Great article by Jacqueline Sparks and Michele Muro applying client directed, outcome informed practices to wraparound services.

1. Journal of Systemic Therapies, Vol. 28, No. 3, 2009, pp. 63-76
CLIENT-DIRECTED WRAPAROUND:
THE CLIENT AS CONNECTOR
IN COMMUNITY COLLABORATION
JACQUELINE A. SPARKS
University of Rhode Island
MICHELLE L. MURO
Southwest Behavioral Health Services
Systems of care emphasize the needfor effective collaboration between com-
munity agencies assisting families where a child or adolescent is at risk of
out-of-home placement. Unfortunately, community collaborations may not
privilege the voices of family members, including the young person. Research
affirms the critical importance of honoring clients ' views in any change en-
deavor. Wraparound and client-directed, outcome-informed (CDOI) projects
support this imperative, with CDOI offering client-report feedback measures
to formally amplify clients' perspectives. The connection between these two
distinct movements provides a philosophical and operational basis to create
productive and even inspiring community partnerships.
The removal of children from their families and homes can incur significant trauma,
complicating efforts to strengthen and reunify families. Out-of-home placements,
particularly those longer-term, have tended to isolate the young person from school
and family environments. Moreover, placement interventions, despite significant
costs, have fallen short of achieving benchmarks for success (Stroul, 1996). As a
result, home, school, and community-based services are now first-line responses
for identified "at risk" children or adolescents. Within the past decade, these young
people and their families have been invited to participate in a form of ecologically-
based intervention known as wraparound (Burchard, Bruns, & Burchard, 2002;
VanDenBerg, 1996).
Wraparound embraces a family and community-centered, strength-based, and
culturally-responsive philosophy. It also involves a flexible array of formal and
informal supports gathered together to form "the team." The team transforms its
Address correspondence to Jacqueline Sparks, University of Rhode Island, 2 Lower College Rd.,
Kingston, RI 02881. E-mail: jsparks@uri.edu.
63

2. 64 Sparks and Muro
membership, goals, length of involvement, and funding structures to adapt to each
family situation and idiosyncratic change process. In its ideology, wraparound
represents tbe evolution of systems of help from punitive, discouraging, and
restrictive to family-driven, optimistic, and responsive, theoretically capable of
addressing tbe complexities inberent in multi-level intervention.
In practice, wraparound may not live up to its philosophy. Wbile communities
have struggled to find ways to work together, protocols, hierarchies, and beliefs,
entrencbed over time, often differ significantly from one agency to the next. Fur-
thermore, the fundamental values of wraparound may be major departures from
how an agency and its staff understand problems, families, and helping. For ex-
ample, the belief in child and family wisdom to know what is needed to resolve
dilemmas may contradict professional training, policy, and procedure. Tbe sought-
after collaboration between diverse and sometimes historically competing enti-
ties can falter, inhibiting wraparound's potential to assist troubled families.
While practitioners and researchers continue to define an effective wraparound
process (Walker & Bruns, 2006), a substantial body of research bas attested to
tbe soundness of putting clients' voices and preferences at the forefront of their
change. For example, the formal incorporation of clients' views regarding the
direction of service and the helping alliance bas shown to improve the outcome
for both individuals (Howard, Moras, Brill, Matinovich, & Lutz, 1996; Lambert,
in press) and couples (Anker, Duncan, & Sparks, 2009). Brief, reliable, and valid
client-report measures administered throughout intervention make clients' views not
only visible and usable, but meaningful indices of outcome, a key interest of sys-
tems that shoulder the financial responsibility for services. Recently validated child
measures have expanded client-directed, outcome-informed work to families, al-
lowing children to finally bave a meaningful say in their preferences for help.
This article focuses on efforts to unite the systematic collection and utilization
of client views with wraparound service. We describe wraparound and client-
directed, outcome-informed practices (CDOI), with an emphasis on the successes
realized to date and anticipated barriers. We suggest tbat making the "voice and
choice" of clients a guiding light not only can translate into improved outcomes
but can become the linchpin of true partnerships witb families and diverse help-
ing systems. Most importantly, we articulate the vision of a process that honors
clients' voices not only in theory but in practice—clients become the "glue" that
holds the team together to create inspiring and transformative collaborations.
WRAPAROUND IDEOLOGY AND PROCESS
Decades ago, the alarm was sounded that children and adolescents experiencing
high levels of distress and troubling behavior were not receiving what was needed
to help them stabilize and flourish in natural, non-stigmatizing environments
(Knitzer, 1982). Disruptive and distressed youths, many experiencing the effects

3. Client-Directed Wraparound 65
of family disarray, poverty, or discrimination, found themselves on a kind of re-
volving wheel. As they were identified and efforts marshaled to help, many were
removed from their homes into foster care or residential placements, frequently far
from their families and social worlds (Burchard, Burchard, Sewell, & VanDenBerg,
1993). In many cases, efforts to help resulted in further identification of the youth as
disabled, a process made all the more pronounced by removal from everyday life.
In such instances, getting back home, back in school, and being seen as "normal"
became increasingly difficult.
Families, too, experienced a similar kind of identity branding. Social and men-
tal health services for families where child abuse or neglect was suspected or where
children exhibited disturbing behaviors often focused on family dysfunction. Well-
intended "treatment plans," created without family input, were frequently im-
possible due to lack of transportation, child-care, financial resources, or other
necessary family supports. Moreover, plans may have overlooked family values,
culture, or views, making the completion of pre-set goals unlikely. These fami-
lies, like the troubled youth in residential and specialized placements, found them-
selves on a revolving wheel, becoming increasingly demoralized and stigmatized,
their journey to stability hampered, if not altogether thwarted. It was recognition
of these failures that spurred interest in more hopeful, less-stigmatizing, and more
effective ways to help. These efforts involved doing "whatever it takes" to keep
the child in the home and supporting and involving the family, with safety still a
critical caveat.
"Systems of care" arose in order to create community and family partnerships
to help maintain children at home, or at least in local community settings, as briefly
as possible (Kutash, Duchnowski, & Friedman, 2005). The wraparound process
gradually evolved out of these initiatives, with the additional recognition that
children and families could be served better through family-centered and culturally-
responsive intervention. According to Burns and Goldman (1999), wraparound
is grounded on the belief that when the child and family's needs are met, present-
ing concerns improve, if not dissolve; neither structures of reimbursement nor
service availability should stand in the way of addressing these needs.
At its core, wraparound is flexible, comprehensive, and team-based. Further-
more, wraparound is driven by the family's perspective incorporated into a collabo-
ratively devised and individualized service plan. The plan, and all efforts that
follow, are culturally congruent and utilize family strengths and both natural and
formal supports. Wraparound is not a specific approach, but is more accurately
considered a process involving trained community personnel who are responsible
for coordinating family/community collaborations and who seek to implement
wraparound's fundamental philosophy of family empowerment.
Wraparound has captured the imagination of many in social and mental health
services at both practice and policy levels. It presents a vision of help that moves
beyond expert-recipient, professional-lay to one of the family as holding the great-
est expertise. According to wraparound principles, the family determines what is

4. 66 Sparks and Muro
needed and the best way to get it, while the wraparound professional provides
information and opens doors to resources that would otherwise be closed. Even
the popular notion of the client as "consumer" is transformed into the client as
leader. Collaboration and the importance of local, client wisdom are central con-
cepts in narrative (White & Epston, 1990), collaborative language systems (Ander-
son & Goolishian, 1988; Anderson & Gehart, 2007), and solution focused (de
Shazer et al., 1986; De Jong & Berg, 1998) approaches. These beliefs have led to
the creation of collaborative family-based models (e.g.. Berg, 1994; Madsen,
2009), implementing shared values in intensive family-centered work. Wrap-
around, a meta-framework for family/provider engagement, is consistent with a
collaborative paradigm. The expertise of the wraparound professional involves
safeguarding the process, with a foundational belief that its proper unfolding will
produce the desired result.
CLIENT-DIRECTED, OUTCOME-INFORMED PRACTICE
Despite its radical philosophy, wraparound in practice is not separate from pre-
vailing "mental health" ideology. On what has been called "Planet Mental Health,"
diagnosis plus prescriptive treatment are standard practice, often leaving clients
out of the decision-making loop (Duncan, Miller, & Sparks, 2004). This equation
is supported by longstanding structures that require DSM derived diagnoses to
trigger funding. In addition, spurred by broad initiatives to implement research-
based interventions for youth mental illness (e.g.. National Advisory Mental Health
Council Workgroup on Child and Adolescent Mental Health Intervention Devel-
opment and Deployment, 2001 ; New Freedom Commission on Mental Health,
2003), child and adolescent services increasingly stress evidence based treatments
(EBTs) (Huey & Polo, 2008; Kazdin, 2000; Weisz, Weiss, Han, Granger, & Morten,
1995). An emphasis on EBTs can disenfranchise families' and youths' views by
mandating specific treatments for certain identified problems. This can occur
despite the definition of evidence-based practice developed by the 2005 Presi-
dential Task Force on Evidence-Based Practice of the American Psychological
Association emphasizing "the integration of the best available research with clinical
expertise in the context of patient [sic] characteristics, culture, and preferences"
(APA, 2006, p. 273).
Wraparound can be found on many EBT lists (see e.g.. Bruns, Hoagwood,
Rivard, Wotring, Marsenich, & Carter, 2008; Walker & Bruns, 2006). At the same
time, guidelines for the wraparound process often include the use of specific EBTs.
For example, a recent survey found that 55% of wraparound practitioners were
required to use EBTs (Sheehan, Walrath, & Holden, 2007) despite the fact that
many practitioners feel that EBTs limit creativity and are not responsive to indi-
vidual client differences (Plante, Andersen, & Boccaccini, 1999). Meanwhile, the
diversity of youth service settings (e.g., juvenile justice, schools, child welfare)

5. Client-Directed Wraparound 67
complicate the implementation of standardized protocols by front-line providers
(Leighton, 2002).
Despite obstacles, the call to provide EBT training and standardize protocols for
youth and family services grows louder (Sheehan et al., 2007). In contrast to choos-
ing from a list of approaches based on expert assessment, a growing body of re-
search attests to the importance of real-time client feedback (continuously throughout
intervention) to inform what is done, for how long, and what modifications may be
needed. Client- directed, outcome-informed practice is based on the robust empiri-
cal findings that therapeutic outcomes derive not from the specific differences be-
tween treatment approaches, but from commonalities between them (Duncan et al.,
2004; Wampold, 2001 ). Instead of adding one more model to the plethora ah-eady
in existence, CDOI tailors treatment to each unique situation based on client feed-
back. CDOl requires the systematic collection and incorporation of client feedback—
beyond tbat, clinicians are free to work creatively using whatever model best fits a
given family's or youth's preferences and resources.
In their review, Lambert, Harmon, Slade, Whipple, & Hawkins (2005) revealed
clinically significant advantages of feedback over non-feedback conditions for
individual therapy. Availability of formal client feedback provided the only con-
stant in an otherwise diverse treatment environment and attained an effect size
(ES = .39) nearly twice that of model differences (.2). Lambert's recent review of
feedback research with individuals concluded that it is time for clinicians to rou-
tinely collect and incorporate feedback in their work (Lambert, in press).
While research on feedback with individuals is extensive, family feedback re-
search is in its infancy, perhaps in part due to the complexity of obtaining fre-
quent measurements for multiple persons in a given family unit. Complicating
matters further, most available outcome measures, although reliable and valid, are
long and intended primarily for research purposes. A small recent study of feed-
back in wraparound services for youth and families (Ogles, Carlston, Hatfield,
Melendez, Dowell, & Fields, 2006) found that provision of feedback using the
48-item Ohio Scales (Ogles, Melendez, Davis, & Lunnen, 2001) did not contrib-
ute to improved youth outcomes or family functioning in comparison to a no-
feedback group. Feedback, however, was restricted to just four times over the
course of treatment. Conversely, a strong feedback effect was found in a recent
study of 205 couples (Anker et al., 2009). The Outcome Rating Scale (ORS; Miller,
Duncan, Brown, Sparks, & Claud, 2003), a reliable and valid four-item, self-re-
port instrument, provided outcome feedback, and the Session Rating Scale (SRS;
Duncan et al., 2003), also reliable, valid, four-item, and self-report, provided feed-
back in this trial. Finally, Reese et al. (in press) found a significant effect for out-
comes for clients of 28 trainees when feedback was incorporated into their work
and supervision. Tbe ORS and SRS were primary measures used in this study.
The brevity and face validity of the ORS and SRS may have allowed for greater
engagement by clients and clinicians in Anker et al. (2009) and Reese (in press)
than would have occurred with lengthier instruments. Both the ORS and SRS

6. 68 Sparks and Muro
collapse multiple items into a few broad domains, minimizing disruption of the
session when administered. This is especially important since CDOI recommends
tracking client progress and alliance at each meeting. All scoring and interpreta-
tion of the measures are done together with clients. This not only represents a
radical departure from traditional assessment but also gives clients a new way to
look at and comment on their experience. Assessment, rather than an expert-driven
evaluation of the client, becomes a pivotal part of an evolving relationship and
change itself.
The ORS is a visual, analog scale consisting of four lines, three representing
major life domains—subjective distress, interpersonal relationships, social role
functioning—and a fourth, overall. Clients rate their status by placing a mark on
each line, with marks to the left representing greater distress and, to the right, less
distress. The ORS score provides an anchor for understanding and discussing the
client's current situation and allows a comparison point for later sessions. Fur-
ther, it involves the client in a joint effort to observe progress toward goals. Be-
cause the ORS is visually easy to grasp, clients often remark about their score on
the different lines in relation to what is happening in their lives. When this does
not happen, the practitioner can initiate a discussion about how the scores con-
nect with the client's account. In other words, the ORS becomes linked to the
described experience of the client's life. In this way, the client and helper can use
ongoing ORS assessment as a tool to chart direction for their work together. Un-
like traditional assessment, the mark on the ORS is irrelevant until and unless the
client bestows meaning on it in dialogue with a helping collaborator.
The SRS, like the ORS, is a paper-pencil measure using four visual analogue
scales. The SRS measures the client's perceptions of a meeting with a helper on a
continuum of three aspects of the alliance as defined by Bordin (1979): the rela-
tionship dimension, "I did not feel heard, understood and respected" to "I felt heard,
understood, and respected"; a goals and topics dimension, "We did not work or
talk about what I wanted to work on or talk about" to "We worked on or talked
about what I wanted to work on or talk about"; and an approach or method di-
mension, "The approach is not a good fit for me" to "The approach is a good fit
for me." Finally, the fourth line elicits the client's perception of the meeting in
total via the continuum "There was something missing in the session today" to
"Overall, today's session was right for me."
The SRS allows all to know, and react immediately to, the client's view of the
alliance; it continues a culture of client privilege and feedback and opens space
for the client's voice. Clinicians or helpers ask clients to provide feedback at the
end of each point of service, leaving enough time for discussion of client's re-
sponses. The SRS is most helpful in the early identification of alliance problems,
allowing changes to be made before clients disengage. When clinicians convey
to clients, via the SRS, that they genuinely want feedback and are serious about
addressing client concerns, they embody "talking the talk" and foster trust and
fruitful collaboration.

7. Client-Directed Wraparound 69
Until recently, persons under the age of 13 have not had an opportunity to pro-
vide formal feedback to helpers about their views. To fill this void, the Child
Outcome Rating Scale (CORS; Duncan, Sparks, Miller, Bohanske, & Claud, 2006)
was developed. The CORS is similar in format to tbe ORS but contains child
friendly language and graphics to aid the child's understanding. Similarly, the Child
Session Rating Scale (CSRS) offers a visual component as well as language ori-
ented towards children to assess a child's perception ofthe alliance. Parents or
caretakers also use these measures to give their perspective of their child's progress.
Tbe adult ORS and SRS have been validated for use with adolescents (ages 13-
17), giving tbis age group a chance to voice their opinions on how well they feel
connected to their helper and the overall process. With these instruments, whole
families can benefit from client-informed practice, and researchers have a tool
for examining the impact of services at family and systems-wide levels.
Based on a growing body of compelling empirical findings, feedback appears
to improve outcomes across client populations and professional disciplines, re-
gardless of the model practiced—the feedback process is a vebicle to modify any
delivered treatment for client benefit. This research, and our own experiences using
client feedback in our work settings, suggested to us an opportunity to put into
practice in a meaningful, concrete way the underlying philosophy of wraparound.
Wbile lip service is often given to having clients lead the way, enculturation into
"Planet Mental Health" tends to be pervasive (Duncan & Sparks, 2007). Instead,
CDOI creates a "culture of feedback" (Duncan et al., 2004)—it is a way to "walk
tbe walk." At the same time, we speculate that tbe system-wide use of standard
measures, gathered often and regularly throughout involvement with a client fam-
ily, has the potential to unify the diverse players in the wraparound drama. For
example, the use of linked databases of routine client measures of progress and
tbe alliance can provide a single orienting point around which discussions about
needs, change of direction, or termination revolve. Of note, wbile efforts to im-
prove interagency collaboration in system-of-care initiatives (such as wraparound)
have been successful at a systems-wide level, outcomes at the child and family
level are less convincing (Farmer, Mustillo, Burns, & Holden, 2008). Could it be
tbat professionals have become better talking amongst themselves, while clients'
voices remain unheard or unheeded?
Witb this history and research as a backdrop, the following relates experiences
of one family program to formally incorporate clients' voices, including the young-
est, as guides to community wraparound intervention.
STORIES FROM THE FIELD
Southwest Behavioral Health Services (SBH) provides services to as many as 2,000
or more children at any given time in Maricopa, Pinal, and Gila Counties in Ari-
zona. The CORS was implemented by Child and Family Team (CFT) programs

8. ^0 Sparks and Muro
in March of 2008 to give children an opportunity to be heard and to unify diverse
helpers. We also began using the Child Session Rating Scale (CSRS) to monitor
the helping alliance and Tracking Graphs to plot child and caretaker ratings (one
graph is used to plot progress from the initial assessment through individual and
family meetings on a weekly basis). We hoped that having access to immediate
client and caretaker feedback could help clinicians make sure they worked on
family goals and kept track of progress being made. We also hoped the process
could foster collaboration with natural supports and community resources. Our
intention was to circulate the graphs to other providers formally involved with
the family in order to help us all to be "on the same page" with clients' views of
progress and the process in general. These views could potentially serve as points
of discussion about what services could best help clients reach desired changes.
Layering the CORS into CFT services is a work in progress, with ongoing
trainings and discussions with clinicians and other staff members. Nevertheless,
stories from the field give us hope that our efforts are already having an impact,
as illustrated by the following examples. A 12-year-old boy, an 11-year-old boy,
and a 9-year-old girl were removed from their home by Child Protective Services
(CPS). The children lived with their mother, who struggled with substance abuse.
The siblings wanted to stay together, and their maternal uncle stepped in to care
for them short-term while their mother tried to stay clean. At the time of this writ-
ing, she had not been successful in this and had not engaged in a family reunifica-
tion effort. Acting in what he surely believed to be in the best interests of the
children, the CPS case manager requested a range of services, including mental
health assessments, psychiatric testing, and psychological evaluations for all of
the children. However, during our use of feedback measures with the family, the
children consistently rated themselves on the CORS between 8s and 9s in every
domain, above the "cutoff and indicative of functioning in a "non-clinical" range.
The uncle also rated the children 8s and 9s; an unlikely long-term caretaker for
these children was telling the team that this family "worked." The children were
saying the same thing in all areas of their lives. They felt happy, safe, and were
adjusting to their new environment. The uncle reported no behavior concerns at
home, and stakeholders from school reported that all children were making progress.
While the verbal reports from family members and the school were significant,
backing these with concrete valid measures provided powerful corroborative sci-
entific evidence. The CPS worker was convinced, and withdrew recommendations
for high-end, intrusive intervention.
Another example involved an 8-year-old Hispanic boy who was referred by his
mother for "help dealing with his parents' divorce." The CFT brainstormed and
suggested multiple community resources and activities, although the family had
been in services for over a year without much progress. The CFT decided to use
the CORS with the boy and his mother (the CORS allows caretakers to track a
child's progress as they see it) in an attempt to better target family needs. As a
result, a new family plan was developed. This time the team used feedback from

9. Client-Directed Wraparound 71
the mother and the 8-year-old's scores on the CORS and graph to gauge what
worked best while continuing to connect the family with resources and natural
supports. Within several months, the team discussed stepping back formal ser-
vices after the child and his mother reported overall improvement on the mea-
sure. Without specific guidance from both the child and his mother via a concrete
and visual tool, this family may have continued to flounder with an array of ser-
vices not suitable to their particular goals and preferences. Instead, we speculate
that not only did use of the measures help target helping efforts, it put family
members in charge of the process, increasing their engagement and subsequent
movement toward a successful outcome.
Another example illustrates how successful outcomes are client driven, even if
the end result does not always line up with the team's plan. The client, a teenage
girl, had been involved in wraparound for several years. The team struggled with
helping her through instances of self-harm, depressed mood, and the passing of
her biological mother. Carla, as we will call her, was placed with a foster mother
who did her best to provide a stable, loving environment for her. But, it was not a
good fit, and Carla did not know how to tell the team. When the ORS and SRS
(adult measures used with adolescents) were introduced into the process, Carla
had a vehicle for telling helpers that what they were doing was not working. She
showed a high level of distress and, when we inquired about this, stated that she
did not connect with her foster mother and, in fact, intended to run away to the
home of her aunt. When her clinician attempted to discourage that plan, Carla gave
their session the lowest rating on the SRS, a 7 (below 36 indicates problems with
the alliance). At the same time, the client reported her highest ORS, an overall of
36 (out of 40, and well above the cutoff of 28 for her age). She told her clinician
that she was "celebrating her freedom and going to make her own choices." Carla
acted on her plan, and some days later called her clinician from her new home
with her aunt to inquire about services in her area. Since she was soon to turn 18,
Carla's chart was closed. Had wraparound initially provided Carla with a formal,
and perhaps more impersonal, way to give feedback, her needs could have been
addressed much sooner. In a sense, formal asking about her wishes seemed to ignite
Carla's will and voice—she stepped out to chart her own course and, all things
considered, made a reasonable decision.
It is not without trying that diverse helpers sometimes miss the mark. Our experi-
ence, to date, has been that we now have a viable way to spend less time "in the dark"
and more time (with less cost and resources) doing those things most likely to work,
even for some of the more complex and seemingly intractable client dilemmas.
THE CLIENT AS CONNECTOR
It has been decades since the recognition that removing children from their homes,
especially far from natural networks, frequently fails to resolve the problems faced

10. 72 Sparks and Muro
by young persons and their families. Despite the creation of community-based
systems of care, out-of-home placement remains an all too frequent event, par-
ticularly for older and Hispanic teens, and continues to be an unstable and inade-
quate solution (Farmer et al., 2008). A curious dichotomy has arisen within systems
of care as they have sought to stem the placement tide. On the one hand, provid-
ers have rallied around a progressive paradigm of family-driven, individualized
service, particularly exemplified by wraparound, based on client voice and choice.
On the other hand, wraparound and like services rest within practice and payment
structures derived from traditional mental health and medical ideology. Diagnoses
still find their way into charts and the language used to talk about persons, their
situations, and possible solutions. Consequently, services to high-risk families and
children often encompass two opposing worlds. And often, the more pervasive
and established medical discourse trumps the local knowledge of clients. Rela-
tionships of helper/helped and expert/impaired that typically define medical in-
tervention render unlikely other kinds of partnerships, specifically those where
clients lead and know best. It's as though when diagnoses speak, clients cannot
be heard.
A third way is possible, one based on evidence from the empirical literature
that centralizes clients in the helping process. Research continues to affirm the
importance of client engagement in a positive outcome in psychotherapy (Bohart
& Tallman, in press). Specific diagnoses are not correlated with outcome, whereas
client involvement is (Duncan et al., 2004). Most standardized measures of pa-
thology fail to differentiate between clients who will and will not ultimately benefit
from psychotherapy (Brown, Dreis, & Nace, 1999). A growing number of studies
suggest that predictions of overall improvement at the conclusion of treatment are
more accurate when they are based on the client's report of change in the first few
meetings rather than on clinicians' pretreatment assessments of client dysfunction
(Haas, Hill, Lambert, & Morrell, 2002; Lambert, Whipple, Smart, Vermeersch,
Nielsen, & Hawkins, 2001). Additionally, obtaining feedback from clients through-
out therapeutic services enhances client involvement by reducing cancellation and
no-show rates (Bohanske & Franczac, in press) and results in significantly greater
improvement than non-feedback conditions (Lambert, in press; Anker et al., in
press).
Centralizing clients' voices via formal feedback has the potential to resolve the
clash between two philosophies—one that values client direction (wraparound)
and one that mistrusts it (medical). Client reports replace diagnoses as centerpieces
of treatment plans and indices of change in any given helping collaboration. The
fundamental wraparound values of individualized, culturally sensitive interven-
tion can be realized for each child and family, without the demoralizing effects of
deficit labeling and prescriptive treatment. Clients author their stories, and the
system of helpers unites around these rather than the depersonalized mental health
narratives with their predictable characters and plots.

11. Client-Directed Wraparound 73
Very real obstacles arise in the implementation of client-directed community
collaborations. Overturning entrenched policies, paperwork, and procedures, the
infrastructure of "mental health," is no small endeavor. As an example, the safety
of children and the community must be a priority, and ways of responding to
extreme crises inevitably revert to traditional thinking and acting. Community
stakeholders have every right, indeed obligation, to protect not only the youngest
members of their community, but the community as a whole, as in circumstances
of child abuse or chronically delinquent youth. The choice between traditional
responses and the one advocated here, however, need not sacrifice this mandate.
Already, the use of client feedback systems has caught the attention of decision
makers (judges, probation officers, administrators, third party payors, etc.) in
a wide array of treatment settings serving children and families (Bohanske &
Franczak, in press).
Ultimately, the best way to test the waters is to pilot CDOI practice, collect data,
and assess outcomes. Communities can begin to have the courage to step into a
new paradigm, to honestly implement the values at the core of services such as
wraparound, based on solid empirical support. Their commitment, however, de-
pends on their own felt experience of "does it work?" We have seen, and heard
tell, how more energy and less demoralization characterize helping efforts, how
goals are realized more quickly, and how workers in the field experience increased
satisfaction in their work when clients are energized and involved. The chance
for a child and family to evolve a new story of who they are is reason enough to
take the risk. Taking it one step further, it is our vision that the community of
helpers "wrapping around" the central connector, the family and its members, will
also evolve a new story—one where competing agendas and philosophies come
together as a vital, effective force in the service of clients' hopes and dreams.
REFERENCES
Anderson, H., & Gehart, D. (Eds.). (2007). Collaborative therapy: Relationships and
conversations that make a difference. New York: Routledge.
Anderson, H., & Gooiishian, H. (1988). Human systems as linguistic systems: Evolving
ideas about the implications for theory and practice. Family Process, 27, 371-393.
Anker, M., Duncan, B., & Sparks, J. (2009) Using client feedback to improve couple
therapy outcomes: A randomized clinical trial in a naturalistic setting. Journal of
Consulting and Clinical Psychology, 77(4), 693-704.
American Psychological Association Presidential Task Force on Evidence-Based Prac-
tice (2006). Evidence-based practice in psychology. American Psychologist, 61,
271-285.
Berg, I. (1994). Family Based Services: A solution-focused approach. New York. W.W.
Norton.
Bohart, A. C , & Tallman, K. (in press). Clients: The neglected common factor in psycho-

12. 74 Sparks and Muro
therapy. In B. L. Duncan, S. D. Miller, B. E. Wampold, & M. A Hubble (Eds.), The
heart and soul of change. Delivering what works (2nd Ed.). Washington, DC:
American Psychological Association Press.
Bohanske, R. T., & Franczak, M. (in press). Transforming public behavioral healthcare:
A case example of consumer directed services, recovery, and the common factors.
In B. L. Duncan, S. D. Miller, B. E. Wampold, & M. A Hubble (Eds.), The heart
and soul of change. Delivering what works {2nd Ed.). Washington, DC: American
Psychological Association Press.
Bordin, E. S. (1979). The generalizability of the psychoanalytic concept of the working
alliance. Psychotherapy, 16, 252-260.
Brown, J., Dreis, S., & Nace, D. K. (1999). What really makes a difference in psycho-
therapy outcome? Why does managed care want to know? In M. A. Hubble, B. L.
Duncan, & S. D. Miller (Eds.), The heart and soul of change: What works in therapy
(pp. 389-406). Washington, DC: American Psychological Association Press.
Burchard, J. D., Bruns, E. J., & Burchard, S. N. (2002). The wraparound process. In
B. Burns & K. Hoagwood (Eds.), Community treatment for youth: Evidence-based
treatment for severe emotional and behavioral disorders. New York: Oxford Uni-
versity Press.
Burchard, J. D., Burchard, S. N., Sewell, R., & VanDenBerg, J. (1993). One kid at a time:
Evaluative case studies and description ofthe Alaska Youth Initiative Demonstra-
tion Project. Washington, DC: Georgetown University Press.
Burns, B. J., & Goldman, S. K. (1999). Promising practices in Wraparound for children
with serious emotional disturbance and their families. Systems of care: Promising
practices in children's mental health, 1998 series. Vol. IV. Washington DC: Cen-
ter for Effective Collaboration and Practice, American Institutes for Research.
Bruns, E. J., Hoagwood, K. E., Rivard, J. C , Wotring, J., Marsenich, L., & Carter, B.
(2008). State implementation for evidence-based practice for youths, part II: Rec-
ommendation for research and policy. Journal ofthe American Academy of Child
& Adolescent Psychiatry, 47(5), 499-504.
De Jong, P., & Berg, I. K. (1998). Interviewing for solutions. Belmont, CA: Brooks/Cole.
de Shazer, S., Berg, I. K., Lipchik, E., Nunnally, E., Molnar, A., Gengerich, W., & Weiner-
Davis, M. (1986). Brief therapy: Eocused solution development. Family Process,
25(2), 207-222.
Duncan, B., Miller, S., & Sparks, J. (2004). The heroic client: A revolutionary way to im-
prove effectiveness through client-directed, outcome-informed therapy. San Eran-
cisco: Jossey-Bass.
Duncan, B. L., Miller, S. D., Sparks, J. A., Claud, D. A., Reynolds, L. R., Brown, J., &
Johnson, L. D. (2003). The Session Rating Scale: Preliminary psychometric prop-
erties of a "working" alliance measure. Journal of Brief Therapy, 5(1), 3-12.
Duncan, B., & Sparks, J. (2007). Heroic clients, heroic agencies: Partners for change.
(Revised E Book), www.talkingcure.com.
Duncan, B., Sparks, J., Miller, S., Bohanske, R., & Claud, D. (2006). Giving youth a voice:
A preliminary study of the reliahility and validity of a brief outcome measure for
children. Journal of Brief Therapy, 3(1), 3-12.
Earmer, E. M. Z., Mustillo, S., Burns, B. J., & Holden, E. W. (2008). Use and predictors
of out-of-home placements within systems of care. Journal of Emotional and Be-
havioral Disorders, 16(1), 5-14.

13. Client-Directed Wraparound 75
Haas, E., Hill, R. D., Lambert, M. J., Morrell, B. (2002). Do early responders to psycho-
therapy maintain treatment gains? Journal of Clinical Psychology, 58, 1157-1172.
Howard, K. I., Moras, K., Brill, P. L., Martinovich, Z., & Lutz, W. (1996). Evaluation of
psychotherapy: Efficacy, effectiveness, and patient Progress. American Psycholo-
gist, 5J, 1059-1064.
Huey, S. J., & Polo, A. J. (2008). Evidence-based psychosocial treatments for ethnic mi-
nority youth. Journal of Clinical Child and Adolescent Psychiatry, 37{ 1 ), 262-301.
Kazdin, A. E. (2000). Developing a research agenda for child and adolescent psychotherapy.
Archives of General Psychiatry, 57, 829-835.
Kutash, K., Duchnowski, A. J., & Friedman, R. M. (2005). The system of care 20 years
later. In M. Epstein, K. Kutash, & A. Duchnowski (Eds.), Outcomes for children
and youth with behavioral and emotional disorders and their families: Programs
and evaluation best practices (2nd ed., pp. 3-22). Austin, TX: PRO-ED.
Knitzer, J. (1982). Unclaimed children: The failure of public responsibility to children
and adolescents in need of mental health services. Washington, DC: Children's
Defense Fund.
Lambert, M. J. (in press). Yes, it is time for clinicians to routinely monitor treatment out-
come. In B. L. Duncan, S. D. Miller, B. E. Wampold, & M. A. Hubble (Eds.), The
heart and soul of change. Delivering what works. Washington, DC: American Psy-
chological Association Press.
Lambert, M. J., Harmon C., Slade K., Whipple J. L., & Hawkins E. J. (2005). Providing
feedback to psychotherapists on their patients' progress: Clinical results and prac-
tice suggestions. Journal of Clinical Psychology: In Session, 67(2), 165-174.
Lambert, M. J., Whipple, J. L., Smart, D. W., Vermeersch, D. A., Nielsen, S. L., & Hawkins,
E. J. (2001 ). The effects of providing therapists with feedback on patient progress during
psychotherapy: Are outcomes enhanced? Psychotherapy Research, 11, 49-68.
Leighton, H. Y. (2002). Problems in behavioral health care: Leap-frogging the status quo.
Administration and Policy in Mental Health, 29, 403^19.
Madsen, W. (2009). Collaborative helping: A practice framework for family-centered
services. Family Process, 48{), 103-116.
Miller, S. D., Duncan, B. L., Brown, J., Sparks, J., & Claud, D. (2003). The outcome rat-
ing scale: A preliminary study ofthe reliability, validity, and feasibility ofa brief
visual analog measure. Journal of Brief Therapy, 2(2), 91-100.
National Advisory Mental Health Council Workgroup on Child and Adolescent Mental
Health Intervention Development and Deployment. (2001). Blueprint for change:
Research on child and adolescent mental health. Washington DC: National Insti-
tute of Mental Health.
New Freedom Commission on Mental Health. (2003). Achieving the promise: Transforming
mental health care in America. Final report. (DHHS Pub. No. SMA-03-3832),
Rockville, MD.
Ogles, M. 0., Carlston, D., Hatfield, D., Melendez, G., Dowell, K., & Fields, S. A. (2006).
The role of fidelity and feedback in the wraparound approach. Journal of Child and
Family Studies, 15, 115-129.
Ogles, B. M., Melendez, G., Davis, D. C , & Lunnen, K. M. (2001). The Ohio scales:
Practical outcome assessment. Journal of Child and Family Studies, 10(2), 199-
212.
Plante, T. G., Andersen, E. N., & Boccaccini, M. T. (1999). Empirically supported

14. 76 Sparks and Muro
treatments and related contemporary changes in psychotherapy practice: What do
clinical ABPPs think? The Clinical Psychologist, 52, 23-31.
Reese, R. J., Usher, E. L., Bowman, D., Norsworthy, L., Halstead, J., Rowlands, S., et al.
(in press). Using client feedback in psychotherapy training: An analysis of its in-
fluence on supervision and counselor self-efficacy. Training and Education in Pro-
fessional Psychology.
Sheehan, A. K., Walrath, C. M., Holden, E. W. (2007). Evidence-based practice use, train-
ing and implementation in the community-based service setting: A survey of chil-
dren's mental health service providers. Journal of Child & Family Studies, 16,
169-182.
Stroul, B. A. (1996). Children's mental health: Creating systems of care in a changing
society. Baltimore: P. H. Brookes Publishers.
VanDenBerg, J. E. (1996). Individualized services and supports through the wraparound
process: Philosophy and procedures. Journal of Child and Family Studies, 5(1),
7-21.
Weisz, J. R., Weiss, B., Han, S. S., Granger, D. A., & Morten, T. (1995). Effects of psy-
chotherapy with children and adolescents revisited: A meta-analysis of treatment
outcome studies. Psychological Bulletin, 117, 450-468.
Walker, J. S., & Bruns, E. J. (2006). Building on practice-based evidence: Using expert
perspectives to define the wraparound process. Psychiatric Services, 57{ 11 ), 1579-
1585.
Wampold, B. E. (2001). The great psychotherapy debate: Models, methods, and findings.
Hillsdale, New Jersey: Lawrence Erlbaum.
White, M., & Epston, D. (1990). Narrative means to therapeutic ends. New York: Norton.