Social Workers at the Kitchen Table: Can Evidence-based Juvenile Justice Services Change Child Welfare?

Patrice Boyce is one of the New York Foundling’s newest therapists and she is struggling. A neatly dressed young woman with wavy hair and a thoughtful manner, she is having trouble staying sympathetic toward a mother on her caseload. Patrice’s job is to keep this woman’s children out of foster care by using a specialized form of in-home family therapy—without taking sides between family members. That’s proving difficult. “Some sessions it’s hard for the mom to sit down. She asked me to just talk to the kids, ‘Fix the kids, just deal with the kids. I don’t want to be a part of this,’” Patrice tells her supervisor and another therapist in a windowless room of the nonprofit New York Foundling. She looks shell-shocked. “I feel like she doesn’t even want to sit with the kids.” The mother has four children, but only the two youngest, a girl and a boy, still live at home. The boy is 10, the girl just shy of 13. Each spent two years in foster care and both are hungry for attention. The oldest especially likes to follow Patrice around the apartment showing her things, like the dress she wants to wear to a party.

The Administration for Children’s Services (ACS) brought in New York Foundling to help this family after the agency received complaints that the mother had left the two children alone at night while she went out drinking. Recently, hostilities escalated. The 12-year-old threatened to kill everyone in the house, Patrice says. The mother attacked her, scratching her eye. ACS workers, who are still investigating the family, called an emergency conference. At the conference, Patrice found it difficult to see the girl with her eye damaged and to hear the mother repeatedly call her daughter a bitch. It was especially painful to watch the young girl react: She slouched and stared into the distance, eventually falling asleep right there at the table.

“What do you think that’s about for Mom?” asks Marta Anderson-Winchell, her supervisor, who has been practicing this particular method of therapy for over two years. Like Patrice, Marta is not long out of social work school and still in her twenties.

Patrice stays silent, so Marta offers a suggestion: “The two youngest were in foster care. The two oldest didn’t make it to 18 before they’re out of the house. What I’m hearing is the system telling her, ‘You are a bad mother.’ The kids are saying, ‘I don’t want to be here.’ That’s a lot of guilt and anger for the mom.”

“If I could see more positive it would help me work with her better,” says Patrice. “The youngest kid is on SSI. The mom doesn’t want that kid going anywhere because she says that’s her money. I feel like on some level that’s a major motivator for her to have the kids around.”

“If we think about a parent who only wants money, who wants the kids because of the paycheck, that’s negative,” says Marta. “How to reframe that? Even if you don’t believe it, try to find the noble intent.”

Patrice is quiet a long time before answering. “I’m having a hard time with that,” she finally says.

Patrice and Marta are therapists in a new pilot project that aims to keep teenagers out of foster care and safe at home by using what ACS loosely calls “evidence-based” services—forms of therapy that have been studied and deemed effective in the juvenile justice world, where most originated, but are in fact relatively new to child welfare, where ACS plans to now use them.

Most are a form of hurried-up family therapy with a focus on changing family members’ behavior and helping them to communicate better with one another. Where many therapies require parents to drag their kids to a remote office for an indefinite number of visits, these sessions unfold in the home for intense, short-term interventions. Children’s Services Commissioner Ron Richter has described them as getting a knock at the door “from a social worker who is in your face, at the kitchen table, being part of your life…they come in like a tornado…and they help the parent to learn how to get control, and they make it very clear to the teen that their parent is the parent.”

This pilot is part of the Administration for Children’s Services’ larger plan to rely more heavily on practices that have been shown to reap results. In the coming months alone, ACS plans to spend $22 million to provide short-term therapies to work with 3,000 families each year, in a targeted effort to reduce the number of children 12 years old and older placed in foster care. These older boys and girls account for more than one-third of all cases investigated by child protective services, and more than one-third of the young people placed in the city’s foster care system each year.

Many of these young people eventually “age out” of foster care to life on their own—something that is associated with high rates of homelessness, unemployment, and incarceration. Over the years, ACS has tried many approaches to help better prepare teens for life after care—from teaching classes geared toward preparing them for life on their own to encouraging families to adopt teenagers. Now, officials are trying a more direct approach: keeping teens out of foster care in the first place.

“We believe that by making this financial commitment to families and teenagers… we will empower parents to take care of their teenagers,” says Richter.

Richter points out that, in the city’s juvenile justice system, these therapies have helped about 1,000 young lawbreakers stay at home with their families instead of being sent to juvenile correctional facilities. A smattering of foster care agencies in New York City have already begun using such programs in their child welfare work. But strictly defined, the therapy models in which ACS is investing are not truly evidence-based when used with children on the brink of entering foster care. Using these services on a large scale with families involved in the foster care system is a largely uncharted terrain, one that is only beginning to be evaluated in a systematic way. It’s not yet clear how effective they will be at ensuring child welfare’s main goal—keeping kids safe.

Nonetheless, using services that have been studied is the next wave of child welfare, and many in the field are cautiously enthusiastic. “In the world of government [funding], everything is tied to outcomes,” says Citizens’ Committee for Children’s Executive Director Jennifer March-Joly, who notes that if family support programs are challenged to demonstrate their effectiveness, that will only strengthen their case for funding and potentially attract more money to the field.

“We have a responsibility as a field to provide our young people and families with interventions that work. If there is a better way of providing services, I think that we need to be open to exploring that,” says Sister Paulette LoMonaco, executive director of Good Shepherd Services.

For child welfare workers willing to give them a try, these models offer something entirely new, and valuable: a systematic, finite, and supported way of approaching, thinking, and talking about their work with families. It’s one with concrete and measurable goals, clearly defined strategies to reach those goals, and tons of support. Evidence-based interventions demand a lot of their caseworkers, requiring them to view all of the individuals on their caseloads in the most positive light possible, and, when things aren’t going well, to consider themselves, not just the families they work with, responsible. Ultimately, they can provide professionals in child welfare a greater sense of control and efficacy. In the murky, hard-to assess, high-turnover business of helping families in crisis, this is no small feat.

***

At its most crude, the world of evidence-based practice is a big business steeped in its own particular jargon and philosophy, beginning with the term “evidence-based” itself and all its scientific associations. Indeed, “evidence-based” is the social science field’s shorthand for a model has been demonstrated, through high-quality, quantitative evaluation research, both effective and replicable.

The models ACS plans to use were developed and researched at universities and research institutes, and their marketing and dissemination is overseen by academically trained teams at “national purveyor organizations,” as they are called in the business. Most are for-profit corporations, many of them doing millions of dollars in business each year.

Purchasing one of these models carries a steep price tag. FFT Inc., the firm that created and owns the Family Functional Therapy model, charges about $61,000 to train and oversee a team of therapists capable of serving 50 families at a time—and that does not include the cost of travel to or from Seattle for training with consultants.

In New York, ACS has created model budgets that estimate that between 9 and 13 percent of the total cost of these programs will be spent on fees paid to the purveyor organizations, rather than in direct services. That cost includes training, manuals, technical assistance and copious staff oversight conducted by consultants.

For most of these therapies, the first year an organization uses them is the most expensive. As an organization becomes more proficient and needs less support, the costs go down. The model developers continue providing oversight and charging a fee for as long as an organization uses the model, something the developers say is vital to using their models with “fidelity” to a proven approach. “There is consistent quality assurance built into the model, so you don’t just have the family and the provider working together. You also have a layer of integrity from the model developer that you pay for, which makes these models cost more,” explains Commissioner Richter.

The models have what some in the business call a “big bang” effect. Most are short, intensive treatments targeted for families and children who meet a specific profile—say, lawbreaking teenagers with substance abuse issues, or the parents of children with medical issues. They move families in and out of their programs as quickly as possible, following a philosophy that they not make families dependent on services. For organizations like ACS, this is appealing not just for its ideological stance: Evidence-based programs have the potential to serve more families each year than traditional social services.

Last winter, at an ACS-hosted, acronym-heavy “evidence-based open house,” directors of dozens of the city’s child welfare nonprofits learned about various evidence-based models from salesmen and women who had PhDs, Power Point presentations and a flair for public speaking. The experts had traveled from distant cities to ACS’ Children’s Center on Manhattan’s east side to take turns endorsing their particular flavor of a scientifically studied program. Richter compared the daylong conference to a dental convention where attendees chose their “particular brand of toothpaste.”

“In every family that’s in trouble there’s a sense of negativity and hopelessness,” Joan Muir of the University of Miami told the crowded auditorium. “How do you get motivation? How do you get that shift?” she asked—and then she explained how the model she represented—Brief Strategic Family Therapy—does exactly that.

As the panelists presented their programs, and as therapists and caseworkers shared their experiences using the models, and as ACS leaders outlined plans to begin converting “unproven” programs to ones that had been tested, deemed effective, and driven by what Lisa Shankweiler of New York Foundling called “data points” as opposed to what “feels right,” there was, among many, a sense of possibility. It may have been similar to what those in the juvenile justice world felt in the late 1990s when they first heard there were therapies proven to help lawbreaking teenagers get back on track.

“It was a really exciting time,” remembers Clay Yeager, who then headed Pennsylvania’s juvenile justice system. “I came out of a 20-year history in juvenile justice where we were all just led to believe that there was nothing we could do, that nothing worked, and that juvenile justice systems especially were stuck in this role of managing kids and counting the days until kids turned 18, because we didn’t believe there was much to do to change them. For me, it was a godsend that there were science and data to say we could do this stuff differently.”

Yeager has since built his career around evidence-based services as a former head of Nurse Family Partnership and now as a consultant at Evidence Based Associates, which helps organizations and jurisdictions use these interventions. The models most prominent when Yeager worked in juvenile justice are among those ACS hopes can now stop thousands of teenagers from entering foster care, including Family Functional Therapy (FFT) and Multisystemic Therapy (MST). Both emerged from what Keller Strother, president of MST Services, calls a knowledge base of decades of research around delinquency and drug use, starting with the recognition that children are part of an ecology, with many influences affecting them, including their families, peers, and communities, all of which need to be addressed when working with young people who have committed crimes.

Many forms of therapy build from the premise that there are deep, psychological issues affecting behavior that must be explored before they will resolve, but these evidence-based models focus on action. They use a system of rewards and consequences to teach parents and children skills that can improve family dynamics and change behavior in measurable ways. “The youth is not seen fundamentally as the problem, their behavior is the problem. But it’s not something that is intractable and unchangeable,” says Strother. “Progress is grounded in what people do.”

They all start with the assumption that people are fundamentally good, and have good intentions—that kids are not bad or cruel by design, that parents are not sadistic or abusive or neglectful by nature, that parents are wired to love their kids and their kids are wired to love them back. “Parents don’t intend to raise criminals, even if a parent himself is a criminal,” says Strother. Even a mother like the one on Patrice’s caseload, who claims she wants her son for the disability money the boy brings in, wants deep down what all good parents want—the best for her children, to protect them from harm. It is this premise that makes the models particularly powerful for families that have already burned through a plethora of services and parenting classes and therapists and caseworkers before arriving at a place where they no longer believe anything can change. It is also what makes them particularly appealing for the therapists who use them.

“It feels like actual casework,” Katie Stoehr, senior vice president for performance, strategy, and advocacy at Graham Windham, told the audience at ACS’ open house. “It’s the reason we all went into this field.”

***

Soft-spoken, intense, and often spotted wearing motorcycle boots, Dr. Sylvia Rowlands is a true believer in the power of evidence-based services. Through her eyes, just about any major problem a family might face is ripe for therapy. Take a mom who can’t afford daycare, so she leaves her kids home alone while she works. This mother’s problem is not about just money, Rowlands insists. It’s about how she makes decisions about what is and isn’t safe, and how she nurtures or neglects relationships with relatives or even systems that could help her out. “There are all these decisions and all these relationships that have or have not deteriorated over time, that you have to check and fix,” she says.

Rowlands is assistant executive director of evidence-based community programs at New York Foundling, which has the city’s largest, most dizzying array of evidence-based programs.She’s one of the visionaries who first imagined using home-based therapeutic services designed for young delinquents to keep children out of foster care instead. To some, it might not seem an obvious fit: Kids who may have been abused or neglected are, for the most part, not committing crimes. But more than 80 percent of the teens that New York Foundling worked with in its evidence-based program for young delinquents also had some sort of involvement with foster care, and Rowlands has seen how these services have allowed many of them to stay at home and out of trouble.

About seven years ago, Rowlands and her colleagues at Foundling worked with a researcher to adapt the evidence-based Family Functional Therapy (FFT) program, designed for the families of young delinquents, to prevent foster care placement in families stretched to the breaking point. The FFT model had been used successfully in child welfare in Europe, where the juvenile justice and child welfare system coexist, and they hoped they could make it work in New York City as well.

Most caseworkers who provide family support services follow no single model as they counsel parents and cobble together services. But these workers must complete specific tasks and meet regulations set by the state, such as visiting with each family twice each month, with at least one visit happening in the home while caseworkers make sure all the children are safe. Sometimes these “general preventive” caseworkers, as the city calls them, work with families for as long as a year and a half, although over the past few years ACS officials have pressured them to close cases within a year.

Foundling’s new preventive model—which FFT, Inc. clunkily named Functional Family Therapy Child Welfare, or FFT-CW—takes a radically different approach. Supervisors push caseworkers to close cases in six months or less. “Everything is quicker and more intense because you do it in half the time or a third of the time,” says Rowlands, who calls it “cute” when asked about caseworkers who want to spend more time working with a family. “We have some of those people who find it really hard to close a family in four months. They’ll say, ‘I want to extend, it isn’t perfect yet.’” Rowland’s firm response? “No, no, no. Close it.”

When they are assigned a new family, therapists must meet with them three times in 10 days. For system-wary parents who have already seen more than their fair share of caseworkers, Rowlands says, this fast, concentrated pace sets a tone right from the start that the program will be unlike anything they’ve experienced before.

Therapists prime families to believe things can and will improve. Some families have primarily concrete needs—they are facing eviction, for example, or struggling with mounting debts—and the therapists can help address them. For families with more complex needs, like domestic violence, therapists begin what they call the “behavior change” phase, where they work with family members around specific skills, like showing a mother who nags her teenage daughter how to keep requests short and concise, so the daughter doesn’t tune her out, and teaching the daughter to echo back what her mother says, so the mom feels heard.

Eventually the therapists help families prepare for situations where they might relapse, like a fast-approaching date in Family Court.

Therapists work in teams that meet with each other every week for over three hours. Together, they discuss their work, update each other on how their families are doing, congratulate each other on their successes, share ideas and brainstorm how to, say, encourage a teenage girl to go to school. If the often-introspective, searching tone of these meetings feels a little like group therapy itself, it is by design. “These models are built around the team working through these problems. Everything is in the context of the group. That’s what the model is,” says Rowlands.

“It’s not my genius. It’s a 30-year-old genius that has been proven to work everywhere,” she says. “That’s what the model does. That’s what the research says it does. That’s what it’s designed to do.”

***

Marta is young, has no children of her own, and, unlike most of the families she works with, white. Just over two years ago, when she was a general preventive caseworker at New York Foundling, most of her days involved trying to get the 10 to 12 families on her caseload to participate in services—to go to therapy, for example, or take parenting classes. When parents refused, Marta was at a loss.

Now a supervisor of FFT-CW, where therapists work with about the same number of families as other city preventive workers, Marta says the model gives her a clear approach and a lot of support—two things she previously craved. “This is focused and purposeful and incredibly highly supervised, and I have a lot more accountability,” she says.

Rather than label families who won’t participate in the program as “resistant”—a term commonly used by child welfare caseworkers—she must now look at what she could do differently herself. “FFT has a philosophy that we can help families make these changes. Our job is to keep these families together, and the therapist is held responsible for that,” says Marta.

Parts of the model are like nothing Marta learned in social work school. Asking lots of questions, for instance—a key tenet of good social work practice—is not part of the FFT-CW repertoire. Instead, therapists describe things for their clients. Patrice, who Marta supervises, explained to one family that the father’s drinking is how he copes with the unexplained death of his 2-month-old son. The mother and two children had gone to therapy to help them deal with the infant’s death, but the father had not. As his drinking increased, so did his remoteness and anger. Now he and his wife rarely interacted. Patrice pointed out the specific sadness behind his drinking. She also helped the family see themselves in a more hopeful light, identifying an important strength of theirs: the parents had been married for 13 years and had chosen to stick together no matter what, no matter that they had lost a child.“They liked that theme,” Patrice told Marta.

Marta has seen how this type of “reframing,” as FFT calls it—the identifying of good intentions behind troublesome behavior—gives even those families who have been told over and over what they are doing wrong a chance to see things differently. This is powerful stuff, says Marta. It motivates family members to do the hard work necessary to, say, start counting drinks each night. It also motivates the therapists who work with them.

Marta’s team has fought to take cases from ACS that would have otherwise been shifted to the foster care docket—in one case a teenage boy slept in the same bed as his mother and a caseworker thought they were too physically affectionate. But despite working in highly volatile family situations, Marta, when interviewed last spring, could not recall a single time when she or one of the therapists she supervises has made a report to the state of suspected abuse or neglect. And neither Marta nor Rowlands could remember a time when an FFT-CW therapist thought a child should be placed in foster care. “It’s not that we won’t do it,” said Rowlands. “It’s just that in several years in northern Manhattan we haven’t had an occasion where we’ve said ‘You need to remove those kids.’ We don’t believe that that’s a good thing to do to kids, so at all cost we’re going to try to keep that kid in the community.”

Sometimes this means finding relatives willing to informally take children in. “We may build supports where a kid will move out of Mom’s house for a minute and we will work with Mom,” says Rowlands.

In one case where they suspected a boy was being sexually abused in his home, instead of recommending he move to a foster home, therapists sent him to live with his grandmother while they figured out what was going on and kept ACS informed of their findings. Ultimately, says Rowlands, they “removed the risk”—meaning they removed the parent who was abusing him—“and the kid came back home.”

If this seems like a lot to accomplish in six months or less, Rowlands insists “the families walk away doing beautifully.”

Rowlands says that an internal evaluation of FFT-CW outcomes was so promising it prompted Foundling to begin training all of its preventive caseworkers to use the model. Two researchers are now studying the program systematically. A sampling of data from ACS provides evidence that FFT-CW is indeed closing cases at a quick pace while also keeping children out of foster care: Citywide, about 80 percent of all general preventive cases opened between April and September 2010 received more than six months of services, but for Foundling’s FFT-CW team, 64 percent of its cases received six months or fewer of services. Equally significant, 78 percent of their cases that closed during a three-month evaluation period did so because the family had progressed toward their goals. Citywide, only about 45 percent were closed for this reason. None of Foundling’s families went into foster care during that time.

The numbers also suggest the program is effective at getting families involved right from the start: Citywide, about 44 percent of families offered preventive services refused to participate, while only 29 percent of families offered FFTCW rejected the therapy.

It can feel almost like a personal shortcoming when a case slips through one of the therapist’s hands, like the teen who returned home after spending three years in a juvenile correction center only to be kicked out by his mother.

“The kid is staying with his girlfriend, then Covenant House, and most likely foster care. The mom is not letting him back in the house,” Marta told her team of therapists. Marta believes she botched things when she indulged the mother’s wishes to focus only on the future and the positive. If she could turn back time, Marta says, she would insist that the mother and son look closely at the problems they’d been having before his arrest. Then, maybe they’d be better prepared to handle the argument that caused the son to storm out of their apartment, leaving the front door open with his younger brother still home, and the mother to vow that she would never let him live there again.

“What I missed was that was a honeymoon phase,” Marta says. “I let sessions stay on service, but I didn’t pull out the negativity and blame, so I set up the family to have a relapse.”

“He’s a sweet kid and Mom just kind of turned on him,” she adds. “I tried. I just didn’t try hard enough. It hurts to lose one. God knows where he’s going to end up without a family.”

***

In January 2012, as part of its pilot project, ACS began sending teenagers on the verge of entering foster care to Foundling’s Manhattan FFT-CW therapists as well as a Bronx program run by the nonprofit Children’s Village for the families of teens with substance abuse issues. If not for these programs, a number of these teens would have gone to foster homes instead, says Rowlands. ACS officials hope to eventually send thousands more families with adolescents to similar evidence-based therapies. But of the five models ACS proposes to use for this expansion, not one is evidence-based for use in child welfare, and only two have been formally adapted for families involved with the foster care system—FFT-CW being one of them. Of those two, only one has published any findings about its effectiveness. Whether or not this is a problem depends on who you ask.

Richard Barth, a researcher at the University of Maryland School of Social Work, has found that most urban teenagers enter foster care not because they are suspected of being abused or neglected, but because of their own behavior, like running away, skipping school, or selling drugs. In his opinion, this makes them a good match for programs designed to help juvenile delinquents. “The idea of child welfare is to help kids when parents are inadequate, but many parents of adolescents can’t figure out how to parent them,” explains Barth.

But others say that filling programs designed for kids who have been found guilty of committing crimes with teenagers who have come to the attention of child protective workers is a lot like using a medication proven to help with heart disease for headaches. It might not work.

“This is an example of really good programs that could very well fail because we made a broad leap that because they were successful with juvenile justice kids that they will be equally successful with teenage child welfare kids,” says Yeager of Evidence Based Associates. “Until the research plays it out, I would be very reluctant to support widespread adoption of these programs.”

Strother of MST Services agrees. “If you are going to use one of these therapies in a way they haven’t been used before, the attitude needs to be one of skepticism. Our advice is that that just fundamentally won’t work,” he told Child Welfare Watch last spring.

Juvenile justice focuses on ensuring public safety and getting lawbreaking teenagers on more hope-filled life paths. Child welfare, on the other hand, is all about the safety of children. Strother believes these differing goals make programs designed for juvenile delinquents an essential “mismatch” for child welfare.

With keeping teenagers out of foster care comes an urgency to address something the evidence-based programs for juvenile delinquents are not built for: ensuring the safety not only of teens, but of the teens’ siblings, as well. It is not yet known how well these programs can do that.

“These models are [designed] to create behavior change in a single identified youth. It’s not clear from a model perspective how a safety plan for a younger sibling would emerge out of a treatment targeted to addressing substance abuse issues,” says Strother.

Those already using the evidence-based models in child welfare insist they have found ample ways to account for children’s safety. Rowlands points out that therapists in all of these models are in the families’ homes far more frequently than the state and city require of general preventive workers, which presumably puts them in a better position to determine how children are faring. “We’re not there twice a month, we’re there all the time,” she says.

When a case is still open with ACS, the FFT-CW therapist and an ACS child protective worker are in frequent contact. Once a case is closed, if the therapist becomes concerned that a child may be in danger, she’ll call a conference with ACS workers and the family to discuss safety. “We’re talking risk all the time,” says Rowlands, who recalls one particularly challenging case where her therapists reached out to ACS 50 times.

But these are critical changes to the tested therapies these programs are built from. And in the evidence-based world, every change matters.

Strother thinks that if ACS workers are able to target only those teens at risk of entering foster care due to their own behavior, then the city would be wise to remove some of the child safety requirements now expected of its therapists. That way the programs can be used the way they’ve been demonstrated to work.

But Keith Hefner, publisher of Represent, a magazine written by and for teenagers in foster care, says that child safety should indeed be a real concern for these caseworkers, pointing out that behind the types of behaviors leading teens to foster care are often significant family problems that can take time to unravel. He praises ACS for providing more families with therapy. “Even if it weren’t evidence-based, I’d generally be in favor of this approach,” he says, but practitioners need to recognize the risks.

“There’s a real difference between a family breakdown, and where a parent is abusive,” Hefner says, noting that caseworkers in a home need to distinguish between the two—something that can be very difficult to do. “These are complicated cases.”

Some Represent writers who entered foster care as teens say they endured years of abuse that no one acknowledged. One young woman whose father repeatedly beat her was placed in foster care as a teen not because of her father’s abuse, but because she had become a chronic runaway to escape home. “She was going to therapy and it was along the lines of, ‘Why are you being a bad girl? You should listen to your father,’” says Virginia Vitzhum, editor of Represent. Vitzhum says this young woman felt she should have been placed in foster care sooner.

Hefner points out that, while studies have documented the poor life outcomes of young people who grow up in foster care, there is little data comparing them to those who have stuck it out in a “toxic” home. He says preventive workers need to be open to the possibility that foster care might be a better option for some teens and their siblings. While a young woman can run away from an abusive home, he adds, her younger siblings generally don’t have that option.

If these agencies are taking cases from ACS’s child protective staff and not once recommending a foster care placement, Hefner asks, is that because they have identified exactly the right families for their programs—or are the therapists overly biased against foster care? He and Vitzhum are among those who worry that the pressure to move cases quickly coupled with a philosophy to avoid foster care could leave some young people vulnerable to abuse.

***

The pressure to close cases fast is nearly palpable in Marta’s team meetings. At one, Jen, the team’s Spanish-speaking therapist, shared details of a case she is particularly proud of: A 14-year-old young woman who assaulted her teacher and other school staff in what the girl refers to as “attempted murder” got sent to Bellevue’s psychiatric hospital. After her release, child welfare workers wanted to send her to foster care in order to make sure she received mental health services. But Foundling’s FFT-CW workers pushed to keep her home.

Since then, the teen and her family have done well, Jen says. In her most recent session with the family, Jen taught the girl’s adoptive mother how to recognize signs that her daughter was about to have an outburst and explained how she could make sure her daughter took her psychiatric medication, something the young woman had avoided by hiding her pills. Jen also connected the family with people they could turn to when trouble hit, including the psychiatrist who agreed to meet with the young woman at her day program so she wouldn’t miss a session.

“Mom is very used to having services and help. She said to me, ‘Help me!” Jen said. “I pushed back to let her know she had the skills to do this. She could link up with providers herself.”

Marta murmured her approval. But when Jen said she wanted to give the family extra time to check in, Marta urged her to move on.

“Clinically we’re done,” Marta said. “We don’t do monitoring. We can’t have a case where all that’s pending is these resources. You’ve done a lot of great work for them. What are you going to do with them for another month? You are our only Spanish-speaking therapist.”

Jen smiled. “You must have gotten a new Spanish speaking case,” she said.

“Yes, and I don’t know what to do with it,” Marta said, laughing.

In contrast, when it comes to Patrice’s case involving the mother who says she wants her youngest child at home for the disability money he brings in, Marta does not push Patrice to move the family any faster. She focuses on helping Patrice find ways to engage the mother, to make her believe that this time, with this program, things can turn out differently. That means Patrice needs to come up with a more hope-filled way to regard the mother.

Jen offers her idea of what the mother’s noble intent might be. “It’s the livelihood,” she says. “Mom wants so badly to take care of the kids, she needs that money.”

Marta nods. “This money is so important to the family that if you lose it, you lose the other kids,” she says. “We reframe around things we don’t fully buy.”

Patrice looks slightly skeptical. “She calls her a bitch throughout the whole meeting with ACS there. There was a fight and mom scratched the kid in the eye. Mom kept saying she fucked the kid up and she didn’t care and she’d do it again.”

“If we don’t find a way to work with her, these kids aren’t going to remain with her and we know that foster care—in most cases—is not a better option,” Marta says, sounding firm and urgent.

“Mom’s homophobic,” Patrice continues, but Marta purposefully interrupts.

“What is causing the most reaction for you?” she asks. “The physical stuff? The way she talks to the kid?”

It takes Patrice a long time to answer. “Seeing her face scratched,” she says quietly. “That was not OK.”

“We aren’t saying it’s OK, but if we can’t find the noble intent, we can’t motivate the mom. Physical abuse we don’t reframe. We don’t want to tell these kids that it’s OK she’s hitting. But one reframe is, this is a mom who isn’t going to hide it. Kids are going to know when she’s upset…You could say, ‘You are going to be real with your kids. The problem is that you are so upset that you’re hitting them and you are talking about fucking them up.’”

Jen chimes in. “Sometimes before, I’ve said, ‘You care so much about your kids that you are trying to protect them. There are all these people in your house telling you what to do that you do the first thing that comes to your mind.’ I say that for the kids, not so they accept it, but maybe to put a different spin on it.”

“‘Maybe you are doing it because your parents did it, that’s how they showed love.’ I know you don’t buy it, but can you say it?” Marta asks.

Patrice considers this. “I think I can say some of that.” She adds that she is worried that if the mom goes on vacation with the younger child and leaves the 12–year–old with family, the girl will run away. “That will cause more fights,” she says.

Marta gives the mother the benefit of the doubt. “Mom is willing to take this kid on vacation to protect him. That shows she really wants to protect him.”

“Yes,” says Patrice. “I guess she really does care. The way it comes out is just so messed up, but I guess she really does care, somewhere in there.”

“Yeah,” says Marta. “We just have to tap into that noble intent.”

For a while the three young women discuss how Patrice could have handled the emergency conference differently, and how she can respond if the mother starts calling her daughter names again. Patrice notes that when the mother walks away and takes a lot of breaks from her children, it is, in a kind of heartbreaking, roundabout way, her way of protecting her children from herself, from her anger and frustration. Pointing that out to the mom, Patrice notes, might help her build more of an alliance with her.

“You do such a nice job of bringing up strengths,” Marta tells Patrice, who looks more assured than when she first began talking. “This is a mom who has not heard a lot of positive things about her family. You are doing a nice job with this family.”