from the
subcontracting of one organization by another to provide specific services
that are part of a larger service array. Table 13.1illustrates examples of some
common partnerships in mental health and human services today.
Similar to coalitions, partnerships may be temporary or long–term. For
instance, a partnership composed of the merging of two human service
organizations is in most cases a long–term partnership, whereas partnerships
that emerge to jointly administer a time–limited funded project are often
short–term. As a result, the degree of interaction and investment of partners
may vary quite a bit. In addition, the scope of the partnership may shift over
time, beginning as a contractor–subcontractor relationship and then
developing into a joint venture.

Preserving Partnerships
Partnerships typically represent the strongest type of relationship between
community organizations, particularly because each of the parties involved
receives concrete and mutually satisfying benefits. As a result, there
naturally is a high degree of interaction and sharing among the partners;
however, even though frequent communication and sharing may be
occurring, partnerships require the same attention to preserving the
relationship as do coalitions. In fact, because of the intense type of
relationship that partnerships imply, even greater efforts must be made to
preserve the partnership. Therefore, in addition to the seven strategies listed
in Box 13.4, in order to preserve partnerships, the members of the
partnership must also pay attention to other issues such as power sharing and
roles of the partners. Indeed, business partnerships are built on a power–
sharing/responsibility–sharing relationship, and as a result, the partnership
must be continuously evaluated to ensure that equality in both areas
continues to exist, lest the partnership itself begin to diminish. This can be
helped along not only by maintaining open communication but also by
adopting transparency with the members of the partnership. Because partners
are akin to colleagues working in the same organization, transparency is
needed to move toward shared goals. In addition, transparency contributes to
a healthy environment that may effectively prohibit one partner gaining
more power than another and, as such, serves to maintain an effective
balance of power.
Table 13.1 Common Partnerships in Mental Health and Human Services

Whereas concerted efforts to ensure appropriate power sharing are

needed to preserve partnerships, the roles that each partner plays in the
relationship also must be given a good deal of attention. Roles are directly
impacted by and directly impact the power–sharing schema that is an
inherent part of a partnership. In order to preserve partnerships, the roles that
each partner/organization will play must be clearly articulated and mutually
agreed on, if not mutually designed. Throughout the partnership, the roles
must be continuously evaluated and efforts made to immediately address any
issues or conflicts related to roles. This type of ongoing evaluation is another
form of transparency that ultimately should serve to strengthen the
partnership by ensuring that all partners remain continuously engaged.
 According to Cohen, Linker, and Stutts (2006), effective partnerships and
other collaborations require the adoption of specific attitudes and behaviors
in order to be successful and sustainable:

Avoid adopting an us versus them mentality

Formalize roles.
Develop partnership language
Take a long–term view of the collaboration.
Allocate sufficient resources.
Consider co–location of services (partners provide different
services in one location).
Require accountability of the partners.

It is believed that by adopting this type of cognitive framework of

partnership and collaboration, a culture of shared responsibility and
collective work can be gained. This culture is pivotal to the sustainability of
partnerships, since without it, the continued engagement of partners is
threatened. Partnerships, like coalitions, are subject to change over time, and
in simple terms, long–term preservation of the relationship requires
communication, evaluation, and negotiation.

Support Agents
Support agents are not partners that mutually share in specific work but
rather professionals/organizations that support the work of you/your
organization in some tangible manner and typically receive some benefit
from doing so. For instance, in the vignette provided at the beginning of the
chapter, Nicole initially was a support agent for Joe, teaching him about her
business and providing him with a letter of support to assist him in garnering
funding for his own program. Joe was not, however, a support agent for
Nicole, as ultimately she did not receive any benefits from the relationship.
And as a result of the one–sided nature of this particular relationship, it was
unable to be sustained or preserved.
Support agents may consist of professionals providing the same type of
services as you do (i.e., competitors), those providing different services to
the same population as you, or those possessing some other relationship to
your work. In addition, a funding source may be a support agent, particularly
when the funding agent is pleased with your work. Regardless of the type of
support agent, these individuals and their organizations have a particular
investment in you/the success of your work/your organization and, therefore,
are willing to support it. Most often, this is because doing so provides some
type of direct or indirect benefit to them as well. For instance, an
organization providing community–based services to victims of domestic
violence may support your efforts to establish a shelter for child survivors of
domestic violence because they believe not only that more services for this
population are needed to ensure the most effective treatment of the issue but
that, ultimately, more attention given to the issue and more services available
will be beneficial to their business as well. Another example of a support
agent is a philanthropic or advocacy organization dedicated to addressing the
same needs that your program/organization seeks to address. This type of
support agent may provide you with funding or a voice in new and different
venues to continue to draw attention to the issue. Finally, support agents may
participate on the same coalition and, as a result, engage periodically or
continuously as supports to one another in fulfillment of their collective
agenda.

Preserving Relationships With Support Agents

Regardless of the nature of the relationship that exists among support
agents, preserving the relationship requires specific effort; however, unlike
coalitions and partnerships, the degree and type of effort needed differs.
Because support agent relationships are the simplest and most
straightforward of the three business relationships discussed here, preserving
these relationships is equally straightforward. As such, the following
strategies may serve to effectively preserve the relationship:

Maintaining open communication that ensures that each

participant understands the type of support provided
Ensuring a mutual understanding of perceived benefits of
support
 Engaging in ongoing evaluation of the relationship and
commitment to quickly address and/or resolve any challenges
in the relationship
Maintaining a mutual understanding of and agreement to the
parameters of the relationship

Relationships with support agents may by nature be especially time–

limited, unlike coalitions and partnerships, particularly if they evolve to
address a specific time–limited issue (e.g., passing specific legislation,
garnering funding). Therefore, a clear understanding of the parameters of the
relationship must be understood by all participants as well as the fact that
gaps in participants’ interactions with one another do not necessarily indicate
the dissolution of the relationship. Support agent relationships are not always
constant but, rather, are utilized when and as needed; therefore, a lack of
constant contact does not pose a threat to the relationship.

The Power of Community Support

In today’s human service arena, most professionals/organizations find that
they are involved in all three types of business relationships—coalitions,
partnerships, and relationships with a variety of support agents—at varying
times or simultaneously. It is in this manner that this unique type of work is
not conducted in isolation but, rather, within a larger helping network of
community support—a support network that works collaboratively toward
shared, over–arching goals and objectives with each organization filling a
specific role in the network. Because of the various business relationships
that mental health and human service providers develop with community
resources, each type of relationship can contribute to a broad community
support network. It is when this happens—when a community support
network is formed—that communities may be effectively empowered to
address their inherent challenges.
The relationships shared among mental health and human service
professionals/organizations is central to the work that organizations do in
addressing social and mental health issues. In addition, these relationships
provide a great many direct and indirect benefits to the participants and, as
such, must be preserved.

Direct and Indirect Benefits of Relationships With Community

Resources
Recall that Chapter 7 discussed the primary benefits of engaging with
community resources, which included

augmenting the existing service array,

building an advocacy coalition,
garnering additional and/or new funding,
promoting long–term sustainability planning, and
strengthening communities from within by recognizing and
utilizing existing resources.

Each of these is extremely significant to the long–term health and

survival of a mental health or human service organization and, moreover, to
the success of the work that is carried out by these organizations. However,
in addition to these primary reasons for initially developing these
relationships, there are several other direct and indirect benefits that may
arise from preserving these relationships.

Direct Benefits
Direct benefits refer to the direct and tangible benefits that organizations
receive as a result of preserving relationships with community resources. In
addition to augmenting the existing service array, building an advocacy
coalition, and promoting long–term sustainability (listed above), two other
direct benefits worthy of discussion here are

exchanging and/or sharing organizational resources and

impacting public policy.

Exchanging or Sharing Organizational Resources. As a result of

relationships with community resources, organizations may explore and act
on sharing and/or exchanging a variety of resources. Resources might
include basic supplies, technology (e.g., client information system), support
services (e.g., finance management, training, research and evaluation),
staff/personnel, or knowledge. For some organizations, sharing resources
may be the only option available due to lack of finances, whereas some
startup organizations may find that sharing resources with an established
organization provides a form of mentoring—learning about specific aspects
of the business from more seasoned professionals.
Another motivating factor for sharing resources today is related to our
current economic climate. As funding continues to shrink and organizations
are challenged with how to continue doing what they are doing for less,
sharing resources may be a necessary tool for survival. This is particularly
true in the 21st century as we continue to witness an unprecedented number
of human service organizations merging with other organizations, being fully
acquired by another organization, or folding altogether. By proactively
working to determine new cost–saving measures built on various types of
resource sharing, organizations that wish to remain fully independent may be
able to do so.
The issue of cost is typically one of the most compelling reasons to share
resources, especially when it allows an organization to have something that
it otherwise may not be able to (e.g., building space, information system). In
addition, because most mental health and human service organizations have
specific and, at times, multiple specialties, exchanging one set of knowledge
for another can be mutually beneficial. For instance, after collaborating on a
number of projects together and while involved in a formalized partnership,
two organizations with which I have closely worked realized that the other
had specialized knowledge of specific clinical assessment tools. Rather than
purchase training for staff from a training company or other venue, the
program managers from each of the companies decided to exchange training
with each other. By doing so, staff from both organizations gained new
knowledge and skills, but in addition, this exchange opened the door for
other types of sharing and worked to further preserve the relationship
between the two organizations.
Impacting Public Policy. In addition to sharing organizational resources,
another significant direct benefit of preserving relationships with community
resources involves impacting public policy at the local, state, or national
level. By working collaboratively with other community
resources/organizations, organizations may be better postured to impact
public policy. Because some public policy can either threaten or support
mental health and human service programming, it is imperative that program
developers and leaders remain keenly aware of any proposed changes to
public policy so that they may be prepared to take action, if necessary.
Indeed, public agencies are more apt to respond to political versus economic
arguments (Heintze & Bretschneider, 2000), and focusing on the political
environment may serve advocacy efforts well.
An example of the power of community partnerships in influencing
public policy is reflected in the work of the Mission Neighborhood Resource
Center (Wenger, Leadbetter, Guzman, & Kral, 2007). A local coalition of
mental health and substance abuse providers and housing, public health, and
other community organizations in San Francisco was created based on their
shared commitment to supporting individuals in transition (i.e., homeless
individuals). In 2004, when a new policy was proposed to close multiple
homeless shelters in the region, coalition members came together to resist
and argue against this policy, using their collective strength. As a result, the
revised policy included reopening shelters, enhancing shelter budgets, and
creating a new immigrant housing development. This type of grassroots
coalition developing in response to a specific threat really highlights the
power of a unified front, which was created quite quickly by a group of
committed individuals, largely driven by their passion for a shared cause.

Indirect Benefits
Unlike direct benefits, indirect benefits refer to the intangible benefits
derived from preserving relationships with community resources—benefits
that do not directly impact the organization but that are important
nonetheless. Strengthening communities from within (discussed in Chapter
7) is one such indirect benefit. In addition, indirect benefits resulting from
relationships with community resources may include

professional development of staff through collaborative

learning experiences,
 informal mentoring,
professional networking and expanding the list of potential
future business partners, and
providing access to new and different business opportunities.

In her discussion on the impact of community partnerships for older

adults, Bailey (2009) further concludes that such partnerships significantly
change communities by

promoting region–wide thinking that stretches beyond turf and

silos,
creating and piloting new best practices as part of continued
efforts to address emerging needs and to work toward
continuous improvement,
changing relationships between stakeholders that foster
collaborative work and develop new programming options, and
advancing coordinated problem solving and action that can be
replicated in other regions.

Whereas indirect benefits do not provide an immediate or concrete

impact on organizations, they may in fact lead to direct benefits of
considerable significance. However, more importantly—and consistent with
Bailey’s (2009) last point—engaging in and preserving relationships with
other community resources contributes to the greater good, further
advancing the central mission of mental health and human service work. As
such, it benefits all those who have committed their lives to this work.

Summary
Whereas historically, it has been the case that mental health and human
service organizations could function independently—working in silos and
protecting their turf, as Bailey (2009) puts it—this is no longer the case. In
order to work in this industry in the 21st century, professionals must not only
be open to collaborative efforts but must participate fully to some degree in
collaborative efforts with other professionals. Such collaborations may be
composed of many types of arrangements, including coalitions, partnerships,
and support agents.
As with most relationships, the types of collaborative relationships that
professionals participate in may change and grow over time, with some
engaging simultaneously in each type of collaboration with different entities
as well as multiple relationships with one entity (e.g., partnership and
support agent). Ideally, through engaging in these relationships, many direct
and indirect benefits are given to the individuals and to the participating
organization. But none of this can be taken for granted, since all
relationships require commitment, determination, and effective work to be
sustained. And particularly because of the significance that these
relationships have in human service and mental health organizations today, it
is imperative that program developers and leaders work diligently to
preserve them in order for their own businesses to continue to grow and
develop. Moreover, only by participating as part of a broader network can
the collective energies of many be fully achieved and, thus, can the
community at large effectively benefit.
 
CASE ILLUSTRATION
Nyree had been successfully managing her transitional housing and
comprehensive care program for runaway gay youth for the past 4 years.
She had just received notice that she had been awarded a new 3–year
contract to expand her service array to include mentoring. Nyree’s
existing program provided an array of services, including counseling,
family and support building, academic coordination and support,
vocational exploration and support, and activities to support permanent
living conditions; however, she had no previous experience operating a
mentoring program. Because of this, she had approached one of her
colleagues, John, at a peer organization. John had been managing a
substance abuse prevention and mentoring program for teens for more
than 6 years, and Nyree and he had become acquainted through the
Coalition for Teens, which Nyree had initiated the year before.
After various interactions with leaders and workers from several
community organizations and schools since the inception of her program,
Nyree realized that a forum was needed by which the various groups
working on teen issues could come together, pool their resources, and
begin to explore collaborative and comprehensive efforts to further their
shared mission, thus the Coalition for Teens was born.
When Nyree discovered the Request for Proposal (RFP) on the
mentoring program, she immediately thought of John and contacted him
to discuss a partnership in the proposed project. As a result of this
partnership, the contract for the mentoring program was awarded to
Nyree.
After discussing the award and enjoying a celebratory coffee, Nyree
and John got to work on planning for program implementation, revisiting
what they had originally designed and planned in the proposal. They had
developed the administrative structure for the program, which included
comanagement of the program and both organizations having specific
staff dedicated to the program. In addition, the program would be
operated through Nyree’s shelter program with staff from John’s
organization having offices there. Nyree and John believed that by
integrating the two organizations in this way, they could promote the
most effective type of collaboration.
John suggested that he and Nyree meet weekly with their staff
involved in the mentoring program during the first 3 months and then
determine if they should continue with weekly meetings or move to
biweekly meetings during the remainder of the program. They agreed
that this type of frequent meeting schedule would ensure continuous
sharing of information. In addition, they agreed to commit to working
fully as partners and to continuously assessing how well they were
functioning as a partnership. Finally, they committed to maintaining
open communication and transparency and to making their ongoing
communication, including regular meetings, a priority.
During the second year of the mentoring program, John found an
announcement for a new RFP for teen vocational training and career
planning programming.
He immediately shared this with Nyree and proposed that they submit
an application to pursue the project as another collaborative effort. Nyree
agreed that since their initial partnership was so successful, they should
continue their efforts and work to further increase the array of services
provided by each of their organizations—and more importantly, to
attempt to increase the continuum of services available to the teens in
their region. John secured letters of support from two of the members of
the coalition, which was still going strong and had recently elected its
first president and vice president. Nyree received a third letter of support
from another coalition member—a woman with whom Nyree had
recently worked while providing testimony about the need for more
funds for children’s mental health services.
Several years later, as Nyree looked back on all that had transpired,
she realized that relationships with other community providers had been
essential to her work in a great many ways and that without them, she
may not have been able to keep her program alive. Moreover, she
realized that as she worked to preserve these relationships, the
connections between each became stronger or led in some new direction.
As a result, she had grown her continuum of programming—and
organization—considerably. She had also experienced two successful
partnerships in new business endeavors and had recently signed on to a
partnership with a new community organization serving kids 7 to 12
years of age that had experienced the loss of a parent/caregiver. In
addition to all the benefits that Nyree and her organization had received
as a result of her ability to not only engage in but preserve relationships
with community resources, the coalition that she had originally
established had accomplished a great deal.
In addition to connecting each of the providers with one another,
seven partnerships had evolved from the coalition, several organizations
shared resources with one another, and three had developed a new
business that they collaboratively oversaw. The coalition had worked
together to successfully pass new hate crime legislation that included
bullying based on sexual orientation and legislation to increase funding
for alternative education and vocational training programs for teenagers
that may not succeed in traditional high school programs. Finally, the
coalition had pursued and received funding as a collective group to
develop an awareness and educational curriculum for teachers, law
enforcement, and others working with teens. The training focused on
issues such as adolescent and teen development, sexual orientation,
communication, family and supports, and independence, among other
 areas, and was designed to promote more effective and broader social
support networks for the region’s teen population. All in all, Nyree was
quite happy with all that had been accomplished, and when she examines
her community today, she realizes just how much it has been enhanced
as a result of the broad support network that now exists.

 
REFLECTION AND DISCUSSION QUESTIONS

Take some time to reflect on the following questions about

collaboration and its role in work.
 

1. What does the concept of collaboration mean to you?

2. How and in what ways has your thinking about collaborative
work been influenced, either positively or negatively?
3. What do you believe poses threats to collaborative efforts?
4. Even though collaboration is so prominent in today’s mental
health and human service industry, do you believe this is a fad
or do you believe that collaboration will continue well into the
future?
5. What types of collaborative efforts have you witnessed in
human services and mental health? What were the strengths
and the deficits of these efforts? If you could have participated
directly in the collaboration, what changes would you make
and why?
6. In what ways do you foresee collaborating in your work and
why?

References
Alliance for Children and Families. (2009). About the Alliance. Retrieved
February 10, 2010, from http://www.alliance1.org
Bailey, P. A. (2009). Community partnerships for older adults. Journal of the
American Society on Aging, 33, 79–81.
Cohen, R., Linker, J. A., & Stutts, L. (2006). Working together: Lessons
learned from school, family, and community collaborations. Psychology
in the Schools, 43, 419–428.
Entwistle, T., & Martin, S. (2005). From competition to collaboration in
public service delivery: A new agenda for research. Public
Administration, 83, 233–242.
Gittell, J. H., & Weiss, L. (2004). Coordination networks within and across
organizations: A multilevel framework. Journal of Management Studies,
41, 127–153.
Hawkins, J. W., Pearce, C. W., Windell, K. W., Connors, M. L., Ireland, C.,
Thompson, D. E., et al. (2008). Creating a community coalition to address
violence. Issues in Mental Health Nursing, 29, 755–765.
Heintze, T., & Bretschneider, S. (2000). Information technology and
restructuring in public organizations: Does adoption of information
technology affect organizational structures, communications, and decision
making? Journal of Public Administration Research and Theory, 10, 801–
830.
Hill, C. J., & Lynn, L. E. (2003). Producing human services: Why do
agencies collaborate? Public Management Review, 5, 68–81.
Homan, M. S. (2004). Promoting community change: Making it happen in
the real world. Belmont, CA: Brooks/Cole.
Lewis, J. A., Lewis, M. D., Daniels, J. A., & D’Andrea, M. J. (2003).
Community counseling: Empowerment strategies for a diverse society
(3rd ed.). Pacific Grove, CA: Brooks/Cole.
Lewis, J. A., Packard, T. R., & Lewis, M. D. (2007). Management of human
service programs (4th ed.). Belmont, CA: Thomson Learning.
Mizrahi, T., & Rosenthal, B. B. (2001). Complexities of coalition building:
Leaders successes: Strategies, struggles, and solutions. Social Work, 46,
63–78.
Nylen, U. (2007). Interagency collaboration in human services: Impact of
formalization and intensity of effectiveness. Public Administration, 85,
143–166.
Roberts–DeGennaro, M. (2001). Conceptual framework of coalitions in an
organizational context. In J. E. Tropman, J. L. Erlich, & J. Rothman
 (Eds.), Tactics and techniques of community intervention (pp. 130–140).
Belmont, CA: Wadsworth/Thomson Learning.
Tefft, B. (1987). Advocacy coalitions as a vehicle for mental health system
reform. In E. M. Bennett (Ed.), Social intervention: Theory and practice
(pp. 155–185). Lewiston, NY: Edwin Mellen.
Wenger, L. D., Leadbetter, J., Guzman, L., & Kral, A. (2007). The making of
a homeless center for homeless people in San Francisco’s Mission
District: A community collaboration. Health and Social Work, 32, 309–
314.
 CHAPTER 14
Develop an Advocacy Plan

 
Learning Objectives
 

1. Differentiate between the four levels of advocacy

2. Identify two strategies to be used at each level of advocacy
3. Describe an advocacy orientation
4. Differentiate an advocacy coalition from another coalition in which you
may participate on behalf of your program
5. Identify the relationship between advocacy efforts and long-term
sustainability of your program
6. Develop your own advocacy plan

 
YES, I’M MAD, BUT WHAT ELSE CAN I POSSIBLY DO?
Tracey had been operating an outreach center for homeless and
impoverished seniors for the past 2 years. She had recently added onsite
Narcotics Anonymous and Alcoholics Anonymous meetings and a senior
support group to further enhance her service array, which also included a
warming center, two meals per day, medical exams, and basic care.
Occasionally, Tracey would learn that one of her clients had been
charged with indecent exposure for urinating in public. Because the city
did not have any public restrooms, the homeless population did not
always have access to restrooms. The situation was worsened by the fact
that most of the shelters and warming centers had limited hours. Each
time Tracey heard about one of her clients being charged in this way, she
became enraged. Finally, on hearing the news that yet another client had
been charged with indecent exposure, she immediately contacted
Danielle, one of the prosecuting attorneys that typically handled these
charges, to express her concern. Danielle stated that there was little she
could do, as the law was the law.
Before Tracey could spend any more time on this issue, a crisis
occurred at the outreach center that required her complete attention. As a
result, she forgot about this issue until it was raised again. Several
months later, one of her clients was arrested as a result of receiving his
third indecent exposure charge. According to the recently passed sex
offender registration and community notification laws in the state, three
or more indecent exposure charges required registration as a sex
offender, and therefore, her client not only received jail time but was also
now required to regularly notify the public of his whereabouts.
On hearing this, Tracey was even more outraged, and this time, she
went directly to Danielle’s office. Tracey argued that it was the
responsibility of the region to provide public facilities to its residents and
that by not doing so, the region and state stood to be punished, not her
clients. She went on to share her utter disbelief that because the region
could not effectively accommodate its residents, one of its most
marginalized groups was being further marginalized through unnecessary
legal action. Danielle replied that she understood Tracey’s frustration and
that she shared it, particularly because of the unintended consequences
that the sex offender registration legislation was causing. Danielle stated
that the legislation was designed to promote safer communities through
closer monitoring of individuals who had sexually offended—not to
classify and punish homeless individuals who did not have access to
 bathroom facilities. But again, Danielle noted that she had to follow the
law as written and that the situation could be changed only through
legislative action. After further discussing this problem as a social justice
issue, Danielle again agreed with Tracey but noted that she could not do
anything about it.
Tracey left feeling that she had at least shared her concerns with
Danielle, and she thought briefly about how she might raise awareness of
this issue in an effort to change it so that her clients were no longer
caught in the middle. Unfortunately, Tracey’s good intentions to rectify
this issue did not last long. She realized that she was only one person and
likely could not do much to change something so big—especially since
statewide legislation was involved. Rather than devote any more time to
thinking about the issue, Tracey turned her attention to her other duties
when she got back to the outreach center—and she quickly realized that
she already had enough to keep her busy.

 
CONSIDERING TRACEY

1. Do you believe that Tracey advocated for her clients? Why or why not?
2. What did Tracey mean when she referred to the issue of charging
homeless individuals with a sex offense for publicly urinating as a
social justice issue?
3. What do you believe Tracey’s responsibility is in this matter?
Danielle’s responsibility?
4. As a busy mental health professional like Tracey, how are you
supposed to get involved in advocacy while still attending to all your
other duties?
5. If you were Tracey, what would you have done differently, if anything?

About This Chapter

This chapter focuses on a topic of specific significance to the mental health
and human service industry—advocacy. Whereas advocacy has historically
had a firm foundation in the mental health professions, as mental health
professionals have continued to grow and develop a more sophisticated
understanding of social justice, we have experienced a renewed sense of
precisely what advocacy means. This is because advocacy and social justice
are highly interrelated, and typically, efforts in advocacy on behalf of clients
and communities are directly related to social justice. Therefore, advocacy—
as well as social justice—plays a significant role in comprehensive program
development and particularly in sustaining programs and organizations.
To frame this discussion of advocacy, we will first explore the history and
significance of advocacy in mental health professions. We will follow this
with an examination of the four levels of advocacy, which include the
individual, community, public, and professional. Next, we will discuss
various types of advocacy strategies, including individual empowerment,
community-level, public arena, legislative-level, and professional. In order
to further clarify the relationship that advocacy efforts have with one
another, we will discuss this specifically. We will follow this with an
examination of the concept of an advocacy orientation and its significance to
work in the mental health professions. And in order to explore how to put an
advocacy orientation into action, we will discuss the development and use of
an Advocacy Plan. Finally, in order to clarify the major points of the chapter,
a case illustration is provided, followed by an advocacy plan exercise.

STEP XII: DEVELOP AN ADVOCACY PLAN

Advocacy in Clinical Program Development
Advocacy is an innate part of clinical program development, since without
some form of advocacy, clinical or human service programs would never
come to fruition. In fact, think of a program with which you are familiar and
then consider how it came to be. What you will likely find is that at the root
of every clinical program is a voice—a voice demanding that a particular
need be addressed, demanding attention to a specific population, demanding
funding to support treatment or services, demanding to be heard, and
demanding action. Without one such voice, the job that you currently hold or
wish to hold in the future would likely not exist.
Unfortunately, Tracey was unable to effectively use her voice, and as a
result, she was unable to prompt any change. This does not mean that all
advocacy results in change, but it does mean that advocacy requires
perseverance and focused efforts and not simply walking away after only a
minimal investment toward change. Indeed, if the voices that helped create
all that we enjoy in mental health and human services had not persevered,
we would likely not have this incredibly rich field of practice. To better
understand the role of advocacy in mental health and human services in the
21st century, it is necessary to both briefly review the history and examine
the significance of advocacy today.

History and Significance

Advocacy is innately related to clinical professions and, as such, has been
the driving force behind mental health and human services programming
since the inception of the field. Regardless of the specific discipline—
counseling, psychology, or social work—advocacy has been the impetus
behind the evolution of that discipline as well as an essential role of the
clinician. In their discussion of the history of advocacy in counseling,
Toporek, Lewis, and Crethar (2009) provide a succinct summary:
Through the years that the profession has existed, there have always
been career and employment counselors who fought against racism
and sexism in the workplace, family counselors who brought hidden
violence and abuse into the open, school counselors who sought to
eliminate school-based barriers to learning, and community counselors
who participated in social action on behalf of their clients. As long as
there have been counselors, there have been counselor-advocates. (p.
260)
In the 21st century, social justice advocacy has taken center stage,
particularly in the counseling profession, as counselors have renewed their
vows and invested new energies into calling the profession to action in
implementing advocacy strategies and interventions (Bemak & Chung,
2005; Stone & Dahir, 2006; Toporek, Gerstein, Fouad, Roysircar, & Israel,
2006). Much of this renewed focus on social justice advocacy has stemmed
from increased recognition of existing inequities and the responsibility of
clinicians to more adequately address the various forms of oppression that
often present significant challenges to the individuals being served (Lee,
2007). As a result of systemic oppression and other inequities, clinicians
must be not only committed to advocacy but able to effectively advocate on
behalf of others in order to dismantle barriers and promote justice wherever
injustice prevails.
In fact, according to Lewis and Bradley (2000),
Advocacy is an important aspect of every counselor’s role. Regardless
of the particular setting in which he or she works, each counselor is
confronted again and again with issues that cannot be resolved simply
through change within the individual. All too often, negative aspects
of the environment impinge on a client’s well-being, intensifying
personal problems or creating obstacles to growth. When such
situations arise, effective counselors speak up! (p. 3)
While advocacy is an innate part of our professional history, the role of
advocacy has been much more specifically illuminated in the 21st century.
This is particularly evident in the promulgation of the American Counseling
Association (ACA) Advocacy Competencies (Lewis, Arnold, House, &
Toporek, 2002). Whereas the model provides a graphical representation of
the three levels of advocacy competencies of the client/student, the
school/community, and the public arena, as well as the major domains of
advocacy needed at each level, the 43 specific competencies that compose
the model are articulated in the advocacy competencies. The ACA Advocacy
Competencies are provided on the ACA
website:www.counseling.org/publications.
The Advocacy Competencies serve a similar function to the Multicultural
Competencies (Arredondo et al., 1996) endorsed by the Association for
Multicultural Counseling and Development. This is because both sets of
competencies highlight the significance that these two areas (i.e., cultural
competence and advocacy) have in the counseling profession and both
provide comprehensive guidance to counselors and other mental health
professionals in these areas by articulating specific practice competencies.
The Advocacy Competencies were endorsed by the ACA Governing
Council in 2003, and through this endorsement, the ACA “acknowledges
that oppression and systemic barriers interfere with clients’ health and well-
being and may even be the cause of their distress” (Toporek et al., 2009, p.
265). Moreover, the development of the Advocacy Competencies
demonstrates the commitment of professional counselors to acknowledging
and further understanding the role of advocacy in counseling.

Levels of Advocacy
As you will see in viewing the ACA Advocacy Competencies, they identify
three levels toward which advocacy efforts can be directed: client/student,
school/community, and the public arena. These competencies illustrate the
need for mental health clinicians to engage in advocacy at multiple levels,
because a different set of challenges is often present at different levels. For
instance, at the client level, the clinician must engage in such advocacy as
ensuring that the client receives the social security disability benefits to
which s/he is entitled, while at the sociopolitical level, the clinician must
advocate for such issues as state legislation for mental health parity. In
addition to the three levels identified by Lewis et al. (2002), I would add a
level of advocacy for the professional arena. This level of professional
advocacy is often necessary to further the profession itself (i.e., counseling,
psychology, social work) and, therefore, will also be discussed here.

Individual/Client
Advocacy at the individual level constitutes the most direct type of
advocacy—connecting the client to the clinician and engaging in specific
action to most expediently resolve an unmet need. Individual/client needs
often are recognized by clinicians or other service providers during the
course of treatment and may include such concrete needs as heat or other
less concrete needs such as access to an entitlement, such as social security
disability. In these situations, the clinician focuses on assessing the need for
direct intervention, identifying allies, and implementing an action plan
(Toporek et al., 2009).
Often, these needs may be shared among several clients with whom a
clinician is working. This is particularly true when clinicians work with a
specific subpopulation that may be treated unjustly or oppressed in a similar
manner. For instance, the inequities faced by some students of color and
students from low-income families indicate the need for clinicians to
strategically address various environmental factors that are barriers to
personal/social, academic, and career development (Ratts & Hutchins,
2009). As a result of continued exposure to this, clinicians may be much
better prepared to specifically assess and address these issues. However,
regardless of the number of individuals with an unmet need that a clinician
recognizes, an unmet need for one individual typically implies an unmet
need for other individuals. As a result, whereas clinicians must first address
the needs of those whom they directly serve, the unmet needs of clients often
reflect the unmet needs of the broader community. Therefore, while
advocacy efforts must first be directed toward the individual, the advocacy
needs of the individual often indicate the need for much broader advocacy at
the community and public arena levels. As such, individual advocacy can
often serve as an initial assessment and roadmap for advocacy efforts—
providing essential information about widespread needs and guiding efforts
to address such needs on a larger landscape.

Community
Community-level advocacy refers to advocacy that is directed at a
broader population, such as a community, neighborhood, or school. Whereas
individual-level advocacy focuses on the individual, community-level
advocacy shifts to the needs of a group. As stated above, individual-level
advocacy may move into community-level advocacy, particularly as one
becomes aware that specific unmet needs go beyond one person and impact
an entire group. The needs of groups may be the same as those noted in
individuals (e.g., concrete needs, entitlements), and they often indicate the
need for systemic or broad-based change in order to be effectively
addressed. For instance, for some years, I worked with teenage girls who
were living in community-based residential placements while they were
involved in the child welfare system. These young ladies had been removed
from their parents/caregivers due to abuse and/or neglect. As residents of
new communities, these teens were often delayed admission to school and
experienced delays in receiving Individualized Educational Plans to aid in
academic placement and coordination of necessary supports. After having
witnessed this occurrence more than once, it was clear that this type of
discrimination was not simply happening to an individual but to a group of
individuals. Moreover, it was clear that this type of discrimination was
systemically generated by the school (i.e., the system). To address this,
community-level advocacy was needed that would specifically target system
change at the school level.

Public
Public-level advocacy goes beyond individual and group advocacy,
impacting multiple and large groups across vast regions. Public-level
advocacy is indicated when sociopolitical change is needed to address broad-
based issues, and the objective of public-level advocacy is to impact public
policy and influence legislation (Lewis et al., 2002). To accomplish this,
increased public awareness is needed. Needs identified in individuals or in
groups may indeed be needs that reach well beyond both individuals and
groups and are much bigger than both, reflecting the need for public-level
advocacy. For instance, as I learned, the discrimination that I witnessed
against teens did not simply reflect the children in my region but, rather,
reflected a widespread issue related to discriminatory practices leveled at
child welfare–involved individuals. This meant that I had to engage in
advocacy at both the individual and community levels in order to effectively
care for my clients, but my efforts could not stop there; public-level
advocacy was also needed to ensure that public policy was in place to
protect these kids and families from further oppression.
Arguably, one of the most well-known public-level advocacy needs of the
21st century is mental health parity. Mental health parity, in the simplest
terms, is pay and treatment access for mental health needs equal to those
provided for physical health needs. And this has been an ongoing public-
level advocacy issue for mental health professionals for several years. As a
result, clinicians across the nation have worked tirelessly and collectively to
raise public awareness and to influence legislation. Whereas these efforts
have been successful at the national level with the passage of federal
legislation, continued public-level advocacy is needed to address this issue at
the state level.

Professional
 Professional-level advocacy differs from individual, community, and
public-level advocacy in that professional-level efforts are not geared toward
directly impacting an individual but, rather, the professionals that belong to a
clinical discipline. This does not mean that individuals/consumers do not
benefit from some of these efforts, nor does it mean that these efforts are not
related to other levels of advocacy; rather, it means that the intent centers on
forwarding the profession. For instance, whereas mental health parity
represents a public-level advocacy need, multiple mental health disciplines
ranging from counseling to psychiatry have advocated for inclusion as
mental health providers within this legislation.

Advocacy Strategies
Whereas advocacy is conducted at multiple levels—client, community,
public, and professional—there are basically six types of advocacy strategies
that can be used. As conceptualized in the ACA Advocacy Competencies
(Lewis et al., 2002), these include individual advocacy and empowerment,
community collaboration and systems-level advocacy, and public
information and social-political advocacy that are targeted at the specific
level (i.e., individual, community, public arena). Advocacy on behalf of the
profession is most often related to other advocacy efforts; therefore, new
strategies are not necessarily utilized, but rely on similar strategies. These
strategies most often include collaboration, public information/awareness-
raising activities, and social-political advocacy. As discussed above, there is
often overlap among advocacy efforts—with advocacy beginning at one
level and then moving to another. This is often the case since smaller-scale
advocacy (e.g., individual, community-level) may serve as the catalyst for
larger-scale advocacy efforts (eg, public-level).
Because advocacy needs go well beyond the purview of mental health
professionals, advocacy lessons can be taught by many. In fact, the advocacy
work of Alice Waters (Box 14.1) provides an effective illustration of how
advocacy efforts may move from one level to the next.
 
BOX 14.1
 ADVOCACY LESSONS FROM A CHEF

Alice Waters, the renowned chef and mastermind behind Chez Panisse
restaurant in Berkeley, initially recognized the need for people to be
intimately connected with their food—understanding its source, caring
for it, and ultimately, bringing it to the table. As a result, the food she
serves is a result of close relationships she has formed with farmers and
gardeners who practice humane and organic farming and who are
completely connected to their land.
Taking her philosophy outside the restaurant, Alice realized that a school serving kids in a
poor neighborhood lacked any type of kitchen and nutritional food options but had a microwave
oven available for cooking pizzas and burgers. As a result, the kids had absolutely no connection
to the food they were eating (not to mention no access to healthy foods). To address this need,
she met directly with the principal and then went to the school board to advocate that the school
grow its own garden. Successful in her advocacy efforts, “she would create a garden at Martin
Luther King, where the children—about a thousand of them in the sixth, seventh, and eighth
grades—could learn to plant, cultivate, harvest, cook, and serve food that they grew themselves”
(McNamee, 2007, p. 259). She called this The Edible Garden, and although it took some time to
bring to fruition, through her staunch determination, perseverance, and undiluted energy, the
garden did come to be. While the idea of school gardens did not originate with Alice Waters—
school gardens were common in the 19th century—Alice Waters did reenergize this movement,
which has long since received significant attention.
The Edible Garden was a monumental success, but Alice knew that large-scale change
required large-scale intervention; therefore, Alice took her advocacy efforts to a broader platform
with her Rethinking School Lunch campaign. One of the results of this was the successful change
that she initiated from steam-table cafeteria food to freshly cooked, seasonal local foods at the
American Academy in Rome.
Through her school and community advocacy efforts, Alice Waters—one woman—was able
to accomplish a great deal in changing how we think about food and our relationships with food,
as well as working to ensure that all people have equal access to healthy foods and, most
importantly, that individuals and communities are empowered to be self-sufficient and hold the
tools to create sustainable food sources.

Individual Empowerment and Individual Advocacy Strategies

When dealing with individual-level advocacy needs, individual/self-
empowerment strategies are often used. Self-empowerment is consistent
with the basic ideology of mental health professions today and initially
evolved from behavioral theory in that mental health professionals strive to
help individuals learn to help themselves. Because self-empowerment is
taught, empowerment strategies must begin with an assessment to determine
if the individual possesses the skills to successfully advocate on her/his
behalf (Ratts & Hutchins, 2009). Empowerment strategies may include
identifying individual strengths and resources, collaborating with others in
advocacy efforts, and developing an advocacy plan (Lewis et al., 2002).
Individual/self-empowerment is necessary when individuals have been
marginalized in some way and, as such, require advocacy. However, rather
than speaking on behalf of the individual, empowerment strategies are used
to teach individuals how to effectively speak on their own behalf. Self-
empowerment is obviously very powerful, as it enables oppressed
individuals to speak out and to take action, directly responding to the issue
without a liaison or middleman. Moreover, once empowered, individuals
may continue to recognize other forms of oppression and utilize their skills
to effectively deal with new situations as they arise.
Whereas self-advocacy can be extremely powerful, it is often not enough
to effect change either sufficiently or quickly enough when an unmet need
exists, and as a result, advocacy on behalf of the individual is also needed.
Advocacy on behalf of the individual means that the clinician must be the
voice of the individual, call attention to the issue, and work to address the
need. Individual advocacy skills include such activities as negotiating
relevant services on behalf of individuals and helping individuals gain access
to needed resources (Lewis et al., 2002).
For clinicians working with individuals who have been marginalized for
any reason (e.g., socioeconomic status, criminal history, sexual orientation,
race, age, mental health status, ethnicity), advocacy typically composes a
core part of the work. As such, clinicians often find themselves working on
behalf of their clients to remove barriers, navigate through complicated
bureaucratic processes, and coordinate access to needed services. Just as
self-empowerment strategies must be taught to individual clients, clinicians
must learn advocacy skills so that they can most effectively speak on behalf
of their clients. However, similar to self-empowerment, once learned,
advocacy skills used on behalf of another have the potential to improve with
use, thereby continuously enhancing the power of the clinician as advocate
—a force to be reckoned with.

Community or System-Level Advocacy Strategies

 Because community-level or group needs often reflect systemic
problems, different types of advocacy strategies are necessary. System-level
needs often are deeply embedded in a system and, as such, may require
paradigmatic or ideological shifts in order to be effectively remedied. For
instance, in the case of educational placement of kids in the child welfare
system that I referenced earlier, practices were put in place by some schools
to prohibit timely placements of these kids, thereby treating them differently
from other residents in the community. Whereas these practices may have
originated as a method for effective school management and not as a
discriminatory practice, the fact is that they evolved into a discriminatory
practice and, therefore, needed to be removed.
In order to advocate at this level, awareness-raising activities are often
the first step. By gathering data pertaining to the issue (Lewis et al., 2002),
clinicians are in a position to increase awareness and knowledge of the issue
for community members and those in positions of power who can effectively
resolve the issue. By engaging in various discussions with various factions,
clinicians may be able to illuminate the problem and engage others in their
efforts to resolve the issue. In fact, it is this type of dialogue with others that
usually is the catalyst for the development of advocacy coalitions. This is
especially true since clinicians and other professionals who work on behalf
of others or who share similar values related to helping are often drawn to
one another and are naturally situated as allies.
Advocacy coalitions are similar to other coalitions (as discussed in
Chapter 13), as they are formed as a result of shared interests and seek
progress through collective efforts and collective strength. Advocacy
coalitions can be extremely powerful, particularly because advocacy work is
driven by passion—passion for a specific issue—and as such, the collective
energy built by passion can be not only contagious but tremendously
powerful. Advocacy coalitions at the community level may focus on such
issues as increasing home health services or developing nonpunitive
measures to support children with behavioral challenges. The work of
advocacy coalitions centers on a specific issue, set of issues, or population,
organizing individuals and groups together in advocacy work.
Organizational actors in an advocacy coalition often serve as members
of policy-making boards and monitor legislation or policy decisions.
 They can organize public education workshops or campaigns to gain
support for specific issues, such as a workshop to educate the
community on the proposed allocation of federal block grant funds.
Their community education work can increase public attention to an
issue by the use of various forms of the mass media. This public
attention can put pressure on elected decision-makers to be more
responsive to the needs of their constituents. Through coalescing
around these advocacy efforts, a bond is created between the member
organizations, as they seek to maximize their supply of scarce
resources. (Roberts-DeGennaro, 2001, p. 137)
While we often think of community-level advocacy work involving a
fight against a system, sometimes the system that must be fought is made of
individual community members, and as mental health professionals, we
sometimes find ourselves on different sides of the aisle. For instance,
consider the dramatic changes in inpatient mental health care that were
marked by the deinstitutionalization of psychiatric facilities that began in the
1970s and the subsequent dismantling and significant reductions in
residential options and hospital stays that have continued to this day.
Throughout this time, mental health professionals have often found
themselves working to get their neighbors and local residents to support
community living for individuals with severe mental illness and/or
developmental disabilities while at the same time advocating for
hospitalization stays when warranted as the most effective form of treatment.
Another example of this type of dual-directional advocacy has resulted
from the more recent sex offender legislation—most specifically, the
community notification and sex offender registration legislation. Whereas
many mental health professionals and legal professionals have argued for
this legislation and its objective of promoting safer communities, others have
argued that the legislation is far too punitive and, in some cases, constitutes a
civil rights violation. As a result, mental health professionals have again
found themselves on competing sides, often trying to balance effective
treatment with community safety and upholding individual civil rights.
Community-level advocacy is often complex for the very reason that
systemic change is usually deeply rooted and, therefore, challenging to
change. At the same time, it is because of the type of significant change that
can ultimately be achieved that community-level advocacy is often so
necessary and the use of advocacy coalitions is so highly effective.

Public Arena–Level and Legislative Advocacy Strategies

Whereas community-level advocacy focuses on systemic issues at a
regional level, public arena advocacy needs often result from systemic needs
at a governmental or national level. As such, the stakes are even greater,
since at this level, advocacy efforts are designed for sweeping change that
will impact a significant population. Advocacy at every level is a
professional responsibility of mental health professionals, and from an
ethical perspective, advocacy work at the public arena level requires mental
health professionals to assume an advocacy role that is focused on affecting
public opinion, public policy, and legislation (ACA, 2005).
There are multiple strategies that can be used in public arena advocacy
efforts that include media communication, working with alliances/coalitions,
and lobbying (Lee & Rodgers, 2009). However, all advocacy efforts begin
with basic awareness-raising efforts—arguably the toughest step in
advocacy.
Raising awareness of an issue often requires an extraordinary amount of
work and an enormous degree of perseverance aimed at getting the message
out. Because of the vast complexities of individuals, a message that is
effectively heard by one may not be heard by another, and as a result, the
advocate must be constantly committed to finding the right message to reach
the most individuals. This can be quite acrobatic as advocates reshape their
message, attempt to reposition it in a slightly different manner, deliver it
through a variety of means with various and changing platforms, and use
different tactics that can speak to specific groups. As a result, advocates
must be dedicated to continuing to move the issue forward, constantly
engaging in a try, try again philosophy. And at times, advocates must use
radical methods in order to be heard.
Florynce Kennedy is an excellent example of this. In 1969 New York,
during a meeting on abortion law reform, only one woman was called to
testify—the one woman being a nun whose views were clearly anti-
abortion/pro-life. Incensed about the legislation and the absence of
individuals with varying perspectives invited to discuss this critical issue,
Kennedy spoke out against compromising on abortion reforms rather than
repealing the abortion law altogether. Trying to get the attention of the all-
male committee about the dangers that illegal abortions cause women, she
cheerfully interjected, “Listen, why don’t we shoot a New York state
legislator for every woman who dies from an abortion?” (Steinem,
1969/1995). Regardless of where one stands on the issue of abortion, it is
clear that Kennedy was determined to be heard and was not willing to stop
trying to raise awareness of the issue, moved more by the issue she was
fighting for than those whom she might offend along the way. It is in this
way that her example reflects the base of advocacy, or the soul of advocacy
—the intense need and relentless nature of the advocate to push forward.
In efforts to raise awareness, the media may prove to be a most effective
outlet, particularly due to its potential reach. A variety of media outlets,
including print media, television, and the Internet, may provide powerful
tools by which to inform the public about the need for advocacy and change
(Lee & Rodgers, 2009). Especially today, with the technology that is
currently available and the access such technology gives to so many,
advocates are wise to utilize these tools in their efforts. In addition to
disseminating information through various media channels, advocates may
engage in editorial writing and staging public demonstrations as other
creative ways by which to use the media to raise public awareness about an
issue.
Collaboration and the development of advocacy coalitions become even
more necessary at the public level than at the community level since the
scale of systemic change needed is that much greater. Moreover, it is
important that advocates collaborate with not only a broad and diverse group
of individuals but also with individuals with specific power to effect change
at this level. In fact, specific qualities in co-collaborators, such as political
credibility, social influence, leadership skills, financial influence,
competence, authority, and diverse cultural perspectives, may contribute
significantly to the achievement of collective goals (Lee & Rodgers, 2009).
In addition to raising public awareness through the use of media and
collaboration and the use of advocacy coalitions, lobbying provides another
effective strategy for advocating at the governmental level. Lobbying
policymakers and legislators is almost always a crucial component of efforts
to effect public policy change, since much too often, public policy is at the
root of advocacy issues in mental health and human services.
To illuminate this, consider Hill’s (2008) concise discussion on the gaps
in research and public policy. In the unpacking of various issues, Hill
identifies three major shortcomings in public policy that specifically
contribute to disproportionate racial and ethnic representation in the child
welfare system: (a) an overemphasis on child removal, (b) limited services to
caregivers, and (c) inadequate funding to regions interested in reducing this
disproportionality. He then further emphasizes the relationship between
public policy and needs by pointing out significant gaps in government
spending that are based in ideology rather than evidence, noting that the
federal government spends approximately $8 billion on child welfare
services (e.g., foster care, adoption), while only $1 billion is spent on family
preservation or reunification services (U.S. Government Accountability
Office, 2007).
To effect change in public policy, effective legislative advocacy is
essential. Letter-writing campaigns, telephone calls, and participating in
town hall meetings and other forums provide various means of direct
communication with legislators. Moreover, establishing public forums in
which legislators are invited to exchange dialogue provides another means
by which to influence legislation and public policy. Finally, hiring a lobbyist
to represent the advocacy needs of a group or coalition may be essential to
effecting change at the national level.

Professional Advocacy Strategies

Whereas advocacy for a profession is substantively different from
advocacy for an individual or group, there often is overlap between the two.
The example of mental health parity provided earlier illustrates this. To
provide another example of this, consider advocacy efforts aimed at
achieving an effective scope of mental health services in the schools. While
one aspect of these advocacy efforts may be directed at increasing access to
comprehensive mental health care for school-aged children and teens,
another aspect may be directed at ensuring that there is adequate
representation among treatment professionals to support this level of care
(e.g., school counselors, school psychologists, school social workers). As a
result, mental health professionals must focus their advocacy efforts both on
addressing the treatment issues of the client group and on their own
professional discipline.
Because advocacy needs are not vastly different from client-focused
needs to profession-focused needs, strategies needed to advocate on behalf
of the profession are the same as those used to advocate on behalf of
individuals and groups. As such, the use of different strategies is based on
the level at which advocacy is occurring, with a need for broad-based
approaches to effect public or legislative change and more grassroots efforts
to confront community-level change.
Advocacy for the profession is predicated on engagement in one’s
profession and a healthy professional identity. As such, professionals are
connected through the affiliations of others and understand the significance
of collective identity and collective work. The major forum for such
collective work is the professional association. Because advocacy work on
behalf of the profession requires such collective work, all mental health
professionals must demonstrate their responsibility to advocacy through
participation in professional associations (e.g., ACA, American
Psychological Association, National Association of Social Workers).
Moreover, without maximum participation at the local, state, and national
levels, progress and change are that much more challenging for the
profession.

Advocacy and Long-Term Sustainability

Whereas advocacy is a primary responsibility of all mental health clinicians
since it centers on the needs of the individual or group, it also is essential to
the long-term sustainability of mental health and human service programs.
The major objectives of advocacy efforts are to treat and/or serve unmet
needs, remove barriers, increase access, and promote equity through
increasing awareness and effecting change. Without such efforts, the vast
needs of individuals would remain unrecognized, and as such, the very
purpose of our work would not be highly visible or valued. Therefore, while
advocacy efforts are designed to ensure access and equity in treatment,
without a strong commitment from mental health professionals to
continuously participate in advocacy efforts, the business that is mental
health and human services is not only threatened but may not be sustained
over time. Indeed, far too many well-designed and essential mental health
programs have failed because the professionals operating them failed to fully
understand the need for ongoing advocacy and the significance of their
voices in effecting change.
Think about it this way: Today, the government has a deficit of more than
$ 12 trillion (I so wish this were only hypothetical) and must create a
balanced budget. This means that money that was previously allocated
elsewhere must now be diverted to begin paying down this debt, which
means that all existing expenditures are vulnerable to significant reduction or
elimination.
Significant portions of governmental spending support an astounding
array of mental health and human service programs and also specifically
target marginalized individuals. However, significant portions also support
defense, medicine, wildlife, and the arts, to name just a few. The decisions
that lawmakers have to make are obviously difficult, since in these types of
financial decision-making processes, mental health needs can be pitted
against ecology and medicine. But these decisions are not made in isolation,
and lawmakers are simply representatives of their respective constituents;
therefore, each faction has an opportunity to voice its concerns and to push
its cause to the forefront in order to protect it. Unfortunately, not all voices
are used—and the only voices that are never heard are those that are never
used. As a result, the dollars that end up being protected typically are
associated with the strongest faction of advocates—individuals who not only
have the skills to advocate but also exercise the perseverance to continue
communicating their message.

Advocacy Orientation
Like all competencies, advocacy requires awareness, knowledge, and skills.
However, advocacy also requires a specific orientation—an advocacy
orientation. An advocacy orientation implies that one not only is capable of
speaking up, taking action, and seeing something to completion but also is
highly sensitive to potential advocacy needs and able to be assertive
whenever and with whomever necessary. This type of orientation does not
usually come naturally but, rather, is developed over time and honed through
practice. However, it also requires mental health professionals to be in touch
or completely connected to the environments in which they work and live—
to be fully present so that they are able to recognize disparities and other
needs. This type of presence is akin to Martin’s (2000) third ear. As he so
eloquently describes, therapists must not only possess the ability to listen to
what is said or the type of emotion being expressed, but they must be able to
identify what the client is not saying and the affect that is beneath the surface
—thus, using their third ear. It is in this way that the presence or intense
connection necessary to an advocacy orientation is best understood.
While mental health professionals work to develop greater sensitivity and
presence with regard to identifying advocacy needs, basic assertiveness
training can serve as an effective preparatory activity. Learning how to speak
up, how to deliver the message, and how to modify the message to increase
its potential to be heard are skills that must be acquired and require a great
deal of attention. As I stated earlier, advocacy is akin to acrobatics, since the
advocate must constantly move and bend to deliver the most effective
message to the various recipients.
One of the exercises that I have my students complete to practice
advocacy is the 60-second sell to advocate for funding of their particular
program or service. A traditional business practice, developing this type of
pitch forces the students to reduce their argument down to its bare essentials
and to adorn the argument with whatever they believe necessary to make it
most effective. While this can create quite a challenge for many, it serves
four primary purposes: It focuses the message, focuses the messenger,
promotes a powerful connection between the message and the messenger,
and provides an opportunity for the student to be assertive and engage in
advocacy.

Developing an Advocacy Plan

Because advocacy is such an essential part of the work of mental health
professionals, it must be given specific and sufficient attention on an
ongoing basis. As such, advocacy work must be treated as a proactive
activity—purposely and consistently initiated by the mental health
professional. Without such a proactive approach, mental health professionals
often find themselves in the unfortunate position of being on the defensive,
quickly trying to articulate a response and taking time away from other
pressing matters because of a failure to make time for advocacy efforts.
The development of an advocacy plan can assist in ensuring that
advocacy efforts are cemented into practice and that this work becomes an
essential part of one’s professional life. Whereas the specific types of
advocacy involvement you and your colleagues engage in on behalf of your
clients will vary based on the needs of your population and the level of
advocacy needed, what is essential is that you are postured to engage in
advocacy efforts as needed. To do this, the following minimal roles and/or
activities should be assigned and put into place:

Advocacy training for all staff, with a specific focus on

advocacy levels, strategies, and responsibilities of mental health
professionals (content training)
Assertiveness training/advanced advocacy training for all staff
(skills training)
Advocacy as an ongoing staff meeting topic to build advocacy
into the program/organizational culture
Community-level advocacy liaison—an individual responsible
for identifying and leading efforts at the community level
Coalition liaison—an individual responsible for representing
the program/organization in existing coalitions or leading the
development of a new coalition to address key issues with other
community partners
Legislative liaison—an individual responsible for identifying
and leading advocacy efforts at the governmental level

By structuring the program/organization in this way, advocacy is

inculcated as a core value of staff and the program/organization is postured
to effectively deal with advocacy issues as they arise. Thus, an advocacy
orientation is achieved at the organizational level, allowing the organization
to maintain a proactive stance in its advocacy efforts.

Summary
Advocacy is a critical function of the mental health professional’s work and
one that requires close attention from the program developer. Engaging in
effective advocacy requires not only awareness, knowledge, and skills that
reflect competence in advocacy but also diligence, long-term commitment,
and an innate ability to remain attentive to needs as they arise. The various
levels of advocacy—client, community, public, and professional—each
correspond with specific strategies for effective implementation, as well as
sharing overlapping strategies. This is largely because needs typically exist
on multiple levels, and therefore, advocacy work must be completed on
multiple levels.
Advocacy work is rarely carried out in isolation since most needs are
rarely limited to one individual. However, the power of one voice—one
advocate—cannot be underestimated, as we are ultimately responsible for
only our own actions. And as such, we must all appreciate not only the
power of our own voice but the responsibility we have to use it whenever
and wherever it is needed. This is the commitment that we all share in our
continuous efforts toward equity and justice for all whom we serve and all
who are marginalized.
 
CASE ILLUSTRATION
After having individually met with more than 60 of her students during
the first 2 months of school for guidance and academic planning, Terri, a
middle school counselor, realized that grief and loss appeared to be a
prominent theme in her students’ young lives. Terri met with her
colleagues and administrators to discuss her concerns. After sharing her
concerns, she stated that she needed to learn more to determine what was
going on. To this end, Terri said that she needed to gain a more objective
understanding of the issue through formal assessment in order to
determine if grief and loss was indeed a clinical issue that required more
systematic action on the part of the school.
Initially, her colleagues argued that their students seemed to present
with so many challenges, including family violence and substance use,
and they felt the school’s primary role was to educate the students.
Further, they felt they should try to help students deal with any severe
clinical problems through outside referrals. Whereas Terri had heard this
type of rhetoric before, she vigorously defended her stance that the
school’s role was to support the entire student and that failure to attend to
a student’s emotional issues may indeed prohibit academic success or
maximal development.
After further discussion and perseverance, Terri won support from her
colleagues to further assess the problem. She got to work designing a
brief survey tool that was distributed to all the school’s students and
parents/caregivers. After collecting all the surveys, Terri was pleased that
57% of the surveys had been completed. Analyzing the data, Terri found
that grief and loss due to recent separation from loved ones, home, and
friends, and death of loved ones was something with which more than
62% of the students were dealing. Terri immediately took her findings to
her colleagues and administrators, arguing that they quickly needed to
develop and institute services to address grief and loss among the
students and also provide specialized training for school personnel to
more effectively support students experiencing grief and/or loss. While
Terri still encountered fierce opposition from several colleagues and
administrators, the principal decided to permit her time to design a
comprehensive program to address the issue. However, whereas he
would allow her some time during the workday to work on the new
program development, there would be no funding available to support it.
Appreciating her responsibility as a counselor to provide the most
effective treatment and services to her clients, Terri knew that additional
funding was not what was needed but, rather, hard work and
commitment. This was especially true as the interventions that appeared
to be most needed (based on the literature review) were ones that could
easily be integrated into the workday simply by modifying schedules.
Two years later, Terri’s program, Tomorrows, consists of support
training for parents, teachers, and administrators to recognize and
effectively respond to adolescents experiencing grief and loss; curricular
changes that promote sensitivity and awareness about grief and loss; an
ongoing therapeutic group open to all students in need of group-based
clinical intervention; and a psychoeducational approach to increase
awareness and knowledge of grief and loss among students. Today, as a
result of achieving successful program outcomes, Terri’s program
 continues to operate in her school and has been implemented in two
other schools in the region—both of which are currently being evaluated
to assess if they are able to achieve the same outcomes that Terri was
able to achieve in her school during the program’s first 2 years.
Terri has received accolades from her colleagues and administrators
and has been officially recognized for her work by the regional school
board. Most significantly, she has made a difference in the lives of
children and families by redefining the role of the school counselor and
the integral role that schools play in caring for the whole child—all with
no additional funding but, rather, embedded into the school’s
programming.

ADVOCACY PLANNING EXERCISE

Using the target population identified earlier in your program

design, consider the following questions:
 

1. What potential or existing advocacy needs currently exist

among the population?
2. For each potential or existing advocacy need, identify the
related level(s) at which advocacy efforts are needed.
3. Identify the various types of advocacy strategies you would use
to address the needs, including the anticipated outcome of each.
4. Develop an initial advocacy plan for your program, identifying
how you would structure the staff and activities around
advocacy issues.

References
American Counseling Association. (2005). ACA code of ethics. Alexandria,
VA: Author.
Arredondo, P., Toporek, M. S., Brown, S., Jones, J., Locke, D. C., Sanchez,
J., et al. (1996). Operationalization of the multicultural counseling
competencies. Alexandria, VA: Association for Multicultural Counseling
and Development.
Bemak, F., & Chung, R. C. Y. (2005). Advocacy as a critical role for urban
school counselors: Working toward equity and social justice. Professional
School Counseling, 8, 196–202.
Hill, R. B. (2008). Gaps in research and public policy. Child Welfare, 87,
359–367.
Lee, C. C. (2007). Counseling for social justice (2nd ed.). Alexandria, VA:
American Counseling Association.
Lee, C. C., & Rodgers, R. A. (2009). Counselor advocacy: Affecting
systemic change in the public arena. Journal of Counseling and
Development, 87, 284–287.
Lewis, J. A., Arnold, M. S., House, R., & Toporek, R. L. (2002). ACA
advocacy competencies. Retrieved September 13, 2010, from
http://counseling.org/Resources/Competencies/Advocacy_Competencies.
pdf
Lewis, J., & Bradley, L. J. (2000). Introduction. In J. Lewis & L. J. Bradley
(Eds.), Advocacy in counseling: Counselors, clients, and community (pp.
3–4). Greensboro, NC: Caps.
Martin, D. G. (2000). Counseling and therapy skills (2nd ed.). Prospect
Heights, IL: Waveland.
McNamee, T. (2007). Alice Waters and Chez Panisse: The romantic,
impractical, often eccentric, ultimately brilliant making of a food
revolution. New York: Penguin Press.
Ratts, M. J., & Hutchins, A. M. (2009). ACA advocacy competencies: Social
justice advocacy at the client/student level. Journal of Counseling and
Development, 87, 269–275.
Roberts-DeGennaro, M. (2001). Conceptual framework of coalitions in an
organizational framework. In J. E. Tropman, J. L. Erlich, & J. Rothman
(Eds.), Tactics and techniques of community intervention. Belmont, CA:
Thomson Learning.
Steinem, G. (1995). The city politic: A nice place to live for revolutionaries.
In C. Heilbrun, Education of a woman: The life of Gloria Steinem (p.
 168). New York: Ballantine. (Reprinted from New York Magazine, pp. 8–
9, March 10, 1969)
Stone, C. B., & Dahir, C. A. (2006). The transformed school counselor.
Boston: Lahaska.
Toporek, R., Gerstein, L., Fouad, N., Roysircar, G., & Israel, T. (Eds.).
(2006). Handbook for social justice in counseling psychology:
Leadership, vision, and action. Thousand Oaks, CA: Sage.
Toporek, R. L., Lewis, J. A., & Crethar, H. C. (2009). Promoting systemic
change through the ACA advocacy competencies. Journal of Counseling
and Development, 87, 260–268. U.S. Government Accountability Office.
(2007, July). African American children in foster care (GAO-07–816).
Washington, DC: U.S. Government Printing Office.
 CHAPTER 15
Develop an Information-Sharing
Plan

 
Learning Objectives
 

1. Identify three costs and three benefits related to information sharing of

program data
2. Identify four primary types of data and the purpose of collecting and
analyzing each
3. Differentiate between process and outcome data
4. Discuss the importance of assigning responsibility for data collection,
analysis, and reporting, and identify who should be responsible and
why
5. Discuss the significance of data reporting methods, including
responsibilities, time frames, methods, and recipients
6. Develop a comprehensive data–reporting plan
  
BUT THE PROGRAM IS EFFECTIVE
On Tuesday afternoon, Reggie received a call from his contract manager
telling him that his contract for mentoring at–risk youth would not be
renewed next year because funding for children’s services had been
reallocated. The contract manager went on to explain that the county was
facing budget cuts and, therefore, had to make decisions about which
programs to continue funding. While these decisions were difficult to
make, they were based on identifying the most essential programs and
those that had produced strong outcomes. Unfortunately, the mentoring
programs were not viewed as essential nor was there evidence of their
success.
When Reggie heard this, he was flabbergasted. He explained to the
contract manager that he had been conducting a program evaluation
since his program’s inception 2 ½ years ago and that the outcomes were
extremely positive. He quickly shared with her some of the highlights of
his program:

Teens who had been successfully matched with mentors: 342

Percentage of mentees who graduated high school compared
with the region’s 67% graduation rate: 94%
Percentage of the mentees who pursued college: 68%
Of the 32% who did not pursue college, percentage who
pursued vocational training or were employed: 25%
Percentage of the mentees who were either living at home or
living independently: 92%
Percentage of the mentees who had been involved in criminal
activities post–mentoring services: less than 5%
Percentage of the mentees who had experienced substance
abuse problems: 6%; less than 3% required treatment
Percentage of mentees and parents/caregivers who identified
having had a mentor as one of the most important aspects of
 their teenage years: 94% and 98%, respectively
Total cost per youth: $302 (compared with the $1,680–$6,440
costs related to much more intensive case management services
and comprehensive community–based programs for court–
involved youth—precisely what Reggie’s program was
designed to prevent being needed)

After quickly reviewing these outcomes with the contract manager,

Reggie promised to send her the full set of evaluation data and the
summary report. He told her that he had been planning to send her the
report and evaluation results once he had 3 full years of data and said he
was sorry that he had held onto the information.
The contract manager shared her surprise with Reggie, stating that she
wished she had known sooner about the program’s success, since it very
well could have meant that the funds for mentoring programs would not
have been cut. However, legislative action had already been taken, so the
funding decisions were final. She did encourage Reggie to make the
evaluation findings available and told him that they may still prove
fruitful in the next funding cycle’s decision–making process.

 
CONSIDERING REGGIE

1. What did Reggie do right, and what mistakes did he make?

2. If you were Reggie, what would you do next?
3. What practices should Reggie put in place to ensure that relevant
program information is shared with all who have a need to know on an
ongoing basis?

About This Chapter

This chapter’s focus is the significance of data, the critical information that
data provides about all aspects of a program and organization, and most
importantly, the invaluable need for comprehensive information sharing. We
will examine both indirect and direct benefits of information sharing. In
addition, we will explore the various types of data that are collected as part
of comprehensive program development, including outcomes data, process
evaluation data, human resource data, financial data, compliance and quality
improvement data, and other pertinent data. We will explore the questions
related to whom information should be shared with and why, as well as how
frequently and through what medium information should be communicated.
To guide comprehensive data collection and to illustrate the importance of
examining all the program data in order to understand the total program
operations, the Quarterly/Annual Comprehensive Data Report Tool is
provided. The chapter concludes with a case illustration to further reinforce
the content of the chapter, followed by a data report plan exercise and
questions for reflection and discussion.

STEP XIII: DEVELOP AN INFORMATION–

SHARING PLAN
Significance of Information Sharing
Seemingly, Reggie did everything right. At the implementation of a new
program (i.e., mentoring), he designed and implemented a comprehensive
process evaluation and a comprehensive outcome evaluation. He
methodically collected and analyzed the data and, as a result, was intimately
aware of the significant details of his program and the impact that it had
made. However, he made one unforgiving mistake: He failed to share the
data that he had collected and analyzed with all the people who had a need to
know. As a result, his highly successful program would cease to operate.
While Reggie’s example illustrates one of the toughest lessons about the
business of which program development is a part, it is unfortunately not
uncommon. As mental health and human service professionals have
continued to become much more concerned with evaluation methods and
other data collection activities, there continues to be a lag in following
through once data has been collected. This can create obvious challenges,
particularly since any data that is collected but not used should not have
been collected in the first place, since it incurred a cost without producing a
benefit.
 There are many other important lessons that Reggie’s vignette illustrates
(see Box 15.1).
 
BOX 15.1

LESSONS FROM REGGIE

Comprehensive program evaluation must be conducted at the start of

any new program.
Outcome data is essential and, therefore, must be collected.
Output data, such as cost–effectiveness, is essential and, therefore,
must be collected.
Program data must be shared frequently and regularly with all
stakeholders.
Collecting and analyzing data without sharing it with stakeholders may
have devastating results.
Collecting and analyzing data and not sharing the results may have the
same effect as if no data had been collected or analyzed.
Conducting various types of evaluation and sharing the findings with
stakeholders may have a direct effect on your program’s sustainability.
 

Whereas each of these lessons is significant, the more critical issue

related to information sharing has to do with why data is collected in the first
place. A large part of this answer is provided in previous chapters in the
discussions related to program design, implementation, and evaluation and
assessment. However, in addition to implementation and evaluation data,
other data must be collected, such as client demographic data and financial
data. Through comprehensive data collection and analysis, mental health
professionals are empowered—empowered to better understand and manage
their program. The notion that information is power can be clearly
illuminated in program development efforts, particularly as the more
knowledgeable the program developer is about the program, the easier it is
to articulate the program to others. Conversely, without detailed information
about the ongoing operations of the program, it’s more challenging both to
communicate the program to others and to garner support for the program.
Because the operations provided by human service organizations depend on
people (Gibelman & Furman, 2008), the central role that ongoing
communication, including information sharing and data sharing, plays in
supporting a program’s operations is critical.
More importantly, without effective means by which to communicate the
work that mental health professionals provide and the impact that this work
makes, mental health care itself is at risk. Morris et al. (2010) speak about
this global issue from an Irish perspective:
As with all areas of health care in Ireland and internationally, the
health information deficit in the mental health services serves to
impede the decisions of policymakers, health care workers, patients,
and their families. It is imperative that mental health information
becomes more accessible, useful, and comprehensible so that a culture
of information gathering and use can be fostered both internationally
and in Ireland. This information can then provide the evidence
required for the provision of high–quality health care. (p. 360)

Direct and Indirect Benefits

In addition to what is listed above, there are numerous other benefits—
both direct and indirect—that may result from sharing information related to
program operations and outcomes with stakeholders. Indirect benefits refer
to benefits that may not produce a direct result but that produce some
impact, whereas direct benefits are those whose effect is concrete. For
instance, by sharing information about program operations with staff,
employees may have an increased level of engagement with the
program/organization. This level of engagement may not be quantifiable, but
it may mean that some employees choose to remain at the organization even
when other more lucrative opportunities arise. Because you may not be
aware of this impact, particularly since you may not have had any idea that
someone was considering leaving, the impact is indirect—yet still
significant. Alternatively, the sum effect of employee engagement may
produce the direct benefit of employee retention, especially since employee
retention results in decreased expenditures associated with hiring. This
benefit can be tremendous, as any effective program developer and human
resources manager can tell you exactly what it costs to replace an entry–
level professional employee (e.g., case manager, therapist), which may range
from $6,000 to $12,000. Thus, reducing unwanted employee turnover is an
objective of most managers, because replacing an employee creates
additional and often unnecessary expense to the organization that cannot be
recouped. The costs are largely attributed to such administrative work as
processing new applicants, hiring–related activities, coordination of
employee benefits, and new employee orientation and training, among
others. Considering these unnecessary costs, it is not difficult to see the
benefit of staff retention.
Box 15.2 provides a snapshot of other indirect and direct benefits related
to information sharing.
 
BOX 15.2

INDIRECT AND DIRECT BENEFITS RELATED TO

INFORMATION SHARING

Indirect Benefits

Increased ownership in the program/organization among employees,

resulting from increased knowledge of shared responsibilities
Creation of a culture of transparency and shared commitment
More flexible workforce that can more easily adapt to changes when
needed as a result of being consistently informed

Direct Benefits

More productive and effective workforce as a result of increased

knowledge of the business
Problems and deficits able to be quickly identified and resolved so that
program/organization is continuously improving
 More competitive program and organization as a result of increased
productivity and effectiveness
Increased business and growth opportunities
Program/organizational sustainability
 

Types of Data
There are multiple types of data that mental health and human service
professionals collect as part of the program management process. Indeed, at
times, some mental health professionals claim that they are more data
collectors than mental health professionals—with responsibilities of
collecting intake information and administering and collecting assessment
data, treatment planning data, quality assurance data, contract compliance
data, and so on. However, the issue is not one of data collector versus mental
health professional but, rather, of mental health professional whose role very
much involves data collection and management. Data is pertinent to our
ability to effectively assess and treat clients, manage staff and other
resources, manage programs and organizations, and continue to enjoy our
livelihood. Or put even more succinctly, “Data collection is the sine qua non
of effectiveness–based program planning” (Kettner, Moroney, & Martin,
2008, p. 19). Data collection and management, therefore, must be both
respected and appreciated—not as an added job but as one of the most
integral parts of our job. Once this has occurred, the power that information
holds can be fully unleashed.
While there is an enormous amount of data that may be collected, the
primary reason for collecting the data has to do with gaining knowledge
about all aspects of the program. However, all data that is collected must be
fully justified. And as Gard, Flannigan, and Cluskey (2004, p. 176) remind
us, the four questions that should guide the data collection process are as
follows:
 

1. What do we want to know?

2. Why do we want to know it?
 3. What should we measure?
4. How should we measure it?
 
Knowing that all data that is collected has a specific use is essential.
Often, the most essential data is collected for a process or outcome
evaluation, human resource management, financial management, or contract
compliance and quality improvement activities. While these data sets can be
reviewed independently, they also must be thoroughly reviewed
concurrently, thus forming a complete picture of the program. By doing so, a
critical understanding of how each of the data sets interacts with the others
can be achieved. Each of these various types of data sets is discussed next.

Process Evaluation Data

As discussed in Chapter 12, a comprehensive process evaluation allows
you to assess the myriad aspects of a program throughout its
implementation. Depending on the type and scope of the process evaluation,
a variety of data can be collected that includes client demographic and other
descriptive characteristics and program outputs such as number and type of
interventions provided, treatment length, and number and qualifications of
staff providing treatment. In addition, coverage and equity data can be
collected to provide specific information about who is being served and who
is not being served.
Demographic and descriptive data can be highly useful in gaining
increased understanding and knowledge of your client population and,
therefore, must also be collected and analyzed. This data has multiple uses,
including as part of a process evaluation in identifying the target population
and needs, increasing knowledge about program outcomes as related to
client subpopulations and specific characteristics, advocacy efforts, and
pursuing funding opportunities. Indeed, possessing specific and
comprehensive knowledge about client populations is essential to effective
program management. Box 15.3 provides a sample of possible types of
demographic information that may be collected and reported.
 
 BOX 15.3

SAMPLE OF DEMOGRAPHIC DATA CHARACTERISTICS

FOR A TRANSITIONAL HOUSING PROGRAM

Age
Gender
Race
Ethnicity
Language
Dependent children (ages, gender, and special needs)
Intimate partner status
Special needs
Academic history
Employment history
History of homelessness
Family, friends, and other supports
 

Demographic data provides rich information; however, it is often in

collecting this type of data that mental health professionals run into trouble.
Much too often, data is collected that is not needed—data that is not going to
be used for a specific purpose. This goes back to the issue that no data
should be collected that does not have a specifically identified use, because
otherwise, you risk doing a disservice to those whom you are serving as well
as wasting time and money For instance, each of the data elements in Box
15.3must serve a specific purpose, to justify why it is being collected. And in
this case, each data element does serve a purpose, as illustrated in Table
15.1.
Table 15.1 Data Elements and Rationale
 In addition to the specific purposes listed above, client demographic and
descriptive data also can be used to learn specifically about program
coverage and program equity—significant information for program
developers, communities, and funding sources.
Coverage data provide feedback on the extent to which a program is a)
meeting the community need and b) reaching its target population.
Monitored during program implementation, coverage data can be used
not only to determine the extent to which the target group is being
reached but also to ensure that individuals ineligible for the program
are not served. (Kettner et al., 2008, p. 258)
Similarly, equity data provides feedback on the various subgroups within
a region to identify what, if any, disparities exist in regard to who is being
served.
Unless a program is targeted at a specific subgroup of a community,
all other things being equal, geographical subareas and subgroups
should be served by a program in roughly the same proportion as their
composition in the community. Equity data can be used to ensure
adequate coverage of subgeographical areas and subgroups during
implementation or at the end of a program to document that a program
is or is not reaching some geographical subarea or subgroup. Utilized
in a performance measurement approach, coverage data provides
stakeholders with information about the distribution of outputs, quality
 outputs, and outcomes across subgeographical areas and subgroups.
(Kettner et al., 2008, pp. 258–259)
In addition to client demographic and descriptive data, various types of
information are collected specifically for the process evaluation to provide
comprehensive information related to program implementation and
operations and to promote further knowledge of outcomes. Several of the
types of data that are collected as part of a process evaluation are reviewed
in Chapter 12; so please refer back to that chapter if needed. Briefly,
information about the implementation process itself is collected, including
the number of resources (e.g., staff, money) allocated to the program,
location of service delivery, and unexpected occurrences, to name a few.
To reiterate, fidelity assessment may be included in the process
evaluation in order to specifically assess the degree to which a treatment is
delivered as intended. The five major areas of fidelity are treatment design,
training, treatment, receipt of treatment, and treatment skill enactment
(Borelli et al., 2005), and each requires specific data to be collected and
analyzed. Treatment design data may include number and type of
interventions and theoretical basis of treatment, while training may include
the content and methods used to prepare staff to deliver the treatment and
staff credentials. Treatment delivery data may include the number and type
of interventions actually delivered, the time frame in which treatment was
delivered, and the credentials of the individual(s) delivering the treatment.
Other specific data that may be collected and analyzed in a fidelity
assessment were also discussed in Chapter 12; so again, please refer back for
a more comprehensive discussion of data types involved in a fidelity
assessment.
Because of the unique power that process evaluation data holds—
including demographic and fidelity assessment data—sharing this
information with stakeholders is critical. Client demographic data can be
particularly useful not only in increasing knowledge of your particular target
population or region but also in informing the broader field about client
needs and characteristics. Therefore, this information is of great value to
staff, funding agents, and other professionals. In addition, this data is pivotal
to ongoing program planning efforts. For instance, program modifications
may need to be made to a program that was originally designed for
adolescents but that currently has a majority client population of older teens,
since there are often significant developmental differences between the two
groups. Likewise, a subpopulation of clients may not speak English, and
therefore, specific program modifications and additional supports will be
required to effectively serve this group. In addition, information about the
type and scope of resources, such as staff credentials, administrative
oversight, and adjunctive services, is essential not only to fully
understanding all the aspects that contribute to the program’s success but
also to understanding all that must be in place to effectively support the
program. This information has specific relevance to planning, managing, and
sustaining programs and is directly related to the program’s finances.
Because treatment fidelity data speaks directly to the design of a
particular treatment, sharing information about the degree to which fidelity
has been maintained throughout implementation is critical for program staff.
As such, this information provides direct feedback about their performance
as well as about the success or failure of the program developer in planning
for retaining treatment fidelity. In addition, this information is critical to
clients as part of the informed consent process and as consumers of services
with a right to know that they did receive what they were told they would
receive. Moreover, this information is significant to funders, as it speaks to
accountability and treatment design. Finally, this information is essential to
other professionals and stakeholders in continued efforts to better understand
treatment design and to understand the relationship between design,
implementation, and outcomes.

Outcomes Evaluation Data

The types of data collected in the outcomes evaluation are specific to the
program’s objectives and, therefore, are unique to a program. However, there
are also often common outcomes relevant to different types of programs. For
instance, a treatment program for juvenile sex offenders and a second–
chance academic program for young adults (i.e., a high school diploma
program for young adults) may share the outcome of academic success.
Whereas both programs may share an outcome related to academic success,
the outcomes for juvenile sex offenders may also include recidivism (i.e.,
reoffending), improved family functioning, and increased independence.
 Outcomes are generated directly from the program design. For instance,
family therapy and the development of a family support network are
designed to improve family functioning and, therefore, must be evaluated to
determine if the interventions did indeed lead to the anticipated outcomes.
This interdependent nature between design, implementation, and evaluation
is essential to understanding the complexity of programs and program
development efforts, and therefore, highlighting these relationships in
discussions of outcomes is helpful in increasing knowledge of the program’s
efforts.
In addition, because outcomes reflect a program’s success, they are
critical to all stakeholders, including clients, staff, funding agents,
community members, legislators, and professionals in the field. Staff are
particularly interested in outcomes since they reflect another measure of
their performance and, as such, provide another integral link to what they do
and why they do it—a critical benefit to us all while working with
individuals. However, whereas it is necessary and healthy for any
organization to continuously evaluate outcomes, caution must be exercised
in the degree to which outcomes are directly associated with employee
performance. Indeed, the employee is a vehicle by which an intervention is
delivered, and therefore, rarely is it the employee who failed but, rather, the
intervention that failed.
Funding sources and legislators are specifically interested in outcomes
since this information is pertinent to decisions about continued and future
funding. Community members are interested in outcomes, since they also
have a particular interest in what works and what doesn’t. After all, as
taxpayers, community members provide primary support for nonprofit
services. Finally, other mental health professionals have a vested interest in
the continued development of knowledge and understanding not only related
to what works but why it works so that efforts can continue to develop and
implement the most effective types of services and treatment.
Continuous collecting, analyzing, and reporting of outcomes must occur
to ensure that all stakeholders are well informed about outcomes. Without
doing so, the dilemma that Reggie faced may become a reality for other
mental health professionals—regardless of just how good the work they are
doing is.
Human Resources Data
Human resources data includes all data pertaining to staff (i.e.,
personnel). This includes but is not limited to such data as illustrated in Box
15.4.
 
BOX 15.4

EXAMPLES OF HUMAN RESOURCES DATA

Hiring
Job descriptions
Performance reviews
Educational records
Medical information
Salary information
Insurance
Company–sponsored retirement plan information
Tax information
Citizenship information
Staff vacancies (unfilled positions)
Training completed by staff
Staff credentials
Retention
Separation
Disciplinary action
Staff challenges/problems
Staff commendations/rewards
 

Sample of Human Resources Data

Human resource professionals maintain various documents and data
pertaining to staff and are responsible for each staff member’s personnel file
to ensure that confidential information remains confidential. The types of
data that are private and, therefore, must be maintained in a confidential
manner include medical and other personal information, salary, tax and
citizenship information, and disciplinary action. Whereas this data is
relevant to program managers/administrators, specific personal information
is not relevant to program staff, and it is not permissible to disclose such
information to staff who do not have a justified need to know. However, data
related to staff that can be reported in aggregate and that is not considered
confidential is highly useful to program developers/clinicians and all
program staff, as it relates to program operations.
This data, including staff vacancies, hiring, credentials, job descriptions,
and training activity, is often most valuable to program managers and staff
when examined as trend data—for instance, you might examine staff
training needs versus training completion on a quarterly basis to strategize
methods to address training needs. Or you may evaluate staff retention to
determine what trends might exist related to when staff end their
employment and the reasons why they choose to do so.
By collecting and analyzing data related to staff, program managers are
equipped with pertinent information about their staffing infrastructure. For
example, if employee exit interview results indicate that 76% of staff
voluntarily terminated their employment last year due to either not feeling
connected to the program/organization or due to the lack of professional
development activities the organization offered, this essential information
can be used in staff retention efforts. However, this data is meaningful to all
staff—not simply the manager/supervisors—particularly because sharing
this type of information among staff and involving staff in retention efforts
may serve to engage staff. As a result, the method by which future retention
efforts are developed may in fact be a critical retention tool.

Financial Data
Financial data comprise all the program’s finances—costs and revenue.
Data such as employee salaries, office space, furniture, supplies,
administrative support services, and the contract rate(s) are all essential
financial data. Financial data is pertinent to program planning, management,
and sustain–ability and, as a result, must be collected and analyzed
frequently. Effective program developers and managers are keenly aware of
the financial aspects of their program(s) and maintain close attention to
financial details. Basic information that all mental health professionals
should know is the per client cost of a program. This is typically gathered as
part of the process evaluation (Byford et al., 2007) and provides essential
information for increasing economic knowledge of the program. A basic
method for computing this cost is to divide the number of clients served by
the total cost of the contract amount or revenue produced. For instance, if the
total contract amount for a mentoring program is $100,000 and you serve
260 youth, the cost per client is $384.62. This means that the cost of
mentoring services per youth is approximately $384.62. Knowing this most
basic economic information is critical to fully understanding a program and
understanding the financial needs related to specific interventions. It has
particular significance to maintaining funding, pursuing new funding, and
advocacy efforts. Moreover, employees and other professionals are
interested in this since it provides another critical perspective of
programming and the financial aspects of interventions.
By frequently sharing financial information, employees are able to feel
more closely connected to the business that is their work—and, at least from
my perspective, one of the most important businesses conducted on earth.
That is precisely why it is so important that we protect it, and one form of
protection is to demonstrate respect for our business by increasing the
knowledge of all stakeholders about the business. Moreover, frequently
sharing financial information with employees promotes transparency and
contributes to a more engaged workforce.
Two other groups with whom financial information has specific
ramifications are community members and funders. In fact, sharing financial
information with community members in concert with information about
program outcomes may also be particularly helpful in garnering more
financial support through donations and other means. In addition, sharing
financial information with funding sources not only is required but also
provides critical information that is useful in ongoing contract negotiations
and decisions about releasing new funds.

Compliance and Quality Improvement Data

 Compliance data refers to compliance with requirements of contracting
organizations, accrediting bodies, licensing organizations, other oversight
organizations, or self–imposed requirements. Compliance data often
includes both outcome data and other types of data. For instance, contracting
organizations are specifically interested in a program’s effectiveness in
treating clients; however, they are often equally interested in the credentials
of staff and the availability of services. Box 15.5 provides a sample of
contract compliance data.
 
BOX 15.5

SAMPLE OF CONTRACT COMPLIANCE DATA

Acceptance rate of all referred clients

Length of time from initial referral to program admission
Number of clients served annually
Percentage of clients successfully treated in accordance with
preestablished success criteria
Percentage of clinicians with a master’s degree or above in major
mental health discipline and licensure as a mental health therapist
Percentage of clients discharged prematurely
 

Compliance data often overlaps with process evaluation data, because

contractors have a vested interest in ensuring that programs/models are
implemented as designed. Because contract compliance data reflects the
degree to which goals or targets are met, contractors or other oversight
organizations dictate the required target thresholds. For some issues, such as
the percentage of qualified therapists, there is no tolerance for
noncompliance, meaning the required compliance rate is 100%; for other
areas, compliance may be set at less than 100% or at a specific number. For
instance, the percentage of clients discharged prematurely (without
completing the program) may be set at 85%, the expected length of time
between referral and program admission may not exceed 48 hours for any
client, and there may be a requirement to serve a minimum of 160 clients per
year.
Contract compliance data has obvious implications. Failure to comply
with performance expectations may result in the cancellation or nonrenewal
of a contract. Therefore, collecting, analyzing, and sharing this data with all
program stakeholders is critical to the program’s sustainability.
Quality improvement data is required by accrediting bodies and is often a
standard part of organizational practices and, thereby, self–imposed by
organizations. Quality improvement speaks to the specific areas in which
improvement is sought and the improvement goals. While it is a standard
part of business operations today, quality improvement originated in Japan
(Senge, 2006) in the 1940s. Unlike contract compliance goals that are
predetermined by contractors or other oversight organizations, quality
improvement goals often evolve organically from data analysis findings. For
instance, if exit interview data indicated that staff chose to leave the
organization due to lack of engagement, a quality improvement goal might
be developed to address this specific issue. The goal, such as 95% of staff
will be engaged with the program within 6 months of employment as
measured by the Employee Engagement Scale (hypothetical standardized
assessment instrument—with sound psychometric properties, of course), is
developed by program staff with specific strategies by which to attain it.
Through the collection and analysis of various program data, staff are able to
quickly identify areas in need of improvement and can then develop means
by which to address these areas.
The structure surrounding quality goals may vary considerably from
organization to organization, with some organizations using quality
improvement committees to lead quality improvement efforts and others
requiring a specified number of quality goals in key areas (e.g., client
satisfaction, community relations). However, what is of greatest import is
not how quality improvement efforts occur but, rather, that they occur and
that their purpose is fully understood by all stakeholders. This is because of
what quality improvement efforts reflect—a commitment to quality and
continuous improvement.
Whereas contractors and/or accrediting bodies often require reporting of
both contract compliance data and quality improvement data—even when
not required—it is wise to share this data with oversight organizations since
it reflects the program/organization’s dedication to quality. Equally
important is that this data is shared frequently and with all staff. Contract
compliance and quality improvement data are byproducts of the work of
staff, and therefore, all staff must have open and continuous access to this
data. By ensuring that this occurs, staff are able to better understand the
critical issues that compose their program and are able to more effectively
participate in ongoing improvement efforts.

Other Pertinent Data

In addition to the five major areas just discussed, there are other types of
data that must be collected and shared with various groups. Other client data,
such as satisfaction with services, is not only required by several accrediting
bodies and/or contractors but particularly meaningful to program staff and
necessary for program improvement efforts. Employee information, such as
employee satisfaction, engagement, and retention each provide pivotal data
for use in continuous improvement efforts. In addition, organizational
structures and decision–making processes are pertinent areas to both
employees and funders, since they directly impact efficiency and
effectiveness and provide additional guidance to employees.
Whereas there are lots of other types of data that are pertinent to collect,
analyze, and share with others, you must be guided by the premise of
collecting and analyzing the right data and sharing that data as frequently as
needed with all who need to receive it. By doing this, data collection and
information sharing can be highly efficient and can contribute to the overall
effectiveness of the program operations.

Data Reporting
 
WE’RE DOING WHAT?
At a recent fundraising event hosted by a nonprofit agency, one of the
agency’s board members was speaking with Kyle, one of the agency
clinicians. The board member shared his excitement about the new
 contract on which the program director (Kyle’s supervisor) was bidding
and discussing how, if awarded, the contract could result in a significant
expansion of services for the agency. Kyle smiled and agreed about the
positive prospects the new contract could bring and then delicately
extricated himself from the conversation, going in search of one of his
program colleagues. On finding a fellow clinician, he recounted the
conversation he had had with the board member, stating that he had no
idea that his supervisor was pursuing a new contract. Kyle’s colleague
was not aware of this either. Flummoxed by the apparent lack of
information they both had about their program, they agreed they would
need to follow up with their supervisor in the morning.
 

Have you ever experienced this type of awkward situation? Someone

knows something about your program/agency that you should know as well,
and after hearing this information from another source, you feel
uncomfortable and not wholly aware of why you weren’t informed.
Unfortunately, this happens all too often and typically not because there is a
motive to withhold information; rather, in the absence of any type of
information–sharing structure, information is not properly or effectively
shared. In other words, there must be a method to your madness, and this is
particularly true where information sharing is concerned.
This can be easily accomplished by putting a specific structure in place to
ensure that information is effectively shared. By doing this, the extensive
work accomplished in the data collection and analysis process can be fully
realized. In terms of developing a basic structure to promote effective
sharing of information, each of the following aspects of data reporting
should be established:

The individual(s) responsible for reporting the data

The time frames in which data will be reported
The means by which data will be reported
The recipients who will receive the various types of data

Each of these issues is discussed below.

Responsibilities for Data Reporting
Assigning responsibilities is a prerequisite for accountability—in any
business or other endeavor. Therefore, the starting point for effective
information sharing lies first and foremost in identifying who is responsible
for reporting what type of data/information. Because there are often various
types of data (as described above), there may be various individuals assigned
to reporting specific types of data to different groups. For instance, clinicians
might report program outcomes to the program staff, whereas the chief
financial officer might report the program’s financial status to the board of
directors. However, as I have emphasized throughout this text, program
developers/mental health professionals must have comprehensive knowledge
about the programs with which they are involved. And there is no better
indicator of the degree of knowledge a program developer has about her/his
program than her/his ability to report on the various data related to the
program. During those times when program developers are not directly
reporting program data, they must be fully aware of the data and its
implications.
Along these same lines, all program staff should be knowledgeable about
the various aspects of their programs—regardless of the degree to which
they directly interact with specific data. This is because information does
often translate into power, and thus, by being empowered to report on
various data, the staff person is gaining new knowledge and is given an
opportunity to develop new skills related to reporting data. Therefore, data
reporting must not be simply the role of one person (e.g., program
developer/director) but a role shared by many and one in which assignments
change related to the type of data reported by the specific staff person. By
spreading out responsibilities for data reporting among all staff persons,
program managers may in fact engage more staff with the program and the
organization while providing specific opportunities for professional
development. Table 15.2 provides an example of how the small staff of a
gambling prevention program for teens shares data reporting responsibilities.
The five staff persons illustrated in Table 15.2compose the entire program
staff: Kimberly (program manager), LaShawn, Rhonda, Dorothy, and Roma
(prevention specialists). Each staff person is responsible for regularly
leading the collection, analysis, and reporting of their assigned data to the
rest of the program staff for a year at a time. By using this type of schema
for sharing data–reporting responsibilities, Kimberly is able to ensure that
each of her staff members is highly knowledgeable about the major aspects
of the program. Regardless of the manner in which data reporting
responsibilities are assigned, the primary objective is that responsibilities are
shared among program and organizational staff to ensure that everyone who
is a part of the program is knowledgeable about the various aspects of the
program.
Table 15.2 Data Reporting Assignments

Reporting Time Frames

Establishing time frames for reporting data can be as important to
ensuring that information is shared as is assigning responsibility for data
reporting. As you witnessed by Reggie’s example, his program may have
continued if short–term and frequent time frames for reporting had been
established.
Time frames provide another necessary level of structure to the
information–sharing process and another level of reinforcement for
accountability. Whereas data about each major area of a program should
minimally be shared on a quarterly basis with all program staff, specific
types of data may need to be shared much more frequently, depending on the
data type and special circumstances. For instance, if program revenue that is
paid on a fee–for–service basis has fallen below the annual projected
revenue, resulting in the possibility of reducing a staff position unless the
revenue improves quickly, revenue data may require analysis and reporting
on a weekly basis. On the other hand, it may not be appropriate to report on
outcome goals more frequently than each quarter, because the limited
number of outcomes occurring on a weekly or biweekly basis may not
reflect aggregate outcome data and will, therefore, skew the actual outcomes
picture as a result of focusing on a few outcomes rather than the total
outcomes.

Methods for Data Reporting

Once decisions about who is responsible for reporting specific data are
made and the time frames within which data will be reported have been
established, the methods by which data will be reported must be identified.
The methods for reporting specific types of data may be varied based on the
recipients, and multiple methods may be used to communicate the same
data. Methods for reporting data include but are not limited to

verbal communication in meetings or other group forums,

presentations of data in meetings or other group forums,
comprehensive written reports,
written snapshots of data (i.e., data briefs),
electronic snapshots of data posted on the Intranet,
annual reports, and
website postings.

Methods should be selected based on effectiveness to reach the intended

recipients and the rationale for sharing the specific data. For instance, verbal
communication of data in biweekly staff meetings may be a highly effective
method for ensuring that critical information is frequently shared with
program staff. However, quarterly board of directors meetings may require
both a formal presentation of data as well as an accompanying report to
ensure that the information is effectively communicated and that the
information provided is thorough enough to allow for effective governance.
Because effective communication is critical to information sharing,
methods for reporting data should be continuously evaluated to ensure that
they are working. Simply because the development of a presentation
involves quite a bit of work and contains significant information, that does
not automatically translate into the information being effectively
communicated. Gathering the input of recipients about preferences of
communication methods, engaging in follow–up dialogue to discuss
information shared, and engaging in more rigorous evaluation of the
effectiveness of information sharing can be helpful in ongoing efforts to
ensure productive information sharing.

Data Recipients
Finally, the various groups of individuals who will receive the data must
be identified—the data recipients. Technically, data recipients are all
stakeholders. This includes but is not limited to program staff, clients,
administrators, contractors, accrediting bodies, the governing board, and the
public. Each of these groups has a need to know specific program
information, and as such, program developers have an obligation to regularly
share data with each group. Further, for some groups, there are specific
requirements about what data must be reported, how often it must be
reported, and in what format it must be reported. For instance, written
reports on contract compliance data might be required on a semiannual basis
by contractors. Alternatively, while specific requirements may not exist
regarding information sharing with program staff, best practices may
indicate that specific program data is shared on a weekly basis to ensure a
well–informed workforce.
The basic rule of thumb regarding who should receive program
information is that anyone who has a need to know should know, and they
should know as soon as possible. This will ensure that what happened to
Kyle does not happen to other clinicians or program staff—that is, learning
about a possible significant change in the program from a board member.
As you can see, all these aspects of data reporting are interconnected—
responsibilities for data reporting, time frames, methods, and recipients. By
thoroughly considering each, program managers posture themselves to
effectively share information and data with their stakeholders. The next
section provides specific examples and tools to aid in accomplishing this.
Data Protections and Safeguards
Because the bulk of data collected by mental health professionals is
related to those whom we serve, our first obligation is to protect the privacy
of our clients and to ensure that information about them is maintained in a
confidential manner. There are several state and federal laws that set forth
rules on this—most notably, HIPAA (1996) and HITECH (2009), which
provide strict guidance for the collection, storage, protection, and use of
health–related information, with strong protections for the privacy of
individuals’ health information (Mai et al., 2007). In addition, federal
guidelines regarding the protection of substance use information—42 CFR
Part 2—confidentiality of alcohol and drug abuse records, and federal and
state therapist patient confidentiality laws provide specific guidance. If you
are not wholly familiar with the federal laws regarding client/patient
protected health information, this is an area with which you will need to
become quite familiar.
All data collection must be conducted in accordance with legal statutes
and with all necessary protections in place. In addition, all research activities
must be conducted with necessary oversight procedures in place, including
authorization and ongoing monitoring from an institutional review
board/human subjects committee. Organizations must have comprehensive
policies and procedures in place specifically dealing with client
confidentiality, data storage and maintenance, data sharing, and reporting
through release and disclosure. Organizations also must ensure that required
hardware and other electronic safeguards are in place to protect electronic
data.
Just as both state and federal laws and other guidance regarding client
confidentiality have changed dramatically over the past several years, with
continued changes in electronic technology and continued development of
knowledge related to data collection and protection, change will likely
continue to occur. It is essential that mental health professionals maintain
current knowledge regarding the rules that govern the collection, use, and
storage of confidential information to ensure appropriate guidance in this
area.

Developing the Data Reporting Plan

 As discussed earlier, without a solid framework to structure data
reporting and information sharing, it is likely that pertinent information will
not be shared with those who have a need to know or that information will
not be shared in a timely fashion. Therefore, structure is needed to guide
these activities. The Annual Data Reporting Plan in Table 15.3 provides an
example of how to structure data reporting by addressing each of the four
key aspects (i.e., responsibility, time frame, methods, recipients). Please note
as you review Table 15.3 that the time frames and methods are intended as a
guide only—contractors, organizational policies, and other oversight
organizations may require more stringent reporting time frames and
methods.
Table 15.3 Annual Data Reporting Plan
 Whereas the Annual Data Reporting Plan illustrates the broad data types
that should be shared, there are numerous details that are needed to guide
this type of data collection, analysis, and reporting. The Quarterly/Annual
Comprehensive Data Report Tool (Box 15.6) was developed precisely to
guide and provide essential structure to the data collection, analysis, and
reporting process.
 
BOX 15.6

QUARTERLY/ANNUAL COMPREHENSIVE DATA

REPORT TOOL
Program:
Data reporting time frame
Reporter:

1. Clients served
a. Total number served during report period:
b. Total program capacity:
c. Is program capacity limited by contract?
d. If unlimited, what is your target goal for number of clients for the year?
e. How does current number of clients compare with last quarter or last year?
f. If reporting quarterly data, how does this quarter’s data compare with the same quarter 1 year
ago?
g. What types of trends in client numbers exist?
h. Provide evidence for item g trends:
i. Reasons/explanations for client population trends:
j. Projected number of clients to be served next quarter:

2. Clients discharged/released/no longer in program

a. Provide the definition of successful termination for your program:
b. Number of successful terminations during report period:
c. Percentage of total terminations that were successful:
d. Number of unsuccessful terminations during report period:
e. Percentage of total terminations that were unsuccessful:
f. Reasons for unsuccessful terminations:
g. Please state how those numbers compare with last quarter/last year data:
h. If reporting quarterly data, how does this quarter’s termination data compare with the same
quarter 1 year ago?
i. Any trends identified in terminations (e.g., increase in unsuccessful terminations due to
truancy during the summer):
j. Any program plans, enhancements, or changes that you made as a result of the successful or
unsuccessful discharge data:

3. Contract compliance
a. What percentage of contract compliance items were you in full (100%) compliance with this
reporting period?
b. Please state each of the specific contract compliance items that were not in full compliance
during report period:
c. How does the percentage of contract compliance results compare with last quarter/last year?
d. If reporting quarterly data, how does the percentage of contract compliance results compare
with the same quarter 1 year ago?
e. Please state any program plans to address any contract compliance challenges:

4. Assessments
a. What standardized assessment instruments, if any, are used within your program?
b. How are the results used in individual treatment planning?
c. If you provide an assessment at entry and at termination, please discuss the
differences/similarities in scores:
d. Please discuss your aggregate program assessment data for report period:
e. If applicable, please discuss how you have used the aggregate assessment data to make
program changes:

5. Quality improvement status

a. Please report on the results of each program outcome goal:
b. Please discuss how you have used the results of your quality improvement data:
c. Please discuss how your quality improvement activities have been used in program changes
and program development:
d. Please discuss the frequency with which your program’s quality plan changes and why:
e. How often is quality improvement data reviewed with staff?
f. Please state the methods that you use to promote and share quality improvement initiatives
with program staff:

6. Human resources
a. What is your current staff vacancy rate?
b. What is your staff turnover rate during the report period?
c. How does your staff turnover rate compare with last quarter/last year?
d. How does your staff turnover rate compare with the same quarter last year?
e. Please share any strategies that you have utilized to increase or impact employee retention or
satisfaction?
f. Please state any plans or successful strategies you have used to address staffing challenges:
g. Please state any methods you have used to modify/adapt staffing patterns as a result of
changes in program utilization or programming design:
h. Please provide any additional relevant HR information:

7. Financial information
a. What was your program revenue during the last quarter?
b. How does your total program revenue compare with the same quarter 1 year ago?
c. Is program paid on a per diem, contract program, or fee–for–service basis?
d. Referring to item 1e, if you are experiencing a reduction in clients or have not been at
capacity during the quarter, how much impact has client reduction had on your
budget/financial implications?
e. Referring to item 1e, if you are experiencing a reduction in clients or have not been at
capacity during the quarter, what types of marketing strategies have you employed to address
program utilization?
f. Please provide any additional relevant financial data:
 8. Comprehensive overview and targeted areas
a. After reviewing all the information in the report, what do you believe your program did well
this quarter?
b. What do you believe are the primary areas of concern that need to be addressed during the
next quarter?
c. Please discuss the methods that you will use to address these concerns:
d. Please provide any additional comments about your findings based on this analysis:

This tool was adapted from one that I originally developed for Spectrum Human Services,
Inc. and Affiliated Companies while employed by the agency. The tool continues to be used by
all the agency’s programs as a critical part of their quarterly and annual comprehensive
program review process.
 

As you can see, the Quarterly/Annual Comprehensive Data Report guides

the data collection, analysis, and reporting process, promoting a
comprehensive picture of the program through which systematic and
ongoing program planning can occur. The report covers each of the major
aspects of the program. The report is used on both a quarterly and an annual
basis to provide guidance and to ensure comprehensive review. Whereas the
report itself provides a summary of data, it does not take the place of other
data–specific reports that provide additional information about specific
aspects (e.g., contract compliance goals, quality improvement plan).

Summary
The collection, analysis, and reporting of data is a critical part of ongoing
information sharing and is often essential to the sustainability of a program.
Because information is not only powerful but empowering, information–
sharing responsibilities must be delegated among multiple levels of program
staff. This only serves as another mechanism by which to possibly engage
program staff with the program as well as reinforce the role that each staff
member has in a program’s success (and failures). In addition, collecting
data without sharing it with all stakeholders who have a need to know is akin
to buying a treadmill and never using it—it’s an investment that yields no
return. Therefore, if data is collected, it must be shared. Furthermore,
information sharing should be systematically guided to ensure that data is
getting to all who need it. Particularly in the 21st century, when competition
in mental health and human services is fierce and only the strong survive,
effective data reporting can only help to ensure a program’s sustainability.
 
CASE ILLUSTRATION
David’s semi–independent living program for adults with developmental
disabilities had been operating for 1 year. David held a 1–year
anniversary celebration with the program staff to mark the occasion, and
he invited all the agency’s staff and administrators.
David had put a great deal of effort into ensuring that all pertinent
information about the program was continuously collected, analyzed, and
immediately shared with all the people who had a right to and a need for
the information—his staff being one of the most important recipients. To
ensure that his staff were fully aware of all aspects of the program, David
had insisted that all the staff collaboratively develop the process
evaluation, outcomes evaluation, and initial quality improvement goals.
In addition, they had developed the contract compliance plan and a
schedule and assignments for regular data collection and reporting.
To ensure that all staff remained personally connected to the data, they
took turns collecting and reporting specific data sets and alternated
responsibility for developing the program’s quarterly report using the
Quarterly/Annual Comprehensive Data Report Tool and for leading the
discussions about the data. By doing so, it appeared that all staff had a
firm understanding of exactly what the program was designed to do and
what it had accomplished thus far.
Since the anniversary celebration was held to mark the program’s
success in being operational for 1 year, David thought it would provide a
good forum to present the program to the rest of the agency’s staff so that
they, too, could fully understand the program. Five of the program staff
members had volunteered to lead the presentation, and they had
completed the Annual Comprehensive Data Report. The staff developed
a PowerPoint presentation to provide a brief overview of their program
and to discuss the results of the process evaluation and initial outcomes.
They outlined the program’s quality plan and contract compliance goals,
providing a progress update on each. They then discussed the costs of the
program, their staff turnover rate, challenges that they had encountered
in retaining direct care staff, and the steps they had taken to resolve this
issue. Finally, the group shared each of the major issues that had been
identified through their various analyses and the measures they had
enacted to address each, reporting on the progress of each strategy.
Finishing their presentation, they took questions from the audience.
Regardless of the nature of the question—be it about the rationale for
a quality improvement goal or the cost needed to replace a staff position
—the program staff readily provided responses, and David never once
contributed to the discussion. There was no need for him to participate,
as his staff understood their program in its entirety as well as he did.
When asked about plans for exploring new business, since their program
was doing well and appeared highly stable, the staff quickly responded
that they had just begun revisiting their strategic plan to thoughtfully
examine their next steps. But another staff member (sitting in the
audience) added that any new planning would be in addition to
continuing all the existing monitoring, evaluation, and improvement
efforts and that maintaining and improving what they currently had was
their primary commitment.
Witnessing this, David knew that he had been successful in ensuring
that all his staff were not only well aware of but completely competent
about their program and all its various aspects. Allowing himself only a
moment to appreciate this, his mind quickly turned to finalizing plans for
a similar presentation to his funding source and other stakeholders,
which he and his staff had been facilitating each quarter.

 
DATA REPORT PLAN EXERCISE

1. Review the Comprehensive Quarterly/Annual Data Report

Plan and identify four additional items that you believe should
be included in this analysis.
2. State your rationale for including this additional data.
3. Discuss this with a partner or in a small group.
  
REFLECTION AND DISCUSSION QUESTIONS

1. How do you determine the types of information to be shared,

with whom to share them, and the frequency of such sharing?
2. What have your experiences been related to information
sharing and data reporting?
3. In your current work, what are the strengths and/or weaknesses
in how data is collected, analyzed, and reported?
4. What do you perceive as the role of data in today’s mental
health and human services, and what factors do you believe
contribute to this?
5. Do you believe types of data can be prioritized in levels of
importance, and if so, how would you prioritize the data sets
contained on the Quarterly Program Data Report?

References
Borelli, B., Sepinwall, D., Ernst, D., Bellg, A. J., Czajkowski, S., Breger, R.,
et al. (2005). A new tool to assess treatment fidelity and evaluation of
treatment across 10 years of health behavior research. Journal of
Consulting and Clinical Psychology, 73, 852–860.
Byford, S., Leese, M., Knapp, M., Seivewright, H., Cameron, S., Jones, V.,
et al. (2007). Comparison of alternative methods of collection of service
use data for the economic evaluation of health care interventions. Health
Economics, 16, 531–536.
Gard, C. L., Flannigan, P. N., & Cluskey, M. (2004). Program evaluation: An
ongoing systematic process. Nurse Educator, 25, 176–179.
Gibelman, M., & Furman, R. (2008). Managing human service
organizations. Chicago: Lyceum.
Kettner, P. M., Moroney, R. M., & Martin, L. L. (2008). Designing and
managing programs: An effectiveness–based approach. Thousand Oaks,
CA: Sage.
Mai, C. T., Law, D. J., Mason, C. A., McDowell, B. D., Meyer, R. E., &
Musa, D. (2007). Collection, use, and protection of population–based
birth defects surveillance data in the United States. Birth Defects
Research, 79, 811–814.
Morris, R., Macneela, P., Scott, A., Treacy, M. P., Hyde, A., Matthews, A., et
al. (2010). The Irish nursing minimum data set for mental health—valid
and reliable tool for the collection of standardized nursing data. Journal of
Clinical Nursing, 19, 359–367.
Senge, P. M. (2006). The fifth discipline. New York: Doubleday.
 CHAPTER 16
Attain Program and Organizational
Accreditation

 
Learning Objectives
 

1. Increase understanding of both the history and current status of relevant

accrediting bodies
2. Compare and contrast the three major accrediting bodies in mental
health and human services
3. Differentiate concrete costs and benefits and soft costs and benefits
related to accreditation
4. Identify potential benefits of pursuing/attaining accreditation
5. Identify various factors used in considering prospective accrediting
bodies
6. Discuss the various steps involved in pursuing accreditation
7. Develop a comprehensive plan for pursuing accreditation

 
 WHY BOTHER WITH ACCREDITATION?
Janet and Eric had been operating their residential program for adults
with dementia of the Alzheimer’s type for a little less than 2 years. For
the past 18 months, the program had been filled to capacity (56 clients),
and their capacity had increased from a previous average of 40 clients.
The families of their clients had consistently expressed praise for the
program, and they had passed each of their licensure reviews with flying
colors. The monitoring reviews from their contractors had also been
quite positive, and their program had been publicly recognized for its
work.
While it was difficult to find cause for concern with the program,
during the quarterly board of directors meeting, one of the directors
asked Janet and Eric about their plans to pursue accreditation. Janet was
familiar with accreditation through her previous experience in hospitals,
but Eric was not since the small outpatient clinic in which he had
previously worked had not been accredited. Viewing their residential
program as quite different from a hospital, Janet responded that she did
not see the value in pursuing accreditation at this point, especially in
light of their program’s success. After a short discussion about hospital
accreditation versus accreditation of mental health and human service
organizations, the board turned to other orders of business.
Six months later, Eric and Janet’s main competitor announced its
recently attained accreditation, using it to further market its program. Not
long after, a new competitor arrived on the scene and attained
accreditation the following year. As both competing organizations
continued to market their accreditation status, Eric received more and
more calls from families of prospective clients inquiring about their
accreditation status, and Janet was specifically questioned during a
meeting with contractors about why their organization was not
accredited.
After a lengthy discussion spurred on by a great deal of concern for
their organization, Janet and Eric decided to begin planning to pursue
accreditation. Unfortunately, this decision came at the same time that
they were forced to lay off a third of their employees, since their capacity
had dropped to 35 clients over the past year.
  
CONSIDERING JANET AND ERIC

1. When should Janet and Eric have begun pursuing accreditation?

2. What significance does accreditation have today in mental health and
human services?
3. What do you believe are the pros and cons related to accreditation?

About This Chapter

This chapter takes up the final step in comprehensive program development
—attaining program and organizational accreditation. The reason that both
program and organizational accreditation are identified is because, for many
accrediting bodies, these are considered two different aspects. And whereas
organizational accreditation is typically required in order for a program to
receive accreditation, in some cases an organization may be accredited even
when one or more of its programs are not.
This step is directly related to Step X (Evaluate the program) and Step
XIII (Develop an information-sharing plan), because accreditation is
dependent on compliance with best practice standards. However, like all the
other steps that compose the comprehensive program development model,
this step is also related to each of the previous steps. Accreditation planning
and attainment is viewed as the final step because of what it signifies—
national recognition for excellence.
In order to fully investigate accreditation and the process by which one
pursues it, we must begin with an examination of the history of accreditation
and its significance today. We will follow this with a discussion of the major
accrediting bodies in mental health and human services today, which include
the Council on Accreditation (COA), the Commission on Accreditation of
Rehabilitation Facilities (CARF), and The Joint Commission.
We will explore major aspects related to accreditation, including the costs
and benefits of accreditation, the relevance of accreditation to clinical
program development, and identifying the right fit between
program/organization and accrediting body. We will follow this with a
discussion of accreditation planning and the development of the
accreditation plan to guide this work. A case illustration demonstrates the
material covered in the chapter. And finally, an exercise is provided to help
you directly investigate and identify the most appropriate accrediting body
for your program/organization and develop a plan for pursuit of
accreditation.

STEP XIV: ATTAIN PROGRAM AND

ORGANIZATIONAL ACCREDITATION
History and Significance of Accreditation
Dr. Ernest Codman’s 1910 proposal to standardize health care by tracking
every patient’s treatment from beginning to end to evaluate its effectiveness
(The Joint Commission, 2009) served as the catalyst for what we know
today as accreditation standards. In fact, answering Dr. Codman’s call, the
first accreditation standards were promulgated by the American College of
Physicians (ACP) in 1917. The very small, yet mighty, Minimum Standard
for Hospitals filled all of one page with requirements. This in turn led to the
collaboration between the ACP, the American Hospital Association, the
American Medical Association, and the Canadian Medical Association to
create the Joint Commission on Accreditation of Hospitals (since renamed
The Joint Commission [2009]). The Joint Commission was established in
1951 as an independent, not-for-profit organization whose primary purpose
was to provide voluntary accreditation, publishing the Standards for
Hospital Accreditation in 1953.
It was not until 1966 that an accrediting body was founded to focus on
rehabilitation facilities—CARF. And in 1969, The Joint Commission turned
its attention to mental health programs. However, without the work of
physicians in the early part of the 20th century, the significance of
accreditation in mental health and human services would likely not enjoy the
stature that it does today. Then, as now, accreditation practices had been
guided from within the profession—by professionals seeking to ensure high
quality and effectiveness.
 Out of recognition of the need to define standards of quality for the
services provided by human service organizations and increase
accountability for the outcomes of services, various organizations
have evolved to formulate standards in specialized service areas and to
enforce them through an accreditation process. (Gibelman & Furman,
2008, p. 83)
Today, it is unusual to find a human service or mental health provider
who is not intimately aware of accrediting bodies and accreditation
standards. Indeed, many an organization is guided by accreditation
standards, seeking this badge of approval and proudly displaying it wherever
possible.

Purpose of Accrediting Bodies

Accrediting bodies fulfill a specific purpose: They define quality standards
related to operations and administration of organizations, and they monitor
compliance with those standards. Accrediting bodies are not unique to
human services and mental health programming but, rather, have become a
standard (pardon the pun) part of organizational life for a diverse array of
industries. Consider ISO, TS 16949, and QS 9000—quality standards for the
automotive industry that are commonly displayed on the business flags of
automotive companies and suppliers (quite a common sight to those of us
living in Detroit). The International Organization for Standardization is a
major accrediting body of industry and commercial businesses. In addition,
accrediting bodies are a primary aspect of K–12 and higher education, with
varying types of state, regional, and national accrediting bodies available as
well as accrediting bodies focused in both the institutional and program
levels. Accreditation in each of these diverse industries illustrates just how
embedded accreditation has become in organizational life.
While accrediting bodies across industries may vary in several key
aspects, they also share commonalities. Primarily, accrediting bodies share
the following major features:

They define quality standards.

They monitor quality standards.
 They require a fee for accreditation and reaccreditation.
They maintain term-limited accreditation/reaccreditation
cycles.

With these four shared characteristics, accrediting bodies assume a

position of power in articulating quality definitions, act as accountability
agents, require payment for their services, and provide ongoing structure for
the accreditation process. As such, they provide comprehensive guidance
and serve as external watchdogs for organizations.

Accreditation Process
The accreditation process begins with the organization seeking accreditation
filing an application/intent, along with the application fee. This is typically
followed by a discussion with a staff person from the accrediting body about
the self-study process, guiding documents (e.g., accreditation standards,
guidance manual), and time frame for submitting the initial self-study. Once
the organization seeking accreditation becomes fully educated about the
accreditation process, the organization then devises its own plans for
completing the self-study and gathering all the necessary documentation
needed as part of the self-study submission. Whereas developing the self-
study is often an enormous task, the more significant work lies in ensuring
that compliance with each standard is met, developing new policies and/or
practices to comply with the standards, or determining what steps will need
to be taken to bring the program/organization into compliance with the
standards. Completion of the self-study typically requires 12 to 18 months.
Compliance with accreditation standards is the basis on which each
organization is evaluated in the accreditation process and is thereby what
each organization seeking accreditation aspires to achieve. Compliance with
standards is typically verified through two measures: written evidence that is
part of the self-study documents (e.g., policies, protocols) and physical
evidence that is verified as part of the on-site visit. Physical evidence may be
gathered on-site by the peer reviewers through discussions with staff and/or
clients to verify that certain practices are in place, through reviewing
documentation logs, or through other means.
 Following its completion, the self-study and supporting documents are
submitted to the accrediting body. The accrediting body typically conducts
an initial review of the self-study and composes a team of peer reviewers
(the size of the peer review team is determined by the size and scope of the
organization seeking accreditation—typically two to five individuals). Travel
plans and scheduling of the on-site visit are then coordinated between the
accrediting body, peer reviewers, and the organization seeking accreditation,
and the on-site visit schedule is developed. Accreditation visits typically
extend from 2 to 5 days, depending again on the size and scope of the
program/organization seeking accreditation. Whereas accreditation visits are
usually packed with activities as peer reviewers seek to obtain the most
information as efficiently as possible, a diverse amount of activity occurs.
The visit begins with a short introductory meeting between the peer
reviewers and administrators and other key staff from the organization
seeking accreditation to explain the purpose of the visit, the protocols that
will be followed during the visit, and review of the visit schedule.
Immediately following this introductory meeting, the peer reviewers may
separate or work in teams to gather additional information and verify
compliance. Box 16.1provides a snapshot of a typical on-site accreditation
visit schedule.
 
BOX 16.1

ACCREDITATION SITE VISIT SCHEDULE SAMPLE

Day 1
8:30 am: Introductory meeting
9:00 am: Individual interviews with president/executive director and other key administrators
10:00 am: Interviews with program directors and/or supervisors and interviews with
administrative support staff
12:00 pm: Interviews with other key staff
1:00 pm: Lunch on-site
2:00 pm: Review of client records, program documentation, and organizational policies and other
documentation
6:00 pm: Reviewers break for dinner and reconvene in hotel to debrief day’s events, plan for next
day’s activities, and begin to develop the on-site visit report of findings
 Day 2
8:30 am: Interviews with board members and program and administrative support staff
10:00 am: Visits to residential sites or other administrative office and interviews with staff and
clients
12:00 pm: Lunch with program staff and/or clients
1:30 pm: Review of program documentation and policies, review of human resource and finance
records, review of information technology and quality policies and protocols, and meetings with
additional program and/or administrative support staff
6:00 pm: Reviewers break for dinner
7:30 pm: Reviewers finalize the on-site visit report and recommendations

Day 3
8:30 am: Exit interview between review team and key organizational staff, with review team
providing brief verbal feedback
9:30 am: Review team leaves site
 

Following the site visit, the organization seeking accreditation receives an

official report from the accrediting body summarizing the findings of the
accreditation process (i.e., self-study and on-site visit) and notification of
accreditation status. Organizations may be granted provisional or full
accreditation status depending on the results. Whereas provisional
accreditation status often requires an interim report (within 1–2 years), full
accreditation status may be granted for 1 to 5 years. Once accredited, an
organization then must continuously seek reaccreditation by completing a
self-study and hosting an on-site visit within the time frames established by
the accrediting body.
Whereas the accreditation process itself is somewhat similar for each of
the three major accrediting bodies, the accrediting bodies differ in somewhat
significant ways. To promote a fuller understanding of this, each of the
accrediting bodies is discussed below.

Major Accrediting Bodies in Mental Health and

Human Services
Within the mental health and human services, there are three major
accrediting bodies:

The Council on Accreditation (COA)

The Commission on Accreditation of Rehabilitation Facilities
(CARF)
The Joint Commission (formerly known as the Joint
Commission on Accreditation of Hospitals)

Table 16.1 provides a snapshot comparison of these three accrediting

bodies.
Table 16.1 Comparison of Major Accrediting Bodies

*List is not exhaustive for each accrediting body but, rather, a sample of
major service areas.
**Rates as of April 2010.
 These accrediting bodies each emerged or included behavioral health as
part of their scope within an 8-year span of one another, with CARF
evolving in 1966, followed by The Joint Commission’s decision to include
behavioral health and the introduction of COA in 1977. Whereas each was
initially designed with a specific and limited focus, over the intervening
years, they have each expanded dramatically in the scope of programs that
they accredit. As a result, today it is much more difficult to identify a
particular programmatic focus or theme for any of these three accrediting
bodies. This can pose an additional challenge to mental health and human
service providers interested in pursuing accreditation. In addition, the scope
of administrative and organization-specific standards (e.g., governance,
ethics, administrative supports) has continued to become more sophisticated
as knowledge regarding organizational structure has continued to increase.
Whereas each of these major accrediting bodies operates as an
independent organization with its own employed staff, their operations are
primarily driven by volunteer peer reviewers. The peer review process is one
of the defining features of the accreditation process. Peer reviewers consist
of human service professionals who serve in a volunteer capacity to review
their peer organizations. Before delving further into the peer review process,
we must first discuss the accreditation process itself by taking a closer look
at the three major accrediting bodies.

Council on Accreditation
COA is the youngest of the three major accrediting bodies. It is arguably
the most well known by child welfare organizations, particularly those
specializing in foster care and other child and family services. According to
its website,
COA is an international, independent, not-for-profit, child- and
family-service and behavioral health care accrediting organization. It
was founded in 1977 by the Child Welfare League of America and
Family Service America (now the Alliance for Children and Families).
Originally known as an accrediting body for family and children’s
agencies, COA currently accredits 38 different service areas and over
60 types of programs. Among the service areas are substance abuse
 treatment, adult day care, services for the homeless, foster care, and
inter-country adoption.
In addition to standards for private social service and behavioral
health care organizations, COA has developed separate business lines
for public agencies, networks and lead management entities, opioid
treatment programs, employee assistance programs, and financial
management/debt counseling services. (COA, n.d., paras. 2–3)
At the time of this writing, COA accredits more than 1,800 private and
public organizations in the United States, Canada, Puerto Rico, Bermuda,
England, and the Philippines—34% with annual budgets less than $2 million
and 44% with annual budgets between $2 million and $10 million (COA,
n.d.a). Both the breadth of service standards available and the number of
accredited organizations that COA counts on its roster reflect the significant
growth of accrediting bodies in mental health and human services over the
past 20 years.
COA receives varying degrees of support and guidance from a host of
sponsoring and support organizations (see Table 16.2; COA, n.d.c). These
organizations are specifically invested in COA and, as such, highlight the
fact that accrediting bodies are guided by professionals within their major
disciplines rather than by external forces.
Table 16.2 Sponsoring and Support Organizations of COA
 The breadth of service standards (i.e., accreditation standards for specific
types of programs) is quite diverse, as noted previously. Interestingly, of the
three major accrediting bodies, COA is the only one that makes its standards
accessible to the public at no cost. The current standards, as well as other
pertinent information about COA, are available on the organization’s website
(COA, n.d.d). Finally, and likely as a result of the more recent trend of
accrediting bodies to expand their scope, COA (n.d.b) has also published a
document comparing COA and CARF.
Commission on Accreditation of Rehabilitation
Facilities
CARF historically has been known for its focus on residential facilities,
particularly those serving the developmentally disabled and mentally ill
populations. Today, CARF continues this focus but also accredits programs
in the major areas of aging, behavioral health, child and youth services,
employment and community services, medical rehabilitation, and opioid
treatment. Some of the specific accreditation standards are for assisted
living, adult day services, mental health and alcohol and other drug
programs, outpatient and residential medical rehabilitation, child youth
protection, and shelter programs.
According to its website, CARF accredits more than 6,000 service
providers in North and South America, Europe, Asia, Africa, and Micronesia
(CARF, 2010). CARF standards are collaboratively developed with input
from consumers, rehabilitation professionals, state and national
organizations, and funders (CARF, 2010). The standards are reviewed
annually, and new ones are developed to address the changing conditions
and current consumer needs.

The Joint Commission

As highlighted previously, The Joint Commission is the oldest of the
three major accrediting bodies, having begun in 1951. Unlike COA and
CARF, The Joint Commission was founded as an accrediting body for
medical health programs and continues to focus primarily on medical health.
However, today The Joint Commission also accredits a variety of behavioral
health providers. In the area of behavioral health, The Joint Commission
currently accredits more than 1,800 organizations, providing such services as
addiction treatment, crisis stabilization, and residential facilities and group
homes, among others (The Joint Commission, 2010). Behavioral health care
composes approximately 10% of the providers accredited by The Joint
Commission, while the other 90% are medical and related providers.
Whereas behavioral health care is only a very small part of The Joint
Commission’s focus, the wide range of service standards for medical
services includes hospitals, long-term care, ambulatory care, and outpatient
medical clinics. And in the medical health field, The Joint Commission is
often viewed as the accrediting body. The Joint Commission offers both
accreditation and certification based on the following definitions:
Accreditation can be earned by an entire health care organization, for
example, hospitals, nursing homes, office-based surgery practices,
home care providers, and laboratories. Certification is earned by
programs or services that may be based within or associated with a
health care organization. For example, a Joint Commission accredited
medical center can have Joint Commission certified programs or
services for diabetes or heart disease care. These programs could be
within the medical center or in the community. (The Joint
Commission, 2010, paras. 2–3)
The Joint Commission is going strong after more than 60 years and is
credited with initially setting the stage for the current state of accreditation in
mental health and human services.

Costs and Benefits of Accreditation

As you likely already know or have gathered through reading so far,
accreditation requires a long-term commitment predicated on an appreciation
for all that is involved in the process. Once accredited, organizations
typically wish to remain accredited; therefore, once accreditation standards
have been met, there is often an intense dedication to continued quality.
Whereas it is the significance of what accreditation status means that is often
sought, there are specific costs associated with achieving such status.
In terms of cost, there are both concrete costs and costs that are much
more difficult to quantify, such as the cost related to the development of new
policies and procedures. Starting with the easier of the two to define, the
primary concrete costs of accreditation include the initial application fee, on-
site visit fees, ongoing maintenance/annual fees, and reaccreditation fees.
The application fees range from $750 to $1,700, fees associated with the on-
site visit may range from $1,000 to $4,000, and maintenance and
reaccreditation fees average $2,000. Because the exact fees are based on the
accrediting body, the institution seeking accreditation, and the type and
scope of accreditation being sought, it is difficult to provide concrete
amounts; rather, it is best to inquire about the specific fees with the
individual accrediting bodies.
In terms of understanding the long-term concrete costs of accreditation, it
is best to think in terms of the cost over a 10-year period, since accreditation
requires a long-term commitment. The 10-year annualized fees typically
range from $3,000 to $6,000, again varying based on size and scope of the
organization. In addition to the accreditation fees, specific purchases are
often required to comply with accreditation standards. These purchases
might include such items as locking file cabinets, software, hardware, office
supplies, and other resources. Therefore, all projected concrete costs
associated with accreditation must be specifically accounted for in the
annual budget. And in keeping with effective finance practices, it is better to
overestimate costs than to underestimate them, particularly since these costs
are extraneous and, therefore, funding for them must be taken from
administrative overhead and/or other non-program-specific funds.
Whereas the concrete costs of accreditation may seem substantial,
particularly in light of the limited finances associated with most human
service organizations, other costs of accreditation are often much greater. I
consider these nonconcrete costs, or soft costs—costs that the organization
incurs in the way of staff time and other resource use that are difficult to
quantify but have to be considered in understanding the total costs of
accreditation. Chief among these costs is staff time, which includes the time
dedicated to the following major activities:

Developing the self-study

Developing new policies and procedures
Training for implementation of new policies and procedures
Participating in the site visit and follow-up activities

In addition to staff time dedicated to the actual accreditation activities,

the other major cost is related to preparing the organization to initially
pursue accreditation. This often means modifying the organizational culture
in order to garner support for accreditation. Because accreditation, like any
new activity, requires change on the part of organizational staff, such change
typically comes with a cost. As a result, a significant amount of time and
energy may be needed to familiarize staff with accreditation—the process
and significance—and to sell staff on investing in accreditation.
Whereas the costs of accreditation cannot be overlooked, they must be
examined in relation to the benefits of accreditation. Similar to costs, there
are both concrete and soft benefits that may result from accreditation.
Especially today, one of the most significant concrete benefits associated
with accreditation relates to the contractors’ requirement that organizations
applying for specific funding opportunities be accredited (see Box 16.2). For
instance, a recent Request for Proposals (RFP) that I reviewed was limited to
organizations that were currently accredited. This means that for
organizations that are not accredited, funding opportunities may be
significantly reduced.
 
BOX 16.2

SAMPLE RFP REQUIREMENT OF ACCREDITATION

State of Michigan Department of Corrections
Residential Substance Abuse Treatment Services
“To be eligible to provide residential treatment services, vendors must hold a Department of
Community Health residential treatment license and have a nationally recognized accreditation”
(State of Michigan Department of Corrections, 2010, p. 10).

In terms of fully understanding this from a financial perspective, if the

potential new funding opportunity that requires accreditation would result in
revenue of $250,000 annually for 3 years, this must be considered in relation
to the annual concrete cost of accreditation (e.g., $30,000 for the initial
accreditation process, including staff time in preparation, and approximately
$6,000 in subsequent years to maintain accreditation). This 3-year cost-
benefit analysis then is $42,000 in costs versus $750,000 in benefits—with
the benefit of $708,000 in potential revenue to the organization. Understood
in these terms, this makes the decision about pursuing accreditation fairly
straightforward, if not incredibly simple.
To provide another example of the financial impact that accreditation
status can have, several studies examined organizational accreditation status
and its relationship to the business of substance abuse treatment programs.
The findings included the following:

Accredited agencies provided more treatment hours than their

nonaccredited counterparts (Lemak & Alexander, 2005).
Accredited organizations were more likely to provide medical
services than their nonaccredited counterparts (Durkin, 2002).
Accredited organizations were more likely to provide mental
health treatment (Friedman, Alexander, & D’Aunno, 1999).

In addition to this specific type of benefit, other concrete benefits may

include preferential evaluation of proposals based on accreditation status
(i.e., not required for applications for funding but preferred) and the ability
to attract specific partners and/or pursue other business as a result of
accreditation status. Soft benefits of accreditation, on the other hand, can be
extremely numerous, including such aspects as staff recruitment efforts
resulting in staff seeking out organizations that are accredited as potential
employers and increased stature among peers. And last, the benefits resulting
from the implementation of best practices, comprehensive policies and
guidance, and effective operations—each of which is invaluable and should
result from accreditation. As a result, the benefits of accreditation greatly
outweigh the costs, as is illustrated in Table 16.3.
Table 16.3 Costs and Benefits of Accreditation
Relevance to Clinical Program Development
One of the many benefits of pursuing accreditation is that accreditation
standards provide guidance for implementing best practices. This is because
accreditation standards are developed from current research findings and
best practices in the field. As stated earlier, accrediting bodies are initially
organized by professionals with a specific focus on ensuring quality within
their respective field of practice. While accrediting bodies employ paid staff
as part of maintaining and handling the day-to-day operations, some, if not
most, of the staff are often professionally affiliated in the field as well, and
the peer review team is just what the name implies—a team of professional
peers. In addition, sponsoring and support organizations that are part of the
larger field provide additional guidance to the accrediting bodies,
particularly in regard to the development of practice and organizational
standards. The development of accreditation standards is then based on this
collective knowledge from professionals in the field as well as current
research and best practices. By utilizing this comprehensive approach to the
development of accreditation standards, standards reflect the current state of
knowledge of the given field—which is precisely the intent, to establish
current quality standards that are used to guide organizational practices.
 This has specific relevance to clinical program development in that
accreditation standards can be seen to do a large part of the work for
program developers. Because accreditation standards have been designed
based on the cumulative review of current and emerging research, program
developers are wise to utilize this knowledge in their program design,
implementation, and evaluation efforts. For instance, accreditation standards
for shelter services for survivors of domestic violence may identify specific
community linkages that should be accessed to promote long-term success.
By reviewing these standards during the program design process,
accreditation standards can provide valuable guidance. As a result,
accreditation standards can guide program design and implementation
processes and, therefore, ensure compliance with best practice standards
during the evaluation process.

Identifying the Right Fit

Determining which accreditation to pursue is largely based on examining
which accreditation standards are most relevant to the program and
organization. This selection process has become more difficult in recent
years, since accreditation bodies have continuously expanded their scope;
however, this may simply result in even greater consideration being given to
such decision-making processes. For instance, if your organization consists
of two programs, an inpatient substance abuse treatment facility and an
outpatient mental health counseling center, a review of the three major
accrediting bodies would tell you that whereas CARF has specific standards
for treatment programs of alcohol and other drugs and mental health, COA
has specific standards in both residential treatment services, including
services for substance use conditions and outpatient mental health services,
and The Joint Commission has specific standards for addiction treatment and
outpatient treatment. In addition, each of these three accrediting bodies has
opioid treatment programs. Since each has service standards developed for
both of your programs, further exploring is warranted to determine which
accrediting body to pursue. These decisions must be guided by identifying
which body is the best fit for your organization.
Determining the best fit is often a unique process for each organization,
since it should be based on many factors. However, to help guide this
decision making process, Box 16.3provides a list of factors to consider.
 
BOX 16.3

FACTORS TO CONSIDER IN SELECTING AN

ACCREDITING BODY

The primary identity of the organization and that of the accrediting

body
The history of the accrediting body in your specific areas of
programming
The specific relevance of the accreditation standards to your specific
programming
The number of major competitors accredited by the specific accrediting
body
The number and scope of similar programs/organizations accredited by
the specific accrediting body
The relevance of the specific accrediting body to existing and
prospective contractors
The degree to which the service/program standards are perceived to
provide guidance and potentially strengthen/enhance the clinical
program
The degree to which the organizational standards are perceived to
provide guidance and potentially strengthen/enhance the organization
 

As you can see, included in the above issues to consider in determining

which accrediting body to pursue is the degree to which the accreditation
standards are perceived to potentially strengthen the clinical program and the
organization. These are indeed key factors, particularly since accreditation
standards should promote more effective and higher-quality programming
and organizational operations. Therefore, accreditation standards that do not
promote further growth and development may be of lesser value than those
that do.
 While there are likely numerous other issues that may be considered in
determining which accrediting body to pursue, some organizational leaders
may choose to pursue more than one accrediting body. This may especially
be the case for organizations with multiple and diverse programs. For
instance, an organization that provides residential care for adults with
developmental disabilities as well as foster care and outpatient substance
abuse treatment may pursue CARF accreditation for its programs
specializing in developmental disabilities, COA for its foster care program,
and The Joint Commission for its substance abuse treatment programs.
Pursuing more than one accreditation may also be done specifically to
improve organizational functioning. For instance, you may find that the
accrediting body that offers the best fit for your program in terms of service
standards lacks in the way of organizational standards. Because each
accrediting body requires applicants to fulfill both organizational standards
as well as program/service standards, you may decide to pursue two
accreditations so that you are confident in both key areas.

Accreditation Planning
As you have likely already surmised, accreditation planning requires a
significant amount of time and long-term planning. This is largely due to
three key activities that are integral to both initially deciding to pursue
accreditation and actually pursuing it:
 

1. Preparing the organization/staff for the pursuit of accreditation

2. Selecting the right accrediting body and standards to pursue
3. Moving forward in the accreditation process
 
Each of these activities individually requires a significant amount of time.
As discussed earlier, making a decision to pursue accreditation in an
organization that has not previously done so means that staff need to be
prepared for this type of change—understanding why this is occurring and,
more importantly, being encouraged to buy in to the purpose and
significance of accreditation so that all employees can fully support the
entire process. Once an accrediting body has been selected, completing all
the activities required to attain accreditation can take more than 2 years.
Because of all that must be accomplished as part of pursuing accreditation, a
comprehensive accreditation plan is needed to effectively guide the process.

Developing the Accreditation Plan

Similar to each of the other planning tools, the accreditation plan is
devised to promote the most effective and efficient accreditation process.
Box 16.4provides a snapshot of most of the elements that should be a part of
the accreditation plan.
 
BOX 16.4

THE ACCREDITATION PLAN

 

1. Communicate the purpose and significance of pursuing accreditation to

organizational staff and other stakeholders (e.g., board members,
clients) to promote buy-in.
2. Form an Accreditation Exploratory Committee charged with leading
the investigation of potential accrediting standards and bodies.
3. Report the findings and recommendations of the Accreditation
Exploratory Committee to staff and other stakeholders.
4. Develop a 5- to 10-year accreditation budget to project long-term
concrete costs that can then be integrated into the existing budgets.
5. Form an Accreditation Planning Committee to lead the accreditation
process, including identifying an accreditation Plan of Work with an
established timeline and all key activities and assignments needed to
develop the self-study/survey identified. In addition, the committee
provides plans for structuring and guiding the accreditation process
(e.g., orientation, meeting schedule, training).
6. Following the attainment of accreditation, design an Accreditation
Maintenance Plan/Quality Improvement Plan outlining all methods
that will be used to continuously evaluate programming and
organizational operations for quality and effectiveness, including
 identifying methods by which compliance with accreditation standards
will be integrated into each program and department.

Summary
The importance of accreditation has grown dramatically over the past 10
years and, as such, is an integral part of organizational life in today’s mental
health and human services. Since the initial evolution of accreditation bodies
more than 60 years ago, the guiding purpose of accreditation has not
changed nor has the process by which accreditation standards are
promulgated. Throughout their history, accreditation bodies have been
dedicated to promoting the highest quality of services and are guided and
supported by professionals that are part of the larger field. The use of the
peer review process promotes a monitoring system of peers for peers, and in
this way, the profession shares and collectively invests in a commitment to
excellence.
While there are specific costs to an organization that must be considered
in accreditation decisions, the benefits that accreditation can bring far
outweigh any such costs. In fact, now more than ever before, accreditation
status is specifically identified as a requirement in RFPs for new or
continued funding opportunities, further highlighting the significance of
accreditation today. As such, accreditation not only has the potential to
improve the service delivery system and organizational functioning, but it
may also play a decisive role in sustaining the business.
Making decisions about pursuing accreditation and the act of pursuing
accreditation are major processes and, as a result, should not be entered into
lightly. Because of the amount of work involved in pursuing accreditation
and the long-term organizational investment that accreditation requires,
comprehensive planning must be in place to guide the process. By gaining a
fuller appreciation of all that accreditation means today and all that is
involved in attaining accreditation, you will be prepared to pursue the right
accreditation for you and your program in order to ensure the long-term
sustainability of your program/organization.
 
 CASE ILLUSTRATION
Kara and Gregory had first discussed accreditation when they were
working out the details of starting their own agency. Once they knew
they were moving forward with the agency, they had investigated the
various accrediting bodies and determined that COA was likely the best
fit. During their initial strategic planning process, pursuing accreditation
was identified as one of the agency’s short-term goals. As a result, it was
determined that Gregory would lead this effort.
During their first year in business, the agency had two programs—a
community-based program and a semi-independent living program—
both of which served juvenile offenders. Gregory had begun discussing
the importance of accreditation with all the agency staff and the board
members throughout the year and had composed an accreditation team
consisting of staff at various levels in the agency to lead the planning
effort. The group had met monthly, reviewing all relevant program and
organizational standards, developing and implementing new policies and
practices, and continuously informing staff and other stakeholders about
the reasons for each new policy and procedure.
To further reinforce the purpose of accreditation and the agency’s
plans, Kara related the accreditation standards back to the agency’s
commitment to continuous quality improvement and excellence. In
addition, she included their pursuit of accreditation as part of fulfilling
their mission to ensure that they were able to offer the most effective and
highest-quality services to those whom they served. Kara also took
several opportunities to provide staff, board members, and other
stakeholders with information related to the long-term economics of
accreditation and, particularly, its relationship to the agency’s future
ability to secure funding.
By the time the COA peer review team arrived for their on-site visit,
Gregory and Kara not only felt confident that they had successfully met
the accreditation standards, they also felt confident that they had
successfully created a climate among their staff that not only was
supportive of accreditation but fully appreciated the meaning it carried.
Gregory had been particularly excited to note how much more
comfortable he felt putting certain policies in place, realizing how much
he had learned from the accreditation process. Both Kara and Gregory
realized that not only had they worked diligently to attain accreditation
for their agency, but that as a result of this pursuit, the organization they
had built had a much stronger foundation in place, both organizationally
and programmatically.

 
ACCREDITATION PLAN EXERCISE

To increase your own knowledge and understanding of each of

the three major accrediting bodies discussed in this chapter and
how relevant each may be to your own program development
efforts, complete the exercise below. The exercise is designed to
provide you with a better understanding of precisely how much
and what type of information is available at no cost from each
accrediting body—information that is necessary to decision
making about which accreditation to pursue.

1. Using the program that you designed earlier, conduct an evaluation of

the three major accrediting bodies to determine which offers the best
fit for your program.
2. Develop a brief summary of your findings, minimally including the
following:

Identification of the relevant service standards of each

accrediting body (if applicable)
Strengths and weaknesses related to the relevant service
standards based on information available from each accrediting
body
Perceived strengths and weaknesses of the organizational
standards based on information available from each accrediting
body
 Analysis of the accreditation status of local competitors and
other national providers of same/similar services
Other information used in the decision-making process

3. Develop a 2-year accreditation plan timeline, identifying each of the

key activities that will be needed to ultimately attain accreditation.
Include training, meetings, and other support activities that will be
used to guide the accreditation process, as well as the time frames by
which the self-study/survey will be submitted and the site visit will
occur.
4. Identify at least five outcomes that you believe will result from
attaining accreditation.

References
Commission on Accreditation of Rehabilitation Facilities. (2010). The public
says: Accreditation matters! Retrieved April 1, 2010, from
http://www.carf.org/consumer.aspx?
content=content/About/News/boilerplate.htm
Council on Accreditation. (n.d.a). About COA. Retrieved March 31, 2010,
from http://www.coanet.org/front3/page.cfm?sect=1&cont=4320
Council on Accreditation. (n.d.b). COA and CARF: A comparison. Retrieved
April 2, 2010, from http://www.coanet.org/files/COACARFcomp.pdf
Council on Accreditation. (n.d.c). Sponsoring and supporting organizations.
Retrieved July 1, 2010, from http://www.coanet.org/front3/page.cfm?
sect=12
Council on Accreditation. (n.d.d). List of standards. Retrieved September 15,
2010, from http://www.coanet.org/front3/page.cfm?sect=55&cont=4191
Durkin, E. M. (2002). An organizational analysis of psychosocial medical
services in outpatient drug abuse treatment programs. Social Service
Review, 76, 406–429.
Friedman, P. D., Alexander, J. A., & D’Aunno, T. A. (1999). Organizational
correlates of access to primary care and mental health services in drug
abuse treatment units. Journal of Substance Abuse Treatment, 16, 71–80.
Gibelman, M., & Furman, R. (2008). Managing human service
organizations. Chicago: Lyceum.
Joint Commission, The. (2009). A journey through the history of The Joint
Commission. Retrieved April 1, 2010, from
http://www.jointcommission.org/AboutUs/joint_commission_history.htm
Joint Commission, The. (2010). Facts about Joint Commission accreditation
and certification. Retrieved September 15, 2010, from
http://www.jointcommission.org/AboutUs/Fact_Sheets/facts_jc_acrr_cert.
htm
Lemak, C. H., & Alexander, J. A. (2005). Factors that influence staffing of
outpatient substance abuse treatment programs. Psychiatric Services, 56,
934–939.
State of Michigan Department of Corrections. (2010). Residential substance
abuse treatment services (Request for Proposal No. LC-2010–007).
Lansing, MI: Author.
 CHAPTER 17
Putting It All Together
Comprehensive Program Development in the
21st Century

 
Learning Objectives
 

1. Summarize the comprehensive program development model

2. Identify the specific knowledge and skills necessary for comprehensive
program development
3. Identify methods by which to continue to develop professionally in the
area of program development
4. Identify methods by which to promote accountability in program
development

Comprehensive Program Development

Engaging in comprehensive program development in mental health and
human services is no easy task, nor should it be. Given that the programs we
design and implement have the potential to impact the lives of individuals—
often those individuals who are most vulnerable—such work should indeed
come at a great cost to us.
Unfortunately, we have often failed to understand that what we do is a
business and that our work must therefore be treated as a business.
Thankfully, much has changed, particularly in the past decade. Chief among
the changes that have helped move our field forward have been demands for
increased accountability and increased calls for the use of evidence-based
practices. Clients, contractors, other oversight organizations, and the general
public have continued to become more knowledgeable about mental health
and human services, and as each has become better informed, pressure has
continued to mount for us to improve our work. In addition, there is
increased emphasis on research and other scholarly literature that is
outcome-driven—establishing evidence of what works and what does not
work. As mental health professionals historically have embraced the
scientist-practitioner model, now more than ever before, there are demands
to not simply support such a model but, rather, to actively demonstrate this
model through our work.
As these changes have been taking place, promoting greater
accountability and demanding more effective treatment, the mental health
and human service industries have become increasingly competitive. While
in many instances funding has increased in specific areas, in other areas,
funding has continued to be reduced. This, coupled with a greatly expanded
number of mental health and human service providers opening their doors
over the past 2 decades, has created a highly competitive marketplace.
Today, this marketplace is defined as one in which only the strong survive.
What is most telling today is the shrinking number of human service and
mental health organizations that has resulted from organizations closing their
doors or merging with other organizations.
However, these conditions that have impacted the field so dramatically in
recent times have reinforced the essential need for mental health
professionals to not only demonstrate their scientific knowledge and skills
but to devote equal energy to demonstrating their business acumen. Fully
appreciating that mental health and human services is a business and, as
such, requires a comprehensive understanding of business planning. This
type of knowledge and skill is key not only to competing in today’s
marketplace but to surviving in today’s marketplace.
The comprehensive program development model presented in this text is
essentially a business planning guide for mental health and human service
professionals. In fact, an alternate title for this book could very well be
Business Planning in the Mental Health Professions in the 21st Century.
Business planning implies a focus on long-term success. It also implies
concentrated efforts, both of which provide necessary structure to the
planning process. But more importantly, business planning implies due
diligence—a commitment to the most thorough examination and analysis of
information and data and subsequent use of such analyses in decision
making.
In the past, some mental health professionals have at times found it
difficult to understand that our work is indeed a business, arguing that such
thinking might be incompatible with the concept of helping. I’ve never quite
understood this, since each of us pursues this as a profession (i.e., work) for
which we are paid. Moreover, I have taken issue with this line of thinking
because on some level, I find it irresponsible to not give our work the respect
that it deserves as a business—a business that is focused on helping. We
must understand that our failure to effectively operate our
practices/businesses may result in the collective failure of our profession to
effectively treat individuals in need. Moreover, we must appreciate that the
concepts of helping profession and business are not at all incompatible but,
rather, intimately connected.
Fortunately, I believe such distaste for accepting and understanding the
business of mental health and human services is largely behind us and has
been held by only a very small number of individuals. In fact, when I began
teaching master’s-level counseling students more than 10 years ago, many
students struggled with making sense of helping as a business, often
producing some wonderfully vigorous debates. Today, however, most of my
students not only acknowledge that they are preparing for a career that is in
fact a business, but they are also committed to ensuring that they can most
effectively conduct themselves within their business in order to reach their
ultimate objectives of improving the lives of others.
 While conditions have changed over the past 2 decades, forcing us to
rethink mental health and human services, I believe that where we are now is
the most exciting place yet. And as a result, now more than ever before,
mental health professionals must be well versed in comprehensive program
development and each of the major phases that compose it—design,
implementation, and sustainability. As a way of summarizing the model, the
next section will revisit each of these major phases and the various steps of
the comprehensive program development model that compose them.

Design
Comprehensive program development begins with the design phase and
involves a tremendous amount of preplanning activities that guide the design
process. Like the entire program development model, design is a linear
process, beginning with the identification of an unmet need. This is followed
by comprehensive data collection and analysis to promote a full
understanding of the need and to explore various ways to most effectively
address the need. A thorough review of current research and other literature
is conducted to ensure that the clinical program design is evidence-based, or
empirically guided when a sound evidence basis has yet to be established to
treat a specific issue. In addition, various multicultural aspects must be
addressed in the clinical program design. A variety of planning tools should
be used in the preplanning, planning, and design phases. A list of several of
the most common design tools is provided in Box 17.1.
 
BOX 17.1

DESIGN TOOLS

Community demography assessment

Needs assessment
Asset map
Timeline
Gantt chart
Service specification model
 Logic model
Organizational chart
Spreadsheet
Line-item budget
 

In addition to the clinical design, all the other aspects that allow a clinical
program to be implemented must be designed. This means that the
organizational infrastructure must be designed, including the staffing,
equipment, facilities, and so on—all that is required for the clinical program
to become a reality. In addition, the various supports, including community
resources that will be utilized in program implementation, need to be
engaged and considered as part of the initial design process. And finally, a
detailed financial plan must be developed and specific funding sources must
be identified in order to prepare for program implementation.
In sum, the design phase of the comprehensive program development
model includes the following eight steps:

1. Establish the need for programming

2. Establish a research basis for program design
3. Address cultural identity issues in program design
4. Design the clinical program
5. Develop the staffing infrastructure
6. Identify and engage community resources
7. Identify and evaluate potential funding sources
8. Develop the financial management plan

Implementation
The implementation phase involves putting most of what has been
devised in the design phase into action. Without having conducted due
diligence and having developed a sufficient design, program implementation
would not be possible. As such, implementation builds directly from design
—again, reflecting the linear nature of program development. Because of all
the work that has been completed to bring the program to fruition and the
stakes that are involved, the implementation phase can be both wildly
exciting and highly stressful. Typically, it is at the point of implementation
or the beginning days of a program that the program is most highly
scrutinized; therefore, mistakes in implementation can negatively mark a
program for a long time to come.
During the implementation phase, several activities need to occur that
allow you to move the program forward. One such activity is thoroughly
reviewing the contract/grant to ensure a full understanding of expectations of
the program and organization. Often, additional planning tools are needed to
ensure compliance with the requirements of the grant/contract, mapping out
time frames for when various activities and documents are due, and
providing additional structure to prevent any problems with contract
compliance. It is also during the implementation phase that you must work
to establish the relationship with the funding source—initiating this contact
and becoming familiar with not only the contract manager but any other
relevant contract administrators. Again, the tone that is used to initially
establish this relationship may play a critical role in sustaining the contract;
therefore, the establishment of these relationships should be given great
consideration.
Concurrent with implementation of the program itself, the program
evaluation must also be implemented. The three major types of evaluation—
fidelity assessment, process evaluation, and outcomes evaluation—are
simultaneously implemented so that from the beginning of a new program
implementation, each of the various aspects of the program are evaluated.
Conducting a fidelity assessment allows you to assess the degree to which
the integrity (i.e., fidelity) of the clinical model is retained throughout the
implementation process, whereas the process evaluation provides more
comprehensive information related to the various aspects of implementation,
such as staffing, outputs, time frames, etc. While both the fidelity assessment
and process evaluation focus on the implementation process, the outcomes
evaluation is conducted to specifically assess the impact of the program in
fulfilling its intended objectives as well as achieving other outcomes.
Together, these three types of evaluation compose a comprehensive program
evaluation—providing a significant amount of information with which to
fully understand the program.
Also integral to the implementation process is specific attention to the
program infrastructure that includes but is not limited to staffing, leadership
and administrative oversight, information systems, quality assurance
planning, and contract compliance. Plans must be made to ensure that
effective leadership and administrative oversight are in place to provide
sufficient support to the program and that specific activities (e.g., meetings,
reviews) are also in place to provide additional structure to the oversight
process.
Information systems, both in the way of hardware and software, as well
as data collection methods and information sharing are also critical aspects
that must be specifically attended to during implementation. Whereas a
client information system may prove fruitful in capturing the most essential
information in one place and allowing for easy retrieval of such information
(unfortunately, the retrieval process continues to plague many organizations
due to how client information systems are structured—and this should be a
key consideration when purchasing a client information system), software
programs specifically designed for human resource management and finance
management (ideally, an integrated human resource and finance system) are
also essential. In addition, basic spreadsheet programs, statistical programs,
and other data storage and analysis programs are needed to support the
program. Information systems typically play a specific role in the collection
and analysis of pertinent program data—comprising much of what is
necessary for quality assurance efforts and ensuring contract compliance. In
addition, structure is needed to guide the quality assurance program, such as
leadership for the quality assurance process, methods by which quality
assurance activities will be conducted, and supports that will be used to
guide the quality assurance process. Quality assurance and contract
compliance are both integral to long-term sustainability, and in addition, they
each rely on adequate information systems and administrative oversight and
leadership. It is in this manner that these specific aspects of implementation
interrelate. Box 17.2 provides a brief summary of the various
implementation activities.
 
 BOX 17.2

SNAPSHOT OF IMPLEMENTATION ACTIVITIES

Implementing the program

Reviewing the contract/grant and setting up systems to ensure
compliance
Establishing the relationship with the funding source
Implementing the program evaluation
Ensuring that an appropriate leadership and administrative oversight
structure is in place
Ensuring effective information systems are in place
Ensuring an effective quality assurance and contract compliance
system is in place
 

Sustainability
Just as a successful implementation is predicated on an effective design,
sustaining a program is dependent on continuous success in program
delivery/implementation. As a result, sustainability is based on the sum of
program design and implementation efforts and requires constant attention
throughout implementation/delivery in order to be achieved. This is because
any deficits related to initial due diligence and preplanning may not prevent
a program from being implemented; however, such deficits may indeed
prevent a program from being sustained. For instance, if initial data
collection efforts were limited—not taking into account any specific factors
that might have artificially indicated a more significant problem than
actually existed or that did not take into account the long-term extent of the
problem—data may have justified the need for the program; however, once
implemented, the program may not be sustainable. See the following case
vignette for an example of this.
 
IS PROGRAM EXPANSION JUSTIFIED?
Trudy and Anne had been operating a 24-bed residential substance abuse
treatment center for the past 4 years, and over the past 3 months, they had
received more referrals than they could handle, necessitating the use of a
waiting list for the first time since they had opened. While they were both
pleased to be able to maintain their program at capacity—especially since
this had been increasingly difficult for them to achieve over the past few
years, often running at approximately 80% capacity—they also realized that
if they expanded their program, they could eliminate the waiting list.
Anne met with the agency president to explain the need for program
expansion, sharing with him the referral data of the past 3 months and
expressing that she and Trudy did not want to miss this opportunity to
grow the program. After discussing the costs involved with adding six
beds and what they would need to do to gain approval from the state for
an expanded license, the president agreed to authorize the expansion. He
had recently been talking to the agency’s directors about his vision of
growth, and he wanted to recognize Trudy and Anne for taking initiative
in this area.
Within 3 months and after expenditures of more than $200,000, the
building renovations were complete and an approval for expansion of
their residential substance abuse license had been authorized. Trudy was
able to quickly move clients from the waiting list into the program after
having hired 14 new staff members. The program remained at capacity
for another 9 months, and then Anne began to notice a drop in referrals.
She and Trudy were concerned and began contacting their referring
agents, but each told them the same thing: They continued to be happy
with the services, and they had already referred all the clients who were
in need. During a meeting with other providers, one of Trudy’s
colleagues noted the state’s recent move to discontinue its prisoner
reentry program. The initiative had resulted in an influx of clients in
need of substance abuse treatment, but because it was based on state
funding, he had been initially leery of how long it would last; so he had
been careful not to make any significant changes in his business for fear
the increase in service needs would be short-lived. He was now very
relieved that he had followed what was going on at the state level and
had not taken any new risks. Sheepishly, Trudy agreed with him about
 how important it was to stay on top of government spending and other
external factors that can significantly influence your business.
Trudy returned to the office and discussed what she had learned with
Anne, and both of them vowed to never again conduct a less-than-
thorough analysis—in fact, they agreed that from here on out, the most
effective due diligence would be used to guide all their business
decisions. Unfortunately, because the increase in referrals that they had
experienced was not sustainable, they were back at their previous level
but with excess beds, which meant they were at 60% capacity. Therefore,
they had to turn their attention to the most difficult task of remaining
fiscally healthy while facing a bloated workforce and a $200,000 loan to
repay.

As illustrated by Anne and Trudy, sustainability doesn’t require specific

attention to only post-implementation activities; rather, sustainability is also
dependent on the strength of justification that led to implementation. This
can be a costly lesson to learn, both in the case of new program development
and in program expansion or program modification.
With solid justification for new program development, effective design,
and effective initial implementation, sustainability requires specific focus on
achieving quality and preserving key relationships and attention to all that is
needed to maintain a program. These needs include building and preserving
resources and relationships with community resources in order to ensure
additional support and access to information and knowledge about the
broader climate. In addition, this involves working with peers and other
organizations as part of a broader coalition and working both collectively
and individually in various types of advocacy. Whereas program evaluation
begins at the point of program implementation, the ability to effectively
conduct ongoing evaluations and, more importantly, to use the evaluation
results in program improvement, marketing, and contributing to scholarly
research, are critical to sustainability. Employing effective data collection,
analysis, and monitoring techniques and engaging in effective information
sharing is necessary for program sustainability, and without such, it may be
difficult to continuously garner support for your program. Finally, pursuing
national accreditation and other forms of credentialing is necessary to remain
current and to demonstrate a commitment to quality. Moreover, accreditation
and other forms of recognition must be part of a broader continuous quality
improvement program that characterizes the work of the program. Box 17.3
provides a brief summary of the various sustainability activities.
 
BOX 17.3

SUSTAINABILITY ACTIVITIES

Building and preserving relationships with community resources

Engaging in advocacy efforts
Participating in coalition building
Conducting program evaluations
Effectively communicating evaluation results and next steps
Engaging in effective information sharing with all stakeholders
Pursuing accreditation and other forms of credentialing as part of a
broader commitment to quality improvement
 

In addition to the specific sustainability activities that are a part of the

comprehensive program development model, sustainability also requires
constant attention to external factors that may influence the program’s ability
to continue. Although knowledge of the external climate is one of the
reasons why relationships with colleagues and community resources and
coalition building are so important, this issue deserves individual attention.
Being fully informed about legislation, national and state trends, and other
factors that may impact your business today is critical, but in addition, you
must be fully informed about what may be on the horizon. In fact, had Trudy
and Anne more thoroughly investigated the reasons behind their influx of
clients, they would have understood that the increase may be short-lived,
rather than reflective of long-term change.

Required Knowledge and Skills of Program

Developers
As you likely have learned from this text, professional counselors and other
types of mental health professionals are charged with an incredible
responsibility as program developers. In order to be effective program
developers, a tremendous amount of knowledge and skill is necessary. In
some ways, mental health program developers must be individuals who not
only possess the knowledge and skills associated with a master’s degree in
counseling (or clinical/counseling psychology or clinical social work) but
also the knowledge and skills associated with a master’s degree in business
administration (MBA) and a master’s degree in public health (MPH).
Whereas the foundation provided by a clinically focused master’s degree
(from an accredited and highly reputable academic program and university)
is most significant, some of the knowledge and skills traditionally associated
with an MBA and MPH are also necessary to be a successful program
developer today. Specifically, due diligence in business planning,
accounting, management, leadership, and organizational development and
change—each of which has historically been associated with business
degrees—are essential skills for program developers. Evaluating national
and local trend data, developing comprehensive response systems, and
understanding the various factors impacting need and interventions—often
associated with public health professionals—are also critically needed skills
in program development efforts. Finally, a strong background in scientific
skills—increasingly emphasized in academic counseling programs—is
paramount to success as a clinical program developer.
While it is not necessary to possess three graduate degrees, mental health
professionals today must have the requisite knowledge and skills that the
combination of these three degrees characterizes. This means that specific
attention must be paid to developing a broad repertoire of knowledge and
skills that allows you to effectively compete as a mental health professional
today.
Table 17.1 provides a snapshot of the knowledge and skills required at
each of the stages of comprehensive program development.
Table Knowledge and Skills Needed in Comprehensive Program
17.1 Development
Where Do You Go From Here?
While the knowledge and skills required to be an effective program
developer may seem a bit daunting, understanding the tremendous
responsibility of program developers may help put this into perspective.
Indeed, the responsibility of another individual’s life and livelihood is
enormous and, therefore, should require an incredible commitment on our
part; however, the commitment is not only to possess the knowledge and
skills to engage in comprehensive program development but, rather, to
remain current in this knowledge and skill.

Remaining Current and Staying Relevant

A former colleague of mine would ask individuals interviewing for a
faculty position, “How do you remain relevant in your work?” I always
thought this was a brilliant question—very straightforward and effective in
prompting critical self-reflection—and more importantly, one that we should
all constantly ask ourselves.
Remaining relevant in the work that we do requires constant curiosity
spurred on by a hunger to continue learning and growing. Such hunger is
fueled by acknowledgment that there is always more to know—that you will
never know it all. Accepting this may be difficult for some, but without this
type of humility, it is often challenging to be inspired to seek more
knowledge.
The work that we do is ever-changing; in fact, it might be the most
dynamic type of work that exists. This is particularly true because
individuals are constantly changing, rarely acting according to script but,
rather, constantly demonstrating what it really means to be unique. In order
to effectively attend to the changing nature of individuals, we cannot tolerate
becoming passive. Rather, we must return again and again to the
understanding that we can never fully understand one another, but we must
be committed to constantly attempting to achieve this. In this regard,
remaining relevant means viewing each new encounter as a new encounter,
not an encounter previously experienced for which you already have the
answers. Even after you have treated 200 teenage girls for sexual abuse, you
must allow each new client/survivor the freedom to teach you about who she
is and exactly what she needs, suspending any preformed judgment based on
your prior experiences.
Maintaining relevance also means remaining current in awareness and
knowledge. Acknowledging that all knowledge is vulnerable to time is
essential to ensuring that you remain current. For instance, when I began my
academic training, eating disorders among males was not addressed either in
the literature or in the practice setting because it was not yet identified as an
issue and, therefore, was not broadly acknowledged or understood. Today,
however, we know that this disorder is not at all limited to females. In
addition, we now have an emerging body of research on female sex
offenders, and I am hopeful that over the next 10 years, we will learn more
and more about this specialized population. I would become irrelevant
quickly if I continued to ignore the fact that boys and young men are
vulnerable to eating disorders and if I failed to acknowledge and learn about
female sex offenders. And even though I may have begun with a solid
knowledge base, it is my responsibility to continue to develop it.
There are multiple strategies that can help you remain current, most that
naturally occur through the use of the comprehensive program development
model (i.e., community resource preservation/maintaining collegial
relationships, coalition building, advocacy work, accreditation planning and
other credentialing, and remaining current with best practices). In addition,
being active politically and remaining keenly involved in legislative and
other external venues that impact mental health and human services can
assist you in remaining current. Reading, conversing, and using other
methods to remain fully informed and to gather multiple perspectives are
also essential. And, related to this, engaging in healthy skepticism and
questioning much of what you hear is often necessary to really digest new
information.

Committing to Continued Professional

Development
Directly tied to remaining relevant is a commitment to continuous
professional development. This means not only learning new knowledge but
acquiring new skills as new knowledge develops. Whereas each of the
activities listed above as part of the comprehensive program development
model is also useful in professional development efforts, other methods are
needed to ensure appropriate growth. First and foremost among these
methods is continued learning—through reading, training, coursework, and
other methods. However, this can also be the most challenging, since the
amount of educational and training opportunities is endless and you must be
vigilant in discriminating among such opportunities. Questioning
information presented, reviewing sources of information, and critically
evaluating information provided are each necessary to effective learning.
Simply digesting new information without evidence of its value is akin to the
old data analysis adage junk in, junk out.
In addition to learning and acquiring new knowledge and skills through
various venues, you also must force yourself to stretch. Stretching in this
regard means pushing yourself to be uncomfortable—be it in an activity
(e.g., public speaking), confronting one of your perceived weaknesses (e.g.,
statistical analysis), or forcing yourself to go beyond what you believe you
are capable of or what you believe you need (e.g., enrolling in a course on
organizational development).
Professional development equals continuous growth. Moreover,
professional development may equal professional satisfaction and
fulfillment. As a result, professional development can be like beginning your
career over and over again—capturing all the excitement and stimulation
that learning holds and thereby constantly renewing yourself and your work
life.

Ensuring and Advocating for Accountability-

Based Practice
Remaining current and relevant in your work and committing to
continuous professional development are cornerstones of a successful career
in any industry. However, with specific regard to program development, you
must also be committed to ensuring and advocating for accountability-based
practices. As counselors and other mental health professionals, we are held
to the standard of care or the mandate of nonmaleficence (i.e., do no harm).
As such, our first responsibility is to ourselves—to ensure that we do not
engage in any practices that could potentially cause harm to our clients. At
the same time, we also must ensure that we do not engage in practices that
we know have not been found to be effective. This level of professional
accountability requires that we remain highly knowledgeable about various
treatment efforts and their effects, that we attend to treatment fidelity when
implementing an evidence-based practice, that we engage in continuous
evaluation of our interventions and programs, and that we continue to use
our evaluation results to further inform treatment strategies and program
development.
In addition, as mental health professionals, we also must engage in
advocacy for the use of evidence-based practices and accountability as a
defining mandate of our profession. This is because we are collectively
responsible for the outcomes of our work, and more importantly, we must be
the voices of those whom we serve to ensure that their needs are most
effectively addressed.

Summary
Engaging in comprehensive program development can be one of the most
meaningful aspects of your career; however, it can also be one of the most
challenging. Over the past 20 years, our field has witnessed dramatic
changes in how we understand program development and all that it entails.
As a result, comprehensive program development today is not simply
something engaged in by a few mental health professionals but, rather, a
prerequisite for all mental health professionals. The major phases of program
design, implementation, and evaluation must be fully understood both
individually and as interdependent parts. And the steps involved in each of
the phases of comprehensive program development must be attended to in
order to ensure success and long-term sustainability. It is my hope that the
comprehensive program development model presented in this text will assist
you in your own program development efforts. As a result, we may continue
to promote greater responsibility and accountability in program development
efforts in the 21st century.
 Appendix

Web Resources Discussed in Text

 
 Glossary

 
Administrative support staff: Employees who do not provide direct
services to clients but who support the work of those who do; typically
work in finance, human resources, information systems, research and
evaluation, fund development, and other similar support departments.
In addition, individuals who provide office support through secretarial
duties, reception, or executive administrative support are also
considered administrative support staff.
Asset map: Inventory of assets in the target region; considered a map
because it provides additional direction to new program development
efforts by identifying various existing strengths and resources that may
be used in program design.
Best practices: Practices that are highly regarded as a result of having an
evidence basis, being empirically guided, or being identified as a
standard that should guide practice.
Breach of contract: An act of noncompliance with a contract. For
instance, if master’s-level professionals are contractually required to
deliver a service and instead these services are provided by bachelor’s-
level staff, this action on the part of the subcontractor constitutes a
breach of contract.
Case management staff: Professionals with either a bachelor’s or a
master’s degree whose primary role is overall case coordination. Case
managers work with other professionals, including clinicians and direct
care workers, as well as school and other support personnel to ensure
the comprehensive needs of the client are being served.
Ceiling: A term often used in relation to the maximum amount of funding
available in funding opportunities. For instance, a ceiling of $500,000
indicates that the maximum amount of funding available for a project is
$500,000, and therefore, funding requests must not exceed $500,000.
Clinical staff: In mental health and human services, professionals
specializing in mental health treatment. These include master’s- and
doctoral-level counselors, clinical psychologists, clinical social
workers, and psychiatrists.
Community assets: Strengths of a community that include process-related
issues such as a community’s ability to organize, work collaboratively,
and meet the needs of its residents, as well as promote safety and a
healthy local economy. The term also refers to concrete aspects such as
adequate community facilities and support organizations, as well as a
thriving business community.
Community demography assessment: A thorough assessment of the
target region that examines the various population parameters in order
to accurately illustrate the demographic aspects of the community; part
of the comprehensive needs assessment.
Community resources: The resources that are available to support the
residents of a community, such as human service or other support
organizations, services, other treatment providers, libraries, gathering
spaces, places of worship, knowledge, and other assets that are
available in the community.
Comprehensive needs assessment: Five-pronged data collection and
analysis activities that consist of community demography assessment,
problem analysis, market analysis, identification of needs, and
inventory of assets and that allow for initial decision making in
program development.
Contingent/contractual workers: Individuals who are employed on an as-
needed basis or to provide a specific and/or specialized function.
Unlike part- or full-time employees, contractual workers are not
entitled to employment benefits and typically work far fewer and less-
structured hours than their part- and full-time counterparts.
Data-based decision making: Results from comprehensive data collection
and analysis. This refers to any type of decision making that is based on
empirical data and other forms of evidence.
Data layering: Involves the examination of various layers of data in
descending order of size in order to further clarify the meaning of data.
This process can be useful for conducting several types of data analysis.
Deliverables: Outcomes or specific items that will be provided or
submitted in completion of a specific task or project.
Direct care staff: In human services, individuals who provide
nonprofessional direct support to clients. These workers often support
clients’ daily living and other basic activities. They may also be
referred to as paraprofessionals. Direct care staff are most often found
in residential programs.
Emerging practices: Interventions that have not yet been fully evaluated
through rigorous means, practices that have a research basis, or
practices that utilize innovative strategies; may also be termed
promising practices, reflecting that there is more than just a hunch that
these practices may be effective and that some preliminary evaluation
has likely been completed. In all cases, emerging practices imply the
need for rigorous evaluation to effectively determine if they are, indeed,
evidence-based.
Empirically based practices: Those clinical practices that are rooted in or
guided by empirical research but have not yet been rigorously evaluated
to determine if they do, in fact, have an evidence basis.
Evidence-based practices: Practices that have an established basis in
evidence—achieved through rigorous evaluation; imply that the results
of a rigorous evaluation support positive outcomes or are directly
related to client success.
Executive leadership: The organizational structure within a mental health
or human service organization, precisely with regard to the top levels of
management. Executive leadership typically refers to the top level (i.e.,
president/chief executive officer/executive director) and the second-to-
top level (i.e., chief operating officer/chief financial officer/vice
 president). The executive leadership team often consists of both
operations (e.g., chief operating officer) and support individuals (e.g.,
chief financial officer). The executive leadership team may vary based
on organizational structure; however, the executive leadership team
refers to the team responsible for making top-level decisions for the
organization.
Floor: Specific to notices of funding opportunities, the minimum amount
of funding available to a given project. Opposite of ceiling, the floor
may be $100,000, while the ceiling is $500,000. When a floor is
identified, it indicates the minimum amount of funding that can be
requested.
Gantt chart: A planning tool that is used to identify activities to be
completed, time frames for completion, and individuals assigned to an
activity; particularly useful in planning, scheduling, and monitoring a
wide variety of projects.
Governance structure: The board of directors/trustees or other types of
board structures; charged with monitoring the organization as well as
representing the organization to the public.
In-kind donation: Items in a proposal’s budget that the applicant will
contribute to the project. For funding opportunities in which a match
funding contribution is required, in-kind donation is typically stated
next to the dollar amount to indicate that the applicant will support the
cost.
Integrated electronic systems: Electronic information systems that are
comprehensive and include various types of business data that can
interact. For instance, an ideal integrated electronic system would
include client information and other program data, finance data, and
human resource data and would have the capability to allow the various
data sets to interact with one another.
Letter of support: A written statement of support provided by a relevant
stakeholder on behalf of an applicant organization. Letters of support
are often required by applicants when submitting a proposal for
funding. A letter of support is used to provide some degree of evidence
 that the applicant organization is capable of carrying out the work
detailed in a proposal, has had past success with other funding sources,
or appears to possess the capability of conducting an effective business.
Managerial and supervisory staff: Individuals who have some
supervisory responsibilities for other staff and for part of the business
operations or support services.
Market analysis: An assessment and analysis of existing providers that are
working to address the identified problems in the region; consists of a
thorough examination of the operations and programming of all
existing providers; a critical ingredient for decision making in new
program development; part of the comprehensive needs assessment.
Match funding: Required funding that must be provided by an applicant
for a particular funding opportunity. Match funding requirements are
often listed in relation to the total percentage of the funding request and
typically range from 10% to 50%. Specific requirements may be placed
on match funding, particularly with regard to the types of expenditures
that can qualify for match funding (e.g., salaries, rent). On budgets that
accompany proposals for programs/projects, match funding
expenditures are typically stated as in-kind donations.
Multisystemic approach: Refers to multisystemic family therapy, which
was developed by Scott Henggeler and colleagues. The multisystemic
approach refers to engaging various systems (e.g., school) that interact
with a client in the treatment process. Multisystemic therapy is an
example of an evidence-based practice.
Need: An established gap between the identified program and existing
services to address the problem.
Partnership: Two or more entities that receive mutual benefits as a result
of a relationship; implies equity in a relationship in which each entity
contributes and receives.
Philanthropic organizations: Organizations that are developed in order to
promote specific interests through the provision of funds. Also known
as charitable organizations, philanthropic organizations support specific
and/or broad interests.
Preplanning stage of program development: Consists of the
identification of a target region and target population and the
completion of a comprehensive needs assessment; provides for the first
stage of program development: establish the need for programming.
Problem analysis: A systematic data-collection process consisting of
review of secondary data sources and various data-collection tools that
include surveys, interviews, and focus groups and that is designed to
identify existing problems in the target region; conducted following the
community demography assessment; part of the comprehensive needs
assessment.
Quality indicators: Specific data that indicates quality and, as such, is
typically defined as part of determining quality outcomes; part of
quality improvement and quality assurance efforts.
Request for Proposal: A notice of a specific funding opportunity in which
the funding source is openly inviting proposals. Also known as an RFP,
a Request for Proposal may specify exactly the type of project or
program that is being funded or may require that the applicant describe
the type of project/program for which s/he wishes to receive funding;
indicates a competition for funding among eligible applicants.
Request for Quote: A notice of a specific funding opportunity in which
the funding source identifies the specific project/program that they will
fund and requires applicants to provide a financial quote for which they
will implement the project/program; also called an RFQ.
Research basis: The inclusive term I have chosen to use in the text to refer
to evidence-based practices, empirically guided practices, emerging
practices, and/or best practices. The term research basis implies that
there is minimally some type of research support for the practice.
Return on investment: The amount and type of benefits received as a
result of an investment. ROI may include savings in time and increased
efficiency and may result in additional revenue. ROI is sometimes
difficult to quantify, but it is an essential part of effective decision
making in any business.
Silo: In the context of mental health and human service professions, refers
to working in isolation rather than as part of interdisciplinary processes
or collaborative efforts.
Staffing infrastructure: The employees and contractual/contingent
workers that compose an organization; referred to as an infrastructure
because it supports part of the functions of an organization.
Stakeholders: Various individuals such as community members, officials,
and various levels of professionals working in the region in schools,
law enforcement, human service agencies, and other organizations that
are either directly (e.g., living, working) or indirectly (e.g., providing
funding) involved in the target region.
Stewardship: Acting effectively on behalf of others. In the case of
receiving funding to provide specific services, stewardship refers to
one’s ability to most effectively manage the funding.
Support agents: Individuals who act as supports to an individual or to the
work of an organization. Support agents may provide letters of support
on behalf of an organization and may be directly involved in providing
services to clients of the organizations. Support agents often work
collaboratively with professionals and organizations.
Target population: The identified population in need that is the proposed
or actual recipient of new or existing program development efforts.
Target region: Area in which initial data collection is conducted and in
which new program implementation is anticipated to occur.
Turf: In mental health and human services, refers to the business that one
has and a desire to protect it rather than work collaboratively.
Author Index

 
Abudabbeh, N., 118
Administration on Aging, 113
Ahmed, L. S., 38, 201
Alexander, J. A., 464
Alliance for Children and Families, 380
Alperin, M., 148, 150
Alter, C., 15
Alvarez-Jiminez, M., 352
American Counseling Association, 107, 178, 410
Anderson, J. E., 203, 205
Andrade, J. T., 94
Annie E. Casey Foundation, 229
Applebaum, R., 234
Arnold, M. S., 402, 404, 405, 407, 408
Aronson, R. E., 201
Arredondo, P., 45, 102–103, 115, 118, 402
Aseel, H. A., 118
Association for Assessment in Counseling, 362–363
Astramovich, R. L., 358, 365
Augustine, J., 148, 150
Austin, M., 83
Babor, T., 142
Baggerly, J., 105
Bailey, P A., 391–392
Baldwin, L. M., 145
Barnett, R. C., 200–201, 202
Baruth, L. G., 101
Batchelder, K., 86, 94
Bauer, T. N., 181
Beamish, P. M., 7
Beck, A. T., 145
Bellg, A. J., 349, 350, 353, 429
Bellido, C., 120
Bemak, F., 401
Benner, G. J., 352
Bernal, G., 120
Bhandari, M., 300
Bishop, D. S., 145
Blair, B. G., 307
Bolman, L.G., 169, 180
Bonilla, J., 120
Bookman, A., 200
Bordes, V., 118
Borduin, C. M., 64, 84
Borelli, B., 349, 350, 353, 429
Boulmetis, J., 365
Bowen, W. R.,307
Bradley, L. J., 401
Breger, R., 350, 353, 429
Brennan, R. T., 202
Bretschneider, S., 391
Brody, R., 132, 142
Brondino, M. J., 64, 353
Brown, G. K., 145
Brown, S., 402
Bruns, E. J., 352
Burchard, J. D., 352
Busch, M., 131, 133
Buyum, A., 148, 150
Byford, S., 433
Caffray, C. M., 7
Calley, N. G., 7, 60, 90, 91, 94
Cameron, S., 433
Camp, T., 56
Campbell, C. D., 143, 144
Campbell, J. W., 234
Campion, M. A., 181
Carpinello, S., 7–8
Carroll, D. A., 238, 284
Carver, J., 167, 265
Chan, E. K. H., 352
Chapman, J. E., 84
Chatman, J., 181
Chatterji, P., 7
Chung, R. C. Y, 401
Cline, G. R., 307
Clingempeel, W. G., 64
Cluskey, M., 364, 425
Cohen, R., 386
Coin, M. A., 86
Coker, J. K., 358, 365
Commission on Accreditation of Rehabilitation Facilities, 80, 461
Comprehensive Juvenile Sex Offender Management Initiative, 138
Conlon, D. E., 181
Conner, K. O., 120
Connors, M. L., 381
Cotton, S., 352
Council for Accreditation of Counseling and Related Educational
Programs, 110
Council on Accreditation, 80, 81, 113, 459, 461
Council on Accreditation of Rehabilitation Facilities, 80, 461
Crethar, H. C., 401, 403
Crisp, K., 352
Crowe, M., 7
Czajkowski, S., 350, 353, 429
Dahir, C. A., 401
Dalal, R. S., 181
Dalton, D., 166
D’Andrea, M. J., 143, 200, 205–206, 377, 384
Daniels, J. A., 143, 200, 205–206, 377, 384
Darboe, K., 38, 201
Darkes, J., 359
Daunic, A. P., 349
D’Aunno, T. A., 464
Deal, T. E., 169, 180
Del Boca, F. K., 359
Dennis, M., 142
Department of Health and Human Services, 77, 111, 114, 297–298
Devine, E. B., 295, 310, 313
Diamond, G., 142
Donahue, S. A., 7–8, 302
Donaldson, J., 142
Dow, M. G., 147
Droge, C., 166
Drucker, P. F., 167, 330
Dubruiel, N., 148, 150
Duchnowski, A., 352
Dulcan, M., 145
Durkin, E. M., 464
Dutwin, P., 365
Egan, M., 15
Eisman, E. J., 145
Emerson, D. M., 54
English, W., 7
Entwistle, T., 377
Epstein, M. H., 352, 353
Epstein, N. B., 145
Erikson, E., 101
Ernst, D., 350, 353, 429
Essock, S. M., 7–8 Ezell, M., 238
Farquhar, C., 234
Felton, C. J., 7–8, 302
Fielding, G., 166
Fields, S. A., 145
Finifter, D. H., 40
Fischer, M., 284
Fisher, w. p., 145
Flannigan, P. N., 364, 425
Flowers, L. R., 102
Fodchuk, K. M., 178, 181
Folaron, G., 131, 133
Force, M. M., 352
Ford, J., 166
Fouad, N., 401, 402
Frances, T., 335
Frederickson, J., 166
Friedman, P. D., 464
Frumkin, P., 284
Fry, L., 166
Furman, R., 182, 225, 231, 261, 281, 283, 330, 338, 423, 454
Gant, L. M., 61
Gard, C. L., 364, 425
Gareis, K. C., 200–201, 202
Garthwait, C. L., 264–265
Gathercoal, K. A., 143, 144
Gee, D., 352
Gerstein, L., 401, 402
Gibbs, L., 6
Gibelman, M., 182, 225, 231, 261, 281, 283, 330, 338, 423, 454
Gilster, M. E., 61
Gittell, J. H., 377
Glauner, T., 45, 102–103, 115
Godley, S. H., 142
Golden, S. L., 251
Gordon, T., 284
Gray, G. C., 131
Green, J. W., 47
Greenlee, J., 284
Grogan-Kaylor, A., 61
Grote, N. K., 120
Grunewald, D., 261, 281
Guzman, L., 391
Haggard-Grann, U., 7
Hakim-Larson, J., K., 118
Hallmayer, J., 234
Halls, S., 147
Hansen, J. T., 10
Hatfield, D. R., 145
Hawkins, J.W., 381
Haynes, R. B., 6
Hecht, J., 349
Hegyvary, S. T., 311
Heintze, T., 391
Henggeler, S. W., 64, 84, 353
Hensley, L. G., 7
Heppner, P. P., 359, 360
Hernandez, M., 150
Hidalgo-Tenorio, C., 86
Hill, C. J., 377
Hill, N. R., 7
Hill, R. B., 411
Hitchenor, Y., 201
Hodges, K., 146
Hodgins, G., 201
Homan, M. S., 200, 201, 206, 296
Horejsi, C. R., 264–265
Horman, M. S., 251, 377
Horner, S., 348
Horwood, C., 147
Houlihan, C., 148, 150
House, R., 402, 404, 405, 407, 408
Hur, M. H., 170
Hutchins, A. M., 403, 407
Hutchins, T., 335
Hyde, A., 423
Illes, J., 234
Inman, A. G., 105
Internal Revenue Service, 282
Ireland, C., 381
Israel, T., 401, 402
Jensen, C. J., 40
John D. and Catherine T. MacArthur Foundation, 235–236
Johnson, M., 83
Joint Commission, The, 454, 461–462
Jones, J., 402
Jones, L. M., 7
Jones, L. N., 7
Jones, V., 433
Jonsson, A., 300
Jungquist, C. R., 86
Kamoo, R., 118
Kantor, M., 176, 180
Katz, R. D., 261, 262
Kazdin, A. E., 359
Keating, E., 284
Kelley, S. D. M., 7
Kellogg Company, 138
Kendzia, V. B., 131
Kennedy, A. A., 180
Kessel, D., 300, 307
Kessler, G., 167
Kettner, P. M., 48, 81, 143, 147, 148, 263, 331, 336, 353, 355, 356, 425,
428
Khamphakdy-Brown, S., 7
Kissane, D. W., 352
Kivlighan, D. M., 359, 360
Klein, K., 302
Knapp, M., 433
Koenig, B. L., 40
Kohout, J., 145
Konovsky, M. A., 181
Koys, D. J., 181
Kral, A., 391
Kregor, P. J., 300
Krentz, S. E., 56
Kurtines, W. M., 118
Kutash, K., 352
Lambert, M. J., 145
Lanzara, C. B., 7–8, 302
Larke, S. C., 203, 205
Latham, D. P., 181
Law, D. J., 441
Lazzeroni, L., 234
Leadbetter, J., 391
Lee, C. C., 401, 410–411
Leese, M., 433
Lemak, C. H., 464
Letourneau, E. J., 84
Leverentz-Brady, K., 352
Lewis, J., 401
Lewis, J. A., 38, 79, 132, 143, 152, 170, 176, 186–187, 200, 205–206,
262, 266, 272, 283, 299, 329, 333, 354, 355, 356, 376, 377, 384, 401–402,
403, 404, 405, 407, 408
Lewis, M. D., 38, 79, 132, 143, 152, 170, 176, 186–187, 200, 205–206,
262, 266, 272, 283, 299, 329, 333, 354, 355, 356, 376, 377, 384
Linden, M., 335
Linker, J. A., 386
Locke, D. C., 402
Loesch, L. C., 357–358
Logan, T., 335
Love, A., 352
Lowe, J. I., 234
Lucas, C., 145
Lum, D., 101, 115
Lynn, L. E., 377
Macneela, P., 423
Maden-Bahel, A., 105
Mai, C. T., 441
Mancilla, Y., 118
Manning, M. L., 101
Marcus, B., 181
Marotta, S. A., 7, 84
Martin, D. G., 414
Martin, L. L., 48, 81, 143, 147, 148, 263, 331, 336, 353, 355, 356, 425,
428
Martin, S., 377
Mason, C. A., 441
Matovina, T. M., 118
Matteson-Rusby, S., 86
Matthews, A., 423
Maybery, D., 201
Mayers, R. S., 282
McCabe, K. M., 118
McCart, M. R., 84
McDavis, R. J., 103
McDowell, B. D., 441
McKenzie, M., 352
McNamee, T., 406
Melkers, J. E., 81
Meyer, C. J., 181
Meyer, R. E., 441
Miller, D., 166
Miller, F., 145
Miller, P. W., 310
Millon, T. M., 145
Minicucci, D. S., 349
Mizrahi, T., 383
Montgomery, M., 225
Mooney, P., 353
Moroney, R. M., 48, 81, 143, 147, 148, 263, 331, 336, 353, 355, 356, 425,
428
Morris, R., 423
Mours, J. M., 143, 144
Mowbray, C. T., 61, 209
Murray, V., 367
Musa, D., 441
Nassar-McMillan, S. C., 118
Nath, S., 105
National Association of Social Workers, 103, 107
National Institute of Health, 113
Navarrete-Navarrete, N., 86
Nelson, J. R., 353
New, C. C., 294, 302
Nickerson, I., 166
Nilsson, J. E., 7
Nordness, P. D., 352
Nowakowski, J. M., 181
Nydell, M. K., 118
Nylen, U., 377
O’Brien, C., 86
O’Campo, P., 201
Office of Juvenile Justice and Delinquency Prevention, 150
Office of the Assistant Secretary for Administration and Management,
Department of Labor, 113
Ogles, B. M., 145
O’Looney, J., 164
O’Neill, I., 352
O’Reilly, C., 181
Orwin, R. G., 347, 353
Ory, M., 349
Packard, T. R., 38, 79, 132, 152, 170, 176, 186–187, 262, 266, 272, 283,
299, 329, 333, 354, 355, 356, 376
Padgett, D., 335
Paniagua, F. A., 118
Pantin, H., 118
Paronto, M. E., 181
Payne, M., 234
Pearce, C.W., 381
Pearce, T., 352
Pedersen, P., 101
Penner, K., 147
Penner, L. A., 181
Peralta-Ramirez, M. I., 86
Peters, S. W., 105
Peterson, M., 143, 144
Phares, E. J., 78
Phelps, R., 145
Pickrel, S. G., 64
Pigeon, W. R., 86
Pleshko, L., 166
Pope, R., 201
Porcerelli, J. H., 118
Porter, L., 166
Porter, R., 313, 326
Psych, D., 335
Pugh, S. D., 181
Puterbaugh, D. T., 7
Pyrkosch, L., 335
Quick, J. A., 302
Raggio, D., 275
Ratts, M. J., 403, 407
Regehr, C., 120
Reid, R., 353
Resnick, B., 349
Rew, L., 348
Richardson, W. S., 6
Riebe-Estrella, G., 118
Righthand, S., 94
Rioux, S., 181
Roberts, A. R., 120
Roberts-DeGennaro, M., 205, 383, 408–409
Robles-Ortega, H., 86
Rodgers, R. A., 410–411
Rosenberg, W., 6
Rosenthal, B. B., 383
Rossi, P., 142
Rowland, M. D., 353
Royse, D., 335
Roysircar, G., 401, 402
Rozen, D., 86, 94
Sabio-Sanchez, J. M., 86
Sackett, D. L., 6
Saggers, S., 335
Saleh, F. M., 94
Santisteban, D. A., 118
Saunders, T., 147
Schafer, P., 201
Schewe, P. A., 84
Schoenwald, S. K., 84, 353
Schrepf, S., 352
Schuler, H., 181
Schuster, M. H., 167
Schwab-Stone, M., 145
Schwallie-Giddis, P., 7
Scopetta, M., 118
Scott, A., 423
Seivewright, H., 433
Senge, P. M., 169, 435
Sepinwall, D., 350, 353, 429
Shaffer, D., 145
Shanks, T. R., 61
Sheidow, A. J., 84
Shepherd, A., 201
Singh, J., 234
Skarlicki, D. P., 181
Skillman Foundation, 229
Slocum, J., 166
Smith, M. T., 86
Smith, S. W., 349
Spendolini, M., 166
State of Michigan Department of Corrections, 464
Stater, K. J., 238, 284
Steer, R. A., 145
Steinem, G., 410
Stone, C. B., 401
Strauss, S. E., 6
Stufflebeam, D. L., 346
Stutts, L., 386
Substance Abuse and Mental Health Services Administration, 247, 297–
298
Sue, D. W., 103
Sue, S., 120
Suter, J. C., 352
Szapocznik, J., 118
Taylor, G. G., 349
TechSoup Global, 331
Tefft, B., 384
Thompson, D. E., 381
Thyer, B., 335
Tims, F. M., 142
Todor, W., 166
Toporek, R. L., 401, 402, 403, 404, 405, 407, 408
Torghele, K., 148, 150
Torres, R., 348
Treacy, M. P., 423
Triangle Foundation, 138
Trull, T. J., 78
Trussell, J., 284
Truxillo, D. M., 181
U.S. Government Accountability Office, 411
Valentine, D., 86, 94
Van der Haas, M., 147
Van Roody, D. L., 181
Vincent, G. M., 94
Viswesvaran, C., 181
Vitiello, B., 234
Wade, D., 352
Wagner, A., 234
Wallis, A. B., 201
Wampold, B. E., 359, 360
Ward, J. C., 147
Watts, R. E., 7, 84
Weiss, L., 377
Welch, C., 94
Wenger, L. D., 391
Whitman, D. S., 181
Wilderman, R., 7
Willoughby, K., 81
Wilson, C. E., 40
Windell, K.W., 381
Winokur, M., 86, 94
W. K. Kellogg Foundation, 150, 235–236
Woolley, M. E., 61
Worling, J. R., 94
Xia, Y., 86
Yeager, K. R., 120
Yeh, C. J., 105
Yoon, I., 61, 201
Zalaquett, C. P., 105
Zandbergen, P. A., 47
Zane, N., 120
Zlowodzki, M., 300
 Subject Index

 
Page numbers followed by f or t indicate figures or tables.
Abortion advocacy, 410
Accountability
advocating for, 489
of boards of directors, 167–168
federal government funding and, 78–79
for financial management, 261
focus on, 76
Government Accountability Office, 81
supervision and, 178–180, 183–184t
See also Accreditation bodies; Evaluation programs
Accreditation, 22, 453
costs and benefits of, 462–465, 465–466t, 483
history of, 453–454
maintenance of, 470
planning for, 468–470
process of obtaining, 455–458, 471
program development and, 466–467
skills needed for, 486t
Accreditation bodies
Commission on Accreditation of
Rehabilitation Facilities, 80, 113, 458t, 461
Council on Accreditation, 22, 80–81, 113, 458–461, 458t, 460t
cultural competence, influence by, 109–110, 110t, 113
impact of, 79–81
Joint Commission, The, 80, 113, 458t, 461–462
 Joint Commission on Accreditation of Hospitals, 454
Joint Council on Accreditation of Health Organizations, 22
purposes of, 454–455
quality assurance and, 336
quality improvement data for, 435
selection of, 467–468
staffing patterns and, 185
Accreditation Maintenance Plan/Quality Improvement Plan, 470
ACP (American College of Physicians), 454
Adams, John Quincy, 169
Adjunctive interventions, 140–142, 141t
Administrative support staff, 172, 495
Advocacy, 399–400
history of, 400–402
levels of, 402–405
perseverance, importance of, 400
Advocacy coalitions, 205–206, 408–409, 411
Advocacy Competencies, 402
Advocacy plans
for accountability-based practice, 489
assertiveness training and, 414
community-level strategies, 403–404, 407–409
development of, 21, 414–415
example of, 416–417
individual advocacy strategies, 406–407
legislative advocacy strategies, 409–411
orientation for, 413–414
professional advocacy strategies, 412
skills needed for, 486t
strategies for, generally, 405–406
sustainability of agency and, 412–414
Affectively based outcomes, 356–357, 357t
Aging services, funding trends for, 234
Agoraphobia evaluation program example, 368–370
Alcohol, Drug Abuse, and Mental Health Administration, 77t
Alliance for Children and Families, 380, 382
American College of Physicians (ACP), 454
American Counseling Association
Advocacy Competencies, 402
multicultural issues, 103, 106–107, 107t, 108t
supervision standard, 178
American Psychological Association, 106–107, 107t, 108t
Analysis of problems, 48–54, 499
Annie E. Casey Foundation, 228t, 229, 244
Annual Data Reporting Plan, 441, 442–443t
Annual reports, 22, 282, 441, 442–443t
Applications. See Proposals
Assertiveness training, 414
Assessment. See Evaluation programs
Assessment tools
client satisfaction surveys, 147–148
cultural competence and, 146
for cultural identity, 117–119, 119t
level of functioning scales, 146–147
for outcomes evaluation, 361–363
selection of, 20
standardized assessments, 145–146
status evaluations/numeric counts, 147
Asset inventories, 60–64
Asset Map Guide, 62
Asset maps
for community resource development, 17
community resources and, 209–211
defined, 495
process of creating, 62–64
purposes of, 12
Assets
community resilience and, 208–209
cultural identity as, 61, 63
defined, 61
diversity as, 101
types of, 496
Association for Assessment in Counseling, 362–363
Association for Multicultural Counseling and Development, 103, 402
Audits, 283
Autism, 234, 340–341
Awareness-raising efforts, 410
Banking industry, 260
Beck Depression Inventory II, 145
Behaviorally based outcomes, 356–357, 357t
Behavior Change Consortium, 349–350
Benefits (compensation), 268
Best practices
accreditation standards as reflecting, 22
defined, 86, 87t, 495
growth of literature about, 7, 8
literature for, 91
See also Evidence-based practices
Bill and Melinda Gates Foundation, 244
Block grants, 79
Boards of directors, 167–168, 281–282
Branding, 132, 133–134
Breach of contract, 327, 495
Budgets, 271–272
annual operating budgets, 274–278, 276t
development of, 285–287
information systems and, 332–333
multiyear operating budgets, 278
need for, 18
project-specific budgets, 272–274, 273t
proposals and, 313–314
staffing infrastructure and, 285–287
Business as usual decision making, 101
Business principles
Comprehensive Program Development Model compared, 23–24, 23t
mental health professionals’ need to know, 4, 6, 476–477
for program development, 9–10
CACREP (Council for Accreditation of Counseling and Related Educational
Programs), 109–110, 110t
CARF (Commission on Accreditation of Rehabilitation Facilities), 80, 113,
458t, 461
Case management staff, 174, 495
Casey, Jim, 229
Ceilings, 246, 285, 495
Census, U.S., 44–45, 46t
Centralization structures, 166, 177
Chaldean youth, characteristics of, 118
The Change Masters (Kantor), 176
Checklists. See Tools
Chez Panisse, 406
Chief executive officers, 168–170, 281–282
Chief operating officers, 170–171, 281–282
Child and Adolescent Functional Assessment Scale, 146
CIS (Client Information System), 332–333
CLAS (National Standards on Culturally and Linguistically Appropriate
Standards), 111–112
Client Information System (CIS), 332–333
Clients
costs per, calculation of, 433
marginalized, 407
mission and vision statement to communicate with, 131, 133
resource knowledge, importance for, 202–203
Client satisfaction data, 436
Client satisfaction surveys, 147–148
Clinical interventions, in program design, 140–142, 141t
Clinical program design. See Program design
Clinical program development. See Comprehensive program development
Clinical staff, 173–174, 496
COA (Council on Accreditation), 22, 80–81, 113, 458–461, 458t, 460t
Coalitions
for advocacy, 205–206, 408–409, 411
defined, 377
examples of, 379–382, 391
 preservation of, 383–384
purposes of, 377–378
success, factors in, 383
types of, 378–382
Codman, Ernest, 453–454
Collaboration. See Community resources
development; Interagency
collaboration
Commission on Accreditation of
Rehabilitation Facilities (CARF), 80, 113, 458t, 461
Communication
for implementation phase, 328–329
interagency collaboration and, 303
in organization process, 176–178, 176t, 183–184t
in partnerships with community resources, 213
See also Information-sharing
Community, defined, 200–201
Community assets, 61, 496
Community demography assessments
community resources development and, 211
cultural identity and, 117–119, 119t
defined, 496
for needs assessment, 42–48, 46t
purposes of, 12
Community Demography Assessment Tool, 43–44
Community-level advocacy, 403–404, 407–409
Community resources
defined, 201, 496
identification of, 13
inventory of, 60–64
market analyses to identify, 56
Community resources development, 17, 20–21, 199–200
benefits of, 212–213, 483
benefits of support from, 388–392
community defined, 200–201
community resources defined, 201
 engagement of resources, 212–214
example of process for, 215–218, 393–394
identification of resources, 209–212, 210t
importance of, 375–377
initial preservation efforts, 214
literature review for, 201–202
need for, 203–204
objectives of, 204–209
partnerships, 212–213, 384–387, 385t
public policy impacts due to, 390–391
purposes of, 198–199, 202–203
resource sharing and, 389–390
skills needed for, 485t, 486t
support agents and, 387–388
See also Coalitions; Interagency collaboration
Community Resource Snapshots, 209–210, 210t
Community support, benefits of, 388–392
Complexity structure, 166
Compliance data, 434–436
Comprehensive needs assessment. See
Needs assessment
Comprehensive program development accreditation and, 466–467
as business plan, 476–477
business principles for, 9–10
considerations for, 5
cost analyses, inclusion in, 7
defined, 8
expectations for funding and, 2–3
factors to consider in, 7–8
proposal writing as part of, 306–307
relevancy, retaining, 487–488
skills needed for, 308–309, 309t, 484–485, 485–486t
tasks involved in, overview of, 8–9, 9f
See alsoCommunity resources development
Comprehensive Program Development Model, 10–12, 11f
business principles compared, 23–24, 23t
 design phase, 478–479
implementation phase, 479–481
preplanning phase, 130, 139, 499
proposal requirements and need for, 299
sustainability issues, 481–484
See also specific steps
Comprehensive program evaluation.
See Evaluation programs
Computer technology for data collection, 331–335, 334t, 480–481
Conference publications for literature review, 92
Contingent or contractual employees, 182–184, 496
Contracts
breach of, 327, 495
compliance with, 339, 434–435
Memoranda of Understanding/Agreement, 303
review, importance of, 326–327
Contractual or contingent employees, 182–184
Control groups, 359
Coordination of services. See Community resources development
Cost analyses, 7, 365–366, 366t, 433
Council for Accreditation of Counseling
and Related Educational Programs
(CACREP), 109–110, 110t
Council on Accreditation (COA), 22, 80–81, 113, 458–461, 458t, 460t
Counseling, defined, 25
Counterproductive work behaviors (CWBs), 181
Coverage data, 428 Cultural competence, 99–100, 100f, 103–104
academic preparation for, 109–111, 110t
assessment tools and, 146
cultural identity, 100f, 102–103
defined, 15, 103
diversity and, 100–101, 100f
as funding requirement, 113–115
history of, 104–106
importance of, generally, 106
Multicultural Competencies, 402
 multiculturalism, 100f, 101–102
national standards for, 111–112
outcomes evaluation and, 119–120
professional associations and, 106–107, 107t, 108t
scholarship about, 108–109
Cultural identity, 14–15, 100f, 102–103
aspects and subtypes that contribute to, 115–117, 116t
assessment of, 117–119, 119t
as asset, 61, 63
changing nature of, 14–15
as contextual, 47
defined, 45–47
example of process for determining, 122–123
in program development, 47
skills needed for issues about, 485t
types of, 103
See also Cultural competence
Cultural relativism, 102
Culture of organizations
coalition preservation and, 383
evaluation programs and, 366–367
partnerships and, 386–387
quality assurance planning and, 338
staffing infrastructure development and, 180–181, 183–184t
CWBs (counterproductive work behaviors), 181
Data-based decision making, 35, 496
Database subscriptions for funding, 240–241, 242t
Data collection
decision making based on, 35
funding source requirements, 249
importance of, 64–65
information systems for, 331–335, 334t
justification for, 425, 427–428, 427–428t
layering of, 43, 496
methodology explanation of, 51
 for need identification, 35–38
selection of data for, 333–335, 334t, 481–482
See also Evaluation programs; Information-sharing
Data collection tools, 39–40, 39t, 40f
Asset Map Guide, 62
community demography assessments, 42–48, 46t
cultural competence and, 104
for cultural identity, 118–119, 119t
Market Analysis Checklist, 57–58, 58t
Problem Analysis Guide, 48–50
selection of, 20
Data Element Evaluation Tool, 333–335, 334t
Data layering, 43, 496
Data reporting. See Information-sharing
Data types, 425
client satisfaction data, 147–148, 436
compliance data, 434–436
coverage data, 428
demographics, 35–37, 426–430, 427–428t
equity data, 428
financial data, 433–434
human resources data, 431–433
layering of, 43, 496
process evaluation, 426–430, 427–428t
quality improvement data, 434–436
treatment design and delivery, 429
See also Outcomes evaluation
Deliverables, 274, 496
Demographics, 35–37, 426–430, 427–428t. See also Community
demography assessments
Department of Health and Human Services, 77t, 111–112, 297–298
Department of Health, Education, and Welfare (HEW), 77, 77t
Diagnostic Interview Schedule for Children IV 145
Direct benefits of community support, 389–391
Direct care, 174
Direct care staff, 174–175, 497
Disraeli, Benjamin, 169
Diversity, 100–101, 100f
Division-level managers, 170–171
Donations, treatment of, 18
Due diligence, 477
EBPs. See Evidence-based practices
Economic and neighborhood resources, 61
The Edible Garden, 406
Effectiveness. See Outcomes
Efficacy. See Outcomes
Electronic database subscriptions for funding, 240–241, 242t
Emerging practices, 83, 85–86, 87t, 497
Empirically based practices, 497
Empirically guided practices, 86, 87t
Employee retention, 423–424, 432–433
Empowerment strategies, 406–407
Enron, 260
Equity data, 428
Ethics, 107, 108t, 359
Evaluation programs, 19–20, 480
costs and benefits of, 365–366, 366t
culture of organization and, 366–367
evidence-based practices and, 83–84
example of process for, 368–370
funding source requirements for, 249
organizational sustainability and, 365
planning for, 364
program design, relationship with, 346, 347–348
for proposals, 299
quality assurance planning and, 335–338
skills needed for, 486t
standardized assessments, 145–146, 356
status evaluations, 147
sustainability, relationship to, 483
timeline for, 152–153, 154t
 See also Assessment tools; Fidelity assessment; Information-sharing;
Outcomes evaluation; Process evaluation
Evidence-based practices (EBP)
change as driven by, 6
clinical and adjunctive interventions compared, 141
cultural competence, lack of, 120
defined, 6
effects of, 7
fidelity assessment and, 352–353
increase in use of, 4
literature utilization issues and, 8
multisystemic approaches as, 64, 84
for program design, 83–85, 87t
Executive directors, 168–170
Executive leadership, 168–170, 497
Expenditures. See Financial data;
Financial management
Family Assessment Device, 145
Federal government
agencies, establishment date, 77t
Alcohol, Drug Abuse, and Mental Health Administration, 77t
budget, advocacy and, 413
Department of Health, Education, and Welfare, 77, 77t
funding and accountability, 78
Government Accountability Office, 81
Government Performance and Results Act, 81
HIPAA, 441
HITECH, 441
Office of Juvenile Justice and Delinquency Prevention, 77t, 150, 353
publications for literature review, 91–92
research basis establishment, role in, 76–79, 77t
Substance Abuse and Mental Health Services Administration, 76–78, 77t,
85, 297–298
U.S. Census, 44–45, 46t
See also Funding sources
Feedback. See Evaluation programs
Fee-for-service funding, 230–231
Fidelity, defined, 141, 348–349
Fidelity assessment, 345–347
evidence-based practices and, 352–353
modifications to treatment model and, 143
process evaluation, as part of, 429
program evaluation, as part of, 19, 348–353
Stop the Violence example, 344–345
Financial data, 266
projected expenditures, 266–270, 267t
projected revenues, 270–271, 271t
sharing information about, 433–434
See also Budgets
Financial management, 18, 259–260
boards’ role in, 281–282
data collection, 433–434
example of process for, 288–289
external oversight, 283–284
financial planning as, 263–266
history, lessons from, 260–261
information systems and, 332–333
internal monitoring and reporting processes for, 279–282, 280t
logic models and, 285–287
per client cost calculations, 433
Program Administrator’s Financial Management Aid Checklist for, 279–
281, 280t
proposals and, 306
public reporting requirements, 282
skills needed for, 486t
stability in, 284–285
staff understanding of, 266
trends in, 261–263
See also Budgets; Financial data; Funding; Funding source evaluations;
Funding sources
Financial planning, 263–266
Floors, 246, 285, 497
Focus groups for data collection, 50–54, 52–53f
FOIA (Freedom of Information Act), 226
Formalization structure, 166, 177
For-profit corporations, 261, 263–265
42 CFR Part 2, 441
Freedom of Information Act, 226
Functional Assessment Rating Scale, 146–147
Funding
acceptance of, 325
accreditation and, 464
block grants, 79
budgets and, 274–275
collaboration requirements for, 206–207, 247–248
competitive nature of, 225, 476
cultural competence requirements for, 113–115
diversification in, 238
donations, treatment of, 18 expectations by sources for, 2–3
federal expenditures for, 78
for fidelity assessment, 353
historical changes in, 5
implementation timeline and, 151–152, 151t
in-kind donations, 274, 498
logic models and, 150
matching funds, 498
per diem versus lump sum, 270–271, 271t
projected revenues from, 270–271, 271t
proposal development as basis for seeking, 19
responsive versus proactive process for, 224
60-second sell for, 414
skills needed for, 485t
sources of, 79
staffing patterns and, 183
timing considerations for, 295
trends in, 234
See also Financial data; Financial management
Funding Opportunity Evaluation Tool, 251, 252f
Funding source evaluations, 243–244
direct contact with funders, 250–251
example of process for, 253–255
Funding Opportunity Evaluation Tool for, 251, 252f
funding parameters of, 245–249
history of funding by source, 250
philosophical foundations of, 244–245
project director requirements, 248–249
Funding sources, 17–18, 223–226
common sources, 236–238, 236t, 239f
database subscriptions for, 240–241, 242t
diversification in, 239f, 262, 284–285
example of process for, 253–255
feedback from, 225–226
fee-for-service sources, 227, 230–231
for-profit corporations, 229–230
identification of, 239–242, 242–243t
matching funds, 248
parameters of, 285
philanthropic sources, 226–229, 228t, 235–236, 237, 242–243t, 499
public/governmental sources, 226–227, 231–234, 235, 236t
relationship with, implementation and, 324–326
short-term versus long-term, 237–238
Gantt charts, 497
Gates Foundation, 244
Geographic information systems (GIS), 47–48
Global Assessment of Functioning, 146
Goal statements, 336–337
Governance structure, 16, 167–168, 498
Government Accountability Office, 81
Government Performance and Results Act (CPRA), 81
GPRA (Government Performance and Results Act), 81
Grant applications. See Proposals
Grant writers, hiring, 304–307. See also Proposals
Haverhill Violence Coalition, 381, 382
Heppner, P. P., 360–361
HEW (Department of Health, Education, and Welfare), 77, 77t
HIPAA, 441
HITECH, 441
Hogg Foundation, 228t
Human resources data, 431–433
Implementation, 19, 323–324, 479–481
contract review, 326–327
evaluations and, 346–347
monitoring of, 328–329
relationships with funding sources and, 324–326
skills needed for, 486t
sustainability planning and, 481–483
timeline for, 150–153, 151t, 153t, 154–155t
See also Accountability; Program management
Implementation evaluation. See Process evaluation
Implementation update meetings, 328–329
Indicators for the Achievement of the
NASW Standards for Cultural
Competence in Social Work
Practice (NASW), 103
Indirect benefits of community support, 391–392
Individual capability, 300–302
Individual-level advocacy, 403, 406–407
Information is power, 423
Information-sharing, 21–22, 421, 436–437
client satisfaction data, 436
of compliance data, 434–436
example of process for, 447–449
of financial data, 433–434
of human resources data, 431–433
methods for, 439–440
of outcomes evaluation data, 430–431
plan for reporting data, 441–447, 442–443t
of process evaluation data, 426–430, 427–428t
of quality improvement data, 434–436
recipients of, 440
 responsibilities for, 437–438, 438t
safeguards about, 441
significance of, 422–424
skills needed for, 486t
time frames for, 439
See also Data collection; Data types
Information systems, 331–335, 334t, 480–481
In-kind donations, 274, 498
Insurance, 230–231, 268
Intake, for cultural identity, 118–119, 119t
Integrated electronic systems, 332, 498
Integration structure, 166, 177
Interagency collaboration
as funding requirement, 206–207, 247–248
as proposal requirement, 297, 301–304
role of, 7–8
See also Community resources development
Internal validity, 359
Intervention fidelity. See Fidelity assessment
Interventions, 140–142, 141t
Interviews for data collection, 50–54, 52–53f
Inventory of assets, 60–64
JCAHO. See Joint Commission, The
John D. and Catherine T. MacArthur
Foundation, 228t, 235–236, 238, 244
Joint Commission, The, 22, 80, 113, 454, 458t, 461–462
Joint Commission on Accreditation
of Hospitals. See Joint
Commission, The
Journal for Social Action in Counseling and Psychology,109
Journal of Counseling and Development, 7, 109
Journal of Lesbian, Gay, Bisexual, and
Transgendered Issues in
Counseling,109
Journal of Multicultural Counseling and Development, 109
Kantor, Moss, 176
Kennedy, Florynce, 410
Kivlighan, D. M., 360–361
Knowledge-based outcomes, 356–357, 357t
Language considerations, 111–112, 133–134
Lau Tzu, 169
Leadership, 168–170
Legislative advocacy strategies, 404–405, 409–411
Letters of support, 301–302, 498
Level of functioning scales, 146–147
Licensing rules for staffing, 186
Literature review
about assessment tools, 146
best practices literature, growth of, 8
for clinical program design, 15
for community resource development, 201–202
cultural competence and, 108–109
cultural competency and, 99
multicultural issues and, 14
for research basis of program design, 13–14, 88–93
sources of, 90–92
staffing infrastructure development and, 185
strategies for, 88–90
Lobbying, 411
Local coalitions, 378
Logic Model Development Guide (W. K. Kellogg Foundation), 150
Logic models
budgets and, 285–287
community resources development and, 211–212
defined, 15
as evaluation tool, 348
for program design, 15, 148–150, 149f
Managed care movement, 6, 79
Managerial staff, 173, 329–331, 498
Mandate of nonmaleficence, 489
Market analyses
benefits of, 56
for community resource development, 17
community resources development and, 211
defined, 54–55, 498
of funding sources, 17–18
funding sources identification and, 239–240
information included in, 57–58, 58t
need identification compared, 60
for needs assessment, 54–58, 58t
purposes of, 12–13, 55
staffing infrastructure development and, 16
staffing patterns and, 186
Market Analysis Checklist, 57–58, 58t
Marketing, 132, 133–134
Master’s degree in business administration (MBA), 484
Master’s degree in public health (MPH), 484
Matching funds, 498
MBA (master’s degree in business administration), 484
McGowan, A. Scott, 7
Media, awareness-raising efforts using, 410–411
Memoranda of Understanding/Agreement, 303
Mental health parity, 404–405
Mental health professionals
business knowledge needed by, 4, 6, 476–477
defined, 24
professional development by, 488–489
relevancy, retaining, 487–488
resource knowledge, importance for, 202–203
roles of, 4, 24
Mental health programs, defined, 24
Mentoring, 85
Meta-analysis, 84, 90
Methadone clinic mission example, 128
Mexican youth, characteristics of, 118
Micro-evaluations, 358
Microsoft Access, 331
Microsoft Excel, 331
Mid-Center Coalition, 379–380, 381–382
Millon Adolescent Clinical Inventory, 145
Minimum Standard for Hospitals (ACP), 454
Minnesota Mining and Manufacturing Company (3M), 229
Mission Analysis Tool, 136–137
Mission Neighborhood Resource Center, 391
Missions, 130–132
defined, 15, 130
problems with losing sight of, 128
statement, construction of, 132–137
Monitoring. See Process evaluation
MPH (master’s degree in public health), 484
MST (multisystemic therapy), 84
Multicultural competence. See Cultural competence
Multicultural Competencies, 402
Multiculturalism, 100f, 101–102
Multicultural issues. See Cultural identity
Multisystemic approaches, 64, 498–499
Multisystemic therapy (MST), 84
Name That Organization Exercise, 134–136, 159
National Association of Social Workers (NASW), 103, 107, 108t
National Center for Cultural Competence (Georgetown University), 111
National coalitions, 378
National Institutes of Health, 76, 77t, 145, 349–350
National Registry of Evidence-Based Programs and Practices, 85
National Standards on Culturally and Linguistically Appropriate Standards
(CLAS), 111–112
Navigator Project, 203–204
Needs, defined, 42, 499
Needs assessment, 12–13
activities included in, 38–39
asset inventories for, 60–64
community demography assessments, 42–48, 46t
 contents of, 33
data collection, importance of, 64–65
defined, 38, 496
example of process for, 66–71
importance of, 65–66
market analyses for, 54–58, 58t
problem analysis, 48–54
problem avoidance in, 40–42
process of, 38–42, 39t
proposal development and, 19
purposes of, 12
skills needed for, 485t
stakeholder involvement in, 41–42
summary report after, 66
Needs identification
accuracy, importance of, 42
data collection for, 35–38
data reporting, 35–36
market analyses compared, 60
objectivity requirement for, 35–36
open mind required for, 38
as preplanning stage, 33–34
problems with not establishing need, 32–33
process for, 58–60
rationale development, 34–35
Neighborhood and economic resources, 61
New Deal, 79
Nixon administration, 78–79
Nonmaleficence mandate, 489
Nonprofit corporations, 261–265
Numeric counts, 147
OCB (organizational citizenship behavior), 181
Office equipment expenses, 268
Office of Juvenile Justice and
Delinquency Prevention (OJJDP), 77t, 150, 353
Office space expenses, 268
Operating budgets. See Budgets
Organizational capability, 300–302
Organizational charts, 16, 186–189, 188f
Organizational citizenship behavior (OCB), 181
Organizational processes, 175–176
checklist for, 183–184t
communication, 176–178, 176t
culture, 180–181
defined, 164
example of, 190–192, 191f
organizational charts, relation to, 187
staffing and scheduling, 182–184, 183–184t
supervision and accountability, 178–180
Organizational structure, 163–167
administrative support staff, 172
case management staff, 174
clinical staff, 173–174
defined, 163–164
direct care staff, 174–175
example of process for, 190–192, 191f
executive leadership, 168–170
governance structure, 167–168
management staff, 170–171
organizational chart for, 186–189, 188f
other program staff, 175
supervisory staff, 172–173
Organizational theories, 176–177, 176t, 179
Organizations. See Community resources
Outcome Measurement Resource Center, 358
Outcomes
defined, 81, 143
measures of, 145–148
outputs compared, 142
in program design, 143–145, 144t
staffing patterns and, 183
 types of, 144
Outcomes evaluation
assessment tool selection for, 361–363
cultural competence and, 119–120
defined, 355–356
design of, 358–361
program design, relationship with, 348
program evaluation, as part of, 19, 355–358
reasons to conduct, 144
sharing of data from, 430–431
time frames for, 363–364, 363t
Outputs, 81, 142–143
Parity in mental health, 404–405
Partnerships
community impacts of, 391–392
community resources development and, 212–213, 384–387, 385t
defined, 499
in need establishment phase, 63–64
Peers for peers. See Accreditation
Performance accountability, 81
Performance monitoring, 249
Performance standards, 81
Personnel files, 431
Philanthropic organizations, 226–229, 228t, 235–236, 237, 242–243t, 499
Populations. See Demographics; Target populations
Pre-jection, 225
Preplanning phase, 130, 139, 499.
See also Cultural identity; Literature
review; Needs assessment
Pre/post-test designs, 359, 363t
Presidents, 168–170
Principal investigators, 300
Priority skills, 308–309, 309t
Privacy issues, 441
Privitization of social services, 79
Problem analysis, 48–54, 499
Problem Analysis Guide, 48–50
Process evaluation, 353–355
defined, 328
fidelity assessment as part of, 349
program evaluation, as part of, 19
sharing of data from, 426–430, 427–428t
Professional advocacy strategies, 412
Professional associations, 91–92, 106–107, 107t, 108t
Professional development, 488–489
Professional-level advocacy, 405
Professional School Counseling, 109
Program administrators, 262, 279
Program Administrator’s Financial
Management Aid Checklist, 279–281, 280t
Program design 15, 129–130, 138–139
adjunctive interventions in, 140–142, 141t
as building on preplanning phase, 130, 139
differentiating your program in, 56
example of process for, 156–158
logic models for, 15, 148–150, 149f
outcomes, 143–148, 144t
outputs, 142–143
philosophical foundations of, 139–140
program evaluation, relationship with, 346, 347–348
program interventions, 140–142, 141t
project timeline tools for, 150–153, 151t, 153t, 154–155t
skills needed for, 485t
staffing patterns and, 186
sustainability planning and, 481–483
who are we anyway? mission example, 128
See also Cultural identity; Missions; Research basis establishment; Vision
Program design tools, 148
logic models, 15, 148–150, 149f
project timelines, 150–153, 151t, 153t, 154–155t
types of, 478
Program development.
See Comprehensive program development
Program directors, 171, 330–331
Program implementation. See Implementation
Program interventions, 140–142, 141t
Program management, 329–330
contract compliance and, 339
example of process for, 340–341
information systems for, 331–335, 334t
oversight by leaders and administrators, 330–331
quality assurance planning and, 335–338
See also Implementation
Program managers, 171
Project directors, 300
Project timelines, 150–153, 151t, 153–155t
Promising practices. See Emerging practices
Proposals, 19, 293–295, 304
budget considerations and, 313–314
collaboration requirements for, 301–304
depth of information required for, 296–299
evaluation of, 299
example of process for, 314–317
feedback on, 311–312
internal reviewers for, 311–312
internal versus external grant writers for, 304–307
letters of support for, 301–302
modifications of, 327
planning for, 307–308
professional and organizational capability, justification of, 300–302
reviewer experience and, 312–313
RFP, importance of following in, 292–294
skills needed for, 308–311, 309t, 486t
timing considerations for, 295–296, 307–308
websites for, 310–311
Providers’ lists, 241
Public-level advocacy, 404–405, 409–411
Public policy, impacts on, 390–391, 404–405, 411
Quality assurance planning, 335–338
Quality improvement data, 434–436
Quality indicators
data collection for, 434–436
defined, 81, 336, 499
quality assurance planning and, 336–338
Quarterly Annual Comprehensive Data Report Tool, 443–447
Quarterly reports, 280–281, 443–447
Randomized clinical trials (RCTs), 358–359
Random selection, 359–360
Rationale. See Needs identification
RCTs (randomized clinical trials), 358–359
Relapse Prevention Therapy-Fidelity Scale, 352
Reporting requirements, 325–326
Requests for Proposals (RFP), 231–234, 235, 251, 499
Requests for Quotes (RFQs), 232–233, 499
Research-based practices
best practices, 86, 87t
defined, 82–83, 87–88, 87t
emerging practices, 83, 85–86, 87t
empirically guided practices, 86, 87t
federal government role in, 76–79, 77t
See also Evidence-based practices
Research basis establishment, 13–14
accreditation bodies, impact on, 79–81
defined, 499–500
example of process for, 93–94
federal government, role in, 76–79, 77t
literature review for, 88–93
performance standards and, 81–82
as rationale for program design, 76
research-based practices for, 82–88, 87t
skills needed for, 485t
See also Cultural identity
Research design, 360–361
Research Design in Counseling (Heppner et al.), 360–361
Research proposals, 307
Resource Directory of Funding Sources, 241, 242–243t
Resource sharing, 389–390
Responsibilities of Users of Standardized
Tests (Association for Assessment in Counseling), 362–363
Rethinking School Lunch campaign, 406
Return on investment (ROI), 237–238, 500
Revenues. See Financial data; Financial management
RFP (Requests for Proposals), 231–234, 235, 251, 499
RFQs (Requests for Quotes), 232–233, 499
ROI (return on investment), 237–238, 500
Salary determinations, 267–268, 267t
Salary ranges, 269
Sarbanes-Oxley Act of 2002, 167, 261, 281–282
Scheduling, 182–184, 183–184t
Scholarly literature, 90–91
Secondary skills, 309–311
Self-report measures, 356
Service agency assets, 61
Service contracts, 233
Sex offender legislation advocacy, 409
Sharing information.
See Information-sharing
Silos, 500
60-second sell, 414
Skillman, Robert, 229
Skillman, Rose, 229
Skillman Foundation, 228t, 229
Social assets, 61
Social justice, 36
Sooke Navigator Project, 203–204
Spectrum Human Services Inc. and Affiliated Companies, 4–6
Spreadsheet programs, 331, 338
Staffing infrastructure development, 16–17, 163, 184–185
accreditation bodies and, 185
budgets and, 285–287
contingent or contractual employees, 182–184, 496
credentials, proposals and, 300–302
defined, 164, 500
employee retention, 423–424, 432–433
expenses from, 267–268, 267t, 269–270
human resources data and, 431–433
manager role and, 329
market analyses and, 186
organizational chart, importance of, 16
orientation about implementation requirements, 327
program design and, 185–186
skills needed for, 485t
See also Organizational processes; Organizational structure
Stakeholders
annual reports for, 282
defined, 500
mission and vision statement to communicate with, 131
needs assessment, involvement in, 41–42, 45–51
philosophical foundations of program and, 140
Standardized assessments, 145–146, 356
Standard of care, 489
Standards for cultural competence, 103
Standards for Hospital Accreditation (Joint Commission), 454
State of Michigan Department of Corrections, 464
Status evaluations, 147
Stewardship, 326, 500
Stretching, 488–489
Substance Abuse and Mental Health
Services Administration, 76–78, 77t, 85, 297–298
Substance abuse information, protection of, 441
Substance Abuse Subtle Screening Inventory, 145
Supervision and accountability, 178–180, 183–184t
Supervisory staff, 172–173, 498
Support agents, 387–388, 500
Surveys, 50–54, 52–53f, 147–148
Sustainability planning, 207–208, 481–484
Swaninger, Roger, 4–6
System-level advocacy, 403–404, 407–409
Target populations
cultural identity issues, 14
data collection to identify, 37–38
defined, 37, 500
process evaluation and, 354–355
Target regions, 35–37, 500
Task forces, 91
Tax return documents, 282, 283–284
Technology, 47–48, 331–335, 334t, 338
TechSoup Global, 331
Therapy, defined, 25
Third ear, 414
3M (Minnesota Mining and Manufacturing Company), 229
Tomorrows, 417
Tone of organizations, 180–181. See also Culture of organizations
Tools
Annual Data Reporting Plan, 441, 442–443t
Community Resource Snapshots, 209–210, 210t
Data Element Evaluation Tool, 333–335, 334t
for design phase, 478
Funding Opportunity Evaluation Tool, 251, 252f
Gantt charts, 497
logic model as evaluation tool, 348
Mission Analysis Tool, 136–137
organizational charts, 186–189, 188f
Problem Analysis Guide, 48–50
Program Administrator’s Financial
Management Aid Checklist, 279–281, 280t
Quarterly Annual Comprehensive Data Report Tool, 443–447
Relapse Prevention Therapy-Fidelity Scale, 352
Substance Abuse Subtle Screening Inventory, 145
 surveys, 50–54, 52–53f, 147–148
Treatment Fidelity Assessment Checklist, 350–351
United Way’s Outcome Measurement Resource Center, 358
Wraparound Fidelity Index, 352
See also Assessment tools; Asset maps; Data collection tools; Program
design tools
Transparency in partnerships, 386
Transportation expenses, 268–269
Treatment delivery data, 429
Treatment design data, 429
Treatment fidelity. See Fidelity assessment
Treatment Fidelity Assessment Checklist, 350–351
Treatment Fidelity Workgroup, 349–350
Turf, 500
Turnaround planning, 261–262
United Parcel Service (UPS), 229
United Way’s Outcome Measurement
Resource Center, 358
University of Detroit Mercy, 134
UPS (United Parcel Service), 229
U S Census, 44–45, 46t
U S government See Federal government
Vice presidents, 170-171
Vision, 130–132, 137–138
Wampold, B. E., 360–361
Waters, Alice, 405–406
Websites, 491–494
Welfare reform, 79
W K. Kellogg Foundation, 150, 228t, 235–236, 244
Wraparound Fidelity Index, 352
Wraparound Model, 352
 SAGE Research
Methods Online
The essential tool for researchers

Sign up now at
www.sagepub.com/srmo
for more information.