EDITOR'S NOTE Because of production schedules, the following story was prepared before the terrorist attacks of Sept. 11. Following the event, the mental health clinicians featured in the story have reported that their established presence in the schools enabled them to quickly advise teachers and administrators about helpful school responses and classroom activities and to provide individualized counseling. Clinician Tom Sloane cautions, "These are uncharted waters, and this crisis may continue indefinitely. We need to brace ourselves for the long haul."
There's a knock at Tom Sloane's office door shortly after school has begun at Southern High School in Baltimore, and three students enter. A close friend of theirs, only 12, committed suicide by shooting herself, they tell Sloane. Can he schedule them in to talk about it?
When the girls return at the appointed time with passes from their teachers, Sloane will listen closely to what has happened and respond with compassion and empathy. He may read them a poem. High school students often respond well to poems, he has found, and he has one that seems to help them understand that grieving is a normal and necessary process. It describes the stages a cut finger goes through before it heals, leaving a small scar. The last lines liken grief to the deepest wound a person has ever had.
Sloane is not a grief counselor brought in to help students cope with a death at their school. He's a mental health clinician, in a program run through the University of Maryland School of Medicine, who works full time at Southern. He provides a range of services at school that exceeds what students in years past could get only at a community mental health clinic.
For one reason or another – the stigma attached to mental health services, transportation problems, cost, difficulty arranging an appointment – students in Baltimore and many other parts of the country do not regularly use community clinics. Although all schools provide some mental health services, the professionals who provide them cannot meet the needs of all students. Often school psychologists must focus on special education services, for example, and guidance counselors on academic counseling and testing.
As a result, many students struggle with mental health issues -- such as grief, depression, attention deficit disorder (ADD), anxiety disorders, obsessive-compulsive disorder (OCD), exposure to violence and bullying -- and never get help. It's not difficult to find connections between unmet mental health needs and academic failure, dropping-out, drug and alcohol abuse, and sometimes crime and suicide. But today at Southern High and 86 other Baltimore City schools, often in neighborhoods riddled with shootings, domestic abuse and drug deals, students are getting help from clinicians like Sloane, in programs provided by the University of Maryland, Johns Hopkins University and community mental health agencies.
The programs are referred to as expanded school-based mental health to indicate that the clinicians build upon the schools' existing mental health services. The clinicians provide prevention, early intervention and treatment services. They do not work with special education students, because the latter are already receiving federally mandated services.
However, annual data suggest that, because of the clinicians' services, Baltimore schools with expanded mental health programs have fewer teacher referrals to special education for emotional and behavioral reasons, and more students whose mental health needs are met outside of special education.
On a typical day Sloane counsels seven individuals in 30-minute sessions, and one or more groups of three to five students who have an issue in common, such as anger management or parent-child conflicts, in 45-minute sessions. Almost weekly he addresses grief and loss, often related to violence, with at least one student.
About 10 percent of the students Sloane sees on a continuing basis take medication for mental disorders. In some cases, the students were on medication when Sloane began counseling them. In other cases, after completing his assessment of the student and obtaining permission from the parent or guardian, Sloane referred the student for a psychiatric evaluation at a nearby University of Maryland satellite clinic, where a child psychiatrist prescribed medication. In both cases, Sloane can provide the counseling element of the student's therapy at school, consult with the psychiatrist and help monitor the effects of the medication.
"We certainly believe that counseling is key," Sloane says, "but we recognize that certain students may need medication." Sometimes, though, parents refuse to permit psychiatric evaluation or the use of medication. The reasons can be complicated, he says, but often seem related to a stigma associated with medicine. Recognizing that their child has a disturbance that may warrant medication, he says, is "a heavy dose of reality that many parents shy away from."
One of the most difficult aspects of his work occurs, Sloane says, when he believes that medication will help a student succeed at school, but parents refuse to try it. "The number of kids that are not being treated and would do much better on medication is unsettling in my mind," he says.
Preventive mental health care is an important aspect of Baltimore's expanded school-based programs. Sloane's prevention strategies include presentations in health classes about stress, anger, depression and suicide. Anyone can refer a student to him, and teachers, guidance counselors and nurses in the school's health clinic often do. Like the girls at Sloane's door, students often refer themselves and their friends.
Although he has become a familiar person in his four years at Southern, Sloane says that his foremost mission continues to be presenting a non-threatening image to students that gets them beyond the idea that he is the "crazy" counselor, the guy who talks to the "mental" students. "We're always fighting the stigma in a setting like this," he says. "But now there's a face being associated with mental health."
A National Health Crisis
The National Action Agenda offers data that one in ten children and adolescents in the U.S. have mental health problems that interfere with normal development and functioning, but only one in five of them receives any services. Other data show that 20 percent or more of children can benefit from mental health services, with needs being even greater among families living in poverty and the numbers served far fewer among minorities.
"The burden of suffering experienced by children with mental health needs and their families has created a health crisis in this country," Surgeon General David Satcher wrote in his introduction to Children's Mental Health: A National Action Agenda, issued in January 2001. "Children and families are suffering because of missed opportunities for prevention and early identification, fragmented services, and low priorities for resources. Overriding all of this is the issue of stigma, which continues to surround mental illness."
How did Baltimore, a city which lacks a strong revenue base, become a leader in the growth of school-based mental health services across the country? The answer seems to be influential leaders in local and state health, mental health and education systems who championed the importance of mental health for children and adolescents and found multiple ways of funding it. Although most states limit mental health services to students in special education because those are the only mental health services that government funds cover, Maryland funds services in general education as well.
The earliest school-based mental health programs in Baltimore grew from health clinics set up in seven inner-city schools in the mid-1980s, in an attempt to make health care more accessible to students there. Staff at the health clinics quickly recognized the need to offer mental health services as well, because 22 percent of student visits were for mental health reasons. So in 1988, the Baltimore City Health Department contracted with the medical school departments of psychiatry at the University of Maryland at Baltimore and Johns Hopkins University to provide and supervise mental health services at four school health clinics.
Silence That Promotes Stigma
For six years Lorraine Kaplan taught at a school close to Pilgrim, a New York state mental hospital, and didn't notice the jokes people made about it. Then her bright and talented son, a high school senior, became sick in 1973. The family had no idea why his behavior was changing gradually in troubling ways until a psychiatrist diagnosed schizophrenia.
"Because of the stigma," the doctor advised, "I wouldn't tell anyone."
For a long time the Kaplans didn't. During her last 12 years of teaching, Lorraine Kaplan says, "Very often somebody would say, 'If I don't get this kid off my back, I'm going to end up in Pilgrim,'" she says. "No one dreamed that my son was in a hospital like that, because of one of the episodes he had had, and that my heart was breaking."
In time, Kaplan and her husband joined the National Alliance for the Mentally Ill (NAMI), a support and advocacy organization for persons with severe mental illnesses and their families and friends. Talking to other families in NAMI who were coping with a similar, unexpected illness helped them enormously.
"We decided that we had to speak out, that not speaking about mental illness is very unhealthy in every way," Kaplan says.
Today mental health professionals are unlikely to advise a family to keep mental illness secret. But in many homes and schools, the issue is still never discussed. Today Kaplan is helping to change that pattern in classrooms with a curriculum called Breaking the Silence.
She developed it with two other teachers whom she met at NAMI Queens-Nassau and who also have an adult child who has suffered from a mental illness. The curriculum is available through NAMI in upper elementary, middle and high school levels. Several activities, such as the middle school board game, can be adapted for use at all levels.
With true stories, activities and a board game or posters, Breaking the Silence debunks myths about mental illnesses and teaches the importance of getting care for them early. It sensitizes students to the pain that words like "psycho," "schizo" and "nuthouse," as well as frightening or comic media images of mentally ill people, can cause. Teachers and parents can find other helpful information and resources about mental illness under "Education" and "Children and Adolescents" at the NAMI Web site.
Founded in 1979, NAMI now has more than 210,000 members who have severe mental illnesses or have a family member or friend who does. NAMI focuses its education and advocacy efforts on the most severe mental illnesses, pointing out that they are now recognized as brain disorders: schizophrenia, major depression, bipolar disorder, obsessive-compulsive disorder and anxiety disorders.
Without education, children at school often make fun of students with those illnesses, Kaplan notes. "Kids who are different are always made fun of," she says. "And if children are very depressed or have obsessive-compulsive disorder, they're going to be different."
But as with offensive language, Kaplan says, students can be taught sensitivity to unusual behavior.
"They can be taught that some children can't help being different, and that they're suffering from something," she says. "Then kids can support others who are sick, and not feel it's something to be ashamed of."
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The partnerships between the school district and two well-respected universities proved beneficial for both sides, and more schools requested services. Both universities increased the numbers of schools they served throughout the 1990s and early 2000s. Ten community mental health agencies also established programs. Like the universities, the agencies served schools in the geographic area close to them and supervised their clinicians.
Today the two universities and ten agencies provide expanded mental health services in 87 of Baltimore City's 174 public schools. All clinicians hold a master's degree in social work, psychology or a related field, and have experience working with young people. All programs have back-up from child and adolescent psychiatrists that ranges from off-campus consultation to on-campus treatment.
Baltimore's school-based programs have the common goal of helping to promote learning by removing the barriers to learning. Improved academic performance, improved attendance and decreased numbers of suspensions and drop-outs are all measures of success. Early data indicate that expanded school-based programs are succeeding, and more extensive evaluation is under way. Another goal, when students and their families require social services or more intensive treatment than the clinician can provide at school, is to connect the families with the appropriate services.
The Diagnosis Dilemma
Clinical psychologist Dr. Mark Weist has directed the University of Maryland's program, called the School Mental Health Program, since 1992. In that time the program has grown from four to 23 schools, with some clinicians in schools full-time and others part-time.
One of Weist's concerns today, because of its effect on children and funding for school-based programs, is diagnosis of mental illness in children. While many diagnoses are legitimate, others are unreliable, he says. "If you go to one [mental health] center, you may get this diagnosis; if you go to another, you may get a different one," he says. "We see kids all the time with multiple diagnostic labels."
Diagnosis is appropriate, Weist says, in illnesses such as major depression, obsessive-compulsive disorder and bipolar disorder, for which evidence has shown a physiological basis. He believes diagnosis can also be appropriate in anxiety disorders and phobias. "I'm not saying diagnosis is inappropriate," he says. "I just think it needs to be used with much more caution and with acknowledgment of the limitations."
A clinician will not be successful in a school without first establishing good relationships with administrators and teachers, Duval-Harvey stresses. Often it's little things that convince principals and teachers that the clinician really wants to work with them and to become a part of the school. For example, when Duval-Harvey worked as an elementary school clinician, her school was trying to get a uniform with school colors. To help the effort, she always wore those colors, blue and white, on days when special events occurred. "It made such a difference," she says.
At Bernard Harris Elementary, a school served by the Johns Hopkins program, clinician Theron Pride has built those important relationships in his two years there, and now reaps the reward: a stream of referrals and requests for his services. Pride is one of only two African American male professional staffers at the predominantly Black school in East Baltimore. Children, particularly boys, flock to his office in their free moments – and sometimes when they are supposed to be somewhere else.
That presents Pride with a challenge similar to the one he sometimes encounters as he makes his way around the building, observing how the children he is working with are doing in their classrooms, halls, open quads and cafeteria, and making himself accessible to teachers. If he comes across students who are acting out, he must judge what response is best. "There's a fine line between clinician and disciplinarian," he notes.
Pride leaves minor disciplinary matters to teachers. If a child seems out of control, though, perhaps slamming doors or using profanity, he may take the child to his office and calm him or her with art or simple games like checkers. Often the children are acting out because of something that has happened at home, such as abuse or the locking up of a parent for probation violation, he points out.
"I find out what has happened, and through games and talking, get the child to feel better," Pride says. "Then I help him problem-solve for that morning." Pride helps the child set up helpful short-term goals, such as following directions for two days, and offers a small reward like a coloring book, if the child succeeds. The long-term goal, Pride says, is preparing the child to solve problems independently.
Pride keeps in touch with the parents of the children he sees. In addition, principal Lucretia Coates sometimes calls him down to the office to help with parents who are irate or hurt because of a decision the school made. He works individually with teachers who request help in improving their classroom management plans. Pre-school and first grade teachers call him in to observe their classes and identify behavior problems early, so that children can get help before negative patterns set in.
Occasionally, a teacher with whom Pride is working asks advice on a personal issue. "I tell them, 'The couch is yours; sit down,'" he says.
In 1995 University of Maryland program director Weist established and became director of the second of two national centers committed to advancing school mental health throughout the country, the Center for School Mental Health Assistance (CSMHA). Based at the University of Maryland, CSMHA was funded through a federal grant, which was renewed in 2001 for five years. (The other, the Center for Mental Health in Schools, is at UCLA.)
Weist's idea was that the Center would assist schools and mental health agencies to develop a framework similar to Baltimore's. "The partnership is important because schools can't and shouldn't have to do all this on their own," he says, adding that without such partnerships, schools offering services get saddled with extra liability, extra pressure and extra expenses.
In addition to technical assistance, the national center provides a Web site, training through annual national and state conferences, a monthly newsletter, opportunities to network with other schools, and a resource library. Any individual school or district interested in setting up an expanded school mental health program can contact CSMHA.
The hallmark cooperation among health, mental health and school systems in Baltimore is also apparent among the 12 providers. The directors of the programs gather monthly for meetings presided over by Marcia Glass-Siegel, coordinator of school-based mental health services, a position jointly funded by the school district and the Baltimore Mental Health Department. During the meetings, the directors often share experiences and exchange ideas. Clinicians and directors alike train together twice a year.
Glass-Siegel has two suggestions for schools interested in setting up a school-based mental health program. First, start laying the foundation for a successful program by seeking out advocates of school-based mental health in the school district, the health and mental health departments, and among legislators.
"Based on those connections, you can grow," Glass-Siegel says. And second, don't try to do everything at once. "It's fine to start small," she says. "If you can put in one program that works well, it will grow."
Whether the thousands of Baltimore students who attend schools that provide extensive mental health services grow into adults who see beyond the stigma of mental health remains to be seen, or may never be known. Still, it seems clear that the programs are changing attitudes. One positive sign of acceptance, Glass-Siegel points out, is that, once middle and senior high students get to know the clinician in their school, some begin coming on their own for services.
"By virtue of having services on site in school, you dramatically reduce the stigma," she says. "It becomes much more normalized that the clinician is just a familiar adult in a school building, not thought of in a significantly different way from any other personnel – except, perhaps, that the kids feel so comfortable with them."
by Tu-Uyen Nguyen
When I was a little girl,
I never said,
I want to grow up and be
What?! Speak up!
I can't hear a word
Of what you're saying
Speaking comes so easily
Just open their mouths
And words come streaming out
Voice is like a lonely wanderer
Who rarely ever comes by
You see, to come, my wanderer
Must come through many miles
Miles of silent longing
Miles of silent struggling
Miles of silent tears
Miles of silent years...
So you tell me to speak up
Speak up! You say
You, not knowing the miles
I must trod everyday
How do I speak up?
When I don't even know how to speak down
Speak left or speak right
Speak even a sound
I've known only silent travels
All kinds of silent fears
I am so very tired
Of silence all these years
I don't mean the silence
Of dew drops, fragile
In the glistening dawn
Nor of a slowly falling leaf
Cradled as a boat
By gentle waves of wind
For these things speak of what they are
In their graceful natural beauty
No, I mean the silence
Of a child being told
Not to say how she feels
Why do you always talk so much?
Be quiet! Silence!
The silence of asking for a glass
And not getting one
Because the waitress didn't hear you
And telling yourself it's O.K.
Drinking your soda from the can
The silence of being invisible
In the eyes of those
Who only want to see
Their ready-made image of the Other
The silence of having others name you
Internalizing the wrong pronunciation
Of what you want your name
Nujen? Ne gyen?
The silence of feeling trapped
Between two worlds
Vietnamese hyphen American
American hyphen Vietnamese
Opposite ends of the alphabet
Outer edges of two cultures
The silence of emptiness
A hollow more vast than nothing
A void within history
Of the voices of women unheard
The silence of Lotus Blossoms
And Dragon Ladies
Of virgins and whores
Of battered women
I mean the silence
Of my own voice
Of the stories that are locked
In unspoken words
Of the pains and triumphs of women warriors
My mother, my grandmother, my great–grandmother and her mothers
Yes, I mean the silence of
I've known only silent travels
All kinds of silent fears
My mind angry, disgusted
Of silence all these years
So you tell me to speak up
Speak up! You say
You think I haven't tried?
Day after aching day?
Breaking my silence,
Can't you see?
Not like you break an egg
It's not that easy
Takes more than dew drops
And falling leaves
Takes lots of heartache
With no reprieve
Takes many dreams
And remembering too
Takes my whole being
Takes also you
So open your ears
And listen, take heed
You can begin to hear my voices emerge
In chorus, with others no longer silent
Saying, we will be heard, we will be heard!
Tu-Uyen Nguyen is a doctoral student in the Department of Community Health Sciences at the University of California, Los Angeles.