Therapeutic Access: From Supervising Access to Building Parent-Child Relationships
By Mary Rella, BA Dip C.S.

This article was first published in IMPrint: The Newsletter of Infant Mental Health Promotion, Volume 47, Winter 2006-07, revised April 2010. Excerpts have been taken from the original article for this publication.

A new approach to "supervised access" has been unfolded in Ontario over the past four years. Developed by the author in her work at the Intensive Family and Community Resource Program (INTERFACE) at Thistletown Regional Centre and in conjunction with the Children‘s Aid Society of Toronto and others1, the model takes advantage of traditional supervised access opportunities and uses them to actively engage child welfare workers and parents in working together to build secure parent-child relationships, while teaching parenting skills.

"Therapeutic Access" is an innovative teaching and intervention program that trains child welfare protection workers to change their role in relation to supervised access. Workers are taught to assess parenting risks in the context of the parent-child relationship during supervised visits. This focus provides a road map for developing interventions to help parents improve their parenting skills and their relationships with their children. The normally silent worker—one who observes and takes notes during supervised access visits—becomes the proactive worker—one who serves as an available and valuable resource to educate parents and help them to better know and respond to the needs of their children. This new approach recognizes that parents provide significant information about the parenting skills they learned (or did not learn) from their own experiences of being parented. Grounded in attachment research and theory, Therapeutic Access empowers and supports parents to gain understanding about their own experiences of being parented, apply this new insight to their current parenting, learn new skills, reduce the risks that resulted in the placement of their child or children in the first place, and whenever possible, work towards permanency and/or reunification. By conceptualizing parenting behaviours as rooted in past experiences that can be changed today, workers and parents can work together to shift the focus away from a parent‘s "love" for the child or "desire" to be a better parent to one of concrete skill-building and behaviour change. The approach also provides a framework for the court system so decisions about permanency planning can be achieved more expediently.

This paper describes some of the limitations in current supervised access practice, provides a brief review of attachment theory and research, and presents Therapeutic Access as an alternative intervention model for supervised access. Grounded in attachment and the realities of child welfare practice, Therapeutic Access is designed to promote secure attachment and build parent-child relationships. The paper concludes with a brief description of how the model is unfolding in Ontario.

WHY CHANGE SUPERVISED ACCESS PRACTICE?

Established under the authority of the Child and Family Services Act (CFSA) in Ontario, Children‘s Aid Societies (CAS) act to protect children from harm. Most of the children who come into contact with CAS require intervention as a result of parenting behaviours that place children at risk of emotional harm, physical harm, and/or sexual abuse. Efforts to help parents use more adaptive parenting skills have tended to focus on helping parents learn instrumental care skills (i.e., supervision, feeding, etc.) rather than emotional care skills. However, the child-parent relationship itself is emerging as the target for most effective intervention and prevention efforts in infant mental health research (Clark, Paulson, & Conlin, 1993; McDonough, 1993). Focussing on the relationship between parent and child and how the caregiving pattern affects both instrumental and emotional care as well as how it contributes to abuse behaviours, is critical to assessing risks and the potential for reunification.

In most situations, children are protected without being removed from their homes. However, in those cases where the risk to a child is deemed to be so significant that she or he cannot remain at home and be protected from harm -and in its goal to reunite children with their families where possible- CAS uses a service called supervised access. This means that parents can have direct contact or visits with their child or children in the presence of a CAS worker. Most often, this involves the worker observing the visits and making notes of his or her observations. When changes are observed, be they positive or negative, the worker recommends changes to the access arrangements. The observations and recommendations are shared with the parents and submitted to Family Court where judges make decisions to maintain or change access arrangements.

Making infant-parent or child-parent relationships the centrepiece of evaluation and intervention for families involved in child welfare and in child welfare settings raises a number of challenging issues for workers, families and the courts. For example, can assessing the relationship between parent and child provide evidence that simultaneously illuminates the risks identified and clues to help change the relationship? Can identifying adult attachment representations provide crucial understanding that can be used to minimize current parenting risks? Can parents be taught to identify, respond, plan and act on their children‘s signals for distress differently from the ways they learned when they were being parented? Can supervised access provide sufficient opportunity to strengthen a parent‘s position as a consistent protector in the eyes of their children? Our experience, to date, is showing that all of these challenges can be addressed through Therapeutic Access, an approach that is grounded in attachment research and theory and conceptually designed to function therapeutically unlike some current supervised access practices.

With increasing numbers of children coming to the attention of child protection and a desire for the system to provide tailored and flexible support to meet the needs of vulnerable children and families, child welfare service providers, families and communities need to use every opportunity to build practices that support parents, foster healthy child development and well-being, and prevent abuse and neglect. Therapeutic Access is emerging as one such practice squarely aimed at changing passive and repetitive sequences of supervised access visits into proactive learning and practice windows that can advance the development of healthy relationships.

THERAPEUTIC ACCESS IS GROUNDED IN ATTACHMENT

The behaviours of parents and their children are well understood when they are situated and explained through attachment research and theory. The works of Bowlby, Ainsworth, Main, Zeanah, and Crittenden, for example, offer indispensable insight into the behaviours that unfold in families everyday and that child welfare workers witness in families‘ homes and later in supervised access visits.

Between 10-20 months, the child‘s symbolic representation of the attachment system develops. The child develops a representation of attachment through repeated experiences of the parent via the ways the parent attends to cues of distress (fear, illness, physical pain) from the child. Such cumulative experiences form the child‘s understanding of how his or her parent will respond consistently to their cues for proximity.

Bowlby, for example, found that all infants are biologically predisposed to maintain proximity to caregivers. However, he also recognized that children differ in the ways they achieve this goal by virtue of their experiences with their caregivers. Through repeated experiences with caregivers, infants and children develop expectations—"Working Models" or cognitive/emotional representations of their interactions with primary caregivers—which serve as guides for future relationships. A lack of a consistent strategy for coping with threats to security explains the link between disrupted attachment to the caregiver and subsequent developmental, social emotional and cognitive difficulties in the child (Zeanah & Boris, 2000).

Bowlby (1969,1982) emphasized the development of a "goal-corrected partnership" between infant and caregiver. The behaviours of the infant are organized around the goal of maintaining proximity to the mother hence establishing security. When the attachment system is activated by a potential threat (i.e., physical pain, fear, illness) the infant attempts to increase signals to communicate proximity to the caregiver, retreating for a sense of safety and reduction of stress. The concept of goal-corrected attachment behaviours provided the foundation for Ainsworth‘s identification of the three patterned subtypes of the organization of infant-parent attachment behaviours: secure, avoidant, and ambivalent/resistant, each characterized by a distinct strategy for the achievement of proximity that becomes apparent by the end of the child‘s first year (Ainsworth, Blehar, Waters & Wall, 1978). In their work with parent-child relationships, Main and Solomon (1990) later identified the disorganized/disoriented subtype.

Infants who have not had their needs met consistently and appropriately by caregivers either minimize emotional displays (avoidant) in an effort to reduce the risk of future disappointments, or heighten their expression of negative emotions (ambivalent/resistant) in an effort to engage an inconsistently responsive caregiver. Both relationship patterns pose risks to the dyad. Mothers of avoidant-insecure infants are more covertly rejecting of their babies, especially when the infant expresses negative affect, and show a narrow range of emotional expressiveness (Ainsworth et al., 1978; Malatesta, Culver, Tesman & Shepard, 1989). Mothers of ambivalent-insecure infants are "unavailable" in the home environment. For example, parents miss cues for distress and/or act on their own feelings thereby failing to respond to the internal state of the child (Crittenden, in press). These patterns are observed throughout the development continuum.

With respect to disorganized infant-mother attachments, Main and Hesse (1990) proposed that infants have been exposed to frightening experiences or frightened parents who themselves continue to experience unresolved complex trauma. As a result of these traumas, parents behave in ways that are confusing to infants and therefore frightening to them. An infant frightened by a parent‘s behaviour will be in conflict with respect to seeking proximity (for security) and avoiding proximity as a result of fear. Simultaneous needs promote disorganization.

Lyons-Ruth, Bronfman, and Parsons (in press) expanded the above based on observations of mothers and infants in which the mother had documented unresolved trauma. The two types of disruptions in maternal affective communications were: 1) "failure of repair" and 2) "competing strategies." "Failure of repair" is characterized by unresponsiveness to the content or intention of the infant‘s communication. The mother responds with hostility, intrusiveness, withdrawal, or parent-infant role-reversal. In the absence of a minimal level of appropriate parental responsiveness, infants have difficulty activating attachment strategies leading to fear and a breakdown of organized behavioural strategies. "Competing strategies" refers to fear-based contradictory caregiving behaviours that both elicit and reject infant attachment behaviours thereby confusing the infant‘s ability to form a coherent attachment strategy. Such mothers provide infants with contradictory messages and respond inappropriately or not at all to communications by the infant. These mothers also engage in more negative intrusive behaviours and role confusions (Lyons-Ruth et al., in press). Hence, mothers who continue to be significantly confused about their own self-worth promote confusion in the attachment relationship. Current caregiving behaviours towards their children include rejection, role reversal and intrusiveness.

Many parents who have harmed their children or increased the risk of harm have often been puzzled when child welfare characterizes their behaviours as negative or abusive. They report that their own care experiences were far worse and they believe that the corrections they have made are sufficient. As well, continued research suggests that parent intentions to keep their children safe from harm, for example, do not necessarily translate into protective behaviours. Instead, they find their behaviours being evaluated by child welfare as either physically or emotionally abusive (Crittenden, in press). Without intervention, these parents would likely continue to believe that their "improved" or "well-intended" approaches are sufficient while failing to recognize the limitations and the continuing need to learn how better to protect their children.

There is growing evidence that infants in high risk families characterized by maternal depression, neglect, abuse, alcoholism, or domestic violence are especially likely to be classified as disorganized. Moreover, violence or abuse in the mother‘s childhood increased the tendency for insecure attachment to take disorganized rather than avoidant forms of attachment. Different types of childhood experiences appear to be associated with different patterns of maternal caregiving. Violence or harsh punishment was associated with more hostile-intrusive maternal behaviour, whereas abuse including sexual abuse was associated with maternal withdrawal. (Lyons-Ruth & Block, 1996). All such behaviours are observed in the child welfare office during supervised access.

According to Cassidy (1994) and as evidenced by the work of Main, Kaplan, and Cassidy (1985), parents‘ "working models" of relationships influence all relationships including those with their children. Mothers who are dismissing of attachment relationships convey this orientation to their children, whereas mothers who are preoccupied with their attachment convey their preoccupation. Each develops a parenting model, behaviours affecting parenting and subsequent attachment relationships that can promote risks to their children in the form of neglect and abuse and become a focus for child protection intervention. Given that many parents who become involved in the child welfare system have experienced both trauma as well as early relationship disruptions, it stands to reason that current caregiving behaviours are seen as increasing risks to their children. It also confirms that parents generally continue to do what they have learned to do with their children in access visits.

The most disruptive parent/child relationships occur when the parent is both the source of security and the source of terror for the child. In such relationships the parent makes affective errors, for example, by responding inconsistently or with contradictory behaviours to cues for proximity, or is non-responsive or inappropriately responsive. The child experiences disorientation from the parent as the parent responds in a confused or disorganized manner. The child experiences the parent‘s behaviour as intrusive (verbal or physical), frightening, withdrawn or frightened of the child (verbal or physical) (Lyons-Ruth & Jacobvitz, 1999). While the absence of an appropriate attachment figure is apt to negatively impact the social and emotional development of the child, the parent who is present to provide protection yet absent in the ability to do so because of inconsistent and disruptive caregiving efforts promotes more devastating effects in the attachment representation for the child (Lyons-Ruth & Jacobvitz, 1999). Understanding the significance of such relationships may provide clarification regarding the efforts required to promote positive change for the child in access. Clarifying the ability of the parent to change the above noted behaviours is crucial to the permanency plans for children.

Unresolved complex trauma and/or unresolved loss in the parent promote a continued lineage with respect to child maltreatment over generations. For example, in two separate studies disorganized attachment was found to be a factor in 82% of maltreated infants (Ward & Carlson, 1995) and 55% of maltreated infants. The disorganization of the attachment relationship was found to be a central mechanism in the emergence of many of the disturbances associated with child maltreatment (Lyons-Ruth & Jacobvitz, 1999). Children cooperate in maintaining their parents‘ state of mind by creating their own psychological distance thereby behaving avoidantly, or by continuing to engage in power struggles in an attempt to engage the parent, thereby behaving ambivalently/resistantly, and/or developing a number of unsuccessful strategies that attempt to avoid and engage the parent simultaneously. These behaviours appear to promote risks to children in that avoidant children are at risk of neglect and resistant children are at risk of abuse including failure to thrive.

On the whole, children come to understand from repeated experiences with their parents and caregivers that a pattern exists in their interactions. The parent's past experiences produce a present day ability (or disability) to respond to their child's negative affect. Hence, while a parent may learn better what to feed the child, the manner in which the parent feeds the child is very important. The content may improve, however, helping the parent to recognize negative affect while feeding, and teaching the parent to respond sensitively and consistently would also address the emotional health of the relationship.

BRINGING ATTACHMENT KNOWLEDGE AND PARENTING STRENGTHS INTO PRACTICE

Understanding maternal and paternal caregiving patterns may by helpful in determining interventions and treatment to lower current parenting risks as well as increasing secure attachment possibilities. To be effective in altering parenting behaviours related to insecure and/or disorganized attachments, the research tells us that clinicians, mental health workers and child welfare workers need to understand parent events in childhood prior to determining treatment and planning interventions regarding their current parenting. Given that specific patterns of maternal and paternal caregiving affect the nature of the infant‘s attachment strategies, it stands to reason that most of the dyads identified as at risk in the child welfare spectrum have experienced various forms of difficulties that are manifested in poor parenting, neglect, abuse, failure to thrive, and/or behaviour problems in children.

How does one weave this knowledge into child welfare practice and specifically into access visits? An obvious implication of the research and findings is that in order to promote the development of secure attachments and to alter insecure attachments in infants and children, it is necessary to change the behaviours of the primary caregiver. In addition to its grounding in attachment, Therapeutic Access is similarly rooted in recognizing and harnessing parental resources of strength, coping and resilience.

The concepts of strength and empowerment have been used with a wide variety of individuals and in a broad range of situations including mental health (Rapp, 1992), people with disabilities (Mackelprang and Salsgiver, 1996), people suffering from substance abuse (Miller & Berg, 1995), children exposed to trauma (Aldwin, 1994; Poertner & Ronnau, 1992), homeless women with children (Thrasher & Mowbray, 1995), and adults dealing with stress and coping (Saleebey, 1996). According to this literature, strength can be conceptualized using a number of overlapping and related approaches such as cognitive and appraisal skills, reframing parenting experiences, practicing behaviours, and direct hand-over-hand teaching. Therapeutic Access is based on the derivates of the above noted approaches to change while focussing at all times on the overall significance of changing attachment relationships to build secure patterns of engagement with the child and consistent appropriate responses from the parent.

USE AND TIMING OF THERAPEUTIC ACCESS

While Therapeutic Access is designed to address parent-child relationship problems and give parents an opportunity for reunification with their children, child safety and healthy development are central to decisions concerning the use and timing of the intervention. For example, interventions to protect children and support secure attachments must minimize the amount of time infants spend in foster care and the frequency of caregiving disruptions. This necessitates an expedient and thorough understanding of children‘s risk factors in their home and a similarly expedient and thorough understanding of whether parents can change their maladaptive behaviours towards their children.

If Therapeutic Access is offered and parents decide to participate, the planning begins shortly after the child is placed in care. With a focus on learning relationship-based skills and practicing adaptive parenting skills, each session is longer in duration (e.g., two - four hours) than typical supervised access. Because the sessions are intended to bring about demonstrable behaviour change, the CAS worker prepares documents for court that concretely stipulate what the parents need to learn and demonstrate, as well as the amount of time offered to help them learn. For example, "the mother will attend four hours of therapeutic access, twice a week for a period of six weeks. This period of time will provide the mother with forty-eight hours in which to learn about the instrumental care of her child, (feeding, supervision, structure, routine) and the emotional care of her child, (sensitivity, responding to cues for distress, delighting in play activities)." This kind of clear understanding regarding the risks and opportunities provided to reduce those risks is helpful to parents, lawyers and judges in making decisions to continue or terminate therapeutic access.

THERAPEUTIC ACCESS IN ACTION

Setting the stage

In Therapeutic Access, the parent assumes all parenting responsibilities for the child. The time with the child becomes "parenting" the child rather than "visiting" with the child.

However, Therapeutic Access planning and joint work with the parent begins well before an actual structured visit takes place. The desired changes can perhaps only occur while providing the caregiver with the opportunity to make the changes in a secure environment, thereby fostering the parent‘s ability to accept negative and positive affect from their children while learning how to recognize and respond to it differently in themselves. The work of van IJzendoorn (1997) suggests that attempts to facilitate changes in parenting relationship be considered carefully and systematically. This is very important when parents are engaged with child welfare. Attempting to increase sensitivity in the parent/child relationship in light of poverty issues and/or addictions and/or mental health issues may not be possible. It is also likely that such relationship changes towards the infant by the parent are not possible given the internal insecure and/or dissociative state of mind of the parent. However, attempts at assessing the nature and extent of these problems should always be considered and recommendations regarding reunification can be made during access.

Information gathered about the parent‘s past and the formulation developed allows the worker to begin to predict with the parent the areas of concerns that may be observed in the access visit, as well as to plan interventions to help the parent recognize their behaviour and change the outcome. The worker and the parent plan together to reduce the risks identified and agree that they are both able to evaluate the improvements identified.

Assessment

The case history provides an understanding of the risk factors already identified: the parental risk factors, unique characteristics of the child that place him or her at risk, extended family risk factors and community risk factors. Given this information, the assessment process focuses on clarifying the child‘s exposed difficulties that require treatment and the skills parents need to learn to reduce the risk factors.

Assessing adult representations of attachment relationships is done primarily by using the Adult Attachment Inventory (AAI) (Main, Kaplan, & Cassidy, 1985). A history of the parents‘ recollection of their own childhood experiences including a description of: the immediate family, relationships with parents as a young child, five adjectives for relationship with mother/father and memories for each, a description of closeness in the relationships, an account of care at times of illness or fear, physical pain and a description of rejection (minimized or promoted) in the relationship, parental threats, discipline, losses, and current relationships with parents. Scoring is done on the basis of coherence, quality of information (i.e. believable without contradiction), quantity of information, (i.e., too much, too little), relevance (i.e., answers the questions asked), and manner (i.e., answers questions in clear language). The outcome of the questionnaire provides a formulation of the individual‘s state of mind regarding representation of relationships in general. The "state of mind" scales are classified in four categories: Balanced: a coherent state of mind characterized by a valuing of relationships; Dismissing: characterized by a deactivated attachment system therefore dismissive of the task of attachment representations; Preoccupied: characterized by a preoccupation with past attachment relationships either angry or fearful as past experiences contribute greatly in the present; and Unresolved/Disorganized: characterized by lapses in monitoring of reasoning, changes in mood, content, lapses specific to talking about trauma or loss.

The AAI is a tool used in individual therapy and requires specific training to score accurately and reliably. However, for the purpose of Therapeutic Access, key relationship questions modified from the AAI are useful. For example, we learn to mother from our mothers and father from our fathers. What did you learn from your mother/father? Describe your relationship when you were young. How did your mother care for you when sick/scared/hurt? What did you learn about trust, conflict, and rejection? What did your mother do when you were hurt? How did your father show you affection/rejection? What did you learn from your mother about mothering? What are the things you are repeating in your own mothering?

Hence while the AAI is not the tool used to obtain a history of relationships, key components can help identify and clarify a learned style of engagement from the parent.

Risks are then re-evaluated once skills have been learned to the best of the parent‘s capacity, and reduction of risks promotes recommendations regarding permanency. For example, has the parent increased her or his capacity to act as a protector for the child and hence move towards a secure attachment relationship? The focus on increasing the parent‘s ability to be the protector and increasing the child‘s confidence in the parent as protector has significant implications in all areas of care for the child--both instrumental and emotional.

The sessions

The goal of Therapeutic Access is to determine whether parents can increase sensitive behaviours towards their children, reduce rejecting behaviours, decrease inconsistent parenting behaviours promoting confusion for the child and eliminate frightening, frightened or dissociated atypical behaviours in the parent. Interventions in the sessions are aimed at helping parents eliminate parenting behaviours that contribute to the child‘s view that the parent is ineffective, frightening, inconsistent and rejecting, and aimed at helping parents increase parenting behaviours that foster the child‘s confidence in the parent as a protector, thereby promoting the secure attachment relationship.

The parent arrives fifteen minutes early to meet with the worker and plan the time together. The parent is responsible for bringing a meal to eat with the child as well as other things the child would require. If the child is an infant, the parent is responsible for bringing a diaper bag that contains formula, diapers, blanket, toys, etc. If the child is older, the parent brings food that is prepared by them. This is particularly significant in that it demonstrates the parent‘s ability to plan ahead, organize and meet the needs of the child. It also places the parent in the caregiving role with the child thereby emphasizing the role of parent as protector for the child.

Therapeutic Access involves structuring the supervised access from "hello" to "goodbye." Parents are encouraged to join with their children, meet their unique needs, plan and practice playtime, prepare meals/snacks, communicate, demonstrate listening skills, prepare for the separation, and plan for the next access. All of the essentials that we would want to see any parent provide for their child are brought to life in a Therapeutic Access visit.

Most children in access are old enough to have the parent explain to them the purpose of the Therapeutic Access time. With support the parent is asked to explain to the child the reasons they have supervised access as well as the purpose of the parent‘s learning. For example, "I‘m here with you because I am learning better how to take care of your feelings when you get upset," or "I‘m learning how not to use physical punishment when I get angry with you," or "I‘m learning how to keep you safe and make sure I know what to do when you get scared." Such statements promote feelings of security for the child as feelings of responsibility for the foster care placement shifts away from the child and on to the parent. Further it prevents children from making up their own inaccurate stories about what is happening to them (Wilkes & Milne, 2002).

Part of the session allows for "unstructured activity" that provides an opportunity for the parent and child to experience free play. The worker observes the tone of the relationship, mutual engagement, scaffolding opportunities for the parent to teach affect regulation, cognitive development, social reciprocity, sensitivity and responsiveness. The worker intervenes at different times providing feedback in areas the parent needs to change and positive feedback in areas of strength. Such feedback is always provided in the context of improving the relationship between parent and child and with a reminder that the parent may not have learned the skills in their own experiences growing up.

The worker remains involved with the parent during access and does not assume any care responsibilities for the child. The message to the parent is that parenting their child requires all their attention and that the child would like to see the parent assume that role in their relationship. The role of protector is always encouraged for the parent so as to increase security for the child. Hence corrective experiences begin to reshape previous attachment representations.

Workers need to understand the organization of parental actions in order to help parents reorganize their actions to include adaptive parenting skills. The parent‘s own childhood experiences can help the worker clarify distortions and/or errors the parent makes in their relationship with the child. The greater the risk the more correction the distortion requires; the greater the correction the greater the involvement from the worker in access. Treatment is directed towards reducing distortions by allowing the parent to learn to see themselves as protective and safe to their child. This framework is carried through in all areas of care the parent provides.

The parent also learns the language of the child‘s behavioural expressions addressing feelings rather than unsuccessful behaviour management. This would be particularly important for the parent who has been physically punitive with their child and the child who has learned to express their anxiety either by non-compliance or over-compliance. The access time serves to create a corrective narrative for the child regarding past abuse experiences. The child learns through repeated experiences that their parent is learning to be a "protector" thereby strengthening the relationship between the dyad.

Participation in parenting groups or other interventions should become relevant in the child/parent relationship in the session. In other words, the positive effects of learning how to control anger in other programs (or child management skills, depression management, etc.) should be evident in the care parents provide to their children.

The access time incorporates opportunities to correct greetings and goodbyes between the parent and child, to strengthen the position of the parent to recognize cues of distress from their child and learn how to respond to the cues by assuming proximity in a safe and gentle manner. The parent learns to help the child with feelings associated with the transition of returning to the foster home while remaining in relationship with them. This is particularly helpful for avoidant attachment relationships.

After the sessions

The parents and the worker debrief, reflecting on what happened and what the parents found helpful, identifying parent strengths and continued learning goals and looking at ways parents can continue to build their learning outside the access visit setting. The debriefing segment with the parent provides significant opportunity to evaluate the positive changes in the relationship as well as the instrumental care provided to the child.

Documenting the work

The notes of the access session are reviewed by the parent and signed, and the next access is planned. A Therapeutic Access plan is written by the worker. It is designed to help the parents and the courts identify learning areas, time frames for learning, and review dates once the learning begins. Recommendations regarding any changes to the access status (from supervised to semi- or non-supervised) are made when learning and behaviour change demonstrate that the risk factors are lowered.

UNFOLDING THE MODEL IN ONTARIO

Therapeutic Access is becoming a useful tool in current child welfare reform efforts in Ontario to meet growing needs and the complexity of families coming to the attention of child welfare. This model is helping to promote understanding, shift the thinking of workers, and appears to expedite permanency planning.

Over the past three years, CAS workers across the province of Ontario have been trained to use the model. Training has focussed primarily on helping CAS professionals to structure access in a manner that produces organized information regarding parenting changes. Although training has also included helping workers to learn to bridge adult early care experiences with current parenting practices, participants have identified that they require more opportunities for concrete learning.

Looking forward, this model may also come to be used with families who are involved with child welfare, but whose children remain at home in the care of their parents. Further, an exciting emerging application of the model involves using Therapeutic Access with parents who have a child or children in care, but who also are parenting other children outside of this arrangement. In other words, parents involved in co-parenting another child or who have had a recent baby may soon be actively supported to carry over their therapeutic access learning into their other parent-child relationships. With respect to new infants, for example, they‘ll have access to learning early attachment signals with their infants from the very beginning stages of development thereby reducing risks from the start.

Thus far, the courts appear to applaud the efforts made by workers utilizing Therapeutic Access. Feedback from CAS workers themselves is twofold: on the one hand, they like the notion of returning clinical practice to their work; on the other hand, the process can be daunting because a decade of risk assessment tools aimed at evaluating risks have to a large extent overshadowed and diminished the clinical skills required to do this work effectively. Workers who would like to use Therapeutic Access as a viable alternative to supervised visits are still being constrained by high caseload numbers and ongoing time constraints.

As a promising approach for tackling the difficult and deeply entrenched issues in providing quality protection services for children, Therapeutic Access provides a proactive movement toward more dynamic and responsive supervised access designed to achieve better outcomes for children and vulnerable families. It equips child welfare protection workers with tools to provide effective prevention, permanency, protection, and family preservation services. By training child protection workers to understand the complexity of attachment relationships and by helping them to teach parents to increase their parenting capacities essential to meeting the needs of their children, Therapeutic Access facilitates a greater likelihood for reunification of children and their parents whenever it is possible and may prevent recidivism in the child welfare system. Thus, Therapeutic Access has a potential for tremendous cost savings as well. In situations where reunification is questionable, Therapeutic Access is still considered as an approach that improves permanency planning for children, delivered in a manner that is planned and evaluated.

SUMMARY

In summary, while each access visit is but one snapshot in time, it provides an opportunity to understand the risks in the family and those in the parent-child relationship. The greeting, feeding, play and goodbye structure provides ample opportunity for the parent to learn and/or demonstrate capacity for nurturance, social interactions, and sensitivity to a child‘s cues. The parent‘s ability to assist in all areas of regulation, child‘s readability, and the child‘s strategies to engage or avoid the parent, or confusion regarding both, are observable and thus provide opportunities for learning.

The process allows the parent to articulate the relationship he or she wants to have with their child and the manner in which to have that happen successfully. The reflective process of utilizing the narrative of the parent‘s past care experiences, their resulting internal representation of relationships, and parenting style is helpful in enabling the parent to reweave their parenting quilt with their child and provide more adaptive parenting.

If the parent has learned that physical force and punitive punishments are essential to obtain compliance, it is likely that in their attempts to teach their children respect they would promote fear in their children and recreate a disrupted relationship. It is also likely that the parent who experienced fear and threats in his or her own childhood and learned to hide away, dealing with their own fear and uncertainty, learned that adults were not protective in the resolution of such emotional dilemmas. As a result, they continue to avoid engagement with their own children.

Therapeutic Access works to construct the bridge necessary to help parents understand their past experiences, their current behaviours, their effects on their children and the parent-child relationship.

Understanding a parent‘s developmental process and how they have made meaning from their childhood environment helps to explain the process by which parents organize their behaviours towards children. Therapeutic Access can focus on supporting parents as well as providing corrective interventions for the purpose of change thereby possibly breaking the lineage of disrupted attachment relationships and minimizing risks to children.

ENDNOTE

1. INTERFACE has worked to implement this model with the Children‘s Aid Society of Toronto (CAST), Catholic Children‘s Aid Society of Toronto (CCAS) and Children‘s Aid Society York Region. In particular, North Branch CAST has implemented the model in an organized manner and hired a coordinator as the key worker in developing Therapeutic Access plans. The program has recently been granted core funding as it successfully moved from a pilot to a program.

ABOUT THE AUTHOR

MARY RELLA, BA Dip. C.S. Mary is the Manager of Consultation Assessment and Training Services at the INTERFACE Program, Thistletown Regional Center part of the Ministry of Children and Youth Services. Mary leads the clinical assessment teams to further provide consultation and service in collaboration with other Children‘s Mental Health agencies and Child Welfare. Mary has worked with families in clinical settings and Child Welfare for over 20 years. Mary continues to provide parenting assessments, attachment assessments and training to professionals across the province of Ontario. Mary‘s professional focus is in the areas of: parent/child relationships and the repair of relational trauma. Mary has developed extensive training in the area of Therapeutic Access in conjunction with the Child Welfare System and she provides clinical consultation to mental health professionals as well as Children‘s Aid professionals. Mary has a private practice specializing in working with individuals, families and couples. Mary is a energetic presenter who is passionate about her work and continues to include current research and clinical applications providing knowledge and training regarding parent/child interactions.

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