EDITOR’S NOTE:

This case study examines the complexities of navigating the child welfare system on behalf of a three-year old. It is made clear quickly that the Infant Mental Health (IMH) therapist has to become familiar with competing individuals, relationships, and issues, as often is the case when working with child welfare involved families. These types of cases can pose many unique challenges that can be difficult to assess in the moment.

An example of one of these challenges, played out in this case study, is the mandated reporting requirement. Most therapists face a time in their clinical career when they are confronted with the difficult decision of when to report suspected abuse and/or neglect; this decision is not always clear. The IMH therapist in this case had numerous concerns about the safety of her three-year old client and relied on her relationships with her reflective supervisor and the foster care worker to relay those concerns. By the conclusion of this case study, it is apparent that the foster care worker did not communicate the therapist’s concerns to anyone, but most specifically, she did not share them with Child Protective Services (CPS) or the lawyer-guardian ad litem (LGAL). Because of the severity of the therapist’s concerns, there was an opportunity for her and her reflective supervisor to consider notifying CPS in addition to the foster care worker all throughout this case. This may have made for an even stronger case about the seriousness of the therapist’s concerns and could have accelerated the process of involving the LGAL.

It is important to address the challenge of this situation, as we know that it is not unique to this case. Many therapists and supervisors struggle with the conflicting roles and relationships that are placed upon them within the legal and foster care systems. In this case study, the route that the therapist took – fiercely advocating for her client’s safety – led to his ultimate security, however, there are many different routes that could have been taken to achieve the same outcome.

It is of additional importance to examine the therapist’s mode of intervention; she utilized the Infant Mental Health Home Visiting (IMH HV) model (Weatherston & Tableman, 2015) as a basis for intervention within this case study. The IMH HV model came out of Selma Fraiberg’s model of “kitchen table therapy” which was coined and created in the 1970’s. It has not escaped our notice, that when Selma Fraiberg created this technique, it was used as a prevention service for parents who were still capable of being good parents, however, needed additional assistance in doing so. As the need and demand for services for 0 – 3 year olds has evolved over the years, traditional IMH services have expanded to incorporate intervention and treatment services. The IMH field has been challenged with how to incorporate the traditional model, created by Selma Fraiberg, into the legal and foster care system.

We invite you, the reader, to utilize the comments window found at the end of this article to share your own experiences, including challenges, successes, and questions, in working with child welfare involved families.

Three-year-old Jordan* was referred to a Community Mental Health infant mental health program because he was displaying signs of what his foster mother thought might be Post-Traumatic Stress Disorder (PTSD). His symptoms included severe separation anxiety, reoccurring nightmares, shaking, and stomachaches before visits with his biological father, Stan. Jordan would hide under furniture, screaming “Don’t take me! I am scared!” According to the referral, Jordan’s foster mom and teacher had also decided that it was not in his best interest to remain in his Early Head Start (EHS) classroom because of his persistent fear that his foster mother would abandon him there.

  “Don’t take me!  I am scared!”

Jordan’s biological parents had a history of life threatening and extensive domestic violence. He was removed from his parents’ care when he was 18-months old because of extreme neglect and physical abuse. After his removal, Jordan had had unsupervised visits with his mother and separate, supervised, visits with his father. Stan was not supposed to attend the unsupervised visits, but once, after Jordan’s mother invited him over, Stan held a knife to Jordan’s neck in an attempt to get his mother to do something he wanted. Jordan’s mother escaped and called the police. Neither she nor Jordan were physically injured; however, this experience added greatly to Jordan’s experience of trauma. Both parent’s rights were terminated soon afterward. Then, a year after Jordan saw Stan for the last time, Stan appealed his case and his rights were reinstated. A judge ruled that Jordan was to begin having supervised visits with his father again, effective immediately.

When Jordan entered the infant mental health program, he had been having weekly visits with his father for 6-months. Based on the information from the intake referral, it was clear to the therapist that she needed to attend the supervised visits both to observe Jordan and Stan together and to build relationships with them. Stan’s many concerning behaviors and statements were soon evident.

The IMH therapist believed that Jordan was being re-traumatized during the visits by things that his dad would say and do. Specifically, Stan regularly referred to knives and told incredibly violent stories; more often than not, he was part of the stories. The IMH therapist observed Jordan while Stan told these stories. Jordan’s face, which was typically flat and vacant during the visits, would transform. His eyes would widen and his jaw would tighten. If he was engaged in an activity, he would stop and his body would tense. Although he was very still, he looked as though he could run out of the room at any minute if he wanted to. The IMH therapist was aware of her own feelings of fear and wish to flee from the room as well.

The IMH therapist brought her own fears to her next reflective supervision: “How do I balance my feelings of being frightened with my wish to protect Jordan, while understanding my need to first build an alliance with Stan?” The IMH therapist wanted to react and move quickly to keep Jordan safe. The supervisor listened carefully, acknowledging how frightened the IMH therapist felt, and wondered if she might try to understand what explained Stan’s need to tell violent stories that frightened her and Jordan as well.

“How do I balance my feelings of being frightened with my wish to protect Jordan, while understanding my need to first build an alliance with Stan?”

During the next visit, the IMH therapist spoke with Stan about how Jordan might be experiencing hearing his father talk about knives. “That was a scary story. What do you think Jordan is feeling or thinking about what you just said? Could he be remembering past events where there was a knife?” she wondered aloud. Stan dismissed the IMH therapist’s questions and said, “That whole knife thing was long time ago. He was a baby. He’s fine now.” The therapist continued and said, “Just now, when you said, ‘knife,’ I saw Jordan’s face and body tense. Do you see his face right now?” Stan said, “That ain’t nothing. You’re making that up.”

On several other visits, the IMH therapist observed Stan scare Jordan purposefully and laugh when Jordan appeared hurt or sad. One incident was especially difficult. A small table tipped over and fell on Jordan. Jordan cried and looked first at the IMH therapist and then at his father. Stan laughed and taunted him, “Don’t be a baby!” and did not move to be near Jordan. The IMH therapist spoke aloud for Jordan, who was still crying, “That was scary, dad. The table fell on me and I am hurt.” Stan said, “I was toughened up like that when I was a kid and that’s how I’m raisin’ him.” “No kid should be toughened up or frightened like that. I am sorry that happened to you,” the IMH therapist said softly. She paused and both were quiet. She continued, offering developmental guidance about appropriate ways to talk with a 3-year-old, including the type and content of information that Jordan could understand. Again, Stan dismissed the IMH therapist’s concerns; it seemed as though he was unable to take on the perspective of others.

The supervised visits went on over the next two months, and Stan periodically related violent incidents that he had recently been involved in. Once, the IMH therapist observed Jordan look at his father, with his eyes large and his voice weak, and ask, “If I go to your house again, are you going to lock me in the basement again?” The IMH therapist waited for Stan to respond. Instead, he laughed and replied, “I only did it a couple times and I was joking.”   The therapist replied, “Stan, Jordan looks terrified. Look at him. His facial expression tells me that he did not think it was a joke. I am very worried about what that experience was like for Jordan. He continues to show us, week after week, that he is fearful of you when you say terrifying things and I am very concerned that these are the types of things he believes you will do to him if he lives with you again.” She was extraordinarily concerned at this point about Stan, the possibility that he might regain custody of his little boy, and the possibility of abuse.

Following this visit with Stan, the IMH therapist reported her concerns about emotional abuse to Child Protective Services (CPS), citing many of the concerning statements she had heard Stan say to Jordan during their visits together. The IMH therapist was incredibly disheartened and troubled when she received a letter in the mail a week later stating that what she described did not meet the definition of abuse and neglect.

At the same time, the IMH therapist balanced the complexities of building a relationship with Jordan and his foster mother, Ms. Stewart, within his foster home. The IMH therapist arrived on the same day and at the same time each week. Jordan and Ms. Stewart came to anticipate the therapist’s arrival and would wait for her at the window. Trust between Jordan, Ms. Stewart, and the IMH therapist was beginning to form. Ms. Stewart shared how relieved she felt that the IMH therapist was “really listening to her.” She believed that the IMH therapist was taking her concerns about Jordan seriously. During their visits, the IMH therapist observed Jordan smile, laugh, play and interact, as she would expect a 3-year old to do.

Within these same visits, the IMH therapist also observed the anxiety and panic that Jordan experienced when Jordan’s foster mother left the room. He threw his body on the floor and screamed, “Don’t leave me! Don’t leave me!” The IMH therapist observed Ms. Stewart go to him and calmly explain what she was going to do and that she’d be back in a few moments. The IMH therapist observed Jordan’s body remain tense as he added, “You won’t come back!” Although she returned in a few minutes, it took Jordan twenty minutes to calm down. All the while, his foster mother sat next to him, rubbing his back, and using her words to attempt to comfort him. Ms. Stewart shared, “This is how he acts every single day. He did this every morning when I dropped him off at Early Head Start. There wasn’t anything that I could say or do that would convince him that I would come back. That’s why we had to take him out of the program.” The IMH therapist said quietly, “That must have been so difficult for Jordan and for you. He was very, very frightened when you left him.”

The IMH therapist also was in regular, weekly, contact with Jordan’s foster care worker. Each time they spoke, the IMH therapist emphasized her concerns about Jordan’s well being, sharing specific observations of Stan’s behaviors and comments. On one particular call, she shared that she had made a CPS report with concerns about emotional abuse. She elaborated aloud, “Jordan asked Stan if he was going to lock him in his basement if he were to return to Stan’s home. He appeared absolutely terrified when he asked Stan this.” The foster care worker sounded surprised but shared that she had concerns as well; however, her main concerns were specific to Stan’s inability to behave age-appropriately with Jordan. She went on to say that Stan was following his treatment plan, which included getting his own mental health treatment and regularly attending the supervised visits, and said that neither she nor her supervisor felt that the foster care agency had much of a basis to terminate his rights at this time.

After a few months continuing this way, the therapist told her supervisor that she felt stuck and discouraged because Stan’s behaviors and Jordan’s reactions were not changing. The therapist was still incredibly worried about Jordan’s well-being and continued to believe that Jordan was being re-traumatized by his visits with Stan. The therapist wondered with her reflective supervisor about the depth of treatment that could occur given the limited reflective capacity that Stan had demonstrated so far within individual sessions with the therapist and the supervised visits with Jordan. Ultimately, they decided that the therapist should shift gears and use her time to advocate on Jordan’s behalf with court professionals. The therapist needed to ensure that Jordan would be safe. Only then would he be ready to process his trauma.

The therapist approached Jordan’s foster care worker with her plan and shared that she hoped that the two of them could join forces and advocate for Jordan. Unfortunately, Jordan’s foster care worker and supervisor felt “their hands were tied” since Stan’s rights had been reinstated. Despite her concerns, the foster care worker said she wouldn’t ask for termination of rights.

The therapist believed that she needed to continue to advocate for Jordan despite the foster care worker’s stance. Stan signed a release agreeing that she could speak with the child’s lawyer-guardian ad litem (LGAL), who had been working on the case for the previous two years. But before the therapist was able to express her concerns during a telephone conversation, the LGAL said that she was happy with Jordan’s progress – noting that the foster care worker had reported that Stan had actively been participating in his treatment plan and attending all supervised visits – and that she thought Jordan might eventually be returned to his father’s care. When the therapist reported that she had many concerns about Jordan’s and Stan’s relationship and ultimately Jordan’s safety and that she wanted to talk with her in person, the LGAL seemed surprised but agreed to meet. Upon hanging up the phone, the therapist wondered if the LGAL hadn’t known that anyone was concerned about Jordan’s situation or well-being.

The IMH therapist recalled that Jordan’s foster care worker had videotaped some of her observations of Jordan. She encouraged the foster care worker to share this video with the LGAL so that the therapist and LGAL could watch the video together. The LGAL started the meeting a bit defensively, talking about her observations of Jordan and Stan and saying, “within those few minutes that I was present, he always seemed fine, so I assumed he was.” The therapist shared her observations and concerns, including a videotape Jordan’s foster care worker had taken immediately before one of Jordan’s visits with Stan. In the video, Jordan can be seen visibly shaking and saying that he is scared to see his dad. He said, “I don’t want to see him EVER AGAIN! I want to stay home forever.” Jordan was also heard saying that his stomach hurt and that he didn’t want to go. The LGAL appeared shocked and thanked the therapist for sharing the video. She explained that during her observations, once every three months, she did not pick up on the fact that Jordan seems “terrified of his father,” which is what she said she strongly believed after seeing the video.

The therapist asked the LGAL if there was anything else that she should do to advocate for Jordan, and, ultimately, help Jordan feel safer. The LGAL stated that the therapist could encourage the foster care worker to let the prosecutor see the same video, but noted that Stan’s attorney would also need a copy of it. Within a day, the therapist contacted the foster care worker and asked her to make copies of the video and to make sure that Stan received one. Next, the therapist met with the prosecutor, who agreed to collaborate with her and helped create questions that the therapist could answer in court so that observers could understand the concerns about Jordan. They decided that the therapist should also share these questions with the LGAL.

On the day the IMH therapist was to appear in court, she and her reflective supervisor made plans to keep her safe; she was concerned and scared about Stan’s reaction to her testimony. During the permanency planning hearing, the prosecutor and LGAL both asked the IMH therapist the questions they had rehearsed: “Will you share with the court what you have observed of Jordan prior to visits with his father?” “Can you please share with the court your concerns of dad bringing up violent stories during supervised visits in front of Jordan?” “What have you observed Jordan’s reactions to be of these stories?” “Have you discussed with Stan the concerns of him sharing these stories in front of Jordan, and has he been able to make any changes to the stories he shares since your discussion?” At the hearing’s conclusion, the judge determined that supervised visits were not in Jordan’s best interest and that Stan’s parental rights would be terminated. The judge concluded by saying, “Jordan has made it very clear in the best way he knows how, that these visits are harmful to him. Stan has been given plenty of time and support to make changes to help Jordan feel safer in his presence and he has not been able to make these changes. Jordan has been more than patient over the last two years as we gave Stan another chance to parent his son. It is in Jordan’s best interest that he is given the chance to move forward with adoption by his foster family and continue in therapy.”

Relieved with this result, the therapist and foster mom decided to share the news with Jordan together. After Jordan’s foster mother told him that he wouldn’t have to meet with his father anymore, he smiled broadly and said, “Really!? I don’t have to go anymore!? You promise!?” The therapist knew she had made the right decision to press forward and work to keep Jordan safe.

“Really!? I don’t have to go anymore!? You promise!?” 

Jordan had been living with his foster family – who wanted to adopt him – for 2½ years when Stan’s rights were terminated. Now, the work to develop a narrative for Jordan and help him work through the trauma he had experienced could begin.

It has been three years since the therapist was introduced to Jordan; two years since his last visit with his father; and 1½ years since Jordan was officially adopted by his foster parents. Through extensive home visit services provided by the therapist, which include play therapy, supportive counseling, developmental guidance, advocacy, emotional support and infant-parent psychotherapy, when appropriate, Jordan has been able to work through his trauma and to develop a secure attachment relationship with both of his adoptive parents. Jordan is now 6-years old, thriving in kindergarten, and engaging in activities within the community.

*Names and certain details of this story have been changed to protect the privacy of the families described.