THE STRUGGLE FOR TREATMENT INTEGRITY IN A "DIS-INTEGRATED" SERVICE DELIVERY SYSTEM

Gary A. Bernfeld

Chapter 8 in

Offender Rehabilitation in Practice: Implementing and Evaluating Effective Programmes

Gary Bernfeld
David Farrington
Alan Leschied

A Book in the Wiley Series in Forensic Clinical Psychology

2001

Now available online at Behavior Analyst Today, 7(2), 188-204, 2006
at http://www.baojournal.com/BAT%20Journal/VOL-7/BAT-7-2.PDF (link opens in new window; Acrobat file, pages 27-43)

DRAFT 3: DO NOT CITE WITHOUT PERMISSION

QUALITY...

"Quality is never an accident; it is always the result of high intention, sincere effort, intelligent direction and skilful execution; it represents the wise choice of many alternatives."

Anonymous

The purpose of this chapter is to describe an innovative family preservation programme for delinquents, which exemplifies effective correctional treatment: Community Support Services of the St. Lawrence Youth Association in Ontario Canada. Over 7 years, the programme utilised the Teaching-Family Model's (Fixsen, & Blase, 1993) integrated clinical, administrative, evaluation and supervision systems to ensure quality and treatment integrity. These systems will be delineated, along with some of the challenges of implementing an integrated treatment within a fragmented children's' services delivery system. The intention is to do so from a "multilevel systems perspective" (Bernfeld, Blase and Fixsen, 1990), in which four levels of analyses are used to examine the delivery of human services: client, programme, agency, and societal. Finally, suggestions are made for contextual supports for innovative programmes, so as to foster their effectiveness, longevity and key role as catalysts for systemic change in children's services.

EMPIRICAL FOUNDATIONS

Community Support Services of the St. Lawrence Youth Association was specifically developed in 1988 to offer intensive, short-term and flexible support to 12-15 year old young offenders (juvenile delinquents) who are "at risk" of being placed in more restrictive residential settings, such as closed or secure custody. The aim was to start with the treatment orientation and procedures used by Alberta Family Support Services (Fixsen, Olivier, & Blasé, 1990; Olivier, Oostenbrink, Benoit, Blase, & Fixsen, 1992) with mostly child welfare clientele, and adapt them for use with young offenders. Thus, the two programmes shared the same broad goal of integrating the well-researched treatment methods of the Teaching-Family Model (Fixsen & Blase 1993) with the service delivery strategies of the Homebuilders Model (Whittaker, Kinney, Tracy, & Booth, 1990), an exemplary family preservation programme.

Other areas of the literature support the development of the Community Support Services model. They include the following:

 

  • "clinically appropriate treatment", as defined in meta-analytic literature reviews (i.e. Andrews, 1995; Gendreau, 1996), includes behavioural systems family therapy, intensive structured skill training, and structured one-on one paraprofessional programmes.
  • Andrews, Leschied, and Hoge's (1992) review which identified a number of key risk factors for delinquency, which establish appropriate targets for treatment, including: cognitions (antisocial attitudes and values), family factors (low levels of affection/cohesiveness and supervision/monitoring, poor discipline, and neglect and abuse), and peer influences (association with antisocial companions and isolation from non-criminal peers).
  • Patterson, Reid, and Dischion, (1993) provided detailed empirical support for their developmental model of antisocial or coercive behaviour, in which the "basic training" for antisocial behaviour prior to adolescence takes place in the home, and family members are the primary trainers. As well, their research targeted the teaching of appropriate family management skills as an essential means to rehabilitating delinquents;
  • Christensen and Jacobson (1994) reviewed research on psychological treatment delivered by paraprofessionals. They concluded that paraprofessional therapists usually are as effective as professional therapists are. The authors noted that the need for mental health services exceeds the supply of professionals and the potential costs savings afforded by paraprofessionals. This suggests that services delivered by non-professional therapists merit wider use and further research;
  • Multisystemic therapy, developed by Scott Henggeler (1996; this volume) targets risk factors across the delinquents' family, peer, school and neighbourhood contexts. It uses an intensive family preservation approach, combined with an eclectic mix of cognitive-behavioural services. Its effectiveness has been supported by several controlled evaluations. Tate (1995) and Levesque (1996) note that it is the only treatment programme to demonstrate short- and long-term efficacy with chronic, serious, and violent juvenile offenders;
  • Andrews et al. (1992) have continued to emphasise the importance of treatment integrity for programmes treating delinquents. Some of the key elements of therapeutic integrity, detailed in the Forward of this volume by Leschied, Bernfeld and Farrington, include: a coherent and empirically-based theoretical model; an individualised approach to assessing and treating client risks/needs; a detailed programme manual; structured and formal staff training; meaningful staff supervision; and monitoring of treatment process. These and other factors are incorporated in Gendreau and Andrews' (1996) Correctional Program Assessment Inventory (CPAI), which is discussed in this volume by Gendreau. Andrews, Gordon, Hill, Kurkowski, and Hoge, (1993) have used the CPAI in a meta-analytic study of the role of programme integrity in studies of family intervention with young offenders. ? Gendreau (Gendreau & Goggin, 1997; this volume) and others (e.g. Losel, 1998, this volume) have also stressed the importance of system factors. These include: the programme's careful selection of line staff for their skills and values; the efforts at disseminating knowledge to staff; the Programme Director's credentials and skills in the area of behavioural intervention; the support for the programme from the host agency; and the broader service delivery system; funding; etc.

Several Annual Reports on Community Support Services provide further details on its empirical "roots"(Bernfeld et al., 1990 and Bernfeld et al., 1995).

OVERALL PROGRAMME GOALS

The programme is delivered to young offenders and families in homes, schools and the community at large. This in-home service is designed to work in collaboration with the family to reduce the youth's offending behaviour, prevent the youth's placement in a more restrictive residential setting, strengthen the emotional and psychological well-being of the youth and family and promote their self-sufficiency. Community Support Services aims to empower the young person and family with information, skill-based teaching, respect, responsibility and empathic relationships. This service is concerned with the ecology of the youth and family in the context of the community.

The broad goals of Community Support Services are to:

  1. Develop a home-based programme for young offenders who are about to reoffend and be removed from their family.
  2. Support the young offenders' transition from institutions to their families and the community and link them up with local resources.
  3. Evaluate the programme to facilitate its growth and assess its viability.
  4. Develop the foundation of a programme technology that can be replicated.

The first two goals reflect the different referral routes to the programme. Whenever possible, the former type of referral is preferred. Goal #1 reflects a family preservation mode, which involves accepting younger children currently on probation in the community, who are moderate to high risk to reoffend. Goal #2 describes an alternate type of referral of youths currently in custodial settings, who need assistance in returning to their families, or, in the case of older offenders, preparing them for semi-independent living. This reflects a family reintegration or semi-independent living approach.

The preference is to work with referring agents (probation officers) to identify clients who are "at risk" for the most intrusive intervention, secure custody, early on and assist their families in maintaining the young offender in the home environment. This early intervention approach (Goal #1) is designed to not only reduce costs by preventing future offences and residential placements, but also to maximise the impact and brevity of our services.

Specific Goals of Community Support Services are to:

 

  1. Promote family self-sufficiency and autonomy by teaching the skills necessary to avert the youth's further involvement in the juvenile justice system.
  2. Provide youth and family with treatment services that are individualised, practical and skill-oriented.
  3. Help the family access complementary services and community networks that facilitate family goals.

Further details on the development of Community Support Services are provided by Bernfeld et al. (1990).

HALLMARKS OF COMMUNITY SUPPORT SERVICES

Community Support Services treats young offenders who are 12 to 15 years of age at the time of their offence--and therefore only serves post-adjudicated youth. Referrals are made by probation officers in the 6-county area around Kingston, Ontario, Canada. This area, over 200 kilometres in length and 150 in width, is largely rural, with one larger city (population 125,000) and two small urban centres. Total population is over 250,000. Travel times by car to serve rural clients range from one-half hour to 90 minutes or more, weather permitting. Electronic pagers and cellular phones are the primary means by which the staff use to keep in touch with clients. There is a total of 6 front-line staff working a 40-hour flexible workweek along with a Director (the author), a Supervisor, and an Administrative Co-ordinator.

As noted earlier, Community Support Services integrates the treatment methods of the Teaching-Family Model (Fixsen & Blase, 1993) with the service delivery strategies of family preservation programmes such as Homebuilders (Whittaker et al. 1990). The first six hallmarks of Community Support Services listed in Figure 1 reflect the service delivery strategies it generally shares with family preservation programmes, as well as other ecological programmes like Multisystemic Therapy (Henggeler, 1996; this volume).

Overall, Community Support Services is similar to the other programmes in the scope of its services or "to whom" it is directed, the youth's social ecology, as well as in its service delivery model or "how" it operates. The latter refers to programmes which are home based; strength-oriented and family preservation focused; intensive and time limited; individualised and client-driven; as well as combining clinical and concrete services

However, the last five hallmarks listed in Figure 1 underscore the differences between Community Support Services and ecological or family preservation programmes in content or "what" interventions are offered. While others use an eclectic mix of cognitive-behavioural treatments, Community Support Services specifically organises the implementation of these interventions within the Teaching-Family Model's standardised human service systems.

FIGURE 1
HALLMARKS OF COMMUNITY SUPPORT SERVICES

FLEXIBLE

COMMUNITY-BASED

INTENSIVE TREATMENT / DIRECT SERVICE

FAMILY-CENTRED

BASIC NEEDS

FOLLOW-UP

TEACHING

GOAL-DIRECTED

EMPIRICALLY BASED

STAFF TRAINING/SUPERVISION MODEL

Hallmarks of Community Support Services include:

  1. Flexibility. The staff are on-call 24 hours a day, 7 days a week; fit the family's schedule; and are willing to work with any problem (staff are generalists).
  2. Community-Based. Employees, called "Specialists", work wherever they are needed (school, home, etc.), but not in an office. They work in the family's context, to decrease problems in generalisation and maximise relevance and learning of the skills taught. Thus, staff are more like coaches than therapists.
  3. Intensive Treatment/Direct Service. The intensive phase of service lasts 8 to 12 weeks. Caseloads are of 2 young offenders and their families at a time. Thus, at any one time, staff serve 2 youths in the intensive phase of service and 6 to 8 in the follow-up mode. On average, over 214 hours of service is provided of which 35% is face-to-face (Bernfeld et al, 1995). The intensive phase of service starts with 3 to 5 visits face-to-face per week and fades to one direct contact per week and several phone contacts.
  4. Family-Centred. The programme works with the young offender and the entire family with the goal of preventing problems in the younger siblings and strengthening parenting capacity. The services offered are "driven" by the family, "fit" their context and are implemented in a respectful and collegial manner. We put families in charge of their own service and help them become more aware of a broader range of options available to them. The choices that they make are up to them. Staff establish supportive, empathetic relationships with family members, in keeping with the philosophy that "everyone is doing the best they can with what they've got."
  5. Basic Needs. The family's needs for food, transportation, employment, budgeting, etc. are assessed and the focus is to teach the family skills in this area (e.g., how to successfully apply for a job), including self-advocacy.
  6. Follow-up. After the intensive phase of service ends, there is a one-year follow-up period, during which services gradually fade to monthly phone contact. "Booster sessions" are provided on a planned basis (e.g., at the start of a new school year), or as needed during crises. The use of a one-year follow-up period and booster sessions are unique.
  7. Teaching. Community Support Specialists build on strengths of families and use a cognitive-behavioural approach to counselling to teach a wide range of skills to young offenders and their entire family (e.g. anger management, positive parenting skills, effective communication, rational problem-solving, social and life skills, etc.). The service is individualised, practical, and skill-oriented. Teaching is "matched" between parents and children. For example, a parent is first taught how to appropriately give an instruction, then a youth is taught how to follow one, and finally, the parent is taught how to effectively praise the youth (by being behaviourally specific and commenting on youth skills). The goal is to develop positive, self-sustaining spirals of appropriate interaction between parents and children which will be maintained long after the direct service has ended.
  8. Goal-Directed. Initial psychological testing which is part of the evaluation process, plus the programme's intensive in-home assessment help develop the master treatment plan within the first 2 weeks of service. Thereafter, weekly and daily goals are derived and reviewed with supervisors and peers. The goals involve working with the youth's "social ecology". This is because difficulties are not conceptualised as residing solely "in" children, but in the reciprocal, mutually impactful interactions between the child and others in the environment (Fixsen et. al., 1990).
  9. Empirically-Based. Community Support Services was based on the research literature on delinquency and the Teaching-Family Model, which are discussed elsewhere in this chapter.
  10. Staff Training/Supervision. These areas are critical and often underdeveloped in less structured community programmes. This is because intensive support is needed for employees working in an intensive, crisis-oriented service. Staff are provided with a weeklong, 40 hour Pre-Service Workshop (half of which involves didactic instruction and half of which consists of behavioural rehearsals of clinical skills) along with a 500 page manual. This is followed by a two week orientation period, and then weekly case consultations with the Supervisor, along with bi-weekly team meetings to allow for case reviews with peers, and bi-monthly In-Services to develop new programme technology. In addition, there are at least monthly field observations, in which the Supervisor observes the employees working with families during home visits and provides the staff with written feedback. Finally, professional development plans are reviewed monthly, to guide the maturing clinical skills and judgement of the Specialists. Overall, employees spend more than 20 percent of their time in individual, group or peer supervision, and this is critical to programme integrity and quality.

Taken as a whole, Community Support Services, like Alberta Family Support Services upon which it is modelled, offers "Contextual Therapy". Bernfeld et al. (1990) define this as "helping people learn to cope with their emotional and interactional issues in their own settings to maximise relevance, acquisition, and implementation and to minimise generalisation problems" (p.22). This report also provides more details on the treatment model, including an example of the treatment planning process, and case profiles. As well, it presents the extensive list of services provided by staff, that are documented in case files in order to track programme implementation.

The family-centred approach to treatment ensures that the treatment plan developed jointly with the family members "fits" their unique context. Staff also share their weekly goals and daily agendas with the family -- and, most importantly, are prepared to be flexible as families' needs change. The intensity, on-call support, and strength-oriented focus of the service help us build a solid relationship with family members and to facilitate behaviour change. Ultimately, our ability to work in the family's home depends on how we help the family accomplish its goals.

PROGRAMME EVALUATION: A SUMMARY

Bernfeld et al. (1995) describe the computerised Management Information System developed for Community Support Services. This system integrates the programme evaluation needs of the programme with supervision, management and administrative systems. This practical and cost-effective programme evaluation approach is integrated with routine service delivery. It generates automated monthly reports of the service's processes and outcomes. As an example of the former, time management data is collected on each staff, in order to track their different activities. These range from direct work with families (i.e. face-to face and on the phone), to indirect services (e.g. preparing for family visits, meetings, paperwork, travel, etc).

Outcome evaluation data collected at pre- and post-treatment, and at 3 month follow-up on 155 youths over 5 years is discussed in detail by Bernfeld et al. (1995) and will only be briefly summarised here. A home-based, family-centred treatment technology is evolving which seems to reduce the penetration of young offenders into the residential care system. While the results are encouraging, they should be interpreted with caution, given the lack of a comparison group. Bernfeld et al. (1990) discuss the principles that guided the development of the "in-house" programme evaluation model. These recognise the challenges in evaluating a flexible, strength-oriented programme, without compromising its implementation with families in crises. In depth analyses of these and other issues are provided by Pecora, Fraser, Nelson, McCrosky, and Meezan (1995).

Client benefits demonstrated by the programme include reliable or statistically significant reductions in youth behaviour problems, as measured by the Child Behavior Checklist (Acenbach, 1991) and parent-youth communication problems, on Robin and Foster's (1989) Conflict Behavior Questionnaire. Reliable improvements were also noted for the youths on the Social Skills Rating System (Gresham & Elliot, 1990).

Youth recidivism after a 15-month follow-up period (55%) compared favourably to the 67% rate reported by Hoge, Leschied, and Andrews (1993) based on 6 month follow-up for young offenders in open custody in Ontario. Moreover, the data indicated that Community Support Services achieved reliable reductions in the seriousness of offences, the total number of offences, the number of multiple convictions, as well as a longer interval between offences. Consumers (parents, youth, probation officers, etc.) were generally satisfied with the programme and provided detailed feedback about the programme's strengths and areas for improvement.

While 97% of the young offenders were predicted by probation officers at intake to the programme to require residential placements, only 42% were actually placed out-of-home in the 15 months of follow-up, averaging less than two months per placement. A cost analysis indicated that for every $1.00 spent on Community Support Services over 5 years, about $1.48 might have been saved in residential care costs. The data suggest that cost savings of about a quarter of a million dollars per year in residential dollars alone could be attributed to Community Support Services. It was in fact suggested that these modest savings are a conservative estimate of the benefits of the programme, for a number of reasons.

Hoge et al. (1993) reviewed Ontario-wide young offender programmes and found that they averaged a relatively low score of .29 on the sub-group of scales reflecting treatment on the CPAI (Gendreau and Andrews, 1996). The provincial average of .29 means that 29% of the 56 items were present across all Ontario programmes. Sector specific averages were: probation, .21; open custody, .26; secure custody, .29; and, the 9 community support teams (including Community Support Services), .51. In comparison, using the scoring guide provided by Leschied, Hoge and Andrews (1993), the Community Support Services programme scored above .70 on the scale -- meaning that more than 70% of the programme characteristics indicative of effective treatment were present.

LINK TO THE TEACHING-FAMILY MODEL

The Teaching-Family Model is the "heart" of Community Support Services. From its original roots in a 1968 group home for delinquent adolescents called Achievement Place, the Teaching-Family Model has developed into an integrated service delivery system. Today there are over 300 [get current # ???] group homes serving over 2,500 children annually across the United States of America that serve not only delinquents but also abused, neglected, emotionally disturbed, autistic, and developmentally challenged children and young adults. In addition, the Teaching-Family Model has been recently adapted for youths in treatment foster care, independent living, and home-based services, serving over 1,200 annually. Over 100 [get current # ???] publications on the Model have researched its effectiveness and carefully evaluated its individual treatment components over the past 30 plus years. In fact, over $30M of the United States' government funding have supported the careful research and detailed development of the clinical, administrative, evaluation, and supervision systems which ensure that the Teaching-Family Model is delivered with integrity.

Appendix A details the Home-Based version of this Model, in terms of its goals as well as its treatment, programme, and treatment planning systems. All have been carefully integrated so as to support the systematic implementation of the Teaching-Family Model. Articles by Fixsen and Blase (1993; this volume) and Bernfeld, Blasé, and Fixsen (1990) present the conceptual and research basis for programme development and dissemination vis-à-vis the Teaching-Family Model.

The Teaching-Family Association oversees the quality assurance evaluations that hold organisations accountable for the programmes that utilise and disseminate this model. To become a member of this Association, a new organisation must be formally affiliated with an already certified site for 5 years, receive systematic help in developing Teaching-Family Programmes, and undergo a rigorous evaluation at the service or treatment level and the organisation level. The agency must meet all practice standards regarding the selection, training, supervision and evaluation of front-line staff, trainers, evaluators, and supervisors. The Association has established standardised procedures for how these functions are delivered in a certified organisation. A site must be re-certified annually.

In addition to maintaining records of staff supervision and training to assure the quality of the programmatic support, treatment implementation is ensured by the annual certification of individual staff. This involves a combination of consumer satisfaction data, in which staff must average a rating of 6 out of 7 on a scale that reflects satisfaction of consumers (parents, youths, case managers and others) with various aspects of service. As well, independent reviewers assess the actual in-home performance of staff and a 50-page report is completed which summarises both the consumer and on-site data and qualitative observations. Thus, the Teaching-Family Association provides a mechanism for assuring the consistency and quality of the implementation of the Teaching-Family Model internationally. Note that this is a non-profit organisation whose primary function is to disseminate the Model and ensure its planned, databased, evolution.

What is hopefully apparent from reading this Appendix, is that the Teaching-Family Model's vertically and horizontally integrated systems represent our "best practices" in how to translate knowledge about effective correctional treatment into practice with integrity, while ensuring quality assurance. The Model addresses the previously noted treatment integrity and systems factors in the literature by Gendreau, Andrews and others. As well, it represents the only systematic, published attempt in the area of Human Services to develop, disseminate, and evolve an integrated service delivery system.

Community Support Services worked towards site certification in the Teaching-Family Model from the early to the mid 1990s, when a change in the leadership of the provincial government drastically altered the funding arrangements that made this possible. The programme was about one year away from being certified, when the attempt had to be formally halted. Currently, Community Support Services is operating without formal implementation of all of the Teaching-Family Model systems. However, as it enters its second decade of service, it represents one of the oldest family preservation programmes in Canada, and the most experienced programme of its kind for young offenders.

CHALLENGES TO IMPLEMENTATION

In this section, some of the challenges of implementing an integrated treatment like Community Support Services within a fragmented children's services delivery system will be described. The intention is to do so from a "multilevel systems perspective", in which four levels of analyses are used to examine the delivery of human services: client, programme, organisation, and societal. Bernfeld, Blase and Fixsen (1990) originally delineated this perspective.

Client Level

Clinical challenges occur at the interface of the treatment planning, programme and treatment systems reviewed in Appendix A. For example, given the intensive, home-based nature of the service, it is not surprising that the family's potential "resistance" represents a challenge to overcome. As reviewed by Serin and Kennedy (1997), internal treatment responsivity factors include client motivation, personality and cognitive deficits, while external factors reflect therapist, offender and setting characteristics. Treatment effectiveness depends on matching types of treatment and therapists to the types of clients.

Intensive supervision of staff in Community Support Services is critical to the "matching" process, so that the treatment "fits" the family. This is because the families of young offenders can sometimes be either difficult to engage, non-reinforcing to work with and/or reside in locations which are inaccessible or hazardous for staff. As well, the multiple problems of the target families and the intensity of the service impact directly on staff, who are immersed in the family often on a daily basis. Therefore, Specialists need support from a supervisor who is intimately familiar with their own professional issues, so that these do not interfere with the optimal delivery of services.

Also key to the "matching" of treatment to family is the expectation that there be a two-week long, in-home assessment of family issues before a contextually sensitive master treatment plan is designed. Finally, the weekly review of this plan allows for adjustments to the intervention, as the family's needs or outside circumstances evolve. This is especially important, as optimal matching must be a dynamic process. Moreover, in order for staff supervision to successfully impact on treatment effectiveness, it has to be intensive (occupy about 20% of staff time), multimodal (occur at individual, peer and group levels) and extensive. The latter reflects the range of supervisory activities (including regular field observations of staff interactions, and various meetings) and the various paperwork and time management systems which document programme implementation.

The above examples should not imply that issues at the client level operate in isolation to other levels to be discussed below. The fact that there are interactions between multiple levels of the service delivery system underscores the importance of this perspective on treatment integrity. For example, proposals by the labour union (at the Programme level), which had the potential to limit service intensity, accessibility and flexibility, had to be addressed to protect the integrity of the service. Also, shifting priorities of the juvenile justice system (at the Societal level) impact continually on the targeting of the service. Finally, the programme's preference for working at the "front end" of the juvenile justice system (in a family preservation mode) continually brought the programme in conflict with systemic pressures to serve youth currently in custodial care or those being released after spending long periods of time in out-of-home placements.

Programme Level

The family and community-centred nature of the service was at odds with the focus of the other programmes offered by the agency, which were residential. It often took the personal (and creative) intervention by the agency's Executive Director, Merice Walker Boswell, to solve any inter-programme misunderstandings or rivalries that undermined Community Support Services. Special meetings of all agency staff and the involvement of the Community Support Services supervisor in regular meetings with her colleagues helped share information and build informal interdepartmental "coalitions". Throughout, the Executive Director reminded employees of the superordinate goal that all agency staff shared-- to support, rehabilitate and advocate for children within the young offender system.

However, once again, the interactions between the multiple levels were critical to effective implementation of the service. For instance, at the Organisational level, the agency's structure facilitated efforts at the programme level to set up and evolve towards the Teaching-Family Model's treatment planning, programme and treatment systems. This is because the agency was relatively "loosely coupled", so that individual programmes like Community Support Services could set up independent systems to select, train and supervise staff, and evaluate employees individually and the programme as a whole. Moreover, the programme was autonomous enough to integrate these functions within its own operations and tie them directly to the Teaching-Family Model's protocols. This is quite unlike large bureaucratic organisations, like those in Corrections, which usually set up independent departments in these key areas, with differing mandates and procedures.

Moreover, because Community Support Services was positioned as a "leading edge" programme by the Executive Director (a key Organisational issue), it was supported in its efforts to pilot and refine new staff training and programme evaluation systems, which were later "exported" across the agency. The latter has been alluded to earlier when the development of a computerised Management Information system was discussed. Elements of this system were incorporated later in all other agency programmes.

The personnel selection process for Community Support Services was adapted from structured interviews used in the Teaching-Family Model. Applicant ratings on similar interviews have been shown to predict on-the-job performance (Maloney et al., 1983). Our interviews included an hour-long written package requiring, among other things, answers to a series of behavioural vignettes that assess the applicant's responses to hypothetical problem situations similar to those encountered on the job. The 90-minute interview itself assessed the applicant's answers to similar questions, along with performance on behavioural role plays. The latter assessed an applicant's teaching ability at baseline, after instructions in using the teaching interaction techniques of the Model, and after feedback. Three interviewers rated the applicant's performance in these and many other areas, and the comparative data was analysed in making hiring decisions.

Organisational Level

The Executive Director of this small (50 employee) non-profit agency actively encouraged innovation. This is unlike the process in large organisations, like Corrections, as "the greatest strength of any bureaucracy is marshalling cogent arguments against change in the status quo" (p. 58, Zakheim, 1998). Due to her skilful efforts with staff and managers, the Board of Directors passed a motion committing the agency to the Teaching-Family Model. This supported the agency's work at achieving certification as a site. Resources were gathered to support this effort in a "low profile" manner, as the external zeitgeist shifted to a "punishing smarter" perspective. While Community Support Services was the focal point, the new secure custody programme was set up according to some key treatment aspects of this Model.

As well, the mentorship of the Community Support Services Director by the Executive Director (the present author) was essential in the development of his networking skills with other peers in the local and provincial juvenile justice system. These included the programme's key consumers--the local Supervisor of Probation and senior policymakers in the Provincial government. In fact, the programme's interactions with the referring agency (Probation) were critical to efforts to operate in a family preservation mode, and serve youths with appropriate risk levels. As Bernfeld, Fixsen and Blase (1990) noted, a Programme Director's personal relationship with key administrators and policymakers continues to be critical to programme survival and dissemination.

Finally, the management philosophy of the Executive Director was compatible with the Teaching-Family Model's view of administration as integral to effective treatment services. From this perspective, "there is no such thing as an administrative decision--every decision is a clinical decision" (D. L. Fixsen. Personal communication, December 12, 1988). This requires flexibility in the application of everything from accounting, budgeting, and human resources systems, so as to support short-term, community based, crisis services. For example, there was a need to develop a unique system to calculate "flex time" while ensuring staff accountability. As well, given the highly mobile and decentralised nature of the service and the fact that staff usually worked out of their own homes, new policies governing staff travel had to be established. These are just a few of the many procedures that needed to be developed or creatively interpreted to accommodate programme implementation.

Societal Level

Bernfeld, Cousins-Brame, and Knox (1995) comprehensively delineate the challenges of implementing an integrated treatment like Community Support Services within a fragmented children's services delivery system. The paper also describes a "sister" programme for child welfare clients, operated in collaboration with another agency. The authors demonstrate how the different structural and systemic supports for the other programme, were essential to mitigating the impact of challenges to integrity and enhancing its implementation and effectiveness. The major types of issues identified by Bernfeld, Cousins-Brame, and Knox are listed below, each with an example:

 

  1. Referrals. These reflect periods of scarcity, times when too many referrals arrive at a time when the programme has only a single opening or other occasions when inappropriate types of referrals are made. An example of the latter is when a youth is suddenly referred just a few months prior to his 16th birthday, when he will "graduate" from the Phase I young offender system, to services run by another government Ministry. This has more to do with assisting probation officers in managing their workload, than in working with those most at risk of reoffending. On one occasion, Community Support Services received many simultaneous "priority" referrals that were caused by an administrative decision to save money by quickly returning many young offenders in care to their families. The local justice system's fiscal crisis necessitated our involvement to prevent family crises, irrespective of the risk level of the youths.
  2. Roles. Government policy favouring custodial dispositions, the legal role of probation officers and their lack of extensive training in the juvenile delinquency field make it difficult for some of them to see the benefits of community-based treatment in general, and intensive family preservation/multisystemic treatment in particular. Not surprisingly, they favour legal sanctions (e.g. charging a youth with breaching probation), threats of punishment and re-incarceration. They feel that these are the best means at their disposal to protect society--and reduce their liability--should a youth re-offend, or begin to experience non-criminal (e.g. family) problems in the community. Thus, government policy, the "hard line" political climate and the reluctance of key "gatekeepers" in the juvenile justice system to take risks impacts on the autonomy and integrity of programmes like Community Support Services.
  3. Communication. Success in formal communication with Probation Officers is variable at best, in spite of continual efforts by managers of Community Support Services and Probation to have regular meetings, staff retreats to strengthen relationships, etc. There is little regular communication with some probation officers, lots of supportive contact with others and intermittent, crisis-oriented communication with the rest. Thus, problems can "fester" or be expressed obliquely by the officer's premature removal of a child from the home. The communication problem and the different focus of Probation vis a vis Community Support Services (crisis/reactive vs. prevention) may also be exacerbated by the more "loosely coupled" management structure in Probation Officer.
  4. Commitment. It was difficult to build commitment in Probation Officers to Community Support Services, as it was a new, pilot programme. Also, the timing of its introduction in 1988 was unfortunate, as it was linked in the minds of the officers to the government's recent move to privatise public agencies. Other factors which hindered the effort to convince probation staff that the family preservation effort was not a "flash in the pan" was the government's history of "pushing fads" on the probation system and the lack of training offered to staff about the benefits of intensive cognitive behavioural services. Though this was eventually offered years later, Probation Officers had little direct experience with this approach to treatment and little supervision in how to implement it on the job.
  5. Envy and Power. Given that Probation Officers are primarily concerned with case management, some of them are understandably envious of the small caseloads carried by family preservation staff, as well as their flexible working hours. This is especially true for the probation officers that preferred front-line work, or for those upset by the increasing caseloads, paperwork and office-bound nature of their work. Issues of the probation officers' blatant use of power were especially apparent in the early years, when they would tell families (sometimes inaccurately) what Community Support Services staff would do for them or would make placement decisions without consulting the Specialists. More subtly, there is the above noted power struggle over referrals and the continued pressure on the staff to "inform" on family members who were suspected of performing other illegal activities.
  6. Value Systems and Practice. Overall, the values and practices of family preservation staff are quite different than those of traditional casework. In Community Support Services, the focus is the home and community, as well as an immediate response, flexible hours of work, and a short-term, intensive orientation. These attributes, as well as the goal of empowering families by building on their strengths, often challenges the case manger's focus on what is wrong, or on information obtained "second hand" rather than via direct observation. This is because their legal role and large caseloads do not permit an intensive, collegial approach with families. Finally, probation practice is still "punishment-oriented" and reactive, even if the theories they're being occasionally exposed to are more therapeutic. This is likely to continue until their job description permits more time for them to deliver treatment, or their supervision structures become more intense to guide this desired change in practice. Ultimately, probation practice will not change until there are major shifts in the broader government policies and the "hard line" attitude which are popular in the current political climate.

The above is a brief overview of some the challenges discussed by Bernfeld, Cousins-Brame, and Knox to implementing an integrated treatment like Community Support Services within a fragmented children's services delivery system. It is contended that these and other issues are critical to the integrity of any human service delivery programme. As well, a programme's ultimate effectiveness is a function of its ability to surmount "on the ground" challenges to its implementation--no matter how strong its empirical base or its success in limited demonstration projects.

THE IMPORTANCE OF STRUCTURAL SUPPORTS

An eclectic literature exists on the diffusion of innovations and the management of change in large-scale Human Service systems, some of which has been reviewed by Bernfeld, Blase and Fixsen (1990), Bernfeld, Cousins-Brame, and Knox (1995), and in the Introduction to this volume. This literature teaches us that the long-term survival of innovative human service programmes requires a unique confluence of supportive factors at the programme, organisational and societal levels. Some of these factors were already delineated in the previous section, which detailed the organisational structure of Community Support Services' host agency. Moreover, specific suggestions can be made for contextual supports for innovative programmes like Community Support Services. These include a detailed plan at the senior levels of government which:

 

  • anticipates resistance to change system-wide and is prepared to support long-term implementation;
  • ensures adequate numbers (or a "critical mass") of programmes across the province
  • provides immediate top to bottom staff training; and
  • shifts a proportion of fiscal resources from existing residential services to innovative community programmes.

Overall, in order to systematically disseminate innovation, government needs to develop a comprehensive, long-term implementation plan. For example, if such a plan was in place when Community Support Services began, it would have not have allowed the programme's referrals to be managed by the Probation Service. Problems arising from this situation discussed earlier were a result of "the fox being in charge of the Hen house". Instead, the referral structure should have resembled the system for Alberta Family Support Services.

There, an independent government committee at the Regional level made referrals if and only if they had already decided to remove youths from their homes. This committee was accountable to senior levels of government for reducing reliance on residential services, and could only refer youths to the family preservation programme if it had an opening. This structure preserved the autonomy and integrity of the programme and ensured a steady supply of referrals. In Alberta, the agency making referrals had a vested interest in the success of the innovative service and was not in competition with it. As discussed previously, the state of affairs was quite different for Community Support Services, which resulted in an ongoing struggle for integrity. This is just one way a comprehensive implementation plan by government could have worked .

It is contended that contextual supports are essential to innovative programmes like Community Support Services, so as to foster their effectiveness, longevity and key role as catalysts for systemic change in children's services.

REFERENCES

Achenbach, T.M. (1991). Manual for the Child Behavior Checklist/4-18 and 1991 Profile. Burlington, Vermont: University of Vermont, Department of Psychiatry.

Andrews, D.A. (1995). The psychology of criminal conduct and effective treatment. In J. McGuire (Ed.), What works: Reducing re-offending (pp. 35-62). Chichester, UK: John Wiley & Sons.

Andrews, D.A., Gordon, D.A., Hill, J., Kurkowski, K.P., & Hoge, R.D. (1993). Program integrity, methodology, and treatment characteristics: A meta-analysis of effects of family intervention with young offenders. Manuscript submitted for publication, Carleton University.

Andrews, D.A., Leschied, A.W., & Hoge, R.D. (1992). Review of the profile, classification, and treatment literature with young offenders: A social-psychological approach. Ministry of Community Social Services, Toronto, Ontario.

Bernfeld, G.A., Blase, K.A., & Fixsen, D.L. (1990) Towards a unified perspective on human service delivery systems: Application of the Teaching-Family Model. In R.J. McMahon & R. DeV. Peters (Eds.), Behavior disorders of adolescents: Research, intervention and policy in clinical and school settings (pp. 191-205). N.Y.: Plenum.

Bernfeld, G., Bonnell, W., Cousins-Brame, M. L., Kippen, J., Knox, K., Kyte, D., Landon, B., Simmons, C., & Wright, P. (1995). Community Support Services: Annual Report. Kingston, Ontario: St. Lawrence Youth Association. [Reprints of the entire (90+pgs.) report: $10.00 to cover copying & postage]

Bernfeld, G., Cousins, M., Daniels, K., Hall, P., Knox, K., McNeil, H., & Morrison, W. (1990) Community Support Services: Annual Report. Kingston, Ontario: St. Lawrence Youth Association. [Reprints of the text portion of this report (up to pg. 32): $5.00 to cover copying & postage].

Bernfeld, G.A., Cousins-Brame, M.L., & Knox, K. (1995, May). Contextual challenges to family-centred services: Can integrated treatment operate in a "dis-integrated" service system? Workshop at the Growing '95 conference, Toronto.

Christensen, A., & Jacobson, N.S. Who (or what) can do psychotherapy: The status and challenge of nonprofessional therapies. Psychological Science, 5, 8-14.

Fixsen, D. L., & Blase, K.A. (1993) Creating new realities: Program development & dissemination. Journal of Applied Behavior Analysis, 26, 597-615.

Fixsen, D.L., Olivier, K.A., & Blase, K.A. (1990). Home-based, family-centred treatment for children. Unpublished manuscript. Hull Child & Family Services.

Gendreau, P. (1996). The principles of effective intervention with offenders. In A. T. Harland (Ed.), Choosing correctional options that work: Defining the demand and evaluating the supply (pp117-130). Thousand Oaks CA: Sage.

Gendreau, P., & Andrews, D.A. (1996). Correctional program assessment inventory (CPAI) (6th ed.) Saint John, NB: University of New Brunswick.

Gendreau, P., & Goggin, C. (1997). Correctional treatment: Accomplishments and realities. In P. Van Voorhis, D. Lester, & M. Braswell (Eds.), Correctional counselling (3rd ed.) (pp. XX- XX). Cincinnati Ohio: Anderson.

Gresham, F.M., & Elliott, S.N. (1990). Manual for the Social Skills Rating System. Toronto, Ontario: Psycan.

Henggeler, S.W. (1996). Multisystemic therapy using home-based services: A clinically effective and cost effective strategy for treating serious antisocial behavior in youth. Unpublished manuscript, Medical University of South Carolina, Charleston.

Hoge, R.D., Leschied, A.W., & Andrews, D.A. (1993). An investigation of young offender services in the Province of Ontario: A report of the repeat offender project. Ministry of Community and Social Services, Toronto, Ontario.

Leschied, A.W., Hoge, R.D., & Andrews, D.A. (1993). Evaluation of the Alternative to Custody Programmes in Ontario's Southwest Region. Ministry of Community and Social Services, Toronto, Ontario.

Levesque, R.J.R. (1996). Is there still a place for violent youth in juvenile justice? Aggression & Violent Behaviour, 1, 69-79.

Losel, F. (1995). The efficacy of correctional treatment: A review and synthesis of meta- evaluations. In J. McGuire (Ed.), What works: Reducing re-offending (pp. 79-114). Chichester, UK: John Wiley & Sons.

Maloney, D.M., Warfel, D.J., Blase, K.A., Timbers, G.D., Fixsen, D.L., & Phillips, E.L. (1983). A method for validating employment interviews for residential child care workers. Residential Group Care & Treatment, 1, 37-50.

Olivier, K.A., Oostenbrink, A., Benoit, G., Blase, K.A., & Fixsen, D.L. (1992). Alberta Family Support Services: Annual Report. Hull Child & Family Services, Calgary, Alberta.

Patterson, G.R., Reid, G.D., & Dishion, T.J. (1993). A social interactional approach to family intervention: Antisocial boys. Vol. 4. Eugene, OR: Castalia.

Pecora, P.J., Fraser, M.W., Nelson,K.E., McCroskey, J. & Meezan, W. (1995). Evaluating family-based services. N.Y.: Aldine de Gruyter

Robin, A.L., & Foster, S.L. (1989). Negotiating parent-adolescent conflict: A behavioral-family systems approach. N.Y.: Guilford. Serin, R. & Kennedy, S. (1997). Treatment readiness and responsivity: Contributing to effective correctional programming. Ottawa, Ontario: Correctional Services of Canada.

Tate, D.C., Reppucci, N.D., & Mulvey, E.P. (1995). Violent juvenile delinquents: Treatment effectiveness and implications for further action. American Psychologist, 50, 777-781. Whittaker, J.K., Kinney, J., Tracy, E.N., & Booth, C. (1990). Reaching high-risk families: Intensive family preservation in human services. N.Y.: Aldine de Gruyter.

Zakheim, D. S. (1998) Time to shake up America's peace team. The Jerusalem Report, 8, 58.

** REPRINT REQUESTS FOR CSS ANNUAL REPORTS. Please write: Ms. Mary Lynn Cousins- Brame Acting Program Director, Community Support Services, St. Lawrence Youth Association, 845 Division St. Kingston ON K7K 4C4 (613) 542-9634 Please make cheque payable to The St. Lawrence Youth Association

APPENDIX A
ELEMENTS OF TEACHING-FAMILY HOME-BASED SERVICES: OVERVIEW


NOTE: The Figures in this Appendix (except for the last one on Treatment Planning) were adapted from those developed by Fixsen & Blase during their consultations with Community Support Services. They are also based on the 1994 TFA Standards for Home-Based Services. TFA can be contacted at: 910 Charles St., Fredericksburg, Virginia 22401; phone (540) 370-4439; or visit their web page at http://www.teaching-family.org/.

Teaching-Family Model
Home-Based Services
GOALS

Adapted from Dean L. Fixsen and Karen A. Blase, 1989

  1. HUMANE
    1. Compassion
    2. Respect
    3. Positive Regard
    4. Cultural Sensitivity
    5. Adherence to TFA (Teaching-Family Association) ethical standards
  2. EFFECTIVE
    1. Resolve referral issues
    2. Achieve treatment goals
    3. In-house evaluation validates service utility
    4. Contribute to the systematic evolution of the Teaching-Family Model
  3. INDIVIDUALISED
    1. Service tailored to "fit" unique needs and strengths of family
    2. "Fit" of services determined via referral issues, family goals and direct observations of staff
  4. SATISFACTORY TO STAKEHOLDERS
    1. Consumers: children, family members, referral sources, allied professionals
    2. Dimensions: co-operation, communication, effectiveness and concern of staff
    3. Achieve treatment goals
  5. COST-EFFICIENT
  6. REPLICABLE
  7. INTEGRATION OF ABOVE GOALS

Teaching-Family Model
Home-Based Services
INTEGRATED PROGRAM COMPONENTS

Adapted from Dean L. Fixsen and Karen A. Blase, 1989

  1. PROGRAM CLARITY
    (guides for decision-making)
    1. Philosophy
    2. Goals
    3. Treatment Processes
    4. Ethical Standards
  2. STAFF SELECTION
    (the general "unteachables")
    1. Caring and Commitment
    2. Common Sense
    3. Intelligence
    4. Background Knowledge
    5. Willingness to Learn
    6. Philosophical Fit
  3. STAFF TRAINING
    (treatment related skills and knowledge)
    1. Pre-Service and In-Service training in:
      • Program Goals and Philosophy
      • Treatment Processes and Skills
      • Clinical Judgements
      • Program Operations
    2. Emphasis on teaching of concepts and skill development
    3. Opportunities for shared learning and program development
  4. STAFF SUPERVISION
    (putting it into practice)
    1. Assure Treatment Implementation
    2. Develop Staff Skills
    3. Enhance Clinical Judgements
    4. Solve Special Problems
    5. Create New Technology
    6. Support Personal Development
  5. STAFF EVALUATION
    (assessing clinical implementation)
    1. Treatment-Related Skills
    2. Clinical Judgements
    3. Youth, Parent & Stakeholder Surveys
    4. Annual Staff Certification by Teaching-Family Association
  6. PROGRAM EVALUATION
    (assessing program implementation)
    1. Family Benefits & Program Costs
    2. Accountability to Consumers
    3. Demographic Information
    4. Feedback for Program Development
    5. Annual and Triennial Site Certification by Teaching-Family Association
  7. PROGRAM ADMINISTRATION
    (putting/keeping it all together)
    1. Facilitate Treatment Processes and Integration
    2. Support Treatment Staff
    3. Meet Operating Requirements
    4. Interface with Other Systems
    5. Encourage Innovation
    6. Evolve Effective Programmes

Teaching-Family Model
Home-Based Services
INTEGRATED TREATMENT COMPONENTS

Adapted From Dean L. Fixsen and Karen A. Blase, 1990

  1. TEACHING SYSTEMS
    1. Proactive
    2. Reactive
    3. Intensive
  2. RELATIONSHIP DEVELOPMENT
    1. Non-Judgemental
    2. Person-Centred
    3. Partnership
  3. MOTIVATION SYSTEMS
    1. Flexible and Individualised
    2. Precise and Positive
    3. Person-Centred
  4. SELF-DETERMINATION
    1. Rational Problem-Solving
    2. Self-Control
    3. Expressing Feelings
  5. COUNSELLING
    1. Empathy and Concern
    2. Support and Reassurance
    3. Feelings and Relationships
  6. SKILLS CURRICULUM
    1. Individualised
    2. Appropriate Alternatives
    3. Social Prosthesis
  7. ADVOCACY
    1. Self-Advocacy and Assertiveness
    2. "Systems" Issues
    3. Professionalism
  8. CONTEXTUAL TREATMENT
    1. Relevant Settings and People
    2. Fosters Acquisition & Generalisation
    3. Matching Skills and Supports
  9. COMMUNITY STANDARDS
    1. Social Acceptability
    2. Community Values
    3. Ethical Standards
  10. TREATMENT PLANS
    1. Interactional Nature of Problems
    2. "Fit" the Family
    3. Implementation Issues Monitored
  11. INTEGRATION OF TREATMENT COMPONENTS
    1. Maximise Opportunities for Change
    2. Clinical Judgement
    3. Outcome Oriented, Process Sensitive

Teaching-Family Model
Home-Based Services
TREATMENT PLANNING AND IMPLEMENTATION

Dean L. Fixsen, Karen A. Blase, Karen A. Olivier, & Arlene C. Oostenbrink, 1990

  1. REFERRAL ISSUES
    • Legal Reasons
    • Problem Oriented
  2. TREATMENT RATIONALE
    • Youth/Family Reasons
    • Solution Oriented
  3. TREATMENT GOALS
    • Focus on Key Issues
  4. SKILLS RELATED TO GOALS
    • Appropriate Alternatives to Problems
  5. BEHAVIOURS RELATED TO SKILLS
    • How To Do and Say Things Differently

 

 

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