PART I
My professional career in the field of Psychology extends over 45 years, and includes over 35 years within foster care settings. The challenges facing a mental health provider in such setting are particularly daunting because of the nature of the target population as well as the often unwieldy foster care system which one must traverse. A substantial number of children and adolescents in foster care come with developmentally based and/or trauma based behavioral, emotional, social and/or educational deficits. Many come with a history of being physically, sexually and/or psychologically abused, most often at the hands of the very same adult(s) who were counted on to be principal sources of safety, nurturance and secure attachment. Many come with a history of being raised within a home environment where they were regularly exposed to adult caregiver “models” practicing domestic violence, engaging in substance abuse, saddled with mental illness, or simply ill prepared to discharge the responsibilities required of an adequate, full-time caregiver. All of the children and adolescents in foster care have one thing in common: All have experienced the trauma of being separated from their parents for extended periods. Many children and adolescents, even those with egregious abuse histories, consider the day of being removed from family to be their worst, most traumatic life experience.
A number of years ago, I joined with several distinguished mental health providers in foster care in publishing an article which delineated what we considered to be essential guiding principles that should inform the treatment of children and families in foster care (Schneiderman, M. et al., 1998). It was argued that treatment efforts must be “consistent with the clinical needs of children in care and the child welfare goal of permanency.” Mental health services should:
1. “be integrated with the social service system of child welfare agencies”;
2. “focus on prevention as well as dysfunction”;
3. address “the various reasons for placement as well as the consequences of placement”, thus focusing on reversing the impact of grief and loss due to separation or abandonment, neglect due to parental substance abuse or mental illness, physical, psychological and sexual abuse, and exposure to domestic violence.
4. include “short-term and in some cases, long-term treatment interventions…at critical junctures in the placement life of the child and his or her family.”
Nine years later, I participated in the formulation of best practice guidelines for psychosocial interventions at The Best Practices for Mental Health in Child Welfare Consensus Conference in Washington, D.C. in 2007. In our ensuing article, (Romanelli, L.H. et al., 2009), it was concluded that interventions should:
1. be evidenced based when clinically indicated, or at least ensure “the adherence by mental health providers to an evidence-based practice approach”;
2. be “individualized and strengths-based…(reflecting) the goals of the permanency plan, actively involve the current caregivers, and, when feasible, include the caregivers of origin at a clinically appropriate level”;
3. feature collaboration between child welfare agencies and mental health providers;
4. provide the means for outcome tracking, including measures of psychosocial functioning, placement stability, permanency and client satisfaction.
The principles and guidelines delineated in 1998 and 2009 offer much needed guidance in establishing goals and standards, but they do not address the question of how best to deliver mental health services within a foster care setting. What complicate matters in foster care are the many players, often with competing agendas, who are involved in the life of the child/adolescent in need of treatment. Birth parents in an intact family are always involved collaterally with their child’s treatment, and are often involved conjointly, but they may not be readily accessible or motivated for participating when their child is in out of home placement. The foster parent, as current caregiver, is asked to participate collaterally, and possibly conjointly, but not every foster parent welcomes the opportunity. Some even feel put out by having this burden added to various other responsibilities imposed on them by foster care agencies. Each child in foster care has a caseworker or case planner assigned, who plays a crucial role in making sure the service plan is implemented, while being overseen by his or her supervisor, foster care director, regulatory agency representative, the child’s law guardian, and, ultimately, the Family Court judge or referee. Each and every player has an interest in what is being addressed in the child’s therapy, and in progress shown towards meeting treatment goals. The players, however, do not necessarily always agree on priorities, or even about whether certain goals are necessary. The topics of goal-setting and decision-making in foster care merit a separate discussion which will be offered in another blog. That so many people have a stake in the foster child’s treatment raises an important question: Is there a service delivery model that is best suited to accommodate everyone, while maximally allowing for observance of the principles and guidelines alluded to earlier?
The two most frequently used models have featured treatment that is center based vs. treatment that is home based. Center based treatment is conducted in settings located within clinics, foster care offices or private provider offices. Home based treatment occurs at the current residence of the child/adolescent. In the former instance, the client comes to the therapist’s domain; in the latter instance, therapy takes place within the client’s domain. Furthermore, there are significant distinctions to be considered regarding treatment occurring within a community mental health clinic, a hospital out-patient clinic, a foster care office setting or a provider’s private office. With respect to the home based model, such variables as relationship of caregiver to child (e.g. birth parent vs. kinship foster parent vs. non-kinship foster parent vs. adoptive parent), others living in the home, and length of time child has been living there, may impact outcomes. For the present, I shall focus discussion primarily on the advantages and disadvantages inherent in delivering mental health services at offices within a foster care agency vs. delivering comparable services at either kinship or non-kinship foster care homes. The observations and opinions that I will be offering are based upon the extensive administrative and clinical experience that I have had with each model during the 35 years that I have been involved with foster care.
Four years after joining what was then known as St. Christopher’s Home in 1979 (now SCO Family of Services), I was asked to establish a central Department of Mental Health Services, staffed by licensed Psychiatrists and Psychologists (Clinical Social Workers were not independently eligible for Medicaid funds at the time). For over 28 years, from 1983 through 2011, when I retired from the position, I served as the Director, M.H. Services. As such, I was responsible for ensuring that all children in need, who were within the agency’s foster care and group home programs (the total client census exceeded 2,000 youngsters for a number of years) received any individual psychotherapy, play therapy, family therapy, and/or pharmacotherapy deemed to be necessary. In 1992, along with several other mental health professionals, I established the Institute for Emotional Health (IEH), as an essentially private, group practice, with the aim of offering mental health services to other children, adolescents and families in foster care and group home programs under the auspices of other voluntary child welfare agencies in the New York City area. Most agencies did not have such extensive in-house mental health services as we had at SCO, and some sought assistance from IEH. In this circumstance, since office space at the agencies was not readily available, we developed a home-based service delivery model, by necessity. For the past 22 years, and counting, IEH therapists have travelled to the foster homes of children/adolescents in foster care to conduct individual psychotherapy, or play therapy within client’s bedrooms, living rooms or whatever space was available. Almost all Family Therapy involving birth parents has been conducted, usually after hours, at the respective foster care agency office. In part II of this blog, I will offer my observations, contrasting the advantages attached to each model, from a first hand, 35 year perspective.
REFERENCES
Romanelli, L.H., Landsverk, J., Levitt, J.M., Bellonci,C., Gries, L.T., Pecora, P.J., & Jensen, P.S. (2009). Best Practices for Mental Health in Child Welfare: Screening, Assessment and Treatment Guidelines. Child Welfare Special Issue, 88(1), 163-188.
Gries, L.T. & Jensen, P.S. (2009). Best Practice Guidelines for Mental Health in Child Welfare: Context for Reform. Presented at Annual Conference on Treatment Foster Care, Foster-Family Based Treatment Association, Atlanta, Ga.
Schneiderman, M., Conners, M., Fribourg, A., Gries, L., & Gonzales, M. (1998). Mental Health Services For Children in Out-Of-Home Care. Child Welfare, 77(1), 29-40.
Leonard T. Gries, Ph.D. DABPS
Part II
One of the guidelines put forth in the 2009 Best Practices article calls for an evidence-based practice approach. Implicit in this guideline is the expectation that M.H. providers be appropriately trained and experienced in the treatment of children in foster care with social, behavioral, emotional, externalizing or internalizing disorders. It is generally more likely that M.H. providers hired by or contracted with foster care agencies have a full understanding and appreciation of the goals, organizational features, legal variables and decision-making process governing the operation of those agencies. In other words, the M.H. providers, whether their services are center-based or home-based, learn to speak the same language that is spoken by other members of the service plan team. Consequently, they are more likely to adhere to the second 2009 guideline that psychosocial interventions reflect the goals of the permanency plan. To some degree, M.H. providers at hospital or community outpatient clinics, are removed from the workings of the foster care process, and may be less familiar with how to interface their plans and efforts with the service plan team. There is no basis to assume that outpatient clinic providers are more or less versed than are foster care employed or contracted providers in how and when to apply evidenced-based interventions.
Another aspect of the second 2009 guideline pertains to the importance of involving the current caregivers within the child’s treatment. Whereas M.H. providers routinely have at least some contact with a client’s foster parent when the child is brought to the agency or clinic for sessions, greater involvement is almost guaranteed when sessions are conducted at the foster parent’s residence. Regular collateral contact with the foster parent is built into the structure of home-based services. A related advantage pertains to consistency of sessions, i.e. the regularity with which sessions take place. The attendance rate for clients seen in home-based treatment is most often higher than for clients seen in center-based treatment. On the negative side, however, in-home therapy does not always offer the degree of privacy that is customarily available during center-based, office sessions. This can diminish the chances of forging a sufficiently confidential forum within which to establish a maximally trusting therapeutic relationship. An additional disadvantage to the home-based model pertains to the last aspect of the second 2009 guideline, that interventions include the caregivers of origin at a clinically appropriate level. It is usually not feasible for home-based M.H. providers to schedule collateral or conjoint sessions with birth parents at the foster parent’s residence. Clearly, such involvement is facilitated within the center-based model, when services are offered at the foster care agency. For home-based cases, the solution is usually to schedule contacts or sessions with birth parents to occur at the foster care agency, although this may not be necessary when a kinship foster parent is involved, who is amenable to having these sessions at her residence.
Both the first principle listed in the 1998 article and the third guideline listed in the 2009 article call for collaboration via the integration of mental health services with the social service system of child welfare agencies. Although by no means guaranteed, it is more likely that such collaboration would occur when service plan team members work in the same office setting, and actually see each other regularly. One does not have to wait for a formal case conference or phone conference to be scheduled when matters that arise can be addressed by just going down the hall or upstairs. Of course, the culture within the office must be such that informal collaborative contacts are supported, eventuating in a clear advantage for the foster care office-based model over the home-based or the outpatient clinic models. This is not to suggest that M.H. providers within the home-based model are any less cognizant, than their foster care agency office-based counterparts, of the importance of addressing within treatment the various reasons for placement as well as the consequences of placement, as suggested in the third principle listed in the 1998 article. On the other hand, outpatient clinic treatment may sometimes be attuned to ameliorating presenting behavioral problems without being fully informed about reasons for placement. Furthermore, outpatient clinic providers may not be as universally trained and experienced in trauma-focused treatment as are clinicians who are employed by or under contract with child welfare agencies.
Perhaps the most significant advantage inherent to the home-based model is that treatment is provided in the context of a milieu approach. The therapist gets to see the dynamics within the foster home, first- hand. He or she gets to observe how the current caregiver and others within the home interact with the child or adolescent. This positions the therapist to provide feedback and guidance to the foster parent about home environment factors which may be facilitating or impeding adjustment and recovery from past abuse, neglect and/or traumatic loss. When therapy is center-based, the therapist must rely solely upon what is reported, accurately or inaccurately by the child, caregiver, caseworker or others, i.e. second hand data. The home-based therapist may even be in a position to help nip emerging problems within the foster home environment in the bud, before they escalate into the kind of intractable difficulties that may ultimately lead to a failed placement. This is in line with the second principle listed in the 1998 article, which emphasizes the importance of focusing on prevention as well as dysfunction.
Many children and adolescents in foster care have a history of being deprived of object constancy in their young lives. Their most basic relationship with one or both parents has been disrupted; they may have lived a nomadic existence, going from home to home, school to school, community to community. Once in foster care, they may have had several foster home placements, and may have had to adjust to changes in their caseworker, case planner, nurse or others involved in their case. Peer friendships either fail to materialize or are fleeting. For foster care children who are in treatment, the greatest constant in their lives is often the therapist. It is fortuitous that, compared with other departments and disciplines, there is little turnover of mental health staff within established foster care agencies. Similarly, there is relatively little turnover with therapists affiliated with established home-based programs. This ensures commendable constancy and continuity of the therapeutic relationships that are established. Even when a course of treatment is ended, the therapist is typically waiting in the wings should a consult or resumption of therapy be needed. One advantage of the home-based model is the therapist portability that is available. This is very useful when a child is transferred to a foster home in another community, making it logistically impractical to continue treatment at the initial foster care office or clinic. Within a home-based model, the therapist can remain with the client, following him or her to other communities, counties, and/or foster care agencies. In this way, the same familiar, trusted therapist is available, as needed, particularly at critical junctures throughout the child’s stay in foster care. This addresses the fourth principle listed in the 1998 article regarding the need for M.H. services which accommodate the child’s needs in the short term as well as the long term. The long term relationship in turn positions the M.H. provider to assess the outcomes of treatment interventions with respect to changes in psychosocial functioning, placement stability, permanency and client satisfaction, as prescribed in the fourth guideline listed in the 2009 article.
CONCLUSIONS
There are advantages attached to each of the M.H. service delivery models discussed. Neither model is the “winner” in this analysis. Each has unique features to offer, and may be better suited for some, but not all cases. Perhaps the best outcome measure to use in determining which model works best for a particular case is client satisfaction, including feedback from the child/adolescent, foster parent, birth parent and caseworker. Only the results of a randomized clinical trial could tell us whether one model expedites permanency and yields changes in psychosocial function that are significantly greater, more generalizable and more durable than the other. My guess is that the advantages for one model in some cases would be balanced out by advantages for the other model in other cases. Additional lines of inquiry cover comparisons in cost and timely access to treatment. To the extent that less office space time is required of the home-based model, and client transportation costs are eliminated, the overhead cost is lower, but the difference is mitigated to some degree by therapist transportation costs. Ideally, a hybrid model, featuring center-based, as well as a home-based capability is what I would pursue if I were starting all over again.
Leonard T. Gries, Ph.D. DABPS
October 27, 2014
My professional career in the field of Psychology extends over 45 years, and includes over 35 years within foster care settings. The challenges facing a mental health provider in such setting are particularly daunting because of the nature of the target population as well as the often unwieldy foster care system which one must traverse. A substantial number of children and adolescents in foster care come with developmentally based and/or trauma based behavioral, emotional, social and/or educational deficits. Many come with a history of being physically, sexually and/or psychologically abused, most often at the hands of the very same adult(s) who were counted on to be principal sources of safety, nurturance and secure attachment. Many come with a history of being raised within a home environment where they were regularly exposed to adult caregiver “models” practicing domestic violence, engaging in substance abuse, saddled with mental illness, or simply ill prepared to discharge the responsibilities required of an adequate, full-time caregiver. All of the children and adolescents in foster care have one thing in common: All have experienced the trauma of being separated from their parents for extended periods. Many children and adolescents, even those with egregious abuse histories, consider the day of being removed from family to be their worst, most traumatic life experience.
A number of years ago, I joined with several distinguished mental health providers in foster care in publishing an article which delineated what we considered to be essential guiding principles that should inform the treatment of children and families in foster care (Schneiderman, M. et al., 1998). It was argued that treatment efforts must be “consistent with the clinical needs of children in care and the child welfare goal of permanency.” Mental health services should:
1. “be integrated with the social service system of child welfare agencies”;
2. “focus on prevention as well as dysfunction”;
3. address “the various reasons for placement as well as the consequences of placement”, thus focusing on reversing the impact of grief and loss due to separation or abandonment, neglect due to parental substance abuse or mental illness, physical, psychological and sexual abuse, and exposure to domestic violence.
4. include “short-term and in some cases, long-term treatment interventions…at critical junctures in the placement life of the child and his or her family.”
Nine years later, I participated in the formulation of best practice guidelines for psychosocial interventions at The Best Practices for Mental Health in Child Welfare Consensus Conference in Washington, D.C. in 2007. In our ensuing article, (Romanelli, L.H. et al., 2009), it was concluded that interventions should:
1. be evidenced based when clinically indicated, or at least ensure “the adherence by mental health providers to an evidence-based practice approach”;
2. be “individualized and strengths-based…(reflecting) the goals of the permanency plan, actively involve the current caregivers, and, when feasible, include the caregivers of origin at a clinically appropriate level”;
3. feature collaboration between child welfare agencies and mental health providers;
4. provide the means for outcome tracking, including measures of psychosocial functioning, placement stability, permanency and client satisfaction.
The principles and guidelines delineated in 1998 and 2009 offer much needed guidance in establishing goals and standards, but they do not address the question of how best to deliver mental health services within a foster care setting. What complicate matters in foster care are the many players, often with competing agendas, who are involved in the life of the child/adolescent in need of treatment. Birth parents in an intact family are always involved collaterally with their child’s treatment, and are often involved conjointly, but they may not be readily accessible or motivated for participating when their child is in out of home placement. The foster parent, as current caregiver, is asked to participate collaterally, and possibly conjointly, but not every foster parent welcomes the opportunity. Some even feel put out by having this burden added to various other responsibilities imposed on them by foster care agencies. Each child in foster care has a caseworker or case planner assigned, who plays a crucial role in making sure the service plan is implemented, while being overseen by his or her supervisor, foster care director, regulatory agency representative, the child’s law guardian, and, ultimately, the Family Court judge or referee. Each and every player has an interest in what is being addressed in the child’s therapy, and in progress shown towards meeting treatment goals. The players, however, do not necessarily always agree on priorities, or even about whether certain goals are necessary. The topics of goal-setting and decision-making in foster care merit a separate discussion which will be offered in another blog. That so many people have a stake in the foster child’s treatment raises an important question: Is there a service delivery model that is best suited to accommodate everyone, while maximally allowing for observance of the principles and guidelines alluded to earlier?
The two most frequently used models have featured treatment that is center based vs. treatment that is home based. Center based treatment is conducted in settings located within clinics, foster care offices or private provider offices. Home based treatment occurs at the current residence of the child/adolescent. In the former instance, the client comes to the therapist’s domain; in the latter instance, therapy takes place within the client’s domain. Furthermore, there are significant distinctions to be considered regarding treatment occurring within a community mental health clinic, a hospital out-patient clinic, a foster care office setting or a provider’s private office. With respect to the home based model, such variables as relationship of caregiver to child (e.g. birth parent vs. kinship foster parent vs. non-kinship foster parent vs. adoptive parent), others living in the home, and length of time child has been living there, may impact outcomes. For the present, I shall focus discussion primarily on the advantages and disadvantages inherent in delivering mental health services at offices within a foster care agency vs. delivering comparable services at either kinship or non-kinship foster care homes. The observations and opinions that I will be offering are based upon the extensive administrative and clinical experience that I have had with each model during the 35 years that I have been involved with foster care.
Four years after joining what was then known as St. Christopher’s Home in 1979 (now SCO Family of Services), I was asked to establish a central Department of Mental Health Services, staffed by licensed Psychiatrists and Psychologists (Clinical Social Workers were not independently eligible for Medicaid funds at the time). For over 28 years, from 1983 through 2011, when I retired from the position, I served as the Director, M.H. Services. As such, I was responsible for ensuring that all children in need, who were within the agency’s foster care and group home programs (the total client census exceeded 2,000 youngsters for a number of years) received any individual psychotherapy, play therapy, family therapy, and/or pharmacotherapy deemed to be necessary. In 1992, along with several other mental health professionals, I established the Institute for Emotional Health (IEH), as an essentially private, group practice, with the aim of offering mental health services to other children, adolescents and families in foster care and group home programs under the auspices of other voluntary child welfare agencies in the New York City area. Most agencies did not have such extensive in-house mental health services as we had at SCO, and some sought assistance from IEH. In this circumstance, since office space at the agencies was not readily available, we developed a home-based service delivery model, by necessity. For the past 22 years, and counting, IEH therapists have travelled to the foster homes of children/adolescents in foster care to conduct individual psychotherapy, or play therapy within client’s bedrooms, living rooms or whatever space was available. Almost all Family Therapy involving birth parents has been conducted, usually after hours, at the respective foster care agency office. In part II of this blog, I will offer my observations, contrasting the advantages attached to each model, from a first hand, 35 year perspective.
REFERENCES
Romanelli, L.H., Landsverk, J., Levitt, J.M., Bellonci,C., Gries, L.T., Pecora, P.J., & Jensen, P.S. (2009). Best Practices for Mental Health in Child Welfare: Screening, Assessment and Treatment Guidelines. Child Welfare Special Issue, 88(1), 163-188.
Gries, L.T. & Jensen, P.S. (2009). Best Practice Guidelines for Mental Health in Child Welfare: Context for Reform. Presented at Annual Conference on Treatment Foster Care, Foster-Family Based Treatment Association, Atlanta, Ga.
Schneiderman, M., Conners, M., Fribourg, A., Gries, L., & Gonzales, M. (1998). Mental Health Services For Children in Out-Of-Home Care. Child Welfare, 77(1), 29-40.
Leonard T. Gries, Ph.D. DABPS
Part II
One of the guidelines put forth in the 2009 Best Practices article calls for an evidence-based practice approach. Implicit in this guideline is the expectation that M.H. providers be appropriately trained and experienced in the treatment of children in foster care with social, behavioral, emotional, externalizing or internalizing disorders. It is generally more likely that M.H. providers hired by or contracted with foster care agencies have a full understanding and appreciation of the goals, organizational features, legal variables and decision-making process governing the operation of those agencies. In other words, the M.H. providers, whether their services are center-based or home-based, learn to speak the same language that is spoken by other members of the service plan team. Consequently, they are more likely to adhere to the second 2009 guideline that psychosocial interventions reflect the goals of the permanency plan. To some degree, M.H. providers at hospital or community outpatient clinics, are removed from the workings of the foster care process, and may be less familiar with how to interface their plans and efforts with the service plan team. There is no basis to assume that outpatient clinic providers are more or less versed than are foster care employed or contracted providers in how and when to apply evidenced-based interventions.
Another aspect of the second 2009 guideline pertains to the importance of involving the current caregivers within the child’s treatment. Whereas M.H. providers routinely have at least some contact with a client’s foster parent when the child is brought to the agency or clinic for sessions, greater involvement is almost guaranteed when sessions are conducted at the foster parent’s residence. Regular collateral contact with the foster parent is built into the structure of home-based services. A related advantage pertains to consistency of sessions, i.e. the regularity with which sessions take place. The attendance rate for clients seen in home-based treatment is most often higher than for clients seen in center-based treatment. On the negative side, however, in-home therapy does not always offer the degree of privacy that is customarily available during center-based, office sessions. This can diminish the chances of forging a sufficiently confidential forum within which to establish a maximally trusting therapeutic relationship. An additional disadvantage to the home-based model pertains to the last aspect of the second 2009 guideline, that interventions include the caregivers of origin at a clinically appropriate level. It is usually not feasible for home-based M.H. providers to schedule collateral or conjoint sessions with birth parents at the foster parent’s residence. Clearly, such involvement is facilitated within the center-based model, when services are offered at the foster care agency. For home-based cases, the solution is usually to schedule contacts or sessions with birth parents to occur at the foster care agency, although this may not be necessary when a kinship foster parent is involved, who is amenable to having these sessions at her residence.
Both the first principle listed in the 1998 article and the third guideline listed in the 2009 article call for collaboration via the integration of mental health services with the social service system of child welfare agencies. Although by no means guaranteed, it is more likely that such collaboration would occur when service plan team members work in the same office setting, and actually see each other regularly. One does not have to wait for a formal case conference or phone conference to be scheduled when matters that arise can be addressed by just going down the hall or upstairs. Of course, the culture within the office must be such that informal collaborative contacts are supported, eventuating in a clear advantage for the foster care office-based model over the home-based or the outpatient clinic models. This is not to suggest that M.H. providers within the home-based model are any less cognizant, than their foster care agency office-based counterparts, of the importance of addressing within treatment the various reasons for placement as well as the consequences of placement, as suggested in the third principle listed in the 1998 article. On the other hand, outpatient clinic treatment may sometimes be attuned to ameliorating presenting behavioral problems without being fully informed about reasons for placement. Furthermore, outpatient clinic providers may not be as universally trained and experienced in trauma-focused treatment as are clinicians who are employed by or under contract with child welfare agencies.
Perhaps the most significant advantage inherent to the home-based model is that treatment is provided in the context of a milieu approach. The therapist gets to see the dynamics within the foster home, first- hand. He or she gets to observe how the current caregiver and others within the home interact with the child or adolescent. This positions the therapist to provide feedback and guidance to the foster parent about home environment factors which may be facilitating or impeding adjustment and recovery from past abuse, neglect and/or traumatic loss. When therapy is center-based, the therapist must rely solely upon what is reported, accurately or inaccurately by the child, caregiver, caseworker or others, i.e. second hand data. The home-based therapist may even be in a position to help nip emerging problems within the foster home environment in the bud, before they escalate into the kind of intractable difficulties that may ultimately lead to a failed placement. This is in line with the second principle listed in the 1998 article, which emphasizes the importance of focusing on prevention as well as dysfunction.
Many children and adolescents in foster care have a history of being deprived of object constancy in their young lives. Their most basic relationship with one or both parents has been disrupted; they may have lived a nomadic existence, going from home to home, school to school, community to community. Once in foster care, they may have had several foster home placements, and may have had to adjust to changes in their caseworker, case planner, nurse or others involved in their case. Peer friendships either fail to materialize or are fleeting. For foster care children who are in treatment, the greatest constant in their lives is often the therapist. It is fortuitous that, compared with other departments and disciplines, there is little turnover of mental health staff within established foster care agencies. Similarly, there is relatively little turnover with therapists affiliated with established home-based programs. This ensures commendable constancy and continuity of the therapeutic relationships that are established. Even when a course of treatment is ended, the therapist is typically waiting in the wings should a consult or resumption of therapy be needed. One advantage of the home-based model is the therapist portability that is available. This is very useful when a child is transferred to a foster home in another community, making it logistically impractical to continue treatment at the initial foster care office or clinic. Within a home-based model, the therapist can remain with the client, following him or her to other communities, counties, and/or foster care agencies. In this way, the same familiar, trusted therapist is available, as needed, particularly at critical junctures throughout the child’s stay in foster care. This addresses the fourth principle listed in the 1998 article regarding the need for M.H. services which accommodate the child’s needs in the short term as well as the long term. The long term relationship in turn positions the M.H. provider to assess the outcomes of treatment interventions with respect to changes in psychosocial functioning, placement stability, permanency and client satisfaction, as prescribed in the fourth guideline listed in the 2009 article.
CONCLUSIONS
There are advantages attached to each of the M.H. service delivery models discussed. Neither model is the “winner” in this analysis. Each has unique features to offer, and may be better suited for some, but not all cases. Perhaps the best outcome measure to use in determining which model works best for a particular case is client satisfaction, including feedback from the child/adolescent, foster parent, birth parent and caseworker. Only the results of a randomized clinical trial could tell us whether one model expedites permanency and yields changes in psychosocial function that are significantly greater, more generalizable and more durable than the other. My guess is that the advantages for one model in some cases would be balanced out by advantages for the other model in other cases. Additional lines of inquiry cover comparisons in cost and timely access to treatment. To the extent that less office space time is required of the home-based model, and client transportation costs are eliminated, the overhead cost is lower, but the difference is mitigated to some degree by therapist transportation costs. Ideally, a hybrid model, featuring center-based, as well as a home-based capability is what I would pursue if I were starting all over again.
Leonard T. Gries, Ph.D. DABPS
October 27, 2014
RSS Feed