Illuminations on the way to be accessible and non-stigmatising for families began for me 12 years ago - during my doctoral thesis. I chose to study the stories of asylum-seeking families. They are notoriously an elusive group for services to engage due to completely understandable and obvious reasons; fear of statutory authorities, high level of trauma, stigma and often a very different cultural explanation for mental health symptoms.
I spent 6 months (6 months!) trying in vain to recruit participants via schools and organisations. Despite a lot of effort, travel and payments to interpreters I was failing entirely to find even ONE family. Then, having exhausted my resources and everyone else's resources so that I had no childcare options left, I came across a friend of the family who ran a drop-in group for asylum-seeking and refugee families. She invited me to come in and help. I had to take my son (aged 8 months) with me. With baby on hip I made a few cups of tea for families. We chatted about them and their appreciation of the drop-in family centre. Then...bingo! I had 8 families to participate in my study!
The lessons learned: be where people enjoy and value going, be human, approachable, make sure people know you are not judging or critical. I have had numerous situations of engaging families in community work since then and I don't think this 'discovery' has become any more sophisticated - common sense after all.
There is some great practice in engagement that I have encountered on the Fellowship which I hope will enrich BrightPIP in reaching Brighton families. All in all, I have visited and talked to people about nearly 20 programmes. They all approached things in unique ways using different combinations of clinical interventions but all with the mission to reach the babies that most need preventative infant mental health. Here are some of the best ideas:
Universal screening proposed in the Early Intervention city wide project within 'Thrive New York City' helped me learn about the power of their strategic work group (Evelyn Blanck). This will ensure the policy is that all professionals will be involved in making sure no family goes unseen or unheard. This includes ACE and ASD screens (see Blog 20/11/16).
Early is best and the research based program of PREPP: Practical Resources for Effective Postpartum Parenting http://pregnancy.bmedcumc.org/ (Dr Catherine Monk) gathers pregnant women in a non-stigmatising way using a screen for likelihood of PND. The support offered is focused on bonding and caring for baby so that crying is reduced and ability to regulate and settle at night is increased (a tempting offer for all parents-to-be!) and it is called ‘coaching’ rather than therapy.
Avoiding stigma of therapy is a big challenge. This can permeate those of all social groups and backgrounds. The power of sharing and talking to others during normal family social events may be just as therapeutic. This was used by a post 9/11 project specifically for families with babies (Candi Cuchero, NYS-AIMH) as families were rejecting of the stigma of therapy. It was fascinating to learn from Bonnie Cohen (Early Childhood Division, University Settlement) about a similar approach which she coined 'stealth mental health'. In their Early Intervention model, there is a whole range of possible services that a family can access (e.g. baby groups, play sessions, parent groups, parenting skills). Child Parent Psychotherapy work is only offered as an additional if needed and then when the family are engaged in other support.
In stealth mental health there is what the Americans term a 'warm hand-off', an expression I have heard a lot in New York. This means that the family are introduced to the therapist by an already trusted worker. Meeting Tonia Spence at the Jewish Board, Harlem Child Development Centre, we discussed the success of instigating a service that is essentially 'familiar' in every way to the families. This would mean training the key referrers already working with the families to do this warm hand-off as well as considering the importance of ensuring workers are from the same ethnic and social group as the families we are trying to reach.
Community presence can mean stepping outside what we expect to deliver and starting by designing the service requested by the parents. This means building trust with a community (and might include less clinical work to begin with). An agency needs to simply provide the very information that families need at any given time e.g. showing them a nearby food pantry or providing information if they become homeless. From the 'Power of Two' programme (Erasma Monticciolo) I have learned that a person who makes those contacts locally and gets to know key leaders in the community can then build the trust and respect of that community from grass roots up (always the best way!). The ideas from this programme link to the discussion with Tonia as they use specially selected and trained Home Visitors to deliver intervention, often with more of a history in common with the families.
When building trust with fearful or ambivalent families who are in the system and are having to participate due to mandatory court ordered treatment, it is essentially a make or break time to engage. I spoke with Dr Susan Chinitz 'Strong Start Court Initiative' ( http://www.courtinnovation.org/project/strong-starts-court-initiative) and Hazel Gacman about the 'Babies First' programme. This works alongside the court process but making it very clear that the therapeutic work is with the family rather than against them. This, like the 'Babies Can't Wait' programme (Dr Marcy Safyer) helped me understand further about combining early work with parents and babies and Child Protection Plans while not alienating the families due to the helping stance that we take. It is such a fine line for clinicians to tread - but such programmes show that it can be done.
The right location is essential and from the GABI programme: Group Attachment Based Intervention http://www.attachmentresearch.com/gabi (Dr Anne Murphy) I learned that a key way to hold families when they most need it is to provide groups regularly (they provide 6 per week!) in their community. The groups are nurturing and containing and use key reflective clinical skills. Also, hospital based programmes, such as the teen-parents group at Bellevue (Susan Linker), the Family PEACE Trauma Treatment Centre at New York Presbyterian (Dr Erica Wilheim) and national Healthy Steps (http://healthysteps.org/) where clinicians link with paediatric services confirm that the best way to meet these families is to be where they are at. In the US this happens to be their regular checking appointment with their paediatrician (they don't have Midwife led-care or universal Health Visiting here so the hospital is where it's at). These, like all good programmes, demonstrate very good relationship building with other professionals in the hospital.
Personally, it is reassuring to see the same dilemmas and to see ways of approaching and successfully overcoming barriers - even in another system and culture. The value of seeing first-hand the success of innovative thinking and diverse projects gives confidence in the work in the UK and is energising and inspiring. But what stands out? What can we take back to the UK for those families? I think all of this and more.
There is, as with all such dilemmas, a tidy way to think about engagement. I am at the excellent Zero to Three national conference (http://annualconference.zerotothree.org/right now and this morning in a talk about leadership in this field, Paul Schmitz outlined collective impact and 'doing with the community (not to or for)'. This approach requires integrity, humility and commitment to the cause of infant mental health. In the same way, engagement with a community of families needs us to be alongside respectfully. This takes some attunement, just as when trying to form a secure attachment. My understanding is that often this comes back to ourselves. We can be good (enough) attuned parents if we can attune to ourselves, think clearly and attune to our children. We can be good engaging practitioners if we hold the same genuine qualities. This goes back to my first steep learning 12 years ago. If we can be real, then families will know this and work with us.
Did you find the ideas here surprising? Obvious? Different? Please go to the comments button below and let me know!