Evaluating a Social Work

Engagement Approach to Involving

Inner-City Children and Their Families
in Mental Health Care

Mary McKernan McKay

Ruth Nudelman
Kathleen McCadam
Jude Gonzales
University of Illinois at Chicago

This article will focus on increasing the ability of social workers to provide mental health services
to urban, low-income children and their caretakers. A conceptual model for understanding the
process of engagement will be presented. Further, a protocol for training social workers to
conduct first interview/engagement interviews and the results of a study evaluating its impact
will be highlighted. One hundred seven children and their families were randomly assigned to
one of two conditions: (1) first interviewers trained in specific engagement skills, and (2) other

therapists within an urban mental health agency. Of the 33 children assigned to first interviewers,
29 (88%) came for a first appointment and 97% (n 28) of those returned for a second
=

appointment. In comparison, of the 74 clients assigned to the routine first interview condition,
47 (64%) came for an initial appointment and only 83% (n = 39) returned for a second
appointment. The average length of treatment during an 18-week study period for first interview
subjects was 7.1 sessions, as opposed to 5.4 sessions for the comparison group. The applications
of this model for social work education are discussed.

It has been estimated that two thirds of all children in need of mental health
services never receive them (Kazdin, 1993). Urban, minority children are at
greater risk for the development of a wide range of mental health difficulties,
but less likely to be met by responsive service providers or relevant interven-
tion modalities (Cheung & Snowden, 1989; Flaskerud, 1986; Hu, Snowden,

Authors’ Note: A version of this article was presented at the 41st annual program meeting of
the Council on Social Work Education. Correspondence may be addressed to M. McKay, Institute
for Juvenile Research, 907 South Wolcott, Chicago, IL 60612. The authors wish to thank the two
anonymous reviewers for their comments on the manuscript. This work was supported by a grant
from the National Institute of Mental Health ( 1 R24MH54212-O1 ).
Research on Social Work Pracuce, Vol 6 No 4, October 1996 462-472
0 1996 Sage Publications, Inc

462
 463

Jerrell, & Nguyen, 1991; Jacobs, 1979; Kazdin, 1993; Sue, 1977; Wallen,
1992). There is mounting evidence that the most vulnerable child populations
in terms of seriousness of presenting problems or complexity of social
situation are less likely to be retained beyond the first mental health session
(Armstrong, Ishiki, Heiman, Mundt, & Womack, 1984; Bui & Takeuchi,
1992; Cohen & Heselbart, 1993; Kazdin & Mazurick, 1994; Miller & Prinz,
1990; Russell, Lang, & Brett, 1987; Wahler & Dumas, 1989). The delivery
of social work services to vulnerable client population rests on the engage-
ment of the clients in the helping process. Therefore, it is critical that social
work educators-both in the classroom and at field practicum sites-help
new social workers develop focused, culturally sensitive engagement skills
that address the range of barriers that can exist within families, urban
environments, and agencies interfering with the process of engagement. This
article will focus on increasing the ability of social workers to provide mental
health services to urban, low-income children and their caretakers. This
article will present a conceptual model for understanding the process of
engagement. Further, a protocol for training social workers to conduct
first/engagement interviews and the results of a study evaluating its impact
will be presented. Finally, implications for social work educators will be
discussed.

REVIEW OF ENGAGEMENT LITERATURE

The prevalence of mental health difficulties among children has been

estimated to range from 17% to 26% (Brandenburg, Friedman, & Silver,
1987; Landsverk, Madsen, Litrownik, Ganger, & Newton, 1994; Tuma,
1989). Of the youth who are referred, 50% to 75% do not initiate treatment
or drop out prematurely if they do in fact begin. Rates of service usage are

particularly low for children residing in low-income, urban communities

(Griffin, Cicchetti, & Leaf, 1993). Traditionally, engagement within the
helping fields has been addressed in terms of compliance (Mull, Wood, Gans,
& Mull, 1989; Steffenson & Colker, 1982) and resistance (Stanton & Todd,
1981). Clinical strategies to address client reluctance to change are often
offered (Anderson, 1983; Schlosberg & Kagan, 1988).
Specific transactions between the social worker and the client during the
first interview have also been linked to attrition and outcome of mental health
services (see Orlinsky & Howard, 1986, for a review of therapy process
literature). In considering initial entry into social work services for children,
adult caretakers play a critical role in that they must recognize (or at least
agree with an outside source of) a child’s need, follow up on referrals to
464

services, and come to scheduled appointments (Achenbach & Edlebrock,

1984; Landsverk et al., 1994). Increasing parental efficacy and helping
parents invest in the process of obtaining services during the initial contact
were found to reduce missed intake appointments by 50% with Latino,
adolescent substance abusers and their families (Szapocznik et al., 1988).
Further, parental expectations for services and the match with those offered
have been found to be related significantly to treatment engagement and
outcome (Crane, Griffin, & Hill, 1986). Initial experiences of cultural sensi-
tivity and respect with service providers have been identified as necessary
ingredients for the ongoing engagement of minority families in the clinical
literature (Aponte, Zarski, B ixenstene, & Cibik, 1991 ; B oyd-Franklin, 1993).

SOCIAL WORK ENGAGEMENT MODEL

The engagement of inner-city children and their families might best be

understood from an ecological perspective (Bronfenbrenner, 1979; Germain,
1980). From this perspective, barriers to engagement are not seen as exclu-
sively resulting in a client’s &dquo;unwillingness to change.&dquo; Rather, barriers to
engagement can be found within a child’s behavior, the beliefs of the family,
the parent’s history of negative experiences with institutions, lack of sensi-
tivity by the workers, and urban obstacles such as violence within commu-
nities (McKay, Tolan, Kohner, & Montaini, 1994).

FIRST INTERVIEW/ENGAGEMENT TRAINING

Based on an ecological perspective of engagement, 8 second-year social

work interns were intensively trained around engaging families during the
initial meeting at the Institute for Juvenile Research (IJR), the Child Psychia-
try Division of the University of Illinois at Chicago. IJR is an urban, child
mental health agency, with 67.3% of the children living with their mothers
in single-parent households and an additional 21.3% residing with a single,
female relative, such as a grandmother or aunt. Approximately 85% of the
450 families who requested services last year were supported by public
assistance. Almost two thirds of children seen at the agency are African
American, 12% are Latino, and the remaining portion are White.
The initial interview with a client system was defined as having two
primary purposes: (a) to understand why a child and family were seeking
mental health services and (b) to engage the child and family in a helping
process, if appropriate. Four critical elements of the process of engagement
 465

were identified for social work interns by the authors: (a) clarify the helping
process for the client; (b) develop the foundation for a collaborative working
relationship; (c) focus on immediate, practical concerns; and (d) identify and
problem-solve around barriers to help seeking.
First, the need to carefully introduce self, agency intake process, and
possible service options was stressed. Training sessions focused on helping
interns to not assume that the clients had been given accurate information
about services or that they know what is expected of them and what they
should expect from the worker. Practice exercises helped interns to explore
with the clients whether the information matched what the clients had been
told by the referral sources and their own understanding of what the process
of obtaining mental health services would be like.
Next, the foundation of a collaborative process between the client and the
worker began during the first interview. Therefore, discussions with the social
work interns centered around how to balance the need to obtain intake
information with helping the child and family to &dquo;tell their own story&dquo; about
why they have come to the agency. During training sessions, the social work
interns viewed videotapes of trainers conducting collaborative first inter-
views.
The third aspect of engagement training was a focus on concrete, practical
concerns that families bring to the first meeting with a social worker. Social
work interns were prepared to respond to crisis situations, particularly by
being ready to schedule a second appointment sooner than the following
week. Further, parents often requested help in negotiating with other systems,
such as with a school setting. Responding to these presenting concerns
provided an opportunity for the social work interns to demonstrate their
commitment and potential capacity for help. Examples of this practical focus
include helping a parent complete an SSI application for her child or arrang-
ing for a conference at the child’s school to determine how the agency, school,
and parent can best work together.
Finally, a significant factor in every first interview was the exploration of
potential barriers to obtaining ongoing services at the agency. Specific
obstacles, such as time and transportation, were always addressed by the
social work interns. The impact of other types of barriers, particularly
previous negative experiences with helping professionals and discourage-
ment by others to seek professional help, is explored. Differences in race or
ethnicity between the social work intern and the client are always raised. For
inner-city families, experiences with racism and its impact on their willing-
ness to receive services from a &dquo;system&dquo; need to be carefully explored.
A critical component of this study relates to the degree to which the first
interview engagement training differs from the training of therapists in the
466

comparison condition. During an orientation training at the research site, all

therapists are informed of the diagnostic information that needs to be obtained
during a first meeting with the client. Necessary demographic data need to
be collected along with diagnostic data, including information about present-
ing problems, family composition and history, social and educational func-
tioning, past psychiatric treatment, and medical problems. The orientation to
the first interview emphasizes information gathering and diagnostic assess-
ment. The first interview engagement protocol also requires therapists to
gather information. However, it expands the first meeting’s purpose substan-
tially to focus on the process of gathering diagnostic data in a sensitive
manner and with a look toward why and how clients will return for a

follow-up meeting.

METHOD

In this study, 107 new cases at an urban child mental health center were

randomly assigned to trained first interviewers comparison group of

or a

therapists who did not receive specific engagement training. A total of 20

therapists were assigned to either intervention or comparison. Approximately
15% of trained first interviewers sessions were videotaped to ensure inter-
vention integrity.

Client Sample

Children and families involved in the study were representative of the

agency’s demographic characteristics in that 81 % (n = 88) of the children
were African American, 11 % (n = 12) were Latino, and 7.4% (n = 8) were
White. The average age of the children was 9.3 years. Approximately two
thirds of the children in the study were male. Approximately 46% of the
families were involved with state child protective services at the time of
referral to the agency. Single-parent households accounted for 53.7% (n =
58) of the sample, with an additional 20.4% (n = 22) of the children residing
in the home of a single grandmother.
Even though random assignment was used, additional analyses were
conducted to ensure that clients and therapists were comparable in the two
conditions. In relation to the age of the children, the average age of the
children in the experimental group was 9.2 years, as opposed to 9.0 years in
the comparison group. Approximately 76% of the children in the experimen-
tal group were African American, whereas 84% were African American in
the comparison group. No differences were found between the two groups in
 467

relation to gender. There were two significant differences between the two
groups in relation to therapist characteristics. First, the comparison group of
therapists was more likely to match the clients in terms of race in that 23%
of the African American clients were seen by an African American therapist.
There were no African American therapists in the experimental group.
Second, the experimental group consisted of solely second-year master’s-
degree-level interns. The comparison group consisted of trainees and faculty
with more advanced training and experience, such as clinical psychology or
child psychiatry fellows.

Procedures

The clinic procedures of the research site are as follows. All clients initially
have contact over the telephone with a master’s degree social worker. During
this telephone intake, information is obtained about a child and the family
preliminary information about a child’s presenting difficulties is recorded on
an intake sheet that is passed on to a therapist for assessment and intervention.
Children that presented with serious risk of harm issues (e.g., high risk for
suicide) were referred for emergency services. It is following this acceptance
for service on the telephone that the random assignment to therapist condition
occurred. The worker, either experimental or comparison, then calls back the
client to schedule an initial appointment.

Outcome Measures

Outcome measures for the study were (a) percentage of second appoint-
ment kept, (b) percentage of third appointments kept, and (c) proportion of
sessions kept during an 18-week study period.

RESULTS

Results of the study are summarized in Table 1. Of the 33 children assigned

to first interviewers, 29 (88%) came for a first appointment, 28 (97%) of
whom returned for a second appointment. In comparison, of the 74 clients
assigned to the routine first interview condition, 47 (64%) came for an initial
appointment, 39 (83%) of whom returned for a second appointment. The
average length of treatment during an 18-week study period for first interview
subjects was 7.1 sessions, as opposed to 5.4 sessions for the comparison
group. In summary, first interviewers lost only 5 cases between the assign-
ment and the third interview, in comparison to therapists without specific
468

TABLE 1: Engagement and Retention Rates for First Interview Intervention

Versus Routine First Interviews

NOTE: Numbers in parentheses are percentages.

engagement training, who lost 35 families between the assignment and the
third session.
Chi-square analyses yielded the following results. There were statistically
significant differences between the number of families who actually came to
meet with the therapist at least once when first interviewers were compared
to other therapists (x2 3.84 ; p < .01). However, there were not statistically
=

significant differences between return rates for second interviews (x2 2.74;
=

p < .10) and third interviews (x2 =1.54; p < .30). In relation to the proportion
of appointments kept during the 18-week study period, first interviewers saw
their clients significantly more than those not specifically trained in engage-
ment techniques (x2 8.68; p < .O1).
=

DISCUSSION AND APPLICATIONS

TO SOCIAL WORK EDUCATION

The first interview engagement intervention was designed to increase the

return rates for second and third appointments and to increase the overall
proportion of sessions kept. Results indicate that the engagement training was
associated with a significant increase in the latter. However, differences in
the return rates between the experimental and comparison groups of thera-
pists were not found. There does appear to be a significant unintended effect
of the engagement training that should be explored further in future studies.
It appears that for the study’s urban sample the critical point for attrition is
not following the first interview, but occurs earlier, between the request for
service and actually coming to the agency. Only 64% of families came for a
 469

first appointment in the comparison condition, as opposed to 88% in the

engagement training condition. Because demographic differences were not
found between conditions, this difference could be explained by the engage-
ment skills of the therapists as they called to schedule an initial appointment
with the clients. Anecdotally, first interviewers identified using many of the
problem-solving skills to address obstacles to coming to a first appointment
during this initial call. In future studies, this portion of the interaction on the
telephone between the worker and the client should be examined more
closely.
The necessity of engagement in the helping process is clearly recognized
within the field of social work. However, when training social workers to
work with specific populations, such as urban children and their families, the
impact of supplementing generic engagement skills should be explored. Both
the clinical and empirical literature identifies a range of obstacles that
low-income, minority clients encounter as they attempt to access mental
health services. When an ecological perspective is applied to the process of
engagement, it becomes clear that engagement does not solely have to do
with the motivation of clients to obtain help. This study provides some
preliminary indications that when clients are met with sensitivity and skill
they are at least more likely to come to an initial appointment and more likely
to keep proportionally more appointments. These results should encourage
more specified research in the area of engagement and encourage social work
educators to consider the need for more advanced training of engagement
skills tailored to unique populations. With this additional training, we might
be able to increase the number of children identified as needing mental health
services who actually receive treatment. Another finding that has particular
clinical significance is the number of clients lost after the first call to the
agency by therapists not specifically trained in engagement skills. This
finding highlights the fact that the helping process and engagement begin
prior to the client coming to the agency rather than in the first interview.
The current study is limited in several areas. First, the sample size limited
the ability to detect differences in return rates. This study examined a number
of appointments kept as the primary outcome variables of interest. Informa-
tion from the key reporters in the engagement process-the therapists and
the clients-is clearly needed in future research. Process information from
the clients related to their satisfaction with the session and the therapist, their
perceptions of being met with respect and understanding, and their motiva-
tion to return for the next appointment need to be collected in a future study.
If the engagement training actually shifted interview techniques, then per-
ception of the clients should also differ. Feedback from the therapists about
the engagement process is also critical if future studies are to specify further
470

the complex helping exchange that occurs during early meetings with the
clients’ systems. Further, the training provided to social work interns is meant
to target a range of barriers to help seeking. More research clearly is needed
as to whether different types of barriers serve as more important obstacles to

help seeking than others. Additional refinement and specification of the

training are necessary to more clearly define the processes that are more likely
to help vulnerable client populations access services.
Another flaw in the current study relates to the lack of specifics of the
routine first interviewers’ behavior in sessions. Although the therapists in
the intervention condition were videotaped to ensure treatment integrity, the
therapists in the comparison condition were not. Clearly, a more rigorously
designed study is necessary to this preliminary evaluation. In future studies,
a careful analysis of therapist behavior in both conditions is needed to
increase understanding of how such behaviors facilitate or block problem
solving around specific barriers to help seeking.
The foundation for any future child mental health services research is the
ability to engage children and their caretakers in services. Clearly, large
research initiatives are needed if there is to be an increase in quality and access
to care by minority children and families. This article has begun to examine
ways that social workers practicing within urban communities can increase
their own and their agency’s responsiveness to the client’s needs.

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