University of Southern California Dissertations and Theses

Narrative therapy-based preventative therapy for children living in poverty

(USC Thesis Other)

Narrative therapy-based preventative therapy for children living in poverty

PDF

Download a page range

Download transcript

Copy asset link

Request this asset

Transcript (if available)

Content Running head: Capstone Finalization
Capstone Finalization:
Narrative Therapy-Based Preventative Therapy for Children Living in Poverty
by
Kimberly Riley
Doctor of Social Work
Suzanne Dworak-Peck School of Social Work
University of Southern California
August 2020
Capstone Finalization

2
Executive Summary
When children are forced into accepting a mental disorder diagnosis while their behavior
is still mild and in the preventative stage of the problem, all so that they can receive behavioral
health care, they sometimes take on the label of that diagnosis and suffer from negative thoughts
or experience negative behavior. Insurance does not cover preventative behavioral health without
a qualifying diagnosis from the Diagnostic and Statistical Manual of Mental Disorders 5 (DSM5)
(Administration, 2019). A study that was focused on young girls who were labeled as being
obese looked at the modified labeling theory (MLT) to understand the connection between the
label and their mental health issues later in life. It was found that when girls were labeled as
obese the cultural stereotypes became a part of their identity and they suffered from
psychological distress and other negative outcomes (Mustillo, Budd, & Hendrix, 2013). MLT
suggests that “stereotypes are learned during early socialization and reinforced over time”
(Mustillo, Budd, & Hendrix, 2013, p. 271) . When children who are living in poverty try to
manage their identified problems and seek out behavioral health care, they are either turned away
because their symptoms do not meet the requirement of a mental disorder or they are given a
diagnosis, even while barely meeting the symptoms so that they can receive care that will be
covered by their insurance. Although that may seem like a solution to getting care to children
who are in need preventative therapy, the results from the stigma and shame are not worth it for
the child in the long run.
The need for preventative behavioral health care is immediate and many policies speak to
implementation processes for getting behavioral health care to all children. The American
Academy of Pediatrics leads the program Bright Futures, which is a national health promotion
and prevention initiative that recommends and provides guidelines for theory based and
Capstone Finalization

3
evidence-driven preventative care screenings. Bright Futures requires all insurance companies to
cover children’s preventative counseling provided by their pediatricians when necessary and
published a guide with approved CPT codes to use, yet all of the preventative counseling codes
cover specific topics such as tobacco, alcohol, substances and suicide. The counseling sessions
take place during the child’s routine visits and are usually limited to fifteen or thirty minutes
(Achieving Bright Futures, 2010). Mental and behavioral health screenings and assessments
during children’s exams are to be covered by their insurance plans also as a way to meet the
preventive requirements of Achieving Bright Futures. The focus on prevention is needed,
especially for children who may already be in a higher category for behavioral health risk
factors, as well as increased attention should be put on the therapeutic side of prevention.
Children should have the option to communicate their behavioral health needs when they are
ready, and have at least a few sessions covered where they can work out and explore their
feelings so that they can learn to manage their emotions in an effective way.
Possibly in the near future primary prevention will be the vehicle to preventative
behavioral healthcare for children, similarly to the way that primary prevention is used in the
form of vaccinations for children. Primary prevention is described as promoting health and well-
being as well as preventing disease and harm before it occurs (Unknown, Prevention, 2020).
American Academy of Pediatrics looks at primary and secondary prevention in relationship to
youth suicide. It talks about the ways that pediatricians can intervene either before or after
suicidal behaviors show up in children by providing screenings, assessments, and interventions
(Horowitz, PhD, Pao, MD, & Tipton, BA, 2020). Primary prevention could be useful for
teaching children in therapeutic groups how to manage their feelings in general, while secondary
prevention could be beneficial for teaching children how cope in individual preventative therapy
Capstone Finalization

4
sessions when they have an experience that has caused them to worry. With the suicide primary
and secondary prevention information, suicide risk assessments are recommended, but when
working with children who are living in poverty it is known that there are several risk factors
specific to poverty, so providers could be prepared to provide the most effective prevention to
the children based on their specific needs. Removing the financial barrier for children within this
population should be seen as a primary prevention tool also, since it removes stress from the
child and their family’s life before it can start to show up in other areas of their behavior. If
insurance companies changed its policy and added preventative behavioral health therapy for
children in the way that alcohol or tobacco prevention programs are covered, children would
have a well-rounded experience with learning the things they need or mentally successful.
Most children who are living in poverty are seen at community mental health offices.
CMH systems operate by using EBPs, so one survey looks at the ways that implementing this
practice into the system possibly can cause burnout for the providers (Joanna, Brookman-Frazee,
Gellatly, Stadnick, & Barnett, April 2018). This study suggests that therapists are at an increased
risk of having emotional exhaustion that is associated with their use EBPs in a system that is
driven by EBP context, work hours, their caseload, and amount of EBPs used; although the
climate of the organization and activities that were associated with the EBP such as supervision
or consultations were not associated with emotional exhaustion (Joanna, Brookman-Frazee,
Gellatly, Stadnick, & Barnett, April 2018). Burnout is seen often in therapists working in CMH
settings because of the large caseloads where poverty is a factor as well as the client’s clinical
seriousness, complexity, and comorbidity (Joanna, Brookman-Frazee, Gellatly, Stadnick, &
Barnett, April 2018).
Capstone Finalization

5
The way that therapists see themselves and their skills may have an impact on their
burnout rates when mandated to learn how to use the new EBPs and these mandates can cause
the therapist to believe that their experiences and skills used in the past are not valuable anymore
as well believing that they do not have the ability to contribute to the decision making (Joanna,
Brookman-Frazee, Gellatly, Stadnick, & Barnett, April 2018). Using EBP’s is the norm for
mental health providers, although there is evidence that other theories and interventions are more
effective for certain populations, such as narrative therapy and culturally aware or culturally
appropriate interventions. To prevent burnout and also increase the use of appropriate
interventions, Narrative Therapy is a researched based alternative to an evidence based practice
that is not tailored to meet the specific cultural needs of the children they are being used with.
Using Narrative Therapy would fit extremely well with prevention because children can benefit
from the ways that People experience the problem outside of themselves, which is a wonderful
place to start for children who are in the secondary prevention stage. Something has to change
for the mental health of the providers and of the children. People experience a reduced life
expectancy when they are dealing with mental health illnesses as well as stigma and
discrimination in places like work or in relationships such as marriage family, and friendships
(Abdulmalik & Thornicroft, June 2016).
If researchers or providers only see a problem once a child is really struggling with their
mental health, then they may not take the results of studies seriously and overlook the
opportunities to make changes to systems that would increase the likelihood of children and their
families in this population attending therapy or using mental health services if available for them
and having a reduction in their behavioral health problems over time. Taking what already exists
and creating something that is preventative and culturally aware, that takes care of the financial
Capstone Finalization

6
needs for children who are living in poverty seems like the most powerful next step, but
innovation isn’t that easy, even when implementing projects based on ideas that exist already.
Multisystemic Therapy (MST) Services is a really great example for how to make a new
and unique approach work as part of a for profit business. MST is an at-risk youth, community
therapy based, Limited Liability Company (LLC). It is based off of the Multisystemic Therapy
model and focuses on interventions that help reduce family conflict, improve relationships, and
much more. The challenges for implementing MST were cost related, most specifically the cost
of implementation rights to MST, monitoring, training, and consulting (Palinkas & Soydan,
2012). The implementation of this type of therapy is in a setting that is similar to where the
Narrative Therapy-Based Preventative Therapy for Children Living in Poverty Project will be
hosted also. MST spread to other places outside of where it originated and it grew so that
children and their families could overcome challenges in a new and different way. Evidence
became apparent and MST was added to SAMHSA’s EBP’s registry (Palinkas & Soydan, 2012),
which opens the possibility for Narrative Therapy to break through and an EBP also. The design
of this for-profit model is encouraging and the spread of it throughout areas that are not within
the community it began in is promising.
The Grand Challenges of Social Work’s “Ensure Healthy Development for All Youth”
brings all of these ideas about caring for all children in the preventative stage and using
culturally appropriate interventions while working with them together. It is focused on the needs
of children who have disparities and is focused on using research over the last thirty years to
create change within systems and reduce behavioral health problems by 20% over the next 10
years. With funding from community members and partnering organizations so that children in
need can be seen in the preventative stage at no cost to them and as well as the use of Narrative
Capstone Finalization

7
Therapy as a way to help children embrace their story and break free from problem narratives,
the future looks a little brighter.
Children Living in Poverty
According to the National Center for Children in Poverty (NCCP), 21% of children who
are living in the United States are living in homes where the income is below the poverty line
(National Center for Children in Poverty, 2019). There are statistics available for the different
ways that children are not receiving adequate care on the NCCP website where some of the areas
mentioned were environmental factors, juvenile justice, having a parent in the military, and low
income (Stagman & Cooper, 2010). Children who are living in poverty in the United States have
many needs that are unique to them and their situation in areas such as hunger, homelessness,
and behavioral health. Those needs are usually met through the giving of others or through
government funded programs, but sometimes they are not met effectively or at all. Some of the
basic needs that children who are living in poverty have are met while in the preventative stage,
while others are not. Children within this population of poverty have a high rate of behavioral
health needs, although they are recognized as being important, they are not being met in the
preventative stage often. Financing for children’s mental health is still not at the place it should
be, which causes many children to not receive the care they need. With restrictive funds,
providers are unable to provide the services that children or their families need causing them to
use places like the emergency rooms in hospitals (Stagman & Cooper, 2010).
Children take on the stress of their family’s income level and family living situation. The
problem of poverty can feel like it belongs to the child, although the child does not have a way to
change the income level of the family and the effects of the problem still creates distress in the
child’s life and well-being (Brown, Stykes, & Manning, 2016). Children who are living in
Capstone Finalization

8
poverty are also at a higher risk for developing and maintaining externalizing behavioral health
problems throughout their life (Harris, Fox, & Love, 2014). It is possible that when children in
this population work with therapists who are not aware of the culture of poverty, they can miss
that the child’s ownership of the problem may be causing some of the behavioral health
problems they are experiencing. Behavior problems are frequently seen in children in general,
but children who are living in poverty have an increased risk at having intense behavioral health
problems (Mattek, Harris, & Fox, 2016). People have a belief system about themselves, their
future, and their world view combined with their economic situation and their culture; it is
necessary that a therapeutic environment is created to support this (Mattek, Harris, & Fox, 2016).
The Substance Abuse and Mental Health Services and Administration (SAMHSA)
partners with many organizations to make sure preventative behavioral health care information is
available for children in various settings, but the grants that are provided through SAMHSA for
prevention does not include preventative behavioral health services in the form of therapy
(Administration, 2019). Children who are living in poverty do not have the opportunity to
receive preventative behavioral thrapy because of their inability to pay for services that are often
provided in private practice settings. Children who are living in poverty and seeking out services
will still need to meet the requirements set forth by their insurance, which is often Medicaid, as
well as the mental health diagnosis requirements that are necessary before their therapy is
covered. SAMHSA defines “Serious Emotional Disturbance” for people under the age of 18 as
being diagnosed with either a behavioral, mental, or emotional disorder within the last year that
caused the person to be impaired in their functioning in a setting such as school, their family
setting, or other places within the community (Administration, 2019). By the time children reach
the point of having a serious emotional disturbance they are far beyond the preventative stage,
Capstone Finalization

9
and that outcome is a something that preventative behavioral health care could have possibly
stopped from happening in that child’s life.
There is also a need to be concerned about the rates that children who are living in
poverty are diagnosed with mental disorders so that they can qualify for services through their
insurance plans. The problem of labeling children with a mental disorder for perceived benefits
is highlighted in one study that looked at the outcomes of children who were diagnosed with
Attention Deficit Hyperactivity Disorder (ADHD) when only mild symptoms were present. One
expert in child neurology stated that “mild symptoms are being diagnosed so readily, which goes
well beyond the disorder and beyond the zone of ambiguity to pure enhancement of children who
are otherwise healthy.” (Owens, 2020). Children with mild symptoms who are diagnosed with
ADHD because of classroom academic pressures and desired benefits of the diagnosis, such as
increased concentration or self-control achieved through medication (Owens, 2020) are similar to
children who are living in poverty with mild symptoms who receive a mental diagnosis in
community mental health settings to receive behavioral health care or access to benefits like
therapeutic groups or other connected services related to their poverty status.
The study mentions that children who are diagnosed with ADHD while only having mild
symptoms become triggered by their awareness of differences that exists between them and their
peers, as well as experience negative social feedback from their teachers and peers (Owens,
2020). It is also mentioned, in relationship to labeling theory, that children who receive the
diagnosis of ADHD may begin to negatively internalize stereotypes and their behavior may
actually become worse (Owens, 2020). Although parents and teachers have the expectation that
children who have mild behaviors before being diagnosed with ADHD will somehow be
different after their diagnosis, those children tend to have poorer social and academic behaviors
Capstone Finalization

10
than their comparable peers who are undiagnosed (Owens, 2020). Adults in these children’s
lives, according to the study, started to view them differently and the children themselves started
to have a stigma about their diagnosis (Owens, 2020). Children who are living in poverty could
be dealing with their natural response, just like the children in the study, to being labeled after
their diagnosis in the preventative stage of their problem and that response, combined with the
other effects of poverty, leads to the many behavioral health problems that they have to manage
for the rest of their life.
Medicaid or Children’s Health Insurance Plan (CHIP) coverage is extremely effective for
meeting the needs of children who are living in poverty and have severe or multiple mental
health illnesses, but it is not as beneficial to children who have behavioral health problems that
minimally effect their lives (DeRigne, Porterfield, & Metz, 2009). Children with minimal
behavior health problems are believed to be better served by using private insurance (DeRigne,
Porterfield, & Metz, 2009), yet children who are living in poverty do not have access to private
insurance, leaving them still with unmet needs in the preventative or minimal stages of their
behavioral health problem. One of the Grand Challenges for Social Work “Ensure Healthy
Development for All Youth” specifically calls out the fact that behavior health problems can be
prevented if children receive the care they need in time. This financial barrier is keeping children
who are living in poverty at a disadvantage to their peers who can pay to have therapy during the
first stages of their problem. Although one study points out the fact that even affluent families
struggle to meet the mental health care needs of their children (DeRigne, Porterfield, & Metz,
2009). It can be thought that those unmet needs are not because of a lack of finances, but rather
they are connected to some other barrier to care specific to those children and their families.
Capstone Finalization

11
Research is limited in certain areas in regards to children, especially children of color and
children who are living in poverty. The research that exists is valuable and can be used to make
changes to the current system when providers are open to trying something new in practice. Most
research that looks at children who are living in poverty also includes children of color, while
children of color are included in these studies they are mostly focused on African American or
Mexican American populations, without just looking at the effects of poverty on children in
general. It is difficult then to understand if the problems children who are living in poverty are
experiencing are due to their ethnic background, economic status or both. In a study conducted in
2012, researchers looked at poverty and the effects that it has on children and their mental,
emotional, and behavioral health as a way to understand prevention and intervention within this
population of children and their families. The study found that the harmful ways poverty effects
children does not differ based on their race or ethnicity (Yoshikawa, Aber, & Beardslee, 2012). It
also found that family and neighborhood poverty is a risk factor for children’s mental, emotional,
behavioral health and that prevention is helpful when reducing poverty, which was the focus of
the study also (Yoshikawa, Aber, & Beardslee, 2012). The study looked at reducing the effects
of poverty on children’s mental, emotional, and behavioral health by using preventative
interventions as well as many other interventions that would add income to the families so that
the children have a lower risk at developing mental, emotional, and behavioral health issues
(Yoshikawa, Aber, & Beardslee, 2012). This study is helpful for thinking about ways to
understand the overall problem of poverty and its role in the lives of all children’s behavioral
health, while it is important to recognize that other systemic problems exist for children and their
behavioral health, like racism, this study helps the reader see that some problems for children
that are associated with poverty are universal. It is hard to find data that looks at children’s
Capstone Finalization

12
preventative behavioral health care with an understanding of poverty that is not targeted at or
focused on specific ethnic groups as well.
Current behavioral health treatment models used with children who are living in poverty
are also sometimes a part of the problem because of the lack of cultural understanding and
integration of culturally appropriate interventions when working with this population.
Community mental health (CMH), therapists have to make a treatment decision about the
children they see so that they can achieve the best outcome. One study explores the ways that
therapists choose which treatment to use with the clients they see and how it is hard for them to
conduct treatment with children because of the adults and systems they are a part of (Love,
Okado, Orimoto, & Mueller, January 2018). This study validates the hard work that therapists in
the community mental health setting do and reminds the reader that therapists can use additional
scientific resources that might be more affective for the child (Love, Okado, Orimoto, &
Mueller, January 2018). The conclusion of the study mentioned that since people know the
factors that might be behind the children and family therapist’s decision in CMH, they can use
the results and client outcomes to see the “target practice matching” (Love, Okado, Orimoto, &
Mueller, January 2018). This type of matching seems appropriate when deciding how to work
with children from varying population groups, but it is clear that individual matching does not
happen often or correctly because of the high drop-out rates that are seen in practices while
working with children who are living in poverty based on the reasons that are given for the early
termination of treatment by them and their parents.
Although unique financial barriers can sometimes stop children who are living in poverty
from receiving behavioral healthcare at any time, some of these children and their families
overcome the barriers, begin therapy, and still drop out of therapy early, generally after the first
Capstone Finalization

13
session according to one study (Lavigne, et al., 2010). High drop-out rates from therapeutic
programs for children who are living in poverty is part of the problem because of the models
used. Research shows that people who are living in poverty and people of color are looking for
specific things and have their expectations in mind when seeking out and continuing therapy
(Delgadillo, Moreea, Murphy, Ali, & Swift, 2015). It is possible when those things are not
present, children and their families do not attend therapy sessions or finish their treatment plans.
Another study looked at a behavioral parent training model that is often offered to parents who
have a low socio-economic status (SES) and found that it was not something those parents or
minority parents wanted (Lavigne, et al., 2010). When thinking through what could be behind the
low return rates of children and their families to therapy, it can be reasonable to think that if
there were a change in therapeutic approach, including culturally appropriate interventions,
children living in poverty and their families would be interested in building an alliance with the
therapist, working towards their treatment plan together, and remaining in therapy until their
treatment plan is complete. When that happens, especially in the preventative stages of the
problem, behavioral health problems are likely to be reduced for children in the long term.
Narrative Therapy-Based Preventative Therapy for Children Living in Poverty Project
Research supports these ideas for all children; preventative therapy to reduce long term
behavioral health problems and interventions or models that are culturally appropriate. The
Narrative Therapy-Based Preventative Therapy for Children Living in Poverty Project is
designed to use Narrative therapy as the intervention and therapeutic approach as well as provide
preventative therapy in the form of individual sessions or groups to children who are living in
poverty. The desired outcome for this project is to see a reduction in the behavioral health
problems of the children who use the services. This project was created to be implemented by
Capstone Finalization

14
licensed providers who work with children in private practice or guide providers who are curious
about different ways to work with children in any setting. It should inform providers and others
in the behavioral health care field about power of prevention and the benefits of using culturally
appropriate methods. The project’s logic model can be used as an educational tool for providers
in any field, as it talks about prevention, intervention, and change. This project will partner with
other organizations in the community to make preventative therapy and groups available to the
children who are already receiving a service offered there. Partnering with organizations is not
just how the project will obtain the finances to provide therapy to children, it will produce a
system of people who can support the child as they navigate multiple areas of their life at the
same time.
Narrative Therapy can be instrumental when used with children and their families, as it
can help the family deconstruct unproductive stories so that they can reconstruct new productive
ones (Nichols, 2014). A Narrative Therapy informed therapist can ask externalizing questions to
help families shift their perception of themselves and align with the belief that problems happen
in families because people have narrow and self-defeating views of themselves (Nichols, 2014).
Narrative therapists help families become free from cultural assumptions that are oppressive as
well, which is important when working with children and their families who are living in
poverty. Narrative Therapy during the preventative phase of a child’s identifiable problem will
have the same effect when externalizing questions are being used that way. Children who are
living in poverty may have a story that they need to reconstruct about their position in life. A
Narrative Therapy approach for children who are still developing a sense of who they are or who
they want to be can be fruitful before the world they are a part of creates their identity for them,
which then may lead to the ownership of someone else’s negative view.
Capstone Finalization

15
The Narrative Therapy approach will give children a space to share and learn about
themselves in a nonjudgmental way. Narrative therapy, when used in a mental health setting can
allow the client to become an expert of themselves as a way to find healing and understanding
through their story, without the expectation of finding what might be considered a normative
reason for the problem that exists (Launer, 1999). When using a narrative perspective in practice,
a diagnosis can be helpful or not, depending on how it is used for the benefit and understanding
of the provider or the client, although if a diagnosis is given the provider should be thinking
about how it fits into the client’s story when they have given permission for the provider to do so
(Launer, 1999).
The project hopes to be seen by children and their families as a secondary option to more
traditional therapy that generally happens at a different stage in their identified problem. The
Narrative Therapy-Based Preventative Therapy for Children Living in Poverty Project will be
intentionally different than most mental health interventions. It will not unnecessarily add stigma
to children’s behavioral health care by focusing on a mental diagnosis during therapy or
restricting care by following the mental diagnosis requirements of their insurance, which is
consistent with Narrative Therapy principles. See Figure A1
Grand Challenge “Ensure Healthy Development for All Youth”
The Grand Challenge for Social Work and Society lists 13 challenges that have problems
in society that social workers and others can work towards correcting through innovative ideas.
Grand Challenge number one is “Ensure Healthy Development for All Youth”. This Grand
Challenge focuses on the behavioral health of young people from birth through age 24. There is
an initiative within this challenge called “Unleashing the Power of Prevention” that takes
research from the last 30 years and supports the use of prevention as a way to reduce and
Capstone Finalization

16
overcome childhood behavioral health problems (Jensen & Hawkins, 2018). The Grand
Challenge’s initiative provides ways to reduce behavior health problems in children from birth to
age 24 and also lower the economic and racial disparities within these children’s population
groups by 20% over the next ten years (Jensen & Hawkins, 2018). The Grand Challenge “Ensure
Healthy Development for All Youth” says it is necessary for preventative interventions to
include both the “overall population health and health equity for the most vulnerable and
underserved populations.” as a way to reduce rates of behavioral health problems for all young
people (Jensen & Hawkins, 2018).
The Narrative Therapy-Based Preventative Therapy for Children Living in Poverty
Project was created by using the Grand Challenge “Ensure Healthy Development for All Youth”
as a road map for preventative care. There are three levels of preventative interventions listed in
the Grand Challenge that are based on a public health approach. The systems are: “Universal,
Selective, and Indicated” (Jensen & Hawkins, 2018). The Selective Prevention intervention helps
youth who are at high risk but don’t show symptoms of behavioral health problems. The Grand
Challenge suggests that prevention intervention is geared towards children and adolescents who
have indicators or symptoms of behavioral health problems, but do not yet have disorders that
can be diagnosed, engage in illegal behavior, or have health-compromising behaviors (Jensen &
Hawkins, 2018). The Grand Challenge encourages parents, teachers, social workers, doctors,
nurses, and public health workers to use preventative interventions to help them increase the
opportunity for a child to participate in a program that is evidence based and geared towards
prevention, so that child will have less behavioral health problems in the future (Jensen &
Hawkins, 2018). The project used the preventative intervention concepts to form the basis for
preventative care when working with children who are living in poverty because of the unique
Capstone Finalization

17
outcomes that are associated with poverty and the risks that is poses to children. It also focused
on therapy participation by using Narrative Therapy as an intervention, since studies have shown
the inability to be in charge of one’s own care or treatment plans are a few of the reasons for
impoverished families dropping out of behavioral health programs early.
Stake Holders: Providers, Funders, Organizations, and Children and Their Parents
While conducting interviews with possible funders from the community, it was
discovered that most of them didn’t fit within the category of ever living in poverty, but
understood the concept of the Narrative Therapy-Based Preventative Therapy for Children
Living in Poverty Project and were interested in being a part of the installation stage by
providing funding streams (Palinkas & Soydan, 2012). In the planning stages of the project, it
remains difficult to find ways to connect with community mental health centers because of their
use of EBP’s and Medicaid or another insurance for funding the care they provide to children
who are living in poverty.
Some providers who showed an interest in the project currently work in Community
Mental Health settings. They were mostly interested in the use of Narrative Therapy as an
intervention and the preventative factors to meeting with children in the beginning stages of their
identified problems, instead of waiting until their behavioral health problems are extreme. One
article looks at the burnout that therapists experience when working with children while using
evidence-based practices (EBPs). These providers expressed how much easier it is to use an
intervention that would let children express themselves freely instead of trying to guide them
with some of the EBP’s they use, although they did say that they use Narrative Therapy at times
with their clients in the CMH setting. They were curious about the financial details of the project
and how they would independently practice as independent providers without being set up to do
Capstone Finalization

18
so, so although they will think differently about working with children, they were not ready to
leave their jobs in CMH. These providers and others who work with children in the community
will have the secondary benefits from the children using the free preventative therapy option
because they will see a reduction of behavior problems in the children, will gain a support
system to assist in the progress they are already trying to make towards children in these
populations, and it frees up those who may not be equipped yet to work with these children.
Children and their families will benefit from this project because it gives them an
opportunity to receive preventative care that is culturally and economically appropriate for their
specific needs. It gives children and their families the chance to decide when they should receive
care without the financial barrier getting in the way. Teenagers who are part of the organization
that the project will be connecting with gave a list of topics they were interested in having a
therapist answer. Their parents attended webinars that talked about parenting through a crisis, so
when free therapy was offered as a next step if needed, the organization reported that there was
interest from the parents. The project is purposely including the wants and needs of children and
their families in the community because the overall goal of the project is to respond to what
people want in a financially and culturally way, otherwise the project will just be a repeat of
what children and their families from this population are accustomed to. Although, through
research some parents have been known to want the benefits of their child’s mental diagnosis
(Owens, 2020) others would rather not have their child receive a mental diagnosis because of
their own perceived stigma about what the diagnosis means for their child. For example, one
study showed that mothers were concerned about the social risks that come along with services
and protecting their children from the system they themselves were familiar with (Slashinski,
2016), although some mothers thought that treatment could actually be helpful they still would
Capstone Finalization

19
not want them participating. This thinking could dominate parents who do not want their child to
be part of any behavioral health programs, although providers should still remain hopeful that if
they were given a chance to try something new with their children, they would. There is always
the chance that approaching children from a Narrative Therapy perspective is not helpful and it
would then be necessary to work with the children and their parents to find a solution that may
be a better fit. Although Narrative Therapy is appropriate for all people, there still may be
children who have needs that require something different and are outside of what the project is
designed to do.
One major organization in the community has shown interest in partnering with the
Narrative Therapy-Based Preventative Therapy for Children Living in Poverty Project. This
Christian based organization works with children in various ways by going to their schools,
being engaged with juvenile justice, mentoring teenage parents, and supporting the parents of the
children they work with. The organization was hoping to have an additional way to meet the
needs of children they come in contact with, so they started spreading the word that “mini
sessions” were available to youth who were struggling with different emotional disturbances.
This organization has applied for funding to support the work of the provider who will be
meeting with children and has discussed other grants that they can apply for in the future. The
organization has this statement “Give Life To Your Story” on their webpage, which instantly
connected the drive behind their work to the passion behind the desired outcomes of the
Narrative Therapy-Based Preventative Therapy for Children Living in Poverty Project. Their
mission statement includes a plan to work with other partners in the community who think
similarly to them and help young people by equipping them with skills in many areas, including
mentally. The only concerns mentioned by the organization was client privacy and being clear
Capstone Finalization

20
that there is a line between the information shared with the providers and the volunteers and staff
of the organization, they felt that it was important the members of the organization and the
children had a concrete understanding of what could and could not be shared between the
provider and the organization.
Past, Present, and Future Conversations About Practice and Prevention
An article published in 1990 looks at intervention and prevention in adolescents and
defines the term “preventative intervention” as “measures which are implemented before any
symptoms of problem behavior are manifest.” (Hurrelmann, 1990). The article suggests that
interventions should encourage and make individual and social resources stronger as well as
promote the individual competency of the adolescent (Hurrelmann, 1990). Interventions that
function this way allows the adolescent the opportunity to organize their life and which then
makes it possible for them to be a part of their own health (Hurrelmann, 1990). The article goes
on to point out the importance of adolescents satisfying their own needs and understanding how
to achieve their dreams so that they can have a great sense of their social, mental, and physical
well-being (Hurrelmann, 1990). This view from 30 years ago is still very relevant for working
with children from all population groups, but it seems that many conversations have not been
centered around the idea of making teens in therapy the experts of their own lives and
encouraging them to meet some of their needs, unless interventions that used therapeutic models
such Narrative Therapy have been a part of the treatment plan.
Globally the conversation has included a lot of thought about insurance and the barriers
that exist for children in regards to their behavioral and mental health. When the funding for
children’s mental health care was compared between the United States (US), Netherlands and
Canada, it was found that their systems were similar. There are similarities between the three
Capstone Finalization

21
places when looking at the services that are not covered by public health, leaving the family to
pay out of pocket (Ronis, Slaunwhite, & Malcom, 2017). In one study, three federal initiatives
were compared. Those initiatives were “Healthy People 2020 initiative” in the US, the “National
Agreement on the Future of Mental Health Care in the Netherlands”, and the “Changing
Directions, Changing Lives” in Canada (Ronis, Slaunwhite, & Malcom, 2017). By digging into
the details of the initiatives, it was discovered that the US wants to improve mental health
through prevention and giving access to appropriate care, as well as reduce suicide attempts by
children. These outcomes are slightly different that the desired outcome of the other initiatives.
The Netherlands is focused on reducing stigma and reducing the division between physical
health and mental health care, while Canada wants to prevent mental illness and suicide by
providing services as well as reducing the access disparities to getting care (Ronis, Slaunwhite,
& Malcom, 2017). It is nice to look at the mental health conversations taking place in other parts
of the world to get focused on what children need in your own areas and how those other ideas
can be implemented into local care. Canada included all of the ways that they would meet the
mental health needs that children might have in addition to their financial needs. The US had a
short list of priorities that included “Health equity, full continuum of behavioral services, and
healthy communities that prevent chronic illness” (Ronis, Slaunwhite, & Malcom, 2017). The
US was headed in the right direction with its focus on prevention, although at that the limited
focus combined with the insurance requirements still left children behind who needed
preventative care or could have benefited from the removal of disparities and stigma, especially
children who were living in poverty.
It is interesting to see how the US provides prevention in the area of behavioral health
care now and plan to continue doing in the future within the Medicaid and CHIP system. In the
Capstone Finalization

22
US, Medicaid, which is a government funded program, insures the largest number of children
(Ronis, Slaunwhite, & Malcom, 2017). There is a change that happened within the Medicaid and
CHIP system in October 2019 that was pretty significant in the fight for behavioral health
prevention for children. This change was part of the SUPPORT for Patients and Communities
Act and it was amended to include coverage to prevent, diagnose, and treat mental health and
drug disorders in a way that is culturally appropriate as well as being linguistically appropriate
(Medicaid.gov, 2019). With this change, it was thought that the strict rules for a mental health
disorder diagnosis would be removed and the barrier of insurance will be removed as well, but
neither were. What happened was a win for children and pregnant mothers who have Medicaid.
Preventative therapy is still not included in the preventative coverage for children, yet some
preventative counseling is covered for pregnant mothers. What is now covered for children and
pregnant women is; for children and adolescents: Developmental Screening, Autism Spectrum
Disorder Screening, Developmental Surveillance, Psychosocial/Behavioral Assessment,
Tobacco, Alcohol, or Drug Use Assessment, Tobacco Interventions, and Depression Screening
and for pregnant women: Maternal Depression Screening, Perinatal depression: counseling and
intervention, Tobacco use counseling, and Unhealthy alcohol use screening, counseling and
interventions (Lynch, 2020). Medicaid approaches access to care by saying in a statement
discussing timeliness and benefits, “states assure access to covered services, monitor and treat
enrollees with chronic, complex, or serious medical conditions” (Lynch, 2020). This call to
action for access is needed, because children who have severe behavioral health problems do
require timely access to care. Unfortunately, children who are having mild behavioral health
problems are not included in these changes, but the changes that have happened show that very
soon Medicaid could revisit their ideas about prevention and add preventative behavioral health
Capstone Finalization

23
therapy for children, which would be similar to the preventative Tobacco Counseling for
pregnant mothers.
An article highlights a conversation about the responsibility of everyone in the shared
commitment of mental health promotion. The idea of mental health promotion is based on the
concepts that say mental health is determined by the diverse factors such as “biological,
psychological, cultural, and social” and should happen in people’s communities like their “home,
school, or workplace” while looking at different systems (Jung PhD & Aguilar PhD, 2016). The
article states what the World Health Organization (WHO) says is necessary to promote mental
health. The WHO says that the elimination of barriers to positive mental health such as “poverty,
poor living environment and have more factors that are supportive like “community capacity,
social capital, and social cohesion” (Jung PhD & Aguilar PhD, 2016). It is said that when you
bring in people to help with mental health promotion, you are able to see the needs of the
community and make the activities specific to those needs (Jung PhD & Aguilar PhD, 2016).
People being involved in mental health promotion can produce positive change in the community
and in the structure of the system that influences mental health (Jung PhD & Aguilar PhD, 2016).
One conversation in a newspaper article focused on a senator who asked that funding be
made available for children with Autism Spectrum Disorder whose parents are in the military.
Tricare cut the reimbursements for ABA therapy and the providers and family members were not
happy, so a few U.S. Senators got together and sent a letter asking that funding be included to
cover the costs so that those children could continue to have the care they needed (Sen. Murphy,
Colleagues Call for Sustained Funding for Autism Therapy for Military Children, 2016). The
request included a sentence that we should all think about as we ask for funds to support children
who are living in poverty. It said “These funds will ensure that military children with ASD in
Capstone Finalization

24
need of therapy can obtain the services they and their families deserve.” (Sen. Murphy,
Colleagues Call for Sustained Funding for Autism Therapy for Military Children, 2016). The
idea that children deserve to have care can be new to some people, but this senator reminded the
public that children do deserve to have care, almost implying that it is their right. Children who
have the financial means to electively choose therapy at any time have an advantage over
children who do not have those same opportunities because of the lack of finances. The public
should be reevaluating the rights of all children and thinking about what they deserve, especially
children who are living in poverty, so that they can have the same chance as their peers when it
comes to preventative therapeutic care.
Conversations about community funding is difficult to find, but community financing in
the form of small grants for behavioral health needs conversations have happened. One news
report came out in 2017 that highlighted a company who gave small grants in the amount of
$1000 to five different community based non-profit organizations with the focus on
homelessness and physical as well as mental health in Kansas. The group, WellCare Health
Plans, Inc manager said “In order to support the best health outcomes possible, medical and
social needs must be met.” (WellCare Gives $5000 in Micro-Grants to Community Based
Organizations in Kansas, 2017). Although, $1000 may not seem like a lot, it was just enough to
meet the needs of those in the community. One school who received the funds was able to put on
a resource fair for homeless children (WellCare Gives $5000 in Micro-Grants to Community
Based Organizations in Kansas, 2017). This information is valuable because it shows an interest
in community funding on a smaller level to support the community’s social needs. It confirms
the idea that a small amount of money can go a long way.
Using What Already Exists for Innovation
Capstone Finalization

25
Narrative Therapy is used widely with many groups of people because of the safety that it
provides, by being set up to encourage the use of stories to find meaning in one’s life. A few
studies specifically looked at the use of Narrative Therapy with homeless populations and those
living in addiction, tobacco use in Native American populations, and children in domestic
violence situations. All of the groups studied were successful at helping children and adults find
meaning and healing in their stories. One housing group program integrated Narrative Therapy
into their work with the homeless by helping them look at the details of the problem they were
experiencing, while also allowing them to see the problem outside of themselves (Williams &
Baumgartner, 2014). Narrative Therapy allowed the people in the housing group program to
freely own and tell their stories. In the other study where Narrative Therapy was used, it
addressed the high rates of tobacco use by Native Americans beginning at age 12. By using
Narrative Therapy with the Native American people who wanted to reduce their tobacco use it
allowed them to us the oral tradition of passing down information or stories with the therapist.
The study focused on the 5 steps the program used which were; “Externalizing, Reconstructing
Stories, Searching for Alternative Stories, Constructing Preferred Stories, and Using Narrative
Endings” (Haring, 2013). A unique study looked at an overnight program in Singapore called My
Happy Ending for children and their mothers who were in domestic violence situations where
Narrative Therapy was used as a way to help them process their stories (Lee, 2017). One
outcome of the program was allowing children to re-tell their stories with an alternative ending.
The program empowered children and took them from being a victim to being a survivor (Lee,
2017). The positive outcomes these Narrative Therapy groups had are supportive of a more
individual approach to providing the same atmosphere these groups provided to the group
members. The Narrative Therapy-Based Preventative Therapy for Children Living in Poverty
Capstone Finalization

26
Project will include groups for children in their familiar settings, such as schools, churches, or
other places they regularly visit in their communities, but the main focus will be on providing
one on one sessions. Taking what already seems to work in the area of Narrative Therapy within
multiple people groups and creating an intervention that is individualized for children should
produce something rewarding for the children who participate.
Parent child programs are preventative and are also designed to meet the behavioral
needs of preschool aged children. Research shows that parents who attended the Parent Child
Interaction Therapy (PCIT) program attended more when they believed they were the cause of
their children’s problems and they attended less when they believed that their child was the cause
of their own problems. It also showed in one study that Cognitive Behavioral Therapy (CBT)
should probably not be used in the beginning stages of the program, but instead start with the
parents talking about their beliefs and the way that they contribute to their child’s behavior, so
that they will attend and remain in the program (Mattek, Harris, & Fox, 2016). Children and their
families who are living in poverty currently drop out of child and parent therapy programs at the
rate of 50% or more (Mattek, Harris, & Fox, 2016). There are a wide variety of programs that
exist to be proactive and preventative for children’s behavioral health problems. Many of the
programs are broken down to meet the needs of one population at a time, instead of focusing on
the larger group of children who may fall within the category, like the focus on preschool aged
children with PCIT instead of looking at ways to introduce prevention to children through young
adulthood. For example, there is a bully prevention program for American Indian and Alaskan
Native youth that is specifically geared towards the needs of children who are within those
populations, which can be helpful when that type of focus is desired or necessary, but other
children in different population groups could benefit from a bully prevention program too. A
Capstone Finalization

27
quote from bully prevention program fact sheet says “Culture, as a protective factor in tribal
communities, has been shown to be effective. The provision of cultural knowledge means
implementing culture-based interventions.” (Substance Abuse and Mental Health Services
Administration (SAMHSA)). There are practices in place with the intentions of being
preventative and recognize that culture-based interventions are part of the prevention, yet these
practices do not include therapeutic process, but do include a shift in the ways that they try to
help children be successful in keeping behavioral health problems away. This idea of having
tribal leaders and elders be a part of bullying prevention is very innovative when it comes to
prevention, as the fact says, bullying affects more than just the person being bullied because of
the witnesses as well (Substance Abuse and Mental Health Services Administration
(SAMHSA)).
The bullying prevention fact sheet also says that although there is a lot of research that
exists about bullying and the effects of bullying on the general population, it doesn’t include the
bullying’s effect on American Indian and Alaska Indian populations (Substance Abuse and
Mental Health Services Administration (SAMHSA)). The creator of this innovation took the
details of what they knew about bullying and matched it with the details of what they know to be
helpful and meaningful to the children within these populations and combined it to make
something that is innovative and functioning. It meets the criteria of helping children make
different choices so that they do not have behavioral health problems in the future or cause
anyone else to either. The fact sheet gives a few references to effective evidence-based
interventions in Indian Country. So, the innovation also takes into consideration that other
evidence-based interventions do exist, such as the “American Indian Life Skills and
Development Curriculum” which is listed under Mental Health Promotion.
Capstone Finalization

28
This bullying prevention program takes place in the Tribal Training and Technical
Assistance Center and is funded by SAMHSA. It connects with the context of the environment
because it is centered around a population of children who are often under-privileged or under-
represented in research and takes culturally and holistic stance when providing training on
mental health and other subjects. It is connected with what is meaningful to the children and their
families and uses researched methods to make a difference in their behavioral health outcomes.
The creation of the bullying prevention program has been important information to have
during the devilment of the Narrative Therapy-Based Preventative Therapy for Children Living
in Poverty Project because it looks at varying pieces of a child’s life. It combines the voices of
elders, the economic and ethnic background of those who will attend the program, community
placement, behavioral health, and outcomes of those in the program from all angles. It is an
effective way of providing prevention, but in a targeted subject matter and with a targeted group
of people. The same ideas were used to develop the project for children living in poverty. It was
designed by using voices of community members, researched information about the culture of
poverty, use of appropriate interventions to improve behavioral health, intentional placement in
the children’s community and concern for ways that everyone who comes in contact with
children in the community interact with one another.
CMH is the most dominant system that provides mental health care for people who are
living in poverty. The CMH system provides evidence based mental health care, resources, and
support to people in their greatest times of need. There is a general understanding that the CMH
system is in place to help people who may be unable to receive care anywhere else or overcome
and manage their behaviors as well as other mental health challenges. A lot of what happens in
CMH initially is in response to a person’s mental health crisis because of the way that it is
Capstone Finalization

29
funded through Medicaid. The CMH system works wonderfully for those who have more high
needs in the mental health area of their life, but it is not set up too well to incorporate those who
minor symptoms and just need some preventative care to stop their behavior from getting out of
hand. The “balanced care model” for mental health services explains what is needed to meet the
mental health challenges of people. One study suggests that the integration of mental health
services into a person’s primary care is necessary along with supervision and referral services by
mental health care providers, having general adult and children’s mental health services like
community teams, and specialized adult and children’s services (Abdulmalik & Thornicroft,
June 2016).
The setting of the survey is in low-income counties, so it found that it is best to look at
the requirements of the area where the CMH services will be, so it is suggested that the things to
focus on are “availability of resources, cultural, political and other environmental
considerations” as well as the specific needs of children and teens, since they make up half of the
populations in countries that are still developing (Abdulmalik & Thornicroft, June 2016). The
article also points out that most mental health disorders begin by the age of 14, so it is important
to start early with detection and intervention to help reduce the adult mental health disorders
(Abdulmalik & Thornicroft, June 2016). There is another model that is part of the CMH system
called “Systems of Care” that went into effect in the early 1980’s and is geared towards children
and adolescents who have “serious emotional disorders” (Potter, February 2016). Systems of
Care was initially created to help with collaboration between agencies, but over time it became
“family-focused” where family members participated in all parts of the delivery and planning of
the services, and then there was lay-professional integration into the model (Potter, February
2016).
Capstone Finalization

30
The development of the CMH system from beginning to where it is at now has taken
years to master, so it cannot be ignored when planning another system to meet the needs of
children who are living in poverty. There are too many working pieces of the system to
incorporate into the project, but there are important parts that influence the thinking. The project
will always remain focused on the other barriers to care outside of finances when working with
children who are living in poverty and it will remain open to change always, because CMH has
been a great example of how to change with the data that comes out. Although CMH looks at
and works towards prevention through a different lens, prevention is still acknowledged as being
important for children who are living in poverty and their families, so the connection remains
between the passion displayed in the CMH system and work can actually be done between the
two systems if providers were open to it. The work may look like a child who has extreme
behaviors in one area getting mental health care in the CMH setting while they are also getting
preventative therapy for more mild behavioral health problems through the Narrative Therapy-
Based Preventative Therapy for Children Living in Poverty Act.
Prototype: Giving Back
A prototype in the testing phase is set up on the internet currently to see how responsive
community members and organizations are to hearing and reading about the behavioral health
needs of children who are living in poverty. The Narrative Therapy-Based Preventative Therapy
for Children Living in Poverty Project falls under the business You Are Beautiful, PLLC and on
this webpage www.youarebeautifulpllc.com there is a “Giving Back” tab which is where the
prototype is. On the “Giving Back” page there is a video describing the problems children who
are living in poverty face when it comes to being able to receive preventative behavioral health
care, tells how people can be part of the solution, and what the outcome would be if they helped,
Capstone Finalization

31
and gives links to explain Narrative Therapy and the Grand Challenge more and directs the
viewer to the organization’s webpage that the project is partnering with. On the page there is also
a contact form for those interested in the project.
The page is intended to reach organizations who are interested in having the children they
see in their locations benefit from this type of preventative therapy and is designed for a person
to give $50 as many times as they like through the link provided. This prototype will gauge if
people are interested in giving this way or want more information about the project.
With the prototype being virtual, it can be given to anyone outside of the service area.
Individuals and organizations can give financially or inquire about the project from where they
are. This virtual method is intentional because family members, friends, and others may have
children they know personally who could use these services and are unable to pay, so they can
give therapy sessions to them through the payment application. The prototype for this project
provides people with the opportunity to give now or begin a partnership which is helpful for the
implementation of the project on a larger scale. The goals of the prototype is to increase
awareness about narrative therapy and preventative therapy, raise funds or partner with
organizations to provide preventative therapy to children who are living in poverty, and reduce
long term behavioral health problems for children in the future. See Figures A2-A5 for a visual
description of prototype.
Project Implementation
Through the use of implementation research that looked at the outcome of using Narrative
Therapy as an intervention, it seems that it would be more effective with children within population
of poverty than other EBP’s. One study indicated that EBP’s do not work well for all people
because they are not culturally competent, since EBP’s are often based off research that doesn’t
Capstone Finalization

32
look at cultural diversity (Kirmayer, 2012). Narrative therapy has been used in various research
studies and the benefits connected with the theory does translate into real world situations.
System thinking analysis is used to determine how all of these different pieces of the project
will work together to create the desired outcome. In the case of this project, system thinking will
correlate the use of a Narrative Therapy, a culturally aware technique, by providers with the
increase use of the project by children who are living in poverty. This idea comes from the
research that looks at what children and their families from this population name as reasons they
do not attend therapy sessions after going the first time. The EPIS model was used to explore,
prepare, implement, and sustain the project. During the exploration phase it was discovered that
the largest barrier in the outer context was the funds that exist for the non-profit organizations,
but do not exist at the same rate for private for-profit businesses. In the outer context the
facilitator was the MST theory that was designed to meet needs by introducing interventions that
help reduce family conflict and improve relationships (Palinkas & Soydan, 2012). In the inner
context the biggest barrier was the structure for the various behavioral health organizations that
are located in the community. It is difficult to break through that system as a new, different
thinking provider in a private for-profit practice. Although it is difficult to make an immediate
impact through the already established system, it is nice to have a facilitator like the participating
provider and partnered organization in the inner context because they can provide support during
the exploring phase and come up with great ideas or recognize what may have been overlooked.
Financial Plan
The Narrative Therapy-Based Preventative Therapy for Children Living in Poverty
Project will fall under the for-profit business You Are Beautiful, PLLC. The financial auspices
will be Kimberly Riley and Kenneth Riley, as they are the owners of You Are Beautiful, PLLC.
Capstone Finalization

33
They will remain in control of the project, as it is hosted by the business they own and the
business operates as a private marriage and family therapy practice and will continue to operate
as such. The financial plan for the project includes the most expensive piece of it, which is the
children’s one and one sessions. Funds that come in for the project goes directly to the provider.
That fee should be half of the provider’s typical rate for a 55-minute session fee. That fee will
vary based on the provider’s individual fees, but for the purpose of this implementation plan, the
fees will be specific to the therapist who will be providing these services first in the early stages
of the project. There are also sample costs in the financial plan of what a provider may need to
pay to be licensed in their area. This particular financial plan will include the amount of a grant
that has been applied for by a partnering organization as the funding source for the preventative
sessions that will be offered to children filtered to the therapist from the organization.
A local organization has shown an interest in the idea of having narrative therapy-based
preventative therapy available for the children that they serve. Their mission statement on their
website includes language that matches some of the goals of the project. Their mission statement
is “we engage young people in healthy relationships; equip them with skills to live a balanced
life-physically, mentally, socially, and spiritually.” (Unknown, Who We Are, 2020). They are
committed to partnering long term with the Narrative Therapy-Based Preventative Therapy for
Children Living in Poverty Project and applying for grants when they are available. The project
provider is willing to partner with them even if funds are not provided and will use other options,
like the virtual giving tool to provide services to children who are affiliated with organization. It
will be scaled out and delivered through social media, flyers, videos/webinars, workshops, and
program design templates. See Figure A6 for a visual financial plan.
Assessment and Evaluation of the Project
Capstone Finalization

34
Every provider who uses the Narrative Therapy-Based Preventative Therapy for Children
Living in Poverty Project as a way to provide services to children will understand that they will
be expected to monitor the outcomes as they go to make sure the project is effective and working
properly. Because drop out from therapy programs for children who are living in poverty
generally happens after the first session, it is important to capture the return reasons immediately
when children come back to their next session, so the surveys that ask the children about why
they continue to come will be given during the 2nd session, 5th session, and last session when the
treatment plan is completed. These surveys will be held in the same locked area as the children’s
other protected information. The provider will know that the project is successful at retaining
children in therapy as they continue to return. The survey also includes other information about
the child’s behavioral health as a way to see progress in the identified problem area.
To be completely culturally appropriate, the survey does not ask for identifying
information that is not necessary. It does not ask about finances or gender, because neither are
important when looking at the data. Although, if a child is receiving free preventative therapy,
the provider will know and will be able to match their information with survey.
The survey asks narrative style questions that can be answered to give a qualitative response,
which is in conjunction with the therapy technique being used. See Figure A7 for the survey.
Conclusion
It is believed that with an increase in preventative behavioral health care for all children,
there will be a reduction in the prevalence of behavioral health problems. That is the goal of the
Grand Challenges for Social Work “Ensure Healthy Development of All Youth” and the goal of
the Narrative Therapy-Based Preventative Therapy for Children Living in Poverty Project. The
benefits of having children receive narrative based, culturally aware and sensitive therapy in the
Capstone Finalization

35
preventative stage will be lifelong. Having people within the community give towards the care of
children who live in their neighborhoods means that they get to witness and experience the
change in children’s behavioral health firsthand.
As children attend preventative therapy that has been geared towards their specific wants
and needs, their long-term behavioral health needs will be reduced and they can actively
participate and give back to the same community that gave to them. The future mental health
care costs will be lower for the community when financial care is given in the beginning stages
of the identified problem. The financial barriers for children who are living in poverty will be
removed because of the giving of funds from community members and partnered organizations.
Children will no longer have to wait until they have a mental disorder to have care covered by
their insurance, they will be able to decide when they want to begin therapy to overcome
whatever behavioral health problems they may be experiencing. This will allow them to be in
charge of their behavioral health care like some of their peers.
The Grand Challenge supports the idea that the public should be made aware of cost
savings in the community when effective preventative interventions are implemented to increase
positive behavioral health in children (Jensen & Hawkins, 2018), so this project will inform
funders and organization partners, as well as children and their families of the excellent
outcomes of prevention. The success of the project will be an example of how research-based
practices can be just as effective, if not more effective than evidence-based practices. Therapists
within the community and beyond will be focused on the use of narrative therapy to bring a
different approach to working with children living in poverty and their unique situations.
Possibly, after the project proves to be helpful in reducing behavioral health problems with
children because their therapy starts in the preventative stage it will gain popularity within
Capstone Finalization

36
private practices and CMH settings and insurance companies will change their policy around
preventative mental health care and it will be covered.
As the project is implemented and in the beginning stages of partnering with the local
organization, there is always the risk that children and their families will not be interested in
receiving preventative therapy because they do not fully understand the benefits of putting effort
into a problem while it is still minor. It is also possible that children who are filtered to use the
project have more mental health challenges than expected and need a larger range of care or
more of a team approach. Funding could run out if the partnering organization is unable to secure
grants and community members do not give individually. Providers could also reject the idea of
using Narrative Therapy instead of an EBP like CBT. Even with all of these risks and possible
negative outcomes of the project, it is still worth trying to implement the project based on the
research that supports prevention, cultural aware interventions, and community-based programs.
A Narrative Therapy trained provider is available to begin working and has space to see children
immediately. Funding is being acquired through the partnership with a local organization as well,
so the time is now to begin this project that will change the way the behavioral and mental health
field looks at prevention and culturally appropriate care for children.

Capstone Finalization

37

References
Abdulmalik, J., & Thornicroft, G. (June 2016). Community mental health: a brief, global
perspective. Neurology, Psychiatry and Brain Research, 101-104.
Achieving Bright Futures. (2010). Retrieved from American Academy of Pediatrics:
https://www.aap.org/en-us/Documents/practicet_periodicity_AllVisits.pdf
Administration, S. A. (2019, April 13). Mental Health and Substance Use Disorders. Retrieved
from SAMHSA.Gov: https://www.samhsa.gov/find-help/disorders
Binkley, J., & Koslofsky, S. (2016). Una Familia Unida: Cultural Adaption of Family-Based
Therapy for Bulimia With a Depressed Latina Adolescent. Sage Journals.
Bischoff, R. J., Springer, P. R., & TaylorNathan. (April 2017). Global Mental Health In Action:
Reducing Disparities One Community At A Time. Journal of Marital and Family
Therapy, 276-290.
Brown, S. L., Stykes, J. B., & Manning, W. D. (2016). Trends in Children's Family Instability .
Journal of Marriage and Family.
Cheung, A. (2018). Fix the tax code to really help those with mental health needs. Retrieved
from Kitsap Sun: https://www.kitsapsun.com/story/opinion/columnists/2018/09/14/your-
turn-tax-code-social-problems-mental-health/1307958002/
Delgadillo, J., Moreea, O., Murphy, E., Ali, S., & Swift, J. K. (2015, December). Can Low-Cost
Strategies Improve Attendance Rates in Brief Psychological Therapy? Double-Blind
Randomized Controlled Trial. Journal of Clinical Psyhcology, 71(12), 1139-1152.
DeRigne, L., Porterfield, S., & Metz, S. (2009). The Influence of Health Insurance on Parent’s
Reports of Children’s Unmet Mental Health Needs. Matern Child Health , 176-186.
Capstone Finalization

38
Haring, R. C. (2013). Using Narrative Therapy With Native American Recreational Tobacco
Users. Substance Use and Misuse, 1434-1437.
Harris, S. E., Fox, R. A., & Love, J. R. (2014). Early Pathways Therapy for Young Children in
Poverty. Counseling Outcome Research and Evaluation, 3-17.
Horowitz, PhD, L., Pao, MD, M., & Tipton, BA, M. V. (2020). Primary and Secondary
Prevention of Youth Suicide. Pediatrics.
Hurrelmann, K. (1990). Health promotion for adolescents: preventative and corrective strategies
against problem behavior. Journal of Adolescence .
Jensen, J. M., & Hawkins, D. J. (2018). Ensure Healthy Development for All Youth. In R. Fong,
J. E. Lubben, & R. P. Barth, Grand Challenges for Social Work and Society (p. 19). New
York: Oxford University Press.
Joanna, K. J., Brookman-Frazee, L., Gellatly, R., Stadnick, N., & Barnett, M. L. (April 2018).
Predictors of burnout among community therapists in the sustainment phase of a system-
driven implementation of multiple evidence-based practices in children's mental health.
Professional Psychology: Research and Practice, 132-141.
Jung PhD, H., & Aguilar PhD, J. (2016). Everyone's responsibility: Community Partenrships and
shared commitement for mental health promotion. Social Work in Mental Health, 474-
496.
Kirmayer, L. J. (2012). Cultural competence and evidence-based practice in mental health:
Epistemic communities and the poolitics of pluralism. Social Science & Medicine, 249-
256.
Launer, J. (1999). A narrative approach to mental health in gneral practice. Narrative Based
Medicine, 117-119.
Capstone Finalization

39
Lavigne, J. V., LeBailly, S. A., Gouze, K. R., Binns, H. J., Keller, J., & Pate, L. (2010).
Predictors and Correlates of Completing Behavioral Parent Training for the Treatment of
Oppositional Defiant Disorder in Pediatric Primary Care. Science Direct Behavioral
Therapy , 198-211.
Lee, J. (2017). Responding to children in situations of family violence: Narrative therapy group
work with children. The International Journal of Narrative Therapy and Community
Work, 57-69.
Lee, J. (2017). Responding to Children in situations of family violence: Narrative therapy group
work with children. The International Journal of Narrative Therapy and Community
Work, 57-69.
Love, A. R., Okado, I., Orimoto, T. E., & Mueller, C. W. (January 2018). Factor Analysis of
Therapist-Identified Treatment Targets in Community-Based Children's Mental Health.
Administration and Policy in Mental Health and Mental Health Services Research, 103-
120.
Lynch, C. (2020, March). Access to Mental Health and Substance Use Disorder Services for
Children and Pregnant Women in the Children’s Health Insurance Program. Retrieved
from Medicaid.gov: https://www.medicaid.gov/federal-policy-
guidance/downloads/sho20001.pdf
Mattek, R. J., Harris, S. E., & Fox, R. A. (2016, March/April). Predicting Treatment Success in
Child and Parent Therapy among Families in Poverty. The Journal of Genetic
Psychology, 177(2), 44-54.
Medicaid.gov. (2019, June 20). Retrieved from Benefits:
https://www.medicaid.gov/chip/benefits/index.html
Capstone Finalization

40
Mustillo, S., Budd, K., & Hendrix, K. (2013). Obesity, Labeling, and Psychological Distress in
Late-Childhood and Adolescent Black and White Girls: The Distal Effects of Stigma.
Social Psychology Quareterly.
National Center for Children in Poverty. (2019). Child Poverty. Retrieved from National Center
for Children in Poverty: http://www.nccp.org/topics/childpoverty.html
Owens, J. (2020). Relationships between an ADHD Diagnosis and Future School Behaviors
among Children with Mild Behavioral Problems. Sociology of Education , 191-214.
Palinkas, L. A., & Soydan, H. (2012). Translation and Implementation of Evidence-Based
Practice. New York: Oxford University Press, Inc.
Potter, D. A. (February 2016). Situated Motives of Lay participants in Community Collaboratives
for Children's Mental Health, 426-437.
Ronis, S. T., Slaunwhite, A. K., & Malcom, K. E. (2017, November). Comparing Strategies for
Providing Child and Youth Mental Health Care Services in Canada, the United States,
and The Netherlands, 44(6), 955-966.
Sen. Murphy, Colleagues Call for Sustained Funding for Autism Therapy for Military Children.
(2016, October 4). Washington D.C., United States.
Sharma, P. (2019). Firstpost. Retrieved from As mental healthcare remains inaccessible to most,
narrative therapy provides an inclusive approach: https://www.firstpost.com/living/as-
mental-healthcare-remains-inaccessible-to-most-narrative-therapy-provides-an-inclusive-
approach-4798091.html
Slashinski, M. J. (2016). Mother protection, child survival: narrative perspectives on child
mental health services underutilization. Critical Public Health, 394-406.
Capstone Finalization

41
Stagman, S., & Cooper, J. (2010, April). Nccp.org. Retrieved from National Center for Children:
http://www.nccp.org/publications/pub_929.html
Substance Abuse and Mental Health Services Administration (SAMHSA). (n.d.). Bullying
Prevention in Indian Country. Substance Abuse and Mental Health Services
Administration (SAMHSA).
Unknown. (2020). Prevention. Retrieved from The Commonwealth Health Hub:
https://www.thecommonwealth-healthhub.net/prevention/
Unknown. (2020). Who We Are. Retrieved from West Sound YFC:
https://www.westsoundyfc.org/who-we-are
WellCare Gives $5000 in Micro-Grants to Community Based Organizations in Kansas. (2017,
January 10). Retrieved from PRNewswire: http://www.prnewswire.com/
Williams, B. D., & Baumgartner, B. (2014). Standing on the Shoulders of Giants: Narrative
Practices in Support of Frontline Community With Homeless, Mental Health, and
Substance Abuse. International Journal of Child, Youth and Family Studies, 240-257.
Wilson, C. J., & Cottone, R. R. (2013). Using Cognitive Behavior Therapy in Clinical Work
With African American Children and Adolescents: A review of literature. Journal of
mutlicultural Counseling and Development.
Yoshikawa, H., Aber, J. L., & Beardslee, W. R. (2012, May-June). The Effects of Poverty in the
Mental, Emotional, and Behavioral Health of Children and Youth: Implications for
Prevention. American Psychologist, 67(4), 272-284.

Capstone Finalization

42
Appendix A
Logic Model
Figure A1
Inputs: Consumers (children), Donors (community members), Partners (Schools, Churches,
Organizations) Licensed Providers (Mental Health Counselors, Marriage and Family Therapists, Social
Workers, Physicians, Psychologists)

Activities: Donors in the community give financially to provide preventative therapy sessions for
children, Partners provide funding through grants and referrals to the project, Licensed Providers set up
the project in their private practice and provide narrative therapy-based and culturally appropriate services
to children, and Consumers attend preventative therapy sessions or groups.

Outputs/Inputs:
• Increase in use of preventative therapy by children who are living in poverty. Decrease in
behavioral health problems for children.
• Change in interventions (Narrative Therapy) used to best meet the needs of all children.
• Increased partnerships between consumers, providers, and community.
• Children who are living in poverty understand their unique stories and see the problem outside of
themselves, feel valued, and cared for in the world.
• Creatively increase funds to support project.

Capstone Finalization

43
Appendix B
Narrative Therapy-Based Preventative Therapy for Children Living in Poverty Prototype
Figure A2

Figure A3

Capstone Finalization

44
Figure A4

Figure A5

Capstone Finalization

45
Appendix C
Project Financial Plan
Figure A6
*Individual providers assume the cost for their private practice setup where they will host the
project. These are typical startup and yearly costs listed below as a guide*
Expenses
Professional Licensing: $65
Professional Liability Insurance: $400
City Licensing: $75
Occupancy Permit: $73
Monthly Rental Space: $100
Furniture/Office Supplies: $500
Advertising: $300
Reduced Rate Preventative Therapy: $25 per child
Narrative Therapy Certificate: $75
Total: $1,123 (therapy sessions not included)
Revenue:
Grant money provided by partnering organization to fund preventative therapy and groups for
children who are living in poverty. $2300.
Community giving, various amounts.

Capstone Finalization

46
Appendix C
Survey at session 2, 5, and completion of treatment plan
Figure A7
Name
___________________________________________________________________________________
Age
___________________________________________________________________________________
Identified Ethnic Background
___________________________________________________________________________________
What number session is this for you today?
___________________________________________________________________________________
What are you enjoying?
___________________________________________________________________________________
What are you not enjoying?
___________________________________________________________________________________
How have you been feeling?
___________________________________________________________________________________
Name one or more reasons you come back each session.
___________________________________________________________________________________
Does anyone else come with you sometimes?
___________________________________________________________________________________
What would you like to work on next?
____________________________________________________________________________________
If this is your last session, CONGRATULATIONS! How do you think you made it so
far?_________________________________________________________________________________

Abstract (if available)

Abstract When children are forced into accepting a mental disorder diagnosis while their behavior is still mild and in the preventative stage of the problem, all so that they can receive behavioral health care, they sometimes take on the label of that diagnosis and suffer from negative thoughts or experience negative behavior. Insurance does not cover preventative behavioral health without a qualifying diagnosis from the Diagnostic and Statistical Manual of Mental Disorders 5 (DSM5) (Administration, 2019). When children who are living in poverty try to manage their identified problems and seek out behavioral health care, they are either turned away because their symptoms do not meet the requirement of a mental disorder or they are given a diagnosis, even while barely meeting the symptoms so that they can receive care that will be covered by their insurance. Although that may seem like a solution to getting care to children who are in need preventative therapy, the results from the stigma and shame are not worth it for the child in the long run. The need for preventative behavioral health care is immediate and many policies speak to implementation processes for getting behavioral health care to all children. Possibly in the near future primary prevention will be the vehicle to preventative behavioral healthcare for children, similarly to the way that primary prevention is used in the form of vaccinations for children. Primary prevention is described as promoting health and well-being as well as preventing disease and harm before it occurs (Unknown, Prevention, 2020). As children attend preventative therapy that has been geared towards their specific wants and needs, their long-term behavioral health needs will be reduced and they can actively participate and give back to the same community that gave to them.

Linked assets

University of Southern California Dissertations and Theses

Conceptually similar

PDF

Behavioral Health for All Kids

PDF

Brazos Abiertos: addressing mental health stigma among the Latino Catholic community

PDF

Acculturation team-based clinical program: pilot program to address acculturative stress and mental health in the Latino community

PDF

Conjoint homeless prevention services for older adults

PDF

Reducing the prevalence of missed primary care appointments in community health centers

PDF

Kids Cope Primary Prevention Services: evidence-based practices for supporting children impacted by parental incarceration

PDF

Healing parent application for parents who have experienced trauma

PDF

Inter professional education and practice in the health care setting: an innovative model using human simulation learning

PDF

Staying the Course: runaway prevention program

PDF

Implicit provider bias in cardiovascular disease care of Black women: the lives of Black women with heart disease matter

PDF

County of San Diego Child Welfare Services Hotline Redesign

PDF

A compassion fatigue informed approach: the wellness trail for refugee workers

PDF

Strength-Based Reporting: a trauma-informed practice for mandated reporters, to address behavioral health concerns in children at risk of child welfare involvement

PDF

From “soul calling” to calling a therapist: meeting the mental health needs of Hmong youth through the integration of spiritual healing, culturally responsive practice and technology

PDF

Adoption of virtual healthcare, self-sufficient wages and paid neighbors concept will ensure optimal living for vulnerable people and their paid caregivers

PDF

Empowering and building resilience with youth in congregate care

PDF

Mental health advocacy and navigation partnerships: the case for a community collaborative approach

PDF

Capstone project: Project prepare, plan, and provide

PDF

Incarceration trajectories of mothers in state and federal prisons and their relation to the mother’s mental health problems and child’s risk of incarceration

PDF

#BrainCareSavesLives

Asset Metadata

Creator Riley, Kimberly Lynn (author)

Core Title Narrative therapy-based preventative therapy for children living in poverty

School Suzanne Dworak-Peck School of Social Work

Degree Doctor of Social Work

Degree Program Social Work

Publication Date 08/21/2020

Defense Date 07/31/2020

Publisher University of Southern California (original), University of Southern California. Libraries (digital)

Tag Children,Community,culturally appropriate,Diagnosis,families,Medicaid,narrative therapy,OAI-PMH Harvest,Poverty,preventative,Prevention,therapy

Language English

Contributor Electronically uploaded by the author (provenance)

Advisor Lewis, Jennifer (committee chair)

Creator Email kimberlyriley@youarebeautifulpllc.com,rileyk@usc.edu

Permanent Link (DOI) https://doi.org/10.25549/usctheses-c89-366589

Unique identifier UC11666600

Identifier etd-RileyKimbe-8930.pdf (filename),usctheses-c89-366589 (legacy record id)

Legacy Identifier etd-RileyKimbe-8930.pdf

Dmrecord 366589

Document Type Capstone project

Rights Riley, Kimberly Lynn

Type texts

Source University of Southern California (contributing entity), University of Southern California Dissertations and Theses (collection)

Access Conditions The author retains rights to his/her dissertation, thesis or other graduate work according to U.S. copyright law. Electronic access is being provided by the USC Libraries in agreement with the a...

Repository Name University of Southern California Digital Library

Repository Location USC Digital Library, University of Southern California, University Park Campus MC 2810, 3434 South Grand Avenue, 2nd Floor, Los Angeles, California 90089-2810, USA