Inclusive School Based Therapy for Adolescents: A Proposed Community Mental Health Program

The following article proposes a depth oriented and trauma informed community mental health program for youth. It was submitted in June 2022 as a final project paper in a course toward my masters degree in counseling psychology and depth psychology at Pacifica Graduate Institute. The prompt for this paper was to design a community mental health program that addresses the needs of my community.

I enjoyed researching and writing for this project. I hope you enjoy it too!

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Inclusive School-Based Therapy for Adolescents:

Community Mental Health Program

Shawna McGrath

June 21, 2022

Community and Population

Social worker Patricia Wilcox (2017) said in Trauma-Informed Treatment that “approximately 25 percent of children in the United States are believed to experience at least one potentially traumatic event in their lifetime, including natural disasters, life-threatening accidents, maltreatment, assaults, and family and community violence” (p. 7). Several years after she wrote those words, we entered a global pandemic accompanied by civil unrest, and political unrest throughout the US. These global crises have undoubtably affected every individual, especially children and families, at varying levels. These collectively traumatic events are possible in our lifetime, no one is immune. Based on the statistic and recent events, I propose a community mental health program that provides school-based therapy for all students in middle schools and high schools throughout the United States. These services will be provided throughout the school year during regular school hours at no cost to families, parents, or guardians. Each student will be offer voluntary weekly counseling from a depth oriented and trauma informed therapist. The intention of this program is to provide support for youth through the initiatory transition of adolescence when they are exposed to new experiences, developing sexually, and individuating into future adults. In this phase, the youth are encountering new inner and outer experiences while many are coping with past and present traumatic experiences in an environment where they progress through a continually increasing punitive environment (public school). The goal of this program is to provide a safe, regulated, affirming adult to be available youth and to accompany them through their process of development and individuation. This support will provide an increase in the quality of life for youth, families, and communities across the country.

Trauma Informed Care

A core component of this program is the perspective that all maladaptive behavior is either a lack of resource or lack of skill (Heilveil, 2022). Essentially, if a youth could do better, they would. Wilcox (2017) defined a trauma informed program as “a treatment environment in which all staff understands the prevalence and impact of trauma . . . staff provides appropriate interventions that will decrease, rather than increase, the effects of trauma” (p. 13). She explained that the critical dimensions of trauma informed care involves: safety, trustworthiness, choice, collaboration, and empowerment (p. 14). To facilitate this trauma informed care, clinicians would be trained to in biosocial theory to understand that biological emotional vulnerability combined with an invalidating environment (family and/or school system) lead to pervasive emotional dysregulation (Heilveil, 2022; Linehan, 1987). This would prevent psychologically harmful shaming, blaming, guilting, and moralizing a youth’s actions – no matter how extreme or destructive. Further, this model provides a pathway for clinicians to effectively work with youth that are especially difficult or posing harm to themselves or others (suicidal, homicidal, or self-harming). Clinicians would be trained in strategies to break the cycle by acknowledging client’s sensitivity and validating their experience. However, trauma informed care also requires the clinicians themselves to be regulated and to engage their youth clients from a solidly regulated state.

Managing Vicarious Trauma & Burnout

For clinicians in this program to provide effective care, they will need to have the space and capacity within the confines of the program to find their own regulation. Psychiatrist Bruce Perry (2020, March) said in Emotional Contagion that “a regulated calm adult can regulate a dysregulated child, but a dysregulated adult can never regulate a dysregulated child” (9:15). To accomplish this goal, clinicians would be trained to identify individual indicators of their own distress, dysregulation, and burnout such as “anger, sadness, prolonged grief, anxiety, depression, headaches, stomach aches, lethargy, constipation, self-isolation, cynicism, mood swings, irritability, avoidance of certain clients, missed appointments, tardiness, and lack of motivation” (Perry, 2020, April, 10:20). The program would emphasize clinicians recognizing these symptoms as serious issues that interfere with their effectiveness, not simply personal faults to push through as this would perpetuate the dysregulated state. Perry (2020, April) recommended managing these likely symptoms of caretaking work through incorporating “regulatory breaks” for “ somatic sensory regulation” and “relational regulatory activities” in 2-3 minute long doses. This community mental health program would include built-in time for these regulatory breaks between each client. Clinicians would have a physical space dedicated to their break-time with healthy snacks and beverages, yoga mats, foam rollers, couches, blankets, and communally sectioned areas for clinicians to chat and check-in with each other. Finally, brief collaborative workshops will be available each week during work hours to facilitate regulatory experiences with clinicians involving breathwork, mindful movement, and team connection activities. As Perry (2020, April 17) said, “these things are fundamentally regulating” and they will help clinicians to gain tools for use on their own as well as facilitate a relationally corrective experience through the group workshop format (17:25). Through this process, clinicians will be trained in practices to regulate themselves and how to return to regulation even when others around them (teachers, kids, families) are dysregulated. Finally, clinicians will be required to be engaged in their own personal therapy with a depth oriented licensed therapist as this would increase their resiliency against burnout and vicarious trauma. Clinicians would have access to a network of low-cost play therapists through this community mental health program. Play therapy would specifically be encourages as it has been shown to foster resiliency against burnout, cultivate peer support, increase self-efficacy (Born, S. L., & Fenster, K. A. D., 2022).

Working within a Restorative Approach

This program will embody a restorative and person-centered approach through humanizing students as clients and fostering the healing function of authentic relationship. Wilcox (2017) said the “Restorative Approach is an integrated treatment method for child and adolescent-serving congregate-care settings, in which the clinical . . . staff create a therapeutic milieu together from a common understanding of the healing power of positive relationships” (p. 1). She emphasized that “the approach rests on the assumption that children will do well if they can and that symptoms are adaptations” (p. 1). In practice, this means that clinicians will prioritize authentic connection with their clients above any type of perceived behavior change. The therapeutic principles are relational and humanistic as opposed to behavioral. Psychiatrist Mark Ragins, M. (2006) in Person-Centered vs. Illness Centered said, “a crucial step to open a clear vision of recovery is to move from an illness centered perspective to a person centered perspective (p. 1). He elaborated that clinicians should accompany clients “through the process of building hope, empowerment, self-responsibility and attaining meaningful roles in life . . . techniques that emphasize growth, building skills and natural supports, learning from successes and failures, internalizing recovery gains to enhance resilience and wellness, rather than emphasizing stability, caretaking, risk reduction, and treatment compliance” (p. 4). Based on this approach, the youth’s maladaptive behavior is not the foundation, “the relationship is the foundation” (p. 6). To further emphasize the restorative approach, this program would adopt the four core values of the reclaiming environment as described by authors Brendtro, Brokenleg, & van Bockern (2002) in Reclaiming Youth at Risk. They defined a reclaiming environment as one that involves: “1. Experiencing belonging in a supportive community . . . 2. Meeting one’s needs for mastery . . . 3. Involving youth in determining their own future . . . 4. Expecting youth to be caregivers, not just helpless recipients overly dependent on the care of adults” (p. 3). These foundational concepts would inform the goals of the program and each individual session.

Funding Sources & Barriers to Support

Funding for this program will be provided by the federal government through redirection of funds from military spending and defense budget. However, there will be many psychological and political barriers to support. In the US, we are highly attuned to managing crisis but rarely attuned to long-term restorative care (Heilveil, 2022). The intention of this program is to fill that void with proactive, long-term, and restorative care for adolescent youth. Unfortunately, our cultural context views acting out as a moral problem to be fixed (rather than dysregulation or trauma response). And, most people see no problem if there is no maladaptive behavior present. Thus, adolescents either quietly suffer or their symptoms build until they are in crisis before they can receive support. Another part of this barrier to support is our culture’s view of therapy. In the US, most people assume there must be something wrong with a person if they need therapy. If enacted, this program could actually shift that cultural view. If a youth’s initial experience of therapy were a comforting, connected, and even enjoyable, the stigma against therapy could slowly evaporate over the generations. Positioned a different way, this program could be promoted as an initiative to improve our education system and improving academic performance. For example, Wilcox (2017) explained that trauma has a significant effect on one’s education and that “learning becomes more difficult” for children who have experienced trauma (p. 21). However, using this concept as a strategy for acceptance of the program could eventually lead the focus away from the relational and restorative approach. The social and cultural barriers to support for restorative care will remain in place until we create new experiences for young people around therapy and educate the public on the effects of trauma.

Managing Tendency of Coercive Practices

This program will be entirely voluntary because choice is essential to trauma informed care (Wilcox, 2017). Both parent/guardian(s) and the youth must provide informed consent. The youth will be able to decline services without any negative consequence or subtle coercion. If a youth is initially hesitant, clinicians would accept this by acknowledging the youth’s hesitancy, inquiring about the youth’s concerns (confidentiality, CPS reporting, explaining how correspondence with parent works, mandated reporting, etc.) and letting the youth know that they can take a few days to think about it and come back with questions or concerns. The children who are tentative, cautious, or reluctant are the ones who may benefit the most from therapy because “relationship reluctant children need corrective relationships to overcome insecure attachments. The helping adult must be able to offer warm, consistent, stable, and nonhostile attachments. Because such youth may reject friendly overtures, the adult must find ways to become more attractive to the youth while minimizing threat. This encourages relationships unencumbered by ambivalent emotions” (Brendtro, Brokenleg, & van Bockern, 2002, p. 73). In practice, this may involve incorporating arts, crafts, walking, or sports as a therapeutic activity. For example, one highly active youth may benefit from therapy sessions that consist of a game of basketball. In this approach, the adult is allowing the youth to lead by engaging in an activity of their choice and allowing the youth to decide how to connect. Upon following up days later on consent, if the youth is still hesitant or adamantly declines, the clinician will warmly acknowledge their decision and make it clear that the youth is welcome to return for services if they ever change their mind. Clinicians will provide psychoeducation to parents on the negative outcomes of coercive treatment. In the event a student declines services, they will always be welcome to join the program mid-school year.

Structure, Staffing & Physical Space

Though the funding will be federal, the program will be overseen and managed locally within each school district by licensed clinicians employed through the school district. The number of therapists hired at each school will be based on the number of students at each school. Funding and hiring will be sufficient that each student will have access to a therapist each week. Therapists hired in this program will be assigned a maximum of five regular students each day with a maximum of fifteen students on their caseload in total. Progress notes will be kept incredibly brief (3-4 sentences) with minimal information in an effort to protect the student’s confidentiality and to allow the clinician to focus the bulk of their day on face to face contact with youth. At the onset of treatment, the clinician and youth will select a time that is most favorable and least intrusive to the youth’s studies. The clinician will also collaborate with the youth’s teacher to adjust times as needed for special projects or tests. Once assigned to a clinician, the youth and therapist may continue throughout the school year or discontinue at any point if the youth decided to transition out of therapy. There will be sufficient confidential space provided at each school for therapists to see their clients. This may involve creativity in utilizing empty classrooms, storage spaces, or conference rooms.

Therapists will be hired based on credentials including Licensed or Associate status, at least 2 years working with youth, and either an existing depth oriented approach or the interest in continuing education toward proficiency in depth therapeutic practices. Therapists will be paid based on their level of experience within the average base salary for their location. Since clinicians will not be working during the summer, they will have the choice between receiving their annual salary over the 10 months of the school year or spreading the paycheck out over a full year. The employment package for clinicians will also include health benefits, 401k/Roth IRA options, and paid sick leave.

Crisis Response

Clinicians would be trained to focus on establishing safety, restoring connection, and then setting the stage for support to de-escalate crisis and handle mandated reporting issues (Heilveil, 2022). There would be an emphasis on awareness of watching for possible vulnerabilities that may potentially lead to a mandated report so that clinicians could provide referrals and resources if possible (Heilveil, 2022). Clinicians would talk about mandated report with the youth at the onset of treatment and throughout the therapeutic process about what they can and cannot do/promise. They would discuss the process of a potential mandated report where therapist and youth would discuss together the requirement to expand their circle and talk to other people to try to keep the youth safe. Assessment questions may include: do you ever feel unsafe in your home? has someone touched you in a way that felt uncomfortable or unsafe? Do you have to keep secrets? Clinicians would be encouraged to seek consultation and support from one another or from outside colleagues in managing difficult crisis cases.

Theoretical Foundations

This program will be oriented around a relationally focused approach. As Wilcox (2017) said, “the antidote to trauma is attachment” (p. 18). The program will rely on person-centered and humanistic therapy principles as well as dialectical behavior therapy (DBT), and nondirective play therapy. Nondirective play therapy will be especially useful for hesitant or shy where the clinician facilitates a “theoretically based, consistent way of understanding and communicating with their clients through doing rather than just talking” (Kottman & Meany-Walen, 2018, p. 6). Non-directive play therapy allows for a depth psychological approach as the youth is processing and expressing themselves in a symbolically communicative language. Through this person-centered approach, the youth feels mirrored, validated, and the therapy provides an integrative effect. Further, in a study of school-based child-centered play therapy with Hispanic children, researchers found that (Garza & Bratton, 2005) “Child-Centered Play Therapy (CCPT) was successfully implemented in a school setting where Hispanic children are more likely to have access to services and are less likely to drop out of treatment. This is particularly important since Hispanics generally under-utilize community mental health services. They emphasized the value of implementing CCPT in schools “where all Hispanic children can be afforded services when at-risk behaviors are first detected” (p. 13).

Another component of this program will involve the option for monthly connection meetings between therapist, student, and their parent/guardian. These sessions will focus on supporting family connection. Physician Judith Landau (2007) in Enhancing Resilience said that clinicians should “respect families’ knowledge, competence, and values, reinforce their natural support systems, and avoid secrecy and isolation while helping them to address unresolved losses” (p. 352). These sessions would differ from traditional family systems therapy sessions in that the focus would be on how the family system can work together to support the child. This would ideally be an empowering and validating experience for the child as well as involve practical problem solving scenarios that also relieve pressure and stress from the parents or guardians and facilitate greater connection in the family through expression of authentic feelings and active problem-solving. The goal of this program is to improve our communities and our families through providing a safe and secure relational space for adolescents as they grow and mature toward eventually creating their own families in the community.

References

Born, S. L., & Fenster, K. A. D. (2022). A case application of Adlerian play therapy with teachers to combat burnout and foster resilience. International Journal of Play Therapy, 31(1), 46–55. https://doi-org.pgi.idm.oclc.org/10.1037/pla0000159

Brendtro, L., Brokenleg, M., & van Bockern, S. (2002). Reclaiming youth at risk: Our hope for the future (Rev. ed.). Solution Tree Press.

Garza, Y., & Bratton, S. C. (2005). School-Based Child-Centered Play Therapy with Hispanic Children: Outcomes and Cultural Consideration. International Journal of Play Therapy, 14(1), 51–80. https://doi-org.pgi.idm.oclc.org/10.1037/h0088896

Heilveil, B. (2022, Sprint). Unpublished lecture presented in the course, Community Mental Health Counseling II, Pacifica Graduate Institute.

Kottman, T., & Meany-Walen, K. K. (2018). Doing play therapy. Guilford Press.

Linehan, Marsha. (1987). Dialectical Behavior Therapy for Borderline Personality Disorder. Theory and Method. Bulletin of the Menninger Clinic. 51. 261-76.

Landau, J. (2007). Enhancing resilience: Families and communities as agents for change. Family Process, 46(3), 351-365. http://dx.doi.org/10.1111/j.1545-5300.2007.00216.x

Ragins, M. (2006). Person-centered vs. illness centered. http://mhavillage.squarespace.com/writings/

Perry, B. (2020, March 30). 3. Emotional contagion: Neurosequential network stress & trauma series | Info NMN [Video]. YouTube. https://www.youtube.com/watch?v=96evhMPcY2Y&t=577s

Perry, B. (2020, April 16). 7. Self-care & organizational care: Neurosequential network stress & trauma series | Info NMN [Video]. YouTube. https://www.youtube.com/watch?v=96evhMPcY2Y&t=577s

Wilcox, P. D. (2017). Trauma-informed treatment: The restorative approach. NEARI Press.