We first talked about finding a therapist for Mr. Toddler a year ago. We talked, and talked, did some looking around and in the end made some decisions that worked for our family, but the entire process was so tricky it gave me pause. Being a therapist, and one who works with kids at that, gives me insider trading info here, and even with all my work knowledge the process was just confusing. So I decided to write out my thoughts on how we navigated this way back when, and some thoughts on the business of finding a therapist for kiddos in foster care.
A year ago really hard things were happening in our family. Permanency planning was unclear, visits were terribly disruptive for all the kids, Mr. T’s daycare was not a good fit, neither was the next one we found for him. His little body was struggling; not sleeping, dysregulated, disorganized and even his little GI system was telling us he couldn’t keep up the life and stress he was being asked to. Initially, in the midst of making many other changes, we looked around for a therapist who would do dyadic therapy with us. Dyadic therapy is really just a fancy phrase for holding therapy sessions with caregivers and kiddos together. It’s not family therapy, where the client is the entire family and the clinician is supporting the family in healing, dyadic therapy is where the kiddo is the client and parents are there to be a support and learn skills for regulating and phrasing things for kiddos. Dyadic work means the parent is the parent in the room and the therapist facilitates the work between them to support healing. The therapist might make up games about how to create coping skills for calming down that they can practice at home, or maybe talk about bed wetting or encopresis in a way that supports reducing the shame and coming up with plans to manage it better, or maybe it is about working on a Lifebook together or grieving birth parents together.
My general thoughts are that for kiddos about 4-5 and under, there really isn’t an individual therapy process. I know other therapists have different ideas, so I will share here and claim all these rambling thoughts as my own. Little kids don’t need an outside adult they see once a week to forge an intimate and solitary connection with. Building an attachment with another adult, who is essentially a stranger, and is talking about hard things or sad things with you, creates confusion about what intimacy and primary attachments are for little kids. Developmentally, little kids typically get their needs met from their parents. Ideally, parents support them in building skills for regulating (you can have the toy back when you’re ready to not use it as a “monster-man-sea-guy” in the toilet, take deep breaths and let your body relax and feel loose before we move on from this fit of fury). Ideally intimacy, trust and feeling that you belong together is what helps kiddos feel they will get their needs met and helps them in developing that super important skill of moving on. Moving on is often what kiddos who’ve experienced trauma struggle with the most, transitions require the ability to move on from one thing to the next and take a leap of faith that it will be okay, moving on is the ability to not worry about saving face, or feeling embarrassed by accepting help and being okay with feeling vulnerable with someone else. The foster care overlay to all this, is that kiddos in foster care were hurt by their parents or people in charge of them, which is super confusing for them, as they receive messages from so many other places that parents love you more than anyone in the world and are the best people in your life (books, movies, commercials…). So on the one hand they are your best people. On the other hand they are scary and make you feel nervous about when or if bad things will happen and for how long it will last. This is a big break in the “parents as regulators” rule that kids need. Ergo therapy to help. And here I’ll add again, that my wish would be for a therapist to facilitate the strengthening of connections between kiddos and their caregivers, rather than building rapport, connection and trust independently with little kids, as developmentally that is not what they need. The skill they need now is a secure base, a person to be their go-to, parents who are able to hang in with them when it gets tough, parents who can get skills and can help these kiddos when they need help, parents who have language on how to set limits in a connected and regulating way. Sure a therapist can talk, practice skills, work on narratives of kiddos life in individual work, but then what? Where does it go when session is over? Nowhere. Dyadic work is the work here.
I think it is more a question of developmental stage, not chronological age that matters most with kiddos when determining what they need, or what will help them heal. Although as a general rule I’m in support of individual therapy for latency age kiddos, or kids like 6-7 and up. Older kids might need space to air feelings they worry caregivers won’t like (like that they don't like living with you, miss their birth parents, have shameful things they don’t know how to say, want privacy because things in the home aren’t going so well, etc.) or often they need help figuring out what the heck happened in their life. Complex trauma is tricky as it really causes such a host of tough behavior, internal discomfort and impacted self-esteem. All of that deserves support and healing. Lots of clinicians specify they work with complex trauma - which is great. Things I offer to friends when looking for a therapist: How much training and what kind have they gotten? There is a world of difference between international adoption, private adoption and foster-care adoption clinically. Someone who offers adoption expertise would be able to tell you specifically what his or her area of expertise is. For kiddos in the child welfare adoption process I would want someone who has worked for years with child welfare adoption families. Theraplay, Circles of Security, ARC, Bruce Perry’s Neurosequential model, and PCIT are all good places to look for credentialing.
For kiddos in foster care I’m primarily looking for a therapist who will be around. Interns are wonderful - I was one in many different placements, and they can be such a gift, but the shortened timeframe of their learning year makes this match so challenging. Interns typically have an 8-month rotation, following the academic school year, which isn’t a good match for kiddos who will likely need longer relationships than 8 months. When you figure it takes a few weeks or sometimes longer to really get a good assessment and relationship going, we are looking at around 6 months of therapy all told which is unfair to kids. So a clinician who is working at their job for at least the foreseeable future, check. A clinician with experience working with kids in foster care, check. A clinician who sees parents as an integral and important part of the work, check. My ideal here is a therapist who brings parents in for the last portion of the session (I usually do the last 10-15 minutes) and the focus is never on how the week went, troubles that are happening or an update as kids find that shaming and distancing. We focus on connecting, calming down (called down regulation if we’re being fancy) and stitching parents and kiddos together so I’m in essence handing off the connection I built up over the hour to the kid and family which is where it should be. If there are hard things to discuss, or if we’re processing a crisis which is typically the case, we do that in the beginning at the start of session, maybe that’s all together, then kiddos and I do some work around that, which usually means we have to find a way to tolerate talking about the hard thing, we make a plan for how we can repair and talk to your parents about the hard thing and maybe that means it’s not all happening today, and then we do joint session work at the end. This is the ideal, and many weeks we do our best to keep some routine in session so everyone knows what to expect. Little details change up based on what each family needs. I’ll add that the work for kiddos in foster care is to keep working at those skills of accepting help from adults, tolerating hard feelings and feeling safe in relationships. Really, these are the life skills they need when they grow up to support them in multiple domains. I need to get at these early and often, in a different way than I would if I was not working with kiddos who were hurt in their homes, in America, by people they are socialized to trust and feel incredible loyal to.
The biggest kiddos need much more privacy. Teenagers developmentally need privacy to be working on all that separation and individuation stuff they should be doing, so I still do joint session work at the end, but for a different purpose. The work often (although certainly not always) is to help everyone enjoy one another in the face of all the challenges or tough stuff. We do a lot of processing the hard things; the rule breaking, the drugs, sex and rock and roll, but big kids need connection and love, too. They don’t lead with it, but it can’t be missed so therapists who know kids find creative ways to get this done.
Okay, I imagine this sounds a bit like - ya, sure this is great but I’m on a waitlist and am going to get whoever is able to see us first because we need someone like four weeks ago, and my insurance limits me so I can’t be picky.
I tell my friends that when they first call for a therapist or agency to be clear about their wants, yes even if there is a waitlist. The list might look like this: long term therapist, someone who values and is engaged in family work, someone who has worked with foster kiddos for a number of years. The male/female, ethnic background preferences matter here too. When they are finally assigned to a therapist I often support them in asking the clinician to describe how a typical session goes for them, how they structure their session routine, how they handle getting calls during the week for updates and family info, how they plan to involve you in sessions. Even if you have someone who is newer or less experienced, this gives them an opportunity to take your questions back to supervision to get advice and guidance. It helps everyone start off knowing what to expect. It’s such a bummer when you feel like you have wasted months in therapy, have no idea what is going on, don’t feel like it’s helping and are worried starting over is worse then just keeping on. I also support folks in asking (and love when families ask me this) if this is not a good fit how will you know, how would it make sense to bring it up? These kiddos have been through so much, they deserve good, committed and quality therapy and there are so many folks out there doing it, or getting supervision to learn to do it better. My last piece here is if you feel this is not a good fit, or feel like nothing is changing or wonder what is happening in that therapy session, bring it up. When I’m facing uncomfortable conversations I always ask myself: Does my kid deserve me to do right by him here? If this is a clear yes then I do it. Bad therapy is worse than no therapy in my opinion. And many off track therapies can be changed with communication.
Healing takes time, certainly, but healing should be happening in small or important ways all along. Sometimes as the Mama, I’m often only able to see progress in reflection as I’m so absorbed in the day-to-day work that is our little family, like today for example, Mr. T walked out of a trampoline park after making a sweet friend (!!!!) and without incident, which is becoming a more frequent occurrence and offers us a chance to feel humble and grateful for how far we’ve come in a year. He walked out like it was nothing, like we would come back and he trusted us to be doing fun things at home with him, and it was just a normal day. I mean this is huge for us, just huge. And so easy to minimize or expect as most kiddos can just do this all the time. Growth is small and subtle and heroic. Healing happens and often this healing looks simply like living. Eyes wide open Mamas and Papas. I’m right in there with you, walking the path called healing right beside you.
Fostermom (The Therapist)