5TH ANNIVERSARY NATIONAL MENTAL HEALTH AWARDS
Category: Social Innovation
Award Winner: STRONGEST FAMILIES INSTITUTE Halifax, N.S.
strongestfamilies.com
STRONGEST FAMILIES HELPS OVERCOME BEHAVIOUR AND ANXIETY ISSUES IN EARLY STAGES OF DEVELOPMENT
BACKGROUND
Halifax, N.S., Psychologist Dr. Patrick McGrath loved to help families. The full-time clinician was eager to work with as many troubled families as possible, yet grew frustrated because many families who were looking for support for their children waited for up to a year to receive services. While psychologists have a lot to offer families, there are simply not enough of them in Canada to meet all of the need.
He also noticed that families would typically drop out after four or five sessions, despite seeing improvements in their child. The issue wasn’t lack of motivation, but a flawed system. The hours, scheduling and appointments were all set to accommodate the professionals and not the families.
Data shows that 15–18 per cent of Canadian children experience mental health problems, the most common of which are disruptive behaviour disorders and anxiety disorders. Fewer than one-third of these children and their families receive timely mental health services. If children’s problems are not effectively treated in childhood, evidence suggests they may struggle with schoolwork, their family and social lives, and other aspects of their development. They are at risk of continued and potentially more severe mental health problems throughout their lives.
OVERVIEW
The Strongest Families Institute was founded in 2000 by Drs. Patrick McGrath and Patricia Lingley- Pottie as an initiative within the Centre for Research and Family Health research lab at the Izaak Walton Killam (IWK) Health Centre in Halifax, N.S. In 2011, it became a federally registered not-for-profit organization, with McGrath serving as its Chief Executive Officer and Lingley-Pottie as the President and Chief Operating Officer. As of 2012 it is fully independent.
Strongest Families offers innovative, cost-effective access to mental health support through an evidence based “distance treatment” model. It works beyond traditional service-availability hours to better accommodate a clientele that needs support.
Highly trained non-professional coaches work with families through weekly telephone and/or e-mail contact, following protocols established by international mental health experts. The coaches — motivated individuals with relevant education and experiential backgrounds — work days, evenings and weekends to encourage and problem-solve with families, helping them learn the skills to deal with mild to moderate behaviour and anxiety issues being experienced by their children (issues that can be treated using proven skills). Families learn from a handbook and demonstration videos sent to
their home and telephone support from their coach.
“Often, our service system is very provider-oriented,” McGrath explains. “It’s not that people don’t work hard or are not committed, but the system is designed for appointments from 9–5.” Lingley-Pottie notes: “Working flexible hours built around families’ schedules provides an opportunity for parents to have a 9 p.m. appointment (local time) should they need it.”
In 2011, six coaches worked with an average of 30 families per week (approximately 90 cases per coach per year), tallying a total of 700 families. Since the inception of Strongest Families, more than 2,000 children have been helped.
Coaches are well trained on evidence-based Strongest Families protocols and scripts, and performance is monitored. All cases are discussed in weekly meetings with a coach supervisor, and all interactions between coaches and families are recorded. Coaches are also supported by a professional as needed. Although coaches and families do not meet face-to-face, the therapeutic relationship is strong.
While Strongest Families focuses primarily on one-on-one interactions, group-based help was added in 2012 and a coach hosts up to 10–12 families over the phone using the same established program curricula. This enables a number of people to share their experiences and potentially learn from one another. Coaching protocols, based on best evidence, were well established prior to the launch of the group initiative.
The Canadian Institutes of Health Research (CIHR) has provided funding for Strongest Families as a CIHR research project. Current funding derives from contracts for services provided to all Nova Scotia district health authorities’ local mental health services, Alberta Health Services, Canadian Mental Health Association–B.C., Peel Children’s Centre in Toronto, and George Jeffery Children’s Centre in Thunder Bay, Ont. In 2011–12, Strongest Families had 15 staff in the Halifax office and annual revenue of about $650,000.
CHALLENGES AND OPPORTUNITIES
Helping families overcome a number of barriers has been a driving force behind the evolution of Strongest Families, which “fits the pressing need to fill those access gaps,” according to Patricia Lingley-Pottie. The Institute has addressed those, as well as challenges to its own service model.
Stigma, the cost of transportation, parking and food for those coming from a distance, and missed school time for the child, are all barriers to seeking help. “There are just so many indirect costs, even for free treatment,” McGrath notes. Parents who must ask their employer for time off work to care for their children’s mental health problems could find their employment threatened. “Imagine you have to go to your boss and say ‘I need to take the next 12 Wednesdays off because my kid has a mental health problem.’ These people might end up on the first-to-be-laid-off list.” Compounding this is that mental health concerns seldom garner the same levels of sympathy and support as physical health issues.
The stigma surrounding mental health problems and illnesses is a particular barrier for families who live in smaller communities. “If people see your car at a mental health clinic, they begin to wonder what’s going on,” Lingley-Pottie says, explaining that this could lead to further hesitation when seeking help.
Strongest Families also faced challenges of its own, notably an early level of scepticism from some professionals questioning how the coaches would never meet face-to-face with the families they were helping, and suggestions that “people who don’t know what they are doing” would be acting as therapists. Both were overcome by professionals who were directly involved with establishing
Strongest Families and who believed in both the need for the service and the group’s potential.
Continued research by Drs. McGrath and Lingley-Pottie has shown that a strong therapeutic alliance can exist between a coach and parent or child, and that families are highly satisfied with services received and few drop-out (less than 10 per cent). Because families stick with the program, the majority of children referred to Strongest Families receive successful, complete treatment yielding strong health outcomes.
To counter concerns that coaches would replace work done by professional psychologists, McGrath observes: “There is definitely enough work for everyone.” Lingley-Pottie adds that “the goal is to bridge the access gaps and treat issues early before they become unmanageable and more difficult to treat.”
Because Strongest Families offers services Canada wide and is based in Nova Scotia, coaches embrace the challenge to accommodate each family’s schedule, often working with clients in the early hours of the morning or late into the evening. Despite this, a very low employee-turnover rate reflects the positive work environment and how rewarding it is to be a coach.
While the Institute itself has received funding from specific agencies, “our goal is to extend services to as many families worldwide as possible,” Lingley-Pottie explains. A general lack of funding for mental health services means requests for service from other provinces and the U.S. cannot currently be met.
INNOVATION
The distance treatment model developed by Strongest Families is unique (it received the 2012 Progress Innovation Award from Progress Magazine), and is continually being refined as new evidence informs change. “The best science is really important,” McGrath says. “Science is a major contributor to advancing well-being. Don’t be afraid to take a chance. Don’t be afraid to do something differently.”
It was recognized, for example, that coaches could work with more families if they spent less time writing final progress reports. Families and doctors indicated they preferred to have important information communicated via graphs, which are now generated automatically by the Institute’s computer system.
Software called IRIS (Intelligent, Research and Intervention Software) provides the personalized web architecture and interactive research for families engaging with Strongest Families online.
IRIS enables families to receive information that is appropriate to their particular situation, and can personalize this information through such things as including a youth’s name, and specifics on how to use the skills to address their family’s issues. IRIS also offers interactive videos that help parents and children learn skills to overcome problems.
MAKING AN IMPACT
Strongest Families is a concrete resource for families. It measures and reports outcomes as well as progress for each family. “We had an 89 per cent success rate in overcoming child mental health problems in 2011,” Lingley-Pottie says. “Imagine the impact this will have over time, not just on the child, but their whole trajectory of life. They are learning coping strategies that will provide them with strategies for years to come.” The results also show an impact on strengthening family relationships and lowering parental depression scores. “Successfully treating these issues early will likely have a positive impact on the health system long-term, if many of these children do not require additional help.”
The number of families who drop out of Strongest Families is a fraction of the average seen in
traditional services — 8.2 per cent in 2011 as compared to the 40–50 per cent experienced with other approaches.
In addition to helping relieve pressure on wait times for mental health services, the availability of Strongest Families services helps to free up psychologists’ time so they can focus more on complex or severe cases that require their specialized knowledge and expertise.
LEARNINGS AND INSIGHTS
Parents almost always want to help their kids. Strongest Families has learned that the key is to approach the situation with parents in a non-judgmental way. Coaches make it clear that parents are not inadequate, but are building upon existing skills and expertise. Parents often engage with coaches once the kids are asleep, which gives them the opportunity to focus on the session, ask questions, work through written materials, watch videos and even role-play for upcoming scenarios that have proven difficult in the past.
“You [as a parent] work with someone who can teach you,” McGrath explains. “You are a partner with the coaches. That is what we really encourage. Our staff always treat the families with a great deal of respect. The families are experts on their own kids. They are a valued partner.”
Anonymity is also cherished by the majority families who work with Strongest Families, which is why there are no online video conversations. “We call it visual anonymity,” Lingley-Pottie explains. “People will tell you more and feel more comfortable if they can’t see the person they’re talking to. By seeing the other person, you form judgments.”
THE FUTURE
The Strongest Families model continues to contribute to the global body of evidence about mental health services for families, and the impact of early intervention in preventing lifelong issues.
The Institute is part of a research project in Finland, in which the CIHR and the Finnish Academy are focusing on disruptive behaviour prevention in children. The group is analyzing and screening a group of four-year-olds, and offering intervention and conditioning services for families of those children who score in the top 15 per cent in aggression.
Two CIHR grants are enabling the Institute to take part in research projects in Canada. It is working with Dr. John Walker in Winnipeg on a project focusing on anxiety for 4-5 year olds, and methods for combatting this problem at an early age. And with Dr. Mandy Newton in Edmonton, it is focussing on anxiety among teenagers.
Strongest Families is also continuing to develop its model. Although the dropout rate is less than 10 per cent, some families still terminate their sessions or are not as successful as others. To determine why, the Institute is looking to conduct a study to compare a sample group of families who did well in the program with a sample group of families who did not, based on the recorded interactions with coaches. “We hope the results will inform us about new ways to be able to retain these families,”
Lingley-Pottie explains. “We want to be able to help and make a difference with as many families as possible.”
Finding ways to increase exposure to Strongest Families services and to disseminate the impact of its work more widely is also seen as the key to improving child mental health, especially as it relates to making funding available in regions needing services. Plans are underway for French translation of materials and for revising materials to be more sensitive to Aboriginal families.
By Séamus Smyth and Cathy Nickel Mental Health Commission of Canada
