A pregnant woman undergoing methadone treatment may find herself in an extremely difficult position. According to a recent article in The Daily Beast confusion, uncertainty, and disagreement among professionals may put expectant women in danger of losing their infants to the foster care system if they are considered to be drug addicted because they are receiving methadone to manage opiate withdrawal.

She may be cautioned by her addiction specialist that attempting to stop methadone treatment precipitously could lead to a relapse and/or a miscarriage or premature birth. Yet medical personnel who are not familiar with methadone treatment may simply consider it a narcotic, like any other, and evidence that the woman is a drug addict who is putting her unborn child at risk.

Although methadone maintenance is surely safer than a relapse and return to illicit drugs, infants exposed to methadone in utero can and do undergo withdrawal. Child welfare workers, judges, and some medical personnel consider this child abuse and grounds for removing infants from their mothers. Once the child has entered foster care the problem may become compounded because the mother’s continued treatment will make her test positive for opiate use. If, as is frequent, a condition for the return of her baby is that she be “clean and sober,” she faces the same dilemma that she did during pregnancy—risk a relapse that could endanger her life and put her at risk for not being able to provide adequate care for her child—or continue the treatment that could actually enhance her capacity to provide care and risk leaving her child in foster care.

As new medications for the treatment of opiate withdrawal become available, some of these problems may be lessened. However, in the meantime, strongly held beliefs about drug use and addictions, even when not supported by scientific evidence may lead to the unnecessary disruption of the lives of parents and newborns.

If some newborns do indeed have to suffer through the pain of withdrawal and the simultaneous loss of their mothers, we need to recognize that they will be starting their lives in double jeopardy. Certainly policies and programs that could offer these mothers the support they need to manage their pregnancies under competent medical care so that their babies can leave the hospital with them are a far preferable alternative to beginning life in foster care.

By Toni Heineman

Teenagers are interested in sex. Not only are they interested, but many of them are having sex. Some of them become parents as a result; in fact, seventy-one percent of young women in foster care will be pregnant before the age of twenty-one, many of them more than once.

Yet, according to a recent article by Ryann Blackshere of Fostering Media Connections, adults who are responsible for caring for foster youth appear to treat information about sex as something to be kept secret. At least, it’s not clear who, if anyone, is responsible for talking to foster youth about sex and pregnancy prevention.

Although sex education has become a routine part of the curriculum in many school systems, it is parents who are ultimately responsible for ensuring that their children are knowledgeable about sexual relationships. We want all teenagers and young adults to appreciate the importance of sexual behavior that is not only physically safe, but emotionally safe as well.

Photo courtesy of”Pushthisbutton”

Unfortunately, when the parent is not available it is not clear who holds the responsibility for teaching children about their bodies — including the care they need and the pleasures they offer. Unless someone is clearly designated to address these issues, it is too easy for adults to avoid conversations they may find anxiety-provoking or embarrassing.

Parents may take it upon themselves to learn about the best ways to talk to their children about sex. Teachers who are responsible for sex education have access to training and resources. If no one in the foster care community clearly has responsibility, then it is also unclear who should be trained in best practices.

And best practices are essential when it comes to teaching responsible sexual behavior in the foster care community. Given that parents who have grown up in the foster care system are five times more likely than their peers to lose their children to foster care, the prevention of premature pregnancy should be a top priority. Not only are these young parents vulnerable to losing their children to foster care, they are in danger of losing their adolescence to premature parenthood.

By Toni Heineman

This interview first appeared on Daily RX – Relevant Health News on June 4th, 2012.
To view the feature in its original location, click here to visit www.DailyRX.com.

It’s a staple of mental and emotional health that you must know how to build and maintain healthy relationships with others. But foster students lack this luxury.

After all, if the only relationships you ever knew ended in under a year, how would you ever learn the skill of forming lasting relationships and keeping them going even when the going gets tough? This dilemma is just one of the many challenges that face foster kids, some of whom may move homes more times than the number of years they’ve been alive.

A Home Within, a nonprofit organization with 50 chapters spread across 22 states, is aiming to change that cycle of broken relationships, one child-and-therapist pairing at a time.

For the past ten years, A Home Within has sought therapists who are willing to take on a single foster child for no fee as a long-term client, meeting them once a week to help them with the various emotional troubles that come with being in the foster system while simultaneously providing them at least one relationship that will last longer than a few months.

Dr. Toni Heineman, the executive director of A Home Within, recently shared with dailyRx the mission and the rewards of being a therapist for A Home Within. She hopes other mental health professionals across the U.S. will be inspired to commit some of their time and expertise to the organization.

How does A Home Within work?
A Home Within is a very simple model. We have clinicians that understand the importance of a consistent relationship and they agree to see one foster child for as long as it takes. The average length of treatment is three and a half years, but we have kids who have stayed in touch with their therapists for over 10 years.

We know the relationship makes a huge difference in the lives of these kids. They usually don’t get long-term relationships. They usually get interns, who leave after six months or a year, so these kids do not have the stability of relationships that all kids need to thrive. On the one hand, it’s a big “ask.” On the other hand, it’s just one kid and it can make a difference in the life of that child.

Describe the big picture of foster children’s lives.
By and large, their relationships are kind of like quicksand. They aren’t really stable. They’re usually separated from their biological parents, and they become separated from their foster parents. According to some surveys, most [non-foster] kids don’t become financially independent until age 26, and those are kids who are raised by parents so they’re pretty well-positioned for adulthood. In foster care, kids haven’t had the kind of stable childhood that prepares them to go into successful, productive adult lives. You need a lot of stability in your life to grow up.

Why kinds of mental health issues and challenges do foster children face?
They find it understandably incredibly difficult to trust people because people have let them down again and again and again – which makes it hard for them to get close to people. They often suffer from low self-esteem because it’s human nature to blame ourselves when things go wrong, and so they think they’re not lovable. We see a lot of depression and anxiety.

The biggest thing is that they find it hard to form relationships, and we all need relationships. We need people to turn to when we’re sad and need a shoulder to cry on. We need people to turn to when we’re happy and have good things to share. With their difficulties in trusting and building relationships, foster children often don’t have the opportunity to mourn all the losses they’ve experienced.

In foster care, we keep teaching kids how to start over. We don’t teach them how to stick around, and that doesn’t make for very good long-term relationships. Sticking around is what builds relationships. How do you go through the hard part of being in a relationship? How do you stick it out?

There are 500,000 kids in the system at any given time. About 800,000 pass through the system in a given year. They’re a vulnerable population, and they can really make use of psychotherapy. We have kids who have been in five or thirty different homes. I have one child who’s been with a therapist with five years, but she’s 9 and she’s had 14 different foster placements. We have moral responsibility to make things better for these kids.

What kinds of volunteer mental health professionals do you need?
We need three kinds of people: therapists, consultation group leaders and clinical directors. A therapist commits to seeing one foster child, teen or young adult once a week in therapy free of charge. Therapists also participate in a consultation group that connects them with colleagues. It’s hard work, and you need a lot of support. You might watch a webinar at these meetings, talk about the work or read relevant literature.

Consultation group leaders are people who are willing to lead weekly meetings for therapists to get professional development. It’s a learning community with continuing education credits free of charge, and it’s a great way to build a referral basis and network with people in the community. One of the things we hear over and over again is that the consultation group is one of the highlights of their week and an incredibly important part of the therapists’ development and network.

Clinical directors are the point persons of each community who become Fellows for us and establish and maintain a chapter of A Home Within, and that’s a three-year commitment of four hours a week and an annual training and retreat in San Francisco. The fellowships are also volunteer – we pay for the retreat, but we don’t pay any stipend. The retreat is a fabulous experience. People love it.

How do you match clinicians with children?
We have a pretty extensive process. We do a screening to make sure the therapists are qualified and know what they’re doing. We also find out what they’re more interested in – a little kid, a teenager, a young adult. Then when we have a child or adolescent or young adult that seems to match, we let the clinical director know and he or she is responsible for actually making the connection.

What if there’s not a local chapter?
If someone really wants to help out a foster kid, we want to do everything we can to make that happen, so we have a conversation with that person and see what we can do to make it work. We ask if they can help us find a clinical director, or maybe they could be part of an electronic consultation group. We have the technology, so let’s use it. We’ve had people call in by Skype, and we do board meetings electronically.

How does helping these children affect society?
It means that instead of having over 50 percent of the kids who spent time in the foster system in homeless shelters, unemployed or incarcerated or sending their children back into the foster care at a rate six times higher than the general population, they are finishing high school, attending college, getting educated, holding down jobs, paying taxes and becoming productive, satisfied members of society. That’s good for them, and that’s good for us.

What are your goals for the future?
We would like for therapists to think of A Home Within when they’re wanting to do pro bono work. I would love to have clinicians who are interested in providing mental health services to foster children and therapists who are in the communities we are currently not in if they are interested in helping us establish a community for A Home Within.

We’re also trying to reach out to the non-therapeutic community, like caseworkers or staff in group homes, to give them tools they can use. We have a web-based platform with materials for working with pregnant and parenting teens and aimed at staff working with a range of foster kids.

We can provide them with the resources to help with these populations even if they’re not mental health professionals. Often they’re asked to do the work without any training or education or support. Sometimes there are no therapists geographically or the culture doesn’t support psychotherapy, but that doesn’t mean they can’t have access to best practices in theory to be helpful. We’re translating best practices into curriculum that’s useful for non-mental health professionals.

How can non-clinicians become involved with A Home Within?
If people can, they can help spread the word. They can help with media, they can do a small fundraising or awareness event. They can bring people over, share the materials, let them know what the needs of foster kids are, and if someone has an idea, we’d love to hear it. When I say we want to hear ideas, I really mean it. We know we have not cornered the market on ideas, and there may be something about spreading the word that we’re not doing. If anybody has any thoughts, they should be in touch.

Last Wednesday morning, the movers arrived at the office we had occupied for five years. By Friday afternoon, we were more-or-less settled into our new space. In all respects, the move from one end of San Francisco to the other went seamlessly—nothing was lost or broken; all of the furniture fit, as expected; and we were cut off from the electronic connections that we have come rely on for only a short time.

Psychologically, it was also a seamless move. We had ample warning from our landlady that she needed the space to house her own growing non-profit. Although we quickly found another office in a new neighborhood, we had time to think about what we would be leaving behind and to visit our favorite restaurants and take out spots one last time. We had a chance to say “goodbye” to all of the people who had been our companions in the building we shared.

Sorting through all of the files and “stuff” we had accumulated prompted us to reflect on our growth over the last five years. More often than not, the files at the back of a drawer made us remember that we don’t easily discard things, even when they have long outlived their usefulness. Memories of staff who had moved on were stirred by the unexpected discovery of a signature on a post-it or a long-forgotten reminder to return a phone call.

By the time the movers began delivering boxes and furniture, we had already begun exploring the new neighborhood, excited by the discoveries of different restaurants and the ease of walking to stores and public transportation. We noticed the differences in the light, the feel of the air, and the sounds of this part of the city. Although we had not initiated this move, we quickly welcomed it as the beginning of an adventure into the next stage of growth.

How different our moving experience is from that of many foster children. The most obvious difference is that we are adults who work together and return home each evening to our families, not children being moved from one family to another.

The circumstance that prompted the need for us to move is not uncommon for foster children. The space that we had occupied temporarily was needed for those who truly belonged there. We had been welcomed and well treated, but we were never truly part of the “family,” and, as the organization that had taken us in grew around us, we knew that our days there were numbered.

Photo Courtesy of “Svacher”

Unlike foster children who often have little warning or time to prepare for a move, we had time to reflect on what we were leaving behind and to bid a fond farewell to people who had become a part of our daily lives. We also had each other to share in the physical and emotional work of the transition. Because we weren’t rushed, we could give thought to the recurring decisions about what to leave behind and what to take with us. Sorting through the accumulation of books and papers and files also led us to sift through ideas and values and practices and to talk about what was serving us well and what might be improved. The move created an opportunity to make conscious choices about what routines we enjoyed and supported our work and which should be left behind.

Foster children don’t have this choice. When a foster child is moved from one family to another, he often loses important things that belong to him. He also loses the familiar sites and sounds of his home and his neighborhood, without a chance to say “goodbye.” More importantly, he leaves behind the daily routines and rituals that have organized his life. Because foster children cannot carry enough of what is familiar with them, each move has the potential to become a step into a terrifying unknown rather than the beginning of an adventure.

For foster children seeing a therapist through A Home Within, the picture may be a little brighter. If geography and the collective will of the responsible adults allow it, the child can continue with the same therapist through two, three, or even ten changes in foster homes and/or caseworkers. The therapist can help the child hold memories and mourn losses. The stability of this relationship can provide the ballast the child needs to hold her emotional ground. The continuing presence of this one, familiar, caring adult can transform a potentially terrifying experience into one that can be mastered. Children need adults to depend on, especially in frightening times. We owe this to all children, especially those who are the most vulnerable.

By Toni Heineman

Much in the child welfare system calls for swift action — children who are in dangerous or neglectful situations must be removed quickly. But other situations, such as the implementation of policies that will affect thousands of children for many years, call for deliberation and reflection. Angie Schwartz makes a compelling case for taking time to carefully consider the impact of “realignment” on California’s foster youth in this guest blog for the John Burton Foundation for Children Without Homes, re-posted below.

TIME TO PRESS THE PAUSE BUTTON ON REALIGNING CHILDREN’S MENTAL HEALTH

By guest blogger Angie Schwartz, Alliance for Children’s Rights California is in the midst of a grand experiment regarding the funding structure of programs designed to protect vulnerable children.  In July 2011, the California Legislature adopted “realignment,” a fiscal policy that shifts a portion of the state sales tax, along with seven functions from the state level to the county level, including the core programs of California’s child welfare system.  These core programs include Foster Care, Child Welfare Services, Adoptions and Adoptions Assistance, and Early Periodic Screening, Diagnosis and Treatment (EPSDT) mental health program. While realignment of programs aimed at providing support and protection to vulnerable children is problematic, the realignment of EPSDT is particularly troubling and will likely result in lasting harm to our state’s most fragile citizens.

Early and Periodic Screening, Diagnosis, and Treatment (EPSDT), is part of the federal Medicaid program, known as Medi-Cal in California. EPSDT provides comprehensive medical benefits, including mental health services, for low-income children from birth and up until age 21.  The mental health services that are required under EPSDT are especially critical for children in foster care. Research has shown that up to 80% of youth involved with the child welfare system experience emotional and behavioral problems that indicate a need for mental health treatment.

Prior to realignment, counties paid a small portion of the cost of EPSDT mental health services, just 5%. The rest was paid by the federal government (50%) and the state (45%).  Under realignment, the amount paid by counties will now increase from 5% to a full 50%; the federal government will continue to pay its 50%; the state will pay nothing.

Photo Courtesy of “MadamPsych”

Even before increasing the county share of cost tenfold, California was doing a bad job of providing medically necessary mental health services to children in foster care.  According to a report, from the state’s own California Department of Health Care Services, just 60% of youth who required mental health services received them. That’s right – only 60%!  Why?  Because that relatively small share of cost was still a cost to counties – and one they felt they could contain by controlling the services offered and access to those services.

Realignment will exacerbate the problem of access to critical mental health services by creating a greater fiscal incentive for counties to reduce or curtail access to medically necessary mental health services for children.  Under realignment, counties will be responsible for a full 50% of the cost of EPSDT services, with no guarantee that the level of realigned revenues will be adequate.

What is a predictable response for a county in this position? Manage costs by controlling caseload. This notion that caseloads can – or should – be controlled is completely contrary to the legislative intent and mandate of EPSDT.  EPSDT is not intended to be limited or capped based on arbitrary fiscal allocations.  Rather, it is supposed to provide each child the care he or she needs to thrive.

In addition, the capped allocation makes little sense given pending policy changes that will greatly expand the population of youth eligible for EPSDT.  Over the next couple of years, an additional 878,000 new children will enter the Medi-Cal program due to the elimination of the Healthy Families program. In addition, thousands more children will be newly covered by Medi-Cal due to implementation of the federal Affordable Care Act.  Finally, the recent settlement in Katie A. v. Bonta will require that specialized clusters of EPSDT mental health services be provided for youth at risk of group home placement.

However, the legislature is in the process of establishing the fiscal base line for EPSDT when we have no idea how much counties will require to serve these newly eligible children. The combination of these three policy changes create a perfect storm that, without careful deliberation and planning, will likely leave many needy children without critical care and supports.

The Governor’s approach to realignment of EPSDT should be reconsidered. The Legislature should slow down the process and ensure that adequate time and attention is paid to ensuring that our EPSDT mental health system will meet the needs of children and families. Rather then proceeding full steam ahead with all of these changes at once, I believe the Legislature should establish a statewide working group tasked with developing a plan to improve the service delivery system, ensure equity of access between counties, increase accountability, develop outcome measures, determine if EPSDT should be realigned ongoing, and if so, ensure adequate funding for the program in the realigned system.

This Thursday, April 12th, the Senate Budget Subcommittee will hold a hearing on EPSDT realignment starting at 9:30 a.m. in Room 4203. Please join me in encouraging the legislature to press the pause button on the realignment of EPSDT to provide more time for careful deliberation and planning. Yes, the state budget is in a crisis. That is no excuse for proceeding recklessly with the lives of abused and neglected children.

By Toni Heineman

Two articles crossed my desk recently that underscore the vulnerability of children in the foster care system. Individually, they each warrant attention; taken together they should prompt us to action. Preliminary research coming out of Purdue University suggests that adoptive mothers are vulnerable to depression following adoption. The fatigue, worry, and isolation that contribute to post-partum depression may also be contributing factors to depression in the wake of adoption.

From Rise magazine comes a report of a twenty-year study of the number of childhood deaths resulting from abuse and neglect annually in Sacramento, California that demonstrates a direct correlation between decreases in preventive services and increases in death rates.

One of the goals of the child welfare system is to provide permanency for children. When children cannot be reunified with their biological parents, adoption offers foster children the chance to have a “forever family.” But adoption is a complex process for both parents and children.

Creating a family is not easy, under even the most ideal circumstances. Parents and infants must get to know each other—they must learn to send and receive cues and to respond sensitively. Parents must reconcile their conscious and unconscious expectations with the baby who is actually before them—whether they have a girl when they had hoped for a boy, or whether they have an active baby when the baby of their dreams had been easy-going and mellow.

Add to this the emotional complexities contributed by infants and children who have been separated from their parents and are very likely to be wary of new relationships because of the maltreatment they suffered. And, just like biological parents, adoptive parents must relinquish their fantasies about the child or children with whom they would create a “forever family” in order to fully embrace those who have actually been placed in their care.

Photo Courtesy of “ZeRoSKiLL”

New parents need a lot of support. They need help with the additional work that children bring. They need emotional support as they try to manage the inevitable anxieties and responsibilities of parenthood. Common sense would tell us that parents adopting from the foster care system would need even more support because of the inherent vulnerability of the child they are bringing into their lives.

While parents adopting from the foster care system can certainly benefit from the support of family and friends, professional help is often called for. They need to have the counsel of social workers and specialists who understand and can help them meet the emotional needs of children who have been traumatized and subjected to multiple losses. Yet, these are exactly the kinds of services that are cut when budgets decline.

When we think about preventive services we, understandably, think first of programs that will keep children with their biological parents and out of the foster care system. However, it is also important to attend to programs that will ensure that when children are adopted from the system that their parents have the support they need to keep their promise of creating a “forever family.”

Through A Home Within, children leaving the foster care system and their adoptive parents can have pro bono support from an experienced therapist who can help them with the challenges of building a family together.

Watch this video to hear what Lorry, a parent who adopted a foster child, has to say about the help her daughter received from A Home Within – http://youtu.be/kxSNMN-cAbc.

By Toni Heineman

We know that lasting relationships are vital for children to thrive, but sometimes we forget. Sometimes we think we can take shortcuts. We think that children need only a little of our time or that we can give them just enough to get by. Sometimes we forget that children need to be loved with every ounce of our hearts and souls. This story offers a lovely window into the difference a stable relationship can make in the lives of a foster child and the adults who come to love her.

If you didn’t see this article in Sunday’s New York Times, I hope you will take
time to read it now.

At the age of seventeen, transgendered Christina lands on the couch of one of her former teachers. Cris, who had been taken with Christina’s intelligence and fierceness, discovers a ferocity in herself as she moves in to protect this child from a child welfare system that is unable to protect and care for her. Thirteen years later, they are off to celebrate Christina’s birthday, in the tradition of the “messy family” that they have made together.

Photo courtesy of lanier67.

Sadly, the stories of many of the adolescents in foster care don’t end so happily, nor do they always end well for the adults who reach out to try to give them the support of a positive relationship. But, as they did for Christina and Cris, sometimes when people really believe in the power of unconditional love and care, things do turn out well.

Their story reminds us that lasting, positive relationships help to heal the trauma that hides in the dark corners of our minds and propel us into the light of shared joys.

School is just around the corner for most children. For both children and parents, that usually means a mixture of excitement and anxiety—along with sadness about the end of the lazy days of summer and relief that school will bring some more structure to family life. But for foster children and teens and their caregivers worry may dominate the days before school begins, particularly if the foster placement is a new one. Even if the children will be attending the same school as last year, they will be going from a new home.

Parents and other caregivers can help to smooth the transition back to school for all students, but particularly for those entering a new school. A visit to the school can help to orient new students, but even if buildings are open a few days before instruction begins, it’s a good idea to call ahead to make sure that visitors are welcome. If it’s not possible to visit, tracing the route the student will travel to school–whether walking, taking public transportation, or riding with parents or other families—will help the student begin to get oriented.

It’s also helpful to establish mealtime and other routines before school opens. What time are kids expected to be at the breakfast table? Are they supposed to dress before or after they eat? Will they have breakfast at school? If they take lunch or a snack from home, do they help prepare it? Do they have input into what they take? This kind of information helps to alleviate uncertainty and confusion. Some children benefit greatly from having a checklist to help them remember to brush teeth and hair, what they are supposed to put in a backpack, and whether they are supposed to make their bed before they leave for school.

Photo courtesy of  Gioia De Antoniis.

Knowing the afternoon routines can help avoid struggles. For
example, adults may assume that kids know where to put their backpacks or that they are supposed to change out of school clothes. If those weren’t the rules in a previous foster home, it’s likely that they will revert to the patterns they followed there. Having a quick snack available also helps to reduce the
grouchiness that comes from low blood sugar! Sitting with students while they eat also offers an opportunity to hear about the events of the day and review expectations for the rest of the afternoon and evening—homework, dinner, and any other activities that will come before bedtime.

Some children will be so exhausted at the beginning of school that they will fall asleep quickly and sleep soundly. Others will be so anxious or excited that they will have trouble falling asleep and sleep fitfully. We can easily forget that interacting with teachers and peers for several hours during a school day is tiring. It can also be stressful to have to follow a predetermined schedule without the opportunity to rest when you want to or to have to sit quietly at your desk when you want to be talking to your neighbor.

All of this is harder if you are the new kid. All children need a little extra TLC at the beginning of school, but particularly those who are new to the school and the routines of the family.

By Toni Heineman

“I just wanted to talk to someone and they gave me pills.” This lament, which we have heard repeatedly from those who have spent time in foster care, is becoming increasingly common in all factions of the population. Brandon Gaudiano, professor of psychiatry at Brown University, in a recent New York Times Op Ed, suggested that among the reasons for the decline in psychotherapy as a treatment of choice for emotional distress is that psychotherapy has an “image problem.”

Psychotherapy is often perceived by consumers and medical professionals alike as being costly, time-consuming and ineffectual, while psychotropic medications are perceived as inexpensive, fast-acting, and effective. As in so many cases, the truth is not so simple.

Psychoactive medications help some people some of the time, as does psychotherapy. Answering the question of which is the better choice for any individual at any given time is not nearly as easy as advertisements for anti-depressants and anti-anxiety medications would have us believe. And, as Gaudiano points out, pharmaceutical companies have enormous budgets to create and promote the positive image of their products, while advocates for psychotherapy lack those financial resources and the will to develop practice guidelines that would aid mental health professionals and consumers alike.

Image courtesy of Curtis Perry.

There is abundant evidence that relationships are a powerful agent of therapeutic change, yet, too often, we deprive those in emotional distress of the chance to develop a relationship with a skilled and experienced mental health professional. Psychotherapy can help relieve suffering without risking the physical and psychological side-effects of medications. When we medicate too quickly we also deprive people of the chance to enjoy the longer lasting effects of psychotherapy.

It takes more time to build a therapeutic relationship than it does to take a pill, but the benefits last longer because people who are medicated passively ingest the thing that promises to cure them, while those who undertake psychotherapy must actively engage in the process of building or reestablishing their mental health. Through the clinical process they have the opportunity to internalize the knowledge and experience the therapist offers. Unlike a prescription, it will not have to be refilled endlessly to remain effective.

When people turn to us for help we need to remember that there is no medication that can cure the sense of abandonment when a child is removed from her parents and no pill that can create trust in the face of repeated losses and disappointments. Those who have suffered the trauma of chronic loss, the mind-numbing effects of poverty, or the brutality of discrimination need us to end a hand before handing out drugs.

By Toni Heineman