I find it rather fascinating that Treatment or Therapeutic Foster Care is finally coming into vogue in California; I mean, the state is 30+ years late to the party. Seriously.
By way of history, I started working in the human services industry in 1971 as a Deputy Probation Officer. For the next 15 or so years, I wrangled my way up through the ranks, serving seasons as a camp administrator, Chief Deputy, overseeing juvenile services for about eight years, and Chief for one year. For a chunk of that time, my department did Child Protective Services (CPS) as well.
It probably goes without saying, but over this tenure I became quite knowledgeable about services available to youth who needed treatment—traumatized kids with significant behavioral problems. Their options were limited. There was the California Youth Authority (CYA) for serious offenders, and then juvenile camps/ranches and group homes. Treatment/therapeutic foster care was never an option. There were some mom and pop group homes, but in reality, they did not offer a family setting, and especially not Therapeutic. Child welfare clients with behavioral problems also went to group homes, but an awful lot of them were hospitalized in psychiatric settings.
While serving as a Chief Probation Officer, I was exposed to the work of Robert P. Hawkins, PhD from the University of Virginia who was pioneering, in partnership with Presley Ridge, a new treatment model called “Foster-Family-Based Treatment.” Here is a quote from a research abstract Dr. Hawkins wrote in the mid-80s, “A foster-family -based treatment program recruits couples from the community that are willing to learn a set of treatment procedures and accept a disturbed or disturbing child or youth into their family. The couples apply the learned procedures consistently, and under clinical supervision, while they also provide good care and parenting. Though superficially similar to foster care, foster-family-based treatment exists for the purpose of providing treatment, and not just food, clothing, and protection.”
I was so impressed by Hawkins’ research and the wonderful outcomes being produced, far better than those of group homes, that I became determined to bring TFC to California. I finally found a very effective, family-based alternative to institutional care. I quit my job as Chief and plotted a way to accomplish my new goal. Nearly 30 years ago, in August 1987, I started Family Care Network, Inc., soon licensed as an FFA, and begin providing Therapeutic Foster Care following Dr. Hawkins model. To my knowledge, we were the first agency in California to provide treatment/therapeutic foster care as a primary program.
Our model was simple: we only hired licensed therapist as Social Workers, our foster families had extensive training, we limited the number of children/youth per home, provided very intensive, 24/7 support services to the child and family, and maintained small caseloads. We were providing a full array of mental health services before there was such a thing as EPSDT funded mental health contracts!
However, there is a caveat to this story—we received major push back from some County placement workers, their consensus being that “these kids need ‘real treatment’ in a group home.” I won’t bore you with the process of winning over our County partners, but we did, and we ended up developing one of the most effective, collaborative, TFC models in California.
Our program was an anomaly. There were many really great FFAs in the state, but none were doing truly therapeutic, mental health services. In 1993, Ken Berrick, the Seneca Center Founder, was successful in getting legislation through which created a pilot project for Intensive Treatment Foster Care (ITFC), which also included Families First. In 1995, legislation was passed to open up ITFC statewide. We jumped on that bandwagon as soon as we are able.
ITFC was a great step forward, but it was really not “therapeutic” foster care; rather, it was more of an intensive services foster care model. Yes, some of the basic TFC elements from Dr. Hawkins model were included, (e.g., specially trained families, small caseloads and behavioral supports), but there was no requirement or funding for a mental health services component. A few agencies like ours had the capacity to provide mental health interventions. It wasn’t until the late 1990s when we were able to negotiate EPSDT, children’s mental health services contracts, with the County, but only a few agencies statewide were successful in this regard. This process was substantially clouded by a pronounced misconception that the ITFC rate included payment for mental health services, which it did not. In fact, health services are disallowed under federal funding rules.
In 2008, ITFC was legislatively updated to clarify that EPSDT children’s mental health services were not included in ITFC, and were to be provided through a separate contract or made available through another provider. Reality check—there are very few ITFC providers in California and only a handful have been able to secure EPSDT mental health services contracts.
In 2002, along came major litigation against the state, a class action known as Katie A v. Bonta. It challenged California’s failure to provide home-based and community-based mental health services to children who are in the foster care system or at-risk of removal from their families. The lawsuit was especially concerned with California’s practice of confining children with mental health needs in hospitals and large group homes instead of providing services that would enable them to stay in their own homes and communities. One of the services being denied was TFC!
LA County settled the lawsuit in 2003, but California did not reach a statewide settlement until September 2011. Under the settlement, the state agreed to provide Intensive Home-Based Services (IHBS), in essence Wraparound services, Intensive Care Coordination (ICC), collaborative case planning and Therapeutic Foster Care. IHBS and ICC have been implemented, but nearly six years later, still no TFC! Oh sure, Katie A-TFC is close to implementation, but really…
Add to this challenge California’s “Continuum of Care Reform” (CCR), AB 403, which is designed to promote family-based care as an alternative to expensive, less efficacious group home care. CCR has great potential for implementing a national model of “family-based” care. However, rolling out CCR will take several years, and it is yet to be properly funded to effectively realize its desired goals.
To be blunt, the answer that has been staring the state in the face for over 30 years has been “Foster-Family-Based Treatment.” Unfortunately, there has not been the insight, will or leadership to make this solution happen. Had the state ventured down the necessary path three decades ago, there would have been no need for litigation or major reform initiatives!
I shared the Family Care Network’s TFC story for one reason: effective TFC is absolutely possible through commitment, collaboration, leadership and a shared vision to do what is best for foster children and youth. In San Luis Obispo County, since the advent of TFC and SB 163 Wraparound, group home placements have decreased by around 75% since the late 1990s. This County and my organization provides a model of what is possible—now is time for California to make a genuine commitment to have the most effective family-based treatment program in the country for children and youth.