What Really Matters in Team Effectiveness?, with Elizabeth McGuier, Ph.D.

Season 4Episode 21December 2, 2022

What is the key to team effectiveness? We talk to Elizabeth McGuier, Ph.D., from the University of Pittsburgh about her research into multidisciplinary teams.

Children’s Advocacy Centers (CACs), have been growing in the U.S. and around the world as the gold standard response in child abuse intervention for the last 40 years. Central to a CAC is its multidisciplinary team, made up of different professional disciplines, work for different partner agencies, have differing laws that regulate their work, different mandates, and different professional cultures. Those differences can be a source of strength in applying the professional expertise of the group in a holistic way to kids and to the cases that come in. But they can also be a source of tension and conflict. So the key question becomes: What really contributes to team effectiveness? Is it getting along with one’s peers, hanging out and having happy hours? Is it having trust and mutual respect? Is it one’s own perception of team performance? While all those things help, it may surprise you to find that it’s something else entirely. Join us in our conversation with Elizabeth McGuier, Ph.D., assistant professor of psychiatry and pediatrics at the University of Pittsburgh.

Topics in this episode:

  • Origin story (1:50)
  • Team functioning (5:43)
  • Perceptions of caregivers vs. team performance (10:03)
  • The key to team effectiveness (12:33)
  • What are appropriate outcomes to assess? (21:01)
  • Implications of the study (23:02)
  • Youth Feedback Survey (28:40)
  • A team-focused approach (31:03)
  • Burnout and vicarious trauma
  • For more information


Elizabeth A. McGuier, Ph.D., assistant professor of psychiatry and pediatrics, Department of Psychiatry, University of Pittsburgh

“Team Functioning and Performance in Child Advocacy Center Multidisciplinary Teams,” McGuier, E. A.; Rothenberger, S. D.; Campbell, K. A.; Keeshin, B.; Weingart, L. R.; & Kolko, D. J. (2022). Child Maltreatment, 0(0). DOI 10.1177/10775595221118933

NCA members receive research-to-practice briefs every Monday morning as a benefit of membership. “Team Functioning and Performance in Child Advocacy Center Multidisciplinary Teams” was the subject of the message on September 12, 2022.

Care Process Model for Pediatric Traumatic Stress, developed through a collaboration of the Department of Pediatrics at the University of Utah and the Center for Safe and Healthy Families at Intermountain Healthcare’s Primary Children’s Hospital

Outcome Measurement System (OMS) currently has four surveys that CACs can administer: Youth Feedback Survey, Caregiver Initial Visit Survey, Caregiver Follow-Up Survey, Multidisciplinary Team

For more information about National Children’s Alliance and the work of Children’s Advocacy Centers, visit our website at NationalChildrensAlliance.org. And join us on Facebook at One in Ten podcast.

Season 4, Episode 21

“What Really Matters in Team Effectiveness,” with Elizabeth McGuier, Ph.D.

[Intro music]


Hi, I’m Teresa Huizar, your host of One in Ten. In today’s episode, “What Really Matters in Team Effectiveness?”, I speak with Elizabeth McGuier, assistant professor of psychiatry [and pediatrics] at the University of Pittsburgh.

Now, Children’s Advocacy Centers [CACs], have been growing in the U.S. and around the world as the gold standard response in child abuse intervention for the last 40 years. And central to a CAC is its multidisciplinary team [MDT]. There are teams in lots of places, but what’s unique about the teams that work with and in CACs is that they’re comprised of different professional disciplines, work for different partner agencies, have differing laws that regulate their work, different mandates, and different professional cultures.

That’s a lot of differences! And those differences can be a source of strength in applying the professional expertise of the group in a holistic way to kids and to the cases that come in. But it can also be a source of tension and conflict. So in an environment in which the differences can go either way, the key question becomes: What really contributes to team effectiveness? Is it getting along with one’s peers, hanging out and having happy hours? Is it having trust and mutual respect? Is it one’s own perception of team performance?

While all those things help, it may surprise you to find that it’s something else entirely. And to hear more about Elizabeth’s surprising findings and what they mean for your own multidisciplinary team, please take a listen.

[Music begins to fade out]

[1:50]  Teresa Huizar:
Elizabeth, welcome to One in Ten.

Elizabeth McGuier:
Thanks for having me.

Teresa Huizar:
So I’m curious, how did you come to this work, sort of researching child abuse and Children’s Advocacy Centers?

Elizabeth McGuier:
Yeah, so I have always been interested in child maltreatment and children’s mental health. I grew up with foster and adopted siblings, my mother was a child welfare case worker for a lot of my childhood, so it’s always been something I kind of was broadly interested in.

A lot of my research during graduate school was focused more on physical abuse and neglect and looking at parents’ risk for perpetrating physical abuse and neglect. So I really wasn’t aware of CACs at that time. I had some interactions with CACs when I was on my clinical internship. I was getting trained in Trauma-Focused Cognitive Behavioral Therapy [TF-CBT], and so some of the children that I saw were referred from Child Advocacy Centers. I didn’t really think about CACs as a research setting until after I was done with graduate school and internship and I was thinking about how we can improve the access and quality of mental health services for children who experience maltreatment.

And I was really especially interested in rural areas. And I happened to come across CACs through a project that my mentor at the time was working on and realized, “Wow, this is a really neat setting.” It, you know, has mental health services for children who experience maltreatment as a core piece of the model and has really high reach into rural areas, which is just not true for most of the other things that we do.

So that’s what got me excited about doing research with CACs.

[3:29] Teresa Huizar:
Oh, my goodness. I mean, you had an interest in this from childhood really. You’re the perfect person to have done this research.

So kind of moving on to your most recent research, which is what interested us, and I was so delighted to see a study on team functioning. I think this is something that deserves some further unpacking, and especially what we know about how it ties to performance of the same multidisciplinary teams when working child abuse cases.

And I’m just wondering, you know, you had a general issue in the area, you were familiar with CACs, but what made you want to sort of dig into this piece between team functioning, team performance, and mental health care for kids, which was the interesting sort of triad that you started to look at?

Elizabeth McGuier:
The question I started with was how do we create change in this setting? Right? So the project that I mentioned earlier and then I started with was looking at implementing a mental health screening and referral protocol in Child Advocacy Centers. And so it’s the Care Process Model for Pediatric Traumatic Stress, developed by a team at the University of Utah.

And so I was thinking about, how does that get into practice? And I was really interested in figuring out, how does teamwork play into that? Because we know a lot about how to implement new things, but it’s mostly focused on organizational factors or individual level factors. And we don’t really know a whole lot about what’s happening at the team level and how that affects teams’ ability to support change in their setting.

So I actually started from this, like, implementation question. And realized then to do that: Wait. First I need to learn more about what aspects of team functioning matter just for performance generally.

[5:14] Teresa Huizar:
There are lots of articles on change management. My own leadership team just read one this week that we discussed. As you say, they tend to be within organizations, or even within networks, but not necessarily on teams that are cross-discipline from actually different agencies.

You know, it’s not just that you’re a different discipline in your own agency, but you’re from different agencies with differing mandates, differing roles, all of those things. So I think that’s an interesting insight and also interesting to kind of take a look at.

So, first of all, because everybody didn’t read this article—although we tried to get them to, I mean, I did send out a research-to-practice brief on this—but can you describe, when you use the term team functioning, what sorts of sort of aspects and behaviors are you looking at specifically?

Elizabeth McGuier:
Yeah, that’s a great question because, you know, teamwork and team functioning and team performance, like what does that all mean?

So when I say team functioning, I’m thinking about what teams think, feel, and do. So I’m trained as a clinical psychologist, so that cognitive triangle—

Teresa Huizar:

Elizabeth McGuier:
—of like thoughts, feelings, and behaviors is really central for me.

But so team functioning is all of the things that team members do, right? The ways they communicate, coordinate with one another. The ways they think about their work. So, are they on the same page? Do they have the same goals? What level of shared understanding do they have, and how they feel, right? Do they like each other? Do they get along? Is there a lot of conflict or tension? Do they trust each other? So I think of that cognitive triangle for teams. What are they thinking? What are they feeling? What are they doing? And then how does that affect their performance?

And by performance I’m thinking about the quality of their work, efficiency of their work, kind of the output of what the team does.

[6:56] Teresa Huizar:
And in this case, one thing that you were looking at in regard to that was mental health referral and screening, correct, yeah?

Elizabeth McGuier:
Yeah. So we looked at three different outcomes that we all considered kind of different aspects of team performance. So one was just team members’ ratings of how well they think their team is doing. The second was mental health screening and referrals. So how frequently are they using a standardized protocol, providing families with the right resources, and that sort of thing. And then the third outcome was the OMS, Outcome Measurement System Caregiver Survey.

[7:32] Teresa Huizar:
Great. Well we’re going to dig into all those aspects, um, in the course of the conversation. But one thing that I did really appreciate that the study did was tease out a little bit between how teams think they’re doing and also looking at how are they actually doing on the thing we want them to be doing. Because those are not identical questions. So I really appreciated that you kind of separated those things out.

Now going into this, of course you had to have some hypotheses, you know, things that you thought you might find. What were they in this case? What did you think you might see?

Elizabeth McGuier:
Yeah, so I think we know from a lot of research, right, that different aspects of team functioning are associated with team performance. So I expected to find that, but it was kind of trying that out in a new sample.

The real question for me was, which of these things seem to jump out the most? Right? So if we take this kind of big blob of team functioning, what are the things that really seem to jump out the most for Child Advocacy Center teams?

So, if we’re trying to improve teamwork, we need to know which aspects of teamwork to target. So I think like that was really the question for me, and it goes back to that trying to figure out how can teams support change in their settings. Well, you need to know a little bit more about these different aspects of functioning first.

[8:50] Teresa Huizar:
Well, in a minute I’m going to tell you what surprised me most about your findings, but I’m curious about whether it will align with what surprised you most about your own findings. So, when you got the data back and you started analyzing it, what did you have this sort of moment of “Well, that’s interesting,” or, “I wasn’t expecting”?

Elizabeth McGuier:
I think on the positive side—like a good surprise—was that all the teams seem to be functioning pretty well. And so I think on this, you know, from the clinical outcome side, I was like: Oh, that’s great. I’m glad these teams are mostly, like, doing well. From the researcher side, I was a little worried, because if we don’t have a lot of variation, then it’s really hard to figure out what explains that variation.

So part of me was—I was glad to see teams are doing well, but I was also like, ooh, are we going to be able to find out anything about teamwork from teams that overall seem to be doing okay? And thankfully we could. There was still enough variation even within teams that are doing well to be able to learn more, which I think is really important because sometimes when we talk about teams, people get stuck on, like, really problematic teams or: “When our team is falling apart, that’s when we need to do something.”

But I think this work showed that even when your team is doing pretty well overall, there’s still variation and room for improvement in all those different areas.

[10:03] Teresa Huizar:
Well, and also, you know, the importance of learning from positive variance, too.

You know, if teams are doing particularly well, why are they, relative to their peers? Which this didn’t specifically look into, but I think is one of those questions that, as you say, we get bogged down sometimes in underperformance instead of going: “Yeah, but why is this one doing as well as it is?” or “why did these 21 seem to be high performing overall, even though they had room for improvement?”

So thank you for that.

Well, I’ll tell you what surprised me a little bit. Surprised and didn’t surprise me because, you know, the window that caregivers have into what teams should even be doing is very small, right? They’re very focused on their kids. They’re very focused on how the victim is thinking, feeling today, and the explosion in their own family that’s happened by this allegation coming forward. But I was very interested to sort of find that there didn’t seem to be any real correlation between the perceptions of caregivers—at least at the moment of the forensic interview and initial services—and sort of the reality of whatever the team’s actual performance was and their perceptions of their own performance.

Did that surprise you at all?

Elizabeth McGuier:
It surprised me in that it’s something that I would like to find something. [Laughter] But it also didn’t surprise me mostly because of the data that I was working with.

Teresa Huizar:

Elizabeth McGuier:
So one of the things is that with the OMS data, we had a pretty limited range. So most of the ratings are really positive, which is good for CACs. But it also again goes back to, when there’s not a lot of variation—

Teresa Huizar:

Elizabeth McGuier:
—it’s really hard to explain that variation.

The other thing is—from a, like, research and statistical perspective—is that, when we looked at the Outcome Measurement System readings, we basically had one value per team. Right? So we had 21 teams in this study, so we had 21 values. And that’s a lot less than when we are looking at something where we have lots of different team members’ readings.

So we just don’t have as much power to be able to explain things when we have less data.

Teresa Huizar:
Mm-hmm. No, that makes complete sense to me.

Elizabeth McGuier:
Yeah. So I think like from the research perspective, I wasn’t super-surprised that we didn’t find anything based on the data we have. I do think there’s a lot we need to do to better understand caregiver’s experiences through the investigative process, through the process of getting connected to services.

And I think that’s where the quality of teamwork’s probably going to play a bigger role.

[12:33] Teresa Huizar:
Yeah. You know, while many CACs use our follow-up survey for caregivers, many don’t, you know. And so I think for those that do, they may be in a certain way of more interest to researchers because there’s that issue about being able to look six months down the road or three months down the road and say, “OK, how did … you know, how did that change for you and how are you doing now?”

But sort of back to your own study here. Can you just share with folks what did turn out to be the most important factors to team functioning and performance? Which by the way, I thought was good news because these are all pretty practical things you can do something about, but I don’t want to steal your thunder. So you share it with everyone.

Elizabeth McGuier:
Yeah. So I think the most central finding for me is that: The extent to which team members felt like they had really clear goals in a shared direction, that mattered for all the outcomes. And it mattered even when we were considering, you know, how they felt about each other or what they were doing.

So to me that suggests that, like, having clear goals in that agreement might be a really central piece for CACs and for MDTs. So if you can agree on your goals, then it’s going to be a little easier to figure out what to do next. Right? Because you know your why. And if you agree on your goals, you’re going to see more value in building relationships to work towards those goals. So I think—

Teresa Huizar:
And it also sets a clear direction, right?

Elizabeth McGuier:

Teresa Huizar:
You’re not confused about what you’re there to do anymore.

Elizabeth McGuier:
Exactly. Because I think that that’s a really common challenge for CACs, for precisely those reasons that you mentioned earlier: These teams are across organizations, across disciplines. Everybody has different things that they need to do, different ways of doing them.

And so if you don’t have a really clear shared goal, then why would you need to work with these other people?

[14:25] Teresa Huizar:
Well, especially if someone annoys you.

I mean, at a very practical level, you know, if you work on teams long enough, there’s going to eventually be some personality clash or something like that, which you can let run away with you if you don’t really already have a shared goal that you have alignment around, which allows you to kind of put some personality stuff aside and go, “Yeah, but we’re doing this” and keep going toward that thing. As opposed to getting bogged down into, you know, “This person is really getting on my last nerves at every case review,” [laughter] or whatever it might be.

Elizabeth McGuier:
Yeah. And on the flip side of that too, I think having good relationships is nice, but it’s not enough. Right? So if you have a great relationship with other people on your team and you love hanging out together, that’s wonderful. But if you don’t also have a clear shared goal, you might not be doing anything to actually improve outcomes for kids and families.

So I think that, you know, that affective piece is nice and good and might be a necessary kind of precursor, but it’s probably not sufficient for MDTs to have the impact that they could.

[15:29] Teresa Huizar:
I can’t tell you how happy I am to hear you say that, and also [laughter] that this demonstrated it.

Because I think that people, when they’re having a conflict on their team, often do think that it’s all going to come down to these elements around how people get along and whether they’re doing enough happy hours together or whatever. I mean, I’m not making light of it. You do need positive relationships and positive regard. But at the same time, as you say, it’s not enough and you can have all of the sort of happy feelings in the world, but what are you really doing for kids? That’s kind of the ultimate test of whether we’ve worked on all the right aspects of our team functioning and performance.

Can you talk a little bit about this business of sort of psychological safety and these feelings of trust and respect? Because it wasn’t that they were totally unimportant, right? It was something else. So it’s not enough, but to what degree is it important?

Elizabeth McGuier:
I think it is important. Um, we did find that like our affective measures, which you said—so psychological safety, which is really: It’s safe to take risks in this team, to speak up about something and not going to be shut down or penalized for saying what’s on my mind.

So we did find that liking and trust and psychological safety, those things were associated with team members’ ratings of performance. They were associated with the frequency of mental health screening and referral. But it was more that, when we put everything kind of into the bigger model, with all these different dimensions together, it still mattered for team members’ ratings of team performance but we didn’t see it showing up anymore for the mental health screening and referral.

Teresa Huizar:
So the actual thing you wanted folks to do versus how people felt about their team?

Elizabeth McGuier:
Mm-hmm. Yeah.

Teresa Huizar:
Yeah. Interesting.

Elizabeth McGuier:
And you know, the mental health screening and referral is a pretty narrow outcome, right? It’s only one piece of what teams are doing. And our team member performance members’ ratings is a much broader outcome.

So it could just be that, you know, because it’s a more specific outcome, that thing is less relevant for this piece. You know, it could be that like maybe affective—you know, those relationships between CAC staff and mental health are what really matter for that piece. Versus these team relationships matter more for the overall picture.

[17:49] Teresa Huizar:
Right for other aspects of the investigation, coordination, or something like that. Well, you know, that’ll be future research that you all could tease out. I’ll be very curious about that.

I also think though, that there can be some sense of—I mean, just like any group you work in, if, if people are getting along and feeling that they are, their overall feeling and intuition about their performance may be a little higher than if folks are squabbling and not. So it’s just, it’s interesting to see these differences.

What I was thinking as all this was going on is, it would be very interesting to see the ratings of team performance—how people felt about their own sort of team effectiveness—and compare that to their MDT survey in OMS. Because those are so specific, and some things pop up in a very interesting way on there where people may overall feel that things are going well, but at the same time, they may have a very specific complaint that really is affecting team performance.

You know, it’s lack of information-sharing in a timely manner or something about case review that is, you know, really making them feel like it’s not as effective. So … your research raises many questions as well as answering some good ones, so thank you for that.

Elizabeth McGuier:
Yeah, it’s interesting with OMS, because I think that the OMS team survey really is designed to get feedback and be discussed and to be a place to provide specific suggestions. And so I think you could see that potentially eliciting more negative feedback because you’re really seeking it out. You’re saying, “What can we do to improve?” And so people are more likely to do it if they have a specific thing that they would like to see change.

[00:18:38] Teresa Huizar:
Yeah. A specific indicator. You know, what this does point out to me, though, is that, you know, we have not included something specific to mental health screening and referral on it as one of the indicators.

And you know, like as you’re talking, I’m making a little note to myself, like, we should take a look at that. Because the things that teams are involved in today are not necessarily the things they were … you know, even in our most recent refresh of this, they may not have had the same role. And so I do think it’s something for us to take a look at periodically.

Talk a little bit to me about what the tie is between overall team functioning and mental health screening and referral. If the team performance measures are good, did you find that they had a higher likelihood of appropriately screening and referring kids for mental health services?

Elizabeth McGuier:
Yeah, that’s a really good question and one I’m not sure I can quite [cross-talk] answer yet.

Teresa Huizar:
Yeah. [Laughter]

Elizabeth McGuier:
So one thing to keep in mind is that the state that I did this survey in was implementing a screening protocol statewide.

Teresa Huizar:
So they were in the middle of this implementation.

Elizabeth McGuier:
Yeah. So for a lot of these centers, you know, the questions I asked about mental health screening referral were general. So they didn’t refer specifically to what was being implemented.

Teresa Huizar:
I see.

Elizabeth McGuier:
But if a center had been implementing that, they’d say, “Yes, then we’re doing that, and we’re doing this, we’re doing that.” [Laughter] So it’s a little hard to tease apart what’s, you know, the model that was being implemented versus what they’re just kind of doing on their own and informally, or other models that they might have been following.

[21:01] Teresa Huizar:
Right. Well again, more to look into at some other point.

Did you find that there was any real difference between the sort of perceptions of the team’s effectiveness by the team members themselves—any significant ones—and their actual performance overall?

In other words, were people fairly accurate in the way they perceived their own performance, or did you find, eh, maybe not?

Elizabeth McGuier:
So, that’s a really good question that I can’t answer. Because I think the challenge is, what does it mean? Like what is actual performance?  Right?

Teresa Huizar:
And on what domain, right? So—

Elizabeth McGuier:

Teresa Huizar:
Oh, interesting. Yeah.

Elizabeth McGuier:
Yeah. There’s so many things that MDTs are doing, and they’re not all related to each other. So when we think about what makes it—you know, what are the appropriate outcomes to assess or what, when is an MDT being effective? It’s really hard.

You know, you could think about, like, the quality of the forensic interview, or the extent to which kids are getting mental health treatment, or, you know, participation in case review meetings. Like there are all these different things happening, you know. And how much, you know, cases are moving forward to prosecution. All these different things could be really unrelated to each other. And some of them are easier outcomes than others. Right. So like something like: Is more prosecutions good, bad, in the middle? Does it depend on the case characteristics?

There’s a lot of complexity, I think, in trying to figure out how to measure team performance and what those different dimensions are and which ones really matter for children and families.

[22:37] Teresa Huizar:
You know, you’re really articulating all the challenges we had with the OMS MDT survey. And the reason we selected the indicators we did were the ones that we felt not only that there was literature behind them really actually affecting something, but also, they’re the things that seemed measurable. There’s some aspects of this that are very difficult, I think, to measure, and—but that doesn’t mean we’re not going to keep, you know, trying and coming back to this.

Elizabeth McGuier:

[23:02] Teresa Huizar:
I’m wondering what you think the implications of this study are for, specifically, Children’s Advocacy Center directors and MDT coordinators within Children’s Advocacy Centers. Those people who are really tasked with the health and care of the MDT, but also ultimately what happens with kids.

Elizabeth McGuier:
Mm-hmm. I think the central piece for me is that, the importance of shared goals in a clear direction and really being sure that your team has a why, and they know what it is, and that you come back to it.

Right? So, I think early in the process of, like, forming a Child Advocacy Center and building your team, there’s a lot of discussions about why are we doing this and what, you know, what are we hoping to get out of this? And getting everybody on the same page.

But Child Advocacy Centers have matured, right? Like this is no longer a new movement. It’s come a long way. And so a lot of those centers are maybe now a good ways out from that initial process of forming a team and having those discussions. And so I think it’s really critical that centers and teams are revisiting their goals and really making sure that they understand why they’re doing what they’re doing, what they’re hoping to get out of it. They’re setting goals for themselves, and they’re kind of coming back and reflecting on whether they’re able to meet their goals.

[24:24] Teresa Huizar:
You know, it’s so interesting to hear you talk about that because you know, for those people who started a CAC or were on a team at the beginning, you’re right, they remember what it was like before. And what I found is, they can talk very passionately about the before and after because they experienced that.

However, once you get to the third, fourth, fifth, sixth generation CAC director or team member who are coming in, on the one hand, it’s positive because this is now kind of standard of practice around the country, right? And so people come in, in some ways with less resistance to the idea of working in this model because their agency has been working with the CAC for many years at this point. The flip side of that is that they didn’t experience the before, and so they may not really understand just how damaging to kids and how difficult for team members it really was. So I think you are pointing out something really important about helping people as they come into this movement, into this system, to really understand why we do what we do, and why that makes such a difference for kids that we do it in this way.

Elizabeth McGuier:
Yeah. And making sure that the model is continually improving and getting better because, those early stages, right? Even the research then was just comparing, “Hey, what happens when you have a CAC versus you don’t have a CAC?” And now we’re not doing that research because—

Teresa Huizar:
We’re done!

Elizabeth McGuier:
—most places have a CAC [laughter] and we know, like, that’s the better thing.

But now the question is, well, what makes the CAC more effective? Or at it’s most—

Teresa Huizar:
That’s right.

Elizabeth McGuier:
—effective? How do we improve this model over time? And I think that really for CACs, it’s coming back to like: What are their goals? Why are they doing this? What do they want to see improve and change? And how are they going to measure that and pay attention to that over time?

[26:11] Teresa Huizar:
Well, and I think also even the goal has shifted some.

In the sense that, you know, in the earliest days of CACs, I think we would’ve said that we were primarily an investigative aid in order to get criminal justice for these victims. And we’ve learned a lot since then about the fact that justice is rare. And not because people don’t want it or teams don’t work hard toward it, but you cannot predict juries, things go wrong in cases, you can’t control whether or not you have corroborating evidence, and that there’s something beyond an investigation that’s important. I mean, the body of evidence that really emerged around the importance of mental health care is the thing that really made the difference—along with parental support for kids healing.

And I think that, you know, we have to evolve what we view as the appropriate outcome as well that we’re sort of testing ourself against, because it’s no longer just: Did this case get forwarded for prosecution? Or was it prosecuted? Or even was it appropriately investigated? Although that has to be an important thing.

But for so many, what’s going to make the difference for kids, it’s going to be something else entirely. So I appreciate that you’re looking at that aspect.

When you think about the work still to be done in this area, research wise, what do you think still needs to be unpacked about team functioning or how that relates to mental health care or any of the questions that are currently intriguing you about CACs, multidisciplinary teams?

Elizabeth McGuier:
So the big-picture questions that I have are: One is related to what we just discussed about what are the outcomes that matter, right? What should we be measuring to tell us if an MDT is effective? All right. And those are both process outcomes and, you know, more hard outcomes, right? Like what’s happening for the, the children and families seen by them.

Another piece that I think is lacking in research on CACs generally is a better understanding of family’s experience. There’s a lot of research with professionals who work with CACs and MDTs, and there’s not a whole lot asking the children and families who’ve been served in this setting what it was like for them.

And that’s a challenging thing to do, right? Because they’re not exactly at a point where they’re like, “Yeah, I’d love to participate in a research study.”

Teresa Huizar:

Elizabeth McGuier:
But I think that’s a really important piece for us to be thinking about, is making sure that this experience is really centering children and families and not just what we as professionals think children and families need.

So those are the big-picture things. And then—

[28:40] Teresa Huizar:
It’s such an important point that you’re making, because I think more and more in human services we’re really understanding the importance of the input of individuals with lived experiences and shaping services, and that nothing really substitutes for that. And so I look forward to more research being done about that because I think that we may well learn some things.

I mean, even for the youth survey in OMS. That has been interesting what kids write about. Because, you know, there are questions, but then they’re allowed to write whatever they want to write about their experience.

And while I would say, overall in the movement, early on we focused very heavily on the physical environment, right? How kid-friendly it was, how warm and inviting. And then I think there was a little bit of—even though CACs are warm and inviting; I’ve not been in one that hasn’t been. There was a little bit of sort of a shift away from the physical environment in terms of emphasis to some other things—which was necessary in terms of focusing on services.

Like, yes, it’s nice that it’s warm and inviting, but what are we doing about mental health care? However, it’s interesting that kids write about the physical environment more than almost anything. Whether it was too cold. Whether it was too quiet. You know, all these things that affect their perception of whether this is a warm and inviting place that might not have to do with something an adult would pick up on.

So it’s just been very interesting looking at that data and saying, “Hmm,” you know—and that’s a small thing. I mean, in comparison to things that were on the forensic interview or other services. But it’s interesting that that piece of it, when they can write about anything they want to—aside from writing that people were nice, or often they write that they felt such a tremendous sense of relief—that’s usually one of the key things that they write.

Elizabeth McGuier:
Mmm. Yeah, I’m so glad that the youth survey is being done, and I think that’s such a great addition. And, you know, some things might be small, but small things matter, right? Small things are easy to fix. Why not change, you know, the temperature—

Teresa Huizar:

Elizabeth McGuier:
—if that’s something people are commenting on.

Teresa Huizar:
Or, you know, play a little music so it doesn’t seem like you walk in and it’s so quiet you’re whispering and afraid to say anything, you know?

Elizabeth McGuier:

Teresa Huizar:
Or something like that.

You know, for obvious reasons, the youth survey is only available to kids between certain ages, but I would really like to find a way to appropriately ask younger kids, too. Because so many of the kids we see are ages that fall below kind of our cutoff for the youth survey.

So, you know, the interesting thing about this sort of, you know, delving into this is there’s no end to it. Because there are always going to be really fascinating questions about this and things that need to be explored.

Elizabeth McGuier:

Teresa Huizar:
So what’s next for you? Sort of beyond MDT work and the things you’re doing there, is there something else that you’re like, “Yeah, I’m in the middle of this paper,” or “I’m writing this,” or “I’m in the middle of a research study on that.”

Elizabeth McGuier:
Yeah, I’ve got a few things going on, so [laughter] what—

Teresa Huizar:
Always, right?

Elizabeth McGuier:
Yeah, definitely.

So one is looking at the same teams in this survey, but using that survey data and some interviews with team members to look at how teamwork and team members’ involvement affected implementation of this mental health screening.

So, it’s been very interesting because I think there are a lot of different ways for implementation to go well, a lot of different ways for it to be challenging, and trying to figure out what are aspects of team members’ involvement or teamwork that we could target to improve our implementation. So I’m exploring that right now and then, once we identify what those targets are—which I’m working with some wonderful partners on right now—we’ll be testing—it’s a kind of a team-focused approach to implementing the same mental health screening—and see if that’s any more effective than our usual training one person to do it and then saying, “OK, good luck.”


My hope is that it’ll be more sustainable, right? Like I think when we have one person, it’s: “OK, it’s your job. You go do this.” You know, that’s great, and that person can take it and run with it and make it happen. But maybe they don’t like it and so they don’t do it. Right? Or maybe they love it, and they do it, and then they leave.

Teresa Huizar:
Or they go out on parental leave, or they get sick, or a million different things that can happen, right?

Elizabeth McGuier:
Yeah. Yeah.

So I’m thinking about things like backup behavior, right? Like what are the things that other team members who, you know, if it’s not their primary responsibility, they don’t have to, like, learn how to do it all. But are there people who could be trained to kind of step in in those situations? Or just know that it’s supposed to be happening and say, “Hey, wait, who’s doing that?” So thinking about how to increase team members’ awareness of the protocol, their support for it, so that it will happen more often, and then it’ll happen for longer. It’ll be more likely to be sustained.

[33:19] Teresa Huizar:
You know, I would be very interested also in sort of the team members’ perceptions about their own ownership, and responsibility to, kids getting mental health care and their mental health outcomes.

Because it seems to me—speaking of clear directions—that that’s the critical thing.

If you believe that it’s this person over there’s responsibility to make sure that kids get better. then you sort of trust that they’re handling “their job” in air quotes. And on the other hand, if you think your entire team, including yourself, is responsible for it, you may speak up more in case review around how the kid is doing.

You may make sure that they’re getting screened. You may want to see what the screenings said, you know, and understand better, if they’re not getting better in treatment, what can be done differently. So I just wonder, beyond the implementation of a tool, you know, kind of what people’s perceptions of their roles and responsibilities are to those better mental health outcomes.

Elizabeth McGuier:

Yeah, they’re really varied. At ___ I spoke in my interviews with some CAC directors with people who are doing the screenings—so advocates and coordinators—and with law enforcement and child welfare. And there’s just a lot of variation across team members and across centers in how they see the mental health piece. And you’d be surprised. It doesn’t always fall the way you’d think it would, right?

Teresa Huizar:

Elizabeth McGuier:
So sometimes you, you know, you get a law enforcement detective who’s like, “Yeah, that’s not my role at all. But like, I think it’s super cool and important, and I always ask about it and I check in on it.”

I’m like, “That’s great.”


[34:52] Teresa Huizar:
Yeah, it’s great. And what you want is for every single person to feel that way about it. You know, not just some people.

And I think, you know, this is the next wave, right? It’s like with anything where you’re doing change management, you have people who are early adopters for whatever reason. And then it’s bringing others along and bringing others along until you have more folks concerned with that.

And I just wonder how this will all tie into team member burnout and vicarious trauma in that I just—anecdotally, we get a lot of reports that, of teams who see kids get better are able to cope with all the things that go before that better than teams for whom, once they’re referred off to mental health care, that’s sort of the last time they ever hear about it. And so what they have in their job is really just a parade of kids at their most damaged points without ever seeing the ultimate outcome of that, or any kids get better. So I’m just so curious for someone to take that up as a research topic. Because it’s—you know, we hear these kind of reports from different CAC directors and teams, but I don’t know that anybody’s really looked at that question if very in depth about, does it make any difference?

Elizabeth McGuier:
Yeah, that’s such a good question, and you actually hit on something I care a lot about, which is this, the workforce.

Teresa Huizar:

Elizabeth McGuier:
So one of the things I love about MDTs and the Child Advocacy Center model is that I think it can really add a lot of value for the workforce across all these different disciplines and professions.

So I think a well-functioning team can be a really good buffer against the hard day-to-day work. Partly because you’re talking to people in different disciplines and in different organizations who get the work you’re doing, but also aren’t doing the work you’re doing. Right? So it’s hard to talk about the work you’re doing with people who don’t understand child abuse, who don’t know what it’s like to talk to a family that’s just experienced something really horrific.

But talking to just people in your own discipline or in your own agency, you know, there’s a lot of just stress and organizational culture that affects that. And I think having a more neutral place and people who get the work but aren’t in it the same way that you are, can be really valuable and a huge support for people in this, you know, in these professions.

[37:16] Teresa Huizar:
I also think that there’s something about the shared decision-making that happens on teams when people … when teams are operating well that reduces some of the moral distress because it’s not just me and my decision and living with it. You know, in some ways the entire team is living with the decisions that are made for kids. Instead of it like, “It’s all on me whether this child is safe.” That’s a lot to carry around as opposed to getting to hear perspectives from team members, you make a joint decision with the best information you have from everybody, and then you carry forward with that, living with whatever the ultimate outcome is. And I just think that for so many reasons that that is a better thing.

You know, I remember when I was a CAC director, we often had teams who would come and work at our conference table, and I’d be like [laughter], “Do you have a case coming up?” They’re like, “No. Do you mind?” I’m like, “No, that’s fine.” I think we felt like a safe place, and I think that’s true for a lot of CACs, that they’re that safe place for their team members, even if they’re not housing them. Or even if they don’t have a forensic interview in the next hour, and that way they’re perceived that way by their teams.

Elizabeth McGuier:
Absolutely. I think a lot of the directors that I’ve spoken to have made that a very explicit part of their role is having a safe space for not just the kids they serve, but for their team members so that it feels safe and welcoming for everybody who’s coming there.

[38:37] Teresa Huizar:
So what question have I not asked you that I should have or anything else that you just want to make sure that people walk away from this conversation going, “OK, that’s one change I could make,” or “that’s something I’m going to pay more attention to,” or anything else you’d like to share with our listeners?

Elizabeth McGuier:
So one thing I’d love to see CACs working on—I think that many of them already are, but I’d love to think about how to support them in this—is how to build capacity to do their own evaluations of the things that they think matter.

So, you know, it’s lovely to have research, it’s lovely to have national evaluations, but in your day to day, how are you evaluating whether you’re doing good work?

And I think that’s a really … just an important thing for everybody. Because if you are doing good work, and you have the data to show it, you can feel really good about what you’re doing. If your data’s not showing you what you want it to, right, what can you change? What can you do differently, and how will you know if it’s making a difference?

So I really am trying to think a lot about ways to support teams and continuous quality improvement, right? How do we reflect on what we’re doing? How do we get better over time? And that’s hard because in your day to day, you just want to get the things done that you have to get done. And this whole like “reflect on your performance and think about how you could do better,” that’s a whole ’nother layer.

But I think it’s a really rewarding layer if you can spend the time on that.

[40:01] Teresa Huizar:
And you know, I’ve just found that CAC folks and their teams care a lot about doing that better work, and that when we are able to share with them something that the evidence demonstrates is better, that they do in fact, you know, adopt it because they want to do better.

So I think you’re talking to a group of people that if we build that sort of evaluation—literacy may be too strong a word, but just the ability, even, to carve out the time to do the kind of program evaluation you’re describing is just so important for our teams, these kids, and frankly our own sanity. [Laughter] So thanks for pointing that out.

Elizabeth McGuier:

[Outro music fades in]

Teresa Huizar:
Well, Elizabeth, it’s been a delight to talk to you. I just love talking to researchers who research CACs specifically, because we can just get right into it. So you have a standing invitation. The next time you publish something that’s related to this, come on back to One in Ten, and we would love to talk to you.

Elizabeth McGuier:
Oh, thank you. I have been so impressed by the openness and welcoming of the CAC world to researchers. It’s been really enjoyable and rewarding for me.

Teresa Huizar:
Music to my ears. Well, thank you again, Elizabeth, and we hope to see you back here soon.

Elizabeth McGuier:


[41:08] Teresa Huizar:

Thanks for listening to One in Ten. If you liked this episode, please review it wherever you listen, and please share it with a friend. And for more information about this episode or any of our others, please visit our podcast website at www.OneInTenPodcast.org.

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