Last year, when St. David’s Center for Child & Family Development, a comprehensive pediatric mental health nonprofit providing a range of therapeutic programs for children and families, opened its new Harman Center for Child and Family Wellbeing at Westminster Presbyterian Church in Minneapolis, it seemed that they were on the cusp of an “if you build it, they will come,” moment.
The multimillion-dollar Minneapolis expansion had an appeal to the Minnetonka-based St. David’s because many of the organization’s clients lived in the city. The urban facility, conveniently located on metropolitan bus lines, would work for families that had formerly struggled to make it out to the west metro for services.
In many ways, Harman Center, with its expansive new facilities for speech therapy; gyms for occupational therapy; and sunny, open day-treatment classrooms, has been a smashing success with the program’s client base, said Julie Sjordal, St. David’s CEO.
“Our families love it here,” she said. “They appreciate the new location and there are many wonderful things about the way it’s being used.”
But one service offering hasn’t taken off the way St. David’s leaders thought it would.
When the new facility was planned, the intention was that mental health treatment for parents and children would mostly be conducted on site in shiny new treatment rooms — but it quickly became clear that for many St. David’s families, a weekly trip to Harman Center still felt out of reach.
Most St. David’s families live at or below the poverty line, Sjordal explained. They struggle to make ends meet, working multiple jobs and raising children on a shoestring. Making the trip to Westminster for a regular appointment can feel like a real hardship.
“For some families, the question comes down to, ‘Are you going to put food on the table or are you going to get your kid to a mental health appointment?’” Sjordal asked. “When faced with choices like that, most parents are going to choose to get the food on the table.”
The comforts of home
St. David’s families don’t usually start their relationship with the nonprofit with a home visit, said Kishon Whittier, a psychologist and mental health professional at St. David’s. Many clients come to Harman Center for their first appointment — and commit to future meetings. But after a few sessions, she said, many of her clients’ complicated lives become clear — and their attendance at therapy sessions gets spotty.
“We see families drop off really quickly if they have to figure out how to get to us by themselves,” Whittier said. She understands why this happens: “When a client has a lower socioeconomic status and is struggling just to meet their basic needs — like food, shelter and a sense of actual safety — this creates barriers that interfere with a family’s ability to participate in therapy.”
For some families, Whittier said, making the trip to a therapy appointment, even if the facility where it is held is only a few miles away from home, “can still feel like a real burden.”
Whittier and her colleagues want to lift as much of that burden off their clients’ shoulders as possible. If bringing mental health services to a family’s home makes treatment more accessible, they’re more than willing to go the extra mile.
“We want to do what it takes to see our families,” she said. “If that means that we have to leave the office and meet them where they live, we’re going to do that.”
History of service
Since the organization’s founding in 1961, St. David’s therapists have always provided some form of in-home mental health treatment for families. When it became clear that Harman Center clients needed this service to continue, therapists re-packed their treatment bags and started heading out into the field.
Whittier said that she appreciates being afforded the flexibility to meet families where they are most comfortable. “By having that option and putting it on us as clinicians to travel to the home, we’ve been able to more consistently provide the services that these underserved populations need — and to a large degree want.”
This flexibility is a hallmark of the St. David’s treatment model, Sjordal said. Meeting the needs of children and families facing adversity is a central tenet of her organization, she explained, so, “When our therapists saw that sometimes families couldn’t make it to therapy, they turned on a dime and said, ‘I can go to their home.’ That’s the deep-end commitment of people who truly understand and care for children and families.”
Whittier is one of the therapists who keeps a packed treatment bag in the trunk of her car. While at first she expected that she’d be seeing more families on site in St. David’s new Minneapolis facility, she has a deep understanding of why she’s ended up spending so much time on the road, driving to her clients’ homes.
“Our clientele is a population that faces many barriers, so the consistency isn’t always there for them,” Whittier said. “Even if they commit to coming to the Harman Center for their sessions up front, there are still things that come up in their lives that they need to take care of. Those things often take priority over therapy. That makes complete sense — but that leads to less treatment consistency for our families.”
And consistency is important in the therapeutic relationship, Whittier added: “We really do see greater impact when it can be a more consistent relationship.”
One service offered by St. David’s mental health professionals is better done at home, Whittier said. Known as Attachment and Bio-behavioral Catch-up (ABC), it is a mental health intervention designed to help caregivers of children age 4 and younger who have experienced early maltreatment and/or disruptions in care learn to re-interpret children’s behavioral signals so that they provide nurturing support even when it is not clearly requested.
Young children who have faced trauma often react by pushing caregivers away, Whittier explained. Thorough ABC intervention, St. David’s therapists can help caregivers understand how to rebuild bonds with their young children. It’s an essential step to building strong relationships and supporting a child’s mental health going forward.
This therapeutic approach works best in a home environment, Whittier said, because “It is really focused on the in-the-moment relationship between the child and the parent.” During treatment, she said, “We make frequent in-the-moment comments highlighting things parents are doing with their child are that beneficial and the research behind that.” In an ABC session, therapists cover specific information about child development and offer ways to handle dis-regulated behavior and tantrums.
“We offer parenting strategies that our clients can use,” Whittier said.
Working in a home environment also helps therapists observe subtle behavioral cues that might not come up in an unfamiliar setting.
“The advantage of providing therapy in the home is that children are in their own environment,” Whittier said. “That way we get to see typical behaviors that the parents may see their child exhibit that you might not always see outside the home.”
Whittier is happy that in-home sessions can make life easier for families. When she meets people where they live, she gains a deeper understanding of their family dynamics and feels her parenting tips and advice carry more weight.
“It’s nice that we have the flexibility to meet our families in their homes, or at the homeless shelter or at a chemical health facility where they are being treated,” she said. “Having that option just lifts the stress off some families. Asking them to use their money for gas to get to the center or to travel on the bus with their infant and other children is just an added hardship. We want their experience with us to be about hope, not hardship.”
While St. David’s staff understands the importance of keeping in-home treatment options available for families, they are now faced with the practical challenge of funding this more intensive model of care.
“The in-home model is difficult to keep afloat because of the time clinicians spend traveling,” Whittier said. “There is a cost to that. And the reimbursements for these services that aren’t enough to maintain that type of model.”
Sjordal said that her therapy team’s commitment to meeting the needs of their client base is key to her program’s success, but the cost of this commitment wasn’t factored into the budget of the Harman expansion.
Whittier agrees. “I think we really didn’t anticipate the added expense of our time traveling to clients’ homes,” she said. Plus, seeing clients at the center is a more financially efficient care model, she added: “Clinicians who can see clients back-to-back at Harman can see many more families in a day. We didn’t know the percentage of clients that would be able to come in for treatment. It is hard to predict how consistent that would be. We need to figure out new ways to make this a sustainable model.”
A little more than a year in, Harman Center still bustles with families and children, but the client-driven push for more in-home outreach means that St. David’s increasingly needs to turn to outside funders to support their programs.
The nonprofit’s board of directors is in the midst of a major fundraising campaign: By the end of 2019, St. David’s must raise an additional $1.9 million to meet their $4.5 million overall goal. Maureen Walsh, St. David’s chief advancement and strategy officer, said that contributions to the fund will offset the costs of building and equipping the Harman Center and fund unreimbursed services like in-home treatment.
“Our overall goal for this campaign is to change the trajectories of children and families who have experienced trauma and adversity, who are in and at risk of out-of-home placement, and who need services to be within their reach,” Walsh said. “Our vision is to partner with families and communities to support healing, health and wellbeing, to produce the strongest long-term outcomes for children and families, and to create a vibrant society in which every member fully contributes to its success.”
This kind of intensive service comes at a cost, Whittier said. “It is hard to fund this kind of treatment solely on reimbursements,” she said. The fundraising support will be key to making St. David’s treatment model successful. “I can’t think of any other organization in the community that has been able to provide this level of service on a long-term basis, but,” with the support of donors, “we’re trying to make that work.”
Childhood trauma can have a lifelong impact. At St. David’s, therapists focus on getting in early, on working with the youngest children to reduce the impact that disruption can have on their lives and on the lives of their families.
For many of Whittier’s young clients, early trauma comes in many forms.
“Typically the children we serve are being raised in families that are facing significant financial barriers, intergenerational poverty, struggles with domestic violence, child protection involvement, severe mental health needs of the caregiver or parent, and racial discrimination,” she explained.
These factors add up to a life that lacks stability. When children are raised in such an environment, it can impact their development and cause delays in language, social interaction and emotional expression.
“Young children who are exposed to trauma feel like they don’t have a safe place to live,” Whittier said. “Their basic needs aren’t being met. When that’s happening, the caregiver-child relationship suffers significantly.”
It’s not just the parent-child relationship that suffers. Early childhood trauma has a lasting impact on a child’s overall development. “Up to 90 percent of the kids who have faced trauma end up with global developmental delays,” Sjordal said. “The goal of the clinic is to address those issues as early as possible.”
The St. David’s approach to mental health care can help families build strong bonds that enhance overall well-being in the face of great obstacles. When parents and children work with a therapist together, good things happen, Whittier said.
“We can’t talk through things with a very young child. Developmentally they’re not capable. But what we can do is talk with the parent. We can coach parents on their reactions and guide them in healthy behaviors. When we work with the parent to enhance the relationship that they have with their child, that’s when great progress is made.”