The Go-Between

      Elaine York had been working at the Department of Public Health for 3 years when she met Luisa Ramirez shortly after Luisa's second child, Ramon, was born. Routine tests showed that the baby had been exposed to cocaine prior to birth. The hospital made a referral to the Department of Social Services to determine whether Ramon's mother would be allowed to take him home from the hospital. After an investigation that included interviews with Luisa and with the teacher at the child care center attended by Ramon's sister, Tina, it was decided that Ramon would be released to his mother. Ramon was classified as at risk for developmental delay, making him eligible for early intervention services. Elaine York was assigned the role of service coordinator.

Making Arrangements

      Elaine's first meeting with Luisa was a home visit shortly after Luisa returned home from the hospital. Luisa, Ramon, and Tina were there when Elaine had arrived at the home. Luisa seemed very proud of both Ramon and his sister. There were photographs of Tina, Luisa, and a man about Luisa's age on the living room wall. In response to Elaine's questions about the photographs, Luisa said that the children's father had left the area shortly before Ramon was born and that she had not had contact with him since his departure. Elaine explained that, as their service coordinator, she would do her best to see that Luisa and her family received the services they wanted and were entitled to, and that they were provided in the way that Luisa wanted.

      Elaine explained that Ramon would be eligible for well-baby care through the Special Infant Care Clinic at the Department of Public Health where her office was. The clinic provided comprehensive health services for babies who were at risk for developmental delay. Luisa was glad she would not have to take Ramon to the clinic at the hospital, where she had had to wait 2 hours or more to see the doctor. Luisa volunteered that she was not currently taking cocaine, although she said that she had done so in the past. She said she wanted to take advantage of the services being offered and was pleased that they were available to her. The fact that Elaine spoke fluent Spanish made everything much easier than it would have been if an interpreter had been needed.

      An IFSP meeting was held the next day at the Department of Public Health, which was near Luisa's apartment. The meeting was attended by Luisa, Elaine, the nurse from the Special Infant Care Clinic, and Suzanne Smith, the protective services worker from the Department of Social Services, who had conducted the investigation while Ramon was at the hospital. When Suzanne suggested substance abuse counseling, Luisa said she did not see the need for counseling because she was no longer using drugs. The subject was dropped. It was agreed that Luisa would bring Ramon to the Special Infant Care Clinic monthly, that Tina would continue at her preschool, and that Elaine, as the service coordinator, would maintain regular contact with Luisa. Suzanne would keep informed of the situation through Elaine. Finally, the Department of Social Services would provide financial support through Aid for Families with Dependent Children payments, and the family would also qualify for food stamps.

      Over time, Elaine and Luisa saw each other frequently, as Elaine visited Luisa at home regularly. When Ramon was 3 months old, he began attending the same child care center that Tina attended 2 days a week, and Luisa began to look for work. Luisa kept her appointments for Ramon at the Special Infant Care Clinic and, although he remained slightly hypertonic, Ramon seemed generally healthy. Elaine kept in touch with the lead teacher at the child care center, who had grown quite attached to Ramon. His interactive skills seemed age-appropriate, and his motor development was within normal limits. Overall, things were going quite well for Luisa and her children.

      The only issue that had not been resolved was finding a job for which Luisa was qualified. Luisa brought up this concern during several home visits, saying she was growing tired of being home all the time and really wanted to work. Elaine gave her the name and telephone number of a counselor at the Employment Security Commission. Luisa had an interview with the counselor and passed a test qualifying her for classes at the Employment Security Commission. Luisa, however, took no further action toward attending the classes.

A Cry for Help

      Elaine continued to visit Luisa. Ramon, who would be 1 year old in a few weeks, remained healthy, and his delays were minimal. During one visit, Luisa asked Elaine if she could drive her to a doctor's appointment the next day because her car was not working. She said that she did not like relying on others for rides, and she hoped her car would be fixed in the next few days. Elaine was not available to drive Luisa, so she gave her the number of the County Ride Service. Elaine sensed that something else was bothering Luisa and asked if there was anything else she wanted to discuss. Luisa assured her that everything was fine, but Elaine was not convinced.

      Luisa called a week later to ask if Elaine could come to her apartment. A meeting was arranged for the next day, and Luisa was waiting for Elaine when she arrived. Luisa began to cry as soon as Elaine entered the apartment. She said she had learned last week that she was pregnant. After Luisa regained her composure, she said she had to tell Elaine something else. She began by saying she had used cocaine on occasion since before Ramon was born. Although she hadn't used it regularly and knew it hadn't affected the way she cared for her children, she had realized after Ramon's birth that it could be harmful to use cocaine during pregnancy. She didn't want to hurt the baby she was carrying, and she really wanted to stop using drugs altogether.

      Ramon's and Tina's father had come to visit the month before and was the father of the baby she was now carrying. He was a drug user and had introduced her to cocaine. He had left the area again, and she hoped he would not return. As she put it, "I want to turn my life around." Luisa and Elaine talked for a long time. During their conversation, Luisa played down the seriousness of her drug use, insisting that she used cocaine only occasionally. At the same time, she talked about a close friend who had become addicted to drugs and lost her job and custody of her children. It was clear that Luisa was afraid the same thing could happen to her.

      Luisa was definite about wanting to begin substance abuse treatment as quickly as possible and said that she hoped to be able to receive treatment on an inpatient basis. She didn't see how she could do that while taking care of her children and asked Elaine to help her sort out her options. Luisa thought Medicaid would cover inpatient substance abuse treatment, but had several questions: Could the Department of Social Services arrange for child care while she was in the treatment program? Would her AFDC payment continue during the treatment? Could she go to a treatment program on an outpatient basis and live at home while getting treatment? Would Medicaid cover outpatient treatment? Should she tell her obstetrician about her drug use?

      As they talked, it became apparent that Luisa needed considerable support. In order to plan for herself and her children, she needed information about substance abuse, funding for treatment, the treatment program, and the assistance available through the Department of Social Services.

      Elaine suggested that they meet with the DSS caseworker and a representative from the drug treatment center to consider how to proceed. Although Luisa did not want to discuss the issue openly, she realized that she needed information and assistance from DSS and from the treatment center and agreed to a meeting. Luisa said she would like Anna MacKenzie, the lead teacher at Tina's and Ramon's child care center, to attend the meeting because she respected her opinion and considered her a friend. She also felt that Anna needed to know what was happening. Elaine agreed to arrange the meeting as soon as possible. Elaine also offered to talk with Suzanne Smith, the DSS caseworker, prior to the meeting to tell her about Luisa's desire for substance abuse treatment, and to gather some background information. Luisa agreed that this might be helpful.

The System's Response

      Elaine called Suzanne Smith the day after she and Luisa had their long talk. Elaine told Suzanne about Luisa's desire to enter a substance abuse treatment program and suggested the joint planning meeting. Elaine was unprepared for Suzanne's reaction. Suzanne said that, in light of this new information, she needed to reasses Luisa's ability to care for the children immediately. She would visit Luisa that afternoon to decide whether Ramon and Luisa would be placed in foster care. There was a long pause while Elaine thought about what Suzanne was saying. She understood that Suzanne was responsible for ensuring the safety and well-being of the children, but she was also convinced that Luisa was providing adequate care for Tina and Ramon. Elaine was afraid that Luisa would, in effect, be punished for becoming motivated to deal with her problems. Elaine tried to discuss this with Suzanne, but Suzanne didn't seem to listen. Elaine offered to go to Luisa's home with Suzanne and serve as an interpreter. Suzanne refused her offer, saying she thought it would be best if she arranged for a certified interpreter to attend. Suzanne said she would call Elaine after she saw Luisa and hung up the telephone. Elaine wondered whether she had somehow betrayed Luisa by talking to Suzanne. She had other home visits scheduled for the afternoon, so there was little she could do but wait until the morning.

      The next morning Suzanne Smith called. She had gone to the home the previous afternoon and talked at length with Luisa. Suzanne was satisfied that the children were safe with Luisa and would not proceed with alternative living arrangements. Elaine was relieved and again suggested a meeting to discuss how Luisa could be supported in caring for the children and considering the choices she faced. Suzanne gave Elaine some times when she would be free to meet. Elaine said she would check with Luisa to see which times were convenient for her, but Suzanne responded by saying that was unnecessary since Luisa did not need to attend the meeting. She said that the professionals working with Ramon, Tina, and Luisa had to decide on an appropriate plan for the family so that they could make a single recommendation to her. Luisa and the professionals could make specific service plans at an IFSP meeting, which was to be held soon anyway.

      Elaine disagreed strongly with Suzanne and now was faced with a real dilemma. Elaine believed that Luisa should be present at the meeting. In fact, she saw little point in meeting without her. After all, she thought, the meeting was in response to Luisa's request for information about her treatment options. Its purpose was to support Luisa in making an informed decision about how to proceed. Elaine knew that no plan would be successful unless Luisa was fully committed to it, and Luisa was not likely to be committed to a plan that she had no part in formulating. Elaine also knew that the service providers in this situation could not possibly understand Luisa's priorities without her direct involvement. When Elaine voiced her objections, Suzanne reiterated that she felt it it was up to the professionals to determine what was best for Luisa under the circumstances. She thought it was their responsibility to decide on an appropriate plan and to present Luisa with a single recommendation, rather than with a number of options that might be confusing.

      Elaine reluctantly agreed to a meeting without Luisa. She was afraid that if she insisted on Luisa's presence, the meeting might not take place at all. Perhaps a group discussion in which all of the options were considered would provide helpful information, even in Luisa's absence. After she hung up the telephone, she thought more about what she could do to ensure that Luisa's decision-making authority was not undermined. She decided that after the meeting she would discuss the various options that had been presented and any other issues that were raised with Luisa. She would tell her about the group's recommendations, but be sure Luisa knew that it was up to her to decide how to proceed. Elaine discussed her idea with Luisa, who, instead of being upset, seemed almost relieved about not attending the meeting. Luisa asked Elaine to tell the group about her pregnancy only if it became necessary and relevant to the discussion.

Surveying the Possibilities

      It was 2 P.M., and the meeting would begin in half an hour. Elaine was making coffee and setting out cookies when Suzanne arrived at the front desk. Anna MacKenzie, Ramon's child care teacher, arrived a few minutes later, followed by Richard Downs from the Substance Abuse Treatment Center. After everyone had helped themselves to refreshments, Elaine welcomed them to the Department of Public Health Office and asked them to introduce themselves to each other. Although she had explained the purpose of the meeting to each of them when it was scheduled, she began by explaining the purpose of the meeting again in order to set the tone and ensure that expectations were clear. They were here to discuss Luisa's request for substance abuse treatment, and consider how they could support her expressed desire to "turn her life around."

      Richard Downs began the discussion, saying that he could add Luisa to the waiting list for admission to the inpatient program at the Substance Abuse Treatment Center, but that their current waiting list was 8-10 weeks long. Suzanne was surprised to hear there was a waiting list, as clients she had referred in the past had entered the program immediately. Richard agreed that had been true in the past, but over the past several months requests for admission had increased dramatically and the staff had to resort to a waiting list. The group was momentarily stymied. Suzanne finally broke the silence by pointing out that the wait would allow her time to plan for Ramon's and Tina's care while Luisa was in the program. She said Luisa could choose from among several options including temporary foster care, having a home visitor come to the apartment, or full-time child care if she chose outpatient treatment.

      Elaine realized that a 10-week delay meant Luisa would be almost half way through her pregnacy before she began treatment. She decided that the group needed to be made aware of the pregnancy. She calmly announced that Luisa was pregnant, and that the pregnancy meant that treatment could not be delayed. Richard responded with surprise. He had assumed that everyone knew of his center's strict policy against serving pregnant women. He said there was a drug treatment center in a neighboring county with a short waiting list that might be able to accommodate Luisa. He could get the name of a contact person at that center for Elaine. It had not occurred to Elaine that Luisa's pregnancy might limit her access to treatment. She knew that Luisa would be very disappointed to learn that the local treatment center would not serve her. Now the group needed to determine what other options Luisa had.

      Elaine asked Richard about the other center and he described the program in some detail. Suzanne, who had been listening closely, responded, "There's no point in contacting the center in that county. They don't accept Medicaid payment for inpatient services. Since Luisa doesn't have any other medical insurance, she has no way of paying for that program."

      To Elaine, Suzanne sounded as though she was speaking to a group of children who should have known better. Elaine had the distinct feeling that Suzanne thought Luisa "belonged" to her department because Luisa needed financial support in order to get services. She decided not to address this issue directly, but she felt herself becoming frustrated with Suzanne and with the progress of the meeting.

      Elaine asked whether there were other inpatient programs in their county that might be able to serve Luisa. Richard knew of a small program at the southern end of the county, but said that it had a very long waiting list. Elaine asked whether outpatient treatment was a possibility. Suzanne said that the local mental health center accepted Medicaid payments for outpatient services, but that she knew of several clients who had been disappointed in their outpatient treatment at the substance abuse unit. She thought they should consider it only as a last resort.

      Anna MacKenzie had said nothing up to this point. Now she asked the group whether the substance abuse program would also help with job training. She told the group that Luisa had been working hard to find a job, but she had not been successful and the situation didn't look promising. Perhaps more job opportunities would be available to her if she had additional training. Richard said that the treatment program Luisa had expected to attend worked with the Employment Security Commission to help residents gain job-related skills. Elaine proposed that she could talk with Luisa about the job training programs available at the Employment Security Commission again and about including job training as one aspect of her involvement with any treatment program.

      Suzanne then warned the group about some additional hazards of postponing treatment. If Luisa did not begin treatment quickly, her continued drug use could disqualify her and the children from receiving the assistance to which they were currently entitled. Almost as an afterthought, Suzanne added that Ramon's eligibility for early intervention services should be re-evaluated at the next IFSP meeting. Elaine became alarmed. Her involvement with the family could continue only as long as Ramon was receiving early intervention services. Luisa needed an advocate now more than ever and, although Ramon was progressing well, he was still at risk for developmental delays. Elaine agreed to plan for a discussion of Ramon's progress and eligibility at the IFSP meeting, but her thoughts raced ahead in planning ways to ward off Luisa's loss of her services. She planned to suggest to Luisa that a comprehensive evaluation be carried out before any final decisions were made.

      There was more discussion and, in the end, everyone agreed that further information was needed about treatment options and service availability. Elaine said she would research other inpatient and outpatient facilities. They agreed it was unfortunate that the local program did not serve pregnant women, and that this issue should be addressed in future discussions. The meeting ended after an hour and a half, leaving many unanswered questions.

Breaking the News

      As planned, Elaine went to Luisa's apartment immediately after the meeting. She reviewed the entire meeting, listing who had attended and what they had said. When Elaine told Luisa about the local treatment center's policy against accepting pregnant women, Luisa was stunned. She didn't understand why her pregnancy should disqualify her from inpatient treatment. She began firing questions at Elaine. Had she misunderstood that drug use during pregnancy could hurt the baby? If it could, why would they refuse to accept her in treatment now? Luisa began to cry. Elaine felt helpless. She realized that she could not answer Luisa's questions because she did not fully understand the reasons for the policy. She suspected that it had been established to protect the center from liability for medical problems related to pregnancy and substance abuse. The policy certainly didn't reflect any sensitivity to the issues faced by women in Luisa's situation. Elaine told Luisa that she did not fully understand the reasons for excluding pregnant women from treatment, but that she planned to find out more about it. She said she would tell Luisa what she learned, but cautioned that it might take some time.

      Luisa agreed that she needed to consider her other options. Elaine brought up the outpatient treatment program at the local mental health center. They talked at length about its positive and negative aspects. Luisa said outpatient treatment had helped her neighbor, but she had heard that others did not like the program. She was also afraid that Carlos, the children's father, might come back while she was in treatment and "mess things up." Luisa began to cry again. Through her tears she began to tell Elaine about Carlos. He and his brother had been taking drugs for years and she was really afraid for him. She had seen enough of what had happened to others like him to know the dangers he faced. Although she did not know where he had gone, she thought he would eventually come back because, in his own way, he cared about Ramon about Tina. Luisa had said little about Carlos before that day and Elaine had not realized how much she cared for him.

      Luisa told Elaine about how she and Carlos had met, about his drug use, and how she had begun taking drugs with him. She said that after he left the second time she had realized that her own drug use had become a problem, and that she needed to get treatment for herself. Luisa was worried that she might have harmed Ramon and didn't want to do the same thing to the child she was carrying. She said she had to begin in the program now, while Carlos was gone. One advantage of the outpatient program was that she could begin there immediately. She also liked the fact that Tina and Ramon would not need to go into foster care while she was in treatment. Elaine brought up the issue of job training, asking if Luisa would be interested in some combination of job training and outpatient treatment. Luisa became more animated as she talked about job training and the jobs she might qualify for if she took some classes. They talked for a while longer, until Luisa had to leave to pick up Tina and Ramon from child care. She said she wanted a few days to think about everything. They arranged to meet again 2 days later to plan how to proceed.

      As she left Luisa's apartment, Elaine reviewed the day -- the meeting with the service providers and her conversation with Luisa. Elaine was glad that Luisa had told her about Carlos. Although Elaine knew relationship building took time, she was struck again by the fact that it had taken almost a full year for them to establish enough trust for Luisa to share these personal concerns. Elaine now understood that Luisa's sense of urgency about treatment was the result of more than just her pregnancy.

      Elaine thought about all of the issues as she drove back to the office. Anyone who wanted treatment for substance abuse had to wait at least 10 weeks for admission to the local inpatient program, and pregnant women were excluded from the program altogether. Ironically, the very fact that Luisa had cared about her children enough to request substance abuse treatment meant she risked having them taken away from her. Elaine wanted more information about the Substance Abuse Treatment Center. What exactly was the policy? Why had it been established in the first place? Could anything be done about the waiting list? It seemed that Luisa had decided on outpatient treatment as an acceptable alternative. However, she still needed vocational training to increase her chances of finding work. Would it be possible to coordinate Luisa's outpatient treatment with a job training program? Elaine decided to discuss the situation with her supervisor, Anita. Anita was a social worker who had been with the agency for approximately 12 years. Elaine respected her and often sought her advice. This time, she wondered if even Anita could help.

Words of Encouragement

      The next morning Elaine saw Anita in the hall and asked if they could talk for a few minutes. They went into Anita's office, where Elaine presented her with a complete picture of Luisa Ramirez's situation. Anita was surprised that Elaine had not known that the Substance Abuse Treatment Center did not accept pregnant women and had a long waiting list. Anita made a mental note to schedule a meeting for the agency's service coordinators. She knew that service coordinators needed complete and up-to-date information about local agencies and services in order to be effective. Elaine's situation made it obvious that they did not have all the information they needed. The purpose of the meeting would be to consider possible strategies for ensuring that their information about resources was current. But now Anita needed to address Elaine's specific concerns.

      Anita asked about the severity of Luisa's drug problem, about Luisa's informal and formal supports, about Ramon's development and prognosis, and about the financial support available to the family. They discussed Luisa's options and possible strategies for dealing with the agencies offering the resources Luisa might need. In talking about Luisa, Elaine expressed her concern about the local treatment center's policy regarding pregnant women and wanted to know if Anita thought anything could be done about it.

      Anita knew the history of the treatment center's policy. She said it had been established several years ago under a director who had been concerned about issues of liability and had decided that the center would not risk serving pregnant women. That director had since left. Anita agreed that the need for substance abuse treatment for a woman in Luisa's situation was urgent. They talked about the issues and brainstormed about possible solutions. Maybe someone from the state medical school could consult with the treatment center. Maybe an interagency agreement could be developed, whereby several agencies would share the cost of hiring a local obstetrician to consult so they could more safely serve pregnant women. Anita decided to meet with the new director to raise the issue again. If he agreed to rethink the policy, she would support his efforts in any way she could.

      Aside from the issue of pregnant women, a 10-week waiting period for inpatient treatment was unacceptable for those who had resolved to seek services. Anita did not know how many people were currently using substance abuse services in the county or how many women could benefit from a change in the center's policy regarding pregnancy, but she realized that the adequacy of substance abuse treatment programs within their community should be examined. To do so, local agencies would have to collaborate to determine the need for expanded services and improvement of available services. Anita decided to arrange an interagency meeting to consider these issues. She told Elaine she would begin making phone calls that afternoon. What she didn't tell Elaine was that she doubted she would get the cooperation necessary to make a difference. Nevertheless, she would try.

      They talked about Luisa's tentative plan to enter the outpatient program and Elaine said that Luisa also needed job training. Elaine mentioned the collaboration Richard Downs had described between his center and the Employment Security Commission. Anita said she would mention the need for close coordination between employment training and substance abuse treatment at the interagency meeting when it was held. In the meantime, she suggested that Elaine work with both the outpatient program and the staff at the Employment Security Commission to assure that they collaborated on Luisa's behalf.

      Anita asked for Elaine's ideas about collaborating with Suzanne Smith. Elaine had given this more thought since yesterday's meeting and had decided that the process of developing the IFSP could, in fact, be very beneficial. It would provide important information about Ramon's progress and status as well as information about Luisa's concerns. Maybe Suzanne would be more supportive when she was more aware of Luisa's priorities and concerns. Development of the IFSP might also provide a structure for facilitating collaboration among the service providers and she would coordinate that effort. Finally, Elaine thought that she might try to involve Suzanne more directly in the assessment process so she would have firsthand knowledge of Luisa's priorities for her family. Anita thought her ideas were good ones and suggested she begin planning with Luisa as soon as possible.

      Elaine left Anita's office feeling more hopeful. As a service coordinator, she was responsible for helping Luisa to obtain services. Although she couldn't create services herself, she could advocate for needed services and resources. She was glad that she had taken the issues to Anita. By involving Anita, she had taken a first step toward improving services. She hoped the multi-agnecy problem-solving that Anita was about to initiate would be successful in improving substance abuse services. Even if Luisa would not benefit from a change in the policy for pregnant women, others might benefit in the future.

This case story originally appeared in McWilliam, P.J., & Bailey, D., (Eds.). Working Together with Children & Families, Case Studies in Early Intervention. (1993). Baltimore: Paul H. Brookes Publishing Co.

The Go-Between Discussion Questions