What is Family and Group Conferencing for adults? Part 1: Characterising the model and methods of enquiry

Patient and public involvement

An important aspect of this study is the involvement of individuals with lived experience in a number of different capacities. To ensure that we have captured all perspectives on our data, the study employed two peer researchers with lived experience in the research team to support our literature review, interviews, and subsequent analysis. In addition, the study was guided by a panel of four individuals with lived experience of an FGC, either in the capacity of being the central person or a network member to provide advice, guidance, and challenge. In particular, our lived experience advisory panel (LEAP) was instrumental in shaping our survey and interview questions and in providing feedback on our findings. Through the deliberative forum, we were able to gather extended feedback from other individuals with a lived experience of an FGC, which enabled us to capture a wider range of perspectives and validate our findings. Further details on the contribution of individuals with lived experience is provided in the following sections.

Research methods

The aim of this study was to examine how FGC for adults and mental health is being delivered in the UK and, in particular, how practice model(s) may be characterised (the focus of this paper) using a realist approach (Pawson & Tilley, 2004), which may be the programme theory that underpins this (the focus of the Part 2 Paper to follow). We sought to achieve a comprehensive understanding through an integrative approach, drawing together findings from an analysis of the international literature, a national online survey, interviews with selected stakeholders, and a deliberative forum comprising a cross-section of informants from the field.

Out of this process, certain key questions emerged where there remained a lack of clarity or gaps in understanding, and these questions were then put forward for discussion at a Deliberative Forum. Putting this together provided a basis for an initial formulation of (a) how adults’ FGC practice model(s) may be characterised and (b) what key context-mechanism-outcome configurations (CMOCs) may constitute their underpinning programme theory. This initial formulation was used to inform subsequent evaluative research conducted at the selected case study sites. Figure 1 provides a schematic diagram of the methods employed.

Figure 1. Schematic diagram of methods employed.

Literature review

Drawing on international literature, this review aims to provide a narrative synthesis of key themes relating to adult FGCs with a particular focus on how the practice model may be described and defined, its underpinning values and principles, and for whom it was considered a suitable approach. In the early stage of the review process, it was considered whether to include literature relating to FGC in children’s services, where practice may be significantly different but might nevertheless provide useful insights into how FGC for adults might be working. However, given the volume of the literature available relating to children’s FGCs, a decision was made to focus the review on literature relating to FGC practice generically or that which specifically relates to adults and mental health services, while also drawing on some theoretical perspectives that have been proposed in relation to FGC practice with children and families.

To identify relevant literature, database searches were conducted in APA PsycINFO- OVID, Applied Social Science Index and Abstracts (ASSIS), Social Services Abstracts, and ProQuest Social Science Journals (Social Science Database). Each database was searched for word combinations of family group conferencing/family group decision-making AND

*Adult, *social work, *mental health, *outcomes, *FGC theory, *empowerment, *evaluation, *community mental health, *public mental health, *quality of life, *resilience, *social support, *restorative justice, *recognition, *social capital

In addition, multiple combinations of the above search terms were used to ensure the inclusion of all or nearly all relevant articles pertaining to our topic. For example, we combined terms such as ‘family group conferencing’ AND ‘adult’ AND ‘mental health’ NOT ‘child. ’ We also conducted a search for grey literature across UK based professional and policy agencies. Initially, upon identifying relevant documents, we used snowballing to further identify organisations/resources related to adult FGCs. Our inclusion criteria were as follows: (a) all articles, book chapters, and gray literature produced between 2000 and 2023; (b) national and international literature emerging from the UK, Europe, USA, Australia, New Zealand, and Canada; and (c) literature that focuses on any or all contexts, mechanisms, and outcomes relating to adult FGCs. The selection of appropriate literature was based on the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines (see Figure 2 below).

Figure 2. Breakdown of study selection.

The final selection of literature is presented in Table 1 (below). Zotero referencing software (https://www.zotero.org/) was used to manage this information in a database that was available to all members of the research team.

In the process of analysing and synthesising the evidence from the literature, we saw it as important in maximising the validity of our findings that we incorporated the ‘standpoint’ expertise of people with lived experience (Tew et al., 2006), practitioners, and people from different cultural and ethnic backgrounds, so that the content could be viewed from different perspectives and potentially significant evidence was not missed. To this end, a research team was formed that included two peer researchers with lived experience, two researchers with current practitioner experience, and four with academic backgrounds. Half of the research team was from a minority ethnic background. All researchers held similar responsibilities, including reviewing and summarising shortlisted articles, writing up key points emerging from their designated articles, and taking part in group discussions in which we started to draw together understandings of FGC models and processes as applied in adults and mental health contexts.

Prior to undertaking the analysis, the research team held a series of discussions to determine the areas of interest and the scope of the review. To maintain focus and consistency, a reviewing framework was developed that recorded the (a) reference; (b) theory relating to FGC; (c) contextual factors including who could be offered a service, cultural/community acceptability, and wider service context; (d) processes and mechanisms; (e) outcomes for individual, network, and/or service; and (f) other relevant material, including values, perceptions, and assumptions relating to FGC. All articles were independently reviewed by an academic researcher and a team member with either lived experience or practice background. Upon completion of the dual review process, we realized that an additional round of review was required to comprehensively capture the subtleties of FGC. For this round, each member of the research team was instructed to write additional notes on the overarching themes that emerged from their selection of the assigned literature. This material was collated and further analysed by Mitchell, Mahesh, and Tew to provide a comprehensive thematic analysis of the literature and subsequently developed into an initial characterisation of the FGC model for adults and program theory statements.

National survey

A national online survey was conducted alongside a literature review. The aim of the survey was twofold: (a) identify adult FGC services in the UK that are in operation or in a set-up phase, and (b) capture an in-depth understanding of the practice model(s) adopted in these services. Survey questions were devised via an iterative process to maximise the opportunity for input and scrutiny from peer researchers and from those with a practice background. A preliminary list of survey questions based on our research questions and initial themes identified from the literature was developed by Mahesh and Tew and circulated to the wider research team for input. Upon receiving feedback, necessary changes were made to reflect their comments and concerns. Feedback included refining the language, changing the ordering of questions, and identifying gaps (for example, including explicit questions regarding the review process and cultural appropriateness of FGC). Version two of the questionnaire was then circulated to the research team for additional review. This generated further minor changes to the language and length of the questionnaire. Questions within our survey were directed towards gaining a coherent understanding of the three phases of the FGC process (preparation, conference, and review), context, and potential outcomes. Online Surveys software, version 2 (https://www.onlinesurveys.ac.uk/), provided a platform for the survey and was used to assist in the analysis and presentation of the findings.

The survey was conducted between January and June 2023. To create sufficient awareness, we employed a variety of platforms, including dissemination through social media (our project website, X and LinkedIn handles), through our practice partners to share with relevant stakeholders, the Chief Social Worker (adults) and the Principal Social Workers’ Network for England, our FGC adult research and practice network group, and by directly approaching organisations that had indicated an interest in setting up an adult FGC service or had already set up one. Despite adopting an active dissemination strategy, we received a low response rate (n=7), suggesting a low level of current adult FGC activity in the UK. Following consultation with the study’s strategic advisory group, the survey was reopened for two months (May and June) to confirm that the low response rate was due to the scarcity of services offering FGC. Alongside reinstating our survey, a simple poll using Online Surveys was created to allow organisations an opportunity to share their longer-term plans regarding FGC. This was primarily conducted to gather responses from a wider pool of organisations with a potential interest in FGC to better gauge whether our low response rate was indicative of the actual level of FGC activity across the UK. The poll was circulated via the Chief Social Worker (adults), the Principal Social Workers’ Network for England, and equivalent networks in Scotland and Wales. We were informed that although there had been an initiative to trial FGCs for adults by the integrated Health and Social Care Board in Northern Ireland, no actual conferences were offered and the initiative was no longer active. Responses to this poll elicited 16 responses, all but one indicating no plans to set up an FGC service in the near future, confirming our capture of the limited extent of current FGC activity in the UK.

Data was descriptively analysed through the analytical functions of the Online Survey. For closed-ended questions, frequency tables and charts were used to determine the number of responses to each option. Open-ended questions and/or responses to free text boxes were subjected to thematic analysis, mapping them against themes generated through the literature review whilst also identifying outliers. Our analysis helped further refine our initial characterisation of the FGC model(s) generated from the literature review.

Stakeholder interviews

To gain a more contextualised and holistic understanding in relation to how current FGC services were operating, we interviewed a purposive sample of stakeholders connected to the services from whom we had received survey responses. Survey respondents who agreed to be contacted for an interview were invited to participate in our stakeholder interviews, and additional participants were sought using a snowballing approach within local service networks. A total of 11 interviews were conducted between July and August 2023 with a cross-section of Team Managers, FGC coordinators, referring social workers, and people with lived experience (n=3). Upon sending an initial email invite to potential participants, information sheets and consent forms were sent, providing an overview of the study and detailing their rights as participants. Upon receiving a positive response, an interview date for a virtual interview was set up.

Our survey themes formed the basis of our interview topic guides, which were drafted in collaboration with peer researchers. These were then refined with input from our Lived Experience Advisory Panel (LEAP), a group of people with lived experiences of either being the person at the centre of the conference or being a network member. This was instrumental in ensuring that relevant questions reflective of a service user perspective were included and that the language used was simple and appropriate. The development of the interview topic guide for service users was led by peer researchers, with input from a wider research team. Service-user interviews were undertaken by peer researchers, as they were deemed more effective in establishing rapport and facilitating an open and honest conversation. Peer researchers also actively contributed to our topic guide developed for professionals by providing feedback on the inclusion and/or deletion of specific questions. In addition, one peer researcher participated in coding and analysis of the interview data.

Interviews were analysed using a hybrid approach to thematic analysis, using the overarching framework identified in the literature and a national survey. To arrive at codes related to our themes, we used inductive thematic analysis, which provided us with rich explanations, corroborations, and/or variations among our datasets. In doing so, our interview data supported the successful integration of findings at the theoretical level (Proudfoot, 2022). Upon completion of our analysis, the findings were sense-checked with the LEAP, who provided corroboration that these fit well with their own experience with an FGC.

Deliberative forum

Deliberative methods are best viewed as an approach to research rather than as a method in itself that aims to involve people in decision-making in a meaningful way (Rawls, 1997) while also providing an opportunity for participants to discover more about a topic and discuss with other participants before presenting their views. Employing this approach was particularly helpful, as it helped us arrive at a broad agreement (or disagreement) among all participants (Burchardt, 2012) especially on contentious issues that were identified through the survey and/or interviews. Particularly, we were able to gain ‘informed views’ (Carson, 2006) by providing prior evidence from our literature review, survey and interviews in a simple and digestible manner (Barnes, 2008) thereby gaining maximum benefit from the deliberation process.

The invitation to the Deliberative Forum was extended to all our survey and interview participants, and via them invitations were cascaded to others with involvement in relation to FGCs in their localities. We also extended invitations to our LEAP members, other statutory and non-statutory organisations interested and/or involved with adult FGC, and academics researching FGC or related approaches. From our synthesis of evidence from the literature, the national survey, and stakeholder interviews, we provided participants with a document in advance that summarised where we thought we already had clarity around the model, process, and outcomes, and what stood out as the main unanswered questions where evidence seemed to be lacking, unclear, or potentially contradictory.

Participants (n=36) were divided into four subgroups, with each group focusing on a specific set of questions. Each group comprised people with practical, academic, and lived experiences. To effectively capture discussions, each group was assigned a facilitator and note taker, who then fed back a summary of their deliberations to the wider group for further reflection and discussion. Summary feedback and subsequent discussions were digitally recorded to assist with our analysis. In addition, arising out of the small group discussions and wider group responses, there emerged some additional points relevant to the FGC process and outcomes on which there was broad agreement, which were also captured. Findings from the Forum assisted in filling notable gaps, validating our previous findings, and highlighting variations in practice models.

Characterising the model – findings from the literature and the practice field

Although emerging practice model(s) of Family and Group Conferencing for adults may differ significantly from what has become an established practice with children and families, there is still substantial common ground. In both adults and childrens contexts, FGC is an inclusive process in which an individual and their social and family networks come together to make plans in relation to the care and support of a potentially vulnerable individual. Facilitated by an independent coordinator, FGCs follow a staged approach to planning and decision making. Although subject to some degree of flexibility, the basic outline of FGC in an adult context may be characterised as follows:

As will be discussed in more detail later, there is less clarity or consistency in terms of the final stage of the process in which the plan is implemented, reviewed, and potentially modified to take into account changing circumstances and people’s experience of how it is working. While Metze and colleagues (2015) proposed that the fifth phase (carrying out, evaluating, and adjusting the plan) is ‘entirely up to the central person and their network’ (ibid.), it was reported to us that it is usual practice in UK FGC services for the coordinator to oversee some form of the review process in conjunction with the central person, network members, and relevant professionals.

The typical context and purpose of an adult’s FGC can be subtly different from those of a children ’s FGCs. While the purpose of the former is often for a family to develop a plan that satisfactorily addresses professional concerns regarding the safety or welfare of a young person, the purpose of the latter may be seen as more explicitly emancipatory: it is about enabling an adult to have control over their life in conjunction with the people that matter to them. It may be seen ‘not as a source of assistance, not as an intervention or help, but a decision-making process that makes citizens active’ (Van Pagée, 2007, cited in Jenkins, 2010 p.2).

Values and principles underpinning Adult FGC

A consistent theme from the stakeholder interviews was that, while flexibility and creativity in practice were to be encouraged (in itself a value statement), it was crucial to the integrity of the process that it remained true to the core values and principles of Family and Group Conferencing, and this is echoed in the literature (Merkel-Holguin, 2004). However, there is currently no clear and agreed statement of what these values are, and these may be more implicit than explicit. Therefore, in characterising FGC practice for adults, it will be important to tease out the underpinning values and principles.

First, it may be seen as a privileging of a relational perspective over an individualistic one:

Sustainable improvements for an individual are seen as being more likely to be achieved if family and friends are directly involved in identifying and finding solutions to current difficulties (De Jong et al., 2018; Ramon, 2021). Within the context of mental health, interrelationships and connections may be crucial to the recovery process (De Jong et al., 2014; Tew et al., 2012; Topor et al., 2006).

Perhaps reflecting more potentially coercive scenarios where the professional system may be poised to use statutory powers to intervene, children’s FGC literature frequently emphasizes a rights-based perspective – a human right to a family life that is not overridden by the state wherever possible (Pennell et al., 2011). By contrast, in the context of adult social care in the UK, similar statutory powers do not exist, leading to a less potentially coercive ethos (although there may still be professional concerns), and such an explicit rights-based perspective is much less a feature of adults’ literature. Similarly, from our interviewees, there was less of an explicit view that the option of an FGC should be a human right, although an implicit right to self-determination wherever possible was seen to underpin FGC practices. Instead, they saw FGC as primarily being about organizing care and support by leveraging individual, network, and community resources and in a way most relevant to the central person.

FGC is seen as an ‘inclusive and democratic approach’ in which all viewpoints are valued (Merkel-Holguin, 2004; Tew et al., 2017), and there is a clear consensus both from the literature and from the interviews that a defining value of FGC is that the process must be family and network led, focusing on what matters to the individual at the centre and their family/network members (Górska et al., 2016). Being ‘family led’ suggests FGC can empower families and wider networks to support each other to find solutions to the problems they face. In short, it gives families ownership of decisions made (Hobbs & Alzoni, 2013). Jenkins emphasizes a focus on the strengths, capabilities, and leadership of citizens and family networks in decision-making’ (2010, p.1).

The practice experience that was shared in the stakeholder interviews suggested that putting this value into practice was not always straightforward; for example, when a particular family or network member had their ‘own agenda, ’ which might not be aligned with the needs and wishes of the person at the centre of the process:

There could also be issues where members of the professional system were uncomfortable about the coordinator stepping back and giving power to the person and their network to make their plan without professional oversight. Similarly, there could be concerns from individuals and/or members of their network that they should not be left alone to make plans or decisions without professional assistance. Some interviewees suggested that this could be due to the legacy of previous experiences of services that had ‘done to’ or ‘done for’ people, taking away their confidence that they could do things for themselves. However, in other instances, this might be due to real concerns that dominant or potentially abusive members of the network might exert undue influence over the process and outcome. It was felt that coordinators should have the flexibility to use their judgement to adapt structure and format to maximise people’s abilities to work together, resolve conflicts, and achieve outcomes that they could own.

Central to the model is valuing the specific knowledge and expertise that family and network members have in relation to their situation:

In contrast to what may be usual in many professionally led decision-making processes, it is this knowledge and expertise that is seen to be paramount in shaping the decisions that are made, although professional views and assessments are also shared, discussed, and valued as part of the overall process.

Equally central to the model is the principle that the coordinator should be independent (Górska et al., 2016) and not act as either a representative of the wider social care or health system or as a provider of (or gatekeeper to) other services. There was consensus within the interview sample that (a) the coordinator should be separate from other professionals (such as social workers), and (b) their role within the FGC process should be limited to coordination with no input into decision-making. Their role should not be to offer expertise, influence outcomes, or make suggestions as to what should go into the plan. Instead, their role is simply to facilitate a process whereby the person and their network can devise their own plan.

While acknowledging this as a core principle, informants from the practice field shared how it was not always easy to uphold this in practice – for example, where services were being cut back, and it might seem pragmatic for the coordinator to take on other roles or tasks in order to fill gaps in provision.

Although ultimately all decisions are made by the central person and their network, informants from the field of practice stressed how the independence of the coordinators also allows them to take on a challenging or even a ‘devil’s advocate’ role by encouraging individuals in thinking through some of their choices or decisions. A common example cited was gently challenging, where a person might be reluctant to invite someone who could be potentially important in relation to their support – perhaps due to feelings of shame or not wishing to burden people.

There can be a strong alignment of values between FGC and the wider field of restorative practice; however, themes of reconciliation and dealing with past harm may not be relevant in all FGCs. The focus on making a plan imbues FGC with an inherently forward focus, and there is a commitment to avoid destructive processes of blaming (Fisher et al., 2018). A restorative approach provides space for openness in which feelings of shame can be shared (De Jong & Schout, 2013) and in which participants can agree to acknowledge past experiences of hurt or harm and share and listen to each other’s feelings in relation to these, so as to be able to come together and resolve their current issues.

Although there is general agreement across the literature and the practice field that FGC services should be culturally appropriate and accessible to all communities, there is a tendency in the literature to take the cultural adequacy of FGC for granted and not question how successful FGC is in challenging paradigms and decolonizing social work (Nygard & Saus, 2019). Because FGC was originally developed for Māori families, it is not necessarily culturally appropriate for other contexts. These authors argue that implementing FGC in new communities requires a strong foundation in the local cultural context. Based on their interviews with practitioners, Barn and Das (2016) proposed that, wherever possible, people should be offered the option of a coordinator who is matched on the basis of a shared ethnic, cultural, and/or religious background. Overall, it is suggested that the inherent informality and non-institutional nature of FGC practices can facilitate central persons and their networks in dealing with problems in a way that is consistent with their own culture and lifestyle (Meijer et al., 2019).

A core value of the FGC model is that it seeks to determine the strengths of individuals, their families, and social networks (Hardy, 2017). Similar to other strength-based and (potentially) preventative approaches in social care (Tew et al., 2023a), FGC is predicated on the changed relationship between the state and citizens in which welfare practices are no longer ‘done to’ disadvantaged or vulnerable people, and they are instead invited to be active agents in determining what would be a good life for them and how to achieve this (Blundell et al., 2021; De Jong et al., 2018; Metze et al., 2015). Ramon (2021) highlighted that the recovery approach to mental health is also a relevant practice framework within which FGCs can operate, as this prioritizes reclaiming a satisfying and meaningful life that can, in turn, lead to specific mental health difficulties remitting or being better managed.

However, beneath this, there is a political tension as to whether FGC is seen as an emancipatory practice that enables citizens to take control over their lives by making relevant decisions to them (Blundell et al., 2021; Frost et al., 2014), or whether it is seen as fitting with the neoliberal agenda of rolling-back state support (Bredewold & Tokens, 2021; see also Jackson & Morris, 1999). Within international contexts such as Holland, the development of adult FGC has been seen as linked to a political movement in which citizens have increasingly been expected to be ‘self-reliant’ and assume responsibility for their own care needs as well as for those others close by in their communities (Bredewold et al., 2020). Within the UK context, some practitioners reported having to steer a path in their conversations with families where they acknowledged a wider landscape in which social care or health services were being cut back but did not situate FGC as a mechanism whereby such cuts could be achieved.

More broadly, stakeholders located FGC within a wider context of implementing strengths-based, person-centred or recovery-oriented approaches, with a focus on the (potential) capabilities of individual, network and community to enable the central person to live what would be, for them, their ‘best life.’

Within mental health settings, FGC is perceived as a unique service that offers a value-based alternative to the medical model, which can often be dominant, particularly within health settings.

Role, training, and professionalism of FGC coordinators

The role of the FGC coordinator is seen as crucial in all FGCs, particularly in the preparation phase, and is crucial in ensuring that relational experiences in FGC are supportive. There is consensus across the literature and practice informants that the role requires considerable skill and sensitivity, particularly in more complex situations where there is conflict in the network, or where the central person may need a lot of support in building up their confidence and ability to articulate their needs and preferences. Where there may be concerns about abuse or safeguarding, it may be seen as important that the coordinator has ‘an in-depth knowledge about family dynamics and the impact of intimidatory dynamics on processes of participation’ (Connolly, 2006, p. 350).

However, within the literature, there is quite a divergence of view as to whether the role is best undertaken by a citizen with relatively little formal training – ‘a gifted citizen with natural abilities to mobilise groups’ (Schout & De Jong, 2017 p. 1198), or whether it should be a much more professionalised role, perhaps undertaken by someone from a social work or social care practitioner background. Proponents of the former approach, the model developed in Holland, argue that this is the best way to ensure that the coordinator is seen as a ‘neutral fellow citizen’ who is completely independent of state services (ibid). A contrasting view is presented by Blundell and colleagues who suggest that the role of the FGC coordinator (in this case working with adults experiencing elder abuse) involves the ‘ability to assess risk and signs of safety, negotiate directly and unambiguously, challenge effectively while understanding and respecting network cultures and processes, [all of which] requires sophisticated and ethical practice skills and processes’ (Blundell et al., 2021 p.313).

Currently, there is no specification and regulation on training for adult coordinators in the UK, and the norms within the field are either that coordination is undertaken by practitioners who have trained in children’s FGC work and then take on work with adults, or that bespoke adult-focused training is offered, either by an independent training provider or by more established FGC services. Interviews with stakeholders indicated that initial training may be as few as three to four days, and this is then supplemented by shadowing opportunities, co-working, and service-based continuous professional development. Professional supervision usually comprises a combination of peer group supervision and supervision by an FGC service manager. Hobbs and Alonzi (2013) raise some concern about the wide variety of training and experience of FGC coordinators when working with ‘at risk’ adults. They contend that further work is required to provide training and accreditation for FGC coordinators in the adult context to ensure standards and consistency in practice.

From the practice survey and stakeholder interviews, we established that there are currently a variety of ways in which coordinators have been employed in the UK, typically either separately from or in combination with statutory responses. Perhaps offering the greatest independence to coordinators is the model in which coordinators are either independent contractors or employed by a dedicated voluntary sector provider, and their services are purchased on a case-by-case basis by mainstream services. When coordinators are independent, they are expected to be responsible for their own training and continuous professional development. Some adult FGC services are nested in-house in local government or health service organizations – managed at arms length from community or hospital teams and therefore able to maintain an ethos where they are clearly seen as being separate and independent. Where levels of adult FGC activity may be limited, coordinators may be based on teams primarily located alongside children’s FGC services or as members of an adult social care team. This latter configuration offers the advantage of greater visibility and connection with wider social care activity, but may make it harder for coordinators to feel and be seen as fully independent.

For whom may an FGC approach be suitable?

Both the literature and the practice survey indicated the wide applicability of the FGC approach across adult social care and mental health sectors, with relevance across the board for people with learning or physical disabilities, older people, and people with mental health difficulties (see Figure 3).

Figure 3. Circumstances in which people may be offered FGC services in the UK – practice survey.

Fisher et al. (2018) summarise the range of contexts in which adult FGCs may be used in the UK:

•   Where there is a breakdown of (or need to review) current care and support arrangements, a challenge in relation to mental or physical health or functioning, social isolation, homelessness, or a need to plan end-of-life care.

•   Where service contexts are changing, for example, at the point of hospital discharge or transition from support from children’s services.

•   There are professional concerns about safeguarding in relation to personal safety (for example, for people with dementia), abuse or coercive control, neglect and self-neglect, substance misuse, or hoarding.

While it can be helpful in setting up an FGC if there are already respectful and trusting relationships between people and support services (Ramon, 2021) it may also have particular value in situations where this is in itself an issue. For example, in Holland, FGCs have been offered to people with multiple problems who would ideally need care, but do not access it or ask for help (De Jong & Schout, 2011). Specifically, in relation to mental health, conferences have been offered in the contexts of voluntary help, assertive outreach, and the possibility of involuntary admissions (ibid.) However, there is an argument that offering FGCs in more coercive contexts may not necessarily provide the conditions for a process that is citizen-led and empowering.

There were divided opinions reported in the literature as to whether FGC could be appropriate for use in crisis situations:

One possible model that was suggested was to convene an initial professionally led crisis meeting to agree with a short-term plan to hold the situation and make arrangements for immediate safety and support. This would then create a sufficiently safe space in which more thorough preparatory work could be undertaken for a Conference, including, where relevant, looking to widen the network so that a more sustainable system of support might be achieved.

There may be circumstances in which the central person may lack the capacity to make an informed decision regarding participation in the FGC or to participate in the process in a meaningful way, for example, due to more advanced dementia (Górska et al., 2016). Similar concerns were encountered in situations where participating in a Conference was likely to aggravate psychotic problems (De Jong et al., 2014). In principle, it was seen as possible to proceed with an FGC process in which only network members participated in the actual Conference but with the interests and wishes of the central person still being represented within the conference discussions, perhaps through the involvement of an advocate. There may be other scenarios in which the central person elects not to be present at the Conference itself but is happy for the process to proceed with their wishes being represented by other means, perhaps via a recorded statement or the briefing of another person to speak on their behalf.

Metze (2007) cautioned that FGCs may not always be appropriate in situations of domestic violence, reporting both an instance where the FGC resulted in an effective plan with good results and one where there was minimal support provided and no evidence of change for the better. However, Tapper (2010) reports more positive results with a nearly 50% reduction in the number of domestic violence crimes reported since have an FGC and a 73% drop in approaching the police 6 months after the FGC. There may be possibilities for restorative change, but also dangers and challenges, if the perpetrator of the violence is allowed into the room as part of the process (Sen et al., 2018). To mitigate these, interviews highlighted the option of conducting two separate conferences or holding hybrid conferences to ensure the safety of individuals.

While Blundell and colleagues suggest that FGC has the potential to put an older person experiencing abuse ‘at the centre of the intervention and focus on their context and relationship’ (2021 p. 311), it may not appropriate in all cases because of the intersection of contributing risk factors, ‘including intrafamilial dynamics, mental health, intergenerational transmission of violence, the impact of cognitive impairment and dependency’ (Blundell et al., 2021 p. 314). Nevertheless, they argue that FGC can be successful in working with elder abuse if sufficient resources are put into preparation and implementation of the agreed plan.

Based on their experience of offering FGCs in situations where there were safeguarding concerns, Daybreak (a voluntary organization that has offered adult FGCs) proposed that the decision about whether to include a perpetrator of abuse in the FGC should depend on:

Ground rules may need to be established, with the central person having the right to withdraw from the meeting if they feel that they are unsafe or intimidated, or network members may be asked to withdraw if they are acting inappropriately. Where a central person may lack capacity, a meeting of just network members may be a viable way forward to plan for their safety.

In situations where people did not feel that they had the basis of a viable network, there were examples in the literature from the Holland of people feeling pressured to invite neighbours or others to be part of their support network (Bredewold & Tokens, 2021). This could be humiliating and undermine rather than support people’s weak social networks. ‘Forcing people to ask relative strangers (may) merely add shame to their loneliness’ (ibid. p.2185). One interviewee described similar scenarios, in which they were unable to proceed following a referral because they had no success in identifying people who might be potential members of a network of support:

Though we gained limited data on issues around cultural appropriateness, some participants highlighted that for some individuals, FGC may not fit well with their accustomed ways of doing things, perhaps due to issues around stigma and family shame associated with external ‘help seeking’ behaviours. In some instances, ‘people with certain religions might say … we could sort it out for ourselves, we don’t want somebody coming in” (Interviewee 2, social care practitioner). In some instances, FGC may feel inappropriate due to strongly embedded age- or gender-based hierarchies in which women might not feel able to speak out openly in front of men, or members of a younger generation might not feel able to question the judgement of their elders.

Descriptions of format and process

Consistent across our interviewees and survey responses, the FGC format is seen to consist of a preparation phase, conference phase, and review or follow-up phase. Within this framework, stakeholders emphasized that effective engagement depended on coordinators being able to be flexible with the format of the overall process to suit people’s particular circumstances and preferences.

Preparation phase

From both interviewees and the literature, it was clear that the preparation phase is crucial to the success (or otherwise) of the conferencing process. Broadly, the central role of the FGC coordinator is to create the conditions and support for a process wherein the central person and other participants are willing to meet ‘on a level’ with each other and be able to behonest and open about their concerns, aspirations, and preferences. If appropriate preparation and support to meet and communicate respectfully does not exist, the FGC experience may become humiliating rather than helpful (Blundell et al., 2021).

Although the coordinator will benefit from some information through the referral process, their first task is to establish contact with the central person and gain an initial understanding of their situation, their concerns and aspirations, and the people around them who are currently (or potentially) part of their support network. Sometimes, a central person may be reticent about inviting certain people (perhaps due to feelings of shame or embarrassment), and the coordinator may have a role in gently challenging this and encouraging them to invite all the people who matter to them. In most services, the central person appears to be at the centre of all decisions made regarding which network members and professionals should participate. However, such decisions could partly be influenced by the professional judgement of the co-ordinator regarding ‘important and relevant’ persons close to the central person and/or by any safeguarding issues that may have arisen – although this would be done in a way that still left final decision-making power:

In addition, the coordinator establishes contact with relevant professionals and services to elicit their input and, if possible, their willingness and availability to take part in the first part of the Conference – something that may not always be straightforward, particularly where other services are unfamiliar with the FGC process:

There may be a need for the central person to have an advocate, a role that may be provided by someone from an advocacy service or, quite commonly, by another FGC coordinator that would bring the added benefit of greater familiarity with the FGC process. There was some variation between services in the degree to which independent advocacy was offered, partly reflecting differences in typical clientele (and their levels of capacity), but also reflecting whether the preparation process itself (such as the formulation of a personal recovery plan) was usually seen as sufficient to ensure that the central person would have a voice in the decision-making process. However, any blurring of the coordinator / advocate role may perhaps be seen as undermining the perceived independence of the coordinator – and the potential to manage this could depend on the co-ordinator’s own training and experience in this regard.

Although the interviews highlighted some differences in the precise way it would be put together, there was general agreement that a working document would be circulated to everyone before the Conference. This document would include all relevant information and concerns to ensure that there are no surprise disclosures of agendas on the day of the Conference, and it would be written in a way that foregrounded the aspirations and preferences of the central person.

Conference

Our interviews and surveys highlight a common set of frameworks and practices within the Conference phase. However, services appeared to have adopted significantly different approaches to how these were operationalised. The choice of venue was considered important, and there was consensus that health or care service settings were generally inappropriate. Neutral venues, such as libraries or community centres, were often used to conduct the conference; however, in some other services, people’s homes were also considered as an option. Where homes were used, this would be where individuals preferred it or if they had mobility issues.

In addition, flexibility or variation appeared in the format of the Conference. While in general, planning and decision-making took place within a single inclusive Conference, there could be alternatives in terms of two or more mini-conferences, and online or hybrid options, in order to better include different network members (including those who may be geographically dispersed), or in situations where there may be issues around abuse or safeguarding.

The Conference itself may be seen as comprising four stages as outlined below:

Feedback from interviewees indicated that the process could be very different from that of a professionally-led meeting or a Ward round (Tew et al., 2017), with both network participants and practitioners reporting (and appreciating) conversations that felt genuinely dialogical. This suggests strong parallels with the process of network meetings undertaken as part of the Open Dialogue approach in mental health (Seikkula, 2011). A key underpinning principle common to both FGC and Open Dialogue is the importance of practitioners being willing and able to live with uncertainty while issues are explored, so that there is space for solutions to emerge from the central person and their network, rather than these being proposed (or imposed) by professionals (Seikkula et al., 2003; Tew et al., 2025b).

Review/Follow up

Our participants shared the perspective that some form of review and/or follow-up is important in determining the progress made with the plan. While FGC reviews may be seen as a necessary part of the process to sustain resilience and maintain momentum (Fisher et al., 2018), we noted variations in the purpose of offering a review, the format of the review process, the number of reviews offered, and the timing of these reviews. Such variation could be between different services and also within services, depending on the preference of the individual, but equally on the contents of the plan. Similarly, we noted variations in who was invited to the review, the setting for the review (choice of venue or online), and the timing of offering the review.

In most services, a review is offered to determine the immediate progress with plans, usually four to six weeks after the Conference. In some services, reviews were also used to address other issues that may have arisen, and perhaps, two or three further reviews could be offered to support and adjust the implementation of the plan over a longer timescale. Some services stipulate a maximum number of reviews. In some instances, reviews can be used to celebrate success with all involved. There was some lack of clarity as to what extent (and for how long) a coordinator could (or should) remain involved to ensure that what had been agreed was actually being delivered, either by services and/or by network members. In some instances, such follow-through would be undertaken by the referring practitioner, but, particularly when services were stretched, there could be a danger that there would be no one who could provide this sort of ongoing support, with potential implications for the sustainability of positive outcomes.

Confirmations and clarifications from the Deliberative Forum

Prior to the forum, we circulated a summary of what we thought we understood based on the findings discussed above, and what remained as key unanswered questions or areas of contention. There was broad agreement with much of our preliminary characterisation of the model, including its outline structure, values and principles, the role and independence of the coordinator, and the potential applicability of the model across all adult service user groups.

There were three key questions relating to our preliminary characterisation of the model that we brought to the forum. As outlined in the previous sections, there is a limited understanding of the feasibility of offering FGCs in specific situations, such as those in a crisis or the conditions necessary when offered to those with diminished capacity. Similarly, we considered that assumptions about the cultural appropriateness of FGCs needed to be explored more rigorously to gain an understanding of whether current model (s) are able to adapt the process to accommodate the social and cultural requirements of the central person and their networks. While there was consistency within the literature and interviews regarding the flexibility of FGCs, there was a lack of clarity on the aspects and extent to which flexibility was acceptable. These questions were presented in the Forum, and the responses that emerged from the deliberations are summarized in Table 2.

While FGCs may be offered in all situations, including to those experiencing a crisis, they may not always be appropriate as a first response in an acute crisis, especially where there may be safeguarding concerns that may take precedence, but it can be a viable option once immediate problems have been addressed. However, in any type of crisis, FGCs can provide an opportunity for services and networks to come together to manage a situation in a more collaborative manner. There was agreement that there needed to be flexibility and creativity where the central person may lack some degree of capacity in relation to particular aspects of decision-making. It may be useful to employ an advocate to engage with the central person to establish their wishes and preferences prior to the Conference and find the best way of communicating these, either supporting the participation of the central person at the Conference or representing their views to the network and practitioners if the person would prefer not to be present. Central to managing networks and situations was the confidence and skills of coordinators, particularly in enabling the central person to have their voice within a wider collaborative process.

Overall, a balanced and pragmatic approach prevailed in which it was recognised that situational and cultural factors might affect people’s willingness to engage with the approach, but that a willingness by coordinators to offer time and flexibility to take account of such factors could often (but not always) lead to agreement to participate in something that may initially seem somewhat strange or counter cultural. Similarly, issues of shame in discussing family matters with professionals could potentially be overcome by coordinators offering sensitivity and acceptance, and demonstrating cultural competence could be important. While it could be helpful to offer people the choice of working with a ‘matched’ coordinator from the same ethnic or cultural background, it was recognised that this may not always feel comfortable or appropriate. It was noted that, for some traditional families, there may be particular concerns about shame if the coordinator was to be seen as having connections with other individuals within their community, and hence a fear that other members of their community might become aware of the family situation.

Characterising the model for FGC practice with adults: Summary of findings

Based on the foregoing synthesis of findings from the research and practice literature, a national survey of practice, and targeted interviews with a range of stakeholders, we present, in summary form, our preliminary understanding of how the practice model for adult FGCs may best be characterised.

Values

Our conclusion is that FGC is a strongly values-driven process, but its underpinning values and principles are often implicit. These values demarcate a practice space with its own culture that may be significantly different from wider service cultures in social care and health, and practitioners appear committed to defending this ethos against any encroachment by hierarchical or professionally driven ways of working. Based on the evidence we obtained or reviewed, we present a summary of the key values and principles in Box 1.

Who for, when and in what circumstances?

From our inquiry, we conclude that FGC can be a universal offer that should not be limited to specific service user groups or offered only in response to particular sets of circumstances. More specific considerations are outlined in Box 2.

The practice model

Although there can be flexibility in how each stage of the process is delivered, the practice model may nevertheless be characterized as a sequence of three stages – preparation, conference, and follow-up/review–each comprising specific activities and interactions. These are summarized in Box 3.