Forced adoption support services scoping study Daryl Higgins, Pauline Kenny, Reem Sweid and Lucy Ockenden Report for the Department of Social Services by the Australian Institute of Family Studies February 2014

51.1Modes of delivery

As discussed in the previous section, there are numerous treatment interventions considered appropriate for responding to the wide range of trauma-related symptoms that may exist for survivors of trauma and which can be delivered in a number of different treatment settings/environments. This section will explore examples of treatment modalities to help inform the possible structuring of a system to deliver the range of services covered in this review—including specific types of interventions across different systems (e.g., health, welfare), jurisdictions, and locations (including regional and remote).

52Case management model

Integrated approaches to treating individuals with multiple and often complex needs/conditions are widely recognised as the most effective way of providing a continuity of care for clients, and thereby enhancing the likelihood of more positive treatment outcomes.

Case management is the linking of service systems to a client through an integrated, planned and individualised approach. It is designed to provide continuity of care for the client, which maximises efficient use of services by eliminating accessibility and service fragmentation problems (Wong, Yeung, & Ching, 2009). Most research on the effectiveness of case management has been conducted in the area of severe mental health disorders (Penk & Flannery, 2004). Case management is recommended for trauma survivors who are experiencing severe symptoms, such as serious mental disorders or co-occurring PTSD diagnoses (Foa, Keane, & Friedman, 2004; Glynn, Drebing, & Penk, 2009).

There are two ways to deliver case management: simple case management, where the client is instructed on their treatment and is then linked to required services; and intensive case management, where the client participates in social skills training and is more actively involved in their treatment options (Penk & Flannery, 2004). Research favours the form of intensive case management, with more positive outcomes such as a decrease in inpatient hospitalisation, greater satisfaction with services, social functioning improvements, and a reduction of psychiatric symptoms and alcohol and drug abuse being reported (Glynn, Drebing, & Penk, 2009).

Case-management services are recommended for trauma survivors who are experiencing severe PTSD symptoms when the client “will not or cannot locate and schedule” support services including:

employment services;

housing services;

education services;

social skills training services;

family education services; and

independent living skills (Penk & Flannery, 2004).

Case management is also recommended when the client requires frequent hospitalisations and fails to:

follow treatment plans or access recommended community-based services, or is not able to negotiate the complexities of receiving services from many different agencies in a variety of locales. (Penk & Flannery, 2004, p. 237)

A common response expressed by participants in the AIFS National Study was their frustration with the provision of health services, and a lack of sensitive, consistent information and referral advice from these health services (Kenny et al., 2012). Case management may be necessary for some people affected by forced adoption, particularly when the client is experiencing severe symptoms and is having difficulty following their treatment plan. However, the demand for it could be reduced among some clients if a consistent service was introduced that addressed the current service fragmentation. This could allow people affected by forced adoption to better “negotiate the complexities” of their appropriate therapeutic service needs on their own with support from ongoing counselling rather than a case manager.

53Online therapy and web-based interventions

Providing counselling options and information through online means has developed significantly over the last decade, with research consistently demonstrating support for the value of online therapy in producing positive treatment outcomes. There are several key advantages to delivering intervention via the Internet, such as improved accessibility, to anonymity and privacy, and that it can be a very effective first point of reference for visitors seeking further help, information and referrals. Findings to come out of the AIFS National Study (Kenny et al., 2012) and Senate Inquiry (2012) suggest that improving online support programs and providing 24-hour access to advice, support, information and referral services for adoption-specific areas could enhance existing services and provide those restricted by physical isolation with better access to advice, information and counselling services.

Potential interventions/services online modalities can offer include:

psychoeducation;

search and contact service;

psychotherapy;

peer-facilitated supportive groups; and

referral to face-to-face assessment and treatment services.

Psychotherapy delivered via a web-based format can be provided with or without therapist interaction, in an individual or group format. However, online group interventions are not as common as individual interventions and have not proved to be as successful as online individual interventions at this stage (Barak & Grohol, 2011). Other types of online interventions include forums, support groups, webcam or audio only counselling and blogging. Barak et al. found that email modalities produced higher effect sizes than forums or webcams, and that blogging may have potential therapeutic benefits as well as the additional benefits of peer support through feedback from others.

There is evidence for the success of self-help and therapist-assisted web-based interventions for common psychological disorders, including depression (Andersson et al., 2005, Christensen, Griffiths, & Jorm, 2004; Ruwaard et al., 2012), panic disorder (Carlbring et al, 2005; Klein & Richards, 2001; Richards & Alvarenga, 2002; Klein, Richards, & Austin, 2006), alcoholism (Riper et al., 2008) and PTSD (Hirai & Clum, 2005; Klein et al., 2010; Klein, Meyer, Austin, & Kyrios, 2011; Knaevelsrud & Maercker, 2007, 2009; Lange, van de Ven, Schrieken, & Emmelcamp, 2001; Lange, Rietdijk, et al., 2003; Litz, Engel, Bryant, & Papa, 2007; Lange, van de Ven, & Schrieken, 2003). Most research regarding online interventions has been conducted based on CBT protocols, with various reviews and meta-analyses supporting the general effectiveness of the model (Andersson, 2009; Barak, Hen, Boniel-Nissim, & Shapira, 2008; Griffiths, Farrer, & Christensen, 2010). Some studies have found online interventions to be equally as effective as face-to-face treatment (Barak et al., 2008; Carlbring et al., 2005). Importantly, one study found that gender, the level of Internet expertise, and delay from trauma to treatment were not influential in the outcomes of online therapy (Lange, van der Van, et al., 2003).

Web-based interventions provide improved possibilities to people affected by forced adoption through information, search and contact services, online counselling and referral to face-to-face services. Furthermore, a study that evaluated a United States chat-based online hotline for sexual assault victims noted that only 10–14% of visitors were seeking help for a recent incident (Finn & Hughes, 2008). This suggests that most visitors using the online service had not previously sought help or were using the service as continuing help for ongoing issues (Finn & Hughes, 2008). Victims may withhold from seeking support because of the stigma associated with counselling and because they feel ashamed and unworthy of help, which are common themes among trauma survivors. The option of receiving support while remaining anonymous, often in the comfort of their own home, is very appealing for trauma survivors.

Funded by the Australian Government Department of Health, Mental Health Online (previously “Anxiety Online”) is an example of an Australian Internet-based treatment clinic that was developed as part of an initiative of the National eTherapy Centre at Swinburne University of Technology. It provides information, online clinical psychological assessment, publically available treatment programs (including free online self-help programs and low-cost therapist-assisted programs), and treatment programs for research trials.

The advantages of online interventions include:

improved accessibility—rural or remote persons, people with a disability, people with restrictive schedules can all participate;

available any time of the day;

privacy, anonymity, convenience;

when exchanges between patient and therapist are not synchronous, the therapist has appropriate time to reflect and formulate effective feedback, and the patient can revisit material as often as he/she likes;

increased flexibility of services; and

cost-effectiveness (Barak et al., 2011; Robinson, 2009).

The limitations of online interventions include:

technical concerns—for example, Internet dropouts, computer illiteracy;

some demographics may be less comfortable using the computer and/or Internet for counselling—for example, older people or those from a different cultural background;

self-help programs are generalised—education and therapy cannot be tailored specifically to the individual without therapist interaction;

less effective for crisis intervention;

therapist cannot assess non-verbal cues;

difficult to verify therapist credentials, or that the therapist and/or client is the person online;

security risks—for example, email that is misdirected or intercepted; and

confidentiality and privacy issues (Barak et al., 2011; Lange, Rietdijk et al., 2003; Robinson, 2009).

54Telephone counselling and support

The implementation of a telephone support service for people affected by forced adoption practices was identified in the AIFS National Study (Kenny et al., 2012) as a way of improving access for clients in rural and remote areas. There are a number of telephone counselling services already in practice in other trauma-related fields such as domestic or family violence and sexual assault. There is limited research on the efficacy of counselling techniques using the telephone. However, the large number of services that provide a telephone counselling support service and information line suggests that telephone services are beneficial for people who have experienced trauma or are experiencing ongoing health and mental health problems such as depression, anxiety and PTSD symptoms.

As well as improving access for clients in rural and remote areas, a telephone counselling and support service has additional benefits for people who have been exposed to trauma. Some of the benefits of telephone counselling and support services are that it:

is cost-effective;

eliminates the fear of stigma, often associated with seeking counselling;

meets the immediate needs of people affected by trauma—for example, crisis intervention, counselling support, information and referral advice; and

validates the experiences of those who were affected by that particular type of trauma.

Some of the limitations of a telephone counselling and support service are that:

it may not be suitable for all clients—for example, some clients might be concerned with privacy or may be uncomfortable receiving treatment via telephone;

establishing rapport with a client can be more difficult over the telephone than in person;

the counsellor cannot assess non-verbal cues; and

the counsellor may not be aware of community resources when counselling a client from another area—therefore, it may not be suitable for less stable clients (Coman, Burrows & Evans, 2001).

1800RESPECT is an example of a 24-hour telephone counselling service for people who have experienced or are experiencing domestic or family violence, or sexual assault. It runs in conjunction with a complementary web-based counselling service that provides information, referral advice, counselling options and information on where to get support. A similar model could be useful for people affected by forced adoption, with the addition of a search and contact service, where information on the search and contact service is available both on the website and by contacting the telephone number.

A freecall telephone number was set up as a critical component of the Find & Connect service for Forgotten Australians and Former Child Migrants, and is regarded as a necessity for meeting the needs of people affected by forced adoptions (Kenny et al., 2012).

An additional advantage of a telephone service is that the name of the service, such as 1800RESPECT, Lifeline, beyondblue, Veterans Line or Kids Help Line, actually increases awareness of that subject area among the general community. Increasing community awareness through a highly recognisable telephone support line would help to legitimise the experiences of people affected by forced adoption and encourage those affected to seek support.

55Service hubs

The Senate Inquiry (2012) and the AIFS National Study (Kenny et al., 2012) identified that a number of submitters/participants were unsure of where to go for appropriate health services or reconnection services, and many experienced negative reactions to services because of fragmented service options and the need to continually retell their “story”. Participants also noted that a one-stop-shop service model would be useful for addressing the diverse needs of people affected by forced adoption. The implementation of a service hub could address these issues by offering a range of different services—medical, counselling, information searching and referrals—all at the one place; however, given the diverse needs of people who were affected and the large number of people affected who are located across a huge geographical area, the costs associated with establishing service hubs are likely to be too high and there may be difficulties in deciding on appropriate locations.

Another type of service hub that may be an appropriate or more cost-effective option is a service centre that acts as a gateway to appropriate services rather than delivering a one-stop-shop service. An example of a service model that uses this gateway approach is the Family Relationship Centres (FRC) in the family law field. FRCs were developed to provide an educational, support and counselling role for the needs of people experiencing divorce or separation (Parkinson, 2006). They provide an initial point of information, advice and assistance, as well as offering referrals to appropriate community-based services (Parkinson, 2006). Parents inquiring at the centres have the option of an individual session with an adviser to receive basic information and advice specific to their individual needs, as well as other sources of help for related problems that may arise (Parkinson, 2006). Rather than a one-stop-shop service, FRCs act as gateways to appropriate services by providing relevant information and advice specific to the individualised needs of each client. FRCs may provide an appropriate model from which to develop a service centre model for people affected by forced adoptions.