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What are mental health services?

School personnel are often faced with the need to ask for interagency collaboration with other child serving agencies in order to address the presenting needs of their students. Most of the time, this has to do with student behavior and the school is seeking help from the mental heath system. Mental health representatives often then offer such services such as partial hospital or wrap around.

These are really modes of providing services and not services or supports in themselves. In fact, they better described funding sources than services. One might assume that people staffing these program models provide services like:

  1. psychodynamic [insight] counseling for individuals, groups and families;
  2. cognitive restructuring
  3. medication prescription and monitoring;
  4. behavior planning and reinforcement;
  5. play, art & music therapy, etc.

But you won’t know until you ask. You are referring the child for specific reasons and we would assume, have specific expectations. Unless or until you specify what your outcome expectations are and ask what specific services will be provided to address these expectations, you have merely succeeded in removing the child from your presences. While this may be sufficient, it has a downside: s/he will be back! And unless the service was really helpful, the probability is that s/he will be more difficult than ever. For not only has the referral issue not been properly addressed, but the child’s social roles has been usurped, his/her ties and relationships with family, friends and teachers has been breached; and his/her self image has been lessened.

One might first address the issue of appropriate services by casting all services in a most valued setting in the least intrusive style. Essentially, this means a setting where the student would be if s/he had no problems in living. While some of the established modes do this [e.g., Therapeutic Staff Support], they tend to implement services in an intrusive manner. The intrusiveness occurs out of two major factors: 1) the technologies used are intrusive and 2) the staff roles are artificial to the setting. A TSS who is not seen as, nor feels a part of the school; has no role with other students, particularly the key students peer’s; and who participates as a ‘control’ mechanism is intrusive to the school environment and the key student feels this intrusion both as a stigma and as a restriction. The intrusiveness also occurs out of an attitude: this student is not capable. The design of a non-intrusive mode must start with an exploration of standard staff or family roles. In the ideal, these staff would carry out their roles differently based on the identified goals of the services. This would require different training or different staff in those roles.

SCHOOL: Two examples of role enhancement in schools come to mind as worth immediate consideration: Emotional Support Teachers and Classroom Aides or Assistants. Emotional Support Teachers may or may not have training in techniques to serve students with emotional problems. But experience demonstrates that they most often simply teach academics to students. The goals and outcome expectations of their actions are academic, not social. They are by nature of their role, more tolerant of behavior and perhaps more accepting of the students, but there is very little actual goal oriented social service addressing the behavioral issues carried out.

Classroom Aides are often untrained and therefore pick up the skills that are available through the classroom teacher. They do what the teacher does [and if the teacher has poor social skills, they emulate the problems as well] , but do it in more individualized ways or in partial ways. Again the goal of the actions are academic, while the identified problems are often social.

Both of these staff might better carry out their roles by using the opportunity to teach social performance. Emotional support teachers should have a full curriculum of social content and be prepared to teach it as needed. They are the social teachers; just as someone else is the math teacher or the music teacher. As with academics, if the student has certain knowledge and skills and can demonstrate this, they do not need to take the class.

Classroom Aides can become social education or cognitive behavior management mentors. In that role they work will all students for the benefit of specific students [those without the capacity to meet the requirements of interpersonal expectations] in the classroom and use every opportunity to focus students on the social and cognitive elements that hinder or help their performance. The involvement recognizes that social behavior is an interactive experience. The Aide would move around the class helping where required. The expectation of present requirements would naturally move them towards the students who are finding academics difficult. For many of these students the a priori need is social education before the academics can be absorbed and used. However, there is a corollary in that students with academic difficulty often act out this difficulty in social ways.

Any regular education classroom can have a Classroom Aide/Assistant. The role is not intrusive. The Aide is often a member of the community, and perhaps someone’s mom, as well. This is really a process of training a natural support, rather than imposing a professional intruder. The presence of such Aides should diminish the referral to special education and emotional support programs. However, recognizing that we live in an imperfect world, referral to emotional support classes [social education classes] can be scheduled like any other subject. If the student needs to learn how to listen, take directions, manage anger or make friends; such classes can be scheduled. Since students display a range of behaviors and the characteristics of serious emotional disturbance are relative to all other behaviors, it offers an opportunity to normalize social education. In fact, classes can be so developed [if the School District chooses to do so] that some may become electives for students who seek to go into the helping professions, making it an inclusionary process.

FAMILY: The role of parent is the most dominant role in the family and the professional community should not attempt to usurp that role. However, more time might be spent determining whether we can help the parent play their role better. If a parent has a child who they consider to be “out of control”, two assumptions can be made: 1) what they are doing is not working, and 2) they are seeking all of the help they can get. Social education for parents [adult education] becomes an option that we have not exploited fully. Part of the reason for this is our professional belief that our technologies are beyond them. However, the technologies of cognitive behavioral management [social education] are quite accessible to the common (wo)man. While they may not be ready for cognitive restructuring, they certainly can learn the principles of transactional communication, directive communication, mental schema, cognitive errors, and social skill building including problem solving. If Myrna Shure can teach inner city welfare mothers to teach their four-year-old children to problem solve, this intervention process is certainly worth consideration. That single effort has the potential to change for the better both parent and child interpersonal competence. And the parent controls the intervention, which is substantive concern.

A second familiar role is the “baby sitter” or “nanny”. While it is true that families with fewer resources will often use family member in this role, the idea of an outsider providing this service is known to them. Two options develop: select and train the most obvious family member and pay them to provide this service. For older children the role may be favorite ‘aunt’ or ‘uncle’, but either way it is a role that is accepted and works. The school, in these cases does what it does: teach these ‘nannies’ how to provide cognitive behavior management techniques and procedures. Only the content is different.

If successful, the benefits of ‘improving’ natural supports are multiple. Not only does the student benefit directly, but the community benefits indirectly from one more person with the enhanced social competence. If this competence enhances the role as clerk in the Supermarket, the impact is exponential. The down side, of course, is that the school does not build a new bureaucracy and acquire a lot of new staff. However, we would be naive to assume that all of difficulties that now exist can be solved through improved natural supports. For some situations, professional trained staff may need to assume or model parts of these roles on an extended basis.

CLINICAL: Sadly, many professional roles have become all too familiar in families with problems in living. The “caseworker” or the parole officer are roles that the family and the community too often know. The question is how can the profession uses these accepted roles to provide social education. Again, the school can use the role in which it is proficient – teaching. By developing training for professionals from Children, Youth & Families or Juvenile Probation Officers, they can potentially influence the technologies of all systems.

In addition, of course, they can use the role of “caseworker” to provide services to the family. This is a more direct involvement in the family systems for the school, but allows for the accepted presence in a familiar role, a more experienced person to provide services.

EVALUATION: The final focus of all service involvement must be on measuring outcome. The failure to measure and document outcome is unconscionable. Only through measurement of outcome and extrapolation of success, can we expect to move towards a continuous quality improvement.

FINANCES: The question of funding is skewed somewhat by our efforts at seeking more appropriate roles and natural supports. The natural source of funding for children with emotional and behavioral problems beyond the school is medicaid, usually through an Early Prevention Screening, Diagnosis and Treatment [EPSDT] designation. However, it is unclear that the funding for training of adults can be billed despite its obvious connection to the medically necessary services for the child. Certainly, once trained, natural support providers [NSPs] can be paid through fees generated by the provision of medically necessary services through medicaid billing. The training costs may be covered through these payments along with the payment to the NSP, but a budget would need to be developed to ascertain this. Certainly the use of NSP raises the problem of credentialing . It is unlikely that they can be credentialed as professional providers [PP] unless other studies existed circumstantially. This would mean that you could bill only for an TSS Aide, not a professional, regardless of productivity.

The Local Education Authority or the Office of Mental Health can program fund the training of community adults [NSP] and recoup the funds through normal agency sources; using the fees only for payment to providers. The training of professional providers will definitely require program funding. If training is desired by Children Youth & Families and Juvenile Probation Offices, that training may be funded through their training budgets. The provision of remedial services for severe and persistent problems in living is probably billable to Medicaid.

It is difficult to separate out the question of STRUCTURE from finances. In the case of family based services in particular and perhaps Classroom Aides [Social Education Mentors]. A temporary services model is far superior and far less costly. In the traditional “factory” model, staff must be paid regardless of whether they are assigned or productive in generating fees. This is overcome by employing professions as “temporary service workers”. When they work they are paid. Computerized scheduling can allow the school to access highly skilled workers who do not want to work full time and pay them a decent wage. Any time a person is employed full time for a position which is required intermittently, costly employment circumstances will endure.

CONCLUSIONS: The Department of Education has an opportunity to develop social education services for students throughout the county. It can do so as a direct service entity: training and deploying staff as necessary in homes, schools or communities. It can operate as a “parent corporation” – meaning that it can train local schools and their selected community people to carry out these services and allow billing through their license. Or they can involve local mental health agencies and staff to provide those services.

This brief outline is simply a starting point for dialogue about the development of cognitive behavior management services within a community fabric. If the principle assumptions are sound, creative discussions can take place. The technologies are always based on learning theory and are not compatible with psychodynamic or biomedical approaches. The difficulty in changing technology without changing systems is explored elsewhere, but it needs to be understood that without addressing structure, staff, style, systems, strategy and superordinate goals together, and incoherent system will self destruct.