Introduction of Clinically Managed Access Visits

1. Introduction of Clinically Managed Access Visits A Road Map, Vehicle and Tool Box to Child-Focused Visitation

2. A Road Map for Clinically Managed Access Visit Presentation

3. INTRODUCTION:Stress and Trauma of Separation within the Context of Access Visits

4. Why Clinically Managed Access Visits?Re-enactment of original apprehension, grief, loss, and guilt • “Often the problems arising in the visit relate to parent’s discomfort about having their child in care. Parents who have lost their children, even temporarily, to public care may feel a deep sense of shame (McAdams 1972).” • “…As well, they are experiencing the pain of loss, which they sometimes cover up with anger and resistant behavior.” • “…Parents need a sensitive approach from caregivers and workers to help them handle these feelings around visits…” • “…It is important to remember that, because each visitation is a reenactment of earlier reunions and separations (Hess 1999), reactions tend to mimic original separation reactions.” • For example, a child with a history of traumatic disruptions in the parent-child relationship will feel that trauma repeated when she enters foster care. The reunion with the parent during visitation may then feel quite desperate, as the child anticipates, based on past experience, that it will only lead to another traumatic separation. • “Without appropriate intervention with the child, each visitation will replay this scenario.” • Source: P.68, children in Limbo Task Force, Sparrow Lake Alliance

5. Stress and Trauma: A Primer

6. Stress & Trauma Client Stress & Trauma • What it looks like • How it affects clients • Impact on client behaviours Practitioner Stress & Trauma • Vicarious trauma • Our responses • Burnout and self-awareness

7. What is Stress? • DEFINITION: • Psychological and physical strain or tension generated by physical, emotional, social, economic, or occupational circumstances, events, or experiences that are difficult to manage or endure (Colman, 2001).

8. The Effects of Stress on the Developing Child • Stress kills brain cells and disrupts/upsets neuro-development in children causing: • Higher Thinking Issues • Social Thinking Issues • Language Issues • Expressive and Receptive • Motor Skill Issues • Handwriting, and fine motor skills • Spatial and Sequential Ordering Issues • Memory and Attention Issues

9. GENERAL DESCRIPTION:Stress Mechanism • General Adaptation Syndrome – (GAS) • Hans Selye • Three (3) STAGES: • Alarm: characterized by an initial fall in body temperature and blood pressure, followed by a countershock phase during which hormones such as cortisol are secreted into the bloodstream and a biological defensive reaction begins. • Resistance: the body copes actively with a stressor by mechanisms such as sending leucocytes to the sit of an injury or infection. Put another way, body’s immune system kicks it into overdrive. • Exhaustion: this phase is reached when the person has failed to adapt to a stressor, characterized by physical and/or mental disorder or disease.

10. GENERAL ADAPATATION SYNDROME - Selye

11. STRESS: SUMMARY AND DISCUSSION • Warshaw (1979) states that stress reactions can also be helpful and positive. Depending on the intensity and the way they affect the individual, these reactions can be helpful and even pleasurable. Stress can be turned into motivation and positive energy. It isn’t so much the event that determines whether the individual is stressed or not, it his/her reaction to it.

12. Introduction to Trauma • Trauma = Greek for “wounding” • Trauma wounds the mind, body and souls of individuals as well as groups of people • Trauma alters a person’s biochemistry • (Friedman, 1991; Kolb, 1987; McDonaugh-Coyle et al., 2001; Murberg, 1996; van der Kolk, 1988, 1996)

13. What Trauma May Look Like: • States of hyperarousal alternating with states of numbing • Sometimes results in mental and emotional disorganization, leaving survivors feeling out-of-control, even terrified unless they have ways of managing them. • Observations: • Survivor may be: • Argumentative • Withdrawn or asocial • Hostile • Alienating

14. What Trauma May Look Like: • Survivors of trauma may avoid inter-personal situations or anything involving social interactions. • Survivors often seek relief from trauma through self-medicating means: • Chemical means • Drugs • Alcohol • Food

15. What Trauma May Look Like in Clients: SUMMARY

16. Vicarious Trauma • Sarah Haley (1974) was first to articulate vicarious trauma • Effects of trauma survivors on other people. We are the ‘other people’. • Effects of traumatic stress somehow can be transmitted to people who were not themselves exposed to the traumatic events. Knowledge of the ‘history’ of the client and the impact of current situation for the client impacts the practitioner with vicarious trauma.

17. On Professionals Working with those who have been traumatized Vicarious Trauma within the context of Child Welfare All terms that are used in an attempt to define what happens to professionals working with a traumatized population. Whether one conceptualizes the process of listening/witnessing trauma as soul sadness, caregiver’s plight, co-victimization, or emotional contagion, the outcomes remain the same. • For the purpose of this presentation I will use the term vicarious trauma.

18. On Professionals Working with those who have been traumatized • Build upon memories obtained while listening to the stories of one inhumane act of cruelty after another. • Creates a permanent, subtle or marked change in the personal, political, spiritual and professional outlook of the counselor (Richardson. 2001). • The effects of vicarious trauma are cumulative • Vicarious trauma has a life-changing effect, ultimately affecting the world-view of professionals • Also affects relationships and connections to family, friends, community and professional relationships with colleagues and clients.

19. On Professionals Working with those who have been traumatized BURNOUT: • Vicarious trauma is the result of hearing about the cruelty, exploitation and atrocity inflicted to trauma victims. • The emotional impact of hearing about another’s pain and continual exposure to the pain of the human condition is different from work over load, role conflict, unrealistic self-expectations, poor communication and inadequate leadership/supervision. • An accumulation of stress with no resolve can lead to ‘burnout’. • Sometimes the cause is external, for example an oppressive supervisor, increased demands, too little opportunity for autonomy, or unclear work/home boundaries. • Munson (1993) – Research has shown that practitioners in some fields are more susceptible to self-imposed unrealistic expectations, whereas child welfare workers are more susceptible to external-societal or bureaucratically imposed unrealistic expectations. • Self-awareness, self-assessment and self-care are critical to preventing a toxic, unhealthy build-up of the negative and invasive effects of both direct trauma and vicarious trauma (Richardson, 2001).

20. What BURNOUTMay Look Like: • Similar to primary trauma, the severity and longevity of practitioner symptoms varies from person to person. • The practitioner’s view of self, world and future may be affected. • This may lead to shattered assumptions held about identity, worldview and spirituality. • Behaviors resulting in vicarious trauma may be parallel to behaviors of primary trauma survivors, e.g., isolation, disconnection, mistrust, pessimism, chaotic relationships and increased substance use. • Self-awareness is a key component. • Symptoms:

21. Assessment within the context of Access Visits

22. Assessment within the context of Access • Definition: A Clinically Managed Access Assessment, involves a thorough evaluation of a family’s strengths, needs and functioning, bringing clarity to planning, intervention, decision-making, and focus for outcomes concerning family issues and attachments.

23. ASSESSMENT: Who? What ? Where? When? How? Why?

24. ASSESSMENT: Who? • Clinical Access Facilitators (CAF) carry out clinical assessment and intervention with the family during access visits. • Case Manager provides CAF with known historical information, recent risk assessment, plan of service, court application/documentation, assessment information. • Coordinator assists with planning and orchestrating visits, setting child focused goals for access/intervention focus, and guidance of CAF’s intervention – teaching parents new approaches to parenting while recognizing parent’s feelings about visiting (Osmond, Palmer, Perlman, Dale, Steinhauer, Role of Access in Permanency Planning) ; Aug. 2000)

25. ASSESSMENT: Who? • Other parties essential to the intervention process are the; • Child Care Worker, • Foster Care Resources Worker, • Foster Parents, • Parent Support Worker, • Other Collaterals such as Pediatrician, Child and Family Centre Clinician etc.

26. ASSESSMENT: What? • First access visits are CAF’s opportunity to observe and assess a family’s parenting ability *(with the exception of the 1st visit after an apprehension). • An “Access Plan” is created from this assessment, that builds upon family strengths, with the aim towards risk reduction, improvement in familial relationships, and ongoing safe, positive visits between family members.

27. ASSESSMENT: Where? • Parenting Centre • Parents Home • Outside Resource – Foster Home, Group Home, Hospital • The location of access must be as least restrictive as possible ensuring child safety and allow for natural exchange (i.e. attending dental/medical appointments, shopping for food or clothes, attending school functions, a fun family outing).

28. ASSESSMENT: When? • As per the best interests, protection, and well being of the child. • As per court order. • Frequent and long enough to enhance the parent-child relationship and mobilize the parent’s care giving ability and for the family to engage in familiar routine activities.

29. ASSESSMENT: How? • Ecomaps/Genograms/Nipissing Development Scale, …. • Ecomap intervention – families tell their story their way. An Echomap is a pictorial representation of life, relationships/involvements, both formal and informal. • Genograms are also used to help the Access Facilitator understand familial relationships.

30. Tools of Intervention • Based on accurate assessment of child and family functioning. • Begins with goal identification and contracting. • Proceeds with active work on goals within the access visit.

31. Identification of Strengths: • See past risk issues looming in rear view mirror, dig deeper. • Develop a Helping Relationship/Un-earth Client Strengths. • Goals are built upon family strengths that thereby radiate throughout parent child interaction / parenting.

32. Client strength identification • As a group- lets list some of the strengths our families might have….

33. Preparation – Instruction: • Engage parent and child in planning. • Support communication skills. • Support parent and child to share and contribute to access. • Plan activities that are enjoyable. • Anticipate issues and thus develop strategies ahead of time (Safety Plan).

34. Goal Development – An Access PLAN: • Plan- structure gives predictability and optimizes success and lessens trauma impact on participants. • Be clear with families about why their children were apprehended. • Help families accept reasons for Society involvement. • Safety plan- lets participants know expectations and ‘rules’. • SMART – Simple, Measurable, Achievable, Realistic, Teachable. • Must not overwhelm or intimidate rather should built up (positive vs negative). • The “key” to goal setting is to just pick 3 at any one time.

35. Choosing key points / Rationale for change: • Family’s level of Motivation? Cooperation? • Goals and Objectives developed for intervention need to be client driven/determined. • Contracting goals for access gives families back the power to help themselves, - rationale for change.

36. Access Agreement • Demonstrated Collaboration - The Clinically Managed Access Program is a voluntary program. • To participate in the program, clients must sign the Access Agreement. Not as successful with individuals who: are not capable or refuse to accept their role, unwilling participants, refuse to practice parenting skills, parents who do not complete homework assignments, individuals in severe crisis or with untreated mental health or substance abuse issues.

37. Choosing Your Vehicle

38. Choosing an appropriate intervention vehicle within access • Parents may love their child but lack the ability to speak courteously to their child, to ready a book to or play a game with their child, to share a chore, or to take to a recreational outing. • For visiting to be positive and child-focused, the plan must deal with these areas and provide parent(s) with an opportunity to practice these skills.

39. The Map • STEP 1 – “PRE-WORK” • Assessing both child and family’s needs and strengths • Work with child and family toward an understanding of how the events of their lives have affected their thoughts and behaviours • STEP 2 – CONTRACTING • Agreeing on goals, behaviours, expected outcomes, consequences, etc. for visits • Identifying key issues that interfere with positive interactions • STEP 3 - PREPARATION • Updating the parent on the child’s progress since the last visit, and vice versa • Planning for mutually enjoyable activities • Anticipating challenges during the visit and how to handle these • Determining what issues, questions, events, etc. they wish to communicate, and discussing how to deliver this message

40. The Map • Step 4 – THE VISIT • Greetings • News and issues • Visit plan and goals • Activity • Snack • Activity • “How did it go?” • Good-byes • Step 5 – ‘POST-VISIT’ AND PLANNING FOR THE NEXT • Foster parent should drive child home from visit wherever possible • Allow for ‘down time’ to unwind, act out, or discuss feelings about visit • Discuss what went well and what they wish had been different • Set goals for next visit

41. The Map Continuum of Structure for Visits: HIGHLY STRUCTURED -agency based, fully supervised, scripted MEDIUM STRUCTURE -begins and ends with structured activity, around independent time LOW STRUCTURE • supervisor checks in at beginning and debriefs at end of visit NO STRUCTURE - family makes arrangements with foster parent

42. Teachable Moments • Key to success is positive reinforcement, • If an opportunity is missed, it is not too late to bring forward during the debriefing session, • Is there something you could do in the situation you are observing? Would learning or change occur by you intervening? Is the client in a state of mind to be receptive? Catch them doing something ‘right’. Role model and explain what you are doing while doing it…Do the ‘dance’, fade in and fade out. • The Parent coach must her/himself have a positive attitude toward the parent. Low self-esteem and their resistance in acknowledging problems and issues often cause the worker (parent coach) to have the impression the client is not ‘workable’. • Analogy of parent climbing a rock wall with parent coach holding onto the support rope; the parent coach supports with the rope, gives encouragement to keep climbing, parent may seem reluctant but they are the one on the wall and reaching for each ledge to hold onto. This includes new learning and physical energy.

43. The Vehicle • Utilizing visits to change a parent’s approach and understanding of discipline; • Hands-on coaching during visits can help a parent change: you must take into account (cultural, social, and parental knowledge of child development) recognizing that 1) the parent will only implement something new if he/she really believes it is better for the child, 2) the new approach should fit the parent and child, 3) the parent will change if he/she has a real understanding of the complex interaction between the parent’s discipline methods and the child’s response (Beyer, 1999). • Parents can be made aware of the harmful consequences of viewing their children as “bad”; see their behavior as not intentional and normal for their age. • There is a need for re-direction (and possible intervention by the facilitator) before the child’s behavior gets out of control.

44. The Vehicle Cont’d • Parents often have to meet the needs of several children simultaneously. A supervised visit preparation plan is good opportunity for the parent to identify the individual needs and strategize how to provide individual attention to each child. • Infant needs; holding, eye contact, feeding, singing, reading, etc • Toddler needs; follow the child’s lead in play, play on the floor, follow the leader, etc • School aged children; the child needs to have the parent ask a question about something the child did that day and have the parent listen without interruption or distraction, etc • Older children; the child needs to have separate and individual time with the parent, etc • The access facilitator should have some teaching resources to share with the parent and identify toys, games and activities that the family can share.

45. Does Your Vehicle Have All-Wheel Drive?

46. Case Study • Abby and Mark are the parents of 2 young children, 4 year old Tandy, and 6 year old Darren who are currently in the care of the Society. The family home is a very small 2 bedroom, 300 square foot apartment with no yard space for their children to play. Their home is very cluttered and disorganized. Mark works out of the home and is away much of the time with Abby having been the primary caregiver. Mark and Abby have a history of domestic violence and substance abuse. Abby is tired much of the time. She has had little motivation to clean and organize her home, and tend to the needs of her busy family, or play and interact with her young sons. Both Randy and Darren present with behavioural challenges, that have been displayed at home and at school. Abby is at a loss how to handle her young son’s behaviours. Abby is refusing to work with community resources, but is attempting to cooperate with the Clinically Managed Access Program. According to Abby the children’s school and previously accessed community resources have blamed her for her children’s troubles and make her feel like a “bad parent.”

47. Case Study Cont’d Prework • Read file • Learn history and patterns • Assess/reassess parent’s attitude and capacity • Identify strengths • Develop plan; communicate logistics for upcoming visits • Observe interactions, reactions and opportunities for connections Contracting • Agree on goals • Behavioral outcomes • expectations

48. Case Study cont’d Identify 3 strengths, points for change, 3 goals for this family…and possible intervention vehicles (4 tires).

49. Cognitive Behavioral Approaches within ‘Child-Focused Interaction’ • Clinically managed child focused interaction lends itself to cognitive/behavioral approaches: collaboration and active involvement of clients, problem focused and goal oriented, emphasizes the present, educational, time limited, structured, variety of techniques geared to needs of child/parent, homework follow-up and debriefing.

50. Cognitive Behavioural Theory (CBT) • Description: • Combination of Cognitive Therapy and Behavior Modification • Active, problem-focused approach based on understanding the role of thought, feeling and action in dysfunctional thinking and social interactions • Client learns to replace dysfunctional self-speech/talk with adaptive alternatives; • Examples: • dysfunctional self-talk =I knew I’d never be able to cope with these kids • Functional self-talk = I am capable of working out a plan to overcome problems • CBT used for a variety of issues: • Anger control, stress management, coping with anxiety, developing social skills. • Summary: • Considerable effort is directed towards helping the client to identify and change thinking patterns, behavior and problem-solving.