THE NORTHERN CHILD AND FAMILY CLINIC INCENTIVES AND BARRIERS TO UTILIZATION: A CONTRADICTION by LynComeau B.S.W. , Laurentian University, 1983 THESIS SUBMITTED IN PARTIAL FULFILLMENT OF THE REQUIREMENTS FOR THE DEGREE OF MASTER OF SOCIAL WORK © Lyn Comeau, 1998 THE UNIVERSITY OF NORTHERN BRITISH COLUMBIA June 1998 All rights reserved. This work may not be reproduced in whole or in part, by photocopy or other means, without the permission of the author. The Northern Child and Family Clinic ii Abstract Declining referrals from local Ministry for Children and Families (MCF) child protection social workers threaten the viability of the multidisciplinary approach to child maltreatment operating out of the Northern Child and Family Clinic (the Clinic) in Prince George, British Columbia. This exploratory study used grounded theory methodology to discover and describe the incentives and barriers to referrals for local MCF child protection social workers. In-depth open ended personal interviews were conducted with six local MCF child protection social workers who had used the Clinic at least once. The findings of this study suggest that local MCF child protection social workers would value and use a multidisciplinary approach that has specific characteristics. However, additional findings indicate that the design of the approach in use at the Clinic contradicts what child protection social workers need to do their job and relates to alienation and non-utilization of Clinic services. The findings that emerged from this study are used to develop recommendations about the multidisciplinary model used at the Clinic. The Northern Child and Family Clinic iii Table Of Contents Abstract _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _u Table Of Contents - - - - - - - - - - - - - - - - - - - - - - - - - - - - 111 List OfFigures_ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _v Acknowledgments ____________________________ VI Chapter1 _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ 1 Introduction 1 The Purpose of the Study, Research Problem and Research Question 1 The Northern Child and Family Clinic 2 Chapter 2 _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _8 Rationale for the Study 8 Professional Practice 8 11 Literature Review Chapter 3 _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ 19 Research Design 19 Naturalistic Inquiry 19 Methodology 24 Chapter4 _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _34 Findings 34 Incentives 34 More Complex Incentives Barriers More Complex Barriers 45 54 61 Chapter5 _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _75 The Contradiction 75 Multidisciplinary Approach versus Inappropriate Design 76 One Stop Shopping versus Missing or Unsuitable Components 76 Child-Centered versus Client Intimidation 79 Accessibility versus Inaccessibility 80 Team Expertise versus Lack of Team Expertise 80 Collaborative Clinic Practice versus Uncollaborative Clinic Practice 82 Hierarchy versus Mutual Respect and Status 83 Commitment to Mutual Goals versus Lack of Commitment to Mutual Goals 83 Integration versus Alienation 85 Collaboration versus Powerlessness and Isolation 85 The Northern Child and Family Clinic Meaningfulness versus Meaninglessness Legitimate Inclusion versus Self-Estrangement Regular Utilization of the Clinic versus Normlessness iv 86 86 86 Chapter 6 Discussion Implications for Practice Limitations of the Study Suggestions for Future Research 88 88 90 93 94 References 97 Appendix A: Interview Guide 101 Appendix B: Transcription Conventions 102 Appendix C: Category and Concept Definitions 103 Appendix D: Category, Subcategory and Concept Connections to Data 108 The Northern Child and Family Clinic v List Of Figures Figure 1. Sample of transcription conventions and identification codes ................. ..................... 29 Figure 2. Example of category, subcategory, concept, and subconcept definitions ...... ........ ....... 32 Figure 3. Example of category, subcategory, concept, and subconcept connections to text ........ 33 Figure 4. Incentives . ..... ....................... .... .... ....... ................................ .. ... ................................. 3 5 Figure 5. Barriers .... ................. .... ..... ....................................................................................... 36 Figure 6. Theoretical framework .......... ....... ....................................... ..................... .................. 74 The Northern Child and Family Clinic vi Acknowledgments I wish to express my sincere thanks and appreciation to the six MCF child protection social workers who were participants in this study. Without your voice, this study would not have been possible. Your courage, honesty, and dedication to improving services for the children and families that you work with gave life to this project. I also wish to thank Professor Glenn Schmidt, my committee supervisor, who provided support, encouragement, and advice throughout the planning, implementation and completion of this study. Your understanding and flexibility were invaluable. In addition, I want to acknowledge the important contributions ofthe other members of my committee: Dr. Anne Lindsay, who inspired me to use grounded theory methodology and who provided support, clarity and guidance; Professor Graham Riches for his time and advice in the preparation of this thesis; and Dr. Cindy Hardy, who fulfilled the vital role of outside examiner. A special acknowledgment and thank you to my friend, colleague, and mentor Jackie Harper who provided consultation and encouragement, and who understood. Finally, I owe a special thanks to my husband, AI, who gave endless hours of support and encouragement, and whose belief in my ability to complete this project made it possible. Your love and patience will always be remembered. The Northern Child and Family Clinic 1 Chapter 1 Introduction This thesis examines the incentives and barriers that promote or inhibit referrals by Ministry for Children and Families (MCF) child protection social workers to the Northern Child and Family Clinic (the Clinic) in Prince George, British Columbia. By discovering the conditions under which MCF social workers decide to utilize the Clinic or not, action may be taken to create conditions or remove conditions that will promote referrals. As an introduction, this chapter outlines the research problem, the purpose of the study and the research question. This is followed by a description of the historical evolution, implementation, and operationalization of the Clinic. Chapter 2 provides the rationale for the study. It will examine factors from the researcher' s professional practice as the mental health therapist at the Clinic as well as explore relevant information from the academic and professional literature on the multidisciplinary team approach to child maltreatment. Some of the literature on program evaluation will also be highlighted. Chapter 3 introduces the research design and includes the theoretical underpinnings of naturalistic inquiry and the procedures of grounded theory methodology. Chapters 4 and 5 present the research findings. Chapter 6 suggests how the findings may be applied to professional social work practice and concludes with a discussion of the limitations of the study and suggestions for future research. The Purpose of the Study, Research Problem and Research Question The purpose of this study is to explore and describe the factors that inhibit or promote MCF child protection social worker referrals to the Clinic in Prince George. The Clinic uses a community based, interdisciplinary team approach to respond to child maltreatment in the The Northern Child and Family Clinic 2 northern interior region ofBritish Columbia. From the time of its inception in 1993, the Clinic has not been utilized to its fullest capacity by referral sources. In the 1995-1996 fiscal year, only 122 out of 195 available appointment times were utilized. Referrals decreased by 18% during 1996-1997. Only 80 out of 179 available appointments were booked in that year. In April 1997, it was apparent to staff and management that the number of referrals was continuing to decline. Statistics for the period between September 1997 and January 1998 were startling, as only five independent referrals from local MCF child protection social workers in Prince George were received. Although clinic statistics revealed that the number of case referrals from all referral sources were down, the number of referrals from local MCF child protection social workers had declined considerably. This phenomenon threatens the future viability of the Clinic program (Northern Child and Family Clinic, 1995/1996, 1996/1997, 1997/1998). In order to explain this phenomenon and to gain insight that can be used to reverse this downward trend, it was necessary to ask local MCF child protection social workers the research question: What are the factors that serve as incentives or barriers to referrals by MCF child protection social workers to the Northern Child and Family Clinic? The Northern Child and Family Clinic The Inter-Ministry Child Abuse Handbook (Ministry of Attorney General, Ministry of Social Services and Housing, Ministry ofHealth, Ministry of the Solicitor General, & Ministry of Education, 1988) outlines a child abuse community response protocol for the province ofBritish Columbia. This document was the first provincial child abuse protocol in Canada and reflects the provincial government's mandate to prevent the occurrence and negative consequences of child abuse and neglect. The coordinated effort of the Ministries of Social Services and Housing, Attorney General, Health, Solicitor General, and Education produced the protocol and is reflected The Northern Child and Family Clinic 3 in the document' s objectives. These objectives are: to communicate the policies and procedures of these ministries to ensure consistent practice throughout the province; to provide timely information to service providers; and to ensure that an integrated approach to child abuse is adopted by all those in the province who are involved in responding to this problem. The third edition of this handbook (1988) included a new section on prevention and reflects the beginning ofthe government' s shift in policy away from a purely reactive role to assuming more of a proactive, preventative role in responding to this social problem. In keeping with provincial government policy and philosophy calling for an integrated community response to child abuse, the Clinic opened in Prince George in December, 1993 . It developed from the coordinated efforts of community agencies and government ministries including the Ministry of Social Services and Housing, the Ministry ofHealth, and the RCMP . This clinic was the first child-centered, interdisciplinary, community based, child abuse clinic in British Columbia. At the time of inception, the only other child abuse clinic in the province was the hospital based child abuse clinic operating out ofB. C. Children' s Hospital in Vancouver. The Clinic is an independent center of multidisciplinary professionals assisting the community to respond to child maltreatment in a coordinated fashion that is particularly responsive to the needs of the child, the family and the community (NCFC, 1997). It is a regional facility mandated to provide services to all children under the age of 19 years, and their families, who are suspected of or have actually been the victims of child abuse or neglect. The Clinic' s mandated geographical boundary is consistent with three out of the four MCF northern regions and includes communities bounded by Williams Lake on the south, the Alberta border on the east, the Northwest Territories and the Yukon border on the north and west to Smithers. The Northern Child and Family Clinic 4 The Clinic has three broad goals (NCFC, 1997). These are: to improve medical and mental health assessment and follow-up services to children and their families where there is suspected or actual child maltreatment in an environment which is respectful of a child's needs for safety and well being; to improve support to the child and family throughout the diagnostic, assessment, and follow-up process; and, to provide opportunities for professional development in the field of child maltreatment through training, consultation and research. When the Clinic opened in 1993, the core team included a full time clinic coordinator who was a social worker employed by MCF, a half-time mental health therapist who was employed by a local children' s mental health agency, a half-time administrative assistant who was also employed by the same mental health agency, a part-time public health nurse, and community pediatricians who had specialized training in the area of child abuse and who attended at the clinic on a sessional basis. At the time of this study, the public health nurse' s involvement had been changed to a liaison role only and the nurse no longer attends at the Clinic on a regular basis. The RCMP act in co-operation with the Clinic and use the Clinic' s facilities to interview child victims but they are not part of the core team and conduct their interviews separately from Clinic core staff Similarly, MCF child protection social workers are not part of the Clinic core staffbut may use the clinic facilities on a 24 hour basis for interviewing children and families. The core staff are on site together two half-days per week. The pediatricians attend on a rotational basis and are at the Clinic two afternoons a week. The therapist originally attended two afternoons a week as well, but this has been extended to two full days a week in the last year. Although the core staff comprises a limited number of people, the actual core team on any given clinic day may be different depending on which physician is on duty that day. All personnel are appointed by their The Northern Child and Family Clinic 5 respective employing agencies, or, in the case of the physicians, attend from their community private practice. The staff are paid by their respective employers. Supervision of core staff is provided by an off site management team which includes supervisory personnel from each core team member's base agency. The management team meets once a month at the Clinic. Their time is viewed as voluntary as no extra funding was allocated for supervision of core clinic staff The management team meets with a community advisory board on a quarterly basis. The advisory board was initially made up of the community and government stakeholders who developed the Clinic program. Few of the original people remain on this board and the number of advisory members has decreased considerably from the time of its creation. This committee has no direct role in the supervision of staff and has the following terms of reference: (a) to advise the management team in their decision-making; (b) to provide a community perspective for the delivery of service; (c) to promote collaboration between the clinic and the community in regard to prevention, identification and treatment of child abuse; (d) to participate in the evaluation process to ensure the Clinic is efficient and effective; and, (e) to participate in the development and revision of clinical objectives with the management team and clinic staff (NCFC, 1997). The Clinic is located in a small retail plaza away from the downtown core in Prince George. It is not attached physically to any other social service or medical facility and maintains a low profile with only small lettering on the main door to announce its existence. The Clinic is bright, spacious and child friendly and is well supplied with modem video, audio, computer and medical equipment. As staff time is limited, the Clinic is only available to provide medical examinations two afternoons per week. Clinic staff can comfortably see two children on each of these clinic The Northern Child and Family Clinic 6 afternoons. A maximum of four children could be medically examined in a week, however the physicians are somewhat flexible and will sometimes see one or two additional children under special circumstances. The mental health therapist can accommodate two trauma assessments per Clinic day and, similar to the physicians, may complete additional assessments if the need arises. Referral sources are limited to the RCMP, MCF child protection social workers, community physicians, and Carrier Sekani Family Services. Referrals are accepted in person, by phone, or in writing, and are screened for appropriateness by the Clinic coordinator. The Clinic can be contacted by phone five days a week from 8:30A.M. to 4:30P.M. and through an answering machine after hours. The receptionist is on site Monday to Friday in the afternoons. As the Clinic team is only available to see clients two days a week, appointments must be booked "" ahead and emergency services are not available. Clients may be booked for both medical and trauma assessments or for either of these services individually. Upon acceptance for service, the Clinic coordinator completes a psychosocial assessment on all clients and books them in for a trauma and/or medical assessment as soon as possible. If the client is having both a medical and trauma assessment, the client is booked for the trauma assessment before seeing the physician. A typical move through the process would involve a meeting with the Clinic coordinator either at the Clinic or in the client's home if the client lives in the local area. This is usually followed by a visit to the Clinic another day in the morning to see the therapist and another visit to the Clinic in the afternoon of the same day to have the medical. The Clinic coordinator, therapist, and physician meet to discuss findings and formulate a treatment plan and recommendations once the medical is completed. Following this meeting, findings and recommendations are presented to the child and family before the family leaves the Clinic. The Northern Child and Family Clinic 7 Three separate reports, the psychosocial, the trauma assessment, and the medical/legal, are generated and distributed as per the guardian' s consent. The term medical/legal is given to the medical report as it is often presented as evidence in court. All reports may go to the referral source, the family itself, and the family physician. Direct follow-up services are not provided by the core team at the Clinic. However, referrals on behalf of the client population are made to community resources and further consultation is provided to help clients and referral sources find appropriate resources in their local area. One unique advantage of the Clinic for Prince George clients is that the clinic therapist also provides direct therapy services to victims of child maltreatment at the local children' s mental health agency. As a result ofthis arrangement, local clients seen at the Clinic are often referred directly to the same therapist at the mental health facility and can therefore bypass the intake process at that agency. There is no financial cost to the client for this service and there is no financial or other personal gain for the therapist as a consequence of this service. It does however, promote expedient service, confidentiality and continuity of treatment for the client. In summary, this chapter has introduced the research problem, the purpose of the study and the research question. An introduction to the Clinic has also been provided through a descriptive outline of the historical evolution, implementation and operationalization of the Clinic. The rationale for this study is examined in Chapter 2. Included are specific issues from professional practice at the Clinic as well as relevant areas from the academic and professional literature. The Northern Child and Family Clinic 8 Chapter 2 Rationale for the Study The rationale for this study was developed out of specific areas of professional practice at the Clinic in addition to relevant areas that were found in the professional and academic literature in the fields of child maltreatment and program evaluation. The rationale will be explained by examining issues from professional practice at the Clinic and by a discussion ofhighlights from the literature. Professional Practice The Clinic was originally funded by joint contributions from the Ministry of Social Services and the Ministry ofHealth. Both of these Ministries received funding from the federal government through the transfer payment system of the Canada Assistance Plan (CAP). Through this system, the federal government acknowledged its responsibility for promoting the health, welfare and safety of all Canadian children by providing cash payments to provinces under a cost sharing plan that earmarked funding for specific services. In addition to this funding, the federal government provided direct grants for research and education on child abuse (Baker, 1995). Under CAP, provincial ministries were able to allocate resources specifically for the needs of maltreated children. In April 1996, the federal government ended the CAP program and announced a new program to provide financial assistance to the provinces. This new Canada Health and Social Transfer (CHST) program radically changed the allocation of funds for Canada' s abused and neglected children. The CHST provides block funding and does not specify where the provincial government must spend the funds. As a result of this funding arrangement, it is not known how The Northern Child and Family Clinic 9 much funding will actually be allocated to social welfare and subsequently allocated to the subspecialty field of child abuse and neglect programs. In addition to this change, on September 23 1996, the British Columbia government announced a complete restructuring of the province' s child protection system and streamlining of child and family services. This is to be achieved by consolidation of services and programs from five different ministries into one new Ministry for Children and Families. The announcement was reflective of recommendations made by Cynthia Morton, the Transition Commissioner, who was appointed by the provincial government in February 1996 to assess the provincial child-serving system (Morton, 1996). One ofMorton' s recommendations concerning the operational priorities of the new ministry involved developing a budget for the 1997/98 fiscal year. She recommended that savings must be found through the " ... streamlining and integration of administrative and management services, contract management and the elimination of programs not serving clients' needs, so adequate funding is available for new services such as early intervention and prevention" (p.7). This recommendation heightened the uncertainty around funding allocation for the Clinic and pointed to the timeliness of a study that would explore the program' s usefulness. In addition, the interdisciplinary approach to service delivery used by the Clinic could serve as a model for other communities as they prepare to develop interdisciplinary teams and integrated services under the new Ministry for Children and Families. It is therefore critical that the variables that serve as barriers and incentives to the use of the Clinic be identified and described. The Clinic has been operational for four years and has not had a program evaluation. Needs assessments and feasibility studies were not completed before implementation of the The Northern Child and Family Clinic 10 program and proper outreach was not done to familiarize the referral sources with the Clinic process or the benefits of the service. In addition, the Clinic has funding to do research in the field of child abuse and has begun to explore various topic areas of research. It is fitting that a study be undertaken that will assist the Clinic and professional practice by developing hypotheses about the usefulness of an interdisciplinary approach to child maltreatment in northern British Columbia and also help fulfill the Clinic' s mandate to do research. It is also noteworthy that although MCF referrals from communities outside Prince George have been minimal since the opening of the Clinic, there have been more referrals from these sources during the last year than from local MCF social workers. This is occurring in spite of the obvious obstacles of travel and cost. Attempts to obtain concrete statistics on the number of child maltreatment cases investigated by MCF in the Clinic' s jurisdiction were unsuccessful. Service statistics are not kept locally and due to the recent creation of the new MCF, these statistics were not published consistently after January 1996 (R. Harvey, personal communication, June 12, 1997). An important regional, community and practice issue arising from this state of affairs is concern about where, and if, child victims of maltreatment are receiving appropriate services. In 1997, it was apparent to this researcher and the other clinic staff that the Clinic did not have any measure of the success or failure of the clinic program. The core team did not know if they were achieving clinic goals or if they were responding in a meaningful way. The Clinic had no way of knowing if the process in effect at the Clinic was the appropriate process to bring about positive change for the clients in northern British Columbia or if it should be revised. In addition, clinic staff did not know if the lack of referrals was a result of dissatisfaction with the service, lack The Northern Child and Family Clinic 11 of community and regional awareness of clinic resources, or other external circumstances that served as barriers to clinic referrals. It was vital that clinic staff and management take action to increase referrals if the Clinic was to remain a viable resource in the northern region ofBritish Columbia. In April 1997, as a result of these circumstances, the Clinic contracted with the Child Welfare Research Centre at the University ofNorthern British Columbia to conduct a survey of the Clinic' s referral sources to determine the cause for the lack of referrals (Hewlett, 1997). Building on the need to further evaluate circumstances at the Clinic, this supplemental study attempts to elaborate on specific factors that serve as barriers or incentives to the utilization of Clinic services. Literature Review Krugman (1984) cited in Untalan and Mills (1992), reports that the first multidisciplinary child protection team was formed in 1958 at the University of Colorado University Hospital. Its purpose was to discuss the diagnostic and therapeutic problems of cases of child abuse. However, the concept of using the multidisciplinary team approach to deal with the prevention and treatment of child and family problems was not heeded by the professional child welfare field until the late 1970s and early 1980s. The interdisciplinary foundations of the professional subspecialty field addressing child sexual abuse grew out of the concerns of several separate groups dealing with this problem in the United States in the 1960s and early 1970s (Corwin, 1988). Reference' s to intra-agency and interagency teamwork and multidisciplinary team models began to appear in major social work and child welfare texts and in professional social work literature in the 1970s (Madison & Schapiro, 1973). The Northern Child and Family Clinic 12 Although U. S. federal programs supporting the expansion of social services during the 1960s grew from social and political consciousness that emphasized broad social reform, Untalan and Mills ( 1992) concluded that the policies and services in the field of child welfare at that time were reactive, narrow, and tended to be residual. According to these authors many new programs were limited to provision of services that dealt with specific problems and as a result, families often received fragmented and conflicted services from multiple service providers. Untalan and Mills argued that ideally child welfare programs should provide comprehensive services to maintain and reinforce family functioning . They maintained that, by definition, effective resolution of child and family problems required interaction between different disciplines, and a highly coordinated service delivery system. The authors found little in the professional literature produced in that era that spoke to multidisciplinary team skills in child welfare practice. They found one exception in a 1959 Child Welfare League of America document that tried to define child welfare as a field of practice. The League recognized that child welfare services may be conducted by many different organizations such as schools, hospitals, law enforcement agencies, and courts, and that these services could all be considered child welfare services. The League specified that the child welfare worker role was to include coordination of multiple services by multiple providers and collaboration with other professionals and non-professionals to provide for the well-being of children. The authors pointed out that although the League referenced the need for collaboration, it did not specify a need for formal training and skills in multidisciplinary team development in its standards. Alexander (1993) explained that associations with other disciplines in the response to child sexual abuse have grown from the necessity for the expertise of different professionals as the process of disclosure, investigation, prosecution, and treatment unfolds. The nature of child The Northern Child and Family Clinic 13 sexual abuse demands intervention from many different professional disciplines (Leblang, 1979). Alexander (1993) and Reichard (1993) explained that the goals and purpose of intervention with the child victim are different among the disciplines working in this field. Traditionally, these differences have created conflict. Early co-ordination of the separate disciplines produced teams that were labeled multidisciplinary and although there was recognition of the need to co-operate and co-ordinate the services provided, the team members remained in their separate settings and operated under discipline specific procedures. Alexander reported this team structure often resulted in clashing reports about the same case. Since the 1980s at least four types of teams have been identified in the child welfare literature. Untalan and Mills (1992) offer the following definitions. Unidisciplinary teams are made up of people who practice only one discipline and work cooperatively on a single case. Multidisciplinary teams include people from different disciplines who work cooperatively to provide a variety of services to clients. These services are often coordinated by a case manager. Interdisciplinary teams have members from different disciplines who function together to provide coordination and monitoring of case input and progress. There are two types: those that provide direct coordinated services to clients and those that provide consultation to the coordinator of the case. Transdisciplinary teams include members of different disciplines but members may carry out tasks that are primarily the role of other members but are shared by the team. This type is based on the coordinated learning of the roles of other disciplines. The multidisciplinary and interdisciplinary approaches have been used most often in the field of child protection. Multidisciplinary and interdisciplinary approaches were pioneered by early child abuse specialists such as Kempe and Helfer through a hospital based child protection team in Denver, Colorado (Kempe, Silverman, Steele, Droegemueller, & Silver, 1962). The Northern Child and Family Clinic 14 The team at the Clinic is somewhat similar to the multidisciplinary type as it includes people from different disciplines who work cooperatively to provide a variety of services. It is dissimilar in that it does not provide the case management function. It also has some of the characteristics of the interdisciplinary type as clinic team members work together to provide services out of one facility. Unlike the interdisciplinary type however, the clinic team does not provide coordination and monitoring of case input and progress. Today, the child sexual abuse intervention literature strongly advocates the use of community interdisciplinary teams to respond to the problem of child sexual abuse (Bross, Krugman, Lenherr, Rosenberg, & Schmitt, 1988; Corwin, 1988; Daro, 1988; Faller, 1988; Furniss, 1991 ; Goldstein and Griffin, 1993 ; Harper, 1990; Johnson, 1993; Kellogg et al., 1993; Pence & Wilson, 1994; Sgroi, 1982). Many communities now have interdisciplinary teams working out of one location to respond to the investigation and treatment of child sexual abuse. The literature reveals varying models of the interdisciplinary approach to child abuse but all models include some combination of law enforcement or legal representation, child protection social workers, medical personnel, and mental health representatives. One of the fundamental goals of these teams is co-ordination of roles and integration of services in order to maximize the investigative efforts and minimize the psychological and physical trauma to the child victim (Kellogg, Chapa, Metcalf, Trotta, & Rodriguez, 1993). The literature on the use of multidisciplinary and interdisciplinary teams in child abuse and neglect shows the effectiveness of this approach. Fontana and Robison ( 1976) found this approach was successful in preventing the separation of families and improving the growth and development ofthe children involved. Starbuck (1977) found that team-handled cases had more favorable outcomes than non-team handled cases. Hochstadt and Harwicke (1985) suggest that The Northern Child and Family Clinic 15 teams perform a number of functions that increase service delivery to clients by reducing the fragmentation and duplication of services. Gilgun ( 1988) found that case decision-making tends to be enhanced by the sharing and discussion of observations of the abused child and family by the different members of a multidisciplinary team. Findings from a study of a rural Canadian multidisciplinary model of service delivery for dealing with child sexual abuse cases indicated that this type of service delivery model is more beneficial to clients than an uncoordinated model (Trute, Adkins, & MacDonald, 1994). Specifically, they found that many more families in the test community received treatment services (71 %) compared to only a small number of families in the comparison community (29 %). Further, they found that when investigation and treatment services were coordinated and when agencies collaborated in the investigation and early treatment of child sexual abuse, families recovered more quickly from the trauma of child sexual abuse. Goldstein and Griffin (1993) explain that the manner in which teams function internally varies among communities; however, the challenges facing team members, no matter what the team composition, are the same. The authors suggest an interdisciplinary team approach requires commitment, co-operation, communication, and co-ordination, and teams should be built upon the principals of good communication, mutual respect and trust, and the sharing of common goals and values. Goldstein and Griffin indicate that such teams provide important rewards including "more accurate conclusions, earlier and more effective therapeutic intervention and a fostering of the 'wholistic' [sic] approach to patient care" (p.93). The literature dealing with the interdisciplinary team approach to child sexual abuse is limited to: (a) descriptions ofteam and program implementation; (b) lists of principles for a successful team approach; (c) descriptions of goals that serve to make the job easier and more The Northern Child and Family Clinic 16 efficient for the professionals working in the field; and, (d) descriptions of the roles of the various disciplines working on these teams. The literature is written from the perspective of the staffwho work on these teams or from the perceptions of the authors as they interpret the professionals involved with these teams. There is much discussion about the benefits of the interdisciplinary process and the holistic approach to intervention. Nothing was found in the literature that was written from the perspective of the referral source describing their experience working with a multidisciplinary team. It is also noteworthy that although there was ample discussion in the literature about the issue of coordination and collaboration among the differing service ideologies of the disciplines that are involved in the multidisciplinary approach, nothing was found about the experience of using this approach with specific ethnic client groups such as First Nations or other populations who may have different philosophies about responding to child maltreatment. A greater understanding of the experience of referral sources is needed to guide program development and professional practice in the area of child sexual abuse intervention. Several authors report that the use of a multidisciplinary/interdisciplinary approach to child maltreatment stimulates an increase in the number of cases referred for service (Trute, Adkins, & MacDonald, 1994; Whitworth, Lanier, & Haase, 1988). There were no examples found in the literature of multidisciplinary/interdisciplinary approaches that brought about a decrease in child maltreatment referrals for service. Further, there was a gap in the literature about what action to take if this happened. Although some authors caution about community resistance and discuss the importance of including front line workers in the planning and operationalization of a multidisciplinary approach, no studies were found of implemented programs that were not utilized The Northern Child and Family Clinic 17 fully by referral sources (Trute, Adkins, & MacDonald, 1994; Whitworth, Lanier, & Haase, 1988). Bagley and Thomlison ( 1991) call for comparison and standardization of existing child abuse protocols as well as evaluation of programs where they are operationalized. These authors specifically mention the British Columbia protocol that is outlined in the Inter-Ministry Child Abuse Handbook (Ministry of Attorney General et al. , 1988) and suggest that in theory, it appears to be an excellent way to proceed. They recommend that a systematic description of how these protocols are used in practice is needed. In addition, these authors call for investigation ofhow these protocols and professional practice might be revised. The Clinic in Prince George is a prime example of one region' s attempt to operationalize this protocol and a study producing information that will assist with implementation of this protocol will be valuable. Meyers (1993) reviewed organizational theory, case studies, and evaluations of interagency projects to identify structural, resource, and implementation variables within agencies that serve as either incentives or barriers to successful service coordination. The author noted that organizational factors must be considered when developing strategies for service coordination. Acknowledging that her review did not reach '\Jnambiguous prescriptive conclusions about implementation" (p.568), she explained this is due to the small amount of available case study literature in the coordination of human services. In addition, the author cited the complex nature of interagency ventures as another reason for her lack of conclusive implementation prescriptions. Meyers cautioned that if all or some of the variables identified are crucial to implementation, then the best design and implemehtation strategy is likely to be location The Northern Child and Family Clinic 18 and project specific. She stated: The administration structures and organizational culture of participation agencies, the specific objectives of collaboration, the distribution of power and resources in the community, and the contingencies facing professional line staffwill create a unique set of incentives and barriers to action (p.568). A review of the literature found only eight integrated programs in Canada that utilized some model of the multidisciplinary approach to respond to child maltreatment, and that had undergone an evaluation (National Youth in Care Network, 1993). None ofthese programs reported a problem with a lack of referrals. It is the purpose of this study to discover and describe the unique set of incentives and barriers to local MCF child protection social workers' referrals to the Clinic in Prince George. By uncovering the conditions under which MCF social workers arrive at the decision to refer or not refer to the Clinic, action may be taken to create conditions or remove conditions that will make referrals to the Clinic more beneficial. This chapter has examined the rationale for this study. Specific issues from professional practice at the Clinic as well as relevant issues from the literature in the field of child maltreatment and program evaluation form the basis of this research. Chapter 3 will present the research design including a discussion of naturalistic inquiry and a description of the methodology chosen for this study. The Northern Child and Family Clinic 19 Chapter 3 Research Design The research design for this study is based on the axioms of naturalistic inquiry and grounded theory methodology. This chapter will present a discussion of these axioms and then a description of the methodology used for the study including data collection and data analysis procedures. Naturalistic Inquiry The purpose of this study is to discover and develop hypotheses about the specific conditions under which MCF child protection social workers are more likely to refer clients to the Clinic in Prince George and not to test a priori theory. This requires a research design that can be undertaken in the natural setting of the phenomenon in question, a design best suited to a qualitative approach within the naturalistic paradigm. This study will not focus on cause-effect relationships but will be concerned with establishing inferences and hypotheses about the conditions under which MCF child protection social workers make referrals to the clinic. Although findings are not generalizable to all settings, they may be insightful to program planners in some other settings that have similar contexts. The naturalistic paradigm will be used to guide the study. The axioms of naturalistic inquiry are well suited to the study of social/behavioral phenomena in general, and the specific professional practice area under study. The five axioms, as outlined in Guba and Lincoln (1982), will be examined in relation to the proposed area of study. The first axiom states that there are multiple, intangible realities that can only be studied holistically and that inquiry into these realities The Northern Child and Family Clinic 20 will inevitably diverge so that prediction and control are unlikely outcomes but some understanding can be achieved. The proposed area of study, the decision to refer, has no tangible reality in the physical sense. It is a phenomenon that is the result of many actions, values, beliefs, personal interactions, and circumstances that are found in the context of the referral source. These factors all contribute to the decision to refer and are variables that change constantly. The variables cannot be controlled due to the idiosyncratic context and circumstances of each individual involved in the decision-making. The naturalistic paradigm is not concerned with the tangible variables that make up this decision but the meaning and interpretations that make up the constructions of this decision to refer or not refer for each person. Guba and Lincoln (1982) state that " These constructions do not have reality but exist only in the minds of people" (p.239). Thus, there are as many constructions of the decision to refer to the clinic as there are referral sources who make these decisions. As these constructions reside in the minds of the referral sources and are therefore inaccessible, they cannot be divided into parts or variables and must be treated holistically. Therefore to control one variable in the decision-making process would not be useful as the aim of this study is to discover the whole decision-making process. Further, as the realities in the referral source context are multiple, it will not be useful to expect realities to converge. One cannot converge on a "common" reality as each person making the decision to refer will have a unique experience as they interact with clients and other significant people in their different contexts. Inquiry will therefore diverge as each different person' s experience is explored. The Northern Child and Family Clinic 21 This research will bring about an expansion of our knowledge about implementing the interdisciplinary process used at the Clinic. The aim is not to fully understand the broad concept of the usefulness of an interdisciplinary approach to child maltreatment but to build our understanding of the factors that serve as incentives and barriers for one type of referral source in northern British Columbia. The second axiom is about the inquirer-respondent relationship. Guba and Lincoln (1982) suggest that the inquirer and the "object" of inquiry interact to influence one another and the knower and known are inseparable. They add " ... one cannot abandon one' s humanness in the interest of'objective' inquiry ... ." (p.240). As the phenomenon under study is a construction in the mind of the referral source, it will be necessary to interact and use verbal conversation to obtain the individual' s perception of the decision-making process. This can only be achieved through close contact with and observation of the person. Only by using the inquirer as an instrument will it be possible to gather the facts and perceptions of the referral source. It is only through in-depth interaction that the totality of the MCF child protection social worker experience can be discovered. The third axiom is about the nature of truth statements. Unlike the rationalistic paradigm, where one is concerned with making broad generalizations, the researcher in the naturalistic paradigm believes the aim of inquiry is to "develop an ideographic body of knowledge in the form of working hypotheses that describe the individual case" (Lincoln and Guba, 1985, p.38). The naturalistic paradigm argues that in the social/behavioral sciences what is known to be true at one time and in one context may not be true in another time and context. Therefore, within this paradigm one rationalizes that generalizations about human behavior cannot be made with certainty. Human behavior is context bound and although there may be some measure of The Northern Child and Family Clinic 22 transferability or generalizability from one context to another, situations and contexts must be carefully examined before transfer can occur (Guba & Lincoln, 1982). Within the naturalistic paradigm one considers differences as well as similarities when making decisions about transferability. Guba and Lincoln ( 1982) suggest: It is as important to know the ways in which fit does not occur as to know the ways in which fit does occur. The naturalist, then, is concerned first with developing an adequate ideographic statement about the situation he or she is studying, accompanied by sufficient "thick description" to make judgments about transferability possible (p.241 ). The purpose of the study is not to isolate one "true" understanding of the phenomenon that occurs in the minds of referral sources when they are making the decision to refer or not refer. Nor is the purpose to prove that this phenomenon will be true of every referral source's experience. The aim is to develop an ideographic statement about the decision-making process and to obtain enough description about the process to make better judgments about the transferability of the process to another referral source or another context. The fourth axiom states that "all entities are in a state of mutual simultaneous shaping so that it is impossible to distinguish causes from effects" (Lincoln & Guba, 1985, p.38). Proponents of the naturalistic paradigm believe that causality is not conditional but depends on meaning. Therefore, they argue that causality is a construction of the mind and not a construction of some single reality. It is proposed that just as reality is constructed, so is causality. Guba and Lincoln (1982) argue that there can be no certain way of determining cause-effect relationships. Further, the authors suggest that action is not caused but is shaped from the " ... constant interplay of its shapers, all ofwhich are themselves part of the action, indistinguishable from it and shaping and being shaped simultaneously" (p.242). The Northern Child and Family Clinic 23 Within the naturalistic paradigm one does not find the concept of causality very useful for understanding a phenomenon. It is not the cause of the phenomenon but the meaning ofthe phenomenon that aids in knowledge building. It is not one specific action or event in the experience of the referral source that can be said to cause a specific decision to refer or not refer, but the holistic experience that makes up the decision. The aim is not to isolate the cause of the decision to refer or not refer but to discover what the referral decision-making process is. The fifth axiom is the assumption about the role of values in inquiry. From a naturalistic perspective it is maintained that inquiry is value-bound and that values cannot be set aside, controlled or eliminated (Lincoln & Guba,1985). Lincoln and Guba state that values may influence the study in five ways: (a) they influence the decisions about what to study; (b) they influence how and what interpretations of the data are made; (c) inquiry is influenced by the paradigm used to investigate the problem; (d) the inquiry is value-bound by the substantive theory and methods used to collect and analyze data and in the interpretation of findings; and, (e) the inquiry is influenced by the values that are found in the context and it is either value-resonant or value-dissonant and must be value-resonant to produce meaningful results. This axiom fits the referral source context where multiple realities and multiple value systems are found . Each MCF social worker brings experience laden with unique values and ideas about what will be useful to their clients. They also have different levels of knowledge about and familiarity with the interdisciplinary approach to child maltreatment. This divergence is the very heart of the problem of inquiry. What is needed is a paradigm that recognizes and may uncover these different value systems and explore how they relate to the rate ofMCF referrals to the clinic. In summary, the naturalistic paradigm is appropriate to guide an exploratory study of the MCF child protection social worker referral decision-making process where the goal is to achieve The Northern Child and Family Clinic 24 some understanding of the process and not to test preconceived theory about the referral decision-making process. Methodology The study uses qualitative methods because they are more adaptable to the multiple, less aggregatible realities inherent in the research context. Qualitative methods are more appropriate when the phenomenon under study is subjective and can be described but not easily quantified. In addition, qualitative methods allow close examination of the interaction between the inquirer and respondents and these interactions are necessary to assess meanings and understanding of the phenomenon. Qualitative methods are also more appropriate when verbal descriptive data are sought. These methods are also required to adapt to the mutually shaping influences and value patterns found in the context of this study. Grounded theory methodology (Glaser & Strauss, 1967) was chosen for this research for a number of reasons. First, Gilgun ( 1994) advises that grounded theory procedures are relevant to the development of practice knowledge. A goal of this study was to add to the development of practice knowledge by discovering and describing the incentives and barriers to MCF referrals to the Clinic. The intent was not to measure a priori theory and test preconceived hypotheses about the interdisciplinary approach but to develop hypotheses and practice knowledge from the data. Based on recommendations ofLincoln and Guba (1985), the researcher' s intent was to have the guiding substantive theory emerge from the data as a priori theory could not encompass the multiple realities found in the research context because: (a) the inquirer does not want any preconceived notions of what the respondent' s answers should be; (b) a priori theory generalizations may not fit with the clinic context and there may be properties of the referral source experience that are unique to this specific referral source setting; and, (c) grounded theory The Northern Child and Family Clinic 25 is more likely to be responsive to the values found in the referral source context. Lastly, grounded theory is a general methodology and not bound by either discipline or data collection methods (Glaser, 1992). Glaser explains " ... it is a useful methodology for multidisciplinary studies, since it ties the varied perspectives together through the conceptualization of the data and its implicit social organization of processes and problems" (p.18). Grounded theory was thus judged as suitable for a study being conducted in a setting where multiple realities are found . Data Collection Procedures Following theoretical sampling procedures as outlined by Glaser and Strauss (1967), where the goal of research is to generate theory, data collection proceeded jointly with data analysis in order that data collection could be guided by the theory as it emerged from the analysis. A description of the participant recruitment and consent procedures, the research participants and the data collection method will be presented. Participant recruitment and consent procedures. The initial selection of participants was made based on the general problem area of the referral crisis at the clinic and the need to collect data from those people directly involved. A list of names of local MCF child protection social workers who had taken part in a previous study completed by the Child Welfare Research Center at the University ofNorthem British Columbia (Hewlett, 1997) and who had indicated an interest in participating in further research, was used to obtain the initial participants. From this list, seven MCF child protection social workers were telephoned to confirm their continued interest. Of the seven people telephoned, five people responded positively. These five potential participants were then sent a package outlining the purpose of the research, the research question and a summary of what their role would be in the study. In addition, a statement of confidentiality and an interview guide was included. A copy of the The Northern Child and Family Clinic 26 interview guide is provided in Appendix A To ensure that all participants were voluntary, each person was asked to confirm their willingness to participate only after reading the material sent to them and by returning the enclosed consent form to the researcher by mail. Two people returned the consent forms immediately. These people were contacted again by telephone and appointments were made to conduct an interview at their convenience. The three remaining potential participants were contacted a second time by telephone after several weeks to inquire if they were still interested. All three affirmed their interest and appointments were made for their first interview. Of these three people, one person had to withdraw for personal reasons. Foilowing preliminary analysis of the first interview where the analytical framework began to emerge, it was apparent that some variation among participant characteristics would enhance data analysis. By maximizing the similarities and differences among participants it was believed that analysis would be enhanced. Glaser and Strauss (1970) explain " From these similarities and differences are generated the theoretical categories to be used, their full range of types or continuum, their dimensions, the conditions under which they exist more or less, and their major consequences" (p.293). Two additional child protection social workers were chosen from a general list ofMCF staff As child protection social workers in Prince George are assigned to different teams, it was believed that some variation could be achieved by selecting participants from different teams and also by selecting participants with various lengths of experience working with MCF. The first two people on the list who fit this criteria were contacted by telephone and agreed to participate. The previously described steps of sending information packages and subsequently contacting potential participants by telephone to book appointments for the interviews were followed. The entire participant selection process was lengthy and continued over a period of four months. This The Northern Child and Family Clinic 27 was partly due to the busy schedules ofMCF child protection social workers and several unpredictable delays. Research participants. A total of 6 participants, 5 females and 1 male, took part in this study. Participants ranged from 27 to 49 years and all participants had at least a bachelor level university degree. Three held B.S.W. degrees. Two held bachelor degrees in other fields. The final participant held a degree at the master' s level. Their length of employment with MCF varied from 1.5 to 9 years and all participants had used the services of the Clinic in some way. None of the participants had ever received any specific training or education in the area of the multidisciplinary approach to child maltreatment. Data collection method. The method of data collection was in depth open-ended interviews. The researcher was the data collection instrument. An interview guide which was comprised of only the research question was used initially to focus the interviews but the researcher encouraged the participants to take control and make decisions about what and how much information they were willing to share. Each interview was audio taped after obtaining signed informed consent from the participants. In addition all participants were informed that the tape machine could be turned off at any time during the interview if they preferred not to be tape recorded. To protect confidentiality, each participant was assigned a specific colour and each tape was colour coded for identification purposes. During a six month period of time, one interview was completed with each participant. Three participants chose to be interviewed in their own homes. Two participants preferred to come to the researcher' s home and one participant chose to be interviewed in his/her 1 office 1 His/her or he/she will be used throughout to protect the identity of participants. The Northern Child and Family Clinic 28 environment. The interviews ranged from 1 to 2.5 hours in length. A total of 10 hours of audio taped data was collected. Upon completion of each interview, participants were asked if they would agree to be contacted once the data analysis was completed to meet with the researcher and review the findings . The purpose ofthis meeting was to have participants check interpretation of the data and to explore areas that were not clear in the initial interview. All participants agreed to take part in these follow-up meetings. Five participants met with the researcher in person and one took part in the follow-up process by telephone. Data Analysis Procedures All audiotapes were transcribed verbatim immediately following each interview. Transcription conventions were used to capture the emotional content of the interviews and served to alert the researcher to areas that were particularly important to the participants. They also helped clarifY specific meanings of the participants when their words alone could have been ambiguous. In this way, data analysis began even while the transcription process occurred. These conventions actually helped the researcher "re-live" the interview process and experience the participants again. Some of Lindsay' s ( 1996) transcription conventions were used in addition to some that were developed by the researcher. See Figure 1 for examples. A complete list of transcription conventions is provided in Appendix B. Each transcribed interview was then divided into idea units. Idea units are defined as each separate idea or thought within each comment made by the participant and the researcher as judged by the researcher. The Northern Child and Family Clinic Identification Transcript Symbol Explanation .. double period longer than normal Code 11GG90 Just a lumpy couch~ and all pause between that .. equipment propped up under their nose cause we're all worried we're not going to hear EVERY BREATH AND SOUND .. 11GG91 and then they're looking straight ahead at that two way glass again. I mean, words Times New Roman Special Emphasis-words Font 14 clearer than normal Upper case letters accelerated speech font 14 higher than normal voice volume I sit there and stare at the glass in location in tum vocalization- laughs and the kids do too. in Arial Font chuckling, laughing, giggling, Very uncomfortable. 11GG92 groans, tongue clicking Like I WOULD HAVE MORE RUGS TO SIT ON THE FLOOR WITH THE KIDS YOU KNOW, SIT UP. Kids don't sit up when they are two years old on the couch formally. They sit on the floor. They hang out, they play .. and they like bean bag chairs and just comfortable things. Figure 1. Sample of transcription conventions and identification codes. font 10 lower than normal voice volume 29 The Northern Child and Family Clinic 30 Thus within lengthy comments more than one idea unit was often found. Each idea unit was given an identification code to protect the identity of the participant and to allow the researcher to track the interview data. For example, the first comment in the first interview with participant "green" was given the code Il GG 1. Il represents interview number 1. "G" translates into "with green" and "G 1" translates into the first comment made by green. To continue this example, the fifth comment by the researcher in the interview with green would be coded as I 1GL5 . "L" represents the first initial of the researcher's first name. Figure 1 reveals how these codes were applied . Following the selection of idea units and application of identification codes to each unit, the transcribed interview was entered into the Nud*ist (1994) computer data analysis program. Using the data analysis procedures of grounded theory, as outlined by Glaser and Strauss ( 1967), and using the constant comparison method of analysis, each idea unit was examined, first to identify incentives and barriers, and second to identify what conceptual incident it represented. Each incident was given a conceptual label and constantly compared to each other unit in the data. Similar incidents were given the same conceptual label and different incidents were assigned different conceptual labels. Nud*ist was helpful during this stage of the analysis as it has a method for storing and keeping track of the conceptual labels. In addition, the computer program displayed these concepts in a tree format that was useful to continuously visualize what had been coded previously. After coding all of the incidents in the first interview, and following the procedures of open coding (Glaser & Strauss, 1967) similar concepts were grouped together into categories and properties of categories were articulated. Foil owing a period of reflection and once the relationships between the larger categories became evident, a theoretical framework began to emerge. It was then necessary to return to The Northern Child and Family Clinic 31 Nud*ist and continue coding the rest of the interview transcripts. As each subsequent interview was analyzed, additional categories, subcategories and their properties emerged as idea units continued to be compared. Coding continued until the researcher could find no new categories in the data. Figure 2 shows an example of category, subcategory and concept definitions that emerged from the conceptual labels given to the incidents identified in the text. A complete list of definitions is provided in Appendix C. Figure 3 displays an example of the connection between interview text, categories, subcategories and concepts. A more extensive sample of the connections between interview data, categories and concepts is presented in Appendix D. This chapter has presented a description of the research design through a discussion of the axioms of naturalistic inquiry and an outline of the methodology used in this study. It has explained that grounded theory methodology was appropriate for a research project that aimed to develop practice knowledge through discovery and description ofMCF incentives and barriers to referrals to the Clinic. The incentives and barriers will be examined in Chapter 4 as the findings of this study are presented. The Northern Child and Family Clinic ~ Subcategory Concept Place of Expertise: A physical environment where specialized skill and knowledge in a particular field are found. Muhidisciplinary Approam: Conditions that promoteMCF mild protection social worker referrals to the Northern Child and Family Clinic One stop shopping Definition having all the services offered out of one place at the same time Subconcept doneatonce, rigbtaway One Location out of one place Needed Service Components the different service fum1ions needed by MCF social workers Holistic whole thing looked at from everybody' s perspective Broader Mandate Child-centered make the whole investigative process really comfortable for kids Comfortable environment Child' s pace Child-focused Accessibility Team expertise Collaborative Clinic Practice Mutual Respect and Status Commitment to Mutual Goals service available on a regular basis, or when you need it Immediate Service Professionals who are "qualified or able to do the kind of exam that needs to be done" Specialized training Actions that promote co-operation, equality and working together having equal respect for and recognition of other professionals' area of expertise actions demonstrating agreement with the goals ofthe clinic Definition Timelines Flexibility Extensive experience Specialized Knowledge Direct Personal Contact expanded service informal process clinic process proceeding at mild' s speed and attention level undivided attention to mild rigbtaway the ability to accommodate unpredictable need lots oftraining well seasoned; lots of front line work really knowing what mild protection is about meet in person Ongoing Contact long term involvement Group Decisionmaking arriving at decisions collectively Direct, Shared Communication easy open verbal exmange with all people involved Coordination of roles clear specific protocols for roles and responsibilities acknowledgment of all areas of expertise Recognition Equality Training and Education Information about the Clinic Workload adjustment Encouragement to use Figure 2. Example of category, subcategory, concept, and subconcept definitions. all persons having the same level of authority provision of knowledge in the area of mild abuse timely provision of accurate facts describing clinic functions employer provisions for time spent at the Clinic actively promoting the Clinic as a viable resource; making Clinic use standard practice 32 The Northern Child and Family Clinic Categories Place of Expertise Subcategories Multidisciplinary Approach Concepts One stop shopping Subconcepts Timeliness: done at once, right away One Location: out of one place Needed Service Components: the different service functions needed by MCF social workers holistic: whole thing looked at from everybody' s perspective Broader Mandate: expanded service Childcentered Comfortable environment: informal process Child' s pace: clinic process proceeding at child' s speed and attention level Link to Text Well, back to sort of the focal11oint of it in that its multidisciQiin;yy. The one stQQ shQI!Qing a§l!ect. Urn, you can sort of go in and you ga evervthing sort of done at once. Urn, that's useful for us in the sense that sometimes we need that information, right away, to daermine what the protection criteria is. Urn, two, its often good for the parent because even though its overwhelming in the beginning. there's a certain sense of relief in havin!! e;ervthin!! done ri!!ht awav 110014 so that having all of the services offered out of one11lace..... is, is a real incentive 11BB5. if you wanna do the clinic..... do it right, do it full time, have all of the services there.... that are needed Right? To have your ~ or... ~ investig;!tors....with that multidisciQlina[Y team with your h ~ with your ah ...Qediatrician ..... and stuff I mean I see that as ..... It makes Qerfect sense to me. That's what makes, that's what makes more sense to me..... and it's out there investigating ahm... sexual abuse or serious physical abuse. IIBB240 Because the.....the kids we're coming across these days are ahm.... so complex.._like multi- problems ahm, stuff that's just not.... .not clear and, andj think it needs a multidisciQlinaJ:Y a1111roach, I mean it can't just be the medical model.... I think the whole ahm ...thing needs to be looked at from everybody's Qerspective. That would be really neat. That would be.. see that would be a good service .. for the clinic to offer. 11BB178 Urn, I'm thinking. I think it would be really it would be great if there was a Qerson like a social worker or a theraQist or someone there who would if there were referrals needed to be made on behalf of that family or that child that they would make them there. They would sort ofthe referring agents, vou know. 11RR162 An ~ kind of mandate uh to address other uh you know concerns and in terms oftheirwell being as a child and I sort of talked a bit sort of mental health concerns I talked about neglect you know a you know a broader sort of mandate for me. I1RR240 Before it gas, like it almost needs to feel like you're just walking into daycare. That would be my Qercq>tion of it. Nice fluffY couches, no more chairs, no more desks. Pop the computer somewhere where you can't see it. Just make it a very informa!Qrocess and I think that would be very, that would make families more comfortable 110027 My gut instinct is we should have just examined her immediately or that information should have been gotten earlier without the child in the room. Kid should have been able to go Qiay and stuff Because that physical space for her was the I'm bored now ... my ~ c would have been Ia her go Qlay with the doll for awhile and then we'll come back to the medical exam and instead .. it was pushed to keep her in the room and I disagree with that 110056 Figure 3. Example of category, subcategory, concept, and subconcept connections to text. 33 The Northern Child and Family Clinic 34 Chapter 4 Findings The findings of this study will be presented in terms of the theoretical framework that emerged from the data analysis. The major categories, subcategories and concepts can be seen in Figures 4 and 5 and provide insight into the incentives and barriers for MCF child protection social worker referrals to the Clinic. This chapter will describe the theoretical connections between the categories, subcategories and concepts that make up the entire framework. The incentives will be presented first and then the barriers. Incentives The participants identified several factors that appeared to be incentives for utilization of the Clinic. These included characteristics ofthe multidisciplinary approach and aspects of integration. The first of the multidisciplinary approach characteristics was one stop shopping. One stop shopping. One stop shopping was described by participants as having all needed services offered out of the same place at the same time and offered in a timely fashion. The one location for all services and timeliness aspects are highlighted in the following comment: The one stop shopping aspect. Um, you can sort of go in and you get everything sort of done at once. Um, that's useful for us in the sense that sometimes we need that information, right away. Um, two, its often good for the parent because even though its overwhelming in the beginning, there's a certain sense of relief in having everything done right away.2 2 Italics in regular size font represent participants' speech from interview transcripts. The Northern Child and Family Clinic PLACE OF EXPERTISE MUltidisciplinar ~ o ch I Collaboration Child-Centered Meaningfulness Accessibility Legitimate Inclusion Team expertise Utilization of Clinic Mutual Respect and Status Commitment to Mutual Goals Figure 4. Incentives. Capitals indicate categories Courier New font indicates subcategories 5 Regular font indicates concepts 4 Integration of MCF,Social Workers One stop shopping 5 Collaborative Clinic Practice 3 3 35 The Northern Child and Family Clinic SHOWPIECE6 I Inappropriate Design 7 Missing or Unsuitable Service Components8 Powerlessness Client Intimidation Meaninglessness Inaccessibility Isolation Lack of Team Expertise Self-Estrangement Uncollaborative Clinic Practice Normlessness Hierarchy Lack of Commitment to Mutual Goals Figure 5. Barriers. 6 Capitals indicate categories Courier New font indicates subcategories 8 Regular font indicates concepts 7 I Alienation 36 The Northern Child and Family Clinic 37 Although the participant acknowledged that the client may be overwhelmed initially with the prospect of going through everything at once, the participant believed that the relief experienced by the client when everything was done immediately, outweighed the client's original discomfort. Not only did the one stop shopping aspect offer immediate service benefits but it was also seen by the participants as being more convenient for clients. This is expressed in the following example: I guess another incentive probably would be the fact ... that its kind of one stop shopping which is very useful for clients especially if they don't have a car or if they don't want to be running around to all these different places. Another valuable aspect of one stop shopping that was identified by the participants was the type of discipline components that were needed to help them do their job. They believed that one stop shopping should include investigation components as well as medical and mental health components. One participant said: if you want to do the clinic.. do it right, do it full time, have all of the services there .. that are needed right? To have your expert or... expert investigators.. with that multidisciplinary team with your therapist, with your ah. ..pediatrician.. and stuff The investigation components were further defined as police and child protection. One participant clarified: to have them going to one place, ahm .... say for the RCMP interview where every.... where all the information is gathered, sort of in one place. Another participant stated: have the child protection happening too.... out of there. One participant expressed the need for the multidisciplinary approach to be holistic by stating: I think it needs a multidisciplinary approach, I mean it can't just be the medical model.... I think the whole... thing needs to be looked at from everybody's perspective. All participants indicated that one stop shopping meant a broad service mandate. They indicated a need for the provision of a variety of services that would respond to the needs of all The Northern Child and Family Clinic 38 types of child abuse, not just sexual abuse, and all types of child abuse victims not just those in need of protection. In addition, participants described specific aspects of these services that would be helpful. The following example illustrates how one participant thought that it would be beneficial for one stop shopping to include having responsibility for referring clients on to other agencies or services if they were required, instead of placing that responsibility solely on the child protection social worker: it would be great if there was a person like a social worker or a therapist or someone there who would, if there were referrals needed to be made on behalf of that family or that child. that they would make them there. They would sort of be the referring agents, you know. Another participant identified a need for services to address mental health and neglect issues: An expanded kind of mandate uh to address other, you know, concerns and in terms of their well being as a child and I sort of talked a bit, sort of mental health concerns.. I talked about neglect ... Several participants suggested there was a need to provide child abuse education to families who do not qualifY for child protection services from MCF but who have ongoing concerns in that area. It was noted by the participants that some families have suspicions of abuse or have alleged abuse but are not in circumstances that warrant child protection involvement. The participants believed there was a gap in services for these families and that clients would benefit if the Clinic could provide educational and crisis counselling services. One participant explained: Ahm ... in terms of our mandate ... he's not a kid in need ofprotection, he has a protective parent, the alleged offender is not an adult... we get a Iotta those. So that's something that, that's a piece the clinic could pick up that would really be helpful. Because we don't have the time to be.... be doing that. The Northern Child and Family Clinic 39 Another property of the broad service mandate was identified by one of the participants as the need to provide specific services for the First Nations population as the majority of his/her clients are from that ethnic group. The participant suggested that a First Nations representative on the team at the Clinic would be more helpful than the current on-site social worker: The majority of our clients are native and it's pretty white over at the clinic. But I just wondered if that's ever been looked at or considered in terms of even ifyou 're talking about a multidisciplinary team .. but including a native person, a native family support worker as part of that team. So I think I see that.. I see sort of a person like that as more important than a sort of. an on-site social worker. Child-centered. It was also discovered that participants valued an approach that was child-centered. According to the participants, child-centered meant a comfortable environment which was characterized by an informal process that proceeded at the child's pace and also was child-focused. The following comment expressed the child-centered concept: ... like it almost needs to feel/ike you're just walking into daycare. That would be my perception of it. Nice fluffy couches, no more chairs, no more desks. Pop the computer somewhere where you can't see it. Just make it a very informal process and I think that would be very, that would make families more comfortable. The child-pacing aspect of child-centered was described by the participants as having the child proceed through the different components of the multidisciplinary process at a speed that was consistent with the child's developmental level. The participants believed that to achieve the goals of assessment, it was vital that the child's sense of time be accommodated. One participant suggested that a medical examination be conducted in stages if that was what the child needed: The Northern Child and Family Clinic 40 My experience would have been let her go play with the doll for awhile and then we'll come back to the medical exam. The child-focused aspect of the child-centered characteristic was valued by participants and described as providing undivided attention to the child. One of the participants illustrated this concept by comparing his/her experience of taking a child to a community pediatrician' s office with his/her experience of taking a child to a pediatrician at the Clinic where enough time is allotted for only one child to attend at a time: When you go into their office they've got all the other patients sitting there. And you can sense that they're tense, because it's taking time and you know they're in a hurry. And that when you go to the clinic it just seems like they can really focus all their attention on the child and I think it comes across.. for the kids, it comes across quite differently ... Accessibility. Another incentive that emerged was accessibility. All child protection social workers expressed emphatically that the service must be available on a regular basis or when they need it and that it must be flexible and have the ability to accommodate their unanticipated needs. The participants explained that the nature of child protection work is mainly crisis-oriented and unpredictable so they are not able to plan ahead for services. They emphasized that when a child discloses abuse they need service immediately. One participant illustrated: I mean, you know, seven days is probably a bit excessive, but I think five days a week. .. .even ahm... .five half days a week would work. A h. ...in terms of. so if there's any, any kind of trauma to a kid, we can take them for immediate assessment and that avoids the whole trip to the emergency room. The need for flexibility is underscored by this participant: Um, for the simple fact that we can't decide when a kid's going to disclose and when they're not. There's no schedule or pattern for that. It needs to be completely flexible. The Northern Child and Family Clinic 41 Team expertise. All participants indicated that team expertise was an incentive. Team expertise was described as having team members who were qualified to do the type of work that needs to be done and who had specialized training, extensive experience, and specialized knowledge in the field of child abuse. The general consensus was that a multidisciplinary team responding to child abuse needed to include people with child protection expertise as well as the other areas of expertise. The participants believed that in order for the place of expertise to be worthy it needed to have a team that was more knowledgeable than they were about child protection matters. Expressed another way, the team should have specialized knowledge that would enable the child protection workers to gain something from utilizing the place of expertise. This was expressed in the following example: The other thing too is to have ahm .. the training the people at the clinic have .. . so the expertise at the clinic is ahm ..is really important ... Yeah. I think the person in there needs to be.... very well seasoned and you know, lotsa training and ... ahm... lotsa.front line work. But really too, that clinic, you know, you need somebody there I think that really knows the .. you know what protection is about. Collaborative Clinic practice. Collaborative Clinic practice seemed to be another incentive. It was described by the participants as the Clinic team acting in ways that promoted cooperation, equality, and working together with child protection social workers. The participants suggested that direct personal contact, ongoing contact, group decision-making, direct shared communication and coordination of roles were aspects of collaborative Clinic practice. The need for direct personal contact between the participants and the Clinic team was seen as being vital as the child protection social workers were the people who had the most knowledge about the client and were responsible for carrying out any recommendations made by The Northern Child and Family Clinic 42 the Clinic team. One participant said: I would be happy to go to make an appointment with the receptionist take the kids or the parents or both in, and talk directly to the doctor myself You know I don't really need that person in.. that middle man you know. Ongoing contact between the child protection social workers and the Clinic team was seen as a method ofbringing all players closer together. The participants pointed out that if they had the opportunity for regular consultation as opposed to a one time visit to the Clinic, collaboration would be enhanced. One participant suggested: in terms of the clinic and in terms of consultation ahm.... multidisciplinary consultation would be really nice .. I mean we're getting some pretty bizarre kids.... with outrageous behaviours. I mean I'm ... really stumped, you know, what's going on with this child. And that kind of consultation would be really helpful. Another participant explained that ongoing contact was needed to feel more connected to the Clinic team: So I think in order to, to be less removed you guys would need to have sort of more longer term involvement. Collective decision-making was another activity that was seen as a necessary component of collaborative Clinic practice: But we would sort of decide really decide as a group and that would include the family. Participants explained that direct communication that is shared with all people involved and is characterized by easy and open verbal exchange, was an incentive: ... that same sort of easy open communication ... There should be another way of communicating if all these people are involved and that sort of the purpose is to involve all the players. Coordination of roles was defined by participants as the development of clear specific protocols that specify who has what role and who has what responsibility. In addition, coordination of roles was identified as being essential to collaborative Clinic practice. The The Northern Child and Family Clinic 43 following example illustrates the point: Ahm..... have very clear, specific protocols in place around how things are done and who's ah. .. responsibility or role is what. Mutual respect and equal status. The participants explained that recognition of all areas of expertise and equality of team position and rank were vital ingredients. These concepts are revealed in the following example: I mean a multidisciplinary team needs to have ....people need to have respect for other people's area of of expertise right.. more mutual respect.. she needs to work more as a team player. Commitment to mutual goals. A commitment to mutual goals emerged as another incentive for referral. The participants indicated that all disciplines that were part of the Clinic should demonstrate through practice that they are in agreement with the goals of the approach. The participants distinguished four types of practice that would demonstrate all discipline components were in agreement with the same goals. The first practice was training and education. Participants believed they needed to be trained in the multidisciplinary approach to child abuse before they could understand how it could help in their work. One participant suggested: I think it would be kind of interesting if they would consider some kind of educational component for workers as well because as I mentioned to you before we get very little training about abuse.. The timely provision of accurate factual information about the Clinic was seen as another practice that would demonstrate a commitment to mutual goals. Participants believed that ifMCF was committed to the approach, MCF would ensure that child protection social workers had all the information they needed to facilitate that use. This concept is heard in the following comments: I uh think it might be useful if the clinic staff or someone on staff actually made an effort to.. because we.. there are so many new workers.. I guess from time to time, to come over The Northern Child and Family Clinic 44 and talk about the clinic and talk about the services and talk about sort of you know the communication system and all that kind of thing and to refresh people like me. Workload adjustment appeared as another practice that all participants believed would demonstrate a commitment to mutual goals. The participants indicated that it would be necessary for MCF to restructure workloads or make provisions that would free up some time for them to use a multidisciplinary approach. One participant said: I mean the time ....factor is still an element. It is probably about two hours or an afternoon. ... that we spend there. Ahm...but you can't get away from that. And I think it is preferable that we are there because we are the workers. But you do have to book off time to be able to get there. The final practice that emerged as an incentive was explicit encouragement from MCF to use the Clinic in their daily practice of doing child protection work. One participant explained: There's no supervisor to say, so guys how are things going have you had anybody at the clinic or you know.. are we using that facility, you know it's one of ours remember. I've never heard anybody say that. But that's the kind of thing that needs to be happening. The multidisciplinary approach. In summary, seven specific incentives for referral to the Clinic were identified by the participants. Grouped together, these incentives appeared to comprise a model of the multidisciplinary approach to child maltreatment. In addition, the participants implied that these incentives were related to four additional, more complex incentives. A description of these additional incentives will be followed by an examination of the connection that appeared to exist between the seven previously described incentives and these four more abstract ones. The Northern Child and Family Clinic 45 More Complex Incentives The first more complex incentive was collaboration and was described by the participants as working together, having equal power and sharing responsibility for child protection. The second was meaningfulness and it was outlined as feeling that the multidisciplinary approach had value and was worthy and useful to the job of child protection. Legitimate inclusion was the third additional incentive and was distinguished as recognition of the unique skills and expertise of child protection social workers. The fourth concept was regular utilization of the Clinic and was depicted as incorporating the multidisciplinary approach into the day to day standard practice of doing child protection or making it a practice norm. It appeared that each of the seven previously identified incentives related to one or more of these more complex incentives. Each of the initial seven incentives will be examined individually to illustrate these connections. One stop shopping. It appeared that the inclusion of all needed discipline components aspect of one stop shopping was meaningful to participants and related to utilization of the Clinic. This example shows that inclusion of the child protection component is meaningful and is connected to utilization: I think that.... the expansion of services and the focus of it being child protection, right? So.. getting a team together at the clinic that, that you know, to look at it from a multidis.. .you know, multidisciplinary approach and support for the line workers so that they in turn can. ..deal quickly and ah. .. .efficiently with the family. And ah. ...y eah, that'd be neat. Child-centered. The child-centered aspect was considered to be meaningful and connected to utilization of the Clinic. All of the participants valued an approach that would make children more comfortable and respond to the child' s needs. In addition, child protection social workers believed that a comfortable environment was vital to obtain the information they needed from the The Northern Child and Family Clinic 46 children and they indicated they would prefer to use a Clinic that was sensitive and designed to reduce the trauma of the whole investigation process. All participants indicated that if they had the choice, a child-centered environment would be used instead of taking children to the busy emergency department at the hospital. One participant remarked: I think they do an excellent job in terms of making children feel comfortable or as comfortable as they can. I really thank them. It's by and large a much better sort of situation than taking a family down to emergency at the hospital.. much better. Another participant remarked: Well..... environmentally it's a much nicer place to go than the hospital. At the clinic, it's sorta out of the way, it's more private.. ahm.. there's generally not lots of other people in there that you're gonna run into. I think that in itself is a real incentive. Accessibility. Accessibility was seen: (a) to be meaningful; (b) to be connected to collaboration; (c) to relate to the legitimate feeling of inclusion; and, (d) to be connected to utilization of the Clinic. Participants indicated that a multidisciplinary approach needed to be available on a regular basis to be valuable to their work. If it was accessible when they needed it, it would be meaningful. If they could use it on a regular basis, they would have more direct contact with the Clinic and feel that there was a genuine sharing of responsibility for child protection. The participants indicated that a multidisciplinary approach that was designed to accommodate their needs would make them feel included, feel supported and feel a legitimate part of the whole multidisciplinary process. This example illustrates how accessibility was valuable and helped the participant feel that her needs were recognized and supported: And ah. ... having the clinic more available is a, is a really big one. And ah. ... one of the best..... situations I ever had, which was unusual for the clinic... . but shouldn't be, is I went out on a call, so I asked.. can I get this, you know, this kid into the clinic and she said well it just happens the doctor's here The Northern Child and Family Clinic 47 and .... the other appointment fell through. So I feel that's the kind of response the clinic needs to have you know, real support to the kid.... immediate support to the kid, to , and to the field Another participant had similar feelings: If we could get in..... and not book so far in advance.... if I could pick up the phone and know that there's a doctor there five days a week and phone and say.... this is what I've got and you guys have space available, I would go there. I mean it's a definite benefit for me ... If I could do that, I would use it more often. Participants also indicated that if the Clinic was available on a regular basis, it would become part of their day to day way of doing child protection. If it became a practice norm, child protection social workers would feel that the process was set up to help them protect the child and they would feel they were a legitimate part of the process. The following comment illustrates how accessibility is meaningful and is related to utilization of the Clinic as a standard of practice: Again, if the clinic was always there, then that would just be part ofyour practice.... that okay, I will... like I'll phone the clinic and... ahm.... and they'll be able to see this kid and .. I'll know its taken care of Team expertise. All of the participants emphasized the need for team expertise. This meant having multidisciplinary team members who are qualified and able to do the type of assessments that are needed to protect children. In their opinion, inclusion of an experienced, well trained and expert child protection worker on the team along with the medical and mental health expertise, was necessary to make it meaningful and useful. This was needed to legitimize the unique skills and knowledge of the child protection social workers and to help them feel confident in the results of assessments done by the multidisciplinary team. The participants believed a child protection expert on the team could offer them guidance, support, direction, and genuine recognition and understanding of the role of child protection. Participants indicated they The Northern Child and Family Clinic 48 needed to respect the expertise of members of the team before they could confidently follow any recommendations made by the team and find meaning in this type of approach to child protection. One participant explained that the MCF position on the multidisciplinary team at the Clinic was a coordinator position and that the qualifications for that position did not require child protection experience. It appeared that meaningfulness and utilization of the Clinic was related to an MCF position that was filled by someone who had child protection expertise. One participant stated: Had they put somebody there with experience, somebody who was respected by the line staff and the supervisors, and management, they would have had a different clinic. That's part of it. That's definitely a part of it. One participant explained that all child protection social workers do not have the same level of expertise and that they would welcome direction from a child protection social worker with specialized training in sexual abuse. Another participant implied that an expert child protection worker at the place of expertise would be meaningful, be necessary for collaboration and be important for utilization of the Clinic: What makes sense to me is to have a child protection worker at the clinic, full time. Not that they'll do it all, but they can direct.... the investigation. They can assess the information.... and they can support the line workers right? Ahm... because you know, they've got that level of expertise. And they had that expert training. Collaborative Clinic practice. All of the participants suggested that collaborative Clinic practice was valuable and was an incentive. Direct personal contact, ongoing contact, coordination of roles, group decision-making, and direct shared communication emerged as vital components of collaborative Clinic practice. Direct personal contact allowed the sharing of opinions and knowledge, and helped the child protection social workers feel that the multidisciplinary team members genuinely believed The Northern Child and Family Clinic 49 child protection social workers had something vital to offer. It was also related to feeling that they were recognized as an equal and legitimate part of the process. Ongoing contact related to shared responsibility for child protection and was connected to reduced feelings of isolation. Coordination of roles was identified by the participants as a necessary component of collaboration and was related to the reduction of role conflict and role confusion. Additionally, coordination of roles was described by the participants as being connected to feelings of legitimate inclusion by recognizing that all players had a unique part to play in providing the whole gamut of services that was needed to respond to child maltreatment. Group decision-making was related to collaboration, legitimate inclusion and equality among team members. Participants indicated that inclusion in the decision-making process made them feel valued and recognized as an equal partner in determining the best way to attend to client needs. Direct, shared communication was identified as being vital to achieving genuine collaboration and legitimate inclusion. Easy open communication was described as necessary to help child protection social workers feel more comfortable using a multidisciplinary approach on a regular basis. They indicated that this type of communication was connected to feeling that there were other people who cared about and supported the work they did. The following statement reveals that direct contact and shared communication with the multidisciplinary team was meaningful to the participant because the child protection worker had a necessary role to play and was responsible for ensuring any recommendations made by the team were dealt with: If there's anything.. sort of a discussion afterward, I really like to talk to the parents and the doctor and I like to know what's being told to the parents. So I really know when it.. .. calls have to be done or The Northern Child and Family Clinic 50 anything has to be done and I really think it's important for me to know what the parents' reactions are to information they're given. Another participant found meaning in direct contact, shared communication, and the group decision-making process: You don't just go in and get it done. Ahm... I really like when the medical piece is done .... everybody sits around and we have a discussion about what's..... been found, instead of the doctor just coming over and telling you, like what happened in emergency. The whole process itself I find is much better ... One participant explained how working collaboratively produced benefits that could not be attained working in isolation: Like even for me as a worker, like I said you share the responsibility a little bit cause it's.. you know it's nice to have some fresh new ideas too. Cause lots of times, you know you can go through the whole case and you miss things and somebody just throws in sometimes just one word you never thought about.. so it's the knowledge and the support both for the kids and for the workers. That's what I found really positive. Mutual respect and status. The participants indicated that to be meaningful and utilized, the Clinic needed to value equal recognition of the opinions and knowledge of all areas of expertise including child protection, and that no specific profession or discipline should have power over the others. It seemed that mutual respect and status was an incentive for the child protection social workers as it meant they were genuinely included in the multidisciplinary process in a manner that communicated to them that their opinions were needed and valued as much as those of the other team members. The following example illustrates that mutual respect is an incentive for referrals to the Clinic: I think it would be really beneficial if ( ' ) would be more respectful to clients and workers. Ahm.. that would make a big difference. I think people would be more open to going. The Northern Child and Family Clinic 51 Commitment to mutual goals. Commitment to mutual goals by all parties involved in responding to child abuse was deemed essential for Clinic utilization. Participants signified that specific practice by MCF that demonstrated agreement with the goals of the multidisciplinary approach was connected to regular use ofthe Clinic. This practice included: (a) the provision of training and education in child abuse to help child protection workers understand how the multidisciplinary approach to child abuse could be helpful in their work; (b) the provision of timely and accurate factual information about the specific services offered by the multidisciplinary approach; (c) workload adjustment to allow child protection social workers the time that was required to use the multidisciplinary approach; and, (d) encouragement to use the multidisciplinary approach as a viable resource and as a standard practice in child protection work. The participants indicated that ifMCF used explicit guidelines, policies, and/or directions to communicate that they valued a collaborative method of doing child protection, participants would feel validated in the use of the Clinic as this participant indicated: Like it's not sort of. .I don't find that it's sort of a standard norm.... to use the clinic. And it's just sorta there and ifyou remember it great and if not, nobody's sort of like makes a big fuss about it, so I think in order for it to be utilized more effectively, it should be become standard. Another participant implied that encouragement to use the multidisciplinary approach by MCF and the provision of information about the Clinic was valuable, especially to newly hired child protection social workers, and was connected to utilization. The participant explained that it was important for supervisors to recognize the value of the approach and to encourage utilization by sending new child protection social workers to the Clinic with the more experienced workers so they could personally see the benefit of this type of practice. The participant explained: I mean they could send these new workers with a worker that they know is going to have something at The Northern Child and Family Clinic 52 the clinic ... like that part of it is important. Cause a lot of those people are not interested in the ministry but maybe if they saw something like this, they might think "oh there is a different way ofpracticing". The provision of training and education in the area of child abuse was also an incentive. Participants seemed to imply that they needed training in the multidisciplinary approach to know when to use it and to know how it could benefit them in their job. In addition, the next example seemed to indicate that child protection social workers would be more comfortable using the approach when they understood how it could be meaningful in their work: I think that ahm.... offering some more training and having line workers comfortable and ... going there for consultation.... is really important. All of the participants seemed to imply that they needed their employer to make some adjustment to their workloads to give them time to take part in a collaborative process: I don't have that kind of time. The issue is..... ifyou're going to interview a kid around this stuff. ...you need to be able to take the time to establish the rapport and do all that kinda stuff I don't have that kinda time. In summary, participants described four more complex incentives that appeared to be connected to the seven previously identified characteristics of the multidisciplinary approach. These four more complex concepts seemed to reflect the integration ofMCF child protection social workers into the multidisciplinary approach at the Clinic. Integration of child protection social workers. Integration is defined by Webster's New Collegiate Dictionary (Merriam-Webster, 1977) as "incorporation as equals into society or organization of individuals of different groups" (p.600). The four additional incentives, (a) collaboration, (b) meaningfulness, (c ) legitimate inclusion, and (d) utilization of the Clinic, The Northern Child and Family Clinic 53 seemed to indicate the concept of integration as the participants described what they needed to feel that they had meaningful, equal, and legitimate membership in the multidisciplinary approach. These findings suggest that the seven characteristics of the multidisciplinary approach that were identified by the participants were meaningful to their work and were connected to the integration ofMCF child protection social workers. In addition, it appeared that the seven characteristics of the multidisciplinary approach together with the four identified characteristics of integration, described a place of expertise where specialized skills and knowledge in the field of child abuse are located. Place of expertise. The child protection social workers who participated in this study indicated that they needed a place of expertise that would help them with their child protection duties. One participant remarked: Well, obviously because I do child protection and because I remember when I first moved here that the clinic was always seen as sort of a .. a place of expertise particularly for sexual abuse.. And for me that was interesting coming from a smaller centre where.. there's not necessarily that service available. So it was nice to see. Specifically, participants explained that the credibility of specialized sexual abuse assessments and reports that are generated by a place of expertise, helped the child protection worker protect the child during the court process. The worth of a place of expertise to the child protection worker is revealed in the following statement: This leads to the clinic... The focus is the sexual abuse piece, the assessment piece, um the value that comes from assessment and the reports. The medical validity that's attached for court purposes.. It really helps us protect the child. In summary, the findings seemed to imply that a multidisciplinary model with the seven characteristics previously specified as well as the four characteristics of integration describe a The Northern Child and Family Clinic 54 place of expertise that is valuable to participants and provide incentive for MCF child protection social worker referrals to the Clinic. The participants implied however, that what they experienced when trying to utilize the Clinic was very different from their expectations and needs. The remainder of this chapter will describe the barriers to MCF referrals to the Clinic as indicated by the participants. Barriers The participants described several factors that appeared to be barriers to their referrals to the Clinic. One of these factors was missing or unsuitable components. Missing or unsuitable components. Participants identified missing or unsuitable service components as barriers to referrals. A narrow service mandate and the lack of a child protection investigative component were particularly disturbing to participants. The following comments are demonstrative: The other sort of concern I had too was that um.. the clinic seems to be geared and I could be wrong to assessing cases of sexual abuse like child sexual abuse but that's, in my experience, that's only a small maybe.. that's significant, but that's only part of what we see. Participants identified the inability to refer cases of neglect and cases of emotional abuse as a barrier. This comment explains the consequences of a narrow mandate: and I think..... I just haven't had any referrals that in my understanding fit, fit the mandate of the clinic. The participants implied that the lack of a child protection investigation component was a barrier. The message was that since children often disclose abuse during a visit to the Clinic, a child protection social worker with designated authority to process the disclosure was needed on site: So then the feeling is that they need a child protection role for there ... in case it starts to happen so that the kids can.... the child protection worker can take that report, you know, it's kinda like they started to make a disclosure to you, but somehow you're not allowed to take that The Northern Child and Family Clinic 55 information. And that's kind of to me.. is a silly setup to be quite frank. So that definitely creates a barrier. Client intimidation. Client intimidation was also identified as a barrier. The participants described specific Clinic staff actions and various things in the Clinic environment that made clients uncomfortable, timid or fearful. One participant commented that the pacing of the Clinic process was inappropriate and seemed to be professional-centered or designed to accommodate staff needs and not client needs: Umm, the piece of the process too even though it's good to sit down with the parents and get the social history and do you know, the psychological part and get a feel for things.. some families I think would find that like whoa, "this is too much for me" and I think sometimes we have a tendency to run too quickly with families sometimes and that's not healthy for them. Other participants claimed that staff were condescending and failed to treat clients with respect and empathy, as in this comment: I had one Mom who was very intimidated by the pediatrician.. and really felt that the pediatrician was.. very devaluing of her as a parent.. and very condescending.. Umm, Mom just.. felt like she was, like, nothing and was very upset by the process.. and didn't want to go back to that person ever again. One participant objected to an aspect of the doctor' s office environment at the Clinic that made children feel uncomfortable and feel like the "kid in the bubble" . Specifically, the participant referred to a special window that was placed for training purposes between the doctor's examining room and a small room next to it. The participant said: Umm .. the fact that that two way glass is there, I find annoying. I don't know if that needs to be there for the medical exam. Like I've noticed some parents who kind of keep looking at it and wondering if other people are watching them or their kid or.. are they being observed Umm, its almost like sort of being the The Northern Child and Family Clinic 56 kid in the bubble. I notice myself looking sometimes too. So if its uncomfortable for me, I know its uncomfortable for others. Inaccessibility. Inaccessibility, the limited and inflexible availability of Clinic services, was another barrier for all participants. The following example illustrates how inflexibility was a barrier: Like the two half days a week, it's like well, ifyou happen to have a problem on that day..... or.... it's a problem you can plan.... a couple weeks in advance, but that's not real.. real. Like.. we're so crisis oriented.... The need for immediate accessibility is heard in this comment: and generally we need medicals like right away. And so.... if I've made a referral.. .. if I phone.... sometimes I'll phone and say okay, I've got this kid, I need to bring him in right away..... there is no space or it's like two weeks down the road or it's....you know, a month down the road and that doesn't work. Lack of team expertise. Lack of team expertise appeared to be a barrier for all participants. There was a general perception that the coordinator position on the team at the Clinic did not require the qualifications or experience of a child protection social worker and therefore did not offer the kind of expertise that was needed by the child protection social workers. One participant explained: I would think that they feel that the people that maybe that are there, particularly the ministry workers that have been there, really don't have the knowledge of child protection. It was also expressed this way: Well I think that, that putting a social worker in without any experience is....part of that. We need somebody there, let's plug this person in without any real thought, or overall view of the impact of that right? On, on the clinic and on the .. on the community. Uncollaborative Clinic practice. Uncollaborative Clinic practice emerged as a barrier that seemed to hinder cooperation, equality, and working together. Three specific practices were The Northern Child and Family Clinic 57 identified as barriers to referrals: (a) insufficient contact or lack of direct personal interaction with the team; (b) dysfunctional communication, which was described as the unsatisfactory process of submitting or transmitting messages; and, (c) inadequate coordination efforts which was understood as the failure to clarify roles. One participant commented on the insufficient contact concept: And I think if there was more contact and more multidisciplinary work on cases.. because it does seem quite separate. It's a very time limited, short, intervention, so it's not like you guys are an ongoing connection for us with specific families. And I think that's a big piece of why it's removed We don't have that with the clinic. Dysfunctional communication was identified in this example: there doesn't seem to be a lot of sort of direct communications between the pediatrician and myself so it doesn't feel like a multidisciplinary.. multidisciplinary approach to me. I can't sit down and explain all the facts to that person you know and that person doesn't have an opportunity to ask me questions. And that's a real barrier in terms of communication. Unsatisfactory coordination efforts can be heard in this remark that illustrates one participant's experience during a summary meeting where it was thought that one of the Clinic team members took over the child protection role. This participant was angry and upset at the apparent lack of accountability when the role violation was reported and this appeared to be a barrier: And I think those roles get conflicted at times. And that's very confusing for the parent. It's also confusing with the worker because you can't come and jump up in the middle and go "you're treading on my part of the grass here". This is not appropriate at this point in time. Umm and some of that stuff has been brought up at later dates, but I feel that nothing's ever been done about it. The Northern Child and Family Clinic 58 Hierarchy. The structural organization of the Clinic was described by the participants as a hierarchy which was characterized by intimidation and devaluation ofMCF child protection social workers. Participants implied that the hierarchical structure has subordinate levels that place the child protection social worker at the bottom and was viewed as a barrier. Devaluation, the lessening of child protection social worker status is clear in the following pronouncement: sometimes it feels not like a multidisciplinary sort of approach ... it feels like a bureaucracy and you have these levels but and it goes up you know. I'm sort of at the bottom here, maybe, I don't know why I feel that way. I'm sort of here at the bottom as a line worker and there's a succession ofpeople sort of you know a hierarchy. Intimidation ofMCF child protection social workers, which was described as fear, was identified by participants as another barrier: So part of going to the Clinic I think is that people feel, they really do, I think they feel, "God what if they find out that I don't know everything they think I know". Is it the medical profession or specific personalities um that people just.. ( ) I think they're really scared of ( ), they're afraid that ( ) going to chastise them for whatever I don't know. Lack of commitment to mutual goals. Another barrier that emerged was lack of commitment to mutual goals. This was described by participants as the absence ofMCF practice which would demonstrate commitment to shared goals. Participants indicated that this absent practice included: (a) lack of training /education or failure to provide child protection social workers with knowledge about child abuse; (b) lack of information or the failure to provide current and accurate facts about the Clinic which seemed to be connected to; (c) things in the workplace, which one participant called word of mouth information sharing; (d) lack of workload adjustment which was the failure to lessen child protection social workers' workloads to The Northern Child and Family Clinic 59 legitimize time spent at the Clinic; and, (e) lack of encouragement to use, which was the failure to inspire or foster use of the Clinic as a standard practice in performing child protection duties. One participant implied that lack of training/education was a barrier: And I think that's... a big one. We get training in interviewing and stuff like that, but in actual... .I mean I think. .. .I've learned what I know through. ...you know, being there and sort of. .. what I can read, what.. people have told me and I don't know that there's any real formalized stuff Failure to provide information is seen in the following and shows a lack of knowledge about the Clinic mandate: I don't even know what would be the minimum age for the clinic, but..... umm, if it's a non-verbal child, I don't think I'd ever pick up a thing in there. It's maybe just a lack of knowledge about the clinic. Another participant spoke about the confusion that was experienced from his/her lack of information about the researcher's role as the mental health therapist at the Clinic: And I'm not really, I'm not really even sure who else is a part of that team. I know it's the social worker, I know it's the pediatrician and I understand it's you but I rarely, I rarely see you.. I'm not really sure what your role is or what you can basically do for me you know. I don't know, I don't really understand that part of it. The lack of accurate and current information seemed to relate to «things that are around in the workplace" which was a type of word of mouth information sharing between child protection social workers and became a barrier to those who had not experienced the Clinic personally. One participant explained that some workers, especially inexperienced workers were deterred from using the Clinic as these things around the workplace frightened them: I'm talking about some people within the ministry and they made negative comments about the clinic ... I The Northern Child and Family Clinic 60 couldn't think who..... is it or where have I heard that, but it's kinda like there's these things that are around in the workplace. The failure to adjust workloads to enable child protection social workers time to spend at the Clinic appeared to be a barrier as one participant stated: and then you sort of get.... an ov [computer memo]jrom the clinic saying the clinic has openings for such and such a day next week, please do referrals. And I'm going well I can give you some work.... but it's.. . that's the frustration. It's not.... it just feels really frustrating because then if I do a referral to the clinic, then they go well you need to be here. And I'm going I don't have time to be there. The lack of encouragement by MCF to use the multidisciplinary approach or the failure of MCF to inspire or foster use of the Clinic as a standard of practice was a barrier. This was illuminated in the following example: Well.... ! find that every once in a while, the management will remind us that the clinic is there, but there's really nothing sort of either/or. Like it's, it's probably like you were saying before, kind of apathetic. There's no real.. ..push or barrier, it's just sort of .. .Ifind that it.. .I mean it's part of our ministry and it's part of Child Protection, but it's quite removed It was also revealed in one participant's comment which was made in response to the researcher asking if the participant was aware that the Clinic was available to MCF social workers 24 hours a day for interviewing. Yeh, yeh It hasn't been um.. in my time here it hasn't been really pushed on us though. Its been kind of like mentioned, but I don't really know very many people who actually do that. It just doesn't happen. I don't know why, it just doesn't. One participant described how lack ofMCF commitment to shared goals is a barrier: Gave is now collecting dust on the or the um.. recommendations are collecting dust on the shelf. You know they, they implemented whatever they thought well, gotta look good It's all P. R. But The Northern Child and Family Clinic 61 I think a lot ofpeople view the clinic as this is just another way of the government saying hey, or management in this town saying hey we're cool, we're out for the times, we have this super duper clinic, but I really don't think they believe it. I really don't think there's a commitment there really. When grouped together, the seven factors, identified by the participants as barriers to referrals, seemed to describe an inappropriate design of the Clinic. Inappropriate design. The participants indicated that the design of the Clinic was a barrier to utilization. One of the participants said: I think it needs to be redesigned and to be looked at, cause I think it's valuable. Can be. You know, if it's used right. Another participant exclaimed: I think you should pull the whole thing down and build a new one. In summary, it appeared that the seven characteristics of the inappropriate design that were identified by the participants were barriers to MCF child protection social worker referrals to the Clinic. Grouped together these barriers seemed to comprise an inappropriate design of the multidisciplinary approach to child maltreatment. In addition, the participants implied that these barriers were connected to five more abstract barriers. The next section will describe these additional five barriers and examine how the seven barriers previously described appear to relate to these five additional barriers. More Complex Barriers The participants seemed to indicate that five additional, more abstract and affect laden concepts served as barriers to their referrals to the Clinic. The first of these was powerlessness. This sense of powerlessness was described by the participants as having no choice or being forced, and was described as feelings of frustration when they felt ineffectual, discouraged, or dissatisfied. The second was meaninglessness. Meaninglessness was described by the participants when they discovered the approach at the Clinic was worthless to their job, had no The Northern Child and Family Clinic 62 value or credibility, and did not meet their needs. Isolation was the third additional concept and was encountered when child protection social workers were left out and segregated and did not feel involved, included, or part of the Clinic. Self-estrangement was the fourth and was expressed as feelings of indignation and humiliation. The final concept was normlessness and it was ,described as feeling that utilization of the Clinic was not a standard of practice and that their decision to refer to the Clinic had no significance one way or another. The participants indicated that utilization of the Clinic was not part of the day to day norm of doing child protection. It seemed that each of the seven previously identified barriers related to one or more of these more complex barriers. Each of the initial seven barriers will be examined individually to describe how they connect to the more complex barriers. Missing or unsuitable components. Missing or unsuitable components seemed to be connected to meaninglessness and non-utilization of the Clinic. Several participants commented that the inability to refer different types of child maltreatment cases made the Clinic meaningless to their work. When the multidisciplinary approach did not satisfy their needs, they had no reason to use it. One participant remarked: but they don't seem to be equipped to deal with cases of neglect ... I think there are physical ways or there are means to test children for neglect or lets say chronic under-nourishment or malnourishment. That really, that.. that concerns me because they're not set up to do that. Many participants implied that the lack of child protection investigation component at the Clinic was connected to feelings of meaninglessness. Participants were frustrated because the MCF social worker position at the Clinic, which was the coordinator position, did not have any child protection designation or authority attached to it. This meant that the coordinator position could not adequately respond to disclosures of child abuse that were made by children at the The Northern Child and Family Clinic 63 Clinic and therefore another MCF child protection social worker had to be called in to handle the case. Participants perceived this to be a waste ofMCF resources when there were not enough child protection social workers to handle the cases they already have. The following statement illustrates the frustration: And I guess ... this artificial.. in my mind.. separation between what a Child Protection Worker can do .... andwhat another worker can do ... .is.... is part of what I think is a barrier and creates the frustration. And that's kind of. to me, is a silly setup to be quite frank. The narrow mandate aspect of missing or unsuitable components also was connected to feelings of powerlessness and self-estrangement for participants. One participant who was a very experienced child protection social worker expressed feelings of frustration and indignation when he/she was refused service because the staff at the Clinic assessed that his/her case did not fit the criteria for service. He/she was powerless to obtain the type of service that he/she had assessed that the client needed. The following comment illustrates this point: What I've been told on several occasions is that the doctor won't examine a child unless there's been a disclosure and that just drives me absolutely crazy. I'm sort of stopped at the first stop there .. by a person.. and I mean really I really resent it. I feel/ike I've had a lot ofyears of experience and I've put a lot of what I do in assessment .. Someone is already making that decision for me and it really bothers me. I really think I know if a child needs to be examined I think I have good reasons, good instinct, good evidence you know and facts you know and sometimes it feels not like a multidisciplinary sort of approach. Client intimidation. Client intimidation was another characteristic that was related to meaninglessness and non-utilization of the Clinic. Child protection social workers do not value things that frighten or traumatize clients and therefore were reluctant to subject their clients to The Northern Child and Family Clinic 64 aspects of the Clinic environment with which their clients were not comfortable. In addition to the one way mirror in the doctor's office that some participants believed made clients feel anxious and like ''the kid in the bubble", other equipment and tools that were used by the staff were viewed as intimidating to clients and more professional-centered than client-centered. Participants believed they would not get the type of information they needed from their clients in a frightening environment and therefore found no meaning in using the Clinic to do their interviews. This is reflected in the following example where this participant believed clients felt like they were in the "hot seat": I find that interview room where, I don't know, just the big room where, where you actually do videoing. I think that is not really, to me it's not a comfortable place to interview with all the furniture ... I don't know.. it's the distance, there's a camera, and the way we're sitting at right angles to one another. And with the R. C.MP. there, we all look.. we're all sort of sitting there and the mike is there and you know it just doesn't feel comfortable for me and I notice kids are a bit intimidated by it. They're just tensed right up when you sit them and it's like you're in the hot seat now. Tell me everything. Another worker expressed her strong objection to the way one of the clients was treated and made it clear that this type of practice was unacceptable and meaningless: when I've had any concerns at the clinic about um, things that have been said to the parents or concerns that I've had about the way they've been treated, I've directed them right to the clinic, and the sense that I get is.. there wasn't a lot of accountability attached. and !found that very unfortunate. That's a management piece that needs to change. Because if it doesn't, families will continue to be treated like dirt in my opinion.. and that's not what that clinic 's there for. Inaccessibility. Participants seemed to imply that inaccessibility was connected to meaninglessness. The inability to have their needs met at the Clinic because it was not available The Northern Child and Family Clinic 65 when participants needed it, related to feelings that the Clinic had no meaning for their job. One participant explained how inaccessibility related to meaninglessness: See and that's another thing, is people think, ifyou can't do it five days a week and have staff available when we need them then why bother. You know, we don't really need them then. Cause we exist without them, you know. Another participant indicated that fiustration which was understood as powerlessness was experienced when inaccessibility related to non-utilization of the Clinic and the very situation that the child protection worker believed the Clinic was implemented to prevent: On more than one occasion I have called and they've been booked already.. and then I'm left with going to emergency. And I've waited or I've had people wait all night to see a pediatrician you know and um again I don't you know, we're trying to avoid that whole sort of situation for the child .. taking the child to the hospital and all that sort of thing and yet more often than not that is what I'm forced to do. So I've, it really frustrates me that that's not operating on a, it's not really accessible. Lack of team expertise. Lack of team expertise was another characteristic that was connected to meaninglessness and non-utilization of the Clinic as a standard of practice. The participants found little value in having team members that do not have the knowledge and experience that are needed to help them in their work. Specifically, the participants explained that the coordinator position lacked the level of child protection expertise that was needed to make the approach credible. One participant said: I would think that, they feel that the people that maybe that are there, particularly the ministry workers that have been there, really don't have the knowledge of child protection.. I think that attitude's always been there. I think there were people in definite disagreement from the time this clinic was set up. But really too, that clinic, The Northern Child and Family Clinic 66 you know, you need somebody there I think that really knows the .. you know, what protection is about. Another participant said: And, and that's been. .... and there's been different workers in there and that's varied....you know.... worker to worker.... but I'm not sure that that's really a social work position. So in the line there's some real question about that job seen as being a piece a cake. Yeah, so it's a coordinator position. The expertise that you have as a social worker, ah. ....protective social worker.... isn't....! mean that's not a good utilization of the FTE. One participant explained that the lack of child protection expertise at the Clinic was connected to meaninglessness because they could not trust that their clients' needs would be met appropriately from the child protection viewpoint. When asked why child protection social workers had difficulty with the coordinator position, one participant replied that it was essential that the MCF position at the Clinic was one that could assess the protection issues based on child protection knowledge and experience: Well it's like anything else.. any service in town. If .. .I don't have respect.... ahm ... or belief that they're credible or believe that they will do right by a family.. Yeh, feeling like people are gonna get served, that, you know, that their needs are gonna be met.. with empathy and ... ah. ...you know, professionalism ... That they're able to assess whoever, you know, like that position is one, is a child protection person. Uncollaborative Clinic practice. Uncollaborative clinic practice, appeared to be connected to feelings of isolation, powerlessness, self-estrangement and normlessness. One participant explained how dysfunctional communication related to exclusion of the participant from the process and to feelings of isolation: So it's that kind of communication mix up. So I mean somewhere something got lost along the way you know and that that really sort of concerns me. There should be another way of communicating if all these people are involved if that.. sort of the purpose is to involve all the players. It doesn't involve all the players sometimes. The Northern Child and Family Clinic 67 Lack of direct contact with the doctor on the multidisciplinary team at the Clinic was connected to feelings of powerlessness, isolation and self-estrangement for one of the participants. Self-estrangement occurred for another participant when he/she was made to feel less important than the MCF representative at the Clinic who acted as a liaison between the participant and the doctor. The child protection social worker was humiliated because this practice made her feel less worthy than her knowledge, experience, and responsibility in child protection would otherwise make her feel if she was able to speak directly to the doctor herself But seldom does the doctor really want to hear from me directly and that's.. it kind of bothers me you know because I'm the person who has to sort of deal with the families. In response to the researcher asking how this made the participant feel, the MCF social worker replied: Well, kind of out of the picture. I just don't feel/ike I'm really part of the process.. an important part of the process. Um, like the clinic social worker takes the information I have and sort of redoes it for the doctor which may be useful but I really feel kind of left out because I can't have any direct contact with that doctor. The participants implied that isolation and normlessness were linked to the lack of direct and ongoing contact between child protection social workers and the Clinic team, as the following comment illustrates: We're not over there a lot, we don't hear from you [Clinic team]. .. we don't have a lot of contact with you guys, so it's somewhat removed, even though it's still part of the ministry. It's not that day to day stuff. Like we refer families over there, you guys do your bit, it comes back, and then that's sort of the end of it.. so it's not like you guys are an ongoing. .... connection for us with specific families. Unsatisfactory coordination efforts were connected to meaninglessness and selfestrangement. Participants explained that lack of protocols for roles and responsibilities led to crossing of role boundaries and situations where the Clinic team took on functions that were The Northern Child and Family Clinic 68 viewed by participants as child protection functions. The participants indicated that investigative re-interviewing of children at the Clinic was not appropriate and was meaningless to child protection social workers because they believed it contaminated the evidence and also traumatized the child. In fact, this practice seemed to make child protection social workers feel as if the team did not trust their ability to do it properly and appeared to be related to feelings of indignation. One participant explained: She'll start re-interviewing the kid ... and that in itself is traumatic. Ahm.. .I'm somewhat hesitant sometimes, when I think about where I could send the kid, because I don't want to further traumatize them because being interviewed is bad enough. Because you know, if she starts asking leading questions..... that's gonna throw the whole criminal case out. And that's just not appropriate, cause that's not her job. I mean she needs to ask some questions.. but.. give me .. [credit for doing my part ofthe process] Hierarchy. Hierarchy seemed to be connected to isolation and feelings of selfestrangement. Participants implied that the hierarchical structure of the Clinic related to child protection social workers feeling that their skills and knowledge were not valued as much as those of the Clinic team members. The following comment illustrates: I think a big piece of it is cracking that ah, the barriers to work.. as a multidisciplinary team I think is , is an issue. Social workers see themselves as their opinions not being ahm, taken seriously or not really mattering. That the professionals at the clinic will rush around and do .. what they need to do and, and the social worker 's sort of ah, .. you know.. [left out] However, it was apparent that feelings of self-estrangement were less for child protection social workers with more years of experience in the child protection role. It seemed that more experienced workers had developed enough confidence in their skills to withstand the hierarchical nature of the Clinic. Even though they did not like feeling that they were "low man on the totem The Northern Child and Family Clinic 69 pole" and still felt uncomfortable at the Clinic, the more experienced child protection social workers stated that it would not stop them from referring when they believed it was in the best interest of the client. One participant explained that inexperienced child protection social workers were impacted more by the hierarchy than those child protection social workers with more experience and confidence: I know if I was brand new, and knowing what it was like for me to be brand new, if I had come into this right away and gone to the clinic, um .. I, I think it would have a huge impact. I wouldfeel/ike .. dumb, for lack of a better word, you know. Education is not everything and some folks think that if they get the letters behind their name, they know it all. The next example implied that child protection social workers were reluctant to use the Clinic a second time when it produced feelings of self-estrangement the first time around: I mean there's resources available in this community that we really don't use. And I think a lot of it has to do with the fact that when people have tried they've been just sort of .. yahoo.. you think you are special, come on get a grip, you know, that kind of thing. Not only did participants indicate that the level of training and the status held by the members of the Clinic team were connected to feelings of devaluation, but, they also implied that the R.C.M.P. attitude toward child protection social workers in the community and at the Clinic was related to feelings of intimidation and self-estrangement. One participant explained that child protection social workers were reluctant to use the Clinic for joint interviewing with the R.C.M.P. because they felt intimidated by the police: I think that, for a lot of workers I think they are really intimidated by the R. C.MP. There are some R. C.MP. that are very negative towards social workers. They basically think they're a bunch offlakes. Like I think a lot of workers have had that experience with R. C.MP. not necessarily in the clinic but outside of the clinic and I think The Northern Child and Family Clinic 70 that right away when they know that they are going to interview with an R. C.MP. I think a lot of them are quite frightened by that whole experience. Lack of commitment to mutual goals. Lack of commitment to mutual goals also appeared to relate to the additional barriers. The following statement implies that the lack of information about the mental health component at the Clinic, which was understood as a lack of commitment to mutual goals, was connected to meaninglessness and non-utilization of the Clinic: But I didn't really know that that existed and there's some... .! still have confusion around ... what exactly that... goes on in that piece of it, in terms of the referrals to the Mental Health piece and so.. , but most often, I'll just refer them directly to the Sexual Assault Centre .. instead So I think that that's a big barrier for a Iotta people cause I would suspect that a Iotta people don't know. The next example suggested how lack of encouragement to use the Clinic by the participants' own management was related to meaninglessness, isolation and normlessness for child protection workers: ... let's say they're not convinced that it's a worthwhile project. I think management maybe is so removed from the actual hands on work that they don't know what actually gets happened there. You know I think that if they saw it, they'd realize hey, we need to get people in here ... but it's usually the .. work in isolation because you don't put anything on the line. It's kind of, you know it's almost, I was honest to say [workers] wouldn't know, but let's face it we're putting that money there but obviously they [workers] haven't been educated, nobody's told them about it, nobody's told them that it's worthwhile. Isolation, powerlessness, and non-utilization of the Clinic were connected to lack of workload adjustment for this participant: Umm, I'm not necessarily sure if I want to be part of it, because I do a separate role and I'm comfortable in that. Umm .. time, I always think that I go back to time, because there's no way in hell I'd have a day to go hang out at the clinic. It's The Northern Child and Family Clinic 71 impossible. Cause if I spend an hour or two hours sitting and talking to somebody at the clinic, that's two more hours that I spend back at the office later on doing intake cause I have no coverage and I will not have coverage. Um, and there's an expectation if we go do those nice things that you're going to clean up your stuff when you get back. Um, and that's just the sad fact of reality. So I think a lot.. a lot of it depends on being able to have that choice. The next example shows how the lack of guidelines or mandated procedures directing child protection social workers to use the multidisciplinary approach in their work related to normlessness, meaninglessness, isolation and non-utilization of the Clinic. It was apparent that use of the approach depended on individual choice and individual practice style as there were no policies or guidelines to follow: You know a lot of workers, not a lot, but there are some workers who feel that this is a lot of work and it takes a long time and I don't have the time. This is something I can write off, write it up quickly and get rid of it. The kids are not going to disclose anyway so why go through all of that. I don't want to go through this because it's not worth it. These findings seem to imply that the seven characteristics of the inappropriate design that were identified by the participants were not meaningful to their work and were related to five more complex barriers. These five additional barriers appeared to be manifestations of alienation. Alienation. Alienation was understood to be manifest in the five major concepts that emerged as additional barriers to MCF child protection social worker referrals to the Clinic. Powerlessness, as described by participants is consistent with Powell's (1994) definition which is the sense that one can control neither the conditions of work nor the purposes of one's labour. The second additional barrier was meaninglessness and was similar to Powell's ( 1994) definition which is the sense that one's work is devoid of meaning (Powell, 1994). Isolation, the third The Northern Child and Family Clinic 72 additional barrier was similarly consistent with Powell's ( 1994) definition of the same term which is the sense that each individual struggles alone and that no sense of community exists. Selfestrangement seemed to be consistent with Seeman's ( 1972) definition which is being something less than one might be if the circumstances in society were different. The final additional barrier was normlessness and it seemed to be similar to Powell's (1994) definition which is the sense that there are no superordinate rules to which all subscribe. It appeared that the seven characteristics of the inappropriate design together with the five emergent manifestations of alienation described a showpiece that was oflittle value to participants. Showpiece. The participants in this study seemed to perceive the Clinic as a showpiece. It was described as something that was used for exhibition as a prime or outstanding example but was lacking in authority, expertise, and authenticity. One participant claimed that the limited hours of accessibility seemed to lessen the credibility of the Clinic: It's a .. a big idea it takes a .. a fair bit of money um.. and I think its some body's sort of showpiece and yet it's only open as I said through the space of a week very little. Another participant rationalized that the continued funding of a facility that wasn't being used was good public relations for management. The implication was that although the Clinic was not being utilized by child protection social workers as an authentic method of doing child protection, it was serving the purpose of showing the community that the Ministry was following policy which directed them to share responsibility for child protection. This perception is revealed in this example: I think maybe, that they think, this is a good P. R. It's good P. R. to have this clinic. Cause why do we keep it open you know, because they, they do bitch about the money and how much it's costed and we're not getting the use of it. And 1.. gee, they must think "hey we look The Northern Child and Family Clinic 73 pretty good in the community" when we have these people that are experts and you know in the community and you know this is a positive thing. So I think that part of it for, for management is uh very positive. In summary, the purpose of this study was to examine and describe the incentives and barriers that promote or inhibit referrals by local MCF child protection social workers to the Clinic. The findings that emerged from this study suggest that seven characteristics of the multidisciplinary approach that are valued by the participants, together with four more complex aspects of integration, describe a place of expertise where specialized knowledge and skills in the field of child abuse are located and are incentives for local MCF child protection social workers' referrals to the Clinic. In contrast, it appeared that the seven characteristics of the inappropriate design that are not valued by participants, along with five more abstract and affect laden manifestations of alienation, describe a showpiece that lacks authenticity for participants and are barriers to local MCF child protection social workers' referrals to the Clinic. Grouped together, all of the findings seem to indicate that local MCF child protection social workers who were participants in this study experienced a contradiction when trying to utilize the Clinic. Figure 6 presents the entire theoretical framework that emerged in this study and illustrates the contradiction. A more in depth examination of the contradiction and a description of the relationship between the contradiction and local MCF child protection social worker referrals to the Clinic will be discussed in Chapter 5. The Northern Child and Family Clinic Core Category Incentives Barriers Contradiction I ~I wptece . Categories Place ofExprse Subcategories Multidisciplinary Approach Inappropriate Design One stop shopping Missing/Unsuitable Service Components Child-Centered Client Intimidation Accessibility Inaccessibility Team Expertise LackofTeam Expertise Collaborative Clinic Practice Uncollaborative Clinic Practice Mutual Respect and Status Hierarchy Commitment to Mutual Goals Lack of Commitment to Mutual Goals Concepts Subcategories Concepts I I Integration I Collaboration Meaningfulness Legitimate Inclusion Utilization of Clinic - Alienation .. ..------.. .. .. - - .......-. -.. .. ------- - I Powerlessness .. .. Meaninglessness Isolation Self-estrangement Normlessness • Contradictory Relationship - - - Connecting Relationship Figure 6. Theoretical framework. 74 The Northern Child and Family Clinic 75 Chapter 5 The Contradiction The findings outlined in the previous chapter suggested that MCF child protection social workers who were participants in this study experienced a sense of contradiction when attempting to utilize the Clinic. Using the concepts from the theoretical framework that were presented in Figure 6 and beginning with a definition and explanation of the core concept "contradiction", this chapter will progress down through the framework to compare and contrast some of the concepts that represent the incentives and barriers to explain the contradiction, and to explore the relationship between the contradiction and MCF referrals to the Clinic. In addition, some examples from the literature presented in previous chapters will be discussed to aid in clarification of the contradiction. Contradiction is defined by Webster's New Collegiate Dictionary (Merriam-Webster, 1977) as "opposition of factors inherent in a system or situation" (p. 247). As previously noted, the seven characteristics of the multidisciplinary approach together with the four identified characteristics of integration were the incentives or conditions under which MCF child protection social workers would be more likely to refer clients to the Clinic. In contrast, the seven characteristics of the inappropriate design along with the five manifestations of alienation were the barriers or conditions under which the participants of this study would be less likely to refer to the Clinic. As can be seen in the theoretical framework in Figure 6, each characteristic of the multidisciplinary approach is the opposite of its corresponding characteristic found in the inappropriate design. The opposition of concepts in the theoreti al framework can be seen consistently at every level. The contradiction can be understood as the phenomenon that was The Northern Child and Family Clinic 76 experienced by the participants in this study when they found that the conditions in the Clinic context were more consistent with the characteristics of the inappropriate design of the showpiece than with their expectations for a multidisciplinary approach at a place of expertise. Multidisciplinary Approach versus Inappropriate Design The participants indicated that in reality, the Clinic contradicted their expectations for a multidisciplinary approach at a place of expertise. The Clinic was viewed as a showpiece with an inappropriate design that lacked credibility and authenticity. One participant made the following statement: I.. I mean I'd like to say I understand it's a multidisciplinary.. a multidisciplinary sort of approach that the clinic utilizes but I don't feel that um that really is the case and ... I know that people are trying to achieve [it} but it doesn't seem to be borne out you know in terms of how I'm dealt with how the family's dealt with. A closer examination of the opposition between some of the concepts that make up the multidisciplinary approach and those that make up the inappropriate design will enhance understanding of the contradiction. One Stop Shopping versus Missing or Unsuitable Components As noted in earlier chapters, the literature suggests that a multidisciplinary approach to child abuse should represent a coordinated, interdisciplinary service response and identifies several different professional discipline components that are necessary for a coordinated response (Trute, Adkins, & MacDonald, 1992). Typically, a multidisciplinary approach would include: (a) a child protection investigative component to investigate the risk to an abused child, (b) a criminal justice component to investigate and prosecute if a crime has been committed, (c) a medical component to assist with the investigative component and to ensure the health needs of the child are attended The Northern Child and Family Clinic 77 to, and (d) a mental health component to deal with the crisis of disclosure and the long-term psychological effects of child abuse. The first characteristic of the inappropriate design of the showpiece indicates that there are missing or unsuitable components in the approach used at the Clinic. For example, participants noted that the child protection investigative component is missing. This is a contradiction to what is prescribed in the literature as well as a contradiction to the one stop shopping aspect that was needed and valued by the participants. One of the participants explained that the lack of child protection component at the Clinic impeded or blocked the ability to provide the best service possible to child abuse victims and their families and perpetuated fragmented service delivery. The perception was that the lack of a child protection investigation mandate at the Clinic prevented the staff at the Clinic, who had the most training in sexual abuse, from dealing with child abuse disclosures. Frustration was experienced by the participant because when children disclosed abuse at the Clinic, the Clinic staff had to stop the process and call on child protection social workers to interview the child. The participant suggested that the disclosure interruption often resulted in a lost disclosure as the child was not willing to disclose again at a later date to a different person. In addition, this process contradicted the participant's perception that a multidisciplinary approach was supposed to eliminate the necessity of subjecting the child to multiple interviews. The participant reflected on an actual situation where the researcher, in the therapist role at the Clinic, obtained a disclosure from a child at the Clinic and subsequently telephoned MCF to report the disclosure. The participant said: But because ofyour role, you couldn't take the report. But then before we can proceed ... the procedural rules say that a child protection worker has to interview these kids that you were interviewing. So the child protection worker goes and The Northern Child and Family Clinic 78 interviews these kids.. they don't disclose anything. So I still have, sitting on my desk, a .file that I opened about another family and another kid. So basically, probably what I'm gonna have to do is just sort of ... close it.. And that's kind of to me, is a silly setup to be quite frank. Not only did the participant believe that a child protection component was needed at the Clinic to deal with abuse disclosures but another contradiction was experienced when referrals to the Clinic were precluded by a limited Clinic mandate which dictates that there must be an open MCF protection file to refer to the Clinic. The end result of the previous case was that the participant planned to close the file because there was no disclosure and therefore no protection mandate. If there was no protection mandate, the child protection social worker did not have a case to refer to the Clinic. The original disclosure given to the team at the Clinic in the above example was not validated as the team had no authority to do anything with it but pass it on to a child protection social worker. There is an apparent contradiction in the fact that the team at the Clinic had the experience and knowledge but no authority to process the disclosure and the child protection social worker had the authority but admitted he/she did not have the same level of understanding or comfort around sexual abuse issues and was not able to obtain the disclosure at a later date from the child. The consequence of this type of protocol is that abused children may be left in abusive situations. The following analogy offered by one of the participants is worth repeating to underline the contradiction: It's kinda like ifyou had a . .a team of heart specialists.. heart attack specialists at emergency right? But you said okay the GP has to assess first. And.... ahm .. that's how the level of. .. ah. .. intervention that's required by the GP.... may deny or mask the issue, before you get to the specialist. Like I think the way the system is set up..... that the ... the all knowing Child The Northern Child and Family Clinic 79 Protection Workers.... have to do the investigation, or the first part of the investigation before you can do a referral to the clinic or participate in that investigation somehow. The literature suggests that the basic goal of the multidisciplinary approach to child abuse is to "maximize investigative efforts and minimize the psychological and physical trauma to the child" (Kellogg, Chapa, Metcalf, Trotta, & Rodriguez, 1993, p.2). The idea is that a coordinated, collective response is better than a fragmented response. Pence and Wilson (1994) explain that ''By working together, the team can accomplish the goals of all investigative agencies in a more efficient manner and with enhanced results" (p. 13). As noted by the previous examples, participants do not believe the investigative efforts are maximized by the approach used at the Clinic. In actual fact, participants believe that the lack of child protection investigation component at the Clinic hinders investigation efforts, does little to eliminate fragmented service and in some cases, when it is necessary to have the child interviewed again, actually increases the trauma to the child instead of decreasing it. This is certainly contradictory to what is advocated in the literature. Child-Centered versus Client Intimidation Another contradiction emerged between the child-centered aspect of the multidisciplinary approach and the client intimidation characteristic of the inappropriate design. Although all participants remarked that the Clinic environment was preferable and more comfortable than the hospital emergency room environment, some aspects of it needed changing. As identified in the findings, participants were particularly unhappy about using a service that frightened, devalued and overwhelmed their clients. Not only did this aspect contradict social work principles but it also jeopardized participants' ongoing relationship with the client, prevented participants from obtaining the type of information they needed from the process, and made the participants think The Northern Child and Family Clinic 80 twice about using the Clinic. The next example describes how the professional-serving process aspect of client intimidation that participants experienced at the Clinic contradicted their perception of a child-centered approach and negatively impacted their work: And sometimes I think there is an expectation that when they [clients] come in they sort of have to aah.. There 's door number one, two, and three, and we 're going to do all this stuff and we 're going to do it right away, and.. I think that's something that we need to lessen our expectations of what we feel the parents have to do. They need time to have.. the ability to ask questions, not feel intimidated And if the parent's feeling uncomfortable, the kid knows it. And then the kid's uncomfortable and then we've got a real mess on our hands. And that just makes it more difficult for us and then we set up a situation where we're going to medical a kid who's just going to be really uncomfortable. And I don't like the idea of doing that at all. Accessibility versus Inaccessibility The inaccessibility aspect of the inappropriate design was found to be in opposition to the desired accessibility aspect of the multidisciplinary approach and appeared to be a third major contradiction for participants. As depicted in the findings, the nature of child protection work is unpredictable and crisis oriented, and in many cases child protection social workers need access to medical and mental health services immediately or at least within 72 hours. The limited hours of operation at the Clinic contradict the need for a facility that is accessible on a full time, daily basis. Team Expertise versus Lack of Team Expertise The team expertise characteristic of the multidisciplinary approach contradicted the lack of team expertise characteristic of the inappropriate design. Lack of team expertise also contradicts the literature. Kellogg et al. ( 1993) emphasize that "Essential to the framework of child abuse centers are extensively trained and experienced personnel" (p. 2). Although it is pointed out in The Northern Child and Family Clinic 81 the literature that the expert components of multidisciplinary teams are varied, teams should be made up of professionals that have expertise in their respective disciplines. The participants in this study explained that the failure to include child protection expertise on the team contradicted their expectation that MCF would provide a representative on the team that could advocate for their needs. They were being asked to consult with and follow the recommendations of a MCF staff member on the team who, in their opinion, could not provide the expertise that was needed to advise child protection social workers on child protection matters. One participant explained that this contradiction occurred right at the planning stage when MCF management made a direct appointment for the clinic coordinator position and decided to choose a non-designated child protection social worker to fill the position: ... management gave line workers and experienced workers and the supervisors, [the idea] their [management's] opinion was hey this is just fluff, we'll just put whoever can't do protection, we'll put in there. They'll be a nice little hostess, they could pour coffee and tea all day and that is the role that people have viewed that of the clinic coordinator. The staff were so turned off by the whole project that ... people just didn't even want any part of it. They just washed their hands of it. There were people who were really looking forward to paneling, really felt that they had the skill to do the job, and when they appointed somebody, somebody that really didn't have the experience, they didn't have the protection experience, uh they didn't have the respect of the staff, cause they didn't have the experience and uh basically the message was that hey this isn't an important position. Trute, Adkins, and MacDonald (1994) recommend that the coordinator of a multidisciplinary team be filled by someone who has extensive experience in both child and family services and child protection investigation. They stress that professionals without investigation of abuse experience cannot fully understand the key aspects of the child protection role. In addition, The Northern Child and Family Clinic 82 Trute et al. suggest a coordinator of this type of team should be someone who understands both the protection and treatment issues inherent in child abuse cases. It was the participants' perception that the clinic coordinator position provided neither child protection investigation nor treatment expertise. Collaborative Clinic Practice versus Uncollaborative Clinic Practice The uncollaborative Clinic practice aspect of the inappropriate design contradicted the collaborative Clinic practice characteristic of the multidisciplinary approach. Participants indicated they had a need to be personally involved with a team that was assessing and making recommendations for their clients. Lack of personal contact, dysfunctional communication, and unsatisfactory coordination of roles contradicted what participants needed to do their job and served to isolate and alienate child protection social workers from the Clinic. In fact, uncollaborative practices described by the participants seemed to undermine their role and sometimes made it more difficult for them to provide service to their clients after their clients had been at the Clinic. Personal and ongoing contact, direct communication, shared decision-making and coordination of roles was understood as being related to integration of participants and seemed to enhance their job. Uncollaborative Clinic practice also contradicts what is recommended in the literature. As stated earlier, the purpose of a multidisciplinary team responding to child abuse is to support and maximize child protection investigation, eliminate duplication of services and reduce trauma to the child (Pence & Wilson, 1994). It is therefore vital that the child protection social worker be involved and included in all actions and decisions concerning the abused child. Trute et al. (1994) suggest that successful collaboration efforts increase the effectiveness of interventions and the The Northern Child and Family Clinic 83 quality of service. Further, they report that effective service coordination at the front line level is vital for successful collaboration. Hierarchy versus Mutual Respect and Status The hierarchy aspect of the inappropriate design contradicted the characteristics of mutual respect and status that was considered to be valued in a multidisciplinary approach. It appeared that the high level of authority and responsibility mandated to child protection social workers was contradicted by the lower status and intimidation experienced by the participants when they utilized the Clinic. It is ironic that those persons with the most responsibility for the welfare of children felt they were considered lowest on the hierarchy within an approach that was supposedly designed to support their role. One participant expressed her frustration with the contradiction: Umm, and I think the way our structure and our system is set up and it's very ironic that, like here we are.. we're trained.. to help people. We're trained to empathize with people. We're trained.. to do all this nice resource stuff and to be there for them, yet the system that, we come from is very dysfunctional in the sense that it does not.. empathize with social worker needs. It does not provide self-care. It does not provide incentives to be in this type of work.. umm, and there's devalue placed on it. It's like we're victimized in our own system. It just does not make sense to me. Commitment to Mutual Goals versus Lack of Commitment to Mutual Goals As noted in the findings, commitment to mutual goals was the final characteristic of a multidisciplinary approach that was identified as being meaningful to the participants. Five specific actions were identified that would indicate to them that there was commitment to shared goals. The absence of these actions in the inappropriate design contradicted what participants believed was needed to promote utilization of the Clinic. Lack of commitment to mutual goals is The Northern Child and Family Clinic 84 also contradictory to the preferred characteristics of a multidisciplinary approach outlined in the literature. Morrison ( 1996) and Trute et al. (1994) emphasize the importance of genuine commitment to shared goals. Trute et al. suggest " ... commitment needs to be developed at the senior administration level of each of the participating agencies .... These administrators can sanction and support the efforts of their line staff, or they can sabotage interagency activities ... " (p.60). One example of failure to support the efforts of line staff emerged when participants revealed that they had not been consulted during the planning and development stage of the approach used at the Clinic. It appeared contradictory that a Clinic approach would be designed without the input of the people who were expected to use the Clinic. According to the participants, information was not provided to front line child protection workers about the design of the Clinic until it opened for business. Three of the participants were employed by MCF at the time the Clinic was being planned and recalled that they were excluded and isolated from the planning process. One participant stated: my memory of that is that ( ) was seconded into the position and she worked out of area and sort of went around and did her thing and there wasn't a Iotta feedback..... to the line about... even what it was about.... until it was ready to open. Lack of training and education was another factor that emerged in the findings as a characteristic oflack of commitment to mutual goals. This contradicted the participants' need for training and education in the multidisciplinary approach. Participants clarified that they needed to understand how it could be useful for their child protection role before they could fully appreciate the value ofthis type of approach. They reported that the failure ofMCF to provide adequate training in this area contradicted their expectations as they believed that if their employer was genuinely committed to Clinic goals, essential training would be encouraged and provided. Lack of training also contradicts the recipe for success found in the literature. For The Northern Child and Family Clinic 85 example Morrison (1996) suggests that multiagency and in-house training about the "ethos and practice of collaboration" (p.137) are vital for collaborative efforts and need to be owned by management and provided to staff as early as possible. Morrison further advises that training in the multidisciplinary approach must include not only "knowledge and skills but also values especially around discrimination, perceptions, roles, feelings, and conflict resolution" (p.l37). It is clear from the literature that child protection social workers as well as front line personnel from other disciplines who are committed to the multidisciplinary approach need training not only in the field of child abuse but also in the area of collaboration. In addition to the contradiction between the multidisciplinary approach and the inappropriate design that was experienced by the participants, a contradiction could be found between the additional more complex and more abstract concepts that emerged as part of the theoretical framework. The following discussion illustrates this contradiction. Integration versus Alienation As previously described in the findings, the design preferred by the participants appeared to be related to integration of child protection social workers while the inappropriate design seemed to be connected to alienation. Reference to the theoretical framework in Figure 6 reveals that the properties or characteristics of integration contradict the manifestations of alienation. Collaboration versus Powerlessness and Isolation The participants implied that collaboration meant working together, having equal power, and sharing responsibility for child welfare. In contrast powerlessness, an aspect of alienation, meant having no control or choice and is understood as the opposite of the having equal power aspect of collaboration. Isolation, another aspect of alienation, contradicted the working together The Northern Child and Family Clinic 86 and shared responsibility aspects of collaboration as it meant working separately and being excluded from the team. Meaningfulness versus Meaninglessness Meaningfulness, a second aspect of integration was contradicted by the meaninglessness manifestation of alienation. As previously noted, the characteristics of the multidisciplinary approach had meaning for participants, while in contrast, the characteristics of the inappropriate design were worthless and had no meaning for t.he participants. Legitimate Inclusion versus Self-Estrangement Legitimate inclusion, a third aspect of integration contradicted the self-estrangement aspect of alienation. It appeared that legitimate inclusion meant that the unique skills and opinions of child protection social workers were needed and valued by the multidisciplinary approach and this was understood to be the opposite of self-estrangement where the participants experienced feelings of indignation and humiliation. Regular Utilization of the Clinic versus Normlessness Finally, regular utilization of the Clinic, another aspect of integration, contradicted the normlessness aspect of alienation. Regular utilization or the standard practice of using the Clinic in the daily practice of doing child protection contradicted normlessness or the lack of standard practice that was characteristic of the inappropriate design. In summary, this chapter has examined the contradiction that participants seemed to experience when attempting to utilize the Clinic. A comparison of some of the concepts that emerged as incentives and barriers in the theoretical framework was used to explain the contradiction and to explore the relationship between the contradiction and MCF referrals to the The Northern Child and Family Clinic 87 Clinic. In addition, some examples from the previously cited literature were presented to aid in clarification ofthe contradiction. The contradiction that was experienced by the participants in this study may account for the dearth ofMCF child protection social worker referrals to the Clinic. The concluding chapter will examine and discuss some inferences that can be drawn from the findings of this study and will also suggest recommendations for professional social work practice in the Clinic context. The Northern Child and Family Clinic 88 Chapter 6 Discussion The purpose of this study was to explore and describe the factors that inhibit or promote MCF child protection social worker referrals to the Clinic in Prince George. This thesis has presented a description and analysis of the factors that serve as incentives and barriers to MCF child protection social worker referrals to the Clinic. This chapter will present a summary of the overall findings, suggest recommendations for professional social work practice, examine the limitations of the study, and finally, examine recommendations for future research. The data suggest that child protection social workers need and value a place of expertise utilizing a multidisciplinary approach that has specific characteristics. The aspects that the participants identified as being worthy included: (a) one stop shopping, (b) child-centered, (c) accessibility, (d) team expertise, (e) collaborative practice, (f) mutual respect and status, and (g) commitment to mutual goals. It appeared that a place of expertise with these characteristics was related to the integration of child protection social workers and utilization of the Clinic. The participants indicated that integration was manifest through: (a) collaboration, (b) meaningfulness, (c) legitimate inclusion, and (d) utilization of the model in their daily practice. These findings suggest that the factors that serve as incentives for referral are the characteristics of the multidisciplinary approach that participants identified as having meaning for their work together with the four aspects of integration. Additionally, it seemed that the design of the approach operating at the Clinic had little value for participants and was considered to be a showpiece or something that looks and sounds worthy but in reality lacks the authenticity that is needed to be useful. The aspects of the The Northern Child and Family Clinic 89 inappropriate design that participants implied were of no value to their work included: (a) missing or unsuitable service components, (b) client intimidation, (c) inaccessibility; (d) lack of team expertise, (e) uncollaborative clinic practice, (f) hierarchy, and (g) lack of commitment to mutual goals. It appeared that these characteristics were related to alienation of the participants which was experienced as: (a) powerlessness, (b) meaninglessness, (c) isolation, (d) self-estrangement, and (e) normlessness. These findings suggest that the factors that serve as barriers to referrals are the characteristics ofthe inappropriate design that participants identified as having no meaning for their work along with the five manifestations of alienation. The results of this study imply that the experience ofMCF child protection social workers with the Clinic can be understood as a contradiction. Not only were the characteristics of the inappropriate design contradictory to participants' needs, but also, seemed to be connected to alienation. These findings contradict the purpose of a multidisciplinary approach which is to actualize integration. The overall findings indicate that the third objective of the British Columbia Inter-Ministry Child Abuse protocol (Ministry of Attorney General et al. 1988), which is to ensure that an integrated approach is adopted by all those in the province who are involved in responding to the problem of child abuse, has not been achieved by the implementation of the Clinic. The participants in this study implied that they were not integrated into the community multidisciplinary response to child abuse but in fact were alienated from the multidisciplinary model in place at the Clinic. The Northern Child and Family Clinic 90 Implications for Practice In response to Bagley and Thomlison' s (1991) call for systematic description of how child abuse protocols are used in practice and how professional practice might be revised, a number of recommendations can be made from the findings of this study that could inform practice at the local front-line and senior management levels of those community agencies committed to the goals of the Clinic. It is suggested that if the characteristics of the multidisciplinary approach that were identified by the participants of this study as being incentives were adopted by the Clinic, regular utilization of the facility by child protection social workers may occur. Inclusion of a child protection investigation component on the multidisciplinary team is necessary to achieve the one stop shopping aspect needed by child protection social workers. The findings indicate that the child protection social workers who participated in this study, want a multidisciplinary approach that includes the child protection investigation component. Without it, services will continue to be delivered in an isolated fragmented manner. It is recommended that MCF reassess the type of position they contribute to the team at the Clinic in order that it will best represent and respond to the needs of the child protection social workers and maximize the investigation process. It is also recommended that the Clinic adopt a broader mandate to include provision of services to respond to all types of child abuse including emotional and physical neglect as well as services for clients who are victims of child abuse but not in need of protection. Other services such as a family support worker or a liaison worker for First Nations clients may be more useful to MCF child protection social workers. This study points to the importance of considering the specific aspects of context when designing a program. The consequences of designing a program without a First Nations component in a regional facility that serves a large population of First The Northern Child and Family Clinic 91 Nations people emerged in this study. In addition, an expanded consultation service for child protection social workers may be useful. Consultation for child protection social workers might occur right from the beginning stages of the investigation process and continue until all of the needs of the client are met. The findings indicate that the child-centered characteristic as defined by the participants be adopted by the multidisciplinary team at the Clinic. Although it is recognized that all persons involved will have different opinions and conceptualizations of what constitutes the child-centered characteristic, discussions by all parties involved may lead to a more consensual definition and also facilitate changes to the environment that may be needed to maximize client comfort and minimize client trauma. Consistent with the findings ofHewlett' s (1997) study (p. ii), that was undertaken approximately one year ago, it is concluded that expanded service and full-time accessibility to the Clinic would be more responsive to the needs ofMCF child protection social workers. Several options could be explored that would respond to these needs. Full-time staff could be hired to provide the coverage that is needed for acute as well as historical child abuse cases. An on-call system could be incorporated that would facilitate the use of the more comfortable Clinic surroundings for medical and crisis intervention assessments while still allowing the staff to attend to other duties during periods when their services are not required. A trial of the on-call system might provide an accurate assessment of the actual number of cases that require the services of the Clinic and therefore serve as concrete evidence of the need for increased funding to provide a full-time service. It is recommended that inclusion of a team member at the Clinic with child protection expertise is needed to help child protection social workers manage their cases and to provide the The Northern Child and Family Clinic 92 type of support and collegial understanding that only another person who had done the job of child protection could provide. Without this expertise, the participants in this study indicated that a visit to the Clinic did not provide anything more than a visit to the local pediatrician' s office could provide or a referral to the local mental health agency could provide. It seems vital that detailed protocols and procedures be developed to define and implement collaborative practice by the multidisciplinary team at the Clinic. The findings in this study confirm warnings found in the literature (Morrison, 1996) that collaboration does not happen automatically just because service components are co-located under one roof Actions need to be adopted that will: (a) promote direct and ongoing contact between all those responding to child abuse in Prince George, (b) facilitate group decision-making, (c) promote direct and shared communication, and (d) ensure coordination of roles. Action is needed to address the hierarchical structure of the multidisciplinary team at the Clinic. Explicit understanding and agreement needs to be achieved among all team members that a multidisciplinary approach needs to value equal recognition of all areas of expertise and value the equality of rank or status of all players in the response to child abuse. It is suggested that the commitment to mutual goals be revisited to ensure that all community agencies involved in the delivery of service by the Clinic are genuinely in agreement with the philosophy of an integrated community response to child abuse. The lack of encouragement, from local MCF management, for child protection social workers to use the Clinic seems to imply that the provincially mandated level of commitment to integrated service has not trickled down to the local management level. There appears to be a large gap between policy and practice. Provincial level policy makers will need to create some means of monitoring implementation of their integration policy at the local level and also will need to ensure local The Northern Child and Family Clinic 93 agencies are accountable for failure to comply with policy. The findings of this study indicate that front-line child protection workers are frustrated at the lack of concrete movement towards shared responsibility for child protection in Prince George. As one participant exclaimed: the Clinic needs more of a presence in the child protection community. Another recommendation arising from this study is that unless there is genuine commitment to the child abuse protocol in this province from all levels of government and unless this commitment is demonstrated through adequate funding and resources, operationalization of this protocol will not be successfuL It will be necessary for management who control budgets for services at the local level to understand the rationale for integrated service and understand that the benefits of an integrated approach to child abuse can outweigh the costs. A major recommendation is that any attempts to plan or redesign an integrated community response to child abuse must include front line child protection professionals at every stage of the planning process before any real integration can take place. It is recommended that a needs assessment be completed on referral sources to ensure the design of the multidisciplinary approach in operation at the Clinic is meaningful and useful to all stakeholders and particularly child protection social workers. Limitations of the Study The limitations of this study must be observed when interpreting the findings. One limitation is the nature of grounded theory research. It is not possible to generalize these findings to other contexts. The findings that emerged from this study are provisional and limited to the specific context of the Clinic. It may be applied only to the child protection social workers who were participants in this study and child protection social workers with similar characteristics who use the Clinic. The Northern Child and Family Clinic 94 Another limitation of the study is that only local child protection social workers participated in the study. MCF child protection social workers from other communities who make referrals to the Clinic and other referral sources such as the RCMP and physicians were not included because it was apparent that referrals from local child protection social workers had declined the most. It should also be noted that only six participants took part in the research process. Although some variation of the characteristics of the participants was achieved, additional participants might have produced a more elaborate description of the phenomenon under study. A related limitation is that the number of variables influencing the decision to refer to the Clinic are unlimited and not static as each child protection social worker will have a different reality when interacting with the Clinic. Therefore it was not possible to discover every variable, only those experienced by the participants. Another limitation is the fact that the researcher is a member of the multidisciplinary team at the Clinic. Participants may have been reluctant to discuss or disclose some information that may have been more freely volunteered if the researcher was not connected to the Clinic. In addition, the researcher was not free of preconceptions about the context of the study due to previous training and extensive reading in the area of child maltreatment as well as the day to day experience of working at the Clinic. Suggestions for Future Research In light of the present findings, additional qualitative studies could be undertaken with other Clinic referral sources to obtain rich descriptions of the factors that serve as the unique incentives or barriers to their decisions to refer to the Clinic. The findings of this type of study could be used to improve the usefulness of the Clinic for more of the people it was created to serve. It is suggested that this type of research needs to be conducted in a timely manner when a The Northern Child and Family Clinic 95 program is in the early stages of implementation. In this way, variables or characteristics ofthe program that are worthy could be identified and implemented and those that are not useful could be discarded before referral sources decide to stop using the Clinic completely. In addition, quantitative studies could be designed to test the recommendations that emerged from this study. For example a pre-post test design would be useful to measure the effects of the implementation of any of the variables or characteristics of the multidisciplinary approach that were identified by participants as being valuable. In summary, this thesis has explored and described the incentives and barriers to local MCF child protection referrals to the Clinic in Prince George. The findings of this study indicate that the seven characteristics ofthe multidisciplinary approach: (a) one stop shopping, (b) childcentered, (c) accessibility, (d) team expertise, (e) collaborative Clinic practice, (f) mutual respect and status, and (g) commitment to mutual goals, that were valued by participants together with four aspects of integration: (a) collaboration, (b) meaningfulness, (c) legitimate inclusion, and (d) utilization of the Clinic, are incentives for referral to the Clinic. In addition, the findings indicate that the seven characteristics of the inappropriate design of the Clinic: (a) missing or unsuitable service components, (b) client intimidation, (c) inaccessibility, (d) lack of team expertise, (e) uncollaborative Clinic practice, (f) hierarchy, and (g) lack of commitment to mutual goals, together with five manifestations of alienation: (a) powerlessness, (b) meaninglessness, (c) isolation, (d) self-estrangement, and (e) normlessness, are barriers to referral. The findings implied that the MCF child protection social workers who were participants in this study experienced a contradiction when trying to utilize the Clinic. The participants indicated that they needed and valued a place of expertise but in reality experienced the Clinic as a showpiece that did not fit their needs. The Northern Child and Family Clinic This study underscores the importance of designing a multidisciplinary Clinic that responds to the needs of all stakeholders, especially front-line professionals who have the responsibility for ensuring the safety and welfare of children. It is their initiatives that are necessary for the success of an integrated response to child maltreatment. 96 The Northern Child and Family Clinic 97 References Alexander, R.C. (1993). To team or not to team: approaches to child abuse. Journal of Child Sexual Abuse. 2 (2), 95-97. Bagley, C.R. & Thomlison, R.J.(Eds.). (1991). Child sexual abuse: Critical perspectives on prevention. intervention. and treatment. Toronto, On: Wall & Emerson, Inc. Press. Baker, M. (1995). Canadian Family Policies. Toronto, On: University of Toronto Bross, D.C., Krugman, R. D., Lenherr, M.R. , Rosenberg, D. & Schmitt, B. (Eds.). (1988). The new child protection team handbook. New York: Garland Publishing. Corwin, D.L. (1988). Early diagnosis of child sexual abuse. In G.B. Wyatt & G.J. Powell (Eds.), Lasting effects of child sexual abuse (pp. 251-269). Newbury Park, CA: Sage. Daro, D. (1988). Confronting child abuse: Research for effective program design. New York: The Free Press. Faller, K.C. (1988). Child sexual abuse: An interdisciplinary manual for diagnosis. case management, and treatment. New York: Columbia University Press. Fontana, V. & Robison, E . (1976). A multidisciplinary approach to the treatment of child abuse. Pediatrics 57. 760-764. Furniss, T. (1991). The multiprofessional handbook of child sexual abuse: integrated management. therapy. and legal intervention. London: Routledge. Gilgun, J. (1988). Decision-making in interdisciplinary treatment teams. Child Abuse and Neglect 12. 231-239. Gilgun, J. ( 1994). Hand into glove: The grounded theory approach and social work practice research. In E . Sherman & W. J. Reid (Eds.), Qualitative Research in Social Work (pp. 115-125). New York: Columbia University Press. Press. Glaser, B. G. (1992). Basics of grounded theory analysis. Mill Valley, CA: Sociology Glaser, B. G., & Strauss, A. L. (1967). The discovery of grounded theory: strategies for qualitative research. New York: Aldine De Gruyter. The Northern Child and Family Clinic 98 Glaser, B. G., & Strauss, A L. (1970). Discovery of substantive theory: A basic strategy underlying qualitative research. In W. Filstead (Ed.), Qualitative Research (pp. 288-304). Chicago: Markham. Goldstein, J. , & Griffin, E . (1993). The use of a physician-social worker team in the evaluation of child sexual abuse. Journal of Child Sexual Abuse. 2 (2), 85-93 . Guba, E. G., & Lincoln, Y. S. (1982). Epistemological and methodological bases of naturalistic inquiry. Educational Communication and Technology Journal. 30 (4), 233-252. Harper, K. (1990). Child sexual abuse: A coordinated interagency response. Canada' s Mental Health. 38 (2-3), 7-9. Hewlett, M. G. (1997). Northern Child and Family Clinic utilization survey: 1997. research report. Prince George, BC: University ofNorthern British Columbia, Child Welfare Research Centre. Hochstadt, N ., & Harwicke, N . (1985). How effective is the multidisciplinary approach? A follow-up study. Child Abuse and Neglect. 9, 365-372. Johnson, C .F. ( 1993). Use of an MD-social worker team in the evaluation of child sexual abuse: a response. Journal of Child Sexual Abuse. 2 (2), 99-101. Kellogg, N .D., Chapa, M.J., Metcalf, P., Trotta, M., & Rodriguez, D. (1993). Medical/social evaluation model: A combined investigative and therapeutic approach to childhood sexual abuse. Journal of Child Sexual Abuse. 2 (4), 1-17. Kempe, C.H. , Silverman, F.N ., Steele, B.F., Droegemueller, W. & Silver, H.K. (1962). The battered child syndrome. J. of the American Medical Association. 181 , 17-24. Leblang, T. (1979). The family stress consultation team: An Illinois approach to Protective services. Child Welfare. 18 (9), 579-604. Lincoln, Y. S. & Guba, E. G. (1985). Naturalistic inquiry. Newbury Park: Sage. Lindsay, A C. (1996). Developing methods for recording and describing dyadic classroom discourse between teachers and young children. Unpublished doctoral dissertation, University ofVictoria, Victoria, British Columbia, Canada. Madison, B. & Schapiro, M. (1973). New perspectives in child welfare: Services.staffing. delivery systems. San Francisco: California State University. Merriam-Webster. (1977). Webster' s new collegiate dictionary (8th ed.). Springfield, MA: Merriam. Meyers, M. ( 1993). Organizational factors in the integration of services for children. Social Service Review, December, 547-575 . The Northern Child and Family Clinic 99 Ministry of Attorney General , Ministry of Social Services and Housing, Ministry of Health, Ministry of Solicitor General, Ministry of Education. (1988). Inter-Ministry child abuse handbook: An integrated approach to child abuse and neglect. (3rd Ed.). British Columbia: Ministry of Social Services and Housing. Morrison, T. (1996). Partnership and collaboration: Rhetoric and reality. Child Abuse and Neglect. 20 (2), 127-140. Morton, C. (1996.) British Columbia' s child. youth and family serving system: Recommendations for change. Victoria, BC: Queen' s Printer. National Youth in Care Network. (1993). Treatment programs for child sexual abuse victims in Canada. Ottawa: National Youth in Care Network. Northern Child and Family Clinic. (1995/1996). Annual statistics report. Prince George, BC: Northern Child and Family Clinic. Northern Child and Family Clinic. (1996/1997). Annual statistics report. Prince George, BC: Northern Child and Family Clinic. Northern Child and Family Clinic. (1997). Policy and procedures manual. Prince George, BC: Northern Child and Family Clinic. Northern Child and Family Clinic. (1997-98). Semi-annual coordinator' s report. Prince George, BC: Northern Child and Family Clinic. Nud*ist [computer software]. (1994). Melbourne, Australia: Qualitative Solutions & Research. Pence, D . & Wilson, C. (1994). Team investigation of child sexual abuse : The uneasy alliance. Thousand Oaks: Sage. Powell, W. E . (1994). The relationship between feelings of alienation and burnout in social work. Families in Society: The Journal of Contemporary Human Services. 75 (4), 229-235 . Reichard, R. D . ( 1993). Dysfunctional families in dysfunctional systems? Why child advocacy centers may not be enough. Journal of Child Sexual Abuse. 2 (4), 103-109. Seeman, M . (1972). On the meaning of alienation. In A.W. Finifter (Ed.), Alienation and the social system. New York: John Wiley & Sons. The Northern Child and Family Clinic 100 Sgroi, S. (1982). Multidisciplinary team review of child sexual abuse cases. InS. Sgroi (Ed.), Handbook of clinical intervention in child sexual abuse. Lexington, MA: D.C. Heath and Company. Starbuck, G. (1977). Collaborative team approach to non-accidental injury and neglect in children. Hawaii Medical Joumal36, 309-15. Trute, B., Adkins, E., & MacDonald, G. (1994). Coordinating child sexual abuse services in rural communities. Toronto, On: University of Toronto Press. Untalan, F.F. & Mills, C.S. (Eds.). (1992). Interdisciplinary perspectives in child abuse and neglect. New York: Praeger. Whitworth, J.M. , Lanier, M.W., & Haase, C.C. (1988). The influence of child protection teams on the development of community resources. In D.C. Bross, RD. Krugman, M.R. Lenherr, & B.D. Schmitt (Eds.), The new child protection team handbook (PP.571-583). New York: Garland Publishing. The Northern Child and Family Clinic 101 Appendix A Interview Guide 1. Introductions and review of the purpose of the research. 2. Discuss confidentiality and voluntary nature of participation. 3. Explain audio recording procedure and give assurance that tape recorder may be turned off at any time during the interview at the request of the participant. 4. Obtain signed consent for audio recording. 5. Ask the participant the following question: What are the factors that serve as incentives or barriers to your decision to refer clients to the Northern Child and Family Clinic in Prince George? 1. What are the factors that serve as personal incentives or barriers to referrals? 2. What are the factors that serve as organizational incentives or barriers to referrals? 3. What are the factors in the environment and society that serve as incentives or barriers to referrals? 6. Thank the participants for their participation in this research and invite them to take part in a follow-up interview once the interview has been transcribed and analyzed. Explain that the second interview will be for the purpose of validating the interpretations of their comments and to elaborate on areas that need to be explored further. The Northern Child and Family Clinic 102 AppendixB Transcription Conventions Definitions Conventions Vocalizations: giggling, chuckling, laughing, giggling, groans, tongue clicking, idiosyncratic forms such as urrgh In location in tum in Arial font Inbreaths HI-I Outbreaths hhh Overlapping speech Inset in brackets approximately under point of overlap in previous speech in bracket Volume, higher than normal Font 14 Volume, lower than normal Font 10 Identifying information left out to protect confidentiality In location in tum in empty parentheses Emphasis, words clearer than normal and emphasized Times New Roman Special Fontl4 Pauses- time between words shorter than normal - time between words longer than normal =joining two words Speed of speech - accelerated speech -slower speech Upper case letters Letters separated by periods i.e. S.l.o.w. Unfinished sentence Unintelligible content Located in tum as Interruptions- interrupting speech Inset in parentheses approximately at point of interruption in previous tum The Northern Child and Family Clinic 103 Appendix C Category and Concept Definitions Core Category Categories Subcategories Place of Expertise a physical environment where specialized skill and knowledge in a particular field are found Multidisciplinary Approach Conditions that promote MCF Child Protection Social Worker referrals to the Northern Child and Familv Clinic Integration of Social Workers MCF child protection social workers feel they have meaningful, equal, and legitimate membership in the place of expertise Showpiece Something used for exhibition as a prime or outstanding example but lacking in authority, expertise and authenticity; not real Inappropriate Design Conditions that inhibit MCF Child Protection Social Worker referrals to the Northern Child and Family Clinic Contradiction opposition of factors inherent in a system or situation (Webster' s) Alienation a condition... whereby the individual experiences self and significant aspects of the physical and social environment as estranged and out of his or her control. (Keefe, 1984) Figure C 1. Core category, category, and subcategory definitions. The Northern Child and Family Clinic 104 Subcategory Muhidisciplinary Approach Concept One stop shopping Definition having all the needed services offered out of one place at the same time, in a timely manner Subconcept done at once, right away One Location out of one place Needed Discipline Components the different disciplines identified by MCF child protection social workers as being needed on a muhidisciplinary team. Holistic Broader Mandate Child-<:entered accessibility Team expertise Collaborative Clinic Practice make the whole investigative process really comfortable for kids service available on a regular basis, or when you need it Professionals who are "qualified or able to do the kind of exam that needs to be done" Actions that promote cooperation, equality and working together Comfortable environment Commitment to Mutual Goals having equal respect for and recognition of other professionals' area of expertise actions demonstrating agreement with the goals of the clinic whole thing looked at from everybody's perspective expanded service informal process Child' s pace clinic process proceeding at child's speed and attention level Child-focused Immediate Service undivided attention to child right away Flexibility Specialized training the ability to accommodate unpredictable need lots of training Extensive Experience well seasoned ; lots of front line work Specialized Knowledge Direct Personal Contact really knowing what child protection is about mea in person Ongoing Contact Group Decision Making Direct, Shared Communication Mutual Respect and Status Definition Timelines Coordination of Roles Recognition Equality Training and Education in Child Abuse Information about the Clinic Time Accommodation Encouragement to use long term involvement arriving at decisions collectively easy open verbal exchange with all people involved clear specific protocols for roles and responsibilities acknowledgment of all areas of expertise all persons having the same level of authority provision of knowledge in the area of child abuse timely provision of accurate fads describing clinic functions Sanction of time at clinic actively promoting the Clinic as a viable resource; making Clinic use standard practice Figure C2. Multidisciplinary approach concept and subconcept definitions. The Northern Child and Family Clinic 105 Category Place of Expertise Subcategory futegration Concept Collaboration Meaningfulness Legitimate inclusion Regular Utilization of Clinic Definition to work jointly with others; sharing opinions and knowledge Subconcepts Definition equal power; having choice possessing authority and control shared responsibility for child protection mutual goals all working toward the same end useful meets the need maintaining selfrespect having regard for one' s standing or position a standard of practice Use of the clinic becomes part of the normal day to day way of doing child protection; worthy, has value Recognition of child protection social worker skills and expertise recurring referrals by MCF child protection social workers at prescribed or expected intervals Figure C3 . Integration: concept and subconcept definitions. active participation in process The Northern Child and Family Clinic 106 Subcategory Inappropriate Design Concept Missing or Unsuitable Service Components Definition services that are improper or that the clinic does not provide that would be useful and beneficial to MCF social workers Subconcept Narrow mandate Client Intimidation actions taken by clinic staff or things in the clinic environment that make clients uncomfortable, timid or fearful professionalcentered process; lack of investigation component threatening office set-up; condescending failure to treat clients with empathy and respect failure to respond in a timely manner unable to perform child protection duties not capable of being used limited availability Lack of team expertise lacking qualifications or experience to do the kind of work that is required Those elements of the process used at the Clinic that hinder co-operation, equality and working jointly with MCF social workers co-ordinator position lacking authenticity Insufficient Personal Contact Hierarchy Lack of commitment to mutual goals the feeling of MCF child protection social workers that the clinic is organized into subordinate levels that places them at the bottom and causes intimidation lack of practice demonstrating agreement with the goals of the clinic unfulfilled need ofMCF social workers inappropriate pacing of the process; kid in the bubble Inaccessibility uncollaborative clinic practice Definition failure to respond to all services needed by MCF social workers Dysfunctional Communication Unsatisfactory Coordination Efforts Devaluation not enough direct personal interaction with the team the unsatisfactory process of submitting or transmitting messages failure to clarify roles a lessening of MCF social worker status Intimidation fear Lack of encouragement to use Failure to inspire or foster use of Clinic as a standard of practice Lack of Information Lack of training/education Things in the Workplace No workload adjustment .. Figure C4. Inappropnate design: concept and subconcept defimtlons . Failure to provide social workers with current and accurate facts about the Clinic Failure to provide MCF social workers with knowledge about child abuse Word of mouth information sharing Failure to legitimize time spent at Clinic The Northern Child and Family Clinic 107 Subcategory Alienation Concept Powerlessness Definition The sense that one can control neither the conditions of work nor the purposes of one' s labour (Seeman, 1959). Subconcept No Choice Definition Being forced, no control frustration feeling ineffectual, discouraged, dissatisfied Meaninglessness The sense that one' s work and life narrative are devoid of meaning (Seeman, 1959). worthless has no value, not meeting the need Isolation The sense that each individual struggles alone and that no sense of community exists (Seeman, 1959). To be something less than one might ideally be if the circumstances in society were different. (Seeman, l972) The sense that there are no superordinate rules to which all subscribe (Seeman, 1959). left out, segregation not involved, not included, separate from, not part of indignation feeling indignant, resentful and humiliated not standard practice feeling that actions have no significance, that actions are not part of the day to day norm of doing child protection Self-estrangement Normlessness Ftgure C5. Alienation: concept and subconcept definitions. The Northern Child and Family Clinic 108 AppendixD Category. Subcategory and Concept Connections to Data Categories Subcategories Concepts Subconcepts Place of expertise Muhidisciplinary Approam One stop shopping Timeliness: done at once, Link to Text ~ away One Location: out of one place Needed Discipline Components: the different service functions needed by MCF social workers holistic: whole thing looked at from everybody's perspective Broader Mandate: expanded service Childcentered Comfortable environment: informal process mild's pace: clinic process proceeding at mild' s speed and attention level mild-focused: undivided attention to mild Well, back to sort of the focal point of it in that its muhidisciplinl!!Y. The one stQP shQPping aspect. Urn, you can sort of go in and you get evervtbing sort of done at once. Urn, that's useful for us in the sense that sometimes we need that information, ~ away, to determine what the protection criteria is. Urn, two, its often good for the parent because even hou~ its overwhelming in the beginning, there's a certain sense of relief in having evervtbing done right away IlGGI4 so that having all of the services offered out of one place..... is, is a real incentive IlBB5. if you wanna do the clinic..... do it ~ do it full time, have all ofthe services there.... that are needed ~ To have your expert or... expert investigators ....with that muhidisciplinan:: team with your therapi!!!, with vour ah ...nediatrician ..... and stuff. IlBB240 I think it needs a muhidisciplinan:: ai?Proam, I mean it can't just be the medical model.... I think the whole ahm...thing needs to be looked at from evervbody's pSl!]pective. That would be really neat. That would be.. see that would be a good service.. for the clinic to offer. IlBB178 An expanded kind of mandate uh to address other uh you know concerns and in terms of their well being as a mild and I sort of talked a bit sort of mental heahh concerns I talked about neglect you know a you know l!. broader sort of mandate for me. IlRR240 Before it gets, like it almost needs to feel like you're just walking into daycare. That would be my perception of it. Nice fluffY coumes, no more mairs, no more desks. Pop the computer somewhere where you can't see it. Just make it a ~ informal process and I think that would be very, that would make families more comfortable Il GG27 My gut instinct is we should have just examined her immediately or that information should have been gotten earlier without the mild in the room. Kid should have been able to go play and stuff. Because that physical space for her was the I'm bored now ... illY experience would have been let her go play with the doll for awhile and then we'll come back to the medical exam I 1GG56 . And that when you go to the clinic it just seems like they can really focus all their attention on the mild and I think it comes across .. for the kids, it comes across guite differentlv. Il YY30 Ftgure Dl. Place of Expertise categones, subcategories, concepts, subconcepts: Links to text. The Northern Child and Family Clinic 109 Category Subcategories Concepts Subconcepts Place of Expertise Muhidisciplinary Approach accessibility Immediate service: ril!ht away Flexibility: the ability to accommodate unpredictable need Team expertise Specialized training: lots of training Extensive Experience: well seasoned ; lots of front line work Collaborative Clinic Practice Specialized Knowledge: really knowing what child protection is about Direct Personal Contact : meet in person Ongoing Contact: long term involvement Group Decisionmaking: arriving at decisions collectively Direct, Shared Communication: easy open verbal exchange with all people involved Coordination of Roles: clear specific protocols that fit roles and responsibilities together Mutual Respect and Status Recognition: acknowledgment of all areas of expertise Equality: all persons having the same level of authority Link to Text and generally we need medicals like right aWl!Y,_ Il005 Drives me crazy. Absolutely insane. Urn, for the simple fact that we can't decide when a kid's going to disclose chuckles and when they're not. There's no schedule or 12attem for that. It needs to be CO!!!J2lftely flexible. And if we don't have a hundred 12er cent accessibility, then the clinic is not useful to us. Il 00291 The other thing too is to have ahm..the training the ~ at the clinic have ... so the el!J2ertise at the clinic is ahm.. is really important Il8823 . That thev're able to assess whoever, you know, like that 12osition is one, is a child 12rotection 12erson. Uh huh, yeah. Yeah. I think the person in there needs to be.... very well seasoned and you know, lotsa training and .... ahm ... lotsa front line work Il88131 But really too, that clinic, you know, you need somebody there 1 think that really knows the.. you know what )2rotection is about Il YY135 I would just be as happy I would be happy to go to make an appointment with the receptionist take the kids or the parents or both in and talk directly to the doctor myself You know I just find that much easier to do. IlRR95 So I think in order to, to be less removed you guys would need to have sort of more longer term involvement and I don't know ifthat's appropriate....necessarily, although you could be used as a consult.... consulting on the multidisciplinarv team for sure. Il 00259 But we would sort of decide really decide as a ll!:Q!!P. and that would include the family what has to be done and I don't find that that happens. IlRRI63 uh . .. but I don't, I don't sort of sense that same sort of easy QJ2en communication and that sort of maybe respect you know. IlRR34 There should be another way of communicating if all these people are involved and that sort of the purpose is to involve all the m!!Y..ers IlRR49 Ummm ....well the muhidisci]2linary aJ2J2roa .... approach I think is that everybody has their individual role..... in terms of what they're doing and that everybody brinp;; their knowledge and expertise and 12iece of information together Il8876. Expand to full time services. Abm.....have very clear, ~ c c J2rotocols in 12lace around ahm...how thinp;; are done and who's ah... responsibilitv or role is what. Il88266 No, I understand, I mean a multidisci]2linary team needs to have....people need to have ~ c for other ~ area of, of el!J2ertise ri...l?h.t? Il 8879 but she needs to learn to deal with social workers better, because she bad mouths us in public forums, which I've seen .... ahm... she needs to work more as a team 12layer and I don't find that she is. Il0053 Ftgure D2. Place of Expertise categories, subcategories, concepts, subconcepts: Links to text. The Northern Child and Family Clinic 110 Category Place of expertise Subcategories Muhidisciplinary Approach Concepts Subconcepts Link to Text Commitment to Mutual Goals Training and Education in Child Abuse: provision of knowledge in the area of child abuse I think, I don't know what the clinic's mandate is but it would be.. I think it would be kind of interesting ifth!;Y would oonsider some kind of educational component for workers as well because as I mentioned to you before we get very little training about abuse.. I don't know a lot about the training budget for us but I know that uh in my experience uh well I've received 11racrically nothing in the seven years I've been here in terms ofthe work that I do urn 11RR129 Because maybe we would use it more often .... because I that that ahm..... after I found that out, I did refer a family there, where there was some sexual abuse..... to try and get them into some counselling. 1100103 I would think that there are !100!Jie who don't really at this 11oint don't even know what cases would be good there. You know they might use i!, but th!;)i might not know, this is not an a1111rQ12riate case for the clinic. Like I've known a few like that too where they didn't really they thought that you did everything at the clinic well that's not a nossibilitv or that's not ril'ht11 YY219 I mean the time.... fador is still an element. It is probably about two hours or an aftemoon ....that we spend there. Ahm ... but you can't get away from that. And I think it is preferable that we are there because we are the workers. But you do have to book off time to be able to "et there. 1100166 And it's, and it's ..... well that's kind of system stuff, so it's like ....that's the frustration because then if I do a referral to the clinic, then th!;Y 11hone and go well you need to be here. And I'm going I don't have time to be there. 11 WW29 You know when you think about it we don't really hear a Jot about the clinic down here we really don't. There's no su11ervisor to say, so !I!!YS how are thin!ll! going have you had anybody at the clinic or you know are we using that facility, you know it's one of ours remember. I've never heard anybody say that But that's the kind of thingthatneedsto beha1111ening, I don't think it happens a lot cause I just don't think that.. it's really management that really doesn't really 11ush it. I mean you don't hear hardlv anvthing about the clinic 11 YY 189 Yeah, I think we need to do more education around that.. .. or have a clear 11oli5