Author Archives: ir315

Of Podiatry and Oncology


Working in residential treatment, I often feel like my goals are different from those of my fellow corps members who work in family foster care. An institution is no place to grow up. In residential, finding a family, even if it is a foster family, takes primacy over permanency. You want your kids to get out of the system but if you can’t make that happen you try and get them at least out of congregate care. A child I wrote about a few months ago went home with a loving foster family at the beginning of the year. My greatest triumph.

The kids who come to residential are often the most troubled with the most challenging behaviors and diagnoses. Sometimes they are just teenagers and there are no foster homes accepting teens. They quickly learn challenging institutional behaviors.

All workers fear that something bad will happen to one of their kids, knowing that the odds aren’t in their favor. Sometimes I feel like I am waiting with baited breath for the next crisis or worst, the next tragedy.

I think about the boy I met the first day I came to the campus where I work. He was a baby faced thirteen-year-old who immediately tried to climb into my car. I took him to see his attorney in person, thinking that if he felt like someone was fighting for him, he might start to listen to me and to the mental health professionals working with him. I told him to be patient even though his permanency hearing had been adjourned thrice; by the time it actually happened, it was fourteen months after he came into the system. On the way back to the agency, he told me he wanted to be an architect.

Fourteen months in residential care because his sixty-seven year old grandmother was overwhelmed with two teenagers and couldn’t make them listen. They were the wrong color, the wrong income level and lived in the wrong neighborhood. ACS was called time and time again and after preventive failed to get him and his sister to go to school, refrain from marijuana use, and refrain from gang or criminal activity, he and his sister were remanded to foster care.

He didn’t really spend fourteen months in residential care. He AWOLed time and again to his grandmother’s. Once, he found me on the Metro North and talked to me the entire ride. I tried to convince him to come back to campus with me. He was too worried – grandma hadn’t picked up her phone in two days and was in poor health. He wouldn’t let me come with him to check on his grandmother and told me he would run away. I believed him. I asked that he call me and let me know if his grandmother needed help by leaving a message on my machine. He did, and came back a few days later but began to AWOL again and again. His grandmother told me that he sobbed in her arms after he realized she was alright. Mr. Tough Guy.

He usually refused to come back with me to campus. Once he got in the car and informed my coworker that he would be getting out at the next traffic light but not before giving her directions to the highway.

He desperately wanted to be home with his grandmother. He was removed from her care because he was smoking marijuana, involved in gang activity, and truant from school. In placement, he smoked marijuana, refused to go to school, and ran with the same gang. We weren’t helping him. We tried.

A new program designed to get kids out of residential quickly with intensive services began on campus and he was selected. We had a conference. We got the family to agree. He even met with the ACS worker after I promised we wouldn’t try and bring him back. He trusted me. He listened to her. That program lost funding. Court was supposed to be a few days later. It was adjourned again.

I kept checking up on him. I saw his face get harder and noticed that when I met with him outside his building, he had to tell several other young men that I was cool and to let me be. I saw his tattoos appear and multiply. I had to hand off his case to the missing child investigator. After the case was dismissed in court, he showed up on campus to go to school. He jumped up and down on the car I was driving. I told him to get off my car and he told me that it was the agency car and he would never do that to mine.

I did everything I could think of to keep him safe. I hoped he would be okay. I went above and beyond what was expected, often at the expense of paperwork because that child stole a piece of my heart with his impish mischief. When I found out that he shot himself in the head, perhaps on purpose, perhaps playing with a gun, that piece of my heart he had shattered. Last I heard he was in a coma.

Broken hearts heal like skin. They harden into scar tissue and that tissue doesn’t feel in the same way it did before. I know I did everything that I could do for this child, and I still replay every moment, thinking about how I could have prevented this.

Sometimes I wish my heart hardened more. It may have been easier then when I got a text message this week informing me that a child I worked with was dead. Coincidentally, he shared a name with the aforementioned baby faced architecturally inclined gun carrying child whose grandmother didn’t know what to do.

I met this other child at a state psychiatric institution where he had been for several months. He had been in residential care since he was eleven or so and learned how to grow up in an institution. I visited him monthly and marveled at his child-like wonder. He was seventeen. Eighteen came, and he decided to leave the hospital. There was nothing we could do. His therapist reminded him that he was going from the highest level of care in the system to being on his own. He refused to stay. He refused to come back. As we walked to the bank to have his withdrawal of consent to remain in care signed, he inhaled deeply and smiled. “Fresh air” he said. “I’ve been locked up since I was fifteen.” It was a long hospitalization. He was out longer than he was in before he committed suicide.

It wasn’t my choice or in my power to keep him safe. I still feel like it’s somehow my fault. I wish there were an instrument within the system other than a competency hearing in mental hygiene court to continue to help children in care older than 18 but younger than 21 even when they don’t want help.

During training, Barry spoke about expectations. He told us that we would see a lot of setbacks and to appreciate the victories. He told us an anecdote about two friends of his who were doctors. One of Barry’s friends loses a lot of patients. The other loses none. He asked us if we thought one was a better doctor. I don’t remember what we said. He then explained that both were excellent doctors but one was an oncologist and the other a podiatrist. Residential care can feel akin to oncology specializing in patients with stage four cancer who will lose their health insurance in a few months. I don’t know what the foster care equivalent of podiatry is. There probably isn’t one – it’s all too risky and tumultuous.

I know that I am an excellent worker. I know that I do everything I can for my kids. I go head to head with attorneys in a way that leaves my colleagues in awe. I’ve gotten pretty good at manipulating the system to benefit my kids and families.

I’m a great oncologist. I don’t know that losing clients will ever get easier. I don’t know that I want it to. I don’t want my heart to break so many times that it is all scar tissue. I want to still care. I want to still feel like my world will end if something bad happens to one of my kids because I need to have that passion in order to keep at it.

That being said, sometimes I wish I were a podiatrist.

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How Long Is A Year?

Alternate care. Out of home placement. Congregate care. Institution. There are a lot of descriptors for my placement. I work at a Residential Treatment Center, aka an RTC.

In the alternate, out of home, foster care system, there are many levels of care. Starting from the least restrictive moving on up to the most, we have Foster Care, Treatment Family Foster Care (also known as Therapeutic Foster Care), Group Home (first level of congregate care), and Residential Treatment Centers. RTC is the highest level, the last stop. If a child is at risk at an RTC, they will more likely than not be moved to a OMH (Office of Mental Health) facility such as an RTF (Residential Treatment Facility – in my experience, they look pretty similar to RTCs) or a psychiatric hospital, either acute (usually fewer than 6 months) or state (long-term).

Ideally, the level of care is appropriate to the child’s need. Today is my one year anniversary of being a Caseworker in Residential Care. It took me less than a week to realize that within the foster care system, nothing is ideal. The past year flew by. I still feel like I don’t know how to do a lot of things. I still cry from the stress and I still struggle with prioritizing 25 tasks a day that are all urgently needed by someone somewhere. It doesn’t seem like it’s been that long. A year is a long time however, especially if you are a child in residential placement.

Recently, there has been a push away from residential care. Children’s advocates were concerned that children were languishing in group homes with no concern for their permanency, safety and well-being. As is often the case complications arise when good policy is put into practice. Ideally, the only children in RTCs would be children whose behavioral or emotional needs are so great that they could not be kept safe in the community but I’ve noticed several kids come in to the RTC who would have thrived in a group home.

Again, nothing is ideal in foster care. Far from it. When I think about my year, I think about a child who has been at the RTC for 9 months. I think about the fact that we have been trying to step him down to a foster home since the day he arrived. I think about how he has decompensated and I think about how sad he looks when he asks me if he’s ever leaving. He should have left 9 months ago. He never should have arrived.

The truth is, there is a paucity of foster homes who are willing and licensed for teenagers. Especially male teenagers. Especially male teenagers coming out of Residential Treatment. A child emergently placed at an RTC because there is no immediate family foster care bed often lingers in the RTC. The longer he stays the harder it is to step him down into a family foster home. Foster parents are familiar with the system and many have bitter memories of the disrupted placements of former foster children who had to be stepped up to residential.

When I started at my agency, I was asked why I wanted to work in foster care. I said that I felt a calling to service and was told that a calling isn’t enough. Working in residential care was described as being akin to being drafted into a war. I wage war against the system, against my children’s worst instincts, and against the worst instincts of their caregivers.

At first I was terrified of working with emotionally disturbed teenagers. I was scared they would vandalize my car (it happened), steal my wallet (also happened) and run away from me in the community (has happened multiple times). My boys are the highlight of my work day and also my biggest headache.

I saw The Dark Knight Rises this weekend. My boyfriend rolled his eyes when I starting talking about the foster children in the movie, as I do about any movie involving children in care (Moonrise Kingdom was the most recent). I cried at one scene in particular, when Officer Blake recounts his time in care and tells Batman the following:

Not a lot of people know what it feels like to be angry, in your bones. I mean, they understand… foster parents.. everybody understands – for awhile. Then they want the angry little kid to do something he knows he can’t do: move on. So after awhile they stop understanding. They send the angry kid to a boys home. I figured it out too late. You gotta learn to hide the anger, practice smiling in the mirror. It’s like putting on a mask.

Working in foster care you quickly become acquainted with the weaknesses of the human heart. You will eventually be impressed with the resiliency of your kids. Resilient is maybe the wrong word. Children recover from trauma, but their behavior often reflects their emotional scars. I see the scarred tissue of my boys’ souls every day and every day it pains me not to be able to do more for them. In Residential Care, there are no foster parents. My kid has an off campus appointment? That’s me. Criminal court? Also me. School meeting? Me. Discipline and clinical work intersect as you and the treatment team constantly tries to figure out how to help each child within the limited flexibility of a highly structured program.

Sometimes I feel like it’s all too much for me. When I first started, I cried multiple times a day from the stress and feeling like I was doing a terrible job. I later learned I was doing a fine job but simply didn’t know the minutia of case planning in residential care. I still cry a lot, usually from the stress (it should be noted that I am a crier: last week I couldn’t find my shoe, I was hungry and my cat declined to cuddle and I was reduced to tears).

Today I cried for a different reason. Today I cried because of the aforementioned child, a child for whom I have done everything I can think to do in order to get him out of residential care. It hasn’t worked. It hasn’t been enough. I hate the system for sending him to the RTC and I hate myself for not being able to get him out faster. To care about a child in foster care, especially residential, is to have your heart broken a thousand times in a hundred ways. Today’s tears were angry tears, because I am angry too. My mask is anger, because it’s easier than being heartbroken all the time.


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