Youth in foster care are particularly vulnerable to instability and impermanence (Hyde & Kammerer, 2009; Samuels, 2009; Unrau, Seita, & Putney, 2008) and experience trauma and childhood adversity at rates that far exceed that of the general population (Bramlett & Radel, 2014). Prevalence rates of trauma exposure among youth in care range from 80 to 97%, with many youth reporting four or more different types of traumatic events (Bramlett & Radel, 2014; Dorsey et al., 2012; Griffin, Martinovich, Gawron, & Lyons, 2009; Salazar, Keller, Gowen, & Courtney, 2013). Studies have linked placement instability to a multitude of adverse outcomes, including substance misuse, criminal justice system involvement, and failure to graduate from high school (Herrenkohl, Herrenkohl, & Egolf, 2003; Rubin, O’Reilly, Luan, & Localio, 2007).

It is not surprising that youth in foster care would be susceptible to adverse outcomes. Chronic impermanence weakens the material and social supports that youth need to cope with the environment in which they live, where relationships with adults may be perceived as unreliable (Hyde & Kammerer, 2009). Placement disruptions tend to re-traumatize youth and can affect their capacity to form new attachments (Geenen & Powers, 2007; Greeson, Thompson, Ali, & Wenger, 2015; Hiles, Moss, Wright, & Dallos, 2013; Hyde & Kammerer, 2009; Unrau et al., 2008). Thus, youth in foster care may benefit from trauma-informed programs that help them maintain relationships with supportive adults. The purpose of this study was to explore the experiences of staff who implemented a newly developed trauma-informed model called Intensive Permanence Services (IPS) and to identify the key characteristics of the model. IPS was designed to help youth in out-of-home placement who have experienced past trauma achieve permanency and strengthen their connections to supportive adults.

Background and Significance

Youth in foster care have reported feelings of instability, loss, anger, mistrust, and hopelessness (Geenen & Powers, 2007; Hiles et al., 2013; Unrau et al., 2008). Exposure to trauma exacerbates feelings of distress and increases youths’ susceptibility to posttraumatic stress disorder, depression, and maladaptive internalizing and externalizing behaviors (Greeson et al., 2011; Griffin et al., 2009; Salazar, Keller, & Courtney, 2011, 2013). Trauma exposure can impact socio-emotional development by changing how people process information and regulate their emotions and behaviors (Cook et al., 2005). These trauma reactions can also cause hyper-arousal, attentional deficits, and increases in risk-taking behaviors (Cook et al., 2005; van der Kolk, 2014). Fortunately, caring relationships with supportive adults may moderate the harmful consequences of past trauma, grief, and loss (Greeson & Bowen, 2008). Studies have found improved physical and mental well-being and enhanced academic performance among youth who had access to stable sources of social support (Ahrens, DuBois, Richardson, Fan, & Lozano, 2008; Munson & McMillen, 2009). Also, youth who have long-lasting connections with adults might be less likely to exhibit risky, violent, aggressive, or illicit behaviors (Ahrens et al., 2008; Munson & McMillen, 2009).

In addition to legal permanence achieved through reunification with biological families or adoption, the field of child welfare is increasingly paying attention to relational permanence, or the development of sustained, lifelong connections to caregiving adults (Samuels, 2009; Semanchin Jones & LaLiberte, 2013). Relational permanency is especially salient for youth aging out of foster care without legal permanence who are losing the support of their child welfare workers (Cusick, Havlicek, & Courtney 2012). Individuals with strong social networks typically enjoy greater access to financial resources and material assets (Greeson, Usher, & Grinstein-Weiss, 2010) and are more inclined to depend on trustworthy adults for practical advice (Hiles et al., 2013; Storer et al., 2014). Assistance from adults may contribute to favorable outcomes for youth. For instance, in Collins, Spencer, and Ward’s (2010) study, youth with natural mentors were far less likely to experience homelessness than their counterparts who lacked social support. Cushing, Samuels, and Kerman’s (2014) study found that youth who received financial assistance and had stable relationships with multiple caregiving adults were more likely to be employed and were better able to pay for their living expenses in adulthood than were youth who lacked these supports. These youth were also less susceptible to risk behaviors (Cushing et al., 2014). The results of the studies described above reflect the positive impact of supportive connections on resilience in young adulthood. Youth often address and heal from past trauma within the context of safe and supportive relationships, and this healing can help youth become more hopeful about the future (Greeson, 2013). There is evidence that youth who have positive future orientations are more resilient, purposeful, and perform better academically (Edmond, Auslander, Elze, & Bowland, 2006; Hines, Merdinger, & Wyatt, 2005), and that resilience may buffer the deleterious effects of trauma (Griffin et al., 2009).

Development of IPS

Anu Family Services (Anu), a treatment foster care agency that serves youth throughout Wisconsin and Minnesota developed Intensive Permanence Services (IPS) to fill a gap in existing practice approaches. IPS is a trauma-informed intervention model that utilizes family search and engagement strategies, as well as strategies that help prepare youth for permanency by addressing trauma, grief, and loss (Anu Family Services, n.d.). The goal of family search and engagement is to identify and engage family members and other supportive adults who are important to the youth and may be willing to support the youth in their path to permanency (Campbell & Turnell, 2014; Louisell, 2008). Although few studies have examined the efficacy of family search and engagement, the existing body of literature on this intervention points to its potential for improving outcomes for youth (Vandivere & Malm, 2015). For instance, youth who participated in a family search and engagement program called Family for Iowa’s Children were over two times more likely to achieve relational permanence and eight times as likely to achieve legal permanence than those in a comparison group (Landsman, Boel-Studt, & Malone, 2014). The youth in the family search and engagement group also had significantly reduced odds of aging out of care without a permanent placement (Landsman et al., 2014).

The model borrows from the works of Bruce Perry and Bessel van der Kolk to help youth heal and restore their capacity to connect. Perry (2009) used neurodevelopmental models and theories of human evolution to explain the impact of trauma on the brain during early childhood and the importance of supportive relationships to healing. Van der Kolk (2014) described the ways in which trauma impacts brain development and functioning and stressed the importance of self-awareness and mindfulness in trauma healing. IPS was also informed by the 3-5-7 model, which promotes the healing process as crucial to preparing youth for making and sustaining supportive connections (Henry, 2005). IPS workers use strategies that support the youth in answering the following questions: Who am I? What happened to me? Where am I going? How will I get there? and When will I know I belong? (Henry, 2005). Finally, IPS draws from White Hawk’s (2005) work, which promotes spiritual connections to one’s origins as a core component of healing. Trauma and grief-focused treatments such as these increase resilience and psychosocial functioning among youth (Day et al., 2015; Weiner, Schneider, & Lyons, 2009). In one study, for example, a trauma-informed treatment model was more successful than traditional foster care at enhancing youths’ sense of belonging and willingness to rely on informal supports (Nesmith & Christophersen, 2014). Youth who received the trauma-informed intervention were more likely than the comparison group to feel hopeful and prepared for their transition to adulthood (Nesmith & Christophersen, 2014).

Description of the Model—IPS

IPS is delivered by staff who have completed extensive training in providing intensive services to youth and their supportive connections. IPS workers typically hold degrees in social work, counseling, or psychology, as well as clinical licenses, or have previous experience working with children and youth in care who have experienced trauma. IPS workers are responsible for guiding the youth in their healing process, searching for and connecting the youth to supportive adults, and collaborating with the youth’s treatment team. IPS staff maintain low caseloads so that they can spend a considerable amount of time working with each client. Referrals are made to IPS by other service providers, such as county child welfare workers, who are working with youth in need of permanency, including youth in adoptive homes, foster homes, or residential settings. IPS is delivered in four phases that take approximately 24 months, on average, to complete: Phase I—the Trusting Phase (0 to 10 months), Phase II—the Healing Phase (6 to 18 months), Phase III—the Connecting Phase (12 to 18 months), and Phase IV—the Supporting Phase (18 to 24+ months). Although many youth progress through IPS in the timeframes specified above, IPS can be an iterative process. The length of each phase, as well as the overall program, vary substantially based on youths’ past experiences with loss, grief, and trauma, and on cooperation and support from the funding partners, treatment team, and others. Ongoing loss and trauma can require more time and attention in each of the phases. A brief description of each phase is outlined below.

Trusting Phase

During the Trusting Phase, the IPS worker’s primary role is to build trusting relationships with the youth, which can take months to establish and sustain. During this phase, the IPS worker begins an exhaustive search for family using multiple strategies, such as in-depth case record reviews, mapping possible connections with the youth and their immediate family members, and listening for clues about who is important to the youth. The IPS worker also begins to build trust with other stakeholders during this phase, including the treatment team and family members.

Healing Phase

As the youth continues to build trust, the IPS worker begins to support the youth in processing past grief, trauma, and loss. Trauma work during the Healing Phase involves helping the youth identify and address trauma responses and pain-based internalizing and externalizing behaviors that may have prevented them from developing positive relationships with caring adults in the past. IPS workers use specific tools (i.e., genograms, connectedness maps, timelines) during both the Trusting and Healing phases to help the youth identify meaningful connections and build hope for the future. IPS workers also help children and youth integrate and maintain memories and mementos of significant life events that took place before, during, and after out-of-home placement.

Connecting Phase

During the first two phases, IPS staff collaborated with the youth to identify people they loved and to whom they felt a connection, as well as places, items, groups, or memories that were relevant to the youth. The primary aim of the Connecting Phase is to facilitate new or rekindled connections between the youth and their potential supports. During this phase, the IPS worker ensures that the connections are safe and coaches the supportive adults before facilitating any contact with the youth. The IPS worker also supports the youth in building relationships with supportive adults, continuing to heal from past traumas, and learning healthy socio-emotional skills.

Supporting Phase

During the final stage of IPS, the Supporting Phase, the IPS worker continues to help the youth trust and depend upon their supports. The central goals of this phase are to support the caregiving adults in managing and sustaining their new responsibilities to the youth and to help the youth integrate their new connections and re-connections with caring adults. Youth in IPS have experienced many disrupted relationships, so it is crucial for the IPS worker to develop a shared language with both the youth and the supportive connections that creates realistic expectations and builds understanding about the impact of past losses on current relationship building.

Preliminary Pilot Outcomes

Data from the initial pilot projects of IPS point to promising outcomes for youth who discharged from the program (N = 34), particularly those who were able to complete the first two phases and at least begin the third phase. Eighty percent of youth who completed at least 13 months of IPS (N = 20) achieved legal permanency. However, youth who were unable to complete IPS did not achieve legal permanency at this rate. There was also a significant increase in scores on the Youth Connections Scale (YCS) from the time youth initiated services (M = 43.10, SD = 14.24) to the time they were discharged (M = 52.68, SD = 15.03); t(30) = 2.75, p = .01. The YCS measures the number, strength, and types of support for youth in out-of-home placement from caring adults (Semanchin Jones & LaLiberte, 2013). Although further outcome research is needed, initial evaluative data suggests that IPS may help strengthen supportive connections for vulnerable youth.

The Present Study

The purpose of the current study was to explore the perspectives of staff who implemented IPS at Anu, a treatment foster care agency that serves youth throughout Wisconsin and Minnesota, and to identify the key characteristics of the model. Youth in IPS have experienced significant trauma, abuse, neglect, or medical issues, and many have undergone multiple placements in out-of-home care before being referred to Anu. We aimed to answer the following research questions: (1) What are the key characteristics of IPS? (2) How do IPS workers characterize their experiences implementing the IPS model with youth? and (3) What barriers did IPS workers encounter in their work with youth? We used qualitative data analysis of agency reports, surveys, and interviews with Anu staff to answer the guiding research questions and to explain the model’s underlying conceptual framework.

Methods

Sample Participants

Study participants were staff who piloted the IPS program at Anu (N = 7), including administrators, supervisors, and IPS workers. All of the participants were women and had worked with the agency for at least two years. Four of the participants reported working directly with youth, one was responsible for supervision and oversight, but had prior experience working with youth, and two were administrators. Administrators were included in the sample, as they were integral to the implementation of the model and were able to speak to the key characteristics of IPS. Participants had implemented IPS with 12 youth on average, with a range of four to 27 youth total. Most (n = 5) had Master’s degrees or higher, and all participants had between 9 and 25 years of child welfare experience. Examples of previous work experiences reported by staff include public child welfare casework, mental health counseling, and group therapy at residential treatment centers. We recruited staff via an email that explained the purpose of the study and the procedures involved. All of the participants we approached agreed to participate in the study. The email contained a waiver of the signed consent form and an invitation to join the study. The option to take part in the study was voluntary, and it was made clear that all responses would remain anonymous. Individuals were eligible to participate if they had experience in designing, implementing, or overseeing IPS services. The study protocol was approved by the institutional IRB of the research team.

Data Collection

After participants reviewed the consent form, we invited them to complete an electronic survey that contained questions about the strategies they had used to guide youth through the phases of IPS and what they had learned while implementing the program. The survey consisted of 10 open-response items and was administered via the Survey Monkey website. At the end of the survey, participants were prompted to provide their email addresses and phone numbers so that we could contact them for follow-up interviews. The qualitative interviews were conducted via the phone, audio-recorded with a digital recorder, and lasted for approximately 60 to 90 min. The recordings were transcribed verbatim. The interviews were semi-structured and included questions that allowed participants to elaborate on their survey responses. We also asked participants to draw from specific case examples to discuss the challenges they faced while working with youth and what they learned from their experiences. After completing their interviews, we invited two staff members to participate in member checking to ensure the credibility of preliminary findings (Creswell & Miller, 2000).

Data Analysis

After de-identifying the survey responses and interview transcripts, we used a qualitative data analysis software, ATLAS.ti, to analyze the data. First, we reviewed the relevant literature and program materials to develop a list of predetermined codes and subcodes (Saldaña, 2016). We applied these deductive codes, as well as inductive codes that emerged from the data to our first round of coding. We used an iterative coding process to account for the development of new codes as each additional interview transcript was analyzed, using cross-case comparisons (Creswell, 2013; Miles & Huberman, 1994). We coded and recoded the interview transcripts and survey responses separately and met between each round of coding to refine our list of codes until we reached full agreement and no new codes emerged from the data. After completion of the initial stage of coding, we used the query function in ATLAS.ti to look for potential patterns across respondents. We identified themes that highlighted key characteristics of the model according to participants’ experiences, as well as themes related to the barriers participants faced during implementation. We had no conflict of interests in this study, and we aimed to increase the credibility of the study by using member checking to ensure that our findings accurately reflected the experiences of the participants and by triangulating the data from multiple staff perspectives and agency documents.

Findings

Between November 2016 and March 2017, we interviewed and administered electronic surveys to seven IPS workers who implemented IPS. We identified three overarching characteristics that participants described as key to the IPS model, including: (1) using a youth-driven approach; (2) having an organizational culture of well-being; and (3) promoting overall systems changes in work with children, youth, and families in child welfare. We also located subthemes within each of these areas that highlighted the strategies that staff felt were critical to implementing the IPS model. Finally, we outline several barriers that participants encountered as they implemented IPS.

Youth-Driven Approach

“Showing Up”

The model’s youth-driven approach necessitated a high degree of accountability to the youth. Staff followed through with their commitments to the youth, consulted with the youth before making decisions, and gave the youth the power to set and maintain standards of accountability. All of the participants in our study agreed that consistency and transparency were critical to breaking patterns of relational trauma that had compromised the youth’s ability to trust adults. Staff frequently used the term, “showing up,” when discussing these characteristics of the model. According to one participant, “showing up,” meant, “doing what you say, and saying what you mean … If we can’t, we explain why through authentic transparency.” Another participant used the following words to describe youths’ appreciation for honesty and consistency from their IPS workers:

You know our youth are hypervigilant, and they’re checking like, do you come when you say you’re going to come? Are you on time? Are you present? Do you let me leave? … I don’t think it matters if you are rock climbing or getting ice cream or doing a life book. I don’t think it matters. I think it’s the act of showing up when you say and being present.

All participants underscored the need to take actions that offset power imbalances, such as allowing the youth to choose the activities in which they were interested in participating and waiting for the youth to grant them permission before they looked through their files or shared information with others. Below, one participant summarizes her use of an accountability tool for building trust and mutual respect in relationships with youth.

I typically start with setting the precedent that the youth is the boss … Our first visit, we pick out a planner or a calendar and a fancy pen together because bosses keep track of making sure their workers show up when they say they will … I see this as an opportunity for the youth to feel important and test follow-through—I encourage them to use it as an accountability tool.

Another participant explains why the model’s hiring and firing process is crucial to building trust with youth and showing respect for youths’ rights to initiate and terminate connections.

You get to choose if you want to hire me to work with you … or you could even choose to fire me … You’re not going to hurt my feelings by any means. This is something that you have control over. It’s not something that you have to do if you don’t want … Usually they don’t get a choice for the things that they’re referred for, so usually they’re like, “Oh that’s cool.”

Many youth with histories of child welfare involvement have been given little control over decision-making in their relationships, so IPS workers, as illustrated by the above examples, made conscious efforts to share power with the youth.

Attunement

Another youth-driven strategy used by IPS workers was attunement, which participants defined as an act of present-mindedness that permitted them to tune in to in-the-moment emotional triggers and reactions. Attunement helped IPS workers predict when and how the youth might respond to positive and negative events, allowing them to formulate appropriate interventions and coach the youth’s team to support the youth. Staff actively observed indicators of the youth’s thoughts and feelings (e.g., body language, facial expressions) and used this feedback to shape their responses. The quote below demonstrates one participant’s application of attunement to her work with youth:

I don’t like bringing kids to a dark place and not bringing them out of it successfully … So I want to make sure that I can help them regulate out of whatever I bring them into … I at least know their triggers and … their body cues, so if they can’t figure out they are going to blow, I am watching them, and I’m like “we are close, and I need to back off.”

Another participant used attunement to gauge the youth’s readiness to transition from the Healing Phase to the Connecting Phase: “If the kid is still harboring some past pains … do I want to connect him with mom right now? … It’s important to gauge where they’re at, making sure before I connect somebody.”

As shown by the quotes above, youth set the pace for their progression through the four phases of IPS. IPS workers communicated with youth by developing a common language based on their understanding of youths’ body cues, facial expressions, typical reactions to triggering events, and emotional readiness for new experiences, such as forming connections with supportive adults. They identified the ability to speak the youth’s language as central to discussions about loss and trauma, particularly during the Healing Phase. Although the youth were ultimately responsible for driving this process, IPS workers shared some of their own language with youth and relied on their expertise to guide the dialogue. For example, all participants stressed the importance of teaching youth about the psychoeducational model of grief, which facilitated healing by normalizing feelings associated with loss.

I think the critical thing is telling the truth and relieving guilt and shame. So it is helping the youth understand in context that this is a normal, natural response to what happened to you and it wasn’t your fault. Like you’re not alone, you’re not weird, and it’s not your fault.

As youth began processing their grief and trauma, staff taught them self-soothing techniques to help them cope with emotional flooding. Again, these tools were specific to the needs of individual youth. Below is one participant’s depiction of how she supported a youth in learning to regulate his emotions during the Healing Phase:

I had a youth who started to talk about his adoptive family and how they gave him up … I drove him to the cornfield and asked him to just start throwing rocks … He tested me by quietly saying a swear word … When I said, “Good, do another,” and he saw that I was not going to punish him for swearing, he began to throw hard, far and was shouting things with intensity … He cried and admitted how much pain he had been hiding not ever feeling safe enough to let it out because he didn’t know what it would look like and he was scared he would not be able to calm himself down afterward. I went to the team and gave them the lens of what his actions were really telling us. The foster family immediately hoisted a bucket into the silo really high so that if he ever needed to get those emotions out, he could go in there, swear, yell, and throw tennis balls as hard as he wanted …

The above quote provides just one example of how staff took note of strategies that were beneficial to the youth so that they could teach supportive adults how to intervene in moments of conflict. This strategy was particularly important during the Supporting Phase.

Empowerment

Staff used youth-driven strategies to empower the youth to pursue positive growth and self-advocacy. Several participants suggested that identity work, in particular, was crucial to creating a foundation for the youth’s development of a strong sense of self and positive future orientation. IPS workers engaged youth in activities—not only to build trust in the beginning phases of IPS, but also to provide youth with opportunities for self-discovery. Participants acknowledged that these activities prompted youth to learn about their interests and, “build their sense of identity, which often feels disjointed … as a result of the disruptive attachments and trauma … This is key to Phase I, as it will become the baseline for the youth … to integrate and actualize healing connection with others.” Another participant explained how one youth was able to integrate healthier and more positive interests into his identity:

He just wanted me to take him to all these historical sites … He always had a specific location he wanted to see, and we would go and find that place together … Before I met him, he was really entrenched in … crime detective TV shows … It brought him into a very dark place because it was a lot about murder and dangerous stuff like that. But he was able to see, “Hey I really want to know about this historical stuff …” So being able to see a different way of using those skills or the personality characteristics I think was really beneficial for him to understand what he wanted in life and who he is and what he needs from people.

In addition to engaging youth in activities, IPS workers guided youth in exploring their histories, making sense of past events, and constructing coherent narratives. Some participants observed youth becoming more hopeful about their futures as they moved through this process. To motivate youth to reflect upon and plan for the future, one participant reported using an “extended timeline,” saying,

Later on, when you’re … at the end of the healing phase or something and you’re looking at the future, then I’d pull out another paper and say, ‘okay, let’s do another timeline for you for the next 20 years. What’s it going to look like?’

The participant above supported youth in constructing visions for their futures and, by doing so, encouraged them to take control of their life trajectories.

Many IPS workers expressed the importance of building on previous work with the youth to nurture future success. According to the participants, open and honest communication with their IPS workers increased youths’ resilience, especially during the Connecting Phase when they encountered obstacles in building relationships with adults. By this phase, youth had processed past trauma and loss and were better equipped to practice coping with setbacks. Open conversations with the IPS worker provided the youth with opportunities to reflect upon their emotions and process guilt, shame, disappointment, and anxiety. These challenges continued throughout the Supporting Phase, during which IPS workers empowered the youth to transfer the healthy interpersonal skills they had developed in their relationships with IPS workers to their relationships with supportive adults. Youth also needed to learn that failure is a normal part of life and that people are not infallible. Staff worked with youth and supportive adults to help youth recover from disappointment and resolve problems associated with the all-or-nothing thinking they had adopted to cope with instability, trauma, and loss throughout their lives:

They are testing them and saying, “Are you going to be consistent? Are you going to do what you say you are going to do?” And then what? Do we cut them out? It’s that all-or-nothing thinking that a lot of foster youth have that if you messed up on one thing, I’m going to shut you out completely because I don’t want you to hurt me. So, no. People are human. So how do we work through that?

Finally, staff facilitated self-sufficiency and self-advocacy among the youth with whom they worked. For example, youth worked with staff to plan for permanency by identifying adults on whom they could depend for various forms of support after their discharge from IPS. Attending team meetings gave youth chances to assert their needs and make critical decisions about their lives.

Culture of Well-Being

Another characteristic that participants felt facilitated successful implementation of the IPS model was the context in which they delivered the program. Pervasive to all aspects of the agency’s culture was an emphasis on organizational well-being. Administrators modeled self-care for their employees, regularly evaluated workforce well-being, and encouraged staff to take paid wellness days. An emphasis on self-care helped workers deal with the stress and intensity of permanency efforts involving youth in foster care who had experienced significant past traumas. Intentional self-care also helped staff remain present and mindful in their interactions with youth:

Each one of us has a self-care plan with [our supervisor], so before we are in need of self-care, we have to sit down with her and tell her, “okay, this is what it looks like when I’m not well” … [and if she sees those signs] then she’ll say, “hey, what’s going on?” Because it’s a mess, and it’s a mess in my head. I know that.

Taking breaks throughout the day to focus on their self-care plans gave staff the time to process secondary traumatic stress, self-doubt, and fear, and to rest from emotional exhaustion. All participants expressed appreciation for the support they received at work and spoke highly of the agency’s values:

We do not judge, blame, or shame … We don’t do that with each other. We don’t do that with supervisors, the supervisees. The CEO doesn’t do it. It’s not a part of our culture. We are an extremely supportive place to be.

Finally, the agency’s commitment to reflective practice inspired collaboration and brainstorming among employees. Staff spoke of an environment in which everyone shared wisdom and strategies with one another. For example, the agency paired each worker with another employee who could provide advice and emotional support during challenging situations, held training sessions and retreats on a regular basis, and each month, the supervisor shared the latest research on trauma-informed care with staff so that they could integrate new strategies into their work with youth.

Systems Change

Parallel Process

Another fundamental characteristic of IPS was staff’s advocacy for the adoption of a more trauma-informed approach throughout the system of care. Systems changes consisted of strategies that IPS workers used to engage members of the youths’ teams. Participants described a parallel process across multiple stakeholders, whereby the referring workers, IPS workers, supportive adults, and youth all moved through the four phases of IPS. Below, the first and second quotes, respectively, illustrate how the parallel process helped IPS workers build trust with family and referring workers:

I remember having a conversation with a supportive connection, of like this feeling of guilt and shame that she didn’t do enough to protect or she didn’t do this or that and really just hearing that and acknowledging, but reassuring her … It’s nobody’s fault, but it’s how do we move forward … It’s a definite parallel process … When we’re in the connecting phase with the youth, that’s really when we start the trusting phase with the family. (Quote 1)

What we’re learning is the referring [worker] has got their own junk too, right? … The original judge did the removal or the social worker, and now they feel guilty because they’re learning about all the crap this child went through … So we just have to do all of this healing and connecting and trust-building with the referral source. (Quote 2)

Staff built that trust by approaching interactions with referring workers and supportive adults with the same level of transparency and openness that they had used in their interactions with the youth. Many participants pointed to feelings of frustration, fear, and insecurity among the workers and suggested that sharing successes with the team, creating safety, and working with referring workers as equal partners helped mitigate these issues:

Everyone will suffer for a little bit sometimes when I’m getting to the healing, touchy-feely stuff, so you can see how this can be frustrating to people on the team. So if I have those team meetings, I pull them in and say, “Oh, look at the success we had … So he’s going to be a little touchy tomorrow, maybe a little irritable.”

Consulting regularly with the whole team through weekly phone calls promoted stakeholder buy-in, especially from the referring workers whose support was essential to implementing IPS. As stakeholders became more trusting of the team, they began to adopt a more youth-driven approach to supporting the youth’s growth and path to permanency.

Healing Relationships

One of the most transformative changes identified by participants was the transfer of the agency’s trauma-informed framework to other systems. When the workers used trauma-informed language, other stakeholders, such as schools, caseworkers, and therapists, began doing so, as well. In fact, the trauma-informed perspective had such a profound impact on youths’ providers that some started to transfer this trauma lens to their work with other youth.

… [A girl] was banging her head against the wall and ripping up the carpet at school and they are trying to put her in holds. I got the school on the phone and I said, “… When you put hands on a child who’s been traumatized, what does that remind them of and are they going to calm down, or are they going to fight harder?” … The principal got on and said, “Enough with this then. Let’s not focus on her grades this month. Let’s focus on her ability to ask for help when she needs it, self-regulation.” … There has not been a behavior incident since we started doing that. Now that they see that it works, they are trying it with other kids … They change the life of one kid, and it’s a ripple effect for everyone else they work with.

Not only do IPS staff educate youth and the professionals on youths’ teams about grief and the impact of trauma, but they also teach foster parents and other caregiving adults about these issues through a parallel process that can help explain some of the youths’ challenging behaviors. According to participants, assisting the youth and their supportive adults with preparing and delivering healing messages to one another is an essential part of connecting and re-connecting. Before disclosing the results of their family finding efforts to the youth, IPS workers searched for potential supports and reached out to them to “assess for safety,” and explore the role they might play. Later in the process, IPS workers gauged the willingness and ability of potential supports to commit to the youth as a permanency resource. Staff used their initial interactions with supportive adults to develop a rapport with them and to gain their trust. Staff then coached the youth and supportive adult to prepare them for re-connection:

I say, “I found your dad … I want you to write down the things you want me to tell him … What questions do you have for him, and … what do you hope?” … Then I can say, “Dad, if you really want to be engaged, he has what he needs to hear. He’s telling us right here … Can you answer this and give him this information?” So I write an outline for dad to write this healing letter … I have them tweak it, tweak it, tweak it, and get it right where I think it’s going to benefit you the most.

Almost all of the participants said that during the final phase of IPS, the Supporting Phase, helping the family overcome inevitable challenges and setbacks contributed to the development of ongoing and lasting trust and was essential to achieving permanency. For one participant, supporting meant helping parents respond to pain-based behaviors:

The adoptive parents called in crisis stating that he had locked himself in his room and was destroying it … I gave them a new lens and asked them to go up and ask him to do one of his favorite activities … The adoptive family was worried that this would only validate that bad behavior gets you rewards. I had to explain that youth who have been traumatized do not think like other kids … Ten minutes later, the adoptive mother sent me a text stating, “OMG it worked! … He is talking about his feelings.”

This example illustrates how IPS workers reminded the supportive adults about trauma responses and modeled conflict resolution skills while the youth tested the trustworthiness of the permanency resource.

Barriers to Implementation

Participants identified several barriers to success and described the key learnings they gained throughout the pilot project after encountering potential challenges with stakeholders and professionals, youth, and supportive adults. Local child welfare jurisdictions were responsible for funding IPS, so participants discussed several barriers related to the very real concerns of some of the referring workers. Some foster parents, legal guardians, and potential connections were not prepared to deal with increases in the youth’s pain-based behaviors during the healing process and when the youth was learning to cope with failure and disappointment. Participants discussed the need to balance supporting the youth in addressing past trauma and working toward permanency, while still maintaining safety and stability within current placements. Below is a case example that illustrates this tension:

I had a meeting with a county worker and her supervisor, and we just had an open dialogue about it … They truly had to weigh the cost-benefit, and losing a placement for him would have been very detrimental … It would’ve been extremely difficult for them to find another one … The foster parents weren’t happy, and they want the foster parents happy.

Some referring workers attempted to protect the youth by limiting their opportunities to connect with adults that the workers viewed as potential threats to the youth’s well-being.

Participants also highlighted barriers posed by the referring workers’ feelings of guilt, shame, fear, and insecurity. According to one participant, “there’s a fear response from the adult that says, ‘I don’t think this is working,’ or, ‘how come it is working, and they told you instead of me, and I’ve been their social worker for 5 years?’” Participants believed that some service providers might have felt responsible for re-traumatizing the youth or might have projected their feelings of guilt onto the youth’s situation. Due to these issues, staff made efforts to build relationships and trust with other professionals.

[Referring] workers … are overworked and very underpaid … They are coming to meetings … almost as traumatized as our youth are because they are having to do the work and make these tough decisions … So when I could change my lens and see that they needed validating and support, it created a relationship within that relationship … that trickles down to the youth.

Paid professionals were not the only individuals who struggled with these feelings during the Connecting Phase; family members also expressed fears and concerns about youth connecting, especially with relatives who may have contributed to past trauma. For example, one participant describes:

A youth was voluntarily placed by his parent into custody and [she] retained all rights … Once she understood that [her son] wanted to make connections with his father, she would not allow him back into her home. She did not want to allow him to connect with anyone. Her own trauma seemed to get in the way.

In addition to the barriers noted at times with service providers, caregivers, and supportive adults, participants noted that there could be a barrier to the IPS model for youth who lacked the cognitive abilities or insight to address these past traumas and losses, or were otherwise unable to engage fully in the program.

Discussion

Key Findings

The purpose of this study was to explore staff’s experiences implementing a trauma-informed, family search and engagement model with youth in foster care and to identify key characteristics of the model. IPS utilizes a blend of trauma-informed care, family search and engagement, and psychoeducation on grief and loss to help prepare and better support youth in their paths to permanency. Our findings identified three key characteristics of implementing the model: a youth-driven approach, culture of well-being, and systems change. In describing their experiences working with youth, participants identified several barriers to implementing the model, including those that involved referring workers, supportive adults, and youth themselves.

First, we found that IPS was youth-driven; staff held themselves accountable to the youth, relied upon feedback from the youth to shape their interventions, and empowered the youth to participate in decision-making and activities that helped them build skills for future success. Other studies have indicated that youth appreciate and benefit from relationships with adults that have these qualities and that youth prefer to be included in decision-making (Geenen & Powers, 2007). Some scholars have argued that allowing youth to participate in placement decisions might reduce disruptions that occur as a result of incompatibility between caregivers and youth (Hyde & Kammerer, 2009). As youth transition to adulthood, they will be required to make their own decisions, and so building healthy decision-making skills and learning from mistakes while in care may be less risky when supports are in place (Cunningham & Diversi, 2012; Nesmith & Christophersen, 2014). Another critical component of youth-driven programming was IPS workers’ use of trauma and grief education to enhance youths’ socio-emotional development and growth. As indicated by the findings of the current study, youth in foster care might repress their feelings to protect themselves and may need to learn how to express and regulate their emotions. Prior studies have shown that treatment models that incorporate psychoeducation for grief, trauma, and loss facilitate relational healing (Nesmith & Christophersen, 2014) and reduce posttraumatic stress symptoms among foster youth (Day et al., 2015).

Second, participants indicated that the culture of well-being at the agency was a critical component of implementing IPS successfully. The agency utilized workplace strategies that are beginning to gain support in the literature for their effectiveness in reducing burnout, such as training on secondary traumatic stress, peer support, and structured supervision (Salloum, Kondrat, Johnco, & Olson, 2015). Working with youth in foster care, who are likely to have experienced multiple traumas, can be emotionally taxing. Many youth in care have difficulties trusting and building connections with adults due to their experiences with disrupted relationships (Greeson et al., 2015; Unrau et al., 2008). For these youth, it is even more critical that IPS workers be committed to completing all of the phases. Our findings suggest that it may be worth investing in employee self-care and promoting a culture of well-being, as these strategies may help to reduce employee turnover and burnout.

A third key finding of this study was the transformative potential of sharing a trauma-informed lens with other systems with whom the youth interacted. Participants used a variety of strategies to stimulate change, including parent coaching and meetings with stakeholders. These findings highlight the importance of ongoing communication with other professionals and supportive adults working with the youth. Trauma education is crucial, as stakeholders may lack an understanding of how the youth’s prior exposure to trauma influences the youth’s current experiences (Dorsey et al., 2012). Communication about the youth’s trauma also helps stakeholders modify their behaviors to avoid re-traumatizing the youth (Ko et al., 2008) and shows stakeholders how to have necessary, but difficult dialogues about grief and trauma. The presence of high-quality relationships with institutional staff (e.g., teachers) has been linked to increased well-being and resilience among foster youth (Mota & Matos, 2015), so it is imperative to improve interactions between youth and stakeholders. Participants also coached supportive adults to respond to youths’ pain-based behaviors in a healing way, which shifted the dynamics among family members and transformed the family system. Finally, the IPS workers encountered distrust and guilt associated with stakeholders’ unresolved traumas, which posed barriers to successful collaborations. Evaluations of family search and engagement programs have reported similar challenges with stakeholder buy-in due to these issues (Vandivere & Malm, 2015). Thus, a critical component of IPS was the multiple parallel process; IPS workers engaged referring workers, youth, and supportive adults in all four phases of the model to build trusting relationships with both youth and stakeholders.

Limitations

This study has several limitations that influence the interpretation and application of our findings. First, we examined the characteristics of IPS from the perspectives of seven staff who had experience designing, implementing, or overseeing IPS services, and only five of those staff worked directly with youth. Future research might explore IPS from other points of view, such as those of youth or their supportive adults. Second, this was a small pilot study that focused on only one agency that served youth in Wisconsin and Minnesota. Larger scale experimental research is needed to validate the effects of the model on youth outcomes and to determine whether IPS is truly an evidence-based program. Third, implementation of IPS may require considerations that are unique to specific settings, such as larger agencies, public child welfare settings, or agencies located in other regions of the country.

Although these limitations remain, we did include safeguards to strengthen the credibility of our findings from this qualitative inquiry. For example, we each coded the interviews and surveys separately before meeting to discuss our codes, and we coded until we reached full agreement. We also used member checking to ensure that our findings accurately reflected the experiences of the participants. Finally, our analysis relied on multiple sources; we interviewed staff occupying a variety of positions within the agency and reviewed agency reports and documents. Themes were consistent across all data sources, which helped to triangulate the data and establish the trustworthiness of our findings.

Conclusion

Despite its limitations, our study sheds light on the importance of improving coordination across systems by becoming trauma-informed, providing stakeholders with information, and ensuring ongoing collaboration between stakeholders on service planning and permanency goals. IPS is not therapy, but it does utilize a holistic team approach to promoting well-being for youth. Youth with histories of trauma often exhibit challenging behaviors, even as they work to heal from these past traumas. To help youth progress in their healing and work toward permanency, all stakeholders in the youth’s life, including caregivers, service providers, mental health professionals, county agencies, and schools might benefit from adopting these trauma-informed practices and maintaining consistency across systems. This study also highlights the importance of taking the time to address trauma and grief with youth in foster care. This work can be demanding, particularly with this population of youth who are in or at risk of entering the child welfare system. Our findings indicated that staff at all levels of the agency needed support and prioritized workforce well-being as key to the success of this model. Overall, participants valued the IPS model’s holistic, trauma-informed, and youth-driven approach to improving permanence and well-being outcomes for youth in out-of-home placement. Further consideration may be warranted in applying these characteristics of the model to other contexts within child welfare that seek to promote permanency and well-being of youth.