Mary Ballantyne, Grant Macdonald, and Leslie Raymond
Abstract: Adolescents who are at risk of imminent family breakdown present a significant challenge to youth-serving agencies as well as to families and youth themselves. Although some limited research exists on strategies to help support high-risk families with troubled adolescents, comparatively little attention has been paid on what might be called the fundamental generic components of family-worker interaction and service provision that are necessary for successful interventions with high-risk adolescents and their families. This paper examines what is known about effective fundamental processes and is based on two principal sources of information: a review of the child and family literature, and interviews with key informant experts in the field of child welfare. The findings indicate that a positive therapeutic relationship based on trust and respect is critical to effective interventions. In addition, a number of factors related to service were found to be important, such as flexible hours, prompt response to requests for help, and services that are culturally relevant and sensitive. Finally, studies indicate that face-to-face contact between practitioners and families is positively associated with successful outcomes.
Adolescents who are at risk of imminent family breakdown present a significant challenge to youth-serving agencies as well as to families and youth themselves. Millions of dollars are spent annually providing placements in children's mental health facilities, Children's Aid Societies” foster homes, psychiatric hospitals, or institutional care facilities, when relationships in the family home have broken down.
Although some limited research exists on strategies to help support high risk families with troubled adolescents (e.g., Butts & Barton, 1995; Hayward & Cameron, 1993; Johnson, 1993; Kazdin, 1993; Wells & Whittington, 1993; Whittaker & Tracy, 1991; Wood & Davidson, 1993), comparatively little attention has been paid to what might be called the fundamental processes of service delivery. Fundamental processes can be defined as the generic components of family-worker interaction and service provision that are necessary for successful interventions with adolescents and their families. These processes focus not so much on what one does when providing service, but how one does it. These processes concern the environment and context of the provision of help, workers” philosophical approach to providing help, as well as the workers” sensitivities to cultural and ethnic influences.
The fundamental processes for interventions are the generic components of interaction and service provision that are essential to the effectiveness of any intervention strategy. In fact the effectiveness of a specific intervention method or treatment program can totally depend on whether the fundamental processes for intervention have been applied. If service delivery to adolescents and families does not include these processes, the intervention, regardless of its established effectiveness, may be doomed to fail.
This paper will attempt to pull together information on effective fundamental processes tat has been obtained from two principal sources: a review of the child and family literature; and interviews with key informants. The key informant interviews were conducted over a six-month period by two experienced child welfare workers. Three groups of key informants were interviewed. First, interviews were conducted with research and clinical experts working in the field in Ontario, Canada. Second, interviews were also conducted with service providers serving adolescents and their families in cases where the adolescent was at risk of having to leave the family home. These field practitioners represent a variety of settings and included children's mental health, child welfare, psychiatric and residential institutions. Finally, key informants also included parents and adolescents. The findings reported here form a small part of a much larger study on the strategies for effective intervention in cases where adolescents are at risk of out-of-home placement (Ballantyne & Raymond, 1996).
A review of the literature and key informant interviews have identified the following as the essential fundamental factors for effective intervention.
1. Variables Related to Service Providers
The relationship between the service provider and the person receiving assistance has been described as the "heart" of service delivery (Coady, 1993). An analysis of studies conducted on the importance of relationship building in treatment found that one of the most important predictors of successful outcome was the quality of the therapeutic relationship. In addition, studies have reported that the relationship was a much better predictor of successful outcome than the actual technique or intervention method employed in treatment (Coady, 1993; Gaston, 1990).
Some studies of programs aimed at working with adolescents and families have found that the relationship between the family, the adolescent, and the service provider was critical to the success of the program (Bribitzer & Verdieck, 1988; Tolan, Cromwell & Brasswell, 1986). One study in particular focused on a program that worked with families who had refused to work with other agencies or had dropped out of treatment after only a few sessions.
This program found that for the intervention methods to be effective, the initial intensive focus needed to be on developing a relationship with the families (Reid, Kagan, & Schlosberg, 1988). Similar findings were obtained in a study of foster care breakdown, noting a high correlation between placement breakdown and the service provider having a negative relationship with the foster parents (Pardeck, 1985). A positive caring relationship was also found to be especially helpful to adolescents with attachment difficulties, because caring interaction is necessary to develop attachment (Halverson, 1995).
The factors that have been found to be crucial to the development of a positive relationship are trust and respect (Association of Parent Support Groups of Ontario [APSGO], 1996; Bradley, 1996; Coady, 1993; Conifict Resolution Group [CRG], 1996; Cunningham & Leschied, 1995; Mathews, 1996). Families will choose to listen to practitioners and act on their suggestions when a trusting and respectful relationship exists. Building trust in a relationship does not come from clinical facts or book knowledge, but through a process of listening, acknowledging, and caring so that the person feels understood (Carkhuff & Anthony, 1979; Coady, 1993; Cunningham & Leschied, 1995). In fact, it is often more important that the person being helped feels understood than the service provider feeling understood (Halverson, 1995). Families who are receiving service involuntarily will often lessen their resistance if tine has been spent developing a trusting, respectful relationship (Cunningham & Leschied, 1995; Cameron, Hayward & Mamantis, 1992).
Parents and adolescents interviewed for this study described the following attitudes and approaches by service providers as detrimental to the development of a positive relationship, often resulting in the families moving to other places for assistance (APSGO, 1996; CRG, 1996):
a patronizing attitude
blaming the parent for the problems of the child
judging the activities of the parent and the family to be wrong
using tactics of intimidation
asking for input yet not listening to this input or incorporating it into the service being provided
Parents, practitioners, and several studies described positive qualities that service providers must display in order to develop a trusting and respectful relationship. These qualities include (APSGO, 1996; Carkhuff & Anthony, 1979; Coady, 1993; Halverson, 1995; Mathews, 1996):
warmth and calmness
a genuine interest in the adolescent and family
positive emotional involvement
a non-blaming, non-adversarial approach where the trust of the adolescent is gained without aligning with the youth and blaming the parents
an ability to listen and allow people the opportunity to vent
a sense of humour
Parents and experts reported that service providers should be aware that their views of what constitutes a "successful family" or "good parenting" can be perceived as judgmental. Service providers should suspend judgment and not form conclusions until they get to know the family. In this way the family’s real stressors will become more apparent (APSGO, 1996; CRG, 1996; Mathews, 1996; Steinhauer, 1996). Service providers should also be prepared to acknowledge that their interaction with the family may be the cause of a negative relationship. Sometimes service providers, without even being aware of it, can use coercion and manipulation with families. Given that many high-need families are characterized by having power imbalances and using coercion themselves, service providers can perpetuate this coercion by using it in the service provider-family relationship (Mathews, 1996).
If difficulties do exist in the relationship between the service provider and the family, the service provider should take responsibility for addressing the relationship problems. Even if practitioners work to display all of the qualities important to building positive relationships, some less trusting relationships will still result (Persi, 1996). Practitioners should, however, assume that their interaction with the family may be the cause of some of the difficulties and should be prepared to alter their approach (Coady, 1993; Cunningham & Leschied, 1995; Mathews, 1996; Steinhauer, 1996; Waddell, 1996).
Thus, a trusting, respectful relationship is essential to the success of any form of intervention. Service providers need both technical skills and relationship skills as both are associated with successful outcomes. Even though social service agencies are under increased pressure for accountability and more measured proof of effectiveness, the importance of relationship building must be maintained at the centre of helping practice and theory (Coady, 1993). Assisting families and adolescents to resolve the issues necessary for them to remain together as a family is extremely complex and challenging work. It involves negotiating many different kinds of relationships: adult to youth; youth to youth; husband to wife; and family to community. As a result, particularly when dealing with families who have been encountering difficulties for a long period of time, an advanced level of knowledge, training, and skill on the part of the practitioner is critical (Weisz, Weisz, Alicke. & Klotz, 1987).
Service providers who work on a regular basis with families of troubled adolescents need to be well supported. Most of the practitioners interviewed for this study indicated that working with adolescents and families at risk of breakdown is challenging and often frustrating. Service providers can lose energy for and effectiveness in doing this work. Some practitioners may even lose interest in dealing with these situations altogether and move on to different places of work. Because working with adolescents and families at risk of family breakdown is such important, complex, and sometimes arduous work, ongoing support is necessary to maintain highly skilled and highly committed service providers. Forms of support that have been suggested as being helpful are the following (Bradley, 1996; Light, 1996; Mathews, 1996; Nicoloff & Watson, 1996):
opportunities for peer support
ongoing training and professional development
opportunities for periodic relief from difficult situations
organizational assistance with workload
opportunities for involvement in program design and implementation
opportunities for regular debriefing and/or supervision
Not all people working with families at risk of adolescent/family breakdown, however, must be mental health professionals. In fact, the life experience of surviving a difficult adolescent-family relationship can be an important form of training. Also, studies and practitioners indicate that people from "the natural helping system" and other para-professionals can be effective in providing assistance to families and adolescents at risk of breakdown (Arch, 1978; Gordon & Arbuthnot, 1988; Summerhaze, 1996). The natural helping system includes extended family, friends, neighbours, the clergy, and teachers who can provide assistance that is accessible, culturally appropriate, and empowering (Cameron, 1996; Cunningham, 1996; Persi, 1996). Many practitioners indicate that the "natural" helping system is the true helping system and the professional one is adjunct.
2. Factors Related to the Service
Accessibility of service for adolescents and families takes many forms. Parents and service practitioners indicated that the most helpful programs are accessible in the following ways:
a) Flexible Service Hours
Most families are available or are having difficulties with their adolescents during the evenings and weekends. Service to families is more effective if practitioners are willing to provide assistance during these times (APSGO, 1996; CRG, 1996).
b) Service Provided Close to Home
The most successful programs are offered in community neighbour-hoods. People are more likely to come for assistance if it is available locally, either in their homes or in less formal community settings (Cunningham, 1996; Persi, 1996).
c) Service is Easy to Find
Families and adolescents must know where to go to find assistance. Many parents indicated frustration wit not knowing where to start looking for service, sometimes causing them to wait for long periods of time until the problem had escalated.
d) Service is immediate
Several families expressed extreme frustration when they called a service provider only to be told that their problem was not extensive enough to require service at that time or was not specific to the mandate of that organization (APSGO, 1996; CRC, 1996). Families indicated how important it was to them to have someone to talk to and preferably meet with when an initial request for service was made. They found it frustrating and even potentially dangerous to be turned away and denied access to at least an initial form of service (APSGO, 1996; CRG, 1996).
Parents and practitioners expressed the importance of having assistance available during times of crisis. Families stated that they were comforted to know that someone was willing to come to them when they really needed it. Organizations that offer a crisis service report that it is rarely used and almost never abused, yet the knowledge that it is available is a critical support for families when maintaining a youth at home (APSGO, 1996; CRG, 1996; Nicoloff & Watson, 1996).
e) Service is Offered in "Normalized"
Many of the studies and most of the practitioners indicated that interventions were more successful if they could be provided in more natural or normal settings. The more closely intervention resembles the family’s or the adolescent’s life the more effective it will probably be (Kazdin, 1993; Mathews, 1996; Persi, 1996).
Some programs that have done evaluations of their effectiveness have found that the more often home visits occur, the more successful the program (Light, 1996; Summerhaze, 1996). The studies of "family preservation" programs indicate that home visiting is an important aspect of providing support to families (Hayward & Cameron, 1993). Home visiting is particularly important for some ethnic groups for whom the formalized social service offices may be perceived as an uncomfortable setting (Mathews, 1996; Summerhaze, 1996).
Practitioners indicated that when developing programs, particularly for youth, the interventions should be delivered from settings that are more natural and conducive to relationship-building with teens. Programming for youth has been found to be more effective if it is conducted in the classroom, the gym, or other normal "hangout" places rather than in a traditional office atmosphere. These spaces can offer opportunities for positive interaction with adults and peers in a manner that is more conducive to changing an adolescent’s behaviour (CRG, 1996; Kazdin, 1993).
Not all services can be offered from environments where families and adolescents live or spend their time. Formal office settings, however, can be more conducive to helping families and adolescents than they are currently. Many parents indicated that they found many of the service settings to be intimidating. Many offices are set up with "jail-like" features such as secure entrances, identification cards, locked doors between waiting rooms and staff offices, and receptionists greeting people from behind heavy glass.
These settings are not welcoming to families and adolescents, and as such, put barriers between them and the service providers. Families indicated that environments that greeted them in more of a "home-like" manner, where seating was comfortable and food and drink were offered, were more conducive to building a relationship.
Some organizations have encouraged the people receiving the service to become more involved in the planning for and operation of the service centre. By doing this, families and adolescents are able to feel ownership of the setting and are able to organize it to better meet their needs. Organizations that have encouraged this kind of participation have found an increase in the families” and adolescents” willingness to enter into relationships with the service providers (Cameron, 1996; Mathews, 1996; Nicoloff & Watson, 1996).
f) Service is Culturally Relevant
In order for intervention strategies to be effective, they must be developed and selected taking into account the cultural values of the individuals being served. Social programs are usually viewed as culturally neutral, yet they are developed and implemented based on dominant values, realities, and research methodologies. Most of what Canadians and Americans currentiy know about parenting is based on studies from these two countries.
Many cultures, however, have children that are physically and psychologically very healthy even though they have been raised in a different manner than is traditionally accepted in Canada and in the United States. Much of what is thought to be important for children is culturally bound, and researchers do not fully understand what contributes to good parenting (Cunningham, 1996; Schwager, Mawhiney, & Lewko, 1991).
Different cultures also have varying values regarding the most appropriate techniques for helping and healing people. The Canadian and American cultural values of self-disclosure and talking with others are seen as important elements for resolving problems. These methods are not readily accepted and sometimes even contra-indicated in other cultures (Cunningham, 1996; Mathews, 1996).
In some of the communities that were examined during this research, the service centres are in upper middle-class areas and most of the people needing assistance live in lower middle-class areas. Poorer working-class individuals are often reluctant to attend such service centres even if transportation is provided (Light. 1996; Waddell, 1996).
Similarly, many of the alternative care facilities, particularly foster homes, are in upper middle-class parts of the city. This results in teens from lower middle class areas being placed in upper middle-class homes. Different standards of living exist for the different socio-economic groups. Practitioners indicated that sending lower-class youth to upper- class foster homes can make the natural family feel inadequate, inhibiting visiting and as a result lessening the chances for reunification (Morris, 1996).
Some organizations have service providers from a particular cultural group providing service to people from similar groups. Although ideally it is best to have a service provider that is from the culture being served, some organizations have found success by at least providing a worker that has some familiarity with the issues of living in a different culture. For example, one organization employs a Spanish immigrant service practitioner who works with many immigrant families and is able to relate to them regarding issues relevant to all new immigrants (Light, 1996).
The attempts being made by organizations to address the cultural issues are only the beginning of what is necessary to adequately assist people from different cultural groups. More needs to be learned about the cultural underpinnings of the current services being offered instead of viewing them as culture-free. Differences exist in the way each culture looks at social problems and this impacts service.
When developing parenting programs and all other forms of intervention, the people from the culture being served need to be a part of developing, designing, implementing, and evaluating these programs. One key informant conducted a study in which he found that people from cultures other than the "traditional" Canadian culture were only about half as likely to enroll in programs, even if they were available in their own community. Enrolment increased significantly when they were part of the development or operation of the program (Cunningham, 1996). Expertise from people outside of the culture may be required in the beginning, but eventually distinct cultural communities should be able to develop enough expertise to be independent of the services that are not relevant to them (Schwager, Mawhiney, & Lewko, 1991).
3. The Process of Delivering Service
The manner in which interventions are delivered to adolescents and families will have an impact on their success. Throughout the intervention process certain elements are important for service delivery to be effective. Parents and adolescents are the most important people influencing change in a family. As such, parents and adolescents must be viewed as capable of making changes. The service practitioner’s role is not to rescue the family or the adolescent from the family (Fuchs, 1990). Intervention models must be based on doing things with people instead of doing things for them (Bradley, 1996; Cameron, 1996). By not involving the family in finding the solutions to their own issues, the service system is merely replicating the problematic patterns of communication that already exist in many families (Mathews, 1996).
Studies and practitioners indicated that families and adolescents who were able to set clear goals were more successful in maintaining a youth in the home. The families that set clear goals spent most of their time with the service providers resolving the issues identified in the goals. The families that did not have clear goals spent most of their time with service providers discussing what goals, if any, should be set. As a result interventions were less effective (Cunningham & Leschied, 1995).
Service providers can assist families to set goals in the following ways:
allow the youth and family to take the lead in defining the issues (Davidson & Totten, 1996; Mathews, 1996).
assist the family with redefining and refraining issues so that goals are set that will address the risks relevant to adolescent/family breakdown (Davidson & Totten, 1996; Light, 1996).
assist the family in setting goals that are clear and realistic. The service provider can help demystify for the family what can be accomplished (Mathews, 1996).
attempt to obtain congruency of goals with all partners in the change process, as families will have greater success in meeting goals if all partners involved agree with them (Cunningham & Leschied, 1995).
develop a plan or a framework so that all parties, and especially the family, know what issues they are going to address and how they are going to address them. This plan must be developed with the family, and may be more or less complicated depending on the parents” level of sophistication (Bradley, 1996).
Several studies have been conducted that indicate the amount of face-to-face service practitioner contact is significantly correlated with successful intervention (Kelley, Kelley & Williams, 1989; Lewis, Walton, & Fraser, 1995; Savas, Epstein, & Grasso, 1993). Research on the reunification of adolescents with families after placement found the amount of face-to-face contact to be one of the most important characteristics of the service correlated with program success Lewis, Walton, & Fraser, 1995; Savas, Epstein, & Grasso, 1993). One study found that an increased amount of face-to-face contact between a service provider and a child and foster parents was a significant predictor of a successful placement (Pardeck, 1985).
Another study compared face-to-face versus telephone contact, and found face-to-face contact to have much greater impact on success. The high-face/low-phone contact combination produced the highest success rate for maintaining youth in their own homes. The low-face/low-phone contact situations were the least successful. Almost as unsuccessful were the low-face/ high-phone contact situations (Savas, Epstein, & Grasso, 1993).Most of the parents indicated that one of the most frustrating aspects of receiving service was having to move from service provider to service provider. Families were frustrated with having to tell their "story" over and over again and build new relationships with service providers in the different organizations and often with different service providers within the same organization. Parents were particularly angry when they saw their child having to re-establish relationships with different practitioners.
Most of the time relationships need to be re-established not because practitioners are moving to different jobs or because families leave services when they do not get exactly what they want. Inconsistency of service providers usually occurs because many agencies and programs are organized in such a way that people need to move from one worker or one organization to another to receive the different forms of intervention necessary.
Several studies indicate that program effectiveness is linked to families having access to or at least being coordinated by one person (Butts & Barton, 1995; Reid, Kagan, & Schlosberg, 1988). These studies report that changes in workers make it difficult for families to build trusting relationships. Maintaining strong relationships is particularly important for families who are dealing with past traumas, losses, and lack of trust. Families that have exp erienced many stresses often have numerous, severe, and chronic problems that require extensive efforts to improve their ability to cope and to lessen individual symptoms (Reid, Kagan, & Schlosberg, 1988).
Finally, because of the importance of matching interventions to the needs of the family, practitioners should no longer offer families only those models of intervention that they prefer or that their organization is authorized to provide. Practitioners and service organizations can no longer afford to be true believers in any one model of intervention. If a family needs a different method, then practitioners must be ready and willing to offer it or refer to another practitioner. Given families” frustration with having to move from worker to worker, however, practitioners should aim towards having a variety of interventions available in order to adapt to the needs of families (APSGO, 1996; Mathews, 1996; Pardeck, 1985; Steinhauer, 1996).
The fundamental processes for interventions are the generic elements of f amily-worker interactions that are necessary to enhance the likelihood of successful outcomes with families with adolescents at risk of out-of-home placement. This study reports on the collective wisdom of experts and families, as well as the findings in the research literature. At the heart of any successful intervention, regardless of the method or technique employed, is the therapeutic relationship. Those things that support and build this alliance between the worker and the family are critical to successful work with high-risk adolescents and their families.
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This feature: Ballantyne, M., Macdonald, G. and Raymond, L. Fundamental Processes for Interventions: Working with High-Risk adolescents and their families. Journal of Child and Youth care, Vol.12 no.3 pp.69-81