Starting the Conversation
To address mental health concerns, there are a variety of services available to youth in foster care. The most common services are traditional outpatient talk therapy, intensive home/field-based services, congregate care and qualified residential treatment programs, and medication. Below is some brief information about each service.
Traditional Outpatient Talk Therapy
As a teenager, I was required to do conjoint counseling with my mother and sister because I didn’t want to reunify with my mom. I was more talkative in these sessions. It felt like a place where I could bring up my past hurt with my mom and my worries about returning to her. It helped me, but honestly, I don’t think my mom thought they were useful. She used to call them “bash mom” sessions.
Talk therapy is a service youth are often referred to when there is an active child welfare case. Talk therapy can take place in a one-on-one setting with the patient and the clinician or in a family-based setting with two and sometimes more patients and the clinician. “The American Academy of Child and Adolescent Psychiatry recommends specific evidence-based psychosocial interventions (e.g. trauma-focused psychotherapy) as the first-line of treatment for nearly every childhood mental health disorder” (Barnett & Concepcion Zayas, 2019). A common therapeutic modality used with youth in foster care is trauma-focused cognitive behavioral therapy (TF-CBT). TF-CBT can be provided to youth aged 3 to 21 (Trauma Focused-Cognitive Behavior Therapy). TF-CBT is used to target symptoms of fear, anxiety, and depression related to traumatic life events. Research shows TF-CBT to be effective in the foster youth population (Weiner et al., 2009). TF-CBT does not require a child to have a diagnosis like post-traumatic stress disorder to receive this treatment, but it is not uncommon for youth who receive TF-CBT to have a depressive diagnosis.
Intensive Home-Based Services
Home-based services are another common service families can be referred to during an open child welfare case, especially when a youth has high mental health needs. These programs go by various names depending on location but are generally called “wraparound” services. This service’s purpose is to meet the family where they are, usually in the home or a community-based setting. This is easier on the family as it does not require the family to travel to a clinician’s office. Wraparound services can be used to assist in the stabilization of a youth in the youth’s home environment, which can often prevent removal from the family unit.
While wraparound is typically part of court-ordered service plans, and therefore families may feel it is required, wraparound services value a family’s voluntary engagement. Wraparound’s model follows a strengths-based approach. This allows the clinical team to focus on the family’s strengths and how to build on those strengths to achieve greater success (Cal. Dep’t of Social Servs., Wraparound). The team usually includes a clinician for the child, a child family specialist, a parent partner, and a facilitator. Each of these team members has a unique purpose to help support the family (National Wraparound Initiative).
Congregate Care and Qualified Residential Treatment Programs
Residential treatment programs are unfortunately common placements for youth in foster care, but they can be instrumental in stabilizing youth who need additional support if used for a limited time. In 2018, Public Law 115-123, which included the Family First Prevention Services Act, was signed into law with the goal of enhancing services to maintain youth in a family setting whenever possible. The act established new requirements for youth who are placed into qualified residential treatment programs. The programs are required to provide trauma-informed and family-focused treatment with aftercare services for up to six months after a youth is discharged from the program.
Medication
Psychotropic medication is another service made available to youth in foster care to help them manage their mental health needs. According to a report by the Congressional Research Service, youth in foster care are 6 percent more likely to be prescribed psychotropic medication than their peers who are not in care (Cong. Research Serv., Child Welfare: Oversight of Psychotropic Medication for Children in Foster Care (July 2015, rev. Feb. 2017)). A youth’s placement can affect the number of medications the youth takes. The Congressional Research Service’s research concluded that youth placed in residential treatment facilities due to their higher needs take even more medication than their peers in less restrictive placements. The report went on to state that while a youth’s status in foster care increases the youth’s exposure to psychotropic medication, the use of evidence-based treatment, such as TF-CBT, in conjunction with medication can be effective in treating some mental health diagnoses.
It is critical to understand that while medication can be helpful, it does have limitations. A youth’s trauma history is not erased because the youth began taking an anti-depressant. Medication can assist youth in coping with the physiological effects of their mental health condition, but it does not provide necessary coping skills to “restore the [youth’s] sense of safety” (Am. Acad. of Child & Adolescent Psychiatry, Recommendations about the Use of Psychotropic Medication for Children and Adolescents Involved in Child-Serving Systems (2015)). In other words, medication is helpful to treat a mental health condition but not helpful in healing the trauma youth in care experience.
Each state has different rules regulating how clients receive authorization to take psychotropic medication. Some states, like California, require the court to authorize psychotropic medications (Cal. Welf. & Inst. Code § 369.5(a)(1)). In Washington, the stage of the proceeding can affect the authorization process (Wash. State Dep’t of Children, Youth & Families, Policies and Procedures § 4541, Psychotropic Medication Management). And in Delaware, parents or legal guardians are the decision-makers when it comes to permitting a youth in care to take psychotropic medication (Del. Children’s Department Policy).
Barriers to Talking about Mental Health Services
Systemic Barriers
Both logistical and attitudinal factors may serve as barriers to talking about mental health with clients involved in the child welfare system. Chief among the logistical problems are the continued high caseloads of attorneys, social workers, and other professional stakeholders. This may often leave limited time to spend talking with the youth about any mental health concerns they may have. Ensuring child welfare workers and advocates have caseloads that allow them to fully address their clients’ needs is critical to ensure mental health needs are being met.
Availability and Timeliness
Another significant barrier is the availability and timeliness of services. In many localities, particularly in economically stressed cities and rural areas, a mental health workforce shortage makes it difficult to access mental health services in a timely manner. The problem is even worse for underserved populations, such as children of color and LGBTQ+ youth, who are also overrepresented in the child welfare population. This creates a situation in which social workers can refer, advocates can advocate, and youth can agree to engage in services, but those services are simply unavailable. Therefore, policies designed to address the provider shortage—such as salary parity, increases in scholarships and loan forgiveness programs, and providing better career pathways for mental health professionals—are essential to solving the problem. Unfortunately, a lack of attention to this issue and the failure to prioritize the availability of mental health services in the past mean that the needs of children in the child welfare system are unlikely to be positively impacted for several years.
Stigma
Other barriers are more attitudinal in nature. Stigma and misinformation concerning mental health continue to influence people’s willingness to access mental health services. Media portrayals of mental illness often focus on violence and chronicity, along with an underemphasis on recovery and coping. Children with mental health conditions are found to face much stigma from the public at large. Therefore, it is important that professionals who work with these youth do not avoid conversations about mental health due to their own internalized views of mental health being a shaming or sensitive topic that cannot be discussed. Because it is not the role of attorneys to assess or treat their client’s mental health, they may lack familiarity with how to approach this topic with youth. It is important to remember that mental health is not just about symptoms. Attorneys and others are most likely to understand a client’s mental health when they ask about the client’s relationships with peers and adults, their comfort and self-efficacy in the school setting, and whether they feel connected to a larger community or culture. These are familiar topics to talk with youth about, even for those who are not mental health professionals.
Lack of Youth Voice and Choice
Perhaps the most important barrier, however, is that youth lack a voice in their own mental health treatment. Because of a reluctance to discuss mental health issues with youth due to the other barriers already discussed, youth are often not appropriately consulted about being referred to mental health services. Instead, they are sent to psychotherapy not understanding the purpose of the referral. Thus, they feel they are a problem that needs to be fixed, rather than being invited into a process that is focused on their goals and how they can best achieve them. In the mental health professions, the “therapeutic alliance” is crucial to treatment success. This alliance is often boiled down to interpersonal relationships, but it also includes the mental health professional engaging in a collaborative process with the youth in developing the youth’s own treatment plan. When youth are referred to treatment without any consultation, they may feel resentful and suspicious of the process. Mental health referrals need to be initiated with a focus on what youth want for themselves and not what other people have decided they want for the youth. Inviting, rather than demanding, that youth engage in the process of thinking about their lives and how they would like their lives improved or changed creates a different tone and atmosphere at the beginning of a youth’s mental health journey that can lead to more positive outcomes.
While some may be willing to embark on this journey, others may not. This is to be expected. DiClemente and Prochaska’s article “Stages of Change” offers a model to understand that seeing a need for change or wanting to change is a process, not an event. Their model includes six stages ranging from pre-contemplation (not considering change) to maintenance (maintaining progress made through intervention). Each of these stages may require different questions and different ways of engaging the client. If we automatically assume all individuals are ready for change, then we may get “resistance” or a reluctance to engage in services. When we meet clients “where they are,” then we are better able to align ourselves with what they are thinking and feeling about mental health intervention, rather than what other people are thinking. This is an essential part of motivating and engaging clients in a discussion of their own goals and the best ways to achieve those goals.
What Do Clients Want to Know about Engaging in Services?
When I was in care, I never went to court even though I wanted to go and told my attorney’s investigator I wanted to be there to know what was going on with my life. Everyone was making decisions about me without me. I was just told after the fact that things were happening, and no one was explaining what it was and what was the purpose. I was told I was doing individual counseling. I was told that I was going to do conjoint counseling. I didn’t want to do these services because I didn’t know what they were and didn’t think it would help. I remember family therapy when I was six and how that was usually my parents fighting while I played in the waiting room until I was brought in to share my feelings in front of my parents, which was hard, awkward, and I knew if I said anything, I’d hear about it later. Things that were said in therapy never stayed in therapy.
Clients want to know what the court ordered and why. It’s important to let clients know the court ordered a mental health assessment to see if there are services that could be helpful. Clients want to know if they must do these services and do they have a say in what the services look like? What does it mean to have a mental health diagnosis? In California, youth have a right to participate in the development of their treatment plan and know their diagnosis, if any.
Clients want to know about privacy and what it means for the therapist to talk with caregivers, parents, or social workers about coordinating treatment. How much is shared and what can be limited? What will be in a court report? Even though reports are not public documents, a lot of strangers read them. Reports contain very intimate details of a youth’s life, and youth are expected to just be OK with that.
How to Talk to Clients about Mental Health Services
Education
Education is an essential step that all children’s counsel should take before speaking with a client about mental health services. It is possible that attorneys have a limited understanding or exposure to some of the services discussed, and that is OK—you do not need to become an expert. However, you should be educated. Reading this article is a great first step. Speak to providers who routinely work with your clients or your client population. If you know a client is going to be referred to a specific program, does that program have a website that discusses the services offered? Does it provide links to the evidenced-based practices used by the providers? The internet can be a very useful tool but can also be misleading, so be sure to use reputable resources when conducting your research. The Substance Abuse and Mental Health Services Administration (SAMHSA) and the National Alliance on Mental Illness (NAMI) are great places to start. If you are confused about something, there is a possibility your client will also be confused. Be mindful of your word choice when discussing mental health services with your client. It is not uncommon for clients to say, “I don’t want therapy. I’m not crazy.” Be prepared for how you want to respond to this concept. If need be, practice this conversation with a colleague before meeting with your client.
Be Honest
Remember, you are not a clinician, and you are not going to know everything. When you do not know an answer to a question your client asks, do not make up the answer. Let your client know you do not know the answer, but maybe you both can look for the answer together. When discussing specific services like residential treatment or medication, be mindful these types of services usually take time to be effective. Be sure to manage your client’s expectations about how these services work. Unfortunately, there is no magic wand to solve a client’s mental health needs, and these things take time. Acknowledging how difficult therapy or other services can be is very validating for clients.
Use Age-Appropriate Language
Describing mental health and therapy to youth can be challenging. While many youth are used to talking about it with peers or in school, it can be hard for adults who are not used to talking about it so freely to think of age-appropriate language on the fly. Remember, mental health is daily health. In simple terms, our mental health is our thoughts, feelings, and reactions to the world around us. Some days our mental health is strong, and the brain is filled with positive thoughts and can handle challenges throughout the day. On hard mental health days, things feel like a disaster. Mental health is a scale that changes throughout the day. Sometimes it’s tilted to the strong side, other times to the hard side, and sometimes in complete balance. PBS has a lot of resources on how to talk to young children about mental health. NAMI has a coloring activity book, called Meet Little Monster, that talks about mental health and what therapy is. It helps kids identify feelings and safe adults to talk to. The activity book is free on NAMI’s website and is a great way to talk with youth about their feelings and mental health. You can use the entire booklet or just a few pages to go over with your client.
Empower Your Client
Mental health is health. Just as going to the doctor or dentist is important, so is working on mental health. This may be through a formal service, like individual counseling, or an informal activity like self-care. Talk to your clients about assessing their mental health needs and what do they feel they need to have strong mental health. Encourage your clients to actively involve themselves in their treatment by using their voice and action. Encourage them to do activities they enjoy and that bring them peace.
While encouraging youth to be engaged in treatment and activities that bring them joy, your role as their attorney is to make sure they have access to these activities. Some child welfare agencies will pay for extracurricular equipment or supplies that are needed, so be sure to familiarize yourself with your local agency’s policies. Many jurisdictions have a reasonably prudent parent standard that is applicable to all caregivers (e.g., Cal. Welf. & Inst. Code § 362.05). This standard usually allows the caregiver to permit a youth to participate in age-appropriate extracurricular activities. Some caregivers may be unaware they can make these types of decisions for the youth, so be sure the caregiver is properly informed. It’s possible your state has a Foster Care Youth Bill of Rights that enumerates the right to participate in extracurricular or other activities, like California’s Welfare and Institutions Code section 16001.9(a)(16). If this right is not explicitly enumerated, be creative in drafting arguments that rely on laws or other legal frameworks where these rights or similar ones can be inferred.
Services
When talking about services with clients, speak with them before, during, and after. At the beginning, set some expectations for the client. Remember, these interventions take time. There could be an assessment process to determine what services should be provided, if any. This can be a frustrating process for clients because they must repeat traumatizing events to a stranger. After beginning services, the client will need to build rapport with the clinician. Using the attorney-client relationship is a great way to analogize this process: Remind the client there was a time when the attorney-client relationship was new and time was needed to develop that relationship; this is the same thing that needs to happen with a therapist.
During services, check in with the client to get their own assessment of the progress they are making. Be sure the client understands why they are in the service. This helps evaluate the effectiveness of the service. When asking clients about the effectiveness of the service, a common response is “It isn’t working. I don’t like it. It’s dumb.” A great response to this is “Have you told your therapist this?” Clients may be taken aback by this question. However, it’s essential a therapist know how the client is feeling about the intervention. Without this, the therapist cannot make modifications to help improve the client’s outcome. A great thing to mention here is everyone’s time is valuable and a client and therapist should not spend time on something when it is not working. This is a way to empower clients to advocate for themselves. Throughout this process, be sure to always ask open-ended and follow-up questions. It’s common for clients to report things are “fine” or “good,” so always follow up with “What makes it good?” or “Why isn’t it working?” Therapeutic services are not a one-size-fits-all. Feedback from the client is essential when working toward success.
Medication
Before clients start taking psychotropic medication, it is important for their attorney to explain to them their rights. Every state is different on what a foster youth’s rights are as they relate to medications, but some states, like California, have a Foster Youth Mental Health Bill of Rights. Does your state have a foster care bill of rights like West Virginia’s? If not, does your agency have a policy team that could use other states’ foster youth bill of rights to draft one for your own state? It is essential youth are counseled about their rights surrounding medication. Without proper counseling, misleading beliefs can be formed. Lola Barber, a current peer advocate with the Children’s Law Center of California, said this about her experience taking medication while in foster care: “As a youth, I often felt that taking my psychotropic medication was a mandatory expectation of being a foster child. I did not feel that I had the power to make any decisions in my mental health treatment or services because the adults around me would inform me that I was obligated to or else there would be consequences.”
Conclusion
You are an attorney and there is no expectation you take on the role of a social worker; however, foster youth are entitled to understand their legal rights and receive unbiased information about services. Arming yourself with tools for discussing these issues will greatly benefit your clients.
