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SAFE RELATIONSHIPS, SAFE CHILDREN

A GUIDE TO ENHANCE PRACTICE

Revised Draft Document v.03 13 January 2015

Revised Draft Document v.03

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ABOUT THE GUIDE

The Safe Relationships, Safe Children initiative seeks to build on existing evidence-based practices and strong community partnerships already in place throughout the province. The guidance provided in this document is meant to enhance existing service mechanisms – not replace or restructure them – in order to ensure a more comprehensive, family-centred and collaborative approach to supporting families with needs related to mental health, substance use and/or intimate partner violence (MH, SU & IPV) as well as challenges related to the co-occurrence of any of these issues.

MH, SU & IPV issues often go unrecognized, are misunderstood or are not addressed due to stigma, yet such issues can have a substantial cumulative impact on adults, their parenting capacity, and the needs of their children. Indeed, the presence of these three complex and sensitive issues, separately or in combination, can significantly reduce protective factors and increase risk factors for children. Invisible needs equal unmet needs, therefore it is essential that parents be supported in a safe manner to disclose their concerns and seek help for themselves and their children. The Guide to Enhance Practice is intended to support a shift in practice for staff in their collaborative efforts to better identify, understand and support adults, children and families affected by MH, SU & IPV.

The Guide to Enhance Practice is one of three main resources being developed as part of the Safe Relationships, Safe Children initiative. Other resources include the Community Implementation Toolkit, and the Safe Relationships, Safe Children Curriculum.

Qualifying Statement

The material provided in the Guide represents the best information available at this time. It was informed by extensive literature reviews on research and best practices, environmental scans of existing processes and resources, by the expertise of those working within service systems and by extensive consultation processes with representatives from the Ministry of Health (MoH) including the Aboriginal Health Directorate, the Ministry of Children and Family Development (MCFD) including the Provincial Office of Domestic Violence PODV), and provincial health authorities including the First Nations Health Authority (FNHA).

Feedback on the Guide was also obtained through provincial and community-level engagement and consultation efforts with representatives from the anti-violence sector, including the Ending Violence Association of BC, the BC Society of Transition Houses and BC Women’s Hospital Woman Abuse Response Program. The use of Family Journey Mapping exercises with individuals who have accessed services in pilot communities was a valuable means of obtaining family perspectives to strengthen the approach. Ongoing engagement is expected, including plans to engage with the First Nations Health Directors Association, Métis Nation BC, the BC Association of Aboriginal Friendship Centres, and others as they are identified.

The terminology used for the three core issues that are the focus of this initiative was chosen very carefully.

The terms “mental health challenges” and/or “problematic substance use” are used as they are the most inclusive and are consistent with the language in Healthy Minds, Healthy People: A Ten-Year Plan to Address Mental Health and Substance Use in British Columbia. The term “intimate partner violence” was chosen over the historical term “domestic violence” as the latter can also encompass child or elder abuse, or abuse by any member of a household (World Health Organization, 2012).

There is an important distinction to be made about IPV in relation to the other two core issues. Specifically – whereas MH & SU issues may or may not involve violence, IPV by definition does. IPV is best understood as a

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pattern of intentionally coercive and violent behaviour towards an individual with whom there is or has been an intimate relationship. It is a predominantly gendered phenomenon with women much more likely to be the victims and men the perpetrators. Untreated and unaddressed IPV is more than a health and social concern – it is a criminal matter involving the overt use of violence that calls for a justice system response.

Treatment is critical of course, but not the only issue. The involvement of the anti-violence sector to help reinforce the practice change recommended by the Safe Relationships, Safe Children initiative is key.

The nature of such diverse and complex needs related to MH, SU & IPV means that there will be multiple evidence-based intervention frameworks of relevance, depending on the nature of the main risk factors/problems.

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Table of Contents

PRACTICE PRINCIPLES ... 1

A. THE SAFE RELATIONSHIPS, SAFE CHILDREN INITIATIVE ... 3

Engagement, Collaboration and Planning ... 4

Implementation ... 5

Roles and Responsibilities ... 5

Aim of the Initiative ... 6

B. SHIFTING PRACTICE – CONTEXT AND KEY CONCEPTS ... 8

Parenting and the Intersections between Mental Health Issues, Problematic Substance Use, and Intimate Partner Violence ... 8

Why Family-Centred Practice? ... 11

C. THE SAFE RELATIONSHIPS, SAFE CHILDREN PRACTICE MODEL ... 14

A Focus on Three Concurrent Activities: Engaging, Safeguarding, and Collaborating ... 15

Engaging... 15

Safeguarding ... 16

Collaborating ... 17

The Five Steps of the Safe Relationships, Safe Children Practice Pathway ... 18

STEP 1 THINK PARENT: INCORPORATE PARENTING ISSUES INTO PRACTICE ... 20

a) Identify Adults in a Parenting Role ... 20

b) Engage Parent on Potential Needs Related to the Three Core Issues ... 20

STEP 2 THINK CHILD: MAKE CHILDREN VISIBLE ... 24

a) Inquire about Child Needs ... 24

b) Identify Risk and Protective Factors for Children ... 25

STEP 3 THINK SAFETY: RESPOND TO SAFETY RISKS ... 28

a) Identify Emergent/Urgent Issues that Require Immediate Action ... 28

b) Stabilize and Plan for Future Safety... 32

STEP 4 THINK FAMILY: THE IMPORTANCE OF A JOINED-UP APPROACH ... 35

a) Collaborate with Parents and Others to Actively Connect Families to Required Supports ... 35

b) Share Information to Support Safety and Wellbeing ... 37

STEP 5 THINK OUTCOMES: STAY CONNECTED AND ENGAGED WITH FAMILY ... 41

a) Monitor Risk and Review Goals and Progress ... 41

b) Reflect on Progress and Practice ... 43

D. MOVING FORWARD ... 46

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What Will Success Look Like? ... 46 GLOSSARY ... 48 APPENDICES ... 54

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PRACTICE PRINCIPLES

The Safe Relationships, Safe Children initiative is guided by the following practice principles:

Safeguarding children is everyone’s responsibility.

Invisible needs equal unmet needs. Outcomes for parents and their children are improved and risk reduced when parental needs related to mental health, problematic substance use and intimate partner violence (MH, SU & IPV) are identified and supported early.

MH, SU & IPV issues are inter-related issues that affect the entire family. A comprehensive, family-centred and collaborative approach encourages practitioners to view and work with clients as individuals while also understanding them within the context of their family.

In cases of IPV, the safety and well-being of children are often dependent on the safety of the non-abusing mother. Wherever possible, supportive services should be offered to the mother in order to enhance her ability to continue to care safely for her children. In order to maximize women’s safety and the safety of their children, practitioners must have a firm understanding of the dynamics of power and control inherent in relationships where IPV is a factor.

Trauma-informed practices are essential given that MH, SU & IPV often occur in combination and that all are potentially linked to adverse experiences including past and present trauma. Witnessing or experiencing traumatic events can have a particularly devastating impact on children’s wellbeing and development. In addition, the gender imbalance in intimate partner violence places women at more frequent and greater risk of harm including trauma. The impact of women’s previous experiences of violence and the potential for re- traumatizing women seeking care must be closely considered.

A strengths-based approach looks for what parents and children do well despite problems and how they have tried to overcome their problems. It also inspires hope and encourages expectations for improvement and change. This approach is transparent and does not avoid difficult conversations about discrepancies in family member’s understandings of the issues at hand.

Collaboration and communication by professionals across child-focused and adult-focused services is vital to enable improved understanding, assessment and responses to parental and family issues. Improved outcomes for parents and their children are more likely to be met and risk reduced when information is shared effectively across agencies and when multi-agency and multidisciplinary partnerships are collaborative and coordinated.

Culturally safe and culturally appropriate services to children and families demonstrate respect for and builds on the values, preferences, beliefs, culture and identity of the child and family as well as their community. Practitioners need to be aware of and understand that parenting and family functioning are strongly influenced by culture and background, as are individual responses to MH, SU & IPV.

Outcome-based approaches are required – practitioners should tie the goals and strategies of services and supports to observable and measurable indicators of success, monitor progress in terms of these indicators, and revise strategies accordingly.

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ACKNOWLEDGMENTS

Currently under development.

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A. THE SAFE RELATIONSHIPS, SAFE CHILDREN INITIATIVE

The Safe Relationships, Safe Children initiative is one of many initiatives arising from Taking Action on Domestic Violence in British Columbia.1 The action plan was developed in response to the 2012 Representative for Children and Youth’s (RCY) report, Honouring Kaitlynne, Max and Cordon: Make Their Voices Heard Now.2 That report details the RCY’s investigation into the deaths in April 2008, of three young children, Kaitlynne, Max, and Cordon Schoenborn, at the hands of their father, Allan Schoenborn. Schoenborn had a long history of violence (including intimate partner violence), untreated mental health issues and problematic substance use problems.

The RCY’s report makes eight recommendations across five ministries. Taking Action on Domestic Violence in British Columbia provides full details of the comprehensive action plan for responding to the eight recommendations. A 2013 progress report3 on the plan is available on the Provincial Office of Domestic Violence (PODV) website. In addition, the government of BC released the Provincial Domestic Violence Plan4 in early 2014. The plan is the result of engagement with the community anti-violence sector, government partners, and others, and seeks to build on many areas of success and strength, and to identify and address priority areas in need of immediate attention.

Safe Relationships, Safe Children is but one component of these coordinated efforts. The initiative focuses specifically on the first recommendation of the RCY report, Honouring Kaitlynne, Max and Cordon: Make Their Voices Heard Now. Recommendation One is that the Ministry of Health (MoH) work in partnership with the Ministry of Children and Family Development (MCFD) to introduce protocols, policies and tools within health and child serving systems to ensure that all staff and professionals understand, identify and reduce risk factors for children and families affected by serious parental mental illness, problematic substance use and/or domestic violence (MH, SU & IPV). The RCY report underscores the importance of approaches that are family- oriented and family-sensitive, while promoting the safety and well-being of children.

The Safe Relationships, Safe Children initiative also speaks to recommendations made in two other RCY reports released in 2014. In Lost in the Shadows: How a Lack of Help Meant a Loss of Hope for One First Nations Girl,5 the RCY reiterates the need to improve service coordination and collaboration for families where there is a parent with a mental illness, and highlights the significant barriers that First Nations families living in rural or isolated communities face in accessing required services. In Children at Risk: The Case for a Better Response to Parental Addiction,6 the RCY points to the need to fill existing service gaps for parents with substance use issues, their children, and other involved family members.

1 http://www.mcf.gov.bc.ca/podv/pdf/domestic_violence_response_booklet.pdf

2 http://www.rcybc.ca/Images/PDFs/Reports/RCY-SchoenbornReportFINAL%20Feb%2027.pdf

3 http://www.mcf.gov.bc.ca/podv/pdf/progress_report.pdf

4 http://www.mcf.gov.bc.ca/podv/publications.htm

5 https://www.rcybc.ca/sites/default/files/documents/pdf/reports_publications/rcy_lost-in-the- shadows_forweb_17feb.pdf

6 https://www.rcybc.ca/sites/default/files/documents/pdf/reports_publications/rcy_childrenatrisk-finalweb.pdf

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The success of the Safe Relationships, Safe Children initiative is also linked to and will be supported by other government commitments, including those in Taking Action on Domestic Violence in British Columbia, in Healthy Minds, Healthy People: A Ten-Year Plan to Address Mental Health and Substance Use in British Columbia,7 and in A Path Forward: BC First Nations and Aboriginal People’s Mental Wellness and Substance Use – Ten Year Plan.8

Engagement, Collaboration and Planning

The specific focus of the Safe Relationships, Safe Children initiative is clearly articulated in the RCY’s first recommendation in Honouring Kaitlynne, Max and Cordon, and the planning and collaboration actions to support it are described in Taking Action on Domestic Violence in British Columbia. The scope of Safe Relationships, Safe Children is intentionally directed towards one key area – ensuring that staff within health- and child-serving systems understand, identify and reduce risk factors for children and families affected by parental MH, SU & IPV.

The Safe Relationships, Safe Children initiative takes an evidence-informed approach to improving outcomes for families with complex needs related to one or more of the three core issues. Early work for this initiative included the development of two comprehensive best practice literature reviews – one that focused on tools and processes to identify parents challenged by MH, SU & IPV issues (Oliver, 2012) and another that focused on building resilience and reducing risks in children affected by the three core issues (Templeton, 2013).

There is recognition that success will require that those in health and child serving systems will need to work collaboratively with other government and community organizations, and in particular community anti- violence organizations, to support these children and their families. To that end, planning and development work for Safe Relationships, Safe Children was and continues to be informed by ongoing engagement and consultation with the following stakeholders:

o Provincial representatives from MoH, including the Aboriginal Health Directorate, MCFD including Provincial Office of Domestic Violence (PODV), with future engagement planned with Ministry of Education;

o Provincial representatives from the community anti-violence sector (including the Ending Violence Association of BC, the BC Society of Transition Houses and BC Women’s Hospital Woman Abuse Response Program);

o Representatives from the regional health authorities (inclusive of primary care, acute care and community MHSU services), local MCFD services, DAAs, community anti-violence sector groups, physician representatives, representatives from justice, and others;

o Representatives from the First Nations Health Authority;

o Local community representatives of the twenty (formerly twenty-one) Phase 2 implementation sites.9

7 http://www.health.gov.bc.ca/library/publications/year/2010/healthy_minds_healthy_people.pdf

8 http://www.fnhc.ca/pdf/FNHA_MWSU.pdf

9 The communities of Hope and Agassiz have merged into one pilot site, and some other sites have expanded to other communities.

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Further consideration and processes to reflect the distinct needs and desires of First Nations, Aboriginal and Métis individuals, families and communities are planned (including, for example, consultation with Métis Nation BC, BC Association of Aboriginal Friendship Centres).

Implementation

Safe Relationships, Safe Children is being implemented in three stages:

Phase 1 (2013) One urban and one rural pilot community (Richmond and Vernon)

• Best practice literature reviews

• Development of resources (including the Guide to Enhance Practice, a Community Implementation Toolkit, protocols, identification tools, an online curriculum and an evaluation framework) and local community processes (as described in the Community Implementation Toolkit) to support the identification and reduction of risk factors for children and families affected by parental MH, SU & IPV

• Lessons learned from Phase 1 have informed subsequent materials and implementation Phase 2 (2014) Two urban and two rural pilot implementation sites in each health authority region

• Further refinement of materials

• Development and piloting of training curriculum

• Development of evaluation framework

• Additional consultation with other community stakeholders including representatives from local women-serving agencies in the anti-violence sector

• A separate or parallel process for developing resources for the initiative specifically for Aboriginal and First Nations communities

• Lessons learned from Phase 2 will inform subsequent materials and implementation Phase 3 (2015) Implementation of model province-wide

• Finalization and launch of training curriculum

• Evaluation Framework

It is important to recognize that practice will best be enhanced within an infrastructure that invites a comprehensive, collaborative approach that utilizes a family-centred lens. Training will be provided to support practitioners to manage issues that are outside of their traditional core area of expertise, but developing the trust needed to work with others will be essential. Provincial and local mechanisms (such as protocols, policies and guidelines) are being developed to support collaborative practice.

The Guide to Enhance Practice and the Community Implementation Toolkit are currently utilized as draft documents intended to guide and support the work in the implementation sites. Resources and tools for Safe Relationships, Safe Children will be available online at (exact location to be determined).

Roles and Responsibilities

MOH, in partnership with health authorities, and MCFD, in partnership with DAAs, are responsible for ensuring that practitioners in their organizations meet the requirements of government’s commitment to implement family-centred and family-sensitive approaches across systems to better identify, actively refer and support the safety needs of children in families identified as having MH, SU & IPV issues.

The Guide to Enhance Practice describes a 5-step Practice Pathway for supporting families with needs related to MH, SU & IPV. Although it is impossible to specify all of the details regarding specific roles and

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responsibilities of all different providers within the various settings, Appendix A provides an illustrative summary table outlining practitioner roles within some key entry points to health and child-serving services.

Essentially, within the 5-step Practice Pathway there are 10 Minimum Practice Requirements expected to be met at all entry points to service within health authority and MCFD jurisdictions. Organizations are responsible for determining the best means of ensuring that practitioners and/or teams in those settings (with support from specialized services as required) meet the following minimum expectations:

1. Identify Adults in a Parenting Role

2. Engage Parent on Potential Needs Related to Three Core Issues 3. Inquire about Child Needs

4. Identify Risk and Protective Factors for Children

5. Identify Emergent/Urgent Issues that Require Immediate Action 6. Stabilize and Plan for Future Safety

7. Collaborate with Parents and Others to Actively Connect Families to Required Supports 8. Share Information to Support Safety and Wellbeing

9. Monitor Risk and Review Goals and Progress 10. Reflect on Progress and Practice

To clarify, the Minimum Practice Requirements apply to Health and MCFD. Other agencies/groups may also adopt these as best practices if/as appropriate, but are not required to do so.

Appendix B comprises a table of Supports and Services related to the Safe Relationships, Safe Children initiative. See Community Implementation Toolkit for details on the initiative’s governance structure.

Aim of the Initiative

MH, SU & IPV are problems that can occur separately or in combination in adults, yet such issues often go unrecognized, are misunderstood or are not addressed due to stigma. When a parent experiences one of these issues it can have serious implications for the children and the entire family. The risk to children’s safety and their ongoing development are most severe when all three factors are present, with risks and harm cumulative as factors coalesce. Children’s needs are best met when parental needs related to MH, SU & IPV are identified and supported.

Unfortunately, the fear, chaos, uncertainty, secrecy and stigma of living with any of the three core issues under discussion can be barriers to parents seeking help. For example, women who are being abused may be reluctant to share information due to fear or reprisal from a partner, previous experience of judgmental or blaming responses from health and social service providers, and other concerns about inappropriate responses such as service providers sharing information with an abusive partner or family member. For children it can be hard for them to understand and be able to articulate what they are experiencing, how they feel and what they need. Often there is collusion between family members, with children wishing to protect and be loyal to their parents and family. Service providers may also contribute to barriers through a reluctance to actively seek information about these issues due to anxiety, perceived lack of organizational support, time constraints, concerns about what to do if they identify problems, fear of offending parents, fear of impacting a trust relationship with a parent if a child protection report must be made, lack of awareness and training, and similar issues (Registered Nurses’ Association of Ontario, 2012). The Safe Relationships, Safe Children initiative is about reducing these barriers and making the invisible visible.

The overall goal of Safe Relationships, Safe Children is to promote child safety and well-being by enhancing system capacity to strengthen support to families where adults with parenting responsibilities are challenged or affected by one or more of the three core issues. For the current initiative, the term “parent” is used in a

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broad sense to encompass all adults acting in a parental or care giving role to children and youth (including, for example, an expectant parent, step-parent, grandparent, foster parent, other relative or caregiver, or a partner to a parent).

The key objectives of the initiative are to:

 Increase awareness about the three core issues and their frequent interconnectedness and increase understanding of how issues related to MH, SU & IPV – on their own or together – affect parenting responsibilities and ultimately pose risks to children and families;

 Establish processes to identify all adults in a parenting role at entry points to health and child serving systems (“parents” can include an expectant parent, step-parent, grandparent, foster parent, other relative or caregiver, or a partner to a parent);

 Shift practice such that practitioners specifically develop approaches that address the safety of children and family members in relation to MH, SU & IPV;

 Ensure that professional interventions across adult and child services are sufficiently family-centred, strengths-based, trauma-informed and sensitive to the distinct needs of women impacted by violence and children exposed to violence. This might include extending the reach of existing initiatives such as Trauma Informed Practice (TIP) training and/or MCFD domestic violence training;

 Strengthen community collaboration efforts to better support parents, children, and families with needs related to parental MH, SU & IPV issues by leveraging successful community models and processes (e.g., Richmond’s Supporting Families model, Interagency Case Assessment Teams - ICAT,10 Violence Against Women in Relationships Coordination Committees - VAWIR);

 Ensure that services are culturally safe, culturally competent and informed by awareness that some groups, such as First Nations and Aboriginal families, new immigrants, and others can face particular challenges that require culturally-informed approaches. This should include extending the reach of existing initiatives such as the Indigenous Cultural Competency (ICC) training;

 Ensure that practitioners are aware of how to monitor for factors associated with increased risks to children and family members related to MH, SU & IPV issues, and that they can use active outreach and similar strategies to connect with at-risk families experiencing barriers to engagement.

The guidance developed as part of the Safe Relationships, Safe Children initiative is intended to supplement – not replace – existing processes, and to increase capacity to support completion of any of the required practice elements that are not in place. Many health settings/services and social service agencies already have existing processes that address issues related to parental MH, SU & IPV. In a time of scarce resources, communities and organizations will be encouraged to identify and build on existing strengths.

10 In some BC communities, the ICAT acronym stands for Interagency Case Assessment Team.

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Key Fact:

A study of 405 children living with parental mental illness found that 42% were also exposed to intimate partner violence and 25% to parental drug or alcohol problems.

(Gorin, 2004)

B. SHIFTING PRACTICE – CONTEXT AND KEY CONCEPTS

The importance of shifting practice to better identify and support the parenting role of adults affected by mental health challenges, problematic substance use or intimate partner violence (MH, SU & IPV) is hard to overstate. Being a parent can be a major motivator for individual change. It can also be a major stressor.

Exploring parenting issues can enhance services and support provided to adults in a variety of ways, including:

o An increase in motivation to access help ;

o More open and honest relationships between service providers and clients who use services;

o An increase in sense of hope that change is possible;

o An increase in focus on the reasons for seeking help;

o An extension of harm minimization to include the whole family.

Exploring parenting issues also benefits the children in the care of the adult. These include:

o Early identification of problems;

o Increased opportunities to offer preventative strategies to deal with emerging challenges;

o Earlier linking of children and families with required support services (Micah, 2012).

Identifying service users as parents often provides the most direct route to supporting their children's well- being (Oliver, 2013).

Parenting and the Intersections between Mental Health Issues, Problematic Substance Use, and Intimate Partner Violence

Individually, the presence of MH, SU or IPV represents a significant risk factor for children, but in reality, such problems rarely occur in isolation. Experiencing one of the three issues can lead to problems with the other two. For example, intimate partner violence is associated with increased risk of mental health problems and substance abuse in women. In turn, people struggling with mental health problems and substance abuse are more susceptible to further violence.

When these serious issues co-exist, they often take place in a context that can include complex family needs (e.g., child or intimate partner safety concerns, intergenerational trauma, socio-economic adversity including poverty, housing instability, employment challenges, and limited educational options). Risk factors are located at the individual, parental, familial or environmental level. No two children and no two families are the same; siblings will be affected differently by the problems that they face. Not all children whose parents struggle with MH, SU & IPV will experience poor outcomes.

All of this makes it extremely difficult to come up with straightforward and generalizable associations between a risk factor and a poor outcome (Templeton, 2013).

Parents who struggle with one or more of the three core issues are often preoccupied by attempts to deal with and manage pressures related to those issues. Unable to give parenting the required attention needed to parent effectively, their parenting capacity can become compromised and even depleted. Parenting may come to include disengaged, unresponsive, inappropriate and even abusive responses to children. Over time,

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Key Fact:

Although rates generally vary across studies, on average over 50% of women seen in a range of mental health settings either currently are or have been abused in the past by an intimate partner.

(Warshaw, Brashler & Gil, 2009) the stress, compounding difficulties and cumulative impacts of unsupported issues can overwhelm families, exacerbating the contexts in which MH, SU & IPV occur or escalate (Bromfield, Sutherland and Parker, 2012).

At a very broad level, it is recognized that children who live with MH, SU & IPV are themselves at increased risk of developing mental illness, problems with alcohol or drugs, or becoming aggressive and violent.

Children can also be at risk because of the ways in which the problems affect their education and their relationships with parents, families and others. For example, over the past decade, increasing attention has been paid to the invisible population of “young carers” in Canada, young people who provide significant care to family member because of illness, disability or other challenges in the family including mental health or substance use challenges. A recent survey of high school students in Vancouver found that 12% of youth assume a caregiving role in their families (Charles, Marshall and Stainton, 2010). Young carers are often required to put the caregiving needs of their family ahead of everything, including school and education.

There are similarities across all three issues in the risks which children face but there are also unique features according to the problem which children are living with. The presence of intimate partner violence is believed to be a particularly significant risk factor for children (Templeton, 2013).

Gender Differences

Both genders can be impacted by MH, SU & IPV. Overall rates of psychiatric disorders are nearly identical for men and women, and there are no significant differences in the rates of serious mental disorders such as bipolar disorder and schizophrenia (World Health Organization, 2013). There are gender differences in some other disorders such anxiety and depression, which seem to be higher for women. As for substance use problems, the Statistics Canada Canadian Community Health Survey (2012) indicated that men are significantly more likely than women to experience a substance use disorder (alcohol or drug) during their lives (31.1% of males versus 12.5% for females).

The most pronounced area of gender difference is related to intimate

partner violence. Women are much more likely to experience intimate partner violence and to experience more significant harm as a result of such violence, with men entirely more likely to be the perpetrators. For women, there is a strong association between violence and the subsequent development of mental health issues and problematic substance use – the same association appears significantly weaker for men.

Therefore, in practice, it is important to be aware of the potential connection to past trauma from violence to avoid mislabelling, mistreatment and stigmatization of women seeking services (Canadian Women’s Foundation, 2011).

In order to maximize women’s safety and the safety of their children, practitioners must also have a firm understanding of the dynamics of power and control inherent in relationships where intimate partner violence is a factor (British Columbia, 2010). A narrow focus on physical manifestations of violence obscures the atmosphere of control and terror that frequently characterize a woman’s experience of the relationship and the range of behaviours that that can be used to assert power and authority in a relationship. A broader definition of violence includes sexual assault, threats of violence towards a woman (or her children, family members, friends), showing her weapons, damaging property or objects, financial control, emotional manipulation, monitoring her behaviour and isolating her. Such behaviours may intensify in order to restore dominance when is control is perceived to be threatened. This is why more severe violence may occur when a woman attempts to seek help or leave a relationship.

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Key Fact:

Aboriginal women, in addition to reporting three times higher instances of spousal violence, report severe and potentially life- threatening forms of violence:

being physically beaten, choked, having a gun or knife used against them, being sexually assaulted.

Because of the serious nature of these types of violence, the consequences are more severe:

suffering physical injury, requiring medical attention, not able to perform daily activities or go to work, experiencing 10 or more separate episodes of violence from the same perpetrator, and fearing for their lives.

(British Columbia, 2010)

Cultural Differences

The cultural, ethnic, and linguistic diversity of British Columbians requires that services and supports to families impacted by the three core issues be culturally-informed, culturally-appropriate, and culturally-safe. Of note, while there is no statistical evidence to indicate that IPV is more prevalent among immigrant and refugee women than it is among the general population in Canada, current and ongoing research, coupled with the experience of frontline service providers indicate that immigrant and refugee women who are IPV victims are faced with additional barriers to reporting violence and to accessing support and assistance. These barriers include: social isolation, language issues, immigration and sponsorship barriers and economic vulnerability (Light, 2007, Smith 2004, Shirwadkar 2004, Russell 2002, Status of Women Canada 2001, McDonald 1999). The ability to determine the incidence of IPV is hampered by the underreporting of this crime in general. Statistics related to incidence with respect to immigrant women are particularly problematic in this regard (Ending Violence Association of BC, MOSAIC and Vancouver &

Lower Mainland Multicultural Family Support Services Society, no date).

Practitioners need to remain aware that immigrant women and families are often marginalized due to social isolation and stigma and therefore family members may only connect to services through medical needs. The window of opportunity to identify MH, SU & IPV needs for this population may only come through routine questioning in primary care (clinic/family practice) or acute care (emergency department) visits and even then may not be disclosed due to language or cultural barriers.

For First Nations and Aboriginal Canadians, the effects of multiple adversities such as colonization, land appropriation, residential schools, and Indian hospitals have impacted communities and families in many ways, and health disparities for First Nations and Aboriginal people include higher rates of hospitalization for MH & SU disorders (First Nations Health Authority, BC Ministry of Health, and Health Canada, 2013). In Not Fully Invested: A Follow-up Report on the Representative’s Past Recommendations to Help Vulnerable Children in B.C., the RCY places special emphasis on the over-representation of Aboriginal children and youth in the BC child welfare system.11 First Nations and Aboriginal intimate partner violence and abuse has been described in the literature as being a multifactorial syndrome that operates at the individual, family, community, social and political levels, and as having roots in First Nations and Aboriginal traumatic historical experiences that contribute to an increased likelihood of intergenerational abuse (Bopp, Bopp & Lane, 2003).

As part of the Safe Relationships, Safe Children initiative, practitioners will be encouraged to take advantage of Indigenous Cultural Competency training.12 Failure to work in in culturally safe ways with First Nations and Aboriginal families may well result in failure to engage. In BC, Delegated Aboriginal Agencies (DAAs) are part of the effort to restore the responsibilities of child protection and family support to Aboriginal communities.

11 https://www.rcybc.ca/reports-and-publications/reports/monitoring-reports/not-fully-invested

12 http://www.culturalcompetency.ca/

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DAAs provide culturally-appropriate services to the whole family and have delegated authority under the Child, Family and Community Service Act to provide child welfare services, including responses to suspected child abuse and neglect. Practitioners should be familiar with and collaborate with DAAs as available.13 In addition, practitioners are encouraged to make use of Aboriginal patient navigators and Aboriginal liaisons available in each health authority to support Aboriginal clients with their health care experience, ensuring it is culturally safe and inclusive.14

Socio-Economic Issues

Men and women in all occupations and of varying educational and income levels can be affected by the three core issues that are the focus of the Safe Relationships, Safe Children initiative. For this reason it is important to proactively support individuals at all socio-economic levels. At the same time, it is important to be informed by awareness that social problems, rather than being evenly distributed across the population, tend to “cluster within certain communities, families and individuals” (Spratt & Devany, 2011). For example, statistics from across various Canadian cities suggest that between 23% and 67% of homeless people report having a mental illness (Canadian Institute for Health Information, 2007). In 2008, researchers from the Centre for Applied Research in Mental Health and Addiction at Simon Fraser University estimated that approximately 70% of British Columbia adults with identified severe MH & SU issues were inadequately housed and inadequately supported (Patterson, Somers, McIntosh, Shiell & Frankish, 2008).

The provision of effective supports for families with complex needs often requires a focus beyond the presenting MH, SU & IPV issues and extends to include planning for supports and services to address the socioeconomic and other factors that increase the risk to the parents and their children.

Why Family-Centred Practice?

Family-centred practice is a process that links behaviours of practitioners with outcomes for families. Supporting families and ensuring the safety of children and other family members affected by MH, SU

& IPV issues requires professionals to have an understanding of risk and protective factors at the individual, family and environmental levels. This whole-of-family approach consists of identifying and addressing the needs of the children, adults and the family and ensuring that support provided to them is coordinated and focused on concerns affecting the family unit as a whole (Bromfield et al, 2012; Chovil, 2009) as well as safety concerns specific to certain individuals within the family unit. This includes paying close attention to intergenerational and family dynamic issues.

13 To date, 148 of the approximately 198 First Nation bands in BC are represented by agencies that either have, or are actively planning toward, delegation agreements to manage their own child and family services. For more info visit http://www.mcf.gov.bc.ca/about_us/aboriginal/delegated/pdf/agency_list.pdf

14 For information on First Nations liaisons and navigators visit

http://www.healthlinkbc.ca/commonhealthconcerns/aboriginalshealth/

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A family-centred approach:

1. Works to ensure the safety and well-being of children and other family members;

2. Views clients and family members both as individuals, members of a family and a kinship network, and a community;

3. Emphasizes a partnership between parents and service providers, as appropriate. The planning process is driven by family members’ own perceptions of what they need and what is safe, level of readiness to engage and change, and what strategies are most likely to be successful in helping them to meet their needs;

4. Focuses on strengthening and supporting family functioning, seeking to offset deficits through use of a family’s successful coping and adaptive patterns, its natural support networks, and other resources;

5. Emphasizes the positive, but does not ignore or minimize behaviours or circumstances that place children, women, or other family members at risk. This is particularly relevant in cases where IPV is present;

6. Treats clients and their families with dignity and respect. Family decision-making is respected and supported (within the context of legal mandates regarding protection of safety);

7. Pays attention to intergenerational issues in families, whether such issues present as problems or as possibilities;

8. Links clients and families with collaborative, comprehensive, culturally relevant, community-based networks of supports and services.

Family-centred practice:

1. Does NOT exclude a focus on individuals – rather it focuses on the unique needs of the individual and views them within the context of their family.

2. Is NOT incompatible with women-centred or child-centred practice – as above – it enhances those practices as it ensures that practitioners understand clients within the context of their family.

3. Is not an all or nothing approach.

4. Is NOT always the most feasible or desirable way of partnering in all instances. Rather, the degree and nature of family involvement is impacted by the willingness, capacity, and ability of other family members and the family members involved.

5. Is NOT synonymous with family therapy, family preservation or family reunification.

The family-centred approach in British Columbia

At the provincial level, family-centred approaches to MH have been promoted in BC at least since the release of Healthy Minds, Healthy People: A Ten-Year Plan to Address Mental Health and Substance Use in BC (HMHP).

Developed in response to action requirements in HMHP, Families at the Centre: A Call to Action for Cross Sector Mental Health and Substance Use Planning for BC Public Systems is a planning resource to help translate the needs of families experiencing MH & SU challenges into effective system responses that support the safety and well-being of all members. Families at the Centre has been strongly influenced by Families Matter: A Framework for Family Mental Health in British Columbia (F.O.R.C.E. Society for Kids’

Mental Health, 2012)15 and was informed by Taking Action on Domestic Violence in British Columbia.

There is a close philosophical and practical connection between family-centred practice and “patient-centred care.” In BC, Patients as Partners is a provincial health care initiative that promotes the family-centred care approach.16 It recognizes the importance of patients, families and caregivers being supported and encouraged to participate in their own care and decision making about that care. Furthermore, a holistic

15 http://www.forcesociety.org/sites/default/files/23154_FAM_Framework-3.6-LR.pdf

16 https://www.patientsaspartners.ca/

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approach that encompasses more than just the individual and considers relationships with and impacts of the family and community is also a major focus of A Path Forward: BC First Nations and Aboriginal People’s Mental Wellness and Substance Use – Ten Year Plan.17

At the regional health authority level, the Vancouver Coastal Health Authority is breaking new ground with its Family Involvement with Mental Health & Addiction Service Policy.18 The policy recognizes that family involvement is a vital component of the framework of recovery, and that consumers, service providers and families benefit greatly when family members are involved as full partners in the care and support of people with mental health and addiction problems.

At the community level in British Columbia, Richmond’s Supporting Families initiative is an innovative example of a collaborative practice model that fosters a family-centered approach to service delivery.

Since 2008, via a range of innovative programming, Supporting Families has provided parents dealing with mental illness or addictions relevant insight into their condition, as well as tools and strategies for successful parenting. For children and youth, Supporting Families provides information on disorders, access to services and an opportunity to meet and gain support from other young people who are experiencing similar challenges in their families. Rather than focusing on the disorder itself, Supporting Families functions as a resiliency-building program to help children and families cope with disorders.

For Parents, Supporting Families provides mental health and addiction and parenting education, an opportunity to connect and gain support from parents in similar circumstance, opportunities to engage in leisure activities with their children and an opportunity for a day of respite when their children are able to participate in leisure activities with other Supporting Families children.

For information on the Supporting Families project visit: http://supportingfamilies.ca/

17 http://www.fnhc.ca/pdf/FNHA_MWSU.pdf

18 http://www.mdabc.net/sites/default/files/pdf/Family%20Involvement%20Policy%20-%20January%202014.pdf

Promising Practice Model: Richmond’s Supporting Families Initiative

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C. THE SAFE RELATIONSHIPS, SAFE CHILDREN PRACTICE MODEL

The Safe Relationships, Safe Children practice model is offered as a straightforward application of the initiative’s Practice Principles (p. 5).19 The model, which consists of three concurrent activities and a 5-step Practice Pathway, is intended to assist practitioners and service providers to better identify and support families who require services for issues related to mental health challenges, problematic substance use and intimate partner violence (MH, SU & IPV). Most service agencies and programs already have existing client engagement, needs-identification and support processes or procedures in place. The practice model is intended to enhance existing mechanisms – not replace them – in order to ensure a more comprehensive family-centred approach to supporting families with complex needs.

Children and family are at the very centre of the model, surrounded and supported by the practitioners who make up the care team (including a lead practitioner, where possible) as well as other community resources and supports. Refer to Appendix A of this Guide for more information related to the roles and responsibilities expected of practitioners for this initiative. The model can be visually represented as follows:

19 The Safe Relationships, Safe Children Practice Pathway is adapted in part from the Think Child, Think Parent, Think Family framework and also borrows from the concept of the three concurrent activities described by Buckley, Horwath &

Whelan (2006).

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We don’t know how to ask for help, and we don’t always know we need help. If you (service providers) don’t reach out to us and guide us, how will we get help and how will our children get help?

(A Parent)

A Focus on Three Concurrent Activities: Engaging, Safeguarding, and Collaborating

In simplest terms, the Safe Relationships, Safe Children initiative is intended to change practice by taking a broad, integrated approach across the various agencies and partners within each community (including health, community anti-violence, and child-serving systems) to identify and serve the needs of children and families who struggle with the three core issues that are the focus of this work. Conceptually, at the service provider level, it will be helpful for practitioners and staff to remain concurrently focused on three overarching, principle based activities – engaging, safeguarding, and collaborating. The focus on these three activities is borrowed from a framework for working with vulnerable children and their families developed in Ireland (Buckley, Horwath & Whelan, 2006). The three activities are intended to be kept in mind and interwoven with the five steps that make up the Safe Relationships, Safe Children Practice Pathway.

Engaging

It can be very difficult for people to ask for help. Various factors can make it difficult for people to engage – e.g., internal (psychological – stigma, anxiety, low self- esteem, shame, hopelessness, fear, past trauma) and external barriers (lack of resources, services, funds).

Service providers will need to help identify and address barriers through relevant strategies which will vary depending on the individual’s history and circumstances.

Effective engagement needs to start at first contact and is

a crucial element of working with parents and families affected by MH, SU & IPV. Engagement efforts should include a variety of approaches that let parents feel connected and know that they will be supported by available services. Recovery-oriented, trauma-informed and culturally-informed approaches are essential.

Practitioners who engage effectively with families:

 Treat family members with courtesy and respect

 Focus on building on family strengths

 Promote positive relationships between parents and children

 Develop trust through sensitive inquiry about family circumstances

 Take an active, caring and whole-of-family approach to the family’s situation

 Link with other relevant services to avoid conflicting requirements and processes

 Focus on child needs

 Ensure safety of all family members

 Maintain a continuous relationship with the family, but do not create dependence (McArthur et al, 2009 in Bromfield, Sutherland and Parker, 2012).

It is also important to recognize that parents experiencing challenges with MH, SU & IPV will present for services at varying levels of readiness to engage and/or make changes, necessitating different supportive approaches. Appendix C provides a tool to support engagement and related service planning based on the Stages of Change Model (Prochaska & DiClemente, 1983). The tool suggests how best to engage with parents according to where they are at along the continuum of change (pre-contemplation, contemplation, preparing to change, action, maintenance, or relapse). Practitioners may also wish to acquaint themselves with the concept and practice of Motivational Interviewing (MI), an evidence-based method based on the Stages of

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The provision of parenting support is increasingly being recognized as a core method of safeguarding children

(Barlow and Calam, 2011)

Change Model shown to promote effective engagement and improve service retention and outcomes.20 The Justice Institute of BC offers courses on MI.21

Due to the high incidence of past trauma in the population experiencing MH, SU & IPV, utilizing a trauma- informed approach is also critical when working to engage and support these parents and families. BC’s Trauma Informed Guide (TIP) Guide22 argues that effectively engaging individuals impacted by MH, SU & IPV requires that particular attention be paid to the principles of safety and trustworthiness, and collaboration and choice, principles that align with the practice principles governing the Safe Relationships, Safe Children initiative. According to the TIP Guide, these principles are relevant regardless of whether someone is seeking support on their own accord, or if they have been mandated or ordered to by another party (p. 25).

The TIP Guide also discusses the many parallels between the principles of MI and trauma-informed practice and notes that the practice of integrating the two approaches appears to be gaining attention. The TIP Guide devotes an entire appendix to skills and strategies for engagement using MI and trauma-informed practice (pp. 58-65 of the TIP Guide). Briefly, from the Guide, some of the skills and strategies that support effective engagement with clients throughout all steps of the Practice Pathway include:

o Starting appointment with an opening statement to set tone of conversation, conveying intention to support and figure out strategies together (rather than lecturing or telling tell the client what to do);

o Using open-ended questions that allow people to tell their story in their own words;

o Using affirmations to acknowledge effort and strengths, recognize success;

o Using reflective listening to allow individuals to feel valued and heard;

o Formulating summaries of what you hear the client saying, repeating back and asking for clarification or correction;

o Using agenda (priority) setting to learn what is most important to the individual at that time.

Engagement is not a discrete task, but a dynamic, ongoing and interactive process between practitioners, parents and other family members, including children (Buckley, Horwath and Whelan, 2006).

Safeguarding

Safeguarding children is everyone’s responsibility, not solely the responsibility of those working in child welfare. Everyone who works or comes into contact with children – including teachers, public health nurses, social workers, the police, the courts, professionals, the voluntary sector and individual members of local communities – needs to be aware of, and appreciate each other’s respective roles in this area, and understand how they can best work together on behalf of children.

One of the most effective ways to ensure that children will be safeguarded is by viewing adults through the lens of parenting and acknowledging parental risk factors such as MH, SU & IPV (Royal College of General Practitioners, 2011). Children are safest in families where parental needs are supported – stronger parents equal stronger children. For example, a major focus of British Columbia’s Violence Against Women in Relationships

20 http://www.motivationalinterview.org/quick_links/about_mi.html

21 http://www.jibc.ca/course/ad204

22 http://bccewh.bc.ca/wp-content/uploads/2012/05/2013_TIP-Guide.pdf

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(VAWIR) policy is recognition that the safety and well-being of children are often dependent on the safety of the non-abusing mother and that, wherever possible, supportive services should be offered to the mother in order to enhance her ability to continue to care safely for her children.23

Ensuring the safety of both children and parents is a crucial piece of the Safe Relationships, Safe Children initiative and the entire focus of Step 3, below.

Collaborating

Working collaboratively with parents and families is important in family-centred practice. Practitioners need to respect a parent’s role, expertise, knowledge and ability to choose to change. As has been noted

previously, recognizing an individual’s level of readiness to change and offering support related to those levels, is crucial when working with families with complex needs. However, practitioners also need to determine when working with one parent poses a risk to the other, as in a case where IPV is present and the offending parent poses a safety risk to the non-offending parent. In such cases, safety of the non-offending parent takes precedence over working collaboratively with the offending parent.

Working collaboratively with other service providers is also essential. The difficulties that such families face are typically numerous and chronic, inter-related and can be inter-generational. The bedrock to successful collaborative work is ongoing development of positive relationships between all stakeholders.

Collaborative work deepens engagement, which in turns improves working relationships and improves outcomes.

Collaboration between service providers and practitioners can range from informal sharing of information about a service user (with their consent) to formalized interagency referral processes or service level agreements between organizations. Working collaboratively on the behalf of parents and families who are experiencing challenges related to MH, SU & IPV is beneficial for both service users and the professionals who support them.

For clients, successful collaborative working helps reduce:

o The number of inappropriate referrals between agencies;

o The number of times someone has to “tell their story”;

o The number of appointments with and phone calls/letters from professionals to deal with which can be overwhelming;

o The time and stress of co-ordinating different professionals;

o The feeling of being “passed from pillar to post” without getting anywhere;

o The likelihood of getting lost in the gaps between services which in the case of IPV may result in exposure to further violence or death.

The benefits of collaborating for professionals are also many:

o Not feeling alone in supporting clients with complex, intersecting needs;

o Better understanding of the client as a whole person and how different parts of their life can impact on areas of practitioner specialization;

23 http://www.pssg.gov.bc.ca/victimservices/shareddocs/pubs/vawir.pdf

It is when we are faced with supporting and working with these often very complex families, that we as service providers need each other most.

(Roz Walls, Facilitator Richmond Supporting Families)

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o More opportunity to intervene early and prevent crisis from arising or escalating;

o Greater engagement with service users who feel more supported;

o Ability to learn from colleagues and see things from a different perspective;

o Inspire innovation and creativity in the development and delivery of services (Against Violence and Abuse, 2013).

British Columbia already has a number of best practice collaborative service delivery models that are relevant to the Safe Relationships, Safe Children initiative. Practitioners are encouraged to refer to Appendix B, Supports and Services for more information about existing collaborative models, as well as the Community Implementation Toolkit for specific guidance related to developing or strengthening the collaborative community relationships that will be of most benefit to families.

The Safe Relationships, Safe Children initiative requires a practice shift to identify and support families experiencing MH, SU and/or IPV challenges earlier. As part of the Safe Relationships, Safe Children initiative, practitioners are encouraged to learn more about, as well as consult and collaborate with existing committees and resources already in place in some communities to address IPV, such as VAWIR Committees and/or ICAT Teams.

Violence Against Women in Relationships (VAWIR) Coordination Committees are open membership groups within British Columbia communities that include service providers who work with women and children victims of domestic violence as well as with offenders. VAWIRs identify and address service gaps and safety needs, using a strategic planning model. Networking, training and agency/service information sharing is part of a typical agenda, but information about specific cases is not shared.

There are also approximately 31 high-risk domestic violence teams across the province, known as Interagency Case Assessment Teams, or ICATs. ICATs are partnership groups which include criminal justice, child welfare, health and anti-violence workers with a goal of keeping intimate partner violence victims and their children safer. This goal is achieved by legally and ethically sharing risk related information and building a safety net for victims, their children and the community and initiating interventions and monitoring of suspects. Agencies in the community who are not ICAT members can still refer cases into the ICAT. In some communities, ICATs are a subcommittee to the VAWIR committee.

The Five Steps of the Safe Relationships, Safe Children Practice Pathway

Throughout their work with parents, families and communities, practitioners are encouraged to maintain a focus on the three concurrent activities described above as they consider the five steps of the Practice Pathway. The Practice Pathway supports a “thoughtful” approach to working with parents and families.

Practitioners are encouraged to “think” through the five principle-based steps and where applicable and possible, make related changes to their practice to ensure coverage of the 10 Minimum Practice Requirements (two per each step.) In addition to recognizing potential limits due to scope of practice and/or capacity to move

Promising Models in Collaboration: Violence Against Women in

Relationships (VAWIR) Coordination Committees and Interagency

Case Assessment Teams (ICAT)

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through the Pathway, practitioners are reminded to consider client level of readiness to engage/act at each step, and to support accordingly.

Step 1 Think Parent: Incorporate Parenting Issues into Practice a) Identify Adults in a Parenting Role

b) Engage Parent on Potential Needs Related to Three Core Issues Step 2 Think Child: Make Children Visible

a) Inquire about Child Needs

b) Identify Risk and Protective Factors for Children Step 3 Think Safety: Respond to Safety Risks

a) Identify Emergent/Urgent Issues that Require Immediate Action b) Stabilize and Plan for Future Safety

Step 4 Think Family: The Importance of a Joined-Up Approach

a) Collaborate with Parents and Others to Actively Connect Families to Required Supports b) Share Information to Support Safety and Wellbeing

Step 5 Think Outcomes: Stay Connected and Engaged with Families a) Monitor Risk and Review Goals and Progress

b) Reflect on Progress and Practice

The five steps are not necessarily designed to be taken in the linear fashion presented. Rather, practitioners are encouraged to use professional judgment about sequencing. At the same time, practitioners need to be aware of what is within their own scope of practice and what needs to be referred.

It is particularly important to note that as part of Step 1, all service providers are required to ask a few high- level questions about child and family safety. However, if as a result of that questioning a parent identifies concerns about IPV, engaging further on IPV must be done by practitioners supported by adequate knowledge and training regarding IPV. Engaging with parents on issues related to IPV needs to be done in ways that involve flexibility and awareness that the enquiry should not be strictly driven by adherence to a specific protocol or “screening” form, but should be embedded in the context of a respectful, non-judgmental, and caring conversation. This approach aligns with recommendations set out in A Framework for Addressing Violence against Women (British Columbia, 2012, pp. 7-8). Service providers not adequately trained in IPV need to refer parent on to a specialist practitioner.

Relatedly, clinicians not qualified to assess and diagnose MH or SU disorders should not be undertaking those tasks, but referring clients on as appropriate. The importance of referrals for MH, SU & IPV issues is stressed throughout Steps 3 and 4. Additional guidance on this issue is provided in Appendix A, Summary Table of Health and MCFD Practitioner Roles and Responsibilities.

A Summary of the Safe Relationships, Safe Children Practice Pathway is provided as Appendix D. The Summary is not intended to replace the comprehensiveness of the Guide to Enhance Practice, however it is hoped that it will prove a useful, concise tool that can be employed by practitioners across all settings. The tool can be further adapted for different settings, for example, in general practice settings or hospital emergency rooms.

References

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