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

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

3. Therapeutic Access
BACKGROUND….

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

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

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

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

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

9. From Supervising Access Building Parent Child Relationships
THERAPEUTIC ACCESS
From Supervising Access to
Building Parent Child Relationships
Mary Rella, B.A. Psych., Dip. C.S. Psych. INTERFACE Program Thistletown Regional Centre Ministry of Children & Youth Services
Mary Rella 2006

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

46. For More Information… Mary Rella, Thistletown Regional Centre
Tel:
Shannon Deacon, Children’s Aid Society of Toronto
Tel: , ext. 3424