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
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
The journey
Australian Association of Family Therapy 38th Annual Conference, 19 - 20 October 2017
Australian Association of Family Therapy 38th Annual Conference, 19 - 20 October 2017
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
Australian Association of Family Therapy 38th Annual Conference, 19 - 20 October 2017
Professor Jenn McIntosh
Deakin University
Risk framework
Australian Association of Family Therapy 38th Annual Conference, 19 - 20 October 2017
From DOORS Handbook
(McIntosh & Ralfs,2012)
DOORS framework
Australian Association of Family Therapy 38th Annual Conference, 19 - 20 October 2017
From DOORS Handbook
(McIntosh & Ralfs,2012)
• 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
Australian Association of Family Therapy 38th Annual Conference, 19 - 20 October 2017
The DOORSFrom DOORS Handbook
(McIntosh & Ralfs,2012)
Screen Elaborate Assess
Map Explore Navigate
DOOR 1 DOOR 2 DOOR 3
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
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?
Australian Association of Family Therapy 38th Annual Conference, 19 - 20 October 2017
WOMEN
MEN
Australian Association of Family Therapy 38th Annual Conference, 19 - 20 October 2017
“…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
Australian Association of Family Therapy 38th Annual Conference, 19 - 20 October 2017
“…in past year, concerned for your family’s safety because of someone else
(e.g., partner, former partner, family member etc.)?”
27% 29%
15% 9%
Total N=4,519
(splits n=1,416m; 2,068f)
Question from DOOR 1
(McIntosh, 2011)
Raising
a child
Child about to
leave home
WOMEN
MEN
Family safety – family stage
Children may also face risks
Australian Association of Family Therapy 38th Annual Conference, 19 - 20 October 2017
“…in past year, concerned for your safety because of someone else
(e.g., partner, former partner, family member etc.)?”
Total N=3,675
(splits n=1,548m; 2,115f)
WOMEN
MEN
Question from DOOR 1
(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
Australian Association of Family Therapy 38th Annual Conference, 19 - 20 October 2017
18% 25% 24% 18% 23%
12% 20% 15% 6% 11%
Total N=4,519
(splits n=1,416m; 2,068f)
Question from DOOR 1
(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
Australian Association of Family Therapy 38th Annual Conference, 19 - 20 October 2017
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
Australian Association of Family Therapy 38th Annual Conference, 19 - 20 October 2017
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?
Australian Association of Family Therapy 38th Annual Conference, 19 - 20 October 2017
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
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
Australian Association of Family Therapy 38th Annual Conference, 19 - 20 October 2017
How Have Early Intervention Services Responded to Universal Screening ?
• Introduction and dilemmas
• RASA uses DOOR 1 (McIntosh, 2011) across services
‘Doing DOORS’ at RASA
Australian Association of Family Therapy 38th Annual Conference, 19 - 20 October 2017
2 concerning client situations
Example 1
Disclosing abuse in front of the perpetrator
Example 2
Transfer between services
Australian Association of Family Therapy 38th Annual Conference, 19 - 20 October 2017
How we screen
Australian Association of Family Therapy 38th Annual Conference, 19 - 20 October 2017
Request
One partner calls asking for couple counselling
One partner calls asking for couple counselling
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
Australian Association of Family Therapy 38th Annual Conference, 19 - 20 October 2017
Request
One partner calls asking for couple counselling
One partner calls asking for couple counselling
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
Australian Association of Family Therapy 38th Annual Conference, 19 - 20 October 2017
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
Australian Association of Family Therapy 38th Annual Conference, 19 - 20 October 2017
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?
Australian Association of Family Therapy 38th Annual Conference, 19 - 20 October 2017
Concerns
Australian Association of Family Therapy 38th Annual Conference, 19 - 20 October 2017
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
Australian Association of Family Therapy 38th Annual Conference, 19 - 20 October 2017
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
Australian Association of Family Therapy 38th Annual Conference, 19 - 20 October 2017
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
Australian Association of Family Therapy 38th Annual Conference, 19 - 20 October 2017
Practice changes
Australian Association of Family Therapy 38th Annual Conference, 19 - 20 October 2017
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
Australian Association of Family Therapy 38th Annual Conference, 19 - 20 October 2017
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’
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
‘Satisfied customers’
Australian Association of Family Therapy 38th Annual Conference, 19 - 20 October 2017
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’
Australian Association of Family Therapy 38th Annual Conference, 19 - 20 October 2017
Anonymous survey of 94 ‘just screened’ clients
from Family and Relationships Services
Lee and Ralfs (2015)
Australian Association of Family Therapy 38th Annual Conference, 19 - 20 October 2017
On ‘being screened’
Lee and Ralfs (2015)
‘He says, she says’?
Australian Association of Family Therapy 38th Annual Conference, 19 - 20 October 2017
From Wells, Lee, & McIntosh (under
review)
Practitioners’ responses
Australian Association of Family Therapy 38th Annual Conference, 19 - 20 October 2017
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
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
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
Australian Association of Family Therapy 38th Annual Conference, 19 - 20 October 2017
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
Australian Association of Family Therapy 38th Annual Conference, 19 - 20 October 2017
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?
Australian Association of Family Therapy 38th Annual Conference, 19 - 20 October 2017
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
Australian Association of Family Therapy 38th Annual Conference, 19 - 20 October 2017
www.familydoors.com