CLINICAL QUALITY OF CARE – PRACTICE PARAMETERS 

Office of the Chief Medical Officer 
Clinical Operations 


Family Engagement and Inclusion for Adults 

ClinP-16
 
Category: Clinical Programs 
Published Date: January 2014
  1. INTRODUCTION
    1. Client families are often potential sources of social and emotional support, and this role should be addressed in all service delivery.
    2. A client should be encouraged to involve his family in treatment unless the clinician believes it is contraindicated.
    3. Client’s family members can be key resources in allowing clinicians to provide comprehensive assessment and quality treatment and should be invited and encouraged to participate in these activities, whenever it is consistent with the wishes of the client.
    4. Client families have a unique relationship with the mental health systems and professionals who provide care to their family member, and staff should appropriately address the needs of the family that stem from this relationship. Staff should have the skills to clinically, ethically, and legally balance client autonomy with family inclusion as appropriate in the assessment and psychotherapeutic interventions of clients, including the abilities to weigh values of client choice, family focus, privacy, and public safety.
    5. These parameters provide staff guidance on how to:
      1. Gather and document relevant clinical information regarding family in assessment and services delivery for individual clients;
      2. Properly include a client’s family members in assessment and service delivery; and,
      3. Assess and address the needs of a client’s family.
    6. These parameters focus on family engagement of adult clients 18 and older. Clinicians should note that family engagement and inclusion with child clients and older adult clients may have different legal requirements and may entail additional special considerations.
       
  2. DEFINITION
    1. Family: Parents, siblings, children, spouses, extended family, foster family, life partner, and potentially other persons defined by the client who is significant in a personal support system.
       
  3. ASSESSMENT
    1. Client assessment should include questions to the client about family history, current relationships, and availability of the family for support or participation in treatment, including:
      1. The wish to include any family members as part of the assessment or care planning;
      2. The meaning of family to the client;
      3. Affinity to any specific family members; and
      4. Current and past family interactions and issues, including:
        1. Family conflicts, abuse, or trauma;
        2. Past family interactions or experiences that have resulted in the client’s seeking and obtaining mental health services; and
        3. The roles, past and present, that family may have played in the client’s life, plans, and goals, especially as it relates to support and conflicts.
    2. Client assessment should include questions to identified family members, when authorized, including:
      1. The wish of family to be included as part of the care planning;
      2. The ways the family sees the client’s strengths and weaknesses;
      3. Information the family may have about course of illness and response to interventions;
      4. Specific family concerns, including:
        1. Family interactions that may have resulted in the client’s seeking and obtaining treatment
        2. Family conflicts with client; and
        3. Potential for abuse or violence by or toward the client.
      5. Availability for family to participate in the client’s treatment.
    3. Assessment should contain sufficient information to determine whether or not direct inclusion of family in further assessment and treatment is in the best interest of the client at this time.
    4. Assessment should include information regarding the degree to which the client wishes family to be involved in assessment, treatment, and communication with mental health staff.
    5. Assessment should include the process and results of any suggested, attempted, and completed family contacts, including documentation of client’s written authorization before initiating contact and the outcome of such contact in client’s clinical record.
       
  4. TREATMENT PLANNING
    1. Staff should include family participation as appropriate in DMH service provision, including:
      1. Family presence during individual client treatment;
      2. Family-focused treatment;
      3. Family communications;
      4. Opportunities to include culturally relevant spiritual and religious support, resources, and goals for families in recovery-based treatment planning; and
      5. Referrals to family for psycho-education and peer support groups (see resources).
         
  5. CLIENT AND FAMILY CHOICE REGARDING INVOLVEMENT IN SERVICES
    1. Staff should use sound professional judgment taking into account legal, personal, interpersonal, and cultural effects when choosing to disclose client information with families and family information with clients.
    2. Clinicians should always return calls from family of a client regardless of the wishes of the client (see sample script below):
      • Script: Hello, my name is John Smith from the Los Angeles County Department of Mental Health, and I am returning your call regarding John Doe. How may I help you?
      • Depending on query: I’d be happy to listen to and potentially use any information that you might give me, but I cannot release information about anyone who may be receiving services at DMH without explicit consent from them to do so. You might ask the person that you are concerned about to provide that consent. I will also do what I can to facilitate communication between you and anyone that you have concerns about who may be seen in our clinic.
    3. A client may decline to authorize staff to initiate contact with the client’s family or to include his/her family in any treatment at any time over the course of their treatment/services.
    4. In instances in which a client has declined to authorize the release of information to his/her family, staff should clearly state in respectful language to inquiring families that staff may receive, but not provide information (see sample script below):
      • Script: I understand how concerned you must be. However, I must tell you that by law, I cannot disclose any information about any person that I may be treating unless I have explicit permission from that person to do so. I do not have such permission from the person that you mention, nor can I even tell you if he or she is somebody for whom I have provided care. With this understanding, I would be happy to listen to or review any information that you feel important to give me. I am sorry for any distress that this may cause for you, but please know that at DMH we strive to include family whenever possible.
    5. When client declines to give authorization to include family members in treatment, staff should use clinical judgment relative to making on-going attempts to work with the client to engage the family.
    6. Clients may consent to disclose specific types of information, but withhold consent for other information to family. In such instances, staff should carefully inform families that they do not have authorization to disclose certain information and that the lack of authorization may preclude the staff members’ ability to transmit significant facts or concerns (see sample script below):
      • Script: I must tell you that, while I’ve been authorized by John Doe to disclose certain information from you, I have not been authorized to disclose other information. The information that I cannot disclose limits my ability to provide you with a full description of relevant issues. It is unfortunate that this is the case, but I want to be sure that you understand this limitation exists.
         
  6. STAFF TRAINING
    1. Evidence-based practices regarding client family assessment, case formulation, and treatment planning should be a part of both clinical and cultural competence training on an ongoing basis.
    2. Topics covered by training should include:
      1. Important clinical and administrative issues related to client-family aspects of assessment and treatment;
      2. The value of family education and associated evidence-based practices in clinical care;
      3. Definitions and explorations of client-family inclusion as it relates to hope, wellness, and recovery;
      4. Discussion of therapeutic dynamics and cultural biases related to client-family inclusion;
      5. Discussion of the cultural context, relevance, and variations in family relationships in local and regional communities;
      6. Assessing the role family has in the mental health and life experiences of clients;
      7. Incorporating relevant client-family information into case formulations, treatment planning, and overall treatment;
      8. Understanding and noting how clients describe the quality and meaning of family relationships; and
      9. Linking to client-family support resources in the community.
         
  7. DMH PROGRAM RELATIONSHIPS WITH CLIENT FAMILIES - DMH programs and staff should:
    1. Publicize and maintain an avenue for receiving information from client families;
    2. Assist client families to connect with support resources of their choice in the community (see referrals in resources);
    3. Always be sensitive to the value of information provided by client families;
    4. Inform client families about available mental health services;
    5. Refer families to available community psychoeducation classes and provide available educational materials on mental health and family relationships; and
    6. Consult with the program manager if at some point staff learns that a specific family issue may be illegal or harmful to the client.
       
  8. RESOURCES