Published on

Great article by Jacqueline Sparks and Michele Muro applying client directed, outcome informed practices to wraparound services.

1 Like
  • Be the first to comment

No Downloads
Total views
On SlideShare
From Embeds
Number of Embeds
Embeds 0
No embeds

No notes for slide


  1. 1. Journal of Systemic Therapies, Vol. 28, No. 3, 2009, pp. 63-76 CLIENT-DIRECTED WRAPAROUND: THE CLIENT AS CONNECTOR IN COMMUNITY COLLABORATION JACQUELINE A. SPARKS University of Rhode Island MICHELLE L. MURO Southwest Behavioral Health Services Systems of care emphasize the needfor effective collaboration between com- munity agencies assisting families where a child or adolescent is at risk of out-of-home placement. Unfortunately, community collaborations may not privilege the voices of family members, including the young person. Research affirms the critical importance of honoring clients views in any change en- deavor. Wraparound and client-directed, outcome-informed (CDOI) projects support this imperative, with CDOI offering client-report feedback measures to formally amplify clients perspectives. The connection between these two distinct movements provides a philosophical and operational basis to create productive and even inspiring community partnerships.The removal of children from their families and homes can incur significant trauma,complicating efforts to strengthen and reunify families. Out-of-home placements,particularly those longer-term, have tended to isolate the young person from schooland family environments. Moreover, placement interventions, despite significantcosts, have fallen short of achieving benchmarks for success (Stroul, 1996). As aresult, home, school, and community-based services are now first-line responsesfor identified "at risk" children or adolescents. Within the past decade, these youngpeople and their families have been invited to participate in a form of ecologically-based intervention known as wraparound (Burchard, Bruns, & Burchard, 2002;VanDenBerg, 1996). Wraparound embraces a family and community-centered, strength-based, andculturally-responsive philosophy. It also involves a flexible array of formal andinformal supports gathered together to form "the team." The team transforms itsAddress correspondence to Jacqueline Sparks, University of Rhode Island, 2 Lower College Rd.,Kingston, RI 02881. E-mail: 63
  2. 2. 64 Sparks and Muromembership, goals, length of involvement, and funding structures to adapt to eachfamily situation and idiosyncratic change process. In its ideology, wraparoundrepresents tbe evolution of systems of help from punitive, discouraging, andrestrictive to family-driven, optimistic, and responsive, theoretically capable ofaddressing tbe complexities inberent in multi-level intervention. In practice, wraparound may not live up to its philosophy. Wbile communitieshave struggled to find ways to work together, protocols, hierarchies, and beliefs,entrencbed over time, often differ significantly from one agency to the next. Fur-thermore, the fundamental values of wraparound may be major departures fromhow an agency and its staff understand problems, families, and helping. For ex-ample, the belief in child and family wisdom to know what is needed to resolvedilemmas may contradict professional training, policy, and procedure. Tbe sought-after collaboration between diverse and sometimes historically competing enti-ties can falter, inhibiting wraparounds potential to assist troubled families. While practitioners and researchers continue to define an effective wraparoundprocess (Walker & Bruns, 2006), a substantial body of research bas attested totbe soundness of putting clients voices and preferences at the forefront of theirchange. For example, the formal incorporation of clients views regarding thedirection of service and the helping alliance bas shown to improve the outcomefor both individuals (Howard, Moras, Brill, Matinovich, & Lutz, 1996; Lambert,in press) and couples (Anker, Duncan, & Sparks, 2009). Brief, reliable, and validclient-report measures administered throughout intervention make clients views notonly visible and usable, but meaningful indices of outcome, a key interest of sys-tems that shoulder the financial responsibility for services. Recently validated childmeasures have expanded client-directed, outcome-informed work to families, al-lowing children to finally bave a meaningful say in their preferences for help. This article focuses on efforts to unite the systematic collection and utilizationof client views with wraparound service. We describe wraparound and client-directed, outcome-informed practices (CDOI), with an emphasis on the successesrealized to date and anticipated barriers. We suggest tbat making the "voice andchoice" of clients a guiding light not only can translate into improved outcomesbut can become the linchpin of true partnerships witb families and diverse help-ing systems. Most importantly, we articulate the vision of a process that honorsclients voices not only in theory but in practice—clients become the "glue" thatholds the team together to create inspiring and transformative collaborations. WRAPAROUND IDEOLOGY AND PROCESSDecades ago, the alarm was sounded that children and adolescents experiencinghigh levels of distress and troubling behavior were not receiving what was neededto help them stabilize and flourish in natural, non-stigmatizing environments(Knitzer, 1982). Disruptive and distressed youths, many experiencing the effects
  3. 3. Client-Directed Wraparound 65of family disarray, poverty, or discrimination, found themselves on a kind of re-volving wheel. As they were identified and efforts marshaled to help, many wereremoved from their homes into foster care or residential placements, frequently farfrom their families and social worlds (Burchard, Burchard, Sewell, & VanDenBerg,1993). In many cases, efforts to help resulted in further identification of the youth asdisabled, a process made all the more pronounced by removal from everyday life.In such instances, getting back home, back in school, and being seen as "normal"became increasingly difficult. Families, too, experienced a similar kind of identity branding. Social and men-tal health services for families where child abuse or neglect was suspected or wherechildren exhibited disturbing behaviors often focused on family dysfunction. Well-intended "treatment plans," created without family input, were frequently im-possible due to lack of transportation, child-care, financial resources, or othernecessary family supports. Moreover, plans may have overlooked family values,culture, or views, making the completion of pre-set goals unlikely. These fami-lies, like the troubled youth in residential and specialized placements, found them-selves on a revolving wheel, becoming increasingly demoralized and stigmatized,their journey to stability hampered, if not altogether thwarted. It was recognitionof these failures that spurred interest in more hopeful, less-stigmatizing, and moreeffective ways to help. These efforts involved doing "whatever it takes" to keepthe child in the home and supporting and involving the family, with safety still acritical caveat. "Systems of care" arose in order to create community and family partnershipsto help maintain children at home, or at least in local community settings, as brieflyas possible (Kutash, Duchnowski, & Friedman, 2005). The wraparound processgradually evolved out of these initiatives, with the additional recognition thatchildren and families could be served better through family-centered and culturally-responsive intervention. According to Burns and Goldman (1999), wraparoundis grounded on the belief that when the child and familys needs are met, present-ing concerns improve, if not dissolve; neither structures of reimbursement norservice availability should stand in the way of addressing these needs. At its core, wraparound is flexible, comprehensive, and team-based. Further-more, wraparound is driven by the familys perspective incorporated into a collabo-ratively devised and individualized service plan. The plan, and all efforts thatfollow, are culturally congruent and utilize family strengths and both natural andformal supports. Wraparound is not a specific approach, but is more accuratelyconsidered a process involving trained community personnel who are responsiblefor coordinating family/community collaborations and who seek to implement wraparounds fundamental philosophy of family empowerment. Wraparound has captured the imagination of many in social and mental health services at both practice and policy levels. It presents a vision of help that moves beyond expert-recipient, professional-lay to one of the family as holding the great-est expertise. According to wraparound principles, the family determines what is
  4. 4. 66 Sparks and Muroneeded and the best way to get it, while the wraparound professional providesinformation and opens doors to resources that would otherwise be closed. Eventhe popular notion of the client as "consumer" is transformed into the client asleader. Collaboration and the importance of local, client wisdom are central con-cepts in narrative (White & Epston, 1990), collaborative language systems (Ander-son & Goolishian, 1988; Anderson & Gehart, 2007), and solution focused (deShazer et al., 1986; De Jong & Berg, 1998) approaches. These beliefs have led tothe creation of collaborative family-based models (e.g.. Berg, 1994; Madsen,2009), implementing shared values in intensive family-centered work. Wrap-around, a meta-framework for family/provider engagement, is consistent with acollaborative paradigm. The expertise of the wraparound professional involvessafeguarding the process, with a foundational belief that its proper unfolding willproduce the desired result. CLIENT-DIRECTED, OUTCOME-INFORMED PRACTICEDespite its radical philosophy, wraparound in practice is not separate from pre-vailing "mental health" ideology. On what has been called "Planet Mental Health,"diagnosis plus prescriptive treatment are standard practice, often leaving clientsout of the decision-making loop (Duncan, Miller, & Sparks, 2004). This equationis supported by longstanding structures that require DSM derived diagnoses totrigger funding. In addition, spurred by broad initiatives to implement research-based interventions for youth mental illness (e.g.. National Advisory Mental HealthCouncil Workgroup on Child and Adolescent Mental Health Intervention Devel-opment and Deployment, 2001 ; New Freedom Commission on Mental Health,2003), child and adolescent services increasingly stress evidence based treatments(EBTs) (Huey & Polo, 2008; Kazdin, 2000; Weisz, Weiss, Han, Granger, & Morten,1995). An emphasis on EBTs can disenfranchise families and youths views bymandating specific treatments for certain identified problems. This can occurdespite the definition of evidence-based practice developed by the 2005 Presi-dential Task Force on Evidence-Based Practice of the American PsychologicalAssociation emphasizing "the integration of the best available research with clinicalexpertise in the context of patient [sic] characteristics, culture, and preferences"(APA, 2006, p. 273). Wraparound can be found on many EBT lists (see e.g.. Bruns, Hoagwood,Rivard, Wotring, Marsenich, & Carter, 2008; Walker & Bruns, 2006). At the sametime, guidelines for the wraparound process often include the use of specific EBTs.For example, a recent survey found that 55% of wraparound practitioners wererequired to use EBTs (Sheehan, Walrath, & Holden, 2007) despite the fact thatmany practitioners feel that EBTs limit creativity and are not responsive to indi-vidual client differences (Plante, Andersen, & Boccaccini, 1999). Meanwhile, thediversity of youth service settings (e.g., juvenile justice, schools, child welfare)
  5. 5. Client-Directed Wraparound 67complicate the implementation of standardized protocols by front-line providers(Leighton, 2002). Despite obstacles, the call to provide EBT training and standardize protocols foryouth and family services grows louder (Sheehan et al., 2007). In contrast to choos-ing from a list of approaches based on expert assessment, a growing body of re-search attests to the importance of real-time client feedback (continuously throughoutintervention) to inform what is done, for how long, and what modifications may beneeded. Client- directed, outcome-informed practice is based on the robust empiri-cal findings that therapeutic outcomes derive not from the specific differences be-tween treatment approaches, but from commonalities between them (Duncan et al.,2004; Wampold, 2001 ). Instead of adding one more model to the plethora ah-eadyin existence, CDOI tailors treatment to each unique situation based on client feed-back. CDOl requires the systematic collection and incorporation of client feedback—beyond tbat, clinicians are free to work creatively using whatever model best fits agiven familys or youths preferences and resources. In their review, Lambert, Harmon, Slade, Whipple, & Hawkins (2005) revealedclinically significant advantages of feedback over non-feedback conditions forindividual therapy. Availability of formal client feedback provided the only con-stant in an otherwise diverse treatment environment and attained an effect size(ES = .39) nearly twice that of model differences (.2). Lamberts recent review offeedback research with individuals concluded that it is time for clinicians to rou-tinely collect and incorporate feedback in their work (Lambert, in press). While research on feedback with individuals is extensive, family feedback re-search is in its infancy, perhaps in part due to the complexity of obtaining fre-quent measurements for multiple persons in a given family unit. Complicatingmatters further, most available outcome measures, although reliable and valid, are long and intended primarily for research purposes. A small recent study of feed-back in wraparound services for youth and families (Ogles, Carlston, Hatfield,Melendez, Dowell, & Fields, 2006) found that provision of feedback using the48-item Ohio Scales (Ogles, Melendez, Davis, & Lunnen, 2001) did not contrib- ute to improved youth outcomes or family functioning in comparison to a no- feedback group. Feedback, however, was restricted to just four times over the course of treatment. Conversely, a strong feedback effect was found in a recent study of 205 couples (Anker et al., 2009). The Outcome Rating Scale (ORS; Miller, Duncan, Brown, Sparks, & Claud, 2003), a reliable and valid four-item, self-re- port instrument, provided outcome feedback, and the Session Rating Scale (SRS; Duncan et al., 2003), also reliable, valid, four-item, and self-report, provided feed- back in this trial. Finally, Reese et al. (in press) found a significant effect for out- comes for clients of 28 trainees when feedback was incorporated into their work and supervision. Tbe ORS and SRS were primary measures used in this study. The brevity and face validity of the ORS and SRS may have allowed for greater engagement by clients and clinicians in Anker et al. (2009) and Reese (in press) than would have occurred with lengthier instruments. Both the ORS and SRS
  6. 6. 68 Sparks and Muro collapse multiple items into a few broad domains, minimizing disruption of the session when administered. This is especially important since CDOI recommends tracking client progress and alliance at each meeting. All scoring and interpreta- tion of the measures are done together with clients. This not only represents a radical departure from traditional assessment but also gives clients a new way to look at and comment on their experience. Assessment, rather than an expert-driven evaluation of the client, becomes a pivotal part of an evolving relationship and change itself. The ORS is a visual, analog scale consisting of four lines, three representing major life domains—subjective distress, interpersonal relationships, social role functioning—and a fourth, overall. Clients rate their status by placing a mark on each line, with marks to the left representing greater distress and, to the right, less distress. The ORS score provides an anchor for understanding and discussing theclients current situation and allows a comparison point for later sessions. Fur- ther, it involves the client in a joint effort to observe progress toward goals. Be-cause the ORS is visually easy to grasp, clients often remark about their score onthe different lines in relation to what is happening in their lives. When this doesnot happen, the practitioner can initiate a discussion about how the scores con-nect with the clients account. In other words, the ORS becomes linked to thedescribed experience of the clients life. In this way, the client and helper can useongoing ORS assessment as a tool to chart direction for their work together. Un-like traditional assessment, the mark on the ORS is irrelevant until and unless theclient bestows meaning on it in dialogue with a helping collaborator. The SRS, like the ORS, is a paper-pencil measure using four visual analoguescales. The SRS measures the clients perceptions of a meeting with a helper on acontinuum of three aspects of the alliance as defined by Bordin (1979): the rela-tionship dimension, "I did not feel heard, understood and respected" to "I felt heard,understood, and respected"; a goals and topics dimension, "We did not work ortalk about what I wanted to work on or talk about" to "We worked on or talkedabout what I wanted to work on or talk about"; and an approach or method di-mension, "The approach is not a good fit for me" to "The approach is a good fitfor me." Finally, the fourth line elicits the clients perception of the meeting intotal via the continuum "There was something missing in the session today" to"Overall, todays session was right for me." The SRS allows all to know, and react immediately to, the clients view of thealliance; it continues a culture of client privilege and feedback and opens spacefor the clients voice. Clinicians or helpers ask clients to provide feedback at theend of each point of service, leaving enough time for discussion of clients re-sponses. The SRS is most helpful in the early identification of alliance problems,allowing changes to be made before clients disengage. When clinicians conveyto clients, via the SRS, that they genuinely want feedback and are serious aboutaddressing client concerns, they embody "talking the talk" and foster trust andfruitful collaboration.
  7. 7. Client-Directed Wraparound 69 Until recently, persons under the age of 13 have not had an opportunity to pro-vide formal feedback to helpers about their views. To fill this void, the ChildOutcome Rating Scale (CORS; Duncan, Sparks, Miller, Bohanske, & Claud, 2006)was developed. The CORS is similar in format to tbe ORS but contains childfriendly language and graphics to aid the childs understanding. Similarly, the ChildSession Rating Scale (CSRS) offers a visual component as well as language ori-ented towards children to assess a childs perception ofthe alliance. Parents orcaretakers also use these measures to give their perspective of their childs progress.Tbe adult ORS and SRS have been validated for use with adolescents (ages 13- 17), giving tbis age group a chance to voice their opinions on how well they feelconnected to their helper and the overall process. With these instruments, wholefamilies can benefit from client-informed practice, and researchers have a toolfor examining the impact of services at family and systems-wide levels. Based on a growing body of compelling empirical findings, feedback appearsto improve outcomes across client populations and professional disciplines, re-gardless of the model practiced—the feedback process is a vebicle to modify anydelivered treatment for client benefit. This research, and our own experiences usingclient feedback in our work settings, suggested to us an opportunity to put intopractice in a meaningful, concrete way the underlying philosophy of wraparound.Wbile lip service is often given to having clients lead the way, enculturation into "Planet Mental Health" tends to be pervasive (Duncan & Sparks, 2007). Instead,CDOI creates a "culture of feedback" (Duncan et al., 2004)—it is a way to "walk tbe walk." At the same time, we speculate that tbe system-wide use of standard measures, gathered often and regularly throughout involvement with a client fam- ily, has the potential to unify the diverse players in the wraparound drama. For example, the use of linked databases of routine client measures of progress and tbe alliance can provide a single orienting point around which discussions about needs, change of direction, or termination revolve. Of note, wbile efforts to im- prove interagency collaboration in system-of-care initiatives (such as wraparound) have been successful at a systems-wide level, outcomes at the child and family level are less convincing (Farmer, Mustillo, Burns, & Holden, 2008). Could it be tbat professionals have become better talking amongst themselves, while clients voices remain unheard or unheeded? Witb this history and research as a backdrop, the following relates experiences of one family program to formally incorporate clients voices, including the young- est, as guides to community wraparound intervention. STORIES FROM THE FIELDSouthwest Behavioral Health Services (SBH) provides services to as many as 2,000or more children at any given time in Maricopa, Pinal, and Gila Counties in Ari-zona. The CORS was implemented by Child and Family Team (CFT) programs
  8. 8. ^0 Sparks and Muroin March of 2008 to give children an opportunity to be heard and to unify diversehelpers. We also began using the Child Session Rating Scale (CSRS) to monitorthe helping alliance and Tracking Graphs to plot child and caretaker ratings (onegraph is used to plot progress from the initial assessment through individual andfamily meetings on a weekly basis). We hoped that having access to immediateclient and caretaker feedback could help clinicians make sure they worked onfamily goals and kept track of progress being made. We also hoped the processcould foster collaboration with natural supports and community resources. Ourintention was to circulate the graphs to other providers formally involved withthe family in order to help us all to be "on the same page" with clients views ofprogress and the process in general. These views could potentially serve as pointsof discussion about what services could best help clients reach desired changes. Layering the CORS into CFT services is a work in progress, with ongoing trainings and discussions with clinicians and other staff members. Nevertheless, stories from the field give us hope that our efforts are already having an impact, as illustrated by the following examples. A 12-year-old boy, an 11-year-old boy, and a 9-year-old girl were removed from their home by Child Protective Services (CPS). The children lived with their mother, who struggled with substance abuse. The siblings wanted to stay together, and their maternal uncle stepped in to care for them short-term while their mother tried to stay clean. At the time of this writ- ing, she had not been successful in this and had not engaged in a family reunifica- tion effort. Acting in what he surely believed to be in the best interests of the children, the CPS case manager requested a range of services, including mental health assessments, psychiatric testing, and psychological evaluations for all ofthe children. However, during our use of feedback measures with the family, thechildren consistently rated themselves on the CORS between 8s and 9s in everydomain, above the "cutoff and indicative of functioning in a "non-clinical" range.The uncle also rated the children 8s and 9s; an unlikely long-term caretaker forthese children was telling the team that this family "worked." The children weresaying the same thing in all areas of their lives. They felt happy, safe, and wereadjusting to their new environment. The uncle reported no behavior concerns athome, and stakeholders from school reported that all children were making progress.While the verbal reports from family members and the school were significant,backing these with concrete valid measures provided powerful corroborative sci-entific evidence. The CPS worker was convinced, and withdrew recommendationsfor high-end, intrusive intervention. Another example involved an 8-year-old Hispanic boy who was referred by hismother for "help dealing with his parents divorce." The CFT brainstormed andsuggested multiple community resources and activities, although the family hadbeen in services for over a year without much progress. The CFT decided to usethe CORS with the boy and his mother (the CORS allows caretakers to track achilds progress as they see it) in an attempt to better target family needs. As aresult, a new family plan was developed. This time the team used feedback from
  9. 9. Client-Directed Wraparound 71the mother and the 8-year-olds scores on the CORS and graph to gauge whatworked best while continuing to connect the family with resources and naturalsupports. Within several months, the team discussed stepping back formal ser-vices after the child and his mother reported overall improvement on the mea-sure. Without specific guidance from both the child and his mother via a concreteand visual tool, this family may have continued to flounder with an array of ser-vices not suitable to their particular goals and preferences. Instead, we speculatethat not only did use of the measures help target helping efforts, it put familymembers in charge of the process, increasing their engagement and subsequentmovement toward a successful outcome. Another example illustrates how successful outcomes are client driven, even ifthe end result does not always line up with the teams plan. The client, a teenagegirl, had been involved in wraparound for several years. The team struggled withhelping her through instances of self-harm, depressed mood, and the passing ofher biological mother. Carla, as we will call her, was placed with a foster motherwho did her best to provide a stable, loving environment for her. But, it was not agood fit, and Carla did not know how to tell the team. When the ORS and SRS (adult measures used with adolescents) were introduced into the process, Carla had a vehicle for telling helpers that what they were doing was not working. She showed a high level of distress and, when we inquired about this, stated that she did not connect with her foster mother and, in fact, intended to run away to the home of her aunt. When her clinician attempted to discourage that plan, Carla gave their session the lowest rating on the SRS, a 7 (below 36 indicates problems with the alliance). At the same time, the client reported her highest ORS, an overall of 36 (out of 40, and well above the cutoff of 28 for her age). She told her clinician that she was "celebrating her freedom and going to make her own choices." Carla acted on her plan, and some days later called her clinician from her new home with her aunt to inquire about services in her area. Since she was soon to turn 18, Carlas chart was closed. Had wraparound initially provided Carla with a formal, and perhaps more impersonal, way to give feedback, her needs could have been addressed much sooner. In a sense, formal asking about her wishes seemed to ignite Carlas will and voice—she stepped out to chart her own course and, all things considered, made a reasonable decision. It is not without trying that diverse helpers sometimes miss the mark. Our experi- ence, to date, has been that we now have a viable way to spend less time "in the dark" and more time (with less cost and resources) doing those things most likely to work, even for some of the more complex and seemingly intractable client dilemmas. THE CLIENT AS CONNECTORIt has been decades since the recognition that removing children from their homes,especially far from natural networks, frequently fails to resolve the problems faced
  10. 10. 72 Sparks and Muro by young persons and their families. Despite the creation of community-based systems of care, out-of-home placement remains an all too frequent event, par- ticularly for older and Hispanic teens, and continues to be an unstable and inade- quate solution (Farmer et al., 2008). A curious dichotomy has arisen within systems of care as they have sought to stem the placement tide. On the one hand, provid- ers have rallied around a progressive paradigm of family-driven, individualized service, particularly exemplified by wraparound, based on client voice and choice. On the other hand, wraparound and like services rest within practice and payment structures derived from traditional mental health and medical ideology. Diagnoses still find their way into charts and the language used to talk about persons, their situations, and possible solutions. Consequently, services to high-risk families and children often encompass two opposing worlds. And often, the more pervasive and established medical discourse trumps the local knowledge of clients. Rela- tionships of helper/helped and expert/impaired that typically define medical in- tervention render unlikely other kinds of partnerships, specifically those where clients lead and know best. Its as though when diagnoses speak, clients cannot be heard. A third way is possible, one based on evidence from the empirical literature that centralizes clients in the helping process. Research continues to affirm the importance of client engagement in a positive outcome in psychotherapy (Bohart & Tallman, in press). Specific diagnoses are not correlated with outcome, whereasclient involvement is (Duncan et al., 2004). Most standardized measures of pa-thology fail to differentiate between clients who will and will not ultimately benefitfrom psychotherapy (Brown, Dreis, & Nace, 1999). A growing number of studiessuggest that predictions of overall improvement at the conclusion of treatment aremore accurate when they are based on the clients report of change in the first fewmeetings rather than on clinicians pretreatment assessments of client dysfunction(Haas, Hill, Lambert, & Morrell, 2002; Lambert, Whipple, Smart, Vermeersch,Nielsen, & Hawkins, 2001). Additionally, obtaining feedback from clients through-out therapeutic services enhances client involvement by reducing cancellation andno-show rates (Bohanske & Franczac, in press) and results in significantly greaterimprovement than non-feedback conditions (Lambert, in press; Anker et al., inpress). Centralizing clients voices via formal feedback has the potential to resolve theclash between two philosophies—one that values client direction (wraparound)and one that mistrusts it (medical). Client reports replace diagnoses as centerpiecesof treatment plans and indices of change in any given helping collaboration. Thefundamental wraparound values of individualized, culturally sensitive interven-tion can be realized for each child and family, without the demoralizing effects ofdeficit labeling and prescriptive treatment. Clients author their stories, and thesystem of helpers unites around these rather than the depersonalized mental healthnarratives with their predictable characters and plots.
  11. 11. Client-Directed Wraparound 73 Very real obstacles arise in the implementation of client-directed communitycollaborations. Overturning entrenched policies, paperwork, and procedures, theinfrastructure of "mental health," is no small endeavor. As an example, the safetyof children and the community must be a priority, and ways of responding toextreme crises inevitably revert to traditional thinking and acting. Communitystakeholders have every right, indeed obligation, to protect not only the youngestmembers of their community, but the community as a whole, as in circumstancesof child abuse or chronically delinquent youth. The choice between traditionalresponses and the one advocated here, however, need not sacrifice this mandate.Already, the use of client feedback systems has caught the attention of decisionmakers (judges, probation officers, administrators, third party payors, etc.) ina wide array of treatment settings serving children and families (Bohanske &Franczak, in press). Ultimately, the best way to test the waters is to pilot CDOI practice, collect data,and assess outcomes. Communities can begin to have the courage to step into anew paradigm, to honestly implement the values at the core of services such aswraparound, based on solid empirical support. Their commitment, however, de-pends on their own felt experience of "does it work?" We have seen, and heardtell, how more energy and less demoralization characterize helping efforts, howgoals are realized more quickly, and how workers in the field experience increasedsatisfaction in their work when clients are energized and involved. The chancefor a child and family to evolve a new story of who they are is reason enough totake the risk. Taking it one step further, it is our vision that the community ofhelpers "wrapping around" the central connector, the family and its members, willalso evolve a new story—one where competing agendas and philosophies cometogether as a vital, effective force in the service of clients hopes and dreams. REFERENCESAnderson, H., & Gehart, D. (Eds.). (2007). Collaborative therapy: Relationships and conversations that make a difference. New York: Routledge.Anderson, H., & Gooiishian, H. (1988). Human systems as linguistic systems: Evolving ideas about the implications for theory and practice. Family Process, 27, 371-393.Anker, M., Duncan, B., & Sparks, J. (2009) Using client feedback to improve couple therapy outcomes: A randomized clinical trial in a naturalistic setting. Journal of Consulting and Clinical Psychology, 77(4), 693-704.American Psychological Association Presidential Task Force on Evidence-Based Prac- tice (2006). Evidence-based practice in psychology. American Psychologist, 61, 271-285.Berg, I. (1994). Family Based Services: A solution-focused approach. New York. W.W. Norton.Bohart, A. C , & Tallman, K. (in press). Clients: The neglected common factor in psycho-
  12. 12. 74 Sparks and Muro therapy. In B. L. Duncan, S. D. Miller, B. E. Wampold, & M. A Hubble (Eds.), The heart and soul of change. Delivering what works (2nd Ed.). Washington, DC: American Psychological Association Press.Bohanske, R. T., & Franczak, M. (in press). Transforming public behavioral healthcare: A case example of consumer directed services, recovery, and the common factors. In B. L. Duncan, S. D. Miller, B. E. Wampold, & M. A Hubble (Eds.), The heart and soul of change. Delivering what works {2nd Ed.). Washington, DC: American Psychological Association Press.Bordin, E. S. (1979). The generalizability of the psychoanalytic concept of the working alliance. Psychotherapy, 16, 252-260.Brown, J., Dreis, S., & Nace, D. K. (1999). What really makes a difference in psycho- therapy outcome? Why does managed care want to know? In M. A. Hubble, B. L. Duncan, & S. D. Miller (Eds.), The heart and soul of change: What works in therapy (pp. 389-406). Washington, DC: American Psychological Association Press.Burchard, J. D., Bruns, E. J., & Burchard, S. N. (2002). The wraparound process. In B. Burns & K. Hoagwood (Eds.), Community treatment for youth: Evidence-based treatment for severe emotional and behavioral disorders. New York: Oxford Uni- versity Press.Burchard, J. D., Burchard, S. N., Sewell, R., & VanDenBerg, J. (1993). One kid at a time: Evaluative case studies and description ofthe Alaska Youth Initiative Demonstra- tion Project. Washington, DC: Georgetown University Press.Burns, B. J., & Goldman, S. K. (1999). Promising practices in Wraparound for children with serious emotional disturbance and their families. Systems of care: Promising practices in childrens mental health, 1998 series. Vol. IV. Washington DC: Cen- ter for Effective Collaboration and Practice, American Institutes for Research.Bruns, E. J., Hoagwood, K. E., Rivard, J. C , Wotring, J., Marsenich, L., & Carter, B. (2008). State implementation for evidence-based practice for youths, part II: Rec- ommendation for research and policy. Journal ofthe American Academy of Child & Adolescent Psychiatry, 47(5), 499-504.De Jong, P., & Berg, I. K. (1998). Interviewing for solutions. Belmont, CA: Brooks/ Shazer, S., Berg, I. K., Lipchik, E., Nunnally, E., Molnar, A., Gengerich, W., & Weiner- Davis, M. (1986). Brief therapy: Eocused solution development. Family Process, 25(2), 207-222.Duncan, B., Miller, S., & Sparks, J. (2004). The heroic client: A revolutionary way to im- prove effectiveness through client-directed, outcome-informed therapy. San Eran- cisco: Jossey-Bass.Duncan, B. L., Miller, S. D., Sparks, J. A., Claud, D. A., Reynolds, L. R., Brown, J., & Johnson, L. D. (2003). The Session Rating Scale: Preliminary psychometric prop- erties of a "working" alliance measure. Journal of Brief Therapy, 5(1), 3-12.Duncan, B., & Sparks, J. (2007). Heroic clients, heroic agencies: Partners for change. (Revised E Book),, B., Sparks, J., Miller, S., Bohanske, R., & Claud, D. (2006). Giving youth a voice: A preliminary study of the reliahility and validity of a brief outcome measure for children. Journal of Brief Therapy, 3(1), 3-12.Earmer, E. M. Z., Mustillo, S., Burns, B. J., & Holden, E. W. (2008). Use and predictors of out-of-home placements within systems of care. Journal of Emotional and Be- havioral Disorders, 16(1), 5-14.
  13. 13. Client-Directed Wraparound 75Haas, E., Hill, R. D., Lambert, M. J., Morrell, B. (2002). Do early responders to psycho- therapy maintain treatment gains? Journal of Clinical Psychology, 58, 1157-1172.Howard, K. I., Moras, K., Brill, P. L., Martinovich, Z., & Lutz, W. (1996). Evaluation of psychotherapy: Efficacy, effectiveness, and patient Progress. American Psycholo- gist, 5J, 1059-1064.Huey, S. J., & Polo, A. J. (2008). Evidence-based psychosocial treatments for ethnic mi- nority youth. Journal of Clinical Child and Adolescent Psychiatry, 37{ 1 ), 262-301.Kazdin, A. E. (2000). Developing a research agenda for child and adolescent psychotherapy. Archives of General Psychiatry, 57, 829-835.Kutash, K., Duchnowski, A. J., & Friedman, R. M. (2005). The system of care 20 years later. In M. Epstein, K. Kutash, & A. Duchnowski (Eds.), Outcomes for children and youth with behavioral and emotional disorders and their families: Programs and evaluation best practices (2nd ed., pp. 3-22). Austin, TX: PRO-ED.Knitzer, J. (1982). Unclaimed children: The failure of public responsibility to children and adolescents in need of mental health services. Washington, DC: Childrens Defense Fund.Lambert, M. J. (in press). Yes, it is time for clinicians to routinely monitor treatment out- come. In B. L. Duncan, S. D. Miller, B. E. Wampold, & M. A. Hubble (Eds.), The heart and soul of change. Delivering what works. Washington, DC: American Psy- chological Association Press.Lambert, M. J., Harmon C., Slade K., Whipple J. L., & Hawkins E. J. (2005). Providing feedback to psychotherapists on their patients progress: Clinical results and prac- tice suggestions. Journal of Clinical Psychology: In Session, 67(2), 165-174.Lambert, M. J., Whipple, J. L., Smart, D. W., Vermeersch, D. A., Nielsen, S. L., & Hawkins, E. J. (2001 ). The effects of providing therapists with feedback on patient progress during psychotherapy: Are outcomes enhanced? Psychotherapy Research, 11, 49-68.Leighton, H. Y. (2002). Problems in behavioral health care: Leap-frogging the status quo. Administration and Policy in Mental Health, 29, 403^19.Madsen, W. (2009). Collaborative helping: A practice framework for family-centered services. Family Process, 48{), 103-116.Miller, S. D., Duncan, B. L., Brown, J., Sparks, J., & Claud, D. (2003). The outcome rat- ing scale: A preliminary study ofthe reliability, validity, and feasibility ofa brief visual analog measure. Journal of Brief Therapy, 2(2), 91-100.National Advisory Mental Health Council Workgroup on Child and Adolescent Mental Health Intervention Development and Deployment. (2001). Blueprint for change: Research on child and adolescent mental health. Washington DC: National Insti- tute of Mental Health.New Freedom Commission on Mental Health. (2003). Achieving the promise: Transforming mental health care in America. Final report. (DHHS Pub. No. SMA-03-3832), Rockville, MD.Ogles, M. 0., Carlston, D., Hatfield, D., Melendez, G., Dowell, K., & Fields, S. A. (2006). The role of fidelity and feedback in the wraparound approach. Journal of Child and Family Studies, 15, 115-129.Ogles, B. M., Melendez, G., Davis, D. C , & Lunnen, K. M. (2001). The Ohio scales: Practical outcome assessment. Journal of Child and Family Studies, 10(2), 199- 212.Plante, T. G., Andersen, E. N., & Boccaccini, M. T. (1999). Empirically supported
  14. 14. 76 Sparks and Muro treatments and related contemporary changes in psychotherapy practice: What do clinical ABPPs think? The Clinical Psychologist, 52, 23-31.Reese, R. J., Usher, E. L., Bowman, D., Norsworthy, L., Halstead, J., Rowlands, S., et al. (in press). Using client feedback in psychotherapy training: An analysis of its in- fluence on supervision and counselor self-efficacy. Training and Education in Pro- fessional Psychology.Sheehan, A. K., Walrath, C. M., Holden, E. W. (2007). Evidence-based practice use, train- ing and implementation in the community-based service setting: A survey of chil- drens mental health service providers. Journal of Child & Family Studies, 16, 169-182.Stroul, B. A. (1996). Childrens mental health: Creating systems of care in a changing society. Baltimore: P. H. Brookes Publishers.VanDenBerg, J. E. (1996). Individualized services and supports through the wraparound process: Philosophy and procedures. Journal of Child and Family Studies, 5(1), 7-21.Weisz, J. R., Weiss, B., Han, S. S., Granger, D. A., & Morten, T. (1995). Effects of psy- chotherapy with children and adolescents revisited: A meta-analysis of treatment outcome studies. Psychological Bulletin, 117, 450-468.Walker, J. S., & Bruns, E. J. (2006). Building on practice-based evidence: Using expert perspectives to define the wraparound process. Psychiatric Services, 57{ 11 ), 1579- 1585.Wampold, B. E. (2001). The great psychotherapy debate: Models, methods, and findings. Hillsdale, New Jersey: Lawrence Erlbaum.White, M., & Epston, D. (1990). Narrative means to therapeutic ends. New York: Norton.