NEXIS (Neighborhoods Evolving by Connecting Individuals with Supports) – Ulster County, NY

Ulster County Mental Health Department (UCMHD) is a licensed New York State Office of Mental Health community mental health clinic located in the Hudson Valley. We provide a range of outpatient mental health treatment services to children, adolescents, and adults.

Over the course of the last six years, the Family and Child Unit of UCMHD has undergone a radical shift in how services are provided to the community. In 2003, after reviewing both the current caseloads as well as the wait list referrals, it was determined that the primary reason for referral to our outpatient clinic was environmental/family dysregulation as opposed to more isolated psychiatric disorders in the child being referred for services. Few children were referred for what we might consider “true” genetically-driven psychiatric disorders. Rather, parents/guardians expressed concerns about a host of behavioral manifestations associated with Oppositional-Defiant Disorder, Conduct Disorder, Post Traumatic Stress Disorder, and Parent-Child Relational Disorder which we began to link more directly to environmental causes. It was at this time that we more fully explored the etiology of the problematic behaviors and shifted our conceptualization of the treatment plan for these children and families.

Our attention focused on the population of children and families who presented to our clinic with histories of abuse and trauma. We learned that our traditional outpatient clinic model had proven ineffective at providing services to these families who presented as overwhelmed, stressed and unable to organize themselves. There were resource barriers (i.e. lack of childcare and transportation) and a general mistrust of the system which often resulted in poor engagement in therapy. For many families, the typical clinic environment was stigmatizing and did not provide a setting where the family’s strengths could be identified and general engagement supported. As service providers, we were left with an overall sense of ineffectiveness and acknowledged feeling ill-equipped to manage the level of family stress despite our awareness of its significance.

In 2001, members of our clinical team were introduced to the Trauma Systems Therapy Model at the International Trauma Conference in Boston, Massachusetts. Over the course of the next few years, as the Model evolved and became more refined, we recognized the congruence of TST with our shifting treatment focus.

The NEXIS program, adapted from the TST Model, is a family and community-based intervention program for families and children/adolescents struggling with dysregulated emotions and behaviors. Teams of UCMHD clinicians and Department of Social Services (DSS) caseworkers jointly implement the Model. At this time, the Ulster County NEXIS team consists of five dyadic teams. Four of these teams include one UCMHD clinician and one DSS caseworker. One team includes an UCMHD clinician and a caseworker from a subcontracted agency Family of Woodstock, Inc who provides case management to families not presently open to DSS. The inclusion of one non DSS caseworker serves as a way to prevent the need for entry into the DSS system whenever possible.

Families and children are referred to the NEXIS program from a host of sources including Child Protective Services, Probation, Family Court, school districts, mental health practitioners, child service agencies, and self referrals. The dyadic teams provide the full array of TST services from in-home, intensive services included in the Surviving/Stabilizing Phases through the more clinic-based, therapeutic interventions utilized in the Enduring, Understanding and Transcending Phases of the Model. At the outset, when a family is referred to NEXIS and requires the intensive services of the Surviving/Stabilizing Phases, there is a greater need for case management, wraparound and advocacy services. At this time in the intervention, services are often focused on safety needs and the caseworker partner within the dyad is typically more heavily involved in the actual delivery of concrete services. As the family progresses through the phases of the Model, the treatment moves toward more clinic-based treatment. While both partners in the dyad are involved in all phases of the Model for each family on their caseloads, case management tends to be the primary focus in the initial phases. The dyadic teams create a plan and identifies clear responsibilities for each partner of the dyad and while they work closely together, interventions can include both partners or they may involve only one partner, while the other partner focuses on another aspect of the intervention.

The NEXIS clinical team meets regularly. The team consists of the five dyads (10 staff), as well as three supervisors from the three agencies involved in the project, the staff child psychiatrist and program administrators. There is a weekly team meeting with all NEXIS staff to discuss clinical as well as programmatic issues. In addition to the clinical team meetings, staff receive individual weekly supervision. Both the clinical team meetings and individual supervision are intended to provide ongoing clinical support for managing the caseload as well as providing oversight in maintaining fidelity to the TST Model.

In our clinic setting, TST has strengthened clinical assessment, formulation and intervention resulting in a decrease in psychiatric hospitalizations for children and adolescents and shorter lengths of stay when hospitalization is necessary. Families receiving treatment through NEXIS have also benefited from a more integrated service approach between Ulster County Mental Health Department and the Department of Social Services.