How it started
On April 20, 1999, two teens walked into Columbine High School in Littleton, Colorado, and opened fire, killing 13 people and wounding more than 20 others before turning their guns on themselves.
Shortly after that, Fort Worth Mayor Kenneth Barr met with top city officials to consider how to prevent something similar from happening here. They determined that while they could be prepared, there was little that could be done in the way of prevention.
After the Wedgwood Baptist Church shooting just five months later, they came back together. The church shooter, Larry Gene Ashbrook, had mental problems and they decided that perhaps they would could address that issue.
“I’ve gotten a lot of credit,” Barr said, “but there were multiple people involved and we were very fortunate in the way it all came together.”
“At that very time, Peggy Troy, who was the CEO at Cook Children’s [Medical Center] and some other people were talking about the same stuff and we pulled together what became the Mental Health Connection,” Barr said.
Among those people were Patsy Thomas, executive director of the Fort Worth Crime Commission who would become the executive director of MHC in 2002, and Ted Blevins, then CEO and executive director of Lena Pope Home Inc.
“We discovered that nearly every family out there has someone who has had some kind of mental health issue. But we don’t want to talk about it,” Barr said. “At the same time, we’ve got a lot of resources in the community that people have trouble knowing how to tap into.”
The concept was to create a “no wrong door” process where agencies cooperated and communicated to direct people to resources regardless of which agency they originally approached.
The agencies involved began meeting monthly and continue to do that 15 years later. The cooperative effort has brought millions of dollars into Tarrant County through government and other grants.
“It is one of the greatest community collaborations we’ve ever seen,” Barr said.
That’s true of Fort Worth, but it may also be true for the nation.
Agencies in pilot study
ACH Child and Family Services
Alliance for Children
Cook Children’s Medical Center
Fort Worth Independent School District
MHMR of Tarrant County
Santa Fe Youth Services
Tarrant County Juvenile Services
The Parenting Center
The Women’s Center
The City of Fort Worth recoiled in shock on Sept. 15, 1999, when Larry Gene Ashbrook walked into Wedgwood Baptist Church and began firing into a crowd of mostly young people at a “See You at the Pole” event.
Before he killed himself, Ashbrook killed seven other people – four of them teenagers – and wounded seven more.
City leaders, including then-Mayor Kenneth Barr, immediately launched a focus on mental health that led to the formation of the Mental Health Connection of Tarrant County (MHC), focused on bringing agencies dealing with mental health together through membership in an over-arching organization.
“You cut yourself short as a community when you talk about an event that catalyzed this, because then you imply that other communities just need such an event. No. Everybody gets the event. Only a very few communities make something of it.” says Dr. Kenneth Ginsburg, professor of pediatrics at the Perelman School of Medicine at the University of Pennsylvania. “And here, it created something that is lasting,” he said.
“I’ve gotten a lot of credit,” Barr said, “but there were multiple people involved and we were very fortunate in the way it all came together, frankly.
“It is one of the greatest community collaborations we’ve ever seen,” Barr said.
The Mental Health Connection has just concluded a three-year pilot of Ginsburg’s Reaching Teens: Strength-based Communication Strategies to Support Healthy Development and Build Resilience.
That’s a mouthful of a title that means recognizing that childhood trauma affects teen behavior and must be taken into account in the way that adults, counselors and other mental health workers interact with teens.
Trauma is not used just in the medical sense here – some type of physical wound – but in a broader sense that can include alcoholism and alcohol abuse in the family, drug use, poor health care, sexual abuse, family violence, poor academic achievement and poverty.
Ginsburg and the Mental Health Connection first encountered each other in 2013 when he was a presenter at a day-long seminar with more than 800 professionals serving youth in the community.
He had given similar presentations at other communities across the country, “but there was something qualitatively different about your commitment to actively address the needs of young people,” Ginsburg said in a letter in the MHC report to the community on the project.
That sense of purpose he saw here led him to ask whether Fort Worth and Tarrant County would consider being the pilot region for his program.
“Three years later, I see that as one of the best decisions I have ever made,” he wrote. “I have learned so much from you and genuinely hold you as a national model for community organization and collaboration.”
There’s a “secret sauce” that makes Tarrant County a special place for young people, he said, making the MHC effort a model for the nation that must be replicated.
Lessons learned in Tarrant County will be incorporated into a second edition of the book Reaching Teens, on which the program is based, and Fort Worth already has served as a mentor for other communities “from Maine, to California, to El Paso, Texas,” Ginsburg wrote.
The attention to trauma-base childhood incidents is based, in part, on research by Kaiser Permanente that indicates that such events have a lifelong impact and appear to result in increased risk of developing some diseases. (See: CDC Kaiser Permanente Major Findings, Page XX)
“That study, working with thousands of people, was able to really demonstrate that what happens to you in early childhood affects your body, your brain, your behavior and over many, many years,” Ginsburg said. “It was a pivotal study that really changed the potential of how we view health.”
Ginsburg believes that children are resilient enough to overcome this early childhood trauma, but that the adults in their lives need to understand those events, their impacts and how to talk to the victims in such a way as to recognize that they are hurting and without belittling or demeaning what they are feeling.
“I care about resilience,” he said. “I am fascinated by the fact that when bad things happen to you, it affects your body and your brain and your behavior.” But he cited a parallel body of research showing that “even if bad things have happened to you, but you have a protective, loving, caring adult in your life, you end up looking very much like everybody else.”
Ginsburg says he doesn’t necessarily use the word love, which can be used to exploit and confuse people. “I teach people how to demonstrate love,” he says. “I’m really talking about the concept of love. I’m not stuck on words, I’m stuck on what we display.”
At the heart of the program is the Reaching Teens book by Ginsburg and Sara Kinsand, and associated materials that include evidence-based approaches to engaging teens and their families. There are 69 chapters in the original book of more than 600 pages written by 52 authors. Mental Health Connection identified seven core chapters to be used by all 10 organizations participating in the pilot study.
And, say the participants, it works.
“The Reaching Teens program was an effective community-wide implementation that furthered the interests of the agencies in building capacity and skills in serving teenagers. This project built upon years of collaborative work and enhanced the already strong practice in the agencies. The result was an improved ability of all the agencies to best meet the needs of teenagers and their families in our community,” said Todd Landry, CEO of Lena Pope.
Virginia Hoft, executive director of Santa Fe Youth Services, said an important result of the process in the pilot study was learning a new mindset. “It’s not what’s wrong with you, it’s what happened to you,” she said.
Hoft and Landry were co-chairmen of the Mental Health Connections Resiliency Committee and co-chairmen of the Reaching Teens Pilot.
“Our agencies immediately jumped at the opportunity to do the work,” said Patsy Thomas, president of Mental Health Connection. “It is rare to find evidence-informed training materials related to the adolescent population. No one saw it as extra work but more as an enhancement of tools they already had.”
Thomas said the flexibility of the product allowed use by many different audiences and training could be planned for as much or as little time as agencies had to give it.
PASSION FOR RESILIENCE
Ginsburg says he’s been interested in resilience for more than 20 years, “thinking about all of the things that we can do to make it so that kids can thrive through good times and to be able to overcome challenging times.” It began when he was working with Native Americans in South Dakota and when he was working with homeless kids in other projects.
He’s a physician, but he also was trained through Covenant House, a Catholic-based organization in Pennsylvania that works with street and homeless kids.
“Medicine traditionally had been a risk-based profession. You focused on what it is people were doing wrong and tried to kind of correct their direction. I’m proud to say that medicine’s quite different now,” he said. “But being trained in Covenant House, I was always looking for people’s strengths. I was always looking for the reason that you love someone as kind of the pivotal moment that was going to turn their life around. That’s my personal journey.”
He’s more about action than he is about theory.
“I’m not a guy who’s going to be telling you statistics and telling you the association between trauma and risk and bad behaviors. I’m the guy who’s going to say, ‘Hey, we can do something about this.’
“Even if we can’t change all the circumstances of what happens to them, when there are loving, caring adults in people’s lives, we can make a huge difference. And that’s where I come into the movement,” he said.
Ginsburg puts it in a biblical context: “He who saves one life, it is as if he has saved the world.”
The magnitude of some social problems can be paralyzing and some people will throw up their arms, believing that nothing can be done.
“When we understand that what every child needs, literally, is at least one adult – more is better – but at least one who believes in that child, without condition, and will hold them to high expectations. That’s all every child needs,” he said.
Ideally, that’s the parents, and social workers are additions to the process.
“When it’s not, we become critical. Every caring adult in the world can do something for a child. And when we care for a child, what we communicate very clearly and loudly is, ‘You are worthy of being cared about.’ For the child from a loving home, that’s sweet. For a child who isn’t getting what they have, what they need in a home; it’s transformational,” Ginsberg said.
The variety of social service agencies in any community can be bewildering and complex, with overlapping services and, frankly, with some gaps despite everyone’s best effort. For the system to work most efficiently, there needs to be a handoff from one agency to another to fill those gaps, but there are often communication problems in that process.
One benefit of the Reaching Teens program is that with the agencies all training from the same materials, they share a common language so those handoffs do not result in fumbles but, as Hoft says, improved quality of care.
That’s critical, Landry says.
“Imagine if you were visiting several health care professionals for a medical condition. How frustrating would it be if each provider used different language in describing your treatment? It would be confusing and may actually impair your health versus improving it,” he said.
“The same can be said for teenagers and their families working with multiple behavioral health organizations. Speaking the same language and using the same approach not only increases the speed with which we work with youth but also enhances the ability for them to improve,” Landry said.
A common language, says Thomas, demonstrates the common value created in the community about the way to approach teenagers.
“The strength-based, trauma-informed approach is exemplified with the way we now look at these young people in a different way – what happened to you, not what’s wrong with you. We are better at engagement, at listening, more cognizant about what our body language says as much as what our words say.”
An example of that is described in the Mental Health Connection booklet reporting on the pilot study. It describes a situation in which a therapist from an agency went to see a young male and his parents:
The young male did not want to be any part of it, did not want to be involved. He was sitting on the floor and his voice was really low, and so in this situation, the therapist got down on the floor with him. What did that communicate to him … that she got down on the floor because she wanted to hear what he had to say.
After a pilot project like this, normally the next step would be to take it to scale, but Landry argues that with 10 agencies involved, including schools and physical and mental health, juvenile services and social service agencies involved, it already is at scale.
“We are seeing the positive impact with teenagers and families,” he said.
Thomas agrees. “Many agencies outside our pilot have the Reaching Teens toolkit and are already using it. Many agencies had intended from the beginning to eventually train their entire staff and new hires as time goes on,” she said.
She, Hoft and Landry agree that the next steps are continued expansion to other agencies in the area, and MHC is already working on how to structure that.
“While we are already at scale, the more agencies working in partnership will only continue to improve the community’s response and assistance to youth and their families,” Landry said.
WHY IT WORKS
Back to Ginsburg’s Tarrant County “special sauce.”
What kept these organizations together over three years of implementation, Landry says, is the common value of better serving teenagers and their families and trust among the pilot agencies.
“I continue to be amazed at our community value for collaboration,” Thomas said. “Our volunteers realize we can do so much more together than individually. Working together allows us the opportunity to problem-solve, create innovative ideas, learn from each other and experience valuable peer support.
“They don’t make decisions to participate in this kind of collaborative work without a lot of thought and consideration of the time it takes away from clients and billable hours – not to mention the thousands of dollars they invested in the books themselves. Once they make the commitment, they honor it,” she said.
It is, Thomas said, volunteerism at its best.
About Ken Ginsburg
Dr. Kenneth R. Ginsburg, MS. Ed, is a professor of pediatrics at Children’s Hospital of Philadelphia and the Perelman School of Medicine at the University of Pennsylvania. He also is medical director for Covenant House, Pennsylvania, a Catholic-based care system that serves homeless, marginalized and street youth in Philadelphia.
His research over the last two decades has focused on helping youth to develop their own solutions to social problems and teaching clinicians how to better serve them.
He co-developed the Teen-Centered Method, a mixed qualitative/quantitative methodology that enables youth to generate, prioritize and explain their own ideas.
Ginsburg has more than 125 works published, including 34 original research articles, clinical practice articles, five books, a multimedia textbook for professionals, and internet-based and video/DVD productions for clinicians, parents and teens.
He holds a master’s degree in education from the University of Pennsylvania Graduate School of Education (human learning and development) in Philadelphia and an MD degree from the Albert Einstein College of Medicine in New York City. As part of his master’s program, he lived with members of the Mnicoujou Lakota Nation in South Dakota for three months, and he has returned numerous times through the years. He also trained through Covenant House.
The 7 Cs: The Essential Building Blocks of Resilience
Young people live up or down to expectations we set for them. They need adults who believe in them unconditionally and hold them to the high expectations of being compassionate, generous and creative.
Competence: When we notice what young people are doing right and give them opportunities to develop important skills, they feel competent. We undermine competence when we don’t allow young people to recover themselves after a fall.
Confidence: Young people need confidence to be able to navigate the world, think outside the box and recover from challenges.
Connection: Connections with other people, schools and communities offer young people the security that allows them to stand on their own and develop creative solutions.
Character: Young people need a clear sense of right and wrong and a commitment to integrity.
Contribution: Young people who contribute to the well-being of others will receive gratitude rather than condemnation. They will learn that contributing feels good and may therefore more easily turn to others, and do so without shame.
Coping: Young people who possess a variety of healthy coping strategies will be less likely to turn to dangerous quick fixes when stressed.
Control: Young people who understand that privileges and respect are earned through demonstrated responsibility will learn to make wise choices and feel a sense of control.
Source: Fostering Resilience; fosteringresilience.com
CDC-Kaiser Permanente major findings
The CDC-Kaiser Permanente Adverse Childhood Experiences (ACE) Study is one of the largest investigations of childhood abuse and neglect and later-life health and well-being.
The original ACE Study was conducted at Kaiser Permanente from 1995 to 1997 with two waves of data collection. Over 17,000 Health Maintenance Organization members from Southern California receiving physical exams completed confidential surveys regarding their childhood experiences and current health status and behaviors.
The federal Centers for Disease Control and Prevention (CDC) continue ongoing surveillance of ACEs by assessing the medical status of the study participants through periodic updates of illness and death data.
QUESTION CATEGORIES AND DEFINITIONS
Adverse Childhood Experiences (ACEs) are categorized into three groups: abuse, neglect, and family/household challenges. Each category is further divided into multiple subcategories.
All ACE questions refer to the respondent’s first 18 years of life.
Emotional abuse: A parent, stepparent or adult living in your home swore at you, insulted you, put you down or acted in a way that made you afraid that you might be physically hurt.
Physical abuse: A parent, stepparent or adult living in your home pushed, grabbed, slapped, threw something at you, or hit you so hard that you had marks or were injured.
Sexual abuse: An adult, relative, family friend or stranger who was at least 5 years older than you ever touched or fondled your body in a sexual way, made you touch his/her body in a sexual way, attempted to have any type of sexual intercourse with you.
Mother treated violently: Your mother or stepmother was pushed, grabbed, slapped, had something thrown at her, kicked, bitten, hit with a fist, hit with something hard, repeatedly hit for over at least a few minutes, or ever threatened or hurt by a knife or gun by your father (or stepfather) or mother’s boyfriend.
Household substance abuse: A household member was a problem drinker or alcoholic or a household member used street drugs.
Mental illness in household: A household member was depressed or mentally ill or a household member attempted suicide.
Parental separation or divorce: Your parents were ever separated or divorced.
Criminal household member: A household member went to prison.
Neglect (Collected during Wave 2 only):
Emotional neglect: Someone in your family helped you feel important or special, you felt loved, people in your family looked out for each other and felt close to each other, and your family was a source of strength and support.
Physical neglect: There was someone to take care of you, protect you, and take you to the doctor if you needed it; you didn’t have enough to eat, your parents were too drunk or too high to take care of you, and you had to wear dirty clothes.
Adverse Childhood Experiences are common. Almost two-thirds of study participants reported at least one ACE, and more than one in five reported three or more ACEs.
The ACE score, a sum of the different categories of ACEs reported by participants, is used to assess cumulative childhood stress. Study findings repeatedly reveal a graded dose-response relationship between ACEs and negative health and well-being across the life course.
As the number of ACEs increases so does the risk for the
following (this list is not exhaustive):
Alcoholism and alcohol abuse
Chronic obstructive pulmonary disease
Health-related quality of life
Illicit drug use
Ischemic heart disease
Poor work performance
Risk for intimate partner violence
Multiple sexual partners
Sexually transmitted diseases
Early initiation of smoking
Early initiation of sexual activity
Risk for sexual violence
Poor academic achievement
More detailed information about the study can be found in “Relationship of Childhood Abuse and Household Dysfunction to Many of the Leading Causes of Death in Adults,” published in the American Journal of Preventive Medicine in 1998, Volume 14, pages 245–258.
If you would like to see the questionnaires used:
Family Health History Questionnaire
Health Appraisal Questionnaire
Source: Compiled from the Centers for Disease Control and Prevention