Managed Care: Strengthening the Consumer Voice in Managed Care: V. Helping Professionals Listen

The most direct structural approach to strengthening an organization's skills at listening to consumers is to bring consumers onto the staff of the organization. This approach has been applied most extensively in public mental health systems, typically by establishing an Office of Consumer Affairs. The National Association of Consumer/Survivor Mental Health Administrators cites six criteria for a successful office: consumers must be part of the planning and hiring; the office must be directed by a self-identified consumer; the director must be part of the senior management team; there must be adequate support; the consumer must serve as a change agent; and the consumer's presence on the team must not diminish the degree to which other senior managers interact with consumers (6).

Hiring consumers is a high-risk- high-gain process. To work well it requires skillful consumer employees and committed organizational leadership. One consumer with long experience in organizational roles commented that "if an organization has designated only one person to communicate with consumers and the top management isn't involved, the role is probably a waste of time and a setup for failure." Another observed, "We shouldn't be surprised that stigma is inside of mental health organizations as well as outside. That can make our roles as self-identified consumers very difficult." A third added, "You can be the vessel of the consumers but not the voice…. You have to advocate to have consumer voices at the table again and again."

All mental health disciplines have devised techniques to teach clinicians how to be effective listeners in clinical practice. The best training programs provide extensive opportunity to learn, practice, and improve. Much less has been done, however, to help clinicians and administrators become effective listeners to consumers in managerial settings.

Administrators are accountable for their programs, but to achieve success they must collaborate with consumers and other stakeholders. Such collaboration is often new territory for all stakeholders. We believe that innovative educational techniques will be required to develop the needed skills and attitudes. Educative dialogues and use of alternative dispute resolution techniques are two promising approaches. During our interviews for this column, representatives from a number of organizations told us about using variants of what we call educative dialogue, modeled on a set of pilot projects conducted by the federal Center for Mental Health Services. In educative dialogue, consumers and professionals meet in an extended discussion focused on defined goals but maximally open in process. As an example, the center convened a two-day meeting for 21 consumers and psychiatrists July 24 to 25, 1997. A planning group of consumers and psychiatrists set three goals: to develop better mutual understanding and respect between the consumers and psychiatrists in attendance, to develop a set of recommendations for improving consumer-psychiatrist partnerships, and to prepare and distribute a monograph summarizing the outcomes of the meeting (7).

Educative dialogues combine elements of the "T groups" prevalent in the 1950s and 1960s with quality improvement circles of the 1990s. They are like T groups in their encouragement of open, exploratory conversation and the value they place on heightened self-awareness and interpersonal understanding. They are like quality improvement circles in their focus on using improved collaboration between professionals and consumers to reengineer processes to improve outcomes.

Alternative dispute resolution techniques, especially mediation, are beginning to be used in health programs to avoid litigation (8). In 2000 the William and Flora Hewlett Foundation funded a Collaborative for Conflict Management, based in the Louis de la Parte Florida Mental Health Institute at the University of South Florida. Among other services, the collaborative provides training in conflict management skills to mental health organizations and their consumer constituents. Andrea Blanch, director of the collaborative, commented that in addition to providing specific skills, "when you learn to apply the alternative dispute resolution lens it can shift the culture of an organization. Conflict is a part of life. If everyone has a chance to tell their story it can lead to new resolutions."

Because virtually all discussions of successful leadership include injunctions to "listen to consumers," and because psychiatry has had an elegant model of a "customer approach to patienthood" (9) since 1975, we asked the interviewees to express their views about what impeded energetic listening to consumers.

Consumers identified two major barriers among mental health professionals that interfered with robust collaboration around policy and practice: pessimism about consumers' capacities and a tendency to think narrowly about "treatment," not broadly about "potential for recovery." "I know we can sometimes be strident or obnoxious," one consumer commented, "but I wish more providers thought we were fun to be around." Another added, "I know they are under tremendous time pressure, but it isn't that hard to ask us what we hope for, care most about, and dream of."

Organizational leaders told us that the greatest barriers to drawing consumers into collaborative deliberation about policy and practice are "the straitjacket of expertise" and "the tendency to keep our heads down and stay in our own silos." Health professionals—clinicians and administrators—are socialized to cultivate expert knowledge and take responsibility. Moving from a stance of expertise to one of inquiry and exploration can be very difficult, especially in a fast-paced environment that can be unforgiving. As one organizational leader commented: "There is a natural tendency not to want to identify and then address when our systems are not working well. System change is always difficult. We have been trained that consumers are ill and don't have solid judgment. Being open to criticism and self-evaluation makes our difficult jobs even harder. Sometimes you can't appreciate an issue until you have your nose rubbed into it!"