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Increasingly, the counseling profession has begun endorsing the need for counselors to collaborate with clients, families, and communities (Constantine, Hage, Kindaichi, & Bryant, 2007; Lee, 1998). Collaboration that reaches beyond the counselor’s office to the community is important for family counselors (Boyd-Franklin, 2003), community and mental health counselors (Lewis, Lewis, Daniels, & D’Andrea, 2003), and school counselors alike (Bryan, 2005). Solutions to the complex mental health issues that many clients face lie in engaging family and community members as partners in the treatment process and in social action when necessary (Kiselica & Robinson, 2001; Prilleltensky & Prilleltensky, 2003). Moreover, individual interventions are insufficient to solve the pervasive psychological and systemic effects of oppression, discrimination, and stigma that some clients (e.g., minority and poor clients; clients with mental illness, disabilities, or HIV/AIDS) confront on a daily basis (Con-stantine et al., 2007; Kiselica & Robinson, 2001; Lee, 1998; Lewis et al., 2003). Hence, it is important that counselors use systemic strategies such as client-family-community partnerships to enhance direct counseling services to clients; increase advocacy for the removal of systemic barriers; and promote mental health change and client, family, and com-munity empowerment.

Despite the importance attributed to collaboration in counseling, there is a dearth of models to guide counselors’ efforts to engage clients, their families, and communities in partnerships that promote mental health and social ac-tion. Doherty and Mendenhall (2006) presented one such model in their article Citizen Health Care:A Model forEngagingPatients,Families,andCommunitiesasCo-Pro-ducersofHealth published in the American Psychological Association’s journal Families, Systems, and Health. In their article, Doherty and Mendenhall described origins of the model, principles and strategies for implementa-tion, examples of model projects, how the model differs

from other community-based collaborative models, lessons learned, and future directions. The current article provides a summary of the central aspects of their Citizen Health Care Model and discusses implications for counselors and counselor educators.

The Citizen Health Care Model (Doherty & Mendenhall, 2006) guides professionals in the process of engaging clients, their families, and communities in partnerships to find solutions to health concerns that affect clients and their communities. According to Doherty and Mendenhall, “the driving mission of citizen health care is to create a democratic model of health care that unleashes the capacity and energy of ordinary citizens as co-producers of health for themselves and their communities”(p. 262). When professionals and citizens unite in democratic relationships, they release collaborative energy and power that influence and change their world. Family therapists and other professionals have used the model to partner with citizens to address problems associated with diabetes, depression, overscheduling of middle class children, isolation of newly mar-ried couples, and challenges of new parents in urban settings. In this article, the term citizens refers to patients, their families, and community members whom professionals can engage to find solutions to health challenges.

Principles and Strategies of the Citizen Health Care Model

Doherty and Mendenhall (2006) posited that change in health care rests ostensibly on a reciprocal dynamic between profes-sionals and their patients who are invaluable assets as co-creators of health. They outlined seven action strategies for implementing their model: (a) professionals garner support from administrators and leaders; (b) professionals identify a pressing health concern for both professionals and a commu-nity of citizens; (c) professionals identify citizens with leader-ship potential who have personal experience with the health

Julia Bryan, DepartmentofSchoolPsychologyandCounselorEducation,CollegeofWilliamandMary.JuliaBryanisnowatDepart-mentofCounselingandPersonnelServices,UniversityofMaryland,CollegePark.CorrespondenceconcerningthisarticleshouldbeaddressedtoJuliaBryan,DepartmentofCounselingandPersonnelServices,UniversityofMaryland,CollegeofEducation,3214BenjaminBuilding,CollegePark,MD20742(e-mail:jabryan@umd.edu).

Engaging Clients, Families, and Communities as Partners in Mental HealthJulia Bryan

Counselorsarebeingcalledontoreachbeyondtheofficeandclinictopartnerwithclients,theirfamilies,andcommuni-tiestoaddressmentalhealthandsocialproblems.Counselorsneedmodelsofcollaborationthatguidetheminbuildingtransformativeclient-family-communitypartnerships.W.J.DohertyandT.J.Mendenhall(2006)presentedamodelofcommunity-basedcollaborationintheirarticleCitizen Health Care: A Model for Engaging Patients, Families, and Com-munities as Co-Producers of Health.Afterreviewingtheirarticle,ananalysisofauniversity–communitypartnershipisusedtoframethediscussionofthemodel’simplicationsforcounselorsandcounseloreducationprograms.

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concern; (d) professionals convene a professional–citizen plan-ning team that includes three or four community members; (e) the initial planning team expands by inviting more citizens with leadership potential to join; (f) the full team defines, designs, and implements the project and community-organizing process and determines public visibility; and (g) the team uses key citizen health care processes. These key processes include using a democratic collaborative process, implementing empowerment strategies, and developing a sense of larger purpose and vision. In the following section, I discuss the major processes of the Citizen Health Care Model.

DemocraticCollaborativeProcess

Defining the community is an important initial step in imple-menting the model. Professionals may begin by engaging a small clinic community of families or a larger community within and/or external to the clinic, such as a neighborhood, school district, or faith-based community. Regardless, the professional’s initial role is that of catalytic leader and partner who mobilizes citizens to address a community health need, uses community organizing skills, and ensures a democratic collaborative process. Democraticcollaboration means that professionals and citizens share ownership and responsibility for the project and partner to define pressing community health concerns, reach consensus on the need for the project, expand the group’s leadership, define and engage the local community, and focus and implement the project. Each project should have a unique focus shaped through community conversations. Doherty and Mendenhall (2006) used community-based participatory research (CBPR), also known as actionresearch, to evaluate their projects. At the core of this research model is collaboration; it engages both researchers and community participants in the research process.

One example of a citizen health care project is Partners in Diabetes (PID). After ineffective efforts by a health mainte-nance organization to help urban adult patients with diabetes manage their illness, Doherty and Mendenhall (2006) and other professionals used the model to address the problem. PID provided support partners for diabetic patients; support partners were patients and family members who had suc-cessfully managed the disease. Partners and professionals collaborated to design the program. They met with patients in their homes, at restaurants, and other venues, committing 2 hours per week to the program. Professionals’ commit-ment to democratic collaboration and reliance on support partners’ personal experiences and unique expertise led to a highly successful model. The CBPR process and qualita-tive analyses indicated that partners were empowered by their significant contribution to helping patients manage their disease. Furthermore, providers recognized that PID overcame many of the barriers of traditional top-down provider/consumer models of care wherein consumers are passive recipients of services.

EmpowermentStrategies

Empowerment is an integral component of the model and vital to the democratic collaborative process. Although Doherty and Mendenhall (2006) did not use the term empowerment, it is ap-propriate to group the strategies that they espoused for sharing power with citizens under that term. Some of the empowerment strategies include diminishing professionals’ roles as experts, generating leaders for the initiative from the community, in-corporating the community’s cultural values, and folding new learning back into the community. Professionals who use the model attend to the power differential that typically exists be-tween professionals and patients/clients and intentionally seek to share power with patients/clients, their families, and com-munity members. Hence, professionals deliberately create what Doherty and Mendenhall described as a “flattened hierarchy,” relinquishing their “expert” role and recognizing the valuable expertise that citizens bring to the partnership. Moreover, professionals identify citizen leaders who can lead and sustain the project. Also, professionals help citizens garner support from health care administrators in a manner that advances the citizens’ agenda. Doherty and Mendenhall recommended that professionals urge citizens not to acquire project funds from major health care leaders or funders who may pressure them to define their program according to the funders’ agenda and to justify outcomes prematurely.

Professionals’ use of empowerment strategies is integral in the design and implementation of partnership programs, especially in culturally diverse communities. Consider, for example, the case of professionals and tribal and community leaders who were concerned about the pervasiveness of diabe-tes in a Native American community. Using the Citizen Health Care Model, Mendenhall and community leaders collaborated to design the Department of Indian Work’s (DIW’s) Family Education and Diabetes Series. Professionals took the time to gain the community’s trust and learn about Native Ameri-can culture, values, and beliefs while community members learned about Western medicine. Patients, their families, and professionals met weekly for an evening of fellowship, to check each others’ blood sugar, cook cultural meals, and receive diabetes-related education, using talking circles and other cultural activities.

The DIW attempts to replicate the highly successful model with other Native American groups. The project was highly successful in reaching a hard-to-reach community that was not readily accessible to traditional state and reservation-based systems of care. The project’s success hinged on professionals’ willingness to take time to build trust and relationship with the community, to learn from the community, to involve the community and integrate its culture and customs of healing in the planning and design of the project, and to assume nontraditional roles that required them to leave the comfort of their offices.

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SenseofGreaterPurposeandVision

Successful client-family-community partnerships call for a bold vision that extends beyond service provision to social action and social change. Together, professionals and citizens must identify what Doherty and Mendenhall (2006) described as a BAHG, that is, “a big, hairy, audacious goal” (p. 257). Professional vision and commitment are important because of the long-term, although not time-intensive, investment required to successfully implement the model. Professionals need to devote only 6–8 hours per month to a collaborative project, but they may need several years of involvement for the project to be sustained. Moreover, a minimum of 2 years of mentoring while involved in a collaborative project is neces-sary if professionals wish to acquire the requisite knowledge and skills for implementing the Citizen Health Care Model.

Discussion The aforementioned principles of the Citizen Health Care Model are germane to counselors’ involvement in client-family-community partnerships. The model provides direc-tions for counselors regarding strategies for engaging clients and other citizens as mutual partners in defining, designing, and implementing partnership programs to cocreate mental health and social change. Equally important, the model is suitable for application across mental health settings such as schools, universities, agencies, clinics, and medical set-tings. For example, the principles of democratic collabora-tion and empowerment could enhance partnerships among school counselors; other school staff; families, especially those from marginalized groups who may experience feel-ings of disempowerment in their interactions with schools; and community members. Following is a discussion of the implications of the Citizen Health Care Model for counseling practice and counselor education.

TheCitizenHealthCareModel:ACaseAnalysis

To frame the discussion of the implications of the Citizen Health Care Model for counseling practice, an example of a university-community partnership, the Healthy Workers Program (HWP), is described. I served as the project coordi-nator and a counselor in this program. Although the Citizen Health Care Model was not used during the development of HWP, the program would have been enhanced by using the model or a similar collaborative framework that incorporated democratic collaboration, empowerment, and a vision of social change. The example described here illustrates the potential usefulness of the Citizen Health Care Model for enhancing community-based partnerships in counseling practice and highlights potential challenges that counselors may face in implementing such partnerships.

The HWP was a health promotion program designed to provide a wide range of free medical (e.g., primary care, flu

shots, dental care) and mental health (e.g., personal, preg-nancy, and HIV counseling) services to temporary dining services employees at a large public university in the eastern portion of the United States. The majority of the employees were Hispanic (60%) or African American/Black (36%) and women (80%) from nearby urban economically disadvantaged areas. This community of employees aroused the concern of medical and mental health providers (referred to here as HWP professionals) at the university health center because they often presented with untreated chronic illnesses that were complicated by multiple barriers. The barriers included low English proficiency, lack of health insurance benefits, and access to health care that put them at high risk for illnesses such as depression, diabetes, hypertension, and HIV/AIDS. HIV and smoking prevention education was also offered at dining services work sites with assistance from eight peer supporters, who were dining services employees trained to disseminate prevention information and materials.

Collaboration. The HWP planning committee comprised the clinic director, project coordinator, other medical and mental health providers, and several dining services employ-ees from among the target population. The dining services employees served as cultural brokers for the HWP. Culturalbrokers (also known as culturalinformants) are persons who share and understand the culture of a target minority com-munity and interpret that community’s culture and needs for mental health professionals. They are knowledgeable about that community’s cultural values and beliefs as well as those of the mainstream culture (Singh, McKay, & Singh, 1999). Inclusion of the perspectives of cultural brokers in this initial leadership committee was influential in helping HWP profes-sionals understand the needs of dining services employees, gain the trust of the community, navigate the culture of dining services, move from outsider to insider status, and deliver services appropriately. However, although the HWP plan-ning committee had an appreciation for collaboration with the cultural brokers, the level of collaboration fell short of full democratic collaboration. The democratic collaboration aspect of the citizen health care model would have directed HWP professionals to work closely with employees from the beginning, including them equally at every phase of decision making and implementation. Instead, the employees were in-volved in HWP planning in expert-driven, albeit, useful ways (e.g., cultural brokers, liaisons, peer supporters).

The democratic collaboration process would have been es-pecially helpful in the HIV counseling and testing component of the HWP. One challenge of promoting HIV counseling/testing largely among African American and Hispanic employees was addressing the barriers resulting from cultural beliefs, mistrust, and fear of social stigma. Despite successes in dis-tributing condoms and English and Spanish HIV information materials at work sites and in providing HIV counseling and testing in both English and Spanish, HWP counselors were

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challenged by the relatively low numbers of employees who chose to be tested. Applying the principles of democratic collaboration would have helped HWP counselors involve employees in community conversations about their personal experiences and the barriers to HIV counseling and testing. Collaboration with employees to define the issues and develop interventions would also have led to the development of gender-relevant interventions related to cultural norms.

Empowerment.The HWP successfully provided access to health care and counseling for a significant number of em-ployees, and HWP professionals felt empathic and genuine concern for the employees. Nevertheless, there remained an unchallenged imbalance of power among professionals and employees. The power differential was obvious not only in the expert-consumer dynamics that were maintained between professionals and the employees served, but also in profes-sionals’ permanent job status and health insurance benefit packages. The Citizen Health Care Model would have guided HWP professionals to use their power to mitigate unequal power relations between the university and employees. Professionals could have done so by attempting to garner university administrators’ commitment to addressing the issue of accessibility of long-term health care for the com-munity of employees and to institutionalizing the HWP to create continuity in access to care. Furthermore, profession-als could have collaborated with the employees, university administrators, community leaders, and organizations from employees’ cultural communities to discuss possible solu-tions to the employees’ needs and problems. However, the fact that the community was embedded in the university itself for which HWP professionals worked added another layer of complexity to collaboration. Perhaps professionals may have found democratic collaboration and empower-ment processes easier to implement had they not been employed by the same institution as the dining services employees or had they worked in an institution with social justice as an agenda.

Vision.The HWP’s initial vision was to meet employees’ immediate health care needs as opposed to a larger existen-tial purpose. As the program progressed, HWP professionals began to grapple with increasing awareness of the need to promote change for the employees at a systemic level. How-ever, professionals functioned intuitively because of their compassion for dining services employees who provided an important service to the university, but who were rewarded inadequately. Hence, as program funding diminished, services gradually diminished. If the HWP professionals had a lens such as the Citizen Health Care Model, their vision may have moved beyond interventions that focused solely on service provision to those that incorporated democratic collabora-tion and empowerment geared toward institutional and social change that ultimately increased long-term access to health care for the target community.

ImplicationsoftheCitizenHealthCareModelforCounselingPractice

There are numerous ways that mental health, family, and school counselors could use the principles of the Citizen Health Care Model to collaborate with clients, their families, and communities for mental health and social change. For example, mental health counselors could collaborate with clients and citizens to increase services provided to persons with mental disorders in a community or to help a community successfully integrate clients who have been released from institutional settings into the community. School counselors could collaborate with mental health counselors and citizens to reduce the prevalence of school dropout in a community plagued by low academic achievement, school dropout, and concurrent problems. Family counselors could collaborate with citizens and business leaders to increase job search skills and employment opportunities to a low-income community with a high incidence of unemployment.

A number of implications exist for counselors who desire to use the principles of Citizen Health Care Model (Doherty & Mendenhall, 2006) to foster partnerships with clients, families, and community members. One implication is that counselors who have been trained in a traditional provider-consumer paradigm will need to embrace citizens as mutual experts with shared ownership for collaborative initiatives. Doing so effectively will require them to recognize and tap into the invaluable expertise that families and community members can bring to defining community mental health concerns and designing and implementing relevant interventions. Counsel-ors will need to shift their focus from a top-down approach to sharing power equitably with citizens as they collaborate to enhance citizen empowerment.

As counselors collaborate with clients, families, and com-munities, they must recognize their potential to be valuable brokers of power who can help citizens build their power base to improve their own situations. They must be willing to ad-vocate at the community level so that power relations between citizens and institutions that provide services to citizens are diminished. Indeed, some counselor–citizen partnerships may challenge the status quo. Counselors who advocate for clients with institutions that do not align with social justice may experience inevitable conflicts with institutional leaders. As suggested by Doherty and Mendenhall (2006), counselors will have to examine and accrue a repertoire of strategies for garnering buy-in from institutional leaders (e.g., counselor supervisors and administrators) so that the benefits of collabo-ration for citizens are maximized and the risks minimized.

Regardless of the risks, counselors have an ethical and moral mandate to work toward social justice. Counselor–citizen collaboration can often advance social justice in ways that individual interventions cannot (Constantine et al., 2007; Kiselica & Robinson, 2001; Lee, 1998; Lewis et al., 2003).

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However, for the benefits of counselor–citizen collaboration to outweigh the risks to citizens, counselors will need a lens, such as that provided by the Citizen Health Care Model, which focuses them on a purpose that is greater than mere service provision. In addition, despite the power of counselor–citizen collaboration to effect change, counselors must recognize that it requires an investment of time. Counselors will need to set aside time to “reach and go out” to client and community partners and when a project is convened, to commit to sus-taining the collaboration. Counselors should seek mentorship from clinicians involved in community-based collaboration and service-learning projects to gain valuable insights and experience in the collaborative process.

Implications for Counselor EducatorsCounselor education programs must play an integral role in providing counselors with the framework and skills for engag-ing clients, their families, and communities in partnerships for mental health, and social change. Counselors who have a desire to implement client-family-community partnerships based on the citizen health care principles need knowledge and skills in democratic collaboration, empowerment theory, community organizing, social action and advocacy, conflict management, trust and consensus building in the collaborative process, and community-based participatory research. For example, students should be given the opportunity to study the work of effective community organizers (e.g., Saul Alinsky) and those engaged in community empowerment (e.g., Paulo Freire). In addition, multicultural counseling course work should help students incorporate strategies and skills in enacting social justice in their professional practice and the wider community. Hence, community-based collaborative social action and advocacy projects should be infused in multicultural classes and throughout the counselor education curriculum.

Developing the knowledge and skill set necessary for client-family-community partnerships cannot be gained through mere course readings and class discussions. Relevant field experiences are critical to training in client-family-community collaboration. Furthermore, the importance of mentoring to learning the skill set for implementing client-family-community partnerships means that internship supervisors and counselor educators themselves will have to be actively involved in client-family-community partnerships. Effective mentoring can take place in community service learning projects, practica, and internships in which counselor educators and their students collaborate with professional counselors to implement client-family-community partnerships that address mental health and social issues. Moreover, counselor educators who use an inte-grated model that promotes partnerships, teaching, mentoring, and research could generate valuable collaborative research and grant funding. Within this integrated model, counselor

trainees and counselor educators need to use research methods that are best suited for studying and evaluating client-fam-ily-community partnerships. For example, community-based participatory research (or participatory action research) is congruent with client-family-community partnerships in that it is a collaborative research approach that involves participants equitably at all research phases, through democratic collabora-tion and participant empowerment.

In conclusion, counselors and citizens who engage in partnerships that are grounded in democratic collaboration and empowerment processes and have a bold transformative vision are likely to cocreate mental health and social solu-tions of lasting civic value. Indeed, structured, organized, and thoughtful collaboration among counselors and citizens can be a critical tool of social justice as well as mental health change (Boyd-Franklin, 2003; Bryan, 2005; Constantine et al., 2007; Kiselica & Robinson, 2001; Lewis et al., 2003). Accordingly, the Citizen Health Care Model provides one feasible frame-work for counselors who wish to engage clients, families, and community members as partners and cocreators in advancing mental health, social change, and social justice.

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