ATTC's Pearls of Wisdom: Centering marginalized voices in the change process

By Maureen Nichols, South Southwest ATTC, Jessica Jarvis, South Southwest ATTC, Dawn Tyus, African American Behavioral Health Center of Excellence, Susie Villalobos, National Hispanic and Latino ATTC

In 2021, following the promotion of the ATTC Network’s new core curriculum on stimulants, the South Southwest ATTC received a request from our region’s substance use treatment and recovery providers to develop more resources for family members of people facing challenges from stimulants and other substances.

As the team planned for development of a new resource to serve this need within our region, we chose to adapt the traditional ATTC approach to product development.

In addition to reviewing existing resources and evidence-based practices, we looked to the Seven Principles for Developing Equitable, Recovery-Oriented Behavioral Health Systems a framework developed by Ijeoma Achara-Abrahams, PsyD of Achara Consulting.

Dr. Achara presented these principles at a three day interactive Recovery Oriented Systems of Care Equity Summit. The summit was co-facilitated by Dr. Dietra Hawkins and cohosted by the African American Behavioral Health Center of Excellence, the South Southwest ATTC, the Northwest ATTC, the Great Lakes ATTC.

Seven Principles for Developing Equitable, Recovery-Oriented Behavioral Health System

1. Ensure that the voices and experiences of those who have been most marginalized in your system are leading and are integrated in all aspects of the planning and change process. 
2. Identify goals that build on one another. 
3. Keep bringing people back to the shared vision, goals, and performance indicators. 
4. Continuously over-communicate. 
5. Constantly challenge stakeholders to push beyond individual-level solutions. 
6. Don’t wait for a critical mass of individuals to feel a magical level of urgency; keep moving forward with the strengths and resources you’ve got today. 
7. Continually review your progress and celebrate your successes.

We partnered with the National Hispanic and Latino ATTC, the African American Behavioral Health Center of Excellence and local community partners who have experience working with individuals and communities that historically experience inequitable health care. We formed a workgroup and strategized adaptation of our traditional SSW ATTC development processes to meet these principles. 

Workgroup conversation resulted in the following key takeaways.

1. It’s more than a product or a training

•       There is a significant lack of support for families in our treatment and recovery ecosystems and in their natural communities.

•       Once families have the information provided through the resource, what ongoing support and resources are available for them in communities?

•       How can we empower individuals and families in the communities as healers, and build a workforce that support families?

2. Importance of community engagement

•       Who is our audience and what are they looking for?

•       We need collaborative governance as we create.

•       We must acknowledge and validate that many communities have a reason to distrust systems designed to help, while proactively working to build trust in communities

3: Everything is local

•       Even if we design culturally responsive content that is tailored to specific populations, communities are diverse, and each audience is different.

•       A product needs to include processes for facilitators to gather local community input and support for adaptation.

Initial Actions

Reflecting Principle #1, the workgroup began with a series of listening sessions with family members and loved ones of people using substances. The purpose of these sessions was to gather information to better understand:

• Family members’ experiences supporting and seeking support for their loved one

• What questions family members have about supporting their loved one

• Who or what is providing support for family members 

• Unmet needs for support for family members

Since this was the first time our regional ATTC included individuals with such lived experience as partners in our development process, we utilized a series of specific new strategies:

• We recruited facilitators with deep community connections (including peer recovery support specialists) to outreach to family members and loved one who might be interested in contributing their lived experience and expertise to the process. 
• These facilitators were part of communities that traditionally have not had a voice and representation in health care systems, including Black, Hispanic, and Indigenous communities. 
• We began outreach in three of the five states in Region 6: New Mexico, Oklahoma and Texas, where we had the strongest community collaborations. 
• We paid both the facilitators and the community members for their time and expertise. 
• We provided support and training to the facilitators around the process of facilitating the listening sessions. 
• We established a schedule of 20 online listening sessions, with plans to facilitate six sessions in Spanish, for up to 108 people, with a timeline that fit the parameters of our annual ATTC workplan. 
• We conducted an online follow up survey and phone calls with all listening session participants to obtain their feedback on the process and its impact.

The work group and facilitators conducted outreach to community members in May and June 2022, yielding 38 registrants across the listening sessions in July 2022, 23 of which ultimately attended a session.

Family Member Voices

Family members openly shared their experiences, their concerns, their hopes, and their needs.  Some common themes arose outlining the complexities they face in navigating systems, stigma, and self-care. These themes are outlined in greater detail in the project report.

Process Lesson Learned

Reconvening to reflect on the process, the workgroup identified some key lessons lesson learned. 

1. In our efforts to meet internal deadlines for product development, we failed to fully work together with our community facilitators in Oklahoma. When there was no participant online registration for the Oklahoma sessions, we made an internal decision to not move forward without consulting with our partner community facilitators. As a result, we excluded those facilitators, who were from the Indigenous community and also had lived experience as family members, from participating in the listening session and having their voices heard. This repeated a common harmful experience for them personally and as a community of being discounted and ignored within a health care system.
2. The traditional ATTC product development timelines do not work well for this process. In order to maximize and diversify participation (and maximize the relevance of any subsequent product), we must allow more time to build deep community connections, establish trust, and conduct cycles of action, reflection, and improvement. 
3. Conducting outreach and listening sessions online increases access for some and limits access for others. Ideally, in-person outreach and sessions would also be offered.
4. While the purpose of the listening sessions was to collaborate and include the expertise of the lived experience of community members, an unintended, beneficial consequence of the listening sessions was informal mutual support among the participants, who provided emotional support and shared resources with each other.

What’s next?

• Establishing deeper community connections through outreach. 
• Hosting additional, in-person listening sessions with community facilitators and family members. 
• Conducting cycles of action, reflection, and improvement to further strengthen the new product development process. How can it become more truly collaborative with the community partners who have contributed so far? 
• Developing and piloting resources to meet the community need. 

The full report on the listening sessions can be found here.

We’d like to acknowledge the contributions of members of the Cultural Family Resource project workgroup:

African American Behavioral Health Center of Excellence

Dawn Tyus, PhD, LPC

National Hispanic and Latino Addiction Technology Transfer Center

Maxine Henry, MSW, MBA

Susie Villalobos, Ed.D, M.Ed., CCTS-I

South Southwest Addiction Technology Transfer Center

Beth Hutton, MS, LPC

Jessica R. Jarvis, MSSW

Raynon McGee, MASM

Maureen Nichols, BA

Subject-matter experts

Johnna James, Chickasaw, Ed.D. Candidate SNU

LaNisha Jiles, PSS, RSPS, TOC, PRSS

Shuniqua Ortiz, MA, LPC

Timothie Smith, C-PRSS-Y,S

Ruth Yáñez, MSW, LMSW