Exploring Perceived Factors Influencing Cross-System Collaboration between Child Welfare and Behavioral Health Organizations

Background and Purpose

Parental substance use disorder (SUD) is the most prevalent risk factor for child maltreatment and has also been associated with increased complexity and severity of maltreatment. Sobriety Treatment and Recovery Teams (START) is an evidence-based, cross-systems intervention that has been associated with an increased likelihood of unification and reduced recurrence of maltreatment for families with co-occurring child maltreatment and substance use. The intervention includes multiple sequenced components (e.g., initial screening, shared decision-making, referral and contact with family peer mentors, and access to treatment) that are expected to be completed within specific time periods. Successful implementation is contingent on the quality of collaboration between child welfare and behavioral health providers. However, child welfare and behavioral health organizations have different treatment approaches, cultures, and priorities, which can make collaboration challenging. The current study draws on qualitative data from frontline providers involved in START implementation to highlight key factors influencing the quality of cross-system collaboration between child welfare and behavioral health providers.

Methods

This qualitative study used small group interviews with 25 child welfare frontline workers and 24 behavioral health providers from 24 counties that were working toward implementing START. Interviews captured their experiences and perceptions of collaborations during implementation. Small-group interview transcripts were analyzed using thematic analysis. Descriptive data on county characteristics (community need-severity of the opioid crisis and local behavioral health treatment availability) contextualize the qualitative findings within the counties involved, thereby enriching the understanding of how differences in attitude and treatment models influence collaborative practices.

Results

Four themes emerged from the thematic analysis: differing SUD treatment approaches and services, child welfare attitudes toward substance use, balancing client’s choice and the child welfare caseworkers’ preferences for abstinence-oriented treatment, and practices that improve collaborations. Some behavioral health providers delivered services rooted in the 12-step program and abstinence-based approaches, while others adopted harm reduction approaches and provided services. A small fraction of child welfare caseworkers had negative attitudes towards substance use, resulting in discriminatory language against caregivers and resistance in the agency towards family peer mentors. These caseworkers described challenges collaborating with substance use treatment providers using harm reduction-based approaches because they perceived harm reduction as a “bare minimum” level of treatment with poor outcomes. Caseworkers with negative attitudes also faced challenges in balancing clients’ choice and their treatment preferences. In addition, although medication-assisted treatment (MAT) is an evidence-based treatment for opioid use disorder, a minority of caseworkers indicated they would not recommend MAT services. Collaborative meetings, communication on service alignment, and supportive supervision were reported to help resolve friction.

Conclusion and Implications

Although only a minority of caseworkers expressed stigmatizing attitudes toward substance use, our findings highlighted how front-line professionals’ views and beliefs impact service delivery and cross-system collaborations. Findings suggest the need for developing and testing strategies that address stigma toward substance use and treatments among child welfare workers to improve collaboration and implementation for cross-system interventions like START.