Working with foster children in her private psychotherapy practice in the 1980s, Dr. Toni Heineman realized that the profound effects of trauma and loss experienced by foster children were often exacerbated by another loss: that of their therapists.
Seeing too many foster children lose their therapists just because the allotted number of county-approved sessions ran out or the intern to whom they were assigned left the agency, Heineman set out to develop a better option. In 1994, she founded A Home Within.
Based in San Francisco and now a nonprofit with a network of psychotherapists in 22 states, A Home Within provides open-ended, pro-bono psychotherapy to current and former foster children of all ages “for as long as it takes.” On average, clients served by the program are seen for about three and a half years.
The agency also delivers online mental health tools and trainings for foster parents, court-appointed special advocates (CASAs), teachers, social workers and others working with foster children through its Fostering Relationships program.
Heineman has published prolifically on the topic of psychotherapy for children. (She is also a blogger who contributes to The Imprint.) Her latest book, Relational Treatment of Trauma: Stories of Loss and Hope, published in August by Routledge Press, is a collection of professional journal articles and book chapters Heineman has published over the past couple of decades.
The writing collected in the book, says Heineman, has a common thread: “It’s all about relationships.”
The Imprint recently sat down with Heineman to ask about her new book and how A Home Within inspired and informed it. (This interview has been edited for length and clarity.)
The Imprint: Your book seeks to address a gap in the literature on the treatment of trauma and chronic loss in foster care. Tell us about that gap and how your book fills it.
Toni Heineman: There is a particular trauma associated with the chronic loss that so many foster kids face. The losses are unexpected and unpredictable, although foster kids do come to expect to lose people over and over again, and they don’t let themselves open up, as we know.
What does it mean to not have the stability of a long-term, unconditional relationship with a parent or other caregiver? What is the impact of constantly having to adapt to a new environment if you’re moved from place to place?
Just to get down to real basics: in one place they only eat whole wheat bread, maybe you’ve never had whole wheat bread, and you don’t like it. What if you grew up in San Francisco and then you’re placed in the Central Valley? Those are two different worlds.
We would all rather belong than fit in, [but] it’s a lot of effort to fit in, to get the lay of the land, and figure out what’s the culture, how do people talk to each other, what’s the emotional currency here?
The other thing about foster kids, if they get mental health treatment, they’re often sent to clinics where they see a revolving door of interns.
And we ask these little kids to do this over and over again.
So that’s what I’m trying to address.
CSC: You say in the introduction, “It is through foster care that I have come to truly respect the profound connection between the capacity to think and the capacity to hope.” Tell us what you mean by that.
TH: We know there is an incredibly high rate of burnout and turnover in the foster care system: 40-60 percent of any group. Sometimes people burn out and leave, and sometimes they burn out and stay.
And staying often is made possible for people by going psychically and intellectually numb. One of the ways people manage trauma and try to control vicarious trauma is by stopping feeling but also stopping thinking. And if you’re not thinking, I don’t think you can be hopeful.
In order to be hopeful, you also have to be able to be creative because these are difficult situations. So I think they influence each other. Being able to think creatively creates a sense of hope, and having a sense of hope opens the door to creative thinking.
TH: Relationships are fundamentally interpsychic rather than interpersonal. We have interpersonal interactions just like you and I are doing right now, but the relationship is something we carry inside, and that’s a process that starts at birth.
Children are born with brains but they’re not born with minds. Minds are created, and the mind of the baby is created through the interaction with the mind of the mother or other caregiver. The child gradually takes his or her mind for her own. So a baby has no past and no future, is just in the present. The future is held in the mind of the parent or caregiver.
One of the most insidious things that a child in foster care loses is that single person who keeps them in mind. You get moved from one house to another, and you lose your teddy bear or your favorite blankie or some innocuous toy, but what you really lose is what the foster mother kept in mind for you. That’s left behind.
CSC: Given your long experience in the field, can you speak about the evolution of the understanding of trauma?
TH: I think there’s been a convergence. At the time I was in training, the particular kind of training and thinking I was exposed to had very much to do with internal processes and not paying too much attention to external events. And then, in different worlds, in different times, there’s been more attention to external events and not so much attention to the internal world.
Even though ACEs (Adverse Childhood Experiences study) has been around for decades, we’re just now beginning to understand what the impact of trauma is on behavior.
I was trained to ask, when someone comes into my office for the first time, “How can I be helpful to you? What brings you here?” But that’s not the way a lot of kids in foster care have been treated. They’ve been treated as if they’re bad, as if their inability to pay attention is either because they’re bad or because there’s something wrong with their wiring when in fact it may be that they are in such a hyper-aroused state because of trauma that they can’t think, and they can’t sit still.
A lot of foster kids have avoidant attachment. They stay away. They may push people away because they’re scared, and because that’s been very adaptive for them to learn to take care of themselves.
And that becomes problematic when you put them in a family, and you have these adults who want to take care of them and “boss them around,” and the kids in some ways are saying, “I don’t need you to be the boss of me. Where were you when I was 3 and going through garbage cans to feed myself and my baby brother?”
So I think as we pay more attention to the impact of external events on the child’s internal world, we have a better shot at getting at what’s going on.