Sample pages from self-published report of findings after analysis.

How do providers build trust with vulnerable clients in rural mental healthcare settings?

The Hill Country CARE Center (Redding, CA) supports the region’s most vulnerable through wraparound social services (”Complex Care”). A typical complex care client could be receiving any number of concurrent behavioral health services, psychiatric services, social services, addiction treatment services, physical health care, housing support, vocational services, and possibly others.

Because of clients’ complicated traumatic histories, clients and providers often undergo a lengthy trust-building process before care can truly be established. Hill Country asked me to complete a qualitative research residency of in-depth interviews and ethnographic observation in order to better understand the complex care patient experience and what led to successful outcomes.

While the full report contains sensitive information and is not public, I’ve summarized the key points below.

Hill Country’s questions

What is working well with Hill Country’s complex care programs?

What is not working / what could be better?

What makes Hill Country’s programs different?

What human or resource connections do Hill Country’s programs offer to clients?

Methods

Interviews

This project is an analysis of 15 semi-structured interviews with Hill Country complex care clients. I conducted interviews privately and individually, with the exception of two family members who were interviewed together. I gathered informed consent using a script. All interviews were audio-taped and transcribed. Sessions averaged about 40 minutes, with interview times varying depending on the client’s availability, openness, and emotional state.

Journey lines exercise (user-centered design)

When the conversation permitted it, I walked participants through a “journey lines” exercise to map their progress over time, isolating the high and low points of their treatment at Hill Country. By arranging “incident” sticky notes on a sheet of craft paper to indicate whether a particular event had an emotionally positive or negative charge, participants focused their insights around pivotal moments, isolated key themes and feelings, and arranged major events in chronological order.

Analysis

I qualitatively analyzed the data following a semi-grounded methodology of open coding (close to the text) followed by focused coding (more thematic).

Summary of findings

The following themes appear to correlate to successful engagement in complex care at Hill Country:

1. Both services and relationships are important to engagement, but specific needs vary by client.
2. While services are indispensable, major breakthroughs and turning points seem to center around relationship-based assets.
3. Establishing belief and building confidence are necessary for some clients to embrace even the possibility of recovery.
4. The trust-building process (and the amount of time it takes) varies widely from client to client.
5. About half the participants talked about the process of opening up emotionally and marked it as a key development in their journey.
6. Even very small acts of kindness are memorable for clients and assist in trust-building and engagement overall.
7. Being “checked on” by providers and staff featured heavily in most clients’ stories.
8. Many clients described their providers as friends or family.
9. Provider vulnerability, risk, and disclosure seems to play a big part in establishing client-provider relationships, which in turn seems to strengthen client engagement.

my roles

• on-site interviews + design method exercises
• on-site ethnographic observations
• qualitative data analysis
• written report of findings
• visual + editorial design of written report