THE USE OF A CONSULTATION TEAM TO NETWORK FAMILIES WITH OTHER H E L P I N G SYSTEMS Edward Mel Markowski H a r r y I. C a i n M i c h a e l Cascio

A B S T R A C T : Families, therapists, and other service providers often find themselves uncooperative and at cross purposes when working toward solutions to family problems. Sometimes each professional is involved in one small piece of the problem and m a y never have encountered other providers and all family members. This paper describes a family-agencies-team consultation model intended to address the above issues. The model uses a consultation team to facilitate better understanding of family needs, helping agency roles, and service provider constraints. The approach has been successful in creating dialogue, generating a wide range of goals, engendering cooperation, empowering families, and affirming agency participation.

Agencies that work with individuals and families historically have portioned out individual clients of the same family to different services within agencies. Moreover, many clients receive services from providers in other agencies. Typically, a family m a y be involved with a number of professionals from more than one agency, all strivEdward (Mel) Markowski, PhD, is professor of marriage and family therapy, School of Human Environmental Sciences, East Carolina University, Greenville, NC 27858. Harry I. Cain, MA, is the unit coordinator of the Farmville Satellite Clinic, Pitt County Mental Health Center, Greenville, NC 27834. Michael Cascio, ACSW, is an employee assistance program manager for Burke/Taylor Associates, Greenville, NC 27834. In addition to the authors, the consultation team included staff members at the Pitt County Mental Health Center working with client families and other agencies in Pitt County, North Carolina. Reprint requests should be sent to the first author. Contemporary Family Therapy, 15(4), August 1993 9 1993 Human Sciences Press, Inc.

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ing toward the family's welfare. However, as the number of professionals and service providers increases, the coordination of the overall intervention becomes increasingly complex. In an evaluation of countywide mental health care systems, Grusky and Tierney (1987) cited the serious problem of service fragmentation and emphasized coordination through a collective or systems effort. Tarico, Low, Trupin, and Forsyth-Stephens (1989) noted that parents receiving child mental health services described poor coordination between agencies and a lack of consistency in treatment plans from provider to provider. They also reported that parents desired open communication with service providers, including an active involvement in planning interventions. The importance of an integrated, coherent network of services was also reported by Landsberg, Fletcher, and Maxwell (1987). With the growth of family therapy as a treatment modality in its own right, contemporary family interventions emphasize the networking of the family system with other extrafamilial systems (Rueveni, 1977; Bishop, 1984). Various approaches such as the ecological systems (Auerswald, 1968), the ecostructural (Aponte, 1976), and the multisystems (Henggeler & Borduin, 1990) focus on the interaction of the client family within the larger network of systems in the community. These systemic approaches emphasize interdisciplinary collaboration among agencies and professionals involved with the same family, and each approach considers individual, family, and larger system variables that might be linked with behavioral problems. However, contemporary systems approaches have not eliminated the problems associated with family interventions. Recently, ImberBlack (1988) described numerous dilemma that are encountered when working with families receiving services from several helping systems. She noted that a lack of focus on individual, family, and larger system patterns may bring about impasses in the intervention, which can create patterns that work against problem resolution. To maintain a focus on the family-agency helping network ImberBlack pointed out the importance of determining: (a) who defines the problem; (b) how each participant defines the problem; (c) what is the agenda of each involved system; (d) what is the place of the agency system in a particular family's life; (e) what are the boundaries between family members, between family members and service providers, and between the various professionals and agencies; and (f) what are the structural underpinnings of dysfunctional patterns and binds.

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As a process for remediating the issues implied in the above questions, Imber-Black suggested an interview format in which a consultant, the family, and the service providers join together to clarify roles and expectations and resolve difficult impasses. During the interview, the family's current relationship with the agencies is determined and, perhaps more importantly, the manner in which the family and service providers foresee their relationships in the future is discussed. The goals of the interview are to develop a coordinated relationship between the family and the various helping systems, to develop a cooperative relationship between the agencies, and to facilitate an informational rather than necessarily a solutions oriented session. Throughout the interview the consultant attempts to maintain a neutral stance by avoiding coalitions with either the family or agencies.

THE F A M I L Y - A G E N C I E S - T E A M CONSULTATION MODEL Drawing on the ideas of Imber-Black (1988), the reflecting team ideas of Anderson (1987), and other systemic consultation approaches (Wynne, McDaniel, & Weber, 1986), an alternative consultation model was developed as part of the function of a family therapy team in a community mental health center. The alternative family-agencies-team model involved the family, the family therapist, agency representatives, and a reflecting team. The team was already in use as part of the family therapy treatment process and was used in the initial family-agencies consultations to encourage families and commend the agency representatives for their contributions and concern. In later consultations, patterns of interactions were observed and ideas about the overall family-agencies interventions were shared. After a number of permutations through 21 family-agencies-team consultations, the model was determined to work best when divided into the following five phases: (a) the preconsultation phase, (b) the initial phase, (c) the reflecting phase, (d) the re-entrance phase, and (e) the postconsultation phase.

Preconsultation Phase Preconsultations are used to assist families and agency representatives see the usefulness of the family-agencies-team consultation.

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In individual meetings and contacts, the family and other helpers are informed of the availability of a consultation team as a valuable resource. The therapist indicates to the family that it will be helpful to obtain a wide range of ideas from a team and that families often find communications from the team helpful in achieving solutions for their problems. Helping professionals are informed that the team values their contributions to the success of treatment and may assist the agencies to coordinate their interventions. They also are assured that the consultation process will make it easier to resolve mutual family-agencies issues and concerns. The initial phase is prolonged and delicate. It sometimes takes many telephone conversations and individual contacts with the family and the various agencies to develop the trust, openness, and flexibility required to schedule the consultation.

Initial Phase The initial family-agencies-team phase is the first face-to-face meeting of the entire family with all of the helping professionals. Agency representatives introduce themselves and explain to the group the roles they play in the total care of the family. The team is also introduced to the family and the representatives. The team's role in the meeting, the use of the one-way mirror, videotaping, the telephone system for call-ins, and the possible delivery of messages into the room are explained. During this phase the therapist begins the interview by sharing with the family and agency representatives the expectation that ideas useful to all participants will evolve from the interaction. Initially, the family is asked share information about past interventions or assistance that have helped. The therapist proceeds further in this direction by asking the family members if they have any concerns about the course of therapy, how they would like other participants to help, and what they suppose the agencies' concerns are. Subsequently, the agency professionals are invited to voice their concerns. During the initial phase a collaborative tone is established. Structurally, the therapist empowers the family, slowly introducing the notion that the family is to direct the assistance. Also, attempts are made to avoid portraying one system as knowing better. Focus is centered on a future orientation by asking what will the family look like when the problems are solved; how will the family and others

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know when the problem is solved; and when will the helpers no longer need to be involved (O'Hanlon & Weiner-Davis, 1989). While watching the interview behind the mirror, the team discusses various observations, ideas, and intervention options. On occasion, the team telephones the therapist and provides observations or suggestions to assist the therapist. About 30-40 minutes into the interview, the team briefly meets with the therapist to decide how they will share their impressions with the family and agency representatives. The preferred procedure is the reflecting team process in which the family, agency representatives, and therapist change places behind the mirror with the team.

Reflecting Phase In the reflecting phase the team discusses the initial phase interaction, while being observed by the family, the therapist, and the agency representatives behind the one-way mirror. During this phase the team follows the guidelines outlined by Anderson (1987). Reflections are presented in a speculative, tentative manner. Comments are connected to verbal and non-verbal information that emerge during the consultation interview. Observations about family and agency strengths and abilities are offered within a positive and encouraging framework. The team does not attempt to deliver planned strategic messages or present systemic truths, as might be done in strategically oriented teams (Papp, 1980). The initial comments usually highlight the family's strengths, attempting to portray the family as competent and already taking steps to resolve its difficulties. The agency representatives are complimented on their interest and efforts in helping the family. The team members then share their own observations and ideas about the overall situation. New ideas spontaneously evolve during the reflection process as team members react to the other members' comments. By the end of the reflecting phase, a wide range of impressions and ideas have been discussed. Generally, no one idea predominates.

Re-entrance Phase The re-entrance phase permits discussion of the team's input by the family, the therapist, and agency representatives. After the team finishes its discussion, the family, agency representatives, and thera-

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pist re-enter the therapy room, and the team returns to the observation room. The therapist then asks the family to reflect on what stood out as most important from all the comments members heard when listening to the team. Each family member is encouraged to share these comments with the group. The agency participants also are asked for their comments regarding the team's observations. Finally, the information that has particular meaning for the therapist is shared with the group. The therapist generally neither highlights nor emphasizes any specific observation or comment, tending instead to permit the participants to derive their own meanings from the remarks made by the team. However, if a family member or another participant interprets an observation as critical, the therapist accentuates the positive connotation, including a possible reframing, to offset the negative attributed meaning. In re-emphasizing the positive connotation the therapist is careful not to imply that a person is wrong about what was heard, but instead suggests that there are several interpretations about what was discussed. After the family and agency participants discuss the team's reflections, the therapist reiterates a number of thoughts and ideas that emerged from the consultation. However, except for thinking further about ideas generated during the session, no other specific directives or tasks are presented. The therapist ends the session by thanking everyone for attending the consultation.

Postconsultation Phase The postconsultation phase acts as a deprogramming process in which the family therapist and team review and summarize the consultation. The critical components of the session, including the observations made when the family, agency representatives, and therapist reentered the therapy room are discussed. Often, segments of the video tape are reviewed for clarity and process. The primary focus of the summary is the degree to which the session achieved the goals of the therapist and consultation team. Not only does the team review the impact the reflecting process had for the family but also, and perhaps more importantly, the impact the process had on the various agency representatives. Finally, ideas developed by the team that had particular relevance for the therapist are discussed. Although the team sometimes suggests directions for future sessions, no specific directives are given to the therapist. The consulta-

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tion is ended, as is the session with the family and agency representatives, by having the therapist think and reflect further on ideas generated during the consultation. Finally, the team compliments the therapist's willingness to permit the team to participate and expresses the expectation that some of the ideas presented will prove helpful.

DISCUSSION Twenty-one sessions were conducted with the consultation team serving as the conduit for networking families with other helping systems. Presenting problems included conduct disorders, chronic mental illness, substance abuse, child custody, residential placements, and physical abuse. Agency representatives who participated in the consultation included school counselors, teachers, and principals; social service case workers; juvenile court counselors; probation officers; group home leaders; and an attorney. Several discoveries resulted from the network consultation with the families and agency representatives. First, the consultation was almost always the initial situation in which the family met with all individuals involved in the helping network around them. Although one family member may have had contact with an agency representative, other family members may never have had contact with the agency representative. For example, a mother was the only family member to meet with the school social worker regarding her daughter; therefore, the consultation was the first face-to-face encounter between the social worker and other family members, including the daughter. Second, the consultation was invariably the first time the agency representatives met each other. More often than not, each helper involved with the family worked independently, even when one helper knew of the other's involvement. For example, one family had been involved for seven months with a social services worker and a juvenile probation officer regarding their adolescent son. Although the two workers had corresponded and had talked to each other over the telephone, they met for the first time during the initial consultation. In multiproblem families in which a number of agencies were involved with several family members, the consultation resulted in each provider discovering the involvement of the others. Third, the consultation was frequently the first time the therapist met with other professionals working with the various family

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members. In many cases it also was the first time the therapist met other family members. For example, a therapist arranged a consultation with the entire family, along with the family's social service worker and probation officer. The meeting was the first time the therapist met both the probation officer and oldest son in the family. Fourth, the consultation team often observed dysfunctional patterns and coalitions between family members and various individual helpers including the family therapist. Because each agency had its own mandates and objectives, it was easy for each to undermine unintentionally the efforts of the other professionals. As a result of the consultation the undermining patterns were observed by the team, addressed during the reflecting phase, and discussed during the reentry phase. For example, during the initial phase the consultation team observed that a therapist was aligned with the mother, a school counselor with the son, and that everyone was dismissing the father. As a result of this observation, a comprehensive intervention was formulated by the family therapist and agency representatives that allowed a successful reorganization of the family.

CONCLUSIONS

AND IMPLICATIONS

Postsession discussions, videotape reviews, comments from participants, follow-up reports, and clinical impressions regarding the use of the family-agencies-team consultation model resulted in the following generalizations: a. Communication and interaction between agencies and other involved professionals shift and efforts become more coordinated and integrated. b. Open communication and dialogue develop between families and agencies. A network of support and collaboration is established, trust re-established, and hidden agendas dispelled. c. Families and agencies develop a combined sense of direction. Goals are developed together with all participants actively involved in setting and working toward an achievable solution. d. Families are empowered and actively contribute to the direction of intervention. Agencies also begin to see families as capable entities with recognizable resources and strengths. e. Agencies experience affirmation. Each agency receives thanks for participation, appreciation for efforts, and recognition as a valuable component in the network of services.

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f. Greater flexibility and risk taking develop in systems that are open and responsive to further utilization of this intervention method. Whereas, the success of the family-agencies-team consultation as a viable process can be inferred from the above, it is evident that further investigation is needed. Issues such as continuing agency cooperation over time, the generalizability of agency cooperation with other families, continued cooperation between families and agencies, the short and long term resolution of problems, achievement of family and agencies goals, comparison of the family-agencies-team consultation with other consultation approaches, and the perception of both families and agencies need to be addressed.

SUMMARY The idea of networking families and service providers is a variation of the approach developed by Imber-Black (1988). Both strategies attempt to empower the family, while establishing a collaborative effort between family members and service providers. Instead of focusing on previous and current problems, both approaches assume a future focus. Also, the therapist attempts to maintain a symmetrical relationship rather than assuming a one-up position in relation to the other participants. Finally, both consultation approaches tend to be informational rather than prescriptive, attempting to present a wide range of ideas for the participants to consider. Instead of giving specific directives, seeds are planted that can be cultivated in future meetings. Several of the seeds include the idea that the family is capable of resolving the issues facing it and that the professional providers are resources available to the family. The primary difference between the approaches is the use of the observing team. Imber-Black (1988) suggests that a consultant rather than the family therapist lead the family-larger system consultation. The family-agencies-team consultation, however, is conducted by a family therapist in conjunction with a co~sultation team. When compared to the single consultant model the team approach generates a wider range of ideas, and because of the observation format, the therapist's position in the system can be examined. The reflecting team process appears to generate more intensity, and amplify more issues than the individual consultant model. However, despite these procedural differences, each approach is anchored on a systemic frame-

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work and each appears to be both a powerful consultation and intervention tool. The joining of the available wealth of resources is a valuable and powerful means to intervene in the full range of situations encountered by families and agencies working within large community systems frameworks.

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systemic approach to treating the behavior problems of children and adolescent~. Pacific Grove, CA: Brooks/Cole. Imber-Black, E. (1988). Families and larger systems: A family therapist's guide through the labyrinth. New York: Guilford. Landsberg, G., Fletcher, R., & Maxwell, T. (1987). Developing a comprehensive care system for the mentally ill/mentally retarded. Community Mental Health Journal, 23, 131-134. O'Hanlon, W. H., & Weiner-Davis, M. (1989). In search of solutions: A new direction in psychotherapy. New York: W.W. Norton. Papp, P. (1980). The Greek chorus and other techniques of paradoxical therapy. Family Process, 19, 45-57. Rueveni, U. (1977). Family network intervention: Mobilizing support for families in crisis. International Journal of Family Counseling, 5, 77-83. Tarico, V. S., Low, B. P., Trupin, E., & Forsyth-Stephens, A. (1989) Childrens' mental health services: A parent perspective. Community Mental Health Journal, 25, 313-325. Wynne, L. C., McDaniel, S. H., & Weber, T. T. (Eds.). (1986). Systems consultation: A new perspective for family therapy. New York: Guilford.