Damon is 12 years old. Since his parents, Bob and Carol, were divorced several years ago, he has been living with his mother and brother, John, 15. Until a year ago, Damon regularly spent alternate weekends and some weekday afternoon time with his dad, but he became less interested in visiting, particularly when dad began dating Ruth, a new love interest. John almost immediately began refusing to go for visits, whereas Damon, although somewhat tentatively, continued. He even seemed to like dad’s new female friend, but he asked that she not be present at most visits. Dad acquiesced for a while, but he gradually included Ruth in more and more activities and gatherings. Whereas he initially checked with Damon about his preferences in advance, dad decided to just let his son find out about plans upon arriving for visits. This approach backfired dramatically one day when Damon arrived at dad’s apartment, expecting to enjoy a special father – son excursion to a major car show in town. He was incensed when dad surprised him with the news that Ruth would literally be going for the ride. Damon insisted on cancelling the weekend visit, and demanded to be taken back home, immediately. When dad returned with Damon, he was met by a furious ex-wife, who loudly excoriated him for being so insensitive, and uncaring. She indeed alleged, in full earshot of Damon, that Bob obviously cared about Ruth much more than he cared about his own son.

The above incident occurred a full year ago. For the past year, Damon has refused to have any contact whatsoever with his dad. His anger and displeasure with father have grown substantially during the year, and now seem to be entrenched. Damon has apparently determined that his dad is not a nice person, and that he has nothing positive to offer him. This is in contrast to a rather close father-son relationship that existed earlier in Damon’s life. Damon now declares that he has no desire to ever see his father again. Bob is beside himself. He is convinced that Damon’s feelings and preferences have been hijacked by Carol, whose words and deeds have served to alienate both boys from their father. He has petitioned the Family Court to have Carol cease her alienating behavior, and to ensure that visits be resumed according to court ordered schedule.

Is Damon an alienated child? If so, how did he get to be alienated? Is this something that naturally occurs as children of divorce approach adolescence? Is he merely following in his older brother’s footsteps, and modeling him? Is his alienation totally attributable to mom’s actions? Did dad make things worse? What can be done to remedy the situation?

It is helpful to begin by looking at the child’s presentation, without becoming preoccupied with causality. Most often, there are multiple explanations for why a child behaves as he does, particularly from the perspective of parents who find themselves in adversarial relationships with each other. Ideally, a child enjoys close, secure, favorable relationships with both parents, as well as with other caregivers (e.g. adoptive parents, step-parents, foster parents) who may be involved. As pointed out by Kelly and Johnston (2001), many children, even from healthy, intact families, may have an affinity for one parent, while still desiring contact with both parents. Other children may develop an alignment with one parent over the other, often as a sequela of family conflict. They tend to choose one parent with whom to have more extensive contact, while exhibiting resistance towards the other. Estrangement is seen in children who are exposed to domestic violence, substance abusive parents, child abuse, or excessive negative parenting. Such children have good reason to want to keep their distance from one or both offending parents. On the other hand, the alienated child’s rejection of his parent has little or no basis on actual interactions that he’s had with that parent. Kelly and Johnston define an alienated child as “one who expresses, freely and persistently, unreasonable negative feelings and beliefs toward a parent that are significantly disproportionate to the child’s actual experience with that parent.” Rejection of the parent is intense, total and intended to be permanent.” The child fails to acknowledge the presence of any redeeming qualities about the rejected parent. What makes this so problematic for the child is the very high risk of his eventually failing to find any redeeming qualities about himself as he gets older. A child’s sense of self, slowly develops from infancy as a derivative of the many, many messages of love, competence, and belonging that are internalized through interactions with each parent. In previous blogs, I introduced the construct of psychological permanence as an important mediator in the developing sense of self. In developing psychological permanence, the child gets a better picture of who he is, by first clarifying how he fits in and understands family of origin caregivers. The alienated child’s development of self is disrupted when he regards his rejected parent in such toxic terms to the extent that he doesn’t exist.

Damon’s dad is convinced that his son’s alienation from him is totally attributable to ex-wife, Carol. He surmises that Damon’s disapproval of Ruth’s presence coincides with Carol’s overt criticism of Bob, dating back to when they were still married. He points out how Damon actually uses the same words as he heard mother utter regarding how Bob cared more about his girlfriend than about his son. Is Damon being actively alienated by what mother is saying to him about father, or is the boy being influenced simply by what he has witnessed and overheard in mother’s presence? Carol insists that she has never attempted to undermine the relationship between Damon and his father. She says she feels helpless in her inability to encourage Damon to resume having visits with father. Regardless of the true etiology of Damon’s position, he does indeed present as an alienated child. He is entrenched in his anger towards dad; he wishes to spend absolutely no time with dad; his beliefs and opinions of dad are almost identical to those of mom; there is no ambivalence about dad; there is no circumstance where Damon might be prepared to accept Dad’s apologies; there is no apparent capacity to forgive. Damon’s healthy psychological development, through adolescence into young adulthood, will hinge to a considerable degree on whether he can be liberated from the emotionally stultifying corner he finds himself in. It remains to be seen whether he will cease to be alienated, and instead forge a meaningful relationship with his father.

In the next blog, we will explore how various measures may be used to complement behavioral data in determining when a child is alienated from one or both of his parents. One such measure that developed, the Gries Assessment of Psychological Permanence (the GAPP), is designed to offer a therapeutic pathway for restoring the parent-child relationship. There are also various remedies for this problem that have been applied by Family Court Judges and Referees which will be reviewed.

Leonard T. Gries, Ph.D.

February 28, 2015

                                                        PSYCHOLOGICAL PERMANENCE (part 2)

                                                     DETERMINING WHETHER PROBLEMS EXIST

                                  GRIES ASSESSMENT OF PSYCHOLOGICAL PERMANENCE (GAPP)

In my December 12th blog, I introduced the construct, Psychological Permanence, to help us understand the underpinnings of emotional health in the developing child. A broadened definition of Psychological Permanence includes the following elements:

·                 Psychological Permanence reflects the inner, subjective state of a child, who feels s/he belongs and is at peace with his/her place in one or                       more families with which s/he identifies.

·                 Psychological Permanence is a state of emotional balance or homeostasis, which is durable over time and across events; it may be subject                   to periodic relapse or destabilization due to developmental factors and/or significant new traumatizing events, but recovery is swift and full.

·                 Psychological Permanence reflects resolution of inner conflict concerning separation from one or both birth parents, and about attachment                   to custodial as well as non-custodial caregivers.

Psychological Permanence is particularly relevant in instances where the child experiences physical and/or psychological loss of one or both parents due to death of parent, abandonment by parent, significant mental or physical condition of parent, placement of child into foster care, termination of parental rights, adoption or alienation from parent often in the context of  a contentious custody case. It has been observed that in order to achieve Psychological Permanence, the child at risk may need assistance in addressing various sources of inner conflict, confusion and ambivalence regarding his/her non-custodial, distant, temporarily or permanently absent parent. Furthermore, the child’s perspective of his/her relationship with the custodial parent (e.g. adoptive parent, parent with primary residential custody, long term foster parent) must be sufficiently congruent with what s/he envisions as the ideal family environment.

The Gries Assessment of Psychological Permanence (GAPP), initially developed in 1997, is designed to tap into the child’s perception of his actual and psychological relationship with his/her non-custodial parent(s) and with his/her custodial parent or caregiver. As with other self-report measures, the GAPP yields a subjective estimate of how the child understands and feels about the significant adults in his/her life. In Part I, the child is asked about his/her perspective of the non-custodial parent(s), whereas in Part II, the child is asked about his/her relationship with the custodial parent.

Part I is divided into 6 sections, totaling 35 questions. Section A looks at the degree to which the various losses experienced by the child have been successfully mourned. These losses may entail physical loss, genealogical loss, social status loss, and/or loss of part of oneself corresponding to the absent parent. Section B addresses the presence or absence of feelings of betrayal and rage as consequences of past mistreatment or disinterest attributed to the non-custodial parent.  Section C pertains to the degree to which the child accepts blame for any felt estrangement from the non-custodial parent. Section D attempts to assess the child’s appreciation of the complexity inherent in his/her parent’s capabilities, deficits and personality. In contrast with the demonization of the distant or absent parent, often found in alienated children, the emotionally healthy child is apt to recognize the special qualities of both parents, as well as accept their limitations. Sections E and F reflect the outcomes of successful or unsuccessful resolutions of issues addressed in Sections A – D. Section E registers the child ‘s readiness to forgive others for disappointments experienced, as opposed to being preoccupied with a victim’s identity and need for vengeance. Section F explores the child’s vision of the future of his/her relationship with the distant/absent parent, and the degree to which such future outlook is governed by reality vs. fantasy factors.

In the non-illustrated version of Part I, intended for children and adolescents between 11 and 18 years, the subject is asked to agree or disagree with each printed statement, on a 5 point continuum. E.g. always, almost always/often, sometimes, almost never/seldom, never, feel or think the way the statement reads. An illustrated version of Part I is administered to children between 5 and 11 years of age. Two examples are provided in the following pages. The first shows an item from Section B, which taps into lingering feelings of betrayal and anger that may be active in the child. The second shows an item from Section C, which taps into any lingering sense of self-blame that may be festering.

The examiner introduces Part II by mentioning how there are many things that contribute to a happy, loving and well-run family. Fourteen factors are identified and defined. They include: Unconditional acceptance, unconditional love, full family membership rights, safety and security, basic life necessities met, material needs met, age appropriate opportunities, personal growth support, respect and trust, fairness regarding rules and responsibilities, fair punishment, social freedom to enjoy outside relationships, access to outside help, and permanent commitment to abide by the first 13 factors. The child or adolescent is asked to compare his/her own family with what is described as the ideal level for each of the 14 factors. The child is asked to estimate how close to the ideal score of 7 his/her own family fares. What emerges is a line graph illustrating the ups and downs, the strengths and weaknesses that the child perceives within his/her family at the time of the assessment.

Leonard T. Gries, Ph.D.   1/18/2015

Samples GAPP Items: 

In case you missed the newsflash, the Baseball Hall of Fame Veteran’s Committee failed to select Gil Hodges, again. If you read my November blog, or ever saw Gil play in-person, you have some idea of what a travesty the selection process is. It’s unfair to exclude him when there are so many others with less impressive credentials who’ve been admitted to the Hall. But somehow, Gil’s fans and family will survive this unfair oversight, because we know, deep down, what the truth is. Knowing truth about events that are important to us, about our relationships, and most importantly, about ourselves, far outweighs the significance of what others might think.
 Self-exploration and self-acceptance are the objectives which comprise the bedrock of a positive self-image and self-esteem. When we’ve achieved those objectives, we are in a good position to achieve almost anything we set our minds to. We’re also most likely to be happy campers. For those of us who enjoyed childhoods marked by secure attachments with parents or parent surrogates, and who were spared the experience of traumatic loss, the self-exploration path towards self-acceptance and positive self-esteem usually proceeds without major complication, through the turbulent adolescent years into early adulthood. Conversely, the process can be much more challenging for those who were not dealt such a fortunate hand. It’s not fair when an infant, toddler or young child is forced to traverse the formative years in the absence of a secure attachment to one or both biological parents. Traumatic loss can come in many forms: The death of a parent; abandonment by a parent; parental neglect due to mental illness, substance abuse or other condition; contentious divorce. Regardless of the reason, actual or psychological loss of a parent, particularly during the formative years from birth through six years, leaves a gaping hole in the child’s search for a complete, balanced self-identity. In order to know who I am, I need to know how I came to be, and how I am connected to my family of origin, and to my culture. The young child gradually establishes an individuated, self-identity through the process of internalizing much of the messages about him received from his caregivers. When the messages are incomplete, the development of a sense of self is incomplete. When the child is left to wonder why one or both parents weren’t available to him, or why one or both parents seemed to be uncaring, he is unable to complete the crucial process of self-exploration and self-acceptance.

In my work with children and families who’ve faced the challenges of foster care, adoption, and/or contested divorce, I found it helpful to utilize the construct, Psychological Permanence, to operationalize the meaning of having a comprehensive, balanced appreciation of oneself in the context of his historical connection to both parents, as well as to parental surrogates.The following attachment is an unpublished article that was written a number of years ago in an effort to elaborate on the construct of Psychological Permanence as it applies to adopted children. In my professional estimation, the construct can be equally useful when applied to children in long-term foster care, as well as to children living in significantly dysfunctional families. Children who find themselves in the middle of highly contentious divorce wars, and who are often subjected to the alienating behaviors of one or both parents, are also at great risk of being deprived of a sense of Psychological Permanence. Although life has been unfair in some ways to such children, hope is available as long as they are supported in their search for truth about who they are, and shielded from unhelpful, often toxic information concerning family members within family of origin, or surrogate families. In subsequent blogs, I will share the findings of a pilot study in which a special Psychological Permanence assessment tool was applied. In the meantime, I am hopeful that we can embark on a dialogue about how to expand on applications of this construct.          

Dedicated to my mother, Lillian K. Gries, on this the 109th anniversary of her birth.

Leonard T. Gries, Ph.D.

December 12, 2014

An important role of any mental health professional, who is a member of a service plan or treatment plan team, is that of client advocate.  Often it is the evaluator/therapist who is in a favored position to serve as spokesperson in behalf of the child client’s treatment, developmental and social needs. Within the foster care as well as child custody fields, judges, attorneys, guardian ad litems, service plan team members and family members rely heavily upon the mental health professional when considering major decisions affecting the child. In advocating for one’s client, it is important to be as objective as possible, but without losing sight of the intangible humanistic factors that should not be overlooked. Decision makers want to and need to know the facts about the client’s needs, strengths, and risk factors in his/her life, but they also need to appreciate what the client faces… from the client’s perspective. It is here that subjectivity often enters the mix, thereby increasing the possibility that projective identification, reflecting the needs and wishes of the provider, will complicate matters. The credibility of the human service provider as advocate hinges largely on conveying the perception that objective fact leads the way in decision making. The professional must be willing to allow the facts take him to the recommendations he or she is making. As much as he or she cares about and empathizes with the client, the professional needs to be sufficiently “disinterested” in advocating for any particular direction. In legal circles, this is often referred to as “particularized disinterest.” Whereas this is a worthy ideal to which to subscribe, we in the human service field usually find it almost impossible to emotionally detach to the extent that 100% objectivity is achieved.  Instead, we often inadvertently intertwine objective fact with sentimentality.

To illustrate, let’s take a look at the world of sport, wherein we as fans find ourselves passionately advocating, a.k.a. “rooting” for the player or team of our choice. Anyone who knew me during the early to mid-fifties, saw first- hand what a young, fanatic baseball enthusiast looked like. Sixty years later, I’m still rooting for the Brooklyn Dodgers. They are collectively etched in neuronal amber, preserved in all their glory as if they were still alive, and playing at Ebbets Field. A distinct advantage that I have over current day Yankee and Mets fans (although the Mets are my second favorite team), is the fact that my team hasn’t lost a game in 57 years. The following is a letter that I wrote three years ago in November, 2011, in my capacity as “client advocate”.  My  “client” was and remains one, Gilbert Ray Hodge (later Hodges), who played for the Brooklyn Dodgers very briefly during World War ll, before enlisting in the Marines, and then excelled for them, beginning in 1948 through 1957, after which the Brooklyn Dodgers ceased to exist outside of one’s reveries. It was and is my contention that Gil Hodges deserves to be in the Baseball Hall of Fame in Cooperstown, N.Y. What follows is my letter to the 16 members of the 2011 veteran’s committee who were charged with determining who was to be selected for this singular honor. Although I didn’t intend it, the letter is illustrative of a mix of objectivity and sentimentality. The factual accomplishments that I chose to highlight are indisputable. It is nevertheless possible that some members of the veteran’s committee may not have considered all the points made to have been terribly relevant. Then there is the effect of sentimentality (e.g. “… you simply could not be a Dodgers fan, without loving Gil Hodges;”  “…he was a winner with class”). When I injected these comments, did I simultaneously lower some of my credibility? Perhaps so, as Gil fell a few votes shy of garnering the requisite 12 (75%) votes needed for enshrinement. But, who cares, Mrs. Joan Hodges called to tell me that she loved it, and that she wished she had selected me as her Psychologist years ago.

Now, three years later, Gil is once again up for consideration. The reconstructed veteran’s committee no longer contains such Hodges supporters as the late Ralph Kiner or Tommy LaSorda, seemingly lowering his chances. But, who knows? Perhaps some readers would like to take the ball and run with it. Tell your friends, call the sports shows, or get in touch with such committee   members as Rod Carew, Al Kaline, Joe Morgan, and Ozzie Smith. Hone your advocacy skills and passion!

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November 11, 2011                                                                                                                                                             



Golden Era Veterans Committee
National Baseball Hall of Fame
25 Main Street
Cooperstown, N.Y. 13326

Gentlemen,

I am writing to you as a lifelong baseball fan and student of the game.  Growing up on Bedford Avenue in Brooklyn, New York, I was an avid fan of the Brooklyn Dodgers by the time I entered kindergarten. My earliest baseball memory is hearing from my first grade teacher , on the afternoon of October 3, 1951, that a man named Bobby Thomson  hit a home run to beat the  Dodgers, and win the pennant for the Giants. Rather than discourage me, this served to engender an even stronger emotional bond with the Bums. Beginning in June, 1952, and continuing through September, 1957, I attended many games at Ebbets Field. In most instances, that meant being driven straight up Bedford Avenue, along with my brother, Phil, in my father’s 1937 Dodge. About a mile and a half into the 4 mile trip, we’d  pass  by Gil Hodges’ home. Even as young kids, we were very much aware that Gil, a son of the Midwest, had become a full- fledged  Brooklynite,  once he married his beloved Joan. Of all the Dodgers, he was the one most identified as a local hero, even after Sandy Koufax joined the club as a teenager in 1955. Gil would show up at a Woolworth’s on Avenue U., to sign autographs and chat with us kids, or appear at the Bat-A-Way on Surf Avenue in Coney Island, where he’d blast shots over the elevated train platform in the distance, while we just stood there and gawked. If Jackie Robinson was the incredible dynamo and trailblazer, and Pee Wee Reese was the Captain and leader, and Duke Snider was the acrobatic, flamboyant, sometimes tempestuous superstar, it was Gil who was the quiet, humble, Gary Cooper style symbol of strength. You simply could not be a Brooklyn Dodgers fan without loving Gil.

I’m fully aware that in casting your votes for one or more of the 10 Hall of Fame candidates in this year’s Golden Era election, sentimentality, popularity, and even an individual’s character should not enter into your deliberations. One’s on the field performance, and his record of excellence, in comparison with his contemporaries, should of course be the sole criterion. With this in mind, I’d like to draw your attention to several facts about Gil’s career that may have gone unnoticed or de-emphasized in past deliberations about his suitability for inclusion in the Hall, but which, I believe, make him an eminently worthy candidate.

1.       From 1949 through 1957, Gil teamed up with Hall of Famer Duke Snider to be the key run producers on the team that dominated the National League for a decade. Over those 9 seasons, Gil led the team in RBI’s  five times, Duke three times, and both tied for the lead once. Beginning in 1949, Gil batted in more than 100 runs for seven consecutive seasons, most often while batting relatively low down in the lineup, usually sixth, behind Duke, Jackie, and Campy. During the decade of the 1950’s (1950 – 1959), Gil’s 1,001 RBI’s was the second most of anyone in all of Major League Baseball, trailing Duke by only 30.

2.       Gil batted in the two most important runs in the history of the Brooklyn Dodgers, when he produced the only runs scored by either team in the 7th game of the 1955 World Series.

3.       During his days in Brooklyn, Gil was among the pre-eminent right-handed sluggers of the era. Ralph, everyone knows that you were the man, with a home run to at bat ratio second only to the Babe. Hank, you and Ernie Banks, Frank Robinson and others began to establish yourself as elite, right hand hitting sluggers as the 50’s progressed, and you would eventually take your rightful place as baseball’s all-time home run king, from either side of the plate. But, it was Gil, who became only the second National Leaguer, and second right handed hitter in modern baseball history (i.e. since 1900), to smash four home runs in a game, as he did in August, 1950. He remains the only player to do this feat while facing four different pitchers.

4.       During the decade of the 1950’s, Gil’s 310 home runs ranks him second among all Major League players, trailing only the Duke, his left-handed hitting teammate, by 16. He was the most prolific right-handed hitting home run hitter of that decade.

5.       Gil Hodges ended his active playing career during the first week of May, 1963. He failed to hit a home run in any of his 22 at bats for the Mets that season. He completed his career with a total of 370 home runs, edging you, Ralph, by one. By today’s standards, the total is unremarkable; it places Gil in 70th place on the all-time home run list. But, consider this extremely significant fact. On the day Gil retired, he was the #1 right-handed home run king in his league. No right-hand hitting slugger, in the 86 year history of the National League, had ever hit as many home runs as did Gil Hodges – not Rogers Hornsby, not Hack Wilson, not even Ralph Kiner.

6.       Beyond Gil’s run-producing and power hitting credentials is the simple fact that he was considered by most to be among the elite defensive first basemen of his era. No right-handed first baseman made the 3-6-3 double play better than he did. His exceptional fielding talent wasn’t formally recognized until the Golden Glove award was introduced in 1957, when Gil won the first of three consecutive GG awards. Furthermore, it should not be overlooked that Gil’s defensive versatility  was evident from the day in 1943 when he broke in to the majors as third baseman, and then proceeded to perform admirably at every other position, except pitcher center fielder,  and shortstop.

7.       What Gil accomplished when he turned the Mets into World Champions, only 1 ½ years after his first game as manager, speaks volumes. No one should minimize the impact that Gil’s character, leadership,  and  Branch Rickey-bred baseball acumen had on what had been a moribund team since its inception. It is also so fitting that it was Gil, who hit the very first home run in Mets’ history in April, 1962.

If nothing else impresses you sufficiently about  Gil Hodges’ bona fides  as a Hall of Famer, please re-read fact #5, above. Thank you for giving serious consideration to the points raised in this letter, as well as to Gil’s other qualifying credentials, not the least of which is that he was a winner with class! Thanks also to you Hall of Fame greats for providing so many great moments, thrills, and inspiration to us fans ,  since  the end of World War II.

Sincerely yours,

Leonard T. Gries, Ph.D.

Psychologist and Baseball Fan

11/11/11; 11/10/14

Cc: Hank Aaron, Paul Beeston, Bill DeWitt, Roland Hemond, Dick Kaegel,  Al  Kaline,  Ralph Kiner,     Tommy Lasorda,    Juan Marichal, Gene Michael, Jack O’Connell, Brooks Robinson, Al Rosen, Don Sutton, Dave Van Dyck,  Billy Williams (2011).

Jim Bunning, Rod Carew, Pat Gillick, Ferguson Jenkins, Al Kaline, Joe Morgan, Ozzie Smith, Don Sutton, Jim Frey, David Glass, Phil Pepe, Tracy Ringold, Bob Watson, Roland Hemond, Steve Hirdt, Dick Kaegel  (2014).

  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

The key to happiness is now in the absence of I.