BASELINE MENTAL HEALTH KNOWLEDGE
Duane S. Wright
B.A., California State University, Sacramento, 2009
PROJECT
Submitted in partial satisfaction of
the requirements for the degree of
MASTER OF SOCIAL WORK
at
CALIFORNIA STATE UNIVERSITY, SACRAMENTO
SPRING
2010
BASELINE MENTAL HEALTH KNOWLEDGE
A Project
by
Duane S. Wright
Approved by:
__________________________________, Committee Chair
Kisun Nam, Ph.D.
Date: ____________________________
ii
Student: Duane S. Wright
I certify that this student has met the requirements for format contained in the University
format manual, and that this project is suitable for shelving in the Library and credit is to
be awarded for the project.
, Graduate Coordinator
Teiahsha Bankhead, PhD, L.C.S.W
Date
Division of Social Work
iii
Abstract
of
BASELINE MENTAL HEALTH KNOWLEDGE
by
Duane Wright
Baseline Knowledge Manual
Sustaining the self-determination of professional purpose in non-profit mental
health work is imperative to the wellbeing of an agency, employee, and the client.
Numerous research studies have shown that an increase in employee job specific
knowledge correlates to an increase in their self-deterministic drive, or self-efficacy.
Whether the employee is a new hire, or a senior member of the administration team, their
drive to succeed is the single most important asset a company possesses. This was the
first exploratory study in Sacramento County’s mental health arena that examined the
effectiveness of a “Baseline Knowledge Manual” at increasing the clinical mental health
knowledge of two agencies frontline mental health staff.
Using a voluntary posttest only design, a quantitative and qualitative survey was
distributed to 42 frontline mental health employees working at two private non-profit
mental health agencies. At the time of the survey, the experimental group had reviewed
the “Baseline Knowledge Manual” for one week. The control group had not. Thirty-six
(n=36) were left at the end of the study.
iv
The goal of this needs assessment research was to highlight the importance of
employee training with a cost effective and agency specific “Baseline Knowledge
Manual.” This study proved with statistical significance that a “Baseline Knowledge
Manual” could increase the clinical mental health knowledge of frontline mental health
employees by nearly 20%. It was this researcher’s intent to encourage further research
about the specific contents of an effective “Baseline Knowledge Manual” by capitalizing
on both the successes and flaws of this research project.
__________________________________, Committee Chair
Kisun Nam, Ph.D.
Date: ____________________________
v
ACKNOWLEDGMENTS
Bernadette Martinez (my wife): you have shown me a life of love that far exceeds
my wildest expectation. In the midst of that love, you have laid a foundation that has
driven me to excel at things I never dreamt feasible. Bernadette, I promise that I will
continue to work as hard for our wonderful marriage as I did for this education. Thanks
babe for the nine years of proofreads, sacrificed weekends, and overall missing husband.
Now let’s get on with our life minus this whole school thing!!!
To my loving mother and father (Gary and Linda Wright): You two have loved
me unconditionally from the day I was born. My life ambition as a social worker is to
share your gift of love with those less fortunate. I am truly an extension of your love for
me. Thank you, thank you, and thank you!!!
My sister Sarah Aldrich: You have always believed in me and that has helped me
get here. You are an amazing sister, mother, person, and my best friend. I am
overwhelmed with love and admiration when I think of our relationship. Thanks Sarah!!!
To my sister’s husband, Joe Aldrich: Thanks for cheering me on. Without your,
not so subtle, advice to take three classes a semester, I would still have a long road ahead.
Thanks Brother!!!
Ezra, Aemon, and Addy Aldrich: You three kids are the light of my life. I think
about you nonstop. One of the best parts of graduating is having more time to spend with
you three. You three are everything to me.
vi
Karen Brockopp: You have taught me so much. Professionally, a large part of me
is an extension of you. Thanks for sharing!!
My Best CSUS Friend, Erika Navarro: You were my best friend for three years at
CSUS. Without you, CSUS would have been a completely different experience. You are
an amazing person and I will never forget you. Thanks for always saving me a seat!!!
My favorite faculty member at CSUS: Dr. Russell was a professor and guidance
counselor who exuded positive energy. You made a huge difference with me by simply
being you, thanks Professor!!!
My thesis advisor: Thank you so much Dr. Nam. Without your encouragement
and support, I think this thesis would have killed me. Please never lower you high
standards for future social workers. The field needs professors like you.
vii
TABLE OF CONTENTS
Page
Acknowledgments.............................................................................................................. vi
List of Tables ..................................................................................................................... xi
List of Figures ................................................................................................................... xii
Chapter
1. INTRODUCTION ...........................................................................................................1
Background of the Problem .....................................................................................4
Statement of the Research Problem .........................................................................6
Purpose of the Study ................................................................................................8
Theoretical Framework ............................................................................................9
Definition of Terms................................................................................................11
Assumptions...........................................................................................................12
Justification ............................................................................................................12
Limitations .............................................................................................................13
2. LITERATURE REVIEW ..............................................................................................15
Introduction ............................................................................................................15
Sustaining Employees ............................................................................................19
Benefits of Baseline Knowledge Manual ..............................................................21
The Mental Health Consumer ................................................................................29
viii
3. METHODS ....................................................................................................................35
Research Design and Data Collection....................................................................35
Sampling Plan ........................................................................................................35
Measurement ..........................................................................................................36
Analysis Plan .........................................................................................................37
Human Subjects .....................................................................................................38
4. RESULTS ......................................................................................................................39
Introduction ............................................................................................................39
Post-Test Psychotic Disorder Knowledge of the Experimental Group versus
Control Group ........................................................................................................41
Post-Test Mood Disorder Knowledge of Experiment Group versus
Control Group ........................................................................................................42
Post-Test Overall Mental Health Knowledge of Experimental and
Control Groups.......................................................................................................44
Post-Test Personality Disorder Knowledge of the Experimental
Group versus Control Group ..................................................................................45
Post-test DSM-IV Knowledge of Experimental Group versus
Control Group ........................................................................................................46
Conclusion .............................................................................................................47
Manual Comments .................................................................................................48
NO Manual Comments ..........................................................................................50
5. DISCUSSION ...............................................................................................................52
The Experiment ......................................................................................................52
The Findings ..........................................................................................................53
ix
The Success ............................................................................................................55
Challenges ..............................................................................................................56
Future Research .....................................................................................................57
Researcher’s Thoughts ...........................................................................................58
Implications to Social Practice...............................................................................59
Appendix A. Baseline Knowledge Manual for New Employee’s of TLCS/HRC .............62
Appendix B. Needs Assessment for a Mental Health Manual...........................................78
Appendix C. Consent to Participate in Research ...............................................................82
References ..........................................................................................................................84
x
LIST OF TABLES
Page
1.
Table 1. Results of all Mental Health Knowledge Domains Analyzed .................40
xi
LIST OF FIGURES
Page
1.
Figure 1. Psychotic Disorder Knowledge/Experimental Group ............................41
2.
Figure 2. Psychotic Disorder/Control Group .........................................................41
3.
Figure 3. Mood Disorders/Experimental Group ....................................................42
4.
Figure 4. Mood Disorders/Control Group .............................................................43
5.
Figure 5. Overall Knowledge/Experimental Group ...............................................44
6.
Figure 6. Overall knowledge/Control Group ........................................................44
7.
Figure 7. Personality Disorder Knowledge/Experimental Group ..........................45
8.
Figure 8. Personality Disorder Knowledge /Control Group ..................................45
9.
Figure 9. Multiaxial Knowledge/Experimental Group ..........................................46
10.
Figure 10. Multiaxial Knowledge/Control Group ................................................47
xii
1
Chapter 1
INTRODUCTION
The etiology of severe and persistent mental health is dynamic. The root cause of
mental health can be associated with biochemistry abnormalities at birth or the
consequence of psychological and sociological stress after birth. Regardless of the cause,
modern society’s fast-pace drive to evolve exacerbates and/or challenges the fragile
mental health of America’s citizens.
My interest, compassion, and dedication to the mental health consumer ignited
when I received a third degree burn over nearly half my body while on duty as a
firefighter. Being burned alive, surviving the grueling recovery, and then returning to
“normal” societal obligations as a disfigured 21-year-old challenged my mental health on
many psychosocial levels. Luckily, my mental health challenges were met by a
preexisting support system. Community based mental health providers offer a strong
support system to individuals lacking a “preexisting” support system.
After retiring from the fire service five years post burn injury, I began working as
a human services employee. I was hired to offer drug and alcohol counseling services to
individuals with severe and persistent mental health and substance abuse disorders, or cooccurring disorders. I had my foot in the door of a new and exciting industry that only
asked that I convey my sincere and unbiased belief that people could recover from life
challenging circumstances. I was told I would learn the rest as I progressed in my career.
The new career proved to be a rewarding, yet challenging professional opportunity.
2
Helping people navigate the long road of recovery was invigorating. My
professional strategy was to promote human dignity, hope, and self-esteem. This would
offer long-term benefits at a micro, mezzo, and macro level. I had an unwavering
commitment to navigate the good and bad times with the client because I believed in
them. Having a healthy support system worked in my life and I was determined to make
it work in theirs. I helped my clients establish an ecologically based support system that
offered solutions to a majority of their problems. Between conveying to clients how much
I believed in them and uniting them with a multitude of helpful resources, I was sure my
strategy would transform lives. Unfortunately, a majority of my clients continued on their
self-destructive path and I soon learned that my good-natured optimism was lacking in
clinical knowledge. Subsequently, I refocused my professional strategy on reducing the
harm of people’s self-destructive behaviors instead of trying to eradicate their life
problems with compassion and resources.
Human service work is rewarding, yet extremely challenging and subject to
employee burnout. When I was hired, I had little formal knowledge about mental health
and co-occurring disorders. The myriad of problems associated with a mental health
disordered life seemed endless. These problems included incest, molestation, physical
and verbal abuse, homelessness, suicidal tendencies, high-risk behaviors, drug
dependency, chronic and acute physical ailments, no income source, no family support,
crimes of opportunity, resistance to change, and lack of basic life sustaining resources
such as housing, clothing, and food. The human suffering was a heavy burden to witness
3
and I began to feel overwhelmed, powerless, and burned out. I watched several coworkers fall victim to cynicism and I promised myself that I would protect myself, and
the clients I served, from this deficit-based ideology. My professional and personal
disposition in life had been strength based, so falling prey to negative thinking was
unsettling. Undeniably, my self-deterministic drive was diminishing and I struggled to
find optimism under the dark cloud of human suffering. The career I started with so much
optimism and excitement was becoming an unwelcomed wakeup call about what little
influence my optimism had over other people’s self-destructive lifestyles. I inherently
knew I needed more knowledge about the group of people I was serving.
In response to my declining self-determination, feelings of inadequacy, and
impending job burnout, I enrolled at the local community college and began taking
psychology and substance abuse classes. Learning about the biopsychosocial
complexities of mental health, substance abuse, and human behavior offered me a new
perspective as a human services employee. My days of optimistically hoping people
would see the world through my eyes was replaced with empirically based knowledge
that renewed my faith in the helping profession. The increase in basic job related
knowledge that education offered resulted in a renewed spirit in professional purpose.
This new spirit based in professional knowledge reignited my self-deterministic drive to
help others achieve their goals.
My renewed self-deterministic drive also translated into increased job satisfaction,
job effectiveness, and commitment to heighten my skill level so that I could better
4
understand the realities of living with a severe and persistent mental health disorder. I
was learning to see life through the eyes of my clients instead of hoping they could see
life through mine. For nearly ten years, I have sustained my good spirited commitment to
help people thrive, not just survive thanks to education. Having a manual of basic mental
health facts at the onset of my employment would have been very helpful.
Background of the Problem
The framework of American capitalism relies on each American’s evolutionary
drive to attain the “American Dream” by pursuing financial rewards through
competitiveness and ingenuity. Preexisting benchmarks of accomplishment only serve as
the foundation of what needs to be superseded and/or replaced. While these intrinsic
characteristics and extrinsic values of America’s progressive society act as the
precedence to motivate Americans professionally, academically, personally, and
spiritually, they also create high levels of stress. This stress often leads to both situational
and organic mental health breakdowns that disable and/or completely debilitate
Americans. The California Psychiatric Association (2008) reports that 20% of this
country’s population suffers from a “serious mental health issue” in their lifetime and that
mental health consumers are the “largest and fastest” growing portion of our population.
In other words, large portions of Americans find themselves so disordered with severe
and persistent mental health issues that they are unable to function in modern society.
The financial consequence associated with mental health disorders has captured
government’s attention.
5
An industry of mental health consortiums has evolved from federal, state, and
local tax revenues because of the continued upswing of people deemed unable to work
due to permanent and severe mental health disorders. The government’s primary goal is
to reduce the financial burden that unregulated and untreated mental health has on
government expenditures. The National Institute of Mental Health (NIMH) (2009)
reports that mental health is the leading cause of disability in the United States and
Canada for individuals 15-44 years of age. As a vehicle to combat the direct assault that
untreated mental health has on the American economy, non-profit agencies specializing
in mental health recovery receive taxpayer money to reduce the problem.
Non-profit agencies strive passionately to reduce human suffering. However, they
must operate in a fashion that delivers two distinctly different outcomes. First, the nonprofit agency must meet the goals of the publically funded bureaucracy that awards
public money. Second, they strive to meet their own objective by reducing the human
suffering associated with mental health disorders.
The expectation of a government bureaucracy is to reduce the financial impact
that “untreated” mental health consumers have on publicly funded resources such as
underequipped and highly priced hospital emergency rooms and acute psychiatric
hospital crisis units. In addition to medically based establishments mandated to serve
mental health clients, correctional institutions have become expensive holding tanks for
mental health consumers who are unable to conform to societal norms and consequently
find themselves the focus of legal interventions.
6
Fred Osher, M.D., director of the Center for Behavioral Health, Justice, and
Public Policy at the University of Maryland (as cited in Kanapaux, 2004), told
Psychiatric Times, “The majority of people with mental illness in the criminal justice
system are there for misdemeanors and crimes of survival” (¶ 7). He goes on to state that
the main reason for the high prevalence of mentally ill consumers in the prison system is
that they have inadequate access to quality behavioral health resources. In other words,
mental illness is a substantially underfunded problem that is having a devastating effect
on the micro, mezzo, and macro ecological systems of our society. Because of the
underfunding and underappreciated reality of the mental health industry, employers are
forced to hire inexperienced workers and pay low wages in order to survive.
It is paramount that community non-profit mental health providers supplement
their frontline employees with the necessary knowledge to address the complex realities
of disordered thoughts, feelings, and behaviors associated with untreated mental illness.
Ignoring the personal consequences that underequipped mental health workers face is
neglectful and inhumane to both the worker and the consumer; mandating a “Basic
Knowledge Manual” at the onset of employment is imperative.
Statement of the Research Problem
Social Service non-profit agencies that help a specific population do so because
they inherently care about the group’s wellbeing. Unfortunately, social service non-profit
agencies are usually underfunded, underappreciated, and the first to lose revenue when
the economy tightens. Consequently, mental health nonprofit agencies can only afford to
7
pay their employees a minimal salary while demanding exorbitant efforts. Luckily, entrylevel mental health workers are intrinsically, not extrinsically motivated.
Mental health agencies typically interview perspective employees with the hope
of finding both experiential and academic knowledge accolades. However they are
amenable to hiring individuals without formal education based on their passion, common
sense, and the ability to learn. While these employees often prove to be an excellent
choice, their learning curve is big and company sponsored educational forums are small.
In addition to the common practice of hiring individuals without formal mental
health education, many new mental health employees have advanced education, but not
population specific specialized knowledge. Uniting a workforce at the onset of
employment with a basic knowledge manual is imperative to agency and individual goal
setting.
In the Sacramento County mental health arena, the standard of a “Baseline
Knowledge Manual” remains unrecognized. Therefore, non-profit mental health agencies
are hiring individuals with a host of belief systems, theoretical frameworks, knowledge
bases, personality types, and historical experiences in the human services profession.
While each of these individual characteristics are an asset to any company, it is important
to filter all these personal strengths through clinical knowledge that applies to the
population they will serve. Currently, this is not the standard of Sacramento County nonprofit agencies serving the mentally ill.
8
Purpose of the Study
In this research paper, I will answer the question: Will an employee “Baseline
Knowledge Manual” enhance the professional knowledge of mental health
employees who work in a non-profit setting?
For the past eight years, I have worked for a non-profit mental health agency.
During the first five years, I worked as a direct service staff for three mental health
programs in various capacities. My last three years of employment have been in
management. In this time, I have indentified the need for a “Baseline Knowledge
Manual” that is specifically written to promote our agency’s agenda and maximize the
wellbeing of our employees and therefore improve services for the mental health
consumer.
Non-profit agencies in the mental health arena hire employees who have varying
degrees of experience and education. There are no legal regulations mandating a
minimum level of academic qualification to serve as a mental health professional in
California. Additionally, the pay rate for frontline mental health employment is not
typically enticing to those with higher levels of education. Subsequently, it is a standard
and encouraged practice to hire mental health consumers and people with an empathetic
disposition to serve as mental health professionals. Luckily, the benefit of life experience
that these non-academic employees bring to a mental health team is indisputably
invaluable.
9
Life experience is a critical and invaluable source of empathetic knowledge;
however, it lacks empirical based forethoughts and is subject to misguided treatment
philosophies. Therefore, it is critical that mental health agencies guarantee its employee’s
acquire a minimal set of basic mental health knowledge before entrusting them with
vulnerable mental health consumers. As a positive reward for developing an employee
knowledge manual, an agency can expect to enhance its employee’s effectiveness and
overall job satisfaction. At a minimum, an employee handbook should outline critical
information about the target population they serve, definitions of the common language
shared amongst seasoned staff, and a list of commonly used resources within the agency.
Whether a new employee has substantial experiential knowledge or academic knowledge,
it is critical that all employees start with a key understanding of the specific group of
clients they will be serving.
Theoretical Framework
Self-determination theory focuses on conditions that promote the innate process
of self-motivation and continued psychological development. At the core of promoting,
or sustaining, self-determination (or motivation) is the psychological needs of
competence, autonomy, and relatedness (Ryan & Deci, 2000). Self-determination can be
summarized as the internally inspired motivation to accomplish something.
Self-determination theory encompasses the reason people choose to work in a
profession that is undervalued, underfunded, and overwhelmed with human tragedy. If
not for the intrinsic rewards associated with a self-deterministic drive to help people, the
10
mental health arena would represent a stark and desperate respite for those who could
find nothing better to do for a living. In fact, mental health treatment is a competitive
industry that demands high functioning individuals who invest in the good of humanity.
Ryan and Deci (2000) report, “findings have led to the postulate of three innate
psychological needs-competencies, autonomy, and relatedness-which when satisfied
yield enhanced self-motivation, mental health, and well-being” (p. 68). Selfdetermination is the corner stone of an effective and driven mental health employee who
has the ability to singlehandedly bolster an agency’s effectiveness. Therefore, the priority
of a mental health agency must be to capitalize on the attributes of self-determination by
stimulating the psychological drives that sustain it. Competence is a feeling that one is
productive, skilled, and able to help others. Empowering an employee with baseline
knowledge at the onset of employment guarantees that each employee has a baseline of
practical knowledge to support their self-determined drive to help others meet their
potential. The consequence of failed self-determination is a troubled employee who fails
his/her clients, the agency, and themselves. If an agency honors the ethic of “do no
harm,” then they are obligated to supply each new employee with a “Baseline
Educational Manual” at the onset of employment.
The theoretical framework of self-deterministic theory is integrated into this
research project through the assumption that increased job specific knowledge results in
increased job satisfaction, or self-determination. The vehicle of delivery for the job
11
satisfaction-increasing variable (education) is an educational manual that is job specific,
condensed, and easy to read.
I will assess employee’s self-deterministic drive on two fronts. First, I will
determine if the experimental group has an increase in job specific knowledge after
reading the knowledge manual. Second, I will determine employees’ willingness to read
the manual and take the survey willingly. This will guide future research on the
importance of mandating a manual, and scoring the results, before an employee engages
with agency consumers. I hypothesize that employees will have an increase in job
knowledge after reading the manual and that there will not be 100% compliance because
of the voluntary nature of the experiment.
Definition of Terms
A severe and persistent mental illness (SMI) is defined by Epstein, Barker,
Vorburger, and Murtha (2004) as having at some time during the past year a diagnosable
mental, behavioral, or emotional disorder that met the criteria in the Diagnostic and
Statistical Manual of Mental Disorders, 4th edition and resulted in functional impairment
that substantially interfered with or limited one or more major life activities.
Sacramento County Target Population of mental health disorders include:
Psychotic Disorders:
Schizophrenia
Schizoaffective
Psychosis-Not Otherwise Specified (NOS)
12
Mood Disorders:
Bipolar I
Major Depression, recurrent
Personality Disorder:
Borderline
Anxiety Disorder:
Posttraumatic Stress Disorder (PTSD)
Assumptions
The main assumption of this exploratory research project is that reading a manual
with basic knowledge about the specific mental health population they serve will lead to
increased clinical knowledge. This increase clinical knowledge will promote a better
outcome for the employer, the employee, and the mental health consumer. In other
words, there will be less employee turnover and better customer service.
To obtain the research data to support this claim, it is assumed that preexisting
employees of a mental health agency will voluntarily read the knowledge manual and
take the survey to assess their retention of the educational material.
Justification
Individuals who have severe and persistent untreated mental health disorders are
an oppressed, stigmatized, and marginalized population of individuals who often struggle
with daily hardships such as homelessness, drug addiction, untreated medical issues,
ridicule, and/or lack of life sustaining resources. Mental health consumers deserve
13
knowledgeable professionals that base their intervention skills on empirically sound
principles. The National Association of Social Workers’ (NASW) Code of Ethics (1996)
demands that social workers, and helping professionals alike, do no harm to the people
they serve (NASW, 1996). It is critical that a basic standard of knowledge is demanded
from all new employees regardless of their educational and/or experiential accolades.
People’s lives are the focus of human service workers and the consequences of
misguided and unhealthy approaches to help people “fix themselves” is inhumane and at
times, devastating. It is an unacceptable omission of “good practices” to allow new
human service employees to engage with client’s before passing a simple test of accepted
facts that are specific to the population they will serve.
Limitations
In the past two years, there have been very few new employees hired into the
mental health programs I will sample. This is due to the current economic shortfalls and
subsequent assault on human service budgets. The two agencies I sampled for my
research, Human Service Consortium (HRC) and Transitional Living and Community
Support (TLCS) have laid off over 40% of their management staff and 30% of our direct
services staff. Subsequently, I am using preexisting employees of the two mental health
agencies as my sampling groups.
I am an administrator at one of the programs I will use for sampling, so I have
made every ethical effort to avoid placing undue pressure on employees to participate. As
a consequence, or limitation, the data I will collect will be voluntary, anonymous, and
14
confidential. There was no incentive to read the manual or complete the survey. The data
obtained from this survey will serve as a guide to future “Baseline Knowledge Manuals”
whereas reading the manual is mandatory, and satisfactory survey results are a condition
of employment.
For future research, I encourage the collection of demographic information such
as age, gender, experience, education, life history, and motivating factors leading to work
in the mental health arena for a more thorough analysis of the research findings. As with
most research, looking critically at this research will present ample examples of how it
can be done better and written differently. This research is designed to promote that
competitive spirit.
15
Chapter 2
LITERATURE REVIEW
Introduction
The field of helping professionals is large. It includes doctors, nurses, firefighters,
police offices, social workers, counselors, teachers, and many more. Unlike many other
professions, the helping professionals face human variables that are uniquely tailored to
each individual and their environmental setting. Predictability is impossible. Whether the
human intervention happens in a hospital, medical clinic, police station, office setting,
school, food kitchen, or any other host of environmental possibilities, the professional
task is the same: to promote a positive outcome to the distressed situation.
Badger (2008) highlights the tremendous emotional demand nurses endure as they
fight to help burn victims survive unimaginable pain, or a family devastated by their
loved one’s pain and disfigurement. In the midst of all this emotional stimuli, nurses must
simultaneously present as strong and offer compassion, hope, empathy, and caring
support. A demanding professional task such as this can lead to a reaction coined
“compassion fatigue.” Compassion fatigue, also known as “secondary traumatic stress”
or burnout is not just a reality to nurses working in a burn unit. It is a reality of any
helping professional working to reduce human suffering.
While the profession of nursing is often highlighted as prone to compassion
fatigue or burn out, social workers and mental health workers are equally prone to
emotional exhaustion because of their chronic exposure to human suffering. Protective
16
measures must be put into place to protect social service frontline employees from the
assault that the human suffering can have on their general wellbeing.
There are significant concerns that community-based mental health services will
be difficult to sustain because of the high level of stress, burnout, and demoralization
common among frontline staff (Wykes, Stevens, & Everitt, 1997). Although highly
trained and valued helping professionals such as nurses and doctors receive extrinsic
rewards such as a high pay scale and public support, frontline mental health workers do
not. The tremendous emotional requirements, and the low pay of unlicensed mental
health specialists, create an obstacle to sustaining their longevity with community-based
mental health agencies.
The nature of mental health work is undeniably stressful. Unraveling the root
cause of someone’s dysfunctional thinking can take years of psychoanalytical therapy.
Psychoanalytical therapy is specialized, expensive, and not within reach of many mental
health consumers. Therefore, grassroots and publically funded mental health programs
support the needs of mental health consumers through public money.
This public money is usually limited and non-profit mental health agencies are
expected to offer more service with less money. Subsequently, the efficiency of an
agency is dependent on its ability to pay its employees less while demanding more. In a
recent phone survey of Sacramento County contracted mental health providers, it was
determined the average salary range for direct services staff ranged from $9 to $16 per
hour regardless of education (D. S. Wright, personal communication, February 12, 2010).
17
While the extrinsic financial rewarding system of mental health workers is low, the
intrinsic exposure to human dysfunction, trauma, and catastrophes is alarmingly high. It
is imperative that human service agencies prepare its workers for unavoidable high levels
of compassion fatigue. Acker (1999) emphasizes this when he writes, “Social workers
who work with clients who have severe mental illness may become burdened and
exhausted emotionally and show other symptoms of burnout-a serious problem for these
social workers, their families, their clients, and the quality of their services” (p. 117).
Maslach, Shaufeli, and Leiter (2001) state, “burnout is a prolonged response to
chronic emotional and interpersonal stressors on the job, and is defined by the three
dimensions of emotional exhaustion, cynicism, and inefficacy… highlight[ing] that
inefficacy represents beliefs of professional incompetence and lack of productivity” (p.
397). Maslach and Jackson (1981) also state that burnout occurs more frequently among
helping professionals than many other career choices “and is being recognized as a
serious problem affecting many agencies and employees in the social service arena” (p.
99). Burnout is the wearing out, exhaustion, or failure resulting from excessive demands
made on energy, strength, or resources (Freudenberger, 1977). When workplace stress
results in employee burnout, it becomes very costly in human and economic terms for the
employee, employer, and society (Cushway, 1995). Social service employees
experiencing burnout have been found to become easily angry, irritated, exhibit
stubbornness and inflexible thinking, abuse substances, express cynicism about the
agency, and become increasingly less productive (Azar, 2000).
18
A highly stressful working environment engrossed in dysfunction can lead to
mental health issues for the mental health employees themselves. Mental health issues at
the employee level are detrimental to both the mental health consumer and the employer.
Sprang, Clark, and Whitt-Woosley (2007) reported, “The empirical literature has
documented mental health consequences of professionals’ exposure to trauma patients”
(p. 259). A mental health agency cannot ignore the massive assault that human suffering
can have on an unknowledgeable employee. Knowledge truly is power when a mental
health worker understands the dynamic of trauma, mental health, and other job specific
challenges.
The primary objective of mental health workers is to reduce the harm that
untreated mental health has on the individual’s quality of life. It is common for social
service workers to witness a client with children asking for food and shelter on a freezing
night and not have the resources to provide a solution. It is a sense of powerlessness and
frustration that is all too common for a social service employee. Watching a family leave
the office without a warm or safe place to make shelter on a cold night is emotionally
disturbing on every level of human consciousness.
According to the Transactional Stress Process model (Lazarus & Folkman, 1984),
job stress can be defined as a relationship between a person and the environment. This
relationship between the person (employee) and the environment is assessed by the
person as being overly taxing and exceeding his/her resources (ability) to do something
about the “problem” (Lazarus & Folkman, 1984). For example, the worrisome thoughts
19
of leaving a child with a suspected, but not substantiated, perpetrator is not something a
compassionate employee leaves at work. The work is incredibly encompassing.
Sustaining Employees
Promoting an employee’s self-determination of education is a cost effective
means to capitalize on a company’s most important commodity, its employees. Research
studies are abundant about what sustains employees as an asset to their employers. These
attributes include motivation, job satisfaction, intrinsic rewards, extrinsic rewards,
challenge, training, and good leadership. Research has also captured what leads to the
demise of promising employees. The factors include large caseloads, work intensity,
understaffing, job insecurity, and continuous rapid organizational change (Edwards,
Burnard, Coyle, Fothergill, & Hannigan, 2000).
In the United Kingdom (UK) where research is plentiful on the effects of
emotional stress on social workers, Eborall and Garmeson (2001) found that 81% of local
agencies had problems retaining social workers and concluded in their research that
staffing social workers is more problematic than any other profession. Certainly, the UK
is not the United States (US); nevertheless, the stress of working with human suffering
and dysfunction is universally disheartening when solutions and resources are limited.
The average length of employment for a child welfare worker, regardless of
private and public funding, is less than two years (U.S. General Accounting Office,
2003). Fifty percent of the social service employees working for child welfare agencies,
stated they wanted to leave but were compelled to stay because of the stable income and
20
benefits. It is undeniable that social services has a huge population of employees who
stay because they feel trapped by a system that pays their bills but destroys their morale.
Child Protective Services (CPS) typically demands a master’s level of education. If a
master level social worker is unable to maintain the self-deterministic drive that they
likely started the job with, it comes as no surprise that frontline mental health workers
with no requirement for higher education fall prey to job burnout. Social service and
mental health employees suffering from burnout and who continue to offer services to
their respective vulnerable populations is a gross negligence and must be addressed.
For an agency to thrive, it needs to sustain a workforce of skilled employees.
Unfortunately, skilled workers are in high demand and issues of low pay, diminished
morale and accepted job burnout promote high employee turnover that keep a low-budget
nonprofit mental health agency in constant influx. Nurturing and retaining skilled mental
health employees is critical to a mental health agency’s sustainability. With the many
attributes that contribute to the overall mental health of an employee, it is critical that
employers understand and adapt current research to nurture the self-deterministic drive
that propels an employee to thrive professionally, not just survive.
Retaining mental health workers in New York is equally as challenging with a
reported turnover rate of 37% to 54% among “direct care staff” (Coalition of Voluntary
Mental Health Agencies, 2000). The point is, whether the country with human suffering
is the UK, Philippines, Chile, or the US, the emotional demands of people struggling to
21
survive the devastation of poverty, drug addiction, mental illness, earth quakes, floods, or
a string of bad decisions is daunting and can lead to burnout of a promising employee.
Benefits of Baseline Knowledge Manual
When interacting with individuals who are physically and mentally sick, human
lives are the commodity. Knowledge about the client’s disease and symptoms must be a
fundamental expectation for all staff engaging with the vulnerable and sick consumer.
Coursey Curtis, Marsh, Campbell, Harding, Spaniol et al. (2000) have shown that current
methods of training frontline mental health workers are not adequate to support a
severely mental ill client realize their potential for psychosocial recovery. It is a common
practice among community mental health providers to hire a frontline mental health
worker one day and release them to the mental health consumer the next. This is an
unacceptable practice and must stop, regardless of experience or education. A basic level
of knowledge must be confirmed before s/he engages with clients.
Hromco, Lyons, and Nikkel (1995) conducted extensive research utilizing 41 of
the 48 community mental health centers in Oregon to establish the demographic base of
the state. Two hundred and sixteen (216) mental health case managers responded. It was
determined that 71% of the workforce were between the ages of 31 and 50, 61% were
female, 82% had at least a Bachelor’s Degree, 57% had received outpatient services for
mental health concerns, and 68% had been in psychotherapy. The mean length of
experience was 8.9 years. While these statistics capture a relatively high level of
education and experiential knowledge amongst mental health case managers in Oregon,
22
the author concludes that social work programs are not instilling mental health case
managers with the appropriate tools to meet the expectations and treatment needs of
mental health consumers.
While Oregon’s demographic statistics show that 82% of their case managers
have a Bachelor’s Degree, this information can be misleading. Surveys in several other
states show that 50% of the Bachelor’s Degrees obtained were in unrelated fields (Gellis,
Kim, & Hwang, 2004; Hromco et al., 1997; Rohland, Rohrer, & Tzou, 1998). In other
words, social service frontline staff who studied political science, business, computer
graphics, or astronomy are hired, labeled mental health specialists, immediately put on
the frontline of a war against human suffering and told to make a difference. Without
exception, it should be demanded that individuals working in the social service industry
prove a basic level of knowledge relevant to the population they serve regardless of
educational accomplishments.
A human service employee’s empathic concern for his/her clients is accepted as
paramount to being a qualified and effective force in someone else’s disordered life. It is
the life experience and naturally acquired compassion for another human that leads jobseeking individuals to human service work. In many instances, an employee’s motivation
to help other people stems from their own “run-ins” with desperation, despair, and
hopelessness. The industry of mental health is unique to other professional domains
because it weighs experiential knowledge as important, or often more important than the
23
academic accolades. Therefore, human services workers are revered for their life
experience, not just their academic accomplishments.
Experiential knowledge is considered priceless when working with individuals
who feel alone, outcast, and destitute to a life of continual struggles. Hromco et al. (1997)
illustrate the historical importance that mental health providers and their employees are
given engagement skills, “It appears clear that the vast majority of CMs [case managers]
place a high value on the professional-consumer relationship, and view formal
psychotherapy as a relatively unimportant task in case management for persons with
severe mental illness” (p. 424). This finding encapsulates the argument that engagement
skills are imperative to a successful intervention with mental health consumers, yet it also
highlights the disregard for advanced education (psychotherapy) as an important adjunct
to engagement skills. Disregarding the importance of formal education knowledge and
techniques to the recovery outcomes of mental health consumers is a covert means of
self-preservation for those less educated.
Research shows that employees respond well to training and development. In fact,
it is through training and development that an agency merges it goals with those of the
employee. Maslach et al. (2001) concluded, “One advantage of a combined managerial
and educational approach to intervention is that it tends to emphasize building
engagement with work.” A “Baseline Knowledge Manual” promotes the integration of
agency goals with employee goals. Ideally, this integration of common knowledge will
reduce employee compassion fatigue that often leads to job burnout.
24
The demands on new social services employee serving any population with severe
deficits are daunting. Increasing knowledge about the population they serve will increase
the efficacy of services rendered. A feeling of professional incompetence is a problem
that employers must address at the onset of employment. Target population specific
education that starts at the onset of employment will help minimize workplace stress and
create competent employees. It is imperative that social service agencies help their new
employees align realistic goals to realistic expectations by offering them job specific
knowledge and other coping skills to deal with the chronicity of emotional stress. While
exercise, good diet, and healthy professional and personal support systems are the
standard coping strategies offered by self-help books, physicians and mental health
counselors, they do not address the root cause of professional discord.
Leary and Brown (1995) found that nurses who participated in additional training
after completing their nursing degree were less likely to be emotionally exhausted than
those who did not participate in continued education. In fact, it is no wonder that
professional licensing boards around the world require continued education as a
requirement to continue practicing medicine, social work, therapy, etc. Without continued
education, employees’ skills stall and their ambition diminishes. Whether a college
educated nurse, or a human services employee with solely life experience, skill building
through education is empowering and leads to a healthier sense of professional
investment.
25
Self-efficacy is defined as an individual’s intuition as to whether or not they can
competently perform a specific task (Bandura, 1977). The process of learning the
knowledge and experience required to maintain self-efficacy is described as the learning
curve (Argote & Epple, 1990). The “learning curve” is an important educational
component of the social services arena, and mental health specifically, because of the
complex and unique array of problematic living skills and symptom profile that each
mental health consumer presents.
In an experiment in which two groups of case managers were hired, experienced
and inexperienced, it was discovered that the inexperienced case manager had not
reached a baseline of knowledge established by the experience case managers after 206
days of employment (Bliss, Gillespie, & Gongaware, 2010). In social services, and
specifically the mental health arena, the learning curve is putting a new employee on the
frontlines of human suffering so they can “learn the ropes” as they encounter new
challenges. This is an unacceptable means of training when human lives are the
commodity.
I surveyed two mental health agencies in Sacramento, California. One agency
offered 24 hours of orientation. The issues covered include motivational interviewing,
ethics, policy and procedure, agency history, and the agency’s programs. While this is an
impressive list of training segments compared to many other mental health agencies, it
does not include basic clinical information about the symptoms of the agency’s target
population and only takes place when a certain number of new employees are hired. In
26
other words, a new employee could work with clients for months before attending the
orientation. In addition to the new employee orientation, the agency offers an annual
stipend for job specific trainings and hosts quarterly training at a “staff breakfast.”
The other agency offers a standard new employee orientation that includes
signing required documentation for new employee hires, and teaching effective
documentation standards so the insurance provider (the Federal Government) can
reimburse the agency and local government for services provided. While both agencies
would like to offer more training to their new staff, it is not feasible. The realities of
limited money and excessive workload make it impossible. A “Baseline Knowledge
Manual” is a cost effective means to guarantee a standardized knowledge base before an
employee is hired, or released to the frontline. If basic knowledge about mental health is
not contributing to a new employee’s decision-making process, they might as well be
someone from the local retail store who decides they want to help people.
Jonge, Le Blanc, Peeters, and Noordam (2008) report that the “control,” or
“knowledge” “at work makes it easier to cope with emotional job demands, which in turn
could lead to experiencing motivation and challenge instead of stress [or burnout]” (p.
1467). Educating agency personnel at the onset of employment about the specific
challenges they will encounter will assist them with recognizing, understanding,
normalizing, and adapting to work stress. In other words, help employees understand the
complexity of the mental health disorders, and they have a greater potential to feel in
27
control of their professional environment despite the excessive emotional demands
associated with untreated and chronic mental health.
Whether personally or professional indicated, people need to feel a sense of
control over their lives to achieve emotional stability. Excessive demands often lead to
feelings of inadequacy despite good intentions when working with individuals living with
symptoms of mental health. Research has illustrated that an increased internal locus of
control (more knowledge) is associated with less burnout and higher job satisfaction
(Koeske & Kirk, 1995). The professional expectations inherited by an employee are the
accumulation of intrinsic expectations, agency goals, and the client’s demands. If an
employee is lacking in job specific skills at the onset of employment, regardless of
education, they will succumb to feelings of stress and burnout.
Houghton and Jinkerson (2007) state, “[employees] who envision and mentally
rehearse [the] performance of a task beforehand are likely to experience greater success
than those who do not” (p. 46). A “Baseline Knowledge Manual” encourages employees
to relate what they read to future mental health interventions. The U.S. Department of
Labor (2008) validates the importance of training and education stating that agencytrained employee’s offers an enhanced set of specific job skills, better productivity,
higher quality of work, and a longer lasting loyalty to the agency.
In a study conducted at an acute mental health facility in the United Kingdom,
mental health workers received training that was specific to their job responsibilities.
After conducting a pre-test and post-test experiment with the mental health workers,
28
(Martin, Tyrer, Kalekzi, Lanchahire, 2008) concluded that the study’s participants
displayed a “significant increase in [the] knowledge of core psychological skills and that
“intrinsic, extrinsic, and total job satisfaction” “significantly” increased while job burnout
“significantly” decreased. The knowledge acquired from college, seminars, or a
“Baseline Knowledge Manual” is invaluable and must be promoted.
The desire to help is worthy of admiration but it should not be the sole
requirement for employment unless they can prove a minimum amount of job specific
knowledge. “Flying by the seat of their pants” is an unacceptable means of acquiring the
mental health knowledge necessary to be an effective mental health professional. Without
fundamental knowledge about the target population of people served, there are dire
consequences.
Offering a manual of basic mental health facts at the onset of employment
conveys the “good practices” expectation of empirically based interventions and
objective based assumptions. If a social service agency neglects to demand a basic level
of professional knowledge from their employees, they are guilty of betraying the trust of
the taxpayers who support their mission to reduce the harm and expense of untreated
human suffering.
Addressing the training needs of mental health direct service staff and validating
the importance of the “Baseline Knowledge Manual,” Eack, Greeno, Christian-Michaels,
Dennis, and Anderson (2009) conducted qualitative interviews among several mental
health frontline staff and concluded that “[case management] frankly admitted their need
29
for training in information basic to the current understanding of SMI [severe mental
illness], including basic diagnostic categories” of mental health disorders (p. 311). A
“Basic Knowledge Manual” offered at the onset of employment would provide this
missing information and protect an employee’s self-deterministic drive by fueling their
self-efficacy with specific job related knowledge.
When basic job specific knowledge increases, mental health outcomes improve.
A report by the U.S. Department of Health and Human Services (1999) captures the
importance of “fundamental” knowledge supported by science in the mental health arena.
It is critical for human beings to accomplish goals of any sort; this is especially true when
human beings are the recipients of the intervention. If an employee is overwhelmed,
burned out, or consumed by feelings of inadequacy, their self-deterministic drive suffers,
the agency suffers, and mental health consumers suffer.
The Mental Health Consumer
The consumers of federal, state, and locally funded community mental health
programs represent a group of people that have slipped into a world of cognitive
obscurity and find their lives in disarray. The disarray, or dysfunction, negatively affects
many domains of their lives. These domains include work, school, family relations, and
social supports. The stress of living with both the erratic symptoms of chronic mental
illness and the discord that follows leads to an increase in high-risk behaviors such as
self-mutilation, suicide attempts, unprotected sex, sharing hypodermic needles, and many
30
other destructive behaviors associated with alcohol and drug abuse and dependency
issues (O'Hare & Sherrer, 2009).
Individuals who qualify for publicly funded mental health services generally need
support living successfully within their community. This support includes obtaining an
income source, money management, family reunification, housing, legal issues, medical
issues, and adult daily living skills (ADLs). ADLs taught and/or encouraged include
personal hygiene, self-advocacy, social skills, use of public transportation, parenting
skills, meal preparation, and recreation. Individuals who struggle with an untreated and
severe mental health disorder are forced into a primal existence of trying to survive with
limited to no resources and struggle to realize a self-actualized existence.
Complicating the stress of living with pervasive mental health symptoms, mental
health consumers show an alarming high incidence of trauma. O'Hare and Sherrer (2009)
show that 73.1% experienced an unexpected death of a significant other, 50.2% reported
physical abuse, 39.3% experienced sexual abuse, 34% survived a life threatening illness,
29.5% survived a serious accident, and 18.5% witnessed a significant other harmed, or
killed. In response to living with severe mental health disorder and trauma, people resort
to suicide. Not only is mental illness influenced by the neurochemistry of the brain, so is
suicide. It is critical that mental health professionals appreciate the biological facets of
mental health disorders.
As a means to alleviate situational stress, Americans use a variety of coping
strategies. This includes the well-documented use and abuse of a variety of mind-altering
31
substances including drugs, alcohol and tobacco products. Individuals with chronic
mental health disorders are no exception. The National Institute on Drug Abuse (NIDA)
(2007) finds that 6 out of 10 individuals with a mental health disorder abuse drugs and/or
alcohol. This high number is not surprising due to the lack of financial means, social
support, and job opportunities afforded most severely mental ill people.
The symptoms correlated with untreated mental health disorders are severe, life
altering, and debilitating. An episode of mental health symptoms can last from seconds to
a lifetime. The presentation of symptoms can range from depressed mood to euphoria,
grandiosity to persecutory, and from positive symptoms of schizophrenia such as audio
hallucinations to negative symptoms such as catatonia, or disorganized speech. Whatever
the symptoms, it is critical that frontline mental health professionals begin employment
with a solid understanding of not only the varying symptoms that encompass a disorder,
but the management of those symptoms. One of the most common symptoms that span
many mental health disorders is suicidal ideation.
Each year, the World Health Organization estimates 10 to 20 million people
attempt suicide worldwide each year and of those 1 million are successful (World Health
Organization, 2009). In 2006, the Center for Disease Control and Prevention (CDC)
established that 33,000 people committed suicide making it the 11th leading cause of
death in the United States. For those between the ages of 25-34, it is the second leading
cause of death and for those between 15-24, it is the third.. One American citizen is
32
succumbing to the hopelessness of overwhelming despair and killing themselves every 16
minutes in this country (Centers for Disease Control and Prevention [CDC], 2009).
Scientists researching the human brain are discovering that individual behavior is
strongly influenced by genetically inherited electrical and chemical reactions at birth.
Therefore, the causal factors contributing to mental illness and suicide are no longer
conceptualized as poor living skills manifested by bad life choices. In others words, in the
academic community it is no longer acceptable to simply blame the devastation of
mentally illness and suicide on the poor living skills of the victims. Science proves it is
much more complex than that.
In a research report (Martin, Tyrer, Kalekzi, & Lancashire, 2008), scientists state,
“ Our results suggest that a combination of several independent risk alleles [genetic
diversity] within the NTRK2 locus [position of a gene] is associated with SA [suicide
attempts] in depressed patients, further supporting a role of neurotrophins [family of
proteins] in the pathophysiology of suicide. In other words, markers of biological
irregularities in depressed patients indicated who was at a higher risk for suicide. Mental
health workers are faced with the consequences of these untreated biological
abnormalities daily. This is unacceptable reality of our modern society and a reality faced
by this county’s frontline mental health workers
In a 1990-1992 national comorbidity study updated and published by the Harvard
School of Medicine (2005), illustrates that the 12-month prevalence of any DSM-IV
disorder in the general population was 32.4% and a lifetime presence of a DSM-IV
33
diagnosis was 57.4%. Of the lifetime prevalence of DSM-IV disorder, 21.4% of those
disorders represent a mood disorder such as bipolar or major depression. The NIMH
(2009) found that in 2004 census report that 26.2% of Americans ages 18 and older —
about one in four adults — suffered from a diagnosable mental disorder in a given year.
Whether the actual number is 22% or 32%, America needs a stable mental health system.
The stress of living in today’s fast passed competitive environment does not come
without stress. The stress on our mental health contributes to loss of sleep, overeating,
high blood pressure, overall compromised health, and anxiety. In an effort to regain
control of the stress, Americans consult with a medical doctor for a solution. Highlighting
the tremendous volume of people seeking medical help for psychiatric concerns, Cherry,
Hing, Woodwell, and Rechtsteiner (2006) report that since 1996, the percentage of visits
to the doctor for depression has increased by 27%. This increase in doctor visits for a
psychiatric issue has helped maintain psychiatric drugs, or antidepressants, as the third
most prescribed drug in America. Depression is so accepted as a normal occurrence in
today’s society, it has even been publicized that Prozac has been prescribed for dogs.
While psychiatric medication is widely prescribed in the U.S., the stigmatization
of the outwardly mentally ill individual is undeniable. If a person displays profound
symptoms indicative of a serious mental health disorder, they are stereotyped as
defective, dangerous, lazy, and too weak to fix their aliment. This widely accepted belief
system, perpetrated by the mass media, complicates the holistic recovery of the
psychiatrically ill individual. The chair of the psychiatry department at Mt. Sinai Medical
34
Center, Ritvo (2001) states, “The erroneous belief furthered by such statements—that
mental illness is a character flaw that one can fix by trying harder—is something that we
have heard time and again from our patients and that frequently disrupts our ability to
provide needed treatment.” Unfortunately, there is no association between the increased
dispensing of psychiatric medication and a decrease in the amount of stigma mental
health consumers are subjected too. It is the knowledge of the frontline community
mental health staff that often opens a window of hope for these marginalized and
oppressed people.
Luckily, not everyone struggling with a mental health disorder finds them self in
need of a community mental health clinic. Nevertheless, the prevalence of our family
members, neighbors, co-workers, and friends struggling with mental illness this year, or
within their lifetime is startling. Sadly, a high number of our fellow citizens become
overwhelmed with the symptoms causing the mental illness and commits suicide. The
importance of having community mental health professionals who are knowledgeable
about the clinical presentation of symptoms cannot be underestimated. A mental health
employee can be the difference between life and death.
35
Chapter 3
METHODS
Research Design and Data Collection
The hypothetical assumption of this exploratory research project is that an
increase in job related knowledge correlates to greater self-determination because of
greater job satisfaction. In other words, the greater a mental health workers basic
knowledge about the target population s/he serves, the greater their ability to deliver the
type of services that promote a positive outcome in their client’s lives. The increase in
positive outcomes will validate an individual’s self-determinist drive to excel as an
employee.
The research design for this needs assessment was a non-randomized and nonequivalent single group design that was a pre-experimental, or “two group posttest only
survey.” The independent variable is the introduction of a “Baseline Knowledge
Manual.” The dependent variables were “quantitative” and “qualitative” post-test results
of a non-reactive self-administered, voluntary, and anonymous survey.
Sampling Plan
The research groups of the posttest only were two non-profit mental health
agencies that consisted of approximately 60 employees located in Sacramento, California.
The study utilized a non-probability and haphazard strategy of acquiring research
participants. With the exception of licensed professions, all employees of Transitional
Living and Community Support (TLCS) and Human Recourses Consortiums (HRC) who
36
offer direct services to mental health consumers were eligible to participate in the twogroup posttest only survey.
The “Baseline Knowledge Manual” contained basic clinical information about the
severe and persistent mental health disorders that are inherent to mental health consumers
(see Appendix A). The experimental group consisted of 18 mental health employees that
received a “Baseline Knowledge Manual” one week before taking a survey (see
Appendix B). Of the 18 individuals in the experimental group, 11 elected to participate.
The control group consisted of 25 willing participants. In its totality, the research
consisted of 36 participates (N=36).
The advantage of using a haphazard strategy in sampling this population of
mental health workers is the commonality of their job duties. Each employee sampled
served the same target population of mental health clients and were required to document
their interventions according to a medical model standard. The disadvantage of the
haphazard strategy is the diversity amongst the agency’s employees. These variables
include age, academic achievement, experiential qualifications, professional experience,
cultural considerations, and belief systems. Licensed professionals in the mental health
agency are not included in the survey. The goal is to focus on employees with less
specialized training.
Measurement
The “Baseline Knowledge Manual” was disturbed to 20 frontline mental health
employees on March 3, 2010. The survey was distributed to both the experimental group
37
and the control group one week later along with a consent form explaining the study and
confidentiality procedures (see Appendix C). The rationale for offering the survey one
week after the manual distribution on was to introduce “a window of opportunity” for the
employee to use the knowledge learned from the manual in their everyday work
environment before judging its usefulness. The self-administered “post test” survey
contained 18 quantitative and two qualitative questions.
The quantitative section of the survey utilized 13 multiple choice and true false
questions. The questions were specific to the mental health domains of psychotic
disorders, mood disorders, personality disorders, and multiaxial knowledge taken from
the Diagnostic Statistical Manual of Mental Disorders (DSM-IV) (American Psychiatric
Association [APA], 2000). The qualitative section of the survey contained five questions
utilizing a five point Likert-type scale ranging from 1 (strongly disagree) to 5 (strongly
agree). The intent of the questions was to provoke people’s opinion about the importance
of job specific knowledge to their professional effectiveness and job satisfaction. The two
remaining questions were qualitative and elicited opinions about future “Baseline
Knowledge Manuals.” I will interpret the qualitative data using non-reactive latent coding
techniques.
Analysis Plan
The data from 18 quantitative questions was analyzed utilizing Microsoft Excel.
The researcher differentiated the results according to groupings of psychotic disorders,
mood disorders, personality disorders, multiaxial knowledge, post high school mental
38
health specific education, and employee opinions. The analysis tools used were
descriptive statistics, histograms, and a summary of the qualitative data. The statistical
significance of each question’s data was analyzed utilizing the “t-test: two tailed
assuming equal variance” statistical tool of measurement. The two qualitative questions
were analyzed by looking for patterns and themes that were similar and different based
on the participants membership in the experimental or control group. A copy of the exact
qualitative response’s can results can be found at the end of chapter 4 for further analysis.
Human Subjects
My human subject’s application was approved on February 10, 2010 as “no risk.”
This “no risk” classification was based on several protective measures built into the data
collection process. First, because of the researcher’s position as a manager at TLCS, the
research was designed as anonymous, confidential, and voluntary. To protect TLCS
employees from the fear of retribution for not participating in the research, they received
a self-sealing blank white envelope. The participants put the envelope containing the
survey in a private mailbox at their place of employment at anytime during the week. No
one would know who did not participate. Second, demographic information was forfeited
to eliminate the potential for identifying information.
At HRC, the research participants were told to put the survey in the white
envelope regardless of filling it out or not. This would eliminate disclosing who was
participating in the survey as the envelopes were collected.
39
Chapter 4
RESULTS
Introduction
Listed in this chapter are the findings obtained from the five domains of mental
health questions that made up questions 1 through 13. The mental health domains
included overall mental health knowledge, psychotic disorder knowledge, mood disorder
knowledge, personality disorder knowledge, and multiaxial knowledge. The first chart is
a listing of descriptive statistics and statistical significance findings that are listed as
percentages. The following 10 histograms capture the varying outcomes of the
experimental group versus the control group in all five domains list above. The five
quantitative questions showed insignificant finding and therefore have been excluded
from this study’s findings. Finally, the two qualitative questions are summarized in the
conclusion of this chapter. The exact response to the qualitative questions can be found
after the chapter’s conclusion.
40
Table 1
Results of all Mental Health Knowledge Domains Analyzed
Experimental
Control Group-
Statistical
Group-Manual
Non Manual
Significance
60%
41%
>.01
Questions
62%
43%
>.05
Mood Disorder Questions
64%
38%
>.01
Questions
36%
30%
*
Multiaxial Knowledge
82%
60%
*
Overall
61%
42%
Overall Knowledge
Psychosis Disorder
Personality Disorder
* Cannot rule out chance
This chart clearly illustrates the overall improvement of the experimental group’s
mental health knowledge compared to the control groups. Overall, mental health research
participants who read the “Baseline Knowledge Manual” proved to have 19% more
clinical mental health knowledge than the research participants who did not receive the
manual.
41
Post-Test Psychotic Disorder Knowledge of the Experimental Group versus Control
Group
Frequency
Histogram
Psychotic Disorder Knowledge/Experimental Group
6
5
4
3
2
1
0
Frequency
1
2
3
4
5
More
Bin
Figure 1. Psychotic disorder knowledge/experimental group.
Histogram
Psychotic Disorder/Control Group
Frequency
10
5
Frequency
0
0
1
2
3
Bin
4
5
More
Figure 2. Psychotic disorder/control group.
The two histograms in Figures 1 and 2 exemplify the significant difference
between psychotic disorder knowledge of the experimental group compared to that of the
42
control group. Eighteen percent (18%) of the experimental group missed over half (three
of five) of the psychotic knowledge questions compared to 64% of the control group.
Thirty-six percent (36%) of the experimental group answered four of five questions
correct compared to 12% of the control group. The manual group proved to have greater
post-manual knowledge than the non-manual group about psychotic disorders that was
statistically significant at >.05.
Post-Test Mood Disorder Knowledge of Experiment Group versus Control Group
Frequency
Histogram
Mood Disorders/Experimental Group
5
4
3
2
1
0
Frequency
1
2
3
4
Bin
Figure 3. Mood disorders/experimental group.
5
More
43
Histogram
Histogram
Mood
Disoreders/Control
Group
Mood Disorders/Control Group
Frequency
15
10
5
Frequency
0
0
1
2
3
Bin
4
5
More
Figure 4. Mood disorders/control group.
The improvement in the mood disorder knowledge was dramatic compared to the
control group. Twenty-seven percent (27%) of the experimental group missed over half
(at least three or five) mood disorder questions compared to the 48% the control group
missed. Thirty-six percent (36%) of research participants in the experimental group
answered four of five mood disorder questions correct compared to 12% in the control
group. The improvement of the experimental groups knowledge versus the control groups
was statistically significant at >.01.
44
Post-Test Overall Mental Health Knowledge of Experimental and Control Groups
Histogram
Overall Knowledge/Experimental Group
Frequency
6
4
2
Frequency
0
2
4
6
8
Bin
10
13
More
Figure 5. Overall knowledge/experimental group.
Frequency
Histogram
Overall Knowledge/Control Group
10
5
Frequency
0
0
2
4
6
8
10
13 More
Bin
Figure 6. Overall knowledge/control group.
The experimental group proved a greater overall knowledge about clinical mental
health that was statistically significant at a >.01 standard of error. Forty-five percent
(45%) of the experimental group missed nearly half (at least 6) of the questions compared
to 72% of the control group. Forty-five percent (45%) of the experimental group got 10
45
of 13 questions correct compared to 27% of the control group. One research participant in
the experimental answered all 13 questions correct compared to 0 in the control group.
Post-Test Personality Disorder Knowledge of the Experimental Group versus Control
Group
Histogram
Personality Disorder Knowledge/Experimental Group
Frequency
10
5
Frequency
0
1
2
3
4
5
More
Bin
Figure 7. Personality disorder knowledge/experimental group.
Histogram
Personality Disorder Knowledge/Control Group
Frequency
15
10
5
Frequency
0
0
1
2
3
Bin
4
5
Figure 8. Personality disorder knowledge/control group.
More
46
While the improvement in personality disorder knowledge was not statistically
significant for the experimental group, the improved knowledge illustrated in the two
questions asked was dramatic. Eighty percent (80%) of the experimental group answered
all the questions correct. The remaining 20% marked that they were unsure of the correct
answer. Technically, not one research participant in the experimental group marked the
wrong answer. Fifty percent (50%) of the control group answered the questions correctly
while the other 50% answer then incorrectly. Not one individual in the control group
marked that they were unsure of the right answer.
Post-test DSM-IV Knowledge of Experimental Group versus Control Group
Histogram
Multiaxial Knowledge/Experimental Group
Frequency
15
10
5
Frequency
0
1
2
3
4
5
Bin
Figure 9. Multiaxial knowledge/experimental group.
More
47
Histogram
Multiaxial Knowledge/Control Group
Frequency
20
15
10
5
Frequency
0
0
1
2
3
Bin
4
5
More
Figure 10. Multiaxial knowledge/control group.
While the improved knowledge about Multiaxial Assessment in the DSM-IV was
not statistically significant for the experimental group, it was dramatic. One-hundred
percent (100%) of the experimental group participates answered the question correctly
while 60% of the control group participants answered the question correctly. Because
there was only one multiaxial knowledge question in the survey, chance could not be
ruled out.
Conclusion
In conclusion, there was statistically significant increased knowledge for the
experimental group in the mental health knowledge domains of “overall knowledge,”
“psychotic disorder knowledge,” and “mood disorder knowledge.” Domains of
“multiaxial knowledge” and “personality disorder knowledge” were not statistically
significant yet the increase in knowledge was substantial. The variable that negatively
influenced the statistical significance of these two domains was the low number of
48
questions asked. On the questions utilizing the Likert-type scale, the findings were not
significant and therefore are not included in the findings of this chapter. Lastly, the
qualitative response to this survey overwhelming validated the importance of a “Baseline
Knowledge Manual” for not only new staff, but also current staff. The suggestions for
content in future “Baseline Knowledge Manual” were numerous and are presented next.
Manual Comments
19. Please offer feedback about the type of mental health content you would like to learn
more about.

General information on types of mental health diagnosis

All of it---I learn every day and would appreciate more clinical information at
least on a monthly basis- Knowledge is Power!!!

The more I learn the more I can better serve our clients

All major disorders/diagnosis’. The signs and signals, triggers and medication that
is recommended for each diagnosis

I would like to know more about Schizophrenia and other Psychotic D/O

Why people placed in higher positions appear to get less intelligent

I would like to learn more about psychotic medications

I would like to learn more about the different medications and how they work and
what they are used for.

And also, more in depth information on illnesses we serve to better understand
our clients.
49
20. Please offer thoughts about the importance of developing a condensed manual of
important mental health facts that “new employees” are required to review before they
are allowed to offer direct services.

I think what is important about a condensed manual is having developing a
“theme” or a “philosophy” such as “being client driven” etc. or using person
experience as well as education, in providing services to clients.

The list of disorders and the symptoms of those disorders is very useful when
doing ACAs and service plans.

I think that people could benefit from a simple section that covers engagement
and how to provide validation of client feelings.

It would assist those who are fairly new to the field.

As long as the manual will be easy to understand and have small enough to carry
w/notebook/binder

Having been in this field for 20+ years, I can strongly agree with a user friendly
manual. It’s a means to a better understanding of mental illness.

It will give new employees feel more competent in the job they do. I also feel that
treating people as people and not as their diagnosis is more important.

Very Important! And not just for new employees but for all employees- it would
serve as a great reference tool.
50
NO Manual Comments
19. Please offer feedback about the type of mental health content you like to learn more
about.

Borderline Personality Disorders

More about trauma/PTSD as it is a new DX that we can now serve here

Interventions specific to various disorders for Non-Clinical support person’s of
adults living with psychiatric disabilities.

Theories of therapy and how to apply them when offering basic case management

I would like to know more about symptoms and diagnosis

Engagement and treatment of those with Schizophrenia

New techniques and approaches

Symptom management tools

Rehab skills

It would be good if at our meeting, we would discuss some Mental health
symptoms

All of it- Borderline and Substance abuse

I’m all for Cliff notes

PTSD and how to treat trauma

Strange survey

Borderline Personality Disorders
51
20. Please offer thoughts about the importance of developing a condensed manual of
important MH facts that new employees are required to review before they are allowed to
offer direct services.

Very important 1-Educate 2 Direction

Someone can be employed as SP with not experience, I think this would be
invaluable

These Questions are stressful

We need new examples of effective coping skills to teach clients

It provides a good foundation

Exceptionally

It would be great to have it

Excellent

I think it will be valuable and help all of the employees stay on the same page
about sx’s, tools etc.

I think that there should be a basic, baseline of knowledge for all employees
including admin and clerical.

Great idea!!! However, do not discount ones experiential knowledge of the field.

Open to the idea of its helpfulness

Great idea. Well needed. Makes staff feel more confident quickly and reduce
likelihood of gaps in their knowledge that could cause problems.
52
Chapter 5
DISCUSSION
The goal of this research project was to highlight the need for a cost effective tool
to increase the clinical knowledge of mental health staff. The population targeted for this
research was frontline mental health workers at two non-profit mental health agencies
located in Sacramento, California. My goal was to develop a viable tool that increased the
research participant’s job specific clinical knowledge about mental health. This
researcher hypothesized that a manual containing basic clinical facts about mental health
would accomplish this feat. With the increase in clinical and job specific knowledge, it
was theorized that the employees of this research project would appreciate an increase in
self-efficacy, professional purpose, and overall job satisfaction. This research project
proved successful in providing the means (knowledge) to the end (increase job
satisfaction).
The Experiment
After securing volunteers from two mental health agencies to participate in the
research, the experimental group was given a “Baseline Knowledge Manual” containing
basic mental health information about the agency’s target population. The target
population included schizophrenia (all five types), schizoaffective, mood disorders,
borderline personality disorder, and posttraumatic stress disorder. The experimental
group consisted of 20 research participants who received a “Baseline Knowledge
Manual,” while the control group consisted of 22 research participants who did not
53
receive the manual. One week after distributing the manual to 20 participants in the
experimental group, all 42 research participants received a survey. The survey contained
20 quantitative and qualitative questions. Of the 42 people that received the voluntary
survey, 36 people elected to participate.
The survey contained questions specific to psychotic disorders, mood disorders,
borderline personality disorder, the multiaxial system of assessment, and the design and
purpose of the “Baseline Knowledge Manual” itself. Thirteen questions were
quantitative, multiple choice, and related to clinical knowledge, five asked for the
research participant’s opinion about the manual utilizing a Likert-type scale for
measurement. Finally, the two qualitative questions elicited participant’s opinion about
the importance of basic mental health knowledge at the onset of employment and what
they would like in future manuals.
The Findings
The experimental group had a higher number of correct answers than the control
group on all thirteen mental health questions. At a statistically significant level, the
experimental group proved more knowledgeable on the domains of psychotic disorders
and mood disorders. Additionally, the experimental group answered all 13 knowledgebased questions with greater accuracy than the control group. This also was statistically
significant at a >.01 standard of error. However, even though the experimental group
outscored the control group on the personality disorder and multiaxial questions, it was
not statistically significant and therefore chance can not ruled out. Overall, the
54
experimental group’s knowledge was superior to the control group by the end of the posttest only experiment. Therefore, this research can conclusively theorize that offering a
“Basic Knowledge Manual’ to new frontline mental health employees will offer an
agency’s workforce the benefits associated with higher levels of job specific knowledge.
These benefits include better customer service, increased employee self-efficacy, higher
productivity, and less employee turnover.
In terms of the employee’s opinions captured using a Likert scale, the results
varied. The research participants were asked if they knew enough about mental health
symptoms when they were hired. Of the 35 respondents who answered this question, 24
(69%) responded they did not have sufficient knowledge while 11 (31%), responded they
did have sufficient knowledge. Next, 22 (64%) of the participants stated that it was “not”
important to understand the clinical knowledge taught in school if they possessed “lots”
of experiential knowledge. The remaining 9 (26%) participants “somewhat agreed” that
the clinical knowledge was not important if they had “lots” of experiential knowledge.
Only 3 (.09%) were adamant that the clinical knowledge taught in school was not
important if they possess experiential knowledge.
Research participants were asked if they would have “loved” to get a “Baseline
Knowledge Manual” as a new employee, 33 (97%) agreed it would have been very
beneficial to them professionally. When asked if the participant had formal college
mental health training, 23 (74%) indicated they had while 7 (23%) indicated they no
formal mental health education. Astonishingly, 5 (14%) research participants refused to
55
indicate if they had formal college education. Finally, research participants were asked if
there was a correlation between increased learning and decreased stress as it related to
their job. Of the 33 participants who chose to answer the question, an overwhelming 26
(79%) agreed that leaning more about mental health reduces their job related stress while
only 5 (21%) disagreed that increased knowledge and decreased stress were related.
There were two qualitative questions eliciting feedback about the “Baseline
Mental Health Manual.” The first question asked research participants about the type of
mental health content they would like to learn more about in future “Baseline Knowledge
Manuals.” The responses varied but were very specific to increased knowledge about
their job, new intervention skills, and a better understanding of the client’s mental health
disposition. The second question asked the research participants to comment on the
importance of implementing a “Baseline Knowledge Manual” at the time or hire for all
new frontline mental health employees. The responses were all positive and reiterated the
importance of a “Baseline Knowledge Manual” for all new frontline mental health
employees. The qualitative comments have been broken divided into 4 categories. These
categories include question 19 or 20, manual group, and non-manual group. The
qualitative responses are located at the end of this chapter.
The Success
This research was successful at proving my hypothesis; A “Baseline Knowledge
Manual” would increase the clinical knowledge of frontline mental health workers. In
fact, with a statistical significance of >.01, the experimental group increased their mental
56
health knowledge by 19% compared to the control group. The “Baseline Knowledge
Manual” proved to be a cost-effective vehicle of delivering an increase in job related
knowledge to the mental health programs surveyed. In addition to the quantitative data,
the qualitative data showed that 97% of employees in both research groups reported they
would have “loved” a “Baseline Knowledge Manual” as a new employee. Seventy-nine
percent of all research participants reported that as their professional knowledge
increased, their professional stress decreased. These numbers serve as compelling
evidence that frontline mental health workers are hungry for job related knowledge. A
“Baseline Knowledge Manual” that is written by an agency for their employees with the
goal of job specific knowledge is a cost effective means of enhancing an agency’s most
important commodity, their employees.
Challenges
Because the research project was voluntary, I could not guarantee that everyone
read the manual before taking the survey. In fact, as I handed out the surveys a few
participants exclaimed they neglected to read the manual. I theorize that the experimental
group would have rated much higher if the manual and a test of its contents were a
condition of employment. I also found it challenging as a program manager of one of the
agencies surveyed because I forfeited the collection of demographic information in favor
of protecting the anonymous nature of the research. My ultimate goal was to protect the
agency employees from undo pressure to participate because of my position of authority.
57
It is my hope that future research will capture and address the variables associated with
demographic findings.
The two domains of “multiaxial knowledge” and “personality disorder
knowledge” were inhibited by the lack of questions in each of the domains. The results
were compelling that the manual increase the experimental group’s knowledge over the
control group, yet it was not statistically significant. The statistically significant domains
had one variable in common, a higher number of questions. In future research, it will be
imperative to standardize an equal amount, and sufficient amount, of questions per
domain to acquire statistical significance.
Future Research
In future research, obtaining demographic information about the employees will
offer greater insight into the strengths and weaknesses of demographic variables in the
experiment. The demographic questions should include a person’s age, length of
experience in the mental health field, historical personal and familial mental health
history, and amount and type of education. I also found that my inability to guarantee that
the manual was read before the survey was disconcerting. I would recommend that future
research offer an incentive to research participants who sign an affidavit attesting they
have read the manual before taking the survey.
Finally, I was dissatisfied with the quality of my questions on the survey. I put a
tremendous amount of time and effort into this research project, but the quality of my
survey questions was poor. I would expect future researchers to challenge the quality of
58
my survey and improve on it. This is my hope, and expectation, as the findings of this
research is replicated.
Researcher’s Thoughts
As with any research, a main function of the research effort is to offer others a
chance to learn from the research and explore ways to do it better. In hindsight, I would
do a few things differently. First, I would write better survey questions that focus solely
on job related questions I would expect research participants to know without reading the
manual. For example, I asked research participants how many people with schizophrenia
commit suicide. While the research participants who read the manual would be expected
to get this question right, those without the manual would unlikely know the answer. My
point is, this is very important information for new employees to know, yet it cannot be
expected that a group of employees void of the manual know this fact.
For future research, I recommend utilizing my manual as a framework for basic
clinical mental health knowledge. However, I would expand the manual to include basic
therapeutic interventions, coping strategies for clients and employees, and an expanded
list of commonly used terms. The goal for a future mental health manual is complicated,
yet obtainable. It is difficult to create a manual that is inclusive of large sums of mental
health information, yet easy to read and not overwhelming to a new employee. Having a
dedicated manual that is specific to a mental health agency’s target population is
obtainable.
59
Finally, I have become completely convinced that a majority of those working
with human suffering and trauma associated with untreated and/or unstable mental health
are unrecognized heroes. It is our obligation as researchers and program leaders to
promote the ongoing knowledge and support in these employees so they can feel
empowered and excited for continuing job related knowledge. This empowerment and
excitement should start at the beginning of employment with a “Baseline Knowledge
Manual” that will serve as a building block that future education and professional skill
can be built on.
Implications to Social Practice
Mental health work is complicated and encompasses an enormous amount of
clinical knowledge that is rarely possessed by any individual regardless of education
and/or experience. This research clearly demonstrated the need for mental health training
at the onset of employment for frontline mental health workers based on the dramatic
improvement of clinical knowledge amongst experienced and/or educated staff. This
study demonstrates that by simply giving an employee a “Baseline Knowledge Manual,”
their job specific knowledge went up nearly 20% compared to those employees who did
not receive the knowledge manual.
We as leaders in the mental health industry must elevate our hardworking and
dedicated frontline employees to bearers of knowledge and skills. While seminars and
schooling are great platforms for increasing knowledge, it is undeniable that neither can
60
accomplish the nearly 20% increase in job specific knowledge that this cost-effective and
time sensitive manual can.
61
APPENDICES
62
APPENDIX A
Baseline Knowledge Manual for New Employee’s of TLCS/HRC
Purpose
The purpose of this manual is to offer fundamental mental health knowledge about the
severe and persistent mental health disorders that complicate our client’s lives. By
understanding the mental health condition inflicted upon our clients, you will enhance
your ability to develop effective treatment plans and increase your ability to communicate
with other mental health practitioners. Regardless if the content of this manual is new or
old; its purpose is the same, to reinforce the clinical data that guides successful
interventions. With a great sense of hope, I honor your inspired and invaluable selfdeterministic drive to help other people thrive, not just survive.
63
BaseLine Knowledge Manual
A Multiaxial system involves an assessment on several axes, each of which refers to a
different domain of information that may help plan treatment. The use of the multiaxial
system provides a convenient format for organizing and communicating the clinical
information, for capturing the complexity of clinical situations and promotes the
application of the biopsychosocial model in clinical, education and research settings.
There are 5 axes included in the DSM-IV multiaxial classification:
Axis I
Clinical Disorders
Other Conditions That May Be a Focus of Clinical Attention
Axis II Personality Disorders
Mental Retardation
Axis III General Medical Conditions
Axis IV Psychosocial and Environmental Problems
Axis V Global Assessment of Functioning
*Note: Axis I disorders often have a primary and a secondary diagnosis attached to them.
For an individual of Sacramento County to qualify for the specialty mental health
services that our programs offer, they must have a primary disorder that meets
Sacramento County’s targeted population criteria.
SACRAMENTO COUNTY TARGET POPULATIONS:
Psychotic Disorders
Schizophrenia-all 5 types
Schizoaffective (schizophrenia with addition of a mood disorder)
Psychosis—Not Otherwise Specified (NOS)
Mood Disorders
Bipolar I
Major Depression Disorder Recurrent (MDDR)
Anxiety Disorder
Posttraumatic Stress Disorder (PTSD)
Personality Disorder
Borderline
64
Target Population Disorders
SCHIZOPHRENIA
Schizophrenia is a disturbance that lasts for at least 6 months and includes at least one
month of active phase symptoms. For much of the time, the disorder has substantially
impaired the individual’s ability to socialize, work or maintain some level of self-care. If
the disorder develops in adolescence, the person tends to fall short of realizing and
achieving normative expected scholastic, social, or occupational status.
The schizophrenia cycle has three phases:
1) Prodromal Phase: before the features of the disorder become obvious, level of
function deteriorates prior to onset of the active psychotic phase.
2) Active Phase (what we typically see): Individual exhibits psychotic features including
hallucinations, delusions and grossly disorganized behavior and speech or negative
features such as flat affect, alogia or avolition (see definitions below).
3) Residual Phase: The individual has either been helped successfully or improved to the
point where they no longer have enough symptoms to ascertain the presence of
schizophrenia.
There are 5 subtypes of schizophrenia:
1) Paranoid type: Persecutory delusions are present, delusions of grandeur, auditory
hallucinations (related to the theme) or an unsubstantiated fear that they well be harmed
or persecuted by others. No negative symptoms are displayed (example, disorganized
speech).
2) Catatonic type: Many basic features similar however, it is the abnormal and striking
physical movements or lack of physical movement that sets this category apart. They may
alternate between extremes of agitation and that of a withdrawn stupor. The individual
may require medical supervision in order to prevent hurting themselves or they may be
unable to ear or drink on their own. They can experience complications from untreated
malnutrition, dehydration, electrolyte disturbances or exhaustion.
3) Disorganized type: Disorganized speech, disorganized behavior and flat or
inappropriate affect are all prominent. Incongruous facial grinning or grimacing is
common. If hallucinations or delusions are present, they are not organized around a
central theme. They may show early signs of difficulty with life problems and this course
tends to be chronic. Early symptoms include deterioration in personal grooming and
inappropriate social behavior.
4) Undifferentiated type: The person has met all the basic criteria for schizophrenia but
not specific criteria for paranoid, disorganized, or catatonic.
65
5) Residual type: The individual continues to exhibit a schizophrenic-like picture but no
current active phase is evident. They must have had one full-blown episode and see
remnants such as emotional blunting, social withdrawal, eccentric behavior, illogical
thinking and loosening of associations.
Positive Symptoms of Schizophrenia: Symptoms that appear to reflect an excess or
distortion of normal functions
1) Delusions: A false belief firmly held. The content of delusions often contain
Grandiose: characterized by fantastical beliefs that one is famous, omnipotent, or
otherwise very powerful. The delusions are generally fantastic, often with a
supernatural,
science-fictional, or religious bent (for example, belief that one is an incarnation of
Jesus
Christ).
Erotomanic: A false belief that another person, usually a stranger, is in love with
him or
her.
Being Controlled: The false belief that one's feelings, beliefs, thoughts, and acts
are
controlled by an external force.
Thought broadcasting: The delusion that everyone can read one’s mind, as though
one’s
thoughts are being broadcasted like a radio wave.
Thought insertion: The delusion that thoughts are being inserted into one’s mind
involuntarily.
2) Hallucinations: false perceptions in a conscious and awake state in the absence of
external stimuli that have qualities of real perception, in that they are vivid, substantial,
and located in external objective space (meaning they can hear, taste, smell, feel, and see
things that have no means to exist to anyone else).
Auditory: The false perceptions of voices and sounds.
Gustatory: The false perception of taste.
Olfactory: The false perception of smells.
Tactile: The false sensation or being touched by someone or something.
Visual: A false perception of objects, people, or events in broad daylight, or
illuminated
environment with eyes wide open.
66
3) Disorganized Speech: Known as a formal thought disorder because the
disorganized speech is representation of disorganized thoughts.
Derailment: (loosening of associations) Random leaping from one topic to another
Incoherence: Unrelated words & thoughts joined with a sentence
Neologism: Condensing or invention of new words
Perseveration: Repeating the same words or phases over & over
Negative Symptoms of Schizophrenia: Thoughts, feelings or behaviors that are
normally present which are diminished or absent. The individual is unaffected by what is
happening around them.
Flat Affect: A severe reduction in emotional expressions.
Alogia: A relative scarcity in the amount of speech or poverty its content.
Avolition: Inability to make goal directed choices. The individual is unresponsive
to the
most basic everyday activities such as personal hygiene
SCHIZOAFFECTIVE DISORDER: a mental condition that causes both a loss of contact
with reality (psychosis) and mood problems. In other words, schizoaffective can be
classified as schizophrenia with a diagnosable mood disorder (manic or depressive
episodes).
MOOD DISORDERS
Mood disorders include disorders that have a disturbance in mood as the predominant
feature. “Mood” is defined as a pervasive and sustained emotion that colors the
perception of the world. Common examples of mood include depression, elation, anger,
and anxiety. Mood episode’s constitute a mood disorder diagnosis.
There are four types of mood episodes:
1) Major depressive episode: At least 2 weeks of depressed mood accompanied by a
characteristic pattern of depressive symptoms.
2) Manic episode: At least one week of exhilarated, heightened, or irritable mood
accompanied by a characteristic symptom pattern.
3) Mixed episode: At least one week of a combination of manic and depressive
symptoms.
4) Hypomanic episode: At least four days of exhilarated, heightened, or irritable mood
that is less extreme than a manic episode (will not quality for specialty mental health).
The three primary Mood Disorders are:
67
1) Major Depressive Disorder: is characterized by one or more Major Depressive
Episodes that can last from months to years. Features can include a despondent mood
most of the day nearly every day, a diminished interest or pleasure in most activities,
significant weight change, insomnia or hypersomnia, psychomotor agitation or
retardation, fatigue and or loss of energy, feeling worthless or excessive guilt, inability to
concentrate, recurring thoughts of death or suicidal ideation, significant distress or
impairment in social, occupational or other important areas of interpersonal functioning.
There is growing evidence that genetics plays a role in the cause of the disorder which is
more common in women than men. Up to 75% who have experienced a major depressive
episode will have it happen again. Major depression is NOT caused by street drugs,
medication, physical illness or alcohol.
2) Dysthymic Disorder (Not Target Population): is characterized by at least 2 years of
depressed mood for more days than not, and accompanied by additional depressive
symptoms that do not meet the criteria for a Major Depressive Episode. Features can
include increased or decreased sleep, increased or decreased appetite, low energy,
hopelessness, poor concentration or decision making ability. Difficulties in relationships
are typical and a low sense of self often contributes to the individual’s vulnerability in
using substances and contemplating suicide.
3) Bipolar Disorders: are characterized by the occurrence of one or more Manic Episodes
or Mixed Episodes. Often, individuals have also had one or more Major Depressive
Episodes. Individuals experience periods of depression and periods of extreme elevated
mood (mania). Bipolar disorder occurs almost equally for men and women and usually
starts in adolescence. There is strong evidence of genetic transmission and children who
have one parent affected have a 30% greater chance of developing a mood disorder
sometime in their lives. Bipolar disorders appear more frequently among higher
socioeconomic status groups and are less affected by psychosocial stressors Bipolar
disorders rarely emerge after the age of 40.
 Bipolar Disorder I (target population) refers to severe manic symptoms
accompanied by one or more periods of major depression. Bi-polar I typically
has a poorer prognosis than Major Depressive Disorder.
 Bipolar Disorder II (not target population) refers to the same symptoms but a
major distinction is the degree of severity, impairment or discomfort in
intrapersonal, interpersonal and occupational functioning. Bipolar II does not
typically lead to psychotic behavior or require hospitalization.
Cyclothymia (not target population) is considered a milder form of bipolar II
and refers to a chronic or cyclic mood disturbance that lasts for at least two
years. Symptoms typically alternate in an irregular fashion and last for days or
weeks. During low mood periods these individuals may be described as ill
humored, peevish or overly sensitive to any criticism. During manic periods a
person may be described as enthusiastic, cheerful or at times, irritable.
68
PERSONALITY DISORDER/S
A personality disorder is an enduring pattern of inner experience and behavior that
deviates markedly from the expectations of the individual’s culture, is pervasive and
inflexible, has an onset in adolescence or early adulthood, is stable over time, and leads to
distress or impairment.
Cluster B: Emotional, Dramatic, or Erratic
1) Borderline: is a pattern of instability in interpersonal relationships, self-image and
affects and marked impulsivity.
 Frantic efforts to avoid being abandoned
 Unstable chaotic relationships
 Impulsive spending , sex, substance abuse
 Suicidal
 Feeling “empty”
 Inappropriate, intense or difficulty controlling anger
 History of mutilation
*Note: See appendix #I for entire listing of Personality Disorders and their traits
ANXIETY DISORDER/S
Anxiety is defined as fear mingled with dread or apprehension about future without
cause. Anxiety disorders are the most common mental disorder and affect 25% of the US
population. They are problematic when significantly interfering with social and
occupational functioning. Anxiety disorders are rarely seen in isolation and
accompanying features include depression, suicidal ideation. Somatic complaints are
common.
There are nine primary anxiety disorders:
PTSD is the only anxiety disorder that qualifies an individual for Sacramento County
Specialty Mental Health services. However, many of our clients have a secondary
diagnosis of these anxiety disorders-please ask question for clarification-it is confusing
when you are new!!!!!!
1) Posttraumatic Stress Disorder (PTSD): is characterized by the re-experiencing of an
extremely traumatic event accompanied by symptoms of increased arousal and by
avoidance of stimuli associated with the trauma. Symptoms must last more than one
month and significantly impact important interpersonal areas such as family interactions
69
and employment. Those suffering from PTSD may not make the connection between
depression, being anxious, abusing drugs, cognitive abilities, domestic violence or marital
problems and the traumatic event.
*Note: See appendix #II for all nine Anxiety Disorders
DEFINITIONS
Co-occurring: the combination of a substance abuse and mental health disorder.
Substance Abuse: See Appendix III
Dual diagnosis: the existence of two or more diagnoses.
Co-morbidity: The presence of one or more disorders (or diseases) in addition to a
primary disease or disorder; or the effect of such additional disorders or diseases on the
primary disease or disorder.
Confidentiality: ensuring that information is accessible only to those authorized to have
access by means of a signed release of information (ROI).
Diathesis: The predisposition to have a mental health disorder and a precipitation event
(stressor) that triggers the mental health disorder
Client Centered Approach (TLCS’s/HRC’s philosophy): A non-directive approach to
helping individuals achieve their goals. They direct their treatment goals, not us.
Etiology: The study of causation or origination. The root cause of a disease/problem.
HIPAA: The Health Insurance Portability and Accountability Act of 1996. A Federal
Law that protects who can access an individual’s health records.
Interpersonal: Being, relating to, or involving relations between persons (outside)
Intrapersonal: Occurring within the individual mind, or self (inside)
Somatic: Relating to, or affecting, the human body
Thought disorder: A consistent disturbance that affects the process or content of thinking,
the use of language, and, consequently, the ability to communicate effectively. This term
is most commonly associated with schizophrenia or other psychotic disorder.
70
Suicide Ideation: Refers to thoughts about suicide. This term does not indicate the
severity of thoughts, or risk that person will kill themselves.
Assessing the lethality risk of Suicide: 1-Previous Attempts
2-Detail of Plan
3-Do they have the means to kill self as
planned?
4-Will they write and sign a no suicide
contact for the next 24 hours?
5150: Involuntary hold at a psychiatric hospital that can last no longer than 72 hours
5250: Involuntary hold granted by a judge that can last no longer than 2 weeks
Stages of Change (or motivation to change)
Assessing your client’s readiness or willingness to change is critical for a successful
intervention. To successful support a client with changing something, you must first
assess which stage of change applies to them. These stages of change can be applied to
yourself, or anyone within your life. The process of changing is the same for all of us.
5- Stages of Change
Precontemplation is the stage at which there is no intention to change behavior in the
foreseeable future. Many individuals in this stage are unaware or underaware of their
problems.
Contemplation is the stage in which people are aware that a problem exists and are
seriously thinking about overcoming it but have not yet made a commitment to take
action.
Preparation is a stage that combines intention and behavioral criteria. Individuals in this
stage are intending to take action in the next month and have unsuccessfully taken action
in the past year.
Action is the stage in which individuals modify their behavior, experiences, or
environment in order to overcome their problems. Action involves the most overt
behavioral changes and requires considerable commitment of time and energy.
Maintenance is the stage in which people work to prevent relapse and consolidate the
gains attained during action. For addictive behaviors, this stage extends from six months
to an indeterminate period past the initial action.
71
72
AGENCY RESOURCES
TLCS offers several programs that provide supportive services to enable individuals with
a psychiatric disability living in a variety of housing programs to achieve the goals they
have set for themselves. The following is a brief description of each of these programs.
Palmer House offers housing a cooperative apartment setting and provides case
management, living skills training, and supportive services.
Carol’s Place is a short term residential facility for homeless adults. It provides 24 hour
staffing and supportive services for all residents.
Downtown Cooperatives provide supportive permanent housing for individuals to live
cooperatively and to reduce the stress and expense of independent living.
Cordosa Village Apartments is a 22 unit supportive housing program for adults with
psychiatric disabilities and their families. Support services include a full time program
advisor on site.
Bell Street Apartments is a multi-unit cooperative living program in an apartment-based
setting. Staff is on-site daily to provide supportive services.
HOPWA (Housing Opportunities for People with AIDS) provides housing and support
services to people diagnosed with AIDS or HIV+ and who are homeless and have a
psychiatric disability.
MICA- (Mentally Ill Chemical Abuser) provides drug and alcohol counseling and
supportive services for individuals and their families.
PACT- (People Achieving Change Together) provides comprehensive case management
services to homeless, dually diagnosed and psychiatrically disabled adults.
Project New Direction provides comprehensive case management, mental health,
substance abuse treatment, and related support services to individuals that need an
intensive level of support while they transition back into mainstream society.
WORK-(Widening Opportunities for Rehabilitation and Knowledge) provides case
management services to adults that have been homeless and are ready to re-enter the
workforce.
T-Core-(Transitional Community Opportunities for Recovery & Engagement) is a
collaboration between Human Resources Consultants, Inc. (HRC) and Transitional
73
Living and Community Support, Inc. (TLCS) to provide outpatient services to those
adults living in Sacramento County who have a mental health diagnosis and require
mental health service.
Additional Information
Appendix I.
PERSONALITY DISORDERS
A personality disorder is an enduring pattern of inner experience and behavior that
deviates markedly from the expectations of the individual’s culture, is pervasive and
inflexible, has an onset in adolescence or early adulthood, is stable over time, and leads to
distress or impairment.
Cluster A: Odd and Eccentric
1) Paranoid: is a pattern of distrust and suspiciousness such that others’ motives are
interpreted as malevolent.
 Others seek to harm them
 Preoccupied with unjust doubts about loyalty
 Reluctant to confide in others
 Reads hidden meanings
 Bears grudges
 Counterattacks or reacts angrily
 Recurrent suspicion about fidelity
2) Schizoid: is a pattern of detachment from social relationships and a restricted range of
emotional expression.
 No desire for close relationships
 Chooses solitary activities
 No interest in sex
 Takes little pleasure in activities
 Lacks friends
 Indifferent to praise or criticism
3) Schizotypal: is a pattern of acute discomfort in close relationships, cognitive or
perceptual distortions, and eccentricities of behavior.
 Ideas of reference
 Odd beliefs
 Unusual perceptions
74




Odd thinking and speech
Suspicious or paranoid ideation
Behavior appears odd or eccentric
Inappropriate affect
Cluster B: Emotional, Dramatic or Erratic
4) Antisocial: is a pattern of disregard for, and violation of, the rights of others.
 Failure to conform to social norms
 Dishonest for own profit and purpose
 Irritability and/or aggression
 Impulsivity
 Reckless disregard for self or others
 Irresponsible
 Lack of remorse
5) Borderline: is a pattern of instability in interpersonal relationships, self-image and
affects and marked impulsivity.
 Frantic efforts to avoid being abandoned
 Unstable chaotic relationships
 Impulsive spending , sex, substance abuse
 Suicidal
 Feeling “empty”
 Inappropriate, intense or difficulty controlling anger
 History of mutilating
6) Histrionic: is a pattern of excessive emotionality and attention seeking.
 Uncomfortable when not center of attention
 Provocative behavior
 Uses physical attraction to draw attention to self
 Self-dramatization
 Rapidly changes shifting emotions
 Highly suggestible
7) Narcissistic: is a pattern of grandiosity, need for admiration and lack of empathy.
 Grandiose
 Fantasizes about unlimited success and power
 Striking sense of entitlement
 Lacks empathy
75




Believes self is “special” while others ordinary
Interpersonal relationships exploited and others manipulated
Envious of others and thinks others jealous of them
Arrogant
Cluster C: Anxious or Fearful
8) Avoidant: is a pattern of social inhibition, feelings of inadequacy, and hypersensitivity
to negative evaluation.
 Avoids meaningful relationships with others
 Unwilling to get involved unless “guaranteed” they will be liked
 Shows restraint because they fear shame or ridicule
 Preoccupied with criticism or rejection
 Feels inadequate
 Views self as inept or inferior
 Reluctant to take risks, might be embarrassed
9) Dependent: is a pattern of submissive and clinging behavior related to an excessive
need to be taken care of.
 Difficulty making everyday decisions
 Desires others to assume responsibility for them
 Lacks initiative
 Excessive length to obtain support from others
 Feels uncomfortable or helpless
 Preoccupied with fears of being left alone
10) Obsessive-Compulsive: is a pattern of preoccupation with orderliness, perfectionism,
and control.

Preoccupied with rules and regulations

Perfection interferes with completion of tasks

Over-conscientious

Hoards objects

Rigid and stubborn

Reluctant to delegate tasks
Appendix II
76
ANXIETY DISORDER’S
Competency based assessment investigates: 1) Physical resources (arousal). 2) Cognitive
(responses) distortions. 3) Coping strategies.
-Anxiety disorder is considered if person’s response is exaggerated in at least one of the
above
-Problematic when significantly interfering with demands of daily living (social &
occupational)
1) Posttraumatic Stress Disorder (PTSD): is characterized by the re-experiencing of an
extremely traumatic event accompanied by symptoms of increased arousal and by
avoidance of stimuli associated with the trauma. Symptoms must last more than one
month and significantly impact important interpersonal areas such as family interactions
and employment. Those suffering from PTSD may not make the connection between
depression, being anxious, abusing drugs, cognitive abilities, domestic violence or marital
problems and the traumatic event.
2) Panic Attack: is a sudden onset of intense apprehension, fearfulness or terror, often
associated with feeling of impeding doom. During a panic attack, symptoms such as
shortness of breath, palpitations, chest pain or discomfort, choking or smothering
sensations and fear of “going crazy” or losing control are present
.
3) Agoraphobia: is anxiety about or avoidance of places or situations from which escape
might be difficult or embarrassing or in which help may not be available in the event of
having a Panic Attack or panic-like symptoms.
4) Specific Phobia: is characterized by clinically significant anxiety provoked by
exposure to a specific feared object or situation, often leading to avoidance behavior.
Fear of snakes, spiders or dogs are examples.
5) Social Phobia: is characterized by clinically significant anxiety provoked by exposure
to certain types of social or performance situations, often leading to avoidance behavior.
6) Obsessive-Compulsive Disorder: is characterized by obsessions which cause marked
anxiety or distress and /or by compulsions which serve to neutralize anxiety. They are
often debilitating, severe enough to be time consuming and cause significant impairment
of life functioning. There are 5 interrelated categories:
 Aggression, morality, sinner or religious doubters- fears of terrible consequences if
everything is not done perfectly.
 Washers-fear contamination and wash frequently or something bad will happen.
 Hoarders can not part with anything or something terrible will happen.
 Checkers, counters and arrangers are ruled by magical thinking and strict need for
order and symmetry.
77

Sex is seen as indecent or a lewd act.
7) Acute Stress Disorder: is characterized by symptoms similar to those of PTSD that
occur immediately in the aftermath of an extremely traumatic event.
8) Generalized Anxiety Disorder: is characterized by at least 6 months of persistent and
excessive anxiety and worry. Individuals tend not to focus on any particular object,
situation or person. Uncontrollable worry is the most salient feature. This occurs in
women two times than it does in men and can occur at any age but most often presents
under the age of 30.
9) Substance Induced Anxiety Disorder: is characterized by prominent symptoms of
anxiety that are judged a direct physiological consequence of drug abuse, a medication,
or toxin exposure.
Appendix III
SUBSTANCE ABUSE AND DEPENDENCY
Use: The use of alcohol and/or drugs without consequences. The idea that illicit drugs are
illegal suggest that people who “use” illegal drugs are abusers because of the inherent
legal risk that they subject themselves to while obtaining and using these substances.
Abuse: Continued use of drugs and/or alcohol despite negative consequence.
Dependence:
Psychological: A person obsessively thinks about obtaining or using the
substance and feels driven to engage in the activity at the expense
of important domains in their life.
Physiological: A person must have the substance in order to avoid
withdrawal symptoms. A person who is dependent on a
substance is addicted and puts obtaining and using the substance
above all else so s/he can feel “normal” or balanced.
78
APPENDIX B
Needs Assessment for a Mental Health Manual
1. Axis III in the DSM represents
a) Personality disorders
b) Clinical Disorders
c) Psychosocial and Environmental Problems
d) General Medical Conditions
e) Unsure
2. What percentage of individuals with schizophrenia commits suicide?
a) 40%
b) 30%
c) 20%
d) 10%
e) Unsure
3. There are ____ subtypes of schizophrenia?
a) 1
b) 2
c) 4
d) 5
e) Unsure
4. Individuals inflicted with schizoaffective have both the positive symptoms of
schizophrenia and a mood disorder.
a) True
b) False
c) Unsure
5. The delusions of schizophrenia are typically persecutory and/or grandiose in theme.
a) True
b) False
c) Unsure
6. Bipolar I refers to severe manic episodes and major depressive episodes.
a) True
b) False
c) Unsure
79
7. Bipolar I typical has a poorer prognosis that major depressive disorder.
a) True
b)False
c) Unsure
8. There is strong evidence of genetic transmission of Bipolar Disorders.
a) True
b) False
c) Unsure
9. Bipolar Disorder rarely emerges after the age of 40.
a) True
b) False
c) Unsure
10. Major Depression Disorder is not caused by street drugs, medication, physical illness,
or alcohol.
a) True
b) False
c) Unsure
11. A “thought disorder” or “formal thought disorder” represent terms used to describe
how
people with a personality disorder process information.
a) True
b) False
c) Unsure
12. Thought broadcasting means verbally expressing delusional thoughts loud enough so
everyone in the immediate area hears them.
a) True
b) False
c) Unsure
13. Borderline personality disorder is the only personality disorder that qualifies an
individual for Sacramento County specialty mental health services.
a) True
b) False
c) Unsure
80
14. When I was a new employee in this agency, I did not know as much as I needed to
about the DSM-IV symptoms that justify a mental health diagnosis.
Strongly Disagree
Disagree
Somewhat Agree
Agree
Strongly Agree
1
2
3
4
5
15. With lots of professional/life experience, it is not as important to understand all the
clinical information taught in school.
Strongly Disagree
Disagree
Somewhat Agree
Agree
Strongly Agree
1
2
3
4
5
16. As a new employee to this agency, I would have loved to get a “baseline skills
manual.”
Strongly Disagree
Disagree
Somewhat Agree
Agree
Strongly Agree
1
2
3
4
5
17. I have had formal (college) mental health training after high school.
a) True
b) False
c) Refuse to answer
18. The more I learn about the disorders that challenge our client ability to meet personal
goals, the less professional stress I feel.
Strongly Disagree
Disagree
Somewhat Agree
Agree
Strongly Agree
1
2
3
4
5
19. Please offer feedback about the type of mental health content you would like to learn
more about.
________________________________________________________________________
________________________________________________________________________
________________________________________________________________________
________________________________________________________________________
________________________________________________________________________
________________________________________________________________________
____________________________________
81
20. Please offer your thoughts about the importance of developing a condensed manual of
important mental health facts that “new employee’s” are required to review before they
are allowed to offer direct services.
________________________________________________________________________
________________________________________________________________________
________________________________________________________________________
________________________________________________________________________
________________________________________________________________________
________________________________________________________________________
____________________________________
82
APPENDIX C
Consent to Participate in Research
Purpose-I, Duane Wright, am a Masters of Social Work (MSW) student at California
State University, Sacramento (CSUS). I am currently employed by Transitional Living
and Community Support (TLCS) as a team leader. This voluntary and anonymous
research survey will investigate the need for a manual of mental health facts that are
summarized in a condensed and easy to read manual. The goal of the research is to
enhance employee job satisfaction. The TLCS and Human Resources Consortium (HRC)
administration teams have approved this research project.
Research procedures-I will survey approximately 40 TLCS/HRC employees to assess the
need for a basic manual of mental health facts. Of the 40 TLCS/HRC employees who
agree to participate, approximately 20 will get a “Baseline Knowledge Manual” one week
before all participates are asked to complete a survey. The survey will ask questions
related to the need for a manual of mental health facts.
Risk-This research is related to my academic endeavors as a social work student, not as
an employee of TLCS/HRC. In an effort to address these concerns, the surveys will not
collect any demographic information. Each potential participant will receive a envelope
to return the survey enhance the anonymous and voluntary nature of this survey. No
personal identifying information will be on the envelope. Once I obtain the surveys, I
will keep them in a locked draw at my personal residence. I will also only present the
survey results as a collection of all the data; no single survey will be highlighted,
although your specific suggestions for a future manual may be quoted as anonymous
feedback. After the research is complete, I will shred all the surveys. Please do not
answer any questions that make you uncomfortable.
Benefits-The short-term goal of this research project is to assess the need for a manual
containing mental health facts that are specific to your job and presented in a format that
is concise and easy to read. The long-term goal of this research is to encourage
additional research on an effective and efficient mental health manual. Ideally, this
manual will enhance job specific knowledge and lead to greater job satisfaction. In other
words, develop a manual of facts that is easy to comprehend and exciting to read.
Confidentiality- You will only sign your name on the consent to participate form. This
form will be confidential and only known to me. Your identity on the consent form only
illustrates your willingness to participate in the research study, nothing more. The survey
you complete will be completely anonymous; no identifying information is collected.
Your ongoing participation continues to be completely voluntary and you may dropout at
any point. After the final research paper is approved, I will shred the individual surveys.
Compensation-You will not receive any compensation for this research.
83
If you have any questions about this research, you may contact Duane Wright at 2477345 (duane-wright@sbcglobal.net) or Dr. Nam at (916) 278-4148
(kisun.nam@csus.edu).
You may decline to be a participant in this study without any consequences. Your
signature below indicates that you have read this page and agree to participate in the
research.
________________________________
____________________
Signature of Participant
Date
84
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