In most schools, the guidance counselors and school-based psychologists advise teachers and school administrators about psychological issues faced by students. In traditional programs, counselors seek advice from outside consultants about the more difficult issues, but these consultants rarely treat students directly. In nontraditional programs, however, students often have direct contact with clinicians.
As overwhelmed school districts have struggled to help students with their mental health needs, nontraditional models have rapidly proliferated. A wide variety of new systems of care has emerged. Two innovative consultation systems in different types of schools share several characteristics that have made them effective and enduring.
The Freedom to Innovate
Poor access to mental health services, an urgent need for mental health attention, and a search for new ways to address old problems have led to a creative mix of traditional and nontraditional approaches. At two Boston-area inner-city charter schools, for example, Harvard Medical School psychiatrists Carl Marci and Alexa Bagnell organize weekly meetings during which psychiatry residents—physicians who are completing their training in psychiatry—lead discussions among groups of students who have been referred by the school nurse for help in managing emotional concerns. Marci and Bagnell supervise the residents, who use their training in psychology and skills as mental health specialists to lead the group discussions. Parents permit their children to participate in these groups with the understanding that the group leaders are not responsible for individual care. Instead, the residents will quickly refer students in need of special attention—a suicidal student, for example—to the school administration.
In addition to conducting group meetings, the consultants—Marci, Bagnell, and the psychiatry residents—meet with teachers and staff at least weekly to discuss particularly difficult mental health issues and to facilitate outside referrals for students who need clinical attention. They can also be paged for emergency consultations.
Because charter schools are generally smaller and more intimate than their mainstream counterparts, the consultants, teachers, and student support staff are able to provide mutual emotional support and supervision. The mandate that the charter school be innovative and efficient allows the school and consultants considerable freedom to cross the traditional boundaries between mental health clinicians and teachers.
RALLY for Mental Health
Charter schools may offer the freedom to innovate, but most U.S. students attend traditional schools. For poorer districts especially, innovative approaches are increasingly necessary to provide mental health support for students who would otherwise receive little or no psychological care. In many school systems, the scarcity of available resources and the enormity of psychological need leave many administrators discouraged and overwhelmed.
Gil Noam, a developmental psychologist at Harvard Medical School, has addressed these problems by launching the Responsive Advocacy for Life and Learning in Youth (RALLY) program in selected Boston public middle schools. Graduate students in Human Development at the Harvard Graduate School of Education provide psychosocial consultation and management for all students. Called Prevention Practitioners, they each spend about 13 hours a week in classrooms and offer services ranging from academic assistance to interpersonal problem solving to conflict management. Each Practitioner follows a student throughout the day in different classrooms. The most troubled students meet at least weekly with Prevention Practitioners to discuss pressing issues that interfere with their academic and social development, and many students participate in lunch-time discussion groups headed by Prevention Practitioners. By working in classrooms and throughout the school, the Prevention Practitioners become familiar with the needs of the students and the culture of their academic environment.
The RALLY program addresses key issues of risk and resiliency in adolescents. One clear benefit of the program is that students trust the Prevention Practitioners. Studies examining what best fosters resiliency in troubled youths have shown that the presence of a trusted mentor is the best indicator that a child will overcome significant psychosocial adversity.
Developmental psychologists have also noted that belonging to a group and avoiding exclusion is perhaps the most important developmental challenge for younger adolescents. Middle school students keenly feel the importance of popularity, and those who feel isolated and disconnected are at risk for multiple psychosocial difficulties. The RALLY program's premise is that students function best when they feel involved and part of a larger school and social community. The program achieves this sometimes daunting goal by creating groups within the school to which students are proud to belong and by working in after-school clubs, community clinics, and Big Brother and Big Sister organizations. Students ask to be part of RALLY groups and activities, enabling the program to create cohesion and inclusion.
In addition, child psychiatrists in training rotate through the RALLY program to learn about the problems and successes of inner-city public schools and to teach Prevention Practitioners and school staff. A cadre of psychiatrists and psychologists, of which I am a member, supervises these trainees and Prevention Practitioners. The following fictional example illustrates the coordination of efforts necessary to make this program work.
Teachers at a Boston middle school expressed concern about a 13-year-old Guatemala-born girl who seemed “spacey” throughout much of the day. Although she was never a discipline problem, she often talked quietly to herself and rarely handed in her assignments completed or on time.When the Prevention Practitioner met with the girl, she had a difficult time keeping the girl focused on the conversation. The student would often stare into space, glance furtively over her shoulder, and then smile nervously.The school nurse had difficulty contacting her parents because of the language barrier and the family's work schedule. The Prevention Practitioner asked one of the rotating child psychiatry residents about how best to help the girl, and the resident became concerned that the girl was seriously ill psychologically. After obtaining parental permission, the school referred the student to the psychiatric resident's clinic, where she was diagnosed with a psychotic disorder and treated with medication and counseling.Because of the relationship between the RALLY program and the psychiatry resident, the Prevention Practitioner was able to advise the school on how best to help the student within the school setting.And because the school, the consultation program, and the student have a good relationship, the girl's medical, academic, and emotional needs are being successfully addressed at home, in class, and in the clinician's office.
Common Threads
The profound need of the schools and the strong interest of those who provide the service have contributed to these programs lasting far longer than their planners had initially envisioned. In fact, the programs have grown. Using trainees enables the programs to provide services that are effectively free of charge. Supervisors donate their time as part of their teaching commitment to their parent institutions, and psychiatric trainees and graduate students gain valuable exposure to mental health needs in underserved schools.
In both programs, the school staff and mental health consultants have had time to develop lasting and trusting therapeutic relationships. Although specific trainees typically work in the schools for only a year, the continuity of supervisors has created a coherent institutional memory of the usefulness of each program.
The relationships between school staff and mental health consultants did not form overnight and were not without significant growing pains. The willingness to persevere was important, and both groups of professionals continue to struggle to meet the needs of the school community. Innovative programs, after all, are only as good as their participants.
