CASE 8

Building on Strengths: A School-Based Mental Health Program

OLGA ACOSTA PRICE, JODIE FISHMAN, AND MIMI V. CHAPMAN

A TROUBLED STUDENT WITH A TROUBLED PAST

Juanita, a 12-year-old seventh-grader in middle school in New City, Mississippi, was once again in in-school suspension (ISS) for being disruptive in class, fighting with other students, and refusing to follow instructions. School administrators and staff admitted frustration at Juanita’s behavior, and her classroom teacher was overheard saying, “There are rules in place and she just has to learn to follow them, period.”

By design, the ISS classroom had an open section and a section with cubicles where students were restricted from seeing those around them to help students concentrate on schoolwork they were supposed to be doing while in the ISS classroom. This particular setting, however, was triggering potentially traumatic memories for Juanita.

Juanita frequently mumbled, “I hate it here. I wish everyone would leave me alone.”

Juanita and her mother came to the United States in June of 2009 from a small, poverty-stricken town outside of Mexico City, Mexico. Juanita’s mother wanted to give Juanita a better life, and even a low-wage job in the United States would provide a much better standard of living than they were used to in Mexico. Juanita’s mother had a first cousin living in New City, Mississippi. She heard there was a large community of Mexican immigrants already living there and work was plentiful.

The lure of a better life convinced Juanita’s mother to use a coyote to smuggle her and her daughter illegally across the border from Mexico to the United States. While making this journey, Juanita and her mother were subjected to living in tiny spaces, fed only rice and water once a day. They saw several fellow illegal immigrants die of dehydration. Juanita was left alone more than once in the small confinement and when her mother was returned to the space by the coyotes, she did not talk about what happened; Juanita felt a huge distance from her mother.

Having spent all their money on the coyote, when Juanita and her mother reached New City in June, they moved into a small apartment with cousins. Juanita slept on the floor next to the couch where her mother slept. Juanita’s mother worked at the local chicken processing plant, but rumors abounded that the plant would close any day. Juanita attended school, but she had a rough adjustment; she had no friends there and struggled to understand the expectations of her new teachers. She was lonely, frustrated, and angry that she had to leave everything familiar to her.

A PROBLEM STUDENT, OR STUDENT WITH A PROBLEM?

As part of an externally funded, school-based program called Building on Strengths, a school-family liaison, a Latina immigrant, was able to help Juanita. The liaison talked with Juanita about school and the ISS classroom in which she often found herself. Juanita explained being in the cubicle in ISS brought back painful memories of being in the confined space during her “importation” to New City.

“I start to remember that time when my mother and I were with the coyotes and I can’t get those thoughts out of my head,” Juanita complained.

“Why didn’t you mention this to anyone before?” the liaison asked.

“I don’t think the teachers care,” said Juanita, “and they don’t speak Spanish anyway, so it is hard for me to explain it. I just don’t feel comfortable talking with them.”

School staff members admitted they often did not know what their students and their families had been through and were not always aware of the symbolism of their own actions. The school-family liaison spoke first to the school principal, explaining Juanita was likely expressing retraumatization. Although she was not experiencing a true flashback, the ISS experience was triggering potentially traumatic memories. The principal agreed in-school suspension was not productive for Juanita.

The Building on Strengths program allowed the school-family liaison to help change the ISS, as well as work with Juanita and her mother to further address the traumatic experiences in their past. The liaison completed an intake with Juanita and her mother to better assess their mental health needs, and they were referred to Nuestra Comunidad, a community mental health clinic in their area to facilitate their adjustment to New City. Juanita’s mother was connected to county-funded social services to assist her with learning English and to explore other employment opportunities. She also indicated she was willing to participate in a parent night event after learning that she would meet other parents in similar circumstances.

BUILDING ON STRENGTHS

The Building on Strengths program represented a partnership of the school district, two local public schools, the State University of Mississippi School of Social Work, and Nuestra Comunidad, a bilingual and bicultural community mental health center. The 3-year program started in 2007 and was funded through a private foundation for $100,000 per year. The first year focused on launching the program, while the second and third years were dedicated to program implementation.

The goals of Building on Strengths were to create a system of care with an emphasis on early identification of emotional and behavioral problems through the use of a liaison or cultural brokeri and to improve services for immigrant Latino children and their families by reducing barriers to access. The program plan included diversity and cultural competence training for school staff, training for parents about youth mental health issues, and training to enhance mental health knowledge for teachers and staff. The program conducted a number of parent night events every year, attracting an average of 30 Latino parents at each meeting, a significant increase over previous attempts to bring parents together at the school. The meetings included information on school processes and expectations, resources available to parents and their children, and preliminary discussions of typical stresses children face adjusting to life at a new school. Postmeeting feedback indicated parents were satisfied with these events and found the information useful to their lives.

Building on Strengths offered school-based mental health services at James Middle School and Larson High School, two schools in New City with a high percentage of Latino students. A Latina school-family liaison was hired and assigned to the two schools to serve as a cultural broker and to provide limited direct clinical services as well as referrals to other agencies for specialized services. Building on Strengths’ grant funding fully supported the liaison’s salary, although she was employed by Nuestra Comunidad and supervised by its staff. The liaison was a qualified mental health provider who was well liked by the community and earned credibility among parents and educators alike. She provided consultation to teachers and school staff on issues that were interfering with student academic progress, identified students with signs of mental health problems, engaged families in creating solutions and action plans for their children, and advocated for students and families, especially those who were Spanish-speaking and unfamiliar with the American public school or mental health systems. Individual students were assessed to determine the extent of their emotional or behavioral needs, and referrals were made to Nuestra Comunidad for youth with significant mental health conditions. A 16-week evidence-based counseling group was started in the third year of the program in both schools to try to improve the skills necessary for regulating emotions and behavior among 12- to 18-year-old girls. The group demonstrated positive behavioral outcomes among its participants.

NUESTRA COMUNIDAD: MEETING MENTAL HEALTH NEEDS THROUGH COMMUNITY

A coalition of psychiatry residents, members of social service agencies serving Latinos, and primary care clinicians founded Nuestra Comunidad, which is Spanish for our community. This group united around a mutual concern about the unmet needs of Latinos with behavioral health problems. Nuestra Comunidad incorporated in November 2004, received its first grant in the spring of 2005, and saw its first clients in November 2005. The organization had a staff of six employees and four trainees, all of them bilingual. Nuestra Comunidad described its mission as providing, in collaboration with consumers, university partners, and local, state, and national agencies, best practice mental health and substance abuse treatment and resources for the under-served Latino-Hispanic population of Mississippi in collaboration with consumers and local, university, state and national agencies.

Based in Carter, Mississippi, Nuestra Comunidad opened a second office in New City in July 2006. Approximately 78% of Nuestra Comunidad clients had incomes below the federal poverty level; 65% of clients were uninsured, and another 28% were insured by government programs such as Medicaid and Mississippi’s Child Health Insurance Program. The agency was able to seek reimbursement through Medicaid for the clinical services offered (i.e., individual, group, and family therapy) but public funding did not support the outreach and early intervention services provided by the liaison, so those efforts were supported via a private grant. Although Nuestra Comunidad was committed to the prevention and early intervention goals of the Building on Strengths program, its staff were concerned about how to support these activities after the private grant ended.

RISK FACTORS FACING LATINO YOUTH IN THE UNITED STATES

Although local data on Latino youth are scarce, national research on young Latinos indicates cause for worry. Latino youth are engaged in behaviors and situations that put them at increased risk for mental health difficulties or may be symptomatic of existing, untreated mental illness. Information from the Youth Risk Behavior Survey2 shows higher percentages of Latino youth report carrying weapons to school, and a higher prevalence of drug and alcohol use than other youth their age; over 11% of Latino students report they did not go to school at least once in the last 30 days because they felt unsafe, a proportion higher than any other ethnic group. Other studies have found Latinos experience higher rates of physical and sexual abuse than either black or whiteii adolescents.3 Further, Latina girls have the highest incidence of suicide attempts compared to girls from other groups.4 To complicate the picture, about 35% of Latino adolescents nationally report being sexually active, yet they are less likely than their white or black counterparts to use condoms or birth control to prevent pregnancy or sexually transmitted diseases.6

These risk factors have been associated with poorer academic and economic outcomes. Latino youth are less likely to complete high school, are more likely to drop out of school, and fare worse on educational achievement tests than their white counterparts.7 These phenomena also hold true for students enrolled in the New City public schools. Local estimates are that more than half of the 1,500 self-identified Latino students enrolled in school (of the 7,400 students in the school system) have some type of mental health need, but only 3–5% are accessing services in the community. The stigma associated with receiving mental health care is one barrier, with public sentiments of being “crazy” hindering efforts to seek professional help. In addition, service utilization data from the local public mental health agency show that three times more whites and five times more African American residents are served in community mental health agencies in New City than Latino residents, even though the mental health needs are thought to be as significant, if not more so, for Latino immigrants. Focus groups conducted with local Latino adolescents found that the majority of participants reported incidents of discrimination and that, although they would welcome support to address their family’s mental health needs, they do not know where to go or whom to trust.

MIGRATION TO NEW CITY, MISSISSIPPI

The rapid influx of immigrants to New Cityiii meant Juanita was not the only Latino student in the school identified with behavioral and academic problems. In the decade between 1990 and 2000, the Latino population of Mississippi grew 394%,8 primarily due to booming construction and the proliferation of low-wage jobs. Since the 1990s, New City had seen an influx of Spanish-speaking immigrants due to an abundance of jobs in the chicken-processing industry, with the majority of the new residents being undocumented immigrants. According to 2000 census data, Hispanics of any nationality comprised 39% of the population in New City, a small, rural, and high-poverty community in Mississippi. The median income for a household in New City in 2000 was $33,651.

New City is not an isolated case. Southeastern states have some of the fastest-growing populations of Latino immigrants in the United States. Educators in particular have been caught by surprise at the demographic changes in their classrooms, with the proportion of Latino K-12 students in the South increasing from 5 to 17% from 1972 to 2004 and the rate of English language learners in the state skyrocketing by more than 300%.7 The rapid growth and the lack of empirical data about these new arrivals have left schools and other youth-serving organizations to create interventions in an ad-hoc fashion. In particular, there is a significant lack of cohesive information about the social, behavioral, and academic needs of Latino immigrant youth ages 12 to 18 years, most of whom are U.S. citizens but whose parents are not. The burgeoning Latino population has created additional challenges around service delivery, including the poor provision of mental health and social services due in large part to the limited number of bilingual or bicultural providers. Agencies in and around New City, such as county social services, juvenile justice, and child welfare agencies, have tried to adjust to the changing demographics but these institutions have very specific criteria for inclusion in their services and were able to engage only a small segment of the population given their restricted mandates. Additional groups, such as other community mental health providers, psychiatric service professionals, and mental health advocacy groups, remain limited in their ability to respond to the increase in service needs due to the lack of qualified bilingual staff available to work with Latino families. The board of commissioners and the merchants association are also supportive of efforts to expand services but have little ability to shepherd resources toward this needy population.

Latino immigrants in the New City area face a number of barriers to successful acculturation, especially the significant number who are undocumented. New City can be described as moderate politically, but the surrounding counties are socially and economically conservative. The poverty and unemployment rate in and around New City contributed to a growing schism between those who believed dwindling public resources should only be available to citizens of the United States and those who felt that helping all in need ultimately benefits the entire community. Although significant coethnic communities have been developing, the native population is ambivalent about new Latino immigrants. Some communities reached out to the newcomers, welcomed their business, and hired them for previously abundant low-wage jobs, while other factions reacted with open hostility and aggression about the unfair burden on public institutions and the overuse of social services by illegal residents. Their anger was fueled by the growing number of non-Latino families unable to identify qualified mental health providers who could see their own children. This was due, in large part, to the statewide mental health reform that included privatization of the mental health system. Privatization created some efficiencies but also made accessing mental health care much more difficult for many people, both citizens and noncitizens.

When the migration to New City began in the mid-1990s, national anti-immigrant speakers were brought in to rally residents to protest their presence. Across the state, there was continuing debate around higher education opportunities for immigrant youth who were undocumented but educated in the state’s public schools and whether they should be eligible to attend the state’s 4-year and community colleges. Outspoken advocates for new immigrants received death threats and some required FBI protection. Anti-immigrant sentiment in the community and across the state complicated advocacy efforts to create seamless networks of support for vulnerable families. Media stories highlighted accounts of local raids that resulted in detention and deportation of many adults, leaving parents fearful of venturing from their homes and students anxious that they would not see their parents upon returning from school. In addition, service providers, ranging from public schools to mental health agencies, struggled to find teachers, therapists, and other professionals who were able to simply communicate in Spanish, much less provide culturally appropriate services.

A number of community advocates suggested that a public awareness or social marketing campaign highlighting the benefits of population-based prevention strategies would do wonders to help shift public opinion. Such a strategy had been used with some success in this region around other social and health issues, such as the prevention of HIV/AIDS, teen pregnancy, and domestic violence. Yet, sentiments towards the growing immigrant population were particularly charged, and everyone in New City was aware of the ever-increasing community divide. Local business owners warned that if law enforcement officials continued to deport undocumented immigrants, their businesses would suffer and New City itself would be economically devastated. But other realities led program leaders to be cautious. The fight over dwindling mental health resources added to the tension. Accordingly, publicity about programs that provided mental health services to new immigrants were thought to be particularly ill advised. The general sentiment among residents, advocates, and legislators of New City was that assistance to immigrants, especially undocumented immigrants, was successful only when provided “under the radar.” The demise of any helpful policy or program would be assured when brought into public view and scrutiny, resulting in widespread controversy. The exception was the advocacy conducted by a few pastors or other religious leaders who were respected by the community at large and unlikely to be vilified for their support of the disadvantaged.

ADDRESSING CULTURAL COMPETENCY

James Middle School and Larson High School both employed only one school counselor and one school social worker, neither of whom spoke Spanish. Thus, a substantial responsibility rested on the shoulders of the school-family liaison funded by Building on Strengths. How could one liaison reach all of the vulnerable Latino students? Should she even try to identify every student’s needs knowing qualified mental health care might not be consistently available?

Thus, another Building on Strengths initiative centered around classroom-based consultation and skills training offered to teachers. Program staff believed this might prevent the constant flow of students exhibiting behavioral problems and being referred to ISS.

Like many school systems, the New City school system participated in numerous cultural competency initiatives in the past with the goal of creating a climate that welcomed diverse student populations. However, many of these programs focused on specific instructional techniques or descriptions of particular groups that inadvertently reinforced stereotypes or the notion that members of certain groups were completely defined by their cultural background. Expected changes in teacher and staff attitudes were, therefore, not realized. The school system invested heavily in improving language access for Latino students and families. As a result, the number of English-as-a-second-language teachers increased across the school district (from 3 to 28), more interpreters were hired, and bilingual hotlines were created. Yet, school leaders acknowledged that the majority of school staff could use ongoing cultural competence training to adequately address the education and health needs of Latino families and children.

Building on Strengths program staff conducted cultural competency training for 20 teachers, staff members, principals, and district-level administrators in August of 2007. The innovative curriculum was more intensive and contributed to the development of insights about personal biases and discrimination that affected participants in a deeply personal way. Participants were vocal about the impact of the training and their newfound investment in initiating changes that would improve the climate of their schools. The challenge was to keep that initial work moving and spreading throughout the two target schools and the larger school system. The main barriers were scheduling and funding. The 4 teacher training days per year were largely scheduled to conduct mandatory activities, leaving little room for additional training or dissemination of nonacademic information. After-school times were problematic because teachers and staff are involved with sports teams or school clubs and union mandates required overtime pay for activities falling outside of regular school hours.

STORIES OF CHANGE

As the program was implemented, the James Middle School principal expressed some ambivalence about the program and the services offered. His concerns grew about how much time students might spend out of the classroom and away from academic instruction, whether teachers would be asked to take on new roles or responsibilities, and how much flexibility the liaison would request around the interpretation of mandatory school policies and procedures. The principal’s reluctance to embrace the program caused worry among program leaders who knew that school leadership support would be critical to the success of this school-based mental health program.9 Teachers were unsure at first whether referring students to the liaison would prove beneficial, but, after several months, decreases in classroom disruptions and increases in time spent on academic instruction confirmed the value of the liaison’s support. After hearing the positive anecdotes from the teachers, the principal conceded that allowing the liaison to see students individually and having his staff participate in cultural competence training would likely benefit his staff and help keep students out of ISS. He became convinced that gaining a better understanding of the differences in learning and communication among immigrant children and the impact of trauma and loss on classroom behavior would likely improve teachers’ patience, empathy, and effectiveness.

Accordingly, the principal let the Building on Strengths project director know that he was ready to expand programming. However, he also had some barriers to overcome. When past school budgets provided more plentiful resources, principals and the school board had been willing to help subsidize programs for students and families and to fund nonacademic skill development for teachers and staff. Unfortunately, the school budget no longer allowed for that level of generosity. An additional challenge remained about how to identify days and times that school staff could participate in this training since professional development days were already committed for the year.

LIMITED DATA AND ORGANIZATIONAL CHALLENGES

Building on Strengths was entering its last 6 months of funding. Additional organizations (social service agencies, community groups, churches, mental health providers, and advocates) were interested in the physical and mental health needs of newly arriving Latinos and had a brief history of providing services to this growing population. Despite this interest, program leaders had a difficult time forming an advisory committee for the project, and time constraints and political concerns had limited strategic efforts to increase program visibility among potential partners. Although some efforts were made from the beginning of the funding period, existing partners were unable to secure commitments internally to continue services beyond the grant due to the fiscal instability within most organizations. Yet, all agreed that continuing to build broader community and system-wide connections to the program would be beneficial.

There were some university-based resources and supports available to collect and analyze data for the program, but early data collection efforts were problematic, and information collected was unreliable. There was an underdeveloped evaluation plan guiding program evaluation efforts, and no information technology system was available to improve the quality of data collection. The private funding acquired to support the program was not sufficient to invest in a more rigorous evaluation of the main program components. Advisors to the program strongly recommended that additional attention to monitoring the impact of program activities was necessary to successfully secure future funding. Yet, given the day-to-day pressures facing program leaders, resources and time allocated to evaluation were almost nonexistent.

The lack of comprehensive data about positive outcomes associated with the program put willing supporters at a disadvantage. The two school principals in particular, who were beginning to see the changes at the classroom and school-wide levels, were interested in advocating for funding to the school board and the superintendent’s office, but the ever-increasing demand for accountability and results made them reluctant to champion a cause with little evaluation information. Stories of change were accumulating, but teachers were nervous about sharing them for fear of political retaliation in their community, and parents were frightened their testimonials would bring them to the attention of immigration and law enforcement officials.

Juanita’s mother had a powerful story to tell about the help she and her daughter received through the program and the impact it had made in their lives in New City, but her fear of deportation forced her silence.

On the heels of learning that the school principal was finally interested in taking full advantage of the various components of the program, the project director of Building on Strengths received disheartening news that funds for the project were running low and decisions needed to be made about which aspects of the program could be retained. The sustainability of the program’s hard-won accomplishments was at risk.

AT A CROSSROADS—THE CASE SCENARIO

After working in the school system for 2.5 years, Building on Strengths acquired a quiet, but loyal, following of supporters. The program made progress toward its goals, but the project director, whose time was not fully funded through this project, was often conflicted about what to prioritize and how to build public support for what some considered a controversial program. Long-term sustainability plans for the program seemed to rest on the leaders’ ability to explore opportunities among private and public (as well as local and national) funding sources, but program implementation and management took precedence.

The economic recession, which had an impact on the entire country, hit New City particularly hard in 2009. The chicken processing plant was scheduled to close entirely within months, which created a great deal of anxiety among workers and community leaders, as well as elected officials. Latino students and their families faced the likelihood of increased hardship with few places to turn for reliable support. Nuestra Comunidad was not spared the blow of the economic downturn. The agency relied on public financing for its operations, and those dollars were drying up, so the director of the community mental health agency decided to cut programming and release core mental health staff. The tension felt in the community and within homes fueled anxiety among children and youth who had no control over the social and economic circumstances affecting them. These stressors contributed to an increase in the number of behavioral and academic difficulties demonstrated by students across a number of classrooms.

Building on Strengths was forced to reduce its third-year financial commitment to Nuestra Comunidad so that only 40% of the liaison’s time was covered by project funds. The majority of the budget supported staff—the cultural liaison in particular, as well as a small percentage of time for her supervisors at Nuestra Comunidad and for the project director overseeing the entire project. Moving forward, the liaison would need to supplement her salary by billing Medicaid for clinic-based treatment services outside of her responsibilities in the schools. The project director was informed by the project’s accounting office that $25,000 was available for the remaining 6 months of the grant, half of what was expected at that point in the budget cycle. Building on Strengths leadership needed to decide how to meet program objectives, cover expenses, and prioritize limited time and scarce resources. With the end of the school year looming and the grant ending, time was of the essence.

Key Questions

1.   What aspects of the Building on Strengths program are most important to preserve in light of impending funding cuts (i.e., training parents, cultural competence training for teachers, providing direct services, improving data collection and evaluation, focusing on partnership development, engaging in antistigma campaigns, etc.?). What is the rationale for this choice? What critical stakeholders should be involved in the planning, implementation, and evaluation of these program components? What additional information does the project director need in order to make this decision?

2.   What other sources of funding or strategic actions could the project director engage in to help sustain this school-based mental health project beyond the grant? What program elements are most important to continue, especially given the absence of a strong organizational infrastructure? What cultural and political challenges influence the existence and expansion of such a program?

3.   What other partners or advocates should the project director enlist for help? How could Building on Strengths utilize parents and community members more in the development and sustainability of its program? What barriers to engaging immigrant parents (both documented and undocumented) might they encounter, and how can they address these challenges?

About the Authors

Olga Acosta Price, PhD, is director of the Center for Health

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