Introduction of Introduction of Clinically Managed Clinically Managed Access VisitsAccess Visits

A Road Map, VehicleA Road Map, Vehicle and and Tool Box to Tool Box to Child-Focused Visitation Child-Focused Visitation

A Road Map for Clinically A Road Map for Clinically Managed Access Visit Managed Access Visit PresentationPresentation

INTRODUCTIONINTRODUCTION::Stress and Trauma of Stress and Trauma of Separation within the Separation within the Context of Access VisitsContext of Access Visits

““Often the problems arising in the visit relate to parent’s discomfort Often the problems arising in the visit relate to parent’s discomfort about having their child in care. Parents who have lost their children, about having their child in care. Parents who have lost their children, even temporarily, to public care may feel a deep sense of shame even temporarily, to public care may feel a deep sense of shame (McAdams 1972).” (McAdams 1972).”

“…“…As well, they are experiencing the pain of loss, which they As well, they are experiencing the pain of loss, which they sometimes cover up with anger and resistant behavior.” sometimes cover up with anger and resistant behavior.”

“…“…Parents need a sensitive approach from caregivers and workers to Parents need a sensitive approach from caregivers and workers to help them handle these feelings around visits…”help them handle these feelings around visits…”

“…“…It is important to remember that, because each visitation is a It is important to remember that, because each visitation is a reenactment of earlier reunions and separations (Hess 1999), reactions reenactment of earlier reunions and separations (Hess 1999), reactions tend to mimic original separation reactions.” tend to mimic original separation reactions.” – For exampleFor example, a child with a history of traumatic disruptions in the parent-, a child with a history of traumatic disruptions in the parent-

child relationship will feel that trauma repeated when she enters foster care. child relationship will feel that trauma repeated when she enters foster care. The reunion with the parent during visitation may then feel quite desperate, 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 as the child anticipates, based on past experience, that it will only lead to another traumatic separation. another traumatic separation.

““Without appropriate intervention with the child, each visitation will Without appropriate intervention with the child, each visitation will replay this scenarioreplay this scenario.” .”

Source: P.68, children in Limbo Task Force, Sparrow Lake Source: P.68, children in Limbo Task Force, Sparrow Lake Alliance Alliance

Why Clinically Managed Access Visits?Why Clinically Managed Access Visits?Re-enactment of original apprehension, Re-enactment of original apprehension, grief, loss, and guiltgrief, loss, and guilt

Stress and

Trauma:

A Primer

Stress & TraumaStress & Trauma

Client Stress & TraumaClient Stress & Trauma What it looks likeWhat it looks like How it affects clientsHow it affects clients Impact on client behavioursImpact on client behaviours

Practitioner Stress & TraumaPractitioner Stress & Trauma Vicarious traumaVicarious trauma Our responsesOur responses Burnout and self-awareness Burnout and self-awareness

What is Stress?What is Stress?

DEFINITION:DEFINITION:– Psychological and physical strain or Psychological and physical strain or

tension generated by physical, tension generated by physical, emotional, social, economic, or emotional, social, economic, or occupationaloccupational circumstances, circumstances, events, or experiences that are events, or experiences that are difficult to manage or endure difficult to manage or endure (Colman, 2001).(Colman, 2001).

The Effects of Stress The Effects of Stress on the Developing on the Developing ChildChild

Stress kills brain cells and disrupts/upsets neuro-development in children causing:– Higher Thinking IssuesHigher Thinking Issues– Social Thinking IssuesSocial Thinking Issues– Language IssuesLanguage Issues

Expressive and ReceptiveExpressive and Receptive– Motor Skill IssuesMotor Skill Issues

Handwriting, and fine Handwriting, and fine motor skillsmotor skills

– Spatial and Sequential Spatial and Sequential Ordering Issues Ordering Issues

– Memory and Attention Memory and Attention IssuesIssues

GENERAL GENERAL DESCRIPTION:DESCRIPTION: Stress MechanismStress Mechanism

General Adaptation Syndrome – General Adaptation Syndrome – (GAS)(GAS)– Hans SelyeHans Selye

Three (3) STAGES:Three (3) STAGES:

1.1. Alarm:Alarm: characterized by an initial fall in body characterized by an initial fall in body temperature and blood pressure, followed by a temperature and blood pressure, followed by a countershock phase during which hormones such as countershock phase during which hormones such as cortisol are secreted into the bloodstream and a cortisol are secreted into the bloodstream and a biological defensive reaction begins.biological defensive reaction begins.

2.2. Resistance:Resistance: the body copes actively with a stressor the body copes actively with a stressor by mechanisms such as sending leucocytes to the by mechanisms such as sending leucocytes to the sit of an injury or infection. Put another way, body’s sit of an injury or infection. Put another way, body’s immune system kicks it into overdrive. immune system kicks it into overdrive.

3.3. Exhaustion:Exhaustion: this phase is reached when the person this phase is reached when the person has failed to adapt to a stressor, characterized by has failed to adapt to a stressor, characterized by physical and/or mental disorder or disease.physical and/or mental disorder or disease.

GENERAL GENERAL ADAPATATION ADAPATATION SYNDROME - SelyeSYNDROME - Selye

STRESS: STRESS: SUMMARY AND SUMMARY AND DISCUSSIONDISCUSSION Warshaw (1979) states that stress Warshaw (1979) states that stress

reactions can also be helpful and reactions can also be helpful and positive. Depending on the intensity and positive. Depending on the intensity and the way they affect the individual, these the way they affect the individual, these reactions can be helpful and even reactions can be helpful and even pleasurable. Stress can be turned into pleasurable. Stress can be turned into motivation and positive energy. It isn’t motivation and positive energy. It isn’t so much the event that determines so much the event that determines whether the individual is stressed or whether the individual is stressed or not, it his/her reaction to it.not, it his/her reaction to it.

Introduction to Introduction to TraumaTrauma

Trauma = Greek for “wounding”Trauma = Greek for “wounding” Trauma wounds the mind, body and Trauma wounds the mind, body and

souls of individuals as well as groups of souls of individuals as well as groups of peoplepeople– Trauma alters a person’s biochemistryTrauma alters a person’s biochemistry

(Friedman, 1991; Kolb, 1987; McDonaugh-Coyle (Friedman, 1991; Kolb, 1987; McDonaugh-Coyle et al., 2001; Murberg, 1996; van der Kolk, 1988, et al., 2001; Murberg, 1996; van der Kolk, 1988, 1996)1996)

What Trauma May Look What Trauma May Look Like:Like:1.1. States of hyperarousal alternating States of hyperarousal alternating

with states of numbingwith states of numbing– Sometimes results in mental and Sometimes results in mental and

emotional disorganization, leaving emotional disorganization, leaving survivors feeling out-of-control, even survivors feeling out-of-control, even terrified unless they have ways of terrified unless they have ways of managing them.managing them.

– Observations:Observations: Survivor may be:Survivor may be:

– ArgumentativeArgumentative– Withdrawn or asocialWithdrawn or asocial– HostileHostile– AlienatingAlienating

2.2. Survivors of trauma may avoid inter-Survivors of trauma may avoid inter-personal situations or anything involving personal situations or anything involving social interactions.social interactions.

3.3. Survivors often seek relief from trauma Survivors often seek relief from trauma through self-medicating means:through self-medicating means:

– Chemical meansChemical means DrugsDrugs AlcoholAlcohol FoodFood

What Trauma May Look What Trauma May Look Like:Like:

What Trauma May Look What Trauma May Look Like in Clients: SUMMARYLike in Clients: SUMMARY

Concentration Concentration problemsproblems

Memory Memory ProblemsProblems

Temporal issues – Temporal issues – past, presentpast, present

Depletion of biological and Depletion of biological and psychological resources necessary to psychological resources necessary to

moderate affect and experience a wide moderate affect and experience a wide range of emotionsrange of emotions

Have been shown to Have been shown to have biological basis for have biological basis for

this reaction.this reaction.

(Glover, 1992; Kardiner (Glover, 1992; Kardiner & Spiegel, 1947; Kolb, & Spiegel, 1947; Kolb,

1987; van der Kolk, 1987; van der Kolk, 1988, 1996)1988, 1996)

Difficulty focusing Difficulty focusing on conversations on conversations

and social and social interactionsinteractions

Rage reactions. Rage reactions. Difficulty in organizing Difficulty in organizing behavior to achieve goalbehavior to achieve goal

Fear of having to do Fear of having to do something newsomething new

Retreating from others Retreating from others because energy and because energy and

effort requires to control effort requires to control arousal or numbingarousal or numbing

Vicarious TraumaVicarious Trauma

Sarah Haley (1974) was first to articulate Sarah Haley (1974) was first to articulate vicarious traumavicarious trauma– Effects of trauma survivors on other people. We Effects of trauma survivors on other people. We

are the ‘other people’. are the ‘other people’. Effects of traumatic stress somehow can be transmitted Effects of traumatic stress somehow can be transmitted

to people who were not themselves exposed to the to people who were not themselves exposed to the traumatic events. Knowledge of the ‘history’ of the traumatic events. Knowledge of the ‘history’ of the client and the impact of current situation for the client client and the impact of current situation for the client impacts the practitioner with vicarious trauma. impacts the practitioner with vicarious trauma.

On Professionals Working On Professionals Working with those who have been with those who have been traumatizedtraumatized

All terms that are used in an attempt to define what happens All terms that are used in an attempt to define what happens to professionals working with a traumatized population. to professionals working with a traumatized population.

Whether one conceptualizes the process of Whether one conceptualizes the process of listening/witnessing trauma as soul sadness, caregiver’s listening/witnessing trauma as soul sadness, caregiver’s

plight, co-victimization, or emotional contagion, the plight, co-victimization, or emotional contagion, the outcomes remain the sameoutcomes remain the same. .

For the purpose of this presentation I will use the term vicarious trauma.For the purpose of this presentation I will use the term vicarious trauma.

Compassion FatigueCompassion Fatigue Vicarious Vicarious TraumatizationTraumatization

Secondary Secondary TraumatizationTraumatization

Secondary Stress Secondary Stress DisorderDisorder

Insidious Insidious TraumaTrauma

Empathic StrainEmpathic Strain

Vicarious Trauma within Vicarious Trauma within the the

context of Child Welfarecontext of Child Welfare

On Professionals On Professionals Working with those who Working with those who have been traumatizedhave been traumatized Build upon memories obtained while listening to Build upon memories obtained while listening to

the stories of one inhumane act of cruelty after the stories of one inhumane act of cruelty after another. another.

Creates a permanent, subtle or marked change Creates a permanent, subtle or marked change in the personal, political, spiritual and in the personal, political, spiritual and professional outlook of the counselor professional outlook of the counselor (Richardson. 2001).(Richardson. 2001).

The effects of vicarious trauma are cumulative The effects of vicarious trauma are cumulative Vicarious trauma has a life-changing effect, Vicarious trauma has a life-changing effect,

ultimately affecting the world-view of ultimately affecting the world-view of professionals professionals

Also affects relationships and connections to Also affects relationships and connections to family, friends, community and professional family, friends, community and professional relationships with colleagues and clients. relationships with colleagues and clients.

BURNOUT:BURNOUT: Vicarious trauma is the result of hearing about the cruelty, Vicarious trauma is the result of hearing about the cruelty,

exploitation and atrocity inflicted to trauma victims. exploitation and atrocity inflicted to trauma victims. The emotional impact of hearing about another’s pain and continual The emotional impact of hearing about another’s pain and continual

exposure to the pain of the human condition is different from work exposure to the pain of the human condition is different from work over load, role conflict, unrealistic self-expectations, poor over load, role conflict, unrealistic self-expectations, poor communication and inadequate leadership/supervision. communication and inadequate leadership/supervision.

An accumulation of stress with no resolve can lead to ‘burnout’.An accumulation of stress with no resolve can lead to ‘burnout’. Sometimes the cause is external, for example an oppressive Sometimes the cause is external, for example an oppressive

supervisor, increased demands, too little opportunity for autonomy, supervisor, increased demands, too little opportunity for autonomy, or unclear work/home boundaries.or unclear work/home boundaries.

Munson (1993) – Research has shown that practitioners in some Munson (1993) – Research has shown that practitioners in some fields are more susceptible to self-imposed unrealistic expectations, fields are more susceptible to self-imposed unrealistic expectations, whereas child welfare workers are more susceptible to external-whereas child welfare workers are more susceptible to external-societal or bureaucratically imposed unrealistic expectations.societal or bureaucratically imposed unrealistic expectations.

Self-awareness, self-assessment and self-care are critical to Self-awareness, self-assessment and self-care are critical to preventing a toxic, unhealthy build-up of the negative and invasive preventing a toxic, unhealthy build-up of the negative and invasive effects of both direct trauma and vicarious trauma (Richardson, effects of both direct trauma and vicarious trauma (Richardson, 2001).2001).

On Professionals On Professionals Working with those who Working with those who have been traumatizedhave been traumatized

What What

BURNOUTBURNOUT May Look Like:May Look Like:

Similar to primary trauma, the Similar to primary trauma, the severity and longevity of severity and longevity of practitioner symptoms varies practitioner symptoms varies from person to person. from person to person.

The practitioner’s view of self, The practitioner’s view of self, world and future may be world and future may be affected. affected.

This may lead to shattered This may lead to shattered assumptions held about assumptions held about identity, worldview and identity, worldview and spirituality.spirituality.

Behaviors resulting in vicarious Behaviors resulting in vicarious trauma may be parallel to trauma may be parallel to behaviors of primary trauma behaviors of primary trauma survivors, e.g., isolation, survivors, e.g., isolation, disconnection, mistrust, disconnection, mistrust, pessimism, chaotic pessimism, chaotic relationships and increased relationships and increased substance use.substance use.

Self-awareness is a key component.Self-awareness is a key component.

Disturbed Disturbed sleepsleep

angeranger fearfear

suppressisuppression of on of

emotionsemotions

nightmarenightmaress

FlashbackFlashbackss

irritabilityirritability anxietyanxiety alienationalienation

feelings of feelings of insanityinsanity

loss of loss of controlcontrol

suicidal suicidal thoughts thoughts

►Symptoms:Symptoms:

Assessment within Assessment within

the context of the context of

Access VisitsAccess Visits

Assessment within the Assessment within the context of Accesscontext of Access Definition:Definition:

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

ASSESSMENT:ASSESSMENT:

Who? Who? What ?What ?Where?Where?When?When?How?How?Why?Why?

Clinical Access Facilitators (CAF) carry out clinical Clinical Access Facilitators (CAF) carry out clinical assessment and intervention with the family during assessment and intervention with the family during access visits. access visits.

Case Manager provides CAF with known historical Case Manager provides CAF with known historical information, recent risk assessment, plan of service, information, recent risk assessment, plan of service, court application/documentation, assessment court application/documentation, assessment information.information.

Coordinator assists with planning and orchestrating Coordinator assists with planning and orchestrating visits, setting child focused goals for visits, setting child focused goals for access/intervention focus, and guidance of CAF’s access/intervention focus, and guidance of CAF’s intervention – teaching parents new approaches to intervention – teaching parents new approaches to parenting while recognizing parent’s feelings about parenting while recognizing parent’s feelings about visiting (Osmond, Palmer, Perlman, Dale, Steinhauer, visiting (Osmond, Palmer, Perlman, Dale, Steinhauer, Role of Access in Permanency Planning) ; Aug. 2000)Role of Access in Permanency Planning) ; Aug. 2000)

ASSESSMENT: Who? ASSESSMENT: Who?

Other parties essential to the Other parties essential to the intervention process are the; intervention process are the; – Child Care Worker, Child Care Worker, – Foster Care Resources Worker,Foster Care Resources Worker,– Foster Parents, Foster Parents, – Parent Support Worker, Parent Support Worker, – Other Collaterals such as Pediatrician, Other Collaterals such as Pediatrician,

Child and Family Centre Clinician etc.Child and Family Centre Clinician etc.

ASSESSMENT: Who? ASSESSMENT: Who?

First access visits are CAF’s First access visits are CAF’s opportunity to observe and assess a opportunity to observe and assess a family’s parenting ability *(with the family’s parenting ability *(with the exception of the 1exception of the 1stst visit after an visit after an apprehension). apprehension).

An “Access Plan” is created from this An “Access Plan” is created from this assessment, that builds upon family assessment, that builds upon family strengths, with the aim towards risk strengths, with the aim towards risk reduction, improvement in familial reduction, improvement in familial relationships, and ongoing safe, relationships, and ongoing safe, positive visits between family positive visits between family members.members.

ASSESSMENT: What? ASSESSMENT: What?

Parenting Centre Parenting Centre Parents Home Parents Home Outside Resource – Foster Home, Outside Resource – Foster Home,

Group Home, HospitalGroup Home, Hospital The location of access must be as The location of access must be as

least restrictive as possible least restrictive as possible ensuring child safety and allow for ensuring child safety and allow for natural exchange (i.e. attending natural exchange (i.e. attending dental/medical appointments, dental/medical appointments, shopping for food or clothes, shopping for food or clothes, attending school functions, a fun attending school functions, a fun family outing).family outing).

ASSESSMENT: Where? ASSESSMENT: Where?

As per the best interests, protection, As per the best interests, protection, and well being of the child.and well being of the child.

As per court order.As per court order. Frequent and long enough to Frequent and long enough to

enhance the parent-child relationship enhance the parent-child relationship and mobilize the parent’s care giving and mobilize the parent’s care giving ability and for the family to engage ability and for the family to engage in familiar routine activities.in familiar routine activities.

ASSESSMENT: When? ASSESSMENT: When?

Ecomaps/Genograms/Nipissing Ecomaps/Genograms/Nipissing Development Scale, ….Development Scale, ….

Ecomap intervention – families tell Ecomap intervention – families tell their story their way. An Echomap their story their way. An Echomap is a pictorial representation of life, is a pictorial representation of life, relationships/involvements, both relationships/involvements, both formal and informal. formal and informal.

Genograms are also used to help Genograms are also used to help the Access Facilitator understand the Access Facilitator understand familial relationships.familial relationships.

ASSESSMENT: How? ASSESSMENT: How?

Tools of InterventionTools of Intervention

Based on accurate assessment of Based on accurate assessment of child and family functioning.child and family functioning.

Begins with goal identification Begins with goal identification and contracting.and contracting.

Proceeds with active work on Proceeds with active work on goals within the access visit.goals within the access visit.

See past risk issues looming in See past risk issues looming in rear view mirror, dig deeper. rear view mirror, dig deeper.

Develop a Helping Develop a Helping Relationship/Un-earth Client Relationship/Un-earth Client Strengths.Strengths.

Goals are built upon family Goals are built upon family strengths that thereby radiate strengths that thereby radiate throughout parent child throughout parent child interaction / parenting.interaction / parenting.

Identification of Identification of Strengths:Strengths:

Client strength Client strength identificationidentification As a group- lets list some of the As a group- lets list some of the

strengths our families might strengths our families might have….have….

Preparation – Instruction:Preparation – Instruction:

Engage parent and child in planning.Engage parent and child in planning. Support communication skills.Support communication skills. Support parent and child to share Support parent and child to share

and contribute to access.and contribute to access. Plan activities that are enjoyable.Plan activities that are enjoyable. Anticipate issues and thus develop Anticipate issues and thus develop

strategies ahead of time (Safety strategies ahead of time (Safety Plan).Plan).

Goal Development – An Goal Development – An Access PLAN:Access PLAN: Plan- structure gives predictability and Plan- structure gives predictability and

optimizes success and lessens trauma impact optimizes success and lessens trauma impact on participants. on participants.

Be clear with families about why their children Be clear with families about why their children were apprehended.were apprehended.

Help families accept reasons for Society Help families accept reasons for Society involvement. involvement.

Safety plan- lets participants know Safety plan- lets participants know expectations and ‘rules’.expectations and ‘rules’.

SMART – Simple, Measurable, Achievable, SMART – Simple, Measurable, Achievable, Realistic, Teachable.Realistic, Teachable.

Must not overwhelm or intimidate rather Must not overwhelm or intimidate rather should built up (positive vs negative). should built up (positive vs negative).

The “key” to goal setting is to just pick 3 at The “key” to goal setting is to just pick 3 at any one time. any one time.

Choosing key points / Choosing key points / Rationale for change:Rationale for change: Family’s level of Motivation? Family’s level of Motivation?

Cooperation? Cooperation? Goals and Objectives developed Goals and Objectives developed

for intervention need to be client for intervention need to be client driven/determined. driven/determined.

Contracting goals for access gives Contracting goals for access gives families back the power to help families back the power to help themselves, - rationale for themselves, - rationale for change. change.

Access AgreementAccess Agreement

Demonstrated Collaboration - The Demonstrated Collaboration - The Clinically Managed Access Program is a Clinically Managed Access Program is a voluntary programvoluntary program. .

To participate in the program, clients To participate in the program, clients must sign the Access Agreement. must sign the Access Agreement. Not as Not as successful with individuals who: are not successful with individuals who: are not capable or refuse to accept their role, capable or refuse to accept their role, unwilling participants, refuse to practice unwilling participants, refuse to practice parenting skills, parents who do not complete parenting skills, parents who do not complete homework assignments, individuals in severe homework assignments, individuals in severe crisis or with untreated mental health or crisis or with untreated mental health or substance abuse issues.substance abuse issues.

Choosing Choosing

Your Your

VehicleVehicle

Choosing an appropriate Choosing an appropriate intervention vehicle within intervention vehicle within

accessaccess Parents may love their child but lack Parents may love their child but lack

the ability to speak courteously to their the ability to speak courteously to their child, to ready a book to or play a child, to ready a book to or play a game with their child, to share a chore, game with their child, to share a chore, or to take to a recreational outing. or to take to a recreational outing.

For visiting to be positive and child-For visiting to be positive and child-focused, the plan must deal with these focused, the plan must deal with these areas and provide parent(s) with an areas and provide parent(s) with an opportunity to practice these skills. opportunity to practice these skills.

The MapThe Map

STEP 1 – “PRE-WORK”STEP 1 – “PRE-WORK”– Assessing both child and family’s needs and strengthsAssessing both child and family’s needs and strengths– Work with child and family toward an understanding of how Work with child and family toward an understanding of how

the events of their lives have affected their thoughts and the events of their lives have affected their thoughts and behavioursbehaviours

STEP 2 – CONTRACTINGSTEP 2 – CONTRACTING– Agreeing on goals, behaviours, expected outcomes, Agreeing on goals, behaviours, expected outcomes,

consequences, etc. for visitsconsequences, etc. for visits– Identifying key issues that interfere with positive interactionsIdentifying key issues that interfere with positive interactions

STEP 3 - PREPARATIONSTEP 3 - PREPARATION– Updating the parent on the child’s progress since the last Updating the parent on the child’s progress since the last

visit, and vice versavisit, and vice versa– Planning for mutually enjoyable activitiesPlanning for mutually enjoyable activities– Anticipating challenges during the visit and how to handle Anticipating challenges during the visit and how to handle

thesethese– Determining what issues, questions, events, etc. they wish to Determining what issues, questions, events, etc. they wish to

communicate, and discussing how to deliver this messagecommunicate, and discussing how to deliver this message

The MapThe Map

Step 4 – THE VISITStep 4 – THE VISIT– GreetingsGreetings– News and issuesNews and issues– Visit plan and goalsVisit plan and goals– ActivityActivity– SnackSnack– ActivityActivity– ““How did it go?”How did it go?”– Good-byesGood-byes

Step 5 – ‘POST-VISIT’ AND PLANNING FOR THE Step 5 – ‘POST-VISIT’ AND PLANNING FOR THE NEXTNEXT– Foster parent should drive child home from visit wherever Foster parent should drive child home from visit wherever

possiblepossible– Allow for ‘down time’ to unwind, act out, or discuss feelings Allow for ‘down time’ to unwind, act out, or discuss feelings

about visitabout visit– Discuss what went well and what they wish had been differentDiscuss what went well and what they wish had been different– Set goals for next visitSet goals for next visit

Continuum of Structure for Visits:Continuum of Structure for Visits:HIGHLY STRUCTUREDHIGHLY STRUCTURED

-agency based, fully supervised, scripted-agency based, fully supervised, scriptedMEDIUM STRUCTUREMEDIUM STRUCTURE

-begins and ends with structured activity, -begins and ends with structured activity, around independent timearound independent time

LOW STRUCTURELOW STRUCTURE- supervisor checks in at beginning and supervisor checks in at beginning and

debriefs at end of visitdebriefs at end of visitNO STRUCTURENO STRUCTURE

- family makes arrangements with foster parent- family makes arrangements with foster parent

The MapThe Map

Teachable MomentsTeachable Moments

Key to success is positive reinforcement,Key to success is positive reinforcement, If an opportunity is missed, it is If an opportunity is missed, it is notnot too late to bring forward too late to bring forward

during the debriefing session,during the debriefing session, Is there something you could do in the situation you are Is there something you could do in the situation you are

observing? Would learning or change occur by you intervening? observing? Would learning or change occur by you intervening? Is the client in a state of mind to be receptive? Catch them Is the client in a state of mind to be receptive? Catch them doing something ‘right’. Role model and explain what you are doing something ‘right’. Role model and explain what you are doing while doing it…Do the ‘dance’, fade in and fade out. doing while doing it…Do the ‘dance’, fade in and fade out.

The Parent coach must her/himself have a positive attitude The Parent coach must her/himself have a positive attitude toward the parent. Low self-esteem and their resistance in toward the parent. Low self-esteem and their resistance in acknowledging problems and issues often cause the worker acknowledging problems and issues often cause the worker (parent coach) to have the impression the client is not (parent coach) to have the impression the client is not ‘workable’.‘workable’.

Analogy of parent climbing a rock wall with parent coach holding Analogy of parent climbing a rock wall with parent coach holding onto the support rope; the parent coach supports with the rope, onto the support rope; the parent coach supports with the rope, gives encouragement to keep climbing, parent may seem gives encouragement to keep climbing, parent may seem reluctant but they are the one on the wall and reaching for each reluctant but they are the one on the wall and reaching for each ledge to hold onto. This includes new learning and physical ledge to hold onto. This includes new learning and physical energy.energy.

The VehicleThe Vehicle

Utilizing visits to change a parent’s approach and Utilizing visits to change a parent’s approach and understanding of discipline;understanding of discipline;

Hands-on coaching during visits can help a parent change: Hands-on coaching during visits can help a parent change: you must take into account (cultural, social, and parental you must take into account (cultural, social, and parental knowledge of child development) recognizing that 1) the knowledge of child development) recognizing that 1) the parent will only implement something new if he/she really parent will only implement something new if he/she really believes it is better for the child, 2) the new approach should 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 fit the parent and child, 3) the parent will change if he/she has a real understanding of the complex interaction has a real understanding of the complex interaction between the parent’s discipline methods and the child’s between the parent’s discipline methods and the child’s response (Beyer, 1999).response (Beyer, 1999).

Parents can be made aware of the harmful consequences of Parents can be made aware of the harmful consequences of viewing their children as “bad”; see their behavior as not viewing their children as “bad”; see their behavior as not intentional and normal for their age.intentional and normal for their age.

There is a need for re-direction (and possible intervention by There is a need for re-direction (and possible intervention by the facilitator) before the child’s behavior gets out of the facilitator) before the child’s behavior gets out of control.control.

The Vehicle Cont’dThe Vehicle Cont’d

Parents often have to meet the needs of several children Parents often have to meet the needs of several children simultaneously. A supervised visit preparation plan is good simultaneously. A supervised visit preparation plan is good opportunity for the parent to identify the individual needs and opportunity for the parent to identify the individual needs and strategize how to provide individual attention to each child.strategize how to provide individual attention to each child.

Infant needs; holding, eye contact, feeding, singing, reading, Infant needs; holding, eye contact, feeding, singing, reading, etcetc

Toddler needs; follow the child’s lead in play, play on the Toddler needs; follow the child’s lead in play, play on the floor, follow the leader, etcfloor, follow the leader, etc

School aged children; the child needs to have the parent ask School aged children; the child needs to have the parent ask a question about something the child did that day and have a question about something the child did that day and have the parent listen without interruption or distraction, etcthe parent listen without interruption or distraction, etc

Older children; the child needs to have separate and Older children; the child needs to have separate and individual time with the parent, etcindividual time with the parent, etc

The access facilitator should have some teaching resources to The access facilitator should have some teaching resources to share with the parent and identify toys, games and activities share with the parent and identify toys, games and activities that the family can share. that the family can share.

AntisepticBouncing

Adult removes child from area in clear danger/emergency situation. Used when other techniques won’t work.

Direct Appeal Adult statements directed to child to identify/label his/her behavior and to request more appropriate ones.

Hurdle Help Child’s inability to control/cope with impulses from frustrating events. When child’s needs are denied, blocked, inappropriate behavior may occur. Adult helps child hurdle obstacles in his/her path.

Hypodermic Affection

Child needs burst of affection to regain control of impulses.

Interpretation as

Interference

Child may not understand a situation and how he/she is contributing to it. Child might react differently if he/she understood the situation. (N.B. repeat expectations/rules).

Involvement in Interest Relationship

Child needs direct adult participation in interests. Adult demonstrates socially acceptable use of equipment, games, and materials

Limitation of Space/ Tools

Adult strategically limits space/tools. Impulses can overwhelm child especially when attention control is weak. (N.B. lock up valuables, rooms, cutlery, cupboards, wallets).

Physical Restraint

Child’s total loss of the ability to control self, making it impossible to communicate. Child may be prone to violent fits of rage. (i.e. hitting, biting, swearing, lashing out).

Planned Ignoring

All appropriate behavior is abandoned when child loses interest. Adults can decrease the intensity and frequency of behavior by not attending to them – a form of operant extinction.

Promises/Rewards

Depends upon child’s ability to delay gratification, to fulfill a contract and his/her deservingness of the reward. Must be used sparingly.

Proximity and Touch Control

Physical proximity supports child’s ability to maintain appropriate behavior in face of temptation. Proximity reinforces message everything is alright and that you are there for support. (Ex: touch, hand on shoulder.)

Regrouping Psychological makeup of group may cause problems. Changes in group may reduce incidents of aggressive/violent episodes. (i.e. new school, class, seating, mealtime, room change).

Restructuring Adult recognizes and changes scheduled activities to accommodate child’s needs. (i.e. busy games, quiet activities according to the situation).

Signal Interference

A signal by the adult can stop unacceptable behavior. The signal reactivates the child’s control system and inappropriate behavior may stop. (Ex: glances, gestures, winks.)

Tension Decontamination Through Humor

Child may be kidded out of aggressive/violent acts. Humor shows adult isn’t vulnerable to child’s impulses. Humor allows child to “save face” from guilt of inappropriate actions.

Does Your Vehicle Have All-Wheel Does Your Vehicle Have All-Wheel Drive?Drive?

Case Study Case Study

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

Case Study Cont’dCase Study Cont’d

PreworkPrework Read fileRead file Learn history and patternsLearn history and patterns Assess/reassess parent’s attitude and capacityAssess/reassess parent’s attitude and capacity Identify strengthsIdentify strengths Develop plan; communicate logistics for upcoming Develop plan; communicate logistics for upcoming

visitsvisits Observe interactions, reactions and opportunities for Observe interactions, reactions and opportunities for

connections connections ContractingContracting Agree on goalsAgree on goals Behavioral outcomesBehavioral outcomes expectationsexpectations

Case Study cont’dCase Study cont’d

Identify 3 strengths, points for Identify 3 strengths, points for change, 3 goals for this family…change, 3 goals for this family…and possible intervention vehicles and possible intervention vehicles (4 tires).(4 tires).

Cognitive Behavioral Cognitive Behavioral Approaches within ‘Child-Approaches within ‘Child-Focused Interaction’Focused Interaction’ Clinically managed child focused interaction Clinically managed child focused interaction

lends itself to cognitive/behavioral lends itself to cognitive/behavioral approaches: collaboration and active approaches: collaboration and active involvement of clients, problem focused and involvement of clients, problem focused and goal oriented, emphasizes the present, goal oriented, emphasizes the present, educational, time limited, structured, variety educational, time limited, structured, variety of techniques geared to needs of of techniques geared to needs of child/parent, homework follow-up and child/parent, homework follow-up and debriefing.debriefing.

Cognitive Behavioural Cognitive Behavioural Theory (CBT)Theory (CBT) Description:Description:

– Combination of Cognitive Therapy and Behavior ModificationCombination of Cognitive Therapy and Behavior Modification– Active, problem-focused approach based on understanding the Active, problem-focused approach based on understanding the

role of thought, feeling and action in dysfunctional thinking and role of thought, feeling and action in dysfunctional thinking and social interactionssocial interactions

– Client learns to replace dysfunctional self-speech/talk with Client learns to replace dysfunctional self-speech/talk with adaptive alternatives;adaptive alternatives;

ExamplesExamples: : – dysfunctional self-talk =I knew I’d never be able to cope with these kids 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 Functional self-talk = I am capable of working out a plan to overcome

problemsproblems

– CBT used for a variety of issues:CBT used for a variety of issues: Anger control, stress management, coping with anxiety, developing Anger control, stress management, coping with anxiety, developing

social skills.social skills.– Summary:Summary:

Considerable effort is directed towards helping the client to identify Considerable effort is directed towards helping the client to identify and change thinking patterns, behavior and problem-solving.and change thinking patterns, behavior and problem-solving.

Cognitive Behavioural Cognitive Behavioural Approaches Ideological Approaches Ideological FrameworkFramework In cognitive theory approach to social In cognitive theory approach to social

work practice , human change occurs work practice , human change occurs when the social work helper (CAF) is able when the social work helper (CAF) is able to facilitate a cognitive reflection process to facilitate a cognitive reflection process in which the client identifies, challenges, in which the client identifies, challenges, and changes misconceptions, faulty and changes misconceptions, faulty beliefs, distorted cognitions, and irrational beliefs, distorted cognitions, and irrational self-talk that have created dysfunctional self-talk that have created dysfunctional emotions and behaviour (Lantz, 1996: emotions and behaviour (Lantz, 1996: 100)100)

It is not a ‘one size fits all’ approachIt is not a ‘one size fits all’ approach

Cognitive Behavioural Cognitive Behavioural ApproachApproach Modeling, praise for child or parent behavior, Modeling, praise for child or parent behavior,

and assistance in practicing behavioral and assistance in practicing behavioral strategies are all part of the intervention strategies are all part of the intervention during supervised access. during supervised access.

The approach of utilizing access to enhance The approach of utilizing access to enhance child and family functioning should be the child and family functioning should be the premise for all supervised access, although premise for all supervised access, although paramount in the Clinically Managed Access paramount in the Clinically Managed Access Program. Program.

Group teaching (i.e. mom and infant groups) Group teaching (i.e. mom and infant groups) during access is also incorporated/offered during access is also incorporated/offered within the Parenting Centre space/model.within the Parenting Centre space/model.

Parent Teaching with a Parent Teaching with a Cognitive Behavioural Cognitive Behavioural ApproachApproach Focus of intervention is on Focus of intervention is on

Caregiver Sensitivity (Benoit Caregiver Sensitivity (Benoit 2004)2004)

Can be accomplished in fewer Can be accomplished in fewer than 16 sessions (8 weeks) with a than 16 sessions (8 weeks) with a clear cut behavioural focus on clear cut behavioural focus on families with and without multiple families with and without multiple problems.problems.

Cognitive Behavioural Cognitive Behavioural ApproachApproach ThinkingThinking AttitudesAttitudes

ActionsActions EmotionsEmotions

HabitsHabits How You FeelHow You Feel

CharacterCharacter Decisions Decisions

DestinationDestination

Cognitive Behavioural Cognitive Behavioural ApproachApproachLearning Positive Self TalkLearning Positive Self Talk• Help the client focus is on words, expression.Help the client focus is on words, expression.• CAF “CAF “fades in and fades outfades in and fades out” their ” their

assistance.assistance.• Concrete Examples/Strategies are suggested Concrete Examples/Strategies are suggested

by the CAF. The client is taught the impact of by the CAF. The client is taught the impact of their their expressionexpression, , body languagebody language, and verbal , and verbal communicationcommunication..

• Families learn how to exercise word muscles, Families learn how to exercise word muscles, and self awareness.and self awareness.

Cognitive Behavioral Cognitive Behavioral Approaches within ‘Child-Approaches within ‘Child-Focused Interaction’ Model:Focused Interaction’ Model:

Cognitive behavioral approachesCognitive behavioral approachesUpsetting ThoughtsUpsetting Thoughts Calming ThoughtsCalming Thoughts““I can’t stand it whenI can’t stand it when “I don’t like it when he acts like “I don’t like it when he acts like

thatthat

he acts like that. It driveshe acts like that. It drives But I can handle it”.But I can handle it”.

Me crazy”.Me crazy”.

““What if he never listens!”What if he never listens!” “He’s learned to act this way. I “He’s learned to act this way. I just just have to stay calm and have to stay calm and help him learnhelp him learn

better ways to behave”.better ways to behave”.

Cognitive Behavioral Cognitive Behavioral Approaches within ‘Child-Approaches within ‘Child-Focused Interaction’ Model:Focused Interaction’ Model:Approaches with parents must be:Approaches with parents must be: Strength-basedStrength-based Rooted in the presentRooted in the present Solution orientedSolution oriented Does not assign blameDoes not assign blame Seeks collaboration among everyoneSeeks collaboration among everyone Sees people through their abilitiesSees people through their abilities Acknowledges small steps & victories as Acknowledges small steps & victories as

stepping stones for longer term change. Each stepping stones for longer term change. Each small step and victory is celebrated (Paula small step and victory is celebrated (Paula Cook, 2005).Cook, 2005).

Cognitive Behavioral Cognitive Behavioral Approaches within ‘Child-Approaches within ‘Child-Focused Interaction’ Model:Focused Interaction’ Model:

Clinically managed child-focused interaction with Clinically managed child-focused interaction with cognitive-behavioral approaches ultimately benefits the cognitive-behavioral approaches ultimately benefits the child...child...

Strategies must be goal oriented (stop and Strategies must be goal oriented (stop and think—identify the problem), solution think—identify the problem), solution focused-brainstorming, strategy selection focused-brainstorming, strategy selection and outcome evaluation/acknowledged.and outcome evaluation/acknowledged.

Find every opportunity to find something Find every opportunity to find something positive (positive affirmation strategies); positive (positive affirmation strategies); catch them doing something good, use of catch them doing something good, use of metaphors, storytelling, teachable metaphors, storytelling, teachable moments, role model, share new moments, role model, share new information, engage in skill training and information, engage in skill training and problem solving. problem solving.

Cognitive Behavioral Cognitive Behavioral Approaches within ‘Child-Approaches within ‘Child-Focused Interaction’ Model:Focused Interaction’ Model: Behavioral rehearsal includes; Behavioral rehearsal includes;

prompting, shaping, providing prompting, shaping, providing feedback and giving reinforcement. feedback and giving reinforcement.

Break skill into simple steps, provide Break skill into simple steps, provide homeworkhomework

Rehearse, repeat and practiceRehearse, repeat and practice Model and reinforceModel and reinforce Identify intrinsic valueIdentify intrinsic value

Cognitive Behavioral Cognitive Behavioral Approaches within ‘Child-Approaches within ‘Child-Focused Interaction’ Model:Focused Interaction’ Model: Intervention is fluid and responsive to Intervention is fluid and responsive to

changing circumstances and dynamicschanging circumstances and dynamics Combination of structured and Combination of structured and

unstructured tasksunstructured tasks Child focused parentingChild focused parenting Skill development and practiceSkill development and practice Internalize and generalize parenting Internalize and generalize parenting

approachesapproaches

‘‘Child-Focused Child-Focused Interaction’Interaction’

Remember: not as successful with Remember: not as successful with individuals who: are not capable or individuals who: are not capable or refuse to accept their role, unwilling refuse to accept their role, unwilling participants, refuse to practice, with participants, refuse to practice, with those who do not complete those who do not complete homework assignments, individuals homework assignments, individuals in severe crisis or with untreated in severe crisis or with untreated mental health or substance abuse mental health or substance abuse issuesissues

Thank YouThank You

Questions??Questions??

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