grounded theory and backward mapping: exploring the implementation context for wraparound

Regular Article

Grounded Theory and Backward Mapping:

Exploring the Implementation Context

for Wraparound

Janet S. Walker, PhD

Nancy Koroloff, PhD

Abstract

Within children_s mental health, there is an increasing demand for wider implementation ofwraparound and other interventions that can provide comprehensive, individualized, family-drivencare. Unfortunately, implementation has proven difficult because these approaches do notnecessarily flourish within traditionally organized agencies and systems. This has highlighted theneed for information about how mental health agencies and systems must evolve if they are toprovide a hospitable implementation environment for these interventions. A first step in developingthis information is through research that advances conceptual and theoretical understanding of theimpact of contextual factors on implementation. At the same time, there is an immediate need forpractical information to guide decision making and policy development in settings whereimplementation is being undertaken. This article describes a study of wraparound implementationthat used a combination of qualitative strategies to meet both of these needs simultaneously. It isargued that these strategies are particularly well suited to the study of emerging practices thatreflect—and help drive—transformation in mental health systems.

Recent years have seen the rise to prominence of two trends that profoundly challenge

prevailing practices and systems for mental health care in America. One trend is a heightened

urgency for increasing the availability of mental health programs and interventions for which

there is evidence of effectiveness. The other is the growing affirmation of a set of philosophical

principles promoted as recovery (for adults) and system of care (for children and adolescents and

their families). These principles call for mental health care that is comprehensive, individualized,

and consumer- or family-driven.1,2 These two trends received a great deal of attention in several

recent influential assessments of the state of mental health care,3–5 and they figure prominently in

the vision of a transformed mental health system as expressed in the final report of the President_sNew Freedom Commission on Mental Health.6

Address correspondence to Janet S. Walker, PhD, Director of Research and Dissemination, Research and Training

Center on Family Support and Children_s Mental Health, Regional Research Institute & Portland State University, P.O. Box

751, Portland, OR 97207, USA. Phone: +1-503-7258236. E-mail: [email protected].

Nancy Koroloff, PhD, Director, Regional Research Institute, Portland State University, P.O. Box 751, Portland,

OR 97207, USA. Phone: +1-503-7254040. Fax: +1-503-7254180. E-mail: [email protected].

Journal of Behavioral Health Services & Research, 2007 * 2007 National Council for Community Behavioral

Healthcare.

Exploring the Implementation Context of Wraparound WALKER, KOROLOFF 443

Within children_s mental health, the confluence of these two trends has resulted in a demand for wider

implementation of interventions that can deliver desired outcomes while also conforming to the system

of care principles. However, the implementation of such interventions has proven difficult because these

new approaches do not necessarily flourish within traditionally organized agencies and systems. This

has highlighted the need for information about the specific ways that mental health agencies and systems

must evolve if they are to provide a hospitable implementation environment for comprehensive,

individualized, family-driven care. Unfortunately, implementation research is scanty, particularly with

regard to organizational and system context,7,8 and most of the research that does exist focuses on

programs that are contained largely within a single organization or agency.9–11 In contrast, providing

individualized, coordinated care requires working across organization and agency boundaries. This

creates an extremely complex implementation context and one that is likely to vary substantially from

one community to the next.

The study described in this article examined the implementation context for wraparound, a team-

based planning process intended to provide individualized, coordinated, family-driven care to meet the

complex needs of childrenwith severe emotional and behavioral difficulties.12 In 1999, it was estimated

that as many as 200,000 wraparound teams were at work,13 and it is likely that this number is

increasing given that wraparound has been identified variously as an evidence-based practice14 and as

a Bpromising^9 or Bemerging^6 best practice. The wraparound process requires that families, pro-

viders, and key members of the family_s social support network collaborate to build a creative plan

that responds to the particular needs of the child and family. Team members then implement the plan

and continue to meet regularly to monitor progress and make adjustments to the plan as necessary.

The team continues its work until members reach a consensus that a formal wraparound process is no

longer needed.

The values associated with wraparound require that the planning process itself, as well as the

services and supports provided, should be individualized, family-driven, culturally competent, and

community-based. Additionally, the wraparound process should increase the Bnatural support^available to a family by strengthening interpersonal relationships and utilizing other resources that

are available in the family_s network of social and community relationships. Finally, wraparound

should be Bstrength based^, helping the child and family to recognize, utilize, and build talents,

assets, and positive capacities.15–17

Achieving broad scale, high-quality implementation of wraparound has, however, proven to be

challenging.18–20 Practical experience has shown that the successful implementation of creative,

individualized wraparound plans at the team level requires extensive support from the

organizations that collaborate to provide wraparound, as well as from the larger system context

(or policy and funding context) within which the teams operate.21–23 Achieving the necessary

level of collaboration and support can be challenging given entrenched organizational cultures

and ways of doing business, interagency barriers, funding exigencies, and skepticism regarding

the effectiveness of family-driven, strength-based practice.

The goal of this study was to advance conceptual and practical understanding of contextual

factors that influence wraparound implementation. By focusing on the implementation context,

the study responded to a clearly expressed demand from wraparound stakeholders to know more

about how to make this popular yet difficult intervention successful.17 While this article discusses

some of the findings from the study, the main purpose here is not to communicate findings in detail. A

more comprehensive discussion of the study findings is reported elsewhere.24 Instead, the main

purpose of this article is to provide an example of how particular qualitative research strategies have

been used to study implementation in the context of an evolving system of care. This article uses

the study to illustrate how these research strategies can be employed to provide immediate, practical

information while also laying a theoretical foundation for future research. In the case of the study

described here, the longer term goal is to develop and validate measures of contextual fidelity that

can complement measures of practice fidelity in an overall effort to ensure positive outcomes.

444 The Journal of Behavioral Health Services & Research 34:4 October 2007

Method

The study of the implementation context of wraparound was conducted using an approach that

was based on grounded theory method and that relied heavily on perspectives generated through a

strategy of backward mapping. Grounded theory is a qualitative research method that is typically

used as a means of developing theoretical and conceptual understanding of social and

interpersonal phenomena.25–30 The aim of the method is not to test hypotheses because a focus

on testing can inhibit the generation of a more rounded and dense theory. Instead, the method is a

systematic process for allowing the emergence of a conceptually sophisticated theory that

describes and explains structures and patterns relevant to the phenomenon under study.

Grounded theory research can make use of diverse data-gathering strategies, but strategies most

typically involve interviews and observations, as well as a review of records, literature, and other

documents. The data that are gathered are often in the form of detailed notes and/or interview transcripts.

Interesting aspect or regularities in the data are drawn out of this material through the development of

initial coding categories. As initial codes become better developed, the researcher seeks to draw

connections between categories, grouping them together in such a way that a category is linked to

subcategories that provide information about the properties of the category, such as the conditions that

give rise to a category, its context, its consequences, and so on. As analysis proceeds, one or more

categories may emerge as core categories that appear with high frequency in the data and that are well

connected to other categories. Coding then may becomemore highly focused on the core categories and

the categories connected to them.26,31 A distinguishing characteristic of grounded theory is the use of

the technique of constant comparison as a central feature of the largely simultaneous processes of data

analysis and theory development and validation. As coding proceeds, categories evolve as new data

are continually compared to previously coded data, causing the researcher to validate, modify, or

reject the current understanding of a category.

In an overlapping process, a theory is developed as the researcher begins to form ideas about

structural, causal, or other relationships between the categories. These pieces of emerging theory

are recorded in memos, which then also become the object of constant comparison against new

data. As analysis proceeds, the researcher may see the need to gather new data to use for further

comparisons against the existing coding scheme and emerging theory. The theory is progressively

refined as it is continually verified against new data. The theory gains in conceptual sophistication

as the categories become more fully described and as structural relationships or causal linkages of

the categories are drawn out. This process continues until the researcher is satisfied that additional

data do not yield more information about the coding categories or the relationships between them.

The use of constant comparison is intended to ensure that the emerging theory remains

Bgrounded^ in the data rather than in the biases of the researcher. In a further guard against bias,

the data that are gathered should represent a diversity of relevant perspectives and/or experiences

relevant to the phenomenon under study. Often, this requires that the researchers systematically

search out and attend to data gathered from diverse groups of actors who participate in the

phenomenon. This is particularly important if there is reason to believe that these actors_perspectives or experiences may differ from one another. In addition, while the perspectives of

those closest to the phenomenon are accorded most weight in theory development, the

perspectives represented in other sources—such as existing research literature and theory or

other documents—may also be relevant.

The method, as applied in a given study, can be judged as rigorous if it is apparent that the

researchers have sought out and systematically analyzed a range of relevant perspectives.

Conceptual sophistication and accuracy are judged by the extent to which the theory Bfits^ as a

description of the phenomenon under study. Ultimately, the goal of a grounded theory approach is

to produce theory that can be applied in everyday situations by people engaged in the activities

under study. The theory must make sense to them and be useful to them in confronting practical


problems.25 Thus, final iterations of the verification phase of the research may proceed through a

structured process of seeking feedback from intended users of the proposed theory.

Within this grounded theory method, the study relied on a strategy known as backward mapping.32–34

Backward mapping is a strategy for policy and implementation analysis that begins with a description

of desired behavior at the Blowest^ level of intervention, in this case, the wraparound team level,

where Bpublic servants touch the public^. Analysis then proceeds to identify the policies, resources,

and supports that are needed from Bhigher^ levels if the desired behavior is to occur. Backward

mapping assumes that Bthe closer one is to the source of the problem, the greater is one_s ability to

influence it; and the problem-solving ability of complex systems depends not on hierarchical control

but on maximizing discretion at the point where the problem is most immediate.^32(p.605) This

approach stands in contrast to forward mapping in which policies are determined at the higher levels

and the focus of implementation analysis is on designing mechanisms for control over activity at

lower levels. Forward mapping assumes that Bthe ability of complex systems to respond to problems

depends on the establishment of clear lines of authority and control.^32(p.605)

In the study that introduced the concept of backward mapping, Elmore analyzed youth

employment policy. Other often-cited studies have used backward mapping to study diverse

policy areas such as family support33 and environmental regulation in the United States35 and

policy for primary education in India.36 In each of these instances, backward mapping proved

useful because the policies were to be implemented in contexts that varied widely, making it

difficult to specify from Babove^ exactly what the desired changes should look like. The backward

mapping analyses were intended to help to avoid the Bone size fits all^ solution to policy im-

plementation that is characteristic of a forward mapping approach.

What makes a backward mapping strategy particularly useful for studying wraparound

implementation is that wraparound itself is essentially a backward mapping process. This is explicit

in wraparound at the micro level of care planning because individual teams are required to go through

a process of creative problem solving, formulating an individualized response to the needs of a

particular child and family. The content of the plan then becomes a uniquely designed intervention at

the Blowest^ level. The team then has to answer the question: What policies and resources are needed

from Bhigher^ levels to make plan implementation succeed? For example, if a team identifies a need

for respite and a neighbor who can provide respite at low cost, there is still a need for resources to pay

the neighbor and for policy that allows for this to happen. However, wraparound is also implicitly a

backward mapping process at the macro level because meeting the aggregated needs identified by

wraparound teams implies a realignment of policies and resources organization- and system-wide. For

example, if a growing number of wraparound plans call for mentoring, demand may outstrip supply.

The system must respond by shifting resources and personnel into activities designed to increase the

supply. When viewed in this manner, it becomes evident that wraparound represents a potentially

radical departure from the traditional top-down, hierarchical organization of both treatment

planning—where Bexpert^ professional practitioners determine child and family needs and

solutions—and service design and delivery—where high-level policies determine what kinds of

needs are legitimate and what strategies for meeting needs will be funded.

The combination of grounded theory and backward mapping appears to be useful for the study

of wraparound implementation. As noted above, backward mapping is a particularly appropriate

method for studying implementation when a flexible response at the service level is important.

Thus, the backward mapping perspective is likely to produce data that highlight the variation in

implementation. Furthermore, despite the dearth of formal research on implementation generally,

and wraparound implementation in particular, there is a great wealth of practical experience that

has been developed as stakeholders have worked to implement wraparound in diverse com-

munities and contexts around the nation. There are thus a variety of perspectives to be tapped in

building theoretical and conceptual understanding. The variety of perspectives is not limited, of

course, to geographical and cultural diversity. Family members and service providers often have


very different perspectives about needs and about the strategies for meeting needs. What is more,

professionals and administrators drawn from different agencies reflect perspectives molded by

professional education and organizational cultures and mandates. Grounded theory is a method

uniquely capable of capitalizing on this diversity of perspectives to build conceptual understand-

ing that is also of immediate practical utility.

Study Method and Analysis

Phase 1: initial interviews

Consistent with the backward mapping approach, the study began with a focus on identifying a

desired set of behaviors at the team level. To this end, the researchers interviewed 28 expert team

members from 20 different wraparound sites in 12 states. Each expert had worked with multiple

teams in roles that included facilitator, care coordinator, resource developer, and parent partner/

advocate. Eight of the experts were caregivers for children with serious emotional or behavioral

difficulties. Site directors with established wraparound programs were asked to nominate the most

effective, experienced team member at their site. Two-thirds of the interviewees were identified in

this manner, whereas the others were identified by national-level trainers with experience at

numerous sites. This method of selecting experts allowed the researchers to begin the backward

mapping process with the individuals most intimately knowledgeable about the workings of teams

and the resources required to carry out plans. Among the interviewees were three African

Americans, one Native American, and one Latina. The interviews with expert team members

lasted for about an hour each. The interviews were conducted primarily by telephone although

four were done in person. All interviews were tape recorded, and the tapes were transcribed. The

interviews focused on interviewee perceptions of what constituted successful or unsuccessful

wraparound teamwork and the factors that influenced a success or failure.

Initial coding proceeded in an open-ended manner, with at least two members of the research

team intensively reviewing each transcript, making notes, trying out categories and category

names, and using the method of constant comparison to clarify the parameters of the emerging

categories. As the coding scheme developed, each transcript was intensively reviewed at least two

more times by the different members of the research team. The team met at least twice a week to

develop and then review initial coding categories, to discuss possible groupings of categories with

subcategories, and, later on, to share memos. As coding categories became clarified, the research

team eventually selected supports/barriers as the core coding category. The coding scheme thus

became centered on categories describing factors that, when present/absent, acted as supports for/

barriers to successful wraparound practice. Toward the end of phase 1, the team began to refer to

several of the major groupings of categories as themes. The theme that emerged most clearly at

this stage was related to collaboration and pertained to all levels of implementation. Other

emerging themes included accessing needed services and supports and value-based practice. A

key characteristic of a support or barrier was the actor(s), who were responsible for whether it

existed in the implementation context. Important actors were located at different levels within the

implementation context. At the service level, the most important actors were the team members,

whereas at the organizational level, the lead agency (the agency that hired, trained, and supervised

wraparound facilitators) and partner agencies (other agencies whose personnel participated on

teams) were prominent. At the higher levels, the actors were more diverse and included the state,

the county, high-level agency administrators, local politicians, and others.

Memos created during this phase included using diagrams that depicted groupings of categories

into themes and that drew connections within themes across implementation levels. These

connections often reflected comments made by interviewees that spontaneously illustrated how

team-level barriers (or supports) reflected barriers (supports) at higher implementation levels.


Within the collaboration theme, for example, interviewees cited barriers and supports that

connected across the team and organizational levels as in the following examples.

Coming to a wrapmeeting is not necessarily a high priority for a teacher or a child welfare worker.They have to travel [to get to the meeting], or the meeting is not within the 9–5 day, and if they gothe team will assign them work that is not part of their normal job. You [the wraparoundfacilitator] start by working with that person... to educate... but sometimes that is not enough.Maybe you need your supervisor to get their supervisor... to see that this is important. It can beresolved like that but what you really need is for their bosses to get together and say BYes, wevalue this,^ and decide that they will comp the time for [all system employees who attend]evening wrap meetings... and lighten the load elsewhere because wrap takes more time than forother clients.

People missing meetings was a big problem... We had training in wraparound across all oursystems so that now there is greater buy-in from staff. Everyone got training, up to the heads of[agencies] so they understand what it takes for their staff to participate in wraparound and helpmake that happen.

Say the [probation officer] is just not going cooperate with the team. [The probation officerdoes] not see that [the wraparound plan] or meeting the whole family_s needs is relevant forprotecting the community or that their mandate can be part of the plan. The first question is Doesthe [wraparound facilitator] have the training in how to build cooperation on a team?How to usethat mandate to strengthen a plan instead of weaken the team? [If not] this is a lack of trainingand the fault of [the lead agency].

Connections across levels were also frequently made within the other themes.

The idea of strengths based, the idea of creating partnership with parents, these were not partof the culture of [partner agencies]. They did not see a difference between empower andenable. [Our wraparound program] has worked for years to change that culture throughout oursystem so staff from different agencies are singing from the same book. (value-based practice)

It was a big problem, people who could not or would not accept the values would drag ourteams down. Now [our home and partner agencies] have it written into their job descriptionsso that we are hiring people that come to the work believing in the [wraparound]philosophy. (value-based practice)

In the beginning we were not getting... community based activities for our wraparoundfamilies. We did not have a way for our teams to learn about what might be there [in thecommunity]. So [our agency] started a database, sorted by zip code, of all the communityresources. And every time a resource is part of any plan, it becomes part of the database too.(accessing and creating services and supports)

In sum, after phase 1—the expert interviews—numerous categories of supports and barriers had

been identified, as well as information about the contexts in which these supports or barriers might

arise, what might cause them to come into being, and what types of consequences might follow. To

some extent, these categories were located within themes and at different levels of implementation.

Phase 2: development of a conceptual framework

In the second phase, the research team primarily focused on gathering perspectives from people

with experience at the Bhigher^ levels in the organization and system. However, an additional

seven highly experienced team members from less-successful wraparound programs were

interviewed as well so as to compare their responses with those of their peers at the best-


regarded programs. Other interviewees included one national trainer; 12 directors of wraparound

programs; five system-level administrators from the county, region, or state level; and two

researchers with a national perspective on wraparound teams. Phase 2 interviewees at the team

and organizational level included four African Americans, one Latino, and two Native Americans;

however, none of the system-level interviewees was a person of color. Consistent with the

backward mapping approach, interviewees were encouraged to look Bupward^ and describe

supports and barriers they encountered from higher implementation levels and to describe

supports and barriers they saw there. Interviewees were given an opportunity to reflect in an open-

ended manner on supports and barriers, but they were also asked with specific questions designed

to elicit information about themes or categories identified in phase 1. The interviews were also

individualized to take maximum advantage of the individual_s expertise at team, organization, or

system level. Phase 2 also included an extensive review of literature on effective teamwork,

engagement and collaboration with families, supervision and coaching, system change, and other

topics consistent with the emerging themes and categories of the conceptual model.

Over the course of phase 2, an overarching conceptual framework emerged, gradually taking on

the form of a matrix that Bheld^ categories at the intersections of themes and levels. One main

development during phase 2 was a reconceptualization of the highest implementation levels. In

the early stages of phase 2, the research team found great difficulty in building theory about the

highest levels. While the identified categories of barriers and supports at these higher levels fit

reasonably well with the emerging themes, the higher levels themselves were difficult to

characterize given the large number and diversity of Bactors^ who exerted influence over im-

plementation. These actors could include people, such as county-level administrators, or political

bodies such as the county commission or state legislature. Adding to this complexity was the fact

that, in any particular community, the power to set policy or make funding decisions was

distributed in a unique way among the local actors at the higher levels. This greatly complicated

the efforts to make generalizations about supports and barriers across communities. Midway

through phase 2, however, the research team began to reconceptualize these higher implemen-

tation levels less in terms of the actors involved and more in terms of specific conditions in the

policy and the funding environment that were created through their combined actions. Ultimately,

this line of thinking led the team to label the higher levels of implementation as the policy and

funding context. More generally, this line of thinking brought the team to the realization that it

was easier to understand the emerging theory as a series of hypotheses about conditions that

needed to be present in the implementation environment. The categories of supports and barriers

could then be seen as providing information about what facilitated or impeded the realization of

these desired conditions. As a result, the team recharacterized the matrix as representing theory

about necessary conditions for successful, sustainable wraparound implementation.

Throughout phase 2, the team continued to examine the coding scheme in the light of new data

and to use this information to draw connections within themes and across levels. For example,

administrators at higher levels stressed that building support for policy and funding changes

needed for wraparound implementation required data demonstrating that the approach was

effective. The emphasis placed on this need for the data caused the team to reconceptualize a

collection of previously coded categories as representing an important strand within a new theme

of accountability that spanned implementation levels and included information on how

disagreements across implementation levels about the needs for and uses of data might influence

program success.

When we started out, our whole system was focused on clinical outcomes as the measure ofsuccess. Then we began to see real improvement for kids and families in terms of being in home,in school, out of trouble, but the clinical measures were not showing that... We believe that thebest outcome is if the family reaches its goals. That is something wemeasure and have as one of


our three primary discharge criteria. But it is has been hard to get that accepted [at the higherlevels]. If they only want to focus on clinical measures, that is incentive to narrow the focus ofyour wraparound and eventually you will no longer have wraparound.

There is the expectation that teams will do [in-depth mental health assessments] but not the timeto do it. Rather than doing a full interview, [staff] will fill out the assessment based on the file...To get good data, it has to be clear to everyone that it is serving their purpose and relevant tothem. Administrators need to listen to teams about what_s reasonable and useful, and to educateteams about [administrative] data needs.

Research literature also served as an important Bvoice^ in this phase of theory generation,

strengthening points that were made infrequently or obliquely by interviewees, or providing a

conceptual Bniche^ to hold comments that had not previously been categorized together. For

example, the literature on skill acquisition emphasizes the importance of ongoing, live practice and

coaching as keys in supporting practice change. While comments related to coaching had been

made by some interviewees, the actual terminology of coaching provided a conceptual niche for

these comments and for drawing the distinction between coaching and other modes of supervision.

As the theoretical framework emerged, backward mapping highlighted several underdeveloped

areas in the matrix. For example, the expert interviewees had stressed the central importance of

using the wraparound plan as a mechanism for strengthening families_ social support and

increasing community integration. Midway through phase 2, it became obvious that the cell in the

matrix that would hold categories related to organizational supports for these efforts was quite

empty. At the same time, our observational study of team meetings18 was yielding evidence that

wraparound teams included infrequent representation of people drawn from the family_sinterpersonal and community networks and that nontraditional and highly individualized supports

were rare in wraparound plans. This stimulated a national networking strategy to identify sites,

and knowledgeable interviewees within those sites, that appeared to have developed successful

strategies in this area. Information from these interviews was used to fill in the underdeveloped

area in the conceptual framework with further information about barriers and, particularly,

supports. For example, several communities created positions for community resource developers

to work with wraparound teams. A successful community resource developer is highly

knowledgeable about organizations and individuals within the community and develops

techniques for matching community resources with the needs of wraparound teams. The resource

developer might also work over time with a person or organization providing a resource to ensure

that the match worked out.

[The resource developer] has lived in the community, raised her children in the community.Goes to church... It is not [formal] education, it_s life experience. The job builds on that, to makepersonal connections and have credibility, to know each and every program that may have aspace, or an individual whomay be ready to offer something to a [wraparound] team. She bringsthe resource to the table and then follows through with supports and check ins because that_swhat it takes...

Interviewees described how creating resource developer positions—and providing a salary that

recognized the unique types of expertise required—might necessitate policy and funding

adjustments not only at the organizational level but at higher implementation levels as well.

The emerging conceptual model was captured in two main products that were developed and revised

throughout the course of phase 2. The theory was summarized in precursor versions of the matrix

presented as Table 1, with broad themes connecting across three levels of implementation. Each

intersection of the matrix held one or more necessary conditions. A report reviewed the matrix cell by

cell, describing the conditions in greater detail. The report provided examples of strategies that

communities had used to create conditions and barriers that impeded these efforts. Additionally, the


report discussed connections across levels within themes, describing how meeting a condition at a

lower implementation level might be impacted by the presence or absence of a condition at a higher

level. For each necessary condition identified in the matrix, later versions of the report also included

commentary based on the literature review that was part of phase 2. The commentary described

existing research and theory that could be seen as supporting, extending, elaborating, or qualifying the

hypotheses represented in the conceptual framework. For example, interviewees in the study

expressed strong endorsement of the idea that strength-based, family-driven, and culturally competent

practice at the team level could only flourish when the lead agency—and to some extent the partner

agencies as well—puts these values into practice at the organizational level. While the research team

could find little information about the need for consistency for these particular types of values within

human service organizations, the report described findings from research management and

organizational effectiveness showing that inconsistent value systems on the job are associated with

increased employee stress and lower work satisfaction and performance. The intention behind

including this information was to give users of the report access to relevant further information that

could be helpful in developing or advocating for specific organizational or system-level arrangements.

Finally, the report also included self-assessment questionnaires of organizational and system

(policy and funding context) support for wraparound. For each necessary condition identified at

the organizational or system level, the assessment contained three or more items that reflected

main categories of supports that the coding scheme had grouped together within the condition. For

example, at the highest implementation level, the first necessary condition in the theme of

acquiring services/supports stipulates that the policy and funding context should provide agencies

with autonomy and incentives to develop services and supports consistent with wraparound values

and practice. The system-level assessment, as it existed at the end of phase 2, provided seven

categories of supports within this condition, including the following three examples.

Incentives in the policy and funding context clearly encourage community-based placementsover other placements (residential care, detention, and hospital) whenever possible.Whenwraparound teams or programs are able to save money by avoiding out-of-communityplacements, the resources saved are returned to the community to support furtherdevelopment of needed services and supports.The policy and funding context providesincentives that encourage the development of services and supports that are in high demandby wraparound teams.

Consistent with the backward mapping approach, the assessments called for team members to

provide ratings of the extent to which the organizational supports were in place for their work and

for program managers to rate the level of system support.

Phase 3: expert review and validation

By the end of phase 2, the work on the coding scheme was essentially complete. The

scheme—as now reflected in the matrix and the assessments—mapped the implementation

context for wraparound in all its complexity. The matrix, similar to the final product presented as

Table 1, had three levels and five crosscutting themes, with between one and five necessary

conditions per cell. In turn, the assessments were elaborated on each necessary condition,

presenting between three and ten categories of supports or strategies for achieving each condition.

The report described each necessary condition in some detail, including examples of the main

categories of supports and strategies as well as the research-based commentary described above.

Because of the wide scope and complexity of the theory that had emerged from analyzing the

interview data during phases 1 and 2, the research team perceived a need for external validation of

the conceptual framework as described in the report and assessments. Thus, during phase 3 of the

project, review and feedback were sought from a diverse group of wraparound experts.


Table

1Conceptual

fram

ework

forwraparoundim

plementation

Team

level:desiredbehaviors

Organizationlevel:necessary

conditions

Policy

andfundingcontext(system

level):

necessary

conditions

Practicemodel

Team

adheres

toapracticemodel

that

promoteseffectiveplanning

andthevaluebaseofwraparound

Leadagency

provides

training,supervision,

andsupportforaclearlydefined

practice

model

Leadersin

thepolicy

andfunding

contextactivelysupportthe

wraparoundpracticemodel

Leadagency

dem

onstratesitscommitment

tothevalues

ofwraparound

Partner

agencies

supportthecore

values

underlyingthewraparoundprocess

Collaboration/Partnerships

Appropriatepeople,prepared

to

makedecisionsandcommitments,

attendmeetingsandparticipate

collaboratively

Leadandpartner

agencies

collaborate

aroundtheplanandtheteam

Policy

andfundingcontextencourages

interagency

cooperationaround

theteam

andtheplan

Leadagency

supportsteam

effortsto

get

necessary

mem

bersto

attendmeetings

andparticipatecollaboratively

Leadersin

thepolicy

andfunding

contextplayaproblem-solving

role

across

serviceboundaries

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In the course of phase 3, the research team recruited 45 reviewers spanning the spectrum of

wraparound stakeholders across implementation levels. Of the total number of reviews, 12 were

provided by parents, four by youth or young adult consumers, ten by researchers, eight by

wraparound facilitators or care coordinators, five by state-level administrators, five by system-

level administrators, six by wraparound program administrators, and two by consultants (this total

is greater than 45 due to reviewers occupying multiple roles). Among the 45 reviewers, 7 were

provided by African Americans, 3 by Native Americans, and 3 by Latinos. The rest of our

reviewers were Caucasian, or their ethnicity was unknown.

The three rounds of review and modification in this phase proceeded in the following manner.

First, the conceptual framework was reviewed in a group feedback session with seven nationally

recognized experts in children_s mental health who also had extensive experience with

wraparound. The comments from this session were audiotape-recorded, and the feedback was

incorporated into the subsequent draft of the report (including the matrix and the assessments).

This draft was then circulated to a group of 11 expert reviewers. Ten of the 11 reviewers provided

detailed feedback through an individual interview, whereas seven reviewers provided written

feedback. Two members of the research staff took detailed notes during these interviews. At a

national conference on children_s mental health, the research team held two 2 hour focus groups.

One group included highly experienced wraparound team members. Before the session, each of

the participants had filled out the organizational assessment and made written comments. The

discussion during the focus group was audiotape-recorded, and the participants_ ratings and

comments on the assessments were collected. A similar group was held for wraparound

administrators, who provided feedback on the system assessment. Once again, the feedback from

these activities was incorporated into a subsequent draft, which was the focus of the reviews

provided by the remaining experts. The reviews during this phase reflected a high level of

endorsement of the conceptual framework and suggestions for numerous though relatively minor

modifications. After making final modifications, the research team concluded that the products

were ready for dissemination.

Discussion and Implications for Behavioral Health

One set of implications from this study concerns how the field recognizes and legitimizes the

results of research using grounded theory or other similar qualitative methods. In general,

qualitative research is represented only sparsely in the field_s peer-reviewed journals. This

apparent lack of legitimacy accorded to qualitative approaches may be due in part to the

misunderstanding of their fundamental purposes and nature. To the extent that qualitative studies

are judged by the standards of quantitative methods, they will appear to fall short. The method of

this study, for example, violates several axioms associated with quantitative, hypothesis-testing

approaches. At the most basic level, rather than being determined in advanced and fixed manner

throughout the course of the inquiry, both the main Binstrument^ (the interview protocol) and the

Bsample^ (people to be interviewed) were continually adjusted in response to emerging findings.

Moreover, the products of the study do not represent an attempt to report objectively on

informants_ responses, and the theory does not purport to be a kind of summing or weighted

averaging of stakeholder views. Instead, the presented theory contains stakeholder views both

commonly and rarely represented, as well as ideas drawn into the theory from other sources.

Finally, the full findings of the study are presented in narrative, descriptive form. Rather than

being a definitive statement about certain specific relationships among a relatively small number

of variables (and thus easily distilled into brief accounts about whether the hypotheses were

supported), the conceptual framework holds and organizes essential information about a large

number of variables. While the matrix is a useful heuristic, its content is not deeply meaningful in

the absence of the fuller description. Yet, the fuller description of the framework is contained in a


report that is a hundred pages long. An article-length description of the study such as this one can

only offer highlights from the findings, serving in effect as an invitation to read a lengthier report.

Nevertheless, the study appears to represent a success when judged by the criteria associated

with the method employed. Consistent with the goals of the grounded theory approach, the study

was designed to capitalize on the expertise that has accumulated across thousands of wraparound

teams and hundreds of programs. The goal was to provide theoretical, conceptual, yet grounded

and practical information that is of immediate use to stakeholders involved in wraparound

implementation and that lays a foundation for future research on contextual fidelity. The products

of the study were endorsed by the reviewers, who were representative of the intended target

audience. Beyond this, over 5,000 copies of the entire report have been actively requested, and

more than 30,000 copies of summaries have been distributed. Personal communications with the

authors indicate that at least four states use the report and/or assessments in statewide technical

assistance activities targeting wraparound improvement, and several prominent national con-

sultants on wraparound use the report extensively with communities they are assisting to implement

wraparound. The framework has also been endorsed by the National Wraparound Initiative (NWI),

a collaborative of experts representing diverse stakeholder groups from across the country, who are

working to promote and support high-quality wraparound implementation.17,37 The NWI is using

the framework in current efforts to develop a comprehensive wraparound fidelity assessment system

that includes measures of contextual fidelity. Finally, research drawing on the conceptual

framework has begun to demonstrate a connection between the presence of selected organizational

and system supports and higher quality wraparound.38

In sum, while qualitative studies based on methods such as those described in this study may be

worthy of attention, they are apparently not a good fit with either the epistemological or practical

expectations of peer-reviewed journals in children_s mental health. Yet, without the imprimatur of

peer review, a study_s findings do not acquire the level of credibility that is required to be

perceived as forming part of the knowledge base of the field. What is more, studies that are not

published in peer-reviewed journals are not indexed in research literature databases and thus

remain relatively inaccessible. One response to this epistemological gap would be efforts to build

consensus in the field regarding standards for qualitative inquiry. This sort of development might

be particularly helpful, for example, for researchers who use grounded theory approaches. There

is quite a bit of controversy about the procedures that should be employed or the types of

questions that should structure data analysis in grounded theory,29,30,39,40 and a thorough

positioning of a study_s method in relation to various points of controversy could easily consume

the number of words normally allocated for an entire research article. In contrast, referring to one

or another set of guidelines accepted in the field might make such positioning feasible.

Additionally, some form of guidelines or consensus would allow editors, reviewers, and

researchers to operate from a shared frame of reference for judging quality, perhaps thereby

stimulating an increase in the general level of sophistication in the field regarding the nature—and

uses—of qualitative methods. A different strategy would be to create new journals or other outlets

or mechanisms that would allow for some form of structured peer endorsement and that would

facilitate dissemination and indexing. An electronic medium would be particularly well suited for

this purpose, as space constraints play little role in limiting the length of reports that can be

included. What is more, electronic publication could decrease the typical delay between study

completion and journal publication, thus getting needed practical information quickly out to the

field. Greater openness to qualitative methods in children_s mental health research could also have

the benefit of drawing out a larger volume of higher quality research. This is an important consid-

eration given increasing urgency of transformation efforts and the need to rapidly build practical

knowledge about more macro-level phenomena such as program implementation and system change.

The study itself has broad implications for the implementation of wraparound and allied

approaches for comprehensive, coordinated, and individualized care planning, which are central


in the vision of transformation expressed in the New Freedom report.41 Perhaps the most

important finding is the sheer number and wide variety of contextual features that can impact

implementation success. The conceptual framework is a means of holding and organizing

information about these features and for laying out some of the interconnections between them.

Having the overall conceptual framework also draws attention to several areas within the

implementation context where organization- and system-level strategies for supporting imple-

mentation are few and infrequently implemented. The most notable example of this is the lack of

strategies to support the inclusion of informal and community supports in the plan. There is a

clear need to develop organizational-level strategies to build community capacity to provide this

type of support and for system-level policies that encourage these activities and provide necessary

funding. Given that social network interventions to build social support are a common ingredient

in practice models consistent with transformation, and given that current strategies do not appear

to be particularly successful,42 there is a clear need to build information in this area. Another

example is the dearth of organizational- and system-level strategies for ensuring that the

wraparound plan actually serves to coordinate each collaborating agency_s activity with a child

and family. Often, each collaborating agency maintains its own plan for a child and family, and

these plans may or may not reflect the wraparound plan or the underlying philosophy of care.

Changing this situation is difficult given that participating agencies have disparate legal mandates

as well as different paperwork, data collection, and billing requirements. Finally, strategies for

building organizational and system capacity to supply needed coaching, training, and supervision

were also lacking. More generally, it is hard to imagine that any approach to comprehensive,

coordinated, and individualized planning can succeed without strategies in each of these areas,

and thus focused efforts to develop them should be prioritized.

More generally, the study makes it clear that wraparound will not be successful over the long

run unless it is embedded in an organizational and system context that is transformed or

transforming. What is more, the transformation process must be open to being backward mapped

by wraparound teams and programs as well as forward mapped by higher level policies and

mandates. In other words, there must be an open communication across implementation levels,

particularly in the Bupward^ direction, so that the higher levels remain acutely attuned and ready

to respond to the needs that are identified through work at lower levels. An extension of this

reasoning is seeing accountability in a new light. In systems that are transforming to

accommodate wraparound, it is not just lower levels that are held accountable by higher levels

but also the reverse. There must be mechanisms for upward accountability such that higher levels

have explicit responsibilities to work toward providing the necessary resources and supports to

wraparound teams and programs.

Studying the implementation of wraparound brings into focus the nature of the potential

disharmony between two philosophies of mental health care and two types of systems for delivering

that care. On the one hand is the predominant forward mapping approach: top-down, hierarchical,

expert-driven, and control- and compliance-oriented. On the other hand is an approach that is

informed by backward mapping: bottom-up, individualized, and consumer- and family-driven.

Achieving the transformation envisioned in the New Freedom Commission_s report requires

somehow moving from the former to the latter, and implementing wraparound is one mechanism

for driving this change. Studying wraparound implementation has great potential to inform us about

the conditions that need to be brought Bonline^ if transformation is to be successful and sustainable.

Acknowledgments

This research was conducted with funding from the National Institute of Disability and

Rehabilitation Research (NIDRR), United States Department of Education, and the Center for

Mental Health Services Substance Abuse and Mental Health Services Administration (NIDRR


grant number H133B990025). The content does not necessarily represent the views or policies of

the funding agencies. The authors wish to thank the research participants for the insights offered

during the interviews and feedback sessions described in this article.

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