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Am J Community Psychol (2007) 39:191–196 DOI 10.1007/s10464-007-9104-5 ORIGINAL PAPER Systems change reborn: rethinking our theories, methods, and efforts in human services reform and community-based change Pennie G. Foster-Fishman Æ Teresa R. Behrens Published online: 18 May 2007  Springer Science+Business Media, LLC 2007 Abstract This article introduces the reader to this special issue on Systems Change and highlights six lessons learned about theory, methods, and interventions for systems change that emerged across the included articles. The value of a systems approach to systems change is examined, including the need for frameworks, methods, and change activities that attend to the characteristics of systems. Keywords Systems change  Mental models  Systems thinking  Social change Community Psychology is ultimately concerned about social justice and social change. These goals require a sophisticated understanding of the contexts that give rise to social problems (Seidman, 1988) and the use of research methods and change strategies that attend to the complexities of social settings (Tseng et al., 2002). Although our field has dedicated considerable attention to these concerns, our abilities in these areas still lag behind the considerable need in our society for transformative change. This special issue on Systems Change was developed to increase the conceptual and methodological tools available to those involved in designing, implementing, and assessing social change. Why focus on systems change? We purposively used the frame of ‘‘Systems Change’’ for this special issue for several reasons. First, the term P. G. Foster-Fishman (&) Michigan State University, 125 D Psychology Building, East Lansing, MI 48824, USA e-mail: fosterfi@msu.edu T. R. Behrens W. K. Kellogg Foundation, Battle Creek, MI, USA ‘‘systems change’’ explicitly connotes a change in a system. For us the term ‘‘system’’ better captures the ecological and social change emphasis of our field than the more often used term ‘‘context’’. In general, a system is a collection of parts that interact together and function as a whole (Ackoff & Rovin, 2003). While the term context can also connote this complexity, it more typically refers to a discrete environmental (e.g., neighborhood, school, organization, community) characteristic that has influence on a phenomenon of interest. Sense of community, classroom size, leadership style, and decision-making opportunities are all examples of contextual characteristics that are often measured or targeted for intervention by community psychologists. While these are all valuable foci for research and intervention efforts, these discrete variables do not capture the overall purpose and essence of the contexts within which they are embedded. Neighborhoods, schools, organizations, and communities are complex and dynamic; their character emerges through the interactions and interdependencies across the many actors, niches, and activities that exist within them. Attention to only one or a few system characteristics when attempting to foster social change can create null results and even have dire consequences. For example, Tseng and Seidman (2007) in this issue describe how California’s school reform movement failed, in part, because leaders considered a reduction in classroom size as essential to educational performance and ignored the inevitable fact that the creation of new classrooms would create a need for more teachers within the system. Without this resource the school system hired relatively unqualified individuals to fill this gap and inadvertently sacrificed classroom quality for classroom size. Because significant social change requires that we alter the status quo, and the status quo is maintained and constrained by the systems we live within (Seidman, 1988), a 123 192 focus on understanding and changing systems seems a worthwhile venture for community psychologists. Thus, it is our hope that this special issue reinvigorates a more deliberate consideration of the term ‘‘system,’’ and all it conveys, in the research and intervention work of community psychologists. The second reason for using the systems change frame for this issue is that many recent initiatives by federal and state governments and national foundations have adopted the term ‘‘systems change’’ to illustrate their goal of creating sweeping and sustained transformative impact on neighborhoods, communities, and service delivery systems. In these efforts, a ‘‘system’’ such as a neighborhood, the mental health delivery system, or even a whole community, is the focus of change. Though popular, many of these efforts have struggled to achieve what was promised. As professionals engaged in this work ourselves (as a funder, evaluator, technical assistance provider, and designer) we looked to the literature to help us better understand how to do systems change effectively. We found few articles in our field that were pertinent to this concern. We hope this special issue will help to expand the contributions made by community psychologists to this field of study. Third, for the past 20 or more years, a large academic discourse has been occurring around the concept of systems though this dialogue has not often involved community psychologists. As concepts such as chaos theory have begun to be applied to social as well as biological and physical systems, numerous debates concerning what a system is and how it should be understood, changed, and evaluated have occurred within the fields of systems thinking. It is our hope that this special issue helps to bridge the academic worlds of community psychology and systems thinking because we believe that efforts to create social change can be strengthened by insights gained in the systems science. We also believe that the largely theoretical discourse on systems can benefit from grounding in the practical world of community change work. Am J Community Psychol (2007) 39:191–196 represent the diversity of the work in our field, targeting a range of systems, problem areas, and strategies for change. They include: • • • An introduction to the special issue With these three purposes in mind, we sought articles for this special issue that represented exemplar descriptions of the theories, methods, and practice of systems change work. In the call for papers systems change was defined as: ‘‘change efforts that strive to shift the underlying infrastructure within a community or targeted context to support a desired outcome, including shifting existing policies and practices, resource allocations, relational structures, community norms and values, and skills and attitudes.’’ While authors were not required to incorporate systems thinking into their papers, many did. The following 17 articles 123 • New theoretical frameworks for systems change efforts. Christens, Hanlin, & Speer (2007) describe how the sociological imagination is a powerful tool for facilitating social change. Foster-Fishman, Nowell, & Yang (2007) present their framework for transformative systems change that integrates systems thinking and organizational change principles. Tseng & Seidman (2007) introduce a systems framework for understanding social settings for youth that emphasizes social processes, resources, and a setting’s organization of resources. Valuable methods for assessing systems and documenting change. Durlak et al. (2007) present results from their meta-analysis of competence-promotion outcome studies that demonstrate that social systems affecting children and adolescents can be altered. Emshoff et al. (2007) described their longitudinal analysis of community health collaboratives in Georgia and illustrate, using HLM, that collaborative characteristics, over time, influence the degree of systems changes made. Hirsch, Levine, & Miller (2007) illustrate the power of systems dynamics modeling for explaining the challenges of school reform efforts. Janzen, Nelson, Hausfather, & Ochocka (2007) describe how they engaged consumers of mental health services in a participatory action research process to document and track their systems change activities. Kreger, Brindis, Manuel, & Sassoubre (2007) present a framework for tracking the indicators of collaborative systems change efforts. Rich case examples of systems change. Griffith et al. (2007) present a process for addressing institutional racism in the health care system. O’Connor (2007) describes a strategy for eliciting and altering the mental models used by members of interagency teams. Campbell, Nair, & Maimane (2007) describe their efforts to create a health competent community in a rural South Africa community plagued by HIV/AIDS. Ford (2007) details how his action research efforts with one police department facilitated and supported the transformation to community policing. Staggs, White, Schewe, Davis, & Dill (2007) discuss their attempts at incubating systems change in the service delivery system for children in Chicago. Suarez-Balcazar et al. (2007) describe their efforts at creating a healthy food system within the public schools in Chicago. Commentaries on the future of systems change. Kelly (2007) discusses the implication of these articles for current and future community psychologists. Behrens & Foster-Fishman (2007) generate a list of systems Am J Community Psychol (2007) 39:191–196 change principles that can be culled from these articles. Parsons (2007) posits that complex adaptive systems theory may be particularly useful for the endeavors pursued by community psychologists. Overall, this group of articles tells a compelling tale of the passion for social change within our field and the challenges faced in pursuit of social justice. We introduce you to these articles by first highlighting a few insights about the theories, methods, and processes of systems change that emerge from this body of work. Insights about theory as it relates to systems change Theory is useful because it provides a framework from which to understand or explain what we observe or to predict what we anticipate will happen. Part of our own journey as co-editors of this special was to familiarize our selves with the large body of literature on systems thinking and transformative change.1 As we reviewed the articles in this special issue, from this expanded framework, several insights emerged about the value of integrating a system’s perspective into our field’s systems change efforts. We highlight these insights below. Attention to a system’s boundary and the processes used to define it can improve the efficacy of systems change endeavors For some systems theorists, the process of defining a system’s boundary is the most critical step in a systems change endeavor (Checkland, 1981; Midgley, 2000). Boundaries clarify what is important and valued; they make explicit the focus of inquiry (including the problem definition) and the potential range of impact of a change initiative. Thus, boundary clarity not only helps the configuration of intervention and analyses efforts, but it also increases the transferability of the findings to other similar contexts. In this special issue Foster-Fishman and her colleagues describe how they engage system members in clarifying two types of boundaries in their systems change efforts: (a) how the problem is defined; and (b) who and what should be considered as part of the system given this problem definition. Because system boundaries are an arbitrary construct, the act of defining boundaries is an essential step in any systems change endeavor (Midgley, 2000). For example, Christens et al.’s (2007) article in this special issue illus1 While there is not space in this article to provide a comprehensive review of the systems literature, we refer interested readers to Bob Williams’ website (http://users.actix.co.nz/bobwill) for an excellent summary of key systems theories. 193 trates how the obesity problem in America is redefined when the boundaries of this problem are redrawn to include the increase in corn farm subsidies and thus the abundance of inexpensive fructose corn syrup as an additive in processed foods. By expanding the system boundaries in this way, Christens and colleagues highlight the need for solutions that expand beyond individual or even community level healthy eating programs. The delineation of system boundaries can create opportunities for change or, when drawn too narrowly, reduce the resources available for system functioning. Thus, one lever for change is the intentional expansion of a system’s boundaries. For example, in rural communities in South Africa that were plagued by HIV/AIDs, Campbell and her colleagues (2007) attempted to expand the HIV health care and support system available to these communities in multiple ways, including inviting tribal chief leaders and local service agencies to join these communities in these efforts. In the school system examined in Suarez-Balcazar’s et al.’s (2007), change agents found an opportunity for systems change when they considered the new food vendors as part of their healthy food initiative. Overall, this suggests that more attention is needed to how community psychologists define the problem situation and the boundaries around the targeted system. In many ways, the processes for creating these delineations fit well with the values and practices of community psychology. Systems theorists argue that problem definitions and system boundaries needed to be examined and negotiated with multiple system stakeholders in an ongoing and iterative dialogic process. (See Checkland, 1981 and Midgley, 2000 for excellent descriptions of these processes). These processes not only clarify boundaries for the change agent or researcher, but also serve to expand stakeholders’ understandings. A change in a system level outcome is not the same as, nor does it guarantee, system change Systems change agents and researchers often focus on improving discrete system parts––such as a policy change or the infusion of new resources. The literature is rife with examples of systems change efforts that have yielded these outcomes yet still failed to create a sustained change in a system or a shift in the status quo. Systems thinking helps to explain why system level outcomes often fail to leverage systemic change by reminding us that a sole emphasis on a unitary system part (e.g., policy change) is usually insufficient for sustained system transformation (unless, of course, one is fortunate enough to locate that butterfly flapping its wing). Systems are made of parts––and their interactions––and it is the interaction between parts that define system functioning, give birth to entrenched patterns 123 194 of interaction, and generate root causes to significant problems (Senge, 1990). A shift in a system part––such as a policy change––will only transform the status quo if that part also leverages necessary changes in other system elements. The character of the interdependencies and patterns across system components ultimately determine if such leverage can occur. This suggests that researchers and change agents interested in systems change need to redirect their focus to understanding and shifting the interdependencies within systems and the consequences of those interactions. FosterFishman et al. (2007) describe an approach to systems change that considers system parts, their interactions, and critical levers for change. Hirsch et al.’s (2007) article highlights how inaccurate conclusions can be drawn when system interactions are ignored. Am J Community Psychol (2007) 39:191–196 reader to a third method (complex adaptive systems theory) well suited for dealing with systems that are constantly adapting to their environments. • • Insights about methods for systems change Community psychologists have long lamented the significant gap between the theories of community of psychology and the methods that are employed. Luke (2006) was perhaps the most recent critic, noting the significant incongruity between our foundation in ecological theory and our primary use of methods that rarely go beyond the intra-individual level. Certainly, when systems change efforts are embedded within systems thinking theories, they risk the same lack of alignment. Systems thinking requires attention to a complex web of interdependencies, an awareness of the ‘‘whole’’ not just the parts, and the ability to recognize multi-directional cause-effect relationships with all causes emerging as the effect of another system dynamic. The regularity model of causation (x predicts y) that we typically rely on in our research is frankly illequipped to deal with such complexity. Several of the articles in this special issue illustrate innovative methods for thinking about and changing systems. This leads us to our next lesson learned about systems change. Systems change agents and researchers need methods that are equipped to capture system complexity Systems are complex in many ways. For example, they contain a web of interactions, have members who hold multiple, diverse worldviews, and are self-organizing, adjusting to environmental threats and opportunities. Appropriate methods would attend to these complexities. We highlight two methods that are illustrated in this special issue that are particularly well equipped to attend to system interdependencies and multiple system realities. Parsons (2007) in her commentary to this issue introduces the 123 Systems dynamics modeling. Hirsch, Levine, & Miller’s (2007) article in this special issue illustrates an application of systems dynamics modeling (SDM). SDM is viewed by some system’s theorists as the most advanced methodological technique for mapping and assessing system activities and outcomes. It rests on the notion that systems consists of reinforcing and balancing feedback loops, not uni-directional causal chains, and that an understanding of these interdependencies sheds light on systems functioning. While a statistician familiar with the complexities of SDM is needed to run computational modeling, SDM tools can also be used to visually graph a system manually (Kim, 1999). Soft systems methodology. Soft systems methodology is an approach for understanding human systems that emphasizes the social construction of reality and the presence of multiple, valid perspectives of a problem situation and its solution (Checkland, 1981). One goal in SSM is to generate multiple ‘‘rich pictures’’ of a system that portray these different worldviews and then work with systems stakeholders to integrate and accommodate these different perspectives. SSM fits well with the values and processes of community psychologists; it is intentionally designed to give voice to diversity within a setting and avoids the risk of forced consensus by requiring stakeholders to create a worldview that accommodates different perspectives. Griffith and colleagues (2007) and Suarez-Balcazar et al. (2007) in this special issue describe the value and/ or use of SSM in their systems change efforts. Insights about systems change efforts Five articles in this special issue (Suarez-Balcazar; Staggs, O’Connor, Ford, and Campbell) provide rich case study illustrations of systems change efforts. All articles describe honest portrayals of the complexity of this work and the challenges we face as we engage in systems change efforts. We highlight below three lessons learned that emerge across these cases. Kelly, in his commentary in this issue, does an excellent job of discussing the implications of the lessons learned from these cases for the future of community psychology. Levers targeted for change need to have cross level influences within the targeted system Systems change happens when levers for change are targeted that can trigger shifts across system components. The Am J Community Psychol (2007) 39:191–196 papers in this special issue targeted multiple and diverse levers, including changing organizational policies (Ford, 2007; Suarez-Balcazar et al., 2007), shifting system members (Ford, 2007; Suarez-Balcazar et al., 2007), strengthening and expanding relationships (Campbell et al., 2007; Durlak et al., 2007; Emsoff et al., 2007; Kreger et al., 2007; O’Connor, 2007; Staggs et al., 2007; Suarez-Balcazar et al., 2007); infusing new or different resources (Suarez-Balcazar et al., 2007), altering practices (Ford, 2007; O’Connor, 2007; Staggs et al., 2007), shifting system regulations (Ford, 2007; Tseng & Seidman, 2007) and changing system member’s mental models (Ford, 2007; O’Connor, 2007). In many ways, this list represents the deep and apparent structures Foster-Fishman et al. (2007) emphasize in their systems change framework. As the cases described in this special issue illustrate, levers that managed to alter conditions and practices in other subsystems or system layers were the most effective at facilitating systems change. For example, Ford (2007) describes how the policies and practice ideas implemented by a new police chief initiated some significant changes in community policing efforts by beat cops. Emsoff et al. (2007) discusses how inter-organizational efforts facilitated some changes within local organizations and communities. Stagg’s et al. (2007) and Suarez-Balcazar et al. (2007), on the other hand, describe the challenges to system change efforts when initial levers are not positioned to create these cross-level influences. How can a change agent determine if the targeted levers for change are positioned to trigger system wide transformation? At least in these case examples, the extent to which the initial lever for change was tightly coupled with other subsystems was critical to the success. When targeted levers for change were dynamically linked with other system components, either exerting strong direct influences or having multiple, dense connections within the system, they were more successful at influencing system wide change. This suggests that attention to the character of the connections across system parts is a vital step in identifying which levers to target for change. Systems change requires a shift in system members’ ‘‘skill sets and mindsets’’ (Ford, 2007) Most system change efforts spend considerable energy building the capacities of individuals and communities, with the belief that setting members need the knowledge, skills, and behaviors to implement the required changes. However, if systems change efforts really intend to shift the status quo, shifts in mindsets or mental models are also necessary. Senge (1990) describes mental models as cognitive frameworks that are constructed from one’s knowledge and assumptions that guide decision making and 195 action. Mental models (or mindsets) maintain, constrain, and determine the status quo (Ford, 2007; Foster-Fishman et al., 2007). They provide individuals with frames that dictate their own behaviors, explain other’s action, and direct resource and opportunity allocations. In other words, even if system members have developed the new capacities needed to implement a new program or practice, they are unlikely to implement or sustain these changes if the shifts do not cohere with their worldviews about how things should be done. Ford’s (2007) paper provides an excellent case example of a systems change effort that changed both skill sets and mindsets, ultimately transforming the status quo. O’Connor (2007) introduces in this special issue a systems change strategy for identifying and changing mental models. Discourse processes that engage system members in ongoing opportunities to discover and alter their worldviews are effective mechanisms for shifting mindsets and fostering systems change Discourse involves honest, frank discussions that strive to generate new understandings about organizational and community life. In critical discourse processes, assumptions are revealed and multiple, competing perspectives and solutions are explored, debated, and valued (Fear, Rosaen, Bawden, & Foster-Fishman, 2006). Overall, when real conversations happen in an ongoing manner, new ways of being can emerge; old mental models get unfrozen and reformulated (Lewin, 1951) and significant social change takes hold. Several of the authors in this special issue highlight the role and value of discourse processes in their systems change efforts. For example, Ford (2007), O’Connor (2007), and Suarez-Balcazar et al. (2007) discuss the importance of engaging multiple stakeholders in ongoing dialogic processes where opportunities for exploring the gap between current realities and desired states occur. While community psychologists have highlighted the importance of discourse processes in the past, a commitment to systems change efforts may require a renewed effort in discovering effective processes and strategies for engaging system members in these difficult, though vital conversations. Conclusion In many ways we view this special issue as a call to action for the field of community psychology. We are encouraging the field to embrace the theories and methods called for when one considers a systemic approach to systems change. The articles and commentaries included in this special 123 196 issue describe the successes and challenges in systems change work and highlight, to some extent, the value of a systems focus when we strive to shift the status quo. Of course, if we are to be effective in our efforts, we must strive to socialize not only the next generation of community scholars in the ‘‘system’s way’’, but also the funders and change agents that design and create expectations for these efforts. Only when the initiatives, theories, methods, and resources directed towards systems change efforts become aligned with the complexity and realities of systems will our pursuit of a just world be realized. References Ackoff, R. L., & Rovin, S. (2003). Redesigning society. Stanford, CA: Stanford Business Books. Behrens, T., & Foster-Fishman, P. G. (2007). Developing operating principles for systems change. American Journal of Community Psychology. Campbell, C., Nair, Y., & Maimane, S. (2007). Building contexts that support effective community responses to HIV/AIDS: A South African case study. American Journal of Community Psychology. Checkland, P. (1981). Systems thinking: Systems practice. Chichester: Wiley. Christens, B. D., Hanlin, C. E., & Speer, P. W. (2007). Getting the social organism thinking: Strategy for systems change. American Journal of Community Psychology. Durlak, J. A., Taylor, J. D., Kawashima, K., Pachan, M. K., DuPre, E. P., Celio, C. I., Berger, S. R., Dymnicki, A. B., & Weissberg, R. P. (2007). Effects of positive youth development programs on school, family, and community systems. American Journal of Community Psychology. Emshoff, J. G., Darnell, A. J., Darnell, D. A., Erickson, S. W., Schneider, S., & Hudgins, R. (2007). Systems change as an outcome and a process in the work of community collaboratives for health. American Journal of Community Psychology. Fear, F., Bawden, R., Rosaen, C., & Foster-Fishman, P. G. (2006). Coming to Critical Engagement. University Press of America. Ford, J. K. (2007). Building capability throughout a change effort: Leading the transformation of a police agency to community policing. American Journal of Community Psychology. Foster-Fishman, P. G., Nowell, B., & Yang, E. (2007). Putting the system back into systems change: A framework for understanding and changing organizational and community systems. American Journal of Community Psychology. 123 Am J Community Psychol (2007) 39:191–196 Griffith, D. M., Mason, M., Yonas, M., Eng, E., Jeffries, V., Plihcik, S., & Parks, B. (2007). Dismantling institutional racism: theory and action. American Journal of Community Psychology. Hirsch, G. G., Levine, R., & Miller, R. L. (2007). Using system dynamics modeling to understand the impact of social change initiatives. American Journal of Community Psychology. Janzen, R., Nelson, G., Hausfather, N., & Ochocka, J. (2007). Capturing system level activities and impacts of mental health consumer-run organizations. American Journal of Community Psychology. Kelly, J. G. (2007). The system concept and systemic change: Implications for community psychology. American Journal of Community Psychology. Kim, D. H. (1999). Introduction to systems thinking (IMS––Innovations in Management Series). Vermont: Pegasus Communications. Kreger, M., Brindis, C. D., Manuel, D. M., & Sassoubre, L. (2007). Lessons learned in systems change initiatives: Benchmarks and indicators. American Journal of Community Psychology. Lewin, K. (1951). Field theory in social science. New York: Harper Row. Luke, D. A. (2006). Getting the big picture in community science: Methods that capture context. American Journal of Community Psychology, 35(3/4), 185–200. O’Connor, P. A. (2007). Using system differences to orchestrate change: A systems-guides intervention model. American Journal of Community Psychology. Midgley, G. (2000). Systemic intervention: Philosophy, methodology, and practice. New York: Kluwer. Parsons, B. A. (2007). The state of methods and tools for social systems change (2007). American Journal of Community Psychology. Seidman, E. (1988). Back to the future, community psychology: Unfolding a theory of social intervention. American Journal of Community Psychology. 16(1), 3–24. Senge, P. M., (1990). The Fifth Discipline. New York: Doubleday Staggs, S. L., White, M. L., Schewe, P. A., Davis, E. B., & Dill, E. M. (2007). Changing systems by changing individuals: The incubation approach to systems change. American Journal of Community Psychology. Suarez-Balcazar, Y., Redmond, L., Kouba, J., Hellwig, M., Davis, R., Martinez, L. I., & Jones, L. (2007). Introducing systems change in the schools: The Case of school luncheons and vending machines. American Journal of Community Psychology. Tseng, V., & Seidman, E. (2007). A systems framework for understanding social settings. American Journal of Community Psychology. Tseng, V., Chesir-Teran, D., Becker-Kelin, R., Chan, M. L., Duran, V., Roberts, A., & Bardoliwalla, N. (2002). Promotion of social change: A conceptual framework. American Journal of Community Psychology, 30(3), 401–421. Reproduced with permission of the copyright owner. Further reproduction prohibited without permission. The Behavior Analyst Today Volume 7, Number 2, Spring, 2006 Editor’s Note: This article originally appeared in Bernfeld, G.A., Farrington, D.P., & Leschied, A.W. (Eds.) (2001). Offender rehabilitation in practice: Implementing and evaluating effective programs (pp. 167-188). Copyright John Wiley & Sons Ltd. Reproduced with permission. The Struggle For Treatment Integrity in a "Dis-integrated" Service Delivery System Gary A . Bernfeld St. Lawrence College 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 Abstract The purpose of this chapter is to describe an innovative family preservation program for delinquents, which exemplifies effective correctional treatment: Community Support Services of the St Lawrence Youth Association in Ontario Canada. Over 7 years, the program utilized the Teaching-Family Models (see Chapter 7 by Dean Fixsen, Karen Blase, Gary Timbers and Montrose Wolf in this book) 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 & Fixsen, 1990), in which four levels of analyses are used to examine the delivery of human services: client, program, agency and societal. Finally, suggestions are made for contextual supports for innovative programs, so as to foster their effectiveness, longevity and key role as catalysts for systemic change in children's services. Keywords: family preservation, delinquents, corrective treatment, Teaching Family Models, integrated treatment, contextual supports, 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 (Olivier, Oostenbrink, Benoit, Blase & Fixsen, 1992) with mostly child welfare clientele, and adapt them for use with young offenders. Thus, the two programs shared the same broad goal of integrating the well-researched treatment methods of the Teaching-Family Model (see Chapter 7) with the service delivery strategies of the Homebuilders Model (Whittaker, Kinney, Tracy & Booth, 1990), an exemplary family preservation program. Other literature supporting the development of the Community Support Services model include: • Clinically appropriate treatment, as defined in meta-analytic literature reviews (e.g. Gendreau, 1996; Chapter 2 by James McGuire and Chapter 4 by Friedrich Lösel, both in this book), includes behavioral systems family therapy, intensive structured skill training and structured one-on-one paraprofessional 188 The Behavior Analyst Today • • • • • • Volume 7, Number 2, Spring, 2006 programs. Andrews, Leschied and Hoge's (1992) review 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 noncriminal peers). Patterson, Reid and Dishion (1993) provided detailed empirical support for their developmental model of antisocial or coercive behavior, in which parents are key to the early training for antisocial behavior. As well, their research targeted the teaching of appropriate family management skills as essential to rehabilitating delinquents. Christensen and Jacobson (1994) reviewed research on psychological treatment delivered by paraprofessionals and concluded that paraprofessionals are usually as effective as professionals. Given that the need for mental health services exceeds the supply of professionals and the costs savings afforded by paraprofessionals, they concluded that services delivered by non-professional therapists merit wider use and further research. Multisystemic therapy, developed and carefully evaluated by Scott Henggeler (see Chapter 5 by Daniel Edwards, Sonja Schoenwald, Scott Henggeler & Keller Strother in this book) targets risk factors across the delinquents' family, peer, school and neighborhood contexts. It uses an intensive family preservation approach, combined with an eclectic mix of cognitive-behavioral services. Andrews et al. (1992) have continued to emphasize the importance of treatment integrity for programs treating delinquents. Some of the key elements of therapeutic integrity, detailed by Alan Leschied, myself and David Farrington (see Chapter 1 of this book), include: a coherent and empirically based theoretical model; an individualized approach to assessing and treating client risks/needs; a detailed program 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 Chapter 12 of this book by Paul Gendreau, Claire Goggin and Paula Smith. Paul Gendreau (Chapter 12 of this book) and others (e.g. Friedrich Losel in Chapter 4 of this book) have also stressed the importance of system factors. These include: the program's careful selection of line staff for their skills and values; the efforts at disseminating knowledge to staff; the program director's credentials and skills in the area of behavioral intervention; the support for the program from the host agency; and the broader service delivery system; funding; etc. Two annual reports on Community Support Services provide further details on the model's empirical "roots" (Bernfeld, Bonnell et al., 1995; Bernfeld, Cousins et al., 1990). OVERALL PROGRAM The program 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 behavior, 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. There are two different referral routes to the program: 1. Whenever possible, the program prefers to work in a family preservation mode. This involves accepting younger children currently on probation in the community, who are at moderate to high risk of reoffending. 2. An alternative type of referral involves youths currently in custodial settings, who need assistance in 189 The Behavior Analyst Today Volume 7, Number 2, Spring, 2006 returning to their community and families, or, in the case of older offenders, those who need preparation 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 (Referral Route #1) is designed not only to reduce costs by preventing future offences and residential placements, but also to maximize the impact and brevity of our services. Bernfeld, Cousins et al. (1990) provide further details on the development of Community Support Services. HALLMARKS OF COMMUNITY SUPPORT SERVICES Community Support Services treat young offenders who are 12–15 years of age at the time of their offence—and therefore only serve post-adjudicated youth. Referrals are made by probation officers in the six county areas around Kingston, Ontario, Canada. This area, over 200 kilometers in length and 150 in width, is largely rural, with one larger city (population 125,000) and two small urban centers. Total population is over 250,000. Travel times by car to serve rural clients range from 30 to 90 minutes or more. Electronic pagers and cellular phones are the primary means by which the staff keep in touch with clients. There is a total of six frontline staff working a 40-hour flexible workweek along with a director (the author), a supervisor and an administrative coordinator. As noted earlier, Community Support Services integrates the treatment methods of the Teaching-Family Model (see Chapter 7 in this book) with the service delivery strategies of family preservation programs such as Homebuilders (Whittaker et al., 1990). The first six hallmarks of Community Support Services listed in Table 8.1 reflect the service delivery strategies it generally shares with family preservation programs, as well as other ecological programs like Multisystemic Therapy (see Chapter 5 in this book). Table 8.1 Hallmarks of Community Support Services FLEXIBLE COMMUNITY-BASED FAMILY-CENTRED BASIC NEEDS INTENSIVE TREATMENT/DIRECT SERVICE FOLLOW-UP TEACHING GOAL-DIRECTED EMPIRICALLY BASED STAFF TRAINING/SUPERVISION MODEL Overall, Community Support Services is similar to these programs 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 programs which are home based; strength-oriented and family preservation focused; intensive and time limited; individualized and client-directed; as well as combining clinical and concrete services. However, the last four hallmarks listed in Table 8.1 underscore the differences between Community Support Services and ecological or family preservation programs in content or "what" interventions are offered. While others use an eclectic mix of cognitive-behavioral treatments, Community Support Services specifically organizes the implementation of these interventions within the Teaching-Family Model's standardized human 190 The Behavior Analyst Today Volume 7, Number 2, Spring, 2006 service systems. 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 generalization and maximize relevance and learning of the skills taught. Thus, staff are more like coaches than therapists. 3. Family-centered: The program works with the young offender and the entire family with the goal of preventing problems in the younger siblings and strengthening parenting capacity. It puts families in charge of their own service and helps them become more aware of a broader range of options available to them. The services offered "fit" the family's context and are implemented in a respectful and collegial manner. 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." 4. Basic needs: The family's needs for food, transportation, employment, budgeting, etc. are assessed and the focus is to teach the family skills in these areas (e.g. how to successfully apply for a job), including selfadvocacy. 5. Intensive treatment/Direct service: The intensive phase of service lasts 8–12 weeks. Caseloads are of two young offenders and their families at a time. Thus, at any one time, staff serve two youths in the intensive phase of service and six to eight in the follow-up mode. On average, over 214 hours of service is provided to each case of which 35 per cent is face to face (Bernfeld, Bonnell et al., 1995). The intensive phase of service starts with three to five visits per week and fades to one direct contact per week and several phone contacts. 6. Follow-up: After the intensive phase of service ends, there is a 1-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 1-year follow-up period and booster sessions are unique. 7. Teaching: Community Support specialists build on strengths of families and use a cognitive-behavioral approach to counseling 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 individualized, 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 behaviorally specific and commenting on youth skills). The goal is to develop positive, self-sustaining spirals of appropriate interaction between parents and children that 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 program'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 conceptualized as residing solely "in" children, but in the reciprocal, mutually impactful interactions between the child and others in the environment (Fixsen, Olivier & Blase, 1990). 9. Empirically-based: Community Support Services was based on the research literature on delinquency and the Teaching-Family Model, which was discussed earlier. 10. Staff Training/Supervision: These areas are critical and often under-developed in less structured community programs. 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 behavioral rehearsals of clinical skills) along with a 500-page manual. This is followed by a 2-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 bimonthly in-service training to develop new program technology. In addition, there are at least 191 The Behavior Analyst Today Volume 7, Number 2, Spring, 2006 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 per cent of their time in individual, group or peer super-vision, and this is critical to program integrity and quality. Taken as a whole, Community Support Services, like Alberta Family Support Services upon which it is modeled, offers contextual therapy. Bernfeld, Cousins et al. (1990) define this as "helping people learn to cope with their emotional and interactional issues in their own settings to maximize relevance, acquisition, and implementation and to minimize generalization 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 program implementation. The family-centered 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 behavior change. Ultimately, our ability to work in the family's home depends on how we help the family accomplish its goals. PROGRAM EVALUATION: A SUMMARY Bernfeld, Bonnell et al. (1995) describe the computerized Management Information System developed for Community Support Services. This system integrates the evaluation needs of the program with supervision, management and administrative systems. This practical and cost-effective program 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 all members of 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, Bonnell et al. (1995) and will only be briefly summarized here. A homebased, family-centered treatment technology is evolving which seems to reduce entry 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, Cousins et al. (1990) discuss the principles that guided the development of the "in-house" program evaluation model. These recognize the challenges in evaluating a flexible, strength-oriented program, without compromising its implementation with families in crises. In-depth analyses of these and other issues are provided by Pecora, Fraser, Nelson, McCroskey & Meezan (1995). Client benefits demonstrated by the program include reliable or statistic -ally significant reductions in youth behavior problems, as measured by the Child Behavior Checklist (Achenbach, 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 & Elliott, 1990). Youth recidivism after a 15-month follow-up period (55%) compared favorably to the 67 per cent rate reported by Hoge, Leschied and Andrews (1993) based on a 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 192 The Behavior Analyst Today Volume 7, Number 2, Spring, 2006 interval between offences. Consumers (parents, youth, probation officers, etc.) were generally satisfied with the program and provided detailed feedback about the program's strengths and areas for improvement. While 97 per cent of the young offenders were predicted by probation officers at intake to the program to require residential placements, only 42 per cent were actually placed out of home in the 15 months of follow-up, averaging less than 2 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 program, for a number of reasons. Hoge et al. (1993) reviewed Ontario-wide young offender programs and found that they averaged a relatively low score of 0.29 on the subgroup of scales reflecting treatment on the CPAI (Gendreau and Andrews, 1996). The provincial average of 0.29 means that 29 per cent of the 56 items were present across all Ontario programs. Sector-specific averages were: probation, 0.21; open custody, 0.26; secure custody, 0.29; and the nine community support teams (including Community Support Services), 0.51. In comparison, using the scoring guide provided by Leschied, Hoge and Andrews (1993), the Community Support Services program scored above 0.70 on the scale —meaning that more than 70 per cent of the program characteristics indicative of effective treatment were present. LINK TO THE TEACHING-FAMILY MODEL The Teaching-Family Model (see Chapter 7 in this book) is the "heart" of Community Support Services. From its original roots in a 1968 group home for delinquent adolescents called Achievement Place, the TeachingFamily Model has developed into an integrated service delivery system. Today there are over 134 group homes serving over 1,724 children annually across the United States 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 (over 524 children annually across the USA), independent living and home-based services (over 350 families served annually across the USA). Over 100 publications on the model have researched its effectiveness and carefully evaluated its individual treatment components over the past 30+ years. In fact, over $30M of 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. Figure 8.1 provides an overview and Tables 8.2–8.5 detail the home-based version of the Teaching-Family Model, in terms of its goals as well as its treatment, program and treatment planning systems. All have been carefully integrated so as to support the systematic implementation of this model. Chapter 7 in this book and Bernfeld, Blase et al. (1990) present the conceptual and research basis for program development and dissemination vis-à-vis the Teaching-Family Model. 193 The Behavior Analyst Today Volume 7, Number 2, Spring, 2006 Figure 8.1 Overview of home-based services in the Teaching-Family Model. Table 8.2 Goals of home-based services in the Teaching-Family Model A. HUMANE 1. Compassion 2. Respect 3. Positive regard 4. Cultural sensitivity 5. Adherence to TFA* ethical standards B. 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 C. INDIVIDUALIZED 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 D. SATISFACTORY TO STAKEHOLDERS 1. Consumers: children, family members, referral sources, allied professionals 2. Dimensions: cooperation, communication, effectiveness and concern of staff 3. Achieve treatment goals E. COST-EFFICIENT F. REPLICABLE G. INTEGRATION OF ABOVE GOALS * TFA = Teaching-Family Association. Adapted from Dean L. Fixsen and Karen A. Blase (pers. comm., April, 1989). Note: Tables 8.2–8.4 were adapted from those developed by Fixsen and Blase during their years of consultation and Community Support Services. They are precursors to the 1994 TFA Standards for home-based 194 The Behavior Analyst Today Volume 7, Number 2, Spring, 2006 services. The standards can be obtained from TFA at http://www.teaching-family.org Table 8.3 Integrated program components of home-based services in the Teaching-Family Model A. PROGRAM CLARITY (guides for decision making) 1. Philosophy 2. Goals 3. Treatment processes 5. Ethical standards B. STAFF SELECTION (the general "unteachables") 1. Caring and commitment 2. Common sense 3. Intelligence 4. Background knowledge 5. Willingness to learn 6. Philosophical fit C. 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 D. 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 7. Support personal development E. STAFF EVALUATION (assessing clinical implementation) 1. Treatment-related skills 2. Clinical judgements 3. Youth, parent and stakeholder surveys . 4. Annual staff certification by TFA* F. PROGRAM EVALUATION (assessing service implementation) 1. Family benefits and program costs 2. Accountability to consumers 3. Demographic information 4. Feedback for program development 5. Annual and triennial site certification by TFA* G. PROGRAM ADMINISTRATION (putting/keeping it all together) 1. Facilitate treatment processes and integration 195 The Behavior Analyst Today 2. 3. 4. 5. 6. Volume 7, Number 2, Spring, 2006 Support treatment staff Meet operating requirements Interface with other systems Encourage innovation Evolve effective programs * TFA = Teaching-Family Association. Adapted from Dean L. Fixsen and Karen A. Blase (pers. comm., April 1989). Table 8.4 Integrated treatment components of home -based services in the Teaching-Family Model A. TEACHING SYSTEMS 1. Proactive 2. Reactive 3. Intensive B. RELATIONSHIP DEVELOPMENT 1. Non judgmental 2. Person-centered 3. Partnership C. MOTIVATION SYSTEMS 1. Flexible and individualized 2. Precise and positive 3. Person-centered D. SELF-DETERMINATION 1. Rational problem-solving 2. Self-control 3. Expressing feelings E. COUNSELLING 1. Empathy and concern 2. Support and reassurance 3. Feelings and relationships F. SKILLS CURRICULUM 1. Individualized 2. Appropriate alternatives 3. Social prosthesis G. ADVOCACY 1. Self-advocacy and assertiveness 2. “Systems” issues 3. Professionalism H. CONTEXTUAL TREATMENT 1. Relevant settings and people 2. Fosters acquisition and generalization 3. Matching skills and supports 196 The Behavior Analyst Today I. COMMUNITY STANDARDS 1. Social acceptability 2. Community values 3. Ethical standards J. TREATMENT PLANS 1. Interactional nature of problems 2. Fit the family 3. Implementation issues monitored K. INTEGRATION OF TREATMENT COMPONENTS 1. Maximize opportunities for change 2. Clinical judgment 3. Outcome oriented, process sensitive Volume 7, Number 2, Spring, 2006 Adapted from Dean L. Fixsen and Karen A. Blase (pers. comm., May, 1990). Table 8.5 Treatment planning and implementation for home-based services in the Teaching-Family Model A. REFERRAL ISSUES —Legal reasons —Problem oriented B. TREATMENT RATIONALE —Youth/Family reasons —Solution oriented C. TREATMENT GOALS —Focus on key issues D. SKILLS RELATED TO GOALS —Appropriate alternatives to problems E. BEHAVIORS RELATED TO SKILLS —How to do and say things differently Adapted from Dean L. Fixsen, Karen A. Blase, Karen A. Olivier and Arlene C. Oostenbrink (pers. comm., June, 1990). The Teaching-Family Association oversees the quality assurance evaluations that hold organizations accountable for the programs that utilize and disseminate its model. To become a member of this association, a new organization must be formally affiliated with an already certified site for 5 years, receive systematic help in developing Teaching-Family Programs and undergo a rigorous evaluation at the service or treatment level and the organization 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 standardized procedures for how these functions are delivered in a certified organization. A site must be recertified annually. 197 The Behavior Analyst Today Volume 7, Number 2, Spring, 2006 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 "6.0" on a 7-point 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 summarizes 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 imple mentation of the Teaching-Family model internationally. Note that this is a non-profit organization whose primary function is to disseminate the model and ensure its planned, databased, evolution. What is hopefully apparent from reading the above and Tables 8.2–8.5 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 (1996) and Andrews et al. (1992). 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 and made pursuit of certification impossible. The program was about 1 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, with its start-up in 1988, it represents one of the oldest family preservation programs in Canada, and the most experienced program 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 (Bernfeld, Blase et al., 1990), in which four levels of analysis are used to examine the delivery of human services: client, program, organization and societal. Client level Clinical challenges occur at the interface of the treatment planning, program and treatment systems detailed in Tables 8.2–8.4. 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 Ralph Serin and Denise Preston (see Chapter 10 of this book), 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, nonreinforcing to work with and/or reside in locations which are inaccessible or hazardous for staff. As well, the multiple problems of the target familie s 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 the staff's 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 2-week long, in-home assessment of family issues before a contextually sensitive master treatment plan is designed. Finally, the weekly 198 The Behavior Analyst Today Volume 7, Number 2, Spring, 2006 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 multi-site (office and field based). 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 program implementation. The above examples should not imply that issues at the client level operate in isolation of the other levels that are discussed earlier. 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 labor union (at the program 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 program's preference for working in a family preservation mode continually brought the program 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. Program level The family and community-centered nature of the service was at odds with the focus of the other programs offered by the agency, which were residential. It often took the creative intervention by the agency's Executive Director, Merice Walker Boswell, to solve any inter-program 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 organizational level, the agency's structure facilitated efforts at the program level to set up and evolve towards the Teaching-Family Model's treatment planning, program and treatment systems. This is because the agency was relatively "loosely coupled", so that individual programs like Community Support Services could set up independent systems to select, train and supervise staff, and evaluate employees individually and the program as a whole. Moreover, the program 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 organizations, 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" program by the Executive Director (a key organizational issue), it was supported in its efforts to pilot and refine new staff training and program evaluation systems, which were later exported across the agency. Elements of its computerized management information system (see previous discussion) were incorporated later in all other agency programs. 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 onthe-job performance (Maloney et al., 1983). Our interviews included an hour-long written package requiring, among other things, answers to a series of behavioral 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 behavioral role plays. The latter 199 The Behavior Analyst Today Volume 7, Number 2, Spring, 2006 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 analyzed in making hiring decisions. Organizational level The Executive Director of this small (50 employee) non-profit agency actively encouraged innovation. This is unlike the process in la rge bureaucratic organizations, which supports the status quo. 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 program was set up according to some key treatment aspects of this model. As well, the mentorship of the Community Support Services Director (the present author) by the Executive Director was essential in the development of his networking skills with other peers in the local and provincial juvenile justice system. These included the program's key consumers—the local Supervisor of Probation and senior policymakers in the provincial government. In fact, the program'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, Blase et al. (1990) noted, a program director's personal relationship with key administrators and policymakers continues to be critical to program 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, pers. comm., 12 December 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 decentralized 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 program 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" program for child welfare clients, operated in collaboration with another agency. The authors demonstrate how the different structural and systemic supports for the other program 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 et al. are listed below, each with an example: 1. Referrals. These reflect periods of scarcity, occasions when too many referrals arrive at a time when the program has only a single opening or other occasions when inappropriate types of referrals are made. An example of the latter is when a young offender is suddenly referred just a few months prior to his 16th birthday, when he will "graduate" from one government ministry's services to those run by another 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 200 The Behavior Analyst Today 2. 3. 4. 5. 6. Volume 7, Number 2, Spring, 2006 quickly returning many young offenders in custodial residences 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. 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 treatment in particular. Not surprisingly, they favor legal sanctions (e.g. charging a youth with breaching probation), threats of punishment and reincarceration. They feel that these are the best means at their disposal to protect society—and reduce their liability—should a youth reoffend, 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 impact on the autonomy and integrity of programs like Community Support Services. 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 or 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-à-vis Community Support Services (crisis/reactive versus prevention) may also be exacerbated by the relative autonomy of probation officers. Commitment. It was difficult to build commitment in probation officers to Community Support Services, as it was a new, pilot program. Also, the timing of its introduction in 1988 was unfortunate, as it coincided with the government's privatization of public agencies. Two other factors hindered the effort to convince probation staff that the family preservation effort was not just another temporary "fad". First was the government's history of introducing new program models with little advance planning and then dropping them shortly thereafter. Another factor was the lack of training offered to staff about the benefits of this approach. Though training in cognitive behavioral services was eventually offered years later, probation officers had little direct experience with it and little supervision in how to implement such treatments on the job. 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 who 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 was the above-noted power struggle over referrals and the continued pressure on the staff to "inform" on family members who were suspected of other illegal activities. 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 challenge the probation officer'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 "punishmentoriented" 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 that is popular in the current political climate. 201 The Behavior Analyst Today Volume 7, Number 2, Spring, 2006 This list is a brief overview of some the challenges discussed by Bernfeld, Cousins-Brame et al. (1995) to implementing an integrated treatment like Community Support Services within a fragmented children's services delivery system. It is contended that these issues are critical to the integrity of any human service delivery program. As well, a program's ultimate effectiveness is a function of its ability to surmount day-to-day challenges to its implementation—no matter how strong its empirical base or its success in limited demonstration projects. THE IMPORTANCE OF STRUCTURAL SUPPORTS This chapter has primarily focused on delineating the challenges that one program, Community Support Services, has faced in its ongoing efforts to effectively deliver its rehabilitation services to young offenders in a disjointed service delivery system. As such, its struggles are a microcosm of others. While the use of the highly integrated treatment and program support systems pioneered by the Teaching-Family Model (see Chapter 7 by Dean Fixsen, Karen Blase, Gary Timbers & Montrose Wolf, in this book) reduced implementation problems within the program, it could not completely insulate the program from a variety of external challenges. To fully understand the nature of these challenges to treatment integrity, we need to look "outside the black box" of our correctional interventions. 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 et al. (1990), Bernfeld, CousinsBrame et al. (1995), Fixsen et al. (Chapter 7 of this book) and by Alan Leschied, Gary Bernfeld and David Farrington (Chapter 1 of this book). This literature teaches us that the long-term survival of innovative human service programs requires a unique confluence of supportive factors at the program, organizational and societal levels. Some of these factors were already delineated in the previous section, which detailed the organizational structure of Community Support Services' host agency. Moreover, specific suggestions can be made for contextual supports for innovative programs 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 programs across the province; provides immediate top to bottom staff training; and shifts a proportion of fiscal resources from existing residential services to innovative community programs. Overall, in order to systematically disseminate innovation, government needs to develop a comprehensive, multilevel and long-term implementation plan. For example, if such a plan was in place when Community Support Services began, it would not have allowed the program'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 program if it had an opening. This structure preserved the autonomy and integrity of the program 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 external or contextual supports are essential to innovative programs like Community Support Services, so as to foster their effectiveness, longevity and key role as catalysts for systemic change in children's services. 202 The Behavior Analyst Today Volume 7, Number 2, Spring, 2006 References Achenbach, T. M. (1991). Manual for the Child Behavior Checklist/4-18 and 1991 Profile. Burlington: University of Vermont, Department of Psychiatry. 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. Toronto, Ontario: Ministry of Community Social Services. 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. New York: 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 report (90+ pp.): $10.00 to cover copying and postage.]* Bernfeld, G., Cousins, M. L., 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 p. 32): $5 to cover copying and postage.]* Bernfeld, G. A., Cousins-Brame, M. L., & Knox, K. (1995, May). Contextual Challenges to Family-centered Services: Can Integrated Treatment Operate in a "Dis-integrated" Service System? Workshop presented at the Growing '95 conference, Toronto. Christensen, A., & Jacobson, N. S. (1994). Who (or what) can do psychotherapy?: The status and challenge of nonprofessional therapies. Psychological Science, 5, 8-14. Fixsen, D. L., Olivier, K. A., & Blase, K. A. (1990). Home-based, Family-centered Treatment for Children, Unpublished, Hull Child & Family Services, Calgary, Alberta. 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, pp. 117-130. Thousand Oaks, CA: Sage. Gendreau, P., & Andrews, D. A. (1996). Correctional Program Assessment Inventory (CPAI), 6th ed. Saint John, New Brunswick: University of New Brunswick. Gendreau, P., & Goggin, C. (1997). Correctional treatment: Accomplishments and realities. In P. Van Voorhis, D. Lester & M. Braswell (Eds), Correctional Counseling and Rehabilitation, 3rd ed., pp. 271-279. Cincinnati, OH: Anderson Publishing Co. Gresham, F. M., & Elliott, S. N. (1990). Manual for the Social Skills Rating System. Toronto, Ontario: Psycan. 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. Toronto, Ontario: Ministry of Community and Social Services. 203 The Behavior Analyst Today Volume 7, Number 2, Spring, 2006 Leschied, A. W., Hoge, R. D., & Andrews, D. A. (1993). Evaluation of the Alternative to Custody Programs in Ontario's Southwest Region. Toronto, Ontario: Ministry of Community and Social Services. 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 and Treatment, 1, 37-50. Olivier, K. A., Oostenbrink, A., Benoit, G., Blase, K. A., & Fixsen, D. L. (1992). Alberta Family Support Services: Annual Report. Calgary, Alberta: Hull Child & Family Services. 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. New York: Aldine de Gruyter. Robin, A. L., & Foster, S. L. (1989). Negotiating Parent-Adolescent Conflict: A Behavioral-Family Systems Approach. New York: Guilford Press. Whittaker, J. K., Kinney, J., Tracy, E. N., & Booth, C. (1990). Reaching High-Risk Families: Intensive Family Preservation in Human Services. New York: Aldine de Gruyter. *Reprint requests for CSS annual reports are available from: Ms Mary Lynn Cousins-Brame, Director of Services, St Lawrence Youth Association, P.O. Box 23003 Amherstview Postal Outlet, Kingston, Ontario, K7N 1Y2 Canada. Please make cheque payable in Canadian funds to the St Lawrence Youth Association. Author contact information: Gary Bernfeld, Ph.D. Coordinator and Professor Bachelor's Program in Behavioural Psychology School Of Human Studies and Applied Arts St. Lawrence College 100 Portsmouth Ave. Kingston, ON K7L 5A6 CANADA Tel: (613) 544-5400, ext. 1676 Fax:(613) 545-3900 e-mail: gary@bernfeld.com web: http://www.sl.on.ca/fulltime/bachelor/index.htm 204 CE Questions for Bernfeld article on Treatment Integrity Gary Bernfeld 1. A broad goal of Community Support Services (CSS) of the St Lawrence Youth Association was to integrate the wellresearched _____ methods of the Teaching-Family Model with the _____ _____ strategies of a family preservation program. 2. Describe 3 types of clinically appropriate treatment, as defined in meta-analytic literature reviews that comprise the empirical bases of CSS? 3. A successful treatment model of treatment that targets risk factors across the delinquents' family, peer, school and neighborhood contexts is called _____-systemic therapy,. 4. What are the key elements of treatment integrity? 5. List and explain any three of the first 6 hallmarks of CSS that reflect how it is similar in the scope of its services to ecological or family preservation programs 6. List and explain any three of the last 4 hallmarks of CSS that reflect its uniqueness, in terms of the content or "what" interventions it offers. 7. Taken as a whole, Community Support Services offers ‘contextual therapy’. Define the latter term. 8. List and briefly describe 5 integrated program components of home-based services in the Teaching-Family Model 9. List and briefly describe 8 integrated treatment components of home-based services in the Teaching-Family Model 10. How does the Teaching-Family Association’s site certification process enable quality assurance? 11. Utilizing Bernfeld, Blase et al.’s (1990) multilevel systems perspective, explain some of the challenges in implementing an integrated treatment like Community Support Services within a fragmented children's services delivery system . Provide two examples at the client, program and organizational levels and four examples at the societal level. 12. Provide four examples of contextual supports for innovative programs like Community Support Services. Announcement Important Note for Continuing Education Credits Professional Education Resources & Conferences Services is providing CE hours for reading articles from the Behavior Analyst Today journal and answering some questions to demonstrate that you have read the article. For more information, visit the PERCS website at: http://www.percs.info/ PERCS is an approved CE provider by the BACB, and Approved CE sponsor by the American Psychological Association to offer continuing education to Psychologists. Neither the BACB or APA endorse the programs or events sponsored by PERCS. 205 The Human Services Profession I choose is my current profession, a Mental Health and Substance Abuse Caseworker. I provide professional counseling, life skills training, medication management, time management training, and connect clients to educational support, vocational support, and clinical support for substance abuse and mental health issues. The primary system related to my profession is providing a structured living environment to clients while in the early stages of recovery. A few of many other systems with which I interact are Vocational Rehabilitation, Dress for Success, Housing for New Hope, Intensive Outpatient Providers, and the TASC (Treatment Accountability for Safer Communities) Program. I receive client referrals from TASC for clients who are currently incarcerated and upon release would be in an unsafe living environment or homeless, which would promote continuous drug and/or illegal activity. TASC provides case management services to clients with substance abuse or mental illness who are involved in the justice system. This system combines the influence of legal consequences with treatment and support services to permanently interrupt the cycle of addiction and crime. Vocational Rehabilitation provides counseling, training, education, transportation, and job placement services. I refer clients in need of any of these services to this system because VR can assist them with becoming independent and with finding a job and staying on the job. Another system I utilize through the referral process to assist clients with job placement, resume preparation, as well as image and career coaching is Dress for Success. In order for clients to meet criteria for residential services at the facility I work for, they have to be enrolled with an Intensive Outpatient Provider for substance abuse and mental health treatment via groups and 1:1 sessions. I work very closely with Intensive Outpatient Providers in the development of Person-Centered-Plans and Crisis plans for our clients. In addition to coordinating services and transportation for clients, IOP’s and I tracks a clients progress and devise team decisions on matters such as a clients capability to manage additional privileges and/or employment It is important to think systematically within human services professions to ensure the best result and progress possible for the client/community. For example, I plan to open a recovery house of my own one day. Properties in the Southern area of Durham are inexpensive. One may think that it would be plausible to buy a property in that area because of the price. Unfortunately, this area is infested with drugs and illegal activity. Thinking systematically it would be unrealistic to house individuals who desire to stop using drugs in an area riddled with drugs. Once I open my recovery house have to hire experienced Staff members who have skills in the area of relapse prevention/awareness, medication management, NCIS training, and other skills related to this field. I would not hire someone with a background in accounting or construction to work with my clients. Once I am open I need to have a working relationship with other community and state agencies to connect my clients with resources and a avenue to make and receive referrals for services.
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