The place of single session family consultations: five years' experience

A.N.Z./. Fam. Ther., 1999, Vol. 20, No. 4,

The Place of Single Session Family Consultations: Five Years' Experience in Canberra

pp 195-200

I I I~ I I /~I I~ I I~I I I I~/I I I~/I 87043391

Ralph Hampson, Josephine O'Hanlon, Annie Franklin, Margaret Pentony, Lev Fridgant and Terry Heins* The National Library supplies copies 01 this article under licence from the Copyright

Agency Limited (CAL). Further reproductions of this article can only be made under licence.

Open Day, in the form oftwo halfday single session family clinics, has optraud weekly in the ACT Child and Adolescent Mental Health Service since April 1993 and O'fJtT a thousand families ha'Vt! bun sun. Clinicians art often resistant to tM concept ofsingk sessions andfrequently oWTtstimate chi! amount ofassistance that clients feel they require. HownJt!T in an era of sharply increasing chmand fOT stmces. selectiw uu of single family ussions for miL:kr problnns. screened by a telephone intake process. has value to both familu:s and. workers. Telephone /ollow.ups of100 families in 1994 and 70 families in 1996 found that single session family interwews were well accepted by the large majority 0/families seen. Clinicians see the program as reducing pressure from clients for early attention, mhancing client motivation whm sun at crisis timts, providing readily available consultation supportfrom peers, increasing learning opportunities and building inter-disciplinary leam work.

fied many therapist resistances to brief therapy such as: the beliefs that effective therapy requires 'deep' character changes, that 'more is better', and that therapeutic relationships are fragile and need cautious development; the fact that therapists experience strong countertransference to termination (they need to be needed); and the conviction that btief therapy is hard work and requires special brilliance. We should be reassured that few global therapist behaviours in the first session affected treatment duration in Oddi and Quinn's (1998) study of 38 cases observationally coded. Perhaps we need to remember that even Freud (1955) reported a successful one session treatment, that of 'Katharina'. Talmon (1990) found therapists could not conceive of therapeutic benefit being rapidly achieved, and generally set goals for change greater than the goals set by the clients. However, clients often do not see any need for lengthy treatment. Follow up of 200 non-intended single sessions in adults showed 78 per cent were satisfied with their contact (Talmon, 1990). Rcsenbaum, Hoyt and Talmon (1990) reported that 50 per cent of patients attended for just one session at an adult outpatient service, and found satisfaction and acceptance of pre-arranged single session therapy in 50 adult individual patients. Brief therapies have often been advocated for children (Duncan, 1984; Quick, 1996). Evidence for the effectiveness of brief (up to five) family sessions is accumulating (Diamond, Serrano, Dickey and Sonis, 1996; Lee 1997; Sandberg, Johnson, Dermer, Gfeller-Strouts, Seibold, StringerSeibold, Hutchings, Andrews and Miller, 1997, Smymios and Kirkby, 1989).

INTRODUCTION The systematic use of single session family consultations to provide early access to help was pioneered in Australia by Dalmar Child and Family Care in Sydney in 1991. The results of their survey of 90 families seen in this manner were reported in this Journal (price, 1994). Boyhan (1996) reviewed the use of single session family consultations, including a summary of our unpublished evaluation study (Hampson, O'Hanlon, Pentony and Cramby, 1994). In this issue, Campbell (1999) reports a pre-post study of 38 families seen for single sessions in Launceston. After consultation with Dalmar staff, the ACT Child and Adolescent Mental Health Service began a similar service on one day each week from April 1993. This report describes the development and evolution of single session family consultations over five years and summarises two surveys of parents' and clinicians' views of their experiences. These were aimed at checking the acceptability of the approach and at clarifying how useful it was for particular types of problems, children and families. We, like most clinicians, were initially strongly resistant to the idea of seeing a family just once. Subsequently, we have been accused of 'selling out' to administrators and politicians, who want to pretend that under-resourced services can be stretched even further. Hoyt (1987) identi-

* ACT Child and Adolescent Mental Health Service, Phillip Health Centre, Corinn. Street, Phillip ACf 2606. Correspondence to Terry Heins at this address.

195

Hampson, O'Hanlon, Franklin, Pentony, Fridgant and Helm

The systematic use of intended single session family consultations for problems of children and adolescents have been described only in the last few years and no solid evaluation studies have been published. We teport our experience of more than a thousand families seen in

this manner and our efforts at assessing the acceptability and most s\.litable applications.

1993: HOW IT BEGAN The ACT Child and Adolescent Mental Health Service is a small (ten full-time equivalents) community based team of psychiatrists, clinical psychologists and social workers, seeing families where the child has moderate to severe emotional or behavioural problems. This team serves the 98,000 persons under eighteen in the ACT and provides some services to adjacent areas of NSW Outpatient services were provided to around 700 children, adolescents

and their families in each year from 1992 to 1998. Client demand had increased dramatically from June 1992 as the organisation moved from being a secondary referral service to accepting direct referrals from parents. Urgent referrals were seen within two weeks of being prioritised at a weekly allocation meeting. Those deemed non-urgent were sent a waiting list letter and would be offered an appointment up to five months later, by which time many had dropped out. Referrers were frustrated, often exaggerating the severity of clients' problems to try ro jump the queue. Staff, who mainly worked individually, were feeling overwhelmed. The service had a reputation for being a very demanding place to work and recruitment was often difficult. In late 1992 four staff decided to explore ways of introducing single session consultations and arranged consultations with the Dalmar Child and Family Service in Sydney, which had successfully introduced such a scheme. The service commenced on Tuesday afternoons on 6 April 1993. As confidence grew in the approach, an Open Week entirely devoted to single sessions was scheduled on 7 June to deal with the extensive waiting list. Subsequently, Open Day has operated on a full Tuesday each week until June 1996,when the times changed to Tuesday morning and Wednesday afternoon and evening.

WHAT HAPPENS An experienced clinician undertakes intake telephone

work from 10.00 a.m. to 1.00 p.m. each day. Receptionists routinely advise referring sources and self-referred clients to contact the Intake worker at these times. The Intake worker gathers information about the family structure and concerns, and discusses the best option with parents -whether they prefer single session consultation within two weeks, fuller assessment (usually about two months later), or accessing other services. Experience has shown that 30 to 400/0 choose the early contact single session consultation option.

Four families attend each of the four to five 'Open Day' sessions held each week. One clinician acts as co-ordinator

and assigns clinicians to families. All clinical staff partiei-

pate at least fortnightly and each discipline is represented at most sessions. For each session, two clinicians are available to act as consultants. The clinicians do not normally

know beforehand whom they will be seeing. Families are asked to come fifteen minutes before the session, in order to complete a family questionnaire about family structure) ages, schools and/or work, and current concerns. The clinician usually sees the whole family, then) as seems ap-

propriate, the identified child and the parents separately. After 30-40 minutes the clinician leaves to consult with the team. The clinician presents his/her comments and feedback to the family. The family are given tasks and appropriate resource sheets, invited to recontact the intake service to inform them of progress) and invited

to book into another Open Day in the future if problems recur. Often the clinician will send a brief letter after the meeting. About fifteen per cent of the time, the ptoblem turns out to be inappropriate for a one-off service, and a decision is made to allocate the family to a team member

for longer tertn work. The range of interventions used by clinicians include: • • • • • •

Information, education on child development Direct advice Normalisation and reassurance Behavioural interventions Advocacy for access to other services Family contracting

• Reframing, relabelling • Decision to offer more extended service

CASE VIGNETTE Jenny, 26, who was not working, and John, 29) part-time courier driveTj hadfturchildren, Bradlry 8, Jaron, 6, Aaron, 3 and Samantha, 2 y,ars. Jenny t,l,phon,d at th, suggestion of th, school counsellor. School and parents were concerned about Joson! non-compliance, tantrums and aggression towards his older brotherandpeers. J,ftlty and th, four children attend,d th, Open Day singl, session consultation. They were seen by asenior socialworktr. Jenny explained that when Jason refused her request, h, would argue and d,clare: 'I hat,you t,lIing m, what to do: Th, other children were 'no trouble' and allplayed cooperatively atth, intervi,w. Th, parentJ hadfinancial difficultiu and had moved house seven times during their marriage. John had given most weeken,," in ment months to h,lping build a housefor his moth,r. Jenny had b,en sad and t,arful in th, last two weeks. Jennyfelt quite close to Jason, seeing his stubborn nature as very much like her own. Her att,mptJ to manag' Jason includ,d arguing with' him for an hour about two minutes' work.. Time-out in his bedroom I,d 10 Jason becoming mor, angry. Only when sh, did th, chore alongsid, him did h, ,verassist. IfJohn had a talk with him h, would becom, more upset and say h, was 'bad bof Th, therapist spent ten minutes discussing th,family with two consultants. They suggested planning for positive activities, rewarding compliance by charting compl,tion offour short tasks ,a,h day for Jason and Bradley. R'questing compliance was to b, don, by kneeling down and making eye contact, counting to five, repeating the request, further counting to five, then time outfor two minutes maximum. Th, consultantJ suggested referralfor ongoing couns,lIing. Th, therapist return,d to th, family to convey these suggestions. Jenny was happy 196

A.N.ZJ. Fam. Ther., 7999, Vol. 20, No. 4

to have further counselling. Although she ftltthe tasks were an additional hurtkn, she was prepared to try them. Jenny and Jason Wert seen by a dijfirent social worker nine weeks later. They had implemented with suhstantial success most of the strategies suggested at the Open Day consultation. School reported improvement and Jason thought he wasfixing his ~illintss' thm. The worker discussed with Jenny ways of working with the school to help Jason, and she congratulated them on their good progms. At the planned Itlephonefollow-up seven weeks laltr, continuedimprovement was reporltd.

1994 EVALUATION: WAS IT ACCEPTABLE? A comprehensive evaluation of our single session family consultations would have been a very large undertaking, far beyond our resources. However, contemplating the most optimal evaluation methodology has helped us place in context what we have learned and its limitations. Current psychotherapy evaluation research is debating whether tfficacy or ifftctiveness is the most appropriate paradigm (Seligman, 1995). Efficacy studies aim to assess, most optimally by a randomised controlled trial (Mintz, Drake and Crits-Cristoph, 1996) whether a specified manoeuvre has the predicted impact. The viewpoint in efficacy studies is primarily that of the investigator. They tend to have a degree of 'artificiality' and require large resources.

Effictiveness studies aim to study what works in the field by carefully assessing typical practitioners in typical settings, using variable amounts of treatment, most often by quasi-experimental methods such as waiting list control. The viewpoints of clients, therapists and funding providers are all important in effectiveness studies (Mintz et al., 1996). To extend the picture we need also to consider the efficiency of delivering services, where the most important viewpoint is that of the administrators who seek 'productivity'. Each of these three viewpoints is a current paradigm for evaluating services, and we do well to distinguish them. Our follow up studies were informed by each paradigm. We were assessing the safety and client acceptability of single session consultations, which is a necessary prerequisite step for any definitive efficacy or iffectiveneu studies. Within these limited aims we. did not require a randomised controlled or waiting list control design. Apart from being premature, a waiting list control design would not have been acceptable in the face of strong pressure from administrators and politicians to reduce waiting times. A randomised controlled trial would have been a very large undertaking. A stream of children assessed on standard instruments by intake workers and parents as having mild problems would have had to be randomly assigned to single sessions and multiple sessions. Independent ratings by significant others, perhaps teachers, would have been needed. Higher satisfaction ratings would probably be associated with the multiple session group. Our evaluations have only aimed at assessing safety and acceptability. Assessing efficiency was also a conscious aim. Could milder problems be assisted with less clinician time and more clinician satisfaction?

Pre-trcatment change has to be considered in evaluating these single session consultations. In each family a parent had spoken by telephone with an intake clinician and many had discussed the ptoblem with a school counsellor or family doctor who recommended the service. Johnson, Nelson and Allgood (1998) found such pre-treatment changes remain persistent in many clients' lives and the therapist who paid explicit attention to such changes influenced clients in the direction of earlier unplanned termination. In order to assess the acceptability to families of single session consultations, Ralph Hampson and Josephine O'Hanlon drew on relevant literature and clinical experience to devise a telephone survey. This was piloted with ten families who had participated in Open Day and then, after slight modifications, used with a further 90 families. The aim was to conduct the interviews three months after the consultations. Sixty onc of the families were interviewed at three months, ten families at between three and five months, twenty between one and two months, and nine families at three weeks. A parent or guardian who had attended the consultation was interviewed by a clinician not involved in the single session consultation (RH, JO'H, MP) or by Annalisa Cramby, research assistant. The interviews took fifteen minutes and covered demographic information, referral source. identified concerns, progress with concerns, and qualitative feedback. The results are set out in Table 1. We concluded that the majoriry of the families attending the single session consultation found the experience helpful and useful. Open ended comments showed that parents particularly valued direct advice, support and reassurance from the worker although several would have preferred more meetings. These results are quite comparable to the follow-ups reported at Dalmar (price, 1994), Bouverie (Boyhan, 1996) and Launceston (Campbell, 1999). They are not very different from studies of brief therapy such as Weakland, Fisch, Watzlawick and Bodin, (1974) who followed 97 families seen for brief therapy, averaging seven sessions, three months after termination and found 40% successful, 32% significantly improved and 28% failures.

1996 EVALUATION: WHICH PROBLEMS IN WHICH FAMILIES? In order to understand better what types of child problems might best be suited to single session consultations, a trainee child and adolescent psychiatrist (LF) conducted a further survey of 70 consecutive families seen in this manner. The types of child and adolescent problems where family based therapies in general have been shown to be effective are: schizophrenia, conduct disorder, substance abuse and possibly eating disorders (Diamond et al., 1996). The major problems which parents identified in this small sample were: behavioural 69%, anxiety and/or depression 19% and post-traumatic issues 10%. Parents also completed Child Bchaviour Checklists (Achenbach, 1991) to give a fuller view of their concerns. Ratings of change on three summed target complaints supplemented measures of 197

Hampson, O'Hanlon, Franklin, Pentony, Fridgant and Heins

Table 1. Summary of Results of 63 Completed Telephone Interviews Assessing Single Session Family Consultations Gender of child of concern

Male 58%, Female 42%

Referral source

Medical 30%; Schools, Welfare Agencies, 37%; Family and Friends 24%; Self 9%

Presenting Problems (not exclusive)

Behavioural and/or emotional 55%; Anxiety or stress 45%; Parenting difficulties 9%

Was it easy to find service?

Yes 70%; No 30%

Were they made to feel welcome?

Yes 96%; No 4%

Did they mind filling out information?

No 90%; Yes 10%

Was worker's initial explanation clear?

Yes 90%; No 10%

Overall did they find service helpful?

Helpful 80%; Unhelpful 16%; Both 4%

Did the worker listen and understand?

Yes 87%; No 12%; Unclear 1%

Were they satisfied with way service ended?

Yes 84%; No 15%; Unclear 1%

Any change in problems since?

Improved 71%; Same 9%; Worse 10%

Was the change connected with consultation?

Yes 62%; No 30%; Unsure 8%

. Have they considered or sought further counselling?

Yes 53%; No 47%

Would they use Open Day again?

Yes 94%; No 6%

Would they recommend Open Day to others?

Yes 94%; No 6%

Open-ended question about helpful and unhelpful aspects (Most frequent comments) Comments on worker (helpful)

Gave feeling of support (24), gave insight into problem (12), listened (10), validated problem (6)

Comments on worker (unhelpful)

Drew superficial conclusions (9), did not take seriously (4), seemed to blame the parent (4), did not give not enough input (3)

Comments on process (helpful)

Helpful advice given (43), input from child was encouraged (10), sifted out serious problems (9)

Comments on process (unhelpful)

No definite follow-up (10), not enough practical suggestions (8), not enough advice (6), would have liked one to one session with worker (5), session too short (5), session felt uncomfortable (5)

Comments on outcome (helpful)

Reassuring (34), raised child's awareness (9)

Comments on outcome (unhelpful)

Did not have effect (11), left child averse to counselling (2), suggestions already tried (2)

Consultation Dissatisfaction-Satisfaction Scah ofsixpolnufrom 0 to 5 Group mean 4.32 with standard deviation 1.27 and range 0 to 5. QveraU Dissatisfaction-Satisfaction Scah ofehvenpolnufrom 0 to 10 Group mean 8.82 with standard deviation 1.75 and range 2 to 10

/98

A.N.Z.j. Fam. Ther., 1999, Vol. 20, No. 4

Chamberlain and Gilbert Rosicky (1995) found in their review of 1988 to 1994 studies of family therapy for adolescent problems. This narrower focus for the single session clinic was possible because the appointment of rwo additional staff created more options.

parents' overall perception of change and satisfaction

similar to those in the previous study. A telephone interview was conducted at three months by research assistant

Emma Prime, and a full data set was obtained for 47 families. Satisfaction ratings were again high, with 88% fInding the session helpful, 98% feeling understood, and 96% being satisfIed with the service. Change in perceived severity

ACCEPTANCE BY STAFF There were some early doubts among all staff. However after a few weeks of participation, all staff were impressed with the benefIts and all see a program of single session

summed over three target complaints proved an acceptr

able and useful outcome measure. Interviews indicated that the perceived quality of the interaction berween parent and therapist determined overall satisfaction with the

consultations continuing in the future. This enthusiasm is despite the heavy demands of single session clinics on both clinicians and receptionists. The clinician has to

session and predicted positive outcome.

However the sample size proved too small to detect any signifIcant differences in outcome at three months for

tackle up to three families on the full day clinic. Each

gender or age of child, for socio-economic status, or for

requires a. new file, file index card, data sheet, notes and

the type of the major problem as listed above. On the Child Behaviour Checklist the only association was on the total scores, where predictably, less severe problems were associated with better outcomes at three months.

generally, a summary letter to the family. Often this has meant a shortened lunch break and a later fInish to the day. For a recptionist, being in close proximity to four families at a time, all with 'difficult' children, is very ex-

This evaluation strengthened our belief that single

hausting, but receptionists value these clinics because

session consultations are most appropriate for milder

they reduce pressure from parents demanding early

problems. This is further supported by the Launceston fInding (Campbell, 1999) that families who scored higher

attention. Intake workers value the single session consultations be-

on 'Family Pride', a measure of family morale, showed

cause they can give an acceptable early option to troubled people phoning in. They report a greater ease in prioritisiog families. Crisis intervention was a major model of clinical practice in the 1960s (Caplan, 1964). Its main justification was that clients had hjgh~r motivation when seen at crisis times. This certainly remains valid from our experi-

larger reductions in problem scores, suggesting that better functioning families are likely to benefit more from single sessions. We found that single sessions are

not particularly suited to anyone type of presenting problem. Parents' preference remains the main reason for choosing single session consultations.

ence of single session clinics. Change seems more likely

because of the level of energy created, by the obvious presence of other families in the small waiting area, by the use of consultants, and by the clear expectation that

1998: FROM 'OPEN DAY' TO 'SINGLE SESSION CLINIC'

change can begin in one session.

The reat!Y availability of cons"Itation support is valued. For clinicians, being able to share the burden of people with

On 18 July 1997, CAMHS staff set aside a day to review four years of Open Days. From January to June 1997, 60% of Open Day referrals were for behavioural problems, 300/0 were for suspected attention deficit disorder and 10% for other problems. In this period, 50% of referrals were assessed as needing no further action, 15% did not attend, 10% were put on the waiting list for ongoing case management and 25% went on for a comprehensive ADHD screening. Staff felt that this demand shift required a changed model, which was implemented from 8 July 1998. Instead of a consultation team model, two therapists are now assigned for co-counselling. The name of the service was changed from Open Day to Single Session Family Clinic. All families now receive a summary letter or copy of a new summary form. The target group is restricted to parents and their children under twelve who present with problems consistent with conduct disorders (including suspected attention defIcit hyperactivity disorder) and where the family seems otherwise stable.

difficulties at the time they are being seen is sometimes more useful than later discussions in supervision or at a case presentation meeting. Single session clinics have created

an excellent opportunity for leaming opporfllnities, allowing students to observe experienced clinicians at work. Student

mental health nurses on rwo week placements, psychology students on six month placements, social work students and community paediatric senior registrars on

three month once weekly placements have all actively sought to participate in single session clinics. By agreement, school counsellors have participated in meetings. The format has attracted comiderable inltmtfrom othn- Jervi(e.r. adult mental health counselling units, family welfare services. child health services. community disability services, school counsellors and non-government agencies.

Singl, susion clinic.r bav, b"ilt a strong sens, of ftam 11Iork. There are similatities to a Hospital Emergency Department at a busy time. They can seem a bit like a battle zone and the

Families with histories of trauma. domestic violence and

troops have to rely on support from their colleagues.

child abuse and/or neglect, and those with multiple prob-

They are very egalitarian affairs, with staff all undertaking

lems and stresses, are not offered the single session clinic.

Adolescents are also excluded because they generally need

the same core functions. either as clinicians or as peer consultants. Senior staff seeing families value the insights

more time and opportunities to be seen individually, as

of their less experienced colleagues, who might be acting 199

Hampson, O'Hanlon, Franklin, Pentony, Fridgant and Hein.

as consultants. The clinics are pretty public affairs, where one's work is on display to both students and consultants. In such an environment. the small tensions found in any team between disciplines and between enthusiasts for differing approaches have to diminish. The sense of pioneering a useful initiative has been valued by staff. Administrumrs art lintkrstandabfy mthliJiastic. The equity of the program is very clear. Many more clients are being seen, and seen promptly. Previous comments about child and adolescent mental health services being 'insufficiendy productive' have diminished.

Jacobs, Sue Johns, Juanita Kohric, Catherine O'Brien, Yvonne Poels, Ann Ponsoby, Helen Stoeckel, Georgia Tayler and Zina Kaleniuk. Annalisa Cramby and Emma Prime provided research assistance for the follow up studies. References

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To offer only a single session seems less than ethical. When you only have 75 to 90 minutes you have to ignore areas that are probably important contributing factors and your chances of picking up, say, child abuse, are reduced. However, there are two safeguards. Firstly, the clinician can refer any child whose problem is more serious than anticipated back to the Intake team fur allocarion to longer term contact, often with the same worker. Secondly, all families are invited to make contact with the Intake Worker for a further Open Day session should things get difficult in the future, and such recontacts certainly occur. If you take the community as a whole as your client. then single session clinics constitute a. responsible choice to distribute scarce resources more equitably and to promote skill sharing with students and with staff of other agencies.

CONCLUSION In settings characterised by scarce resources, single session consultations for families of children with milder problems, who have been screened by a telephone intake process, are a useful initiative for a child and adolescent mental health service. Such a service is a safe and ethical approach for the clients. The very large majority of families we followed up regarded the sessions as helpful and useful (95% of 1994 clients would use Open Day again if the need arose; 96% were satisfied in 1996). The program has benefits for skill development and good team functioning. While a small study of seventy families did not inform us about which problems were particularly suited for this approach, accumulated experience indicates that behavioural problems in children up to twelve in otherwise stable families are the best match. Directions for future evaluation efforts are to amass more feedback from referrers, and to look more closely at families who re-present after attending single session clinics.

Achenbach, T. M., 1991. M4nllalfor th, Cbild B,btZviollr Ch,ck/ut 4-18 (J1Jd 1991 Pro/tit. Burlington VT, University of Vermont. Boyh2.n, P. A., 1996. Clients' Perceptions of Single Session Consultations as an Option to Waiting fo, FamilyThcnpy, ANZ]FT, 17, 2: S5-96. Campbe1l. A., 1999. Single Session Interventions: An Enmple of Clinial R.seuch in p"etic., ANZ]FT, 20,4: 11n-194. Capian, G., 1964. prmnp"'1PmmJi.. p!]