WRAP AROUND
A Comprehensive Approach to Adolescent Services

By Rich Furman, Yeshiva University DSW Student and Director of a "Wrap Around" program at teh Devereux Foundation in Pennsylvania

Therapeutic services for adolescents have been one of the most underdeveloped sectors of mental health programming, research and policy. Too often, services have been either too restrictive or not sufficiently intensive, culturally irrelevant, and disempowering to families. The wrap-around model of treatment seeks to address these limitations of adolescent mental health services.

In 1983, the National Institute of Mental Health began to focus considerable energy on adolescent services through the development of the Children and Adolescent Service System Program (CASSP). The principles of this burgeoning program included a commitment to keep families intact, provide the least restrictive setting while benefiting the child, and reduce out-of home placements (Friedman & Kutash, 1992).

CASSP researchers and policy makers also responded to the need for greater cultural sensitivity and overall program integration. At first, CASSP efforts to develop a programmatic knowledge-base and framework was hampered by a weak financial base. However, in 1989, Congress expanded the Early Periodic Screening Diagnosis and Treatment ( EPSDT) provision of Medicaid. This legislation sought to address the disparity between the provision of physical versus mental health services for children and adolescents. Consequently, children and adolescents with severe emotional problems were now entitled to receive "medically necessary" mental health services. Although this legislation was widely overlooked, in Pennsylvania advocates lobbied the state to develop guidelines to comply with the federal statute. Pennsylvania's Department of Health implemented one of the nation's first state-wide efforts in the development of wrap-around services.

Multi-Layered Services
Wrap-around services are intensive, community-based mental health services that seek to prevent more restrictive levels of care. The term itself is a metaphor for enveloping families with all the services necessary to cushion them from the challenges of raising children and adolescents with complex, multi-dimensional problems. The wrap-around model not only provides a comprehensive array of home and/or school-based professional services, but seeks to maximize the strengths of families, personal support systems and community resources.

In addition to the process of coordinating existing resources, wrap-around in Pennsylvania is comprised of three main professional services. Therapeutic Support Staff (TSS) is an intensive one-on-one BSW level mental health worker for children at risk of placement or hospitalization. TSS provides support, encouragement, behavior modification, crisis intervention and other services in the natural settings of the adolescent. The goal of TSS is to empower adolescents and their families to prevent the use of restrictive services merely for respite.

The comprehensive treatment plan that guides the interventions of the TSS and the family is created by the Behavior Specialist Consultant (BSC). This masters level social worker or psychologist develops a treatment plan that is both strength based and culturally competent. Wrap-around providers recognize that interventions that ignore the culture of the family and community are bound to fail. Lastly, Mobile individual and/or family therapy is utilized to improve family dynamics and assist families in implementing the treatment plan. In all cases, the goal is to teach the family and teen "to fish", rather than to "buy fish".

A Positive Outcome
A case example demonstrates these services. "Jose" is a 21 year old man who was able to successfully adjust into early adulthood and community life. Between the ages of 12 and 18, Jose lived in several residential treatment facilities. He was placed in residential treatment by his mother, after years of out-patient treatment and episodic hospitalizations failed to curb his aggressive behavior.

When Jose turned 18, his mother stated that if he could "control his anger", Jose could return to his family home. While he had made considerable progress in placement, Jose was worried that without help, he would be unable to control his anger. He wondered if it would be better to move to a group home for adults. However, through insights gained in therapy, he realized that much of his current anger and depression stemmed from living in institutional settings. He desperately wanted to return home.

Jose's social worker contacted the wrap-around program that specializes in teenagers dually diagnosed with severe emotional problems and mental retardation. A team meeting was convened at Jose's mother's home. As in all wraparound team meetings, Jose and his family were considered the most important members, and in many ways, the key architects of services. Also in attendance were Jose's therapist from his residential treatment program, his case worker and his aunt.

Following the treatment team's recommendations, several interventions were implemented. First, the TSS worked with Jose at home and at school for a total of 20 hours a week. Jose worked with his Mobile Therapist twice a week to reduce the shame he felt from being mildly mentally retarded, and older than most of the other teenagers at his new school. He learned to deal with the teasing of other teens, to make nurturing friendships, and to develop academic skills. Jose's TSS was right there with him, providing him with encouragement and redirection. A BSC supervised the work of the TSS and Mobile Therapist, making sure that their interventions were mutually reinforcing and culturally competent. The intensive coordination that is the hallmark of wraparound services facilitated a smooth transition from the adolescent to the adult service system.

In closing, the wraparound system in Pennsylvania is currently facing two broad challenges. First, it will be interesting to see how managed care entities respond to the needs of adolescents and their families, given the impetus to control costs and reduce "inappropriate" care. Secondly, wrap-around providers are re-evaluating the services provided. All too often, TSS are over utilized, leading to the client disempowerment. There is a fine line between wrapping services around clients, and suffocating them. Providers are working with advocates, families, and teens to develop models of care that are effective, strength-based, culturally competent, and fiscally responsive to the reality of increasingly scarce resources.

References

Friedman, R. M. & Kutash, K.(1992) Challenges for children and adolescent mental health. Health Affairs, Fall, pp.125-136.

Jellinek, M. S., Nurcombe, B., (1993). Two wrongs don't make a right: managed care, mental health and the market place. JAMA, The Joumal of the American Medical Association, 270(3), 1737-1745.

Kutash, K., Duchnowski, A. J., & Sondheimer, D. L. (1994). Building the research base for children's mental health services. Journal of emotional and behavioral disorders. Vol. 2(4) pp.194-197.

Miller, l.J.(1994). What managed care is doing to outpatient mental health: A look behind the veil of secrecy.

Rich Furman is currently pursing a DSW at Yeshiva University He is director of a "Wraparound" program at the Devereux Foundation in Pennsylvania.

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