More Notes from Mary McKay on Family Engagement in Children's Mental Health Treatment

I heard Mary McKay speak on Family Engagement strategies in Los Angeles again.  I told her I wasn't just a fan, I was a groupie.  I heard her speak about a year ago (see notes from that workshop on this blog).

After introducing myself and her offer to help me in the program any way she could (she is an LCSW and PhD too), I handed her my recently completed manuscript about a parenting intervention in schools for her review and feedback.  She is so gracious, warm, witty and wise - reminds me of Bonnie Hunt - love her.

Okay, this is the gist of what she said in her south side of Chicago accent ...

• In children's mental health treatment, 50% of parents never make it to their first appointment (according to national show/no show appointment rates).  

• 25% engage in children's mental health treatment (sadly, 75% do not).

• She interviewed parents to find out what we did well and what we needed to develop, in terms of children's mental health treatment. 

• Messages from therapists to parents:  
• "Life is complicated and there are no easy answers"
• "I don't have all the answers but I'd like to partner with you."

• It takes a lot of hard work to get good outcomes, in terms of family engagement and retention in treatment.  

Barriers/Obstacles to Engagement

• Concrete obstacles - schedule, transportation, language barriers, poverty.
• Perceptual barriers - parents own previous school experiences (in school based mental health services); ambivalence about treatment (are you going to be helpful or harmful?)

• It is good for families to come with a healthy mistrust and skepticism.  They are showing a pretty good sense - "I care about what happens to my family" and that is why they are hesitant about involving themselves in the mental health system.

• For mental health professionals concerned about our alliance with teens vs. parents:  Young people need their families and our task is to teach them how to mend those relationships.

• Parents may be fearful and discouraged and think, "You can't possibly be helpful."

• Parents are suspicious of mental health providers based on previous negative experiences with helpers when they have been called "bad parents."  Parents need to be understood, supported and not judged. 

• The variables found to be most significant when modeled (probably logistic regression) - stigma and fears of being blamed (perceptual barriers) - and not concrete barriers (transportation, child care, etc.)  Not all engagement barriers are created equal.

• Even poor people know how to run their lives (get to appointments that they deem important).  They will overcome concrete obstacles for what's important.  If their fears and concerns are not addressed, they will not use their limited resources to attend appointments.

• Unexpressed questions and concerns are significant barriers.  Yet, no family will say, "I won't come because I am afraid."  "Nice people" like mid-Westerners won't say, New Yorkers might say, "nice people" are strong-minded but nice.

• If you only problem solve around concrete barriers, then you won't increase appointment show rates.

• Some cultural values leave us less skilled/practiced at disagreeing with professionals due to respect for authority - but will go home and not do what they say.

• Don't leave engagement to chance.  If we don't do something differently, then more families will not become engaged.  If we employ empirically supported strategies for engagement, it is more likely that families will engage in treatment.  The hard work is in systematically doing something differently.

• Clinicians can address parental ambivalence about treatment by creating discrepancy and engaging in change talk.  

• How do you help people who do not see they have a problem?
• Psychoeducation - information about the disorder - depression, anxiety, etc.
• Child can tell his father about his experiences with anxiety and depression. 

Goals for Telephone Engagement (first call to families)

• Systematically incorporate engagement skills and tools; systematic attention to engagement
• Clarify the need for mental health care
• Increase caregiver investment and efficacy
• Encouraged disagreement about reason for referral to try to build alignment

• Working with adults:  Adult do not do things because they are told what to do, but because it's in their best interest.  

• Being judgmental is not good customer service.  If you're thinking, "duh," then I wonder how we might come off as judgmental in more nuanced ways, especially to families that may feel reticent or suspicious (or previously burned by mental health professionals).  Parents report, "I've gone to helpers and they haven't been helpful (judged me)."

• Clinician message: "I know you care about your child.  I care about your child too and I care about their success as a student."

Goals of 1st Interview

• Anxiety gets in the way of listening and learning and retaining information.  
• Achieving treatment goals requires intensive parent partnerships.
• "I can do nothing without 'we' " - "How are we going to work together?" - "What can we change?"
• If we see the child instead of the parent, then we can expect slow to non-existent change.  The research shows that seeing the parent is more effective.
• We can only go as fast as the family is able to go, although this may feel as slow as a snails pace.  Important to set a spirit of real collaboration.  Send the message, "I can't go it alone with just the kids," and mean it!  Partnership is necessary for treatment change and not just "nice."
• Parents wonder, "Can therapist offer me something that my sister or mother cannot?"
• If parents walk away without evidence that we can be helpful, they won't come back.
• Proven useful to show parents how to reduce stress, increase parenting skills, using tools created by and for parents.
• End interview with, "how was this for you? Are you interested in returning?"
• Big chunk don't come back because they don't want to - something went wrong in the first exchange.

How to make paperwork more engaging

• Review paperwork - what is most essential? Remove the rest.

• Talk to parents about approach to paperwork.  We come off as disempowered when talking about paperwork.  How can we come off as competent - show our self-efficacy?  Quit apologizing for paperwork because the research shows that this approach wasn't helpful.

• Parents described signing consent and wishing they hadn't after they left.

• Clinican message, "I don't want you to sign anything you don't feel good about.  I don't want you to walk out with any questions or concerns without an opportunity to discuss them."

• Parents want to feel respected and understand process.

• Frame sensitive assessment questions as opportunities to build trust.  Explain who will see the information and how it will be protected.  Families worry about access.

• Need rationale for developmental history questions (such as age of developmental milestones of walking and talking) - especially when working with 16 year old pregnant teen!  If parents don't understand why we are asking certain questions, then they think we are weird or wasting their time.

• Paperwork can be an opportunity to engage and allay fears.

• With systematic incorporation of these strategies, rates of return often double and triple.

• If setting for interviewing family is less than ideal, with regards to confidentiality, then encourage families to have the good sense to share only what is safe to do in such a vulnerable setting.

• Constantly seek feedback from family.

• If client can't articulate goals, then they aren't likely to get good outcomes.  Take out the service plan at every visit to track outcomes.

• If parents have had a "bad" experience, they are less likely to ask for help again.

• After one bad experience, parents are more likely to be suspicious at the next visit and likely to drop out.  Ask about and discuss past negative experiences.

• The most engaging characteristic is authenticity.

• Termination assessment:  "Is this a good time to end?  Has enough progress been made?"

• Clarify the reason for referral from the parents perspective.  Parents critique:  Clinicians miss the opportunity to ask about parents perspective on referral - "Do you agree with this referral?"

• What percentage do you think are excited about referral?  What percentage do you think are in agreement with the need for referral?  Parents usually blame the teacher (and every once in a while, the teacher is a problem).  

• Parent:  "If this encounter is lead by my need, then I will return.  Otherwise, I'm done."

• If parents bring up their concerns - talk about them.  If they don't bring them up, then ask and raise concerns proactively.  Explore by saying, "A lot of families have questions and concerns about...For example..."

• Parents wonder, "how is all this talking supposed to help?"

• Parents are as scared/nervous as we were (as clinicians) at our first intake.  Parents come in with their game face (cool and scary).  It's family's first time - they are worked up - it's our job to help them regulate and relax.  Don't get to the big Question too quickly - "How can I help you?" Talk for five minutes to allow families to take a breath and stop being nervous - so family can make an assessment of you as the clinician.  Parents only agenda at first meeting is to show up (against their good sense to stay away).  If we rush them, they'll leave out important details - "I don't know if I trust her yet.  I don't know if I'll tell her that yet."