Lauren McCarthy, PhD, LCSW shares a brief history of working with youth and families in Philadelphia and how that inspired her to learn more about increasing mental health care access equity. She identifies that we could provide all foster and kinship care providers with the same specialized training that therapeutic foster parents receive to improve placement stability for youth in out-of-home care. Lauren wraps up the conversation by talking about the many challenges that caregivers experience when navigating the mental health care system, particularly when youth enter acute crisis settings and the benefits of investing in better access to early mental health care.
Lauren McCarthy, PhD, LCSW shares a brief history of working with youth and families in Philadelphia and how that inspired her to learn more about increasing mental health care access equity. She identifies that we could provide all foster and kinship care providers with the same specialized training that therapeutic foster parents receive to improve placement stability for youth in out-of-home care. Lauren wraps up the conversation by talking about the many challenges that caregivers experience when navigating the mental health care system, particularly when youth enter acute crisis settings and the benefits of investing in better access to early mental health care.
0:00
You're listening to Radio Kemp, Elevating Voices to Cause Change.
0:05
Join us on our journey to prevent child abuse and neglect.
0:17
Welcome and welcome back.
0:20
This is Radio Kemp.
0:23
I'm Kendall Marlowe with the Kemp Center for the Prevention of Treatment of Child Abuse and Neglect.
0:26
Thank you for joining us today.
0:30
This year, in 2024, we have an opportunity through this podcast to go on a journey to discover new voices and to learn new things.
0:41
We're open to what we find on that journey.
0:44
Come with us.
0:47
The national dialogue now includes serious concerns about the mental and behavioral health of children and youth, and those concerns are even more acute when we think of kids in our American child welfare system.
1:00
Passionate cries for action are common in forms across the country, with lived experience outcries for a response to trauma, mass shootings and even suicide.
1:10
What do we do?
1:13
And how do we know what works and what might cause even further harm?
1:20
We have the blessing today of getting to know Lauren Price McCarthy.
1:26
Lauren McCarthy, thanks for being with us all today.
1:28
Thanks so much for having me.
1:30
I'm so excited to be here.
1:33
I bet you'll agree that if you're going to be a researcher, it's a good thing to have a strong innate sense of curiosity.
1:48
Where did that start for you?
1:51
When did you get curious about kids and families?
1:56
Yeah, that's such a great question.
1:58
I really think about research as the generation of new knowledge and an opportunity to learn throughout your life.
2:05
I first became interested in children and families after completing my MSW at the University of Pennsylvania.
2:13
I started working as an in home family therapist for youth originally in North Philadelphia and then I moved to a new agency that served the entire city and at age at age 1, At age 1.
2:27
Oh, wow.
2:28
I would say maybe 2627.
2:33
How how did that feel?
2:34
Did you feel like you had it all figured out?
2:36
I did not feel like I had it all figured out.
2:38
I felt very, I was excited.
2:40
I had known for a long time that I wanted to work with kids, particularly kids who were having really large challenges with their behavior.
2:49
But it certainly felt a little bit intimidating to have gone from, you know, being in the classroom to within a month sitting in a stranger's living room and talking to them about their child's behavior and things they were scared about in terms of their child's behavior and their child's future.
3:07
So a very steep learning curve, but really rewarding experience for me and, and what brought me to my new career as a researcher for sure.
3:17
And, and from there, what what happened next?
3:20
So I would say that I really swiftly learned, you know, the type of therapy I was doing that was a community mental health program and was essentially the last service that a a child could receive before being placed in a residential treatment facility.
3:37
So for those who might not be aware of residential treatment facilities, at least in Pennsylvania at the time, were settings where, you know, 12 or more kids received 24 hour care, medical, educational and behavioral health or therapeutic care.
3:55
Whether it was because their behavior had gotten so challenging that they weren't really safe to be in their home or community or because they had maybe developmental needs that their caregivers were not able to address.
4:07
And what I really swiftly realized is that a lot of the kids and families that I was working with, you know, these kids had been having smaller issues early in their life that were not addressed.
4:19
Whether that was because the caregiver couldn't get them to necessary appointments because maybe they live in one side of the city and their therapist is on the other side and it's like 2 buses in five hours.
4:30
Or because maybe they had the same provider turn over over and over again and couldn't get a single therapist to stick with them.
4:37
And, and what this really brought to my mind was this stark contrast with what, you know, the experiences I had had when I was a young person who was struggling with their mental health, when my siblings were young people who were struggling with their mental health.
4:52
And because of our race and class, my parents were able to just pick up the phone and get us an appointment with the local psychiatrist.
4:59
And, you know, we got into therapy and things resolved and we were able to move on.
5:03
And this injustice of this disparity in access to quality mental health care really struck me.
5:10
And, and that's when I started to really become curious about how, one, how do kids end up in these residential treatment settings?
5:19
And what are the ways that we can better support caregivers who might have less resources than that top 1% of caregivers in the country so that they can get their kid the help that they need early before their behavior becomes so scary or so unsafe.
5:34
They require that setting, that residential restrictive setting.
5:39
So those are the questions that motivated you then.
5:42
What did you do about that from that family's living room?
5:45
What happened next?
5:46
Well, I continued to work with families for quite some time.
5:49
I did that work for probably about seven or eight years, but that the questions persisted.
5:56
And so I went and applied to multiple PhD programs and was accepted to the University of Maryland School of Social Works PhD program, packed up and moved to Baltimore and started my training as a researcher.
6:12
And in more recent times, you've been something called a Birder fellow.
6:17
What's a birder fellow?
6:19
Yeah.
6:19
So I defended my dissertation in May 2022 and became a postdoctoral fellow, the Burger fellow here at the Kemp Center.
6:29
So this is an endowed fellowship, thanks to a generous donation by the Burger family that essentially supports further research training for a postdoctoral individual, so someone who's completed their doctoral degree in the past five years.
6:44
And it's been a wonderful experience for me.
6:46
I've had time that's protected to allow me to continue my dissertation work and get those changed from, you know, a academic product into a publishable research article or multiple articles.
6:59
As well as help support some of the important work being done here at camp, including evaluating some of our great programs and conducting some independent research as well.
7:10
So what did you learn through all of that?
7:13
And, and actually, I should ask first, you're not going to be a Burger fellow forever.
7:19
So what happens next?
7:21
Yeah.
7:22
So I'm really excited for the next steps, which is I will be coming on to the faculty at camp.
7:28
I'm going to be spending part of my time as heading up the behavioral health division of the Care Network, which is a program at camp that provides support and training to providers across the state of Colorado who maybe don't have access to the same resources that we have here in the Denver metro area.
7:45
And I'm also going to be spending some time, time supporting the work of what's known as Partners for Children's Mental Health, which is out of the Department of Psychiatry.
7:53
So I'll be helping the helping them evaluate some of their programs that are targeted towards increasing access to mental health care for youth in the state of Colorado.
8:02
You mentioned residential care, residential, what we now call residential treatment centers.
8:08
When I was a kid and my family took in teenagers out of foster care, they were called homes for children.
8:16
And the terminology has changed over the years.
8:21
You've had an interest in how congregate care, kids being grouped together, not in family settings, how congregate care is used, why it's used when it's not, who has needs for that kind of care.
8:39
What did you learn?
8:41
Yeah.
8:42
So I'm going to start with some of my findings from part of my dissertation.
8:48
I won't bore you all with the statistics, but essentially what I did is I looked at data from Maryland's child welfare system and based on where youth had been placed when they entered out of home care and how many times their placement setting had moved.
9:06
I identified kind of four groups of patterns of placement experiences kids had.
9:13
But the ones I want to talk about today is there were sort of two groups that were really defined by kids experiences with what's known as treatment or therapeutic foster care, in contrast to their experience with residential treatment and other congregate care settings.
9:30
So what we found in these two groups is there was one group of kids who had a little bit of instability.
9:36
They tended to move around a lot, but they never ended up in residential treatment.
9:39
And these were kids who had a high rate of being in this therapeutic or treatment foster care setting.
9:46
And then another setting that also was defined by kind of this high rate of treatment foster care, therapeutic foster care was also defined by having that low entry to residential treatment.
9:59
They tended to be a little bit more stable in their settings than the previous group.
10:03
But what these two groups had in common was the the kids who were in treatment or therapeutic foster care were not entering residential treatment.
10:14
And we think that's a good thing because we presume that means they're in better shape.
10:18
Well, there are a lot of reasons why we might want to reduce the use of residential treatment.
10:22
It's a very costly setting.
10:25
There's some evidence that it's not helpful for youth development to be in these settings for extended period of time.
10:31
And unfortunately, we've received increasing reports of ongoing abuse occurring in these settings, not only violence between youth, but also unfortunately, violence between staff and youth.
10:42
So there are of course, going to be kids who do require that higher level of care.
10:46
But currently we have so many youth that our resources are being drained just by keeping them.
10:52
And we're not able to devote resources to ensure that kids are getting quality care that we're betting the people who are interacting with the youth in these settings.
11:00
So I don't want to make the blanket statement that residential treatment is blanket a bad thing, but it is a setting that we want to use.
11:08
We want to be smart about how we use and we want to ensure that we're keeping the kids restricted to kids who really need that level of care.
11:16
So kids who do really need it can get the quality of care that they deserve.
11:21
And your article, and I write in thinking this is the article that appeared in the Journal of Public Child Welfare, Understanding subgroups of child welfare placement histories in the context of youth behavior and development, a latent class analysis.
11:36
So if treatment foster care, therapeutic foster care is a good thing for at least some of these kids with what we call a higher level of need, what is that treatment foster care?
11:51
But I want to first challenge you by telling you what a colleague of mine once said it is.
11:57
I was working in a state that was very much trying to increase the use of this and did use it as an alternative, very much in the way that you describe for a kid who might not do well in, you know, a kind of customary foster care setting, but we felt might not benefit by being institutionalized.
12:21
And we thought, is there a way to bring the therapeutic effects to a home setting?
12:28
But I was once in a conversation with the state director who was a big fan of treatment foster care.
12:36
But in a candid moment once, he said, ah, it's just hazardous duty pay.
12:43
We pay those parents more money because they're taking the tougher kids that nobody else will take.
12:50
And he was saying that with a sense of resignation and shame that it wasn't more than that.
12:58
I'm betting you're thinking that it should be more than hazardous duty pay.
13:02
So help us understand, in an ideal world, what is that therapeutic foster care?
13:08
What does that mean?
13:09
I'm a foster parent.
13:10
What's different?
13:11
Yeah.
13:11
So that's a great question.
13:13
As with many elements of the child welfare system, it can vary a lot between states.
13:18
In the ideal sense of what therapeutic or treatment foster care can look like, you have a caregiver who receives specialized training in how to support and respond to youth, particularly youth with a history of of trauma and developmental trauma to respond to their behavior, provide them with the support they need.
13:38
They're not maybe trained at the same level as a therapist might be, but they're giving special skills so that the treatment of youth might be receiving in a therapeutic setting in outpatient therapy or you know, what have you is being consistently carried through with the home.
13:55
Anyone who's a parent who's listening can probably identify with how stressful it might be when your child is behaviorally maybe engaging in things that you don't want them to be engaging in or that that are frightening to you.
14:09
And and that level of stress for the caregiver then becomes a reciprocal relationship with the youth, right?
14:16
So if the caregiver isn't given the tools that they need to support that child in, in de escalating or managing their emotions and coping with strong emotions and managing their behavior, the child's behavior is then going to get worse.
14:30
So in parent, parents get overwhelmed, don't they?
14:32
Parents get overwhelmed.
14:34
The kid has started breaking my precious possessions in my wife's study, things that she had since childhood and, and, and the foster child has started to smash these things.
14:48
I as a foster parent might understand that that foster kid doesn't want to do us harm, that they're expressing something.
14:57
But how do I deal with that exactly?
15:00
And that's what this specialized training can provide.
15:02
And it's not just material possessions.
15:04
I mean, these are sometimes families that have other children in the home.
15:08
And so they may be concerned about those children's safety.
15:11
And sometimes these behaviors are internal as well.
15:13
So we, you know, know that suicide rates among kids, particularly young kids, are increasing across the country.
15:20
And so that can also be really frightening for a caregiver to see a child who's hurting themselves or maybe hurting others and not knowing how to respond to it.
15:28
And so this specialized training for therapeutic foster care, when done right, when it's evidence based, equips that caregiver with the tools they need to provide that child with the environment that allows them to heal as opposed to increasing future behavioral issues.
15:44
Are you optimistic that we can do that with with all of the challenges that we have and state and local government and federal government in providing that kind of thing?
15:55
Can we do it?
15:57
I think that if we can find the will to devote our resources, the evidence on what works and what types of trainings work, what therapeutic foster care programs work is out there.
16:09
We know how to do this right and we know how to do it effectively.
16:12
Think it just comes down to are we willing to put the resources we need, material and, and human and otherwise into making sure that, you know, more caregivers are provided access to these trainings.
16:25
You know, in my ideal world, therapeutic foster care and the training that those caregivers are provided with would not be a unique setting.
16:33
We would give that cool to all, all caregivers of foster youth, both kinship caregivers and otherwise.
16:41
You mentioned resources, and I think many people listening to a podcast like this feel that we need to come up with the resources to do the right thing and that's the end of the discussion.
16:56
But when you get to state and federal budgets, we don't always have all the money to pay for everything.
17:03
Is this going to be a cost effective measure for our taxpayers who want to see these kids treated better?
17:13
Yeah, absolutely.
17:14
As I alluded to earlier, residential treatment is an incredibly costly setting.
17:19
And there are kids who, you know, in the child welfare system maybe don't end up in residential treatment, but instead end up in our juvenile justice system, which is also a costly system.
17:30
So I would encourage those listening who are wondering about whether or not this is a good use of our money to think of it as an an early investment.
17:39
If we invest resources, if we invest money in supporting these youth early, then we won't have to pay to house them in these institutionalized settings later in life.
17:51
And that's not just during their childhood, as youth grow into adulthood, you know, there's a lot of evidence that not having access to mental health care or, you know, experiencing placement in congregate care settings increases risk of problems into adulthood, which adds stress the system and increase cost later down the line.
18:09
So it's an early investment that I think is is absolutely worth it.
18:14
So where are you, have you gone and where are you going as a researcher?
18:19
Then from there, what's next?
18:24
Are we are we to be looking for another article to come out soon?
18:28
You seem like a relatively productive person.
18:33
In a short amount of time, you produced a lot.
18:35
What's next?
18:36
Yeah.
18:37
So I have an article coming out in Families and Society, which is another peer reviewed journal.
18:43
This was also part of my dissertation work.
18:46
Rather than taking a look at things from kind of high up from the large kind of systems wide level, I can For this paper, I conducted a series of interviews with caregivers of youth who had entered residential treatment.
19:01
And I just asked them about, you know, what were your experiences trying to get help for your child?
19:07
What were your experiences in terms of how engaged you felt in the decision making process?
19:13
How equipped you felt to navigate the mental health care system and ensure your child got what they needed in order to address their behavior?
19:20
Kind of what was that journey that ended with your child's entry into these restrictive settings and what did you find?
19:27
I found a lot of things.
19:28
I, I heard so many stories.
19:31
I would say the first thing I want to just emphasize is how much love these caregivers had for the children that they were caring for and how challenging it was for them to both be witnessing what we can just call scary behavior from kids.
19:45
You know, we already discussed things like destroying property, hurting themselves, hurting other people.
19:52
So how stressful it was to be witnessing that behavior, how heartbreaking it was for them to witness that behavior while also trying to navigate what is a really complicated system for caregivers, for youth.
20:06
So stories like we would find a therapist, my child would really like that therapist, and then that therapist would leave and go find another job.
20:15
But what I really noticed was what started happening when youth went beyond kind of your traditional outpatient, you know, you go to see a therapist for an hour and leave when their behavior would escalate to entering inpatient treatment facilities.
20:32
And So what caregivers described is once once kids entered these sort of short, short term acute inpatient facilities is they felt completely cut off from the decision making process.
20:43
They felt very uninformed.
20:45
And that, you know, this is a time when, you know, in order to be placed in an inpatient setting, a a kid needs to be really exhibiting some pretty scary behaviors.
20:55
So that what was probably some of the most heartbreaking and terrifying moments of these parents lives, They were also not being given information about what was going on with their child or given the power to have a voice in what steps were taken next for their child's care.
21:08
And you know that the Kemp Center in its current mission, its current mission statement, talks about things like justice and equity.
21:18
Is this an equitable system for caregivers?
21:22
That's a rhetorical question because I'd now like to read something from the article that you've just mentioned.
21:29
This study included an emergent theme related to power dynamics in their clinical relationship, the sub theme of caregivers attempting to regain power in decision making by refusing to bring their child home from acute inpatient care.
21:45
The presence of this theme has significant clinical implications related to how service providers are engaging with caregivers when there are disagreements about how to best meet children's needs.
21:56
The perception of coercion, that's a big word.
22:00
The perception of coercion in the therapeutic relationship is not unique to children's services.
22:09
Can we do this?
22:11
Can we serve kids in this way and even in some situations, institutionalized them and still do it in a way that is just and equitable for their families?
22:22
Yeah, that's such a sticky question.
22:25
I think the common story that I heard is, you know, parents describing my kid would enter a setting and a suggestion would be made by a provider about next steps.
22:37
And I would say I don't agree with that.
22:38
And the provider would say, well, you have to do what we're telling you to do or we will report you for medical neglect.
22:44
We will report you to the child welfare system and say that you are not providing your child with the care they need.
22:51
You're not, you know, collaborating with us.
22:55
You're not cooperative.
22:57
I want to be very clear that I don't think that you know, this is because people who work in the mental healthcare system, people who work in inpatient or other acute settings are evil.
23:08
People who want to harm families or want to hurt parents think they're overwhelmed.
23:13
I think they're overstressed.
23:15
And so they're often, you know, forced to operate within a system where treatment can be dictated by insurance companies.
23:25
They say you get 3 days and that's it.
23:29
That's all we'll pay for.
23:32
They're operating within a system where they might have, you know, 10 beds and, and two or three staff on a unit.
23:38
And each of those beds has a kit in it with really severe concerns.
23:43
And so they need to, you know, do what they can to kind of move things along.
23:49
And so I think that if we want to create a more equitable mental health care system for parents, we need to give providers the tools that they need in order to provide more equitable services.
24:01
What are those tools?
24:03
So I think more staff is like a pretty basic one, better training.
24:09
You know, there's a lot of research out there on, you know, how can you engage in, in conversations with families and, and not just families, you know, people who are adults who have mental health concerns experience coercion from the mental health care system as well.
24:23
You know, how can we train providers around how do we engage people from a different direction?
24:28
So, you know, maybe more of a carrot rather than a stick.
24:31
Coach them on how to have conversations with parents about what this might look like, you know, as opposed to just, you know, you better do what I say or I'm going to call big bad CPS on you.
24:46
You know, just financial resources I think are important, but again, that early investment and early mental health services, if we can make sure that kids are getting care when they are first exhibiting concerns, behavioral concerns, mental health care concerns, if we can get those concerns addressed earlier.
25:06
Like that story I told you about me and my siblings, right?
25:08
My parents were like, you're a little blue, let's take you to go see the doctor.
25:12
And we got it resolved, right?
25:14
That's not the experience that every kid has.
25:16
And, and these sorts of behavioral problems can act as a cascade, right?
25:21
Like it starts with something small and it snowballs over time.
25:24
If we can stop that snowball from building early, we'll have less kids in these acute care settings.
25:30
And then we can use those resources to, to provide quality care, to have more communication with children and families.
25:38
Providers will have the time they need to collaborate with families to sit down and really do a strong treatment plan, create a strong safety plan as opposed to, you know, I've got 6 discharges to get done today, so I'm going to do each one as quickly as possible so I can get back to my other responsibilities.
25:55
You know, so it's kind of this dual approach of stemming the tie by addressing things early, making sure caregivers have access early so that then those few kids who do and might always need those higher levels of care.
26:10
The providers at those higher levels of care are not overwhelmed, have what they need monetarily and otherwise to provide good care.
26:20
So what happens next with your curiosity?
26:25
I, I think we might all sense that you're not done.
26:28
So what questions do you intend to pursue next?
26:33
Yeah, that's, that's such a great question.
26:36
You know, my new role is going to have kind of two pieces to it.
26:39
One, I'm excited to maybe be dipping my foot a little bit more back into that clinical side through my work with the care network in terms of providing training and supervision and consultation.
26:50
But I'm also going to be supporting some work evaluating programs that are doing exactly what I just described, trying to get those early services.
26:58
So improving the presence of mental health treatment in schools, allowing pediatricians to understand how to screen kids for mental health concerns and respond to those mental health concerns.
27:14
Make sure that they know where to send kids who come into their office for their annual checkup and are maybe having some behavioral or or emotional concerns, as well as evaluating a program where caregivers are matched with a peer navigator.
27:32
So as their kids starts to exhibit some mental health concerns, a parent who has already had experience with that mental health care system will be a partner for them and help them navigate that system.
27:42
They've already been through it.
27:43
They know it well and they're going to help you get through it.
27:47
So that sounds, that sounds brilliant.
27:49
Have, have people done that?
27:51
Have we had, I've, I've heard of those kind of peer advocates, peer support in other fields before.
27:58
How does that happen in the mental health realm?
28:01
So if I'm a parent, I'm struggling this with my kids behavior and this person arrives, who are they and what are they doing?
28:10
So I think a good comparison would be something that we've seen in the educational system where for a parent who's trying to get special education services gets matched with the peer advocate.
28:20
So this is a parent who has already successfully gotten their child the services they need.
28:25
They understand the law, they understand policies and they know where to find help.
28:29
And so they kind of act as like a mentor or a guide to this new parent who doesn't understand these systems as well.
28:36
And most importantly, this is not a provider, this is another your parent, this is your peer, this is someone who understands the unique experience that you are going through, the unique stress that you might experience as a parent watching a child that you love experience these kind of scary emotions or scary behaviours.
28:56
So it's kind of this dual sharing of knowledge and mentorship with this emotional support and and validation and understanding that you that might not be as present with someone who hasn't had that shared experience.
29:08
They've been there, Yeah.
29:15
You know that the Kemp Center does a conference each year that in recent years has been dubbed a Call to Action Conference.
29:22
And so I've become fond of asking everyone I meet and on this podcast with all that curiosity, with all that knowledge that you're gaining and what is clearly a lifelong commitment to doing that, What's your call to action to all of us out here who want to help kids and families?
29:50
I think the first call to action I would have would be empathy.
29:57
When you're in the grocery store and you see that parent whose child is on the ground kicking, screaming, tearing things off the shelves, yes, it's disruptive to your day, but just take a moment to think about what that caregiver might be going through.
30:14
So that's the first thing, empathy for caregivers and also empathy for kids.
30:18
You know, we hear stories all the time about kids, behaviors, kids.
30:21
I think you mentioned earlier, mass shootings, school shootings.
30:24
You know, I'm a firm believer that children are not born bad.
30:29
You can't see I've got air quotes.
30:31
You know, behavior escalates over time and and recognize that every child has the ability to develop into a productive, healthy member of society.
30:44
If we make sure that every child has equal access to the resources they need to learn how to manage their emotions, to learn how to heal from trauma, to learn how to reduce scary behavior is express themselves in safer ways, manage their behavior in safer ways.
31:03
Every child has the capacity to do that.
31:05
We just need to make sure every child has access to what they need to learn how.
31:11
Thank you, thank you.
31:13
That's beautiful.
31:14
Lauren McCarthy.
31:14
Thank you, Lauren McCarthy for being with us and for what you do.
31:19
Thank you.
31:21
Thank you for having me.
31:23
And to our listeners, join us again month after month for this monthly podcast series in 2024.
31:32
Soon and often, this has been Radio Kemp.
31:41
Thank you for listening to Radio Kemp.
31:43
Tell us what matters most to you.
31:46
Go to the Elevate My Voice form on the Radio Kemp page at the kempcenter.org.
31:52
Until next time, Humble Helpers, stay curious.
31:56
Start following and connect with us on Facebook or LinkedIn today.