THERAPEUTIC ACCESS: An Innovative Access Program that Expedites Permanency Planning

1. THERAPEUTIC ACCESS: An Innovative Access Program that Expedites Permanency Planning A Partnership Between: Thistletown Regional Centre, Ministry of Children & Youth Services, Ontario and The Children’s Aid Society of Toronto

2. Therapeutic Access Presenters: Mary Rella Manager of Assessment, Consultation & Training Thistletown Regional Centre Shannon Deacon Therapeutic Access Program Coordinator Children’s Aid Society of Toronto Kathy Duncan Child Welfare Supervisor Children’s Aid Society of Toronto

3. Therapeutic Access BACKGROUND….

4. Why is Access so Important? • Good Access Planning is pivotal to casework success • Well managed access provides opportunities to assess, teach, and correct parenting behaviours • Well managed access allows us to develop early and successful permanency plans for children • Well managed access contributes to placement stability

5. When Access Goes Well… • Maintains continuity in a child’s relationship to their family • Contributes to a sense of psychological permanence for the child • Assists the child and family in confronting the reality of separation, the reasons for it and the need for caregiving behaviours to change

6. When Access Goes Well… (cont’d) • Assists families to cope more adaptively • Provides a time and place to practice new behaviours • Provides an opportunity to assess the reasons for deficits in caregiving behaviours • Provides an important transition when reunification is possible

7. When Access Does NOT Go Well… • Promotes confusion for the family • Disrupts continuity in a child’s life • Promotes anxiety about the reasons for the separation and the reasons change is necessary • Contributes to disagreements between Family and Workers, Workers with Workers, Courts with Workers

8. When Access Does NOT Go Well… (con’t) • It continues with little resolution or understanding • It goes on forever with poor direction towards decisions • It promotes instability and poor permanency planning, ie. environmental or emotional stability

9. THERAPEUTIC ACCESS From Supervising Access to Building Parent Child Relationships Mary Rella, B.A. Psych., Dip. C.S. Psych.INTERFACE ProgramThistletown Regional CentreMinistry of Children & Youth ServicesMary.Rella@Ontario.ca Mary Rella 2006

10. Access as an Opportunity for Therapeutic Intervention Mary Rella 2006

11. THERAPEUTIC ACCESSOverview • Attachment Informed • Research Based • Interventions with parents are specific and linked to the reasons for historical parenting deficits • Risk Reduction Assessment Model • Supervised Access/Semi-Supervised Access • Partnership between Child Welfare and Children’s Mental Health Mary Rella 2006

12. From Supervising Access to Building Parent Child Relationships Productive in the Environment vs Product of Environment Resource-rich Worker Silent Worker Intervention Focused Note Taker

13. INTERVENTIONS • Our understanding of the parents perspective is crucial to help them change. • Change requires Parents to build a bridge between their reality, i.e., “what’s wrong with what I’m doing” and adaptive parenting. Mary Rella 2006

14. Therapeutic Access • Assisting parents to cross the bridge by helping to link the caregiving experiences they received to current maladaptive behaviours in parenting • Building adaptive parenting skills based on their own understanding that change needs to happen • Promoting Secure Attachments Mary Rella 2006

15. Therapeutic Access Interventions • Aimed at helping the parent(s) learn to reduce the risk to their child as defined by Child Welfare • Planned and organized by the Child Welfare Team and the Parent Mary Rella 2006

16. Criteria for Therapeutic Access • Planned shortly after the child is placed in care or when access is re- evaluated. • Included as a part of the Court material with specific criteria that identifies goals and/or process to achieve goals • Longer in duration, e.g., 2-4 hours. • Focused on learning new strategies and/or practicing more adaptive parenting skills. Mary Rella 2006

17. Criteria for Therapeutic Access (cont’d) • Focused on skill building for the parent and child. For example, the skills can be relational or behavioural. • Interventions aimed at increasing skill level and/or demonstrating skill level. • Effects of external therapeutic intervention are evident in Access. Mary Rella 2006

18. Interview: Caregiving Behaviours • Their own childhood experiences “Mothering/Fathering” • Conflicts and how they were resolved • Trust • Impact on current parenting

19. Interview as a Blueprint for Change • The quality of the caregiving relationship is influenced by the caregiver’s: • Own attachment experience • History and experiences of care as a child • Internal working model and mental representation of the self and others • Defensive strategies

20. Identified Risks to Children • Formulation • History of Trust: Parent memories of Caregiving behaviours they received • Adult Attachment & Key Relationships • Attachment: Parent and Child • Child and Parent • Parent Cues to Act: Dispositional Representations Identifying Risks for Parents Information acquired to create a therapeutic alliance with parent Intervention Plan Template Parenting Behaviours Affecting Parenting Patterns of Parent Child Relationships Parenting Model Parental Acceptance of Responsibility for Change Review Recommendations Mary Rella 2006

21. Structure to Therapeutic Access • Saying “Hello” • Playtime/Activity Time: unstructured time • Meal/Snack: structured time • Preparation for Separation and Planning for Next Visit • Debriefing with the Parent Mary Rella 2006

22. Patterns of Parent Child Relationships • Adults with sensitive caregiving behaviours promote secure attachment relationships • Inconsistent, rejecting and/or A-typical parenting behaviours promote insecure attachment relationships

23. Maladaptive Caregiver Behaviours • Unresponsive to child’s cues • Inconsistence in sensitive responses • Parents needs above the child’s needs • Rejecting behaviour • Affectively unavailable • Inability to provide comfort • Frightening to or frightened of child • Dissociative • Intrusive Behaviours

24. Correcting BehavioursParent Focused • Parents who are over-involved behaviourally • Under-involved emotionally • Parents who promote fusion and enmeshment, i.e., unable to separate self from child • Unable to read cues from child • Unable to respond to cues Mary Rella 2006

25. Interventions: Overview • Increase sensitive behaviours • Reduce rejecting behaviours • Reduce inconsistencies in parenting behaviours • Eliminate frightening, frightened, dissociative, or intrusive behaviours

26. Teaching Parent • Containment • Contingent Responsivity • Emotional Regulation • Dyadic Regulation • Communication of Affective States Mary Rella 2006

27. Result: Parent’s positive affect allows child to be more engaged • Joint attention • Affective attunement • Sensitivity and Responsiveness • reads child’s cues, responds appropriately Mary Rella 2006

28. Access is One Snapshot in time • Involve parent and their personal story • Move away from a “Silent” Child Protection Worker to an “Involved” Resource-rich Worker Mary Rella 2006

29. Understand how Parents make • meaning of their caregiving • behaviours with their children • Understand how Parents organize • behaviours towards their children • Result: Treatment can support and be intervention focused for purpose of change. Mary Rella 2006

30. Consider…. If we only focus on Parents’ current skills and do not correct the behaviours, we run the danger of supporting patterns of inappropriate parenting.

31. Access Goals in Child Welfare • Permanency Planning • Understanding of parental limitations, based on historical factors including trauma • Assessment of parent’s capacity to learn, bridged with reducing risk factors • A comprehensive working plan that informs parents and the legal system CAST 2006

32. Fully Supervised Fully Supervised Child Semi Supervised Semi Supervised Unsupervised Unsupervised • Access Plan • casework plan (risk factors) • culture • expected activities • level of supervision • behavioral indicators • frequency • location • safety plan • court plan • documentation Reassessment Access Plan Admission Parent Duncan, Dale, Rella 2006 7

33. Children’s Aid Society of TorontoTherapeutic Access Program • Initiated in the Fall of 2005, initially funded by Society through the Foundation’s Block Grant, it is now part of the Society’s core budget. • The Therapeutic Access Program provided service to 120 children in 68 families in 2006/2007, and as of December 2007, the program had received 125 referrals. • Of those families who have completed the program, reunification has been the outcome for 49% of the children. For the remaining 51%, other permanent plans have been sought, including placement with Kin and Kith. • The program has created new opportunities for collaboration between the Society and various community services, including the Willow Centre, Ontario Early Years Centres, and the Jean Tweed Centre.

34. Therapeutic Access at C.A.S.T. Scarborough Branch North Branch Toronto Branch Etobicoke Branch Referrals Therapeutic Access Program Program Manager Coordinator CYW Consultation Training INTERFACE Consults

35. The Role of the Therapeutic Access Coordinator (CAST) To assist workers in developing and implementing Therapeutic Access Plans (TAPs) • Accepts and coordinates referrals • Creates written therapeutic access plans that outline for the parents, the workers, and the court the risk factors identified in the caregivers’ history and how interventions will be implemented • Conducts developmental interview of parents with their child protection workers • Creates the therapeutic alliance necessary to begin caregiving interventions CAST 2006

36. …Role of the Coordinator • Trains front-line workers on the significance of caregiver history and the link to current parenting • Guides workers to apply clinical interventions specific to each family’s identified needs • Provides clear and supportive communication to the family about changes required • Assists workers in assessment plans • Provides written summary of progress/concerns which can be provided to the court with recommendations CAST 2006

37. The Role of the Child & Youth Worker • Collaborates with the Coordinator in developing and implementing therapeutic access plans • Provides direct teaching to parents on adaptive caregiving • Contributes feedback to the overall assessment and recommendations

38. Referral Process • Referral form is user-friendly and easily accessible to workers • Includes: • Child Protection Risk Factors – current and historical • Reasons for referral (Goals to achieve) • Access plans/observations/concerns CAST 2006

39. The Developmental Interview • Both Family & Children’s Service Workers must be present with parents • Goal is to create a Therapeutic Alliance, necessary to implement parenting changes • Interview of Parents using Key Relationship Questions to assess: • History of caregiving experiences and impact on current parenting • Parent’s responsibility to change • Behaviours affecting parenting • Parent’s strengths & limitations CAST 2006

40. Therapeutic Access Plan • Written Plan includes: • Risk Factors for Parent, Child & Family • Family’s Strengths • Specific learning tasks to address risk factors • Number of planned teaching hours and date for Review • Plan can be added to court documents/protection applications CAST 2006

41. Environment of Access Centre • Family Friendly – decorative, warm, welcoming • 9 Family visiting rooms, including 2 Infant rooms with cribs, change tables, rocking chairs, baths, etc. • Kitchen with stove, microwave, fridge, plates & utensils and dining table • Large open space for unstructured play • Toys for all ages, stored in one room CAST 2006

42. Implementation of Therapeutic Access Plan • Interventions specific to risk factors, applied by worker “in the moment” • Neglect - Practicing Instrumental Tasks – parents to bring all items needed to care for child, such as food, diapers, clothing • Emotional engagement – pointing out to parents child’s cues, teaching attachment rich interactions • Violence/Physical Abuse – parent presenting to child as not scary, identifying physical safety precautions CAST 2006

43. Review & Recommendations • Program duration 10-14 weeks • Review after 4-6 weeks to assess progress, concerns, modify plans • Written Summary at Completion, provided to the Court: • Number of teaching hours completed • Summary of plan/goals • Changes/Progress made and remaining concerns • Recommendations for reunification, permanent removal, or other alternatives CAST 2006

44. Training Clinical Learning Discussions, Ongoing Case Consultation and Direct Support during Access… • To teach workers the importance of understanding the parent’s past caregiving experiences as they relate to their current parenting behaviours • To provide workers with learning opportunities to teach parents more adaptive parenting • To review and implement attachment theory and research CAST 2006

45. Future Directions • Continuing to understand and implement current research in attachment theory in front-line clinical work • Helping parents to develop adaptive parenting models that will ensure their newborns can remain in their care despite past CAS interventions with previous children • Helping front-line workers understand the significance of providing children with developmentally appropriate information about the risks leading to CAS interventions, as well as teaching workers to assist parents to provide the same messages to promote psychological stability for children

46. For More Information… • Mary Rella, Thistletown Regional Centre Tel: 416-326-0767 Email: Mary.Rella@css.gov.on.ca • Shannon Deacon, Children’s Aid Society of Toronto Tel: 416-924-4640, ext. 3424 Email: SDeacon@TorontoCAS.ca