Rethinking Wraparound: Hello, Help, Healing and Hope

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Morning Zen Guest Blog Post ~ Patricia Miles, Mary Jo Meyers, John Franz ~  

Proposing a New Construct to Support an Evolving Understanding of the Wraparound Approach 

Raise your hand if you’re a bit confused about what Wraparound is these days. Don’t be shy. Lots of people are wondering the same thing. And don’t be embarrassed. The fact that there are a number of different interpretations and descriptions of what Wraparound is and how it is carried out can be a good thing. It means the model still has the energy it needs to keep on evolving. On the other hand, it also means that in the Wraparound house there are many definitions.

The goal of this article is not to describe a specific version of what Wraparound practice should be – as if there was only one answer to that question, but rather to propose a new construct to help Wraparound practitioners hone their approaches and improve the impact of their efforts to assist families.

There is no Wraparound bible. Wrap does have a sort of Ten Commandments in the form of its core values, but they don’t describe a specific practice model, only what every model should strive to achieve.1 In fact, even with the range of usual and customary values lists, communities make a range of choices about what values are highlighted. The values list associated with Wraparound has been as high as 25 statements.

Wraparound does have a Canon, a collection of stories and articles, training manuals and statutes, contracts and evaluations that have been accumulating in nearly every state and province in North America over the four decades since the foundational programs on which modern Wraparound practice is based first began operation.

No one has the entire Canon, both the oral tradition as well as the written components, but some of us have been privileged to be a part of many of the episodes of Wraparound design and implementation that have occurred over the years and across the continent. It is from these experiences, and from trying out earlier frameworks, that this new iteration has grown.

Defining Wraparound

One of the great delights of Wraparound is that it tolerates a variety of definitions. A stock definition from the oral Canon is that Wraparound is “what we do when we don’t know what to do and how we get it done together.” There is a Wraparound entry in Wikipedia that begins, “The wraparound process is an intensive, individualized care management process for youths with serious or complex needs.”

The National Wraparound Initiative website defines Wraparound as “an intensive holistic method of engaging with individuals with complex needs (most typically children, youth and their families) so that they can live in their homes and communities and realize their hopes and dreams.”  The NWI website goes on to state: “Since the term was first coined in the 1980s, ‘wraparound’ has been defined in different ways. It has been described as a philosophy, an approach and a service. In recent years, wraparound has been most commonly conceived of as an intensive, individualized care planning and management process. Wraparound is not a treatment per se. The wraparound process aims to achieve positive outcomes by providing a structured, creative and individualized team planning process that, compared to traditional treatment planning, results in plans that are more effective and more relevant to the child and family.”

In the spirit of the continuing evolution in our understanding of what Wraparound is we have developed an updated definition that reflects a slightly different point of emphasis: 

This variation on the definition of Wraparound is designed to bring a stronger focus on the family, without losing sight of the specific treatment and support needs of particular family members. It also puts the goal of reinforcing or re-establishing the integrity of positive family relationships front and center.

Over the years there have been frequent attempts to categorize Wraparound as a service in the sense of a being a specific kind of treatment or intervention. One or both of two interests, research and funding, drive these attempts. Given the widespread use of Wraparound and wraparound-like practice approaches, many researchers have wanted to find out whether or not helping children and families in this way works. Although initial implementations of Wraparound have frequently been supported by grant dollars, for programs to continue agencies eventually need to find some way to pay for using Wraparound.

Testing the benefits of Wraparound by itself, as if it was a new medicine that was being researched, is difficult because Wraparound is only one component of an agency or program’s system of care. So really what’s being measured is whether a program that includes the Wraparound process is helping children and families achieve better outcomes. Early, large-scale studies were ambivalent at best about the achievements of some of these systems of care. More recent studies that focused on smaller programs, some of which had control groups, have shown that programs using some form of Wraparound practice to guide service planning and implementation have demonstrated much better outcomes than the controls.

The challenge with saying that this newer research proves that Wraparound works well, or that the older research says that it doesn’t is that there are many more variables in play than just the way child and family teams are gathered and facilitated. Nonetheless many people are trying to demonstrate that Wraparound is an evidence-based practice in the same genre as the various three-letter acronym practices like Multi-Systemic Therapy, Anger Replacement Therapy and Functional Family Therapy.

But as the NWI website states, Wraparound is not a service in the sense of a particular type of intervention or treatment.3  Instead of a service, Wraparound is a planning and organizing process that is designed to bring helping people together with families who need help so that together they can plan for, access, create and coordinate an array of services, interventions and supports tailored to each family and its unique situation.

But that makes it a problem to find ways to pay for programs and agencies that want to continue to use the Wraparound practice model after the grant money runs out. If you can’t define it, and it isn’t a service, how do you bill for it? The answer is that programs and agencies that have continued to grow and do well after their start-up grants ended bill for delivering good services and use an implementation of the Wraparound approach to insure that their services are well-matched with the needs of the families who are enrolled in their programs.

The vibrant energy that comes from providing help and assistance the Wraparound way leads some people to want to define Wrap in much broader and more inclusive terms than a simple process based on some powerful core values. But this combination of simplicity combined with well-articulated values is what gives Wraparound the flexibility to be useful in a wide range of services modalities, and to evolve and improve as our understanding of what works and doesn’t work in human services continues to advance.

However, although it is a simple process, it is still a process and figuring out how to describe, teach, supervise and evaluate this process continues to be a challenge that confronts every program and agency that uses Wraparound as the central engine of its operations.

Doing Wraparound

Our understanding of the Wraparound process has evolved over the years, starting with a series of steps for conducting child and family team meetings but then expanding to a larger framework of phases that defined the overall relationship between a program using the Wraparound approach and the families who were enrolled in that program. 

Wraparound’s Planning Steps 
Around twenty years ago when Wraparound was first being implemented, the process was described as a set of planning steps that practitioners should follow during meetings with a range of providers, community members and family members and friends. These steps were presented as 8 core activities that were supposed to occur in every team meeting, including starting with a review of the family’s strengths, reaching agreement about the nature and priorities with the family and other team members about needs to set a target for the team’s activities, going through a creative process to design imaginative responses to those prioritized needs, and, finally, getting team members to commit to action.

Over time the original 8 steps expanded to 11 items as it became clear that just having meetings wasn’t enough. Instead, a range of activities outside of meetings also needed to occur. These additional steps began to describe meeting preparation activities as well as service coordination and crisis response activities that would come up between meetings. 

The Phases of Wraparound 
About twelve years ago it became clear that not only was Wraparound about more than just team meetings but also that it was more than a set of tools that an individual practitioner might use in her or his work with families. The more mature programs and agencies were beginning to realize that a Wraparound orientation was something that informed the activities of many different staff and carried over throughout the relationship with each family that was enrolled for care. Not everyone interacted with families through the team meetings, but everyone should structure their actions in the context of the values of Wraparound and the effort to develop, implement and improve the plans for assistance that were generated through those meetings.

To help everyone who might be involved with a program or agency that was helping families using the Wraparound approach understand what was going on, why they were operating that way, and how their specific activities fit in with the big picture,  a framework called the Phases of Wraparound was proposed.

These phases were intended to help both families and agencies visualize the arc of care that a family would experience as they received help through a program that used the Wraparound approach. The four phases were engagement, planning, implementation and transition.

  • Engagement: Typically used to describe actions, procedures and processes during the first 30 days of a Wraparound response, activities during this phase were designed to establish a firm foundation of understanding and partnership with the family as well as creating a sense of enthusiasm, optimism and collaboration among all team members. 

  • Planning: This phase reflected the first meeting together of all stakeholders to develop an initial plan of care that all parties could agree with and commit to implementing. Generally as implemented this phase was designed to last for one or two meetings during which the group gathered with the family, reached agreement and developed specific levels of crisis contingency in the event that unplanned events took place. 

  • Implementation: During this phase, the length of which would vary with the needs of the family, the relationship with the family shifted from planning to doing and a wide range of intensive services and supports targeted to each family’s specific strengths and needs would be deployed. These services, which while not Wraparound themselves, would still be delivered in the context of the Wraparound planning and organizing process. Staff from the coordinating agency might provide some of the services and supports, some would be delivered by other agencies or individuals in a network accessed through the Wraparound process, and many would be offered by community, informal and natural supports unique to the family. But the Wraparound team, including the family members, would assess the impact of all of these efforts and adjust, adapt or modify the service and support response to make it more effective. 

  • Transition: This phase was designed to articulate a set of activities and rituals to insure that when families exited Wraparound this was done with the same care and attention to detail as the engagement, planning and implementation activities.

Using the Phases framework to sort out the ballooning range of activities that took place when programs and agencies using the Wraparound approach assisted families initially proved to be quite helpful. However, over time some difficulties began to emerge.

The articulation of phases did help practitioners and funders understand that Wraparound was more than hosting a series of meetings that started with strengths, but the phases still sounded like discrete steps rather than intersecting components of a dynamic and adaptive relationship.

Engagement, for example, is an ongoing and iterative process that occurs through a series of trust transactions between a care coordinator and family over time rather than a set of techniques that produce a specific moment when families are engaged.

Having a planning phase has also been tricky in the real world of helping families who are often experiencing difficult disruption and destabilization at the time of enrollment. They need a quick, front-end response that keeps people safe and gives them enough room to work on bigger issues. Programs that applied the Phases framework too rigidly sometimes made families in great need wait while care coordinators went through rituals of structured engagement and planning. On the other hand, programs that put everything into the front-end response also had trouble moving back into engagement and planning in order to develop a comprehensive plan that would support long-term gains.

Although the implementation phase was intended to frame everything that took place as help was being provided to families over time and adjusted to improve its  fit and effectiveness, in some places it took on a different connotation. Programs focused on their efforts to implement the various steps of wraparound planning rather than using the Wraparound approach as a way to access services, supports and interventions. At the extreme end, this has led some sites to present Wraparound as an alternative to other sorts of help. Families were then forced to choose between an intensive service such as hospitalization or placement and enrollment in that site’s wraparound program. Wraparound was designed to help all services in a system of care work better and faster.  A well-structured site using the Wraparound approach avoids withholding any services from the family enrolled in Wraparound or even presenting Wraparound to a family as a discrete program or service. It’s not a question of “Do you want placement or Wraparound?” but instead if you elect to use placement how can Wrap make that strategy most effective in meeting needs to produce better outcomes for the family in the shortest amount of time.

Even the use of the transition phase concept raised difficulties. The idea of the transition phase was to capture the sense of increased self-efficacy that families should be experiencing as they, with the team and their circle of support find better coping strategies, improve their relationships with one another, and in general get back on their feet again. However, in some programs transition became something families earned in order to get out of the system. And in others transition was something imposed on families when their funding eligibility ran out.

Not only did the articulation and implementation of each of the phases gradually run into difficulty over time, the phase framework as an overall construct also began to show some weaknesses. First, it was difficult to convey the sense that these phases were not discrete and time limited but instead were overlapping, iterative and adaptive. Second, the most promising programs tended to be evolutionary and aspirational rather than fixed and repetitive. These sites weren’t willing to confine themselves to the constraints that the more rigid applications of the Phases framework were beginning to impose. As a result, a number of wraparound trainers have begun to refer to the engagement, planning, implementation and transition as integrated components of the helping response rather than phases.

Finally, the phases were written from the point of the view of the practitioner or the program rather than the family. This can result in a project “managing” a family in order to achieve the outlined goals for each phase. While it can be argued that the goals outlined in each of the phases are critical to success and are strongly family- focused,4 one of the key tenets of wraparound is that the family’s experience is definitional. So if using the Phases framework has begun to impede the implementation of innovative and family-driven practice in some situations, it is probably time to evolve to a new construct that captures what has been learned during the last dozen years of using the phases. 

4phases

Family Focused Description

We believe that a new construct built on the strengths of the Phases framework, but designed to overcome some of its limitations will be helpful to practitioners. Families being helped by programs or agencies using the Wraparound approach should experience a sense of positive growth that emerges over time with all the natural ups and downs that accompany human relationships.

Hello 
The foundational experience entering a Wraparound experience involves a sense of being welcomed which sets the stage for enduring equal partnership. In the emergent view, this basic element of Wraparound is called “Hello.” We believe this more accurately represents the family’s experiencing of entering the process and that engagement is usually an agenda or goal of the practitioner rather than the family. This simple word conveys the experience of being greeted and appreciated that families deserve to feel as they enter Wraparound.

If we think about how we design and operate our programs and agencies, we can begin to evaluate every component from the physical structure, to staff roles, to the service array, to the process steps in terms of the degree to which they help families experience an initial and ongoing sense of welcome and inclusion.

Individuals practicing in a Wraparound model are expected to simultaneously provide comfort while quickly gathering enough information to assemble a helping response on the foundation of the initial greeting. This is also when staff who are interacting with the family take the time to listen to and seek to understand the family and their concerns and confer with the family on what is likely to be the most helpful for them in their unique circumstances. 

Help 
If hello replaces engagement as the foundational concept in this new construct for Wraparound, we asked ourselves what should replace planning? We decided to re- label this concept as “Help” for several reasons. We noticed that some programs using the Phases framework were carrying out a wide variety of rituals around planning and producing lots of plans, but often we didn’t see purposeful help and interventions flow from those rituals and plans.

Families with complex needs are usually more interested in getting help than in a completed plan. While planning rituals and meetings will be held in a Wraparound process, the point is not to complete a plan but instead to insure that effective help  in the form of individualized strategies, supports and interventions is provided. A Child and Family Team is not the intervention but is the way that decisions get made about the range of interventions. Those interventions should be documented in a comprehensive plan of care format but it’s important to never lose sight of the fact that services and supports actually must be provided to produce outcomes. Holding a series of “wraparound meetings” without building the capacity to provide purposeful actions between those meetings is not likely to yield good results.

Individuals, programs and agencies using the Wraparound approach to structure their operations should be able to evaluate themselves directly by the way in which families access and experience timely, relevant and well-targeted assistance.

Healing 
Replacing implementation with the concept “Healing” reflects our commitment to delivering help that is useful and produces outcomes that families value.  We believe that not only do families have a right to action but also that these actions should make a difference.

Healing is our attempt to capture the difference between a family’s experience of having things being done to them and feeling like the help the family is receiving is having a positive impact on their situation. Implementation speaks to action. Healing speaks to action with a purpose and outcome in mind.

First attempts at helping are frequently awkward and off target. But as relationships with families grow and understanding of the family’s identity, preferences and history deepen helping activities can be adapted. This is an ongoing process that occurs until the help provided becomes not just a thing to implement but instead becomes the right thing to do for families to experience a sense of healing.

Individuals and agencies incorporating this concept in their operations will become more outcome-driven, establish reliable feedback loops for real-time recovery of data about how families are experiencing the help they are receiving and the progress they are making, and develop innovation cycles that use this information to improve their practices and programs.

Hope 
Transition means things are changing, but doesn’t necessarily mean that they are changing for the better, even if that was the intent when the fourth phase was given this label. Re-examining our goal for what families should experience as they reach the end of their involvement with a program led us to call this aspect of the helping relationship, “Hope.”

We believe that if you can understand enough in the hello component to deliver help in the shortest amount of time and continue an understanding process by joining with the family in reviewing and improving your help then hope will blossom. In essence, hope happens when healing help is provided.

In some ways, this was the easiest of the components for us to reframe. When we’ve asked youth and families about what’s different for them as a result of receiving services through a program that uses the Wraparound approach, they frequently start by telling us in one way or another, “I’ve got hope now. I think my family might just have a future.”

But just as hello isn’t something that only happens at the outset of the arc of care, hope isn’t confined to the closing moments. Hello should kindle and nurture hope throughout the course of the process. Help should be delivered in the context of a powerful optimism designed to increase expectancy on the part of all team members as well as families. Healing should be recognized throughout the entire process of Wraparound as a way to acknowledge and celebrate gains and set the stage for a future of possibilities.

hope

Conclusion

As our experience with and understanding of Wraparound has grown over the past twenty-five years, we have moved from describing wraparound as a series of steps that are followed in a child and family team meeting, to a larger number of steps that also take place outside the meeting, to a series of phases that we go through in our relationships with families.

In this paper we suggest that the next evolution in our understanding of what Wraparound is should be to reference the Wrap process from the perspective of families who are receiving assistance from programs and agencies that use the Wraparound approach. Looking at our efforts in terms of the way we would like families to experience them, we believe they should generate an initial experience of being welcomed, which we have called hello, that gradually develops into a much stronger sense of hope as families receive help that in turn brings about healing.

Many of us tend to think about Wraparound as a sequence of activities: first we do this, and then we do that. As early learners in Wrap it may be necessary to begin with this understanding. If we are being paid to carry out a specific role in an agency or program using the Wraparound approach, we need to know what our job is and how to do it. The power of Wraparound, however, has never been in its sequential steps but the connections between these steps and components. Wraparound has survived and even thrived because it is an evolving framework rather than a specific model. This Four-H Construct can serve as a framework to continue this evolution.

We hope you find this article useful and that thinking about Wraparound in this way gives you new energy and enthusiasm for the important work you are carrying out.

Notations:

  1. There have been many formulations of Wrap’s core values, but a good example is the 10 principles of the Wraparound Process as listed in the National Wraparound Initiative website. They are: 1. Family voice and choice; 2. Team based; 3. Natural Supports; 4. Collaboration; 5. Community-based; 6. Culturally competent; 7. Individualized; 8. Strengths-based; 9. Persistence; 10. Outcome-based. In the NWI framework it is interesting to note that Needs Driven is not part of the list.  This is one example of practice communities making clear decisions about what values they highlight. 
  2. As noted in the NWI definition, wraparound is generally associated with services and supports for children and youth and their families. However, in recent years the wraparound process has been used to support people in other situations, such as frail elderly people who are at risk for multiple hospitalizations and older adults who are living with schizophrenia or dementia. These programs have also discovered that active family involvement is essential for positive outcomes even though in many cases generating that involvement is exceptionally difficult.
  3. It’s not Wraparound Therapy because right away there’s a problem: that would only be a two-letter acronym, WT. And if you changed the name to Wraparound Therapy for Families it would be WTF, and that probably wouldn’t fly either. 
  4. Training on the phases should explore ways in which families experience their participation with helpers during each of the phases. Through engagement families should feel a sense of being heard and understood, through planning a sense of having caring people joining with them to make a difference in their lives, through implementation an improved ability to cope with challenges in their lives, and through transition a sense of self-efficacy and optimism for the future. Unfortunately, this reflective aspect of the Phases framework is often lost in translation.

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About the authors: Mary Jo, Pat and John are not that folk trio you sort of remember from the late 80's, however they have been part of the development of the wraparound approach since about that time. Mary Jo was a leading member of the team that designed Wraparound Milwaukee, currently serves as its Deputy Director and also consults with system of care projects using the wrap model in several states. Pat, who lives in Portland, Oregon, was the director of one of the first on the ground implementations of wrap in the Alaska Youth Initiative, then helped get wrap going in Columbus, Ohio. She has gone on to assist agencies and communities throughout the United States with system and practice innovations. John, who lives in Madison, Wisconsin, has been fortunate to work with Mary Jo and Pat in several of their endeavors and has also been privileged to help several wrap and system of care operations get off the ground over the years. Many of Pat and John's articles and presentations can be found on their website, www.paperboat.com.  

Comments

  1. Brittany Rastsmith's avatar
    Brittany Rastsmith
    | Permalink
    Good wraparound can change lives - I am glad to see we are all still considering what makes good wraparound. That said, I think this article is headed in the wrong direction. The whole reasons the NWI was founded was because programs going every which way was creating "wraparound style" programs with poor outcomes that jeopardized the ability to provide (and get funding for) wraparound anywhere. We think we need more structure, not less. Here is a post a wrote about that back in April: http://www.vroonvdb.com/a-call-to-action-steps/
  2. Pamela Ferguson's avatar
    Pamela Ferguson
    | Permalink
    The family focused stages of WRAPAROUND- I believe its a natural progression (organic). Way to go TEAM"" Sometimes I am saddened that people do not fully grasp how crucial the WRAPAROUND process is to sustainability. However, we cannot stop we have to keep moving forward and hope that eventually we all will have the Hah Ha moment..
  3. Teresa Berry's avatar
    Teresa Berry
    | Permalink
    I was a parent of a child with SED needs. We used WA. I eventually began working as a parent support specialist at the mental health center. I also became a Wraparound Facilitator. I totally believe in Wraparound done in the full force of its belief system!! It works!! However, when changes were made by the administrations to make it "simplier" it lost its POWER and effectiveness quickly...it was more the "paperwork process" with somewhat of the wraparound process in mind, but not in full effect. It was saddening really!! Not being able to bill, not being able to get staff always involved fully was a problem! Alot of info could be learned at Wraparounds if the proper relationships were built!!
    I believe it is a crucial piece to helping clients and families survive, get thier needs met and met thier goals....thus ACHIEVING!!!
  4. Laurie Fowler Beckel's avatar
    Laurie Fowler Beckel
    | Permalink
    While I really like the way the authors have 'de-jargoned' the phases and used the language of what the youth/families are hopefully experiencing, I'm not inclined to agree that backing off of practice standards is a good idea. It is the way we can describe what fidelity practice actually is. Additionally,I resonate to the needs that adult learners have for a clear practice model. Implementation Science supports this need as well.
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