Jackie didn’t say much during those first few home visits, but that didn’t stop her case manager, Sherri, from returning to see her every week. Jackie grew up in foster care and had recently ended a physically abusive relationship, so Sherri knew it would require time and patience to gain her trust. At the time, Jackie was seven months pregnant and still heavily using methadone, so Sherri convinced her to enroll in an inpatient treatment center. She picked her up when she completed treatment and drove her to the transitional housing shelter, where she then advocated tirelessly for a public housing voucher and child care. Sherri never gave up on Jackie, even through multiple relapses and associated setbacks; she helped her prioritize goals and a plan for success that was self-driven.

“She wanted to be a good mom. She just didn’t know how,” Sherri says. Two years later, Jackie is sober and has her own apartment, a steady job, and a thriving toddler to care for. Sherri can’t believe the difference between this Jackie and the guarded woman who walked into her office two years ago. “She calls me all the time now,” Sherri says proudly.

Jackie’s story is similar to those of other mothers enrolled in the Parent-Child Assistance Program (PCAP), a home visiting program that, since 1991, has been serving high-risk mothers who abuse alcohol and drugs during pregnancy. The Washington state legislature started funding the program in 1997, and it is now available in 12 counties. Its goal is to help mothers obtain treatment and stay in recovery, ensure the children are in safe homes, link mothers to community resources, and prevent future drug- and alcohol-exposed births. About half of the program participants are involved in the child welfare system.

Case managers work with each mother and her family for three years, beginning during pregnancy or the first six months after a child’s birth. The program is tailored to each woman’s needs. Case managers work with the women to identify personal goals and the steps needed to achieve those goals.

Sherri describes PCAP as a guiding hand: “Many of our clients are constantly encountering a fork in the road where they have two choices. In one direction, they can start using drugs again. In the other direction, they can choose the difficult path of changing their lives for the better. PCAP is there to help them choose the right path.”

Relationships matter most

The majority of women enrolled in PCAP lack positive relationships in their lives — many were abused and neglected and eventually repeated what they learned. These women desired to be “good mothers,” but they were instead giving their babies the same kind of upbringing they had experienced. They didn’t know any other way.

The relational aspect of the PCAP model is the foundation of the program: having a positive, interpersonal relationship with a supportive case manager who believes in the mother, for a realistic and long enough time for her to make lasting changes. Considering the adversity that many clients experienced during their childhoods, case managers believe they need to model a healthy relationship and ultimately “re-parent the client” (i.e., teach her how to nurture and be nurtured), so she can establish close, trusting relationships with others and a caring bond with her child.

PCAP prioritizes hiring those with “lived experiences,” meaning they had similar life experiences as the clients and have successfully overcome them. Program Director Therese Grant says: “The point is not that they were there, but, ‘Look at how I’ve transformed.’ It’s about being a role model, not just being clean and sober.” Having these lived experiences gives case managers more credibility with clients.

‘We do whatever it takes’

For women in recovery trying to reunify with their children, the high expectations and requirements can be daunting. Alcohol and other substances cause significant changes in brain chemistry, which affect a person’s mood, thinking, and behavior. It can be difficult for a person to schedule and keep appointments; therefore, one of the most important parts of the case manager’s job is to help clients make and keep appointments by providing transportation and sending constant reminders.

But the case managers do more than just link their clients to services and provide transportation. Independence is the ultimate goal of PCAP, and case managers start empowering their clients upon enrollment. A core component of PCAP is helping clients develop personal goals and service plans that are reviewed by the case managers every few months. The mothers identify personal goals, such as getting into treatment or applying for college, and the case managers help them achieve these goals in realistic steps. Together, the case manager and client agree on the steps they will each take and who will be responsible for accomplishing each task. For many mothers, overcoming multi-generational poverty is the ultimate goal. Until their basic needs are met, it is difficult for them to be the type of mother they strive to be.

Case managers also work across the provider network to help coordinate services and advocate for their clients. “We know how the system works, so we do whatever it takes to make sure our clients are getting what they need,” one case manager emphasized.

 

 

The relational aspect of the PCAP model is the foundation of the program: having a positive, interpersonal relationship with a supportive case manager who believes in the mother, for a realistic and long enough time for her to make lasting changes. Considering the adversity that many clients experienced during their childhoods, case managers believe they need to model a healthy relationship and ultimately “re-parent the client” (i.e., teach her how to nurture and be nurtured), so she can establish close, trusting relationships with others and a caring bond with her child.

It takes time to heal

Most substance abuse inpatient treatment center programs last for only 90 days; then women are on their own, many without support networks. In addition, support provided while a child is in foster care usually ends when the child is reunified, which can be a time when the mother is at her most vulnerable. PCAP is unique in that it has a three-year duration, and women are not kicked out of the program for any reason. Case managers believe that it takes that amount of time to properly build trust, interrupt a pattern of substance abuse, and teach the skills necessary to build a strong foundation for long-term recovery. Case managers conduct home visits at least twice a month; contact is often much more frequent in the beginning, tapering off in year three as the mother becomes more independent. Case managers are available for their clients whenever they are needed, including nights and weekends. “This is not a 9-to-5 job,” one case manager said.

Parallel process

Working daily with women struggling to regain custody of their children while trying to overcome addiction takes an emotional toll on all those involved. Case managers credit the culture of the office for making a difference. The concept of “parallel process” is key to success. PCAP leadership encourages supervisors to treat case managers the way they would like case managers to treat mothers in the program. These experiences, in turn, model for the mothers how to treat their children in a nurturing way. PCAP leaders take the time to address secondary workplace trauma and encourage case managers to nurture themselves so they don’t experience burnout. As a result, PCAP has a low staff turnover rate.

The support of supervisors is another reason for the low turnover rate. PCAP provides clinical one-on-one weekly supervision, in which each individual client’s case is discussed; supervisors are familiar with the families and are accessible to help the case managers work through a client’s crisis. Case managers credit their supervisors for being available to them as needed. There are also weekly staff meetings to review cases and candidly discuss issues.  

Conclusion

Child welfare systems around the country are experiencing a surge in children placed in foster care due to the opioid epidemic. Mothers like Jackie can still safely care for their children if they have someone in their lives who won’t give up on them and the right support around them for a sustained period. The PCAP model is a proven and cost-effective way to ensure that families stay together.

For more information on PCAP, please visit: http://depts.washington.edu/pcapuw/

1 Casey Family Programs and University of Washington. (2013). Parent-child assistance program outcomes suggest sources of cost savings for Washington state. Retrieved from https://pcap.psychiatry.uw.edu/what-is-pcap/cost-savings/