PSYCHOLOGY IN ACTION
Capacitar: Building mental health capacity in rural Guatemala
By Liz Angoff, PhD
By the end of seven years working as a school psychologist in a large urban public school district in Oakland, California, I was frustrated with the gravity of the issues and the scarcity of resources. I decided to flee the country in search of perspective: with a friend’s recommendation, I applied to volunteer at a hospital in rural Guatemala.
I have always wished there was a program for school psychologists that paralleled Doctors Without Borders: an opportunity to do service in another country and have an impact on a global scale. I work with many Spanish-speaking immigrant communities in the Untied States and have visited some of their hometowns before, but never long enough to engage in real work. Unfortunately, Doctors Without Borders is a nine-month commitment, and they do not accept educational psychologists. Still, I have the summers off from work, fluency in Spanish and an inexplicable exuberance for my job. Why not pack up my skills and my passport and go on an adventure? A physician friend of mine does this regularly and suggested a small hospital in a culturally rich but resource-poor rural area where she had previously volunteered. I filled out an application explaining my skill set, and the hospital staff was ecstatic. So I packed my bags for a month in Santiago Atitlan, Guatemala.
Upon arrival, I quickly realized that my hosts were expecting me to see adults and children with severe trauma. Several years before, a hurricane took out an entire village, and there were some adults who had not left their homes since. Despite the need, however, there was little precedence for mental health intervention. Perhaps amplified because I was working out of a hospital, those who came to see me described their children as sick and often asked, “Doctor, do you think he has something?” One little boy refused to come into the room because he hated doctors: “Doctors hurt!” he explained, tearfully.
I was faced with a dilemma: I was to be in Guatemala for only a month, the people I was encountering professionally suffered severe trauma, psychological services were rare and there were no other supports available for patients if short-term therapy was ineffective. It seemed to me that providing therapy in these circumstances could actually cause more harm than good. What, then, does a psychologist do if not therapy?
An Ethical Short Term Practice
Fighting oppressive thoughts of “What was I thinking?” and chagrined at the idea of “drive-by therapy,” I attempted to shift my lens to a different model of psychological intervention. The professionals surrounding me had deep roots in the community, and understood the struggles and trauma of the area, but were unfamiliar with mental health practices. I wondered if I could make an impact by helping frame the struggles they saw and equip them with a few basic tools to support mental health challenges. Even if psychological services might be viewed as taboo, there could still be ways to address mental health issues.
There are many ways to say “training” in Spanish. On my first day I was informed that the apparent cognate, "entrenar," implies the training of a dog, while the word "enseñar" (to teach) implies a power differential between teacher and student. Rather than training or teaching, we were instead asked to "capacitar": to empower, prepare and entitle. This particular conceptualization of training aligns with the consultee-centered consultation model (Caplan, 1964), in which I received training the United States. The goal of this model is not for experts to fix a problem; it is to use consultation to build the capacity of those who are on the front lines, who have regular access to those affected and who will continue to be around long after the “experts” (or those with official degrees) have returned home.
While this method typically focuses on the interaction between two or more professionals, it has been my practice to also work with parents in this manner, as they are experts: in their knowledge of their child, their community, their resources and their own experience with the problems they are trying to solve.
With so few patients coming to the hospital, the volunteer coordinator partnered me with a school close by. When I introduced myself to the school, I had a chance to explain my role and skills differently; when the school leaders asked me what I did, I explained that I worked with teachers to help them learn how to approach children with difficult behaviors, a history of trauma or difficulties with learning. I explained that I would be available for meetings with teachers, I would be willing to conduct trainings and I would model social skills groups. The school teachers were skeptical: “But we have so many students who need to see you.”
One of my first encounters was with a woman who had the title “Spiritual Guidance Counselor” (it was an Evangelical school). Previously, she had been the Bible study teacher. However, she noticed that the students were having many difficulties in their lives that were not covered in her curriculum. She began meeting with them — by class, in groups of girls and boys, and then in small groups with the most impacted youth. She identified the most pressing issues for each grade and began choosing Bible stories that directly addressed these issues. After this, she changed her title to guidance counselor. She told me that there was no precedent for this: she knew of no other schools with a guidance counselor, and there was no training available for someone with these intentions.
When she asked if I would train her, I was somewhat taken aback. I am not a religious person, and I was raised Jewish; but her response to this information was, “That’s wonderful! What a beautiful people the Jews are. We hold the same values.” In consultee-centered consultation, the first and most critical step is rapport-building. At this juncture, we both put down our notepads and talked at length about these shared values. While my beliefs were not aligned completely with hers, we had a common understanding that propelled much of the work ahead of us.
I asked to spend the first week observing classrooms and building rapport with the teachers. When they asked me to speak with individual students, I instead set up appointments to consult with the teacher directly. By the end of the week, I had become a familiar face in the classrooms, clarified some translations for the English teacher and even briefly taught sex education when the male teacher ran out of answers for his female students.
I observed the guidance counselor on a number of occasions. She was a dynamic speaker and storyteller, but the students never had an opportunity to speak during their sessions. She spoke at them for an hour, asked if they understood, watched them nod and then dismissed them. I used the consultee-centered consultation framework to continue rapport-building and problem definition to help her find interventions. We worked to define the difficulties: first, she wanted students to talk to her about their problems; second, she wanted to help them internalize the lessons about how to solve these problems. We decided I would model social skills instruction with the fifth and sixth graders to help develop these skills.
Social Skills Groups
I frequently run “Friendship Groups” in the United States, which are designed to teach social skills and create a therapeutic environment for the most challenged students. Together, the guidance counselor and I reviewed some of the major difficulties she had identified in her students, and I designed a series of four lessons using her input from the Bible stories she felt most relevant. While I conducted these four sessions with a few groups from the sixth grade, the guidance counselor and principal observed and began learning the strategies. When I repeated the lessons for groups of fifth graders, the guidance counselor co-led some of the lessons to implement the strategies in her own way.
One morning during my last week, the counselor opened her office and excitedly pointed to her wall. She had pinned up a number of papers from an activity with the high school students the evening before. It was a variation on an activity I call “Graffiti.” The papers had the words “honesty” and “dishonesty” in the center and were filled with children’s handwriting. She explained how this activity showed her how little the students understood from her lessons and began brainstorming multiple ways for her students to talk more during the class. She began designing a lesson where they would write out imaginary Facebook postings between Biblical characters, stating that her students might be more engaged if she used more elements from their modern world. Four months after I left, I wrote to the guidance counselor to ask if the work continued. She replied:
There were some difficulties with the girls in the Secondary School, and I used [the techniques] with them. The results were very positive, so I made a formal training for the staff in how to use it. I explained the steps and added some things that I’ve done. There were some very exciting moments because the staff participated as if they were students, writing messages for each other, sharing their drawings, and I told them they could do this with their students. I felt very happy with the results because the teachers learned how to use the technique so they could help their students. I would like to learn more about how to discover what the children keep inside them, and how it affects their behavior in school. [translated from Spanish]
Not only did she continue engaging her students, but she was able to "capacitar" the staff as well. This impact is significantly more than I could have achieved through direct services to struggling students.
When the teachers approached me to counsel their students, they often began by saying the problems “came from home.” Knowing that drive-by therapy was not in my plans, I made appointments with the teachers instead of their students. In the first case, the child cried every day that she missed her mother. I asked the teacher to describe in detail what she saw, what part of the day was most difficult, what seemed to help or what made things worse. We discovered through her description that the student was very capable of the work, but had difficulty focusing because she spent her time seeking comfort from the teacher. We re-defined the problem from “home” to feeling anxious in the classroom. The next week, the teacher brought in a few stuffed animals to be “class helpers” and reported that the target student, as well as a few others, had begun using the animals to calm down on a tough day. The teacher had found a way to help her students cope with difficult emotions even when they came from home.
A second teacher reported that her student was inattentive, getting into conflicts, and often tired and defensive. The student had suffered a traumatic event, and the teacher felt helpless. We discovered that the student was having vicious nightmares with dozens of monster, which he drew for us. Connecting the scary dreams and lack of sleep to his behavior in the classroom, we asked the student to tell us what he wanted to do with the monsters. He replied, “Let’s put them in the compost so the worms will eat them!” By the next week, the teacher had set up a “dream corner” in the classroom with paper and art supplies. Any child who had a bad dream could draw their dream and feed it to the worms. The teacher later reported improved behavior with a few of her students who were using the dream corner as a place to put their worries and fears. Again, by focusing on coping skills instead of wondering how to improve the home environment, the teachers were able to independently develop effective interventions for the classrooms.
On my last day at the school, I ran a workshop for the entire staff and presented a simple concept: behavior, similar to reading and math, is a set of skills. If a child is misbehaving, blaming outside circumstances leaves us powerless; however, if we see behavior as a set of skills, we can identify what we need to teach the children so they can engage in school in a positive way. Then I asked them to share: the guidance counselor presented her plans for Friendship Groups, and the teachers presented their plans for stuffed animal “helpers” and the “dream corner.” Other teachers presented difficult student behaviors, and the staff discussed what skills these students were missing and how to teach them. One of the teachers recently emailed me to say that they are still working from this framework and talking about how to teach skills to difficult students.
While I tried to focus most of my work on staff development, I still saw children at the hospital and at the school for individual sessions. However, my work in this context focused mostly on the parents and how they worked with their child in difficult times. Similar to my conversations with the teachers, I worked to clarify difficulties and to help the parents brainstorm solutions to support the overall mental health of their children. While I cannot be sure of the impact of these parent-focused sessions, I do know that if the parents did take something away, the likelihood of its continued impact is greater than if I attempted intervention with the children themselves.
The Traveling Psychologist
The consultee-centered consultation model provides an avenue for capacitar: building the capacity of those directly involved with the problem or difficulty at hand. While not traditionally a part of global mental health efforts, school psychologists may be particularly well equipped to provide sustainable support for impacted communities. We know how to work within institutions, and we have knowledge of school systems, family systems, child development and the ways that trauma can affect each of these things. By using a consultation model, it is possible to build capacity in communities that lack mental health resources, are resistant to traditional models of psychological intervention and struggle for the means to acquire these services when they are available.
For me, working in Guatemala gave tremendous clarity to my work in the school district. I am part of a large support network for students and all who participate in their care; I am a part of the villages that raises our next generation, and I get to be the “doctor that doesn’t hurt.” Pura utz!
Adapted with permission from Angoff, L. (2013). Capacitar: Building mental health capacity in rural Guatemala. Communique, 41(7), National Association of School Psychologists.