Steps Toward Evidence-Based Practices for Parents
with Mental Illness and their Families
Emerson-Davis Family Development Center
Brooklyn, NY
Program Description
The Emerson-Davis Family Development Center (Emerson-Davis) is a residential treatment program for adults with mental illness and a history of homelessness. Emerson-Davis is located in a remodeled college dormitory in Brooklyn, NY. The dormitory has been converted into 22 one-bedroom apartments for single adults seeking reunification with their children, and 16 two-bedroom apartments for families. The program for families at Emerson-Davis centers around comprehensive case-management and in-home family development services to promote independence and good parenting among residents. A range of services for children in residence with their parents is also available on-site. Emerson-Davis operates eight "satellite" apartments in the community that are available to families after "graduation" from the residential program.
Program History
Emerson-Davis is a program of The Institute for Community Living (ICL), a large human service agency for individuals with mental illness and mental retardation and co-occurring problems such as substance abuse and HIV in New York City. Using a combination of available state and federal funding, ICL opened the Emerson-Davis Center in 1994. According to the current leadership at ICL, the program for parents was a natural outgrowth of existing ICL residential programs for homeless adults with mental illness and chemical abuse problems (MICA programs). As the adults in their MICA residential programs became healthier and more stable, they expressed a desire to reunify with their children, who were living with relatives or with foster families through city child protective services. Initially, there were two separate programs at Emerson-Davis - one for the single adults in residence, and one for families. Experience with this model made it evident that integrating the programs for single and parenting adults fostered a stronger sense of community and recovery.
The program at Emerson-Davis, like all programs for parents with mental illness, was developed in a vacuum of knowledge about "best practices" for parents. Administrators and staff "borrowed" and adapted models designed for different populations (e.g., substance abuse) with which ICL had experienced success. Over time, it became apparent that additional services for children were desirable. Funding from federal Housing and Urban Development (HUD) and private foundations allowed for the establishment of "The Family Enhancement and Learning Program" at Emerson-Davis, a program devoted to educational and preventive interventions for children and families. It was also determined that satellite apartments and a modified program were needed to provide an intermediate step between the more intensive residential program at Emerson-Davis and full independent living in the community. In 1999, ICL leased its first satellite apartment in the Crown Heights sections of Brooklyn.
Funding History
The Emerson-Davis Center was established with funding from the New York State Office of Mental Health and HUD program. HUD grants (McKinney grants) were made available to states to distribute in a competitive grant program according to local priorities. In New York, these monies were assigned to housing for persons with a history of homelessness, and mental illness as part of the historic State/City, New York/New York Agreement. ICL, a New York based human service agency with a history of providing clinical and residential services for a variety of vulnerable populations since 1986, was well situated to respond to this priority. This funding has continued since the program's inception.
In addition to these primary funding sources, Emerson-Davis receives service support from local child welfare agencies, schools, hospitals, child care and legal assistance programs. Local community groups have sponsored funding drives for the Center.
Target Population
Emerson-Davis provides services for adults (18+ years) with serious and persistent mental illness and a history of homelessness (requirements of New York/New York funding) who wish to live with their children and work toward independence. Parents must be eligible for SSI benefits, and be willing to authorize Emerson-Davis and ICL to be payee of these benefits. Emerson-Davis also requires participants to be drug-free for at least one-year, stable with respect to psychiatric symptoms, and to have custody of their children or have a reunification plan. Parents must also show a "genuine yearning" to be with their children, and to learn to manage parenting stresses, that "grows out of their capacity" for empathy and delayed gratification for their child's benefit (p. 44; Lieberman et al., 1999). Children must be twelve years or younger at the time of admission.
Theory and Assumptions
Mission. The mission of the Emerson-Davis Family Development Center is to promote family reunification for its target population and to develop innovations that promote success of this endeavor. Emerson-Davis also shares in the formal mission of ICL, its parent organization.
Program Goals. The goal of the program at Emerson-Davis is "to blend a sufficient number of interventions to establish a safe, home-learning environment which supports parents and children in successfully building a family and personal life" (p. 43, Lieberman et al., 1999). Within this program goal, families determine their own goals and plans to achieve these goals. Independent living is central among goals for all families at Emerson-Davis.
Theoretical Orientation. Emerson-Davis is family-centered and strengths-based. The program is founded upon five "guiding principals" that reflect this orientation and approach. These principles are listed in Table 1 (see below; Lieberman, Campanelli, Ades, Cruz, Nagel, & Palmer, 1999). The family is prioritized as both a social and clinical unit. Parents are supported to develop individual and family goals, and service plans that address the broad psychosocial needs of both parents and children are the center of the intervention at Emerson-Davis. The program at Emerson-Davis is strongly influenced by the "Community as Method" model developed for persons with substance abuse and developmental disabilities. Parents and children are challenged by multiple providers at the residence (e.g., house staff, case managers, family development specialists) to participate fully in a social community of staff and other residents. The Community model is further supported by use of the Social Problem-Solving Skills program developed by Elias and Clabby (1989). This program was originally developed to promote prosocial behavior among children and youth. Clabby has provided direct consultation to Emerson-Davis, and facilitated program modifications to address the needs of the families served by Emerson-Davis.
Table 1: Emerson-Davis "Guiding Principles"
- Parents who want to care for their children are less impaired by psychiatric disability than those who do not.
- Foster care, too frequently, has disappointing results.
- Lack of an adequate residence is a major determinant of poor outcomes for individuals.
- Parents need and can benefit from support in their parenting role. Housing packaged with targeted social services is an ideal vehicle for the purpose of delivering this support.
- Housing must be accompanied by broad social service supports that are available in an integrated fashion.
Community Context
Local History. Emerson-Davis is located in the Clinton Hill district of Brooklyn, NY. Clinton is an ethnically and economically diverse area that has been undergoing gentrification during the last five years. The center is accessible to both bus and subway routes that access the entire city of New York. The Emerson-Davis residence is adjacent to Pratt Institute.
Community Strengths and Weaknesses. Participants in the Emerson-Davis program identify the resources of New York City as an asset of their community. They report that the program at Emerson-Davis helps them access many of the recreational and educational opportunities available to them, and to integrate these resources into their family lives. For example, case managers help parents plan weekend family activities that may include a trip to the zoo or a museum, all accessible (and sometimes free) from the extensive public transportation system. In addition to its proximity to public transportation, the neighborhood itself also has strengths. Most notably, Emerson-Davis is located within walking distance from an elementary and middle school, and from day care centers used by program participants. This encourages parent participation in school, and supports attendance at parent-teacher meetings.
New York City also has its disadvantages, however. The cost of living is very high, work is competitive, and affordable and safe housing is difficult to find. Program staff note that lack of affordable housing provides a significant barrier to independence for residents at Emerson-Davis. There are few realistic opportunities for housing comparable to the apartments at the Center - large enough for a family, safe, and accessible to school and daycare. Additionally, the quality of public school systems varies greatly across neighborhoods in New York.
Relationship of Community to Emerson-Davis. Initially, the community immediately surrounding Emerson-Davis was not welcoming. Neighbors were concerned about having a residential treatment program for adults with mental illness in their neighborhood. With support from ICL, Emerson-Davis engaged in an extensive social marketing campaign directed at both political leaders and the community. Relationships were created with the local state senator, and city council members. Community programs were initiated to introduce Emerson-Davis to politicians and neighbors, to encourage community involvement and participation, and to educate the local community and political leaders about mental illness and stigma. These efforts have been highly successful at eliciting generous support from the community. After seven years, Emerson-Davis is well integrated into the neighborhood. Community members are active members of the program's advisory board (see below), and sponsor a yearly Toy Drive for residents. Holiday parties and yearly block parties provide opportunities for community members to meet the families at Emerson-Davis, ask questions, and see that the families living at Emerson-Davis are "just like everyone else." Staff at Emerson-Davis say that the relationship with the immediately surrounding community is so strong that there is a sense of "community ownership of the children" and an "open door policy" for children at neighbors' homes.
Community Collaborators
Emerson-Davis lists multiple community collaborators across state agencies, local providers, and community organizations. These collaborators include child welfare and local private non-profit foster care agencies, mental health providers, schools, vocational rehabilitation services, day care providers, churches, and local businesses. Members of these constituencies participate on Emerson Davis's community advisory board.
Methods of Collaboration
Collaborators are engaged in different ways on multiple levels. For example, on a political level, Emerson-Davis has forged strong relationships with the local state senator and city councilor, both of whom have been instrumental in the success and continued funding of the program. On the agency level, Emerson-Davis has created strong and cooperative relationships with child welfare, foster care agencies, local daycare providers, and vocational rehabilitation services. These relationships prove mutually beneficial in that Emerson-Davis can access a comprehensive service array for program participants, and the work of providers is facilitated through consistent communication with and support from Emerson-Davis. This collaboration ultimately enhances outcomes for parents and families. For example, state child welfare has a strong interest in family reunification. Housing and supervision of child safety can be major obstacles in establishing reunification. Emerson-Davis can address these issues and facilitate safe reunification by providing supervised apartments for parents with children in state custody.
To support these relationships, ICL sponsors an annual conference for community collaborators and providers focused around issues of local interest. For example, a conference is being planned on Parenting and Mental Illness: What's in the best interest of the child?
Agency Context
Mission and Goals. Emerson Davis is a program of the Institute of Community Living (ICL). The Mission of ICL "is to assist people with mental illness and developmental disabilities to improve their quality of life and to participate in community living by providing high-quality services and support." According to its own administrators, ICL is engaged in an ongoing process to accumulate the resources necessary to meet the multiple service needs of the at-risk populations it serves. The growing array of ICL programs provides access to quality services that the ICL's service population, stigmatized by history, often finds difficult to obtain by other means.
Affiliation with ICL provides benefits to Emerson Davis's residents and staff. ICL's wide array of services are readily available to Emerson Davis families, and can often be better coordinated as a result of existing intra-agency channels of communication. For example, ICL has an "Entitlements" department that specializes in accessing entitlements (e.g., SSI) for which participants are eligible, and is available to all clients of any ICL program. Thus, participants at Emerson-Davis have access to this service by virtue of their affiliation with ICL, and case-managers at Emerson-Davis do not have to be burdened with this aspect of participants' needs.
Affiliation with ICL also offers a wide range of staff development opportunities. ICL offers comprehensive 2-day orientation to all new employees, and regular training seminars for all staff. Staff at Emerson-Davis often come to the program from other ICL programs. High level administrators emphasize the value of this "within agency" experience with respect to skill development, and staff morale and loyalty. Many staff have a genuine investment in the agency and its mission that enhances morale and decreases turnover and disruptions. These features in turn are believed to enhance services to participants.
Agency Characteristics. ICL employs approximately 850 individuals that staff more than 40 programs throughout New York City and eastern Pennsylvania. Emerson Davis staff are all employees of this larger organization. Emerson-Davis supports a masters-level Program Director with extensive experience in working with adults with mental illness and/or substance abuse. In addition to a single administrative assistant, the Program Director oversees two integrated programs for families: Case-Management, and Family Development. Each of these programs is run by an experienced staff member with bachelor's degrees in related disciplines. The supervisor for the Case-Management program supervises four bachelor or associate-level case-managers, six front-desk counselors, and four on-call front desk staff. Case managers provide direct case management and crisis intervention, while front desk staff provide a structured milieu and crisis intervention. The Family Development Specialist supervises four childcare staff who provide supervision and structured recreational and educational activities for children after school. As noted in Figure 1, The Learning Center is an integral component of the program at Emerson-Davis, but is supervised by a doctoral level psychologist. The Learning Center is staffed by a masters-level family specialist, and an academic tutors at either the masters or bachelors level. A subsidiary ICL family and children's services clinic the Guidance Center of Brooklyn provides onsite child psychotherapeutic interventions and parent counseling in the Learning Center.
Staff at Emerson-Davis attend weekly staff meetings that provide regular in-service education and training. In particular, staff are asked to examine their own values about parenting and mental illness, and to develop increased sensitivity and acceptance of diversity in parenting. Staff also attend weekly community meetings that include all staff and program participants. Community issues are raised and addressed at these meeting, and community events are planned.
Program Model: Services and Interventions
The program for families at Emerson-Davis revolves around two fully integrated and complementary programs: The case management program and the family development program. These programs are embedded in the "Community as Method" program that defines Emerson-Davis. Additional programming on-site includes psychoeducational parenting group, Family Enhancement and Learning Program, the afterschool program for children, Scattered Site Program, and Alumni Association. Case-managers at Emerson-Davis also provide referral and coordination of mental health (e.g., psychotherapy, medication management), vocational rehabilitation, and drug treatment services for parents, as well as for any other services and supports need by families living at Emerson-Davis.
Social Problem Solving. For the purposes of finding an easy to use common language for discussing and fostering prosocial behavior among Emerson-Davis program participants, ICL has adapted and modified modules that were designed by Clabby and Elias for inner city school populations. The development of these modules is an ongoing process.
Community as Method. Emerson-Davis is a community residence that is staffed 24 hours a day, 7 days a week. House staff provide round-the-clock supervision, support, and crisis management. All staff at Emerson-Davis function as a whole to foster a sense of community at the residence. Both staff and program participants say that the greater proportion of learning at Emerson-Davis occurs spontaneously through continuous daily interactions between residents and staff that emphasize respect for pro-social behavior and community obligations. Community meetings for both staff and adult participants are held weekly to address both administrative and social house issues.
Case Management. Case managers are selected to provide as good a "fit" as possible for each family. While no formal protocols have been established for this purpose, it has been observed that some families require a warm, but firmer and more intrusive case management approach than others. Case Managers meet with parents a minimum of five visits a month. Initial meetings focus on a comprehensive assessment (see Client Path below), identification of goals and development of an appropriate, goal-directed service plan. At subsequent meetings, participants and case-managers review progress and service plan implementation, and address problems/concerns that have arisen. Case-managers are a source of education for parents about the multiple issues of independent living. They provide comprehensive referral and coordination of all services determined to be appropriate to a family's goals.
Family Development. Each family works with a Family Development Specialist who visits the family in their apartment at least once per week. The Family Specialist provides support and education related to all aspects of parenting and family life. In particular, the specialist discusses child development and parenting concerns with parents, and provides role modeling for good parenting skills, behavior management, advocacy, and general problem-solving. The specialist is also available to accompany parents to school meetings or court dates related to child custody.
Parenting Group. The parenting group is an integral and required part of the program for parents living at Emerson-Davis. The group meets weekly and is led by the Family Development Specialist. Childcare is provided during the meeting time so that all parents can attend. Groups focus on diverse issues related to family life, and can be general or specific. For example, groups may focus on strategies for behavior management or on planning for educational and recreational activities during a school break. Issues are determined in collaboration between the specialist and parents.
The Family Enhancement and Learning Center Program (Learning Center). The Learning Center is located in the basement of the Emerson-Davis Center. This program provides both educational and clinical services for families who have identified these service needs in their service plan. Professional tutors are hired to meet with children to address learning and other school related difficulties. Mental health counselors from a local community mental health center travel to Emerson-Davis to meet with children and families for individual and family therapy.
After School Respite Program. Emerson-Davis hires per diem childcare staff to provide supervision and structured activities including both homework supervision and recreation for children at the residence. Respite childcare is provided daily during the school week from 3 to 5pm. Children are not required to attend the After School program, but participation is strongly encouraged. Parents interviewed at Emerson-Davis reported that the After School Respite program was extremely helpful. It allowed parents time for themselves to take care of necessary errands such as marketing, to "decompress" from the stresses of the day, to focus on preparing dinner, and to gather energy for parenting into the evening.
Summer Program. In the summer when children are not in school, Emerson-Davis coordinates two trips per week for the children who are not in summer school or attending camp. Less regular activities are coordinated that both parents and children can attend together.
Scattered Site Program. Emerson-Davis leases eight apartments in various parts of Brooklyn. These apartments are available for rent to participants who "graduate" from the residential program. Participants at the scattered sites continue to receive a modified program of support and services from Emerson-Davis. They meet with case-managers once a month in their apartments, are welcome to attend the parenting group and receive support and guidance from the Family Specialist. Graduates may also continue to take advantage of the After School and Respite programs available for families at Emerson Davis. Unfortunately, many graduates move to parts of the city that make access to the residence and these services difficult.
Alumni Association. Emerson-Davis continues to provide services to past parents and children who remain in the area. They sponsor a monthly meeting for Alumni to socialize and provide support for each other. Some parents also hold supported employment positions at the residence. Alumni are also offered childcare so that they keep up with important community commitments.
Treatment Team Meetings. The program director and supervisors of the Case-Management, Family Development, and Learning Center programs meet weekly to review participant treatment/service plans and progress, and to address challenging issues related to families. Case-managers are invited to attend when discussions center on participants with whom they work. Input is gathered from all house and childcare staff prior to meetings to inform team discussions.
Client Path
Referrals to Emerson-Davis come from a range of providers. The greatest proportion come from homeless shelters, psychiatric inpatient units, and other ICL programs. All referrals must go through the New York/New York application process, and be eligible for services (i.e. diagnosis with SMI and history of homelessness). Applications are screened by a staff team composed of the program director, director of the Learning Center (doctoral level psychologist), and the family development specialist for promise of success in the program. Applications are examined for strengths, psychiatric stability, and genuine yearning and capacity to parent. Consideration is given to the "fit" of the applicant with current case-management staff.
Applicants are invited for one to two intake meetings in which they learn about the program and about expectations for participants. The directors of the Case Management, Family Development, and Family Enhancement programs, and a case manager are present for the intake meetings. These staff emphasize the "staff intensity" of the program to help potential participants decide whether the approach will be too intrusive for them. If both staff and applicant agree, an admission agreement is signed. Within 24 hours of admission, the client's ability to exercise "self-preservation" in the case of a fire or other house emergency is assessed.
The first six months after admission is considered an "assessment period" where strengths and needs are broadly assessed. An interim service plan is developed immediately that includes regular meetings with a case manager and family development specialist, and attendance at the parenting group. Over the first 30 days in residence, the participant and case-manager complete a "Level of Functioning" assessment, that examines strengths, interests, social networks, medical history, and psychosocial functioning. The completed assessment is reviewed by the participant and the Director of Case Management. In addition, over the first 30 days in the program, meetings with both the case-manager and family development specialist focus on identification of goals across a broad spectrum of functioning, and development of a service plan tailored to meet those goals. For example, participants identify residential, educational and occupational goals. They identify personal and interpersonal development goals such as "Assertiveness" and "Community Integration," and they develop parenting goals. Parents often arrive before having regained custody of their children. In these cases, the reunification plan developed with child welfare or other supporting agency is integrated into the participants overall service plan. Service plans are monitored weekly, and reviewed quarterly for progress and modification.
Treatment and service planning for children is separate and takes place through the Family Enhancement program. Child progress is often discussed at the weekly Treatment Team meetings discussed above.
There are no strict criteria for graduation from Emerson-Davis. Participants together with staff providers determine when rehabilitation goals have been met, symptoms are stable, and parenting skills and family functioning are satisfactory. Lack of available housing is often a barrier to graduation for participants who otherwise feel ready for increased independence in the community. The majority of participants live at Emerson-Davis for 1 ½ to 2 ½ years (contingent upon housing in the community) before entering independent living in the community. Graduates who remain in Emerson-Davis community apartments (scattered sites) continue to meet with their case-manager on a less regular basis of once per month, although more intensive support is available when needed. Some participants continue to participate in activities and groups at Emerson-Davis, while others do not. Distance from the residence can be prohibitive for continued involvement in house activities.
Evaluation
Emerson Davis collects data on family characteristics, family outcomes, and family satisfaction with the program.
Family Demographics. Between its opening in 1994 and January 2000, Emerson-Davis has provided services for 45 parents with 63 children. Ninety-three percent of parents have been mothers, 62% were African American, 20% Latino, 15% Caucasian, and 3% Asian. Parents range in age from 18 to 56 years. Over 64% have never been married, and 36% have completed high school.
Diagnoses. Parents at Emerson-Davis carry primary diagnoses of Schizophrenia and related disorders (42%), mood disorders including Major Depression and Bipolar Disorder (40%), and other Axis I diagnoses. Approximately half of program participants have a history of co-occurring substance abuse diagnoses.
Children's Characteristics. Children at Emerson-Davis have ranged in age between 0 and 14 years old, with 50% being under the age of 6 years. Children older than 12 years at the time of their parent's enrollment are not eligible for residence at Emerson-Davis. Most children at Emerson-Davis have been involved with child welfare and foster care settings. Forty-one percent of the children have psychiatric diagnoses, including Mental Retardation, Learning Disabilities, ADHD, depression, anxiety, and psychotic disorders.
Family Outcomes. Twenty-four of these families have left Emerson-Davis for independent living with families intact. Adherence to service plans developed with case managers and family development specialists are high, ranging from 87% to 100%. Surveys of staff indicate that they perceive that 86% of parents and 90% of children show positive outcomes with respect to psychiatric symptoms, overall functioning and development. Substance abuse relapse rates are low, with 3.6% of parents having some type of relapse. Twelve and one-half percent of the parents require psychiatric hospitalization annually, but can return to the residence and resume family life after discharge. Children can often be cared for in the residence, but sometimes must enter foster care temporarily. Emerson-Davis facilitates their return once the parent's crisis has resolved. There are plans to begin more rigorous data collection on clinical outcomes for both children and parents.
Family Satisfaction. Participant satisfaction reports show that 93% of the participants are satisfied or very satisfied with the program at Emerson-Davis with respect to achieving their goals.
A Success Story
Janice arrived at Emerson-Davis in December 1999. Her stated goals were to maintain sobriety, regain custody of her two children who were in foster care, and become independent. At the time of her admission to Emerson-Davis, Janice had completed a long-term, residential substance abuse program and was involved in an internship to train her to be a drug and alcohol counselor. Janice was living in a homeless shelter.
Janice arrived at Emerson while her children were still in state custody. She began having visits with her children at Emerson-Davis one month after her admission. Janice recalled that her case-manager and the family development specialist helped her arrange the visits with DSS, and provided a lot of support during visits. Janice felt she needed support because she was not used to parenting, and had never parented while sober. The family development specialist also helped Janice understand the special needs of one of her children who has medical issues, and to access the services he needed.
Janice regained custody of her children six months after arriving at Emerson-Davis. When we met Janice, her children who are 10 and 12 years old and in the 4th and 7th grade respectively, had been living with her for just over one month. She reported that they were initially quiet and withdrawn, but seemed to adjust quickly and were now laughing and taking part in house activities with other children. Janice said that the childcare workers and afternoon (Respite) activities have been very important in helping her children adjust at Emerson-Davis and in general.
In addition to regaining custody of her children, Janice has completed her internship since beginning the program at Emerson-Davis, and has begun the practicum component of her training. She is employed as a Residential Assistant at a homeless shelter and drug treatment facility. She facilitates groups and assists with client needs. Janice recalled that things started to change for the better shortly after she arrived at Emerson-Davis. When asked what these changes were, she stated that she began to trust people and to ask for help, and be willing to receive support. She thinks this has been the most important and influential change in her life. In addition, Janice said that she felt that staff at Emerson-Davis listened to her and respected her "voice." They were not rigid, and responded to her expressed needs and goals. For example, Janice's internship was located in the Bronx. The travel time required to get to her internship from Emerson-Davis and back, made it difficult for her to attend more than one meeting with her case manager a week. The program accommodated her need. In addition, the program supported her maintaining her relationship with her prior therapist instead of insisting that she receive services through a more conveniently located clinic.
Janice is currently working on increasing her independence and acquiring permanent housing. At the time of our visit, she was looking forward to celebrating her 4th anniversary of sobriety. She feels that there need to be more programs like Emerson-Davis available for parents, and that providers need to be more aware about resources like Emerson-Davis that are available.
Challenges
At the program level, Emerson-Davis is challenged by the waiting list for enrollment. Applicants often need to wait for six months for an apartment to open up. In addition, the high standard of living makes it difficult to retain staff at the rate of pay that the program can support. At the systems level, safe and affordable housing is in short supply in New York. This influences the waiting list as clients can not graduate.
Next Steps
Program procedures are being formalized through the development of protocols for admissions and community placement. Additionally, a range of parent and child assessment and outcome measures are being gathered at least semi-annually for service planning and program evaluation purposes. The intent is to turn the residence into a shorter-term family reunification center that has a greater range of supported community placement options than currently exists.
ICL believes that family unification programs working with this population have a long-term obligation to serve families longitudinally throughout their vulnerable years. With this in mind ICL has organized a Family and Children's Service with the broad goal of providing family preservation services to at-risk populations in Brooklyn. Already there are four community mental health clinics in place, three new residential programs in development for single parent families (two for HIV+ parents), two school-based mental health clinics, and a juvenile justice program. There is also a plan for comparing the family reunification outcomes of this system with traditional foster care.
Logic Model: Emerson-Davis Family Development Center
Table of Contents | Previous | Next
|
