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Option 2

By Julie Mitchell,2014-11-26 17:02
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Option 2

The “Option 2” Model and

    Homebuilders: A Guide to support the IFS Teams

    Prepared for the Welsh Assembly Government by

    Donald Forrester

    Professor of Social Work Research

    The Tilda Goldberg Centre for Social Work and Social Care

    University of Bedfordshire

    Donald.Forrester@beds.ac.uk

    and

    Anne Williams

    Research Assistant

    Cardiff University

    May 2010

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Introduction

    “Option 2” is an intensive family preservation service based in Cardiff and the Vale of

    Glamorgan. It is an adapted version of an American model (called “Homebuilders”). Versions of Option 2 have been developed in various different ways in different settings within the United Kingdom (somewhat confusingly often with different names).

    Option 2 was identified by the Welsh Assembly Government (WAG) as a promising method of working with families affected by serious issues relating to parental use of drugs or alcohol. As a result, the Option 2 model has had a major influence in defining the approach supported within the pioneer Integrated Family Support Services (IFSS) in Wales. The work of the IFS Teams is largely based on the key components of Option 2, with the Welsh Assembly Government (WAG) providing training, consultation and materials to support the implementation of the model within the three pioneer areas Newport; Wrexham; Merthyr Tydfil and Rhondda

    Cynon Taff (as a consortium). However, there are also important differences. Most obviously, there are new statutory duties placed on IFS Teams with the intention of creating more integrated services and contributing to wider system change.

    This guide is intended to provide a brief introduction to Option 2 for practitioners and managers interested in developing this way of working. It might be useful to the pioneer areas setting up their Integrated Family Support Service, other areas subsequently developing IFSS or simply agencies wishing to develop a service such as Option 2 in their area. It has been written by independent researchers involved in the evaluation of Option 2. Further details on the Option 2 approach are best obtained directly from the project, and contacts and resources to help in doing this are provided at the end.

This guide:

    1. Describes the background to Option 2

    2. Outlines key features of the Option 2 approach

    3. Reviews the evidence for Option 2 and related approaches

    4. Critically considers the strengths and limitations of the Option 2 approach

    5. Provides further resources and contact details for those interested in

    developing Option 2 style working further.

1. Background

    Option 2 grew from concerns that services were failing adequately to meet the complex needs of families affected by drug and/or alcohol misuse. This was felt to be particularly true in relation to families with high levels of professional concern and this was sometimes resulting in children entering care. For these children, Option 2 was created in part to provide an alternative to care (which might be considered to be “Option 1”).

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    A different approach to meeting the needs of such families was sought, and Option 2 built on existing intensive family preservation programmes in the USA (known as Intensive Family Preservation Services or IFPS). The best-known such programme, named Homebuilders, provides an intense short term intervention to improve family living conditions and allow children to remain at home (Kinney at al, 1991). The principles and approach of Homebuilders were adopted, though modified for use in South Wales and for parents with drug or alcohol issues, and took shape as Option 2 (Emlyn-Jones, 2005).

    Option 2 has been operating for 10 years. It has won national awards for its pioneering work and has been the subject of evaluative research. The promising results have made the approach a key element of the Integrated Family Support Service that the Welsh Assembly Government is pioneering prior to rolling-out across Wales. As such, considering the strengths and limitations of the approach is crucial in order to deliver IFSS effectively.

    Homebuilders and Option 2 were initially developed with a primary focus on issues around child protection and reducing the need for children to enter care (or to help them return home if they had entered care), however it is important to emphasise that because the service works with families with complex needs relating to substance misuse and child welfare the potential benefits of the intervention are likely to be relevant to a range of different agencies. For instance, Option 2 style interventions might be expected to reduce levels of problem alcohol or drug use, and to have positive effects on family physical and mental health, children’s education and behaviour. The evidence for some of these benefits is discussed further below.

2. What is Option 2?

    Hamer (2005) sets out the principles and guidelines for Option 2 services in Preventing Family Breakdown. This manual is the main information resource for this section. The service is provided by professionals from a variety of backgrounds (primarily social work and psychology), however the intervention is the same whoever is delivering it. The worker tends to be called the “therapist”.

    Referrals to Option 2 are made at a moment of family crisis when the children are at risk of removal or registration. At this time many people are willing or even eager to make changes to improve matters. Crisis intervention theory suggests that this ‘window for change’ lasts for a short time and this knowledge shapes the timing,

    length and intensity of an Option 2 intervention. Work with families is usually short (4-6 weeks) and very intense: during this time the Option 2 worker is available 24 hours a day, seven days a week, and on average will spend around 30 hours with a family. Services are provided in the family’s natural environment - usually the family

    home - and therapists work with whoever may be present during visits.

    After referral the Option 2 team make contact within 24 hours. Their work with the family is carried out in distinct phases. The first few days are spent carrying out an

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    assessment to decide whether the family is really in crisis and ready to change. With the safety of the child/children of paramount importance this time is also used to explore the risks within the family and decide what changes can be made immediately to address the risk and prevent children’s accommodation. A safety plan is then drawn up for use in the early stages of work to ensure the children are not placed at unacceptable levels of risk.

During the next stage the therapist works to accept and validate the client’s feelings,

    and to identify and reflect the positive attributes existing in the family. Subsequent weeks can be spent dealing with practical problems which may pose barriers to change, as well as working to create discrepancies between how things are and how the family would like them to be. As the therapeutic relationship continues, work turns to setting goals for the future; goals which will help families resolve current problems and build a more positive future. This stage draws on techniques used in Brief Solution Focused Therapy, and sets a limited number of achievable goals for clients to work toward. This stage may well involve teaching and learning new skills needed if clients are to reach their goals e.g. anger management, relaxation, time management skills. In the final stage of the intervention, clients are encouraged to practice their new skills, and attention also turns to identifying and linking families to any other services or resources that may be needed to help them maintain their progress. The therapist now withdraws from the family, but monitoring continues over the next year. During this time families can receive a ‘booster session’ if things are not going well, for instance if there is a further crisis or a relapse in levels of substance use.

    Throughout their work with the family, therapists use a Motivational Interviewing (MI) approach. MI involves attempting to build a relationship with family members through empathic engagement. Resistance (i.e. any form of non-cooperation) is conceptualised as an understandable response to the situation that clients find themselves in, and every effort is made to try to minimise and work with resistance. Once a client is engaged, a variety of methods are used to explore and resolve ambivalence about behaviour change. The resolution of ambivalence may be seen to be a key element in creating change through the Option 2 intervention (more information about MI is provided in a separate guidance handbook).

3. Review of the Evidence

IFPS generally and Homebuilders in particular has a substantial but complicated

    and not always supportive evidence base in relation to its effectiveness. Initial findings and claims for Homebuilders suggested an exceptionally effective service that would stop high numbers of children needing to enter care. Rigorous research did not support this proposition. Indeed, overall there is little evidence that IFPS style interventions reduce the need for or use of public care or that they have a measurable positive impact on child or family welfare. However, while this is the general picture there are examples of individual projects or sites within larger pieces of research that are achieving positive results (Forrester et al, 2008a).

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    Understanding this mixed picture is important. Two key lessons need to be highlighted. First, it needs to be understood that achieving changes with families with complex problems is difficult. Even skilled and professional interventions do not work for all families. The responsibility of services is to deliver the services that are most likely to help families and avoid delivering those likely to make things worse.

    The responsibility for changing is always that of family members and primarily

    parents. However excellent the service, the intervention should not therefore be thought of as a “silver bullet” that will resolve the issues in all families.

    Second, the huge variations in the outcomes of different IFPS services highlight the importance of the quality of the service being delivered. A problem in the evaluation of IFPS was that there was little evidence on the quality of the service actually received by families. Simply putting in an intensive crisis-intervention orientated service is not enough. Those delivering the intervention need to have the skills and support to deliver it to the highest standard.It is for this reason that the WAG have

    invested substantially in supporting the development of IFSS in the pioneer areas.

    In this respect there is encouraging evidence that Option 2 is producing positive findings. An initial evaluation of the service found that it was very well received by clients. It also proved to be effective in reducing children’s use of public care

    (Forrester et al, 2008b). This was not because children were less likely to enter care following Option 2 intervention (around 40% of children in both groups entered care at least once), but because they were less likely to remain in care long-term. It was as a result cost-effective with the reduction in the use of public care more than

    paying for the service itself. Further evaluation is currently underway, looking at the long-term impact on child and family welfare.

    These findings are noteworthy. Option 2 is working with a group that have been found to have particularly poor outcomes in other types of IFPS (i.e. parents with substance misuse issues). Furthermore, the evaluation compared Option 2 to families who received a wide range of other services; the impact of Option 2 was therefore not compared to receiving nothing but to receiving a “normal” range of

    services. The evaluation also had a comparatively long follow-up period (with an average of over 3 years). This is important because one might expect the impact of a brief intervention to tend to fade over time. The fact that Option 2 appears to have produced significant results despite such challenges suggests it has great potential as a way of working with families who have serious drug or alcohol issues.

    The initial evaluation focussed for pragmatic purposes on the potential impact on children entering care. However, the limited number of interviews with families who had received the service in the last year suggested that the benefits of involvement with Option 2 applied to a variety of issues beyond care entry. In particular, families identified significant reductions in alcohol or drug related problems and a far more positive family atmosphere. Current research is providing some promising initial findings suggesting that when Option 2 works with families the benefits are wide-

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    ranging and likely to be of relevance to a variety of agencies that typically become involved with such families.

An adaptation of the Option 2 model, named “Families First” was set-up in

    Middlesbrough in 2006 (see Woolfall et al. 2008). While modelled on Option 2, there are some important differences most of which suggest that IFSS may be closer to

    the Families First adaptation of Option 2. Families First is jointly funded from child and adult services, the service holds case responsibility for families and includes 6 social workers who have statutory responsibilities that enable them to remove children from the family home if necessary. It does not operate a 24 hr service but offers out of hours support if needed. The initial intensive intervention lasts up to 8 weeks with additional “low key” services for up to 4 months, after which the case is transferred to mainstream services along with a maintenance plan or decisions about permanency. During this time the staff member with case responsibility works intensively with the whole family on their strengths and values, using motivational techniques and focussing on solutions and agreed goals. Additional support is given in other areas if required, e.g. resolution of housing and benefit problems. The service was evaluated by Woolfall et al. (2008). The evaluation produced interesting findings, though the lack of a control group and the very small number of families involved in the evaluation are serious limitations. However, positive results included what was believed to be a reduction in the need for care placements (in that staff and families felt there was less use of care) and minimising the time spent in care for some children. Illicit drug use but not alcohol use by parents was reduced and stabilised during the 12 month period. Parental reports showed that levels of anxiety among children reduced but there were no differences in other physical or emotional problems. The parents felt positively about the Families First intervention and particularly valued the “truthful relationship” established with the social worker, as well as the importance of other factors such as the timing of the intervention, housing support, taking personal responsibility for changes and the solution focussed approach. The evaluation also highlighted the need to review the time frame of the support allocated to families, as some needed longer term support.

    In conclusion, evaluation of interventions such as Option 2 is at a comparatively early stage and the evidence we currently have is not strong. However, on balance the evidence for Option 2 and similar intensive family preservation interventions is stronger than that for any other intervention we know of aimed at families affected by serious parental substance misuse. Option 2 or carefully developed adaptations of it (such as Families First) therefore appear to be the best place to start building ways of working effectively with families affected by such issues.

4. Strengths and Limitations of the Option 2 Approach

Strengths

    The most important strength of the Option 2 approach is that there is evidence that it “works”, in that for a significant proportion of families receiving the service it

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    seems to result in positive changes and these are linked to a reduction in the use of care. An important corollary of this is that even where a family does not achieve the desired changes, they have been offered a highly professional opportunity to change. This is ethically important (as if children are to enter care we need to know that families have been offered every opportunity to avoid this outcome). It is equally important from a practical point of view, as it can lead to families accepting the need for children to enter care more readily if this is what is needed.

    Second, a key strength of the Option 2 approach is that it appears to have extraordinary success in engaging some of the most difficult to engage families that services work with. The intensive and highly skilled intervention offered by Option 2 appears to allow it to reach the families that other services cannot reach. This is an important element of the success of Option 2. The service‘s success at doing this opens up the possibility for engaging families in a wide range of longer-term support services as necessary.

    Third, Option 2 (unlike Homebuilders, at least until more recently adapted) uses an evidence based approach (MI). It is likely that this contributes to the comparative success of the Option 2 approach, and that there are lessons for general professional practice with families.

    Fourth, a related point is that Option 2 provides the opportunity to refocus on the core elements of effective professional practice. Option 2 workers have limited bureaucratic demands and are allowed to focus on the business of helping families. This is likely to be a core part of the success of the project.

    Fifth, the service is relatively brief. This makes it more practical to deliver, and also means that where it achieves change, it does so within the child’s timescales.

Limitations

    The most important limitation for Option 2 is not to do with Option 2 specifically, but is a more general issue, namely that we have very limited evidence on what works in this area. In this context Option 2 is a great place to start but it is not intended to

    be a “cure all” and we do not currently know which types of families it is most likely to be effective for and for which it is less likely to work. This requires careful ongoing evaluation by those delivering such services.

    In relation to this broad lack of evidence there are two specific limitations that need to be considered. First, in general the impact of interventions tends to fade over time at least for many families. If this is the case for Option 2 then there is a question about how families needing longer-term support or periodic intensive interventions should best be worked with. This is not an issue solely or even

    primarily for Option 2 or IFSS, but it is nonetheless one requiring careful consideration. The IFS Teams will provide longer follow-up provision than Option 2 have been able to provide, however this issue turns attention to the importance of

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    all the systems and services that come into contact with families learning from services such as Option 2. For if Option 2’s intensive and skilled intervention is

    making such a positive difference, can elements of it be replicated in services that come into families for longer periods of time with less intensity? For instance, would skilled work from social workers, substance misuse workers, health visitors and other professionals help to sustain families in changed substance use behaviour and improved general functioning? Achieving this broader system change is one of the goals of the IFSS reforms and it will be important to explore its potential for supporting families in sustaining change in the long term.

    Second, a related consideration is that for some families it seems likely that there will be a pattern of periodic crises or that there will be improvement for some time and then deterioration. We do not know what the impact on children in such situations might be. It is acceptable to provide help for individuals with substance use problems as often as they need it, and to recognise that for many the process of change may involve a pattern of lapse and relapse over many years (or indeed indefinitely). For children living in such families there is an added layer of complexity. For many of these children helping the family periodically when needed or for

    others in an ongoing manner will be the most appropriate way of helping the child.

    For some, it may place children at risk of ongoing exposure to harm that would best be avoided by the child entering care. Developing IFSS interventions requires a sophisticated and long-term appreciation of issues in assessing child welfare and risk. This is further complicated by the fact that for most children who enter care there are medium-term benefits. It is crucial therefore to recognise that Option 2 aims to reduce the NEED for care, while accepting that for some children this may not be possible and that care can be a positive option for some children. (This is recognised and understood within the work of Option 2 and needs to be an integral part of IFSS work too).

    The final limitation is that the evidence shows that delivering services such as Option 2 which rely on highly skilled direct work with families is very challenging. It is

    easy to set-up a service that looks like Option 2. It is much more difficult to ensure

    that the service actually received by families is of the high quality that Option 2 tends to be. Doing so requires recruiting exceptional staff, providing very high levels of clinical supervision and training and ensuring that staff have the time to devote to delivering high quality work for families.

    A specific issue in relation to this is the issue of adapting the model. There is an extensive research literature indicating that where interventions are adapted they tend to work less well. This has resulted in considerable attention to the issue of “implementation fidelity” i.e. ensuring interventions are accurately replicated. This is not necessarily appropriate or possible in relation to Option 2. Local circumstances may vary, we do not know that Option 2 is the best way of delivering this style of work and the IFS Teams have significant differences to the smaller and more limited Option 2 model. Furthermore, Option 2 itself which is an adaptation of the

    Homebuilders model suggests that adapting an approach does not always result in reduced effectiveness.

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    However, the implementation fidelity literature does highlight one crucial fact: in general when people replicate an approach they “cut corners”. They believe they are delivering the same approach and on paper they may be but the quality of the

    intervention actually being delivered is in general not the same. Typically they cut back on intensity, reduce the focus on the quality of the service and cut back on support for staff. In relation to Option 2 it is therefore perfectly acceptable to adapt and develop the approach but in doing so the focus must always be on the quality

    of the service as experienced by the families.

Summary and Conclusion

    Option 2 is an intensive family support service, which uses evidence based methods (such as MI) as part of their work to help families experiencing parental substance misuse. Option 2 works with the whole family, seeking to empower the family unit and effect changes that allow the family to remain together safely. Although the evidence base supporting the programme upon which Option 2 is based is limited, the early evaluations of Option 2 are promising; they show it to be a cost effective method that diminishes the need for children to enter care.

    A particularly important feature of Option 2 and related services is that they seem to have considerable success in engaging and working with some of the most hard to reach families in the community. Typically these families are reluctant or resistant to engaging with substance misuse and child welfare services and this can exacerbate their difficulties. The success of Option 2 in engaging with this group opens up the possibility of providing meaningful help for them, not just while they are receiving the intensive family support service but also by providing longer-term follow-up support from appropriate agencies.

    Option 2 therefore provides an excellent starting point for developing effective ways of working with families affected by serious parental difficulties such as alcohol or drug misuse. In some instances attempts may be made to follow the Option 2 model very closely. In other circumstances it may be adapted or developed in new ways. Regardless of the approach taken, it is crucial that services focus on the quality of the service experienced by the client. It is also important that there is ongoing evaluation of the services.

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5. Resources

Websites:

http://www.option2.org/

http://www.institutefamily.org/

References

    Forrester, D., Pokhrel, S., McDonald, L., Giannou, D., Waissbein, C., Binnie, C., Jensch, G. and Copello, A. (2008a) Final Report on the Evaluation of “Option 2”, Welsh Assembly Government, 90 pgs available from

    http://wales.gov.uk/topics/housingandcommunity/research/safety/option2/?lang=en

    Forrester, D., Goodman, G., Cocker, C., Binnie, C., and Jensch, G. (2008b) Does Care Work? A Focussed Literature Review on Welfare Outcomes for Children Who Enter Care, Welsh Assembly Government, available from

    http://wales.gov.uk/topics/housingandcommunity/research/safety/option2/?lang=en

    Forrester, D. , Pokhrel, S., McDonald, L., Copello, A., and Waissbein, C. (2008c) How to help parents who misuse drugs or alcohol: findings from the evaluation of an Intensive Family Preservation Service, Child Abuse Review, 17 (6), pp 410-426

    Hamer, M. 2005. Preventing Family Breakdown, A Manual for those working with families and the individuals within them, Russell House Publishing: Dorset.

    Woolfall, K., Sumnall, H. and McVeight, J. (2008) Addressing the needs of children of substance using parents: an evaluation of Families First’s Intensive Intervention, Final Report, Prepared for the Department of Health, Liverpool John Moores University, available from http://www.cjsw.ac.uk/cjsw/files/Woolfall%20et%20al%202008.pdf

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