STAIRS - a collaborative analytic framework for effective psychological and social work practice with children & families

Taylor, J., Hare, R., & Shostak, L., 2017

Introduction

The concept of a STAIRS approach to creating change developed out of work within Children’s Social Care and Youth Justice, and consideration of the key elements of effective practice in interventions that have a good evidence base within these settings, such as Multi-Systemic Therapy, AMBIIT, and the Enhanced Case Management Approach. In both Children’s Social Care and Youth Justice, professionals with a range of different trainings are working to create change in complex patterns of behavior between people (most commonly between parents and children, and between young people and the community). There are a myriad of specific intervention packages, training courses, and whole system approaches on offer for working in these settings. What is less available is an easily accessible overall framework for staff to use when considering which of the range of therapeutic and practical approaches at their disposal is likely to create change in a particular situation.

The increase in information around evidence-based approaches has been helpful in supporting staff on the ground across health and social care to access massed data on the likelihood of any particular intervention helping with any particular problem. What is not always understood is that it is just that - the likelihood of being able to create change - that means that an approach is the recommended approach, rather than any certainty. Some well-evidenced and well-respected approaches which are nationally implemented are only expected to be effective for less than half of the population. Thus whilst standardized evidence-based approaches are certainly the appropriate starting point for any particular presenting problem, their impact needs to be assessed rather than taken for granted, as your ‘client’ may be, for example, one of the 40% for whom the approach is not effective, rather than one of the 60% for whom it is. (We use the term ‘client’ in this paper to refer to the person/persons who the system believes has a problem that needs addressing, and the term professional to refer to anyone being paid to address the problem). In addition, the evidence for most approaches is in relation to a specific presenting issue, which may or may not mirror the issue of the client/s in front of you.

For both these reasons, the process of assessing a problem, choosing an intervention appropriately, and then assessing it’s impact and re-visiting and revising as necessary is crucial. However that analytic process is not usually embedded in the teaching of specific interventions, or in professional trainings in social work or therapy.

Another core issue in relation to work in this field in particular, is the balance of power between professionals and clients. Unlike work in other specialities of mental health and social care (such as treating an adult for depression, or providing support to a family with a child with a disability), much of this work is carried out because someone other than the clients themselves considers there to be a problem. This means that the clients may be ambivalent about or actively antagonistic to the professionals’ conceptualization of the problem. Unless the interventions are seen as addressing issues that the clients themselves see as problems, they are unlikely to be interested in the evidence-based nature of those interventions or collaborate in their delivery. This means that lots of families are written off as ‘impossible to engage’, or appear to engage when in fact just following the path of least resistance.

Lastly, many intervention approaches in this field do not have a significant focus on ensuring that the people who are expected to change understand the processes of creating and sustaining change, and have the skills and capacity to notice future problems and address them without ongoing professional input. So whilst dedicated professionals are often able to create change whilst involved with clients, they frequently then see them 'relapse' once that additional support is removed, or when a new challenges arises.

These issues together indicated the importance of articulating a collaborative and analytic approach to creating change that could be easily communicated and kept in mind by professionals who might come from a variety of different backgrounds, and be relevant whatever the presenting problems and range of interventions. The authors do not suggest that the STAIRS acronym describes new concepts in creating change, rather it is an aide-memoire specifically designed to support workers from a variety of backgrounds to keep in mind the key stages in any collaborative analytic approach to creating change.

What are the stages of a STAIRS approach?

Scoping

Scoping refers to collating sufficient information to be able to understand as precisely as possible what the problems actually are, and their history and mediating factors. This is important for a number of reasons. Vague or inaccurate information about problem patterns of behavior increases the extent to which the professional will ‘fill in the gaps’ in their information according to their own internal models of such behavior patterns and their causes. This can be particularly tricky when the problem issues are of a social interactive nature, such as violent or abusive behavior, or concerns about parenting, as unlike changes in blood pressure, these sorts of interpersonal behavioural problems are ones that all human beings tend to have emotive responses to, coloured by their own experiences. Thus a description of a person ‘repeatedly acting in an aggressive fashion’ will be interpreted in a myriad of different ways by different people, affected by their own relationship to the concept of ‘aggression’. Lack of clarity regarding the actual specific nature of the problems impacts on the professionals' ability to accurately asses risk, to see patterns, and to notice whether or not change is taking place. Diagnostic categories on their own will also not suffice in terms of providing the information required to assess risk, notice patterns, and notice change, as diagnostic categories in mental health allow two people with the same diagnoses to present with very different versions of similar problems. In any STAIRS approach, we expect professionals to have the skills to work with the clients to gather ‘FIDO’ type information (information on the frequency, intensity, duration and onset of the phenomenon in question) and to be able to explain to clients WHY they needed to be clear about this information, in terms of elucidating the reasons given above.

A second core feature of the sort of scoping required in any collaborative analytic approach, is clear information about the resources and the desires of the client/s and the non-professional system around them. If from the start of any work we are aiming to support clients to be able to sustain any positive change WITHOUT professional input, we need to know what the potential resources are that can be harnessed to achieve that aim – who are their family, friends, neighbours, school, workplace – who cares about this problem and who has influence over it? Who are the ‘stakeholders’?

Lastly, but most importantly of all in terms of laying the groundwork for a collaborative approach to change, we need to understand what the client and other key stakeholders actually want to be different – in a STAIRS approach, as in solution-focussed therapy approaches, this is a conversation had early on in the process. What is being asked is not how they think we should help them, but what they would want to be different if our involvement had been helpful. Clarifying what those who are involved in, or have influence over the issue wish to change, both encourages the client and other involved to think about an alternative future and allows an open discussion of what is actually realistic and in the scope of the professionals' task. It also provides the information necessary for the next stage of negotiating a clear destination which would indicate that the intervention task was complete.

Target Identification

The next stage in a STAIRS approach is already embedded in many effective approaches10 to social and mental health work – identifying your endpoint. The T in STAIRS stands for the importance of identifying, with the client, what the final target/s are for the work with the professional. These final targets may not be the endpoint of what the client would want to achieve in that area, but would be the signal that they are functioning at a level that wouldn’t normally require professional involvement. In a collaborative STAIRS approach, this target agreeing is a complex therapeutic endeavor, where the professional looks at how they can weave together the hopes of the client and the other various stakeholders, with the purpose of their service, and what is realistic in their timeframe. This is particularly important in contexts where there are significant power differentials and the client is to a large extent an involuntary client – here, as an absolute minimum, clients can usually be engaged in agreeing that they would like a life where professionals didn’t think they needed to be involved with them. But for most clients there are other aspects of their lives that they would like to be better, or things they would like to achieve differently if only they believed that was possible – a good understanding of the problems but also the client and their networks hopes and dreams is therefore essential.

In addition, there is then the task of working out with the client exactly how improvement in relation to that target will be measured, by whom, and how often. This is important for two main reasons. Firstly, in order to ensure clarity between the professionals and the client about how change is being measured, making sure that this is discussed in an open and non-combative way at the beginning, acknowledging that people tend to have different interpretations of things, so let’s work out together what we are taking as meaning what. Secondly, both client and professional, as human beings, will tend to interpret information according to a number of factors such as their mood or their world-view. This can get in the way of either the client or professional having a balanced view regarding whether progress is being made or not, or patterns in the change process. As part of the collaborative process, in any STAIRS approach, the professional would be expected to be able to explain to the client the above reasons for spending time together clarifying exactly what their targets for their work together would be.

Activators

Activators in STAIRS terminology refers to the factors that lead to, or allow, the problems to occur. An understanding of these is of course required in order to create an informed intervention plan, and this understanding of the activators is termed a ‘formulation’ in applied psychology practice. Key features of a STAIRS approach are that these activators are always identified with the client, and the client is taught how to try to identify them and why that matters, and the set of activators looked at is restricted to activators of problems with reaching the agreed target/s, rather than broader themes running through their life and interactions. What the professional brings to these discussions is their theoretical and professional knowledge as to sorts of things that tend to cause these problems – they then check with the client whether they think those are the relevant activators in their case. The reason why in a STAIRS approach the process of trying to understand the activators only takes place AFTER identification of the targets, is in order to have some boundaries on what activators, of what, are considered. This is in recognition of the complexity of the human condition, rather than an attempt to be reductionist. The human condition, and particularly interactions between humans, is so complex that a general attempt at understanding all the activators of all aspect of a client’s functioning risks leading both client and professional on a never-ending journey. Although much understanding may be gained on such a journey, there is a risk that no specific interventions are actually identified and no actual change therefore takes place. Finally, STAIRS approaches hold that whilst understanding by the client of the causes of their difficulties is a desirable condition for change, as that understanding and the process of coming to that understanding supports the client in being able to understand and create change in future problems, on it’s own understanding is unlikely to be sufficient to lead to sustained change in entrenched patterns of interaction. Which leads us on to the process of co-developing new ways of doing things with the client, based on their understanding of the activators of their difficulties.

Interventions

The term ‘Interventions’ in a STAIRS framework refers to anything any one is doing in a deliberate attempt to create movement towards the collaboratively agreed Targets. Thus ‘interventions’ in STAIRS terminology may be enacted by the professional or the client or other stakeholders, they may be practical or interactional or therapeutic or may be an individual change in thought processes – the essential point is that any intervention is collaboratively agreed on by the client and the professionals BECAUSE it appears likely to impact on an activator of the problems. This means that the exact nature of interventions within a STAIRS framework is entirely open, as their nature will depend on the particular problems under analysis, and their hypothesized activators. In this way a STAIRS approach is not theory-specific – if a particular theoretical understanding makes sense to a client and professional and suggests a particular intervention, then that is the appropriate intervention to move forward with. This is where the knowledge base of the professional becomes important, as what they are ideally bringing to the discussions with the client is their knowledge of what sorts of interventions are likely to work for what, given the evidence-base. Importantly, the decision as to which intervention to try when would wherever possible should be led by the client, as this will obviously increase their engagement with the intervention, and interventions should always be entered into in a spirit of experimentation – ‘we are trying this, as we think it would impact on that, which would reduce the problem, but if it doesn’t we’ll have to rethink’ – see below...

Review / Revise

The reviewing/revising process in a STAIRS approach is also, of course conducted collaboratively, thus allowing check and challenge from the client re any impact of the intervention, and providing the client with an opportunity to learn through direct experience about this sort of problem-solving approach. Thus any intervention that doesn’t appear to have an impact leads to a conversation between client and professional as to whether a) they think it didn’t have an impact as actually maybe that activator wasn’t as important as one or other or both of them thought, in which case it clears the way for an intervention aimed at an alternative activator, or b) whether whilst the activator may be important, this intervention can’t easily change it, in which case an alternative intervention for the same activator might be considered, or changing to a different activator that is easier to change might be considered. Making sure this process of thinking and discussion is followed tends to greatly increase collaboration and reduce conflict about causes and blame.

Sustainability

Lastly, but arguably most importantly for something to be considered a STAIRS approach, there needs to be a belief by the professional that their ultimate aim is for the client to be able to manage without their input in the longer term. This means that from the outset, ‘interventions’ that can occur without professional input are favoured over those that rely on professionals – the professional’s skill is in helping the client to work out what the interventions need to be, not necessarily in being the one to deliver them. It also means that where signs of progress towards targets are evident, the client and professional have an open discussion about what has led to that progress, rather than pre-supposing that any progress has necessarily been caused by the professional intervention. Finally, but absolutely core to the approach, any interventions or indeed accidental circumstances that client and professional consider to have led to positive change are considered together in terms of how those interventions or circumstances can be maintained without use of professionals in the longer term. This aspect of the work should be seen as the bulk of the work in a STAIRS approach, with all of the preceding work serving the function of understanding what needs to be different, whereas this aspect is working together on creating a way of life that maintain the desired changes without the need for paid outsiders.

S = Scoping - Clarity re presenting problems, who the key players are in the child or young person’s life and what change is wanted by whom

T = Targets - Going through a process of checking what is wanted by whom in order to agree what we’re aiming for with as many people as possible, and an agreed way of tracking our progress

A = Activators - Collaboratively identifying the multi-level activators of the problems with reaching our targets

I = Interventions – Meaning anything anyone does, from the practical to the therapeutic, in order to impact on the activators

R = Review and Revise - Real-life monitoring of movement towards targets and modeling going back and revising formulations and plans – experimenting together

S = Sustain - Sustainability thought about from the outset in terms of types of interventions offered and plans for maintaining progress after closure – the bulk of the work!

Moving forward

In summary, the acronym STAIRS identifies a series of steps that can be used by a variety of professionals from different backgrounds, solving different problems in different ways, in order to ensure that they are doing so using a collaborative, formulation-driven, evidence-based approach. The authors have thus far used this framework to successfully develop training, support, and whole system interventions across a range of settings, including via development of the 'FAMILY' approach with Morning Lane Associates, used to date in seven Children's Social Care departments across the UK as well as within the voluntary sector, and the 'SECURE STAIRS' framework with NHS England, planned for roll-out across the entire Children and Young People's Secure Estate as part of the Children and Young People's Mental Health Transformation.

The above is, by necessity, an overview of what we mean by a STAIRS approach, rather than serving as a 'how-to' guide. In our experience, supporting staff to work in a STAIRS way (as with supporting clients by using a STAIRS approach) requires a period of ongoing support and collaborative learning, to ensure that the approach to clients becomes embedded and the new way of working sustainable without ongoing support. Furthermore, our object in the paper is not to suggest that using a STAIRS approach is limited to those undertaking our trainings. Rather we are putting forward the acronym to help commissioners and leaders of both health and social care services objectively consider whether particular services or trainings appear to incorporate these core features, and therefore whether they are likely to be useful in increasing collaborative analytic practice. Our hope in writing this paper is to increase the use of STAIRS methodologies across our communities via creating a shared language as to what they entail.