Mary McKay on Family Engagement Strategies

I attended a conference with Mary McKay, LCSW, PhD about Family Engagement Strategies. Here are some notes ...

Identify one obstacle that you have encountered as you tried to involve children and their families in services.

Parent-level obstacles:

• We want families to question our intentions and validity/benefits of services
• As mandated reporters, we are the arm of the government/child welfare
• Parents are protective of their family from potential dangers (child welfare & immigration) vs. trusting of us

System-level obstacles:

• Stigma around mental health services (accessing mental health services means you are "crazy")
• Work schedule

Identify when is the right time to get mental health counseling, because this service is seen as a last resort by families. Parents are told – “You’re bad parents,” “It’s your fault,” and “This kid would be okay born to a different family” – judgments! They have seen a heap of professionals before they have seen us. Parents experience trauma from helping systems, including horrible experiences requesting food stamps, for instance (parents don’t see a difference between food stamp clerks and mental health professionals).

Track efforts of parents before they get to you (parents seek help from friends, family, past counseling). It takes courage to finally make the call. Parents have tried everything else and feel like a failure when they call us.

Are your services so good that your families want to come back? “Wow, that was really helpful – I better come back.” We are usually on to the next thing ½ an hour before the end of session!

**How do we make services fun and engaging? Remember to nurture and feed parents and kids when they drag themselves in.

Change is threatening – we don’t like change. Families and organizational staff find change challenging = unpredictable, requires effort & hard work, causes confusion, loss, fear.

Parent: “I’ll consider this carefully and get back to you” – parents risk loss, make the effort – this is a lot – it means a lot of different things – “Can I trust you to remake my family?” – only courageous families embark on this journey of change and give us a chance if we go slow enough – “I want to partner with you and bust through my fear.”

Mental health providers should be prepared to:
• Engage
• Explain our role
• Have family therapy skills
• Have cultural application skills

We should be prepared to explain what we do:
• So how is talking supposed to help?
• What exactly is this?
• How will I know if this worked?
• How will I know this is over?

Assumption that families with more concrete obstacles are less likely to come to appointment. This is why research matters - found that not all barriers are created equal. For urban families, race/culture and poverty matter. Stigma and attitudes about mental health treatment are stronger than concrete barriers.

Which barriers matter most:
• Concrete obstacles never predict utilization
• How do I feel about coming?
• What kind of lens do I see help-seeking with based on previous negative experiences?
• I have skills/tools to get to where I need to – going to see you (MH provider) is not the most important
• Parental concerns that this will be a waste of time
• Parents may have less time problem solving concrete obstacles
• Mental Health providers can ask parents - How do you feel about starting with me? How do you feel about coming to me?

**Trainings raise awareness to issues that need to be attended to – things we tend to forget with day-to-day stress!

Focused telephone procedures were associated with increased initial show rates (more parents showing up to their intake appointments). Structural family therapy telephone engagement intervention was associated with 50% decrease in initial no show rates and a 24% decrease in premature termination (more parents and families showing up and staying for mental health treatment).

Mary asked the audience: “Is anybody ever happy when clients don’t show up?”
Our answer illustrates what we bring to the party. We feel overwhelmed by our jobs. We build in appointment schedule expecting "no shows" – what we expect is what we get.

**Parent advisory group critique after observing a conversation between social worker and parent (GREAT IDEA!)

Clarify the need (from parent vs. collaterals) – SWs almost never asked families whether they agreed with referral. “Do you agree with that?” Whose needs are most important? Parents say, “the only way we will engage with you, talk to you, is if you’re meeting our needs.”

Parents have gone through a lot – this is one their bleaker moments – “neighbors know that SW is in my home.”

To Parents in the Audience: Sometimes you love your kids every minute and sometimes it’s just your job (ruining my life).

Throw parents a lifeline – “This is a lot, I can see you journeying on – good for you!” See their strengths, commitment, burden, distress. Contact by parent can be seen as courageous and hardy. Parent Advisory Group came up with "50 ways you can tell parents you see their strength" (“good job for calling” sounds empty).

Ask parents, “How do you feel about getting counseling with us?” “How do you feel about getting help for your kid?” Probe for their unexpressed concerns and unasked questions! (Reevah Simon calls this “exploring their ambivalence” because “we all feel ambivalent about everything”) “There are a set of questions that families wonder about but don’t ask. Many families are wondering about…medication, information sharing…Is that on your mind? Do any of those ring true for you?”

Unanswered questions sort families out of services. “You’ve got help from somewhere else before – tell me about that?” Typically negative experience – distinguish self as not allowing that to happen again. When parent describes negative experience – “That must have been horrible for you” & “Tell me how that…” instead of defending previous provider, “The provider must have meant…”

Telephone engagement interview elements:
• “What do you think your family/child needs?”
• “Do you agree with referral?”
• Probes: “If you have questions or concerns, we want to answer them now”
• Parent courage acknowledged

**When we see their pain & strengths, allay their concerns – parents are more likely to show up.

Comparing two approaches (using a Randomized Control Trial):

1. Telephone engagement with parents using a "structural family therapy approach" resulted in 21 intakes (kept appointments) & 6 no shows (29%)
2. "Business-as-usual" resulted in 13 intakes & 14 no shows (50%)

Treatment Retention vs. Dropout
Jose Szapocznik, Miami – his intensive treatment keeps parents motivated and in treatment for 6 months. In Mckay’s clinic, only 12% were still in treatment 3 months later.

Initial engagement is important but not enough! Must focus on retention too by using engagement interventions at every contact (not just before initial intake).

Train admin staff/intake workers in engagement issues. Implement routine reminder calls before appointment. At what places in our organization do we have to use parent engagement strategies more fully?

Remember to systematically apply 1-4 elements...

Element 1
First session: Parents are so uncomfortable/nervous, they don’t hear the 1st 10 minutes of the intake interview. If you have been a mental health provider for 6 months or longer, then we can’t be nervous meeting people. Don’t forget how nervous the human being in front of us is – chat! – “how can I help you?” is a hard question – parent needed to review problem list first – they need time to assess us – if they feel rushed in, then they will not disclose. “If I don’t trust you, if I don’t know what you’re about…then I won’t disclose.” Re-explain who, what, when, where and why. Talk/chat for the first ten minutes so that the client can catch their breath.

Element 2
What do we mean by collaboration/partnership vs. meeting mandate?
“This better be good – this better help”
Feeling desperate – “I’ve tried everything I can think of, go to it”
**Growing body of research shows that without strong family partnership, disruptive kids don’t do better and have a negative trajectory.
Mental health professional can say, “This really won’t work if we don’t work together.”

Element 3
Focus on immediate, practical concerns (food pantry transportation & pick-up, tutoring)

Element 4
Don’t assume parent will return to next appointment. “I know I’ve asked you a lot of questions.” Explain what we do with their intake information (privacy, sharing of info). Take some stress off – provide info. “After coming here and seeing the inside of our agency, are you interested in doing this again?” “Are you interested in meeting with me again?” It is respectful to check-in to see if parents are interested in coming back – parents need alternatives. Don’t assume overcoming the 1st barrier will mean overcome a 2nd barrier.

McKay debriefed families after intake assessments – families expressed regret after providing so much information (79% felt this way!)

Ask the smallest amount of information that is needed. Parents need to know why we’re asking. Learn the rationale for each question asked on the intake form. Sometimes being apologetic is perceived as not very competent and doesn’t engender confidence (“I hate asking you all these questions and I don’t really know why I have to but I have no choice” vs. “Here are some reasons why we’re collecting it”).

Every session had to be an opportunity to engage, assess and help. Breathe engagement life into EBPs written by academics.

**Provide services that are so relevant, important & helpful, that families want to come back.