Rachel Jacoby, a licensed professional clinical counselor supervisor, once worked at a community mental health agency providing counseling services to youth in foster care. When she began treatment with an older teen, an unusual thing happened: The client referred to her as the number “14,” not by her name.
Jacoby says not using her name was the client’s way of reminding her that she was just another person in a long line of caseworkers and mental health providers they had worked with since being placed in foster care at the age of 3.
“They called me number 14 because I was the fourteenth counselor they saw,” Jacoby explains. Because of this history, the client assumed Jacoby wouldn’t be around for long and wondered why they should bother to build a relationship with her.
Jacoby, a member of the American Counseling Association, says the client’s response to her as a clinician is an example of the attachment problems that foster care youth, particularly those who are aging out of the system, experience.
“Instability is a very frequent experience in foster care,” Jacoby notes. She says she has known children in foster care who have been placed in more than 10 foster homes by age 9.
“If you’re going to build a relationship with a child who is living in foster care, … do your very best to stick around for the long haul,” she advises. “They need that. They depend on that.”
Facing difficult challenges
Jacoby, the current president of the Association for Child and Adolescent Counseling, a division of ACA, says children and youth are usually removed from their home of origin and placed in foster care by their state’s child protective services (CPS) agency if there is a report that their basic living needs are not being met or they are being abused or neglected. They can also be removed if CPS receives a report that their parents have mental health or substance misuse issues or that a parent or legal guardian has died.
And the number of children in foster care is significant. According to data by the Annie E. Casey Foundation, a total of 407,493 children and youth were living in foster care in 2020, and more than 20,000 youth left foster care without reuniting with their parents or finding a permanent home.
The goal of the foster care system is often to safely reunite children and youth with their parents or find them a permanent home with another family, but this gets more challenging the older the children are. Research shows that adolescents have a harder time being placed with a foster family. According to the report Keeping Kids in Families, published by the Annie E. Casey Foundation, only 58% of foster teens live with a family, compared with 95% of kids 12 and under, in 2017.
Chase Chick, a licensed professional counselor (LPC) in Dallas who works with foster care youth, says never getting adopted hits these young people hard and can often make it challenging for clinicians to connect and build trust with them in session.
Brian Russ, a licensed mental health counselor and an assistant professor of counseling at Xavier University in Cincinnati, says when a youth enters foster care, they may feel like something is wrong with them or their family. And this feeling that something is wrong with them or that nobody wants them may intensify if they do not get adopted.
“These feelings are strongly connected to worthlessness. As someone ages out, they may also have more mixed feelings,” Russ explains. “They may feel happy about their new freedom and autonomy. They may feel relief about leaving a system that has been traumatic. They may feel anxious and scared about being on their own without a safety net. They also may feel isolated and abandoned by losing their support system. It is complex and unique to each individual.”
Aging out of foster care can also bring additional hardships for these clients. According to the Annie E. Casey Foundation, one in five youth transitioning out of foster care report experiencing homelessness between ages 17 to 19, one in five have been incarcerated between ages 17 and 21, and nearly one in four report they became parents between the ages 19 and 21.
In addition, the counselors interviewed for this article say youth who are aging out of foster care are likely to have a history of abuse or neglect. In the article “Counseling adolescents aging out of foster care: A neglected and underserved population” published in the Journal of Counseling Research and Practice in 2021, Russ, along with co-author Taylor Tertocha-Ubelhor, stated that “foster youths’ mental health was their primary area of vulnerability because of the disruptions they had experienced during the early developmental stages of life.”
Whether youth are provided mental health services while they are in foster care largely depends on what state they live in, notes Jacoby, a visiting assistant professor in the Department of Counseling at Palo Alto University in California. She says some states provide counseling services and other benefits, while services from other states are more restricted.
Most children and adolescents are linked to counseling services when they are placed in a foster home, group home or other child welfare facility. They can also be referred to a community-based agency or practice that provides foster care counseling.
The management of state child welfare organizations also affects the level of care that youth receive in foster care. Russ and Chick say high turnover rates for caseworkers, due to heavy caseloads, and problems in reimbursing mental health practitioners for counseling services paid by Medicaid can also be factors. (For more on Medicaid and foster care, see a Counseling Today interview with Chick.)
Establishing trust and rapport with these youth is critical for the success of the therapeutic relationship. Clinicians must also be careful not to cause further psychological harm by using therapeutic techniques that focus on the adoption of an authoritative therapeutic stance or delving too quickly into the client’s past.
Calvin Young, a licensed clinical professional counselor in Illinois, says adopting an authoritative stance is counterproductive. “The goal of the clinician is to develop rapport with the client who has already been placed in a situation they may not wish for by authority figures, including the state’s child welfare authorities,” he explains. “An authoritative posture will not abet the development of trust or engender trust in the clinician as a neutral helper. An authoritative posture places the clinician in the role of another imperial authority who will not listen to or treat the individual involved with the child welfare or social system in a fair manner.”
Chick also advises counselors to move slowly and not press for therapeutic gains early in treatment. “A mistake that clinicians tend to make is they try to rush that process,” he says. “They try to get them [clients] to start spilling the beans right out of the gates.”
For example, Chick says asking about a youth’s experience with trauma too early can lead clients to lose trust and then hold back later down the line. Instead, he recommends counselors let clients come to them.
The counselors interviewed agree that clinicians need to be honest and genuine and not take themselves too seriously when building a therapeutic relationship with this population. They also need to be patient and wait for therapeutic gains and not be afraid to encounter resistance from their clients.
If a client has been in foster care a long time, they have learned to “read people real quick” and can easily spot someone who is disingenuous, says Amy Watson, an LPC and owner of a private practice that specializes in foster care counseling in Dallas. “They don’t trust you just because you’re a counselor. … They’re going to feel you out.”
She says these youth have adopted this skill of reading people quickly to maintain their own safety while adjusting to living in different environments and dealing with a revolving door of people in their life. For example, Watson’s says that about 80% of her clients who are aging out of the foster care system have experienced two to three failed adoptions.
Ebony White, an assistant clinical professor in the Counseling and Family Therapy Department at Drexel University in Philadelphia, says clinicians must know how to form a positive connection with others and they must be familiar with youth culture, specifically music, movies and social media.
Clinicians must meet these clients on their level and be able to engage in conversation, White says, often using the same lingo that young people use to communicate through texting (such as LOL or “periodt”).
White, an ACA member and owner of a group practice in Trenton, New Jersey, that serves children and adolescents, says it’s perfectly healthy if a youth is apprehensive or guarded when they begin therapy.
“I don’t believe anyone is resistant to treatment,” she explains. “When we label our clients as resistant, we’ve misjudged them. We’ve already put the onus of blame for their success or lack of success on their resistance.”
White says reticence on the part of these clients is natural, and they shouldn’t be influenced to behave any other way. “We’re asking them to disclose a lot about themselves, meanwhile we’re not telling them anything about ourselves,” she adds.
White suggests clinicians follow the example of “rolling with resistance,” a motivational interviewing technique that acknowledges that confronting someone does not always work and in fact may cause them to hold back or withdraw even more.
“Expect that it [resistance] will be present; it’s a natural part of the therapeutic process,” she says, encouraging her peers to ride the wave of resistance. “You follow the client’s lead.”
Young says cultural awareness and sensitivity are paramount in treating foster care youth, who are disproportionally represented in the foster care system. According to the Annie E. Casey Foundation statistics, Black children made up 20% of the youth entering foster care in 2020, yet they only represented 14% of the total child population in the United States, and Native American children made up 2% of kids entering care and only 1% of the total child population.
“The impact of foster care systems on communities of color in a negative way historically should be a primary grounding of the clinician who does not share the background of the youth in foster care,” says Young, an ACA member who has worked as a caseworker, supervisor and in a combination of clinical and administrator roles in social welfare programs. Primary grounding, he explains, is an overarching term that incorporates a person’s cultural, racial, ethnic, gender and socioeconomic background, which creates many of the unconscious biases that clinicians may bring to their work with clients whose appearance and background differ from their own. “Even counselors who share the same or similar backgrounds should be culturally aware and be constantly vigilant in regard to their own programmed biases,” he adds.
The counselors interviewed for this article all agree that trauma is the most common mental health concern for youth in foster care. According to the Casey National Alumni Study, published in the Improving Family Foster Care report in 2005, former foster children were almost twice as likely to suffer from posttraumatic stress disorder as U.S. war veterans.
Chick, co-founder of Pursuit of Happiness, a group practice in Dallas that provides counseling services to youth in foster care, says the clinicians he works with at his practice have treated young people who are survivors of severe trauma.
“We have had kids whose family members killed each other in front of the kids. We’ve had kids with terminal illnesses in foster care who do not know about their fate and the referral source is relying on us as counselors to break the news,” Chick says. “Our job is to bring these young souls back into congruence with the person they are designed to be so that they can successfully participate in society.”
The counselors interviewed also say person-centered therapy, sand play therapy, reality therapy and cognitive behavior therapy can help these youth build a bridge from their trauma to a healthy self-image and a more hopeful future.
Russ, an ACA member who has worked as a home-based clinician, outpatient coordinator and community support services director at Newaygo County Mental Health in White Cloud, Michigan, says youth who are transitioning out of the foster care system most likely have received less unconditional positive regard, empathy and genuineness — the core tenets of person-centered therapy — throughout their time in the system.
“We need to provide a healthy dose of these core conditions to facilitate growth,” he explains. “Similar to how a plant needs sunlight, water and carbon dioxide to survive, humans need relationships with unconditional positive regard, empathy, and genuineness to thrive.”
He recommends counselors use a four-component, person-centered framework for engaging this population and helping them process trauma:
- Invite the client to share about their trauma when and if they want to. If they do share, it should be at their own pace.
- When a client shares something traumatic, respond with an empathic statement that lets the client know that you understand how they felt. For example, you could say, “My heart goes out to you during that time; it must have been really scary for you” or “I feel angry when you tell me this story. I imagine you were also quite angry at the time.”
- While a client is sharing their experiences, help them clarify their thoughts and emotions by using reflective statements such as “I hear you expressing hopelessness. Is that accurate?” or “I am curious about the thoughts you were having while that was going on.”
- Be sure to communicate to the client that you value them as a person no matter what they have done or what has happened to them.
Although play therapy is designed for young children, Jacoby finds it can help teens process their trauma as well. She says the use of sand tray therapy can be effective. She once worked with a teen who had been in and out of foster homes for most of their life. She explained to the client how sometimes it’s easier to share one’s story by creating a picture in the sand.
Jacoby provided various miniatures for the client to choose from to create their sand tray image. She first encouraged the client to spend time feeling the sand with their fingers to bring a sense of calm. Then she invited the client to gather the miniature items they felt most connected to and use them to create a picture. The client selected miniatures of beer cans (ones for a cake topper), a house and a bonfire.
The client grabbed all the miniature beer cans and threw them into a pile in the center of the sandbox, Jacoby recalls. They placed the house in a far corner of the sandbox and placed the bonfire between the house and the beer cans. The client then scattered the other toys and miniatures on the rest of the sand. When they finished, the client said, “This is what my life looks like. I miss my home, but this is what it looked like; it wasn’t safe.”
The client’s picture represented their experience within their home of origin, detailing their feelings of being unsafe, Jacoby explains. Before being placed in foster care, the client lived in an area that was heavily populated by gangs. The client’s parents had alcohol and substance misuse issues and they struggled to pay the bills. The family often went without water or heat.
This vivid picture of early childhood trauma opened the door for Jacoby to help the client adjust to new environments, advocate for what they needed to feel safe and develop coping skills to help them work through their traumatic experiences.
She then used person-centered therapy to talk about what made the client feel safe, and she used cognitive behavior therapy to help the client reframe their negative thoughts. Jacoby also introduced the client to mindfulness to help them learn how to be aware of their feelings in the present moment. And all of her clinical work with clients embeds a trauma-focused lens, she adds.
Focusing on what clients can control
White, who has worked as a clinician in a group home for female foster care youth ages 15 to 18, says reality therapy can be effective with teens who are aging out of the system.
“You don’t know how long you’ll be with them,” she says. So she often asks these clients, “What can I help you with for the time we have?”
Reality therapy, which was developed by psychiatrist William Glasser, is a type of counseling that views behaviors as choices. Some mental health professionals, White notes, are critical of reality therapy because the approach does not acknowledge mental health diagnoses or the use of psychotropic medications.
But White says this approach helps clients “feel empowered by focusing on what is in their control instead of what isn’t.”
The goal is to “help clients identify and connect or reconnect with others in a healthy and satisfying manner,” White explains. “To help clients avoid recycling the past [and] to move clients to positive change as they see it and support clients in identifying and implementing a plan to get their needs met.”
Practitioners of reality therapy use the WDEP system, which stands for wants, doing, evaluation and plan. This system involves asking clients a series of questions to help determine what they want in life and what they can do to achieve their goals. Some example questions, White says, include:
- Is your behavior bringing you close to or further away from accomplishing your goals?
- What stops you from getting what you want?
- Who can help you get your needs met? How can I help you get these needs met?
- What can you do to sustain this behavior?
White says she uses questions from the WDEP model to encourage youth to think, perhaps for the first time, about how they can leave their painful past behind and build a future all their own. And she measures the success of her clients based on whether “their behavior aligns more closely with their desires, they are having healthy, satisfying relationships, and they have an increased awareness about their needs and how to get them in healthy adaptative ways.”
Preparing foster youth for adulthood
Although these youth need to move forward in their journey of recovery by working to uncover and resolve emotional wounds, they must also acquire the basic life skills to function as adults.
“You would think that kids who have had a rough upbringing would be all hard and ready for the real world,” Watson says. “But they’re not. They’re unprepared for adulthood, and that’s the fault of the system.”
The counselors interviewed for this article agree that these youth desperately need to learn independent living skills, such as how to take care of basic personal hygiene, balance a checkbook, wash their own laundry, go grocery shopping, pay a utility bill, or complete a job application and create a resume.
In their study, Tertocha-Ubelhor and Russ noted that “before an individual exits the foster care system, federal legislation requires that sufficient transition planning and care coordination is provided to the youth in foster care through the development of an independent living plan.”
Because foster care caseworkers are often overwhelmed, helping youth create an independent living plan can be viewed as just another task on a very long list of things to do, Russ and White note.
“The literature also speaks of how the foster youth a lot of times feel disrespected in the independent planning process for transitioning out of the system,” Russ says. “A lot of times they don’t feel they have as many choices as they should have.”
He says foster care youth should be guiding the transition planning process, but when caseworkers get crunched for time, they spend less time gathering their clients’ input. This leaves youth “feeling like they didn’t have a voice in it,” he says.
White, founder of the Center for Mastering and Refining Children’s Unique Skills (MARCUS), a nonprofit that provides youth with tutoring, mentoring and mental health services, says the problem is that transitional plans are not sustainable for these clients. “They have this plan in their hand and then they’re out on their own,” she explains, noting that these youth need support to navigate housing, employment and health care systems.
While youth are in foster care, they rarely, if ever, make decisions about their own well-being, White continues. This is largely the job of caseworkers. However, once these clients age out of the system, they must often make important life decisions with very little guidance.
The current practice of developing transition plans is “not really preparing our young people to be successful,” White stresses.
Young says, if possible, counselors should refer these clients to employment counselors or other vocational skills testing or placement organizations and community groups that provide mentoring and related services so their adult living skills can be addressed.
“Given that many youths in foster care may find themselves without a community or family support system, any strategies that build and reinforce independence should be deployed,” he says, including career and vocational testing as well as psychometric testing.
The counselors interviewed agree that although these clients can face hardships, counseling can help them heal. “Meet them where they’re at, ask them what their needs are and don’t criticize them for their experiences or adjustments to life,” Jacoby advises. Instead, strive to “understand their stories.”
Resilience and reform in foster care
Counselors who are aware of the many trials older adolescents face when they age out of the foster care system say the resilience of these clients cannot be denied. Amy Watson, a licensed professional counselor in Dallas who has worked with children and youth in foster care for more than 20 years, says it has been “a wonderful privilege” to work with this clientele.
“I wouldn’t want to work with this population of kids if it were all dreary and dark or if I never saw anything good happening,” she notes.
Many of Watson’s former clients who have aged out of foster care went on to become the first in their family of origin to graduate from high school or college. Others grew up to be healthy, loving parents who do not abuse their own children.
“I just see wonderful people thriving because they’ve made that commitment to themselves to make better choices,” Watson says. In fact, her clients often tell her that they are going to “break the chain” and not be like their parents.
The possibility for positive life outcomes such as these highlights the need to revamp the foster care system. Viewing foster care through a trauma-informed lens is critical, notes Brian Russ, a licensed mental health counselor in Indiana and Michigan.
“Without a trauma-informed philosophy, the foster system would be ignoring perhaps the most notable concern that foster youth experience — trauma,” he stresses. “Children are removed from their home often due to trauma. The removal process can be traumatic. And living in the foster system itself is full of transitions and uncertainties, all of which can be traumatic.”
Russ helped train mental health professionals, educators and law enforcement personnel in trauma-informed systems of care during his tenure as the community support services director at Newaygo County Mental Health in White Cloud, Michigan, from 2015 to 2018.
“By recognizing these traumas and making active attempts to mitigate them, a trauma-informed foster care system would provide a better environment for foster care youth to succeed,” says Russ, now an assistant professor in the Department of Counseling at Xavier University in Cincinnati. “This reform is more than a suggestion; it is an imperative.”
He stresses the need for counselors to advocate and work for change in the foster care system. “People are amazing. People can overcome a ton. We just can’t write someone off because they were in foster care,” he says. “One positive long-term relationship with a caring adult can be a mitigating factor for a lot of [these] concerns.”
Lisa R. Rhodes is a senior writer for Counseling Today. Contact her at firstname.lastname@example.org.
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