Clinical Consultation as a Family Intervention in Residential Treatment: Exploring What Impacts Outcomes

The Relational Re-enactment Systems Approach to Treatment model is an approach to residential treatment that embraces the need for family involvement through clinical consultation. Clinical consultation is a systems-oriented family intervention that embodies the model’s principles regarding therapeutic alliance and working through ambivalence. Families engage with treatment providers and other collaterals in an ongoing process of developing goals, creating a shared understanding of the youth, and working toward discharge. The current study explored youth characteristics and outcomes. Additionally, the investigation included comparisons between youth with and without the involvement of the Department of Children and Family Services in terms of length of stay, involvement in consultation, and sustained outcomes. Finally, therapists who work with youth and their families discussed their understanding of what differentiated successful and unsuccessful cases.     

Innovations in Family Support: What Are We Learning?

As family support programs develop across the United States through grassroots efforts by families, state demonstration projects, and local initiatives, new opportunities have become available to examine the experiences of families with service delivery systems. In this study, the research team examined key principles of innovative family support and their effects on families with children at high risk for out-of-home placements. The research team used a multi-case study design with indepth participant observation and semi-structured interviews with a purposeful sample of families. The findings on agency implementation and the families' perspectives are described, together with implications for agency change in family support. The findings point to the need for a re-examination of the emerging approaches to family support innovations, including in the context of national policy reform and the agency-based, service delivery system.     

Family therapy and social control with incestuous families

The family therapy and social control model describes first the relationship between unplanned change and developmental growth. With many families, the family therapist works to both provoke change and encourage growth. However, some out-of-control families present a level of danger to a family member that outside controls, such as child protective services, must be used. This model clarifies the complementary but independent roles of family therapy and social control in helping out-of-control families. Intervention with incestuous families is presented as illustrative of the model.My thanks to the staff of Child Protective Services, the Juvenile Court, Yuma Police Department, Yuma County Sheriff's Department, Adult Probation Department, and the staff and group members of Yuma County, Arizona Parents United for showing that shared concern about the well-being of children can make a real difference in working with families. My appreciation to William C. Nichols, EdD, Elora Cornille and Dale Brotherton for their helpful suggestions on a earlier version.     

Involvement,Collaboration, and Empowerment: A Model for Consultation with Human-Service Agencies and the Development of Family-Oriented Care

Systems consultation to provider agencies can contribute considerably to the development of a collaborative, family-oriented approach in these agencies. The possibilities for such an undertaking depend on the establishment of working relationships at two interfaces: between the system consultant and the agency, and between the agency and its client families. A framework for developing these relationships in three sequential phases is proposed: involvement, collaboration, and empowerment (ICE). Each phase is characterized by a dominant issue that is processed at the time. It is possible for relationships to begin at a more advanced phase and to work through two or more phases simultaneously. However, premature attempts to do so, which often occur in agencies’ work with involuntary clients and “difficult to engage” families, generate resistance and lead to an impasse. The applicability and usefulness of the ICE model is demonstrated by presenting the 6-year development of a family involvement and partnership program in Israel's juvenile correction system.     

Treating Inner-City Families of Homicide Victims: A Contextually Oriented Approach

Violence, including youth homicide, has assumed near epidemic proportions in US inner cities, with few signs that such violence is abating. Professionals working with families after the murder of a family member, are faced with the task of helping such families achieve a meaningful restoration of functioning. At the same time, there is a need to prevent retaliatory violence by surviving siblings and other family members. A treatment model will be discussed that uses the basic, theoretical principles of Boszormenyi-Nagy's Contextual Therapy (CT) while incorporating White and Epston's technique of “therapeutic certificates” in work with young people coping with loss via homicide. Case examples, drawn from the author's work at a unique, predominantly African American agency in an urban inner city will be used to illustrate applications of CT principles, and to show how therapeutic certificates can provide tools to clinicians working with this deeply troubling problem.     

The family practices of service providers for young handicapped children

A survey was distributed to service providers in Connecticut working with newborn to 6-year-old handicapped children to examine the degree to which service activities currently focus on the family. Most service-provision goals elicited by the survey were child-focused clinical goals, but family-focused goals were frequently cited However, 30% reported spending no time with families during a typical week. Published programs or curricula were rarely used. The providers felt they were successfully achieving goals set for families but that they encountered some problems, including a lack of time to work with families. Comparisons were made between those working with children from birth to 3 years of age and those working with children 3 to 6 years of age. Suggestions concerning the implementation of the family-focused agenda were made.     

Improving partnerships with families and carers in in‐patient mental health services for older people: a staff training programme and family liaison service

In spite of policies advocating the involvement of families in the care of mental health service users in the UK, there are few examples of initiatives to develop staff confidence and skills in partnership working. This article describes a whole team training initiative and family liaison service to promote family inclusive working on in‐patient wards for older people in Somerset, UK. A three‐day staff‐training programme is described and training outcomes are reported. Staff report a substantial increase in confidence and family meetings held. A pre‐and post‐ training case note audit shows increased consideration of the needs of families. To further increase face to face meetings with families a family liaison service has been established, whereby a staff member with systemic family therapy training joins ward staff to hold family meetings as part of the assessment/admission process. Evaluation of this service has shown it to be effective with positive feedback from families and staff.     

Trusting families: Responding to Mary Ann Meeker, "Responsive care management: family decision makers in advanced cancer"

Mary Ann Meeker's article admirably reminds readers that family members are involved in--or "responsively manage"--the care of relatives with severe illness in ways that run considerably beyond the stereotypes at play in many bioethical discussions of advance directives. Her observations thus make thinking about the role of families in healthcare provision more adequate to the facts, and this is an important contribution. There's reason to be worried, however, that one explicit aim of the article--to ease the standing anxieties that many clinicians and ethicists have about the reliability of family members as proxy decision makers--will be frustrated by its very success. Those already inclined to suspicion may tend to think that the more intricate and pervasive the ways in which families influence the healthcare decision making of their sick, the more chances they have for altering the connection between patients' interests and the actions of professional providers. To determine whether and when such alterations are something to be concerned about, we'll need to supplement a better grasp of the pertinent facts with a deeper sense of how human agency works and why we value it. We may also need some reminders about the defensibility of diverse moral understandings. Although both professionals and family members may profess an ethic that sets patients' interests above those of non-patients--as Meeker's own results suggest--any strict allegiance to such a framework may be more notional than normative--as her findings also hint. The actual working norms (among professionals, as well as within families) will likely be more complex, but not necessarily any the less defensible for that.     

Provider contact with families of adults with severe mental illness: taking a closer look

This exploratory study examined the frequency and nature of providers' contact with families of persons with severe mental illness. Fifty-nine providers in six community mental health programs completed a self-administered survey. A subsample of 8 providers also completed two in-depth interviews. Although most providers had some family contact, the contact was restricted to a small percent of their caseloads. The nature of contact that providers have with families is generally limited by their professional role. Best practice guidelines for the treatment of mental illness and agency administrators responsible for instituting these guidelines will need to clarify the types of providers who are expected to implement various aspects of family involvement.     

Audit and family systems consultation: evaluation of practice at a child and family centre

This audit of practice at a child and family centre included a 16-month case note review covering 319 cases, a postal survey of 45 families and an interview survey of ten GPs who typically referred cases to the centre. The audit furnished information from three different perspectives on the referral process, the consultation process, and outcome for clients attending the centre. The referral rate was about one new case per day and peak referral times were the beginning of the autumn and winter school terms. Almost half the referrals came from GPs; the remainder were largely from Paediatrics, Education and Social Services. Most clients were seen within two months. Half of the families referred had serious psychosocial difficulties including multiple problem members, multi-problem children, multi-agency involvement, psycho-educational difficulties, child protection problems or child placement difficulties. The majority of cases received six hours of consultation. Families where child abuse had occurred or families containing a multi-problem adolescent received a more intensive service. Between a half and three-quarters of cases had positive outcomes as rated by staff and parents. The service was viewed by GPs to be highly satisfactory. On the negative side, many parents felt ill-prepared for the consultation process and most children did not enjoy the experience.     

Development and Implementation of a Multicultural Consultation Service Within an Academic Medical Center

A major challenge for our field is to ensure we meet the growing demand for culturally sensitive and responsive evidence-based practices to keep up with changing demographics in the U.S. as well as calls to action by our field. To address the mental health imperative to improve the multicultural competence of clinicians and to provide appropriate care, it is important to create opportunities for clinicians to receive training in this area. One route to meet these demands is to provide ongoing multicultural peer consultation to clinical providers. This model also facilitates direct application to clinical work. To that end, we present herein a model for developing and implementing a multicultural peer consultation team. In our implementation, our consultation team aimed to function as therapy for therapists in the context of provision of empirically supported, principle-driven cognitive and behavioral therapies, with a consultation focus on multicultural perspectives and multicultural competence. We demarcate consultation needs within an academic medical center, identify facilitators and barriers to implementation of the service, and provide recommendations for future directions. Moreover, herein we present a case study to demonstrate the process of multicultural peer consultation.     

Perceptions Among Child Welfare Staff when Modifying A Child Mental Health Intervention to be Implemented in Child Welfare Services

In order to increase access to child mental health evidence‐based interventions (EBIs) for vulnerable and hard‐to‐engage families involved in the child welfare (CW) system, innovative approaches coupled with input from service providers are needed. One potential solution involves utilizing task‐shifting strategies and implementation science theoretical frameworks to implement such EBIs in CW settings. This study examined perceptions among CW staff who were members of a collaborative advisory board involved in the implementation of the 4Rs and 2Ss Strengthening Families Program (4R2S) in CW placement prevention settings, utilizing task‐shifting strategies and the Practical, Robust, Implementation, and Sustainability Model. Advisory board members reported difficulties in engaging families, heavy workloads, and conflicting implementation initiatives. While 4R2S was perceived as generally aligned with their organization's mission, modifications to the intervention and to agency procedures were recommended to promote implementation success. Suggested modifications to the existing 4R2S training and supervision are discussed. Findings underscore the importance of understanding the experiences of CW service providers, which can inform future efforts to implement child mental health EBIs in CW services.     

Organizational Cultural Competency: Shifting Programs for Latino Immigrants from a Client-Centered to a Community-Based Orientation

This paper discusses how the organizational cultural competency of social service agencies may be improved by shifting the philosophy of service delivery from a client-centered to a community-based orientation. This analysis is based on two years of fieldwork and interviews that were conducted as part of an action research project initially developed to increase the number of certified Spanish speaking Latino family childcare providers and knowledge about Latino immigrant families in the Midwest. In developing a culturally-specific certification program in Spanish, both the Latino participants and the bilingual program director challenged the agency to consider how the social context and social location of its participants required a more holistic community approach.     

The effects of service climate and the effective leadership behaviour of supervisors on frontline employee service quality: A multi‐level analysis

A supervisor's behaviour may not be the only factor that determines the performance of team members ( Kerr & Jermier, 1978 ). Taking this postulation as a basis, we formulated a model to describe how service climate moderates the effects of the leadership behaviour of supervisors. When the organization and working environment are not conducive to providing a good service to colleagues and customers, the supervisor's leadership behaviour makes an important difference. However, when the service climate is good, a supervisor's leadership behaviour makes no substantial difference. This hypothesis was supported in an examination of the service quality of 511 frontline service providers as sampled from 55 work groups in 6 service organizations. The employee service quality was low when both the service climate and the supervisor's leadership behaviour were lacking. However, when the service climate was unfavourable, effective leadership behaviour played a compensatory role in maintaining performance standards towards external customers. When the leadership was ineffective, a favourable service climate nullified the negative effect on service quality to internal customers.     

Trying to remodel the children and youth service system: Observations about barriers and opportunities

From their perspective as participant observers, the authors discuss the initial phase of an attempt to remodel the child/family mental health service delivery system. Conceptualizing families as being at varying levels of risk for dismemberment is seen as: (a) providing a politically viable terminology, (b) permitting each agency to develop a continuum of services tailored to its mandate and clientele, and (c) facilitating legislative efforts to analyze simultaneously the budgets of all those state agencies with major responsibilities for children's services. A planning team endorsed cooperative planning between a state-level coordinating council and individual locales. Cultural communities were invited to participate in a manner paralleling the planning role of local communities. A model for a free standing case management entity is proposed. The concept of empowerment is discussed as a criterion for multi-level outcome evaluation.     

The family empowerment program: an interdisciplinary approach to working with multi-stressed urban families

The family empowerment program (FEP) is a multi-systemic family therapy program that partners multi-stressed families with an interdisciplinary resource team while remaining attached to a "traditional" mental health clinic. The rationale for this model is that far too often, families presenting at community mental health centers struggle with multiple psychosocial forces, for example problems with housing, domestic violence, child care, entitlements, racism, substance abuse, and foster care, as well as chronic medical and psychiatric illnesses, that exacerbate symptoms and impact traditional service delivery and access to effective treatment. Thus, families often experience fragmented care and are involved with multiple systems with contradictory and competing agendas. As a result, services frequently fail to harness the family's inherent strengths. The FEP partners the family with a unified team that includes representatives from Entitlements Services, Family Support and Parent Advocacy, and Clinical Staff from the agency's Outpatient Mental Health Clinic practicing from a strength-based family therapy perspective. The goal of the FEP is to support the family in achieving their goals. This is accomplished through co-construction of a service plan that addresses the family's needs in an efficient and coherent manner-emphasizing family strengths and competencies and supporting family self-sufficiency.     

Beneficial factors in family discussion groups of a psychiatric day clinic: perceptions by the therapeutic team and the families of the therapeutic process

This paper reports a pilot investigation of the perception of helpful events by the therapeutic team and the families in two family discussion groups (FDGs) of a psychiatric day clinic. All participants of the FDG, including therapists and observers, filled in questionnaires measuring events helpful for the individual, for the family and for the group after each FDG session. The results showed that the therapeutic team and the families diverged in their overall perception of which factors were important in family discussion group therapy. The therapeutic team saw the relational climate and the structural aspects of the group (including group involvement and support from the group), and specific therapeutic interventions as more helpful than the families. The process aspects in the group members (including the experiencing of communality and gaining insight) were, on the other hand, more frequently mentioned by the families than by the therapeutic team. The clinical implications of these findings and suggestions for future research are discussed.     

Consultation with the Z Family's Technology Business: A Weekend Retreat

Family business consultation is an expanding enterprise and constitutes an interesting area of practice for psychologists drawn from industrial/organizational psychology, clinical psychology, and family psychology. This paper provides a clinical case example of a weekend retreat established as the forum for consultation to a family owned business that was experiencing a good deal of dissension between family and non-family management team members.     

Job Satisfaction of Child Welfare Workers in an Urban Setting: Status and Predictors

Large urban areas present many challenges to those children and adults who reside in those settings. The social service workers in urban areas have clients with complex, multiple needs. Reliable and consistent workers are essential to successfully working with these families. In the current study, the job satisfaction of 29 social service workers in an urban child welfare agency was assessed using the Job Satisfaction Scale (JSS). The JSS measures satisfaction in 7 areas of one's job (i.e., work, supervision, coworkers, pay and promotion, work environment, training, and position). Data indicated that the staff were relatively satisfied, that satisfaction did not vary by staff position (family worker vs. social worker/supervisor), and that neither demographic factors nor prior experiences were predictors of job satisfaction. Implications for agency management and the provision of social services to urban families are discussed.     

Family Members as Boundary Managers: Behaviors that Promote and Limit Service Members’ Involvement in Daily Family Life

When military service members deploy, they move outside the immediate boundary of their families. However, because boundaries are permeable, service members remain a psychological part of their families in spite of their physical absence. The extent of service members’ continued involvement in daily family life is likely tied to their non-deployed family members’ actions to manage this boundary. In the current study, we were interested in identifying non-deployed family members’ actions to either promote, or limit, service members’ involvement in daily family life during deployment. These actions by family members constitute boundary management behaviors. We collected qualitative data from a sample of Army reservists (N = 13) and their household family members (N = 15). Findings indicated that family members used a variety of boundary management behaviors during deployment, some of which promoted reservists’ involvement, and others which limited it. In addition, boundary management behaviors varied by who they targeted, their intentionality, and their implications for reservists’ well-being. Findings illustrate the value in equipping military families with language that enables them to communicate openly about the significance of their boundary management behavior over the course of deployment so that they may arrive at a balance between stretching and restricting boundaries that best suits their unique needs.