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.

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

Service Model

• FS’s 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

Philosophy of Care

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

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 couldn’t do anything right, and I felt a lot of guilt.”

Half Empty Half Full

Substance AbuseDrug Addicted BabiesAddicted Mom“On methadone”“Dirty Urine”Non-compliant / difficultLost Parental RightsHistory of Substance

Abuse

Substance Use/DisorderSubstance Exposed NewbornsMother with a SUDMedication Assisted Treatment

Positive ScreenNot open to, not ready, has own ideasNon-custodial Parent

In recovery / substance use disorder

Strength-Based Recovery Language

Half Empty Half Full

Suffering from…

Treatment TeamWeaknessesUnrealisticAbstinence

Relapse / Failure

Working to recover from; experiencing; living with

Recovery Support System/Recovery TeamBarriers to change; needs

Person w/high expectations for self /recoveryPromoting/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

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

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

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 dev’t, inadequate supervision, poor reflective functioning, compromised attachment.

Substance Use and Parenting

• Both need addressing concurrently• Parenting as normalizing role and motivator• Can also be a barrier to treatment—fear,

practicalities• Assume ability to parent well and need for

successful parenting moments

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

Family Support

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, don’t just give them numbers and don’t 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, don’t give up but don’t 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

What They Need In Their Words…

COLLABORATION

Collaboration with Other Providers

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

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?

Collaboration--Consents

• First appointment—Checklist• 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 aren’t 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 can’t 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.

Collaboration—Initial Contact

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

Safety Planning

• Establishes common goals for collaboration

• Need to think about relationship between using substances and safety of children

• Sample Forms

Collaboration--Ongoing

• Regular Phone/Email Contact

• Family Conferences

• Joint Appointments

• Safety Mapping and Strengths-Based Work

Collaboration in Action

1. Re-occurrence of substance use

2. Birth while mother is in medication-assisted treatment

3. Safety mapping

Re-occurrence AKA Relapse—Opportunity for Collaboration to

Improve Outcomes

Institute for Health and Recovery

Stages of Change

Pre-contemplation

Contemplation Preparation

ActionRelapse

Maintenance

Institute for Health and Recovery

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)

Relapse is a process, it's not an event.

Mental relapse

Physical relapse

Emotional relapse

The Stages of Relapse

Emotional Relapse

Intolerance

Defensiveness

Anxiety

Anger

Mood swings

Poor sleep habits

Not asking for help

Not going to meetings

Poor eating habits

Isolation

Mental RelapseThe signs of mental relapse are

Glamorizing your past use.

Hanging out with old using friends.

Thinking about people, places, and things you used with. Lying.

Fantasizing about using.

Planning your relapse around other people's schedules.

Thinking about relapsing.

Techniques for Dealing with Mental Relapse

Tell someone that you're having urges to use.

Distract yourself.

Play the tape through.

Wait for 30 minutes.

Make relaxation part of your recovery.

Do your recovery one day at a time.

Physical Relapse* Remember…Relapse is a PROCESS,

not an EVENT* Hard to stop the process

at physical relapse point*Focus efforts on RECOVERY, not

achieving abstinence through brute force

Tracing back

Working together…DCF

• Open Communication• Relapse Prevention /

Recovery Plans• Safety Planning• When relapse happens

CommunitySupports/Services

• Mental Health Providers• Treatment Programs• Family members• Faith-based

Role Play…

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

Congratulations on having your baby in recovery…

Get copies of urine screens. DCF staff is likely to get the screens themselves if you don’t 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 can’t 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.

Safety Mapping

• Sharing Perspectives Using an Organizing Framework

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.

Promising Practice cont’d• 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.

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

When it works…

• Babies go home with their mothers

• Attachments are secure

• Babies are nurtured• Parent & child have a

bond

When it works…

• Children thrive when their parents thrive• Parent is

motivated to maintain recovery

When it works…

• Children learn• Children are

happy• Children develop

appropriately• Children succeed

When it works…

• Parents see their own potential• Parents pursue

their dreams

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

When it works…

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

It’s 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

Questions???

Debra BercuvitzFresh Start DirectorMA Department of Public Health413.887.1761debra.bercuvitz@state.ma.us

Debbie Flynn-GonzalezFamily Services Supervisor Square One /FRESH Start Supervisor413.858.3129dgonzalez@startatsquareone.org