building bridges back home with parents in recovery: the right decisions at the right times...

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 HajjarPhoenix HouseNew York, NY

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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)

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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

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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

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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

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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

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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

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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

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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

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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

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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

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Reunification Begins with Separation:

Parent’s Experiences

Two losses:

Children, and

Status as an able parent

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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”

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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

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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

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Reunification Continues with

Visitation: Parents

Awkwardness common

Not permitted normal parenting responsibilities

Parent viewed as

failure

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Reunification Continues with Visitation: Parents

Hard to enjoy/play with/be with child

Guilt + Overcompensation Poor boundaries

AMBIVALENCE

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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.

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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

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Other Visitation Dynamics

Parent concern re: child’s adjustment to carecut back on visiting

Longer in careless confident in parenting

Family develops new homeostatic balance around child’s absence

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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

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Working With Ambivalence

(cont’d)

4: Explore options and proceed with concurrent planning that is grounded in parents’ participation in making the plan.

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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.

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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.

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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

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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

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(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

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(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

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(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

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(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?

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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

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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!

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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.

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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.

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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.

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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

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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

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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

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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

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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.

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Case Practice Guidelines

Assess parent’s readiness to reunify using multiple measures—abstinence or lack thereof is not an adequate measure

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Case Practice Guidelines

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.

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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

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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

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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

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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

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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

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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

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For more information

Kim Sumner-Mayer, PhD, LMFTChildren of Alcoholics Foundation

164 West 74th StreetNew York, NY 10023

(646) 505-2063 tel. (212) 595-2553 fax

ksumner-mayer@phoenixhouse.org

Joan HajjarPhoenix House/ AmeriCorps Program

55 Flatbush Avenue, Brooklyn, NY 11217

(718) 858-2462jhajjar@phoenixhouse.org

www.coaf.org www.acde.org www.phoenixhouse.org