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THE FAMILIES AND DEMOCRACY AND

CITIZEN HEALTH CARE PROJECT

William J. Doherty

Tai J. Mendenhall

Jerica M. Berge

University of Minnesota

 

Journal of Marital and Family Therapy, 2009, in press.

 

This paper describes and updates the work of the Families and Democracy and Citizen Health Care Project, which engages with community concerns in order to effect change on many system levels.  The project draws on family therapy’s tradition of interest in larger social issues and adds democratic public theory and community organizing strategies.  Since 1999 we have developed 14 citizen initiatives with a wide range of groups on a diverse set of problem areas.  The paper addresses research and evaluation issues and opportunities for marriage and family therapists to learn how to do this work in their own communities.

            Family therapy began as a movement—not just as another way to do clinical practice. Pioneers like Gregory Bateson and Virginia Satir were interested in larger social issues and wanted to make a difference beyond conventional mental health practice. They saw systems theory as something bigger than family dynamics alone. But this broader vision became difficult to sustain as the field matured, professionalized, and fought for its place in reimbursement systems.  This paper describes the origins and latest work of the Families and Democracy and Citizen Health Care Project, which engages with community concerns in order to effect change on many system levels.  Since 1999 we have developed 13 citizen initiatives with a wide range of groups on a diverse set of problem areas, and have begun to train family therapists and other professionals in a new form of community organizing.  

ORIGINS OF THE PROJECT

            As mentioned, pioneers as different as Bateson (1972), Bowen (1976), Auerswald (1968), Satir (1972), and Minuchin and his colleagues (1967) sought to understand and influence the larger social world that families live in. Subsequent innovators extended this vision through the lenses of feminism, race, global politics, and narrative therapy (Boyd-Franklin, 1989; Gould & DeMuth, 1994; Hardy, 2001; Hare-Mustin, 1978; Madigan & Epston, 1995; Walters, Carter, Papp & Silverstein, 1988; White & Epston, 1990.). More recent developments include the work of Almeida, Vecchio and Parker (2008) on social justice and family therapy; Rojano’s (2004) model of Community Family Therapy to engage urban, low income families; and Landau’s (2007) “Linking Human Systems Community Resilience Model,” which specializes in work with communities that have undergone rapid transition or traumatic loss.

          In addition to building on these pioneers in family therapy, our work draws on democratic public theory and community organizing strategies. Our exposure to these fields began in the mid-1990s and was informed by the Public Work Model, developed by Harry Boyte, Nancy Kari, Nancy Shelton and their colleagues at the Center for Democracy and Citizenship at the University of Minnesota (Boyte, 2004; Boyte & Kari, 1996; Boyte, Kari, Lewis, Skelton & O’Donoghue, 2000). The following description of the Public Work model is adapted from Doherty & Carroll (2002):

Harry Boyte, a political theorist who was schooled in the civil rights struggles of the 1960s and the Saul Alinsky tradition of community organizing, moved from a radical-left political philosophy in the 1970s to what he called a “new populism” in the 1980s and 1990s. The Public Work Model brings together strands of American Pragmatism (e.g., Dewey, 1997), public realm theorists such as Hannah Arendt (1958) and Jurgen Habermas (1979), and related philosophical and theological traditions dealing with humans as “homo faber” (constructing the world). The model has three principal orientating ideas:

• Human beings as producers or co-creators of the world. Public work is defined as sustained, visible, and serious effort by a diverse mix of ordinary people that creates things of lasting civic or public significance. In contrast, the provider/consumer dynamic of American culture renders people passive recipients of services (from professionals, the state, and the market) rather than co-creators of important work.
• The importance of public life. Without denying the importance of the intimate sphere of family and friends, the model emphasizes the role of a public life to a full human life. Private life cannot be cut off from the public life in the “commons,” and the privatization of contemporary life leads to the unhealthy dominance of the market and the state over human affairs.
• Democratic, relational power. Ordinary people working together can influence, through “civic muscle,” the world of institutions, professions, and the marketplace. “Democracy” in this sense is not just about voting and volunteering as a private citizen; it is about joining with other citizens to build a robust public world. Although not timid about conflict, the model stresses the development of relationships of mutual interest and collaborative energy to work on public solutions, in contrast to the traditional politics of protest.

The Public Work model sensitized us to the civic and citizenship arenas of health care beyond the traditional clinical setting. We moved away from the language of “intervention” to that of “citizen work”; we think of ourselves as citizen professionals developing initiatives with other citizens and especially with families as citizens. We also became sensitized to the limitations of conventional interdisciplinary, collaborative models of clinical care because the culture of health care emphasizes provider/consumer relationships. In particular, collaborative, wrap-around services and larger systems interventions generally do not move past the provider/consumer hierarchy, and the emphasis remains on care provided for one patient or family at a time. Similarly, we grew wary of advocacy approaches to social change in which the expert professional attempts to obtain resources on behalf of passive communities. Engaging families and citizens as co-creators of health care and cultural change, we concluded, would mean developing new ways of working. That is where the community organizing tradition became appealing.

Modern community organizing originated with Saul Alinsky (1946) and those who followed him in the Industrial Areas Foundation (IAF) and subsequent groups. Contemporary community organizing has moved past Alinsky’s politics of protest and instead emphasizes the renewal of local democracy, the reorganization of relationships between power and politics, and the restructuring of the physical and civic infrastructures of communities (Warren, 2001). From the IAF we learned the importance of listening to individuals and families to determine what is of most importance to them, to work closely with them around understanding a problem before generating action solutions, and to continually identify and develop new leaders in health care settings and communities. Unlike most community organizing approaches, which have been mistrustful of professionals (often for good reason), ours maintains a role for professionals as partners and, at the outset, catalytic leaders. Of course we are not alone in working towards more collaborative approaches to professional/community partnerships.  For example, the Healthy Communities 2010 initiative has stimulated innovations across the United States (http://www.healthypeople.gov/Publications/HealthyCommunities2001/default.htm).  There is there is a rich tradition of Community Oriented Primary Care in medicine (Harper, Baker & Reif, 2001), and important social justice efforts in counseling psychology (Aldarondo, 2007).

OVERVIEW OF THE MODEL

We refer to the overall framework as The Families and Democracy Model. As applied to health care, we call it Citizen Health Care. As described elsewhere (Doherty & Carroll, 2002, 2006; Doherty & Mendenhall, 2006), the model includes six guiding principles and seven core strategies for implementing citizen action initiatives. It stresses the importance of civic engagement to strengthen family life, emphasizes the need to transcend traditional provider/consumer models of health care and professional service delivery, and offers a vision of families and professionals together creating public initiatives. Here are the main principles:

• The greatest untapped resource for strengthening families and improving health care is the knowledge, wisdom, and lived experience of individuals, families, and communities who are facing difficult challenges in their everyday lives.
• People must be engaged as co-producers of health care and community change, not just as patients or consumers of services.
• Professionals can play a catalytic role in fostering citizen initiatives when they develop their public skills as citizen professionals in groups with flattened hierarchies.
• If you begin with an established program, you will not end up with an initiative that is "owned and operated" by citizens. But a citizen initiative might create or adopt a program as one of its activities.
• Local communities must retrieve their own historical, cultural, and religious traditions of health and healing, and bring these into dialogue with contemporary health care and other community systems.
• Citizen initiatives should have a bold vision (a BHAG—a big, hairy, audacious goal) while working pragmatically on focused, specific projects.

We implement these principles through democratic, small group strategies that lead to collective action. We are vigilant about the ever-present risk of lapsing back into a traditional program and professional service models, and we avoid the typical “volunteer” approach that involves people as helpers but not as productive citizens. Here are the core implementation strategies:

• Employ democratic planning and decision making at every step.
• Emphasize mutual teaching and learning among families.
• Create ways to fold new learnings back into the community.
• Continually identify and develop new leaders.
• Use professional expertise selectively—“on tap,” not “on top.”
• Generate public visibility through media and community events.
• Forge a sense of larger purpose beyond helping immediate participants.

           Recently we have developed a less academic way to articulate these principles and strategies as we found the original versions challenging for in communities where many members do not speak English as their first language and where citizen action group members do not have high levels of education. Table 1 contains this version of the core principles, which has become our preferred way to describe the model to all community groups.  Table 2 contains more details about the implementation strategies. 

           The therapist in this work is a citizen professional who provides leadership in initiating projects along with facilitation of the process. A combination of leadership and flattened hierarchy is a distinctive and difficult-to-learn feature. Although each project develops citizen leaders, at the outset the professional brings a democratic vision and set of public skills to the process of identifying key issues of concern to the community and to mobilizing citizen groups to work on these concerns. However, the professional does not control the outcome of the group process. In addition, the therapist does not over-function by doing work that other community members can and should do, reflecting a classic motto in community organizing: “Don’t say what someone else in the community could say, and don’t do what someone else in the community could do.” In terms of time commitment, it takes about 6-8 hours per month of time for the therapist/professional to help most projects to come to fruition, and can therefore be carried out alongside a regular clinical practice or academic career.

           Although all helping professionals can learn to do Families and Democracy work, we have found that family therapists have something distinctive to offer from our clinical training. Systems thinking is obviously the main advantage.  We are also used to working in groups of family members and not just one-to-one. Thus we know how to connect with multiple people who often begin with different needs and agendas; we have skills in forging a common purpose across diverging purposes. We know how to create processes where everyone has a voice and where powerful individuals do not dominate the dialogue. We know how to ask key questions of a group of people and let the interaction flow to surprising places that we could not have anticipated in advance.  We know how to be central to the process when necessary to keep it productive, and how to be peripheral when we are getting in the way. In other words, there is continuity between the knowledge and skills set of marriage and family therapists and this work of the citizen professional. 

THE PROJECTS

           A key point in implementing projects is the delineation of the community to be involved in a project. Here the model reflects the influence of the community organizing tradition and its emphasis on mobilizing relatively small communities where a group of citizen organizers can potentially know many of the stakeholders, or at least have access to them. Our approach is not as suitable for entire metro areas where few ordinary citizens would be networked broadly. We have found that a clinic population often serves as a good community boundary for Citizen Health Care initiatives—and within that clinic community, a sub-community of people dealing with the same health issues, such as diabetes or depression. In a new project, we might start with a clinic and then engage a larger local community, but even then we will work with a sub-community of people facing a common challenge. Other projects outside of health care systems that we have initiated have involved a cultural community in a mid-sized town, and parents in urban neighborhoods. The point here is that the project begins when there is an issue of great concern to everyday citizens in an identifiable community—and is an issue that the therapist or other professionals care deeply about as well.

            Table 3 summarizes 14 Families and Democracy and Citizen Health Care projects. They range in topics from middle class cultural issues such as overscheduled kids and out-of-control birthday parties (Anderson & Doherty, 2005) to health care issues such as diabetes (Mendenhall & Doherty, 2002; 2007; in-press) to challenges faced by populations of unmarried fathers. Community populations have included European Americans, African Americans, American Indians, Southeast Asians, and African immigrants. Social class has varied from upper middle class to low SES groups. Without exception, we have found the principles and strategies acceptable and engaged with—including the language of “citizen” with groups who are not legal citizens but embrace the term in its expansive form—“we the people” working together to solve our common problems. The following descriptions give details on three projects: two in health care and one on a cultural challenge facing middle class families.  Each description contains different kinds of information and detail to illustrate the range of Families and Democracy/Citizen Health Care projects.

Department of Indian Work/Family Education & Diabetes Series (“FEDS”)

            American Indian community leaders and tribal elders in the Minneapolis/St. Paul area were worried about the ever-increasing prevalence of diabetes and its impact on their people. Its pervasiveness was made even more alarming by the acquiescent sense of defeat that many American Indians communicated—that diabetes is expected and not preventable. Providers working with members of the American Indian community shared similar concerns, and were frustrated with the failure of conventional care and educational programs. The following description of the process of initiating a Citizen Health Care project on this area is adapted and updated from Mendenhall & Doherty (2005) and Doherty & Mendenhall (2006):

Tai Mendenhall and leaders in the St. Paul Department of Indian Work (Nan LittleWalker, Betty GreenCrow, Sheila WhiteEagle, and Steve BrownOwl) approached this challenge with a community-based participatory research approach, using Citizen Health Care as a guide. Considerable effort was spent in designing a partnership with providers that was very different than conventional top-down models of care. American Indian community members succeeded in sensitizing clinical researchers regarding the process, pace, and importance of building trust within American Indian circles. As the team engaged in a series of meetings, discussions, and American Indian community events, this trust evolved. Researchers learned about American Indian culture, the diversity of cultures/tribes within this larger frame (e.g., Dakota, Ojibwe, Hocak), belief systems, and manners—all because they were allowed into the American Indian community itself. In turn, community members gained more insight regarding how Western medicine is oriented, and thereby gained insight into providers’ habitudes and perspectives in care delivery.

The Department of Indian Work’s (DIW) Family Education & Diabetes Series was designed and implemented as a supplement to standard care for members of the American Indian community touched by diabetes. Patients, their families (spouses, parents, children), and providers (physicians, nurses, dieticians, mental health personnel) come together every other week for an evening of fellowship, education, and support. Generally 6-7 providers, 4-5 tribal elders, and 30-35 community members attend. Meetings begin with members checking and recording each other’s blood sugars, weight, body mass index, and conducting foot checks. Participants cook meals together that are consistent with American Indian culture and tradition, and a great deal of discussion is put forth regarding the meal’s ingredients, portion sizes, and relevance to diabetes. Educational sequences follow (which are designed according to participants’ interests and wants), and take place in talking circles and a variety of lively activities (e.g., traditional and modern music, chair dancing and aerobics, impromptu theater/role-plays). Instructional topics are similarly diverse, e.g., basic diabetes education, obesity, foot care, stress management, exercise, family relationships, retinopathy, dental care, and resources to facilitate access to medical services and supplies. FEDS evenings conclude with devoted time for informal sharing and support. These bi-weekly series are scheduled to last for three hours, but most participants arrive early and stay late.

Clinical and lay participants in FEDS worked collaboratively throughout every stage of the initiative’s development—from early efforts in relationship-building and establishing mutual respect and trust, to brainstorming the program’s design, educational foci and formats, public visibility, implementation, and ongoing modifications. The DIW and its clinical collaborators are now working to extend their efforts to create new programs in areas of the American Indian community that are not readily reached by state or reservation-sponsored care systems (e.g., inner-city, low-income American Indians).

Discontents among Middle Class Parents: The Case of Overscheduled Kids

            For many middle class children, childhood is becoming a rat-race of hyperscheduling, overbusyness, and loss of family time (Anderson & Doherty, 2005). The following description of the process of initiating a Families and Democracy project on this area is adapted and updated from Anderson & Doherty (2005):

Bill Doherty was invited to give a keynote talk to a large conference for parents in Wayzata, Minnesota on the topic of family time and family rituals. In his presentation, Doherty raised up the problem of the loss of family time to outside activities for children, and the importance of taking back family life from overscheduled family hyperactivity and the consumer culture of childhood. Parents responded enthusiastically to the message, but seemed at a loss about how to turn back the tide of over-busyness. Several school and community officials reflected in private that their organizations unintentionally contribute to this problem by offering more and more activities for children and youth, without alerting parents to the inevitable toll on family time that these activities take.

            Later, Doherty was invited to return the next spring to give a similar talk as part of a lecture series on parenting. He declined, saying that he only gives the same talk once in a community, but that if Wayzata wanted to organize to take action on the problem, he would return to help with that process. In subsequent discussions with Barbara Carlson, the local leader who made the invitation, Doherty suggested an approach to civic engagement based on the Public Work Model.

            Doherty then gave a presentation and facilitated a town meeting for which Barbara Carlson and her colleagues had extensively advertised and recruited parents and community leaders to attend. About 300 parents attended, and afterwards > 80 people went to a smaller room for the town meeting. Consensus emerged that the problem of declining family time was a community problem, not just an individual family problem. At the end of the town meeting, parents and community leaders signed up for a leadership and planning group to provide leadership for a grass roots movement to make family life a higher priority in their community. Putting Family First was the name given to this community initiative; the organization is now independent and ongoing (www.PuttingFamilyFirst.org). This was the launching of the first community project in the country on the problem of overscheduled kids and underconnected families.

Over the next year the leadership group set about developing a mission, a desired future, and a vision of what the community could be if both individual families and community institutions put family first. The leadership group took the important step of conducting stakeholder interviews throughout the community in order to understand how members of the community saw the problem, what resources or solutions they had for tackling the problem, and whether or not they would be interested in joining future initiatives.

            During the following spring, Putting Family First held a public “launch event” to announce the initiative and to generate media attention. Community action initiatives were presented and attendees were invited to participate in putting the new initiatives on the ground, with the previous leadership team splitting up and serving as leaders to the new initiatives. There were several initiatives that developed from this process: a Putting Family First Seal of Approval, which would be given to organizations and businesses whose policies and practices support balancing outside activities with family time; a Consumer Guide which provided parents with a detailed analysis of the time and financial demands of local children’s activities such as sports and music programs which helped parents to make informed choices about what to enroll their children in; a faith community partnership; an on-line internet discussion group for parents; a book titled Putting Family First: Successful Strategies for Reclaiming Family Life in a Hurry-Up World (Doherty & Carlson, 2002); and a focused approach to generating intense media attention around the subject of family time and about the initiative both locally and nationally.

Putting Family First stimulated a national conversation about a problem that had been named by a grass roots group of parents. It coined the term “overscheduled kids” and put it into the American lexicon. And it inspired at least a dozen other community initiatives locally and nationally, including family dinner initiatives (e.g., Eat.Talk.Connect in Minnesota); annual Family Nights during which all community activities are cancelled so that families can be together as families (e.g., Ready.Set.Relax in Ridgewood, New Jersey); and a parent-led boycott of Sunday youth sports in Carver County Minnesota (BalanceforSuccess.org).

STORKS: Sisters Together Overachieving in Raising Kids        

Jerica Berge was approached by several nurses within her family medicine clinic in an inner city neighborhood regarding their frustration with trying to help young teenage mothers in the clinic community with parenting. Commonly at medical visits the nurses would notice in the young mothers’ self-doubt, naïve parenting skills, permissiveness, and a lack of motivation to provide for their family. These observations caused the nurses to worry about the fate of the next generation of children. Several of the nurses themselves had been single mothers and shared stories about how they were able to overcome the difficulties of raising their children on their own through community support.  One nurse described a time-dollars community of sorts (for every hour you spend doing something for someone in your community, you earn one “Time Dollar”. Then you have a Time Dollar to spend on having someone do something for you) (www.timebanks.org/ www.timekeeper.org/whatis.html; www.islandcounty.net/health/timedollars.html For instance, when this nurse was a young single mother trying to increase her potential to provide for her family, she traded off child care with a neighbor in order to go to school to get her nursing degree while she offered her skills in hair braiding to the neighbor and her children in exchange.  The nurses in the clinic wanted to create a similar community for the teenage mothers in the clinic.  This primarily African American community identified the need of taking more responsibility as a community in raising the next generation as an issue, based on their cultural philosophy of “it takes a community to raise a village”. 

Berge met with the nurses and other providers (staff physicians, medical residents, and mental health staff) and identified this issue as a community pressure point and something they wanted to commit to doing something about.  Over the course of four monthly meetings the group worked to identify community clinic members who could add their lived expertise to this initiative. Providers nominated several teenage mothers who were effectively parenting their children and who appeared to maintain solid self esteem and progress in working towards improving their ability to provide for their family—and asked them to join the group as mentors for other young teenage mothers who were struggling.  The professionals and teenage mentors worked together collaboratively throughout the process of creating this initiative (STORKS). The teenage mentors, nurses (who were both mentors and providers), physicians, and mental health staff met monthly for over 6 months to: (a) explore the community and citizen dimensions regarding single parenting and raising the next generation, (b) create a name and mission, (c) conduct one-to-one interviews with a range of stakeholders, and to (d) decide on specific action initiatives and implementation strategies.

During regular medical visits other teenage mothers from the clinic, who were struggling with mothering, were invited to become involved with the STORKS initiative. The mentoring teenage mothers would then contact the potential new members to initiate a connection and mentoring relationship. There were three main components of this initiative: (1) regular phone calls, one-on-one visits, or emails between the mentoring teenage mothers and struggling mothers for support and coaching, (2) a time-dollars element in which all members of the STORKS initiative participated in exchanging goods, skills and talents with each other, and (3) bi-weekly meetings with the struggling teenage mothers to discuss parenting skills. The mentoring teenage mothers took part in the meetings by co-teaching parenting skills with Berge and organizing the time-dollars component of the initiative.

The STORKS initiative began a conversation within a community feeling hopeless and overwhelmed about the fate of the next generation, and went on to tap the expertise of those who had lived experience and wisdom in overcoming these perceived barriers.  Citizen partnering between professionals and clinic community members resulted in action strategies that addressed a local problem that was central to this clinic community.      

 

RESEARCH AND EVALUATION

During the first five years of this work we focused on learning how to engage with communities and put the model on the ground.  Table 4 summarizes a number of these core informal learnings.  In recent years we have developed more formal methods for evaluating Families and Democracy and Citizen Health Care projects, and are implementing these evaluations across individual, family, and community levels. These efforts include both qualitative evaluations of projects’ evolution and process (e.g., Mendenhall & Doherty, in-press) and quantitative assessments of outcomes directly associated with dependent variables of interest unique to a particular project.  For example, outcome evaluation of the FEDS program is focusing on physiological (e.g., A1c, BMI, weight, blood pressure), knowledge (e.g., regarding diabetes, community resources), and disease management behaviors (e.g., blood glucose monitoring, exercise, diet).  In our Hmong Women United Against Depression project (see Table 3) data are being collected on participants’ depressive symptoms and severity, family members’ relief, and public visibility of depression as a safe topic to discuss are being evaluated.  In the Students Against Nicotine and Tobacco Abuse (SANTA) project (see Table 3), we are collecting a broad range of data related to students’ smoking behaviors, readiness to change, and stress. In every case, evaluation tools are discussed and agreed upon by the whole group of citizen professionals and others citizens from the community.

In addition to projects that focus on specific local communities, we think of Putting Family First and its offspring as “cultural organizing” initiatives that harness the power of a local group of parents to name and challenge a problem in the larger mainstream American culture, and to gain media attention to launch local and national conversations. A recent example is the Birthdays Without Pressure Project, through which a group of parents in St. Paul, Minnesota, named the problem of out-of-control kids’ birthday parties, examined its sources in a supersizing culture, its consequences for children, parents, and the community, developed an engaging website (www.BirthdaysWithoutPressure.org), and attracted widespread media attention nationally and internationally. For the Birthdays without Pressure initiative, we developed a way to measure media visibility and web presence as an outcome measure of impact on the broader cultural conversation.  In the overscheduled kids projects and the birthday project, there was enormous national and international media attention and web recognition of the work of the citizen groups.

OPPORTUNITIES FOR MARRIAGE AND FAMILY THERAPSTS

A crucial issue at the beginning of our community engagement work was whether we could teach this model to others or whether it represented only the local connections, vision, and skills of its originators. We now know that is learnable because we have mentored ten professionals beyond the founding team. Our next step is to create a Citizen Professional Center at the University of Minnesota for training therapists and other professionals and students in democratic community engagement and for conducting community based participatory research that advances knowledge and solves local problems. This Center at the University of Minnesota will be sponsored by the College of Education and Human Development, the Medical School (with the main stakeholder being the Department of Family Medicine and Community Health), and the Hubert H. Humphrey Institute for Public Affairs. We will focus initially on building a critical mass of trained citizen professionals in our local region, and then branch out to national and international participants.

Public process skills require time to learn and mature. We have found that learning to do Families and Democracy and Citizen Health Care work well takes up to two years of learning the model and having supervised experience on a specific project.  It cannot simply be taught in a weekend workshop format.  To implement the training, we anticipate offering a formal certificate based on course work and supervised field work in the participant’s home community.

What sort of therapist might be most suitable for this kind of training experience? We envision three MFT audiences for Families and Democracy/Citizen Health Care training:

• Individual therapists. This includes therapists at any career stage who have a passionate interest in this kind of work. Therapists in two particular career stages might especially be interested.  Students and new therapists might want to add this skill set to their repertoire. Retiring therapists might want to give back to their communities in a different way than providing pro bono therapy. On the other hand, therapists at a career stage where they need to maximize income from every hour of professional work might not be suitable.
• Training programs. Clinical programs inside and outside of academia might be interested in faculty development in order to incorporate citizen health care training into their programs.
• Researchers. Those interested in citizen projects using community based participatory research might want to be trained in the practice and research methods involved in this kind of work.

Our model does not require that professionals be connected to any specific kind of community (such as low income, distressed communities) or have expertise in any specific issue (such as trauma or diabetes). This is a generic citizen development/community organizing approach that requires just three elements to instigate: a) a challenge that a community of individuals and families cares deeply about; b) a citizen professional who has a relationship of trust with this community and who also cares deeply about the challenge; and c) the challenge lends itself to local action that accesses the current resources of the community, as opposed to requiring public policy or institutional change for headway to be made.

The first criterion requires a “pressure point” affecting the well being of people and their families in settings such as a geographical community, a school or school district, a clinic or group of clinics, or a faith community. The second criterion emphasizes that the therapist has already established the trust of enough people in this community to be able to start the pubic conversation. The third criterion reflects the difference between the Families and Democracy/Citizen Health Care approach and the advocacy approach wherein the professional tries to mobilize people to influence powerful public or private groups to change their practices or provide more resources (Doherty & Carroll, 2002).  Our model focuses on co-production rather than protest and petition.

This work does not require that the therapist have expert knowledge of the problem area being addressed, at least at the outset, because his or her expertise is primarily in bringing the democratic model to address the problem and in facilitating the process. We knew less about diabetes than anyone else in the room when we began our citizen diabetes work, but soon learned enough. We knew little about the experiences of Liberian immigrants and other sub-Sahara African groups, but could catalyze a community initiative that accesses the knowledge, wisdom and experience of Africans and non-Africans who work with the community.

A downside of this work is that it rarely involves paid positions in the early stages, although funding has come at some point for seven of the thirteen projects. For instance, our Family Education Diabetes Series with the American Indian population and our Hmong Women United Against Depression projects are now funded through both internal and external grants. On the other hand, citizen professional work does not require an extensive time commitment; as mentioned before, it can be done in about 6-8 hours per month over an extended period of time. Many professionals contribute this amount of time to community service work or to pro bono therapy; they could shift their time to citizen professional work.

Finally, we have learned that community engagement must meet the needs of the professional as well as communities. If this kind of public practice outside the office fits within their values and vision, professionals experience an expanded sense of professional contribution and enjoy a much closer relationship to their local community.  They take on a new identity—that of a citizen professional—and feel part of something larger: a movement towards democratic renewal. As a woman from Ghana said in a meeting, “Back in Africa we knew about pseudo-democracy; what I am seeing here is real empowered democracy.”  Her citizen group is tackling the challenge of the ongoing impact of war and trauma on children and families in the African immigrant community of Northwest Hennepin County, Minnesota.  How they will tackle the challenge will be determined by the citizen action group, led by an African marriage and family therapy doctoral student who is being mentored by one of the authors. The group is exploring ways to break the silence that is fragmenting their community and weakening the heart of its people.

If our current health care and human service systems are to be redesigned in the United States, it will take more than new clinical strategies for the consulting room, fairer reimbursement systems, or even universal health care reform (as important as these changes would be).  Quality and cost challenges will continue to overwhelm our care systems if we rely on the two traditional models—front line professionals delivering services to people who are not empowered to take responsibility for their own health and that of their communities, and public health professionals providing education to passive individuals communities.  The driving mission of Families and Democracy and Citizen Health Care Project is to create a democratic model of health care and human services that unleashes the capacity of ordinary citizens as producers of health and social change for themselves and their communities.  This mission requires the development of a new kind of professional—the citizen professional.  With our legacy of valuing social change and our understanding of how complex systems work, family therapists are ideally suited for this work and this mission.   

 

Table 1

 

Families and Democracy/Citizen Health Care Model in Everyday Language

 

 

• See all personal problems as public ones too.

 

• Look to family and community resources first.

 

• See families and communities as producers, not just clients or consumers.

 

• See professionals as citizens and partners, not just providers.

 

• Let citizens drive programs rather than programs service citizens.

 

• Make sure every initiative reflects the local culture.

 

• Grow leaders, then more leaders.

 

• Make all decisions democratically.

 

• Go deep before taking action.

 

• Think big, act practically, and let your light shine.

 

Table 2

Action Strategies for Families and Democracy/Citizen Health Care Projects

(adapted from Doherty & Mendenhall, 2006)

• Get buy-in from key professional leaders and administrators.
• Identify an issue that is of great concern to both professionals and members of a specific community (clinic, neighborhood, cultural group in a geographical location).
• Identify potential community leaders who have personal experience with the issue and who have relationships with the professional team.
• Invite a small group of community leaders (3-4 people) to meet several times with the professional team to explore the issue and see if there is a consensus to proceed with a larger community project.
• This group decides on how to invite a larger g
• Over a series of about 12 meetings 2-3 weeks,, implement the following steps of community organizing:
• Exploring the community and citizen dimensions of the issue in depth
• Creating a name and mission
• Generating potential action initiatives, processing them in terms of the citizen health care model and their feasibility with existing community resources
• Doing one-to-one interviews with a range of stakeholders
• Deciding on a specific action initiative and implement it

Table 3

 

Citizen Health Care / Families in Democracy Projects

 

 

Students Against Nicotine and Tobacco Abuse (S.A.N.T.A.). This initiative, started in 2006 and funded by ClearWay-Minnesota, engages local providers in partnership with students, teachers, and administrators in the HHH St. Paul Job Corps community to address on-campus smoking (and the concomitant reduction of students’ stressors and the adoption of healthier lifestyles). Its mission is to improve the health and well-being of students at Job Corps through smoking cessation, education, stress reduction, and support.

 

Family Education & Diabetes Series (FEDS). This health promotion initiative was created through the collaborative efforts of providers affiliated with the University of Minnesota and local leaders in the Saint Paul/Minneapolis American Indian community. Begun in 2001 and funded through a variety of internal and external grant monies, it works to engage low-income, urban-dwelling American Indians and their families in an active forum of education, fellowship, and support. Its mission is to improve the health and well-being of American Indian people through diabetes education, fellowship, and support in manners that embrace their heritage, values, and culture.

 

Hmong Women United Against Depression (HWUAD). This initiative, begun in 2005, engages local providers and representatives of the St. Paul Hmong community in a collaborative partnership oriented to investigating, understanding and improving the lives of patients and refugees who are struggling with a variety of life stressors related to depression, chronic physical health problems, and psychosocial difficulties associated with relocation. Its mission is to tap the wisdom and resources of the St. Paul Hmong community to empower, support, encourage, and offer hope to Hmong women and their families who live with depression.

 

A Neighbor Giving Encouragement, Love & Support (A.N.G.E.L.S.). This initiative, started in 2002, encompasses providers working in partnership with teens who have diabetes and their parents to connect with families who are struggling with diabetes to others who have lived experiences with the disease. Its mission is to empower and support adolescents and their families as they traverse the crisis of diagnosis and adjust well in early phases of diabetes management. These efforts begin at the time of diagnosis – generally in the context(s) of emergency hospitalization – and continue across a variety of patient/family combinations (adolescents with adolescents, parents with parents, families with families) on and off hospital grounds.

 

STORKS: Sisters Together Overachieving in Raising Kids. This initiative targets at-risk urban single pregnant teens in North Minneapolis. Its mission is to promote healthy child development in children with teenage mothers and to provide community support for young single mothers. It began in 2004 and ended 2006.

 

Parenting Partnerships. First begun in 2007, this initiative targets urban parents of teenagers in North Minneapolis. Its mission is to promote healthy behaviors in at-risk teenagers. This initiative uses multi-family mentoring with parent/teenager groups within the community to address violence and high-risk behaviors in youth.

 

Family Formation Project. This initiative encompasses at-risk urban unmarried couples with children in Minneapolis and St. Paul being mentored by experienced married couples and forming their own leadership group. Its mission is to promote stable family formation and healthy marriage in urban couples who desire this for themselves. The initiative, which began in 2004, has received both federal and state funding. See http://fsos.che.umn.edu/projects/mnffp.html

 

Putting Family First. Parents in Wayzata, a suburb of Minneapolis, began organizing this initiative around the problem of overscheduled kids in 1999. Their mission is: “Putting Family First works to raise awareness about the crucial connections between parents and children, and helps families find balance in their lives.” See www.PuttingFamilyFirst.org

 

Balance4Success. This initiative (started in 2005) involves parents in Apple Valley and nearby suburbs of Minneapolis/St. Paul organizing with a mission to liberate their kids from out of control sports schedules and to change the culture of hyper-competitive childhood by replacing busyness with balance.

 

Community Engaged Parent Education. This initiative, begun in 2004 and supported by the McKnight and Bremer Foundations, engages parent educators in developing citizen awareness and civic action in parents across Minnesota. Its mission is to encourage citizen deliberation on public issues relating to children’s well being. See http://fsos.che.umn.edu/projects/cepe.html

 

Birthdays Without Pressure. This initiative, started in 2006, involves parents in St. Paul, MN organizing against out-of-control birthday parties. Its mission is to raise awareness of the problem of out-of-control birthday parties, to offer alternative, and to launch a local and national conversation about the problem.  www.BirthdaysWithoutPressure.org

 

Intervention Approaches to Reduce Tobacco Use Among Southeast Asian Communities. This initiative partners four Southeast Asian communities in Minneapolis/St. Paul: Hmong, Cambodian, Laotian, and Vietnamese in a mission to design and carry out pilot projects on tobacco use that call upon the culture resources of Southeast Asian communities. Funded by the Minnesota Partnership for Action Against Tobacco, this work was first launched in 2006.

 

Family Health, Child Success. This CBPR initiative involves parents and professionals organizing to promote child wellbeing among sub-Sahara African immigrant families in Hennepin County, Minnesota. Started in 2007, its mission during its first stage of development is to design and pilot a project that accesses the resources of the community to meet challenges facing African families and children.

 

Citizen Father Project.  A group of most African American, low-come single fathers is developing an initiative to make a difference in the lives of children, fathers, and mothers in the community by fostering healthy, active fathering, challenges false images of manhood,  and rebuilding family and community values.

Table 4

The Citizen Healthcare Project: Key Lessons Learned

(from Doherty & Mendenhall, 2006)

 

• This work is about identity transformation as a citizen professional, not just about learning a new set of skills.
• It is about identifying and developing leaders in the community more than about a specific issue or action.
• It is about sustained initiatives, not one-time events.
• Citizen initiatives are often slow and messy during in the gestation period.
• You need a champion with influence in the institution.
• Until grounded in an institution’s culture and practices, these initiatives are quite vulnerable to shifts in the organizational context.
• A professional who is putting too much time into a project is over-functioning and not using the model. We have found the average time commitment to be on the order of 6-8 hours per month, but over a number of years.
• External funding at the outset can be a trap because of timelines and deliverables, but funding can be useful for capacity building to learn the model, and for expanding the scope of citizen projects once they are developed.
• The pull of the traditional provider/consumer model is very strong on all sides; democratic decision making requires eternal vigilance.
• You cannot learn this approach without mentoring, and it takes two years to get good at it.

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