Universal Risk Screening as A Tool to Identify Client Vulnerability … · 2018. 9. 10. · Universal Risk Screening as A Tool to Identify Client Vulnerability in Family and Relationship

Universal Risk Screening as A Tool to Identify Client Vulnerability in Family

and Relationship Counselling

DR JAM IE LEE 1 , M S JANET M UIRHEAD 1 , P RO F ES S O R JENNIF ER M C INTO S H 2

1 R E L A T I O N S H I P S A U S T R A L I A S A

2 D E A K I N U N I V E R S I T Y

Presentation outline

Jamie The journey: why we screen and the framework we use

Jamie The risks we find in daily practice

Janet How we screen

Janet The practice dilemmas of implementing screening

Jamie Our clients’ experience of ‘being screened’

Janet/

Jamie Where next, conclusions

Australian Association of Family Therapy 38th Annual Conference, 19 - 20 October 2017




Janet How we screen



Janet/



The journey



used a counselling, relationship or FDR service before separation

Not just Glenys

Of those reporting physical harms before/during separation

67.3%

70.9% used services after separation

(Kaspiew et al., 2015)

Creator of the DOORS


Professor Jenn McIntosh

Deakin University

Risk framework


From DOORS Handbook

(McIntosh & Ralfs,2012)

DOORS framework


From DOORS Handbook


• Screening vs risk assessment

• Holistic approach

• Victim and perpetration risks

• Think of harms to children/dependents

• Flexible to use

• Signals that: ‘Your safety is important’

• ‘I’m interested in safety and wellbeing’

• Safety has multiple meanings

• Risk conversation builds engagement

• We will help you tell us about important

risks – you’re not alone in doing this

unaided or unprompted

Aims – for the practitioner Aims – for the client


The DOORSFrom DOORS Handbook


Screen Elaborate Assess

Map Explore Navigate

DOOR 1 DOOR 2 DOOR 3




Janet How we screen



Janet/



What DFV risks do we find in our

Family and Relationships Services?

Focus on one domain:

domestic and family violence

Which types of relationships

or family stages show risks?


WOMEN

MEN


“…in past year, concerned for your safety because of someone else

(e.g., partner, former partner, family member etc.)?”

26% 29% 30% 24% 26%

10% 10% 13% 7% 14%

Total N=4,519

(splits n=1,416m; 2,068f)

Question from DOOR 1

(McIntosh, 2011)

29%

12%

Planning to

have children

Expecting

a child

Raising

a child

Child about to

leave home

Child has

left homeAverage

Personal safety – family stage

Possible risks run across family stage


“…in past year, concerned for your family’s safety because of someone else


27% 29%

15% 9%

Total N=4,519

(splits n=1,416m; 2,068f)


(McIntosh, 2011)

Raising

a child

Child about to

leave home

WOMEN

MEN

Family safety – family stage

Children may also face risks


“…in past year, concerned for your safety because of someone else


Total N=3,675

(splits n=1,548m; 2,115f)

WOMEN

MEN


(McIntosh, 2011)

34% 19% 36% 47% 40%41%

18% 9% 14% 20% 19%32%

Recently

started

relationship

In established

relationship

Considering

leaving

Relationship

recently ended

Looking for

relationship

Staying out of

relationships

Personal safety – relationship stage

Possible risks run across relationship stages


18% 25% 24% 18% 23%

12% 20% 15% 6% 11%

Total N=4,519

(splits n=1,416m; 2,068f)


(McIntosh, 2011)

Planning to

have children

Expecting

a child

Raising

a child

Child about to

leave home

Child has

left home

WOMEN

(Victim)

MEN

(Perp)

24%

15%

Behavioural consequences

Average

Not just ‘feeling’ unsafe

“…police ever been called, criminal charge laid, intervention order made

against someone else/you?”

Recap

• DV and FV risk is gendered

• No family stage/type is free of DFV risk when using our service

• No relationship stage/status is free of risk

• Children may face risks independently too

• Risk from both ‘feeling unsafe’ and ‘acting unsafely’

DOOR 1 has many other domains


Screen whom?

How others screen

What happens generally in family therapy

• 24% Masters-level social work students ‘always screen for DV or sexual assault’ (Todahl and

Walters, 2011)

• 11 out of 20 therapists said ‘screening was routine for them in all cases’ (Todahl, Linville, Chou

& Maher-Cosensa, 2008)

• Others relied on ‘sensing’ when to screen

• 53.2% US marital and family therapists screened ‘everyone in the past year’ (Schacht,

Dimidjian, George, & Berns, 2009)

• 3.5% used all three best practice DV screening recommendations


How do you see risks?

Given they come to you, how do you screen their risks?

• Format: when ‘sensing’ risks vs screening everyone (‘universal’)?

• Focus: victimisation risks vs perpetration risks vs both?

• Family: direct/indirect risks to children?

• Purpose: screen to refer somewhere else or to engage with the issues?

• Lead: check ‘safety first’ or straight into the presenting problem?





Janet How we screen



Janet/






Janet How we screen



Janet/




How Have Early Intervention Services Responded to Universal Screening ?

• Introduction and dilemmas

• RASA uses DOOR 1 (McIntosh, 2011) across services

‘Doing DOORS’ at RASA


2 concerning client situations

Example 1

Disclosing abuse in front of the perpetrator

Example 2

Transfer between services


How we screen


Request

One partner calls asking for couple counselling



Process

No screeningCSO - Is the client experiencing Domestic or Family Violence? If

yes, informs the counsellor

Client Services Officer books couple into next appointment up to 8 weeks away

CSO - Are there any safety concerns? Yes - refer to Intake Officer– IO is trained to ask more in-depth questions May book individual sessions.No - a joint appointment is made, confirmation letter sent.

Family Advisor speaks to client and asks an extensive range of safety questions. Immediate case management and external referral if necessary.

Universal screening before session. Counsellor may/will separate the couple in first or subsequent sessions.

Schedules individual session with counsellor. Universal screening before session.From this session the other party is invited in using the same process.

Intake Questions


Request




Process

No screeningCSO - Is the client experiencing Domestic or Family Violence? If

yes, informs the counsellor

Client Services Officer books couple into next appointment up to 8 weeks away

CSO - Are there any safety concerns? Yes - refer to Intake Officer– IO is trained to ask more in-depth questions May book individual sessions.No - a joint appointment is made, confirmation letter sent.

Family Advisor speaks to client and asks an extensive range of safety questions. Immediate case management and external referral if necessary.

Universal screening before session. Counsellor may/will separate the couple in first or subsequent sessions.

Schedules individual session with counsellor. Universal screening before session.From this session the other party is invited in using the same process.

Intake Questions


First session options

1. Invite each person in for an entire individual session first

2. See the couple together first but then see each person separately for 10 – 15 minutes within the first session.

3. See couple together for an entire session and then see each person separately for an entire session booked on different days.

‘Doing DOORS’ at RASA


Concerns from Couple and Family Therapists about individual sessions•Interactions and the dynamic between couples are part of the assessment

•The percentage of people where this process will help is small – do we need a one size fits all approach?

•Couples often ask to be seen together

•Seeing couples individually could lead to bias, or perceived closeness between one client and the practitioner

•Seeing couples together fits with the practitioners agenda not the clients

•Additional financial cost, delays, time etc.

•The screening tool should alert us to safety issues.

•We can always separate people

•Why not normalize people rather than pathologies?


Concerns


A. You are about to walk in to a couple session.

Discuss any concerns or questions you might like to ask – but wouldn’t because both partners are there

Guided activity


The matter of whether and under what conditions individual sessions may occur is one of the most important practical decisions to be made by couple therapists. How therapist (or organisational) policies and procedures about this decision are addressed and implemented carry profound implications for the maintenance of therapeutic alliances and even basic positions on what (or who) is (or has) 'the problem' It is a complex clinical issue that each therapist must think through carefully

Gurman and Burton, 2014

Systemic Therapy is …..not a question of how many people are seen, but refers to the theoretical framework which informs what the therapists does.

(Jenkins, and Asen1992)

Individual sessions – enhancing our couple therapy practice


Therapist’s changes in practice

• Example 1 - always seeing the couple together first followed by two individual session

• Example 2 – always seeing couples individually first


Practice changes


Enhancing Individual SessionsThe Central Place of Curiosity

It sounds like this is difficult information for you to talk about. How can we talk about this when we meet together (with your partner) in a way that would feel OK for you and your partner would understand?

How would you like him to respond? ◦ this is also a useful question to ask with the partner present.

◦ How would you like to respond to him if he responds as you hope. If he doesn’t what might you do?

If your partner were here how would they describe the problem? If they described the problem like that and they were here, what would your response be?

What other ways have you thought of asking for change? If you asked for change in that way how do you imagine she would respond differently? Would you be willing to ask for change in that way when we meet again>Who do you think would be most likely to leave if change doesn’t happen?

Does she know you think this? What would it take to tell her?

How to you normally get to know what your partner thinks? Have you ever been mistaken?

◦ A good question to ask again with both there


Range of Responses to screening

Practitioner reflect on using DOORS in routine practice◦ “People don’t mind being asked the questions at all. In fact I think some people feel

relieved to be asked the suicide question.”

◦ “It’s so good having the domestic violence questions for same sex couples too. It happens so much more than you’d think.”

◦ ‘I use the DOORS as a sort of scaffold in the individual session to help the client unpack and expand upon the stressors in his/her life’




Janet How we screen



Janet/



‘Satisfied customers’


2013 2014 2015 2016 2017

“I was satisfied with the service I received”

97% 97% 98% 98% 97%

Launch ofuniversalscreening

n=424-503

No change on overall satisfaction after launch

On ‘being screened’


Anonymous survey of 94 ‘just screened’ clients

from Family and Relationships Services

Lee and Ralfs (2015)


On ‘being screened’

Lee and Ralfs (2015)

‘He says, she says’?


From Wells, Lee, & McIntosh (under

review)

Practitioners’ responses


From Wells, Lee, & McIntosh (under

review)

48%

32%

52%

68%

81%

No FDV indicated in file FDV indicated in file

Initial service only

One referral

19%Two referrals

9% 91%Three or more referrals

Lee (2016)

1:1

2:1

4:1

10:1

Effects on organisations




Janet How we screen



Janet/



Where next for DOORS?

Innovations in the Family DOORS

• Detailed audit of over 5,000 screens: new FL-DOORS audit under peer

review

• Widen the benefits of evidence-based screening: development of

MyDOORS

• Screening becomes more efficient: launch of the DOORS app

• More information at www.familydoors.com


http://www.familydoors.com/

Conclusions,

recommendations

Take away messages

• DFV is gendered

• Risks affect people across families, relationships and

genders

• It’s not just DFV as a risk

• Different practices can adapt to and adopt screening

• Practitioners see the benefits of a risk screening framework

• Clients don’t mind ‘being screened’ for these risks


Conclusions,

recommendations

Take away messages

• Robust risk frameworks and tools are widely available

• Different approaches to practice can easily accommodate

risk screening

• When and how would you like to find out about the risks

that many of your clients are facing?


ReferencesKaspiew, R., Carson, R., Dunstan, J., De Maio, J., Moore, S., Moloney, L. et al. (2015). Experiences of Separated Parents Study.Melbourne: Australian Institute of Family Studies.

Lee. J. (2016). Are we actually doing more for families affected by family and domestic violence? Australian Institute of Family Studies Child Family Community Australia website, published March 2nd, 2016.

Lee, J. and Ralfs, C. (2016, February). If you ask, clients will tell you: The case for universal and holistic screening in family relationships services. Poster presented at the Inaugural National Research Conference on Violence against Women and their Children, Melbourne, Australia.

McIntosh, J.E. (2011). DOOR 1: Parent Self-Report Form. In: The Family Law DOORS Handbook. McIntosh, J.E. & Ralfs, C. (2012). Canberra, Australia: Australian Government Attorney-General's Department.

McIntosh, J. E., & Ralfs, C. (2012). The Family Law DOORS handbook. Canberra, Australia: Australian Government Attorney-General's Department.

Schacht, R. L., Dimidjian, S., George, W. H. and Berns, S. B. (2009), Domestic Violence Assessment Procedures Among Couple Therapists. Journal of Marital and Family Therapy, 35, 47–59.

Todahl, J. L., & Walters, E. (2011). Universal Screening for Intimate Partner Violence: A Systematic Review. Journal of Marital and Family Therapy, 37(3), 355-369.

Wells, Y., Lee, J. & McIntosh, J.E. (2017). Confirmatory re-validation of the Family Law DOORS. Manuscript submitted for publication.

With acknowledgement to Jenn McIntosh for her leadership

More information: www.familydoors.com



www.familydoors.com


Documents

Universal Risk Screening as A Tool to Identify Client Vulnerability … · 2018. 9. 10. · Universal Risk Screening as A Tool to Identify Client Vulnerability in Family and Relationship