In 2013, the Family Centre (TFC) in Edmonton began collaborating with five other agencies to provide drop-in, single-session mental health counselling (DISSC) in multiple locations. This cooperative effort removed barriers to service and enabled people in crisis to get help quickly. In 2018, TFC lost $100,000 in funding. But despite this setback, the organization managed to increase access to mental health care by an impressive 30 percent, delivering an additional 2500 hours of service!
This 78-year old organization is an exemplar of how creativity, innovation and collaboration can lead to improved service delivery within existing resources. By thinking creatively together and letting go of “the way we’ve always done things”, new possibilities were imagined, and innovative approaches were adopted. In this story, we share some highlights of TFC’s success and lessons learned based on conversations with CEO Pauline Smale.
The Family Centre (TFC) in a Nutshell
The TFC has a legacy of supporting mental health in the community, beginning in the wartime 1940s. This includes traditional 50-minute counselling by appointment alongside extensive mental health supports provided by therapists, youth workers and social workers in peoples’ homes, schools and community centres. TFC also enjoys a long history of fruitful partnerships with other agencies. In the mid-1990s, for example, TFC partnered with the United Way of the Alberta Capital Region, Big Brothers, Big Sisters and FCSS in an initiative called Partners for Kids (PFK). PFK focused on working together to ensure that three inner city schools serving vulnerable children and families had access to mental health supports. Some “key facts”:
- TFC has provided services for children and families in Edmonton since 1942, including extensive supports for mental health in the community.
- 90 percent of services are delivered in the community – homes, schools or other community organizations.
- 240 full time staff and 100 contractors and affiliates. · 20,000 families served each year.
- Three main areas of service delivery:
- Collaborative Service Delivery – TFC works closely with Edmonton Child and Family Services to determine what supports children and parents need for a strong family. Every family with Child and Family Services involvement in North-Central and East Edmonton works with TFC.
- Community-based services – TFC provides extensive support to families, schools and communities; a major component of this work is related to mental health.
- Social enterprise work – TFC generates revenue by providing employee assistance programs, interpretation/translation services and educational workshops/programming
Drop-in, single-session counselling (DISSC) offered in partnership across six organizations
In 2013, TFC took a leap and added free drop-in, single-session counselling (DISCC) to its repertoire of services. You might wonder how a single counselling session can be helpful, but there is ample research-based evidence to support the practice. A study recently conducted in Ontario, for example, found that clients who accessed walk-in counselling improved quicker and were less distressed four weeks afterward, compared to clients receiving traditional counselling. Walk-in clients highly valued the accessibility afforded by DISSC and were frustrated by lengthy waits associated with the traditional model. Furthermore, single-session walk-in counselling has the potential to reduce emergency room visits, reduce long waiting lists and eliminate costly “no-shows” for traditional counselling appointmentsi.
Despite this evidence, DISSC has typically not been a strong focus in therapist education and is still a somewhat novel approach in actual practice.
Pauline: “If you read the research and if you talk to people coming out of therapy and counselling (educational) programs, drop-in counselling is still very, very new. Although it has been written about for 20 to 25 years, and there’s lots of evidence that it works, it’s still not something that’s highly trained to in academia.”
And, TFC folks were a bit skeptical, too. They believed in the research but wondered if it would really work in practice. They had to convince themselves that it would.
Pauline: “It took a lot of faith, initially…Faith was hard. Would people come? Would we upset people if they had to wait?… So, we just didn’t really believe in it. So, we had to learn how to do that. How to believe in it.”
To quell these anxieties, TFC implemented a comprehensive monitoring effort. But we’ll come back to that later. First, we want to talk about the unique staffing model for DISSC, partnerships established by the TFC to deliver DISSC more broadly, and issues encountered in implementation.
Unique staffing model
An innovative aspect of the DISSC partnership program is its staffing model. Counselling is cost-effectively provided by highly trained intern therapists in their final year of their master’s or PhD degree. These interns provide counselling services at all six partnering organizations but TFC provides the infrastructure for supporting them, including intense training and clinical supervision. The TFC internship provides a rich learning opportunity and thus is highly coveted by interns. Each year, TFC receives hundreds of resumes to fill about 34 positions.
Pauline: “We’ve become a real pipeline for students because the experience is so rich. They get to work in community; they get to work in schools; they get to do traditional therapy – 50-minute hours; drop-in therapy; and, on site crisis-oriented supports. So, it’s a very rich sort of experience for them… They’re in their seventh to eighth year… they’re really skilled. They’re already prepared. However, the training model and the supervisory model is pretty intense as well. Every five hours of work that they do, they have to have one hour of supervision. Our infrastructure has to be able to support that. It’s a big commitment.”
Epiphany: Why not increase access to DISSC by partnering with other agencies?
While planning for DISSC, it occurred to TFC leaders that, rather than delivering DISSC just at TFC, why not increase access by partnering with other agencies throughout the city?
Pauline: “We were viewing ourselves as an agency that was really good in collaborations and partnerships because we had done several – including Partners for Kids…and Collaborative Service Delivery with Children’s Services. So, we’d worked with groups of people to provide services in a good way. And so, we thought, ‘Why wouldn’t drop-in, rather than just doing it ourselves and having people come here, why wouldn’t we work with a variety of other organizations… to spread out the accessibility into the community?’”
And so, since 2013-14, TFC has been running drop-in single-session counselling (DISSC), for free, through a partnership between TFC, Boys and Girls Clubs Big Brothers Big Sisters of Edmonton and Area, Canadian Mental Health association – Edmonton Region, Edmonton John Howard Society, Pride Centre of Edmonton, and the Seniors Association of Greater Edmonton (Sage). By offering free drop-in counselling at all of these organizations, access to counselling services has increased considerably.
Implementing DISSC: “Learning on the fly”
DISSC presented some new challenges to TFC and partners – Would people come? How could we market it? How could we get people to use the different locations offering DISSC, not just TFC? Would people wait for a session if they couldn’t get in straight away? How could they be kept engaged while waiting? Implementation required a lot of problem-solving and “learning on the fly”. Here are some of the challenges encountered and how they were addressed.
Marketing DISSC was an early concern. One idea generated during a collective brainstorming session was to place sandwich boards advertising DISSC in front of partnering agencies.
Pauline: “Part of the issue we were having was around marketing and making sure that everybody didn’t come to The Family Centre because they knew us… Our numbers were high and …some of the other agencies were low. And so, we tried a lot of things…Then, in a collective discussion it just [came out]: ‘What about a sandwich board?’… It was one of several strategies, but it was one of those that, ‘Really? A sandwich board for counselling? It’s kind of weird. Do you think
people will do it? Does it increase stigma? Will people be embarrassed to come in?’ And we thought, well it can’t hurt to try, right? So that’s what we did, and it really had an impact. That was something we got feedback on right away and now we have it on bus stops, too.”
Learning to set limits
We can’t be all things to all people. Not fully confident that people would use drop-in services, TFC decided to “welcome the world in” by offering coffee and food. That worked, but then a lot of people started coming for the food, not the counselling. A big learning was that TFC couldn’t be all things to all people.
Pauline: “This was a big, big learning: One of the things we thought we needed to do was welcome the world in, because we were really worried that we wouldn’t reach those who needed us. So, we had coffee and snacks out and we let people sit there for hours reading the paper. We started to get a lot of people that really weren’t coming for counselling.
So, we had a lot of tension because we want to help people who are distressed and if they’re sitting here drinking coffee for eight hours, we feel good about that. However, we needed to realize we were not the right service for everyone, especially those who were not yet ready for counselling …A big learning for us was that, as much as we might like, we can’t do everything… We can’t help everybody with everything.”
Keeping people engaged while waiting for their session
Another concern was whether or not people would wait for their drop-in session. To address this concern, TFC’s IT person set up a texting and chat program so agencies could suggest that people go out for a coffee while waiting, and then the agency would text them if a session came up earlier.
Pauline: Then technology helped us, too. [Our] IT guy was able to help us with texting and chat… so that we could say, ‘Go for coffee and if something comes up sooner than an hour-and-a-half, we’ll text you and you can pop by’. So that kind of stuff we learned how to do.”
Doubts erased: DISSC works!
The early doubts about whether DISSC would work quickly evaporated. Findings from extensive monitoring efforts (see below) have been overwhelmingly positive and access to service has increased:
Pauline: “With our drop-in, what really pushed me hard wasn’t just what we had read but once we heard people consistently say, ‘I went in nine months ago and I made a plan and I’m doing it’. I’m sitting here thinking, ‘Man, I can’t stop eating chocolate for three days and you made a plan nine months ago?’ Something’s happening! How is that happening?”
…The feedback that we receive from the people we serve is so profound. The distress levels are immediately dropped in one session. The long-term impacts, when we do our follow up contact with people after a year… we’re getting positive effects in over 85 percent of the people we see. You can’t deny that it works. It’s like your brain thinks, ‘One session, how can that possibly do anything?’ But when people tell you that it’s working and you’re measuring their distress levels using valid, reliable tools, you know it works.”
One of the most powerful findings from monitoring efforts was that almost one third of people seen in DISSC were suicidal. This reflects the urgency of peoples’ needs, and the power of DISSC to meet those needs very quickly: DISSC may actually be saving lives.
Pauline: “Suicidal was another thing – we were really shocked by that. That was really overwhelming. 32 percent are suicidal when they come to us.”
DISSC effectively diminishes many barriers to service, including finances, location, and the ability to plan appointments, for example. TFC and partners also discovered that DISSC enables them to serve almost twice as many men than traditional counselling:
Pauline: “So [DISSC diminishes] the barriers that people have in terms of finances, location, capacity, their ability to plan appointments, bring kids downtown. Men in particular are very averse to longer term planning, we know, and so we’ve been able to serve far more men. About 48 percent [compared to the general population in traditional therapy, which] is about 25 percent…So, we’ve been able to reduce a whole bunch of different barriers.”
Reduced revenue = more innovation and improved access
“It was amazing. [The Family Centre] lost so much money, but still increased services.”
Jean Dalton [Manager, Community Strategies, United Way of the Alberta Capital Region]
And then in 2018, TFC experienced a significant reduction in funding. They expected this, given economic conditions and reduced philanthropy and knowing that smaller organizations were struggling more than TFC. In discussion with their funder – the United Way of the Alberta Capital Region – TFC chose to stop receiving money for its interpreter and translation services. These became part of TFC’s revenue-generating social enterprise work.
While this shift reduced some of the funding pressure, the TFC took the situation as an opportunity to critically rethink existing practices. They gathered, as is customary in this organization, to think together.
Pauline: “When we started to write our proposal, that was when we sat in a room. There were people in there at the management level, director level. We had our communication people in there. We had our marketing people in there. We had our education people. We had our quality improvement. We really took it as an opportunity to think. So, before we started writing, we just started thinking.”
Through this collective exercise, another epiphany surfaced. DISSC was working well, so why were other TFC clients still having to book appointments, especially when 20 to 30 percent never show up? Wondering why they hadn’t thought of this sooner, they agreed to eliminate appointments for counselling altogether, and to call this new approach, “continuous intake”. Now, people can drop in to TFC six days and four evenings a week. Their first session is free. If more sessions are needed, a fee assessment is completed, and client and counsellor arrange to meet again.
Shifting to the continuous intake model meant revisiting the role of TFC’s Intake and Referral Unit that was responsible for receiving calls, setting up appointments (no longer necessary), and referring people to other services. As a member of the Community Mental Health Action Plan System Integration Leadership Team, Pauline had been involved in discussions about strengthening 211 services in the province. One day, it dawned on her: “Why are we doing information and referral when 211 is doing information and referral?” That insight led to conversations with 211 folks, and ultimately, closure of the TFC’s Intake and Referral Unit. Closure of the unit saved money and the continuous intake model increased access.
Pauline: “How we saved money was to close down our intake unit. Our Intake and Referral Unit would receive calls, set up appointments. [Then] 20-30% of the people wouldn’t come. Then they’d re-set up the appointment and 20-30 percent of those people wouldn’t come. And they’d give referrals and they would tell people to contact whoever or try this or try that – maybe try an education group…
So, I started to look at our intake room and I started to think, what are we really doing in there? What’s being helpful? And I was attending these [Community] Mental Health Action Plan committee meetings and I was part of the Systems group and at some point, it just sort of dawned on me, ‘Why are we doing information and referral when 211 is doing information and referral?’”
It was, again, one of those moments – ‘Duh’. What are we doing?’ So, we send people to them, then they send people to us. And 20 to 30 percent of people don’t show up. So, you start doing the math and it just didn’t make sense anymore. So, we stopped doing intake and referral.”
The TFC website was changed to indicate that people should contact 211 for information. Since then, the results of continuous intake and relying upon 211 for information and referral services are remarkable!
Pauline: “So we’ve saved probably $100,000 because that’s what we lost. And we gained access for people and we’ve increased our numbers. We’ve increased our continuous intake hours from the traditional to that model by 9 percent and we’ve increased our drop-in numbers by 28 percent over the last year…And the no-shows, of course, are zero. Because you’re either here or you’re not.”
By offering complementary services, rather than duplicating them, TFC and 211 are more effectively using resources and optimizing their unique expertise. 211 Alberta Manager, Stephanie Wright speaks highly of TFC’s decision to stop doing intake and referral because it means that TFC and 211 are now each doing what they do well:
Stephanie Wright: “Information and referral takes time away from staff doing other things. But also, it can be done better when you have the time and capacity to focus on really doing that well. So, 211 can be the first piece for information and referral but when more specific information and advocacy supports are needed, that’s where TFC’s role is. So now, TFC and 211 are each doing what we do well.”
The power of ongoing monitoring to learn and inform efforts
Underlying all of the efforts described above is TFC’s commitment to continually monitoring their efforts– measuring, counting, and comparing – in order to understand how things are going and what might need to be improved. In the case of DISSC and eliminating the Intake and Referral Unit, here are some of the things TFC tracked:
- The number of “no-shows” for appointments
- The number of sessions provided each day
- Number of phone calls each day for people who don’t know where to go for service
- Number of website hits and all hits related to marketing (all of the ways people are finding services)
- Client age, gender, presenting issues, nationality; numbers of Indigenous clients
- How many times clients have been seen
- Whether the client is an individual, couple or family
- Pre and post-counselling session distress tests
- ACE questionnaires for each client
- Whether the client is suicidal
Initially, TFC compared many of these numbers weekly, and then monthly, with data collected the previous year. Pauline described numbers after the decision to close the Intake and Referral Unit as “mind-blowing”:
Pauline: “Once you start getting evidence and information you can’t deny it. That was mind-blowing. The no show drop…I don’t know what we thought would happen when you close an intake room or let people come in when they need to come in, but when you go from 30 percent to zero, it’s amazing. Then people kept coming. That was the other thing. So, what if people don’t come? Then does it matter if you have no no shows if nobody comes through the front door? Are we serving enough people? That’s one of the things we did. We measure, measure, measure. I was measuring daily, weekly, then monthly, then bi-annually. And now we’re looking at it annually. But literally weekly. Are we ahead of last July? First week of July? Are we behind the first week of July last year?”
Advice to others wishing to innovate and improve services
Pauline kindly offered some advice to others who similarly want to be innovative and to improve the services they offer:
- Just be open to changing. Don’t be afraid. Have courage to try.
- When making a change, it is important to read the literature and reflect on what you do well. It’s always a jump when you do something new and changing is hard, but you can gain confidence to move forward by drawing upon the research and your own experience. Building on things you do well gives you faith to move forward.
- Ensure sufficient supports for implementation. Pauline noted how important it is to have managers and staff to immerse themselves in, and oversee “all the moving parts” of the innovation Pauline: “You have to have managers and I don’t mean management positions; you have to have managers… I could have the manager list all the moving parts better than I could list them. There’s a lot of moving parts and so what are the pieces you don’t want to lose and what are the pieces you need in place? And it’s like everything. You start off heavy. My manager sat in the waiting room every day so that she could get a feel for what was going on.”
- Train staff in order to build their skills and comfort. DISSC brought with it some new challenges, and it was soon recognized that people, especially receptionists needed additional training: “Pauline: So, we trained our receptionists. They have suicide intervention training…We’ve always trained everybody on trauma informed care for anything that we do. But they were getting scared that somebody would be suicidal, and not that they were going to do an assessment, but just so they could feel comfortable that they had a better understanding of what people were going through that.”
- Be prepared for tons of surprises, learn on the fly and count stuff. Pauline advised that even though you will have a plan going in, there will always be “tons of surprises”. This makes it important to be able to learn on the fly. Measurement and data are critical, otherwise how do we know if we’re having an impact? Counting stuff helps to do that: “Pauline: “You just don’t know what’s going to go sideways. And you can’t write it all ahead of time. You honestly can never think of it… You have to learn on the fly and count stuff. People don’t like counting. People hate to count. But if you don’t count you miss it. You have to count it.”
Reflections on The Family Centre’s successes
While we can’t say definitively what made all of the TFC’s efforts so successful, a few things stand out:
A strong culture of innovation, ongoing learning and improvement. First, Pauline aptly described TFC as a learning organization. There is strong leadership for this. TFC makes a concerted effort to “think together” – including people from all parts of the organization – and to be open to new ideas, realizing there is always a better way to do things:
Pauline: “We are innovators…Because there’s always a better way to do things. There’s always a better way to do things. We just don’t know, and we’re always handicapped by our limitations of our information, education. We’re always trying to keep the windows open. We’re a learning organization.”
TFC intentionally creates space and time for people to think together. Bringing a diverse group of people with different experiences and mindsets together in a safe space fosters creativity and innovation. We heard this several times during our conversation with Pauline. Here’s one example:
Pauline: “We do a lot of meetings where we just sit around and think. We have marketing, we have programming, we have IT, we have everybody in the room, sometimes too many people in the room. I’m always like, ‘Is this the right use of everybody’s time?’ But, that’s where innovation does happen. Because everybody’s brains are different and actually, often [the ideas] don’t come from the program people. It’s very strange because it comes from other people who don’t have a lot of clinical background but have different experiences.”
Drawing from multiple kinds of evidence to inform practice and decision-making. TFC draws upon research-based evidence, but also wisdom gained from practical experience and an understanding of the local context, feedback from service users and evidence generated through monitoring and evaluation activities.
Commitment to, and well-established mechanisms for, monitoring, learning and adapting. As noted previously, TFC is highly invested in ongoing monitoring and measuring to understand and improve service delivery: “We measure, measure, measure”.
Commitment to employee well-being. Although not discussed in this story, our conversation with Pauline revealed a high level of attention to supporting the well-being of TFC’s people. This includes a wellness policy that, among other things, provides each staff person $500 annually to support their own wellbeing; positive psychology and strengths-based training and supervision; encouragement of reflective practice and mindfulness; concerted efforts to foster trust and humility and emotional intelligence; and more.
A long history of successful collaboration. And last but not least, this almost octogenarian agency appears to have mastered the art of collaboration in multiple initiatives and partnerships. This rare capacity has enabled DISSC to be delivered effectively at five other agencies across Edmonton. The agency’s ability to partner effectively is also demonstrated by its collegial relationship with funders such as the United Way.
Inspired? Intrigued? Encouraged? Want to implement something new in your organization? For a smorgasbord of ideas for how you can make it happen, search for the Resources section of Shared Wisdom for Supporting Mental Health.