Capacitar: Building Mental Health Capacity in Rural Guatemala
By Liz Angoff
By the end of last school year, I was frustrated, defeated, and ready to quit. I had been working as a school psychologist in a large urban public school district for 12 years and the gravity of the issues coupled with the scarcity of resources had taken its toll. I decided I would flee the country in search of perspective.
I fantasized that Doctors Without Borders would have a summer program to match my skill set, but they do not accept school psychologists for their projects. Instead, a physician friend of mine recommended a small hospital in rural Guatemala where she had worked previously. I applied, explaining my nonmedical skill set, and was accepted readily. I packed my bags, grabbed my passport, and left the United States for a month of undefined volunteerism.
I arrived eagerly awaiting my assignment, only to find out the hospital had never worked with a psychologist before. Culturally, the community in general associated psychologists with severe psychopathology. But the administration hoped I could help some of the local adults who had survived a hurricane that wiped out an entire village 7 years earlier. Many suffered from significant trauma and were still incapable of leaving their homes. When I explained that I was not licensed to work with adults, the director frowned and asked, “Forgive me, but what exactly do you expect to do here?”
The first patient they found me was a child with behavioral issues and signs of abuse. Excited by the opportunity to help someone, I was also hit with a shattering reality: The reason why School Psychologists Without Borders does not exist is that 1 month is the time needed, in the best of circumstances, to build the relational foundation necessary to establish enough trust with a child for true therapy to begin. It was possible that I would gain the child's trust enough to open up all of her wounds, and then it would be time for me to leave. If providing my services could actually be damaging to the community, what did I expect to do there?
Explaining Mental Health Services
Presenting mental health services in general can be a tricky prospect. The reticence, or perhaps confusion, about working with mental health professionals is not unique to rural Guatemala. In many communities, going to see the psychologist implies mental illness, incapacity, disease, or failure. I have encountered it often in my district where parents are excited for me to work with their children until they discover I am a psychologist. “Never mind,” they say, “My child's not crazy.”
In Guatemala, perhaps amplified by my working out of a hospital, those who came to see me described themselves as sick in one way or another. Despite attempts to soften the harsh hospital room with coloring books and stuffed animals, it still looked like a doctor's office. One little boy refused to come into the room because he hated doctors. “They hurt!” he explained tearfully.
Families cancelled their appointments or simply failed to show. The few parents who brought their children to the hospital almost always asked, “Doctor, do you think he has something?” A parent of a teenager was relieved to find out her daughter's defiant behavior was developmentally typical, but balked at bringing her back for support, asking, “Why would I bring her back if she's not sick?”
After a week I realized I needed to shift my lens to a different model of psychological intervention. Perhaps there was a way to have the same impact as a medical volunteer if I focused more on training the local staff, and less on direct service to individuals. In this way, even if the community viewed formal psychological services as taboo, there still could be ways to find healing.
Capacitar: Crafting an Effective and Ethical Short-Term Practice With Others
There are many words for training in Spanish. The most obvious cognate, entrenar, implies the training of a dog. The word ensenar, to teach, is also loaded, implying the power a teacher has over his or her student. The hospital director suggested that instead, volunteers think capacitar: to empower, to prepare, to entitle.
This conceptualization of training is aligned with the consultee-centered consultation model pioneered by Gerald Caplan in the 1960s: The goal is not to provide “experts” to “fix” but rather consultation to build the capacity of those who are on the front lines, those who have regular access to those affected, and those who will continue to be around long after the so-called experts have returned home.
Instead of resorting to a “drive-by therapy” model, I shifted to a consultative psychological intervention: capacitacion. Surrounded by a number of professionals well versed in the struggles and trauma of the local community but unfamiliar with formal mental health practices, I realized if I shared tools to address basic needs, it might enable them to address many of the issues facing these families without exposing them to the shame of entering a psychologist's office.
To get away from the hospital, the volunteer coordinator partnered me with a nearby Evangelical school. This provided me with a new opportunity to explain my role as a school psychologist. I offered to meet with teachers, conduct trainings, and model strategies for students with difficult behaviors or learning needs. The school leaders were skeptical: “But we have so many children who need to see you.”
I began by meeting with the spiritual guidance counselor. She told me that she had previously been the Bible study teacher; however, she found that her students had many difficulties in their lives not covered in her curriculum. She met with them first by class, then in groups of girls and boys, and finally with those most impacted.
She shared that there was no precedent for her role; no other schools had a guidance counselor and there definitely was no educational program for a person with her intentions. Would I train her? Holding my breath, wondering if I was about to compromise our rapport, I revealed that I was not raised Catholic, but Jewish. “That's wonderful!” she said, “What a beautiful people the Jews are.”
I spent the next week observing classrooms and sharing my reflections with her, continuing to build rapport. Teachers repeatedly approached me to work with different students, but I politely declined, stating I was just getting to know the school. Soon I was a familiar face in the classrooms. I met with most of the target students, briefly subbed in for the English teacher, and even found myself teaching sex ed when the male teacher ran out of answers for his female students.
I observed the guidance counselor on a number of occasions. She was a dynamic speaker and storyteller; however, she spoke at them for an hour, asked if they understood, but rarely gave them an opportunity to offer their own opinions. Staying within the consultee-centered consultation framework, I moved from rapport building to problem definition: She wanted students to see the connection between the Bible lessons and their everyday issues. Sometimes in this type of consultation, the consultee reaches a point where he or she does not have the skills to continue in solving the problem. At this point, I was able to contribute from my own experience.
Social Skills Groups
In the United States, I run friendship groups designed to teach social skills and create a therapeutic environment for challenged students. The guidance counselor and I reviewed the primary issues that we had identified and created a series of four group lessons. She and the principal observed as I conducted sessions with groups from the 6th grade. When I repeated the lessons with the 5th graders, the guidance counselor co-led some of the lessons in order to implement the strategies in her own way.
One morning toward the middle of my final week, the counselor opened her office and excitedly pointed to her wall. She had pinned up papers from an activity with the high school students the evening before. It was a variation on an activity I call Grafitti (picture a large paper covering a table, each seat is a different prompt: Anger is … Happy is … and students take 2 minutes to draw or write their answers before rotating to the next prompt). The papers said honesty and dishonesty and were filled with children's handwriting. She was surprised by how little students understood about her lesson, and was excited to return the next day to hear more from them about where their perceptions had come from.
Many teachers approached me in desperation about children who needed counseling, asking if I would just talk to them. They claimed the problems were out of their control since they all “came from home.”
In one particularly touching case, the teacher reported that her student was inattentive, getting into conflicts, and often shutting down. The student had suffered a traumatic event, and the teacher felt helpless. When we met, the teacher defined the problem as fighting and poor peer interactions. As she talked, she added that he seemed tired and defensive. We discovered the student was having vicious nightmares with dozens of monsters, which he drew for us. When he was done, I asked him if he would like to hold on to his dream or throw it away. He tore up his paper and we went outside looking for a garbage can. In a eureka moment the child said, “Let's put it in the compost so the worms will eat it!”
By the next week, the teacher had set up a dream corner in the classroom with paper and art supplies. Any child who had a bad dream could draw their dream and then feed it to the worms. By defining the problem as a need for coping skills, instead of a need for a different home environment, the teacher was able to develop effective interventions.
Collaborative Profess ional Development
On my last day at the school, I ran a workshop for the entire staff. Based on what I had seen, along with observations from the guidance counselor and the two teachers' recent efforts, I presented them this simple concept: Behavior is a set of skills, just like reading and math. If a child is misbehaving, blaming outside circumstances leaves us powerless; however, if we see behavior as a set of skills, we begin to identify what we need to teach the child so he or she can engage in school in a positive way.
With this concept in mind, I asked them to share. The guidance counselor presented her plans for friendship groups, and the teachers presented ideas like the dream corner. Other teachers offered student behaviors, and the staff began to brainstorm what skills were missing and how to teach them.
About 3 months after my last day, one of the teachers e-mailed to say she was still using these same terms to talk about student behaviors and it continued to help her with her difficult students. The guidance counselor also followed up about how her work was progressing with the friendship groups:
There were some difficulties with the girls in the secondary school, and I used [the technique] with them and the results were very positive so I made a formal training for the staff in how to use it. I explained the steps and added some things that I've done. There were some very exciting moments because the staff participated as if they were students, writing messages for each other, sharing their drawings, and I told them they could do this with their students. I felt very content with the results because the teachers learned how to use the technique so they could help their students. I would like to learn more about how to discover what the children keep inside of them and how it affects their behavior in school. [translated from Spanish]
Not only did she continue her work in directly engaging students, she was able to capacitar the staff as well. This impact is significantly more than I could have ever achieved through direct service to struggling students.
A Proposal for Traveling School Psychologists
The consultee-centered consultation model is very powerful in the way that it provides an avenue for capacitar: to build the capacity of those directly involved with the problem or difficulty at hand. While not traditionally part of global efforts, school psychologists may be particularly equipped to provide sustainable support for impacted communities. We are familiar with working within institutions and have knowledge of school systems, family systems, child development, and the delicate interworkings of the effects of trauma on all of the above. By using a consultation model, it is possible that we would be able to build capacity in communities that lack mental health resources, are resistant to traditional models of psychological intervention, and struggle for the means to acquire these services when they are available.
My experience in Guatemala drove home the power of working with the community to build capacity instead of reacting to individual needs as they arise (the driveby therapy model). This school year, I split my time between three different schools, each with extremely high needs. I receive e-mails and phone calls daily with student names in the subject line and some version of “Could you talk to him? Maybe he has something …” in the body of the message. I could continue trying to respond to each of these students individually, but this would not get at the root of the problem. To maintain a more consultative perspective, I am trying to incorporate a few key concepts:
- Remember my role: While my impact is valuable, the people who will ultimately sustain change in a young person's life are those they come in contact with every day.
- Offer experience before expertise: Expert opinions will not convert into practice as easily as a story from a messy first-hand experience. Teachers benefit from hearing what you have done, not what they should do.
- Define the problem, not the solution: Most often we get stuck because we have lost sight of the actual problem at hand. Once we are able to see clearly, the solutions are evident.
- Empower the system: Every student exists within a complex system that will either reinforce or discourage the changes we are trying to make. Our work cannot exist in isolation.
In Guatemala, I was forced to work with the community to support student needs because the mental health and special education professionals were absent; however, when we operate in silos by isolating each department or person within the school system, we might as well also be absent. Our work is most overwhelming when we are trying to solve problems by ourselves: Degrees and titles do not endow us with magical powers to fix the complex problems our students face. By empowering and capacitando the teachers, community members, and parents who work with students daily, we have a much better chance at creating real change for them in school and in life—and we get to be the “doctor that doesn't hurt.” Pura utz!
Liz Angoff, PhD, is a school psychologist with the Oakland, California, Unified School District. For more about Dr. Angoff, see her website: www.DrLizAngoff.com