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Abstract: This outline is a starting point for conversation about the development of educational services for what is traditionally called ‘mental health’ services. It posits that education has an opportunity to develop social education services for students If the principle assumptions are sound, creative discussions can take place. Note that 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, an incoherent system will self destruct. 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. Often, this has to do with student behavior and the school is seeking help from the mental health system. When these occasions occur, mental health representatives will often offer services such as partial hospital or wrap around service. Or they might suggest therapeutic staff support or mobil therapy. The first set are really vehicles [generalizations based upon type] for providing services and not services or supports in themselves. In fact, they better describe funding sources than the describe services.The second set describe modes [generalizations based upon process] of providing services and do not identify in any way what is the activity, function, or expected outcome. One might assume that people staffing these program models provide services in some of the following processes: 1. psychodynamic [insight] counseling for individuals, groups and
families; But you won’t know what, if anything, exists in the generalizations until you ask. In fact, even the definition of process is vague, even if you understand the nature of each process for the specifics of action, function and expected outcome and well as the expected time schedule are left unsaid. You are referring the child for different services for specific reasons and have, we would assume, specific expectations. Unless or until you specify what your outcome expectations are and ask what specific services will be provided to address these expectations and in what form, you have merely succeeded in removing the child from your presence. While this may be sufficient for your immediate purposes, 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 to handle than ever. For not only has the referral issue not been properly addressed, but the child’s social roles have been usurped, his/her ties and relationships with family, friends and teachers has been breached; and his/her self image has been reduced. In many cases, s/he will have been given diplomatic immunity. Such immunity is based on the fundamental assumption that the behavior for which you referred [atypical] is caused by a pathology. This being the case, the child cannot be held responsible for such behavior and receives immunity from punishment or correction. These downside issues are very real and add to a growing problem in the way that schools relate to the children they serve. All too often mental health services are seen as the means to control the behavior of the child or at minimum, remove the child from the arena presently in conflict. This police function is all too avidly accepted by traditional mental health practitioners, as they medicate and incarcerate as a means of control. But even these harsh coercive measures have limits. Probably the most overused word in traditional mental health services is the word compliance. When people don’t comply to the orders given, [usually to take very toxic drugs] the mental health specialist most often seeks the authority to incarcerate. Based solely, of course, at least in their own minds, on what is good for the child - ignoring the admonition of John Stuart Mill, 1859. “The only purpose for which power can be rightfully exercised over any member of a civilized community, against his will, is to prevent harm to others. His own good, either physical or moral, is not a sufficient warrant. He cannot rightfully be compelled to do or forbear because it will be better for him, because in the opinions of others, to do so would be wise, or even right.” ON LIBERTY The referral to mental health services therefore is not a trivial occurrence and should be approached with some caution. Public schools have a proactive responsibility to protect their students, even occasionally over the objections of the parents. This is not a responsibility that can be performed lightly. Several points of inquiry can help to ensure that such a protective posture is implemented with referral. 1. Ask the mental health agent to articulate what is the agency’s fundamental assumption regarding atypical behavior. Aristotle has told us that any body of knowledge must start first with a fundamental assumption which can be neither proven nor disproved. Fundamental assumptions about atypical behavior typically fall into two categories: • nature - behavior is biologically based. Atypical behavior is caused by a) genetic propensity, b) disease or c) chemical imbalance. • nurture - behavior is learned. Atypical behavior is caused by a deficit or distortion of understanding based on the cultural norms. A third, not often used by human service personnel, is alien control. Each of these fundamental assumptions leads to a different perspective of the problem and a differing explanation of how to solve it, since we solve problems in the context of our perception of the problem. If I believe that the fundamental reason a child is behaving atypically is a ‘chemical imbalance’, then psychodynamic, cognitive or behavioral interventions are mere dressing - since I must overcome the ‘chemical imbalance’. to some extent this fundamental assumption leads to or points us in the direction of an outcome expectation. Again, if the practitioner believes that atypical behavior is caused by a ‘chemical imbalance’, then the outcome is to reduce the atypical behavior. Again, the outcome expectation is an important consideration in selecting a means of intervention, for the manner in which intervention is thought to be related to intended outcomes for a particular population is considered a ‘theory of change’. For example, the presence of foil headpieces is used either to keep alien signals from reaching the brain or to enhance their reception depending upon the perspective taken. If the alien signals are considered to be helpful then attraction becomes the intervention of choice. If they are harmful, the intervention is to block such ‘rays’. Obviously, the next query concerns this issue. 2. Ask the mental health agent to articulate what is the agency’s theory of change. Obviously, if the fundamental assumption is that atypical behavior is caused by a chemical imbalance; the theory of change should provide interventions that balance the chemical base. Psychodynamic ‘talk therapy’ is not likely to have any permanent effect, although the paradox of chemical reactions in the body is one of cause and effect: does the fear increase the adrenaline or the adrenaline cause the fear? Empirical experience would indicate the former. This leads to further questions which can be asked. 3. What are the specific interventions and how are they expected to affect the causes of atypical behavior? 4. What is the track record of such interventions? Do they, in fact, work? 5. If the interventions work, what is the time schedule for such effects to appear? 6. Can you direct me to satisfied customers, who will vouch for the services? Be cautious of the potential for ‘bait and switch’ on this question. Who is the customer? Under normal business strategy, the end user of the products or services is the customer. If the mental health agent sends you to talk to parents, school personnel or the funding body, this is a serious issue. Parents and/or school personnel are likely to be satisfied with the ‘dead man test’, meaning that if the atypical ‘acting out’ behaviors have stopped, the life of the parent/teacher is easier. From their standpoint, the interventions may have worked. Depends on whose problem we intend to solve. If we want to solve the student’s problem, we need to find children and adolescents who have been through the service and are now functioning in a typical manner and feeling good about it. Obviously, if the prevailing fundamental assumption is one of pathology, a separate set of staff with biomedical technologies, and some method of control (medication and incarceration) is required. On the other hand, if the fundamental assumption is that atypical behaviors are primarily learned behaviors, a very different outcome can be developed. The experts of learning theory are schools. If the assumption is that social [interpersonal behaviors] are learned, perhaps expansion of the educational focus is the appropriate response - expansion beyond academics to social education. We may also be able to discern some degree of quality decision from our own experience. This demands that we examine our own ‘attitudes’ about atypical behavior and our beliefs about what might be helpful. If we were suddenly referred to a mental health agency, what would we be seeking? One might first address the issue of appropriate services by rate all services on a most valued setting in the least intrusive style scale. Essentially, this means a valued setting where the student would be if s/he had no social problems. 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. When this TSS person participates as a ‘control’ mechanism s/he is intrusive to the school environment and the key student usually 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 people 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 have attitudes that are more accepting of the students and by nature of their setting more structured, but there is very little actual goal oriented social education 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 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 [interpersonal behavioral] teachers; just as someone else is the math teacher or the music teacher. As with academics, if the student has attained a certain level of knowledge and skill and can demonstrate this, they do not need to take the class. Classroom Aides can become social education mentors. In that role they work with 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 which 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 required need would naturally move them towards the students who are finding traditional academics difficult. For many of these students the a priori need is social education before the academics can be absorbed and used. 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 in regular education classes 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 in reverse. 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 parents 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 behavior management [social education] are quite accessible to the lay parent. While they may not be ready for cognitive restructuring, they certainly can learn the principles of transactional communication, directive communication, mental schema, cognitive error correction, and social skill building including problem solving. If Myrna Shure can teach inner city mothers to teach their four year old children to problem solve, this intervention process is certainly worth consideration. This single effort has the potential to change for the better both parent and child’s 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 use a 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 ‘uncle’ or ‘aunt’, but either way it is a normal role that is accepted and works. The school, in these cases does what it does: teach. 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 their other role as a clerk in the Supermarket, the impact is exponential. Another plus is that the school does not need to build a new bureaucracy and acquire a lot of new staff - increasing budget. However, we would be naive to assume that all of the 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. PROFESSIONAL: 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 use these grudgingly 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 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 a NSP 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 educational sector or the mental health sector can program fund the training of community adults [NSPs] 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 CY&F and JPO, that training may be funded through their training budgets. The provision of services is billable to Medicaid, although EPSDT services must be approved. 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 professionals and NSPs 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, this is a costly employment. CONCLUSIONS: 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. The state, region or county education entity can operate as a ‘parent corporation’ - training local school personnel and their selected community people [NSPs] to carry out these services. Or they can involve local mental health agencies and staff to provide those services. By billing through the coordinating entity when mental health providers are involved, the local district can maintain somewhat more control over what services and how the services are rendered.
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