Journal of Marital and FamilyTherapy

January 2001 ,Vol. 27, No. 1,111-116

ENHANCING FAMILY THERAPY: THE ADDITION OF A

COMMUNITY RESOURCE SPECIALIST
H. Charles Fishman Fred Andes
Health Partners,Inc. Neiv Jersey City University

Roberta Knowlton
Neiv Jersey School-Based Youtlh Services

INTRODUCTION

This project was born of a desire to compound the effectiveness of family therapy by combining it with
intensive intervention in the family's broader social context. In many blighted communities, severe social
problems, such as poverty, violence, drugs, and joblessness, erode the social stability of children and their
families. In designing a family therapy program for such children and their families, we were concerned that
traditional family therapy was not sufficient to affect the toxic social pressures that destabilize them.
We believed that, to be effective, our treatment must go beyond the customary scope of family therapy.
Specifically, it should enhance the family's access to supports from its surrounding social context to
diminish external stress that exacerbates structural problems in the family system. For example, the
treatment team not only might obtain mentors and role models in the community for youngsters but also
might facilitate a family's access to professional or informal support systems.
To achieve these goals, we designed a model of treatment in which a family therapist was partnered
with a community member whom we called a community resource specialist (CRS). This article reports the
initial results of an evaluation of that model in the treatment of adolescents with behavioral problems.

RATIONALE

In a meta-analytic review of drug abuse outcome studies, Stanton and Shadish (1997) concluded that
family therapy was an equally effective treatment with adult and adolescent drug abusers and that it had
higher treatment retention rates than non-family therapy interventions. In the treatment of adolescent
substance abusers, famnily therapy has been found to be more effective than nonfamily therapy (Liddle &
Dakof, 1996), group therapy (Joanning, 1991), and family drug education (Joanning, 1991; Lewis, Piercy,

H. Charles Fishman, MD, is Medical Director for Behavioral Health of Health Partners, Inc., 833 Chestnut St., Philadelphia, PA
19107; e-mail: HCFishman@aol.com.
Fred Andes, DSW, is Assistant Professor of Sociology and Social Work. New Jersey City University, 2039 Kennedy Blvd.,
Jersey City, NJ 07305.
Roberta Knowlton, LCSW, is Director, Office of School-Based Youth Services Program, New Jersey Department of Human
Services, CN 700, Trenton, NJ 08625.
The Family Intervention Program Model as founded and developed by the authors has demonstrated elasticity in its application
to family and community contexts. For more information on recent developments of the model's evolution, please contact
Hinda Winawer, MSW, or Norbert A. Wetzel, PhD, Program Consultants, Center for Family, Community, and Social
Justice, Inc., Princeton Family Institute, Princeton, NJ 08540; e-mail: winawerhi@aol.com or wetzel@rci.rutgers.edu.
We thank Braulio Montalvo for his valuable contributions to project conceptualization, Terry O'Connor, former Assistant
Commissioner, New Jersey Department of Health, and Edward Tetelman, Esq., Deputy Commissioner, Department of
Human Services, State of New Jersey, for their support of the project and Nina Gunzenhauser for her expert editorial
assistance.

January 2001 JOURNAL OFMARITAL AND FAMILY THERAPY ill

Sprenkle, & Trepper, 1990) and equally as effective as the parent group method (Friedman, 1989). Family
therapy has also been demonstrated to reduce treatment dropout of adolescent substance abusers
(Henggeler, Pickrel, Brondino, & Crouch, 1996).
The concept of using community members in family therapy is not a new one. In the late 1960s, a
program was inaugurated in which talented persons from the inner city were trained as family therapists,
successfully intervening both in the family dynamics and in the family's relations with the community (M.
Lindblad-Goldberg, personal communication, June, 1999). More recently, work by Piazza and DelValle
(1992) has emphasized the importance of the client's own community. In a concept akin to the use of the
CRS in therapy, they involve leadership from the youngster's community in treatment. In the
Multidimensional Family Therapy (MDFT) approach, for example, Liddle (1995) focuses on several
subsystems in the treatment of adolescent drug abusers, namely the adolescent, the parent, the interaction
between the adolescent and the parent, and the extrafamilial.
This study fits into the growing trend toward the use of nonprofessionals to enhance the work of health
care professionals. The role of the CRS complements that of the structural family therapist (SFT), adding a
sophisticated awareness of the community to the therapist's family systems intervention.

METHODOLOGY

Subjects
The study sample consisted of 131 New Jersey high school students and their families from districts of
socioeconomic need-some urban and some rural. Each of these schools already housed a School-Based
Youth Services Program (SBYSP), which was geared toward bringing a set of comprehensive health,
employment, and social services to the school. Each SBYSP coordinated with a Family Intervention
Program (FIP), which attempted to avoid the necessity of residential placement for youth. Referrals to the
FIP usually came through the SBYSP when students showed addictive behavior and/or intergenerational
substance abuse and family dysfunction.
Table 1 presents the demographic characteristics of students who participated in the program. They
were all from families with multiple problems, including unemployment, substance abuse, and domestic
violence. They were referred to the program from several sources. Most were referred by school officials
because of behavioral problems, truancy, and poor academic performance, although many were referred by
the criminal justice system because of delinquency problems. In addition, some students were referred by
their families, who reported problems including substance abuse (by students and/or family members) and
domestic violence.
To evaluate the impact of the services provided by the community resource specialists, the students
were randomly assigned either to group A (N = 74), which received both family therapy and the services of
the CRS, or to group B (N = 57), which received family therapy only. The imbalance in group sizes was
caused in part by the random assignment of cases. In addition, nine students and their families who were
supposed to be placed in group B on the basis of random assigmnent were moved into group A because their
need was deemed to be so dire that it would have been unethical to exclude the CRS from their treatment.
This exception to randomization constitutes a limitation of this study. Moreover, the researchers could not
be blind to assignment to experimental and control groups because the family therapist and CRS worked
closely as a team.

Family Therapists
Five family therapists from diverse ethnic backgrounds participated in the study. All lived outside of
the communities in which they worked. The therapists received training at the Institute for the Family in
Princeton Junction, New Jersey. The training consisted of didactic instruction and observation of live family
therapy sessions. The clinical model utilized was intensive structural family therapy (see Fishman, 1993).
This approach seeks to work with contemporary social pressures that destabilize the family's system. In
addition, all-day case conferences were held monthly to discuss cases and monitor the adherence of the
therapists to SFT.

112 1JO RVAL OFMARITL AVD FAMIILY THERAPY January 2001

 TABLE 1
Characteristics of Students Involved in the Program

Group A Group B Total sample

(N= 74) (N= 57) (N= 131)
Age (years):
MeanD 15.89 15.53 15.73
SD 1.30 1.34 1.32
Education (years):
Meanb 9.67 9.62 9.65
SD 1.1 1.01 1.06
Race:
Black 41 (55%) 36 (63%) 77 (59%)
White 22 (30%) 13 (23%) 35 (27%)
Hispanic 9 (12%) 7 (12%) 16 (12%)
Other 2 (3%) 1 (2%) 3 (2%)
Gender:
Male 42 (57%) 24 (42%) 66 (50%)
Female 32 (43%) 33 (58%) 65 (50%)
Presenting problem:
Family 23 (31%) 16 (28%) 39 (30%)
Academic/behavioral 17 (23%) 26 (46%) 43 (33%)
Truancy 12 (16%) 7 (12%) 19 (15%)
Drug use 6 (8%) 4 (7%) 10 (8%)
Runaway 3 (4%) 0 (0%) 3 (2%)
Alcohol use 2 (3%) 0 (0%) 2 (2%)
Legal 2 (3%) 0 (0%) 2 (2%)
Other 9 (12%) 4 (7%) 13 (10%)
Referral source:
School 50 (68%) 46 (81%) 96 (73%)
Criminal justice 11 (15%) 1 (2%) 1 (9%)
Family 5 (7%) 3 (5%) 8 (6%)
Other 8 (11%) 7 (12%) 15 (12%)

Notes. Students in group A received both family therapy and the services of the CRS. Students in
group B received family therapy only. Percentage totals may not equal 100 because of rounding.
a Mean age represents 64 students in group A and 53 students in group B for whom ages were known.
For 14 students ages were not known.
Mean years of education represent 64 students in group A and 52 students in group B for whom years
of education were known. For 15 students years of education were not known.

Community Resource Specialists

A new type of practitioner was added to family therapy in the treatment of group A. In each of the four
locations where the program was held, a member of the community was sought by word-of-mouth
advertising and made a part of the therapeutic team. The CRS was hired for his or her authentic and expert
knowledge of the community in which both the family and the CRS lived. The role of the CRS was to
mobilize essential community resources to assist the family in achieving greater stability. These resources
were determined on the basis of the family's desires and the team's clinical assessment.

January 2001 JOURNAL OFMARITALANDFAAILYTHERAPY 113

 Like the family therapists, the CRSs were of diverse ethnic backgrounds, although they were more
likely than the family therapist to be of the same ethnicity as the family. The mean age of the CRSs was 34
years (SD = 9.70), and they had, on average, 13 years of education (SD = 1.15) and 2.63 (SD = 1.60) years
of experience in the human service field.
The CRSs provided diverse services. First, they assisted the family therapist in identifying both family
and community members who had influence over and concern for the adolescent, and they handled the
logistics of family therapy sessions. For example, the CRS might schedule a meeting with the therapist for
all concerned, make transportation arrangements for a family member, and arrange for the youth to be out
of class. The CRS also participated in sessions when requested to do so by the therapist and/or family.
Second. the CRS worked to develop the necessary links between the family and community resources.
The CRS had to know the community well enough to be able to provide specific information on the location
of a particular resource, the hours it operated, whether or not it could be reached by public transportation,
whether or not there were fees or wait lists, and most importantly, the extent to which that resource was
likely to be appropriate for a particular youth or family member. This meant meeting with community
service providers in advance and observing the services rendered, so that CRSs were referring families to
people who were already known to them. In this way, the CRS assisted youths and family members in
entering job-training programs and obtaining housing, food, and recreation services. The CRSs also served
as liaisons between youths, families, and school officials and/or law enforcement officers. For example, in
one situation the CRS served as an advocate for the mother in a meeting with her son's probation officer.
As an insider in the community, the CRS was sometimes able to access specific resources to meet special
needs of the family. In the case of a young girl who was interested in the graphic arts, for example. the CRS
identified an artist who befriended the girl and gave her an after-school job.
The CRS thus worked to ensure that the family left the intensive therapy with a newly enhanced
network in the community. He or she then visited or followed up with the family. youth, and community
members as appropriate to maintain their involvement in the network. In practice, the CRS and the family
therapist usually became a team, working closely with each other and learning from one another. Because
they were usually demographically different, they provided a model for the development of cooperative
behavior that often became an added bonus for both families and community members.

Procedure
Each student received was initially assessed by the family therapist. Both groups received weekly
family therapy (60-90 min) for an average of five sessions (range = 1-20). Members of group A were
informed that a CRS would contact them within a few days to assist in their treatment. The CRS usually
attended the initial therapy session to deternine how he or she could help to meet the family's needs. The
CRS's participation in the session varied according to the clinical needs of the family and the level of
experience of the CRS. In some cases, the CRS functioned as a resource and support for the family, and in
others as an active cotherapist. Frequently, the CRS facilitated the therapeutic process by providing
transportation to the session.
To control for the possibility that any group differences might be simply caused by the greater attention
received by group-A subjects, those in group B received additional contact time, primarily by phone, from
their family therapists.

MEASURES

Initially, the students' presenting problems (see Table 1) were rated as improved, no change, or
worsened. Pre- and posttest information about the students' problems was provided by both students and
family members who participated in treatment. In addition, referring school officials provided information
on students' academic performance and school behavioral problems. Students who terminated treatment
prematurely were contacted by phone, and those who could not be contacted received a rating of unknown.
The question of the reliability and validity of using presenting problems as the sole criterion for
evaluating the effectiveness of adding a CRS was raised. Beginning in the second year of the program,

114 JOUPRNAL OF MARITAL AN.D FAMILY THERAPY January 2001

 TABLE 2
Treatment Outcome by Group (N = 131)

Group A Group B

Improved 49 (66%) 16 (28%)

No change 24 (32%) 35 (61%)
Worsened 1 (1%) 4 (7%)
Unknown 0 (0%) 2 (4%)

Total 74 57

Notes. Students in group A received both family therapy and the services of the CRS. Students in group
B received family therapy only. Percentage totals may not equal 100 because of rounding.

therefore, standardized assessment instruments administered by family therapists at pre- and posttest were
added to measure family functioning, marital satisfaction, depression, and self-esteem.

RESULTS

Table 2 presents the outcome of treatment from groups A and B in the initial evaluation based on
students' presenting problems. Among those students who received both SFT and the services of the CRS
(group A), 66% showed improvement at treatment termination, whereas 28% of those who received only
SF1 showed improvement-a statistically significant difference (X2 (3) = 20.75, p = .0001).
In contrast, 32% of the students in group A and 61% of those in group B showed no change in their
presenting problems. Fortunately, only 4% of students who participated in the program reported deterio-
ration of their presenting problems; all of these had terninated treatment prematurely. Although the program
was developed to include an average of ten, 1-2-hr weekly family therapy sessions, group A actually
received 6.22 sessions on average (SD = 4.57), whereas group B received only 3.75 sessions on average (SD
= 3.53), which implies that CRS involvement decreased the attrition rate.

DISCUSSION

The greater proportion of the students in group A who showed an improvement in their presenting
problems as compared with group B appeared to be related to the participation of the CRSs in two ways.
First, CRSs created a social-support system that helped to improve family functioning. Second, they reduced
attrition from the program by nearly 40%.
The substantial drop in attrition rate in the group A families in this study is particularly significant in that
the families appear to have greater vulnerability in the areas of family structure (i.e., a higher percentage of
single-parent households), socioeconomic status, and history of domestic violence and substance abuse than
those in the previous studies. Previous outcome studies using SFT without a CRS or equivalent team member
have found that this type of therapy reduces the attrition rate (Szapocznik et al., 1989a, 1989b). We hypothesize
that replication of these studies with the addition of a CRS would lower the attrition rate even further.

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116 JO [RWNAL OF MARITAL AND FAMILY THERAPY Januar,v 2001

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TITLE: Enhancing family therapy: the addition of a community

resource specialist
SOURCE: Journal of Marital and Family Therapy 27 no1 Ja 2001
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