ADMINISTRATIVE SUPPORT

ADMINISTRATIVE SUPPORT

By now it is probably apparent that the activities described herein require substantial administrative support from the treatment facility. Many of the points below are enlarged upon in Chapter 16.

Principle 20.. The treatment agency. must have flexible policies to allow therapist flexibility. The most obvious example of this principle concerns therapists' working hours. Families, especially those with low incomes and/or multiple problems, cannot always get time off to engage in treatment during the 9 to 5 workday. In addition, the working member(s) are sometimes on an evening or night shift, further complicating the scheduling problem. Berg and Rosenblum' ' found that the "work schedule- was the most frequently given reason for the father's failure to become engaged in treatment. These authors also obtained a positive correlation between the per-centage of families successfully engaged and the lateness of the hour the therapist was able to see them. They state, -Family therapists must be more flexible in the hours that they see a family and the agency for which they work must accommodate this flexibility-(p. 91). We feel this is even more crucial for the recruitment effort. When trying to engage a family, there is even greater need to meet them on their turf, and be able to contact them when they are available, usually at night. Consequently, the agency must not only allow, but must encourage late, long, and irregular hours if family enlistment is a goal.

There are other ways in which the agency can be flexible. For instance, simply allowing therapists easy access to the telephone can be important, since this is such a crucial instrument in the recruit-ment effort. Regular consultation time from supervisors can be help-ful, especially when a therapist has reached an impasse or is trying to figure out ways of obtaining leverage with a family. As before, permitting staff to function in the dual role of therapist-drug coun-selor may also be pivotal. Finally, flexibility in the kind of services offered, such as job counseling, may be necessary to allow the thera-pist to make commitments to the family during the goal-tailoring process.

Principle 21: The treatment agency must be willing to back up the recruitment effort through commitment of tangible resources.

While related to Principle 20, this goes beyond flexibility, per se, and refers to the allocation of real monies and related resources for recruitment. It is not enough to tell a therapist to -do your thing," since his time also costs the agency money. The therapist must be given clear indication of the importance attached to recruiting, so that he is not, for example, penalized on his caseload quota while trying to engage a particularly resistant family. Nighttime hours must also be rewarded. A possible way of handling this is to count recruiting time as patient contact time, and unsuccessful attempts to reach family members as -treatment backup- time. Another option is to credit evening hours as compensatory time. In addition, coverage of travel expenses for home visits may be necessary. Other areas for commit-ment of agency resources have been mentioned earlier, such as the provision of incentives for successfully' recruited cases, the use of

beepers during the engagement process, and payment to families for

parking expenses.

DISCUSSION

EFFECTIVENESS OF ENGAGEMENT

It is beyond the scope of this chapter to give data on the success of each of the recruiting principles. Only overall results will be pre-sented. It is worth noting that Black families were more difficult to recruit, and that the recruitment effort—including those successfully and unsuccessfully engaged—required a median of 5.4 direct contacts (telephone or face-to-face) over a median of 20.5 days. A more detailed analysis of the factors leading to successful recruitment, and the cost-effectiveness of our efforts, has been published elsewhere.'69

For the present purposes, the term -engager- will be used to denote those families who participated in the initial Family Evalu-ation Session. The term -refuser- will refer to families in which one or more family members refused to participate in such a session. Out of a total sample of 92 eligible families, we were able to recruit 71% (i.e., there were 65 engagers and 27 refusers). An important variable was whether the IP gave us permission to contact his family directly (Principle 4). As noted in Chapter 3, in the 74 cases where such permission was granted, 88% of the families were successfully en-gaged. Put another way, two-thirds of our failures occurred when we could not get past the IP. The reasons why we think this occurred have been presented earlier in this chapter. Sager et at 26 experienced similar difficulty with single persons, and recommended spending -a great deal of time working through individual problems with the identified patient so that he does not experience family therapy as an attempt to return him to his original difficult family situation-(p. 720). These authors also noted that patients who had difficulty accepting the importance of their families in their problem were also more likely to drop out of treatment prematurely.

The dual role of having therapists also serve as drug counselors deserves special mention. Before this procedure was implemented our recruitment success rate was 56%. Afterward the rate rose to 77%. Under the dual role, therapists required fewer contacts (mean of 6.4 vs. 7.2), a shorter period of time (median of 17 days vs. 33 days),* and fewer home visits (11% vs. 48% ) in order to get families into treatment. More important, our datai69 document that recruiting families under the dual role was more than twice aS cost-efficient than when both a therapist and drug counselor were involved in the recruitment process.

The rate of success with which these families were engaged in treatment is considerably higher than other reports in the literature with similar clients. This is especially true considering (1) the clients' predominantly lower socioeconomic status,[26- 1" (2) the severity of their addictive problems, and (3) the fact that, unlike nearly all of the earlier studies, we considered a case to be successfully recruited only if both parents or parent surrogates appeared together at the treatment site; most other studies satisfied themselves with one parent or a spouse. These results, then, offer general support for the aforemen-tioned principles, as well as for the effectiveness of the major effort applied to recruitment.