PREVENTION NETWORK PROJECT
Culturally Sensitive TEMAS Narrative Treatment
Scholastic Application, Analysis of a Network Experience in Italy, 2012/2013
Pre-adolescence and adolescence are ages that, along with many risks, do offer a unique opportunity for health protection, particularly in the mental health field, through prevention and early intervention strategies, which can effectively reduce risks for the future adult to be.
Back from an ancient and famous migratory history now far in time, Italy is currently joining the list of Countries which are taking more and more in their social structures multicultural characteristics, absorbing in their social fabric, not only generations but also different ethnic groups. It’s therefore becoming crucial to understand how this event is affecting the youngsters, who will have the task to set up a society increasingly oriented to multicultural integration.
September 2012-January 2013: pilot project in the first grade of a secondary school in Como, with the proposal of a prevention action network against juvenile uneasiness, realized over a 5 months period, engaging teenage students of two 8th grade classes, a group of teachers of the two classes and a group of parents having a child in the selected classes. Each group followed a specifically thought pathway, which covered the main themes of adolescence, its difficulties and the ways to manage them. In particular, the students engaged in the TEMAS Narrative Treatment, which is particularly indicated to manage juvenile conflicts and to facilitate multicultural integration.
Pre-adolescence and adolescence are ages recognized as bringing great changes, which for some individuals might result in dysfunctional and symptomatic adjustment. It is an age which, along with many risks, do offer a unique opportunity for health protection, particularly in the mental health field, through prevention and early intervention strategies, which can reduce effectively risks for the future adult to be.
In Italy we don’t have definite data on the general population, but the Health Department recognizes an incidence that matches the European one. Data from the PRISMA (1) research, which analyzed a sample of scholastic population below 15 years old, shows an incidence of 9%, in line with other European nations. In this study the majorly represented diagnosis are the ones of Anxiety Disorders, Depressive Disorders and Conduct Disorders. Furthermore, psychiatric pathologies contribute to the creation of self- hurting behaviors, which are present from the 4% to the 14% of the general population (2) up to suicide, which in developed countries, represents the third cause of teenage death. Moreover, juvenile psychological turmoil highly correlates to damaging behaviors, like alcohol and substance abuse, which in turn, multiply the risks of STD, unwanted pregnancies, car accidents and antisocial behaviors (3,4,5).
Back from an ancient and famous migratory history now far in time, Italy is currently joining the list of Countries which are taking on more and more in their social structures multicultural characteristics, meeting a reverse phenomenon compared to the one which characterized its beginning of the century: it plunged into the new era of migration welcoming. This phenomenon, which shows different characteristics and confluence in different parts of Italy, it’s particularly evident in many classes of kindergarten and primary schools within big cities, where the chance of having schoolmates with different heritages or with immigrated parents, rockets.
Nevertheless, welcoming the phenomenon of multiculturalism in big cities and their schools, through mutual exchange and integration, it’s not immediate, nor granted. Getting to know new classmates, imposes a proper obligation to legitimate and recognize their migratory history, often connected to new opportunities, but also to many difficulties. Migration is painted with the trauma of the loss of physical and cultural points of references, with enlarged family which bonds are geographically spread, with not speaking the language, with parents often fatigued and uncertain of their role as a primary guide in the new country (at times exacerbating old traditions, at times fragmenting a fragile stability). Settling in the new country means children tiered apart in the ongoing conflict between the assimilation of the new cultural context and the respect of their own roots; adolescents dealing with a personal change and evolution which is not clearly scanned anymore (by rituals or tradition), but need to be more and more redefined and negotiated. These are only few factors that might contribute to the increase of requests that immigrated families make to our national health system, more specifically to the mental health services for children and adolescents, which are constantly dealing with the early onset of psychological symptomatology.
During recess, halls and school yards of primary schools are always crowded by different groups of children, but what changes from the past is the current variety of these friendships, their heterogeneity, their cultural background. What changes from the past is also the specific multicultural competence currently required to professors and school staff, often disoriented in front of foreigners’ kids, who despite showing themselves to be intelligent and sensible, are not yet able to respond with the Italian cognitive processes of learning and adjusting. Other times they carry deep signs of traumatic migrations, broken families, unsettlements.
Consequently, for child psychologists and child neuro-psychiatrists working in specific settings the standard psychological assessment is not sufficient anymore, lacking the crucial capacity to stress cultural references and to detect the impact of psychological trauma often linked to labored personal experiences. The risk entailed is the failure in correctly identifying the objectives of care and treatment, that’s why nowadays clinicians’ effort has to be channeled to amplify and to integrate new theories and methods empirically based, in order to cope and manage more effectively the diversity of psychological uneasiness, in its multiple forms and possible meanings. The scholastic space becomes therefore a crucial area, with its high and multiple expectations on the youngsters both under the humane profile of the personal development, under the academic profile of learning and socializing. That’s why the need to focus more on the psycho-social genesis of psychopathology and on an effective and precocious prevention of psychological uneasiness is becoming stronger. It’s extremely important to utilize efficient psycho-educational tools, which on one hand can prevent discomfort and on the other hand can provide support in cases where we need to face pre-existing difficulties, simplifying and valuing referrals to the mental health agencies present in the territory. Moreover, the contact with mental health services is usually more difficult for the migrant population, due to different reasons: a general difficulty in recognizing the needs, a limited knowledge of burocracy and formal pathways, not speaking the language, limited familiarity with the services and their disposition on the territory, feeling ashamed of having failed the dream and the expectations of migration. It becomes necessary to create strategies of prevention and early intervention, from both a scholastic and a social point of view, which take into consideration cultural diversity and which introduce a deeper consideration on more adequate clinical and organizational models. Given these premises, the experimental project here presented aims to explore new instruments and network modalities in a multicultural perspective.
INNOVATIVE PROJECT TR 84: Rosa dei Venti no-profit Foundation and Sant’Anna Hospital Mental Health Department/Clinical Psychology Unit, Como, Italy:
“Primary Prevention of Behavioral Disorders among Adolescents” Introduction
September 2012-January 2013: The pilot project, whose goal was to prevent juvenile uneasiness, was implemented and displaced in a public pre-high school in Como, Italy. The project extended over a period of 5 months, during which the intervention was displaced over three levels: 1) the group of students of two classes, previously selected by the teachers of the school on the base of their behavior and academic performance; 2) the group of teachers of the two classes; 3) the group of parents. The final goal was to share the work done by each sub-group with the others, in order to integrate and explicit the requests subjectively expressed with the available resources and potentials.
The group of students
Distribution of participants
The prevention project was started with students belonging to two 8th grade classes of a public pre-high school, age 13-15 years old, with multicultural ethnical background (Italian, Philippines, Equador, Chinese, Arab, Albanese, Serb, Irish, Turkish): 49 students in total, 30 females and 19 males, 31% with foreign heritage. The modality adopted with each class involved the subdivision of its component thanks to the administration of a Morenian sociogram, a simple technique made out of open structured questions that allows to inquire the relationships existing among the students of each class by asking which ones are their favorite classmates, with whom they don’t get along well with, which ones are the most popular and unpopular people in the class, ecc… The students were therefore distributed in groups homogeneous by age (13-15 years old) and heterogeneous by ethnical background and gender (8 students per each group, except for one which had 9 students; average 3 males and 5 females per each group; average 2 students with foreigner nationality and 6 with Italian nationality per each group), obtaining 3 groups for each class (6 groups total).
The timing for each group was planned as 6 meetings, one every two weeks, held within the school schedule previously agreed with the teachers, plus a final conjoint/plenary session for each belonging class (students-teachers-parents).
Actions and Methods
The modality adopted for conducting the first 5 sessions for each group was the TEMAS (Tell-Me-A-Story) Narrative Treatment (TNT, Costantino, 1987). Specifically indicated for scholastic settings, the TNT is an effective culturally sensitive and preventive therapeutic tool, able to elicit the expression of problematic areas for adolescence and to facilitate moments of comparison among peers. The group treatment is therefore aimed to creatively combine multicultural variety and to stimulate a sensibilization process towards specific differences/similarities, as a foundation for mutual knowledge and for an attentive and respectful integration process. By activating the discussion around the graphic stimuli proposed at each session through the vision of TEMAS cards, the students are helped to constructively confront each other with different topics and problem-solving situations typical of their age. The clinicians investigate on experiential areas of individual difficulties and proposes an adaptive and functional rielaboration of the material, by drawing from the variety of possibilities offered by the group. The attention, focused on psychosocial aspects of development and on the prevention of juvenile uneasiness in the scholastic setting, had the goal of utilizing psychological instruments which could also support in case of pre-existing difficulties. The sixth and last meeting for each group was dedicated to the preparation of material, that was meant to be shared during the final session of the project, in a plenary meeting where every single participant was invited to attend.
TEMAS Narrative Treatment (TNT)
The idea underneath the TEAMS Narrative Treatment (TNT) is that the adaptive behavior identified by the group must be followed by verbal positive reinforcements, facilitating therefore its cognitive, emotional and behavioral acquisition. Moreover, spontaneous verbal reinforcements from peers appear as soon as the group members create bonds or deepen those pre-existing. The stories showed in response to the graphic stimuli motivate attention through the presentation of characters and culturally familiar life scenes, which revoke the same ethnical background of students and promote a cognitive change by embracing different possibilities of interpretations and management of the problem solving situations proposed. This way, beliefs, values and behaviors through which teenagers can easily identify, are shaped and relationships with peers and authority figures are modified. This modality, on the base of precedent experiences (Costantino, Malgady & Rogler, 1988) seems particularly appropriate with teenagers with symptoms which are borderline with conduct disorders. The five selected cards, each in its minority and non-minority version, were particularly adapt to evoke narratives linked to anxiety, depression, fear, destructive/cooperative, aggressive/non aggressive, disastrous/full-filled behaviors. The areas investigated under a multicultural umbrella were: relationships with parents, with peers, with the school and adults of reference, self-reflection in the specific moment of growth/recognition, reflection on ones gender maturation and identification with adults/models of reference, one’s personal choice and scholastic/perspective orientation (Minority and non- minority cards: 1; 8; 6; 13; 9). Some of the TEMAS cards were designed for both gender, during the TNT sessions both single cards showing simultaneously female and male versions and double cards showing different versions for males and females were presented.
TNT session’s format
The length of each meeting coincided with an hour of lesson from the school schedule (55 minutes average), previously agreed with the availability of teachers and having decided that it was counterproductive to lengthen the session over the school schedule, risking to break lessons’ hours. Each session was conducted dividing the time into three phases:
On a weekly basis the teachers of the selected classes were invited to participate to group meetings of 2 hours each.
The teachers, through different modalities like lectures, visions of movies, case presentations, team work, were stimulated to reflect on their own professional experience and subjective life events of the profession, facilitating through the group context their exchange and comparison.
With time, the weekly work with the teachers’ group helped to delineate further areas of criticism, themes and specific needs for the scholastic context, such as:
In addition, some cross-scholastic disciplines objectives were identified, which could have been activated by the same teachers in favor of students to improve the entire school wellbeing: capacity to ask, to protect others and oneself, to choose, to manage time more effectively, to promote spontaneity, to unable the play of different roles depending on the context, to learn how to tolerate frustration, to facilitate peer support, to express someone’s emotions, to recognize and to integrate differences, to promote the development of ethical/social values and to respect/guarantee “safe” relational spaces.
The role of teachers was therefore redefined as a triad among three aspects: Task (content and growth task: cognitive, affective, social), Personal and Professional.
Two different context were proposed to parents: the possibility to access a space for the individual or the couple (which was poorly utilized) and a 2 hour group meeting once a month. The second setting was preferred and more utilized by participant parents, who underlined its utility as a larger contex which provided a chance to self-reflect and to share.
Actions and methods
Group meetings of two hours each were established every fiftheen days, co-conducted by two psychologists, both playing the role of facilitators. The groups were meeting on Saturdays in order to allow more people to attend. During the group meetings an integration between different tools was proposed: role-playing, power point presentations, pieces of movies, blackboard, signs, ecc….
During the meetings many different themes were dealt with, such as the “relief valve” subjectively chosen and intended to be used daily as an essential element, which allows to protect the quality of relationships with children and partners, a helthy space of decompression that parents need to defend. Other themes of shared interest that emerged during the meetings were: teenagers and development (physical and mental); the importance of the peer’s group for children and for parents; the importance and the difficulty to choose the right high school for children of this age as well as the support role played by teachers and parents in the decision making process; the relationship between students and teachers and the relationship between teachers and parents; concerning phenomena that are spreading out precociously, such as bullism in school, sexual acting out or subsance abuse.
On the side of these group meetings, different spaces dedicated to individual parents or couples of parents were maintained, but were barely used. In addition it has been proposed a 2 hour meeting on a weekly night dedicated to the theme: “development in adolescence: adaptive versus maladaptive signs”.
Final plenary session
The project was concluded with a final moment of exchange between students, teachers and parents. The main goal of the plenary session was to “explore and embrace the experiences and reflections that each group matured during the previous meetings, with the goal of exploring the other’s point of view and opening up to dialogue for a profitable good living in the school”. Through boards realized by each group durig the last session with the psychologists, the students spoke about the meaning that this experience had for them and shared their reflections. The participant adults, teachers and parents, spoke about the meaning of their experience too, talking at first with the same students, and later on only with adults figures: the goal of this double modality was to stimulate and to act a direct and indirect preventive intent.
Finally, to all participants was administered a questionnaire of satisfaction, meant to investigate the participants experience related to contents’ importance, to the chosen modalities to deal with them, to the lenth of the process, to those aspects which evoked more interest or sense of completeness, eventual suggestions on areas to be further investigated.
The intervention with the students developed and progressed in dealing with the presented issues along with the increase of time. Having progressively settled in each of the small groups in which they were unespectedly placed, the students enjoyed all the time in which the group sessions were conducted, experiencing it as a possibility to observe and to know each other. Subdivided in small groups that were beyond friendships and affection characterizing extra-scholastic relationships, the students often found themselves in a situation were they had to relate or learn to know some classmates with whom they had less confidence. A surprising result, not taken for granted, of this experiment was that the criteria of sharing and confidentiality were respected and constantly maintained by everyone, as if the students could have understood the importance of protecting their experiences, by respecting also other’s experiences as well. Another aspect that emerged and that characterized the work with students was the interest and the awe for personal histories of classmates with whom they were sharing the daily class context, yet without knowing their family background. Despite in both classes one could detect a good class-climate in respect of multicultural needs and integration showed by the ethnical variety present, the shared stories that caught more people’s attention, awe and apprehension among students were those regarding migratory families, long periods of loneliness and difficulties that these families had to face to finally land in Como, unfortunately not always with positive outcomes. Nevertheless, issues of separations, misunderstandings were themes brought in by teenagers of italian heritage as well as by adolescents of different backgrounds, and this allowed the youngsters to feel a sense of belonging and to recognize themselves in one social and identitary matrix, which prevailed on the ethnical heritage. This matrix has been the engine of sharing and exchanging positive experiences, as well as doubts and fears that juvenile generations had the chance to experience, in a herizon were not only spacial distances but also family bonds have become more rarefied. Italians or foreiners, in many cases share the same difficulty in dealing with separated parents, divorces, losses, and this common sufference has become a ground for sharing, empathizing and mutual supporting each other. These teenagers were also sharing enthusiasm and vitality characteristics of an age where all the doors are potentially open, pending between the desire to gain more autonomy and the regressive need to have a secure base, a family to which return to in case of need. They share a compelling age through which it’s not always easy to manage interpersonal relationships with awareness and serenity, but they also share great hopes and ambitions which allow to hope in a future multiethnical society, more comprehensive and integrated. In respect to the scholastic context, the students made a clear request for a more personalized relationship with the school figures of reference, hoping that their experience could become more and more a subjective experience of mutuality, in addition to the academic relationship. Eventually animated by a human need of sharing and exchanging, in the questionnaires proposed at the end of the project, 2/3 of the students replied that the length of the intervention was inadequate to the contents proposed, suggesting the possibility to prolong it. More than half answered that the aspect which surprised them more of this experience was the chance for each of them to express themselves and to talk about themselves. So me of them stressed how the most interesting part of the project were the TEMAS cards, while others were more taken by the experience of role playing. In complex no criticism, nor negative judgments emerged.
In the complex portrait drawn by the teacher body what emerged was the immage of a teenager pending between isolation, aggression, solitude and sadness, and the difficulty of teachers to appropriately recognize these aspects and place them within an educational path. Teachers feel invested by educational functions that parents delegate to the school, but at the same time unprepared to integrate them in their accademic path, following therefore only their personal experiences and common sense with the result of an ambivalency between modalities connected with the application of rigid norms and those based on excessive protection and total listening. Teachers therefore detect that expectations expressed by students regarding school are focused primarly on the quality of interpersonal relationships with teachers and classmates, more than on the accademic value. Nevertheless, the teacher body adimtted a difficulty in creating formal and informal spaces of comparison on transversal educational issues or on student’s critic behaviors management. Infact, what emerged from the initial portrait was the lack of a “culture of mistake” necessary to the learning process, a difficulty to manifest and manage conflicts among teachers and students. That’s how for teachers the work modality based on learning from experience represented a new aspect compared to the theoretical training modality, whose answers were provided by the trainer: by activating the group resources and by putting at stake everybody’s competences and their exchange a constructive space of methodologic training was created. Particular attention was given to the capacity of questioning as a work modality aimed to avoid a strictly accademic vision of school. As the group work proceeded, teachers were infact trained to bring in their own work difficulties and to find new work hypothesis which came from within the same group instead of looking for external responses, yet self-activating the rescources proposed by the work group.
Regarding skills and keys competencies for teachers, what emerged from the comparison within the group were fragilities that could easily be transformed into resources, having been recongized as fragilities before. It seemed like the attention was entirely centered on students and very little to the relationship between teachers and students and with the peer group, for students as well as for teachers. The laboratory allowed many participants teachers, after a first phase of hesitancy, to express emotional experiences regarding their professional role and some specific situations in a group setting which was utilized as a container to create new thoughts. At the current time the communication between teachers and parents, already extremely poor, was based just on organizational and accademic level, without any confrontation on an educational level: teachers felt invested by educational functions given to them by families, yet at the same time they withdrew more or less in a purely accademic dimension. The proposal to network with students/parents/teachers sanctioned operational and reflective spaces in a co-constructed modality, lowering the intensity of those judgemental communications many time stressed by students as a real limit to their relationship with teachers.
Regarding parents it was overall observed a poor adhesion to the project, just class representatives participated and the mother of a problematic kid. Group meetings were more successfull than individual sessions. These data show the difficulty to activate parents and tell us the need to activate such projects out of the need to share and compare. The project had a great impact, as it was recognized its utility with the direct relationship with children, and with the indirect relationship with teachers. More specifically, it emerged a strong need for parents to confront with professional figures such as psychologists or with adults that could share on parenting. Nevertheless, parents often felt restrained in presenting their own doubts or perplexities on school since they feared teachers’ resentment. These meetings allowed them to clarify on many issues through free confrontation and helped them to present at the final plenary session structured issues to teachers, something that could not have been done without this project. Overall the experience of the parents’ group was to feel that a meeting with the teachers that daily take care of their children was possible and this generated a general sense of wellbeing. The issues elaborated and presented by parents were mainly focused of their difficulties in dealing with their teenager children, who expressed contradictions, oppositions and differences in behaviors set forth by adolescence, difficulties in direcltly delineating and differently managing the group of female adolescents from males when the two polarties were differently interpreted by teachers in class; their recognition of the struggle linked to the teacher’s role and their availability to collaborate through the figures of class representatives; themes of judgement and the wide influence/repercussion that teacher’s evaluations of students have on their self-esteem, contributing to distress them in an age characterized by uncertain personal consideration, especially when directed to the person and his/her behavior, rather than his/her accademic performance. For parents it wasn’t easy to present such an elaboration to the teachers of their children, because they feared a reaction from them that could affect the teacher-student relationship. On the contrary, having the chance to experience the possibility of a confront helped enormously to improve the relationship between these two educational agencies, leaving the door open for further mutual adult comprehension.
The research on risk factors associated with mental health problems indicates an urgent need to develop and assess therapeutic and preventive intervention for the youngsters and adolescents. The present pilot project shows the efficacy of culturally sensitive models to treat conduct problems in school and anxiety symptoms typic of adolescence, in order to create an aimed and screened network of referrals to the national health system. To this goal is linked the importance to introduce a preventive intervention with students within their educational network, which includes parents and teachers, in the view of an effective functioning of the scholas tic system, open to generate new reflections through the experience of comparison and mutual exchange. The therapeutic value of the culturally sentitive modalities adopted in this project has not been empirically assessed, nevertheles the studies on the TEM AS Narrative Treatment (TNT) present sufficient validity to be culturally competent and to be considered an empirically based treatment (American Psychological Association, 2003; Bernal G., Scharron-Del Rio , 2001; Kazdin, A.E. & Weisz, J.R., 1998; U.S. Department of Health and Human Services, 2001). An empirically reliable modality on the assessment of early prevention in the culturally sensitive mental health field for children would imply a pre-post test research design, supported by tools meant to assess specific clinical aspect of the population part of the project and the definition of a control group not treated with TNT. In the present study the control group wasn’t created due to the lack of time and resources, but the identification of possible differences would have been incredibly interesting from a clinical perspective. Nevertheless a guarantee of the realized process is that this research design was able to control a structural similarity between two group-classes part of the intervention. Such a sperimental definition of the research design would have been more specific and informative if it were combined with an analysis of the enlarged outcomes and ripercussions of the project: it would have been interesting to analyze validations of the good outcome of these laboratories on long term students’ assessments and scholastic judgements, in addition to analyze the consequences in terms of effect and severity on the national health system neuropsychiatry units. Another important considertion to face in critically assess this project and it s cultural sensitivity is to stress that the TEMAS cards utilized, as available in the italian version of the test, represent the arab and latino cultures as well as the italian, prevailing in the investigated context, omitting the reduced percentile, yet in increasement, of minors of asian background in the italian schools. Indipendently from this, it’s necessary to stress the result of the project, which is that TNT resulted effective in respect to the general objectives of subjective expression of thoughts and feelings, personal involvment in the storytelling and the sharing of experiences. The TEMAS narrative tecnique has infact the advantage to be less technical, to have a less intrusive and a more clinical perspective compared to different modalities of traditional therapies, which would result less adaptable to preventive aims and scholastic contexts: it holds the extra value of displaying not only as a therapeutic modality, but also to rely on culturally sensitive and competent measures, easily understandable among youngsters of different ethnical background.
Italy (Como), march 2013
Carolina Bazzi (psicologa)
Monica Cavicchioli (coordinatrice progetto) Giulia Galimberti (psicologa)
“Trattamento Culturalmente Competente e Basato Empiricamente per Bambini Latini con Sintomi Post Traumatici relativi alla Catastrofe del World Trade Center”.
Articolo pubblicato ad agosto 2014.