A BRIEF CONSULTATION AND ADVISORY APPROACH …abc4camhs.org.uk/downloads/Manual updated...

Contents1. INTRODUCTION..................................................................................................................................... 2

A guide to this manual............................................................................................................................. 2

2. CONSULTATION AND ADVICE: Key elements.....................................................................................3

User-friendly services.............................................................................................................................. 3

Parental expectation................................................................................................................................ 3

Brief consultation..................................................................................................................................... 3

Non-specific factors................................................................................................................................. 4

Summary................................................................................................................................................. 4

What is the consultation and advisory approach?...................................................................................4

3. HOW IS THIS DIFFERENT TO A TRADITIONAL APPROACH?............................................................6

Checking family expectations and perspectives......................................................................................6

Traditional approaches............................................................................................................................ 6

What distinguishes C&A from therapy?...................................................................................................7

Are there any exclusion criteria?.............................................................................................................8

What about risk assessment?................................................................................................................. 8

4. THE CONSULTATION AND ADVISORY SESSIONS.............................................................................9

Prior to the first appointment: the family..................................................................................................9

Structure of consultation sessions...........................................................................................................9

Prior to the first appointment: the consultant.........................................................................................10

First and Second Sessions....................................................................................................................10

Introduction............................................................................................................................................ 10

Develop an interactive understanding of the referral process................................................................10

Develop an interactive view of the problem...........................................................................................11

Understand the family’s ideology of the problem...................................................................................12

Ascertain the family’s expectations of the consultation and consultant.................................................13

Develop a ‘problem based’ needs assessment.....................................................................................14

Third (follow-up) session.......................................................................................................................15

5. REFERENCES...................................................................................................................................... 15

6. APPENDICES....................................................................................................................................... 17

A) Proforma............................................................................................................................................... 17

B) OPT IN................................................................................................................................................. 27

A BRIEF CONSULTATION AND ADVISORY APPROACH FOR USE IN SPECIALIST CAMHS

1. INTRODUCTION This manual sets out to describe a three-session (2+1) consultation and advisory (C&A) model of service delivery designed for use in work with families by experienced Child and Adolescent Mental Health Service (CAMHS) practitioners working at Tier 2. It is the product of a one-year pilot study undertaken with the support of NW Regional R&D funding. A summary of this can be found in the appendix.

The approach has evolved in response to what we perceive as two pressing challenges facing CAMHS. The first is what is now a general problem in specialist CAMHS – how can supply keep pace with growing demand. Moreover, high rates of non-attendance to first appointments and high attrition rates exacerbate the ubiquitous long waiting lists resulting from this problem, implying that some families may find specialist CAMHS user-unfriendly1. Hence, the second challenge is to review whether mainstream CAMHS, that is Tier 2 services, can make better use of its scarce resources by developing models of service delivery that are more congruent with user needs and expectations.

The current literature on waiting list initiatives2, brief therapies3, parental expectations of therapy4, and models of consultation5 offer a variety of possible solutions to the problems of rationing and user unfriendliness. We integrate key findings from this literature with an approach to therapeutic consultation to families proposed originally by Street and Downey (1996)6. We believe that the emergent C&A approach represents one possible resolution to the dual, yet related imperatives of rationing and user friendliness.

In essence, it is a brief, collaborative, client (parent) centred model of working with families. Our idea of having two sessions plus one follow up was based on Barkham’s (1989) 2+1 model in adult psychotherapy services. The C&A model acknowledges the fact that some families will prefer, and sometimes overtly request, frank ‘expert’ opinions and/or practical advice and do not want repeated contact or a long term therapeutic relationship with the consultant and/or the specialist CAMHS.

From the outset, we want to make it clear that the C&A approach does not make specialist therapies, or so called Tier 3 services within CAMHS, redundant. However, we have found that it may be sufficient to meet the needs and wants of the majority of families referred to specialist CAMHS from primary care; thus reducing the burden on the limited resources of these services. Moreover, it can be viewed as a form of triage, which not only prioritises the most urgent and appropriate cases for more specialist intervention but also ensures that these families make the transition to the next level of service. As a result, they are better prepared for, and therefore more likely to engage with, individual, family or group therapies.

Although we will not be presenting the findings of our pilot study in detail in this manual, the C&A approach received high satisfaction ratings from the majority of families (see appendix). Measures of symptom change also showed positive results, even though the approach is not explicitly change focused.

In sum, this manual attempts to set out the C&A approach in a practical, non-theoretical way, that hopefully, will enable other CAMHS practitioners to judge whether it accords with their existing practices and merits further exploration in their future work with families. In producing this manual, we have struggled with the challenge of describing succinctly what we have learned, and with the issue of for whom it is intended. Eventually, we decided that our audience should be experienced CAMHS practitioners. Because we contend that knowledge and experience of the gamut of CAMH problems, together with an appreciation of the relative merits of the various theoretical models and clinical approaches are prerequisite for using this approach. Given this, C&A is not for the novice.

A guide to this manual

The key elements of the C&A approach, and how we believe it differs from traditional approaches in CAMH services, are outlined in section 2. This gives the reader a sense of the principles and values underlying the model. By way of a question and answer format, we address the differences between C&A and more traditional methods and practices in specialist CAMHS. The questions of exclusion criteria (cases for which the approach may not be appropriate) and risk assessment (accommodating the professional imperatives of CAMH) are also covered in section 2.

Stockport NHS Trust 2

Section 3 details the C&A package, giving details of the process. It describes how to conduct it in step-by-step manner, illustrated with verbatim transcripts from actual case exemplars. We believe that this section is vital in conveying the specific practices of the approach. It also gives the reader sufficient detail to be able to explore the approach in their own practice if they wish. Moreover, by moving beyond general points about what we as therapists think we are doing in the C&A approach, to what we actually do in practice, we invite the reader to judge for themselves whether the claims we make for the approach are borne out by the evidence.

It is probably most useful to read the manual in the order it is written, as it is more likely to orientate the reader and ground what we have attempted in practice in the theory surrounding it. That said, it is perhaps just as useful to read the sections in any order, but we take no responsibility for the novice therapist who believes they can ‘do’ consultation after reading section 3!

In the appendix, we have included some of the tools used and a summary of our findings for the interested reader should they wish to know more about the research project.

2. CONSULTATION AND ADVICE: Key elements The evidence base on therapy process research and large-scale audits of specialist CAMHS provide the rationale for the C&A approach.

User-friendly services

Research conducted on the user experience of specialist CAMHS and other family support services suggest that client dissatisfaction and unfavourable outcomes are associated with ‘clashes in perspective’ or mismatches between users’ and professionals’ perceptions7. This work reminds us that what is a familiar routine and taken-for-granted way of operating for a therapist is a unique and peculiar experience for families8. For example, users have little idea of what to expect at their first appointment or what kind of help they might receive from CAMHS. Moreover, concentration on the routinised, questioning practices of formal assessment can lead us to forget that users’ experiences are of paramount importance. What is more, we know that families come to CAMHS with different expectations. Some many come looking to receive direct, practical advice; some come to ‘check’ that their child or adolescents behaviour is ‘normal’. Some are unsure whether they need help or may not be ready to commit themselves to therapeutic work, with others wanting new insights or therapists ‘expert opinion’ to enable them to find new ways of dealing or coping with their predicament. Moreover, families judge their experiences of CAMHS by how far their expectations have been met. Therefore it is important that CAMHS professionals adopt an approach to service delivery at Tier 2, which is flexible enough to accommodate each individual family’s needs.

Parental expectation

Large-scale audits of specialist CAMHS show that the majority of families have relatively brief contact with the service. For example, in the audit of CAMHS in Scotland9, 61% of families attended three or less appointments. The literature suggests that this reflects the fact that most families either do not need10, want or are capable of sustaining longer term involvement with specialist services11. This appears to be explained by a number of factors. For example, sometimes the child/young person referred and/or their parent(s) may not recognise that they have a problem (particularly if a professional has referred them, who ‘sees’ a problem that the family don’t!). However, more commonly, parents approach the initial contact with CAMHS with marked ambivalence and can emerge feeling blamed in some way12. Moreover, as we have seen, the consumer research shows that parents not only expect, but are also disappointed with what they regard as the limited advice and opinions they receive from CAMHS professionals. Our contention is that these factors may be contributing to the high DNA and attrition rates, experienced currently in CAMHS, with the resulting waste of precious specialist resources.

Brief consultation

The evidence base shows that brief interventions, between one and three sessions, can be just as effective as longer-term therapy13. Moreover, the ‘2+1’ model14 of service delivery has received considerable empirical investigation and shows particular promise in adult services.


Non-specific factors

The findings from psychotherapy process research15 consistently demonstrate those therapists’ interpersonal qualities (such as warmth, empathy and genuineness), and the interpersonal relationship (such as a sense of mutuality and therapeutic alliance) are significant predictors of satisfaction and outcome. What is more, these so-called ‘non-specific’ factors are crucial continuities across different forms of therapy.

Summary

The C&A model of service delivery acknowledges these important, yet often neglected findings from the evidence bases. Moreover, it is configured so as to incorporate them as design features in an approach to routine practice at Tier 2.

In conceiving of a C&A approach to service delivery, we sought an ethical and user-friendly style of practice that provided a better ‘fit’ between families’ perceived needs and expectations, and professional imperatives or service traditions. Hence, the consultation process is guided by certain key principles. Thus the C&A approach: -

is brief and focused reflects on the process of referral elicits parental expectations and wishes identifies and works with any ambivalence or blame assesses severity and need negotiates clear and realistic goals for the consultation agrees realistic goals for any therapeutic intervention that may follow the consultation attempts to demystify the process of therapy and avoids ‘missions impossible’ allows families to ‘opt in’ with ‘informed consent’ to therapy avoids ‘drifts’ into therapeutic relationships and ‘therapy by stealth’

What is the consultation and advisory approach?

In the broadest terms, it is about providing families with an informal, non-judgemental and reflective context in which to talk about the troubles or concerns that brought about the referral. It allows the exchange ideas and opinions on what might have caused the difficulties and what might relieve them and gives an opportunity for the family to decide whether the consultant, other CAMH services or other agencies have a role to play in enabling them to find a satisfactory resolution. Of paramount importance throughout, is that families should feel understood on their own terms. Furthermore, consultations should be custom-built, in the sense that they aim to meet users’ needs as they see them. Thus the approach requires consultant to be sensitive, flexible and versatile. In acting in the role of consultant, rather than therapist, the CAMHS professional does not assume that the involvement with the family will develop into a therapeutic relationship or that the family need on-going therapy.

A major aspect of the brief consultation and advice model is establishing the family’s expectations of the consultant and the service. Families may want a certain type of help (including advice, an opinion, self-help literature or a referral to other agencies) but may or may not demand it during the first session. In addition, within a family there may be many different views about their needs and the family’s differing perceptions of need may not necessarily match the view of the professional. The role of the consultant is to explore this with the family to ensure that, for instance, they do not give advice without having been asked by the family to do so. Similarly, the consultant should ensure that they do not suggest a referral for therapy based on their own idea of the family’s needs, for which the family may not be prepared properly. In some cases, when it is clear to the consultant that there is serious risk to the child (or family) or clear mental health problems, it is useful to complete a comprehensive formal needs assessment. It is important to be clear that in such circumstances, the consultant has a moral and clinical obligation and will therefore need to take control of the assessment, thus ‘switching’ roles (see sections 2.4 and 2.5).

Consultation is deliberately parent centred. This is because it is often the child’s behaviour that the parents see as the problem; thus the interview is directed towards those who are responsible for the child since they will have requested the referral. It stresses the need to build an alliance with parents-giving them advice, opinions, knowledge and ideas to enable them to help their children. Thus, although the C&A approach is not directed explicitly at change, the process itself may act as a “catalyst” for change, in that parents should


feel that they can do something to help themselves or their child, or at least cope better, as a result of the consultation. In other words the consultant is responsible for the successful process of the consultation, that is the conversational practices that constitute the consultation itself, but not responsible for bringing about any changes per se.

A ‘good’ consultation should feel like a ‘good’ conversation, with the consultant engaged in listening, reflecting, validating and understanding. Indeed one of the most important aspects of the approach is listening: listening to how the family’s make sense of the problems, listening to what they want from the consultation, their expectations, desired changes, their strengths and successes. By reflecting back to the family both content and feelings, the consultant concentrates on conveying empathy, warmth and understanding; that is, the non-specific factors associated with successful process and outcome in therapeutic relationships16.

The C&A approach emphasises the importance of these ‘non-specific factors’ and valorises them above the change oriented techniques and assessment methods of specific models of therapy. Thus, the approach places more emphasis on ‘talking-in-order-to-listen’17 (empathic listening and reflection with less emphasis on questioning and intervention or ‘listening-in-order-to-talk’). In this sense, the model draws on a Rogerian, client centred framework. However, the overall theoretical perspective of the approach is eclectic. Therefore, the model allows the experienced CAMHS practitioner to draw on a range of models, and their respective specialist knowledge, from systemic family therapy, to cognitive-behavioural therapies, solution focused approaches and psychodynamic thinking in the execution of individual, bespoke consultations. Hence, we believe it has trans-theoretical appeal.

The consultation process itself is organised around four key areas (see section 3 of this manual). This involves establishing an interactive view of the referral process; learning about how the family understands their problem(s) and their perceived needs; eliciting how the family view the process of consultation and the notion of therapy; negotiating with the family what the consultant can and cannot do to meet the family’s expectations and needs. Underlying the consultation and advice model, and running through each stage of the process, are a number of general principles or prerequisite requirements. These are:-

The consultant should be able to reflect critically on their practice and the process of consultation both during and between sessions18.

A non-expert, collaborative stance should be taken initially during the first session of the consultation process although this may change in response to user requirements.

The prime task is to form a shared understanding of the problem. This may require possible shifts in position regarding previously held beliefs and assumptions by both parties.

The consultant should, whenever possible, aim to make sense making practices transparent and open to correction and revision, and present all knowledge claims as tentative and necessarily contingent.

The consultant will undoubtedly form an opinion about the health care needs of the family, depending on a number of factors, which may include: -

Current help being offered for the problem from other agencies The consultant’s underlying beliefs about what works for the presenting problem (based on formal

knowledge of the evidence base) Whether the help will be effective in reducing the severity of the problem in this individual case

(based on accumulated clinical experience) Whether the family will be willing to accept the help that will be proposed Whether the resources available to offer this help are within or outside of the CAMH service.

The consultant’s skill lies in finding a way of deploying their expertise and specialist knowledge, from whatever theoretical model they derive in a form which both meets the family’s needs and fits with their expectations. Moreover, the challenge to the consultant is to make their intervention useful and meaningful to families. Hence consultations would be judged as ‘successful’ if the user rated them as holding promise or hope. In other words the C&A approach should enable the family to see, or make, a different relationship with their problem and thus feel less stuck.

Consultations are custom-built but in general they lead to common categories or classes of outcome for the family: -

1. An explanation of, and a reflection on, the cause of the problem(s) with the family but with no specific advice.


The decision for the consultant here is how and when to make their opinion explicit to the family. If asked by the family for a professional opinion, the task is then to deliver it so that it promotes new insights and possibilities without inducing blame or guilt.

2. Advice giving and guidance, in order to enable a family to use their own strengths to deal with the problems. Advice may include written material such as self-help literature.

As with opinions, advice giving requires the consultant to make fine judgements about appropriateness, timing and acceptability. Moreover, families may arrive with particular priorities and agendas about the type of advice they want. For instance, some parents arrive armed with specialist knowledge about CAMH problems obtained from the Internet, which can add to the complexity of advice giving and creating challenges for us as consultants.

3. Signposting to, or referral on to, an external agency.

4. Referral on to a specific treatment or assessment programme (e.g. a specialist form of therapy or multidisciplinary assessment / treatment).

The consultation and advice approach is brief in its conception and execution; structured around a 2+1 model of delivery. Two contiguous sessions focus on the problem(s) as defined by the family (usually the parents); concentrating on their perceptions of causation and referral and their expectations of the role that the consultant and/or specialist CAMHS might play in terms of resolution. As we have stressed the approach requires each consultation to be custom-built around the perceived needs and expectations of each family. This requires flexibility, versatility and creativity on the part of the consultant on the timing, as well as the type, of any intervention (i.e. it can occur at any time and at any level of the system). Thus, consultants may offer ‘expert’ opinion or practical advice if requested, self-help literature or they may liaise with other agencies if appropriate at any point during the first two meetings. (Indeed sometimes the consultant and the family will agree that a second meeting may not be required.) After the initial meetings, families are given the option of a follow up or review meeting, to evaluate the outcome of the consultation and to decide if any further specialist CAMHS intervention is required.

3. HOW IS THIS DIFFERENT TO A TRADITIONAL APPROACH?

Checking family expectations and perspectives

In CAMHS in the UK, although most families attend three sessions or less, they routinely undergo some form of formal, intake assessment. The approaches used in assessments are drawn from the diverse theoretical and professional knowledge bases, such as biomedical, family systems, social learning theory and psychodynamic, operating within multi-disciplinary CAMHS teams. Hence, there is variability in the way CAMHS professionals approach and conduct their initial assessment. However, what many of these traditional approaches to assessment have in common is that assessment is viewed primarily as a process of gathering information about the child, the family and the presenting difficulties in order to arrive at a clinical judgement about the nature, cause, likely course and treatability of the problem. Ultimately, assessment is seen as a means to an end, that is, case formulation and intervention. Although traditional approaches to assessment stress that the process should also be seen as the first stage in establishing ‘treatment alliance’19.

Our premise is that the family’s experience of the assessment is critical in determining dynamic outcome20. If the style and content of the assessment does not match with the hopes and expectations that families bring to their first appointment they may not want to return. Moreover, it is likely that the family experience of the initial assessment affects the quality of any subsequent engagement with therapy, which, in turn, predicts clinical outcome21. In sum, the way that CAMHS specialists approach assessment matters and therefore it warrants greater attention and should be theorised and researched with more vigour.

Traditional approachesAs we have already stressed our approach to consultations with families represents work in progress. And as such our ideas are provisional and under constant review within the iterative process of practice development and research. However, our contention is that the C&A approach is essentially different in emphasis and style to the mainstream assessment approaches taken within CAMHS, although in content, it retains some of the features of more traditional assessment approaches. For example, most noticeably, it includes a systemic exploration of the problem and the referral process, which are routine features of the


assessment process in family therapy. However, we believe it challenges some of the traditional assumptions about what constitutes a ‘comprehensive’, indeed some critics might argue ‘adequate’ assessment.

We also recognise that some traditionalists might protest that the approach is too consumer (parent) oriented and too cursory to have any impact on the problems that typically present to specialist CAMHS. Moreover, it could be argued that the approach underestimates the value of a ‘full history’ and the importance of a ‘comprehensive needs assessment’. However, these are the canons of an assessment process, which implicitly assumes that some form of therapy or care plan will follow. In C&A it is important to remember that the consultant suspends any assumption that the family, or its individual members, will want to take up or progress to a long-term therapeutic relationship with the consultant or to some specialist therapy within CAMHS. Indeed, as we have seen, in reality only the minority of referrals to specialist CAMHS proceeds to this outcome. We believe that this fact not only provides the rationale for the development of brief consultation and advisory approaches, but also marks the point of departure from the assumptions and institutional practices of more traditional models of service delivery.

Rather than imposing an assessment based on theoretical imperatives and/or canonical professional practices, the C&A approach adopts a more parent centred and user-friendly stance in the initial meeting with families. The justification being that this leads to: -

a) Better understanding between assessor and the family regarding different perspectives on need b) Explicit consideration of the various possible theories to explain or account for presenting

problems c) Clear articulation of the expectations the assessor has of the family and the family of the assessor

and CAMHS service. Leading to:- d) greater collaboration between the consultant and family in the assessment. Enabling the family

to:-

e) make their own, informed decision about whether to engage in therapy or take an alternative course of action.

What distinguishes C&A from therapy?

Effective consultation contains similar features to, and hence has some overlap with, effective therapy. According to Bateman & Fonagy (2000)22, effective psychotherapeutic treatments contain seven common features: -

a) A clear structureb) Effort is put into enhancing compliance with treatmentc) They have a clear focusd) They are theoretically highly coherent to professional and patiente) They are relatively long termf) They encourage an interpersonal relationship, allowing the therapist to be relatively active rather than

passiveg) They are well integrated with other services

Measured against these criteria, we hold that the C&A approach shares all these features, to lesser or greater extent, with the obvious exception of e). However, as we have outlined above the key distinction between our version of consultation to families and therapy is that C&A is not directly focused on change. If we define therapy as an agreed contract between therapist and client (or clients in group therapy) to remove, reduce or hold stable a problem or problems that the client has then C&A approach is not a therapy. The contract between consultant and family is not to remove, reduce or hold stable a problem or problems the family has. Instead, the contract is to provide access to information, expertise and specialist knowledge that will enable the family to decide first whether they have a problem, second what the problem is, and third, what they want to do about it- with therapy being only one possible option available to them. However, indirectly, this may lead to a therapeutic outcome23.


Are there any exclusion criteria?

Certain types of CAMHS referral were excluded from the evaluation project due to the complex or specific nature of the presenting difficulties: -

Young people admitted to hospital following self-harm Families open to Social Services (e.g. child protection cases) Requests by referrers for psychiatric intervention (e.g. ADHD, severe depression, psychoses and

eating disorders) Moderate to severe learning difficulty Re-referrals to the service

However, the relationship between research and practice is iterative. So, as our work has progressed, we now take the view that the C&A approach can be applied successfully to a wider range of cases. Since most CAMHS referrals are in response to parents’ expression of concern and the C&A model is mainly parent focused, we believe it is an approach that is suitable for the vast majority of referrals from primary care sources. But obviously cases that present with clear and urgent need for specialist care, those that involve complex multi-agency issues and certain types of re-referrals will not be appropriate candidates for this approach. Moreover, it may not be possible to employ successfully with families where there is severe conflict and/or seriously disturbed relationships.

What about risk assessment?

A particular duty of CAMHS professionals is the assessment of risk. For example, the risk people within the family pose to each other and/or to others outside of the immediate household. Moreover, self-harming behaviours are common presenting problems, so are other forms of harm (such as abuse) and reckless behaviour by adolescents (sexual or substance misuse). Information about these areas of risk may not be volunteered readily for reasons of embarrassment, shame and in some cases fear of the social or legal consequences. Hence, in common with routine assessment practices, the consultant may have to gather such information from direct questioning, by observation, and from others involved. And where necessary, the professional imperatives of formal risk assessment may have to take precedence over the user centred principles of the C&A approach. In some cases, when it is clear to the consultant that there is a serious risk to the child (or family) or clearly serious mental health problems, it is useful to complete a comprehensive needs assessment. It is important to be clear in such circumstances that the consultant has both a moral and clinical obligation and will therefore need to take a more active role in directing the focus of the assessment, thus ‘switching’ roles. With this in mind, we have included a section on risk and needs assessment within the proforma for recording consultations (see appendix 6.1). For this purpose we use an adapted version of the Salford Needs Assessment (SNASA)24.

SUMMARY OF KEY ELEMENTS OF CONSULTATION AND ADVICE

The consultation and advice package is designed for experienced CAMHS professionals providing services at Tier 2.

Consultation is not directly change oriented. It is a means of developing conversations with families about their perception of the problem(s), their needs and their hopes and expectations of the service. The aim is to develop a bespoke, mutually agreed, realistic focus which is individually tailored.

The approach does not presuppose that the family need or want therapy. The outcome may take the form of advice or opinion giving, and/or enabling access to specialist knowledge. In which case, it may have a therapeutic outcome. Alternatively, it may lead to the family making an informed decision about further specialist assessment or therapeutic input.

Consultation and therapy are similar in that they both require the professional to listen, understand, empathise and reflect. Thus, the ‘non-specific factors’ are of utmost importance.

This approach is brief, user-friendly, and there is evidence (see appendix 5.4) that it is sufficient to meet the needs and wants of many families referred to specialist CAMHS.


Therefore, it shows promise as an efficient and effective model of service delivery at Tier 2.

4. THE CONSULTATION AND ADVISORY SESSIONS This section details the model of consultation practised and evaluated in our pilot study. We describe below the involvement with families from the referral stage to the follow up session and illustrate our practice with actual case exemplars. We would like to stress that all participants depicted in these exemplars have been anonymised for purposes of confidentiality.

Prior to the first appointment: the family

Approximately 75% of families are referred to our CAMHS by GPs. On receipt of a referral, an opt-in questionnaire (see appendix 5.2) is sent to families, which included for the study details of what they can expect from the three sessions and a description of the service. They are encouraged to explain the purpose of the visit to the child or teenager prior to attendance and some examples are given as to how to do this (see appendix). The questionnaire provides useful information about family members, other agencies involved and their particular concerns or worries. We also ask the parents to complete the Strengths and Difficulties questionnaire (SDQ)25.

The family has the option to return either the opt-in questionnaire (with the SDQ attached) or simply to return a tear-off slip stating whether or not they want an appointment. This questionnaire has been used routinely by the service for many years and in general most families return the questionnaire rather than the tear-off slip. On the basis of this information, the family were seen within four weeks for a consultation. (See section 2.3 for our original exclusion criteria based on case complexity).

Structure of consultation sessions

Generally, the whole family would be invited to the first session, with the option for them to decide who should attend this and any subsequent meetings. It is important to bear in mind that most families will have had little experience of services such as CAMHS. Thus, its rountinised, ‘taken for granted’ practices will be alien, uncharted territory for parents, as well as children and young people. The consultant should therefore introduce the structure of the process of consultation to the family. We have found it useful to inform families from the outset the maximum number of consultation sessions they will be likely receive and what may follow.

The decision to terminate the consultation and advisory process may occur at any time during the three sessions, depending on the information gathered or the family’s decision to end. Examples of factors that may determine exit from the consultant’s perspective may include risk, severity of problem, and specific mental health problems (e.g. psychoses, autism, and obsessive compulsive disorder).

If ending the process is deemed necessary by the consultant, the decision should be made explicit between the consultant and family, and preferably negotiated in order to reach an understanding of the decision making process.

Prior to the first appointment: the consultant

In order to help us structure sessions in the 2+1 format, we developed a proforma (see appendix 5.1) by way of a framework. In the beginning, this felt a little restricting but as we became more confident with our own style of consultation, the proforma became a guide. We would recommend that those ‘new’ to consultation use this initially. By using the proforma in this way, the consultant maintains a certain overarching structure but is guided by the family, thus negotiating the process according to their need. Follow it sequentially would structure the session too tightly and not lead to fluid interaction between consultant and family. It should therefore not be used as a rigid template for the sessions.

Prior to seeing the family, the consultant should be familiar with the content of the referral letter and the questionnaire completed by the family.


First and Second Sessions

Based on Street and Downey’s (1996) model, in the first two sessions the aim is to: -1. Develop an interactive understanding of the referral process2. Develop an interactive view of the problem3. Understand the family’s ideology of the problem4. Ascertain the family’s expectations of the consultation and consultant

And we have added:

5. Develop a ‘problem based’ needs assessment

Introduction

We might begin a session by introducing ourselves and describing how we go about consultation. The following example gives an indication of the type of introduction to the session we might give.

Cons: Today, we’ve got roughly an hour and a quarter together for you to tell me what you feel the difficulties are, what you would like to try and change, and how you feel we might be helpful in doing that. Then, at the end of today, we can think about whether we need to meet again and who might come next time as well. So, this is a chance for me to get a feel of what the difficulties are and what you’d like to achieve by coming here; and for you to decide whether you want to come back, whether you like what we’ve got to offer. I usually start by asking a little bit about how you went to see your GP….

Develop an interactive understanding of the referral process

Initially, we would be asking the family about how they came to be referred to the service, (without necessarily asking for information about the nature of the problem) with questions such as, “Who suggested you should come to this service?” and “What did the referrer say was the reason s/he was referring you?” This helps to develop an understanding as to whether there are discrepancies between the referrer’s concept of the problem and the family’s notion of what is wrong, and to elicit any early indications of the family’s hopes and expectations. The following example illustrates how this might occur.

Example 1

Cons: So in terms of ending up here, how did that happen? Without going too much into the problem, how did you end up coming to our service?

Mo: Well basically I had a word with the Educational Psychologist and asked him if there was anywhere that we could go to, to discuss some things, so he just referred us to here.

Cons: So, he referred you here to discuss things, OK. Did he tell you anything about our service and what we might do? Did he give you any information about it?

Mo: Not really, not really no, no.

In this part of the consultation, we are interested in hearing the story of how the family’s difficulties resulted in a referral to CAMHS and gathering information about the nature of the problem and the family background. Furthermore, the consultant should try to develop an understanding of how other professionals ‘fit’ (i.e. whether the family have had any previous professional experience, whether there is any current involvement and a notion of how they came to be referred).

Some families are anxious to tell the therapist immediately about their problems but the skill of the consultant is to obtain the story within the context of the referral process. The following example illustrates how the therapist tries to resist prematurely engaging in a detailed description of the problems and attempt to expand on their understanding of the referral process.

Example 2


Mo: Well we decided to come, didn’t we, as a family because of just the situation at home, which is disruptive. There’s not a day go by where we don’t have arguments. I feel as though I need to tell Susan that it’s also for me as well, so I can help her because she can get me into such a state, where I end up screaming and I bring myself down to her level. So we agreed that, you know, we’d come and try and sort it out, because basically we’re happy aren’t we?

Cons: So, how did you come to agree that you would try and get some help from outside the family?

The benefits of ‘slowing down the action’ in the early stages of the first session to reach a better understanding of the referral process are illustrated in the following exemplar.

Example 3

Mo: Billy will kick things, people, scream, shout, go upstairs and bang his feet.Cons: Right, so you’re feeling that things were getting more and more difficult- harder to

manage-is that right?Mo: Very muchCons: And did you talk to your G.P. about that?Mo: YesCons: And how did the idea of coming to see us come about?Mo: It was my GP who suggested it. She asked how Billy was getting on when actually I

went to see her because I got very depressed about it. And still am. She said there’s nothing physically wrong and have you thought of going down this road, you know. Which I must admit, I didn’t really want to do because I felt, well, that means I’ve totally lost it.

Cons: So your GP made you feel that you’d completely lost it and when she suggested coming to see us it sounds as if it made you feel, well, maybe things are worse than I thought - is that right?

Mo: Yeah

Develop an interactive view of the problem

Once the consultant has a better idea of how the family came to be referred to the service (and thus whether they are, in solution focused therapy terminology, pre-contemplative ‘window shoppers’ or ‘browsers’ or have definite designs on therapy, and are therefore active ‘customers’26), it is then important to listen to and understand the family’s view of the problem. By listening and reflecting, the family has, perhaps for the first time, the opportunity to ‘hear’ their ‘story’ told by the consultant. It can be useful to read out the referral letter as this helps to focus ‘problem description’.

At this stage, families frequently want to give all the details, often rapidly, to the consultant, which can make it difficult to intervene. One way of slowing the process down is to check out with the family your understanding and to repeat back their version of events. It is useful to take an example and follow it through so the consultant begins to develop a ‘behavioural understanding’ of the problem. That is, with the family’s story about their difficulties, together a picture of events develops. Use phrases such as, “So you’ve told me that incident B happened after incident A, so what happened next?” and “Have I got this right…?”. The next example illustrates this.

Example 5

Mo: It’s a constant battle really from the moment he wakes up.Cons: Would it be a good time for you to try and describe something that happened

recently, like this morning ‘cos that would give me a better idea of what it’s really like at home

Mo: Right, yeah this morning Rob just wouldn’t get out of bed and sometimes he does that. He seems to think that school will wait, everybody will wait for him.

Cons: So what did you do when Rob wouldn’t get up this morning?Mo: I just came downstairs and then went up and shouted out ‘Well I’ll just go without

you’ and then he suddenly came down screaming at me.Cons: Oh right, so things build up then from Rob not wanting to get out of bed, and this

doesn’t happen every day, but when it does you get frustrated and angry trying to


get him up and then Rob gets angry with you and ends up telling you off, is that right?

Mo: Yeah

Understand the family’s ideology of the problem

As we have stressed the stages of consultation are not discrete and tightly structured, therefore the family’s ideology of the problem can emerge at any stage point in the process. Thus the consultant must be alert to this and prepared to take note and, if necessary, develop implicit references to parents understanding of causation at any point in the consultation. An illustration of family ideology unfolding when the consultant is engaged in reaching an interactive understanding of the referral process is apparent in the following extract.

Example 6

Cons: So where did the idea of going to see your GP come from?Mo: Well we were seeing Dr A because Daniel had chest problems. We thought he had

asthma, but we’ve been down that road and he hasn’t and he’s also come off Ventolin, which I believe, and I’ve looked further into it, can cause aggression in children you know.

Cons: Right, so have you noticed any changes since Daniel stopped taking it?Mo: Well he only came off it last week and he’s been quite calmer. It’s a bit of a

coincidence because he started on it last summer when his behaviour started to go from bad to worse

Cons: Right, so its only been a few days then since he stopped taking it but you’ve noticed a difference and you think it might be that his behaviour has been affected by the medicine

Mo: It might not be, it might just be coincidenceCons: Right, so if we go back further than six months then to before Daniel was taking

the Ventolin were you having any of the aggressive ‘flare ups’ that led you to see your GP?

Mo: Yes, but they weren’t as bad or as often as they have been recently

In the somewhat idealized, neatly sequential version of consultation depicted for the purposes of this manual, having gained significant detail about the problem and its impact, it is important to understand the meaning the problem has for the family and how they make sense of it. So, we would ask how the family explain their troubles to themselves, explore any theories they have, and what theories they think significant others have. This questioning also gives the consultant an opportunity to identify how well equipped the family are to deal with the problems and perhaps to normalise the situation, e.g. ask how the parent thinks other people in similar situations might deal with it.

Often, there are significant others involved in the child’s ‘problem’ that may not be able to attend the session. If this is the case, it is helpful to ascertain their view of the difficulties by asking, “How might grandmother describe these difficulties?” or enquiring about possible solutions that may have been suggested, such as, “What has Aunty suggested you do when this occurs?” Asking about previous attempts at solving the problems can bring about conversations that highlight the family’s strengths, which may then generate a different way of looking at the problem.

In the process of eliciting the family’s causal attributions and explanatory frameworks it is important to: -

Avoid imposing consultant’s meaning or solutions onto the problem Remain neutral Try and expand families meaning and understanding through summarising, reflecting

and questioning

The interplay of these features is exemplified in the following extended extract.

Example 7

Cons: Right, you’ve (to both parents) told me about a number of things that are troubling you and the ideas that you’ve had about what might be causing these troubles. So


can I just clarify these ideas with you to make sure I’ve understood what you’ve told me so far? The main problem is that for you as parents Charles battles with you over everything and it’s making the job of being parents very hard work.

Mo: Yeah.Cons: At school he’s had problems because he won’t sit and concentrate with the rest of

the kids in his group.Mo: Yeah that’s right.Cons: The other problem is swearing. And, part of your understanding about these

difficulties is that you think he is lazy, in terms of getting his clothes on and the battleground stuff, you know. And the other theory you had ( looks at Father) was you’re not sure how much of it is about how your wife manages Charles.

Mo: Mm.Cons: And by the sound of it you’re both unsure about how much of it is about Charles

and his personality or temperament-is that right?Fa: Yeah.Cons: Do you have any other theories or ideas about what might be causing these

troubles that we’ve not talked about so far? Mo: Well, yeah, ADD- that’s been one thing I mean.Cons: Was that your idea or somebody else’s?Mo: Well, I first talked about it with my health visitor when he was about three. It was

mentioned then and he got put into nursery earlier than he would have done. And I’d say really that that was his worse period in my opinion. He’s grown out of a lot of his behaviour things.

Cons: So since that nursery stage, have you become less or more convinced that Charles might have something like ADD?

Mo: I’m not sure but I think it might be more about him and how I deal with him. Cons: So is that what you would like me to concentrate on in our meetings or would you

also want me to think about the possibility of ADD?Mo: Ideally I’d want you to do both if that’s possible.

Ascertain the family’s expectations of the consultation and consultant

The last exemplar introduces the crux of consultation - to explore with the family what it is they want rather than assuming the family want advice, therapy, an opinion, or a theory to aid their understanding. In example 7, eliciting the parents’ ideas about causation led directly into an opportunity to ascertain their expectations of the consultant and negotiation of the focus of the consultation. However, if the consultant is attempting to open up the area of family expectation they might begin by asking, “What did you think would happen here today?” or “What had you hoped would happen?” This gives an indication of the family’s view of the potential help they might receive. Some say they “don’t have a clue”, others are clear that they want therapy for their child or advice on how to deal with the problems.

It is often the case that the process of gathering information leaves little room for exploration about what would be most useful to the family. With some families, feeding back a lack of clarity can be useful whereas with others, it could be disastrous. Often families arrive with an expectation that the consultant will ‘give’ them something - advice or an opinion - and will therefore be disappointed if this doesn’t happen. In a more traditional setting, these may be the types of families we ‘lose’ because they do not attend again. The important difference then in consultation is to discuss their expectations and to think with them about the implications of advice giving.

Once the consultant has established what it is the families expects, rather than simply deliver the goods, part of the consultation process is to have a conversation about the impact of what this outcome might bring. For instance, if the family want advice about a particular problem, ask them “What advice do you think is likely to work?” or “How would things improve if I offered that advice?” or “What kind of advice were you expecting?” This again gives clues as to how the family will utilise the information and may encourage the family to generate their own solutions.

Giving advice can sometimes require tentative and sensitive handling, particularly as many parents attending CAMH services already feel to blame for their children’s difficulties. This is perhaps more difficult if the consultant has identified a need for change in a particular area before the family have. When offering advice, the therapist should check out with the family whether they have understood and whether they think


that the advice is a useful way forward. This may highlight similarities and differences in opinions between family members.

Advice can also be given in the form of a letter once the session is over, which may include a brief recapitulation of the assessment. The NHS plan (ref – Leo?) suggests that professional correspondence is copied routinely to families and thus, if the therapist does write a letter, it may serve the purpose of informing the GP or other professionals involved. Most of the letters we have written to families have been to summarise the session and the advice given, particularly when one parent is absent from the session. This helps the parent feed back to the other about what they may need to think about in-between sessions.

Some families want to share their concerns about their child’s problems and simply need reassurance that either they are doing the ‘right’ thing or that it is nothing too serious, so they ask for the consultant’s opinion. The skill of the consultant is to assess whether this should be delivered at that specific moment or whether further exploration of the parents’ views, for instance, would be more productive.

In many cases, families who are unsure about the causes of their difficulties or who want to learn more about various problems may benefit from reading information about them. As a result, we developed a bibliotherapy (a collection of materials) families found most useful (see appendix 5.3 for details).

Sometimes, families try to draw the therapist into ‘therapy’, perhaps prematurely, in a way that makes it difficult to maintain the role of consultant. In situations such as this, it is important to be clear about the limitations of a consultation with the family, the role of the consultant and, depending on the family, to be explicit about the process that is happening in the session. For instance, the consultant might comment on the direction or focus of the conversation and check with the family whether or not this was what they had wanted to discuss and whether they feel it is useful.

Develop a ‘problem based’ needs assessment

Assessing other needs, or conducting a risk assessment, is not necessary in all cases. However, as health professionals, we have a duty to assess risk although it doesn’t sit comfortably within a consultation model. Experienced consultants will have a tacit understanding of when to do this. The proforma encourages the consultant to do this at a pertinent time in the consultation: it may be necessary to do it early in the assessment, or right at the end (as a check, or safety net) to make sure that all significant needs or risky situations have been assessed.

Information should be provided to the family about what to do if there are significant or major problems. This might include contacting the CAMH service or other professionals. Also, it is useful to acknowledge that family members may well hold varying views about what should happen next which could lead to non-attendance at future sessions. Discussion of this possibility may be indicated, especially if the consultant feels that the family is uncertain or ambivalent in the first assessment session.

The consultant should hold in mind the following tasks during the process of the first two sessions:-

Initially, take a non-expert stance with the family. Assess whether the family want or need therapy. Assess whether there is agreement between family members. To think about patterns of discourse used by the family and by the consultant. Be alert to the emergence of issues pertaining to risk.

Third (follow-up) session

This session is arranged with the family, at their discretion, to evaluate the impact of the consultation. For the purposes of the research, we saw families approximately two months after the second session in order to give them time to think about the sessions and to assimilate the conversation we had in consultation into their own lives.

Essentially, the third session would be focused around the following areas: - Ask how things are Check out how things have changed (if at all) since first session Focus on the original presenting problem Evaluate any information or advice given


Ultimately, the family is responsible for producing change and requesting further action with the help of the consultant. At this point in our research project, families were referred on to other agencies, placed on the waiting list or discharged.

Some families may want to leave it some time before they decided whether or not they require any further follow-up or intervention. The consultant would usually let the family know that within a fixed period of time (say, six months) s/he would write to the family asking them whether or not they wish to return. It may be that in the intervening time, the family develops a different way of looking at the problem and thus need a follow-up session to think about where to go next. Equally, this different perspective may be enough for them to carry on in the meantime, although it is made clear to the family that should the need arise they may contact the service via their GP in the future.

5. REFERENCES Riemers, S. and Treacher, A. (1995) Introducing User-friendly Family Therapy. London: Routledge.

2 Stallard, P. and Sayers, J. (1998) An Opt-in Appointment System and Brief Therapy: Perspectives on a Waiting List Initiative. Clinical Child Psychology and Psychiatry, Vol. 3, No. 2, 199-212; Jones, E., Lucey, C. and Wadland, L. (2000) Triage: a waiting list initiative in a child mental health service. Psychiatric Bulletin, Vol. 24, 57-59.

3 Wheeler, J. (2000) A Helping Hand: Solution-Focused Brief Therapy and Child and Adolescent Mental Health. Clinical Child Psychology and Psychiatry, Vol. 6, No. 2, 293-306; Barkham, M. and Shapiro, D.A. (1989) Exploratory therapy in two-plus one sessions. Rationale for a brief therapy model. British Journal of Psychotherapy, Vol. 6, 79-86.

4 Mason, R.A., Watts, E.L. and Hewison, J. (1995) Parental Expectations of a Child and Adolescent Psychiatric Out-Patient Service. ACPP Review & Newsletter, Vol. 17, No. 6, 313-322.; Riemers, S. and Treacher, A. (1995) Introducing User-friendly Family Therapy. London: Routledge.

5 Jones, S., Moss, D. and Holtom, R. (1997) A consultation service to adults referred as having mental health problems. Clinical Psychology Forum, Vol. 105, 21-26.

6 Street, E. and Downey, J. (1996) Brief Therapeutic Consultations: An Approach to Systemic Counselling. Chichester: Wiley.

7 Howe, D. (1989) The Consumers’ View of Family Therapy. London: Gower; Lishman,J. (1978) ‘A clash in perspective? A study of worker and client perceptions of social work’, British Journal of Social Work, Vol. 8, 301-311; Merrington, D. and Corden, J. (1981) Families’ impressions of family therapy. Journal of Family Therapy, Vol. 3, 243-261.

8 Howe, D. (1989): ibid.

9 Hoare, P., Norton, B., Chisholm, D. and Parry-Jones, W. (1996) An audit of 7,000 successive child and adolescent psychiatry referrals in Scotland. Clinical Child Psychology and Psychiatry, Vol. 1, No. 2, 229-249.

10 Stallard, P. and Sayers, J. (1998) An Opt-in Appointment System and Brief Therapy: Perspectives on a Waiting List Initiative. Clinical Child Psychology and Psychiatry, Vol. 3, No. 2, 199-212

11 Riemers, S. and Treacher, A. (1995) Introducing User-friendly Family Therapy. London: Routledge.

12 Furlong and Young,1996; Wolpert, M. (2000) Is anyone to blame? Whom families and their therapists blame for the presenting problem. Clinical Child Psychology and Psychiatry, Vol. 5, No. 1, 115-131.

13 Talmon, M. (1990) Single session therapy. San Fransisco: Jossey-Bass; Wheeler, J. (2000) A Helping Hand: Solution-Focused Brief Therapy and Child and Adolescent Mental Health. Clinical Child Psychology and Psychiatry, Vol. 6, No. 2, 293-306.


14 Barkham, M. and Shapiro, D.A. (1989) Exploratory therapy in two-plus one sessions. Rationale for a brief therapy model. British Journal of Psychotherapy, Vol. 6, 79-86.

15 Roth, A. and Fonagy, P. (1996) What Works For Whom? A critical review of psychotherapy research. London: Guilford.

16 Saunders, C. (1998) Solution Focused Therapy: what works? Counselling, February, 45-48.

17 Shawver, L. (2001) If Wittgenstein and Lyotard could talk with Jack and Jill: towards postmodern family therapy. Journal of Family Therapy, Vol. 23, 232-252.

18

19 Rutter, M., Taylor, E. and Hersov, L. (3 rd edition) (1994) Child and Adolescent Psychiatry. Modern Approaches. Oxford: Blackwell Science.


21 Kroll, L. and Green, J. (1997) The therapeutic alliance in child inpatient treatment: Development and initial validation of a Family Engagement Questionnaire. Clinical Child Psychology and Psychiatry, Vol. 2, No. 3, 431-447.

22 Bateman, A.W. and Fonagy, P. (2000) Effectiveness of psychotherapeutic treatment of personality disorder. British Journal of Psychiatry, Vol. 177, 138-143.


24 Kroll, L., Woodham, A., Rothwell, J., Bailey, S., Tobias, C., Harrington, R. and Marshall, M. (1999) The Reliability of the Salford Needs Assessment Schedule for Adolescents. Psychological Medicine, Vol. 29, 891-902.

25 Goodman, R. (1997) The Strengths and Difficulties Questionnaire: a research note. Journal of Child Psychology and Psychiatry, Vol. 38, 484-486.

26 De Shazer, S. (1985) Keys to Solution in Brief Therapy. New York: Norton.


6. APPENDICES

A) Proforma NAME:

DATE: C1

PRESENT: C1

CONSULTANT:

INTERACTIVE UNDERSTANDING OF THE REFERRAL PROCESS

How did the referral come about? Who proposed it? Did you agree? What convinced you that you need outside help?What did the person who referred you say was the reason for referring you?Any discrepancies between referrer and family perspectives? Can you help me understand how the person who referred you thought it would be a good idea while you believe otherwise?Absent yet significant others

Are other agencies/professionals involved?

How do professionals ‘fit’ in ie; systemic view of the referral process?What are their expectations/attitudes to referral?


PROBLEM DESCRIPTION

The primary problem* in behavioural interactive terms* If more than one problem or problem unclear

What bothers them most? What would they most want to change?What should we focus on in the consultation?

List any secondary problems


FAMILY ACCOUNT OF THE PROBLEM

Family explanations/theories? Are there different, competing accounts from family members? Beliefs about influence of past, present and future? How do you think significant others explain the situation?


GENOGRAM


ATTEMPTED SOLUTIONS - SUCCESSES AND FAILURES AND “NOT YET TRIED”

What have you tried to do to solve this problem?What are you doing to cope with it? Or preventing it getting worse?What have others suggested that you try?Has there been anything that you thought about trying, maybe something “off the wall” but you’ve held back because you didn’t think it would work?

PREVIOUS EXPERIENCE OF PROFESSIONAL HELP

What was most helpful/unhelpful? And why?


FAMILY’S EXPECTATION OF CONSULTANT AND CONSULTATION

What kind of questions did you think I would ask?

If there was one question that you really wanted to ask me about your problem situation, what would that question be?

Worst and best thing I can say or do?

What are you hoping for/expecting from me/this service?

Advice/opinion

To take action or do something

Counselling/therapy - for child, parent or family

Other


CONSULTANT INTERVENTION - C1

Gave advice/opinion (Describe)

Supplied self help literature (What?)

Liaison with professional network (Who? Why?)

Placed on waiting list (For? Priority?)


Other (Describe)

APPOINTMENT FOR C2?


C2 INTERVIEW Follow Up Sessions

Focus on the ‘agreed’ primary problem and the response. Seek out client’s ‘meaning of feedback/response. Focus on changed actions and ideas. “Normalize” within developmental family life - cycle terms Review usefulness of any advice/self help literature Be prepared to change/admit error in understanding client versions. Respect client decisions “not to act” on consultation. Avoid repetition of consultation process. Be prepared to offer one further consultation on “new” problems but they will have to wait.

Anymore runs the risk of drift into therapy.

DATE:

PRESENT:

SUMMARY OF C1

What happened in last session?How did you leave the family feeling?Further thoughts …

Has primary problem changed?


PROGRESS/CHANGE SINCE C1

If so, what?Key areas.

Focus of C2

Continuation of C2 Session


CONSULTANT INTERVENTION C2

Gave advice/opinion (Describe)

Supplied self help literature (What?)

Liaison with professional network (Who? Why?)

Placed on waiting list (For? Priority?)

Other (Describe)

APPOINTMENT FOR FOLLOW UP SESSION?


B) OPT IN INFORMATION SHEET ABOUT YOUR CHILD’S DIFFICULTIES

YOUR NAME: *Single/Married/Widowed/Separated

ADDRESS:

POST CODE: TELEPHONE NUMBER:

RELATIONSHIP TO CHILD: OCCUPATION:

PARTNER’S OCCUPATION:

CHILD’S NAME: DATE OF BIRTH:

SCHOOL/NURSERY:

GP NAME & ADDRESS:

WHERE CAN YOU BE CONTACTED DURING THE DAY?:

1 Please give name and ages of everyone who lives at home:

2 What, in order of importance to you, are the main problems?

3 How long have these problems existed?

Less than a month Less than 6 months Less than 12 months

More than 12 months, please specify:

4 Are there any problems at school/nursery?: Yes No

5 May we contact your child’s school/nursery?: Yes No Not yet

please turn over


6 Have you received any help with this problem? Yes No

If so, who from? please tick and give name

Hospital Doctor May we contact?

Psychologist May we contact?

Probation Officer May we contact?

Social Worker May we contact?

Health Visitor May we contact?

Anyone from School May we contact?

Education Welfare Officer May we contact?

7 Does your child or family have any special needs? For example, cultural, ethnic, language or

disability needs, which we should be aware of to help us prepare for your first visit to the service?

8 Please use the following space for any other information which you think might be relevant such

as your views on the problem, and more detail on the help you want.

Expectations questionnaireFor each of the questions below, please tick the box that best describes your answer to the question.


1) How did you come to be referred to the Child and Family Service?

The person who referred me told me to come

here. I wasn’t asked if I agreed.

The person who referred me suggested it. I

agreed to it but I didn’t really think its a good

idea

The person who referred me suggested it. I

agreed to give it a try to see if it would help.

It was my idea. I wanted my child to see

a specialist.

[] [] [] []

2) What effect do you think being seen by the Child and Family Service will have?

I think this will solve our child’s problems

completely

I think this will help us to deal with many of our

child’s problems

I think this is unlikely to be of much help with our

child’s main problems

I think this will be a complete waste of our

time, no help at all.

[] [] [] []

3) Do you think professional help can help your child deal with the problems he/she has?

I think my child needs things explained

properly and then he/she will be

completely alright.

I think that most of my child's problems can be dealt with, but they will take time to overcome.

I think that maybe his/her problems could be helped a bit, but not

cured properly.

I don't think anyone can help my child with

his/her problems at all. I don't think they can be

cured.

[] [] [] []

4) How important do you think you will be in the help given to your child?

I think I am the most important person. The

professionals are mainly there to help me to work

this out for my family.

All our family will be important in working

with the professionals. I am committed to doing my part to really help.

I expect to be mainly told what to do by the

professionals. I will only be involved some of the

time.

The professionals here will do all the therapy. I won't get involved in it

much.

[] [] [] []

What type of help do you think would most help the problem?

Yes No Don’t know

1. Family work

2. Marital work

3. Individual work for your child (counselling, discussion)

4. Medication (please describe)

5. Social support, help

6. Educational support, help


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