Crossroads Children's Mental Health Centre is a community leader developing and delivering a range of individualized mental health services solely for children under the age of 12 and their loved ones in Ottawa, Canada. They are committed to developing and delivering a wide range of mental health services to help children and families struggling with severe emotional, behavioral, and social challenges. No case is too complicated, complex, or severe, and they never give up on a child.
In 2008, Crossroads, and the larger mental health community in Ottawa, decided to explore different treatment approaches to better serve their hardest to help children. Think:Kids had the opportunity to look back at Crossroads’ journey and use of Collaborative Problem Solving with its Executive Director, Michael Hone.
At Crossroads, we were experiencing very good outcomes with the treatment approaches we used, but we had a subset of families where we didn't have as much impact. These families, about 20% of the clients that we served, would continue to come through the organization year after year. For that population, we thought we needed something different from the traditional operant kinds of treatment approaches.
We had also done a system review using the System of Care Practice Review, a tool that allows us to dive deep into the client experience of service. One of the things that came out of that review was that families reported they felt things were disjointed. Their experience within the system felt like they were constantly stopping and then starting something new as they received services from different agencies. In addition to Crossroads and the schools, families often worked with multiple other agencies, and none of us spoke the same language. We'd have different ways of approaching the situation, making it challenging for families to understand how best to help their children. That prompted us to think about doing things differently as a community in the context of treatment, to create consistency between organizations and less of that stop-start feeling that the parents were expressing to us.
These findings created the second goal that we had, which was to try and get a consistent approach to treatment for these harder-to-serve kids and families across multiple organizations. With a consistent approach and language, when a family aged out of our care, we would be able to transfer that family to the next organization that works with kids over the age of 12, and they wouldn't have to start over with a completely different treatment approach. That was the ultimate reason we pulled together multiple organizations and then set up a Community of Practice.
Our initial Community of Practice consisted of seven staff from five different organizations, each member was a key decision-maker within their respective organization. After vetting a number of programs we decided to check out Collaborative Problem Solving (CPS). What attracted me to CPS was it was a good fit philosophically with Crossroads. Our philosophy at Crossroads is we take the hardest to serve and we don't give up on the family. It doesn't matter how severe, how significant the issues are. We'll stick it out. If they start with us at the age of three, they'll stay with us right through to their 12th year, if they have to, until we can get it right. So philosophically, Collaborative Problem Solving's motto of “Kids Do Well If They Can” matches up nicely to our philosophy of not giving up on kids and families and feeling that there is something that we can do, we just have to figure out what that something is. It also resonated well with our team and it had enough evidence behind it that it felt like it was something to get involved with. I remember having a conversation with one of our partners that had a similar philosophy to ours and we both concluded that CPS felt right. It feels like it's the right side of something to be on in terms of the CPS guiding principal of Kids Do Well If They Can, rather than if they want to.
We applied for and received a grant to support our training in Collaborative Problem Solving. We also received funding to have ongoing supervision and coaching provided by Think:Kids after our initial Tier 1 training. We felt that by having the additional consultation, it would get us moving along as a community in a consistent way. That coaching helped us to begin the implementation process. It was especially helpful in the context of multiple organizations wanting to implement at the same time in different ways within each organization. The next year, we again applied for and received funding to support attending Tier 2 training and ongoing support of our Community of Practice. The coaching we received shifted focus to helping us learn how to coach others as it relates to the treatment approach.
While we started with five organizations in the Community of Practice, it mushroomed pretty quickly. We ended up with about 15 organizations participating. Its growth also allowed us to bring the school boards into the Community of Practice more meaningfully. And that was important. Again, a goal for Crossroads at that time was, these kids are in school all day, every day for the most part, and what better way to have an impact than bring in the school boards. We have four local school boards here in Ottawa that became involved in the process and participated in the Community of Practice. We had mental health representatives from the school boards present and did lots and lots and lots of training. Shortly after that, a number of us made it through Collaborative Problem Solving Trainer Certification, which gave us the capacity, both internally and locally, to train staff and others to continue the implementation.
Each year after that, we ensured a training budget was available to train all of our mental health providers and partners in the Ottawa area. Over the years we have probably trained a few thousand staff in the school boards and the mental health system. They're all trained in Collaborative Problem Solving. The Community of Practice lasted well after the training and continued until a few years ago when there wasn't a need for it anymore because each organization had reached internal capacity for any needed training by having staff become certified in CPS.
Organizations have continued on their own with CPS. We still work with the schools to try to help whenever they need it. We do training about once a year now in Ottawa on CPS that is open to the school boards and mental health providers, and they're always full to keep people trained and able to provide CPS here in Ottawa.
After we had implemented CPS at Crossroads for the 20% of those hardest-to-help children, we noticed that we had better outcomes using CPS than we were having with the operant approaches. So we decided to implement CPS across our entire organization, rather than just in this particular program where we struggled most. So all families then, unless they're under the age of three, go through CPS as our primary treatment modality. We have other things that we do as well, but the core is always CPS. The other thing that we've built into our structure is that any approach that we implement at Crossroads is reviewed through the lens of CPS. If it contradicts the approach philosophically, then it's not something we implement. For instance, we have no behavior management programs in any of our programs because it doesn't fit philosophically. We'll implement things like mindfulness and trauma-focused work, but again, only once reviewed through the lens of CPS. We always ask, "How does this fit with CPS? Does it contradict CPS? Is it going to create any headaches for us in the end?"
While we'll always have kids with challenging behavior that come back for service, it's not to the same degree as it was before we implemented CPS. I also know that the school boards, for example, really appreciate Collaborative Problem Solving and find it very helpful. As do the our other providers in the community; they continue to this day with CPS and still have very positive outcomes as a result. And ultimately CPS doesn’t just resonate with the schools and service providers but with the families we all serve. In the almost 30 years I have been doing this I never hear a family say "I really like Cognitive Behavioral Therapy," or "I really like system's approach to therapy." Interestingly though, the feedback we get from parents, even to this day, is "I really like Collaborative Problem Solving," which I think in and of itself speaks pretty highly to the approach. You just don't get that with other approaches.
The advice I would give to other organizations looking at CPS is to pay critical attention to how you will implement. The implementation science side of things is really important. The training is wonderful, everybody who goes through the training will enjoy it. It's the implementation that becomes the big, big challenge. My advice would be to do the training and get the implementation supports necessary for you to implement properly.
The other thing for organizations to be aware of is the approach challenges organizations, consortiums, and groups to rethink their system. To rethink your system, you can't just decide, “oh, I'll just implement this over here and see what happens.” In a very purposeful way, you've got to know that you need a good two, three years to think through, from an implementation science perspective, what this ought to look like, and how you will sustain it and maintain it over that timeframe. It likely wouldn't have been as successful in the community, if not for that implementation science lens.