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MODULE 3
The Importance of a Collaborative Relationship

GOAL 3

Participants will understand the importance of collaborative relationships in effective mental health consultation.

OBJECTIVES

After completing Module 3, participants will be able to:

Identify the principles that provide the framework for collaborative relationships.
Identify where key relationships that build effective mental health consultation develop: child and family, child care setting, and community.
Identify the roles that race, culture, sex, gender, and class play in influencing relationships.

KEY CONCEPTS

Collaborative relationships are built on respect, sensitivity, commitment to change, shared goals and decision making, and open communication.
Professional perspectives and experiences that each partner brings to the consultation process help build trust and positive working relationships.
Cultural diversity appropriate to each situation and achieving cultural competency is a critical requirement of the collaborative consultation process.

BACKGROUND INFORMATION: A MINI-LECTURE

In the consultation process, two or more professionals with different areas of expertise come together to solve problems, usually more effectively than if just one works alone to tackle the problem. The mental health consultant and early childhood staff are viewed as experts in their own fields. The consultant has no authority over the early childhood staff, who are free to accept or reject any of the consultant’s suggestions.

In consultation, a productive working relationship is not taken for granted; rather, it develops over time. Strong personal relationships enable a consultant and staff to establish the trust and mutual respect essential to “hearing” each other and being able to discuss issues despite differences of opinion. For more information, see pages 11 and 12 of Volume 1, Early Childhood Mental Health Consultation.

ACTIVITY 3-1

WHAT DOES COLLABORATION MEAN? (WARM-UP) (15 Minutes)

PURPOSE

In this workshop activity, participants will experience the importance of clear communication and the variety of ways that problems can be solved collaboratively.

PREPARATION

ARRANGE FOR:	Easel, chart paper, markers, and masking tape Pieces of string or ribbon cut into 10-inch lengths Pen or pencil for each pair Overhead projector and screen
DUPLICATE:	*HANDOUTS:* Planning Guide 3: Ideas to Take Home Handout 1: Key Elements of Partnership *OVERHEAD:* Overhead 1: Key Elements of Partnership

Leading the Activity

1.	Refer to Planning Guide 3: Ideas to Take Home for participants to continue their note taking and planning process.
2.	Ask the participants to divide into pairs
3.	Give each pair a piece of string or ribbon and a pen or pencil.
4.	Ask participant pairs to hold onto a single, shared pen or pencil, using one hand each.
5.	Tell them that they can communicate with each other but must work as a team. Using their other hands, and working together, they should use the ribbon to tie a bow on the pen or pencil.
6.	Give them 2 minutes to accomplish the task.

Discussion Guide

Discuss the experience with the group using the following key questions:

How did you work together?
What made you feel successful?
What made you feel frustrated?
Were both parties heard?
Was this an equal partnership?
Was this a collaborative process?
Did diversity or culture play a role in the outcome?

Summing Up

Ask the participants to brainstorm (use newsprint) the elements they think are critical for good partnerships (2 minutes). Then pass out Handout 1: Key Elements of Partnership and Overhead 1 with the same name. Reinforce the following general points that lead to a better understanding of the collaborative process:

People approach problems differently.
Clear communication is essential.
Goals should be mutually developed.
Developing a joint strategy leads to greater success.
Avoid blaming and labeling.
Avoid stereotypes.
Everyone has different strengths to bring to the collaborative process.

ACTIVITY 3-2

ESSENTIAL PRINCIPLES OF A COLLABORATIVE RELATIONSHIP (30 Minutes)

PURPOSE

In this activity, participants will explore principles that contribute to the success of relationship-based work between the mental health consultant, staff, and parents.

PREPARATION

ARRANGE FOR:	Overhead projector, screen, and overhead slide showing the 5 principles or a flip chart with the 5 principles written in large print
DUPLICATE:	*HANDOUTS:* Handout 2: Principles of a Consultative Relationship Handout 3: Role-Play Cards *OVERHEAD:* Overhead 2: Principles of a Consultative Relationship

Leading the Activity

1.	Explain that this activity will use brief role plays to focus on essential features that characterize early childhood mental health collaboration. The role plays are very short examples of effective and ineffective collaboration and are exaggerated to make specific points in a humorous way. These role-play characterizations are out of context and do not provide full pictures of a situation. Several principles may apply and both positive and negative approaches may be illustrated. The discussion that follows each role play helps illustrate the many factors that influence successful mental health consultation.
2.	Using Handout 2 and Overhead 2: Principles of a Consultative Relationship or a flip chart listing each principle, review the principles that provide the context for building a collaborative relationship. Read each one, telling participants that they will have a chance to see how these principles facilitate collaboration. However, when these principles are not adhered to, collaboration is much more difficult to achieve. *Principles:* Respect for the person Sensitivity to context Commitment to evolving growth and change Mutuality of shared goals Open communication
3.	Tell participants that the activity is a “fish bowl” where the group gets to watch the action and make a judgment about each role.
4.	Choose 3 or 4 role plays for this activity.
5.	Ask for volunteers to come up to the front one at a time to act out a situation.
6.	Give each volunteer a card (Handout 3: Role-Play Cards) with a role to act out. Tell volunteers that all they have to do is read what is printed on the card. If no one volunteers, act out the first role and ask again for volunteers for the next role play.
7.	Ask participants to watch the role play.
8.	Ask participants to identify which principles are or are not being implemented. Elicit different perspectives; point out the complexity of the collaborative relationship.

Role 1	The mental health consultant says to the staff member, “Hello, I am Dr. Kay. I am your new mental health consultant, and I want to tell you some of the things I can do for you. For instance, I know that you do not have enough rules in your classroom and that is why the children are acting out. I will give you some rules to use.”
Role 2	The staff member says to the mental health consultant, “We all agree that James is having trouble at school and at home and that his mom, Mrs. Smith, wants help. I don’t think you should go to his home on your own. I live near Mrs. Smith and know that the neighborhood is very dangerous, and I am concerned for your safety. Maybe I can pick up Mrs. Smith and bring her to the center, or we can go on the home visit together.”
Role 3	The mental health consultant says to the child care program director, “Based on conversations with the classroom teaching team, I think that staff in the bluebird group are feeling like failures because Tomika is so hard to manage. I will spend more time with them in the classroom to model some new behavior management techniques. I also know about a free evening workshop, ‘Teachers Avoiding Burnout: Strategies for Taking Care of Yourself,’ at the community college. Maybe I can call and get tickets so that your staff can attend the event.”
Role 4	The teacher says to the assistant teacher, “I don’t want that new mental health consultant in our classroom. I don’t quite understand how she can help. I asked her to help us stop Mica from crying all the time, but she said she is going to check out our daily schedule and transitions between activities. I’m not sure what that means—she seems to be blaming us instead of doing something to solve our problem.”
Role 5	The staff member says to the mental health consultant, “I am glad you asked me about Johnny, because what I am really concerned about is his not participating in class. He just doesn’t seem to have any friends. I think we need to figure out ways to get him to feel more comfortable in the group. What do you think we can work on first?”
Role 6	The program director says to the mental health consultant, “You can tell me what you observe in the classroom rather than talk directly with staff. I will convey the information to staff, because they really don’t have any free time to meet with you and because I want to hear your observations before staff do.”

Discussion Guide

Share your own experiences about the complexity of collaboration, illustrating that sometimes the best intentions are not adequate for the situation.
Ask participants to share any experiences they have had with mental health consultation. What has worked well and what has not worked well?

Summing Up

Drawing on points made in the discussion by the group, review each principle with a brief description of its definition (pages 11 and 12 of Early Childhood Mental Health Consultation):

Respect for the person. This principle implies an attitude of positive regard toward individuals, including recognition of both strengths and vulnerabilities.
Sensitivity to context. The staff member and the consultant must understand each other as influencing and being influenced by their environment.
Commitment to evolving growth and change. Consultants must be equally dedicated to promoting the development and mental health of both children and caregivers.
Mutuality of shared goals. Sharing and communicating goals forms the basis for the consulting work. It is an ongoing process that occurs throughout the consultation.
Open communication. The channels and process of communication must be clarified from the beginning of the consultation process. Communication must be regular, frequent, and consistent.

ACTIVITY 3-3

THE ROLES OF CULTURE, RACE, SEX, GENDER, AND CLASS IN INFLUENCING RELATIONSHIPS (TOTAL TIME: 45 Minutes)

A. Your Own Culture (15 Minutes)
B. Diversity and Consultation (30 MINUTES)

PURPOSE

In these activities, participants will explore the importance of culture as an influence on the collaborative process.

PREPARATION

ARRANGE FOR:	Easel, chart paper, markers, and masking tape Overhead projector (if available)
DUPLICATE:	*HANDOUTS:* Handout 4: The Cultural Iceberg Handout 5: Vignette Handout 6: Key Definitions *OVERHEAD:* Overhead 3: The Cultural Iceberg

Leading the Activity

Tell participants that this activity comprises 2 parts:

A.	Your own culture
B.	Diversity and consultation

A. YOUR OWN CULTURE

Ask participants the following questions:

A.	When you were a young child and had a bad cold, how did your family or caregivers respond
B.	What do you do when your own children have colds?

Solicit answers and write key responses on a flip chart. Answers may include orange juice, hot tea, chicken soup, lots of clothing and covers, Vicks rub eaten or put on the chest, open windows, and closed windows.

Ask the group why there are so many different answers and whether some answers are better than others. Ask why the group was unaware of all these perspectives.

Use Overhead 3: The Cultural Iceberg of the iceberg diagram or draw an iceberg on flip chart paper with 1/3 above the “water” line and 2/3 below the line. This example will further illustrate how culture influences who we are, what we do, and what we value and believe. Distribute Handout 4: The Cultural Iceberg.

Ask participants to list the visible attributes of culture, and record their ideas (such as language, foods, skin color, gender, music, and dance) on the top part of the iceberg.

Ask participants to list attributes that are invisible and that go below the water line (such as values, attitudes, religion, health practices, child-rearing beliefs, patterns of superior or subordinate roles, and patterns of handling emotion).

Discussion Guide

Use the following points to guide the large-group discussion:

Emphasize that we all have our own cultural beliefs and customs, based on our experiences. We often repeat what we saw as children because it is familiar or natural. As this exercise illustrates, there are many ways to show we “care,” and it is important that we be aware of the variety of practices and approaches that are considered correct and normative.
Remember to encourage participants to transition their discussion on the intrapersonal and interpersonal aspects of cultural beliefs and customs to the ways in which these aspects manifest in the professional area. Some examples include effective communication across cultures, quality assessments, and formulation of treatment plans and treatment interventions.
Point out that the culturally competent consultant is familiar with how self-help and other concepts might manifest differently among various racial, ethnic, and cultural groups. The consultant acknowledges and respects the significant role assigned to any prominent caregiver (mother, father, extended family member, clergy, and community members). Additionally, the consultant must be informed about valued community resources and natural supports within majority and minority communities.

Summing Up

Emphasize the following points:

Tell participants that we are all influenced in some way by our own experiences, culture, sex, belief system, and class.
Culture is very powerful in determining who we are but is not always visible to others. As the culture iceberg illustrates, the majority of culture is out of conscious awareness.
Denying cultural and belief differences can interfere with building authentic relationships. A willingness to examine these factors helps acknowledge both difference and common ground that can eventually lead to a warm and effective collaboration.
Effective cross-cultural consultants have an awareness of their own personal values and beliefs, a well-developed awareness of their personal ways of both relating to others and showing care and respect, and the ability to adapt interventions appropriately to meet staff members’ and families’ needs.

B. DIVERSITY AND CONSULTATION

Background Information: A Mini-Lecture

To ensure cultural competence among consultants and to promote effective response to the mental health of diverse populations, consultants should obtain knowledge and skills in the following areas:

Understanding of populations’ backgrounds
Clinical issues (differences in symptom expression and nonverbal language)
Provision of appropriate treatment (use of culturally informed individuals and interpreters)
Agency or provider role (personal biases)
Effective communication across cultures (listening and establishing rapport using socially and culturally appropriate conventions)
Provision of quality assessments (using culturally appropriate instruments and other tools)
Formation and implementation of quality care and treatment plans (using culturally appropriate community resources)
Provision of quality treatment (using preferred language)
Using one’s self-knowledge (recognizing one’s own limitations)
Attitudes (demonstrating attitudes that indicate respect for diverse heritages)

Leading the Activity

Pass out Handout 5: Vignette and read the following vignette (point out that this is a real situation): Dr. Shannon, a Caucasian therapist beginning work as a consultant at a preschool program, met for the first time with an experienced Mexican American teacher to discuss the children he had observed. Historically reticent to share “her” children with outsiders, the teacher joined Dr. Shannon for a review of her class, all of whom lived in a poor neighborhood where violence and drug abuse were common. Dr. Shannon chose to address two children as his first concerns. He remarked that one well-liked, African American boy might develop gender identification problems because he wore a diamond earring in his left ear. He also expressed concern that a petite, doll-like Mexican American girl came to school adorned in a party dress, crinolines, and shoes with inch-high heels. He felt that these clothes were inappropriate for a school setting and that her parents might not understand what is developmentally appropriate attire.

Ask the participants to break into small groups.

Have each group choose a recorder and someone to report back to the larger group.

Ask each group to answer the following questions that are posted on a flip chart, provided on Handout 5, or shown on the overhead projector:

Questions:

a.	Why do you think Dr. Shannon chose to focus on these issues?
b.	What might the teacher feel in this situation?
c.	What message might this convey to these children if the recommendation to deal with the appearance of each child moves forward?
d.	Is the consultant being culturally sensitive?
e.	What can be done to turn this situation into a learning opportunity that will lead to better consultation?

After the groups finish deliberating, ask for answers to each question. Encourage discussion of different points of view.

Discussion Guide

As groups present the answers to the questions, ask them to look at the role of cultural empathy (the ability to understand cultural differences and appreciate the cultural perspective of others) and cultural knowledge (the willingness to learn about other cultures). Participants might say that the consultant should be fired. Point out that experienced early childhood mental health consultants are hard to find, that we all learn from our mistakes, and that in a consulting relationship, all parties have some responsibility to help one another learn and grow. Encourage the group to address the last question that asks how to turn this situation into an opportunity for growth and change. Ask the participants whether they have been in similar situations.

Summing Up

Summarize the activity by referring to the principles and pointing out that respect, sensitivity, commitment, and mutuality are critical to dealing effectively with cultural differences. Also make the following points:

The success of collaboration ultimately relies on the personal relationships forged between consultants, staff, and families. Many variables, including race, culture, class, gender, and sex, impact those relationships. It is important to recognize and examine differences and commonalities to develop good relationships.
Cultural understanding is part of an ongoing learning process. It starts with an open-minded approach to learning about oneself and others. A good way to begin the learning process is to ask others to share information about their culture.
The attitude that we are all the same may have a negative impact on the consulting relationship and eventually have a stifling effect on the classroom, where children notice differences and want to address issues of race and culture.
Consultants, staff, and parents can plan together to develop an atmosphere that is rich in promoting cultural diversity and competence. All aspects of the classroom curriculum, program policies and procedures, and open communication among children, staff, families, and consultants lead to better communication and mutual understanding.

Pass out Handout 6: Key Definitions for participants to use as a resource. Encourage participants to use the handout to further clarify the language and concepts of cultural diversity. Remind participants to write notes, ideas, and next steps on this module’s Planning Guide 3.

PLANNING GUIDE 3:
Ideas to Take Home

While the information is still fresh, jot down some notes and ideas to take back home as next steps in planning for mental health consultation:

Good Information:

______________________________________________________

Great Ideas:

______________________________________________________

Next Steps Back Home:

______________________________________________________

HANDOUT 3-1

Key Elements of Partnership

Mutual respect for skills
Honest and clear communication
Understanding and empathy
Mutually agreed-upon goals
Shared planning and decision making
Exchange of resources
Accessibility and responsiveness
Joint evaluation process
Absence of labeling and blame

HANDOUT 3-2

Principles of a Consultative Relationship

Respect for the person.
This principle implies an attitude of positive regard toward individuals, including recognition of both strengths and vulnerabilities.
Sensitivity to context.
The staff member and consultant must understand each other as influencing and being influenced by their environment.
Commitment to evolving growth and change.
Consultants must be equally dedicated to promoting the development and mental health of both children and caregivers.
Mutuality of shared goals.
Sharing and communicating goals forms the basis for the consulting work. It is an ongoing process that occurs throughout the consultation.
Open communication.
The channels and process of communication must be clarified from the beginning of the consultation process. Communication must be regular, frequent, and consistent.

HANDOUT 3-3
ROLE-PLAY CARDS

Role 1
The mental health consultant says to the staff member, “Hello, I am Dr. Kay. I am your new mental health consultant, and I want to tell you some of the things I can do for you. For instance, I know that you do not have enough rules in your classroom and that is why the children are acting out. I will give you some rules to use.”

Role 2
The staff member says to the mental health consultant, “We all agree that James is having trouble at school and at home and that his mom, Mrs. Smith, wants help. I don’t think you should go to his home on your own. I live near Mrs. Smith and know that the neighborhood is very dangerous, and I am concerned for your safety. Maybe I can pick up Mrs. Smith and bring her to the center, or we can go on the home visit together.”

Role 3
The mental health consultant says to the child care program director, “On the basis of conversations with the classroom teaching team, I think that staff in the bluebird group are feeling like failures because Tomika is so hard to manage. I will spend more time with them in the classroom to model some new behavior management techniques. I also know about a free evening workshop, ‘Teachers Avoiding Burnout: Strategies for Taking Care of Yourself,’ at the community college. Maybe I can call and get tickets so that your staff can attend the event.”

Role 4
The teacher says to the assistant teacher, “I don’t want that new mental health consultant in our classroom. I don’t quite understand how she can help. I asked her to help us stop Mica from crying all the time, but she said she is going to check out our daily schedule and transitions between activities. I’m not sure what that means—she seems to be blaming us instead of doing something to solve our problem.”

Role 5
The staff member says to the mental health consultant, “I am glad you asked me about Johnny, because what I am really concerned about is his not participating in class. He just doesn’t seem to have any friends. I think we need to figure out ways to get him to feel more comfortable in the group. What do you think we can work on first?”

Role 6
The program director says to the consultant, “You can tell me what you observe in the classroom rather than talk directly with staff. I will convey the information to staff, because they really don’t have any free time to meet with you and because I want to hear your observations before staff do.”

HANDOUT 3-4
The Cultural Iceberg

Handout 3-5
Vignette

READ THE FOLLOWING VIGNETTE AND DISCUSS THE KEY QUESTIONS.

Dr. Shannon, a Caucasian therapist beginning work as a consultant at a preschool program, met for the first time with an experienced Mexican American teacher to discuss the children he had observed. Historically reticent to share “her” children with outsiders, the teacher joined Dr. Shannon for a review of her class, all of whom lived in a poor neighborhood where violence and drug abuse were common. Dr. Shannon chose to address two children as his first concerns. He remarked that one well-liked, African American boy might develop gender identification problems because he wore a diamond earring in his left ear. He also expressed concern that a petite, doll-like Mexican American girl came to school adorned in a party dress, crinolines, and shoes with inch-high heels. He felt that these clothes were inappropriate for a school setting and that her parents might not understand what is developmentally appropriate attire.

QUESTIONS:

A.	Why do you think Dr. Shannon chose to focus on these issues?
B.	What might the teacher feel in this situation?
C.	What message might this convey to these children if the recommendation to deal with the appearance of each child moves forward?
D.	Is the consultant being culturally sensitive?
E.	What can be done to turn this situation into a learning opportunity that will lead to better consultation?

HANDOUT 3-6
Key Definitions

Acculturation: Cultural modification of an individual, group, or people by adapting or borrowing traits from another culture; a merging of cultures as a result of prolonged contact.

Assimilation: To assume the cultural traditions of a given people or group.

Bi-cultural: The ability to understand and function effectively in two or more cultural environments. An individual who is bi-cultural is not necessarily culturally competent.

Bilingual: The ability to speak effectively in two or more languages. Individuals who are involved in serving limited English-proficient persons shall be certified to do so.

Competence: The application of knowledge and the interpersonal, decision-making, and psychomotor skills expected for the practice role (National Council of State Boards of Nursing, Inc., 1996).

Competent: Properly or well qualified and capable.

Culture: The integrated pattern of human behavior that includes thought, communication, actions, customs, beliefs, values, and institutions of a racial, ethnic, religious, or social group. Culture defines the preferred ways to meet needs.

Cultural Competency: An acceptance and respect for difference, a continuing self-assessment regarding culture, a regard for and attention to the dynamics of difference, engagement in ongoing development of cultural knowledge, and resources and flexibility within service models to work toward better meeting the needs of minority populations.

Cultural Sensitivity: Understanding the needs and emotions of your own culture and the culture of others.

Ethnic: Of or relating to large groups of people classed according to common racial, national, tribal, religious, linguistic, or cultural origin or background.

Ethnicity: Ethnic quality or affiliation.

Race: There is an array of different beliefs about the definition of race and what race means within social, political, and biological contexts. The following definitions are representative of these perspectives:

A tribe, people, or nation belonging to the same stock; a division of humankind possessing traits that are transmissible by descent and sufficient to characterize it as a distinctive human type.
Race is a social construct used to separate the world’s peoples. There is only one race, the human race, comprising individuals and characteristics that are more or less similar to others.
Evidence from the Human Genome project indicates that the genetic code for all human beings is 99.9% identical; there are more differences within groups (or races) than across groups.

Definitions 1 and 2 and 9–12 taken from Tawara D. Goode, Georgetown University Child Development Center, Center for Child Health and Mental Health Policy, University Affiliated Program, 1997, Revised 2000.

Definitions 3–8 taken from from Cultural Competence Standards In Managed Mental Health Care Services: Four Underserved/Underrepresented Racial/Ethnic Groups, Center for Mental Health Services, Substance Abuse and Mental Health Services Administration, U.S. Department of Health and Human Services. To obtain a copy, call 1-800-789-2497 or mentalhealth.samhsa.gov to view Standards online.

Other valuable information can be found in Towards A Culturally Competent System of Care: A Monograph on Effective Services for Minority Children Who Are Severely Emotionally Disturbed (1989). Written by Cross, T.L., B.J. Bazron, K.W. Dennis, and M.R. Isaacs. Available through Georgetown University Center for Child and Human Development, www.gucchd.georgetown.edu.

Key Elements of Partnership

Mutual respect for skills
Honest and clear communication
Understanding and empathy
Mutually agreed-upon goals
Shared planning and decision making
Exchange of resources
Accessibility and responsiveness
Joint evaluation process
Absence of labeling and blame

Principles of a Consultative Relationship

Respect for the person.
This principle implies an attitude of positive regard toward individuals, including recognition of both strengths and vulnerabilities.
Sensitivity to context.
The staff member and the consultant must understand each other as influencing and being influenced by their environment.
Commitment to evolving growth and change.
Consultants must be equally dedicated to promoting the development and mental health of both children and caregivers.
Mutuality of shared goals.
Sharing and communicating goals forms the basis for the consulting work. It is an ongoing process that occurs throughout the consultation.
Open communication.
The channels and process of communication must be clarified from the beginning of the consultation process. Communication must be regular and consistent.

The Cultural Iceberg

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MODULE 3 The Importance of a Collaborative Relationship

MODULE 3
The Importance of a Collaborative Relationship