Vera I. Fahlberg, M.D. is a retired pediatrician and psychotherapist. A trainer and consultant with an international reputation, she has travelled around the world sharing her expertise in attachment therapy with families and mental health professionals. For many years she was medical director at Forest Heights Lodge in Evergreen, Colorado, a residential treatment facility for troubled young boys. She has two grown up children and has fostered several children. She lives in Bremerton, Washington, USA.

In this interview, Dr Fahlberg shares some of the pivotal experiences she’s had over her long and influential career; talks about the important changes she’s seen in Child Welfare since the 1950’s; and points to some of the enduring lessons to be learned from her bestselling book, A Child’s Journey Through Placement – now available in the USA from Jessica Kingsley Publishers.

Tell us about your background – how did you first come to work in this field?

As it is for many people, my road to my eventual areas of interest and expertise was not a direct route, but one with detours and several forks. When I applied for medical school in the early 1950’s I was interested in becoming a psychiatrist. However, during my third year, quite to my own surprise, I found that I really loved pediatrics and decided to pursue that specialty.

Following my graduation from medical school and my Pediatrics residency, I assumed that I would end up in academic medicine since my interest seemed to be more in becoming expert in some smaller area than a generalist. However, I decided to first take a break from academia and hospitals for two years and I went to work as a Child Care Worker at Forest Heights Lodge, a residential treatment center for emotionally disturbed boys located in Evergreen, Colorado, USA. The thought of spending more time outdoors in the mountains with kids, as opposed to being in a hospital setting, was most appealing to me. At the time I assumed I would return to academia in a couple of years. However, within a year the director of the Lodge and I got married and my path toward continuing to work with emotionally disturbed, or special needs children, seemed to be somewhat set.

With the birth of our two daughters, I became increasingly interested in Child Development and observing how children acquire and internalize new information. Along with my own parenting experiences, I spent considerable time learning more about parenting techniques, child development, and the characteristics of children who seem to have problems with academic, social or emotional learning. By the time our daughters were in school and I was ready to go back to work full-time I was working under the supervision of a Child Psychiatrist and a Child Psychologist, as well as several other therapists, increasing my skills in this area.

How did your experiences at Forest Heights influence your work in the Child Welfare field?

Treatment at Forest Heights Lodge was based on the theory that it was the interpersonal relationships that children developed with their caregivers, as opposed to more traditional psychotherapy, that formed the basis for real change. Therapists were seen as adjuncts; they helped ferret out the child’s strengths and weaknesses, and decode what the child’s behaviors were trying to communicate. It fell to those who lived with the boys to use this information to facilitate the development of helpful relationships, rather than allowing the residents to set up relationships that could reinforce their unhelpful perceptions of the world around them.

As the emphasis in residential treatment changed from long-term care to shorter term interventions, we became increasingly aware of how important it was for us to incorporate the parents in our treatment of the child, and to actively work at transferring the youngster’s gains in residence to his home setting. We also had become aware of how important home visits prior to placement could be in augmenting our understanding of the child’s issues and the parental strengths and weaknesses. We started including siblings in the assessment process and encouraged them to visit the Lodge so they could visualize where their brother would be, and so that they could meet some of the staff.

About the time that I was returning to full time work, we opened an out-patient clinic at Forest Heights. We found that a disproportionate number of children referred for out-patient therapy were coming from foster care or had been adopted. We realized that these children were frequently coming from backgrounds where they had learned a lot about non-supportive parent-child relationships. In their new settings there was an opportunity for relearning, just as there was for our in-patients. However, frequently the new parenting figures had minimal information about the past experiences and relationships of those children joining their families. No one was available to help assess how the children were interpreting their world, what their strengths and weaknesses might be, and, just as importantly, no one was working with the new parenting figures on creating a helpful environment for these children.

To me, the move from working primarily in residential care to working with children and youth who were in other forms of out-of-home care was a natural one. Working with “new” parents to create a helpful, and therapeutic, environment was very similar to working with Child Care Workers to form healthier relationships with our in-patients.

Your book A Child’s Journey Through Placement is now established as a classic text, which continues to be recommended to professionals, students and families wanting to understand the impact of broken attachments and how best to support children in out-of-home placements. Can you tell us what prompted you to write it, and what the book covers?

In the late 1970’s I started traveling the United States, doing training for Child Welfare caseworkers. This was a time of a rapid changes in the Child Welfare system. It was apparent that caseworkers desperately wanted the knowledge that would help them in making decisions that would be in the child’s best interests. They cared deeply about the children in their care and about their families but in many cases they had little training or knowledge about Child Development, and the impact of parent separation and loss. Child abuse and neglect were being recognized, reported, and responded to in large volume. Professionals were starting to become aware of the frequency of child sexual abuse.

Before I started writing I wanted to make certain that what was in my knowledge base made sense to line workers, that it resonated with their experiences. I was dependent on them to help me clarify and expand my knowledge base. My first writings were a series of four workbooks – one on Attachment and Separation; one on Child Development; one on Helping Children Move; and finally one on Behavior Management. These were created with the help of a group of about thirty child welfare professionals in the state of Michigan. They ranged from line caseworkers to the head of the State Adoption Unit and the heads of a several private agencies known for their focus on special needs adoption. Through a grant we were able to put together a training program that included the group meeting for one week at a time, six times spaced over 8-9 months. This meant that, as we looked at integrating the theoretical material I was bringing with the practical obstacles that people on the job were facing, we could see what worked and what didn’t over time.

Another advantage to this particular group was that, in addition to supervisory staff, it was composed of workers in child protection, long-term out of home placements, and adoption work from throughout the state. Each participant brought skills and insights from their own perspective and added to the knowledge base of all. At the end of each week, we got together to try to formulate exercises, charts, and pictorial representations for concepts that might help subsequent readers internalize and organize the material. Many of these were incorporated in the workbooks.

In 1991, I expanded on the material and put it into a single volume, A Child’s Journey Through Placement. By then I recognized that the information in the book should be aimed not only at Child Welfare caseworkers, but also at other people who came into frequent contact with this population of children – foster and adoptive parents, people who were doing therapy with these children, child advocates, and judicial personnel were some of those who seemed to want a reference to which they could refer. The first three chapters of the book which encompass the topics of Attachment and Bonding, Child Development, and Separation and Loss contain information that people who work with children in any capacity find useful. The next two chapters on Minimizing the Trauma of Moves and Case Planning are most useful to those who are working with children in care. The final two chapters deal with strategies for working with common behavioral problems and for doing direct work with children in a therapeutic context. The text is peppered with many case examples, exercises and tables. Four cases are followed throughout the book.

In the introduction to the book, you highlight how you intend to place the child as a centre of focus – why is this important?

One of the first children I saw in our out-patient clinic was a pre-schooler who had been placed for adoption a year or so earlier. She had lived with her foster family since infancy. They had a close relationship with her and wanted to adopt her, but in those days foster parents were not allowed to adopt children already in their care. In her foster home Beth had seemed like a normal child with no behavioral problems; she seemed to be emotionally close to her foster parents, as they were to her. In contrast, in the adoptive home, she withdrew from affection and control issues were frequent.

The original plan for the move to the adoptive home included several pre-placement visits. The adoptive family met Beth without ever having any contact with the foster parents as this was common practice at the time. Their first visit was an overnight with Beth at a local hotel. At the end of the visit, they asked her if she wouldn’t like to go home with them then, instead of returning to the foster family. She agreed and the plan was changed. She moved to her new home without ever seeing her foster parents again. Because the adoptive parents saw her as “starting a new life” they gave her a new first name and quickly changed her hair style to match that of the adoptive mother and an older child in the family. No one thought about how Beth might perceive these events.

From Beth’s viewpoint, she had abruptly lost the only family she knew; people had told her about one plan and then changed the moving plan; she saw no contact between people she already trusted and those she was expected to trust; she was to become “a new child” with a new family, a new name, and a new haircut. No wonder she was untrusting of the “new” parents. When I asked the caseworker about how the decisions about the move had been made, she was not defensive at all but replied that this was how things had always been done. Nothing had changed in the transfer process since the times of placing children for adoption meant placing newborn infants with adoptive parents. When Beth’s adoptive parents became aware of how the decisions they had made impacted her, they were rightfully angry that no one had helped them understand what the impact of the move might be.

This case had a marked impact on me. I started looking at each case and decision with the headset of “Do the current procedures make sense given the reality of this child?” The agency that had placed Beth started implementing changes immediately, becoming much more child-centered. We all realized that it is easiest for adults to think like adults, rather than to use knowledge of child development in implementing planning.

Throughout the years I learned how important it was in each case to listen to the child or adolescent and incorporate his/her view of life into the decision making. Another example should help clarify this. In the course of a training session on Working with Adolescents in Care, I was asked to interview an adolescent in front of an audience of over 100 participants. Of course, my greatest fear was that they would provide a sullen withdrawn adolescent who would refuse to talk. With great apprehension I agreed to try the interview. Carol, 15, was most anxious to participate and she proceeded to teach me and everyone in the audience me so much! While I was concerned that she might be self-conscious in front of the audience, she was focused on what she wanted the caseworkers to know about how the system was failing her. Basically, she had first been placed in care several years earlier because of parental substance abuse. Carol did well in care; her mother became sober and drug free; they were reunited after about a year. Mom, under the stress, started to reuse and Carol started to act out again. Carol was again placed in foster care. The cycle repeated itself again and now, for the third time, Carol was being told that she would be moved back to her mom’s care. From Carol’s viewpoint it was clear that both she and her mom did better when they lived apart and could just visit each other. The stress of the moves, and learning to live together again, caused each to have an increase in her problems. Carol presented a very compelling case. When in foster care she didn’t have to worry about her mom; her focus was on school and friends (as it should be during adolescence). She enjoyed her time with her mom during visits. “Every time I do well, I have to move again. Why can‘t I just stay here in foster care and visit my Mom. Things go well for all of us then.” Of course, another teen in a similar situation might have seen things differently and have felt “How come I work hard, do well in care, and still don’t get what I want most – to return home.” No matter what decision is made in this type of case, it is imperative that those working with the young person understand their way of looking at things, acknowledge their feelings, and incorporate their perceptions into the decision making process.

Following that interview, I was frequently asked (or sometimes I initiated the request) to conduct panels of kids in care, foster parents, birth parents, etc., before an audience. I quickly learned that if people were willing to participate on a panel they usually had something pressing to them, and worthwhile to the rest of us, to share. In that type of setting, much to my surprise, people frequently shared thoughts and feelings they would have been hesitant to share in a one-on-one setting. Consistently the members of such panels helped everyone in the audience see common situations from a different perspective.

Every policy and procedure in the Child Welfare system should be child centered. Of course, there will be times and circumstances when doing things in a way that will be least traumatic for the child are simply not feasible. However, as adults we must realize that we either “pre-pay” by doing careful planning for moves or we “post-pay” by having to spend considerable time and effort overcoming the impact of a poorly done transition on the child’s subsequent adjustment.

You’ve been speaking about your experiences working around the USA. How can the material in the book be applied in other countries or to other cultures?

By the late 1970’s and early 1980’s I was doing training in Canada, and traveling further abroad. As in all other situations, my experiences in meeting people from other cultures and environs taught me as much as I taught them. In addition, I was blessed to make some long-term friendships with people in far off countries – people who are still my friends today and who have enriched my life, not just professionally but personally.

As my travels expanded to other countries, I quickly learned that although the systems set up to address Child Welfare issues might vary greatly from place to place, the children and the impact of their traumas and the adult responses to what had occurred to them were pretty much the same from place to place.

I had traveled to Scotland several times. One evening a foster dad, who had attended several of my sessions, approached me during an evening reception. He told me that the first time he was encouraged to come to one of my training sessions, he thought “What could this doctor from the U.S. possibly know about children in the foster care system in Scotland?” However, midway through the session he was thinking, “She has been hiding in my closet and knows what is going on in my house.” The children’s needs and behaviors were the same; it was just the governmental and judicial systems that were different.

On another occasion I was attending an International Fostercare Conference in Ireland, but had not yet made my presentations. During a free day, I was on a tour of the Irish countryside and met a woman from Slovenia. When I introduced myself, this stranger reached over and hugged me and said, “My friend – you are my friend, Vera Fahlberg?” I was both startled and confused by her response. She then explained that she was a psychologist working with foster families and the children in their care. She had been at a conference a couple of years before and was commenting to a psychologist from the U.S. about the difficulty finding anything useful in the literature for dealing with the situations she and the families she was helping were facing. He told her about the workbooks I had written and sent her a set when he returned to the U.S. She had been using the concepts in her work in Solvenia and had traveled to this conference to hear me speak.

Again, the basics of child development, the impact of parent loss, and the importance of attachment objects are the same in one country as another. However, in addition to the differences in the systems set up to deal with child welfare issues, and the differences in the legal constructs protecting children and families, varying cultures have relied on their basic beliefs while constructing protective and healing responses to child maltreatment. It is important that anyone working in this field understand as much as they can about the cultural, ethnic, and religious beliefs of those they are working with. By taking these beliefs into consideration and encouraging adults to work with us in creating strategies for intervening with children and their parents, we are more likely to come up with a plan that decreases, rather than increases, resistance on the part of the participants.

Can you talk about the changes in child welfare you’ve witnessed during your career?

In the 1960’s, when I was a Resident in Pediatrics, the medical community was just becoming aware of the extent and impact of child abuse. At that time, pediatricians, as opposed to psychiatrists or psychologists, were at the forefront of the movement to increase awareness of the long-term effects of child abuse and to start to form alliances with people in the field of Child Welfare.

By the mid 1970’s when I was ready to return to work full time, Child Welfare personnel had become aware of the fact that removal of children from abusive or neglectful homes was frequently not, in and of itself, a sufficient intervention. Many of these children didn’t respond like “normal” children in their new foster homes. Many had multiple moves. The concepts of Permanency Planning and Special Needs Adoption were just starting to take hold. Child sexual abuse was starting to be recognized as a significant problem. Legally, fathers of children born to single mothers rarely had any legal rights. Prior to 1975, schools were not required by law to provide an education for children with physical and/or mental handicaps.

In addition to the numerous legal changes made in the subsequent years, other changes in the child welfare system reflected societal and behavioral changes in adults – i.e. the large influx of “crack” babies; HIV positive infants; adoptive placement of children with families of different religious or racial backgrounds; a large influx of international adoptions; placement of children with gay or lesbian couples; the recognition of post-traumatic syndrome in children, etc. When I look back on all these changes, it is amazing how few reflect an actual change in the needs of the children being placed and how many reflect a change in laws and societal values. The basic needs of infants and children have remained constant and the basic importance of families, as opposed to institutional settings, as the primary source of child rearing has remained the same. I think this is why readers today still find A Child’s Journey Through Placement to be helpful and relevant. It focuses on children’s needs and perceptions of the world, and families’ capacities for meeting those needs, and provides guidelines for how agencies can help facilitate the achievement of these goals for the children in their care.

Of course, since I retired in 1998, there have been significant advances in knowledge, especially in the areas of brain development and the treatment of post-traumatic stress syndrome in children. Such advances need to be incorporated into one’s assessment of children and the implementation of planning, but the advances do not obviate the need to make use of the basics of child development; the impact of loss (or separation from family members) on children; and the importance of forming close healthy interpersonal attachments to current caregivers.

What are the things you hope readers will take from the book?

I hope that those who read this book will feel that they have gained skills which will enhance their abilities to help the children entrusted to their care. In addition, I would be pleased if the reader takes from the book a sense of hope and optimism when dealing with children who are part of the Child Welfare system. Most children, with the help of caring adults, can be resilient and become adults who contribute to our society in spite of many past traumas. The rules and regulations of agencies should provide guidelines for good practice, while still maintaining the flexibility that is necessary in planning for young people with such a variety of temperaments, strengths, and weaknesses, as is apparent in this population. As any parent of several children knows, what works with one may be counterproductive with another; this is equally true for children in care. The system, caseworkers, and caregivers must take this into consideration in planning for each child.

I hope that the reader will realize the importance of paying careful attention to children in care. What they are conveying by both their words and their actions is the single most important aspect of case planning and implementing theory into practice for any one child. If the adult knows the child well, understanding his basic temperament; recognizing his learning skills and weaknesses (not just in academic areas, but how he learns basic skills within the family); and if the caregiver knows enough about the child’s background to understand why the young person may perceive adults the way he does, it is easier to come up with behavioral strategies that both meet the child’s needs and modify the behaviors in desirable ways.

It is important that professionals in the field of Child Welfare come to grips with the fact that their job is not to “save” children or families but to help them cope in the best possible way with the realities of their life experiences. In making major life decisions on behalf of clients – such as decisions about moves, reunification, etc. – it is important to realize that there is rarely an absolute right vs. wrong decision. Most commonly we are faced with determining which is the “least harmful” decision in each case. We must recognize that each decision may carry some negative consequences as well as the positive gains we are seeking. The goal is to implement the decision in a way that minimizes the negatives and accentuates the positives, and that helps the child continue to successfully meet challenges in his own individual journey through life.

Copyright © Jessica Kingsley Publishers 2012.

Leave a Reply

Your email address will not be published. Required fields are marked *

This site uses Akismet to reduce spam. Learn how your comment data is processed.