Wraparound: A Different Way of Organizing … · Wraparound: A Different Way of Organizing Assistance to Newcomers - Research Report Prepared for OCASI – October 6, 2009 2 Contents

Wraparound: A Different Way of

Organizing Assistance to Newcomers

Research Report

Prepared for OCASI

October 6, 2009

By Jonquil Eyre Consulting

Email: [email protected]

Wraparound: A Different Way of Organizing Assistance to Newcomers - Research Report

Prepared for OCASI – October 6, 2009 2

Contents

1. Introduction ............................................................................................................. 5

History ....................................................................................................................................................... 6

2. The Wraparound Approach ...................................................................................... 9

Multiple Sectors ....................................................................................................................................... 10

Evidence Based Practice ........................................................................................................................ 11

The Team ................................................................................................................................................ 11

Team Roles ............................................................................................................................................. 12

Strengths Based ...................................................................................................................................... 13

Person Centred ....................................................................................................................................... 14

Culturally Competent ............................................................................................................................... 15

Integration ............................................................................................................................................... 15

Goals and Outcomes .............................................................................................................................. 15

Target Group ........................................................................................................................................... 16

Learning .................................................................................................................................................. 16

Inclusive and Overcomes Isolation ......................................................................................................... 17

Life Domains, .......................................................................................................................................... 17

Unconditional .......................................................................................................................................... 18

Complex Needs ....................................................................................................................................... 19

Creativity and Optimization ..................................................................................................................... 19

Community Based Location .................................................................................................................... 20

Funding ................................................................................................................................................... 20

Monitoring................................................................................................................................................ 20

3. Principles, Benefits and Challenges ...................................................................... 21

Principles ................................................................................................................................................. 21

Benefits ................................................................................................................................................... 24

Challenges .............................................................................................................................................. 26

4. Examples and Case Studies ................................................................................... 31

Wrap-Around ........................................................................................................................................... 31

Circles of Friends .................................................................................................................................... 31

Personal Respect .................................................................................................................................... 33

Refugee Support Program ...................................................................................................................... 34

Achieve Citizenship ................................................................................................................................. 36

Impressive Gains .................................................................................................................................... 38

Integrative Wraparound Process ............................................................................................................ 39

Circle of Support ..................................................................................................................................... 39

Circles Initiative ....................................................................................................................................... 40

Reduce Recidivism ................................................................................................................................. 42

Community Mobilization Teams .............................................................................................................. 43

Understanding Culture ............................................................................................................................ 44



5. Practice in the Ontario Settlement Sector ............................................................. 46

Settlement Workers ................................................................................................................................. 46

Host Program .......................................................................................................................................... 46

Better Access to Services In the Community (BASIC) Program............................................................. 47

Mentoring ................................................................................................................................................ 48

Service Bridging ...................................................................................................................................... 49

Consultation Key to Understanding ........................................................................................................ 49

Bridge Education and Training Programs ............................................................................................... 50

Settlement, Employment and English Language .................................................................................... 51

All Round Support ................................................................................................................................... 52

Learning Circles ...................................................................................................................................... 53

Volunteers ............................................................................................................................................... 53

Recreation and Culture ........................................................................................................................... 53

6. Models for the Sector .............................................................................................. 54

Summary of the Two Models .................................................................................................................. 55

Being Positively Valued ........................................................................................................................... 56

Ontario Newcomer Wraparound Model .................................................................................................. 57

Ontario Newcomer Circle of Friends ....................................................................................................... 61

Organizational Change ........................................................................................................................... 62

Evaluation and Monitoring....................................................................................................................... 65

7. Consultation ............................................................................................................ 66

Select Cases ........................................................................................................................................... 67

Client Knowledge and Readiness ........................................................................................................... 68

Innovative Paradigm Shift ....................................................................................................................... 69

Community Engagement ......................................................................................................................... 70

Empowerment ......................................................................................................................................... 70

Capacity Building .................................................................................................................................... 71

Obstacles ................................................................................................................................................ 71

8. Wraparound in Action in Ontario with Newcomers .............................................. 72

Wraparound with Seniors ........................................................................................................................ 72

Wraparound with Families ....................................................................................................................... 77

9. Training .................................................................................................................... 83

Wraparound Training for Facilitators and Managers .............................................................................. 83

Building and Maintaining Agency Relationships for Successful Client Outcomes. ................................. 85

Cultural Proficiency and Diversity Training ............................................................................................. 86

Interview and Assessment Skills ............................................................................................................. 86

10. References and Further Reading ......................................................................... 87



Acknowledgements

This report is part of a larger OCASI project on training of immigrant and refugee service

workers. Funding for this project has been received from The Newcomer Settlement Program

(NSP), Government of Ontario, Ministry of Citizenship and Immigration, which provides funding

to community-based not-for-profit organizations across Ontario to facilitate the settlement and

integration of newcomers to Ontario. The goal of NSP is to help newcomers succeed and have

the opportunity to contribute to all aspects of life in Ontario. This report has been prepared with

the assistance of Jonquil Eyre.

For further information please contact: Paulina Maciulis, OCASI, 110 Eglinton Avenue West,

Suite 200, Toronto, ON, Canada M4R 1A3 Telephone: 416-322-4950; Fax: 416-322-8084

This report may be reproduced in whole or in part by any charitable and not-for-profit

organization for any non-commercial purpose. Source should be identified.

About OCASI

The Ontario Council of Agencies Serving Immigrants is a province-wide coalition of over 200

immigrant serving agencies. OCASI is a registered charity governed by a volunteer board of

directors. Formed in 1978, OCASI acts as a collective voice for immigrant-serving agencies,

and coordinates responses to shared needs and concerns. The Mission of OCASI is to achieve

equality, access and full participation for immigrants and refugees in every aspect of Canadian

life.

OCASI member organizations provide a wide range of programs and services to facilitate

immigrant settlement and integration. Their services include language training, citizenship

classes, employment counselling, skills training and job placement, individual and family

counselling, interpretation and translation, information and referral, legal assistance, and health

care services. These services support the immediate settlement needs of persons newly

arrived in Canada, as well as long-term settlement and related needs.

OCASI‘s work is informed by the experience of member organizations through ongoing

communication and engagement. As such, OCASI is involved in a wide variety of activities on

behalf of its membership. Grounded in capacity building and information delivery, OCASI‘s

products and services are designed to keep the membership informed, develop their skills,

create networking opportunities and provide members with tools to deliver effective settlement

services to immigrants and refugees in order to support their integration and contribution to

Ontario.



1. Introduction

The overarching goal of this report is to strengthen the successful settlement of newcomers in

Ontario. The purpose is twofold. The first is to assemble information on the approach to services

called ‗wraparound‘. Secondly the report draws on what Ontario settlement organizations are

already doing to assist newcomers to settle successfully, illustrating how aspects of the

wraparound approach are being applied and it proposes two models for how services could be

extended to incorporate more of the benefits of a wraparound approach. This report is intended

to be a resource for immigrant settlement service organizations interested in an alternative

model for providing services to immigrants and refugees with complex needs as well as

background for an OCASI initiated training program for managers and supervisors of settlement

services interested in looking into developing and implementing this alternative model.

Some of the principles of wraparound or wrap-around, are also captured in approaches

variously called ‗joined up‘, ‗integrated case management‘, ‗interdisciplinary‘, ‗circle of support‘

and many others. Central to the approaches is gathering and coordinating services around a

person to help them to succeed. It is an approach used across a number of health and social

service sectors that can be applied to services for newcomers to Ontario.

The report has been organized into ten sections. Following this introduction which includes a

brief history of wraparound, section two presents the main elements of the wraparound

approach that distinguish it and the sectors in which the various approaches are being applied.

Section 3 includes the principles, benefits and challenges of wraparound. The fourth section

consists of many case studies and examples. They illustrate the application in different sectors

and different countries. Section five provides a sample of Ontario settlement services that

illustrate elements of the wraparound approach. Section six presents two models for how

wraparound could be applied to assist newcomers by linking settlement priorities of newcomers

to the anticipated outcomes of the wraparound process. This is an innovative approach for an

already busy sector, so the section includes some of the steps that are required for effective

organizational change. Section seven reports on the findings from consultation in the sector.

Section eight provides two detailed Ontario examples of the application of wraparound with

immigrants. Section nine provides an overview of training needs. The final section cites

references and further reading.

Language

Finding language that is useful across sectors and countries presents a challenge. Wraparound

is a dynamic approach that is being applied in exceptional needs, clinical and community

sectors in the areas of mental health, disability, youth at risk and settlement. Although service

providers have very deliberately chosen other terms, in this report the term ‗wraparound

approach‘ has been used unless there is a specific reference to a service or model with a

different name. Similarly with other terms such as asylum seekers, language more commonly

used in Ontario has been chosen except where it applies to a particular case example. In this

report the term ―newcomer‖ has been used to be inclusive and generally describe a foreign-born

person living in Canada, regardless of their immigration status. Red Cross Australia uses the



inclusive language ―vulnerable by nature of migration‖ to describe the people they work with in

this area.1

For those models that have a client as the focus, the term ‗person at the centre‘ has been used.

This is a bit awkward but selected because the term conjures the appropriate tone and avoids a

sense of the person being defined by their receipt or consumption of services, which may be

connoted by terms such as client or consumer. The people who come together around the

person are referred to as ‗the team‘. Where references apply to one sector, e.g. ‗youth‘, they

have been generalized to refer to ‗people‘, to make the application more inclusive.

History

The idea of supportive networks is not new, many cultures have for centuries gathered around

vulnerable people to assist them. It is a humane and human response for intentional

communities to gather around a person who is facing a particular challenge to provide support.

The wraparound process or circle of support is an evolving model for services which is often

applied when other service models have not been effective. The collaborative and

comprehensive nature of the approach often resonates with individuals, families and service

providers. As cited later, critics point out that there is relatively little rigorous research

demonstrating the efficacy of the wraparound approach compared with other approaches.

The wraparound approach it is more frequently applied in fields other than settlement. In

Scandinavia, New Zealand, and the US for example, the approach is more common in work with

children, youth and families, particularly in the areas of mental health, autism and juvenile

justice.

Writers on wraparound credit the roots of the process in North America to the work of John

Brown, a Canadian who, in the Brownsdale programs, developed some of the first small group

homes as an alternative to large facilities or institutions for youth with emotional problems.2 The

programs focused on providing needs-based, individualized services that were unconditional.

John D. Burchard, who is also thought to be a pioneer of the wraparound process for children

experiencing serious mental health problems, was one of the first researchers to take an

interest in the model. Burchard advocated practicing by the philosophy that professionals do not

have the answers, families do, and that the professional‘s job is to do ―whatever it takes‖ to

ensure that children are supported to live successfully at home and in their communities.3

1 Interview with Bernie Goodwin, Manager, International Tracing, Refugee and Asylum Seeker Services,

Australian Red Cross, Adelaide.

2 Burns, B and Goldman, S.K., Volume IV, Promising Practices in Wraparound for Children with Serious

Emotional Disturbance and Their Families,

1998http://cecp.air.org/promisingpractices/1998monographs/vol4.pdf

3 Bruns, E. J., & Walker, J. S. (Eds.), The Resource Guide to Wraparound. Portland, OR: National

Wraparound Initiative, Research and Training Center for Family Support and Children‘s Mental Health.



Another proponent of the approach is John VanDenBerg, from Colorado in the U.S., who is

known for his work with indigenous people in the U.S. and Canada, as well as his work with faith

communities. VanDenBerg‘s system of care also focussed on children and families. He

proposed that training was important for anyone applying the wraparound process. The

philosophy and practice model is now being used in other areas including youth with mental

health needs, youth in juvenile justice, transition-age youth, adult offenders, elders and many

other types of individuals with complex needs.4

The related idea of a circle of support is attributed to Canada and has been applied, for

example, by Australian and British organizations which focus on inclusive communities and

person centred planning including for people with disabilities, older adults and people dealing

with mental health issues.5 The purpose statement of one wraparound initiative captures the

objective of the approach for the person at the centre: “To achieve the co-operation of

individuals, their families and service providers to develop an integrated response to support

their citizenship.”6

In his work on Asset Based Community Development (ABCD) John McKnight describes the

concept of the community as a collection of community assets. Community based wrap around

models build on this approach of discovering and mobilizing the resources that are already

present in a person‘s community. Community assets are resources that become valuable when

they are brought together and made productive. The ABCD approach, focuses on being asset

based, internally focused, and relationship driven. ―Strength comes from three interconnected

activities: discovering local assets, connecting these assets to work together, and then creating

opportunities for these assets to be productive and powerful together.‖7

A US survey conducted in 2007, found that 91 percent of US states had some kind of

wraparound process. This is attributed to the approach being a popular alternative to ―traditional

service delivery methods that are perceived as uncoordinated, inflexible, professionally driven,

and deficit based.‖8 As illustrated in section five, the term wraparound is also being used in

http://www.rtc.pdx.edu/NWI-book/Chapters/COMPLETE-RG-BOOK.pdf p.3. Burchard was from Ohio, US (b 1936, d 2004).

4 One valuable resource for this report has been Bruns, E. J., & Walker, J. S. (Eds.), The Resource Guide

to Wraparound. Portland, OR: National Wraparound Initiative, Research and Training Center for Family Support and Children‘s Mental Health. http://www.rtc.pdx.edu/NWI-book/Chapters/COMPLETE-RG-BOOK.pdf (A 700 page compilation of related U.S. articles.) p.3.

5 Circles Network, Building Inclusive Communities (UK) http://www.circlesnetwork.org.uk/default.htm

6 Exceptional Needs Unit, Management Assessment Panel Information Package p.2. A South Australian

service for people with severe behaviour disorders. p.10.

7 Green, Mike, Building the Road as You Walk It: Community Partnerships that Work

http://www.shambhalainstitute.org/Fieldnotes/Issue11/communities.php

8 Bruns, E. (2008). The evidence base and wraparound. In E. J. Bruns & J. S. Walker (Eds.), The

Resource Guide to Wraparound. Op Cit Chapter 3.2 p.2.

http://www.rtc.pdx.edu/NWI-book/Chapters/COMPLETE-RG-BOOK.pdf





settlement services, although the same term is used to refer to a variety of approaches. One US

organization, for example, spans more than one sector in its application of wraparound.

Wraparound is applied to care for refugee children with mental health issues.9 The program

objective is to ‗enhance the quality of life for refugee children, adults and families by providing

culturally and linguistically appropriate, comprehensive mental health services for those

children, adults, and families suffering from trauma-related distress or serious emotional

disorders exacerbated by their refugee experience‘. Members of multidisciplinary teams might

include psychotherapists, and art, occupational and dance therapists.

Section two draws together and describes the elements of wraparound and complementary

approaches.

9 International Family Adolescent and Child Enhancement Services, Heartland Health Outreach cited on

Bridging Refugee Youth and Children‘s Services, Washington D.C. http://www.brycs.org/brycs_featuresept2005.htm



2. The Wraparound Approach

The term wraparound appears to have been first used in the 1980s. It refers to a facilitated

team based approach in which the person needing assistance is supported by a carefully

identified circle of people who can help and are committed to doing so. The term is often used to

refer to a flexible and comprehensive approach to service delivery and in some sectors to

keeping a person in the community and avoiding institutionalization. The term is also applied to

mean coordinated, multidisciplinary or multi sectoral services. In all cases, although sometimes

called a wraparound service, wraparound refers to the process or approach not to the actual

delivery of a direct service. If one considers the continuum of settlement ranging from helping

individuals or families to supporting government policy development, wraparound is at the

individual end of the continuum.

In fact individualization is central to wraparound. The focus is meeting the needs of the

individual and family so that their life is improved. Others describe the wraparound process as

doing ‗whatever it takes‘ to ensure the person is supported successfully. There are a number of

elements that are common to many applications of this approach.

The wraparound process is a collaborative, team-based approach to service and support

planning in which teams create plans to meet the needs and improve the lives of people with

complex needs and their families.

In the model proposed by Bruns and VanDenBerg wraparound team members are identified by

the person at the centre or a close family member. Other team members are likely to be family

and community members, mental health professionals, educators, and others. They meet

regularly as a team with the person at the centre to design, implement and monitor a plan to

meet the unique needs of the person. The team:

Creates, implements, and monitors an individualized plan using a collaborative process

driven by the perspective of the person or family

Develops a plan that includes a mix of professional supports, natural supports, and

community members

Bases the plan on the strengths and culture of the person, and

Ensures that the process is driven by the needs of the person rather than by the services

that are available or reimbursable.10

Members of the team may be volunteers or professionals, their relationships with the person

may be formal or informal. All have formed a team with the person at the centre to contribute to

that person achieving successful outcomes. (Figure 1) However although an apparently simple

10 VanDenBerg, John, Eric Bruns, & John Burchard in History of the Wraparound Process in Bruns, E. J.,

& Walker, J. S. (Eds.), The Resource Guide to Wraparound. Op Cit.



E.g.

Mentor

E.g.

Settlement

Worker

E.g.

Friend

E.g.

Parent

E.g.

Host

Family

E.g.

Employment

counsellor

E.g.

Brother

E.g.

Social

Worker

E.g.

Teacher

E.g.

Neighbour

Person at

the

Centre

Figure 1

concept, there are a number of multi faceted and sometimes complicated principles and

practices required to implement and sustain a multidisciplinary team of this kind.

In the Circle of Friends model, the team meets and works on behalf of and for the well being of

one or more refugees and their families. Although their support of the refugee is with that

person‘s consent, they do not include the person in their meetings and instead have one person

as the key liaison with them, in some settings referred to as a ‗befriender‘.

Multiple Sectors

The apparent community

based comprehensive

approach has intuitive

appeal and has grown in a

variety of sectors. A US

national survey found that

the wraparound approach

was more often applied to

working with children,

youth and families, and that

families were significant

beneficiaries of the team

based approach.11 The

sectors included education,

child welfare, juvenile

justice, health, including

mental health, substance

abuse and developmental

disability services. The

survey showed that the

degree of fidelity to

wraparound principles varied greatly. Respondents to the US survey noted the difficulty of

maintaining wraparound principles such as team-based coordination in the face of siloed

systems, staff turnover and limited and increasingly inflexible resources. Although the US

survey did not find the approach was generally applied in services to immigrants and refugees,

the term is used in the settlement sector in the US as well as Australia and the United Kingdom.

11 Bruns, E. J., Sather, A., & Stambaugh, L. (2008). National trends in implementing wraparound: Results

from the state wraparound survey, 2007. In E. J. Bruns & J. S. Walker (Eds.), The Resource Guide to Wraparound. Op Cit. Chapter 3.4 P.4



Neighbours,

friends,

people with

shared

interests,

contacts &

professionals

Close

family and

friends

Person at

the centre

Diagram that helps to explain to the person at the centre

how to map the people they are linked to. There could be

additional circles to reach additional contacts.

Figure 2

Evidence Based Practice

Answering the question: ‗does wraparound work?‘ is challenging because although the term

has been used for over 20 years it remains an evolving approach applied in a variety of social

service contexts.

The question of evidence of success also raises the question of what could work in an ideal

setting and what does work in practice. For example in so many social services rather than

working in ideal circumstances, a person receiving support may be working with professionals

who have large case loads, uneven or lack of training, limited availability and quality of

supervision, deal with staff turnover and manage with restricted resources. Volunteers may be

busy, working full time and have multiple responsibilities. All of these circumstances erode how

well a person is assisted and may be quite different from the outcomes under more ideal

conditions.

Even the many success stories reveal that wraparound principles are much more difficult to

apply in real world practice than they are to embrace in theory, and that fidelity to the principles

requires significant effort, patience and resources.

The Team

Consistent with all wraparound

and related approaches is the

importance of a team. At its most

basic, the role of the team is to

provide support for a person at

the centre who will often lack

natural supports.

In the US model, the people in

the team, often between three

and seven people, are invited

and become involved at the

invitation of the person at the

centre. A commonly used device

used at the outset of this team

building approach is to ask the

person at the centre to identify

the people they know using

concentric circles to prompt

consideration of all the people

they know very well, less well,

etc. (Figure 2).

The job of approaching potential team members is usually undertaken by someone other than

the person at the centre so that declining to be involved is not seen as an expression of



rejection. Involvement is of course voluntary. As pointed out later, the absence of people who

are key players in a person‘s life, as a result of not being invited to participate or declining to

participate, can create awkwardness when planning goals with the person.

Team members typically have both formal and informal relationships with the person at the

centre. Some team members will be professionals who link the person to particular services or

provide services directly to the person. However, as important as professionals are, people with

whom the person has informal relationships including daily living experiences such as

friendship, education or leisure may be equally or more important.

Team members who are assumed to provide ‗natural support‘ to a person include the person‘s

family and network of interpersonal relationships, which includes friends, extended family,

neighbours, co-workers and so on. Natural support is also available through community

institutions, organizations and associations such as faith groups, clubs, libraries, or sports

leagues as well as professionals and paraprofessionals who interact with the person or family.

For many newcomers their circles of contact may be small but application of the concentric

circle exercise may uncover a number of connections. An effective team will by its nature blend

different mandates, perspectives and resources.

Although there are a number of professional services that are provided around the clock, one

point of weakness of professional services is the fact that work-week schedules, i.e. 9-5 Monday

- Friday do not take into account the times that crises most frequently happen and when most

people have their greatest times of need. In fact if an average day is judged to be about 16

hours in length, most professional services are accessible only 36% of the time. Typically

people at the centre of a wraparound approach or a circle of support lack the fulsome life of

activities, friends, mobility and sense of well being that ensures they will be happily engaged

during the work week let alone ‗after hours‘.

Although all members of the team participate voluntarily, some will be paid professionals

participating as part of their work commitments and some will be people giving their time freely

outside any work commitments. This diversity of team member relationships can add tension in

a number of ways to the effectiveness of teams. Sometimes this is because professionals have

difficulty accepting that they are ‗one among equals‘. Common challenges arising out of the

professional – community member mix are:

Deferring to professionals

Diminishing the value of non-professionals

Use of technical language that excludes some team members.

Team Roles

The involvement of people with different skills and experience and the varied ways in which they

connect to the person at the centre, accentuates the many ways people can make a contribution



to the person‘s achievements. Another advantage of having a team of members with diverse

skills is the possibility for distribution of helpful roles and shared responsibility.

One element common to teams is the role to facilitate team members coming together and

providing a constructive role in meetings or team gatherings. The facilitator may be a participant

representing a lead agency or could be a friend or family member who is helping the person to

implement their plan.

The facilitator coordinates bringing the team together when it is needed or according to an

agreed-upon schedule. In applications of wraparound with children and young families the more

informal term ‗family partner‘ is sometimes used, expressing the key role this person has in

supporting the family. Some teams assume joint facilitation of a family partner and a facilitator,

which helps the team when one of the two people is unable to participate.

By speaking with the person at the centre before the meeting or get together the facilitator will

also know what information needs to be shared or decisions need to be made. One of their roles

will be to bring facilitation skills to ensure that discussion is collaborative and fruitful, that

decisions are made and that the desired tone of the discussion is appropriate for the occasion.

The facilitator role can be time consuming especially in the start up phase which may take some

months. If a facilitator from an organization is helping with several teams the issue of managing

a ‗case load‘ arises, because time will need to be factored in to consult with the person at the

centre, invite and engage team members, gather information for and plan meetings, as well as

develop and implement the plan with the team.

Another important role on the team, is that of note taker who takes brief notes to ensure there is

a record of decisions. The note taker ensures that everyone who is at the get-together or who

missed the meeting gets a copy. Good record keeping will also help the team see the purpose

and progress of the team. Another useful role for a team member is responsibility for ensuring

that the meetings are enjoyable. Finding community settings for getting together and including

refreshments add to the feeling of informality.

Strengths Based

A focus of the wraparound approach is building on the strengths of the person at the centre.

This philosophy is a distinct alternative to any model that focuses on the person‘s deficits, their

neediness and what they cannot do. Wraparound focuses on building assets rather than trying

to eliminate deficits. The approach focuses on what can be done and accentuates the talents of

the person at the centre. The wraparound approach strives to validate, build on, and expand a

person‘s assets (such as positive self-regard, self-efficacy, hope, optimism and clarity of values,

purpose and identity), their interpersonal assets (such as social competence and social

connectedness), and their expertise, skill, and knowledge.12

12 Bruns et al in The Guide to the Wraparound Process. Op Cit. Section 2.1 p.8



In addition to the strengths of the person at the centre, each team member‘s strengths are

identified so that their experience, capacities, interests and resources can be brought to the

team. By spending time in meetings focussed on strengths, each team member is better able to

build respect for the contributions of others. This might be especially important for professionals

who are focussed on their own area of special knowledge. Every team get-together or meeting

might begin with what has been achieved and the person‘s successes, even if they are small

ones.

To clarify what is meant and to provide a tool for reflection in relation to strengths based

practice, Franz uses the acronym ADMIRE.13

A – attitude about and conviction that the person‘s strengths will enable them to make the

desired changes.

D – discovery and willingness to search for a person‘s strengths

M – mirroring to reflect back observed strengths to ensure accuracy and mutual

understanding

I – intervention – the offering of competency building services

R – recording or documenting observations, assessments, interventions and impacts

E – evaluation to ensure that the interventions are actually making a difference in helping

the person achieve their hoped for goals

Person Centred

Terms like ‗client centred‘ take on a new meaning in the wraparound approach when the person

at the centre is part of all decisions. Where the approach is utilized with people who are unable

to advocate for themselves, for example a person with an intellectual disability or a person in

custody, an advocate such as a family member or friend may undertake this role. In either case

the focus should be on empowering the person at the centre.

The model developed by the Management Assessment Panel (MAP) usually with people facing

a couple of challenges including intellectual disability, emphasises that the wraparound

approach must transcend organisational boundaries.14 This includes:

Working holistically with individuals, families and service providers within the context of a

mutually determined and monitored management plan

13 Franz, John, Getting Practical about Being Strength based in The Guide to the Wraparound Process

Op Cit. Chapter 2.2.

14 Integrated Service Model and Principles p.5 and Exceptional Needs Unit, Management Assessment

Panel Information Package Op Cit. p.4



Identifying not only individual needs but also structural and systemic barriers to

participation in society for persons with very complex needs and behaviour, and

Providing a system for advocacy.

Wraparound is based on the belief that people have better lives when their biggest needs are

met, when they have a say in their own lives through self-determination, when they build skills to

manage the challenges of the future, and when they are surrounded with support from others.15

Decisions are individualized and uniquely tailored to suit the person so that they capture the

person‘s perspective about how things are for them, how things should be, and what is needed

to achieve the latter. Bruns points out that practical experience with wraparound has shown that

when people are able to fully express their perspectives, it becomes clear that only part of the

help and support they need is available through existing formal services in the traditional service

environment and that the informal environment can offer significant support.

Culturally Competent

Culture and identity often shape what people do and how they do it. Family relationships with

people and organizations with whom they share a cultural identity can sometimes be essential

sources of support and resources. Including others from the same ethno cultural community as

the newcomer may also help other team members see the need to respect diversity in

expression, opinion, and preference, as they work together. Including other members of their

community may not be the preferred approach for some newcomers.16

Integration

Wraparound calls for more coordination than is usually practiced by service providers.

Collaboration may be defined as when agencies are familiar with each other‘s missions and

roles, key staff work with each other but retain single system decision making power and

planning. On the other hand, integration, the operating approach needed in wraparound,

includes shared decision making in a team that includes the person in the driver‘s seat,

producing a single plan that meets all system mandates and that is owned by the entire team.17

Goals and Outcomes

Setting goals directed by what the person at the centre wants is a fundamental part of the

wraparound process. The focus should include the development of clear short and longer term

goals and objectives.

15 VanDenBerg, John in Resource Guide for Wraparound, Op Cit. Chapter 1.4 pp 6-7

16 Bruns, Eric and Walker, Janet, in Resource Guide for Wraparound Ibid. Chapter 2.1 p.7

17 VanDenBerg and Rast (2006) cited in Resource Guide for Wraparound Ibid. Chapter 1.4 p.4



Based on the goals, members of the team work together to develop the objectives and an

individualized plan of action with the person. The role of the team is to move towards the

objectives. Both the goals and the plan should be flexible and regularly reviewed and revised as

needed. A useful technique in developing goals is to use a mapping exercise to determine the

needs of the person. Progress and positive change should be measured based on the

expectations of the person at the centre, with the review process including discussion about

changes and progress that has been made.

Having developed a plan, all team members are accountable for reaching the agreed-upon

goals. By tracking progress the individual has a chance to reflect on how things are changing

and the team members maintain hope and purpose.

Target Group

Typically the target group of people for whom wraparound is thought to be useful include:

People who fall into gaps in service eligibility

People who have no access to services due to lack of appropriate options or a chronic

semi-crisis existence

People who have dual or multiple issues with specialist needs that span at least two or

three service sectors

People who exhibit challenging behaviours that have not responded to other attempts to

assist them

People for whom longer term planning would be useful including life-long planning

People whose behaviour or lifestyle poses a severe threat to themselves and/or the

community

People for whom the option is a last resort to achieve positive outcomes after all options

have been exhausted

People whose needs exceed the capacity of traditional organizations to adequately

address or meet needs

People who repeatedly refuse services resulting in services being reluctant to engage.18

Learning

Despite some people facing complex issues and their plans being long term, one of the

elements of wraparound is the idea that the person at the centre will build capabilities so that

18 Adapted from Exceptional Needs Unit, Management Assessment Panel Information Package Op Cit.

pp.5-6.



members of their team will gradually be able to withdraw. One of the roles of the team members

is to provide informal training which might be by modelling how to do things. Typically a

wraparound approach might support a person for a number of years. When it is felt to no longer

be needed, gradual withdrawal of team support is best accompanied by following up with the

person to ensure that they are maintaining the goals that have been achieved.

Inclusive and Overcomes Isolation

Distinct about the wraparound approach is its attempt to look at the person holistically. The

approach brings together the individual, people in their circle and service providers within the

context of a mutually determined and

monitored plan. The focus is not only

the individual‘s needs but also the

structural and systemic barriers to

their participation in society. Because

the team working with an individual is

multidisciplinary it also may have

some capacity to provide system

advocacy to reduce barriers to

participation not only for the particular

person at the centre but for others

who are vulnerable or excluded.

Often a person who can benefit from

a wraparound approach has very

limited connections or has even lost

their connections to community

including neighbours and friends.

Arising from the mix of team members

in the wraparound approach, a whole

new array of informal resources may become available to the person.

Life Domains, Community Indicators19 and Social Determinants of Health20

There are a number of useful ways to classify the components of daily living that are examined

when a plan is being developed with a person. The classification systems provide a useful

framework for exploring with a person how they are feeling about different aspects of their life.

19 Canadian Policy Research Networks and the Ontario Trillium Founation, Indicators of Healthy and

Vibrant Communities Roundtable Primer http://www.cprn.org/doc.cfm?doc=1918&l=en and Summary Report, by Sylvie Cantin, Romilly Rogers, Samantha Burdett. Ottawa, June 2008.

http://atwork.settlement.org/sys/atwork_offsite_frame.asp?anno_id=2007440

20 World Health Organization, Closing the gap in a generation: health equity through action on the social

determinants of health: final report of the commission on social determinants of health. August 2008.

Life Domains

Community access Behavioural

Culture / Identity Cultural

Day Activities / Employment Educational

Education Emotional

Family involvement Family

Finances Financial

Legal Issues Health

Leisure / Recreation Independence

Mental health Legal

Physical health Living Situation

Residence Safety

Spiritual / Religious

Connections Social

Recreational

Others

Source: MAP Source: VanDenBerg

http://www.cprn.org/doc.cfm?doc=1918&l=en




One frequently used system is life domains. A comprehensive plan would look at all the

domains and make a plan to address concerns. The box on page 17 provides two lists of life

domains from different sources.

The frameworks being used to develop indicators for community well being are also useful

criteria to assess a person‘s situation. Indicators are measurable variables or characteristics

that provide an indication of a condition or direction. There are numerous sources of indicators.

The Federation of Canadian Municipalities (FCM), for example, uses the following 10 indicators:

Indicators for Community Well being

Demographic and background information

Affordable, appropriate housing

Civic engagement

Community and social infrastructure

Education

Employment and local economy

Natural environment

Personal and community health

Personal financial security

Personal safety

The Social Determinants of Health are also a commonly used classification system to look at

aspects of a person‘s social and economic conditions. They are particularly associated with

health and illustrate that health is interrelated with all aspects of a person‘s life. The Social

Determinants of Health include:

Social Determinants of Health

Income

Social status

Social support networks

Education

Literacy (including health literacy)

Biology and genetic endowment

Culture

Employment and working conditions

Social environments

Physical environments

Personal health practices and coping skills

Healthy child development

Health services

Gender

Unconditional

Acting unconditionally is another aspect of the wraparound approach. It means that the team

does not give up if a person‘s behaviour is not the desired one. Instead of seeing adverse

situations as failure, they should prompt a review of the wraparound plan. Associated with the

notion of unconditional care is the idea of persistence, ‗no eject, no reject‘. This attribute like

many others results in wraparound offering either a complement or an alternative to traditional

services that have not effectively addressed the person‘s needs.



Complex Needs

There are several drivers of the wraparound approach including searching for an approach that

will work when others have not. One of the drivers is the huge cost of resolving crises or helping

a person recover from crisis. Often the person at the centre will not be in obvious crisis but may

have suffered from sustained social and emotional deprivation arising from dislocation, illness,

trauma or isolation. Sometimes the complexity of a person‘s needs arises out of the

circumstances of others. For example, in the disability sector one reason to develop more

inclusive and collaborative practices is because ageing parents may not be able to look after

their adult offspring with disabilities or are concerned about what will happen after their death.

‗Wraparound is an exceptional approach for an exceptional situation.‘

Creativity and Optimization

Characteristic of the wraparound approach is the need for participants, both the person at the

centre and the multidisciplinary team members to make a commitment to taking a different and

non - traditional approach. The wraparound approach requires a suspension of the judgement

that assumes that a single professional view is the basis of the plan of action. The wraparound

approach requires taking the person‘s wishes into account in all decisions. It also requires

exchange and reaching agreement between multidisciplinary team members who may see a

variety of ways to reach an improved situation or even a solution.

A focus of wraparound is responding to the needs of the person not the needs of the

organization.21 This comprehensive method may be contrary to the trend in many services to

become specialized. Some will reject a wraparound approach claiming that it will take

unnecessary time to support it. Often integrated approaches are time consuming. However the

wraparound approach is undertaken because it is thought to be the approach that is most likely

to succeed. An additional strength of the approach is the shared responsibility that can optimize

the contribution of each of the players, reduce duplication and enable any member of the team

to build on the contribution of others.

Wraparound experience has found that individuals and families often feel considerably better

when they are in charge of their lives and not dependent on the system for services. When

traditional services are used and there are ‗failures‘ there is a tendency to blame the services or

the client, neither of which is likely to be constructive in developing a plan that will work better.

There are many variations on wraparound that offer creative alternatives. Edgar Cahn describes

a resiliency that comes from ‗co-production‘ in which the person at the centre assumes the role

of assisting others as well as being a beneficiary of assistance.22 One family commenting on

wraparound observed that one strength of the approach is that it ensures the person at the

centre is not described only by a single issue or by a diagnosis.

21 Community Living Project Inc SA. Objective 2. http://www.clp-sa.org.au/CLP/objectiv.htm

22 Cited in The Resource Guide to Wraparound Op Cit. Chapter 2.4 p.5

http://www.clp-sa.org.au/CLP/objectiv.htm



Community Based Location

Professionals may not have the answer to a person‘s issues, or they may have only a part of it.

In keeping with looking beyond formal and professional responses, some proponents of the

wraparound or circle of support approach make a point of team gatherings not happening in

professional offices but in more normative settings such as a person‘s home, a cafe or pub. An

illustration of the usefulness of this practice is the opportunity to create a more real-life situation

in which appropriate behaviours can be modelled to other members of the team. For example if

one of the goals is to befriend a person by inviting them for a meal or encouraging them to get

into their community despite their lack of language or their anxiety about going to new places,

meeting in a community space such as a cafe with other team members provides a supported

illustration of how it can be done.

Funding

Many agencies will be participating in the team or circle as part of their professional mandate,

which may result in some resources to assist the process. However, more time and a new

approach may be required. Dependency on the existing service system for resources may delay

finding constructive solutions. It may limit the ability of team members to find options that will

work because their thinking is limited to what professional services and resources exist. In

settings where only professional and funded services are being considered, thought should also

be given to informal and unfunded activities.

Monitoring

Monitoring and evaluation are part of the process but traditional evaluation tools tend to be

antithetical to the commitment to build on strengths, focus on the positive and avoid any sense

of ‗failure‘. In addition, wraparound is by definition individually based so goals are person

specific and the impact is also individual. Monitoring results requires attention to the person‘s

history, their goals and the broader context of their life.



3. Principles, Benefits and Challenges

Principles

Consistently applying the principles of the approach is seen as essential for success of

wraparound and other similar models such as the Circles Initiative.23 With the expansion of the

application of wraparound and similar approaches there is concern about the variations of the

model that are evolving at a grassroots level, but may still be called the same thing. Some of

this deviation arises from the difficulty of consistently applying some of the principles. Some

advocates of wraparound argue for the need for a tool to measure fidelity of a service approach

to the core principles of wraparound. For this purpose a Wraparound Fidelity Index is proposed.

Practical considerations when setting up a circle or wraparound approach include:

Consulting with and raising

awareness with all the

members of the team about the

purpose and reasons for

starting the activity

Focussing on only one person

or their family at the centre

Providing a safe and non-

judgmental environment for

people to gather and speak

with each other. 24

Various wraparound applications have

developed sets of principles and what

each means to guide its

implementation.

23 Interview with Jayne Barrett, Manager of the Circles Initiative for Community Living Project Inc. in South

Australia in August 2008. More about the Circles Initiative can be found on the website of the Community

Living Project Inc., www.clp-sa.org.au . A DVD, Circles of Support, showing the circles of friends at work

can be purchased from The Education Shop - http://www.metromagazine.com.au/shop/default.asp

24 Adapted from practical considerations for setting up a circle see

http://www.circlesnetwork.org.uk/making_connections.htm

The Circles Initiative values include:

Ensure that all actions and decisions are those

chosen by the person at the centre, i.e. person

centred

Encourage independence and responsibility by the

person and their circle of friends. In difficult times the

facilitator may become the case manager but their

role is to activate the circle of friends to draw on the

appropriate services

Arrange for gatherings of the circle of friends to be

―inviting friends over‖, they should happen in

‗ordinary‘ places e.g. a pub, coffee shop, a person‘s

home, a park, not in an office or institution

Use commonly used language, not the language of

professional service providers.

http://www.clp-sa.org.au/



The U.S. National Wraparound Initiative (NWI) has standardized ten guiding principles focussed

on its work with vulnerable children.

The U.S. National Wraparound Initiative’s (NWI) ten guiding principles25

Principle Which means:

1 Family Voice

and Choice

The family is an integral part of the team and must have ownership of the plan. No

planning sessions occur without the presence of the family.

2 Team Based The team consists of the family and the three to seven people who care and know

the child and family best. The team is selected by the family and typically has no

more than half professionals.

3 Natural

Supports

The process focuses on strengthening the natural family, extended family and

social supports for the child by involving them in the planning and implementation

process.

4 Collaboration Services systems and schools agree to the principle of Collaboration, working

together and moving to Integration where all parties work in a team with the family

to design and implement one plan.

5 Community

Based

When residential treatment or hospitalization is accessed, these services are

used as stabilization resources and not as placements that operate outside of the

plan produced by the child and family team.

6 Culturally

Competent

Services and supports must be tailored to the unique culture of the child and

family. Family culture refers to family race and ethnicity as well as family habits,

preferences, beliefs, language, rituals, and dress, based on ―one family at a time‖.

7 Individualized The individualized plan is child-centered and family-focused with maximum family

involvement, with variation depending on the needs of the child and family.

8 Strengths

Based

The plan is developed by a family centered team, is individualized based on the

strengths and culture of the child and their family, and is needs rather than

services driven.

9 Persistence Persistence in delivery of services and supports is required rather than when

things do not go well, the child and family are ―kicked out‖. Instead the

individualized services and supports are changed.

10 Outcome

Based

Outcome measures are identified and individual wraparound plans are frequently

evaluated.

25 The U.S. National Wraparound Initiative is led by Eric Bruns, Ph.D., Janet Walker, Ph.D., Trina Osher,

Jim Rast, Ph.D., and others. The principles are listed in VanDenBerg, John, Trina Osher and Ira Lourie, Child, Adolescent, and Family Issues: Team-Based Planning and the Wraparound Process, National Research and Training Center on Psychiatric Disability, University of Illinois at Chicago.



The Youth Services Bureau of Ottawa focuses on youth aged 12 and older with difficulties that

affect their physical or emotional well-being and development, to support youth in making

positive health and lifestyle decisions. The Youth Services Bureau describes eleven principles

and critical elements that must be present for the Ottawa Carlton Wraparound. 26

The Ottawa Carlton Wraparound Process has Eleven Principles

Principle Which means:

1 Community

Ownership

Owned by and reflective of the broader community which will include both

formal and informal services, religious and spiritual groups, diverse cultural

groups, business association, service clubs, neighbourhoods, churches,

municipal politicians, law enforcement, advocates, and parents.

2 Community-

based

Based in the community. Services and supports provided to each child and

their family will be made available in their local community. When residential

treatment or hospitalization is accessed, these service modalities will be used

as resources and not just as placements that operate outside of the plan

produced by the child and family team.

3 Individualized

Plans

Each plan will be individualized to a particular child and family and will

encompass at least two or more aspects of their lives in the areas of home,

school, work, and community.

4 Strength based The plan will be developed based on the strengths of the child and family (not

their deficits) and the resources available through their individual child and

family team. No interventions will be allowed in the plan that do not have

matching child, family, and community strengths.

5 Family Access,

Voice and

Ownership

Any child and their family will have the opportunity (subject to eligibility criteria)

to access services through the community effort regardless of their personal

circumstances. In addition, each child and their family who are accepted into

Wraparound will be involved in all aspects of the development of their plan.

6 Collaboration Requires system collaboration. It will be implemented through multiple

involvement and resourcing by both formal and informal systems so that

planning, services, and supports cut across traditional system boundaries.

7 Informal

Resources or

Community

Supports

It is important that the services and supports written into the child and family's

plan will be available on a continuous basis in the community over time and for

as long as is needed by the child and family. The use of informal services will

be maximized as much as possible so that the plan is sustainable, especially

when formal services are no longer available to or needed by the child and

family.

26 Youth Services Bureau of Ottawa

http://www.ysb.on.ca/english/index.php?option=com_content&task=view&id=299




8 Access to

Flexible ('flex')

Funding

Each child and family team will have access to limited approved funding

(money that is not attached to a formal or categorical service) in order to

promote individualization in the wraparound plan for the child and family.

9 Unconditional

Support

The child and family team will be committed to unconditional support. When

things do not go well, the child and family are not rejected, but rather, the

individualized services and supports will be changed.

10 Measurable

Outcomes Outcomes must be observable and measured.

11 Inclusiveness The initiative to implement the Wraparound Process will be inclusive. Any

sector, group or part of the local community will be welcome to play a role in

this community effort.

Benefits

There are many benefits of the wraparound approach. One of the factors that has influenced the

growth of wraparound is the disadvantages of working in silos which has arisen from separately

developed models of care from justice, education, settlement, mental health, developmental

disability, public health, addiction, housing, legal and other services. Even though individuals

and families do not come in neat packages that fit the silos, these systems often do not interact

at the policy, agency, and practice levels. As a result, many people receive multiple plans with

sometimes competing instructions from different systems. When these disjointed plans fail, the

people are often blamed and labelled for example: ‗noncompliant‘ with services‘.27 Wraparound

proposes an integrated alternative.

Benefits of the wraparound approach include the following.

There is potential to improve a difficult situation

The person at the centre has a sense of controlling their own situation, value is placed

on an individual‘s choices which provides an opportunity for empowerment

The person receives multidisciplinary support to emerge from a crisis or overcome a

particular barrier faced by the individual, the family or a family member

There is potential to coordinate varied supports including education, employment,

recreation, health, housing, community services

Formal (services) and informal (volunteers, neighbours etc) work together toward a

common end

27 VanDenBerg, John. The Resource Guide to Wraparound Op Cit. Chapter 1.4 p.4.



The multidisciplinary team attains some authority and has more credibility to advocate

on behalf of the person or articulate the person‘s priorities to others than would any

single family member or agency

There are real and potential

benefits for agencies by creating

synergies among services, sharing

responsibility, reducing duplication,

coordination, synergies and

collaboration

By working collaboratively team

members have the opportunity to

learn from each other which

enhances skills by mentoring each

other or modelling useful practices

The multi disciplinary team

embraces diversity allowing for

innovation

The team builds and strengthens

community links and increases the

chances of making and developing

valuable friendships

The team overcomes social

exclusion and makes a positive

difference to the quality of life for a

person

The model recognizes the

importance of friendships and

relationships beyond family

Some costs are avoided through coordination (reducing duplication), and by preventing

the costs of neglect of people who have fallen through the cracks

Avoids inconsistencies, contradictions and mixed messages.

The Circles Initiative identifies potential benefits for any person at the centre of a wraparound

team. 28 (See box)

28 Adapted from the Community Living Project‘s Circles Initiative for clients who are physically and

intellectually disabled people living in the Southern Region of South Australia. (http://www.clp-

sa.org.au/CLP/support.htm) Many benefits arise out of the physical or intellectual help a person needs.

Circle Initiative Potential Benefits

Being supported by people present to offer

constant guidance

Help to stay healthy

Motivation to try to do new things and a chance

to learn how to do things for themselves

Encouragement to believe in themselves and

helping others see the contribution they make

Encouraging others to give them a chance to

make a contribution, to develop relationships, to

be included in the regular life of the community,

to take on and retain roles that other people

afford a positive status

Someone to take a real interest in them who

can help out if they are in trouble

Help to get out and meet new people including

assistance to join and participate in special

interest groups

Assistance finding somewhere to live or

someone to share with

An advocate who will speak out on their behalf

and ensure their interests are protected

Guidance through, and referral to, the maze of

other community services where appropriate

http://www.clp-sa.org.au/CLP/support.htm

http://www.clp-sa.org.au/CLP/support.htm



Another benefit that arises from the wraparound experience is the reduced dependence on and

use of professional services. A variation on this advantage is the changing relationships that

arise which may include more collegial and less hierarchical relationships with professionals in

the team. The tendency to jump too quickly to a single solution may also be ameliorated by

working as a team.

Another benefit of the approach is the focus on particular goals that by definition get attention

through the approach. By its nature the process also builds coping, planning and problem

solving skills. Generally people feel better about making their own choices rather than being

externally controlled.

Walker describes the theory of why the wraparound approach works.29 In addition to the

inherent value of the principles of the approach, she includes:

The process of effective value driven team work

Choice and motivation of the person at the centre

Shared expectations of all team members

Relevance and feasibility of the planned strategies

Self efficacy, empowerment and self-determination which help build confidence and a

sense of being able to overcome obstacles

The building of hope, which contributes to feelings of optimism

This extended list of benefits and potential benefits illustrates the potential of the wraparound

approach to not only help the individual or family, but also friends and colleagues who would like

to make a difference in the person‘s life and service providers seeking for solutions in what may

be intractable situations. Funders would be pleased to see funds used for positive outcomes.

The interdisciplinary approach could also be of interest to researchers and ultimately useful to

policy makers. These benefits come with some challenges.

Challenges

Ensuring that the fundamentals of the wraparound process are delivered is challenging to

achieve consistently. There are a number of areas that present particular challenges.

Inconsistent Application of the Principles

Practice based evidence confirms that a more comprehensive approach to meeting complex

needs must often include additional elements such as those that are part of the wraparound

process. They include additional coordination, more flexible supports and a team approach.

29 Walker, J. S. (2008). How, and why, does wraparound work: A theory of change. In E. J. Bruns & J. S.

Walker (Eds.), The Resource Guide to Wraparound. Op Cit. Chapter 3.1



However, since its origins in the 1980s when the intervention approach that surrounds a person

with customized services and supports was first named, it has been frequently redefined and

often misunderstood. Many different interpretations of the principles are used to deliver the

approach. Blau observes that ―we still suffer from empty rhetoric and misinterpretation of what it

means to be family-driven and youth-guided...What we have yet to learn is how to consistently

apply the principles of wraparound in practice.‖30

Lack of Team Involvement

One challenge is reaching agreement about who should be invited to be on the team. If a

person who is very involved with the person is not invited to be on the team, their influence,

access to resources, interpersonal support and relationship will miss out from being included as

part of a coordinated plan. If that person is a professional, the team may also lose the

opportunity to access services. Some people may be very important to the team, but not be

popular, such as a probation officer as a condition of probation. The person facilitating the team

should help the individual or family to make informed decisions.

Practical experience with wraparound has shown that formal service providers often have great

difficulty accessing or engaging potential team members from the family‘s community and

informal support networks. Thus, there is a tendency that these important relationships will be

underrepresented on wraparound teams.31 Sometimes obvious participants such as extended

family, advocates, friends, and informal helpers are excluded because they do not appear to

have particular skills. The focus on the person in the wraparound approach addresses the need

to place special emphasis on the perspectives of the people who will still be connected to the

person after professional or agency involvement has ended.

Lack of Ideas and a Plan

The lack of a plan to guide their work is another weakness in the practice of some teams, and

others rarely assess their progress or outcomes in relation to the plan. The lack of evidence of a

strengths focus is also a weakness. Other areas of concern show lack of training, high staff

turnover and lack of supports and ―ownership‖ of the process. 32 Some programs that call

themselves wraparound actually show that teams are not developing creative ideas to meet the

person‘s needs.

Role of the Person at the Centre

The community based nature of wraparound while a strength, lacks the rigour of evidence

based practices and written procedures. Sometimes case management is described as

30 Blau, Gary, The Resource Guide to Wraparound, Op Cit. Foreword

31 Bruns et al The Resource Guide to Wraparound Op Cit. Chapter 2.1 p. 5

32 The Resource Guide to Wraparound, Op Cit. Introduction



wraparound but typically lacks real individualization, individual and family teams, real individual

and family voice and integration of services.33

Other barriers to effectively supporting individuals with complex needs and their families are

previous experiences of stigma and shame which can leave the person or family members

reluctant to express their perspectives at all. A newcomer, for example, may be unwilling to

criticise services or ask for more assistance for fear of alienating service providers. Putting the

principle of the person‘s ‗voice and choice‘ into action requires intentional activity that supports

the person as they explore their perspectives. Team procedures, interactions, and products,

including the wraparound plan should provide evidence that the team is engaging in intentional

activity to prioritize the person‘s perspectives.34

Difficulty of Collaboration

Although a laudable principle, the intention to collaborate and ultimately integrate the approach

often creates tensions in the team. Reaching collective consensus on multiple decisions such as

what goals to pursue and the strategies to use, as well as evaluation of progress, is often

challenging. Team members need to be willing to share their ideas and be open to hearing and

considering the ideas of others. One role of the team facilitator is to ensure that team members

feel welcome to share their ideas. Focussing on the principles of wraparound includes each

team member being committed to the team, the team‘s goals, and the wraparound plan.

Similarly, the use of resources available to the team, including those controlled by individual

professionals on the team, should be governed by team decisions and team goals. Working to

reach agreement often requires team members to focus on the overarching goals and how best

to achieve these goals in a manner that reflects all of the principles of wraparound.

The approach is not intended to avoid conflicting points of view, but instead manage any

disagreement, while keeping the interests of the person at the centre. However, the required

patience to resolve differences requires skills and willingness in the facilitator and team

members. Finding the balance in collaboration between individual or family ‗voice and choice‘

and various team member ideas can be challenging.

This principle recognizes that there are certain constraints that operate on team decision

making, and that collaboration must operate within these boundaries. In particular, legal

mandates or other requirements often constrain decisions. Team members must be willing to

work creatively and flexibly to find ways to satisfy these mandates and requirements while also

working towards team goals.

33 VandenBerg The Resource Guide to Wraparound Op Cit. Chapter 1.4

34 Bruns, Eric J. and Janet S. Walker, in The Resource Guide to Wraparound Op Cit. Chapter 2.1 pp 3-4.



Lack of Available Services

Another challenge is that many needs of a person identified in wraparound situations are not

available through professional services. This results in professionals not being able to assist in

these areas so informal supports are depended on to close the gaps. There may also be a lack

of resources to secure necessary programs. In this case team members may have to find other

avenues for providing the supports.

Requires a Change in Perspective

Practitioners point out that being strengths-based is a new approach and that often their

involvement is predicated on something having gone wrong. It therefore requires not only a

change in traditional approach, but people who have the skills to practice it. People may need

training and mentoring to become good at applying a strengths-based approach which requires

promoting positive outcomes. When there are difficulties, there is often a tendency to revert to

more bureaucratic approaches and away from community based ones.

Respecting Privacy

One aspect of wraparound that presents a challenge is in the area of information sharing.

Ensuring that the person at the centre has given permission for their information to be shared is

essential. Even so, there are aspects of confidentiality and security of information that may arise

in a team. As is shown in the next section, different case examples illustrate how this is dealt

with in different applications of the model. Contributing to challenges related to information

sharing are changing staff resulting from staff turnover or re-assignment of duties, in human

services agencies and also changing personal situations among people in a person‘s circle of

contacts.

Traditional Accountability

Another challenge is in the area of agency accountability. Frequently funding is tied to

productivity measured by services provided to clients and client numbers. Wraparound may

present a challenge to the question ―whose client is this?‖ However if, in complex situations

wraparound results in positive outcomes, the approach will be a better use of funding and will

lead to softening of any rigid requirements of funders that inhibit good outcomes.

Sustainability

An external evaluation of one initiative identifies the challenge of sustainability. In the event of

lack of funding the staff positions that supported and helped to organize team meetings would

be lost. This raised the question of teams being strong enough to continue without staff support.



Compensating for Over Professionalization35

In his paper on children, youth and families, which focuses on children with complex needs,

VanDenberg indentifies the weaknesses in the current system that require a changed response.

The huge human services industry of professional helpers which has been created over the last

50 years has created a dependence on professional advice and decision making. This has

reduced family choices and the opportunity for families and individuals to voice their concerns.

A related concern is the ―silo effect‖, caused by development of separate child welfare, juvenile

justice, education, mental health, developmental disability, public health, addiction, housing,

welfare, medical, vocational, legal, and other services models. The various services do not

interact at the policy, agency, and practice levels and in addition often result in the creation of

multiple and often competing plans for clients. This has led in some cases to team based

planning and the concept of a system of care.

Wraparound is a process for integration of services which is distinguished from collaboration. ―In

a collaborative model of care, child serving agencies learn about each other‘s systems ... and

attempt to establish cross-system values and standards.... However, there are limits to a

collaborative model, even though collaboration is an important developmental step for many

communities and states. In a collaborative model, each system communicates, but at the end of

the day, each system makes their own decision about the intervention for the family. This results

in multiple service plans for the one family, which may potentially be in disagreement and result

in one family having been ordered to go to literally dozens of appointments over a month. When

these well-intentioned plans fail, the family is often blamed.‖

To move beyond collaboration, the concept of integration and system transformation has been

established. In a transformed, integrated system, the multiple systems establish structures for

decision making with the family at the centre of the process, using ‗voice and choice‘ as

foundational principles. In an integrated model of service implementation, the child, youth, and

family would have one plan. The family would be in the driver‘s seat in wraparound plan

development and approval.

Section 4 provides a wide range of examples of wraparound and associated initiatives. They

vary from small faith based community projects to multifaceted and financially resourced ones.

35VanDenBerg, John, Trina Osher and Ira Lourie, Child, Adolescent, and Family Issues: Team-Based

Planning and the Wraparound Process. National Research and Training Center on Psychiatric Disability,

University of Illinois at Chicago. P.8.



4. Examples and Case Studies

As addressed earlier the application of the wraparound approach diverges in many ways across

sectors and places. These examples provide an overview of how the approach is applied to

bring value to people in a variety of contexts. Perhaps the only thing in common is that in all

cases the people at the centre face complex situations.

Wrap-Around36

In a number of places in England ―wrap-around‖ services, which include advice and support, are

provided to asylum seekers (refugee claimants). The model is built around professional service

provision in relation to providing both private and not for profit sector housing. Wrapped around

housing are voluntary sector organizations that are contracted to provide health, counselling

and other settlement services. In this model services may be provided by professionals or

volunteers who conduct home visits, deliver food parcels, provide access to second hand

clothing stores, assist in finding employment, teach English, provide interpretation services and

also educate the community about the plight of asylum seekers.

Circles of Friends37

South Australia is the origin of an innovative community response in support of refugees called

Circles of Friends. It is sponsored by the Australian Refugee Association, a charitable NGO that

provides settlement assistance. The initiative arose out of what is very widely seen as a tragic

period in Australian treatment of asylum seekers, who were incarcerated in a detention centre in

a remote area of South Australia. People of all walks of life were horrified to see this treatment.

The growth of the first Circles of Friends and the strength of the movement are attributed to this

anger in the community. Regular visits were made to the detention centres to support

individuals and families. Mental illness and social dislocation were found to be widespread

among the asylum seekers, and the needs of individuals were often complex. Circles continue

to support asylum seekers and refugees holding temporary or permanent visas who are not

eligible for other services. The number of Circles has grown to over 100 and has expanded

beyond South Australia as members moved interstate and started Circles elsewhere in

Australia.

Circles of Friends is an interesting civic model. It begins when a person, (convenor), contacts

their friends to create a group (circle) to support a single refugee or a family, or multiple people

36 Report to the East of England Regional Assembly May 2004, interview with Bernie Goodwin who

worked with wrap-around in Liverpool, West End Refugee Services Annual Report 2005-06, Newcastle upon Tyne.

37 The information on Circles of Friends came from interviews with Ian Swift, Coordinator - Circles of

Friends, Australian Refugee Association, Adelaide, and a paper written by Ian, from Bernie Goodwin, previous Coordinator - Circles of Friends, from members of the Hills Circle of Friends by attending and speaking with them at their monthly meeting and from the Starter Kit provided by the Australian Refugee Association to people interested in starting a new Circle.



and families, some of whom have no work rights or health care entitlements. Convenors receive

a start up package from the Australian Refugee Association (ARA) by email that includes a list

of ‗dos and don‘ts‘. The cohesion of the group is built by friends coming together around a

common concern, hence ‗Circles of Friends‘. Circles grow by word of mouth, or by placing small

announcements in community newspapers. They are autonomous and they choose their own

approaches on how they help the refugee. Members of Circles bring diverse skills and

experience and their own extensive networks of contacts and resources.

Circles are advised to always act only through the approval and knowledge of the person(s)

they are assisting. They are also advised to avoid duplicating the services provided by existing

organizations and instead provide assistance where government or other agency support is

lacking. Circles may grow to as many as 50 people, often with a core group of 6-10 people who

manage the ongoing activity. ARA suggests planning for succession of the convenor as

important for sustainability. The Circle model accommodates all levels of member commitment

recognizing the changing call on people‘s time, their varied interests and skills or ability to make

donations.

Circle members raise funds through donations and fundraising events such as film evenings

and bake sales. The Australian Refugee Association funds and houses the position of

Coordinator – Circles of Friends and acts as banker, provides bookkeeping services including

charitable receipts to donors. ARA also makes payments from the Circle‘s account at the

request of the Circle for example towards a person‘s rent, or reimbursing a member who has

incurred a cost, e.g. paid the dentist for the person they are helping. ARA charges five percent

of donations to provide this banking, communication and coordination service. ARA produces a

regular e-newsletter which is sent to the database of Circle convenors. Other Circle members

are linked into their Circle through the convenor, not through ARA.

The Circles build trusting relationships with refugee claimants and help individuals and families

according to their need, i.e. ‗enablement in the community‘. Some of these relationships

originated with relationships made when Circle members visited the detention centre. Other

people who are supported are identified as needing help by the Coordinator – Circles of Friends

who sends out an email to all Circle convenors. S/he does this when informed about such a

need, for example from the Australian Red Cross. The Circles agree or decline to help based on

their interest and ability to do so.

Unlike the model of the ‗person at the centre‘ in the US wraparound model, Circles of Friends do

not involve the person benefitting from their help in the Circle. Instead one member particularly

befriends the person and advocates for him or her to the group. Privacy of the refugee is further

respected by avoiding names or identifying markers and avoiding any discussion about an

individual‘s private details.

Examples of the assistance provided by a Circle include gathering household items to assist a

person to set up a home or finding accommodation, others are driving people to appointments,

assisting them with job hunting, paying for them to attend school, providing e.g. $100 a week for

6 months towards their living expenses and paying for dental work. Circle members might make



a donation, help in kind, use their influence to bring results or support fundraising events. Some

Circles rely on contributions from Circle members rather than organize fundraising events.

One Circle created a roster of drivers who drove two men to their night shift jobs (for which there

was no public transport) for several months. Meanwhile another member taught them to drive,

and the Circle purchased a second hand car for them, enabling them to get to work on their own

after some months. Another Circle set up homework clubs to help refugee children with their

schoolwork. Another Circle helped an Afghani soccer team with their expenses and to become

incorporated. Circle members contributed several thousand dollars a year toward the costs of

leasing the playing fields, association fees and paying referees, in the belief that the young men

would benefit from getting regular exercise, being part of a team and meeting others. The Circle

shares the soccer team‘s costs with a corporate sponsor which was recruited by a Circle

member.

Circles avoid judging the people they are helping and work to remain positive even when

outcomes are not as they expect. In one case a Circle helped a newcomer with the cost of a taxi

licence only to find that after one week the person did not want to remain in that work.

Sometimes the help provided by the Circle member is very practical, for example accompanying

the newcomer in their job search or helping them to set up interviews.

Core members of some Circles meet monthly or bi-monthly with an agenda of progress reports

on initiatives, assignment of responsibilities, approval of spending on additional needs and plans

for fundraising. Other Circles rely on communication by phone and email. Many Circles

advocated for immigration policy changes, including articulating the widespread criticism of

mandatory detention. Circles help other Circles by promoting and attending their fundraising

events. Asked how long the commitment lasts, one Circle member answered ―friendships last

forever.‖

Personal Respect38

Dr. Amy Rossiter from the School of Social Work at York University in Ontario conducted

wraparound research with PEACH‘s (Promoting Economic Action and Community Health)

wraparound program which is a partnership with Oolagen Community Services for youth 13-18

years of age in Toronto. PEACH employed a person who facilitated a one year long intervention

with individual youth who are facing multiple challenges, often involving failure or violence at

school, negative peer relationships, and criminal charges. The wraparound facilitator worked

from three cornerstone values: voice, ownership and access. In a framework of a community-

based support team, selected by the youth, the youth learned about his/her strengths, guided

the goal-setting process, and received support from members of the support team when

required.

38 Canadian Evaluation Society, Ontario Chapter 2007 PEACH/Oolagen Wraparound has been supported

by National Crime Prevention Strategy, Royal Bank, and Toronto Community Housing Corporation. http://www.evaluationontario.ca/Events/RossiterWilsonPargassingh.html



The qualitative evaluation of the experiences of youth who participated in the wraparound

program found that students felt supported by the experience of personal respect, concrete

support and self-identified success. The support appeared to lead to increased potential for

long-term social inclusion through employment and further education.

Refugee Support Program39

The Refugee Support Program provides support and advocacy for refugees who have been

discharged from a psychiatric hospital. A group of 18 volunteers have supported groups of men,

from Afghanistan, Africa, Bangladesh, China and Iran. Group members provide non-clinical

psychosocial support including housing, orientation to community, shopping and cooking, linking

to English language classes and tertiary education services, a local doctor and mental health

services, as well as assistance with living skills, bridging cultural gaps, and establishing

education and employment links such as job networks.

The group originally formed to visit and support the refugees who were then in detention

centres, many of whom for five years. The model of care has had to be extremely flexible and

responsive to frequent changes in the lives of the refugees, often arising from ongoing

symptoms of post traumatic stress disorder (PTSD) and other mental health concerns including

depression, a sense of hopelessness, distrust, feeling self destructive and suicidal. Some clients

have experienced psychosis, sleep disturbances and a profound sense of loss and grief. A

psychiatrist describes the profile of the refugee community as ―complex due to experiencing

mental health issues as a result of past traumas, isolation, loss of contact with family, systemic

trauma from detention centres and delays in immigration processes‖. The volunteers often had

to act quickly as the men were discharged from hospital on short notice. Mental health workers

continued to provide four hours a week of support to the refugees.

Goals are identified with the refugee and strategies are discussed and written up into a goal

plan. The goals are regularly revisited and revised as circumstances change. They include

budgeting, paying debts, support for court appearances, liaising with immigration lawyers, and

attendances at cultural celebrations.

The program had to be able to respond quickly to the varying demands and life changes

experienced by the refugees. The refugees had high levels of functioning prior to being detained

and were therefore capable of high levels of functioning on re-entering the community.

Refugees requested assistance in getting a drivers licence, buying a car, going to English

classes, getting their qualifications recognised, organising interstate travel, further advocacy for

overseas families and looking for work. These requests were sought with urgency and created

heavy workloads for team members with need varying dramatically from week to week as the

people gained improved mental health and were reconstructing their lives. The volunteers

39 The Refugee Support Program is a program of Uniting Care Wesley, Port Adelaide (South Australia).

Article by Robert Habel, ―Asylum Seekers to Citizens,from Detention Centres to Independent Housing‖. www.ucwpa.org.au/content/159. The group includes a Circle of Friends.

http://www.ucwpa.org.au/content/159



worked with a variety of organizations to bring their skills together including Survivors of Torture

and Trauma, Australian Refugee Association, Circles of Friends and the Australian Red Cross.

Community support work with refugees identified a number of differences from the support work

with other community mental health programs. They included:

Need to plan and coordinate support often with many other agencies involved

Refugees are responsive to services, appreciative, hospitable, well groomed and have

social skills that help them blend with the mainstream

It can take time to gain trust and recognise a need

Refugees have a high level of pride, and while they have a good ability to advocate for

services, they often feel embarrassed about receiving handouts or assistance

It can take some time to explain in what areas support can be provided

Because refugees have become used to wide range of friendships from supporters,

workers have had to work through boundary issues. For example refugees have often

insisted in seeing a worker after hours on a social basis and have been keen to join in

with the activities of their worker‘s family

Burnout of staff and volunteers arising from the often high demand and urgency from a

refugee, necessitating the sharing of tasks between workers and prioritising goals

There is less welfare dependency due to a refugee‘s ability to work, high levels of

motivation, and an urgency in making up for lost time to set up a new life. Refugees

have also come from countries where there are only family supports and no welfare

Support work has been put into learning about culture, laws, bureaucracy, language,

education and employment systems

Access to funds to pay for bills such as lawyer‘s fees, car registrations and training fees

Some workers have found it challenging not to get distracted, confused and bogged

down by the refugee‘s life stories and that it helps to focus on practical tasks that work

towards the agreed goals

Feedback from refugees included appreciation particularly of practical help to pay for training

courses, to find work and find a house, as well as assistance in advocating and interpreting.

Individuals described improved mental health, more hope for the future and encouragement to

aim higher having taken training. When looking for housing, the refugees advocated strongly to

live alone, saying they had had many years living together and now wanted some privacy and

peace. Some refugees expressed disappointment or surprise at the types of housing available

for low income earners saying they ―don‘t look like the houses that people live in on television‖!



Achieve Citizenship40

The purpose of wraparound varies based on the needs of the individual. The Management

Assessment Panel (MAP) describes the purpose of their application of the model being

‗citizenship‘. The term ‗citizenship‘ is used in the belief that, with extra support, the client will be

empowered to manage their life in the community. It is seen as including rights and

responsibilities, obligations and making a contribution. Citizenship is seen as part of lifestyle;

citizens have expectations. The underpinning premise is that everyone wants citizenship within

his or her community and the respect and dignity that it brings. The MAP process focuses on

facilitating interagency collaboration and developing a coordinated response based on the

Integrated Service Model and Principles. It is a fluid model that is reviewed as required.

The MAP approach developed in response to needing to find useful strategies for people with

complex needs, often disability and mental illness, for whom other strategies had not been

successful. In many cases the belief is that ‗all else has failed‘. The team around the person,

called ‗the alliance‘, is referred to as a community of interest who undertake to set modest goals

with the person usually in relation to the person‘s lifestyle. Evidence that something needs to

change in a person‘s life might include:

Alienation from friends and family

Homelessness

Poverty

Poor health

Lack of social and cultural connections

Unfulfilled vocational aspirations

These vulnerabilities result in the person being stigmatized as a burden. This in turn feeds

personality problems resulting in increased marginalization and behaviour disorders. The goal of

wraparound is to turn negative situations into positive ones. The approach is seen as quite

different from a clinical model that focuses on illness and dysfunction. Critics of the approach

initially saw the focus on friends, family, recreation and work as trite, but advocates point out

that it is exactly these ‗normal‘ experiences that people miss. An action plan might be a brother

regularly inviting the person at the centre to dinner, or if the person likes to go fishing, being

able to do this with someone else who likes to go fishing.

MAP found that wraparound requires different skills from a clinical setting which may make

professionals uncomfortable. It is an approach that requires unconditional commitment from the

40 Management Assessment Panel Integrated Service Model and Principles Service model

documentation, Exceptional Needs Unit, Disability SA, South Australia. Interview with D. Hassam October

2008.



team members. It is ideal to meet in a non-threatening place and develop an integrated service

framework using the life domains. The plan is likely to include crossover in roles among the

team members, the development of goals in each of the domains and the tasks to be done to

realize the goals, who the partners are and the roles they each will have. The team members

are seen as allies on the side of the person, and they often have to put aside ways they would

normally do things. The team has to be willing to do something different from what has been

tried before and failed. As much as possible the person is encouraged to help themselves.

There are several reasons given for why the wraparound approach is not used more widely.

The culture of agencies results in each profession believing their discipline is the only

way of working

The tendency under funding constraints to retreat from community responses to clinical

ones

Rigid values and beliefs in sectors resulting in difficulty of collaboration across sectors

People‘s real life and needs are frequently after hours, not limited to 9-5 Monday –

Friday, and many sectors are not trained to respond at these times

Professionalization that results, for example in using an assessment tool rather than

asking the person‘s family

Participants may be outside mainstream life and the human service system

Wraparound requires being daring to try new approaches

MAP emphasises that plans should be sustainable and to ensure this it is important that team

members are asked to do only what they can reasonably do. Team members should not take on

things that they cannot do. Despite challenges of collaboration, the wraparound approach

values professional skills and aims to create effective ways for special knowledge to be brought

to the person‘s plan. MAP attempts to identify a lead agency in which someone like a middle

manager would chair the alliance.

One of the ground rules is ‗no pessimism‘, the focus is on what people can do not what they

cannot do. All team members are expected to bring enthusiasm and optimism to an alliance

working toward the person‘s goals. As the wraparound approach is used when other strategies

have failed, the MAP program is described as ‗giving another chance‘.



Impressive Gains41

Community Services Coordination

Network‘s wraparound initiative in the

London (Ontario) area supports families,

children, youth or adults with complex

needs. The perspective is seen as a

paradigm shift and identifies key

elements that are fundamental to the

process. (See box.)

One application of the wraparound

process in partnership with the Children's

Aid Society (CAS) of London and

Middlesex had the goals of preventing

children aged 10 - 17 from coming into

care and supporting youth who were in

high cost care to successfully transition

back into their families or into lower cost care facilities. An evaluation of the process showed

positive outcomes.42 (See box below)

41 Community Services Coordination Network, London Ontario

http://www.wraparound.ca/index.php?page=process

42 WrapAround/Children‘s Aid Society, Pilot Project Evaluation Update, as of February 2008

http://wraparound.ca/cmfiles/Microsoft%20Word%20-%20WRAPAROUND_UPDATE_Feb_08[1].pdf

London, Ontario WrapAround Process Key Elements

Unique from traditional services in that:

The family directs the plan

The plans developed are flexible and unique to each

family

Plans that do not meet the needs of the family are

changed

The individual/family always has:

A choice about the services they receive

A voice in the manner in which they receive services

Ownership of decisions that affect their lives

Comments on Evaluation of Application of London WrapAround Process

Cases that have been open to CAS ranged anywhere from 1 to 10 years (1998 - present). Impressive

gains were made in a short time period (2 years or less) when WrapAround services were introduced to

these highly stressed youth and their families.

The feedback from the CAS social workers and the WrapAround facilitators has been overwhelmingly

positive. Seasoned CAS child protection staff have acknowledged that they were skeptical at the outset

of the project that any meaningful change could be accomplished with some of the most challenging of

clients. However, they have been impressed with the WrapAround philosophy and commitment to the

model. In addition, they have reported that they have learned so much clinically regarding a different

way of engaging families and youth which is in keeping with the Agency‘s strength based practice

approach. Families and youth involved in the project have voiced positive feedback and are now feeling

empowered and stronger because of their experiences with this service delivery model. The decrease in

the number of youth and children in care was the primary goal and has also been achieved.

http://wraparound.ca/cmfiles/Microsoft%20Word%20-%20WRAPAROUND_UPDATE_Feb_08%5b1%5d.pdf



Integrative Wraparound Process43

The objective of the Saskatchewan Rural Wraparound Project is to enable families in need and

their communities to share responsibility in support planning and provision, and build on

individual and collective strengths. The partners in the

project include the local health district, school division,

social services, early childhood and native services.

The initiative grew out of the need for improved senior

government coordination of several initiatives and a

growing demand for holistic and integrated services.

The program encourages families in need of

assistance to have authentic ownership of their support

plans. (See box)

About the need for improved coordination, a

community participant in a wrapraound event

commented ―The idea that you have the social work

community, the education community, the medical

community, the psychological community, all working

on their own playing fields, under the general concept

of ‗mine is the only way‘, has to stop.‖

Participants in the Integrative Wraparound Process

described the challenges of the process being that:

It is time-consuming and calls for genuine commitment, and without that commitment

desired changes might not be achieved within human and social institutions

The program‘s success depends largely on non-professionals on various teams. The

observation was made that ―the professionals of the team—home-care people [and]

physical therapists—are usually the ones who drop off.‖

Circle of Support44

In a British example, a group of people, called a Circle of Support or Circle of Friends came

together to help a person achieve something that they cannot do on their own, such as realize

some of their goals in life. The person at the centre, who is referred to as the ‗focus person‘

decides who will be a member of the circle. Typically the focus person is a person with a

disability or in some other way disadvantaged, and may be children, young people, adults and

older people throughout the UK. A facilitator is chosen from the group to keep the group running

43 Amankwah, Dinah, Integrative Wraparound (IWRAP) Process Training, Community-University Institute

for Social Research, University of Saskatchewan 2003

44 http://www.circlesnetwork.org.uk/circles_of_support.htm; also what_is_person_centred_planning.htm;

and sample_relationship_map.htm

The Integrative Wraparound

Process lists as its Principles:

A strength based approach

Advocates community mapping

and connections

Allows individual or family voice

and choice within the group that

works to help parties address their

needs

Provides unconditional support for

needy individuals and families

Blends formal and informal

resources

Family and individual centred

Utilizes a single/common plan to

address multiple issues

Highly collaborative in nature

http://www.circlesnetwork.org.uk/circles_of_support.htm

http://www.circlesnetwork.org.uk/what_is_person_centred_planning.htm

http://www.circlesnetwork.org.uk/sample_relationship_map.htm



efficiently. The members of the community of support include family, friends, neighbours,

support workers, professionals involved in their lives and other community members. They are

involved because they care enough about the focus person to give their time and energy to help

that person to overcome obstacles

and increase the options that are

open to them.

Group members have diverse gifts

and interests. The emphasis is on

seeing people as individuals who feel

they need support in order to take

more control over their own lives. A

circle properly facilitated is

empowering to all of the individuals

involved and, unlike many service

systems, does not reinforce

dependence. The approach assumes

that the focus person is central and in

control. Circles are flexible, set no

limits to the person‘s wants, needs

and dreams for their life and they see

it as important to regularly revisit

plans. Their tools include looking at

what the person enjoys and mapping

the relationships in a person‘s life

using concentric circles. The team

works to determine whose help is needed to achieve goals and the steps that need to be taken.

Drawings, maps and illustrations are used to capture and illustrate goals.

Circles Initiative45

Consistently applying key values is the foundation of the success of the Circles Initiative for

Community Living Project Inc., which supports people with disabilities and their families to

create and maintain a circle of friends consisting of people who have volunteered to ‗look out

for‘ the person with a disability.

45 Interview with Jayne Barrett, Manager of the Circles Initiative for Community Living Project Inc. in South

Australia in August 2008. More about the Circles Initiative can be found on the website of the Community

Living Project Inc., www.clp-sa.org.au . A DVD, Circles of Support, showing the circles of friends at work

can be purchased from The Education Shop - http://www.metromagazine.com.au/shop/default.asp

The Circles Network, Building Inclusive

Communities guides its work using the following

Values of Inclusion

All people have a right to live in and be part of the

community.

All people have a voice and a right to be heard

All people have dreams and aspirations.

All people have capabilities and qualities.

All people should have the opportunity to live an

ordinary and valued life.

All people should have power and control over

what they do now and in the future.

All people need friendships, independent

relationships and a natural support network.

The whole community can benefit from embracing

diversity.

All means all!




The person at the centre (the person with a disability) may make all the decisions or may have a

parent, other relative or good friend help them make decisions. Key attributes of this model of

care are:

The people invited to join the

circle of friends are identified

by the person at the centre

from people s/he is linked to.

The invitation is made on

behalf of the person at the

centre, and only if s/he wants

the person to be invited

The people who join the

circle of friends do so as

volunteers and are not

remunerated

A facilitator who works

consistently with a person

and their circle of friends (on

average 3 hours/week) is a

paid position. (See box for

their roles.)

Circles have an average size of five

people, but may range from 2- 8

people

The roles of the people who

volunteer to join the circle of friends

include:

Doing something social one

on one with the person each

month

Effectively joining the

person‘s circle ‗forever‘

Coming to an informal social

gathering of the circle, a

lunch date, a get together

e.g. every two months

‗Looking out for‘ not ‗caring for‘ the person

The Roles of the Facilitator in the

Circles Initiative

To get to know the person - often three months ahead of

the first gathering of the circle of friends

Speaks with the person to understand who they are linked

with, sometimes using a simple diagram (as shown in the

concentric circle figure on p.11)

To apply excellent listening and facilitation skills to assist

the person at the centre and each circle friend, and also

the effective process of each gathering of the circle of

friends

Approach the people who the person wants invited to their

circle of friends (this enables the invitee to decline if they

choose to, without rejecting the person at the centre)

Have an (unspoken) agenda at the gatherings of checking

in with the person at the centre as well as each of the

circle friends. Also helping the person to speak about their

goals or dreams or other aspects of their well being and

ensuring that the pathway to them is being worked on.

Another goal is to build the capacity of the person which

might be assisted with questions such as ―What are one of

X‘s strengths?‖

To help circle friends make decisions when they are

uncertain about what social activities they could do with

the person

To assist the circle to find information when they need it,

arrange for relevant education and training e.g. telling

circle friends about community workshops

Provide a role model by showing how things could be

done to help a circle friend overcome being fearful e.g.

helping a person who is unable to feed themselves to eat

Be available 24/7 – most of their work is evenings and

weekends.



Motivation to begin a circle may be because something can be better for a person or they have

unrealized dreams. Circles of friends may be especially important when parents of the person

with a disability are concerned about who will take care of their offspring when they are no

longer able. Gatherings (not meetings) include food and refreshments and intentionally have an

informal feel.

The Circles Initiative finds that identifying the person‘s goals in the circle directs intentional

thinking from all the circle friends who often have different interests and need to avoid making

judgements about the person‘s interests and choices.

From time to time the Circles Initiative invites a service provider to attend one part of a circle of

friends gathering, e.g. to educate the friends about how to lift the person safely, or to inform the

friends about some aspect of the person‘s services, e.g. responding to epilepsy. However, the

Circles Initiative finds that often the friends will pull back on their role and begin to defer to and

depend on the professional service provider, rather than appreciate the important, different and

complementary roles vis a vis the person at the centre. ―The paid service provider pushes out

the freely given.‖

The Circles Initiative also raised the issue of accountability, pointing out that although

participating in the Circle, ―any service provider is accountable to their organization and boss.‖

The Circles Initiative finds that this model of care furthers inclusion and is effective in community

engagement. It helps to develop a broader understanding of the issues faced by the person at

the centre which results in members of the circle of friends becoming advocates and informal

educators. On some occasions, with the permission of the person at the centre, a friend may

bring one of their friends who is interested in joining the circle. Sometimes two or more circle

friends are able to do something together which one of them could not do alone, e.g. take a

vacation with the person.

The model builds on the premise that security for a vulnerable person comes from people who

draw together to become a personal network, not from systems which come and go and

change.

Reduce Recidivism46

VanDenBerg cites an initiative tried in 2005 in the state of Oklahoma in an effort to reduce 50

percent recidivism rates in adult offenders who are released from prison with no aftercare plan

beyond a case manager-produced discharge plan. The process is being built one offender at a

time, with the help of all concerned in the effort. The Principles, Phases and Activities of the

Wraparound Process from the National Wraparound Initiative have been adapted for use with

the prison population. The wraparound facilitators begin with the offender six months prior to

discharge, form teams, and initiate engagement with the offenders to set their own goals and

46 The Oklahoma Wraparound Re-Entry Program for Adult Corrections in The Resource Guide to

Wraparound. Op Cit. Chapter 1.4 p.5



determine their priority needs for after discharge. Initial results from the Oklahoma Prison

Wraparound efforts are promising, with dramatic reductions in the rates of recidivism.

Community Mobilization Teams47

Debicki describes an innovative Ontario wraparound neighborhood-based community

development initiative that was influenced by the work of John McKnight. Partnerships were

created with faith-based and other neighborhood-based efforts to establish an innovative

version of the wraparound process in which neighborhoods establish local community

mobilization teams with volunteer wraparound facilitators. The initiative in Hamilton and

Brantford spread to a number of nearby communities.

Initial research on the effort has been promising, resulting in cost savings to child welfare and

juvenile justice agencies when youth are returned from residential services into the

neighborhood wraparound efforts.

The initiative used the term ‗community connectors‘ to describe the convenor or facilitator role.

They are well connected in their community.

They are trusted—this is important because they are asking people to help families with

children and youth with complex needs who are often marginalized and have become

isolated from positive social networks.

They believe that their community is a welcoming and supportive community.

The vision was for a vibrant network of localized community mobilization teams, linked together

across the country. Their strength is the mobilization of the community to acquire necessary

resources for participating families and teams. They are similar to a community service club

which mobilizes the community into a state of readiness or preparedness to help address the

individual needs of families with children, youth or adults with multiple, complex problems. The

community mobilization teams meet for 2-3 hours each month and provide ―real hope that life

could be better on a daily basis‖.

One of the examples in southern Ontario is Stoney Creek United Church which has a faith

based wraparound program called W.R.A.P. (wrapping resources around people).48 The goal is

to serve disadvantaged families in the community and help to stop the cycle of poverty. In this

case wraparound resources included gathering donated household items such as furniture for

families that need to set up a home, volunteers linking people to community resources such as

47 Debicki, A. (2008). A best practice model for a community mobilization team. In E. J. Bruns & J. S.

Walker (Eds.), The Resource Guide to Wraparound. Op Cit. Chapter 5 f.

48 Stoney Creek United Church Annual Program Report, April 2008 p.4.

http://www.stoneycreekunitedchurch.org/Files/Annual_report_apr_08.pdf.



the Self Esteem Network, Parenting Classes, assisting children to attend summer camp, and

providing back to school kits, food, food vouchers and clothing.

Understanding Culture49

Under the auspices of the Wraparound Initiative, the Diversity Project in London, Ontario was

conducted to better understand how culture affects the perception of the barriers newcomers

face in accessing services. Issues that present challenges for newcomers were identified during

interviews with 135 refugees from five ethno cultural groups. The goal was to improve services

by ensuring they are more appropriate for and culturally sensitive to ethno cultural populations.

The study found that any one of dozens of issues can present a barrier to effective settlement

for a newcomer and each is an area that could be usefully addressed in a wraparound

approach.

The dozens of areas include attitudes, information, relationships, communication, health, faith

and access to services. (See box.)

Potential Barriers to Effective Settlement

Adaptation and culture shock including

attitudes to age, gender and family

Changes to family roles, relationships

and status

Education, interrupted education and

training

Eligibility for services, how they are

delivered, lack culturally sensitive

services or services e.g. in rural areas

Employment, unemployment and

underemployment and attitudes to

work

Family life, dating, marriage, roles in

families and extended families and

sexual orientation

Family separation

Family violence

Justice and legal issues

Language and communication

including style, volume, non-verbal,

personal distance, speaking English or

French

Mental health, self esteem, depression

Mourning and cultural practices at the

time of deaths

Parenting and parent child

relationships

Poverty, managing finances and daily

living

Privacy

Racism and discrimination

Recognition of credentials and

experience

49 Llobet, Raul, Wraparound Initiative – Diversity Project. Building Inclusive and Accessible Family

Services in London. Final Report Phase1. November 2005.



Fear of authority and feelings and

practices about safety and security

Food, meals and cultural and religious

preferences

Friends and networks; social life

Housing

Illness and wellness behaviors and

attitudes

Isolation and loneliness

Relating to teachers and schools;

expectations of parents and teachers

Relationships and responsibility for

people back home

Retaining culture and language

Transportation

Trauma and displacement e.g. refugee

camp experiences

Spirituality and religious beliefs

Section five presents examples of how aspects of wraparound are being implemented in the

Ontario settlement sector.



5. Practice in the Ontario Settlement Sector

This section captures some of the services provided by the Ontario settlement sector that

complement the models of wraparound and circle of support proposed in section 6. They are

services that illustrate the range of settlement needs and the variety of useful relationships from

which many newcomers benefit. The examples demonstrate the range of formal and informal,

professional and recreational, comprehensive and specialized services that are part of the

patchwork of what facilitates settlement.

Settlement Workers

It is perhaps inappropriate to describe settlement workers as having any common

characteristics because each person brings a wealth of professional and personal experience to

their positions in settlement agencies, schools or shelters etc. Typically though, a settlement

worker is involved in promoting the personal growth and economic independence of the

immigrants and refugees s/he assists. Settlement workers assess a client‘s needs and build a

plan to address them. They must be familiar with the Immigration and Refugee Law Act and be

cross-culturally sensitive. Settlement workers help newcomers by providing orientation and

access to employment and other kinds of counselling, information and referral, parenting

support, health, housing, education and training, language and computer classes, banking and

other daily living skills, citizenship preparation classes, income tax clinics, business support

services, temporary and permanent accommodation, translation and interpretation. They

advocate for the client when necessary to obtain services always ensuring that the goals of

empowerment and independence are maintained. Settlement workers are also trained to

recognize risk of domestic violence, addiction, trauma and need for mental health support. Many

settlement workers provide workshops for groups as well as working with individuals and

families.

Host Program50

The Host Program links community volunteers with newcomer individuals or families soon after

they arrive in Canada. In their role with the newcomer, on a weekly basis the volunteer provides:

Friendship

Moral support

Information about the community and daily living in Canada to help them get settled

including community services, schools, looking for a job, shopping, transit or banking,

recreational and social activities and orientation to Canadian society and culture

Opportunities to practice French or English conversation and help with language barriers

50 Host Program Ontario website - http://www.hostontario.org/e/index.cfm



The program specifies that the role of the Host volunteer is not to replace the role of

professional settlement worker, or to provide a job, give money or provide housing.

The program benefits all Canadians by:

Facilitating the settlement and integration of new immigrants to Canada

Sensitizing the wider community to the needs of new immigrants, and engaging them in

responding to these needs, and

Assisting newcomers to realize their full potential in Canadian society

A volunteer with the Host Program describes the value of the assistance provided to

newcomers, as ―Simple things that we take for granted, such as buying a monthly pass, making

a long-distance call, finding a family doctor or a local food bank any of which might make an

inexperienced newcomer desperate.‖

The program models the two-way process of integration as both parties learn from the

relationship. The volunteer learns about other cultures and gains insight into the immigrant

experience.

There are group activities associated with the Host Program including English Conversation

Circles which are offered in twenty locations across Ontario at which newcomers come together

to practice speaking English.

Better Access to Services In the Community (BASIC) Program51

The Multicultural Council of Windsor and Essex County‘s BASIC program (Better Access to

Services In the Community) incorporates some elements of the wraparound approach. BASIC,

which is funded by Citizenship and Immigration‘s Client Support Services pilot project, assists

Government Assisted Refugees (GARs) to settle in the Windsor community.

BASIC is especially designed to assist newcomers who require intensive support. Many come

from war torn countries, face pressing emotional and mental health, health, education,

employment, and life skill issues arising from recent trauma, language barriers and difficulties in

cultural adjustment.

BASIC‘s goal is to link newcomers, either through referrals or by developing relevant

opportunities, to regular group meetings and workshops, focus groups, field trips, relevant

information and therapy group sessions offered in the person‘s first language and sometimes, if

appropriate, organized by gender and age range.

The strength of BASIC is the involvement of multi-disciplinary players which results in a

coordinated and holistic service. In addition to the range of services provided by the Multicultural

51 For more information contact Multicultural Council of Windsor and Essex, www.themcc.com.



Council of Windsor and Essex County, such as Host Program, ISAP (Immigrant Settlement and

Adaptation Program) and interpretation services, the program reaches out to many other

services in the community including Victim Services of Windsor and Essex County, other

settlement agencies, City Centre health teams and the School of Nursing, Social Work and

Psychology programs at the University of Windsor. Cultural competence is essential for effective

involvement. Multiple agencies working together require collaboration with regular

communication and clarity about each agency‘s areas of specialization and responsibility.

Avoiding duplication assists the newcomer and the agencies.

Arising from this experience with newcomers with very complex needs is the idea of assessing

the appropriateness of the wraparound approach soon after arrival, rather than trying other

approaches first. The team might include a mentor, counselor, Host family and multiple

agencies including Children‘s Aid Society and a healthcare provider. In this case the newcomer,

the person at the centre, would not yet have formed informal connections, so the approach is

likely to be more professionally led.

Mentoring52

Mentoring provides new immigrants with occupation-specific support. The assumption is that

participants possess the education, experience and language skills needed to excel in the

workforce, but need the connections and knowledge that can be gained from real-life

experience.

The expectations of mentoring opportunities and the role of the mentor can be multifaceted, with

the scope as broad as the mentor offers. Take the example of a retired engineer, Dave, who

mentored a young Liberian man, Tamba, who aspired to be an engineer. Despite regular

tutoring Tamba could not pass the course. His education had not included the mathematical

foundation that he needed; he didn‘t understand the concept of volume, for example. In addition

to help with his courses, Dave accompanied Tamba shopping, sometimes helping him stretch

his limited budget to include some meat or books. Dave tried to link Tamba to a nearby school,

hoping that he would apply his love for soccer by working with the staff and students on the

sports teams, at the same time developing some friendships. Dave worried about Tamba‘s

vulnerability. He had a cleaning job for which he was not paid and had been approached by

several religious groups, eager for him to join their congregation. Dave wondered if they could

exploit his unfamiliarity with local conditions.

Dave would have liked to make his relationship with Tamba more fun and invite him to his home

for meals, but found the age difference was a barrier. He also would have liked to have been

better at conveying the importance of improving his English, practicing discipline in turning up

for appointments and being on time. Tamba subsequently enrolled in International Studies and

52 Toronto Region Immigrant Employment Council (TRIEC)The Mentoring Partnership

http://www.triec.ca/programs/the-mentor-partnership. The case example is derived from an interview with

a mentor, called Dave in this account.

http://www.triec.ca/programs/the-mentor-partnership



did well. Dave wished that there had been an opportunity to meet other mentors to problem

solve with them and find ways to be more useful. He thought that a wraparound team would

have been very useful, speeding up Tamba‘s settlement and reducing his frustration.

Service Bridging

Service Bridging is focussed on building beneficial reciprocal connections between service

delivery organizations both in the settlement sector and among non-settlement community

agencies. One goal is to strengthen the capacity of community organizations to respond

appropriately to immigrant and refugee clients. By building and maintaining positive service

partnerships staff know the complementary services that are available and are able to refer

clients with confidence and follow up easily on the impact of the services they are using. A

Service Bridging project may gather people from different organizations together on a regular or

as needed basis.

Consultation Key to Understanding53

Two innovative initiatives in which St Christopher House‘s Immigrant and Refugee Services

Program has been a part, illustrate the value of and potential for learning from collaborative

responses.

In one activity professionals and clients came together to look at what works. Five social service

providers and 20 clients who represented different gender, language of origin, age groups,

country of origin, immigration status and stage in settlement, discussed a series of questions

about such things as housing, legal issues and accessing health services. The objective was to

explore the factors that affect settlement, the inter-relatedness of different systems of support

and how to better integrate the individual‘s experience with services. Several very practical

learnings from the activity have relevance to the wraparound approach.

Organizational mandates define boundaries of practice. Organizations need to understand each

other‘s mandates and the alignment of functions. They also need to be able to address gaps

among agencies. Clarity of roles and responsibilities is key to success. In a collaborative

arrangement, when one of the players does not do what they say they will do, the only recourse

for people who depend on everyone being reliable, is to find another organization to provide the

required function or service. This may put the original strategic relationships at risk.

The amount of work that will arise with a client cannot be anticipated so a collaborative

approach needs to be flexible to expand or contract.

Effective collaboration requires analytical skills as well as the ability to negotiate, mediate,

establish and maintain good relationships with others. Often clients are fatigued by many

referrals, systemic barriers and their own multiple barriers to settlement. It is important to

support the client to remain motivated.

53 For more information contact St Christopher House, Toronto. www.stchrishouse.org.



In another consultation process, agencies held a forum on best practices. The event was

organized by the Advisory Committee on Access to Services by Socially Marginalized

Immigrants and Refugees. Participants

were from sixteen social services sectors.

(See box). The purpose included building

relationships between sectors, increasing

mutual awareness of the inter-relatedness

of issues and resolving how to work

together more effectively.

Recommendations from the Forum included

coordinating services so that clients have

control over their lives and continually

monitoring the results of services and their

effectiveness for the individual.

Bridge Education and Training Programs54

Bridging projects focus particularly on education and training, bridging the internationally trained

individual‘s experience and ability with appropriate schooling or access to occupational

certification, registration or employment in Canada.

The Public Policy Forum (2007) has defined bridging programs as "... [A]ny program that helps

immigrants fill education gaps or other professional requirements, provides immigrants with

cultural and/or workplace orientation, and/or helps immigrants find work that makes use of their

skill set and former training." The Ontario government's Ministry for Citizenship and Immigration

describes bridging as: "A systematic and comprehensive program, involving teaching,

assessment and other supports (including mentorship, counselling, job placements, workplace

support and occupation-specific language training) designed to provide immigrants with the

knowledge, skills and competencies required to gain access to and employment in their field at

a level commensurate with their background and skills."

Since 2003, the Ontario government has funded more than 145 bridging projects in over 100

professions and trades. In most cases, these programs are:

Associated with a specific profession or trade or an economic sector

Linked with an educational institution and/or regulatory body and/or professional

association

54 Austin, Z, Opportunities and Responsibilities for Post Secondary Institutions, University of Toronto –

UofT Bulletin July 22, 2008. http://www.news.utoronto.ca/forums/bridging-education.html

Mental Health

Health

Psychological

Rehabilitation

Drop Ins

Day Centers

Gender-Specific

Shelters

Employment

City Social Services

Ethno-racial Mental

Health

Ethnic-Based

Youth

Culture-based

Education

Legal

Settlement



Associated with local community and/or settlement agencies

Providing direct connections with employers

Providing employment-specific learning opportunities (such as shadowing, internships,

mentorships, etc.)

The success of bridging education is reflected in the breadth of areas in which it has been

implemented including health professions, technical fields and skilled trades. Generally, these

programs have represented partnerships between post-secondary institutions, regulatory or

licensing bodies and employer groups.

Settlement, Employment and English Language55

The WoodGreen Immigrant Services Unit consists of three programs – Settlement, Employment

and English Language services. Every client accessing the Services goes through a Settlement

counsellor who provides basic assessment and settlement support to the client to access

services.

The client will then be internally referred to: job search workshops, an assessment appointment

for job search coaching, a job developer, language services programs or other programs

(workshops, trips etc) depending on the need. If the needs are outside the Unit, referrals are

made to other WoodGreen services. Each referral is ―live‖ in terms of a phone call being placed

to the ―referral person‖ rather than a service.

If a referral is made to an external agency, again every effort is made to connect to a person.

The client will get a business card from the WoodGreen counsellor to call in case of any

difficulty. The counsellor may call on behalf of the client if the client is unable or faces barriers.

The counsellor may also support the client to script the dialogue to clarify the messages that the

client is trying to convey to the referral agency.

The client is encouraged to call back or come back or the counsellor will check back within the

week to follow up if needed.

If the needs of the client are complex, the counsellor will plan priorities and get agreement from

the client about a follow up appointment focussed on the tasks for which the client is

responsible. The counsellor then becomes the case coordinator for the client and gathers

resources for the client to facilitate smooth transitions. The client may bring a family member or

friend (a framework of support) if they desire.

If the client needs to be accompanied to an appointment due to complex barriers or a crisis the

counsellor will provide the accompaniment in consultation with the manager of the program.

55 For more information go to www.woodgreen.org

http://www.woodgreen.org/



Counsellors also see clients at a variety of public sites including libraries, childcare centers,

community centers and other places where clients naturally congregate. This allows the clients

to bring someone with them for support or be within an environment that is comfortable and safe

for the counsellor and client. The counsellors also connect clients with WoodGreen Services

where there is a wide range of supports to meet the complex needs of clients.

All Round Support56

An example from the Rexdale Women‘s Centre illustrates the multiple complimentary services

provided to a client. A mother of two approached the Rexdale Women‘s Centre counsellor for

domestic violence counselling. The client had not earned a high school diploma. She was in a

relationship with an abusive partner whom she had married when she was 17. At that time she

stopped going to school to start her family life. As a result of her husband‘s insistence and

abuse she also left her work as a retail clerk. She became completely housebound. When she

approached a counsellor at Rexdale Women‘s Centre after an incident of abuse, she needed

assistance to move on with her life. Rexdale Women‘s Centre‘s violence prevention counsellor

offered her supportive counselling on domestic violence issues and connected her to the

following services:

ESL Classes: As her English was limited so she was referred to ESL/LINC classes.

Computer Classes: She wanted to learn basic computer skills in order to find an office

job.

Subsidized Day Care: In order for her to proceed further with her personal and

professional development and make herself available for the job market, she needed

day care. Since she could not afford to pay the regular fees, she was advised on how to

apply for a subsidy.

Development services for Children: As her older child was not progressing at the rate he

should be and as he had also witnessed family violence, she and her child were referred

to a Child Development centre and a centre for evaluation and counselling.

Medical Supportive Services: As she complained of pain in her lower back but did not

want to go to the family doctor because he was close to her husband she was referred to

a General Hospital to be checked out and referred to a different doctor

Subsidized Housing: She could not afford to maintain her apartment , so she was

assisted in filling out forms for housing.

Legal Services: Since she also required legal assistance, she was referred to community

legal clinic to assist her with filling out forms to apply for legal aid.

56 For more information go to: http://www.rexdalewomen.org



Children Programs in Community: She wanted day programs for her younger child, so

was referred to a family drop in and Ontario Early Years centre.

Recreational/Social activities for Children: She wanted her children to get involved with

sports i.e. soccer, so was referred to Parks and Recreation where she filled in the

subsidy forms and received free admission for her children.

Learning Circles57

Learning circles are proposed as a way to get people together to learn and apply new

information together. They include workshops, tools and resources to help people learn

together. The idea arises from belief in the value of developing and supporting collaborative

strategies that engage citizens and institutions to solve major community challenges and to

learn from and share these experiences. The approach of intentionally learning together aligns

with the experience of mutual support that is the goal of groups that come together to address a

common concern.

Volunteers

Many organizations recruit volunteers, some of whom assist newcomers with orientation and

settlement. Requirements to be a volunteer for this role may include having years of experience

living in Canada so that the volunteer can better assist new immigrants learn about the system

and services available.

Recreation and Culture

Some organizations provide recreation and culture for clients such as sports or programs

specifically to help youth or seniors gather together socially. Some organizations provide

heritage language opportunities or cultural programs to enhance identity or opportunities to drop

in to meet others and chat.

Section six presents two models for wraparound-like services that provide new possibilities for

addressing the needs of some newcomers with complex issues.

57 Tamarack Institute for Community Engagement, Annual Report 2006.

http://tamarackcommunity.ca/downloads/reports/tamarack_annual_report06.pdf



6. Models for the Sector

Arising from the research into wraparound and circles, two models for new kinds of services for

immigrants and refugees in Ontario are presented. They both assume a civil society in which

social capital allows people to come together and cooperate on issues or activities important to

them and also provide an environment for trust and expectations of reciprocity.58

Although the models are focussed on

assisting the newcomer, they both

include support for those on the team

assisting the newcomer. It is assumed

that most newcomers face at least some

of the challenges listed. (See box.)

Both models are intensive suggesting

that they are not likely to be useful

models for an individual or family that is

robust and settling successfully in

Canada on a fairly independent basis.

However this is not the good fortune of

many newcomers and both models offer

a useful additional multi layered support

for a person or family who face

challenges to settlement.

At a glance the models might be

dismissed as requiring too much effort,

but the research conducted reveals that

in many cases other avenues for

assistance have been tried and have

proven not to be successful. These

models offer other approaches which

inject new resources and support into the

environment of the newcomer.

In addition to the positive outcomes for

newcomers there are a number of

advantages of operating in teams.

58 Zizys, T, Kosny, M and Bonnell, J, A Review of Social Planning Activities in the City of Toronto,

Prepared for the Social Development and Administration Division Community and Neighbourhood Services Department City of Toronto. June 2004 P.4. http://www.ocasi.org/downloads/Social_Planning_Report.pdf

Migration is challenging and it presents many

issues for refugees and immigrants including:

□ Finding out about schools, other education and

training and information about loans for these

□ Finding employment and having qualifications

recognized

□ Wanting connections into community-life such as

making friends or finding volunteer opportunities

□ Overcoming loss and family separation

□ Wanting models, such as mentors, who can

demonstrate how to get along in the new society

□ Mental health and overall wellness

□ Cultural adjustment and culturally sensitive

emotional supports

□ Learning a new language

□ Understanding rights, rules and law enforcement

and all levels of government

□ Navigating the immigration system and

understanding citizenship requirements

□ Dealing with discrimination

□ Challenges such as disability or chronic illness

□ Finding services such as health care or car

insurance

□ Managing budgets and banking

□ Finding and maintaining housing and tenancy

issues

□ Travel, public transport and getting about

http://www.ocasi.org/downloads/Social_Planning_Report.pdf



Two key advantages are:

Members of the team share responsibility which may reduce reluctance to participate

because of fear of feeling or being solely responsible for outcomes

The intentional community of the team results in an agenda and mutual accountability to

each other, which results in momentum and a focus on results.

The two models: Ontario Newcomer Circle of Friends Model and Ontario Newcomer

Wraparound Model are different and would be applied in different circumstances.

Summary of the Two Models

Both models have as their goal newcomer settlement including fulfilment, empowerment and

independence.

Ontario Newcomer Wraparound

Intended for immigrants and refugees for whom settlement has been complex due to

trauma, unemployment or underemployment, family crisis, health, involvement with the

justice system or other significant concerns

During the time the newcomer has been in Ontario it has become evident that the

person‘s situation is complex and their use of existing settlement services is not effective

enough to achieve satisfactory settlement

A team of people who know and are concerned about the newcomer is formed to make

a plan with the person and support the achievement of the plan‘s goals

The newcomer is an active participant in the team of support that includes professional

and non-professionals all of whom want to support the newcomer to achieve his or her

goals

The newcomer is able and willing to articulate his or her goals and direction, wants to

improve the situation and is willing to invite others to participate in a team to help them to

succeed

Likely to include practical assistance, social and moral support, communication, linkages

to and professional services

Focuses on the person‘s strengths and capabilities

Monitoring is ongoing with a view to phasing out as the person no longer requires the

support



Ontario Newcomer Circle of Support

Intended for immigrants and refugees for whom settlement has been complex due to

trauma, unemployment or underemployment, family crisis, health, involvement with the

justice system or other significant concerns

A group (circle) of friends gather together to volunteer their time to bring together

monetary and other resources to help one of more newcomers during settlement

Because of the value of support for volunteers a variation could be the coming together

of Host families or others who offer their time to support newcomer families

A volunteer advocate brings the newcomer‘s practical needs to the group of people

(circle) who support one or more newcomers or families

The newcomer does not participate in the circle of friends and the newcomer‘s identity is

known only by the volunteer advocate, thus respecting the privacy of the person

Being Positively Valued

Newcomers are an invaluable resource to Ontario, their growing numbers and expanding

contribution to the economic, social, and cultural life of Ontario point to the importance of

continually looking for new and innovative ways to facilitate settlement and increase the

effective inclusion of all immigrants and refugees. These models build on the collaboration and

coordination that are widely valued and practiced among human service and settlement

organizations. The models add an individualized approach and the opportunity to differentiate a

service for an individual or family facing a complex or intractable situation.

The models raise a question. On the one hand through identifying someone as having

exceptional needs, new resources and creative problem solving are mobilized to attempt to

address the person‘s needs. However by differentiating the person as needy or lacking in some

way, is there a risk of the person being implicitly devalued by the intervention?

Decision Tree

Is situation of the

newcomer or their

family complex?

No

Yes

Is newcomer

willing and able

to set goals and

work with a team

to achieve them?

No

Yes

Apply Ontario

Newcomer Circle of

Friends Model

Apply Ontario

Newcomer

Wraparound Model



Social Role Valorization (SRV) is a relationship theory59 that explores how formal and informal

services can be designed and delivered to people who are vulnerable and at risk due to being

devalued or being seen as a burden. In common with other groups, newcomers may find

themselves socially devalued which is isolating, may have long term effects and is

counterproductive to effective settlement. Wolfensberger claims that the ―good things in life‖ are

going to be harder for people who are devalued to achieve. He includes:

Being accorded dignity, respect, acceptance

An education, and the development and exercise of

one‘s capacities

A voice in the affairs of one‘s community and society

Opportunities for work and self support.

At least a normative place to live

A sense of belonging

A decent material standard of

living

Opportunities to participate. 60

The models propose approaches that build on strengths and are intended to not exacerbate

neediness or dependence. By building around a vulnerable person a team of supporters who

are ‗looking out for them‘, the person gains a robustness that is facilitated by more people‘s

concern, ideas and actions. As described in section 3, there are a series of principles that are

essential for successful implementation of the wraparound model.

In addition to benefitting the newcomer the models strengthen cultural adjustment of the

community receiving the newcomer by providing cross learning opportunities. The engagement

of professionals and community volunteers not only helps to enable the person at the centre but

often increases the appreciation for the person and their previously unknown strengths. Team

members then help to further empower local communities by becoming advocates and

spokespeople for the strengths of newcomers and their contribution.

Ontario Newcomer Wraparound Model

Goal oriented and plan driven: The people who are invited to join the team around the newcomer (see

sections 2, 3 and 4) build a plan with the newcomer and work out with them the steps required to achieve

the plan. Team members support the person in the intentional activity required for each of the steps. The

role each person plays will vary with their experience, skills and interest.

Strength based: Focuses on and builds on the newcomer‘s strengths.

Fluid and flexible: The model allows for a high degree of individualization with plans and goals unique to

each person based on the person and their situation. There are no requirements to provide standardized

59 Social Role Valorization is: "The application of what science can tell us about the enablement,

establishment, enhancement, maintenance, and/or defence of valued social roles for people" (Susan

Thomas and Wolf Wolfensberger in Flynn and Lemay 1999, p. 125).

60 Osburn, Joe, An Overview of Social Role Valorization Theory, an updated version of an article originally

published in The International Social Role Valorization Journal in 1998.

http://www.srvip.org/overview_SRV_Osburn.pdf



or the same treatment for different people. The approach is open to expansion or contraction based on

the plan.

Realistic expectations: With the person‘s goals, circumstances, history and motivation in mind, goals

and achievements can be a series of small successes tailored to the individual.

Focuses time: By ensuring that team members are committed to participate in the wraparound team they

assure the newcomer of regular get-togethers (meetings) that provide structure in staff schedules.

Inclusive: A person facing significant barriers to settlement risks being excluded from the community or

society. With wraparound team support the person is provided with connections and greater resilience.

Putting heads together: Although ‗putting heads together‘ to solve problems is common sense,

sometimes the silos that services operate in, prevents this. The group of supportive people (team) who

are looking out for the person bring together a range of skills and many points of view for solving a

problem or opening doors to solutions.

Person at the centre: The newcomer is in a role that respects their knowledge and experience. They are

key to determining the plan and achieving their goals.

Comprehensive: The wraparound team focuses on the person‘s whole situation e.g. family, education,

recreation, mental health, employment, friends, transportation etc.

24/7: The model addresses the newcomer‘s needs outside ‗business hours‘, e.g. evenings and weekends

when informal and social needs may be met.

Creative: The possibilities are limited only by ideas and time. The model draws on the depth and capacity

of concerned people and their communities.

Responsive: Can respond quickly and link the person to activities, services, people or organizations.

Efficient: The team sets out not to replace or duplicate any existing services but instead to ensure they

are appropriately used and properly coordinated.

Opportunity: For a person, professional or non-professional who is concerned about the wellbeing of the

newcomer, a wraparound team is an avenue for making a difference, it responds to concerns for social

justice and builds on caring communities. The team members assume an attitude of ‗doing whatever it

takes‘ to support the newcomer to achieve their goals.

Coordination: The integrated team overcomes the disadvantage of approaches that segregate services,

sometimes resulting in a person receiving mixed or contradictory advice.

Team accountability: Team members set goals with the person and monitor progress with everyone

invested in positive achievements.

Continuity: In the event that there is a change in a team member, for example staff turnover, the

momentum is retained.

Affirms independence: Because the newcomer is the person in the centre, the model requires their

motivation, which prevents or reduces dependency.



The wraparound model relies on people and organizations working together, which often leaves

many questions to be considered by the organizations implementing a wraparound approach.61

Among them are the following:

Who coordinates the team?

Who makes decisions about what?

Which newcomers are eligible for this approach?

How will the referral process work?

How will decisions be made?

If there are family members who will be included?

What information will be shared and how?

How will services be accessed?

How will the need for supports be identified and then applied?

How will staff and volunteer time be made available?

Who will pay for and/or provide any needed services and supports?

How will information be documented and stored?

Is any kind of training needed, who will provide it and for whom?

Teams need to address some of these questions during the first of four phases.

Phase 162: Engagement and team preparation (2-3 weeks)

The facilitator who may be a professional or other person involved with the newcomer, initiates

the process by working with the person to discuss the concept and their interest in utilizing the

approach to assist them to realize their goals. Working with the concentric circle exercise the

facilitator identifies potential team members with the person and then invites each of them to

join the wraparound team.

During this phase, the groundwork for trust and shared vision among the newcomer and

wraparound team members is established, so that people are prepared to come to get-togethers

or meetings and collaborate. During this phase, the tone is set for teamwork and team

interactions that are consistent with the wraparound principles, particularly through the initial

conversations about strengths, needs, and culture. In this phase it needs to be clear that the

newcomer understands that they are an integral part of the process and their preferences are

prioritized. Although not rushed, the activities of this phase should be completed relatively

quickly so that the team can begin meeting and establish ownership of the process as quickly as

possible.

61 Adapted from Walker, J. S. (2008). Supporting wraparound implementation: Overview. In E. J. Bruns &

J. S. Walker (Eds.), The Resource Guide to Wraparound. Op Cit. Chapter 5a.1

62 The following phases have been adapted from Walker, J. S., Bruns, E. J., & The National Wraparound

and Activities of the Wraparound Process. In E. J. Bruns & J. S. Walker (Eds.), The resource guide to wraparound. Op Cit. Chapter 4a.1



Goals of phase 1

1. Orient the person to the wraparound process

2. Stabilize any crises

3. Explore individual strengths, needs, culture, and vision to serve as the starting

point for the development of a plan

4. Engage other team members

5. Make necessary get together or meeting arrangements

Phase 2: Initial plan development (1 -2 weeks)

During this phase, team trust and mutual respect are built while the team creates an initial plan

that addresses the newcomer‘s goals. This should be accomplished using a planning process

that reflects the wraparound principles. In particular, the newcomer should feel, that they are

heard, that the needs chosen are ones they want to work on, and that the options chosen have

a reasonable chance of helping them meet these needs. This phase should be completed

during one or two meetings that take place within 1-2 weeks, a rapid time frame is intended to

promote team cohesion and shared responsibility toward achieving the team‘s mission or

overarching goal.

Goals of phase 2

1. Ensure that the person at the centre is directing the goal setting

2. Develop plan to achieve goals

Phase 3: Implementation (3-18 months or as long as required)

During this phase, the initial wraparound plan is implemented, progress and successes are

continually reviewed, and changes are made to the plan and then implemented, at the same

time maintaining or building team cohesiveness and mutual respect. The activities of this phase

are repeated until the goals are achieved and formal wraparound is no longer needed.

Goals of phase 3

1. Implement the wraparound plan, monitoring completion of action steps and

strategies and their success in achieving outcomes in a way that is consistent

with the wraparound principles

2. Revisit and update the plan to respond to the successes of initial strategies and

the need for new strategies

3. Maintain/build team cohesiveness and trust

4. Document results of reviews of progress, successes, and changes to the team

and plan



Phase 4: Transition (ongoing)

During this phase, plans are made for a purposeful transition out of formal wraparound to a mix

of formal and natural supports in the community. The focus on transition is continual during the

wraparound process, and the preparation for transition is apparent even during the initial

engagement activities.

Goals of phase 4

1. Plan to wind down formal wraparound with a purposeful transition out of formal

wraparound in a way that is consistent with the wraparound principles, and that

supports the newcomer in maintaining the positive outcomes achieved in the

wraparound process.

2. Ensure that the cessation of formal wraparound is conducted in a way that

celebrates successes and frames transition proactively and positively

3. Follow up to ensure that the newcomer is continuing to experience success after

wraparound and to provide support if necessary.

The experience described in sections 2, 3 and 4 provide other useful information for applying

the wraparound model.

Ontario Newcomer Circle of Friends

Opportunity: A person who is concerned about the wellbeing of a newcomer becomes

a member of a Circle of Friends as a way to make a difference. The Circle responds to

concerns for social justice and builds on caring communities.

Coordination: Circles need to be connected into the settlement system so that they can

(i) hear about and respond to newcomer need and (ii) benefit from organizational

support such as bookkeeping and charitable receipt provision for donations.

Confidentiality: The Circle of Friends does not include the newcomer who is advocated

for by one of the Circle members. This way he or she retains their privacy.

Fluid and flexible: The model allows for a high degree of individualization with the

Circle helping in a way that is unique to each person based on the person and their

situation. There are no requirements to provide standardized treatment for different

people. The approach is open to expansion or contraction based on each person‘s need.

(See section 4 for examples).

Realistic expectations: With each newcomer‘s circumstances in mind the help can be

tailored to the individual.

Putting heads together: The group of concerned people bring a range of skills and

connections in the community that can mobilize a more effective response than any one

person is able to do on their own.



Focuses time: Because there are regular meetings, e.g. monthly, Circle members are

committed to achieving and reporting back on outcomes.

Comprehensive: Circle members are able to focus on the person‘s whole situation e.g.

family, education, recreation, mental health, employment, friends, transportation needs

etc and help in a variety of ways.

Creative: The possibilities are limited only by ideas and time. The model draws on the

depth and capacity of people and their communities.

Responsive: Can respond quickly by assembling resources or other help for the person

at short notice.

Efficient: The efforts of Circle members complement existing services.

Inclusive: Assistance from a Circle of Friends provides support and resilience for a

person who faces significant barriers to settlement and risks being excluded from the

community or society.

The experience described in sections 2, 3 and 4 provide other useful information for applying

the Circles of Friends model.

Organizational Change

Although there are aspects of both models that seem like common sense and other aspects that

are being delivered in part by existing service providers, the decision to begin to apply either of

the models requires some significant organizational change. Key new activities are summarized

in the following boxes.

Model: Ontario Newcomer Wraparound

New levels of collaboration including professionals and non professionals working

together

Useful to have a staff person who is credible in their collaborative work in the role of

coordinator

A strength based approach delivered that is consistent with wraparound principles

Unique individual focus for selected clients

Sustained support to achieve goals

Effective team work including planning and conflict mediation skills



Model: Ontario Newcomer Circle of Friends

Encouraging the creation of Circles of Friends that are more like local international

development organization committees than ‗typical‘ volunteers

Communication network to inform Circles of Friends about newcomer needs

Relationships with Circles of Friends including orientation, communication and

bookkeeping role

Accommodating variation of commitment and activity in Circles

Recognition of Circles and their members

Ensuring newcomers know their needs are being conveyed and managed confidentially

As the boxes above illustrate, adopting new models for programs and services will require a

new kind of thinking in organizations. The settlement sector is a dynamic one and familiar with

change. Schein identifies eight options for creating enough psychological safety to open

organizations to change.63 On the next page there is a list of Proehl‘s eight elements required

for a successful change process. Organizations, already busy addressing client needs will have

to prepare for the introduction of new models.

63 Cited in Franz, J. (2008). Planning for and implementing system change using the wraparound process.

In E. J. Bruns & J. S. Walker (Eds.), The Resource Guide to Wraparound. Op Cit. Chapter 5b.

Adaptation of Schein’s eight options to create psychological safety to open

organizations for change:

1. Creating a compelling positive vision

2. Providing useful and functional formal training

3. Encouraging ongoing involvement of the people who are expected to change

4. Providing opportunities for the whole group to practice doing things differently

5. Creating practice fields, coaches and feedback that encourage staff to develop the

skills needed for the change process

6. Providing positive role models so that staff can see how it looks to use the

proposed innovations

7. Establishing structured support groups that help staff work through the stress of

change

8. Designing consistent systems and structures that support the use of the new

approach.



Proehl (2001) describes eight elements for a successful change process in a human services

system.64 The following list is an adaptation of Proehl‘s:

64 Cited in Franz, J. (2008). Planning for and implementing system change using the wraparound process.

In E. J. Bruns & J. S. Walker (Eds.), The Resource Guide to Wraparound. Op Cit. Chapter 5b.

1. Create a sense of urgency. Nothing will happen unless a sufficient number of people feel that

change must happen. What are the internal and external drivers for change? What choices exist

regarding the decision to change? What are the political constraints affecting this change project?

What steps will be taken to create the urgency?

2. Build a coalition for change. Nothing will happen unless a group of motivated and empowered

people works together to produce change. Who are the system members who have the credibility,

power, and interest to support the change? What steps must be taken to build a team to guide the

effort? What strategies will be taken to build broad-based support?

3. Clarify the change imperative. Nothing will happen unless it‘s clear not only why change is

necessary, but also what that change should look like. What are the problems being addressed?

What is the vision for the change and outcomes anticipated? What resources will be needed? How

will legitimacy be established for the coalition team? How will the vision be communicated?

4. Assess the present. Reliable and sustainable change to a future state will not occur unless it is

built on a thorough understanding of the present state. What are the present obstacles to change?

What are the strengths? What data exist regarding the proposed change? How ready is the system

for change?

5. Develop a plan for change. We need to know who‘s going to do what, when it is going to happen,

how it is going to get it done, and how we‘re going to know whether or not it‘s happened and

whether or not it‘s helped. What level of planning is appropriate? What strategies must be taken to

help the organization achieve the vision? What activities will be taken to accomplish the strategies?

What short-term gains will be generated?

6. Deal with the human factors. The best plan in the world is likely to collapse unless the people who

are supposed to carry out the plan are on board and ready to go. What actions will be taken to deal

with communication, resistance, and involvement? What new skills, knowledge and attitudes are

needed to make the change? What incentives have been created to encourage system members to

change?

7. Act quickly and revise frequently. The window for creating and anchoring change is often a short

one. What immediate actions can be taken? What is the timetable for the change? Who will be

involved in the change activities? How will the change be monitored? How will the change be

institutionalized?

8. Evaluate and celebrate the change. How will organization members know if the goals have been

achieved? How will they celebrate their accomplishments? What rewards, if any, will there be?



Evaluation and Monitoring

Ontario Newcomer Wraparound Model

The research on wraparound warns against formalizing evaluation such that the value of the

strength based approach is undermined by a sense of the person having failed when goals are

not achieved. This might arise if the evaluation methodology focuses only on goals without

exploring other self directed behaviour that has been positive. Experience from the wraparound

model emphasizes the need to look at and celebrate even small successes and review and

revise the plan when intended outcomes have not been achieved. This may result in the need to

set smaller steps to achieve the outcomes.

A checklist of considerations for monitoring and evaluation might include:

□ Clarity of the newcomer about the process and their role in achieving their goals

□ Roles of team members including reliability and accountability

□ Realistic plan in place

□ Plan is reviewed and revised as needed and successes are celebrated

□ Wraparound principles applied including being strength based

□ Communication in and between get togethers

□ Problem solving and conflict mediation

□ Effective record keeping

□ Get together effectiveness

Ontario Newcomer Circle of Friends Model

Monitoring and evaluation within Circles of Friends will happen in the Circle and be mostly

related to how well newcomers are being assisted, whether meetings and relationships within

the circle are effective, and whether material in kind is being successfully acquired or the funds

needed are being raised. Other areas of concern may relate to keeping records.

A checklist of considerations for monitoring and evaluation might include:

□ Communication in and between get togethers

□ Response and relevance to identified needs

□ Roles of team members including reliability and accountability

□ Effective record keeping including bookkeeping

□ Achievements are celebrated.

Section seven captures the findings from consultation with the settlement sector.



Focus Group and Interview Participants

Shaida Addetia, Woodgreen Community

Services

Saadia Akram- Pall, Rexdale Women‘s

Centre

Hanadi Al Masri, Halton-Multicultural Council

Mario Bianchi, Mennonite New Life Centre of

Toronto

Natasa Boskovic, Newcomer Women‘s

Services Toronto

Huda Bukhari and Thilaga Jegenathan,

Canadian Centre for Victims of Torture

Melanie Canlas, Kababayan Community

Centre

Nigel Couch, Multicultural Council of Windsor

and Essex County

Sabra Desai, Humber College

Yasmine Dossal, COSTI

Rebecca Hii, YMCA of Greater Toronto

Jacqueline Jean-Pierre, Oolagen Community

Services

Lisa Loong, Catholic Cross- Cultural Services

Mahassen Mahmoud, St.Christopher House

Varsha Naik, Peel District School Board

Bernice Ramakgapola, Welland Heritage and

Multicultural Centre

Saundra Rennie, New Canadian‘s Centre of

Excellence Inc.

Nadia Sokhan, Polycultural Immigrant and

Community Services

7. Consultation

In December 2008, OCASI conducted focus groups

and interviews to test the usefulness of the

wraparound approach as an option for assisting

some newcomer families in settlement. An invitation

to participate in focus groups was distributed to

OCASI member agencies, especially to those that

had identified an interest in the area.

This section captures the valuable learning from and

insights of this consultation with the sector.65

Focus group participants identified a number of

attributes that a wraparound approach would add to

settlement services. They are:

Community non-professional support to

newcomers

Community stakeholder investment in the

person‘s successes

Flexibility including meeting on weekends

and in people‘s homes

Voluntary involvement

An alternative to formal facilities where

meetings are always around an office table –

(wraparound uses ‗a desk free environment‘)

Always checking back with the client/person

Transparency for the client/person

Highly inclusive

Broadens the support from only one person

who often cannot address the multiple needs

of a client

65 OCASI would like to thank everyone who participated in this wraparound consultation process.



An advantage for clients is that meeting with professionals in a team replaces what is

sometimes an overwhelming burden of multiple professional appointments

Provides structure

Gives skills to the person to help them resolve their issues with support

Encourages goal setting by the person which can be motivating and result in more

ownership of decisions and a greater sense of control of their own life

In small communities where there are fewer agencies and therefore restricted

opportunities for professional collaboration, community involvement could provide new

avenues of support

Avoids multiple referrals, multiple intakes and multiple assessments (―Clients are fed up

with referrals‖)

Participants pointed out that the wraparound approach needs a different model of funding,

unlike ISAP funding which is very structured. More flexible funding would be welcomed. This

raised questions of what quota expectations and criteria might be appropriate.

Participants also described other relevant considerations.

Select Cases

A large number of families and individuals assisted by the settlement sector have very complex

circumstances. This client group was referred to as ―service intensive‖. People with complex

issues vary considerably in why their cases are complex. Transgendered, gay and lesbian

clients who require culturally appropriate mental health services are one of the newcomer

groups who face complex challenges. Education and literacy level may range from being

illiterate to being a trained doctor. Because of the nature of the wraparound approach which

requires the person at the centre to be ready, willing and able to direct their own plan,

wraparound would be suitable only for select cases.

Wraparound requires the application of a new range of skills and behaviours from the settlement

worker, so the appropriateness of the option for an individual or family needs to be agreed upon

with the family and with others in the organization. Because the settlement worker with whom a

client works regularly cannot be neutral, someone else would be the facilitator with a

wraparound client. Ideally the settlement worker would participate in the person‘s wraparound

team.

Settlement organizations often work with a large number of cases. The size of the ‗case load‘ of

a worker may have an impact on the likelihood of any client being referred for a new approach.

Participants referred to the high costs of ‗ineffective settlement‘ which are seldom calculated into

decisions about the approach to suggest. Client needs will determine when wraparound is

suitable. (See box on p. 68 comparing case coordination and wraparound.)



Case coordination

- Professional defines goals

- Professional sets direction

- Focuses on a client‘s situation

- ‗Doing for‘

Wraparound

- Client defines goals

- Client sets direction

- Focuses on and builds plan based on person‘s

strengths

- ‗Doing with‘

Client Knowledge and Readiness

It is important for individuals or families who are invited to participate in wraparound to do so

voluntarily and having full knowledge and understanding of the approach. They should provide

their written consent and their commitment to becoming involved and remaining in the process.

Typically in other sectors, wraparound has been applied when other approaches have not

worked. But there was resistance to waiting to apply wraparound with some complex cases in

which it was evident almost at the time of arrival and their first assessment that the approach

would be helpful to a family or individual. The approach provides a vehicle for the injection of

front-end resources. Families who have experienced trauma, for example from Congo or

Burundi, were provided as examples of people who might be in this category. The difficulty of

settlement can lead to isolation and discouragement that could be prevented with the

community support of a team. Another concern was that often the most marginalized of

newcomer families do not come to organizations for assistance. In this case it would be useful

to ‗catch‘ families early after their arrival otherwise connecting with them would be dependent on

peer outreach.

On the other hand some people felt it could be stigmatizing to identify that a person was not

going to succeed using existing settlement approaches before service providers had really got

to know them. Others commented that a good assessment process is important to get to know

clients. Some traumatic experiences can be discerned immediately. This raised the importance

of good early assessments and being able to share information with referral agencies without

asking the person repeatedly for the same information. Others pointed out that the complexity of

some people‘s lived experiences will only be unwrapped over time and after trusting

relationships have been established.

Returning clients were also thought to be suitable candidates for wraparound, i.e. people who

have ‗got lost‘ possibly because of multiple barriers such as language, addiction, finances and

children‘s behaviour which have overwhelmed them. Where a family is involved wraparound

plans should be written with the whole family in mind, not for an individual without taking into

account the family dynamics.

Implementing the wraparound approach assumes that the person at the centre is able to identify

people who could be in their circle of contact who could join their team. A newly arrived person



may have only one or two contacts, e.g. their settlement worker and a member of their

community. In this case building the team would require suggestions from others.

There was concern that many vulnerable families may not be willing or ready to expose their

experience to a group, even though the team members have been chosen by them and are

involved to assist them. An example may be women who have been violated and would not

want or be capable of sharing their personal experience with a group. In such cases settlement

workers have to be very sensitive about who a client will speak to. In one example in which a

wraparound like approach was taken, the person at the centre found church members who were

trying to be helpful, were too obtrusive. It is the team‘s role with the help of the facilitator to

rectify this imbalance. Another challenge is to respect that sometimes family members do not

want each other at the team table, for example youth may not want their parents. Discussion

about the complexity of family dynamics raised the importance of acknowledging the layers of

cultural issues beyond race and ethnicity that exist for many families.

Innovative Paradigm Shift

Although wraparound may look like ‗heavy duty case management‘, it requires a shift in who is

‗steering‘. Case management typically omits the client from the discussion which is the

antithesis of wraparound which respects the choices of the person at the centre even if they are

not the choices that professionals would choose. This is captured in the wraparound phrase:

‗Nothing about us, without us.‘ Using a health analogy, wraparound places the person, not their

doctor, in charge of their own health. As one focus group participant said: ―Wraparound is

qualitatively different, it is change in the power balance‖.

Other observations about the positive merits of wraparound were that it is better for the client,

―Matches need to services, not vice versa‖ which is good, that the approach would require good

listening skills, that it would be helpful in avoiding duplication, including doing multiple

assessments, and would help each organization do its work better.

Participants in the focus groups liked the holistic approach but recognize that it appears to be a

time consuming approach. Others thought that wraparound could be time saving because

professionals would meet with other team members and be able to coordinate their work to

maximize efficient communication and reduce duplication.

One aspect of wraparound is engaging the organization‘s senior and middle management team

to buy-in to a new and innovative approach that focuses on helping the client succeed in the

areas they have self-identified.

Wraparound shifts the role from the ‗care-giving professional‘ to the ‗client as leader‘. In the

traditional model the settlement professional identifies what the client needs. The dramatic

nature of this shift should not be underestimated. Many agencies tend to see services provided

by multiple organizations as an illustration of wraparound but this is not accurate. It was a leader

in the sector who called wraparound a ‗paradigm shift‘.



The fact that the wraparound team meets together would help to address client feelings of being

overburdened by multiple professional appointments. Respecting the client‘s needs rather than

the organization‘s needs is an interesting aspect of wraparound. The values and principles

respect the individual being in control and making choices. The approach asks what can the

community do to help overcome social isolation with community support, but it requires capacity

at the individual client, staff, agency and community levels.

Community Engagement

One of the elements of wraparound that agencies liked was the opportunity to engage other

community agencies intentionally in a coordinated response. Focus group participants identified

the need to be able to engage with a broad range of services including:

Employment

Language

Health

Education

Mental Health

Housing

Recreation

Libraries

Income Assistance

Social Services

Legal

Children and Family Services

Youth Services

Senior Services

Women‘s Services

However participants said collaboration also has its down-sides. Although there is increasing

collaboration and requirement for collaboration among agencies, there are also more skills

required in conflict resolution and knowing, for example, how to deal with a colleague in another

agency who does not do what they say they will do. Another requirement is being able to

advocate effectively for a client when making a referral and being able to resolve a situation in

which a referral has failed to eventuate in any action.

The principle collaboration stages were described as (i) assessment, (ii) collaboration

(iii) shared learning and (iv) coordination.

Empowerment

One of the recurring themes in the discussion was the dependence induced in a newcomer by

multiple care-giving professionals. Wraparound was seen as an empowering process which

would prevent that dependency. The analogy might be ‗doing with, rather than doing for‘. Others

said that newcomers feel that they cannot control their lives because of the number of

professionals they relate to or the nature of their involvement with organizations.

Wraparound was seen as providing an opportunity to build a newcomer‘s strength and

resilience by building life skills appropriate in their new environment. Referrals to wraparound

could come from a number of people including their settlement worker and other service

providers.

Another advantage of wraparound was the opportunity for more established newcomers to be

invited to serve on the wraparound team of a new arrival, thereby affording them an opportunity

to share their experience, give back and possibly enhance their own skills by working with

others in a structured environment.



Participants raised the fact that benchmarks of progress along the settlement continuum are not

clear, so how do organizations evaluate success either with existing approaches or wraparound.

Participants observed that some newcomers go to services that ‗they want to hear‘ and avoid

others. Wraparound supports clients making their own choices and being responsible for their

own settlement plans.

A criticism of the Ontario Circle of Friends model was that it might build dependence, although it

was agreed that this is always behaviour that staff have to be sensitive about. Another

observation was that newcomers would be concerned about not knowing who is helping them.

Capacity Building

Participants felt that the ability to deliver wraparound would be help to build capacity for the non-

profit sector. However, a number of people felt that it would be an expensive model. The

discussion did not include determining the cost of ‗failed‘ or ‗significantly delayed‘ settlement

that could be costly in human and economic terms.

One observation was the difficulty some collaborating organizations found in relating to the

violence and brutality that some newcomers have experienced, making it difficult to work

together.

Some observed that the wraparound approach is aligned with the voucher system and also

some mental health service thinking which focuses on a system of service delivery.

One discussion proposed that the wraparound approach could strengthen communities by

building a community of care, which is being tried among school boards, faith leaders and

support services in some regions.

Obstacles

One of the obstacles the sector identified was the tendency of newcomers to be fairly transitory

and move around, for example to stay with relatives. This would result in it being difficult to

establish a team around families.

Section eight describes two Ontario wraparound services for immigrants in detail.



8. Wraparound in Action in Ontario with Newcomers

In September 2009 the application of the wraparound approach with immigrants and refugees

was explored in detail with two Ontario service providers. Both applications of wraparound

reveal that the investment required has long term benefits for youth, adults and seniors alike,

helping them to stay in their families, their homes and in their communities.

The London InterCommunity Health Centre provides a wraparound program as part of the

Ministry of Health‘s Aging at Home initiative for isolated immigrant seniors who are at risk of

having to leave their own homes.

Wrap Canada66 is a new national association that broadly supports the training and use of the

Wraparound process across Canada with people of all ages and cultures who can benefit by it.

(See the vision and mission of Wrap Canada on p.77.)

Wraparound with Seniors

An interview with Dharshi Lacey, Coordinator, Senior‘s WrapAround Initiative, at the London

InterCommunity Health Centre forms the basis of this section.67

In the first year of its three year program the London InterCommunity Health Centre (LIHC) is

providing the wraparound service to immigrant senior clients both from the Health Centre and

other referrals. The goals of the program are to support ethno-culturally diverse and

Francophone seniors who are at risk of hospitalization or long term care home placement, to

stay healthy, engaged and in their homes, and to support their caregivers.

For the LIHC the approach had appeal because it was ―not bound by the clock‖. The

wraparound process fits comfortably in the health centre where helping one person or one

family at a time is a familiar way of working. LIHC is perceived to be a credible organization that

is trusted to deliver the service. Outreach to invite referrals from community organizations that

provide services to people 55 and older is occurring with agencies such as CNIB (Canadian

National Institute for the Blind), the Hearing Society, settlement agencies and the CCAC,

(Community Care Access Centre).

The LIHC wraparound program has a number of partners including Family Services Thames

Valley which provides counselling services, three Francophone services, Across Languages, an

interpretation and translation service, as well as VON (Victorian Order of Nurses), employment

organizations and Community Services Coordination Network (CSCN) which provides the

training and coaching. The project partners meet 4-5 times a year and discuss de-identified

case studies and provide advice to the program.

66 For more information about Wrap Canada see www.wrapcanada.org

67 Special thanks to Dharshi Lacey for her generous contribution of time to this project.

http://www.wrapcanada.org/



The wraparound coordinator‘s role includes recruiting, coaching and mentoring facilitators,

outreach to community organizations and overseeing the program. The coordinator reports to

the manager of community services.

Training

At the outset of the program, in 2008, training for the coordinator and facilitators was provided

by the CSCN in London, which is the point of access for WrapAround for children and youth in

London-Middlesex, Oxford, Elgin, Huron, and Perth Counties. The coordinator and facilitator

participated in four days of training from 9 – 3 each day. The facilitators also spent time

shadowing CSCN wraparound staff. The trainer continues to meet periodically with facilitators

for coaching purposes and to provide guidance.

Facilitator Skills and Experience

The goal to recruit internationally trained professionals (ITPs) as facilitators resulted in looking

for candidates with transferable skills and experience in working with people in human services.

The recruitment process included outreach to organizations that work with ITPs as well as

Francophone organizations. Sensitive to the challenges of navigating the recruitment process

and aware of how it can impede a qualified ITP‘s ability to compete equitably, shortlisted

candidates were provided with an information package, referral to the website and the list of

questions they would be asked in the first interview. During interviews an attempt was made to

take the pressure off candidates and focus on such things as ―We want to know how you will

work with others‖. Important in an effective recruitment process is ensuring that all members of

the interview panel have agreed on the skills and experience they are seeking.

Three of the four facilitators are ITPs and the fourth is a Francophone. In addition to French and

English, facilitators bring language skills in Spanish, Farsi, Dari and Serbo-Croation. Although

the facilitators are proficient in several languages, the program intentionally avoids a facilitator

working only with cases in their language or cultural community. The backgrounds of facilitators

include teaching, audiology, medicine and rehabilitation. Dependent on funding, the facilitators

are permanent full time staff with benefits and competitive wages.

The facilitators have a case load of 12-15 people. The coordinator meets with each facilitator

every other week to support their work with clients and teams. In year three of the program

three more facilitators will be hired taking the number to seven.

Senior Clients

Fifty percent of participants have been in Canada for more than 5 years and many for 15-20

years. At the time of entering the program clients must have some life expectancy and express

openness to options. All clients are dealing with a different culture from the one in which they

were raised. (The program recently received a referral for a Canadian-born spouse of an

immigrant.) Many clients whose countries of origin include Afghanistan, Croatia, Serbia and

Iran, are dealing with isolation such as being at home alone for long periods. Clients deal with

complex health issues and illness such as cancer, mobility impairment, depression and hearing-



loss. Some clients are dealing with loss of a partner, adult children moving out of the home, or

away, some are unpaid child care providers, others are dealing with family conflict. Aging in a

foreign country is made more difficult by the lack of a network of friends such as they might

have in their country of origin. For older seniors, the English they have acquired is sometimes

lost as they age.

Currently there are 45 clients and families who have chosen to engage in the wraparound

approach. They represent all levels of education and most are literate in their own language.

Clients range in age from 55 to over 80 with most being in their late 60s. About 60 percent are

women. Building a person‘s capacity takes time, but complexity is expected to increase as a

result of aging. Unlike working with children, youth or adults, working with seniors requires

planning for the person to stay in the program, exit for a while when their needs have been met

but possibly returning to the service as they move further along the aging process and their

needs change and increase.

Assessment and Engagement

Wraparound is seen as a facilitation model but from the client‘s perspective it may not be

recognizable as a model. In many ways the program may initially resemble an immigrant

friendly visiting program, especially at the outset when the facilitator works with the client and

family to engage them in the wraparound process. Not all issues are best dealt with through

wraparound, e.g. if the identified goal is to get the house cleaned, the person is referred to the

appropriate service.

Presenting the wraparound approach is sometimes difficult because the role of the client is

different from the more familiar role of services being provided for them. Sometimes there are

expectations of the facilitator ―doing‖ things for the person rather than facilitating. This can be

confusing to clients used to a service delivery model and will ask ―What are you there for (if it

isn‘t to help me)?‖ Other anxieties arise from thinking that other services will be lost or put in

jeopardy. Examples have been fear of losing Ontario Disability Support Program benefits or fear

that an application to sponsor another family member might be threatened if they participate.

When the program is introduced and explained some people decline to be involved. By agreeing

to participate in a wraparound approach a senior might feel that they are implying that their

family is not or cannot take care of them. In some cases the senior may live with family. Many

seniors have huge needs, but often their anxieties are their children. ―I‘m OK, but if my son had

a job or if my daughter‘s income tax rebate came in.‖

Engaging the person may take 3 to 5 meetings. The assessment process utilizes a circular

diagram that captures the life domains. It results in asking people about their spiritual life,

safety, community, health and health care, relationships etc. It is important for people to

understand the need for a team and why people are there. The wraparound approach helps

family members who are often sandwiched between aging parents and children to care for, to

understand the roles they can play. When developing the client plan establishing a regular time

to do things is often useful for seniors who like routine, e.g. daughter takes the person grocery

shopping on Tuesday mornings.



Assessment is conducted either in the person‘s home, at a community location or at the LIHC

offices, whichever the person prefers. Early meetings usually include the facilitator with the

person, their caregiver and an interpreter. The person is invited to talk about themselves and in

this process the facilitator identifies the people in their life e.g. a grandchild, friend or neighbour.

Senior clients when asked if this person might join their team often say ―I don‘t want to bother

them‖. Sometimes potential team members emerge in later conversations. The facilitator

contacts the potential team members. The team sometimes adds the energy and focus that a

person needs to make progress on their issues. The teams tend to be smaller than the LIHC

staff anticipated.

There is flex funding available for immediate needs that cannot be met by other sources. A

month‘s worth of meals at the St Joseph Hospitality Centre is one example of this kind of

assistance. If larger amounts are required, other resources are explored, e.g. if a house burned

down, and a family required immediate assistance to meet basic re-settlement needs. If rides

are needed and public transportation cannot be accessed, LIHC has partnered with Meals on

Wheels to provide the ride and will reimburse MOW to coordinate a trip.

The process tends to be paper intensive. There are a number of tools used and keeping records

and sharing them as appropriate is part of the approach. For example the facilitator completes a

strengths/needs culture inventory with the person which includes their strengths, dreams and

vision for the future. The senior is asked how much of the information can be shared with their

wraparound team.

Teams and Language

Team members include informal members such as family, friends and neighbours and formal

members who provide professional services. Professionals want to provide support and stay

connected but may not participate in team meetings. Family member involvement is almost

always important. Sometimes if family members are away, they may be linked by phone. Team

members are volunteers who receive out of pocket expenses from the program budget. Team

meetings initially occur weekly and last about 2 hours. As the family becomes more self-

sufficient in meeting the needs of the senior, the meetings occur less frequently.

The program has determined the rules for engagement of teams including what language they

will speak. If everyone in the team speaks e.g. Spanish then the facilitator will speak Spanish.

But the facilitator regardless of their language skills is not the interpreter. Facilitators work with

all language groups, regardless of their own languages, and utilize interpreter services.

The program is cognizant of the different dynamics that occur when the facilitator is working with

his/her own language or cultural community. The roles, relationships and expectations are

different, the boundaries become more fluid. Expectations in relation to being ‗in my community‘

and the roles of elders or a younger person raise questions about the facilitator‘s role beyond

the professional one. It led, for example, to one facilitator being asked if they could help sponsor

the client‘s daughter.



Outcomes

By preventing anything falling through the cracks, wraparound helps to make small

improvements in people‘s lives. Sometimes this is by linking participants to services they were

not previously using.

At the launch event in June 2009, speakers included a client and a formal (professional) team

member. The client spoke about how his life had been strengthened, including his use of a

computer to communicate with family all over the world, as well as read a newspaper online in

his own language. He is not letting his hearing loss get in the way of his plans to take a

university course. The professional team member described having personally learned about

the value of getting a full picture of the client in a different context, as well as learning about

community services.

While attempting to remain true to the wraparound model, sometimes facilitators feel it is a

‗tightrope‘ between their roles of facilitator and service provider. As facilitator they work to build

trust and ‗just talk‘ with the client, but then may assist them with tasks such as filling out a

housing application. The biggest obstacle for progress toward client goals is team members or

the client not doing what they said they would do. If it is a critical step in making progress, the

facilitator or coordinator may step in and do it. Often it is easier to do what is needed than

support the client or a team member to do it, especially if the person is without English and has

difficulty accessing mainstream services. But facilitators work hard to remain true to the

wraparound facilitation process that strives to build capacity within the team to meet the needs

of the client.

A few clients are transitioning out of wraparound, but it is more likely to be younger people who

can self-manage their plans and for whom housing is settled. The process is expected to take 8

-18 months. It is important not to rush in at the beginning because a facilitator cannot get all the

information with the client quickly. While it is easy to identify gaps e.g. transportation, it is also

important to ask why transportation is an issue.

Evaluation

A framework for evaluation of the program over the next 3 years is in development. It will

include measuring: (i) whether the service is wanted, (ii) whether the plan is working,

(iii) whether life has improved, (iv) has there been a reduction in inappropriate use of services,

and (v) is the person accessing mainstream services.

Implications for the Immigrant Sector

Wraparound would require a systems change within the immigrant settlement sector and

therefore presents a challenge. Some of the language such as ‗strength based‘ is used,

although there may be a need to develop consistent use of language. One alternative would be

to phase some elements of the wraparound approach into daily practice. Currently intake, job

search and job placement tend to be offered in silos by the sector. Establishing a pilot with 5 or

6 agencies distributed in different regions could test the approach.



Wraparound with Families

Interviews with Andrew Debicki form the basis of this section.68 Andrew Debicki, Wrap Canada‘s

National Development Director, has provided training and consultation to both new and existing

Wraparound initiatives across Ontario, throughout Saskatchewan and, more recently in Alberta,

British Columbia and Norway. He is also employed by Shalem Mental Health Network in the

Hamilton area. Debicki has successfully applied the Wraparound process with new immigrants,

refugees and Aboriginal people in many of the local and national projects that he has led or

been involved with Wraparound

Wrap Canada

The Vision of Wrap Canada

All children, youth and adults and their families will be part of a vibrant supportive community

such that their varied challenges and needs will be heard, addressed and met.

The Mission of Wrap Canada

―Creating Community for All!‖- Wrap Canada will support communities to successfully implement

the Wraparound Process with all children, youth and adults and their families dealing with varied

and complex problems so that they have a better life and can be an active participant in their

community.

Wraparound: a useful process when others have not worked

Most people can get their needs met through one or two services while others have continuing

needs for which flexible application of services can provide the required help. However, for an

estimated 15% to 20% of people using services, multiple, complex problems that may go back

to early childhood or arise from post traumatic stress disorder, need a different approach.

Clients are typically dealing with acute or chronic situations that have often, without support,

become more complex over time. Sometimes dissatisfaction with other services or the feeling

that they have not worked is the reason a new approach is needed. Some people have ―burned

out‖ all their options.

There is significant pressure on services in Ontario and across Canada to work faster, cheaper

and more effectively, but often speeding up services does not achieve the intended outcomes.

In addition, some funders working in silos of services inappropriately compartmentalize people‘s

lives and their issues. Working with multiple services can be overwhelming for families.

Wraparound is helpful when there are two, three or more service providers working with the

same person or family because the approach can help to coordinate the efforts of all the service

providers into one integrated plan.

68 Special thanks to Andrew Debicki for his generous contribution of time to this project.



Remaining true to Wraparound principles

While remaining true to the 10 key principles, the process

needs to be individualized or customized, so that how the

facilitator applies the Wraparound principles will differ with

each person or family.

A much used phrase in Wraparound is ―nothing about us

without us‖. It refers to the importance of including the

person in all discussions and exchange about their lives

and the plans being made to work with them. This is

sometimes disconcerting for professionals who want to talk

about clients in their absence. In Wraparound, if something

is said about the person when they are not present, the

facilitator lets the other professionals know that as part of

their role they share all conversations they have about the

person with the person.

Essential to the Wraparound process is the movement of

the locus of control from external to internal. People are

often socialized when they access services to think that the

professional knows what is best. The more services a person accesses the more they might

come to believe that they can‘t solve their own problems, and only professionals are able to do

so. Focussing only on needs and problems tends to feed a dependency model. Focusing on the

diagnosis or problem is the medical model in which people are socialized to defer to the expert.

Traditionally, not following the direction of ‗the expert‘ was interpreted as resistance or non-

compliance.

The strength based approach used in Wraparound focuses on the person‘s capacity. The

person or family decides who is on their team, what they want to work on and how fast they

want to work on it. The person is being asked to exercise choice. This helps both the person

and their team members see that they have capacity. The facilitator helps the person, their

family and members of the team to make the required paradigm shift. There is no instruction

role in the Wraparound approach. The facilitator has a neutral role and does not provide

instruction. The approach also emphasizes the importance of assisting people to connect or

reconnect to positive social networks and assists them to develop or redevelop a social safety

net. Making change is difficult. The decisions have to be made by the person who needs to

know that they are in charge and have a choice, however, the team can help the person or

family make decisions.

Key to success is self determination of the person, working with them not for them which

requires careful planning by the facilitator. The three rules of Wraparound are preparation,

preparation, preparation! It is important to make the roles of team members clear, otherwise

team members who think they know best may try to impose a plan on the person or family. In

assisting a person to select their team members it is important that they choose people who will

10 Wraparound Principles

1 Family Voice and Choice

2 Team Based

3 Natural Supports

4 Collaboration

5 Community Based

6 Culturally Competent

7 Individualized

8 Strengths Based

9 Persistence

10 Outcome Based

For more detail on each see p. 22.



keep their situation confidential and are helpful, trustworthy and a positive influence. If a team

member is not cooperating they can be fired. When team participants are unable to attend team

meetings the facilitator tries to connect with them before or after meetings to get their ideas.

Person-centred goals

Participating voluntarily in Wraparound is important so self-referral is very useful. However

people often do not know where to get help so the initiative to refer is often taken by an

extended family member, a friend or community or religious leader. When a person is first

introduced to Wraparound they should be given time to think about what it will require from them

in terms of time, before they commit to going ahead.

It is also important at the beginning for the facilitator to discuss with the person what other

services have been used and what has worked and what hasn‘t including what they liked about

how they were treated by services in the past. It helps to reveal the level of trust people have

felt.

The Wraparound process does not assess people; rather, the facilitator spends time with the

person to discover their strengths and culture, the needs they have on a daily basis and who is

there to support them. This discovery process may begin simply with the question: ―Tell me

about a day in your life.‖ This is called the Strengths, Needs and Culture Discovery.

In Wraparound it is important to pay attention to where a person is at in their life and to help

them to move toward their vision at a pace that is comfortable for them. Often people say that

services have focused more on where they think the person should be and what they should be

doing rather than starting with where they are.

Setting goals with a person requires getting a clear sense of what they want their life to look like

when things are ―better‖. Ensuring safety is always the first priority. Sometimes helping the

person set goals is best reached by asking about ―The qualities your life will have when things

are better‖.

The process of the Strengths, Needs and Culture Discovery should lead to the identification of

both short and long term goals. This may include things such as getting food on the table,

getting a job or decreasing the percentage of income being spent on rent. Goals may start small

but build as the person experiences success.

If a person is in crisis the goals associated with just the crisis will emerge. In this context it is

important to help the person resolve their crisis before asking them to set longer term goals.

Wraparound is more aligned with approaches that happened historically and still occur in many

cultures, in which people look to their family or community for support. Although the approach

may seem like common sense, it is necessary to coach the facilitator for skill building and

sometimes provide intense support for them to learn to implement the process effectively.

Wraparound success stories illustrate that participants may benefit in ways that other services

have overlooked. For example one youth who was supported by a Wraparound team



subsequently identified three things that made a substantial difference in helping him get his life

back on track. One was receiving regular meals (in a residential situation), another was having

opportunities for outdoor recreation and the third was working with two adults who cared about

him. Relationships are a powerful factor in motivating change.

Cultural and religious understanding

When applying the Wraparound process with immigrants and refugees it is very useful to

include people on the team who have also had experience as a newcomer. They will be able to

help other team members avoid taking Canadian values and belief systems for granted. Having

a team member of the same culture or same faith, and having an understanding of the person‘s

culture are also useful. Sometimes a cultural advisor may be a way to bring these skills to the

person‘s team.

With First Nations people as well, it is useful for team members who are not familiar with the

cultural context to be reminded that they do not understand it. Team members might naturally

include people with these skills and experiences. Many of the same considerations apply to

working with people in the Francophone community.

Resource requirements

A relatively small percentage of the population dealing with multiple, complex needs, utilizes a

disproportionate percentage of services. When this use of services does not help the person

sort out their issues, a different approach is needed. Wraparound is not a quick fix solution.

Although up to a year is a common amount of time used for the process, a few families have

been involved for 4 to 5 years, while others for as little as one or two months. Sometimes a

friend or member of the extended family can be trained or mentored as the family‘s facilitator

and support the family in the longer term.

Although the facilitator may plan with the person for about 12 months of team support, in reality

people‘s lives have peaks and valleys and there may be a need for booster sessions from time

to time. There may also be a need for time for consolidation of learning and periods of

decreased intensity.

At the outset Wraparound will likely take about 3 hours per week for each client until the process

gets going, after which the required time decreases. Although apparently time consuming, the

approach is more efficient and effective because it focuses on real-life day to day needs as well

as facilitating the team to integrate all of their efforts into one plan that is led by the person or

family.

Generally facilitators can manage case loads of approximately 10 families, which may grow to

12 or 14 as some families are phasing out and new ones are starting. Coaches may be able to

support 6-10 facilitators.



Community involvement and supervisor and agency support

Where Wraparound is a new approach for organizations, managers must sanction staff

undertaking something different and support them in this innovative practice. Another

requirement is collective community commitment because it is a community based model that

benefits from effective system partnerships. The approach allows for creativity such as involving

faith communities that might not normally be considered as valuable partners in a traditional

professional model of service. It is also useful to have a small flex fund to support the person‘s

needs, and people to approach for in-kind resources.

Importance of training

A critical component is training and support including evaluation to determine if change is

happening. Valuable roles, skills, abilities and experience of staff and volunteers involved in

Wraparound are:

Ability to engage with those who are hard to engage

Willingness to advocate for the person and help them to go to appointments by going

with them if necessary and helping them to build relationships with workers if necessary

Being a good listener and seeing the role as facilitating not ‗doing for‘. (Sometimes this is

the hardest shift to make.)

Good time management skills and ability to multi-task

Some related professional training

Not getting stuck ‗thinking in boxes‘

Good conflict avoider and good conflict resolution skills

A details person and good at information management

A good communicator

Training people to implement Wraparound can be customized and approached as an art by

training to people‘s passions and recognizing the organizational culture they come from.

Ideally training for facilitators takes four days with a subsequent two day refresher. Individual

and group coaching of a team of facilitators should be intense at first but then at least monthly

with a focus on learning, case review and peer shadowing. It is useful to have a certified

Wraparound coach on staff so that they are able to work on tough cases with new facilitators.

Training for managers of Wraparound facilitators is usually two days of training.



Example

One newcomer family who benefitted from Wraparound is a Muslim mother, her teenage son

and younger daughter. The son, who was small for his age and entering puberty late was

disadvantaged by the absence of his father. He was having trouble at school, not by acting out,

but by not participating in class as was expected because he was self conscious about being a

visible person of colour and entering puberty. He was asked by the school to stay at home until

he agreed to participate as expected in class.

Culturally it was not appropriate for his mother or aunt to speak to him about issues related to

puberty. He stayed at home for three months, ashamed to go to either school or faith services.

The Wraparound team consisted of his mother, the Imam, his aunt and a young adult male

mentor/tutor from the faith community. The team utilized the skills of a Muslim facilitator from a

country different from the family at their request. The plan with the young man focussed on

helping him get back to and stay in school. A teacher from the school was willing to advocate for

home teaching to start the process. He procured a computer for the young man who was skilled

at computing. He began with a part time job with a member of the Muslim community and slowly

got back to school by doing his school work online.

Section nine introduces the elements of required training for the wraparound approach.



9. Training

To ready the settlement sector to be able to provide the wraparound approach, a number of

training needs were identified during the consultation with the sector. Six areas in which people

said that training would be useful were identified:

Delivering a Strengths Based Approach

Wraparound Training for Facilitators

Wraparound Training for Managers

Building and Maintaining Agency Relationships for Successful Client Outcomes

Cultural Proficiency and Diversity Training

Interview and Assessment Skills

Wraparound Training for Facilitators and Managers

Key to successful wraparound is the facilitator who plays a critical role. The facilitator works

closely with the client, remaining neutral to ensure that the person or family (the client), with the

help of team members, guides their own wrapround plan. The facilitator also contacts members

of the team and invites and supports their participation. The facilitator also ensures the plan is

developed and followed and that notes are taken of meetings. For more detail about the

facilitator‘s role see pages 40-42.

The ability of any organization including a settlement organization to provide the wraparound

approach is dependent on having one or more facilitators who, in a neutral capacity, can work

with the newcomer individual or family. Arising from the consultation with the sector the

recommendation was made to train interested settlement workers to have facilitator skills that

could be applied with a maximum of a few newcomer families at any time while they retained

their role with other clients. The facilitator could also be a person other than a settlement worker

who is a resource person within the organization who could work exclusively as a facilitator with

families. A person working full time as a wraparound facilitator should be able to support 10-15

cases. The facilitator must be able maintain a neutral role.

Being able to deliver a strengths-based approach is important for staff involved in wraparound to

ensure that client abilities are assessed and are taken into account in the person‘s plan.

Learning and training opportunities exist at Humber College and are also described in the

writings of John McKnight.

Wrap Canada as a new national association that broadly supports the training and use of the

Wraparound process across Canada is a source for training information, training and trainers.



Facilitator Training69

Training of facilitators can be customized to meet the needs of participants from the settlement

sector. For example, settlement organizations interested in having a person on staff qualified to

work as a wraparound facilitator could identify such a person and their manager to participate in

the training.

To be a good facilitator the person must buy into the process and recognize that wraparound is

not a therapy, which is a common misunderstanding of social work and psychiatry

professionals. The process requires implementing and supporting a team that will help a person

move forward.

People who might make good wraparound facilitators:

Take a strengths based approach

Are willing to work in a team not as ‗the expert‘

Have strong organizational skills

Defer to others even if they have the knowledge themselves

Are able to multi-task

Are able to coordinate and broker with and for others

Oolagen‘s Wraparound Supervisor describes many people who grasp the wraparound process

as ‗loving it‘ and taking it on as ‗an exciting new project‘.

Training begins with a four day training event for wraparound facilitators and a one-two day

training event for managers.

The training equips facilitators to implement all the wraparound stages which are:

a) Engagement stage – which includes the get acquainted stage. The facilitator, who

always remains neutral conducts discovery with the person, exploring their strengths and

needs using the person‘s own assessment of each of the life domains.

b) Team building – the person identifies team members and the facilitator approaches each

person inviting them to join the team which might be e.g. 50% professional and 50%

non-professional.

69 Special thanks to Catherine Blocki-Radeke, Supervisor of Wraparound & Intensive Services, Oolagen

Community Services, Toronto, for her assistance in developing this section.



c) Implementation – the first and subsequent wraparound meetings are held usually once a

month. Team members may be in contact with the person more frequently. In team

meetings strengths are listed by team meetings and priorities are set and written up into

a plan including who, when and where. The facilitator assists the person to find and have

a voice at team meetings. There is no discussion about the person outside the meeting,

(―nothing about us, without us‖).

d) Transition out and celebration including a written summary. However, in the event of a

crisis meetings might be called at this stage.

Follow Up

A critical part of the support following training is coaching and mentoring. Each trained facilitator

receives many hours of support from a coach for up to one year following the training. Typically

the coach works with the facilitator with one of the families they are working with, attends team

meetings and is able to guide the facilitator on how to strengthen their work.

Management Training

In addition to the newly trained facilitator being supported by the wraparound coach/mentor, it is

important that the person‘s manager be informed about the wraparound approach and be able

to support the facilitator. To this end, managers either attend the four day training with

facilitators or a separate one to two day management training event.

Sustainability

An objective of wraparound support is to build sustainability so that the wraparound approach

can be continued. Failure to plan for continuity has resulted in the approach fading out of some

organizations, even those that trained staff in the approach.

Community Resource Team

The Community Resource Team (CRT) is a support group that consists of experts who can

provide advice or assistance or help wraparound teams find the assistance they need in the

community. The same CRT can support many wraparound teams. CRT members in the

community may include funders, professionals or graduates of the wraparound approach and

other members of the business or faith communities with skills that are required either on a

continuing or an as needed basis. Teams, represented by the facilitator bring non-identifying

questions to the CRT. The settlement sector could provide one or more people to join the

existing Community Resource Teams.

Building and Maintaining Agency Relationships for Successful Client

Outcomes.

Agency relationships are important for staff involved in wraparound to ensure that resources are

used in the best way and that referrals happen successfully. (Participants in the focus groups

pointed out that many referrals are not successful.) Relationships or partnerships may be at

more than one level within organizations, for example at the front line and at the management

level.



Settlement might bring together multiple distinct skills. In many cases working collaboratively is

not new, and it works well or poorly as a result of a variety of factors. Disciplinary interests

sometimes prevent people working effectively together across sectors, even within the same

sector or the same organization. Often mandates and perceived mandates are related to

funding.

The skills needed are both within the organization and with external organizations, some of

which will be worked with often and some will require infrequent coordination. Participants in the

sector identified one of the challenges being to persuade others to participate in a team and

have faith that the outcomes will be worth the time and effort.

Learning objectives of this training would be:

To understand agency mandates and focus, so that alignment with requirements can be

assured

To understand the usefulness of a gap analysis of services

To establish ways to coordinate multiple agency participation

How to establish clarity in roles and responsibilities

How to be collaborative and have effective coordination between settlement agencies

How to conduct effective follow up

How to build effective networks

Advocating for a client and making effective referrals, including live referral

How to effectively share best practices

Agreeing on, implementing and following through on accountability structures

Problem solving when there is a failure to provide agreed upon services

Cultural Proficiency and Diversity Training

Cultural proficiency and diversity training are important for staff involved in wraparound to

ensure that communication and actions are culturally sensitive and appropriate. There are a

variety of learning and training opportunities provided inside and outside the settlement sector.

Interview and Assessment Skills

Focus group participants observed that ‗assessment‘ means different things to different people

and organizations. Interview and assessment skills are important for staff involved in

wraparound to ensure that a client‘s need can be addressed early in the process.



10. References and Further Reading

Amankwah, Dinah, Integrative Wraparound (IWRAP) Process Training, Community-University

Institute for Social Research, University of Saskatchewan, 2003.

Austin, Z, Opportunities and Responsibilities for Post Secondary Institutions, University of

Toronto – U of T Bulletin July 22, 2008. http://www.news.utoronto.ca/forums/bridging-

education.html.

Burns, B and Goldman, S.K., Volume IV, Promising Practices in Wraparound for Children with

Serious Emotional Disturbance and Their Families,

1998http://cecp.air.org/promisingpractices/1998monographs/vol4.pdf

Bruns, E. J., & Walker, J. S. (Eds.), The Resource Guide to Wraparound. Portland, OR: National

Wraparound Initiative, Research and Training Center for Family Support and Children‘s Mental

Health. http://www.rtc.pdx.edu/NWI-book/Chapters/COMPLETE-RG-BOOK.pdf (The 700 page

Guide which is a compilation of mostly US articles contributed by the advisors of the National

Wraparound Initiative, has been a very valuable resource for this project.)

Canadian Evaluation Society, Ontario Chapter, 2007 PEACH/Oolagen Wraparound has been

supported by National Crime Prevention Strategy, Royal Bank, and Toronto Community

Housing Corporation. http://www.evaluationontario.ca/Events/RossiterWilsonPargassingh.html

Caledon Institute for Public Policy. Naomi Alboim‘s report, published through Caledon, ―Fulfilling

the Promise: Integrating Immigrant Skills into the Canadian Economy.‖

Canadian Policy Research Networks and the Ontario Trillium Founation, Indicators of Healthy

and Vibrant Communities Roundtable Summary Report, Sylvie Cantin, Romilly Rogers,

Samantha Burdett. June 2008


Circles Network, Building Inclusive Communities (UK)

http://www.circlesnetwork.org.uk/default.htm

Community Living Project Inc SA. www.clp-sa.org.au. Also interview with Jayne Barrett,

Manager of the Circles Initiative for Community Living Project Inc. in South Australia in August

2008. A DVD, Circles of Support, showing the circles of friends at work can be purchased from

The Education Shop - http://www.metromagazine.com.au/shop/default.asp.

Community Services Coordination Network, London, Ontario.


East of England Regional Assembly Report, May 2004.

Goodwin, Bernie, Manager, International Tracing, Refugee and Asylum Seeker Services,

Australian Red Cross, Adelaide. Interview.


http://www.evaluationontario.ca/Events/RossiterWilsonPargassingh.html


http://www.circlesnetwork.org.uk/default.htm


http://www.metromagazine.com.au/shop/default.asp




Green, Mike, Building the Road as You Walk It: Community Partnerships that Work


Habel, Robert “Asylum Seekers to Citizens,from Detention Centres to Independent Housing”.

Uniting Care Wesley, Port Adelaide (South Australia). www.ucwpa.org.au/content/159.

Host Program Ontario website - http://www.hostontario.org/e/index.cfm

International Family Adolescent and Child Enhancement Services, Heartland Health Outreach

cited in Bridging Refugee Youth and Children’s Services, Washington D.C.

http://www.brycs.org/brycs_featuresept2005.htm

Llobet, Raul, Wraparound Initiative – Diversity Project. Building Inclusive and Accessible Family

Services in London. Final Report Phase1. November 2005.

Management Assessment Panel Integrated Service Model and Principles Service model

documentation, Exceptional Needs Unit, Disability SA, South Australia. Materials and interview

with Dale Hassam, August 2008.

Maytree Foundation www.maytree.com.

Northwest Federation of Community Organizations In Our Own Words: Immigrants’ Experiences

in the NorthWest. February 2006.

Osburn, Joe, An Overview of Social Role Valorization Theory, an updated version of an article

originally published in The International Social Role Valorization Journal in 1998.


Petsod, Daranee, (Ed) Grantmakers Concerned with Immigrants and Refugees. Investing in Our

Communities: Strategies for Immigrant Integration. A Toolkit for Grantmakers. June 2006.

http://www.aecf.org/KnowledgeCenter/Publications.aspx?pubguid=%7B064159E5-692E-48EA-

8B2C-40CEECAC98B0%7D

Stoney Creek United Church Annual Program Report, April 2008 p.4.

http://www.stoneycreekunitedchurch.org/Files/Annual_report_apr_08.pdf

Swift, Ian, Coordinator - Circles of Friends, Australian Refugee Association, Adelaide, Interview

and unpublished paper by Ian Swift. Also Starter Kit provided by the Australian Refugee

Association to people interested in starting a new Circle. Also interview with M. McGregor,

retired convenor of Circle 42, October 2008 and discussion with members of the Hills Circle of

Friends October 2008 monthly meeting, South Australia. The Hills Circle website is

http://hillscof.ourprofile.net/index.html

Tamarack Institute for Community Engagement, Annual Report 2006.

http://tamarackcommunity.ca/downloads/reports/tamarack_annual_report06.pdf

Toronto Region Immigrant Employment Council (TRIEC) http://www.triec.ca/programs/the-

mentor-partnership


http://www.ucwpa.org.au/content/159

http://www.hostontario.org/e/index.cfm

http://www.brycs.org/brycs_featuresept2005.htm

http://www.maytree.com/


http://www.aecf.org/KnowledgeCenter/Publications.aspx?pubguid=%7B064159E5-692E-48EA-8B2C-40CEECAC98B0%7D

http://www.aecf.org/KnowledgeCenter/Publications.aspx?pubguid=%7B064159E5-692E-48EA-8B2C-40CEECAC98B0%7D

http://hillscof.ourprofile.net/index.html



VanDenBerg, John, Trina Osher and Ira Lourie, Child, Adolescent, and Family Issues: Team-

Based Planning and the Wraparound Process, National Research and Training Center on

Psychiatric Disability, University of Illinois at Chicago.

West End Refugee Services Annual Report 2005-06, Newcastle upon Tyne, United Kingdom.

World Health Organization, Closing the gap in a generation: health equity through action on the

social determinants of health: final report of the commission on social determinants of health.

August 2008.

WrapAround/Children‘s Aid Society Pilot Project Evaluation Update as of February 2008

http://wraparound.ca/cmfiles/Microsoft%20Word%20%20WRAPAROUND_UPDATE_Feb_08[1].

pdf

Youth Services Bureau of Ottawa


Zizys, T, Kosny, M and Bonnell, J, A Review of Social Planning Activities in the City of Toronto,

Prepared for the Social Development and Administration Division Community and

Neighbourhood Services Department City of Toronto. June 2004. P.4.


http://wraparound.ca/cmfiles/Microsoft%20Word%20%20WRAPAROUND_UPDATE_Feb_08%5b1%5d.pdf

http://wraparound.ca/cmfiles/Microsoft%20Word%20%20WRAPAROUND_UPDATE_Feb_08%5b1%5d.pdf



Documents

Wraparound: A Different Way of Organizing … · Wraparound: A Different Way of Organizing Assistance to Newcomers - Research Report Prepared for OCASI – October 6, 2009 2 Contents