Building Bridges Back Home with Parents in Recovery: The Right Decisions at the Right Times

1. Building Bridges Back Home with Parents in Recovery: The Right Decisions at the Right Times Presented by Kim Sumner-Mayer, PhD, LMFT Children of Alcoholics Foundation and Joan Hajjar Phoenix House New York, NY

2. Substance Abuse and Child Welfare:Statistics • 8.3 million children live with substance-abusing parents (HHS/ASPE, 1999) • CWLA: 40-80% of parents with children in CW system have substance abuse problems serious enough to affect parenting (Young, Gardner, & Dennis, 1998)

3. Substance Abuse and Child Welfare:Statistics • SA likely a factor in ¾ of all out-of-home placements • CW-involved families with SA problems have more family problems than other CW-involved families • SA associated with significantly higher rates of RE-entry into CW system

4. Substance Abuse and Child Welfare:Statistics • Children from SA families: • More likely in out-of-home care • Longer foster care stays • Less likely to leave foster care within 1 year • More likely to have case plan of adoption

5. Substance Abuse and Child Welfare:Statistics • Problem use of alcohol MUCH more prevalent than use of illicit drugs (HHS/SAMHSA, 1998) • Parenting and custody issues are a major motivator for SA treatment

6. Substance Abuse Treatment and Child Welfare Systems: Disconnects & Misconnects SA approach to treatment: • Multidimensional • Tailored to individual needs (intensity, duration) • Acceptance of relapse as part of recovery process in most models • Often does not consider family relationships/ parenting

7. Disconnects & Misconnects Between Systems (cont’d) SA approach to treatment: • Lacks emphasis, understanding of child safety issues and reunification process • May limit or prohibit contact with children until later in treatment • Perceived info-sharing problems

8. Disconnects & Misconnects Between Systems (cont’d) CW approach to SA problems: • Negative worker attitudes toward parents • Negative worker attitudes toward SA treatment system as a whole • SA treatment as one-shot, one-strike-you’re out

9. Disconnects & Misconnects Between Systems (cont’d) CW approach to SA problems: • “One size fits all” treatment • ASFA timelines do not allow waiting for full recovery • CW workers often hand clients a list of treatment providers without reference to the type of treatment offered and waitlists

10. Recovery is a Family Process Parent’s Recovery Process • A process, not an event. • Redefinition of Self • Partner support important • Spirituality, social support, relapse prevention • Relapse usually part of recovery. • Aftercare very important! • Parenting Education

11. Recovery is a Family Process Family’s Recovery Process • Parents and children must relate without substances. • Reshuffling roles, boundaries, & authority • Denial at the family level • Family members don’t understand parent’s need for continued focus on sobriety

12. Reunification Begins with Separation: Parent’s Experiences Two losses: • Children, and • Status as an able parent

13. Reunification Begins with Separation: Parent’s Experiences Reactions: • Anger, Grief, perhaps Relief • Hold on to maternal role • Grief + Relief  Drug binge, deepening of addiction • “Replacement pregnancy”

14. Children’s Experiences of Separation • Short-term reactions look different than longer-term adaptations • Age of child influences their presentation • More placements, more severe reactions • AD/HD overdiagnosed, PTSD overlooked • Behavior appears willful but is actually survival-oriented

15. Children’s Experiences of Separation (cont’d) Implications for Practice • Sibling contact extremely important to sense of continuity • Contact and Continuity with Parent is important • Children’s support needs are great • Caregivers need help understanding children’s behavior

16. Reunification Continues with Visitation: Parents • Awkwardness common • Not permitted normal parenting responsibilities • Parent viewed as failure

17. Reunification Continues with Visitation: Parents • Hard to enjoy/play with/be with child • Guilt + Overcompensation  Poor boundaries • AMBIVALENCE

18. Visitation: Children’s Issues • Conflicting feelings • Loyalty splits • Circumstances of visit can influence child’s mood and response to parent • Children’s responses to visits can be very challenging to caregivers.

19. Other Visitation Dynamics • Visits may not be regular • Tx program may restrict contact • Pre- or post-visit upsets push for less visitation • Birthparent—caregiver dynamics

20. Other Visitation Dynamics • Parent concern re: child’s adjustment to carecut back on visiting • Longer in careless confident in parenting • Family develops new homeostatic balance around child’s absence

21. Working With Ambivalence (cont’d) 3: Seek to understand its causes and refer to therapy & additional help No bond use visits to build bond Fear incompetence  teach Fear relapse  add supports

22. Working With Ambivalence (cont’d) 4: Explore options and proceed with concurrent planning that is grounded in parents’ participation in making the plan.

23. Case PracticeGuidelines • Develop relationships/referral agreements for parent education, family therapy, and aftercare services • Refer for family therapy—Don’t wait until reunification date is in sight • Encourage parent and kinship caregiver/foster parent collaboration. Expect CW agencies to do same. Set the bar high.

24. Case PracticeGuidelines • Encourage parents to be increasingly involved in day-to-day aspects of their children’s lives (school-related appointments, doctor visits, recreational events, clothes shopping and haircuts, etc.) • Convey to CW and SA treatment agencies that this is an important and expected part of parent’s service plan.

25. Case Practice Guidelines • Obtain information about the quality and context of visits. • Assure that a Relapse Plan has been developed once unsupervised visits are instated. • Refer for parent education that is evidence-based and effective

26. Quality Parent Education • Gold standard = both parents and children involved in the service. Examples: • Strengthening Families (http://www.strengtheningfamilies.org/html/programs_1999/06_SFP.html) • Celebrating Families (http://www.preventionpartnership.us/families.htm) (developed for a FDTC and replication studies currently underway) • www.samhsa.gov for more model programs

27. (Re)Unification: Parent—Child Interactions • Honeymoon period, then • Testing & Acting Out • Children hypervigilant re: dishonesty, broken promises, etc. • Children’s grief & loss issues re: previous caregiver • Children’s anger & fear surface

28. (Re)Unification: Parent—Child Interactions • Parents trying to assert authority for perhaps first time • Parent’s high expectations of self, kids  rigid or inappropriate rules • Role changes for kids are confusing and threatening • Children rebel, regress • Parents surprised, confused by kids’ behavior

29. (Re)Unification: Parent—Child Interactions • Parents may be reluctant to seek help—fear children will be removed again • At same time, parent has new people, places, & things in their life and kids have to adjust to all of these • There may be new children

30. (Re)Unification: The big picture • Parent simultaneously coping with relationships with substitute caregiver(s), partners, employment, housing, finances, any continuing legal issues, and maintaining sobriety. Is it any wonder that relapse vulnerability is high right about now?

31. Relapse • A normal part of recovery for most people • A process, not an event, ending with substance use • Not all relapses are the same • Not all relapses involve a return to pre-treatment level of functioning • Family may react more negatively due to sense of disappointment and failure

32. Relapse Planning Clean or dirty urine is not the only or even necessarily the most reliable indicator of child safety. • Sobriety is an important measure of safety, but it’s not the only measure!

33. Relapse Planning • Just because the parent loses their clean time, it doesn’t necessarily mean they lose all the actual progress they’ve made in altering their thoughts, feelings, behaviors,and relationships.

34. Relapse Planning (cont’d) • Can have clean urine while child is still in danger of being abused, neglected, or hurt. • A parent can have a dirty urine but be taking better care of their child than they were before.

35. Relapse Planning (cont’d) • Clean urine for the drug of choice does not preclude use of another drug (most commonly alcohol) in a way that might be dangerous for a child.

36. Relapse Planning (cont’d) • Let’s be smart about the place of urine testing in making visitation and reunification decisions! Parenting is multi-dimensional and so should our decisionmaking be. • Relapse Planning should be a part of parents’ treatment

37. Relapse Planning (cont’d) • Should include discussion of plan for child safety in case parent relapses • Requires involvement of parent’s support system to provide child safety and/or monitoring & reporting of parent behavior

38. Relapse Planning (cont’d) • Swift reporting of relapse should be looked upon with respect • Relapse should be viewed as indicating a need for additional support

39. Case Practice Guidelines • Recognize parents’ specialized aftercare needs. Develop referral agreements with family therapists and Aftercare programs that provide parenting-specific support. • Encourage the development of additional child, parent, & family services to meet reunification needs in your community—partner with funders and issue or answer RFPs for services

40. Case Practice Guidelines • Recognize children’s special support needs as children of substance abusers. Develop relationships with service providers who meet these needs via support groups, therapeutic recreation, psychotherapy, developmental services, etc. during FDTC Planning process.

41. Case Practice Guidelines • Assess parent’s readiness to reunify using multiple measures—abstinence or lack thereof is not an adequate measure

42. Encourage parent and kinship caregiver/foster parent collaboration. Expect CW agencies to do same. Set the bar high. Refer for family therapy if you have not already Assure that Relapse Plan has been updated to reflect reunification realities. Case Practice Guidelines

43. Indicators of Readiness/ Safety: North Carolina Family Assessment Scale—Reunification (Kirk, 2001) • Developed for Intensive Family Preservation Services programs serving reunification cases • Available at www.nfpn.org

44. North Carolina Family Assessment Scale for Reunification (NCFAS-R) 7 Main Areas of Focus: • Environment • Parental Capabilities • Family Interactions • Family Safety • Child well-being • Parent/ Child Ambivalence • Readiness for Reunification

45. Indicators of Readiness/ Safety: Parent/Child Ambivalence • Parent Ambivalence • Responds appropriately to child verbally & nonverbally • Receptive & responsive to services to bring parent and child closer • Parent acknowledges responsibility for role in family difficulties leading to removal

46. Indicators of Readiness/ Safety: Parent/Child Ambivalence • Child Ambivalence • Comfort with parent • Child responds appropriately to caregiver affect, expressions of love, limitsetting, etc. • Age-appropriately expressed desire to live with caregiver • Acknowledges any responsibility child had for family difficulties leading to removal • Responsive to services aimed at facilitating reunification

47. Indicators of Readiness/ Safety: Parent/Child Ambivalence • Caregiver Ambivalence • Supports reunification even if they have some reservations • Will give parent a fair chance • Disrupted Attachment • Eagerness to repair relationship from both parent and child

48. Indicators of Readiness/ Safety: Parent/Child Ambivalence (cont’d) • Visitation • Positive anticipation of visits • Activities planned and executed • Increased duration & frequency and decreased supervision needed • Incidents during visits are processed • Re-establishing roles and limits

49. For more information Kim Sumner-Mayer, PhD, LMFT Children of Alcoholics Foundation 164 West 74th Street New York, NY 10023 (646) 505-2063 tel. (212) 595-2553 fax ksumner-mayer@phoenixhouse.org Joan Hajjar Phoenix House/ AmeriCorps Program 55 Flatbush Avenue, Brooklyn, NY 11217 (718) 858-2462 jhajjar@phoenixhouse.org www.coaf.orgwww.acde.org www.phoenixhouse.org