What is family and group conferencing for adults? part 2: Developing programme theory

Patient and Public Involvement

Co-researchers with lived experience of social care and mental health services were involved throughout in the design and conduct of the study. In particular, they read and analysed a sample of the literature that was reviewed, undertook interviews with stakeholders and co- facilitated the process of the Deliberative Forum. They took part in the discussion and synthesis of emerging findings and are co-authors of the Paper.

Approach

In this paper, we use a realist approach (Pawson & Tilley, 2004) to explore what may be key components of the programme theory that underpins FGC with adults. We sought to achieve a comprehensive understanding of this by using an integrative approach, drawing on the same sources of evidence as were used for the Part 1 Paper: analysing and synthesising data from a review of the international literature, an online survey, interviews with selected stakeholders (including people with lived experience) and, finally, a deliberative forum comprising a cross-section of informants from the field (for more detail, see Mahesh et al., 2025). Our approach and purpose follows Pawson and Tilley’s (2004) conception of a realist review and synthesis:

We reviewed and triangulated evidence from a literature review and a survey of practice across Great Britain with follow-on targeted stakeholder interviews. Where appropriate, we drew upon relevant RAMESES guidelines, in particular those relevant to analysing and reporting on the literature using a realist approach (Wong et al., 2013) and the specific guidance on constructing and refining a realist programme theory or theories (Wong et al., 2017 p.23). Out of this process we were left with certain key questions where there remained a significant lack of clarity or gap in understanding – and these questions were then put forward for reflective discussion at a Deliberative Forum. Putting this all together provides a basis for an initial formulation of what key Context-Mechanism-Outcome configuration(s) (CMOCs) may constitute the underpinning programme theory for FGC for adults. This initial formulation will be used to inform subsequent evaluative research conducted in selected case study sites. Figure 1 provides a schematic diagram of the methods employed for the Part 1 and Part 2 papers.

Figure 1. Schematic diagram of methods employed.

A more detailed account of the methodologies used for the literature review, national survey, stakeholder interviews and Deliberative Forum, and ethical considerations, is provided in the Part 1 Paper (Mahesh et al., 2025). For ease of reference, the tabulation of literature that was included in the review is detailed in Table 1.

Ethical approval and consent

Ethical permission for the study was obtained from the University of Birmingham Humanities and Social Sciences Ethical Review Committee (ERN_22-0818) on 9 / 12 / 2022. Stakeholder interviewees received a Participation Information Sheet in advance and written consent was obtained before the interview took place.

Positive outcomes that may be achieved through engaging in a FGC process

Within the literature there can be a tension between the sorts of outcomes that were seen as important by agencies and professionals, and those that may have felt more important to the central person and members of their network – an issue that has been highlighted in relation to FGCs in children and family services (Mitchell, 2020). A particular illustration of this in an adults context may be found in the reporting of a case study by De Jong and Schout. The reason for offering a FGC was that a couple were failing to maintain acceptable standards of cleanliness and basic hygiene in their home. The man worked long hours and the woman had become depressed and had ‘started obsessively collecting all kinds of gadgets’. The outcome of the FGC process was judged a success because:

Here the primary professional expectations of a good outcome would seem to be that concerns around unhygienic living conditions had been addressed. By contrast, other outcomes such as overcoming social isolation, and finding a voice in the marital relationship, which may have been seen as of rather more fundamental importance from the perspective of the couple at the centre - are denoted as ‘in addition’ and ‘positive side effect’. As well as demonstrating potential differences as to what sorts of outcomes may be seen as important, this case study also illustrates the possibility that the FGC process may, in some instances, achieve important outcomes over and above just producing a plan - although in some instances the latter may be all that is wanted or needed.

When asked about this, all our survey respondents endorsed the idea that a broader range of outcomes could potentially be achieved as a result of offering an FGC. These outcomes reflected a wider vision of interconnected personal and systemic or relational change, and included:

Drawing upon our analysis of the literature, our survey results and subsequent stakeholder interviews, we worked towards establishing a set of potential positive outcomes for a FGC process. Each potential outcome is discussed in more detail below.

a) Potential outcome: a plan is made and implemented that builds on the preferences, aspirations and capabilities of the central person and their network

Much of the literature indicated that the primary aim of FGCs for adults was to help the central person and their network to understand their particular situation and dilemmas and to develop a plan that would best address this. It was suggested that sharing different perspectives on a problematic situation could lead to better understanding by network members of the challenges that the central person was facing, and the generation of new and creative ideas to deal with the situation (Meijer et al., 2019). The outcome of FGC is therefore ‘a plan that is better aligned with the complex world of which clients are part of’ (de Jong et al., 2018). Whereas ‘professional-driven plans may even lead to disengagement and passivity among clients’, if ‘a person can take responsibility for [their] own plan, with the support of social contacts and with information provided by professionals, [they] may … have a stronger feeling of ownership’ (Metze et al., 2015c, p.169).

All interview participants agreed that making a plan was in itself a valuable outcome from FGC – and that this plan could provide an opportunity to offer help and support that is better tailored to the individual:

The process of engagement with the individual and network members could highlight additional issues and/or that the current service offer was not entirely relevant to the individual. In addition, it was reported that a plan could instil a stronger sense of responsibility and/or accountability towards the central person from both professionals and network members.

b) Potential outcome: enhanced wellbeing for central person and those offering care and support

A key outcome reported by most interviewees was the potential of FGC to improve the wellbeing, not just of the central person, but potentially also those who may be investing a lot of their lives in providing care. Wellbeing may be understood, not just as subjective experience of happiness, but as active flourishing - ‘a dynamic state in which the individual is able to develop their potential, work productively and creatively, build strong and positive relationships with others, and contribute to their community’ (Foresight Programme, 2008 p.10). Such a conception of wellbeing in terms of an engaged and fulfilling life is reflected in Section 1 of the Care Act 2014 - and our interviewees articulated this in similar terms:

Although there is a range of theoretical literature pertaining to wellbeing, within the context of FGC outcomes it may be helpful to conceptualise this in relation to the range of capabilities – or valued opportunities - that may or may not be available to a person in their everyday lives (Sen, 1993; see also Hopper, 2007). The notion of capability focuses on what people can do, be and achieve, and the choices available to them, so it may be seen as describing ‘a kind of power’ in a way that conceptions of happiness clearly are not (Sen, 2010).

Metze (2016) discusses how FGCs may contribute to enhancing individuals’ subjective and objective experience of wellbeing through increased knowledge, confidence, competence, self-esteem, autonomy and freedom. A particular factor enhancing wellbeing may be overcoming a sense of shame, and the (sometimes self-imposed) social isolation that may have accompanied this (De Jong & Schout, 2013). A randomised controlled study showed that FGCs increased perceived emotional wellbeing among Norwegian long-term social assistance recipients (Malmberg-Heimonen, 2011). Johansen (2014) argues that participation in FGC may strengthen a sense of community or belonging with one’s social network and this can improve a sense of self-worth for all. This emphasis on wellbeing gains for the whole network, and not just for the individual, is echoed by Górska et al. (2016) who stress the importance of outcomes in which the responsibility for care is more effectively shared between a wider (and potentially more mutually supportive) network, and hence no longer falls so much on a main carer whose quality of life may have been quite adversely affected, sometimes resulting in stress, emotional or mental health difficulties.

c) Potential outcome: empowerment through recognition and relational agency

In general terms, FGCs have been conceptualised as a democratic or emancipatory process in which both the central person and network members come to feel more in control over their lives – and themes of personal agency and autonomy are highlighted in the literature that was reviewed. FGCs may be seen to have the potential to shift power from professionals to the central person and their networks (Górska et al., 2016) – and this was reported as a key outcome by both interview participants and in the wider literature (Metze, 2016; Parkinson et al., 2018). The achievement of empowerment as an outcome could depend, in some instances, on the degree to which participants actually wanted greater control, and whether their previous experiences of engaging with professionals had been collaborative or otherwise. Taking a more psychodynamic perspective, Ramon (2021) suggests that FGC can have the power to ‘unhook past failures’, leading to at least a temporary sense that it could be safe and advantageous to take a greater degree of control over one’s life. A study by De Jong and Schout (2013) proposed a pattern of change for central persons from shame to self-awareness; expropriation to ownership; and social isolation to recovery and participation.

Where the literature may be particularly helpful is in moving beyond individualistic conceptions of empowerment to more relationally grounded perspectives. Mitchell (2021) applies theoretical understandings of recognition (Fraser, 2000; Honneth, 2004) in elucidating how participants in children and families FGCs felt, perhaps for the first time, that they had been noticed and acknowledged for who they really were in terms of their identities, preferences, aspirations and capabilities. A sense of being recognised in this way can confer and reinforce people’s sense of agency and having the right to be who they are. Through increased ‘appraisal support’, people may come to see themselves, and be seen by others, as having agency and an ability to contribute, rather than being seen as a problem or a burden, or just being situated as a carer for others (Johansen, 2014; Malmberg-Heimonen & Johansen, 2014). This sense of recognition may be experienced both in a central person’s relationships with their family or social network, and/or in their relationships with practitioners and services – and may contribute to an ongoing sense of self-worth that situates them as social citizens whose aspirations and preferences matter.

From the ‘relational turn’ in social theory comes the idea that personal agency is rarely best understood an intrinsic property of the individual, but instead depends on the relational contexts in which we are situated (Burkitt, 2016). This idea of relational agency may be seen to have particular applicability for people who may be more vulnerable, disempowered or lacking capacity: those who, to a more extreme degree, may only be able to exercise agency through the understanding and support of others (see, for example, Klein & Goering, 2023). Relational agency may be seen to interlink closely with experiences of recognition: people’s agency can only be enabled through their interpersonal relationships if significant others are able to recognise them for who they are and what they may want to be and do. A common theme from the practitioners interviewed was that, by participating in the FGC, network members appeared to better understand the central person’s needs and aspirations.

Metze and colleagues (2015c) propose a similar theoretical terminology, using the term ‘relational autonomy’ to describe the interpersonal aspect of relational empowerment that may arise through participation in a FGC process. They argue that it is through the support of others that one may be enabled in ‘finding a way to live in line with one’s values and identity’ (2013 p.171). In practical terms, agency may be enabled by ‘receiving support in making decisions and taking actions’, and ‘being able to ask for help in carrying out decisions’ (ibid.). However, they caution against any idealised view of relationships, recognising that these may also be paternalistic, repressive or manipulative. What may perhaps be a little more controversial in relation to promoting relational agency is their suggestion that a positive outcome, where the central person may have limited capacity or varying motivation, could be that family or network members offer ‘compassionate interference’ in order to help restore a central person’s lifestyle or living conditions back to how they have previously indicated they would like things to be.

d) Potential outcome: better support and opportunities through enhanced social and relationship capital

It is suggested that FGC may contribute to increasing resilience in the sense of the central person and their network having better resources with which to deal with any new challenges or crises that may emerge in their lives (De Jong et al., 2016). This has strong similarities with understandings of social aspects of recovery – and staying well - in the context of mental health (Ramon, 2021; see also Tew et al., 2012). In conceptualising what social and interpersonal resources may contribute to such resilience, it may be helpful to use the idea of recovery capitals (Tew, 2013) and, more specifically, to differentiate between (a) changes within a person’s more intimate network of personal relationships with family or friends (relationship capital), and (b) potentially greater integration within a wider community of social associations (social capital).

From a study of social assistance recipients’ experiences of arranging an FGC, an important finding was that ‘the most important outcome, was improved relationships’ including providing a means whereby ‘to reconnect with lost network contacts’ (Johansen, 2014 p.153). From their interviews with central persons and network members, Tew et al. (2017) found evidence of significant change within relational systems. Both the size of the network and the specific qualities and character of relationships may be important – enabling the central person (and other network members) to do, share and achieve things that would not be possible on their own; to give and receive support; to enjoy each other’s company; and to experience a sense of belonging and connectedness. Practitioner interviewees identified that the FGC process could often improve relational connectivity between the central person and network members, and sometimes, just as importantly, between different network members.

The starting point for some families and networks may be that their patterns of interacting and communicating with one another may not be particularly positive – and hence their relationship capital may be rather limited. Johansen’s (2014) research indicated that coming together in a FGC can open up more effective ways of interacting and communicating, and can thus improve unsatisfying relationships Practitioners identified that the process of jointly developing and agreeing on a plan can create a shared experience that can bring people closer (perhaps on the basis of some honest but challenging conversations), and that this often positively impacted on relationships on an ongoing basis. A restoration of broken or faded relationships was seen as leading to an increased level of social support and resilience for individuals involved in FGC (Malmberg-Heimonen & Johansen, 2014; Schout et al., 2017) – with improvements noted in both the quantity and the quality of their relationships (de Jong et al., 2016). Meijer and colleagues (2019) report that increased knowledge regarding the central person’s situation could boost and strengthen their network’s involvement, support and willingness to take action.

Research around recovery in mental health has highlighted that a key characteristic of recovery-supporting relationships is the ability to move relatively easily and seamlessly from a more one-sided relationship of providing support, when a person may be more unwell and debilitated, to one of ‘doing with’, and giving and receiving, as soon as the person is starting to feel more able (Schon et al., 2009). A similar emphasis on relationships characterised by sharing and reciprocity, rather than ‘doing to’ or ‘doing for’, may be seen as a core component of relationship capital – one which could contribute to the longer term sustainability of the caring system (Metze et al., 2015b).

Alongside potential developments of relationship capital, a number of authors also saw that FGCs could play a role in developing wider social capital which could be important, both in opening up resources and opportunities, and by reducing social isolation and giving people a stronger sense of belonging with the community (de Jong et al., 2016; Johansen, 2014; Meijer et al., 2019). An outward looking community-connecting focus was found to be a key feature of the recovery plans developed in mental health FGCs (Tew et al., 2017), but such a focus on enhancing social capital was seen to be missing in FGCs in public mental health in Holland (de Jong et al., 2015). Following Bourdieu, social capital is understood as ‘the aggregate of actual or potential resources that are linked to a durable network of mutual relationships’ (Bourdieu, 1986, cited in de Jong et al., 2016 p.735). Coleman, another of the early theorists of social capital (1988), highlighted the role that family and network contacts can play in linking people into such durable networks of formal or informal social association. In the context of working with people with more severe mental health difficulties, De Jong and colleagues (2014) found that when the central person felt more respected, trusted and valued (in our terms, receiving recognition), they consequently behaved more accountably towards the community – in turn leading to better acceptance by (and ‘social embedding’ in) the community and hence better access to wider networks of social capital.

e) Potential outcome: enhanced communication and trust between lifeworld and service systems

Another piece of the relational jigsaw is the possibility that the overall FGC process may lead to more collaborative and effective relationships between those in the ‘lifeworld’ (central person, network and wider community) and the various practitioners and agencies that are part of the service systems that may offer support or intervention (de Jong et al., 2014; Johansen, 2014). FGC can be seen as facilitating the development of more trusting and open relationships between networks and practitioners, and may have the potential to shift power from practitioners to the central person and their families (Górska et al., 2016). In some instances, interviewees reported that FGC changed the terms of how the central person and network members came to relate to practitioners and vice versa. Enabling the central person to make their own decisions in a way that is appropriate to them, alongside having clarity on roles and responsibilities of practitioners involved, appeared to positively change the perspectives of the central person and network members towards practitioners, thereby improving their relationships.

Meijer and colleagues’ research found FGC added value where the process provided the possibility to realise partnerships within mental health work between the central person, their social networks and practitioners. They noted that support of the plan by practitioners could lead to shared control and less recourse to coercive interventions (Meijer et al., 2019). De Jong and colleagues (2014) found that, in their research samples, people often had prior negative experiences with mental health care professionals - and learning to trust in them was an important outcome of FGC, both for the central person and their network. They suggest a significant factor in supporting this outcome was where a plan was established where all agreed its content, and this resulted in a bridge between the informal world of the central person and their network and the formal systems world of the practitioners. However, it has to be recognised that such a bridge depends on professionals and services actually delivering on what has been agreed – something which can be outside the control of the FGC service, but which may adversely affect outcomes.

More broadly, FGC may be seen as a mechanism for leveraging a culture shift towards to more coproductive ways of working within social care and mental health services:

f) Potential outcome: a more inclusive safety net around the central person

From the perspective of the central person, seeing network members and practitioners working more collaboratively together could give a sense of a much stronger safety net (Manthorpe & Rapaport, 2020). De Jong and Scout (2013) reported that such a safety net could help break the downward spirals of marginalisation and isolation for those affected by mental ill health. When their social networks are intensively involved, a gradual deterioration can be prevented as relatives and neighbours can be alert to the need to arrange additional formal or informal support at an early stage – thereby helping to head off an aggravation of psychotic symptoms and prevent the need for coercive measures (de Jong et al., 2014). In this way, strengthening social support may be a crucial factor in decreasing the risks and vulnerability associated with living with mental distress.

Within some service contexts, ensuring the safety of vulnerable adult(s) is seen as the primary outcome (see for example, Daybreak, 2010; Daybreak, 2013). A number of interviewees stressed the potential of a FGC to address safeguarding concerns in a way that was acceptable and appropriate to central person as an individual. FGCs may be seen to foster a personalised approach to risk management in which the central person, and those who care about them, think in a positive and productive way about how to achieve the lives they want, while managing identified risks (Hobbs & Alonzi, 2013). Network members may be able to highlight specific resources and potential sources of support that would not necessarily have been ‘on the radar’ of the professionals involved. Using a positive rather than a defensive approach to risk, FGCs may provide a forum in which to explore of the levels of risk that the central person may want to take, enabling them to make informed choices in conjunction with the key people who would need to provide support, or raise the alarm, should things not go according to plan. In these ways, FGC may be seen as providing an effective mechanism whereby to achieve the aims of the Making Safeguarding Personal policy initiative (LGA, 2013). and this was used in two of the early test bed sites (Manthorpe et al., 2014).

In some instances, concerns around risk centre on the relational network – either with particular people acting in ways that may be abusive, neglectful or financially exploitative, or with splits, conflicts or communication issues between network members impacting on the safety or emotional wellbeing of the central person, as in the following instance:

In such instances, although an agreed plan may be important (particularly in the short term), it is the restoration of honest and open relationships between network members that is likely to assure longer term safety and security for the central person – and obviate the need for ongoing professional involvement.

g) Potential outcome: more efficient or better tailored use of social care and health resources (if appropriate)

Where FGCs are offered at an early stage, the central person may not already be in receipt of and social care or health services, and the outcome of the conference may be a plan that just utilises informal and mainstream community resources – and thereby may prevent or delay people’s need for formal service support. A recent evaluation of FGC services for adults in Camden found that 31% had resulted in a Plan that required no care service input (Spencer & Fisher, 2020).

Where such services may already be involved in providing support to the central person, there are indications from local evaluations that FGCs can generate savings by reducing the need for ongoing interventions or (more intensive) care services. A study in Hampshire estimated savings of £77,360 associated with 49 referrals to FGC – an average of around £1500 per FGC. Savings resulted from avoiding admissions to residential care, reduced need for domiciliary care and reduced social work and care management time (Daybreak, 2013). An earlier evaluation of an adult FGC service in Kent had estimated budgetary savings of around £7000 per FGC (Marsh with Kent Adult FGC Service, 2007). In Camden it was found that 8% of adults’ FGCs had resulted in an increase in service budgets, 15% had resulted in no change and 45% had prevented an anticipated escalation of care costs (Spencer & Fisher, 2020).

Other studies have also identified some potential reductions in the use of formal services in different contexts. For example, De Jong and colleagues (2014) found that involuntary admission to a psychiatric ward can sometimes be averted when informal support through a FGC is sufficiently mobilized (see also De Jong & Schout, 2011; Ramon, 2021). Blundell et al. (2021) found FGCs can be used as an intervention tool to stop the risk of escalation or continuation of abuse.

When costs for delivering a FCC service are taken into account, it may be more realistic to see FGCs as tending, overall, to be expenditure neutral – and if FGCs are to be promoted as a positive option to citizens, it is important not to see financial savings or reductions in services as an intended outcome of the process. Rather, the anticipated outcome should be that they may enable resources to be deployed more effectively (and creatively) as part of a network-led plan of support. Bredewold and Tonkens (2021) stress the importance of not over-relying on the family and social network to carry out all the actions within a plan. A sustainable support system may often require a combination of formal and informal support, and expectations around such a collaborative approach need to be built in from the start.

Interviewees stressed that facilitating conversations between network members could shift the type and form of care provided, with network members offering to support the central person in more acceptable and appropriate ways. Rather than being seen as a mechanism for taking services away, FGCs may afford the central person and their network the opportunity to identify gaps in current care provision and discuss with invited professionals what may help to fill these gaps. One study found that FGCs could open up opportunities for the person with dementia to benefit from proactive services focused on promoting independence and participation rather than on the reactive management of dementia symptoms (Górska et al., 2016). So far in the UK, there is little evidence of FGCs being employed when people may be offered the opportunity to directly manage their own support via the use of personal budgets or direct payments – but this could be an area for future development.

Contextual factors that may influence outcomes

Relevant contextual factors may be seen as those which support change and improve outcomes – or alternatively those which may make particular positive outcomes less likely to be achieved. Positive (or negative) outcomes from an FGC may be influenced by a range of service related and individual, network or community related factors.

Wider ethos of strengths-based practice and willingness to devolve power

Successful and sustained outcomes from a FGC process may be seen to be more likely to be achieved if the FGC service is situated within a wider practice ethos across services that is supportive of strengths-based and coproductive ways of working. Conversely, it may be much harder for people to keep control over their support arrangements if their dominant experience of services continues to be one of being ‘done to’ or ‘done for’. Within children’s services, deployment of FGCs has been particularly successful where it was implemented alongside the adoption of a wider practice framework of Restorative Practice (Mason et al., 2017. Meijer, Schout and Abma (2019) argue that FGC requires a change in attitude by practitioners in wider service systems to recognise the capabilities of the central person and their network, and their role as experts in their own lives. In mental health services, this would reflect a shift away from ‘treating’ them as a patient to working with them as a citizen (Ramon, 2021). To support this context, a willingness of professionals is required for them to enter into challenging yet respectful conversations where they make contributions to a shared planning process that is being led by the person and their network.

Independence of coordinators

A key contributory factor that can enable trusting and open relationships is when coordinators are, and are seen to be, independent of any agency or other external agendas (Górska et al., 2016). In practical terms, this means that they should not also be performing other roles such as social worker or care practitioner, or be involved in any process linked to determining eligibility for services or resources, or assessing levels of risk.

In turn, the degree to which coordinators may (or may not) have their independence protected may depend, at a service level, on whether the organisational location and management of the FGC service affords practitioners the space and autonomy to operate according to core FGC values and principles (see Mahesh et al., 2025) – a potential issue of concern that has been identified in relation to FGC in children’s services:

While our interviewees in adults or mental health service contexts did not report that the independence of their services were being compromised in this way (and presented very much the reverse of this picture), this remains a factor to which we may need to be alert if FGC becomes more mainstreamed within local authority and NHS practice in the UK.

Workload, preparation and training

Alongside demonstrating independence, if coordinators are to engender trust from potentially anxious and fearful participants, it is important that, within their workloads, they are allowed (and encouraged) to spend as much time as is needed in order to connect fully with both the person and each of the network members during the preparatory phase (O’Shaughnessy et al., 2010). They must also be able to demonstrate confidence and capability – which may, in turn, relate to the appropriateness and sufficiency of the training and supervision that they are offered (Parkinson et al., 2018) – and this may need to include a specific focus on cultural competence (Barn & Das, 2016). However, as has been discussed in the Part 1 Paper (Mahesh et al., 2025), there can be some controversy as to the degree to which the role should be ‘professionalised’ and hence what sort of training should be seen as necessary and appropriate (see also Blundell et al., 2021; Schout & De Jong, 2017).

Practicalities that support participants coming together on an equal basis

In our Part 1 Paper (Mahesh et al., 2025), we discussed how certain arrangements and practicalities can be crucial in establishing the ethos of FGC as something that is clearly distinct from the inherently professionally dominated and often hierarchically organised world of social care and health provision. Within the context of children’s services, Bernheim et al. (2024) argue that the choice of venue for a FGC should be viewed as a core component of the process as it has the potential to either reinforce or disrupt power imbalances between central persons, practitioners and networks. From our interviews, we learned that a variety of community facilities could be utilised as ‘neutral’ venues but, in some services, cost considerations could limit this to certain publicly owned facilities such as libraries or community centres. For logistical and other reasons, we learned that an increasing number of people were requesting that the Conference should take place in their home – and there were mixed perceptions among those interviewed as to whether this was always appropriate in terms of creating a space that was genuinely neutral.

Equally important for many of our informants was the provision and sharing of food – usually at the start of the Conference. This practice, which dates back to the Māori origins of FGC, was seen by many as crucial in setting a tone that that was welcoming, informal and inclusive (unlike most decision-making meetings involving professionals). This allowed different participants to meet and get to know each other as people (rather than on the basis of role position) on a basis of equality and ‘doing with’. However, within the wider organisational context in which FGC services could be located, the practical and symbolic value of this was not always recognised - and budgeting for food and refreshments could be defined as a luxury that could not be justified, particularly in times of austerity.

Understanding of FGC and social/cultural acceptability

Another important contextual factor is the degree to which potential participants have a clear understanding in advance of what the FGC process entails, how it is organised and what to expect from it. This, in turn, can depend on the degree to local services and potential referrers understand the FGC way of working, the sorts of outcomes that might be achieved and the various expectations that it places on the central person and their network, and on practitioners. Where there is a good understanding, appropriate referrals are likely to be made and people will be well prepared in advance as to how to engage with the process. However, despite their best efforts to educate referrers, interviewees alluded to examples where people did not engage, or Conferences were unsuccessful, because of misunderstanding or misinformation – for example where individuals agreed to FGC because they had been led to believe that this would involve some form of family therapy, mediation or counselling.

While for some potential participants, the idea of being open with friends or family about problems and challenges may seem natural, for others this may be a major concern – and this may be particularly so for certain social and cultural groups where such openness may not immediately feel congruent with established norms, with issues around shame or pride, and exposing vulnerability to others (Nygard & Saus, 2019). It can therefore be seen as important that coordinators have the space to engage with such concerns – and perhaps ‘flex’ the process a little in order to negotiate a better fit without compromising core values and principles.

Factors influencing motivation and willingness to engage

The motivation and disposition of the central person and members of their network towards the idea of utilising a FGC may influence the likelihood of a successful outcome from the process (Meijer et al., 2019; Metze et al., 2015a). It may be helpful to unpick how situational and historical factors may affect motivation. There can be instances where the urgency of the situation acts as a motivating factor and it is possible that relationship issues may potentially increase motivation to ‘sort things out’ rather than necessarily acting as a barrier to engaging with a process. Conversely, in the sample of cases that they examined, De Jong and Schout (2013) found a recurring theme that feelings of shame, and fear of exposing shameful circumstances or actions to a wider audience, could be a major inhibiting factor that undermined motivation and hindered the movement towards a Conference.

In some instances, people’s prior experience of being ‘done to’ or ‘done for’ in their interactions with social care and health services may have undermined their confidence in exercising agency and hence inhibited their motivation. However, in situations where motivation may not have been strong at the point of referral, interviewees described what could sometimes be a long process in which hope and confidence were gradually built up during the preparation phase. In many instances, this could lead to the central person and/or network members coming to the (sometimes quite sudden) realisation that they could actually take control of the decision-making process and, through this, that they could make things different in their lives.

Prior state of people’s relational systems

Another relevant contextual factor can be the state and functioning of people’s networks prior to referral. Positive outcomes may be easier to achieve when there is already a well-functioning network of supportive people involved. Interpersonal relationships in the network which already provide recognition can more easily enable change within the FGC process (Johansen, 2014). Linked to this can be the central person’s already existing ability to articulate their wishes within their network of relationships and hence to reach decisions that reflect these wishes (Schout et al., 2017). However, while these factors may provide an advantageous starting point, they should not be seen as pre-conditions for successful outcomes. Within the interviews, it was stressed that much of the skill of the coordinator can go into preparatory work with both the central person and network members to enable them to reach a point at which they are ready to engage in a process of making plans together. Nevertheless, Bredewold and Tonkens (2021) caution that FGCs may not be appropriate or effective where there are long term entrenched relationship issues or patterns of interpersonal behaviour that are abusive, belittling or blaming, or where there is the potential for some family members to dominate at the expense of others who are less powerful. De Jong and colleagues, 2013; De Jong and colleagues, 2015) highlight that the fragile nature of some participants’ networks could at times lead to problems within the FGC process.

Although requiring substantially more preparatory work (possibly including mediation), it is suggested that FGCs can potentially perform a restorative function in bringing together people who have become estranged or where relationships have been damaged. This has featured in the children’s and domestic violence literature (see, for example, Sen et al., 2018) and is also picked up in a detailed analysis of adult case studies where de Jong and Schout conclude that ‘a limited or damaged network is not a contra-indication but a reason to organise FGCs’ (2013 p.1452). FGCs may be able to provide a context in which relationship issues can be aired and resolved, or in which networks could be brought back together (or created) where a person had become socially isolated. Although more challenging, offering FGCs in such contexts could offer very substantial benefits to the person in terms of (re)connecting with a functioning and supportive network of people around them – thereby both enhancing their quality of life and alleviating their potential dependence on social care services as their only basis of human contact and support.

Similarly, the nature of pre-existing relationships with practitioners and services may be seen to influence how easy it is for both to engage successfully in a shared planning process – and it can be helpful if there are already respectful and trusting relationships between them (Ramon, 2021) As Meijer and colleagues (2019) point out, the process of FGC is complex and builds on the contribution of different actors - the central person, network members, the professionals and the FGC coordinator. A key context for success within FGC is that all these actors contribute and are committed to the success of the process.

When to have a FGC

Within the context of mental health, Tew et al. (2017) found that positive outcomes tended to be associated with having family meetings earlier on when people’s networks were still relatively intact (and motivations potentially stronger), rather than leaving this as somewhat of an ‘add-on’ towards the end of a treatment process, perhaps resorted to when other interventions had not been particularly successful. Research has shown how quickly people’s relational networks may shrink following an episode of mental ill-health (MacDonald et al., 2005). A similar pattern may be seen to apply in many other situations, and interviewees consistently highlighted that offering an FGC as a form of early response increased the likelihood of a successful FGC - providing the individual and their network with an opportunity to receive help and support that was timely and relevant to them from the very beginning.

By ‘getting in early’ as issues are first emerging, rather than leaving this option further down the line when network support could be harder to mobilise, it may be possible to prevent or reduce later reliance on social care services.

Mechanisms and processes

In examining the question of ‘how it works’, we will discuss what have been identified as some of the key processes and mechanisms of change. In contextualising this, it may be helpful to start with a first person account:

While the key mechanisms of change may vary between individuals and conferences, this may give a flavour of some important aspects of process which were important in this instance: the inclusion and bringing together of both family and friends, a sense of having control and having a voice, and the importance of sharing feelings as part of restoring relationships that had become distanced or dysfunctional.

Inclusion and connection – ‘widening the circle’

There is a substantial literature that highlights the importance of key relationships with family or friends within many people’s stories of successful recovery from mental health difficulties (Topor et al., 2006), and support from a wider circle of significant others may be crucial in dealing with other challenges and situations of vulnerability. Although sometimes requiring persistent and delicate negotiation on the part of the coordinator, there was consensus from both the literature and the interviews that a successful outcome would be more likely to be achieved if the central person was willing to invite all those who might be helpful in developing a plan. Potentially, this could involve mobilising a wider network that may not just be limited to family members (de Jong et al., 2017). Key to this could be overcoming reluctance based on people feeling ashamed or embarrassed to admit their difficulties to particular family members, friends or significant others (de Jong & Schout, 2013). In some cases, ‘conferences helped in establishing contacts with new persons who subsequently could come up with creative solutions to be incorporated in the plan’ (de Jong et al., 2016 p.742). However, there could also be instances in which people reported feeling pressured into including people that they did not know sufficiently well (Bredewold & Tonkens, 2021) – and this could inhibit the openness and sharing that could be crucial in achieving a successful outcome. In some situations, coordinators took the contrary view that it was important not to lose momentum by taking additional time to include people who may be reluctant to join the process – and proceeding with a smaller but motivated network was seen as key to achieving positive results (de Jong & Schout, 2013).

Enabling different participants to connect with one another at the start of a conference was seen by interviewees as key to a successful process. Many informants stressed the value of people being able to do this in an informal way that could break down barriers – usually by coming together around sharing food:

In some services there was a strong emphasis in the preparation and agenda setting process towards an outward-looking community focus – seeing the plan as a stepping-stone towards wider community participation, both for the central person and also for those in caring roles who may themselves have become socially isolated (see, for example, Tew et al., 2017).

Preparation and ‘scaffolding’ that enables courageous conversations

There was a strong consensus, both from the literature and out interviews, that the preparation stage is crucial to the success of FGCs – and that this involves coordinators offering time, sensitivity and creativity in order to build trust and to develop and tailor a process that fits the needs, preferences and cultural expectations of the central person and their network.

While some FGCs may be relatively uncontentious processes for planning and decision making, the resolution of more challenging issues may involve the need for ‘courageous conversations’ that would otherwise not take place – either within the person’s network or between network members and members of the wider professional or service system. In these, participants may need to be open and honest about their feelings, and how they each see the situation, potentially sharing what they may never have said before (Meijer et al., 2019). This may include sharing very sensitive matters such as the impact of experiences of childhood sexual abuse (Tew et al., 2017).

As one central person put it, for such conversations to take place and be followed through, there may need to be ‘scaffolding’ in place to provide sufficient structure and safety (Tew et al., 2017). In achieving this, coordinators would need to take time to get to know and gain the trust of each participant:

Once this trust is built, coordinators can facilitate a ‘brave’ space in which there is sufficient challenge and support for an honest exchange around difficult issues (Bredewold & Tonkens, 2021; Schout et al., 2017) – and this may involve negotiating appropriate groundrules to enable a safe and respectful sharing of views and opinions between network members, and setting an agenda that is future- and solution-oriented (Manthorpe & Rapaport, 2020). Both the preparation with individual participants and the formalised staged process of FGC may provide important elements of scaffolding – helping to generate and uphold a respectful style of listening and responding, and hence to open up more effective ways of interacting and communicating. From Johansen’s study,

In some instances, a single conference may not provide sufficient ‘scaffolding’ if a network is going to be able to deal with more entrenched personal and relational issues – perhaps relating to past harm or trauma (Tew et al., 2017; Tew, 2019). In such instances, one possibility may be a referral on to a family therapy service. However, it may also be important to consider whether adapting the model in order to offer more than one meeting over a defined period of time might provide sufficient scaffolding for a successful restorative process to take place.

‘Shared learning platform’

Whereas in some (but by no means all) children and families FGCs, where professionals may come to the first part of the Conference to deliver a set of concerns and ‘non-negotiables’, there is an aspiration in adults FGCs that the first part of the Conference should function as a ‘shared learning platform’ (de Jong & Schout, 2013) in which network and professional participants can move beyond initial viewpoints and preconceptions and discover together new and better ways of understanding what may be going on (and why). Sharing stories and different perspectives on a problematic situation can lead to more understanding and generate ideas to deal with the situation, thereby creating a new, ‘co-constructed actuality’ in which central persons, network members and practitioners can all evaluate information and explore options (Meijer et al., 2019). This experience can not only lead to a better understanding of the central person’s situation, but can also facilitate shared ownership of problematic issues and encourages the formation of a partnership between different network members and between network members and services (Johansen, 2014; Ramon, 2021). However, it has to be recognised that not all professionals may feel ready to ‘cede power’ and may need some additional support and training if they are to enter into more equal and collaborative conversations (de Jong et al., 2018).

Interviewees talked about the role of coordinators in encouraging professionals to move away from certain ways of conducting business – inviting them to join in a dialogue rather than to come with “a list of things they need to check and [using] professional language to communicate” (Interview 7- FGC team lead). From their research, Górska et al. found that the first part of the Conference, ‘which involves the initial contact with service representatives in its information sharing phase, was perceived as an opportunity for the families and the professionals to come together, to listen to each other, and to get to know each other on equal ground’ (2016 p.238). Another factor that was seen by interviewees as important in facilitating participants being ‘on a level’ with one another was arranging for relevant information to be shared with all participants in advance – so that people could feel well prepared and new information or concerns could not be ‘dropped in’ on the day.

Receiving recognition

In her analysis of mechanisms of change in FGCs for children and families, Mitchell (2021) identifies processes whereby network members feel respected and understood – both by others in the network and by practitioners - as a key mechanism that can lead to positive outcomes. This process of recognition needs to start in the building of a relationship between the coordinator and the central person – a process of ‘getting to know’ at a more personal level:

Such recognition and ‘appraisal support’ may be seen as a precondition of an effective dialogic process – both constituting a mechanism for change as well as a valued outcome. Its importance was highlighted in interviews with stakeholders and in the national survey results – and is also highlighted in the wider literature:

As well as experiencing such affirmation, recognition may be seen to empower people within the FGC process. It ‘opens up predispositions regarding future possibilities and is important in the way people vision their future…. This could eventually contribute to an increasing feeling of hope, as people experience more power to influence their possibilities in the future’ (Meijer et al., 2019 p.148). Recognition may not just be important for the central person, but may be seen as a mutual and reciprocal process in which the network is strengthened by people simultaneously receiving recognition and offering recognition to others.

Power and ownership

Central to the working of FGCs is the transfer of power and sense of ownership of the process from professional systems to the central person and their network, letting them experience control and agency (Johansen, 2014). This shift of power may initially be rehearsed through (and, to some extent, symbolised by) offering participants control over practicalities, such has having the opportunity to make decisions around food, venue and who should be invited (Mutter et al., 2002). In order for this to take place, a change in attitude among the practitioners involved in the FGC may also be required. Schout and colleagues (2018) describe the stance required in FGC as ‘egoless care’, where practitioners may contribute suggestions to the plans being made by the individual and social network, but resist taking over the agenda for change. Metze et al. propose that this may be understood theoretically as follows:

As well as engendering opportunities for cooperative power between professionals and the central person and their network, there may also be a need to address potential power imbalances within family dynamics (De Jong & Schout, 2013), perhaps with particular network members tending to exert protective (or sometimes oppressive) power over the central person. It may therefore be important in setting groundrules and structuring the process of the Conference to build in opportunities for sharing and listening, and hence for the emergence of a greater degree of cooperative power relations.

There was broad agreement from the interviews that, fundamental to all FGC services was giving the central person ownership and control in the FGC process, in conjunction with members of their network:

Coordinators were seen as having a key role in countering the assumption that professionals would still be in control and that the coordinator would have final decision-making powers. This can be a gradual process in which confidence and agency are established through a focus on ‘small things’ that can make a real difference in terms of establishing people’s ownership of their own process

Examples were given of the various decisions that the central person would be invited to make during the preparation phase, including decisions regarding inviting potential network members and relevant professionals, where might be a comfortable and neutral space in which to conduct the Conference, what sort of food (or other activity) might be best to set the tone of the meeting, what should comprise the agenda for the day – and whether, indeed, there should be a Conference at all:

This experience of agency can help build their confidence that they could also have control as to what should go into their plan. It is argued that people’s sense of being in control during the FGC process is important in achieving the longer term outcome of relational empowerment (Metze et al., 2015c).

Where the central person may have had little experience of exercising agency in relation to their situation, one informant from a mental health FGC service described a structured process in which the central person was assisted in mapping out what they might wish for going forward using a proforma document called a personalised recovery plan. This comprised prompts consisting of strengths-based questions that helped to explore their aspirations and capabilities, alongside the challenges that they might currently be facing. This plan is owned by and confidential to the central person – but parts of it can then be shared in setting the agenda for the FGC, thereby putting the central person ‘in the driving seat’.

Restorative processes

In situations where relationships within the network have become estranged or conflictual, a specific emphasis on engendering restorative processes may be important. For central persons with limited networks or for those who may have lost contact with their family members, research findings show the FGC can provide an opportunity to mobilise, reconnect, repair and revitalise networks which may have become tired or paralysed (de Jong & Schout, 2011; de Jong & Schout, 2013). In this way FGC can be described as a ‘constructive’, ‘reintegrative’ and ‘restorative’ experience for family and networks to come together and resolve problems (Fisher et al., 2018).

Central to this may be addressing issues of shame, hurt or harm which may be getting in the way of people asking for help or of network members providing support that is effective or joined-up. De Jong and Schout (2013) stress the need to create a safe and structured space in which participants can share their inner feelings as part of the ‘courageous conversations’ that may be needed. In order for this to be possible, coordinators may play a crucial role in the preparation phase by offering acceptance – thereby starting to release personal barriers of shame which might make people feel unworthy of the support of others and unable to contemplate feeling hopeful for a future in which they were more closely connected to people that matter to them. Also crucial, as part of the preparation, can be the establishment of a restorative ‘no blame’ culture (Fisher et al., 2018), in which feelings relating to past harm or trauma can be acknowledged within a process that then looks forward to how people want to be with each other in the future.

By contrast, there may also be situations in which people may be feeling embarrassed when asking for help, or may be reluctant to open up too much for fear of losing control. From their research, Metze et al. concluded that, in order for a FGC approach to be appealing to many older adults, there needed to be respect for the principle that ‘you don't show everyone your weakness’. So, instead of providing a space for the sharing of inner feelings, an effective FGC process may have to be more business-like and task focused, with an emphasis on ‘reciprocity, peer-to-peer support, and solutions instead of problems’ (2015a p.1).

Sustainability

Broadly speaking, the same mechanisms that are seen as promoting successful outcomes are also mechanisms that may influence the sustainability of any positive outcomes that are achieved. Involvement of people’s social networks is seen as inherently likely to promote more sustainable plans and arrangements:

There is an assumption in much of the literature that whereas professionally driven plans may lead to disengagement through lack of ownership over the plan, family and social networks may display a longer-term commitment to support of a person than public services can offer (Johansen, 2014). For the central person, the confidence and control derived from being the driver of the plan can lead to longer term sustainability (Tew et al., 2017) - as not only are the individual’s needs acknowledged but they have direct influence over what is planned to support them.

It is suggested that FGCs can promote an ongoing and self-sustaining change in the relational system, with social networks being strengthened around the central person, thereby reducing their vulnerability (de Jong et al., 2014). Interviewees stressed that a shift in power from professional systems to the network can not only be key mechanism to empower the individual and their network, but can also be sustained, often lasting beyond the FGC process, but largely initiated by it.

An increase in the size and connectivity of the network can lead to a more sustainable arrangement with the responsibility (and potential burden) of care being divided over several shoulders (Meijer et al., 2019). Crucially, it is argued that the longer term sustainability of the caring system may depend on maximising opportunities for cooperative power, ‘doing with’ and reciprocity in the relationships between the central person and network members - and also between different members of the network (Metze et al., 2015c). On an ongoing basis, such relationships may be seen to promote mutual recognition and relational agency. They may also be alert to the signals that indicate that a crisis situation could be emerging (Meijer et al., 2019) – and ongoing trust and communication between central person, network and the professional system can promote an early and coordinated response that might avert the need for hospitalisation or other more intensive responses (Johansen, 2014; Manthorpe & Rapaport, 2020).

From a review of the existing research literature, Ramon (2021) notes that enthusiasm regarding initial positive changes arising out of the process was not always reflected in sustained outcomes at later follow-up. Metze and colleagues (2015c) point out a challenge with FGC (with older adults) is when the family and social network ‘fail to live up to their promises’, resulting in a negative expectation on the part of the social worker regarding the reliability of the social network to fulfil their obligations regarding the agreed actions in an FGC plan. Similarly, it can be the professional system which fails to provide sufficient contact and support during the implementation phase. Ramon argues that support during the implementation and review process does not always receive the investment that it requires from provider services – and perhaps particularly the need to work in ways that maintained the inclusion of family and network in ongoing support planning. While both the coordinator and the wider professional system could have a role to play in supporting the implementation and sustainability of the plan, interviews revealed a potential lack of consistency as to how best this should be achieved in practice, leaving open the possibility that ownership for this might fall between coordinator and professionals, leaving longer term success or failure very much in the hands of the central person and their network.

Findings from the deliberative forum

Having synthesised our preliminary findings from our literature review, national survey and interviews (as summarised above), we also identified particular areas relating to contexts, mechanisms and outcomes where our understanding of FGC was limited and/or there remained key unanswered questions or areas of contention. In order to gain a fuller understanding, we convened a deliberative forum, both to check out what we thought we already understood and to further explore these specific areas. As a basis for deliberation, we circulated a summary of our preliminary findings in advance, alongside some specific questions as set out in Table 2 below. Out of the discussions, the responses we received gave broad support for our synthesis of key contexts, mechanisms and outcomes, and the specific responses to the questions that we posed are detailed in Table 2.

Perhaps the most striking finding to emerge from the forum was the potential complexity of the task undertaken by coordinators during the preparation phase – and hence the need for them to spend sufficient time with the central person and each network member in order build up trust and develop a fuller understanding of the specific issues and dynamics that would need to be taken into account in planning for a safe and successful Conference. Central to this were the co-ordinator’s skills and capabilities in bringing everyone together and setting a positive and constructive tone to the Conference (including the negotiation of ground rules where appropriate). This could involve not only active listening skills but also creative thinking in difficult situations and a confidence to be flexible and ‘go with the flow’ as part of a fundamentally person-centred approach, rather than stick too rigidly to any pre-determined format or formula.

It was seen as essential that coordinators were comfortable being with conflict - validating people’s right to see things differently and have their own opinions, rather than seeking prematurely to try to gain agreement. Managing this effectively could require being alert to imbalances of power and any potential need for advocacy. It could also sometimes involve managing the professional field so that the central person and their network could have the space to make sense of their situation and devise their own plan - rather than feeling pressured by others to see things in a particular way.

A crucial element within this could be negotiating with professionals (and perhaps also some vocal network members) to stand back and be tolerant of uncertainty as the process unfolds, rather than seeking to rush to particular formulations of ‘the problem’ or to impose particular ‘solutions’ to it. For this to be achievable, there needed to be wider recognition within services that staying with uncertainty was an essential prerequisite of any genuinely coproductive process – and hence that professionally led assessment processes may need to be put on hold. However, this could be more difficult when there were safeguarding concerns, where statutory procedures and expectations could take precedence, and meetings between professionals might need to take place ahead of an FGC. In such instances, there would need to be clarity as to what were ‘non-negotiables’ and what could be the scope for the central person and network to make their own decisions.

Anticipated outcomes reported at the forum were similar to those shared by survey and interview participants. Wellbeing was seen as enabling a rich and fulfilling life for the individual that included people and things that matter to the individual. Linked to this was the potential for the recognition that people may receive during the FGC process to affirm and validate their personal and social identities – and hence enhance their sense of self. The process of bringing people together, even if they chose not to go ahead with a full Conference, was seen, in itself, as an important outcome for the central person.

Perhaps the most inconsistent area of current practice was seen to be in the follow-up and review process – and concrete suggestions were made as to how this could be made more robust (for example, by having an online copy of the plan that could be updated as and when necessary). While this was seen as positive in that this could be tailored to the needs of particular individuals and their networks, and that reviews could serve different purposes, it was also acknowledged that a more thorough follow-through process might be beneficial, particularly in ensuring ongoing connections with services when these were experiencing financial strain and cutbacks.