Family-driven Residential Practices that Support Positive Outcomes –

from Basic to Advanced

Beth Caldwell/Director, Building Bridges Initiative /MAGeorgetown Pre-Institute Training ProgramEffective Residential Service Interventions July 2012 Orlando, Florida

What’s it all about?

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Family-driven Leads to Permanency•Permanency is a stable, healthy, culturally

appropriate, and lasting living situation with at least one committed adult. It also involves reliable, continuous, and healthy connections with siblings, birth parents,

extended family, and a network of other significant adults identified by the youth and the family

(Casey Family Programs, 2011).

Definition of Family Driven?Family Driven means families have a primary decision making role in the care of their own children as well as the policies and procedures governing care for all children in their community, state, tribe, territory and nation.

This includes:•Choosing culturally and linguistically competent supports, services, and providers;•Setting goals;•Designing, implementing and evaluating programs;•Monitoring outcomes; and•Partnering in funding decisions.

Source: Federation of Families for Children’s Mental Health

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Why is Family-driven important?•Strongest predictor of post-transition success, after

education, is support from family•Fifty percent (50%) of youth who have aged out will

live with some member of their family within a couple of years (about equally divided between parents and other relatives)

Source: Courtney, M., 2007; Courtney, M., et al, 2004

•“Work with family issues and on facilitating community involvement while adolescents are in residential treatment may have assisted these adolescents to maintain gains for as much as a year after discharge..”

Source: Leichtman, M., et al, 2001

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“The effectiveness of services, no matter what they are, may hinge less on the particular type of service than on how, when, and why families or caregivers are engaged in the delivery of care. While traditional forms of care approached mental health treatment in a hierarchical top down approach (with the clinician maintaining some distance from the recipients of treatment), this approach is not reflected in newer forms of service delivery. It is becoming increasingly clear that family engagement is a key component not only of participation in care, but also in the effective implementation of it.“

Source: Burns, B. et al, 1999, p. 238

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Why is Family-driven important?

What does Research tell us?

•Residential-specific research shows improved outcomes with shorter lengths of stay, increased family involvement, and stability and support in the post-residential environment (Walters & Petr, 2008).

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What is the Reality?Very few residential programs:• have implemented evidence-based/best or

promising family engagement/motivation practices•have provided clinical staff with evidence-based or

best/promising practice training programs on family engagement and family systems

•have developed a promising/best practice framework for supervising and evaluating individual family engagement/satisfaction/ effectiveness throughout the course of treatment

•require staff to spend time weekly in the homes of families using recognized best/promising practices

How do we achieve permanency/how do we ensure that children are raised in communities with families if we have not yet put together and implemented a practice model that has evidence for supporting families in living successfully together in the community?

We achieve permanency by:•Implementing evidence-based/best or promising

family engagement practices•Providing clinical staff with evidence-based or

best/promising practice training programs on family engagement and systems

•Developing a promising/best practice framework for supervising and evaluating individual family engagement/satisfaction/effectiveness throughout the course of treatment

•Requiring trained/quality staff to spend time weekly in the homes of families using recognized best/promising practices

What to do?

•We can develop our own framework based on the work of others who have led the way; AND/OR

•We can use components of tried and true models – e.g., Functional Family Therapy; Multisystemic Therapy.

Some Promising FDC Leaders:Those here at the Pre-Institutes or already mentioned:•Damar/IN - Jim Dalton•MA BBI – Janice LeBel•Hathaway/Sycamores – JoeAnne Hust & William Martone

williammartone@hathaway-sycamores.org•CA Reform - www.rbsreform.orgwww.rbsreform.org• Children’s Village/NY – Jkohomban@childrensvillage.orgChildren’s Village/NY – Jkohomban@childrensvillage.org

There are many others too – HELP US FIND THEM AND There are many others too – HELP US FIND THEM AND SYNTHESIZE THEIR PRACTICES TO INSPIRE AND SUPPORT SYNTHESIZE THEIR PRACTICES TO INSPIRE AND SUPPORT OTHERSOTHERS

Let Beth know: bethcaldwell@roadrunner.comLet Beth know: bethcaldwell@roadrunner.com

Magellan/PA Intensive Residential Project

Jessica Wormer, Lead Primary Therapist, Warwick House, shares during the NYS OMH NYC transformation training:

• “You can’t write this stuff…▫Specific strategies

• Engaging families (i.e. relationship; hope; ‘do whatever it takes’)

• In home work (and community work – i.e. prisons/SA/MH)

•Work with family challenges ▫How “not-interested,” “dysfunctional,” and “resistant”

have been jettisoned to a galaxy far far away… ”

Contact Information Magellan & Warwick House

•John Lees, Care Management Supervisor, Magellan (jglees@magellanhealth.com; 610.814.8041 Ext: 68041)

•Jeff Friedman, Director, Warwick House (jfriedman@warwickfamilyservices.com; 215.491.7404 Ext:20)

Multisystemic Therapy (MST)

Overview

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Core Clinical Skills for Engagement (Henggeler et al., 2009)

Empathy • Striving to maintain an empathetic stance

throughout treatment in order to develop interventions congruent with the family’s current state of being

• Therapists monitoring their own state of empathy & accessing support as needed is important

• When needed, suspend clinical assessment & intervention for “Non-Clinical Time” aka “Cup of Coffee” Intervention in order to gain better understanding of the client’s experience & ecology

Core Clinical Skills for Engagement (Henggeler et al., 2009)

• Demonstrating interpersonal warmth through empathy, posture, facial expressions etc..

• Flexibility – adjusting to changes quickly, managing situations with “can do” attitude & good humor

• General Strategies from Motivational Enhancement (covered below):

• Reflective Listening• Reframing

MST Non-Clinical Approaches to Engagement

• Reviewing Family Photos to show interest and learn more about the family as a whole, not just in terms of their problems

• Bringing Food as a “foot in the door” strategy & accepting food as a sign of respect/honor

• Helping with Practical Needs – going above & beyond with information and goods

• Five Minute Sessions – as an alternative to cancelling, acknowledge the barrier while still trying to complete one task

Questioning versus Affirming and Reflecting

• Research shows interventions and engagement is effective when the interviewer provides twice as many affirmations and reflections than questions

• Doing so shows a real attempt to understand the person’s struggle around changing their behavior

• Too much questioning can start to feel like an interrogation, implying the interviewer wants them to change more than they want it

Affirmations

• Compliments.

• Statement of appreciation.

• Highlights client strengths.

• Are a form of Reflective Listening.

• Is client-focused.

Contact Information

Paul Schiller, LMSW Division Director Multisystemic Therapy The Children's Village 400 East Fordham Road 6th floorBronx, NY 10458 Cell 917 359-8627 Office 212 932-9009 x 7118 PSchiller@childrensvillage.org

Functional Family Therapy:Family Engagement & Motivation

Strategies

Andrea Morgia Functional Family Therapy-Director East

Cayuga Centers Formerly Cayuga Home For Children

FUNCTIONAL FAMILY THERAPYFUNCTIONAL FAMILY THERAPYCLINICAL MODELCLINICAL MODEL

MotivationMotivation

Goal-SkillsGoal-Skills Goal-Goal-SkillsSkills

Goal-Goal-SkillsSkills

InterventionIntervention

AssessmentAssessment

EngagementEngagement Behavior ChangeBehavior Change

Behavior ChangeBehavior Change

GeneralizationGeneralization

GeneralizationGeneralization

EarlyEarly MiddleMiddle LateLate

Resistance is NOT because of: the family/youth’s not wanting/needing

help the family/youth’s lack of “motivation”

We expect them to be discouraged, lack motivation, angry, unhappy with the systems

Services in home offer an advantage/disadvantage :

-Be flexible -Be upfront with your programs expectations-Be relentless -Understand that families are saturated with

services be open to the idea that services can be sequential in nature.

-Immediately look for ways to reduce negativity and blame

WHAT IS HELPFUL…..WHAT IS HELPFUL…..

What we do in E/M to help achieve these things with our families:Work relentlessly to understand and involve family membersWork to reduce negativity and blaming between family membersDevelop a family focus for the problems presented by the family. Talk about the family in an alliance based-non blaming way.Be credibility: It comes from what you are able to do in early sessions .

ENGAGEMENT & MOTIVATION ENGAGEMENT & MOTIVATION

Reframe (“and….)…what you “add to” the session Alternative meaning for what was acknowledged what might be “behind” or “the reason” Focus…

Person focused (their part) Family focused (all of the parts) (“…yes that

is what is important here…) Non-blaming…just an alternative description Non-interpretative

Doesn’t explain away…or excuse….DESCRIBES “theme hint”…just a guess

Based on what you have heard, what you know about them, what is common to adolescents

Over time…. Built a “theme” about the family that is more inclusive than this one event/situation

WHY REFRAMES & THEMES WORK: WHY REFRAMES & THEMES WORK: “RESPECT BASED” REFRAMING“RESPECT BASED” REFRAMING

Reframing…a response to a CLIENT statement Acknowledge (acceptance/support of the intent,

the position, the values) of the client….. not agreement…not empathy…. Personal not general

Reattribution of that statement (change in meaning)

Building Themes…..reframing a CLIENT statement to: Your hypotheses of a theme (theme “hint”) An existing theme in the conversation

Organizing Theme…..a theme that describes: Each persons motivate in non negative ways Links everyone in the family together….to a

common problem, challenge, of situation

REFRAMES, THEMES, & ORGANIZING THEMESREFRAMES, THEMES, & ORGANIZING THEMES

Andrea Morgia M.S. Functional Family Therapy-Coordinator

EastCayuga Centers Formerly Cayuga Home For Children Cell-315.591.7004Fax-315.349.3057andrea.morgia@cayugacenters.org

And one more thing…•In addition to implementing a range of

Family-driven care Practices•In addition to implementing a

promising/best practice family engagement/ motivation framework

•BEWARE OF CERTAIN LONG-TERM RESIDENTIAL PRACTICES

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What to be cautious of:•Events on campus (why?)•Lack of sophisticated/committed Clinical

Supervisors•Group recreation (why?/who to invite? -

build memories with families)•Holiday traditions (“Is it about the

program or about the youth/family?”)•Empowering & Supporting Family

Advocates, but having High Expectations

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BBI Contact InformationBeth Caldwellbethcaldwell@roadrunner.com413-644-9319

www.buildingbridges4youth.org

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