Building Family Recovery Through Client Support and Provider Collaboration AKA Managing Boundaries: Working across Child Welfare, Early Supports and Substance Abuse Systems

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Building Family Recovery Through Client Support
and Provider Collaboration AKA Managing
Boundaries Working across Child Welfare, Early
Supports and Substance Abuse Systems

• Debra Bercuvitz,MPH
• Debbie Flynn-Gonzalez,M.Ed.

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History of FRESH Start (FS)

• FRESH (Family Recovery Engagement Support of
  Hampden County) Start
• Joint initiative with Mass Dept. of Public Health
  and Mass Dept. of Children and Families since
  2008
• with funding from
• U.S. Children's Bureau

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Service Model

• FSs home visiting combines peer mentoring, a
  major component of the program, support and
  advocacy with clinical guidance and treatment
• Staff provides connection to resources, as well
  as direct recovery and parenting assistance.
• Staff partner with child welfare, early
  intervention, and substance use disorder workers
  to increase client engagement with their services
  and improve outcomes

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Philosophy of Care

• Strengths-based
• Trauma-informed
• Collaborative
• Family-focused
• Evidence-based
• Consumer-directed
• Culturally-relevant

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What do we all want to hear?

• For me, I really needed to have at least ONE
  person telling me that I did something right. I
  felt like every single person who came in to see
  me was about to tell me everything I was doing
  was wrong, I just really needed to hear something
  good about me as a mom even if it seemed small,
  cause I felt like I couldnt do anything right,
  and I felt a lot of guilt.

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Half Empty Half Full
Strength-Based Recovery Language
Substance Use/Disorder

• Substance Abuse
• Drug Addicted Babies
• Addicted Mom
• On methadone
• Dirty Urine
• Non-compliant / difficult
• Lost Parental Rights
• History of Substance Abuse

Substance Exposed Newborns
Mother with a SUD Medication Assisted Treatment
Positive Screen
Not open to, not ready, has own ideas
Non-custodial Parent
In recovery / substance use disorder
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Half Empty Half Full

• Suffering from
• Treatment Team
• Weaknesses
• Unrealistic
• Abstinence
• Relapse / Failure

Working to recover from experiencing living
with
Recovery Support System/Recovery Team
Barriers to change needs
Person w/high expectations for self /recovery
Promoting/sustaining recovery
PROLAPSE Person is re-experiencing symptoms of
illness/addiction an opportunity to develop
and/or apply coping skills and to draw meaning
from managing an adverse event Re-occurrence
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Half Empty Half Full

• Discharged to aftercare
• Enable
• Manipulative

Connected to long-term recovery management
Empower the individual through empathy, emotional
authenticity, and encouragement
Resourceful really trying to get help

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Trauma-Informed

• What has happened to you? rather than What is
  wrong with you?
• Service delivery is based on an understanding of
  the vulnerabilities or triggers of trauma
  survivors that traditional service delivery
  approaches may exacerbate
• Place as much control as possible in hands of
  families
• Heighten sensitivity in mothers and providers to
  ways in which past experiences and coping
  strategies might be driving current behaviors

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Challenges to Parenting for Some Women with SUDs

• Own inadequate parenting hx, trauma, co-occurring
  disorders, multitude of stressors, difficulty
  with self-regulation.
• Hard time considering needs of others, responding
  to cues, behaving consistently.
• Limited understanding of basic child devt,
  inadequate supervision, poor reflective
  functioning, compromised attachment.

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Substance Use and Parenting

• Both need addressing concurrently
• Parenting as normalizing role and motivator
• Can also be a barrier to treatmentfear,
  practicalities
• Assume ability to parent well and need for
  successful parenting moments

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Substance Use and Parenting

• We need to normalize the stress of motherhood
  generally, and stress of motherhood coupled with
  active use and with recovery.
• Include parent-child activities in everything,
  model normal family practices which are often
  brand new to mothers parenting in recovery for
  the first time (baby showers, family meals,
  picnics, reading books)
• Identify MH providers in your community who are
  trained in Child Parent Psychotherapy, other
  trauma interventions, or have experience working
  with co-occurring disorders/families

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• Family Support

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Tips for Connecting Moms to Treatment

• Present ALL kinds of treatment
• Know what treatment options are actually
  available and be ready to act on it immediately
• Help them to identify supports and put in place
  if they go in to treatment
• Make calls together, dont just give them numbers
  and dont just do it for them, make them do it
  together
• For moms who are not ready yet, bring them to
  meetings to hear from others, dont give up but
  dont push
• Be honest and upfront, So are you ready to stop
  using? instead of asking vague questions like
  Are you using? when you know they are then ask
  what step they are ready to take
• Congratulate them for even thinking about getting
  into recovery, at least we are having the
  conversation, good for you
• GETTING TREATMENT IS THE BEST GIFT YOU CAN GIVE
  YOUR CHILDREN

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What They Need In Their Words
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• COLLABORATION

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Collaboration with Other Providers

• Child Safety and Family Recovery
• Consents
• Phone Calls and Introductions
• Exchanging Plans
• Family Conferences
• Joint Appointments

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Collaboration for Child Safety and Well-Being and
Family Recovery

• What are barriers to collaborating with other
  providers?
• Any specific to Part C, Behavioral Health, and
  Child Welfare?
• What strategies have proved helpful for you?

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Collaboration--Consents

• First appointmentChecklist
• Get consents right from the start. We are
  creating a team to help support you and we need
  to communicate.
• I can share all of the positive things you are
  doing and we can figure out how to support you
  when things arent going so well.
• I will always be honest with you about what I am
  sharing, and if there is an issue around
  abuse/neglect, we will do it together or I will
  let you know, no secrets.
• If you are uncomfortable, we can place
  limitations on the release, i.e. we can only
  discuss participation in program.
• Without a release, I cant answer questions and
  others will likely assume the worst.
• We have had great success with providers
  approaching us with their worries, asking us what
  we think and then we can talk with them and
  increase support.

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CollaborationInitial Contact

• Phone and email
• Introductions
• Description of roles
• Responsibilities
• Best method of communication
• Exchanging Plans
• Include safety planning and relapse prevention

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Safety Planning

• Establishes common goals for collaboration
• Need to think about relationship between using
  substances and safety of children
• Sample Forms

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Collaboration--Ongoing

• Regular Phone/Email Contact
• Family Conferences
• Joint Appointments
• Safety Mapping and Strengths-Based Work

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Collaboration in Action

• 1. Re-occurrence of substance use
• 2. Birth while mother is in medication-assisted
  treatment
• 3. Safety mapping

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• Re-occurrence AKA RelapseOpportunity for
  Collaboration to Improve Outcomes

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Stages of Change
Pre-contemplation
Contemplation
Preparation
Relapse
Action
Maintenance
Institute for Health and Recovery
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What Does the Individual Want to Do About the
Problem?

• Nothing
• Unsure ambivalent
• Change behavior, but how?
• Take specific action
• Maintain new behavior
• Test need for new behavior

• Pre-contemplation
• Contemplation
• Preparation/determination
• Action
• Maintenance
• Relapse
• (Prochaska, DiClemente, 1982)

Institute for Health and Recovery
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Relapse is a process, it's not an event.

The Stages of Relapse
Emotional relapse
Mental relapse
Physical relapse
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Emotional Relapse
Not going to meetings
Anxiety
Anger
Not asking for help
Isolation
Intolerance
Poor eating habits
Defensiveness
Poor sleep habits
Mood swings
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Mental RelapseThe signs of mental relapse are
Thinking about people, places, and things you
used with.
Lying.
Glamorizing your past use.
Hanging out with old using friends.
Fantasizing about using.
Thinking about relapsing.
Planning your relapse around other people's
schedules.
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Techniques for Dealing with Mental
Relapse
Play the tape through.
Tell someone that you're having urges to use.
Distract yourself.
Wait for 30 minutes.
Do your recovery one day at a time.
Make relaxation part of your recovery.
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RememberRelapse is a PROCESS, not an EVENT
Hard to stop the process at physical relapse
pointFocus efforts on RECOVERY, not achieving
abstinence through brute force
Physical Relapse
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Tracing back
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Working together

• DCF
• Open Communication
• Relapse Prevention / Recovery Plans
• Safety Planning
• When relapse happens

• Community
• Supports/Services
• Mental Health Providers
• Treatment Programs
• Family members
• Faith-based

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Role Play
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Congratulations on having your baby in recovery

•  
• DCF is likely to want to know how you are doing
  to make sure that you and your baby can have a
  safe return from the hospital. This is especially
  true if you have been involved with DCF before,
  or are on methadone or buprenorphine. The more
  information that you can provide them with, the
  easier their job is.
•  
• Here are some ideas of things that you can do to
  be prepared
•  
• Get letters of support from anyone working with
  you, including your
• treatment provider
• therapist
• prenatal provider
• other home visitor (like Early Intervention or
  Healthy Families)
• after incarceration staff person
• religious leader
•  

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Congratulations on having your baby in recovery

•   
• Get copies of urine screens.
•  
• DCF staff is likely to get the screens themselves
  if you dont give them. If you have positive
  screens, you can give them any information that
  might be helpful to understanding those screens.
•  
• Sign two-way consent forms for each provider to
  speak with DCF staff.
•  
• This means that the provider can speak with DCF
  staff and DCF staff can speak with the provider.
  Each consent form should have the name and
  contact number of the person to be contacted
  during a DCF initial assessment or investigation.
  If DCF staff cant speak with your providers,
  they might assume the worst without other
  information.
•  
• Make a cover sheet that lists all of the
  materials that will be provided to DCF.
•  
• Two copies should be made of all items, one for
  you to keep
• and one for the hospital to fax to DCF.
•  
• When you go to the hospital, bring the copy of
  the materials for DCF to give to the postpartum
  social worker and ask her to fax it to DCF
  if/when necessary.
•  

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Safety Mapping

• Sharing Perspectives Using an Organizing Framework

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Promising Practice

•  Our data show that
• when pregnant women or new mothers of substance
  exposed newborns have one face to face meeting
  with a mother in recovery more than 85 engage
  with the project.
• Three quarters of those who engaged initially
  remained engaged for at least 6 months.
• For the clients who were actively engaged with
  the program, the percentage of months spent in
  recovery was 84.   Active use was reported
  for only 5 and the remaining 4 were reported as
  relapse from at least 30 days of recovery.

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Promising Practice contd

• By their 6th month in the program, 86 of mothers
  had physical custody of their babies and by 12th
  month 94 did. Twice as many families had no
  involvement with the Department of Children and
  Families (child welfare) at Time 2 as at
  Baseline.
• An accomplishment given the fact that of the 73
  of FS moms who had older children, 68 had lost
  permanent custody of some or all of their older
  children.
• Engagement in other services--75 of babies in
  EI, 75 of moms received treatment services for
  substance use and co-occurring disorders.

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When it works

• Collaboration happens
• Providers and families work together
• A Recovery Team is formed
• Collaborative partners appreciate skills of home
  visitors
• Community service providers see persons in
  recovery as able to change

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When it works

• Babies go home with their mothers
• Attachments are secure
• Babies are nurtured
• Parent child have a bond

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When it works

• Children thrive when their parents thrive
• Parent is motivated to maintain recovery

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When it works

• Children learn
• Children are happy
• Children develop appropriately
• Children succeed

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When it works

• Parents see their own potential
• Parents pursue their dreams

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When it works

• Parents begin to trust in systems
• Moms begin to see themselves as capable parents
• Families are reunified
• Moms get a chance for a new start

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When it works

• People in recovery become active members of their
  community
• People in recovery are valued by their community

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• Its not only children who grow. Parents do
  too. As much as we watch to see what our children
  do with their lives, they are watching us to see
  what we do with ours. I can't tell my children to
  reach for the sun. All I can do is reach for it,
  myself.
• Joyce Maynard

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• Questions???
• Debra Bercuvitz
• Fresh Start Director
• MA Department of Public Health
• 413.887.1761
• debra.bercuvitz_at_state.ma.us
• Debbie Flynn-Gonzalez
• Family Services Supervisor Square One /
• FRESH Start Supervisor
• 413.858.3129
• dgonzalez_at_startatsquareone.org