Primary Prevention and Treatment

As already noted, many school nurses can and want to be more involved in programs to prevent and correct mental health and psychosocial problems. Among the functions some already are carrying out are

Every school needs to disseminate information that helps protect, promote, and maintain the well-being of students with respect to both physical but mental health. School nurses already play a major role in disseminating health related information. It does not take much imagination to see how important it is that such activity encompass mental health. This includes providing highly visible information related to prevention and correction:

• positive opportunities for recreation and enrichment
  
• opportunities to earn money
  
• how to stay healthy -- physically and mentally (this includes instruction using curricula on special topics such as social skills and interpersonal relationships, substance abuse, violence prevention, physical and sexual abuse prevention, sex education, and so forth)
  
• early identification of problems
  
• what a student/parents should do when problems arise
  
• warm lines and hotlines
  
• services on- and off-campus.
  

During the instructional day, the curricula in many classes touches upon matters related to positive social and emotional development and wellness. In addition, some schools actually have incorporated mental health as a major facet of health education. And school staff are involved each day in dealing with matters related to mental health and psychosocial concerns.

Related to these matters, efforts should be made to capitalize on the school nurse's strengths by facilitating ways for her or him to play a direct role with students as part of a school's efforts to provide comprehensive health education and an indirect role by participating in developing the capacity of other staff to address these matters.

In addition, nurses can play a role in a variety of open-enrollment programs designed to foster positive mental health and socio-emotional functioning. They can also help establish strategies to change the school environment in ways that make it more inviting and accommodating to students. This involves participation in staff development, but even more, it requires working with school staff to restructure the school so that it effectively promotes a sense of community. Examples include establishing welcoming programs for new students and families and strategies to support other transitions, developing families of students and teachers to create schools within schools, and teaching peers and volunteer adults to provide support and mentoring. Intervening at this environmental level also encompasses working with community agencies and businesses to enhance the range of opportunities students have with respect to recreation, work, and community service.

Effective open-enrollment and prereferral intervention programs and environment change strategies can minimize the number of mild to moderate problems that develop into severe ones. This reduces the number in need of specialized interventions and helps reserve such help for those who inevitably require them.

Note: As a follow-up aid for you and your school, included in the accompanying materials is a resource packet entitled Where to Get Resource Materials -- prepared by the Center for Mental health in Schools at UCLA. This packet provides references to sources for materials, curricula, fact sheets (see example at end of this section), and various other forms of assistance for mental health education.

Personalized guidance and support is best provided on a regular basis in the classroom and at home. There are great benefits to be gained from any role the nurse may play in helping teachers function in ways where they directly provide such support or do so through use of various activities and peer support strategies. Nurses also can play a role in mobilizing and enhancing support from those in the home.

Specialist staff also is a logical person for a student to contact if something is amiss between what is happening at school and the student's therapeutic regimen. And s/he is a good person to interface with a student's personal counselor or therapist and to act as a school-site case manager so that there is coordination between the school's efforts to teach and treatment practices.

Guidance and support involves a range of potential activity:

• advising
  
• advocacy and protection
  
• providing support for transitions (e.g., orienting new students and connecting them with social support networks, facilitating students with special needs as they transition to and from programs and services)
  
• mediation and conflict resolution
  
• promoting and fostering opportunities for social and emotional development
  
• being a liaison between school and home.
  
• being a liaison between school and other professionals serving a student
  

Note: Special considerations and concerns arise related to students taking psychotropic medications. As a follow-up aid for you and your school, included in the accompanying materials is a resource packet on this topic entitled Students and Psychotropic Medication: The School's Role -- prepared by the Center for Mental health in Schools at UCLA.

Good counseling builds on the type of caring which is fundamental to all helping relationships. It also encompasses the basics of any good working relationship -- and a bit more. Some basics are highlighted here. You will want to learn more and a good next step is to read some of the works referenced at the end of this unit.

In general, counseling requires the ability to carry on a productive dialogue, that is, to talk with, not at, others. This begins with the ability to be an active (good) listener and to avoid prying and being judgmental. It also involves knowing when to share information and relate one's own experiences as appropriate and needed. Some thoughts about engaging students in a productive dialogue are outlined on the following pages.

Counseling also requires the ability to create a working relationship that quickly conveys to the student

• positive value and expectation (that something of value can and will be gained from the experience)
  
• personal credibility (that the counselor is someone who can help and can be trusted to be keep his or her word, be fair, and be consistent, yet flexible)
  
• permission and protection to engage in exploration and change (that the situation is one where there are clear guidelines saying it is okay and safe to say what's on one's mind).

All this enables the counselor to elicit a student's concerns.

Then, the process requires the ability to respond with

• empathy, warmth, and nurturance (e.g., the ability to understand and appreciate what others are thinking and feeling, transmit a sense of liking, express appropriate reassurance and praise, minimize criticism and confrontation)
• genuine regard and respect (e.g., the ability to transmit real interest, acceptance, and validation of the other's feelings and to interact in a way that enables others to maintain a feeling of integrity and personal control).

Think about the students you have found it easy to talk with. What made the dialogue go so well? Think about those students you found it difficult to engage in a dialogue. What are some ideas that might help next time you encounter such a student?

A Few Thoughts About Engaging Students in a Productive Dialogue

A few are so nonverbal that referral probably is indicated. Many, however, are just reluctant to talk.

How to Facilitate "Talk"

Quite often, one has to start building a relationship around relatively nonverbal activities, such as responding to a structured set of interview questions dealing with common concerns. In some cases, having students draw themselves or significant others and telling a story about the picture can break the ice and provide some leads.

In general, the focus is on enhancing motivational readiness to dialogue by creating a sense of positive value and expectation for counseling, personal credibility for the counselor, and permission and protection for engaging in exploration for change.

Some specific things to do are

• Create a private space and a climate where the student can feel it is safe to talk
  
• Clarify the role and value of keeping things confidential
  
• Avoid interruptions
  
• Start slowly, avoid asking questions, and minimize pressure to talk (the emphasis should be more on conversation and less on questioning and on nonsensitive topics related to the student's main areas of personal interest)
• Encourage the student to take the lead
  
• Humor can open a dialogue; sarcasm usually has the opposite effect
  
• Listen with interest
  
• Respond with empathy, warmth, nurturance, and genuine regard and respect
  
• Use indirect leading statement such as "Please tell me more about ...." or direct leading statements such as "You said that you were angry at your parents?"
  
• If needed, use structured tools (surveys, sentence completion) to guide a student

  (Examples of tools that may be useful are included in the accompanying materials resource packet entitled Screening/Assessing Students: Indicators and Tools.)

  
  

• Sometimes a list of items (e.g., things that students generally like and dislike at school or after school) can help elicit a student's views and open-up a dialogue
  
• When questions are asked, use open-ended, rather than yes/no questions
• Appropriate self-disclosure by a counselor may disinhibit a reluctant student

In addition, for groups

• Facilitate sharing through various activities (pairing a reluctant student with a supportive peer, having the group share backgrounds)
  
• Clarify that trust, respect, confidentiality, etc. are a function of commitment to the group -- not a matter of stating rules

How to Keep Talk Going
In general, the focus is on maintaining motivation.

Some specific things to do are

• Focus on areas of interest, strength, and self-esteem, as well as on analyzing problems
  
• Build on previous discussions by referring to what has been shared
  
• Continue to follow student's leads in analyzing problems and avoid procedures they may perceive as efforts to control them
  
• Continue to convey that the intent is to help not socialize

In addition, for groups

• Draw out similarities in experience and problems with a view to encouraging students to see the value of helping each other
  
• Help students understand that giving advice usually is ineffective

Remember:

• Short periods of silence are part of the process and should be accommodated.

Some Points About Counseling and Student Motivation

Most counseling at a school site is short-term. Some will be informal -- brief encounters with students who drop-in or are encountered somewhere on campus. All encounters have the potential to be productive as long as one attends to student motivation as key antecedent and process conditions and as an important outcome concern.

(1) Motivation is a key antecedent condition. That is, it is a prerequisite to functioning. Poor motivational readiness may be (a) a cause of inadequate and problem functioning, (b) a factor maintaining such problems, or (c) both. Thus, strategies are called for that can result in enhanced motivational readiness (including reduction of avoidance motivation) -- so that the student we are trying to help is mobilized to participate.

(2) Motivation is a key ongoing process concern. Processes must elicit, enhance, and maintain motivation -- so that the student we are trying to help stays mobilized. For instance, a student may value a hoped for outcome but may get bored with the processes we tend to use.

With respect to both readiness and ongoing motivation, conditions likely to lead to negative motivation and avoidance reactions must be avoided or at least minimized. Of particular concern are activities students perceives as unchallenging/ uninteresting, overdemanding, or overwhelming and a structure that seriously limits their range of options or that is overcontrolling and coercive. Examples of conditions that can have a negative impact on a student's motivation are excessive rules, criticism, and confrontation.

(3) Enhancing intrinsic motivation is a basic outcome concern. A student may be motivated to work on a problem during counseling but not elsewhere. Responding to this concern requires strategies to enhance stable, positive attitudes that mobilize the student to act outside the intervention context and after the intervention is terminated.

Essentially, good counseling reflects the old maxim of "starting where the student is." But more is involved than matching the student's current capabilities. As suggested, attending to a student's motivational levels is also critical. Thus, it is the counselor's responsibility to create a process that will be a good fit with the student's capabilities and motivation.

The less one understands the background and experiences that have shaped a student, the harder it may be to create a good fit. This problem is at the root of concerns about working with students who come from different cultures. It is, of course, a concern that arises around a host of individual differences.

As discussed in the unit on working with others, efforts to create effective working relationships require a breadth and depth of knowledge, skills, and positive attitudes. Counseling aims at enabling students to increase their sense of competence, personal control, and self-direction -- all with a view to enhancing ability to relate better to others and perform better at school. When a counseling relationship is established with a student, care must be taken not to undermine these aims by allowing the student to become dependent and overrely on you. Ways to minimize such dependency include

• giving advice rarely, if at all
  
• ensuring that the student takes personal responsibility for her or his efforts to deal with problems and assumes credit for progress
  
• ensuring that the student doesn't misinterpret your efforts to help or lose sight of the limits on your relationship
  
• helping the student identify when it is appropriate to seek support and clarifying a wide range of ways to do so.
  
• planning a careful transition for termination