1
Faculty of Social and Behavioral Sciences
Graduate School of Childhood Development and Education
Working according to the Principles of the
Wraparound Care Model (WCM) within de
Opvoedpoli: the use of Empowerment
Enhancing Practices
.
Research Master Child Development and Education Silke de Klerk, 10082573
University of Amsterdam silke.deklerk@student.uva.nl
Supervisors:
Dr. Floor van Rooij Dr. Frouke Sondeijker Reviewers:
Dr. Henny Bos
Dr. Loes van Rijn – van Gelderen Prof. dr. Frans Oort
2 Abstract
Background: The new Youth Act offered a framework for the transformation of the Dutch welfare system. Empowerment is seen as one of the key elements by which the goals of this transformation can be achieved. However, it is unclear to what extent the development of empowerment of clients is stimulated by the helpgiver and how this is related to child- and family outcomes. Aim: To investigate 1) To what extent former clients of de Opvoedpoli experienced that their helpgiver used empowerment enhancing practices; and 2) Whether the degree of helpgiving practices is related to client satisfaction and goal achievement, and whether it predicts decreased parenting stress, increased family functioning, and decreased problem behavior of the child. Methods: Seventy-one former clients of de Opvoedpoli, who had filled out ROM questionnaires (OBVL, GVL, CBCL) during their trajectory, were asked to fill out the Helpgiving Practices Scale retrospectively. The analyses: Pearson correlation, Mann Whitney U test and Repeated Measures (M)ANOVA were used. Results: Helpgivers used empowerment enhancing practices frequently, but relational practices more than participatory practices. More participatory practices predicted more client satisfaction, and more relational practices predicted less role limitation. Further, no interactions were found between, on the one hand, helpgiving practices, and on the other hand parenting stress, family functioning, and problem behavior of the child. Conclusion: Although empowerment is one of the key elements in the transition of the welfare system, the results do not support the hypothesis that the use of empowerment enhancing practices is related to better child- and family functioning. Future research with a longitudinal design in which the development of empowerment is measured with appropriate instruments on a structural basis, is needed. Until then, policymakers should be careful with popularizing this concept.
Keywords: empowerment, helpgiving practices, relational practices, participatory practices, parenting stress, family functioning, problem behavior.
3 Working according to the principles of the Wraparound Care model (WCM) within de
Opvoedpoli: the use of empowerment enhancing practices.
On the 18th of February 2014 the Dutch senate adopted the new Youth Act (Bosscher, 2014; Ministerie van VWS, 2014). In this act all tasks and means of the municipalities
regarding the youth care system are described. This act offers a legal framework for a rigorous decentralization and transformation of the Dutch child welfare system. Whereas previously the (financial) responsibility for these services was divided over several parties, from January 2015 onwards, municipalities became responsible for the whole continuum of services for families and children. Their responsibility nowadays ranges from universal and preventive services to specialised (both voluntary and compulsory) care, including child mental health provisions. The reason for this decentralization is twofold. On the one hand, the decentralisation should lead to a cost reduction. On the other hand, it is a society-wide
transformation of care in order to enable municipalities to develop integrated policies and to offer care tailored to local and individual situations and needs. This should result in more coherent, more effective, more transparent, and in the end less expensive services for children and their families. Besides that, this transformation should result in a decrease of the number of children receiving specialized care (Bosscher, 2014; Nederlands Jeugdinstituut, 2014).
One of the ways to achieve the aims of the transformation, as explained by the Dutch Youth institute (Bosscher, 2014), is to activate, restore and strengthen the capacities of children, parents and their social network to solve problems. This so-called process of empowerment is not only seen as one of the key concepts within the transformation of the youth care system, but also in the more general transition from welfare society to participation society (Brink, 2013). In fact, the transformation of the Dutch welfare system aligns with a wider process of societal change: from welfare society to participation society (Nederlands
4 Jeugdinstituut, 2014). This implies that the role of the government, with regard to care and support, decreases. Instead, civilians are expected to demonstrate own initiatives so that they will be able to look after themselves and others. In a participation society the government will only act as last backup for the most vulnerable people. In order to let the participation society succeed, civilians have to emancipate and become empowered (Brink, 2013).
Therefore it is not surprising that the concept of empowerment is widely used in policy, and that it is gaining popularity amongst policy makers and healthcare workers (Bouwmans, 2012; Cattaneo & Chapman, 2010; Tengland, 2008). However, the concept seems to have different definitions, interpretations and applications within several contexts. This can be clearly observed within the research literature; in the various studies that are published regarding empowerment, the concept ranges from goal or idealism to specific working methods (Bouwmans, 2012). Because of these various and broad descriptions there is the risk that empowerment will become a vague container concept (Van Regenmortel, 2009). Bouwmans (2012) summarized the most frequently used definitions of empowerment. It is notable that, in these definitions, many elements are in accordance with each other. The definition that is most relevant for the Dutch situation is based on Hermans (2007) and Van Yperen and Woudenberg (2011). Namely: Obtaining control over one’s own living
conditions. This will make families independent from professional care since they are then able to overcome their own problems.
Although a definition of empowerment that is relevant for the Dutch situation is available, one coherent theory that explains how empowerment is developing was still lacking until recently. Cattaneo and Chapman (2010) realised that the notion of empowerment is compelling and already much employed across many fields inside and outside of psychology. Therefore they developed a usable and understandable model that integrates prior theories about the development of empowerment.Within this so-called, Empowerment Process Model
5 (see Figure 1) there are seven core components: goals, actions, reflections, knowledge,
competence, self-efficacy, and the social network. These components are interrelated since the client selects personally meaningful and power-oriented goals. A list of possible actions to achieve these goals is designed and it is assessed by the client whether or not a
professional can contribute to achieving these goals. Consequently, these actions and their
impact are being evaluated and, if necessary, new goals will be formulated. Based on this model, empowerment can be seen as an iterative and circulating process in which the family gathers knowledge and competences. As a result the self-efficacy of the family increases. This whole process is supported by the social context of the client.
Although the Empowerment Process Model (Cattaneo & Chapman, 2010) does provide information about the development of empowerment in an individual, it does not explicitly state what specific types of helpgiving behavior professionals have to perform in order to stimulate the development of empowerment of their clients. This is why the practice-based theory of family-centred helpgiving (Dunst, Trivette, & Hamby, 2006) is relevant. This theory does focus on the relation between specific helpgiving behavior, the development of empowerment, and how this is related to family- and child outcomes. In this theory, both relational and participatory helpgiving practices are described. Relational helpgiving involves behavior that is usually associated with good clinical practices such as empathy, respect, active listening, and compassion. It furthermore includes positive beliefs about family capabilities and strengths. Participatory helpgiving relates to practices that are flexible,
Figure 1. Empowerment Process Model
6
Figure 2. The relation between family centred
helpgiving practices and child development (Dunst, Trivette, & Hamby, 2006).
individualized, and responsive to the concerns of families and their priorities. This involves family involvement in developing goals and achieving their outcomes (Dunst et al., 2006). Several empirical studies suggest that supportive helpgiving practices are a significant predictor of parent empowerment (Dempsey & Dunst, 2004; Dempsey, Foreman, Sharma, Khanna, & Arora, 2001). Dunst, Trivette, and Hamby (2007) argued, based on the findings of their meta-analysis, that there is a relation between family centred helpgiving practices and family- and child outcomes. They found that this relationship was partially mediated by
self-efficacy beliefs, see Figure 2. This finding was explained by arguing that family centred helpgiving practices cause a sense of
empowerment, reflected in improved self-efficacy beliefs. Parents who experience this empowerment are more likely to offer their children better learning and developing opportunities (Dunst et al., 2007). It is because of these findings that Dunst and Trivette (2007) recommend that emphasis on both the use of relational- and participatory practices should be placed, even though it is known that participatory practices are less often practiced by professionals.
Since empowerment is seen as a crucial concept in the transformation of the Dutch welfare system, it is very relevant to gather information about the extent to which
empowerment stimulating helpgiving behavior is actually applied by health care professionals in the Netherlands. This research can be done at de Opvoedpoli, a child welfare organization in the Netherlands, and their subsidiary company named de Care-Express, that has youngsters
7 aged 12 to 23 as target population. Hereafter referred to as de Opvoedpoli. De Opvoedpoli claims to work, since its founding in 2008, according to the ideas that formed the bases of the transformation of the Dutch Welfare system. They base their vision, policies, and working process upon the Wraparound Care (WAC) model. Wraparound is a philosophy of care that includes working in close collaboration and partnership with families. This results in a unique set of community services and natural supports that are individualized for the child and family to achieve a positive set of outcomes. Wraparound was developed to decrease fragmented and largely institutionalized care for youth in the United States (Bruns, Schoenwald, Burchard, Faw, & Santos, 2000).
Wraparound is not only a model to organise youth care. It is a comprehensive model that has impact on both the team, the organisation, and the systems levels (Hermanns, 2009). At de Opvoedpoli this implies that both the working methods and the organisation are guided by the Wraparound principles. It is a demand-driven and system focused model that holds clients accountable for their own process of change (Hermanns, 2009). Within this model ten core elements can be described. These ten elements are: Family voice and choice, Team based, Natural supports, Collaboration, Community-based, Culturally competent,
Individualized, Strengths based, Persistence, and, Outcome based (Bruns et al., 2004). In the Netherlands, ‘Safety’ is added to this list. The element that exhibits the most similarities with the goals and rationale behind the recently implemented new Youth Act and the ensuing transformation for the youth care system is the element: ‘strengths based’.
Although de Opvoedpoli claims to stimulate the development of empowerment of their clients, it is not known to what extent this actually happens in practice according to clients. This is relevant since literature shows that the level of implementation affects the outcomes obtained in (mental) health care programs (Durlak & DuPre, 2008). Therefore, this research focusses on the following two research questions. First it will be investigated to what extent
8 former clients of de Opvoedpoli experienced that their coach used empowerment enhancing practices. Second, it will be studied whether the level of helpgiving practices is related to client satisfaction, goal achievement, and whether it predicts changes in parenting stress, family functioning, and problem behavior of the child. Since one goal of the transformation of the welfare system is to achieve more effective youth care, it is very relevant to know whether or not stimulation of empowerment is actually related to positive child- and family outcomes in the Dutch population.
Although not sufficient, some research into empowerment at de Opvoedpoli is done before. For her master thesis Marcelis (2013) conducted research at de Opvoedpoli in order to clarify what professionals consider to be prerequisites for empowerment. The interviews showed that the professionals consider ‘goals’, ‘action’, ’reflection’, ‘social context’, ‘knowledge’, ‘competence’, ‘self-direction’ and ‘contact’ to be important criteria for
stimulating the empowerment of their clients. This is in line with the Empowerment Process Model of Cattaneo and Chapman (2010). Even though helpgivers of de Opvoedpoli argue that these criteria are important, this does not automatically mean that they actually incorporate them in their work. It neither says something about the ways clients perceive the helpgiving behavior of their coach. Therefore, this study focusses on the clients perspective.
Based on previous research, the principles of the Wrap Around Care model, and the theory of family centered helpgiving (Dunst et al., 2006) it is hypothesized that former clients of de Opvoedpoli will indicate that their helpgiver demonstrated both relational- and
participatory helpgiving practices frequently. Subsequently, it is expected that clients who experienced more empowerment enhancing practices, show higher client satisfaction, more goal achievement, less parenting stress, better family functioning, and less problem behavior than clients whose development of empowerment is stimulated less.
9
442
• Digital questionnaire sent to 442 people
435
• 7 emails were bounced133
• 133 people opened the link in the email that they received
87
• 87 people signed the informed concent form and agreed to participate
59
• 59 people filled out the complete questionnaire
71
• 12 people filled out a part of the questionnaire and the missing answers were imputed
Method Participants
Participants in this study were former clients of de Opvoedpoli. They were parents or caregivers who had a voluntary request for help with regard to the development or upbringing of their child, or they were youngsters older than 18 years with a request for help. People were eligible to participate in this study if they completed a trajectory that started and finished between December 2013 and June 2015. In addition, to be included in this study, clients
should have filled out at least either the pre- and post measurement of one of the Routine Outcome
Monitoring questionnaires (ROM: parenting stress, family functioning, problem behavior of the child) or should have a completed goal achievement form and client satisfaction questionnaire at the end of the
trajectory. ROM is the assessment of treatment outcome at regular intervals in order to monitor clients’ progress during treatment (de Beurs et al., 2011). This is part of the primary helpgiving process at de Opvoedpoli.
Of the eligible clients, the email addresses of 442 former clients were available and these people received a link per e-mail that redirected them to a digital survey. Seventy-one participants filled out the survey (response = 16.1%) (See Figure 3 for an overview of the participants flow.)
Family compositions in this study varied: two-parent family (54.9%), single parent family (19.7%), blended family (7.0%), co-parenting (5.6%), different family compositions (2.8%), or an unknown family composition (9.9%). Parent’s educational background in the
Figure 3. Overview of the participants
10 sample was as follows: MBO (19.7%), HBO (36.6%), WO (12.7%), or unknown (31.0%). The cultural background of the children and youngsters was based on the cultural background of the parents. In this study, 69.0% of the children and youngsters had a Dutch background, 12.7% of the children and youngsters had a different background, and of 18.3% of the
children and youngsters the cultural background was unknown. The mean age of the children and youngsters at the start of the helpgiving trajectory was 11.37 years old (range 0.6 – 22.8 years old, SD = 4.58). The participants of this study received help from various locations of de Opvoedpoli: Opvoedpoli Alkmaar 12.7%, Opvoedpoli Amsterdam-Centrum 2.8%, Opvoedpoli Amsterdam-Noord 2.8%, Opvoedpoli Amsterdam-Oost 7.0%, Opvoedpoli Amsterdam Zuid-West 7.0%, Care-Express Enschede 1.4%, Care-Express Amsterdam 2.8%, Care-Express Zaandam 1.4%, Care-Express Zwolle 1.4%, Opvoedpoli Den Haag 5.6%, Opvoedpoli Den Helder 15.5%, Opvoedpoli Geldrop 1.4%, Opvoedpoli Haarlem 8.5%, Opvoedpoli Heemstede 5.6%, Opvoedpoli Rotterdam 7.0%, Opvoedpoli Utrecht 8.5%, Opvoedpoli Zoetermeer 8.5%). Of all the respondents, 69.0% of the children or youngsters followed a mental healthcare trajectory and 31.0% received a different type of care. Procedure
This study is part of a broader study focussing on the effects of the use of the
Wraparound Care model in de Opvoedpoli. In this large-scale study, differences concerning parenting stress, family functioning and problem behavior of the child before and after treatment were measured by means of digital ROM questionnaires. Information about goal achievement could be retrieved from the electronical client files. This information was partially compared to those of other child welfare organisations in the Netherlands. In the current sub study, clients were contacted again retrospectively in order to obtain additional information about the use of empowerment enhancing practices by helpgivers during the time that they received help from de Opvoedpoli. All participants received an e-mail which
11 contained an information letter and a link to the digital Qualtrics questionnaire that could be filled out as soon as the active digital informed consent was signed. A few weeks after sending the initial link, a reminder was sent by email to all participants that had not filled out the questionnaire yet. Three weeks later a final reminder was sent. The ethical committee of the University of Amsterdam, department Child Development and Education, has approved this study.
Instruments
Stimulation of empowerment by the helpgiver. In this research the Dutch
translation of the Helpgiving Practices Scale (Dunst, Trivette, & LaPointe, 1992) was used in order to learn to what extent clients of the Opvoedpoli feel that their helpgiver used
empowerment enhancing practices. This questionnaire was translated with the help of (former) research master students of the University of Amsterdam and English native speakers, using the back and forth translation method (Brislin, 1970). The questionnaire contains 18 items that measure different helpgiving behaviors and attributes. Answers can be given on a 5-point Likert scale in which 1 = rarely - 5 = almost always. The questionnaire can be divided into two subscales: relational practices (11 items) and participatory practices (7 items). An example item is: “Professional helpers sometimes differ in whether they encourage people to make their own decisions about what is in their best interest. Which rating best describes how [helper] encourages you to make decisions?” (subscale participatory practices). The Chronbach’s alpha’s in this study were all above .90, which represents a high internal consistency.
Separately from the Helpgiving Practices Scale, one other question regarding
empowerment was added to the questionnaire. In this question participants read the following definition of empowerment: “Empowerment is the ability of someone to influence the life course (or situation) and to solve problems or make them bearable.” On a scale ranging from
12 1 to 5 they answered to what extent they felt that their helpgiver stimulated their development of empowerment.
Client satisfaction. To measure client satisfaction, one item of the
EXIT-questionnaire (Jurrius, Havinga, & Stams, 2008) was used. In this item people were asked to judge the care that they received by means of one client satisfaction score ranging from one to ten (1 = lowest grade – 10 = highest grade).
Goal achievement. During the first meeting, the clients formulated treatment goals in collaboration with the professional. At the same time, two scores between 1 and 10 were given. One score that indicates the current state of affairs with regard to the treatment goal, and one that indicates the desired score at the end of the helpgiving trajectory. The
achievement of this goals is scored during the last meeting by the client with a score between 1 and 10 (1 = lowest grade – 10 = highest grade). In this study it was assessed whether people achieved their desired score at the end of the helpgiving trajectory or not.
Parenting stress. Parenting stress was measured with the Dutch version of the Parenting Stress Questionnaire (OBVL; Vermulst, Kroes, de Meyer, Nguyen, & Veerman, 2012). This questionnaire has 34 items that can be answered on a 4-point Likert scale in which 1 = not true - 4 = very true. The questionnaire consists of 5 subscales: problems in caregiver-child relationship (5 items), problems with regard to parenting (7 items), depressive moods (7 items), role limitations (6 items), and health problems (8 items). An example item is: “My child listens to me” (subscale problems with regard to parenting). The internal consistency in this study on both the subscales and totals at both measurement occasions ranges from moderate tot good (α = .73 to α = .91).
Family functioning. Family functioning was measured by means of the Dutch version of the Family Functioning Questionnaire (GVL; van der Ploeg & Scholte, 2008). This
13 completely disagree - 5= completely agree. The scale consists of five subscales: responsivity, communication, organization, partner relation, and social network. Each subscale consists of 9 items. An example item is: “We find it hard to understand our child” (subscale
communication). In this study the internal consistency for the total and the various subscales on the two measurement occasions ranged from moderate to good (α = .70 to α = .92).
Problem behavior of the child. The problem behavior of the child was measured by means of the Child Behavior Checklist (CBCL; Achenbach, 2001). This questionnaire consists of 113 items that are rated by the child’s parent using a 3-point Likert scale in which 1= not true, 2 = somewhat or sometimes true, 3 = very true or often true. An example item is: “my child fights a lot” (subscale aggressive behavior). The CBCL yields scores on eight subscales, which can be combined to create an internalizing scale (33 items), consisting of the Withdrawn, Somatic Complaints, and Anxious/Depressed subscales, and an externalizing scale (33 items) that consists of the Delinquent Behavior and Aggressive Behavior subscales. In this study the internalizing subscale, externalizing subscale and the total scale were used. The internal consistency in this study on both the subscales and totals at both measurement occasions ranges from α = .90 to α = .96 and can therefore be seen as good.
Data analyses
In order to assess whether multilevel analyses were necessary for this study, the design effect measure as described by Muthén (2000) was calculated. There was the possibility for a design effect in this study, due to the fact that some clients were recruited from the same location and might have had the same helpgiver, which could lead to biased standard errors. Both the effects for location (d = 1.96) and for the helpgiver (d = 1.19) were smaller than the cut-off value of 2.0, indicating that the design effect is small enough to be ignored and therefore, multilevel analyses were unnecessary in this study.
14 In order to answer the first research question - to what extent former clients of de Opvoedpoli experienced that their helpgiver used empowerment enhancing practices –
descriptive analyses were used. To answer the second research question, - whether the level of helpgiving practices is related to client satisfaction, goal achievement, and whether it is
related to decreased parenting stress , increased family functioning and, decreased problem behavior of the child - each construct was analysed separately on total- and subscale level. With regard to client satisfaction, it was tested whether the Pearson product-moment
correlation between the client satisfaction score that clients gave at the end of their helpgiving the score on the Helpgiving Practices Scale, including the two subscales, was significant. To be able to make statements about whether or not empowerment enhancing practices are related to goal achievement, the variable goal achievement was divided into people who did not achieve their desired score at the end of the trajectory, and people who did achieve their desired score at the end of the trajectory or scored even higher. By means of the Mann
Whitney U test it was tested whether clients who did achieve their desired score indicated that their helpgiver used more empowerment enhancing practices than clients who did not achieve their desired score.
Lastly, to investigate whether the level of empowerment enhancing practices was related to a reduction of parenting stress, increased family functioning, and decreased problem behavior of the child, first the scores on the Helpgiving Practices scale were made
dichotomous by dividing them in ‘high’ and ‘low’ based on the observed mean. Also the two subscales relational practices and participatory practices were dichotomized in the same way. By means of repeated measures ANOVA and MANOVA it was first tested whether there was a significant difference between the pre- and post-tests for the total- and subscales of all ROM questionnaires. Subsequently it was tested whether more empowerment enhancing practices
15 were related to a reduction of parenting stress, increased family functioning, and decreased problem behavior of the child.
Data screening and cleaning
The data were examined for missing values. 12 cases showed one or more missing value on the Helpgiving Practices Scale. After conducting a missing value analysis, it was found that the data were MCAR based on the results of Little’s test (χ2(84)=82.42, p = .528). Since the data is MCAR, imputation was allowed. Missing cases were imputed separately for the two subscales relational practices and participatory practices, using the estimation
maximisation method. This resulted in 71 complete cases.
The variable ‘helpgiving practices’ was not normally distributed; skewness was -1.85 and kurtosis was 4.41. The variables parenting stress, family functioning, and problem behavior of the child showed a normal or almost normal distribution. Since repeated measure (M)ANOVA analyses are robust to small violations of normality, it was concluded that the test could still provide valid results (Field, 2013). No outliers were detected. Lastly the assumption of linearity was checked and accepted.
Results
To answer the first research question, - to what extent former clients of de Opvoedpoli experienced that their coach used empowerment enhancing practices- the answers of the Helpgiving Practices Scale and the scores on the direct empowerment question were analysed. In total, 71 people filled out the Helpgiving Practices Scale (M = 76.80, SD = 13.89, Range 21-90). For the subscale relational practices the average score (M = 48.39, SD = 7.69, Range 12-55) was higher than for the subscale participatory practices (M = 28.41, SD = 6.28, Range 9-35). This difference was significant (t(70) = 5.78, p < .001) and represented a medium
16 effect size. Based on these results it can be stated that helpgivers of de Opvoedpoli use
empowerment enhancing practices frequently. They use both relational helpgiving practices and participatory helpgiving practices. However, relational practices are more commonly used than participatory practices.
When the total scores on the HPS were divided in ‘high’ and ‘low’ based on the mean score, it was found that 62.0% of the participants answered that their helpgiver stimulated their development of empowerment more than average. On the subscale relational practices it was found that 63.4% of the helpgivers used more than average relational practices. Out of the helpgivers in this sample, 59.2% used more than average participatory helpgiving practices.
When the former clients were asked directly whether their helpgiver actively stimulated their empowerment based on a common definition of empowerment, results indicated that empowerment was stimulated to a large extent (M = 3.82, SD = 1.17, Range 1-5). This finding correlated significantly with the answers that were given at the Helpgiving Practices Scale (r = 0.68, p < .001), the subscale relational practices ( r = .61, p < .001) and participatory practices (r = 0.70, p < .001). They all represent large effect sizes.
To answer the second research question, it was analysed whether the level of helpgiving practices is related to client satisfaction, goal achievement, and whether more empowerment enhancing practices are related to a reduction of parenting stress, increased family functioning, and decreased problem behavior of the child. Of the total group, 38 people gave a client satisfaction score about the provided care (M = 8.13, SD = 0.91). Since the possible range of this score runs from 1 to 10 this score can be interpreted as high, meaning that clients of de Opvoedpoli are on average very satisfied with the help that they receive. The lowest given grade was 6. This implies that everyone who answered this question evaluated the received help as sufficient. No significant correlation between the client satisfaction score and helpgiving practices in general was found (r = .23, p = .163), nor between relational
17 helpgiving practices and the client satisfaction score (r = .12, p = .459). However, the
correlation between participatory helpgiving practices and the client satisfaction score turned out to be significant (r = .34, p = .040) with a medium effect size. This implies that the more participatory helpgiving practices the helpgiver displayed, the more satisfied the client was. With regard to goal achievement (n = 37) it was found that 29.7% of the clients did not achieve their desired score at the end of the helpgiving trajectory. 70.3% of the clients did achieve their desired score, or scored even higher, than their desired score at the end of the helpgiving trajectory. By means of the non-parametric Mann Whitney U tests it was found that whether one achieved their desired score at the end of the helpgiving trajectory or not, was not associated with the empowerment enhancing practices in general that the helpgiver performed (U = 109.00, p = .270) nor with relational practices (U = 119.00, p = .441) or participatory practices (U = 115.00, p = .366).
Results showed that parenting stress reduced significantly during the time that the child or family received help, as can be seen in Table 1. This difference was significant and represented a large effect size. When looking into the various subscales it was found that the subscales relationship problems and parenting problems showed a significant reduction of problems with a large effect size. On the other subscales, no significant reduction of problems was found (see Table 1). No significant two way interaction effect was found between the reduction of parenting stress and the extent to which the helpgiver used empowerment
enhancing practices. This means that the degree of empowerment enhancing practices that the helpgiver showed did not account for the decrease of parenting stress. However, a significant interaction effect with a medium effect size between the subscales role limitation and
relational practices was found. This finding indicates that clients that feel that their helpgiver used more than average relational practices, have on average a larger reduction of problems with regard to role limitation than clients whose helpgiver used less relational practices. No
18 other significant interactions between the main- and subscales of the Helpgiving Practices Scale and the Parenting Stress Questionnaire were found (see Table 2).
With regard to family functioning, no significant reduction of problems was found. This holds true for family function with, and without partner relationship. However, on the subscale communication a significant reduction of problems was found. This reduction represented a large effect. For descriptive information on the variable see Table 1. However, no significant two way interactions were found between the between the main and subscales of the Helpgiving Practices Scale and the the subscale communication. These results mean that the reduction of problems with regard to communication did not significantly change over time depending on the empowerment enhancing practices that the helpgivers displayed. This holds true for the total- and other subscales as well (see Table 3).
Lastly, results showed a significant main effect of time with regard to the problem behavior of the child on both main- and subscale level. This implies that the average amount of problem behavior of the children (age 6-18) was significantly lower at the end of the helpgiving trajectory than at the beginning of the helpgiving trajectory. All differences have a large effect size (see Table 1). However, no significant two way interaction effect was found between the main and subscales of the Helpgiving Practices Scale and the Child Behavior Checklist, see Table 4. This means that the degree of empowerment enhancing practices that the helpgiver showed did not account for the decreased problem behavior of the child.
19 Number of Participants, Means and Standard Deviations of Independent Variables at treatment and post-treatment and Contrast of pre-treatment with post-pre-treatment
Pre-treatment Post-treatment construct N M SD M SD F df p η2 Parenting stress 38 55.21 12.79 59.99 14.03 8.86 36 .005** .20 Relationship problems 38 11.51 3.94 9.97 3.58 12.60 36 .001** .26 Parenting problems 38 16.25 4.55 14.55 3.75 8.82 36 .005** .20 Depressive moods 38 11.68 3.71 10.79 3.32 3.63 36 .065 .09 Role limitations 38 8.83 2.56 9.18 2.81 0.85 36 .364 .02 Health problems 38 11.71 3.84 10.71 2.83 3.35 36 .076 .06 Family functioning mp 38 88.88 19.54 85.00 18.89 3.05 36 .080 .08 Family functioning zp 38 70.32 15.11 67.63 14.80 2.34 36 .135 .06 Responsivity 38 14.80 4.32 14.51 3.62 2.15 31 .153 .07 Communication 38 24.28 6.78 21.47 7.11 8.18 31 .008** .21 Organisation 38 15.51 3.79 15.96 3.54 0.40 31 .530 .01 Partner relation 33 18.94 8.39 17.29 7.09 2.42 31 .130 .07 Social network 38 15.72 5.56 15.68 5.39 0.07 31 .794 .00
Problem behavior age 6-18 39 55.26 25.42 41.65 30.03 22.16 38 < .001*** .38
Internalizing 39 14.82 8.35 10.70 10.44 18.86 38 < .001*** .34
Externalizing 39 16.37 10.84 11.55 9.67 14.32 38 .001** .28
20 Interaction effects of empowerment enhancing practices with parenting stress
Construct F df sig η2
Parenting stress * HPS total 0.03 1,36 .862 .00
Parenting stress * relational practices 0.61 1,35 .283 .03
Parenting stress * participatory practices 1.19 1,35 .440 .02
Relationship problems * HPS total 0.87 1,36 .356 .02
Parenting problems * HPS total 0.13 1,36 .718 .00
Depressive moods * HPS total 0.02 1,36 .885 .00
Role limitations * HPS total 1.01 1,36 .322 .03
Heath problems * HPS total 0.43 1,36 .515 .01
Relationship problems * relational practices 0.72 1,35 .791 .00
Parenting problems * relational practices 0.01 1,35 .932 .00
Depressive moods * relational practices 2.47 1,35 .125 .07
Role limitations * relational practices 4.25 1,35 .047* .12
Heath problems * relational practices 0.23 1,35 .632 .01
Relationship problems * participatory practices 0.05 1,35 .831 .00
Parenting problems * participatory practices 0.14 1,35 .706 .00
Depressive moods * participatory practices 1.40 1,35 .244 .04
Role limitations * participatory practices 1.75 1,35 .194 .05
Heath problems * participatory practices 0.07 1,35 .709 .00
21 Interaction effects of empowerment enhancing practices with family functioning
Construct F df sig η2
Family functioning MP * HPS total 0.00 1,36 .990 .00
Family functioning ZP * HPS total 0.05 1,36 .827 .00
Family functioning MP * relational practices 0.24 1,35 .625 .01
Family functioning MP * participatory practices 0.03 1,35 .863 .00
Family functioning ZP * relational practices 0.06 1,35 .802 .00
Family functioning ZP * participatory practices 0.20 1,35 .660 .01
Responsivity * HPS total 0.25 1,31 .622 .01
Communication * HPS total 0.01 1,31 .924 .00
Organisation * HPS total 0.40 1,31 .530 .01
Partner relation * HPS total 0.02 1,31 .882 .00
Social network * HPS total 0.18 1,31 .677 .01
Responsivity * relational practices 0.24 1,30 .629 .01
Communication * relational practices 2.65 1,30 .114 .08
Organisation * relational practices 0.06 1,30 .811 .00
Partner relation * relational practices 3.88 1,30 .058 .11
Social network * relational practices 2.88 1,30 .100 .09
Responsivity * participatory practices 2.73 1,30 .109 .08
Communication * participatory practices 2.07 1,30 .161 .07
Organisation * participatory practices 0.33 1,30 .571 .01
Partner relation * participatory practices 0.80 1,30 .378 .03
22 Interaction effects of empowerment enhancing practices with Problem behavior of the child (6-18)
Construct F df sig η2
Problem behavior * HPS total 0.81 1,37 .373 .02
Problem behavior * relational practices 0.05 1,36 .821 .00
Problem behavior * participatory practices 0.12 1,36 .735 .00
Internalizing * HPS total 1.82 1,37 .186 .05
Externalizing * HPS total 0.38 1,37 .540 .01
Internalizing * relational practices 0.15 1,36 .698 .00
Externalizing * relational practices 0.00 1,36 .972 .00
Internalizing * participatory practices 0.20 1,36 .659 .01
23 Discussion
This study examined the use of empowerment enhancing practices by helpgivers of de Opvoedpoli, a child welfare organisation in the Netherlands that offers both mental health care and youth care for children and young adults between 0 and 23 years old. Furthermore, it examined the relationship between, on the one hand helpgiving practices and, on the other hand client satisfaction, goal achievement and changes in parenting stress, family functioning, and problem behavior of the child.
According to former clients of de Opvoedpoli, their helpgivers frequently used empowerment enhancing practices, both relational- and participatory practices. However, relational practices were more frequently used than participatory practices. The vast majority of the participants confirmed on a direct question, that their helpgiver stimulated their
development of empowerment actively. Despite the frequent use of relational- and participatory practices, it was found that the extent to which they were deployed, did not account for the decrease of parenting stress, the improvement of family functioning, and the decreased problem behavior of the child. This means that whether the helpgiver used
empowerment enhancing practices less- or more than average; this did not account for the family- and child outcomes.
A couple of exceptions to this were found. First, the more participatory practices the helpgiver displayed, the more satisfied the client was. Second, an interaction between role limitation and relational practices was found. This implies that if a helpgiver demonstrated more relational practices, such as empathy, respect, active listening and compassion, there were less problems with regard to role limitation, which covers the feelings people have regarding items such as ‘less contact with friends because of the child’, and ‘less quality time for yourself as a parent and for your partner due to the child’.
24 The finding that helpgivers used participatory practices less often than relational practices is in line with previous findings of Dunst and Trivette (2007). These results imply that helpgivers are inclined to demonstrate behavior that is usually associated with good clinical practice such as empathy, respect, active listening and compassion. To a lesser extent they also demonstrate practices that are flexible, individualized, and responsive to the
concerns and priorities of the family.
According to Dunst and Trivette (2007), both the use of relational- and participatory practices should lead to better child- and family outcomes. In the practice-based theory of family-centered helpgiving (Dunst, Trivette, & Hamby, 2006) it is described that there is a connection between relational- and participatory helpgiving behavior, the development of empowerment and family- and child outcomes. Despite the fact that in the current study this relation was found with regard to role limitation, the vast majority of the results on the second research question of this study contradict with previous research and the existing theory. Based on these findings one could argue that the focus on empowerment, as one of the key factors in the transition of the Dutch welfare system, is therefore unjustified.
However, this argumentation might be too short-sighted. In correspondence with the definition of empowerment by Hermanns (2007), and Van Yperen and Woudenberg (2011), it can be expected that former clients are less likely to search for professional help in the future if their helpgivers stimulated their development of empowerment. If they do resubmit, it can be expected that the care that they need is shorter, less extensive and therefore cheaper (Hermanns, 2007; 2009). This in contrast to the former clients whose development of
empowerment is not stimulated. If this proves to be true, empowerment would rightly be seen as key concept in the transition of the Dutch welfare system. It is therefore of great
25 account whether or not the client falls back on professional help later in life, thereby paying attention to the type and the prize of this help.
Some more limitations, accompanied with future recommendations, have to be mentioned to be able to place this study into perspective. In this study a retrospective design was used to measure the degree of helpgiving practices. Recall of information depends completely on memory which can often be imperfect and thereby unreliable. People usually find it difficult to remember or accurately retrieve incidents that happened in the past.
Research showed that twenty percent of critical details of a recognized event are irretrievable after one year from its occurrence and half are irretrievable after 5 years (Bradburn, Rips, & Shevel, 1987). Since former clients with a completed trajectory that started and finished between December 2013 and June 2015 were included, recall bias might have occurred during this study.
In addition to this, some of the participants commented that they found it difficult to answer the questions of the Helpgiving Practices Scale because they did not always knew whether the helpgiving practices were focussed on them, as parents, at their child, or at the total family. Because of this ambiguity it becomes apparent that the development of empowerment remains a concept that is difficult to capture. A structural measure that can capture the concept of empowerment better, and that could be applied already during the helpgiving process to avoid recall bias, should therefore be developed.
Another risk is the possibility of selection bias. Since the participants were contacted after they had finished their trajectory, one could argue that only a specific group felt
addressed by this request. For instance the people who were disappointed or extremely satisfied with the received help. However, the client satisfaction score of the clients in this study was exactly the same as in the extensive study into Wraparound Care (Sondeijker, van Rooij, van Gelderen en Hermanns, submitted) that included all clients with a completed
26 trajectory at de Opvoedpoli. Therefore, the participants of this study seem to be a good
reflection of the total population of de Opvoedpoli clients with regard to client satisfaction. A last limitation that should be mentioned is the relatively small sample size of this study. This resulted in a low statistical power to detect differences. Some of the results in this study were close to significant and plots of the repeated measures analyses revealed that a trend between the empowerment enhancing practices and family and child outcomes. Future research with a larger sample size is therefore recommended.
Despite the shortcomings of this research, it has offered us some guidelines for practical, scientific and policy purposes. Policy makers have assigned empowerment a very important role within the nationwide transformation of the Dutch welfare system and the accompanying transformation of welfare society into participation society. Based on the findings of this research it is questionable whether this special focus on empowerment is completely justified. The results of this study tell us that the use of empowerment enhancing practices, especially participatory practices, results in a high satisfaction score. Helpgivers would do well if they, therefore, try to keep using, or even increase, their use of participatory practices. However, the use of empowerment enhancing practices will not necessarily result in better child- and family functioning. To be able to understand the role of empowerment better, appropriate instruments that measure empowerment enhancing practices on a structural basis are essential. It is thereby of great importance that future research has a longitudinal design and takes into account whether or not the client falls back on professional help later in life, thereby paying attention to the type and the prize of this help. Until more knowledge about the role of empowerment is available, it seems wise to be careful with popularizing the concept.
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