11

THERAPEUTIC ACCESS:THERAPEUTIC ACCESS:An Innovative Access An Innovative Access Program that Expedites Program that Expedites Permanency PlanningPermanency Planning

A Partnership Between:A Partnership Between:Thistletown Regional Centre, Ministry of Thistletown Regional Centre, Ministry of

Children & Youth Services, OntarioChildren & Youth Services, Ontarioandand

The Children’s Aid Society of TorontoThe Children’s Aid Society of Toronto

22

Therapeutic Access Therapeutic Access Presenters:Presenters:

Mary RellaMary RellaManager of Assessment, Consultation & TrainingManager of Assessment, Consultation & Training

Thistletown Regional CentreThistletown Regional Centre

Shannon DeaconShannon DeaconTherapeutic Access Program CoordinatorTherapeutic Access Program Coordinator

Children’s Aid Society of TorontoChildren’s Aid Society of Toronto

Kathy DuncanKathy DuncanChild Welfare SupervisorChild Welfare Supervisor

Children’s Aid Society of TorontoChildren’s Aid Society of Toronto

33

Therapeutic AccessTherapeutic Access

BACKGROUND….BACKGROUND….

44

Why is Access so Why is Access so Important?Important?

Good Access Planning is pivotal to Good Access Planning is pivotal to casework successcasework success

Well managed access provides Well managed access provides opportunities to assess, teach, and opportunities to assess, teach, and correct parenting behaviourscorrect parenting behaviours

Well managed access allows us to Well managed access allows us to develop early and successful develop early and successful permanency plans for childrenpermanency plans for children

Well managed access contributes to Well managed access contributes to placement stabilityplacement stability

55

When Access Goes When Access Goes Well…Well…

Maintains continuity in a child’s Maintains continuity in a child’s relationship to their family relationship to their family

Contributes to a sense of Contributes to a sense of psychological permanence for the psychological permanence for the childchild

Assists the child and family in Assists the child and family in confronting the reality of separation, confronting the reality of separation, the reasons for it and the need for the reasons for it and the need for caregiving behaviours to changecaregiving behaviours to change

66

When Access Goes When Access Goes Well… (Well… (cont’dcont’d))

Assists families to cope more Assists families to cope more adaptivelyadaptively

Provides a time and place to practice Provides a time and place to practice new behavioursnew behaviours

Provides an opportunity to assess the Provides an opportunity to assess the reasons for deficits in caregiving reasons for deficits in caregiving behaviours behaviours

Provides an important transition when Provides an important transition when reunification is possiblereunification is possible

77

When Access Does When Access Does NOT Go Well…NOT Go Well…

Promotes confusion for the familyPromotes confusion for the family Disrupts continuity in a child’s lifeDisrupts continuity in a child’s life Promotes anxiety about the Promotes anxiety about the

reasons for the separation and the reasons for the separation and the reasons change is necessaryreasons change is necessary

Contributes to disagreements Contributes to disagreements between Family and Workers, between Family and Workers, Workers with Workers, Courts with Workers with Workers, Courts with WorkersWorkers

88

When Access Does When Access Does NOT Go Well… (con’t)NOT Go Well… (con’t)

It continues with little resolution It continues with little resolution or understandingor understanding

It goes on forever with poor It goes on forever with poor direction towards decisionsdirection towards decisions

It promotes instability and poor It promotes instability and poor permanency planning, ie. permanency planning, ie. environmental or emotional environmental or emotional stabilitystability

Mary Rella 2006Mary Rella 2006

99

THERAPEUTIC ACCESS THERAPEUTIC ACCESS

Mary Rella, B.A. Psych., Dip. C.S. Psych.Mary Rella, B.A. Psych., Dip. C.S. Psych.INTERFACE ProgramINTERFACE Program

Thistletown Regional CentreThistletown Regional CentreMinistry of Children & Youth ServicesMinistry of Children & Youth Services

Mary.Rella@Ontario.caMary.Rella@Ontario.ca

From Supervising Accessto

Building Parent Child Relationships

Mary Rella 2006Mary Rella 2006

1010

Access as an Access as an Opportunity for Opportunity for

Therapeutic Therapeutic InterventionIntervention

Mary Rella 2006Mary Rella 2006

1111

THERAPEUTIC ACCESSTHERAPEUTIC ACCESSOverviewOverview

Attachment InformedAttachment Informed Research BasedResearch Based Interventions with parents are specific Interventions with parents are specific

and linked to the reasons for historical and linked to the reasons for historical parenting deficits parenting deficits

Risk Reduction Assessment ModelRisk Reduction Assessment Model Supervised Access/Semi-Supervised Supervised Access/Semi-Supervised

AccessAccess Partnership between Child Welfare and Partnership between Child Welfare and

Children’s Mental HealthChildren’s Mental Health

1212

From Supervising Access to From Supervising Access to Building Parent Child Building Parent Child

RelationshipsRelationships

Productive in the Environment vs Product of Productive in the Environment vs Product of EnvironmentEnvironment

Resource-rich WorkerResource-rich Worker Silent Worker Silent Worker

Intervention FocusedIntervention Focused Note Taker Note Taker

Mary Rella 2006Mary Rella 2006

1313

INTERVENTIONSINTERVENTIONS

• 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 2006Mary Rella 2006

1414

Therapeutic AccessTherapeutic 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 2006Mary Rella 2006

1515

Therapeutic Access Therapeutic Access InterventionsInterventions

Aimed 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 2006Mary Rella 2006

1616

Criteria for Criteria for Therapeutic AccessTherapeutic 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 2006Mary Rella 2006

1717

Criteria for Criteria for Therapeutic Access Therapeutic Access

(c(cont’d)ont’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.

1818

Interview: Interview: Caregiving BehavioursCaregiving Behaviours

Their own childhood experiences Their own childhood experiences “Mothering/Fathering” “Mothering/Fathering”

Conflicts and how they were Conflicts and how they were resolvedresolved

Trust Trust Impact on current parenting Impact on current parenting

1919

Interview as a Interview as a Blueprint for ChangeBlueprint for Change

The quality of the caregiving The quality of the caregiving relationship is influenced by the relationship is influenced by the caregiver’s: caregiver’s: – Own attachment experienceOwn attachment experience– History and experiences of care as a History and experiences of care as a

childchild– Internal working model and mental Internal working model and mental

representation of the self and othersrepresentation of the self and others– Defensive strategiesDefensive strategies

Mary Rella 2006Mary Rella 2006

2020

Identified Risks to ChildrenIdentified 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

Intervention Plan Template

Information acquired to create a therapeutic alliance with parent

Parenting Model

Parenting Behaviours Affecting Parenting

Patterns of Parent Child Relationships

Parental Acceptance of Responsibility

for Change

Review

Recommendations

Mary Rella 2006Mary Rella 2006

2121

Structure to Therapeutic Structure to Therapeutic AccessAccess

1.1. Saying “Hello” Saying “Hello”

2.2. Playtime/Activity Time: Playtime/Activity Time: unstructured timeunstructured time

3.3. Meal/Snack: structured timeMeal/Snack: structured time

4.4. Preparation for Separation and Preparation for Separation and Planning for Next VisitPlanning for Next Visit

5.5. Debriefing with the Parent Debriefing with the Parent

2222

Patterns of Parent Patterns of Parent Child RelationshipsChild Relationships

Adults with sensitive caregiving Adults with sensitive caregiving behaviours promote secure behaviours promote secure attachment relationshipsattachment relationships

Inconsistent, rejecting and/or A-Inconsistent, rejecting and/or A-typical parenting behaviours typical parenting behaviours promote insecure attachment promote insecure attachment relationshipsrelationships

2323

Maladaptive Caregiver Maladaptive Caregiver BehavioursBehaviours

Unresponsive to child’s cuesUnresponsive to child’s cues Inconsistence in sensitive responsesInconsistence in sensitive responses Parents needs above the child’s needsParents needs above the child’s needs Rejecting behaviourRejecting behaviour Affectively unavailableAffectively unavailable Inability to provide comfortInability to provide comfort Frightening to or frightened of childFrightening to or frightened of child DissociativeDissociative Intrusive Behaviours Intrusive Behaviours

Mary Rella 2006Mary Rella 2006

2424

Correcting BehavioursCorrecting BehavioursParent FocusedParent 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

2525

Interventions: Interventions: OverviewOverview

Increase sensitive behavioursIncrease sensitive behaviours Reduce rejecting behavioursReduce rejecting behaviours Reduce inconsistencies in Reduce inconsistencies in

parenting behavioursparenting behaviours Eliminate frightening, frightened, Eliminate frightening, frightened,

dissociative, or intrusive dissociative, or intrusive behaviours behaviours

Mary Rella 2006Mary Rella 2006

2626

Teaching ParentTeaching Parent

Containment Containment Contingent ResponsivityContingent Responsivity Emotional RegulationEmotional Regulation Dyadic RegulationDyadic Regulation Communication of Affective StatesCommunication of Affective States

Mary Rella 2006Mary Rella 2006

2727

Result: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 2006Mary Rella 2006

2828

Access Access is is

One Snapshot in timeOne Snapshot in time

Involve parent and their personal storyInvolve parent and their personal story

Move away from a Move away from a “Silent”“Silent” Child Child Protection Worker to an Protection Worker to an “Involved”“Involved” Resource-rich WorkerResource-rich Worker

Mary Rella 2006Mary Rella 2006

2929

• 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.

3030

Consider….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.

CAST 2006CAST 20063131

Access Goals in Child Access Goals in Child WelfareWelfare

• Permanency PlanningPermanency Planning• Understanding of parental limitations, Understanding of parental limitations,

based on historical factors including based on historical factors including traumatrauma

• Assessment of parent’s capacity to Assessment of parent’s capacity to learn, bridged with reducing risk learn, bridged with reducing risk factorsfactors

• A comprehensive working plan that A comprehensive working plan that informs parents and the legal systeminforms parents and the legal system

Child

Parent

Access Plan• casework plan (risk factors)•culture• expected activities• level of supervision• behavioral indicators• frequency• location• safety plan•court plan• documentation

Fully Supervised

Semi Supervised

Unsupervised

Reassessment

Fully Supervised

Semi Supervised

Access Plan

Unsupervised

Admission

Duncan, Dale, Rella 2006 7

3333

Children’s Aid Society of Children’s Aid Society of TorontoToronto

Therapeutic Access ProgramTherapeutic Access Program Initiated in the Fall of 2005, 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.

3434

Therapeutic Access at Therapeutic Access at C.A.S.T.C.A.S.T.

Scarborough

BranchNorth

BranchToronto Branch

Etobicoke Branch

Referrals

Therapeutic Access ProgramProgram Manager

CoordinatorCYW

Consultation Training INTERFACE Consults

CAST 2006CAST 20063535

The Role of the The Role of the Therapeutic Access Therapeutic Access Coordinator (CAST)Coordinator (CAST)

To assist workers in developing and To assist workers in developing and implementing Therapeutic Access Plans (TAPs)implementing Therapeutic Access Plans (TAPs)

• Accepts and coordinates referralsAccepts and coordinates referrals• Creates written therapeutic access plans that Creates written therapeutic access plans that

outline for the parents, the workers, and the outline for the parents, the workers, and the court the risk factors identified in the court the risk factors identified in the caregivers’ history and how interventions will caregivers’ history and how interventions will be implementedbe implemented

• Conducts developmental interview of parents Conducts developmental interview of parents with their child protection workerswith their child protection workers

• Creates the therapeutic alliance necessary to Creates the therapeutic alliance necessary to begin caregiving interventionsbegin caregiving interventions

CAST 2006CAST 20063636

……Role of the CoordinatorRole of the Coordinator

• Trains front-line workers on the significance Trains front-line workers on the significance of caregiver history and the link to current of caregiver history and the link to current parentingparenting

• Guides workers to apply clinical interventions Guides workers to apply clinical interventions specific to each family’s identified needsspecific to each family’s identified needs

• Provides clear and supportive communication Provides clear and supportive communication to the family about changes required to the family about changes required

• Assists workers in assessment plansAssists workers in assessment plans• Provides written summary of Provides written summary of

progress/concerns which can be provided to progress/concerns which can be provided to the court with recommendationsthe court with recommendations

3737

The Role of the Child & The Role of the Child & Youth WorkerYouth Worker

Collaborates with the Coordinator Collaborates with the Coordinator in developing and implementing in developing and implementing therapeutic access planstherapeutic access plans

Provides direct teaching to Provides direct teaching to parents on adaptive caregiving parents on adaptive caregiving

Contributes feedback to the Contributes feedback to the overall assessment and overall assessment and recommendations recommendations

CAST 2006CAST 20063838

Referral ProcessReferral Process

Referral form is user-friendly and Referral form is user-friendly and easily accessible to workerseasily accessible to workers

Includes:Includes:– Child Protection Risk Factors – Child Protection Risk Factors –

current and historical current and historical – Reasons for referral (Goals to Reasons for referral (Goals to

achieve)achieve)– Access plans/observations/concernsAccess plans/observations/concerns

CAST 2006CAST 20063939

The Developmental The Developmental InterviewInterview

• Both Family & Children’s Service Both Family & Children’s Service Workers must be present with parentsWorkers must be present with parents

• Goal is to create a Therapeutic Alliance, Goal is to create a Therapeutic Alliance, necessary to implement parenting necessary to implement parenting changeschanges

• Interview of Parents using Key Interview of Parents using Key Relationship Questions to assess:Relationship Questions to assess: History of caregiving experiences and History of caregiving experiences and

impact on current parentingimpact on current parenting Parent’s responsibility to changeParent’s responsibility to change Behaviours affecting parentingBehaviours affecting parenting Parent’s strengths & limitationsParent’s strengths & limitations

CAST 2006CAST 20064040

Therapeutic Access Therapeutic Access PlanPlan

• Written Plan includes:Written Plan includes:– Risk Factors for Parent, Child & FamilyRisk Factors for Parent, Child & Family– Family’s StrengthsFamily’s Strengths– Specific learning tasks to address risk Specific learning tasks to address risk

factorsfactors– Number of planned teaching hours and Number of planned teaching hours and

date for Reviewdate for Review•Plan can be added to court Plan can be added to court

documents/protection applicationsdocuments/protection applications

CAST 2006CAST 20064141

Environment of Access Environment of Access CentreCentre

Family Friendly – decorative, warm, Family Friendly – decorative, warm, welcomingwelcoming

9 Family visiting rooms, including 2 9 Family visiting rooms, including 2 Infant rooms with cribs, change tables, Infant rooms with cribs, change tables, rocking chairs, baths, etc.rocking chairs, baths, etc.

Kitchen with stove, microwave, fridge, Kitchen with stove, microwave, fridge, plates & utensils and dining tableplates & utensils and dining table

Large open space for unstructured Large open space for unstructured playplay

Toys for all ages, stored in one roomToys for all ages, stored in one room

CAST 2006CAST 20064242

Implementation of Implementation of Therapeutic Access Therapeutic Access

PlanPlan Interventions specific to risk factors, Interventions specific to risk factors,

applied by worker “in the moment”applied by worker “in the moment” Neglect - Practicing Instrumental Tasks Neglect - Practicing Instrumental Tasks

– parents to bring all items needed to – parents to bring all items needed to care for child, such as food, diapers, care for child, such as food, diapers, clothingclothing

Emotional engagement – pointing out to Emotional engagement – pointing out to parents child’s cues, teaching parents child’s cues, teaching attachment rich interactionsattachment rich interactions

Violence/Physical Abuse – parent Violence/Physical Abuse – parent presenting to child as not scary, presenting to child as not scary, identifying physical safety precautions identifying physical safety precautions

CAST 2006CAST 20064343

Review & Review & RecommendationsRecommendations

Program duration 10-14 weeksProgram duration 10-14 weeks Review after 4-6 weeks to assess Review after 4-6 weeks to assess

progress, concerns, modify plansprogress, concerns, modify plans Written Summary at Completion, Written Summary at Completion,

provided to the Court:provided to the Court:– Number of teaching hours completedNumber of teaching hours completed– Summary of plan/goalsSummary of plan/goals– Changes/Progress made and remaining Changes/Progress made and remaining

concernsconcerns– Recommendations for reunification, Recommendations for reunification,

permanent removal, or other alternativespermanent removal, or other alternatives

CAST 2006CAST 20064444

TrainingTraining

Clinical Learning Discussions, Ongoing Case Clinical Learning Discussions, Ongoing Case Consultation and Direct Support during Consultation and Direct Support during Access…Access…

To teach workers the importance of To teach workers the importance of understanding the parent’s past caregiving understanding the parent’s past caregiving experiences as they relate to their current experiences as they relate to their current parenting behavioursparenting behaviours

To provide workers with learning opportunities To provide workers with learning opportunities to teach parents more adaptive parenting to teach parents more adaptive parenting

To review and implement attachment theory To review and implement attachment theory and researchand research

4545

Future DirectionsFuture Directions

Continuing to understand and implement current Continuing to understand and implement current research in attachment theory in front-line clinical research in attachment theory in front-line clinical workwork

Helping parents to develop adaptive parenting Helping parents to develop adaptive parenting models that will ensure their newborns can remain in models that will ensure their newborns can remain in their care despite past CAS interventions with their care despite past CAS interventions with previous childrenprevious children

Helping front-line workers understand the significance Helping front-line workers understand the significance of providing children with developmentally of providing children with developmentally appropriate information about the risks leading to appropriate information about the risks leading to CAS interventions, as well as teaching workers to CAS interventions, as well as teaching workers to assist parents to provide the same messages to assist parents to provide the same messages to promote psychological stability for childrenpromote psychological stability for children

4646

For More Information…For More Information…

Mary Rella, Thistletown Regional Mary Rella, Thistletown Regional Centre Centre Tel: 416-326-0767Tel: 416-326-0767Email: Email: Mary.Rella@css.gov.on.ca

Shannon Deacon, Children’s Aid Shannon Deacon, Children’s Aid Society of Toronto Society of Toronto Tel: 416-924-4640, ext. 3424Tel: 416-924-4640, ext. 3424

Email: Email: SDeacon@TorontoCAS.caSDeacon@TorontoCAS.ca