Citation
Low-Income African-American Caregivers' Experience of Having a Son Referred to Mental Health Counseling by the School Counselor

Material Information

Title:
Low-Income African-American Caregivers' Experience of Having a Son Referred to Mental Health Counseling by the School Counselor
Creator:
Tucker, Mary C
Place of Publication:
[Gainesville, Fla.]
Publisher:
University of Florida
Publication Date:
Language:
english
Physical Description:
1 online resource (145 p.)

Thesis/Dissertation Information

Degree:
Doctorate ( Ph.D.)
Degree Grantor:
University of Florida
Degree Disciplines:
School Counseling and Guidance
Counselor Education
Committee Chair:
Amatea, Ellen S.
Committee Members:
Clark, Mary Ann
Smith, Sondra
Koro-Ljungberg, Mirka E.
Graduation Date:
8/11/2007

Subjects

Subjects / Keywords:
African Americans ( jstor )
Caregivers ( jstor )
Child psychology ( jstor )
Mental health ( jstor )
Parents ( jstor )
Poverty ( jstor )
School counseling ( jstor )
School counselors ( jstor )
Schools ( jstor )
Sons ( jstor )
Counselor Education -- Dissertations, Academic -- UF
african, american, counseling, health, mental, phenomenology, poverty, referral, school
Genre:
Electronic Thesis or Dissertation
born-digital ( sobekcm )
School Counseling and Guidance thesis, Ph.D.

Notes

Abstract:
The intersecting factors of social class and race are essential markers of place and shapers of behavior and perception in the United States. In this phenomenological study, six low-income African-American caregivers were interviewed about their experience of having a son referred for mental health care by the school counselor. Issues of how the participants viewed the school, mental health care, and the process of being referred were explored. Key findings of the study included; the caregivers' experiences of alienation and powerlessness in the face of a rigid, hierarchical system for parent involvement in educational decision making, caregivers' perceived lack of power in relationship to school staff members, and caregivers' lack of understanding of school administrative processes. Other findings, as well as implications for practice and research, were examined. ( en )
General Note:
In the series University of Florida Digital Collections.
General Note:
Includes vita.
Bibliography:
Includes bibliographical references.
Source of Description:
Description based on online resource; title from PDF title page.
Source of Description:
This bibliographic record is available under the Creative Commons CC0 public domain dedication. The University of Florida Libraries, as creator of this bibliographic record, has waived all rights to it worldwide under copyright law, including all related and neighboring rights, to the extent allowed by law.
Thesis:
Thesis (Ph.D.)--University of Florida, 2007.
Local:
Adviser: Amatea, Ellen S.
Statement of Responsibility:
by Mary C Tucker.

Record Information

Source Institution:
University of Florida
Holding Location:
University of Florida
Rights Management:
Copyright Tucker, Mary C. Permission granted to the University of Florida to digitize, archive and distribute this item for non-profit research and educational purposes. Any reuse of this item in excess of fair use or other copyright exemptions requires permission of the copyright holder.
Resource Identifier:
660373597 ( OCLC )
Classification:
LD1780 2007 ( lcc )

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Full Text





This dual ordeal of knowing the child has a problem and not getting any help from the

school and the school not yielding to the child's needs is echoed in Felicia and James' story.

Felicia's son, Jaquan, was adopted as an infant from a birth mother who was using drugs. When

Jaquan started school, Felicia told the school staff that she felt his mother' s drug use had affected

Jaquan. She felt the school ignored this information until Jaquan began having serious academic

and behavioral problems. Felicia took Jaquan to have him assessed for ADHD. He was

diagnosed and prescribed medication. Although Felicia gives Jaquan his medication as

prescribed, she feels the school pressures her to ask the psychiatrist to increase his medication

any time he has a behavior problem rather than to work with him to find other solutions. Felicia

says she wishes the school staff would. "Work with him, be more understanding". She feels that

they are trying to push Jaquan into an alternative school to avoid having to help him succeed

where he is. James said he feels that the school is "unbending, all by the book, straight and

narrow". This approach is not working for Jaquan. Both Felicia and James feel that if the school

staff were more "sympathetic" he would have more success.

Teacie experienced similar frustrations with Patrick's first school. She did take him to the

mental health center as requested, but refused to put him on medication. The ensuing struggle

between her and the school principal over the medication led to her decision to move Patrick to

another school. Again, Teacie had explained to the teacher early in the year that she felt Patrick

would respond better to a different style of discipline than the teacher was using. She felt her

input was discounted, and that the school staff was only interested in seeing Patrick medicated.

This frustrated Teacie, "I have never in all my many little years seen a principal encourage a

mother to put their child on something they disagree with...and I felt she wasn't in the best

interest of my child, so I blew up and withdrew him."









American males and how membership in various social classes might impact their academic

performance would be of help to educators and policy makers working to close the Achievement

Gap between African-American and White students.

The ability of the caregivers in this study to transform the negative experiences into a

lesson in advocacy was fascinating to witness. Whether this ability was borne out of their shared

African-American culture or some other factor was not made clear. However, studying the

ability of low-income African-Americans to overcome and transform trying experiences would

be of great use to the helping professions.










poverty areas, possibly confirming the hypothesis that living in high poverty areas induces high

stress, which then triggers mental distress.

In another large scale quantitative study, Angold, Erkanli, Farmer, Fairbank, Burns,

Keeler, & Costello (2002) surveyed 920 parents of public school students in North Carolina

about their children' s behavior. Similar numbers of white (21.9%) and African-American

(20.5%) respondents met criteria for DSM IV diagnosis. However, white students were almost

twice as likely to be engaged in mental health services as African-American students (6.1% vs.

3.2%). These results are reinforced by the work of Alegria, Canino, Rios, Vera, Calderon,

Rusch, & Ortega (2002) using a national sample of 8,098 people. They found that even when

insurance and income status were controlled, African-Americans were almost half as likely as

whites to receive mental health care.

Barriers to Mental Health Treatment for American Children in Poverty

Research reveals that although children living in poverty are more likely to need mental

health care services, they are less likely to receive adequate help than their non-poor age mates

(French, Reardon, & Smith, 2003; Pottick, Warner, Isaacs, Milazzo-Sayre, & Manderscheid,

2002; McKay, Lynn, & Bannon, 2005; Huang, Stroul, Freidman, Mrazek, Freisen, Pires, &

Mayberg, 2005; Bussing, Zima, Gary, & Garvan, 2003). These findings are supported by both in-

depth qualitative studies (Arcia, Fernandez, Marisela, Castillo, & Ruiz, 2004; French, Reardon,

& Smith, 2003; Wilton, 2003) and by larger-scale quantitative studies (Busch & Horowitz, 2004;

Bussing, Zima, Gary, & Garvan, 2003; Chow, Jaffee, & Snowden, 2003; McKay, Lynn, &

Bannon, 2005; Pottick, Warner, Isaacs, Milazzo-Sayre, & Manderscheid, 2002; Takechi, Bui, &

Kim, 1993). Several policy analyses confirm these findings as well (Howell, 2004; Huang, et al,

2005, Leventhal, 2003; Smith, 2005).












Synthesis of Meanings and Essences .................. .......... ........_.. ....... 6
Validity and Trustworthiness, Reliability and Consistency .............. .....................6


4 FINTDINGS ............ _. ..... ...............69....


Textural Description: Anna............... ...............69..
School versus Parent. ............... ........ ...............69...
Problem Solving is the Parents' Job ............ .....__ ...............70
Mom Takes the Initiative................ ..................7
School Makes the Rules, the Parents must Follow............... ...............72.
Structural Description: Anna ....___ ................ .......__. .........7
School versus Parent .................. ........__. ...............72......
Problem Solving is the Parents' Job ........._._. .......... ...............73.
M om Takes the Initiative......................................7
School Makes the Rules, Parents Must Follow ......__................. .........__.. .....7
Textural Description: Teacie ................... ...............74..
The Fight to Keep Her Son Enrolled............... ...............75
Anger and Stigma ......__................. ...............75......
W orries for the Future .............. ...............76....
The School Staff Will Not Listen ........._.___........... ...............77...
Teacie: Structural Description .................. ...............78........... ....
The Fight to Keep Her Son Enrolled............... ...............78
Anger and Stigma ................. ...............78........... ....
W orries for the Future .............. ...............79....
School Staff Will Not Listen ................ ...............79........... ...
Textural Description: Joy .............. ...............80....
The Search for Answers .............. ...............80....
Building the Team .............. ...............81....
The Run Around ................. ...............82................
Structural Description: Joy .............. ...............83....
The Search for Answers .............. ...............83....
Building the Team .............. ...............83....
The Run Around ................. ...............84..............
Textural Description: Sherry .............. ...............84....
School Centered Solutions .............. ...............85....
No Support for Caregivers............... .. .... ...............8
The School Decides which Problems are Legitimate ....._.__._ ........___ ................87
Structural Description: Sherry .............. ...............88....
School Centered Solutions .............. ...............88....
No Support for Caregivers............... .. .... ...............8
The School Decides which Problems are Legitimate ....._.__._ ........___ ................89
F eli ci a and James: Textural Descripti on ................. ...............89......_.__.
No Compassion .............. .... ...... .. .............8
Failure to Communicate with Parents .............. ...............91....
No Flexibility............... ..................9
Structural Description: Felicia and James .............. ...............92....
No Compassion .............. ...............92....









Although Creswell also mentions searching for 'negative cases' to refine 'working hypotheses',

this particular method is not congruent with phenomenology, hence was omitted in this study.

The second pillar of empirical research evaluation is reliability. In quantitative terms,

reliability refers to the likelihood that repeating an experiment will yield similar results

(Merriam, 1995). Phenomenology, however, is not concerned with replicable results but in the

unique experiences of individuals and in finding commonalities between people (Wertz, 2005).

According to Merriam (1995, p. 56), qualitative researchers should be "concerned with whether

the results of a study are consistent with the data collected." Similar to the establishment of

trustworthiness, consistency may be achieved in qualitative research by creating detailed,

transparent steps of data transformation from raw transcripts to finished product. Merriam (1995)

suggests that qualitative researchers use triangulation, peer examination, and an explicit audit

trail to establish consistent results. In this study, the steps of data collection and analysis were

explicitly described, establishing a clear audit trail. Participants facilitated consistency by

reviewing transcripts. Peer reviewers carefully reviewed steps in data analysis and study design

in order to insure that the results of the study were consistent with the raw data.









& Garvan, 2003). During this delay, children's problems often worsen, and parents feel

overwhelmed and frustrated by the time they reach the clinic. Understanding the essence of the

experience of African-American families who are referred to mental health services by school

counselors would add enhance our current understanding of the dynamics of how, where, and

when poor African-American caregivers access mental health care services for their children.

Social Class and Access to Mental Health Care in the United States

Although vast changes have occurred in both standards and methods of care for the

mentally ill over the past two centuries (Grob, 1994), social class disparities are still reflected in

access to mental health care (Busch & Horowitz, 2004; Howell, 2004; Leventhal, 2003).

Differences in access to care occur among rural and urban populations, between wealthy and

poor people, and between various racial groups. Perhaps the group most affected by lack of

access to care is children living in poverty, regardless of race and location (Chow, Jaffee, &

Snowden, 2003; Samaan, 2000; Takeuchi, Bui, & Kim, 1993).

As defined by financial parameters, 16% of American children lived in poverty in 2002

with one in four families in the United States with young children earning less than $25,000 a

year (Child Welfare League of America, October 23, 2005). The federal poverty level (FPL) for

2004 was $19,157 per year for a family of four. Low income was calculated as 100-200% of the

FPL for a family of four (US Census Bureau, 2005). In terms of raw numbers, over 13 million

children in the United States lived at or below the poverty line in 2004, an increase of 12.8%

over the number reported in 2000 (Children's Defense Fund, 2005). Financial need is but one of

many defining characteristics of poverty. In this study, poverty was defined more globally as; "A

condition that extends beyond the lack of income and goes hand in hand with a lack of power,

humiliation and a sense of exclusion," (Raphael, 2005).





SPONSOR- Chi Sigma tota Exceltence Grant


I am pleased to advise you that the Unluersity of FLonda institutional Review Board has
recommended approval of this protocol. Based on its review, the UFIRB determined that this
research presents no more than minimal risk to participants. Given your protocol, it is
essential that you obtain signed documentation of informed consent from each participant.
Enclsed is the dated, IRB-approved informed consent to be used when recruiting participants
for the research.


It is essential that each of your participants sig~n a copy of your approved informed
consent that bears the IRB approval stamp and expiration date~.


If you wish to mrake any changes to this protocol, including the need to increase the number
of participants authorized, you must disclose your plans before you implement them so that
the Board can assess their impact on your protocol. In addition, you must report to the Board
any unexpected complications that affect your participants.


If you have not completed this protocol by October 1, 2007. please~ telephone our office
(392-0433), and we will discuss the renewal process with you. It is important that you keep
your Department Chair informed about the status of this research protocol.

15F:di


Po 8ox ri22so
Gainesvdle, FL32961T-2250
assa,2-OU3 Iesone)
352-392-92341 (Fax)
irb2@nufl.edu


DATE:


October 3,2006


TO: Catherine Tucker. PhD
3324 W. University Avenue #226
Gainesville, FL. 32607
FROM: Ira 5. Fischler, Chair
University of Florida
Institutional Review Board

SUBJECT: Approval of Protocol #2006-U-8654


TITLE:


Low Income African-American Families Experiences of Being Referred to Mental
Healthr Senrvies by School Counselors


.A ~rt Eull O)pportunity~ [nrtihatwr


I115Iitui~nl Review 1B0ard

UNIVErlRSIT~ofFLORIDA









dominant social capital for instrumental purposes (to please teachers, make good grades) and

non-dominant social capital to express themselves and gain acceptance from other African-

American youth as "authentic" members of the African-American community. Balancing both

sets of cultural capital successfully, although difficult, seemed to allow participants to be

successful both in the "white world" and in their racially-identified communities. Continually

reading social signals filtered through two very different sets of lenses and deciding which set of

social skills to apply was reported to be a source of stress for the adolescents in Carter' s study.

In applying Liu' s (2001) construct of social class world view to the concept of dominant

and non-dominant forms of cultural capital, it is possible to see that African-Americans may

experience a nearly constant sense of cognitive dissonance by rej ecting the dominant world-view

for the non-dominant, and vice-versa. Not having a single set of lenses through which to judge

appropriate versus inappropriate actions for any given setting, but a double set from which to

choose would likely lead to frustration and confusion- particularly when the dominant and non-

dominant cultures demand nearly opposite reactions to similar situations. Further, it would seem

that younger and/or those African-Americans for whom switching between cultural lenses is

more difficult may experience more conflict and distress about having two sets of intrapsychic

frameworks by which to judge cultural and social situations. Whether or not, or to what extent,

this duality of cultural and class framing affects African-Americans when making decisions

about whether and how to seek help for mental health problems remains unknown.

Intersecting Issues of Race and Class in Mental Health Referrals

In spite of hints in the literature that both race and class impact both how people perceive

and access mental health care in the United States, it is not clear how each factor influences

people' s ideas and actions regarding mental health care. As discussed in Chapter One of this

document, African-Americans are vastly over represented among the poor (US Census Bureau,










Sampling Criteria

Participants were chosen by matching several criteria so that this sample represented the

local African-American low-income population. In order to qualify for participation, people had

to be: African-American caregivers with sons in elementary school that had been referred to

mental health services by the school counselor. The children had to be eligible for free or

reduced lunch to qualify as "low income" in the study. Caregivers had to be the legal and

physical guardian of the child in order to give consent to participate. School counselors were

give a list of these criteria and made initial contact with families based on these criteria. Once the

family was contacted for the first interview, the criteria were reviewed to insure a homogeneous

sample.

In phenomenological research, a homogenous sample is critical to the outcome of the

analysis (Moustakas, 1994). Method- appropriate sampling methods are crucial to doing solid

qualitative research (Gubrium & Holstein, 1997). According to Kuzel (1999), a homogenous

sample is one that, "focuses, reduces, and simplifies" (p. 39). To insure that participants are

homogenous enough to conduct a trustworthy phenomenological analysis from the data they

provide, as many obvious differences in demographics (race, socio-economic class, geographic

location, age of child being referred, involvement with agencies, custody status) as possible will

be eliminated. A chart containing basic demographic information about the participants is

included in Appendix C.

Data Collection Methods

The caregiver(s) from each family were interviewed either two or three times between

December 18, 2006, and February 20, 2007. Three interviews were requested of each participant,

but not all participants could be reached for the final interview. Three participants, Sherry and

Felicia and James, could not be located via telephone or postal mail requests for a third










maj ority of students identified as emotionally disturbed in the United States (Colpe, 2000).

African-American male students were far more likely than their white or female peers to be

suspended, expelled, or subjected to corporal punishment (National Center for Education

Statistics, 2001). Conversely, African-American males were disproportionately absent from

advanced courses and college campuses (Noguera, 2003).

There have been many possible causes for these discrepancies put forward by researchers.

African-American boys who attended schools in high poverty areas were more likely to be taught

by poorly prepared and inexperienced teachers (Day-Vines & Day-Hairston, 2005). For those

African-American males who lived in poverty, health concerns may have fueled excessive

absences which interfered with learning (Rothstein, 2004). Children in poverty in general also

tended to receive less help and support from their parents for academic issues. However, not all

underperforming African-American males were from poor families, thus seeming to underscore

the influences of race and gender as potentially more powerful variables than social class and

wealth .

There are many theories as to why African-American males suffer negative life outcomes

in such large numbers. Three of these theories, including social and cultural capital differences,

social class world view theory, and oppositional culture theory are discussed in the next section.

Cultural and Social Capital Theory

In examining issues of poverty, social class, and race a discussion of cultural capital

theory is helpful in understanding how these factors pervade everyday life, including health care

and education. In the 1970's sociologist Pierre Bourdieu coined the term "cultural capital" to

refer to an individual's access to "signals" such as styles, attitudes, ideas, jargon, and preferences

that either help or hinder people from entering high-status social groups (Bourdieu, 1977). The










communication (Amatea, 2007). Caregivers felt that the school staff members were not listening

to them when deciding on interventions for problem behaviors.

Low-income African-American caregivers felt disconnected from the school community

during the time when their sons were experiencing behavioral difficulties. Caregivers expressed

feelings of frustration with and alienation from the people in the school who had the power to

determine their son's educational future.

Caregivers felt that they were not viewed as equal partners in their sons' education.

Caregivers talked about not understanding what services were available at school for their sons,

or what services might be appropriate. Caregivers were desperate to do anything necessary to

keep their sons at their current schools but did not feel empowered to demand that the school

staff make any changes. Instead, the caregivers felt pressured to fix their sons. Some participants

felt added pressure to find help for their sons in order to break a cycle of negative outcomes for

men in their families.

However, the caregivers were persistent in their support of their sons and in their quest to

find help for them. Caregivers were able to transform their negative feelings about staff members

and school policies into a catalyst for learning to advocate for their sons.

Essence Statement

The essence of the phenomenon of being referred for mental health care for their sons by

the school counselor was the caregivers' experiences of alienation and powerlessness in the face

of a rigid, hierarchical system for parent involvement in educational decision making. Caregivers

felt that school staff members were not interested in listening to their opinions or relevant past

experiences. Caregivers felt that they had no power or voice in decisions concerning their sons'

futures, and that the school staff members expected them to quietly acquiesce to all









referrals to outside agencies, a significant number (48%) also reported occasional frustration

with parents not following through on their recommendations (Ritchie & Partin, 1994).

Most current school counseling textbooks offer some variation on the following advice to

new professionals about making out-of-school referrals:

* Know what resources are available in your community.

* Be aware of laws and policies regarding sharing confidential information.

* Develop collaborative working relationships with the care providers in your area.

* Keep some record of the dates and places families were referred to service providers
(Baker, 1996; Brown & Trusty, 2005; Erford, 2003; Ritchie & Partin, 1996).

Some texts also offer models for problem-solving with families in crisis (Baker, 1996;

Erford, 2003) which could be employed when making referrals. However, only Erford's text

offers a chapter on helping what is termed "at-risk" students, which is a broadly used and ill

defined term; none of the texts seemed to include any guidance on working with families in

poverty per se (Brown & Trusty, 2005; Davis, 2005 both include chapters on multicultural

counseling, but focus only on race and heritage issues, not class). Additionally, most texts do not

differentiate between sub-groups within races, such as Mexican- American versus South or

Central American or Caribbean Hispanics, or between Haitian and African African-Americans.

Conversely, a large percentage of children seen in mental health facilities have a history of

school problems and are initially referred by school counselors or teachers. The research that

does exist on the process poor families experience between initial referral for and entry into

mental health services suggests that there is often a long delay between the two (Chow, Jaffee &

Snowden, 2003; French, Reardon, & Smith, 2003; Potter, et al, 2002; McKay, Lynn, & Bannon,

2005; Huang, Stroul, Freidman, Mrazek, Freisen, Pires, & Mayberg, 2005; Bussing, Zima, Gary,












APPENDIX C
CONSENT FORM AND IRB APPROVAL










University of Florida
Department of Counselor Education
1212 Norman Hall
Gainesville. FL 32611

De~ar Paren~t,

I am a doctoral student in the Department of `counselor Laluinl;ln as rhe University of
Florida. I am contducting, research an low Income African-American parents' experiences
of the being referred to mental health services by school personnel. I am bopinr: thor wlh.lx
I learn will help school and mental health counselors better understand how African-
American parents make decisions about their children's care.

Parents who choose to participate will be inters iewed; lthre limer. for about an hour each
time. I can do the interviews in any quiet place where we can talk, like your home, the
school, or in an office at the Ulniversity. I will tape record the interviews in order to
transcribe them later. I will~s la senel questions aboutl your experiences wvith being
referred to mental health services. Whether or not you decide to go anywhere for services
will not affect your ability to? paticipalo ;n the intevews. I am interested in how see the
referral process, not what you decide. These interviews are not m~en~tal health therapy,
although I am licensed counselor, I will not be c~ondu.-ring terap) w.ith you. I wrill only
be learning from you about the referral process.

The information I gallerr w~ll be used to help counselors better understand how African-
America, pacrens male decisions regardling their ch;ldren's health care. Thre people I
interview will not be iden ifiedr by name nor will any information that could be used to
identify them be shared. Your confidence will be protected as provided for under the law.
I will use your answers when untingr m: di nrrianon, and in possibly in journal articles,
but will not use your name or other identifying informtin.

Participation in the study is completely voluntary, It will not affect lour Lhllld's garude,
placemewnt, or status unh ttc hool still in ;uty way. 'I bore are no krnown naks or immediater
benefits known to participants. TChere is compensnr;ian for panicipa~ioln After the 11 r:
intenriew, you wiHl receive, a $10 gift card from a grocery store; for the second, $10, and
$20 for the third. loru mu.\ req~uet group results of the study next March, if you wish.
You may withdraw your consent at any time. If you have any questions about the
research, you may contact me at 359-1258. Quesrtions aimvi~ your nght ai s a1 rz ch
participant may be directed to the UFIRB Office, BoX I1 225'0 Gainesville FL 3261.1, or
call 392-0433.

T hsnk ;-ou.
Catherine Tucker Ap~proved by

Institutional Review B~oard 02
Protocol # 2006-U-0864
For Use Througrn 01-0









Phenomenological Reduction

In the process of transcendental-phenomenol ogi cal reducti on, the first step i s for the

researcher to note all of the unique characteristics of the data, describing the observable

information that defines the phenomenon. In interview studies, this usually means transcribing

the recorded interviews verbatim. The data is then examined for 'horizons', or "the invariant,

unique and defining constituents of the phenomenon" (Moustakas, 1994, p. 97). Horizons are

given codes, or titles to make data easier to manage (Wertz, 2005). During this process, it is

crucial for the researcher to adopt a posture of wonder and put aside any preconceived ideas of

what the participants' experience might include (Moustakas, 1994). Adopting this posture

defines the analysis as transcendental, since the researcher is seeking to transcend ordinary, taken

for granted explanations of the phenomenon of interest.

Horizons are then clustered into themes, and from the themes, a textural description of

the data is written for each individual data set, or interview. The textural description is a coherent

description of the participant' s report of his or her experience. According to Moustakas (1994),

creating a textural description, "uncovers the nature and meaning of the experience" (p. 96).All

horizons and individual textual descriptions are considered together, and a coherent description

of the experiences of the entire group is created. This composite textural description aims to

organize the lived experiences of all participants into a cohesive common description of the

phenomenon of interest (Moustakas, 1994).

Imaginative Variation

Once textural descriptions of the data are formed, the researcher then examines the data

for the "structural essences of the experience" (Moustakas, 1994, p. 35). In order to identify

these structural essences (or meanings and causes of an experience), the researcher employs a

form of brainstorming called Imaginative Variation. In this exercise, the researcher imagines all









social class, although it does include level of education, work experience, and historical context

(Arredondo, Rosen, Rice, Perez, & Tovar-Gamero, 2005). Arredondo, and her associates (2005)

go on to say at the conclusion of their content analysis of the Journal of Counseling and'

Development from 1995-2005, "No longer can multiculturalism be relegated to one course,

mentioned as a passing comment in a publication or presentation, or avoided by educators and

administrators... (p.160). This already powerful statement would be strengthened by the

inclusion of class. In a review of tables of contents for the Professional School Counseling from

1997 to the present, similar ratios were found. However, the journal's recent special issue

entitled "Professional School Counseling in Urban Settings" (February, 2005) did include

articles on poverty related issues.

Liu and colleagues (2004) reviewed three j ournals, The Journal of Counseling Psychology,

The Journal of Counseling and' Development, and The Journal of2~ulticultural Counseling and'

Development from 1981-2000, and discovered that social class was a key variable in only 1.4%

of all empirical research articles, even though social class data was collected on participants in

17.5% of the studies. Social class was referred to more often in theoretical/conceptual articles,

and was at least mentioned as a variable in 33.5% of the studies. In total, between 20 and 30% of

all 3915 articles reviewed mentioned social class in some form. However, only a very small

percentage made social class a focus of the research. These findings highlight the need for more

research in the area of social class in the counseling literature. In particular, the subj ective

experience of social class has been excluded from previous work, in spite of the evidence that

subj ective accounts of social class are more reliable and robust than available obj ective measures

(Liu, et al, 2004). The two most frequently used obj ective indices of social class, the

Hollingshead Index of Social Position (1958), and the Duncan Socioeconomic Index (1961) are









Most of the research on programmatic research issues uses large-scale and quantitative

methodologies, often drawing on census or national survey data. There are some qualitative and

smaller scale studies, but they are clearly the minority of the research.

Chow, Jaffee, and Snowden (2003), in their research on the effect of race, ethnicity, and

poverty on mental health service use, drew data from New York State Health records and the US

Census. They conducted a bivariate and logistical regression analysis and found that African-

Americans, Hispanics, and Asians used more services at younger ages than Whites, particularly

in high poverty areas. African-Americans in particular were more likely to be diagnosed with

schizophrenia than other racial groups, and most likely to be referred to mental health services by

juvenile justice or child protection agencies. Only in low poverty areas, Asian and Hispanic

people were more likely than Whites to use inpatient services. By contrast, in high poverty areas,

Asians and Hispanics were less likely to use inpatient services than Whites.

In smaller scale studies, African-American youth were referred more often for mental

health services than were Whites and often more coercively, meaning that they were more likely

to be threatened with negative outcomes for noncompliance, such as foster care placement or

juvenile justice intervention than Whites (Stevens, Harman, & Kelleher, 2005; Takeuchi, Bui, &

Kim, 1993). The interplay of race and poverty is still being untangled, with some findings

showing that race is the primary factor in mental health referrals (Costello, Keeler, & Angold,

2001; Stevens, Harman, & Kelleher, 2005; Takeuchi, Bui, & Kim, 1993), while others claim that

poverty is the key variable (Chow, Jaffee, & Snowden, 2003; Samaan, 2000). Obviously, further

research is needed to examine the effects of both race and poverty on children's mental health.

Which variable contributes more heavily to coercive referrals and varied treatment outcomes is









knowledge, the lack of emotional support from psychiatrists, and the lack of clear answers about

their child' s condition. Many of these parents also mentioned feeling blamed by health care

professionals for their child's mental problems. In a similar study conducted in the United States,

Scharer (2002) reported that parents of children in mental hospital settings wanted more

information about their child's condition and treatment, greater emotional support from health

care staff, and more information on managing the child after he or she returned home.

Interestingly, a qualitative study conducted with parents of obese children found similar concerns

about their interactions with health care staff (Edmunds, 2005). These research findings may

indicate that the problems of communication between parents and medical staff extend beyond

the arena of mental health problems. Mental health problems in children are, however,

particularly stressful to families. A Swedish study involving over 700 parents of non-

schizophrenic and schizophrenic children revealed a lower quality of life rating, a higher

perceived level of stress reported by families with schizophrenic children (Foldemo, Gullberg, &

Ek, 2005).

Another aspect of children' s mental health treatment which needs further study concerns

how parents decide to seek services for their children. Renk (2005) found that mothers who

brought their children to a mental health clinic had significantly higher reported parenting stress

and reported higher levels of acting out behaviors in their children than did mothers in a control

group of Latino children without behavioral problems. Arcia, Fernandez, Marisela, & Ruiz

(2004) found that out of 62 Latina mothers interviewed, about half (32) reached the mental

health clinic' s door "almost by happenstance...the mother's search looked like a pinball in a

game" (p. 1225). About half of the mothers in the study (3 1) were directly referred either by a

school, or a medical professional, or a social worker, or family member and once referred, made









arrangements for services. Six of the Latina mothers were self-referred; out of concern over their

child's behavior (these mothers had significantly more education at 16.1 years on average, than

did the rest of the sample, at 1 1.9 years). In contrast, those mothers who delayed treatment often

reported that increasing actions by the school (such as suspension of the child), increased

concern by relatives, or an escalation in the child's difficult behaviors finally caused the mothers

to make an appointment for services. Whether these findings would be consistent in other ethnic

groups is unknown, however, the important implication from Arcia, Femnandez, Marisela,

Castillo, & Ruiz (2004) is that direct referrals may help facilitate mother's accessing mental

health services, and may reduce the time and worry of the "pinball" effect.

Summary

In examining the current professional literature on school counselors' referral practices,

mental health parity issues, and the specialized needs of low-income African-American families,

it becomes clear that there is very little research that directly addresses the intersection of these

related issues. While literature does exist that examines each strand of this puzzle individually,

there is a lack of literature to guide school counselors' referral practices with diverse families.

This is problematic when viewed in context. African-American males make up a

disproportionate percentage of students with serious behavioral problems which impede their

academic and social development (Colpe, 2000). However, African-Americans are also less

likely to receive mental health counseling than are Whites (Richardson, Flaherty, & Bell, 2003).

How much of this disparity is due to barriers to service that might be ameliorated by improved

referral practices is unknown. It does seem possible that at least some of the African-Americans

who are in need of, but who are not receiving, mental health care, could be linked with needed

services by school counselors who have training in reaching out to low-income families of color

and are using culturally responsive referral practices. This is indicated in past research (Arcia,









Under the Comprehensive Child and Adolescent Mental Health Services Act and Part III

of Chapter 394 of the Florida Statutes, the State of Florida provides five types of CMH services:

1) Baker Act, or short-term involuntary commitment services,

2) non-residential mental health services including outpatient counseling, case management, and

assessment,

3) residential services including state hospitals and group homes,

4) the Behavioral Network, a group of providers working with the Department of Children and

Families (DCF) to meet the needs of children with SED, and

5) Juveniles Incompetent to Proceed Services, which helps young people with severe disabilities

receive counseling, pharmacotherapy, and life skills training, along with assistance in residential

placement in concert with the Department of Juvenile Justice (Department of Children and

Families, 2005). Services in the first four areas are provided by private agencies under contract

with DCF. Services for incompetent juveniles are provided under a separate contracting system.

Much of the funding for CMH in Florida comes from federal Medicaid dollars. Other sources of

funding may include block grants, general revenue, and state trust funds. All totaled, the State of

Florida spent $101 million on CMH in fiscal year 2005-6, not including expenditures for

children receiving mental health services while in the custody of the Department of Juvenile

Justice, or through school funded programs. (www.oppaga.state.fl.us/profiles/50 14).

Low-Income Families in Counseling

A review of the contents of the Journal of Counseling and'Development_from 1 995-2005,

revealed that only 9 articles included terms that directly indicate an emphasis on class and/ or

poverty issues. Words such as: at-risk, marginalized, elitism, disadvantaged, social justice, and

lack of money were used as search terms. By contrast, 90 articles had titles that included terms

related to race, culture, national origin, ethnicity, or multiculturalism. Three special issues of the










Dogra, N. (2005, July/August). What do children and young people want from mental health
services? Current Opinion in Psychiatry, 18(4), 370-373.

Earls, F. (2001, October). Community factors supporting child mental health. Child &
Adolescent Psychiatric Clinical Nursing, 10(4), 693-709.

Edmunds, L. (2005, June). Parent's perceptions of health professionals' responses when seeking
help for their overweight children. FamFFFFFFFF~~~~~~~~~ily Practice, 22(3), 287-292.

Ellison, R. (1952/2000). The Invisible Man. New York: Random House.

Erford, B. (2003). Transforming the school counseling profession. Upper Saddle River, NJ:
Pearson.

Finders, M., & & Lewis, C. (1994). Why some parents don't come to school. Educational
Leadership, 51, 50-54.

Florida State University Center for Prevention and Early Intervention Policy for the Florida
Developmental Disabilities Council. (2001, February). Florida's strategic plan for infant
mental health. Retrieved August 2, 2005, from www.cpeip.fsu.edu.

Foldemo, A., Gullberg, M., & Ek, A. (2005, February). Quality of life and burden in parents of
outpatients with schizophrenia. Social Psychiatry and Psychiatric Epidemiology, 40(2),
133-138.

Fontana, A. (2002). Postmodern trends in interviewing. In J. Gubrium & J. & Holstein (Eds.),
Handbook of interview research (pp. 161-175). Thousand Oaks, CA: Sage.

Freire, P. (1970/2003). Pedagogy of the oppressed. New York: Continuum.

French, R., Reardon. M., & Smith, P. (2003, December). Engaging with a mental health service:
Perspectives of at-risk youth. Child & Adolescent Social Work, 20(6), 529-548.

Garland, A., Lewczyk-Boxmeyer, C., Gabayan, E., & & Hawley, K. (2004). Multiple
stakeholder agreement on desired outcomes for adolescents' mental health services.
Psychiatric Services, 55, 671-676.

Gibson, P., & & Abrams, L. (2003). Racial differences in engaging, recruiting, and interviewing
African American women in qualitative research. Qualitative Social Work, 2(4), 457-476.

Gibson, P., & & Abrams, L. (2003). Racial differences in engaging, recruiting, and interviewing
African American women in qualitative research. Qualitative Social Work, 2(4), 457-476.

Giorgi, A., & Giorgi, B. (2003). The descriptive phenomenological psychological method. In R.
Carmic, & Yardley (Ed.), Qualitative research in psychology (pp. 243-280). Thousand
Oaks, CA: Sage.










Although Teacie was eventually able to realize that her initial reaction was angry and

defensive due to her own history, the negative feelings toward the school staff lingered. Their

rather abrupt referral of Patrick to mental health services did not take into account the potential

for caregivers to have emotional reactions to such news.

Worries for the Future

Instead of stepping in to support her in her desire to raise her son well, the school staff

pressured her to medicate him, which she did not want to do. She said of her experiences

meeting with them, "Maybe they hear me, but they're not listening". She felt that the principal

only wanted Patrick medicated and was not willing to try any other methods of helping him

improve his behavior. The continued requests to have Patrick medicated despite his health

problems was extremely frustrating to Teacie. She felt that her concerns were ignored and

discredited because, "I'm only a Mom".

She saw the staff at that school as acting only in their own interest, wanting Patrick to

comply with the rules. Teacie's concerns about Patrick' s health and the negative effects of the

medication on it were brushed aside. When he was on medication, Teacie saw no real change in

his behavior, except for increased appetite and lethargy. She did not feel these results merited the

risks involved.

School Staff Will Not Listen

The school staff members were not responsive to Teacie's suggestions for a different

approach to classroom management for Patrick. She repeatedly requested a "Hirm" teacher for

him, but the school administration did not seem to regard her request as a serious possibility.

Teacie chose to move Patrick to another school in an attempt to find him a more "firm" teacher.

She generally felt disregarded by the staff of the first school.









counselor, Joy fears she would have been stuck in an eternal run around. She is now waiting for

her appointment at the mental health center. She is, "ready for him to get some counseling,

something, anything".

Structural Description: Joy

The Search for Answers

Joy has been trying to the best of her ability to get help for her often violent and out of

control son for almost Hyve years now. She has been extremely frustrated by the process of help

seeking. With the notable exception of the current school counselor, Joy has been dismissed and

disempowered by professionals from whom she sought help.

The tangled system has not allowed her son to receive treatment to this point, although she

clearly is desperate to Eind out what is 'wrong' with her son. It is possible that if Joy knew more

about how the system works, she may well have been able to access services much earlier. For

example, she did not know that Tyree had an Individualized Education Plan (IEP) or what that

meant. No one had explained the special education process to her in a way that she understood it,

even though she most probably received a handbook of parent' s rights when he was initially

identified. Further, had she been more able to explain to the staff at the Health Department what

sort of evaluation he needed, or was able to pay for a private evaluation, things might have been

very different.

Building the Team

Once Joy was befriended by her son's school counselor, her situation began to change. The

school counselor in this situation acted as one might hope a school counselor would act. She first

listened to Joy's story carefully, asked questions to clarify her understanding, and then offered

appropriate referrals to community agencies. She gave Joy telephone numbers and contact names









American student achievement overall is to better connect with caregivers, which this study

clearly highlights as being problematic, at least in these particular cases. As Bemak and Chung

(2005, p. 197) make clear, the school counselor's role now entails a duty to, "pay close attention

to social, political, and economic realities of families, with an aim to simultaneously address

these as critical elements within the school counselor' s role. For school counselors to ignore the

impact of inherent power structures that contribute to the achievement gap is to participate in the

insidious cycle of low performance and failure for poor students and students of color". One

critical step towards closing the achievement gap for low-income African-American students is

to create better working alliances with their families; a need which this research clearly shows

was not being adequately addressed.

Collaborative Relationships with African-American and Low-Income Families

Effective communication between families and schools is not a one-size fits all structure.

Schools must consider the racial, ethnic, economic, and cultural backgrounds of the families they

serve in order to create appropriate programs of communication (Applebaum, 2002; Comer,

1989). To effectively reach low-income African-American families, school counselors should

draw from existing literature to better inform their practices of engaging these families.

School counselors can begin to shift the family-school communications paradigm in the

schools they serve from one of remediation to one of collaboration by instituting the following

changes:

* Acknowledge and build on the wisdom already present in the family.

* Treat the caregivers as equals, not subordinates.

* Avoid blaming the caregiver for the students' difficulties.

* Establish consistent, two-way communication that is not problem-based (Amatea, 2007).










negative behaviors in detail, but offered no solutions. George was subsequently suspended from

school for 10 days, causing his mother to miss work for several days, and pay a sitter on other

days.

Problem Solving is the Parents' Job

Anna recalled, "It was true, the things they had been saying, but I felt like, it was caving in

on us because there was the counselor, the teacher, the principal, and myself and everybody was

sitting there telling me what my son does". She did not deny the facts of the school staff' s

accusations, but stated that she felt that they expected her to make her son behave on her own,

and that they were not taking equal responsibility for the problems. Anna reported the school

staff kept 'drilling' her son for answers as to why he had done the things he did. She felt this was

unfair because she says children aren't always aware of why they do things. She felt the school

staff expected her to correct the problems at home without help from them. She also said she felt

they were blaming her for her son' s problems and not being supportive of him.

She felt her son was being blamed for not only his share of the problems, but also for

problems that may have arisen from classroom management issues. She felt that the school staff

was not attempting to help her find solutions to the problems George was having, but were

instead blaming her for the problems. She perceived the message to be, "Your child is bad and

out of control. We've done all we're going to do. What are you going to do now?" The school

staff members were very capable of telling her the details of the problems her son was having,

but appeared unable or unwilling to help her find solutions to resolve the problems.

By the time of the second meeting, a few weeks after the first, Anna had already thought

about taking her son to counseling. She had a friend who had been through a similar experience

with her son and counseling had been helpful. She told the school counselor she had been

thinking of taking George to counseling, and the counselor gave her a name and number to call.









access services. Joy's story of help seeking was extremely similar to those of the Latina mothers.

One possible explanation for the difference is that older, more experienced participants fared

better than younger, less experienced caregivers, so that maturity and life experience may make

Ending appropriate care easier.

Caregivers in this study struggled with concerns about the consequences both of not

Ending mental health care for their sons as well as concerns about the effects of going for

treatment. Several participants also expressed concerns about lack of treatment resulting in a

downward spiral for the boys, ending in prison and/or substance abuse. Other worried that their

sons would be teased by their peers for going to counseling or for taking medication. These

concerns are echoed in the professional literature (Black & Krishnakumar, 1998; Brunious, 2001;

Winters, 1993).

The professional literature reflects the multiple barriers facing low-income families

seeking mental health care for their children, many of which were reported by caregivers in this

study. According to the Children' s Defense Fund (retrieved 09/01/2007) maj or barriers to mental

health care for low-income families include:

* Lack of agreement among health care providers about when and how to screen children

* Lack of coordination between multiple service providers and funding sources,

* Lack of accessible resources.

* Too few qualified service providers and inadequate reimbursement for services.

Additionally, low-income families face increased stress levels, often have fewer coping

strategies and social supports, and may have difficulty getting to service centers even when they

exist (Black & Krishnakumar, 1998; Colpe, 2006; French & Reardon, 2003). Joy mentioned

encountering the first three items in the list of barriers in seeking care for her son. All of the










(U. S. Department of Justice, 2006). The maj ority (52%) of all African-American males who

leave school without a high school diploma have prison records before their thirtieth birthdays

(Day-Vines & Day-Hairston, 2005). The caregivers' hopes for their sons to attend college are

common among parents of all races in the United States, but the chances for African-American

males to enter a four-year college are far less likely than for any other race or gender

combination (Noguera, 2003).

The caregivers' perspectives on the ways in which the school staffs chose to intervene with

them and their sons also echoes the professional literature. Caregivers felt that their son's

teachers did not have enough patience, compassion, or training to appropriately help their sons.

This may have resulted from interacting with less well prepared teachers. Day-Vines and Day-

Hairston (2005) document the trend of staffing schools in high poverty areas with teachers who

are not as well prepared to work with high needs students than their peers in more affluent

schools.

Another common conj ecture as to why African-American males do not perform well in

school seemed to be only partially true in this study sample. The caregivers in this sample were

stressed by the demands of raising multiple children (and sometimes grandchildren, nieces, or

nephews), working long hours at one or more jobs, and stretching slim Einancial resources to

cover expenses. Some researchers have postulated that these multiple demands, combined with

single and/or teenage parenting, can lead to a deficit in family support for academic achievement

(White, 1982). However, in this study, the parents were all engaged extensively with the schools

their sons attended and reported making time regularly to check homework. The caregivers also

talked about having high levels of stress, and the difficulties they faced in finding help and

support. In spite of those difficulties, in this group of caregivers, their own perceptions of their









from first through eighth grade with children who lived at the local children's home. These

children had often been placed at the home due to abusive conditions at home, and many of them

experienced difficulties at school. I heard from them about their awful experiences, and I believe

that learning about the harshness of some of my friends' and classmates' lives so early in my

own life helped me to develop empathy.

As a member of the White, middle class, native born, educated, American cultural group,

my personal beliefs about seeking mental health care reflect those of other members of my

demographic group. I generally trust professionals to be helpful and honest, and I believe that

some one who is educated in a particular field is better at helping me with a problem in that area

than some one who is not. For example, if I felt anxious or depressed, I would think of

consulting a therapist before talking to my aunts or my neighbors about my feelings. Doing this

work has helped me understand how much my cultural context influences these feelings and

beliefs.

I worked as an elementary school counselor for nine years, eight of which were spent in a

semi-rural high poverty school. The school had around seven to nine hundred students, about

80% of whom qualified for free or reduced lunch, 70% were African-American, and a significant

number were new immigrants from Central America or Mexico. While at that school, I met

many families whose plight is very similar to those interviewed in this study. As a school

counselor, I was often puzzled and frustrated by families who did not follow through on referrals

from me, other educators, and medical professionals. The child clearly had problems and we told

the parents where to go for help. Why did they not follow through? I helped parents to arrange

transportation and child care, to apply for the state health insurance, and even made the

appointment for counseling with them. Why the lack of follow through? I did not think then, nor









The Fight to Keep Her Son Enrolled

The day of Teacie's first interview, she had just withdrawn Patrick from his first

elementary school. She was extremely frustrated with how she and her son had been treated at

that school, especially by the principal. She was planning to enroll him in another school the next

day and was hoping to be treated better there. For Teacie, withdrawing Patrick was an act of

anger and outrage. Until this point, she had been desperately trying to avoid Patrick being

"kicked out" of this school.

These feelings of desperation began early in Patrick' s kindergarten year (the current school

year). Teacie estimates that she had to go to school "ten or fifteen times in six weeks" due to his

disruptive behavior. During this time, she reports feeling pressured by the school staff,

particularly the principal, to take Patrick to a psychiatrist and have him placed on medication.

She allowed Patrick to take medication for a while even though she disagreed with the idea

because, "He's a doctor and I'm just a mom." She also felt that if she refused Patrick would be

expelled. Teacie remembers thinking, "I did not want him to get kicked out of school and that' s

what was happening. I was willing to try whatever" to avoid expulsion. Teacie was desperate to

keep Patrick in school, and was willing to comply with any suggestions from the faculty in order

to accomplish that goal.

Anger and Stigma

When the school principal said, "Don't you think you need some counseling?" Teacie's

first reactions were shock and anger. She recalls thinking of saying "some bad words" in

response, but her desperation to keep Patrick in the school overrode her initial anger. She agreed

to go to counseling.

In spite of her agreement to attend counseling, Teacie remained concerned that the school

staff thought her son was "crazy". Even though she acknowledges, "that' s not how he (the










appropriate for their sons. If the schools had been operating from a collaborative model,

caregivers might have felt empowered to voice their concerns about these interventions.

Creating collaborative communication with low-income and African-American families

is not a one-time exercise (Comer, 1989; Winters 1993). School counselors need to spend time

intentionally creating and fostering relationships over a long period of time in order to make a

real impact on the alienation and disenfranchisement felt by many parents in that population. In

addition to the suggestions from Amatea (2007) about building collaborative communications

with parents, Lott (2001, p. 255) suggests the following steps to reach low-income families:

* School personnel must take the initiative in creating relationships with parents. Educators
should not expect parents to come to them, but should intentionally find ways to reach out to
families.

* Find ways to involve low-income parents other than as "consent-giver". Invite parents to
participate as collaborators, innovators, and critics.

* Encourage informal communication with families.

* Coordinate services with community agencies so that schools can be seen as community
centers, or hubs of information and services.

* Provide training for all school personnel on reaching and collaborating with diverse
families.

As educational leaders, school counselors should be at the forefront of implementing

such changes in how schools interact with low-income and minority families. School counselors

have specialized training in interpersonal communication and in systems change issues, therefore

making them the ideal agents of change in family-school communications (Erford, 2003).

Making Culturally Responsive Referrals

School counselors making referrals for low-income African-American families,

particularly to mental health services need to be aware of cultural stigmas and fears, as well as

practical concerns, facing these parents. Caregivers in this study were generally not opposed to









Fernandez, Marisela, & Ruiz, 2004; Ghose, 2006; Logan, 2001; Madsen, 1999) and will be

examined further in the remainder of this study.










counselor in mentioning mental health help contributed to Anna' s feelings of isolation and

frustration with the process.

After the meeting when she asked about counseling, Anna also began coming to school to

observe in George's classroom. She also began a more structured approach to rewarding or

punishing him based on his daily behavior report from school. Which, if any, of these actions

changed the way the school staff reacted to her is not known. However, Anna felt that the school

staff became more receptive and friendly towards her after they saw that she was a "concerned

parent". Once she demonstrated her resolve to "keep him in that school", the school staff seemed

more supportive and helpful- to a point.

School Makes the Rules, Parents Must Follow

Even after George's behavior began to improve, Anna reports that she had to call the

teacher to get information about his behavior, and that no one called to let her know if the

strategies they were trying were working. She felt that someone "should have called" but did not.

Anna' s determination to play along with the school rules, even when staff members refused to

listen to her point of view was crucial in keeping her son at that school. She believed strongly

that if she had not toed the line, he would have been expelled from the magnet program. Again,

Anna felt that the school had an us-versus-them mentality when dealing with her. The staff' s

inability or unwillingness to support her efforts to help her son was extremely frustrating and

difficult for her.

Textural Description: Teacie

Teacie is the single parent of five children, four girls and one boy, Patrick. Patrick has two

older and two younger sisters. His father is incarcerated. Teacie was working part time for a

private elder care agency, but quit when Patrick's problems at school began to demand much of

her time. Teacie describes Patrick as funny, friendly, and smart.









versus school personnel. By framing the imbalance of power as a culturally driven disconnection

in mental models, school counselors can lay the groundwork for less blaming and divisive

discussions of these issues.

In this study, caregivers were unable to differentiate between various roles of school staff

members. They understood the role of the classroom teacher, but many of them did not

understand the role of the school counselor versus that of assistant principal or principal. To

these caregivers, the school personnel were a homogenous seeming group, not distinct

individuals. This perception underscores the importance of all school personnel being trained to

work in a collaborative manner with diverse families.

Limitations of the Study

Qualitative research of this variety is limited in its generalizabilty, which is not the goal,

but which may be desired by some readers. This study aimed to describe the lived experiences of

a certain group of people within a specific time, place, and context. Descriptions are rich and

thick, full of possible essences and meanings. However, what was essential about an experience

in 2006 in the southern United States may or may not be essential about the same experience in a

different place and time, or for a different group of people (Wolcott, 1990).

My race (white) may or may not have limited disclosure by participants. Special care was

taken to develop rapport with participants, however, due to a long history of oppression and

mistreatment of African-Americans by Whites, participants may have remained reluctant to fully

disclose thoughts and feelings. There is also a possibility I did not understand subtle language

and posture clues due to difference in culture.

According to Gibson and Abrams (2003), White qualitative researchers interviewing

African-American people are likely to have difficulty getting access to participants and building

trust. However, Gibson and Abrams (2003) also found that African-American participants take









Instead, African-Americans (and perhaps other minorities) developed both dominant and non-

dominant cultural capital (Carter, 2003). That is to say, African-American people develop and

maintain their ability to employ differential standards of dress, speech, and behavior in order to

function differently in various cultural contexts.

In a recent qualitative study of forty four African-American adolescents, Carter (2003)

learned that all of the study participants used both non-dominant ("African-American"') cultural

capital and dominant ("white") cultural capital in their daily lives. In most cases, the students

used dominant social capital for instrumental purposes (to please teachers or to make good

grades) and non-dominant social capital to express themselves and gain acceptance from other

African-American youth as "authentic" members of the African-American community.

Balancing both sets of cultural capital successfully, although difficult, seemed to allow

participants to be successful both in the "white world" and in their racially-identified

communities. Continually reading social signals filtered through two very different lenses and

deciding which set of social skills to apply was reported to be a source of stress by the

adolescents in Carter's study.

African-American males in academic settings often experienced the cultural disconnect

between themselves and their teachers as a lack of respect (Ladson-Billings, West-Olatunji,

Baker & Brooks, 2007). Some researchers asserted that African-American males greatly value

being respected, and when they feel they are not respected at school, this feeling can lead to

disruptive behavior, disengagement, and academic failure (Noguera, 2003). It seems possible

that in attempting to view the world through multiple and conflicting lenses, African-American

males may experience great distress and dissonance.









During that same meeting, Anna told the teacher about strategies that George's previous

teachers had used effectively to help him. Even though Anna tried to demonstrate her concern

about her son' s behavior, she said still felt that the school left all of the solutions in her hands,

without offering much help or support. Anna strongly felt that the teacher's ineffective

management skills were a part of George' s problems, but did not feel that the teacher, or any

other school staff members, was willing to attempt to improve the classroom structure to help

him. She said that the teacher dealt with children's behavioral problems by, "cutting them off

because it was nothing else she could do...she just didn't have any tolerance for them" instead of

trying different strategies to help the child.

Mom Takes the Initiative

Anna was aware that there was in fact a problem with her son's behavior and realized she

would have to take some action to "straighten it out". She had a friend whose son had similar

problems and counseling had helped him. Anna said that although some parents may think that

counseling is, "brainwashing", she had no negative perceptions about counseling, possibly due to

the positive experiences her friend had.

She decided on her own, without guidance from the school, to seek counseling for George.

She did not want him to be expelled, and since it was obvious to her that the school had, "done

about all they were going to do" to work with George, she took the initiative to find outside help

for him. She recounts, "I sat down and really looked at the whole picture as far as him having a

behavior problem and I don't want him to be expelled from school...so I thought, what can I

do?"

She said she thought the school counselor was relieved when she said she wanted to take

George for counseling, "Since they were probably going to mention it anyway". When she told

the school counselor she wanted to go to counseling, she was given a contact number and name.











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principal) said it, that' s what I heard". She felt the school staff was judging her and her son and

implying that he was "crazy and needed some help".

Teacie attributes her angry reaction to the suggestion of counseling to the fact that she had

a negative experience with counseling when she was a child. Teacie had a troubled childhood

(she did not remember much of it) and went to counseling at the same facility Patrick was being

referred. Although she did not remember what happened in the actual counseling sessions, she

does remember being teased by children at her school about being in "the psych ward". The

teasing got so severe that she, "moved back to Miami, and that was why".

These childhood experiences are what she believes caused her to be so angry when the

principal asked her about counseling. When she reflects on that conversation, Teacie says, "I

immediately went into defensive mode when I should have remained calm and heard (the

principal) out, but I didn't want to hear it because the truth was hurting".

Worries for the Future

Teacie feels a great deal of pressure to keep Patrick on the straight and narrow path. She

explains, "I don't want to ruin his life. I don't want him to ruin his life and I don't want no one

else to. I don't want him to be one of those boys on the corner...I want to have him running up

and down the field, that loves football like he does already and (is) productive...not that cycle

that' s already on both sides of his family. I want to stop that." The cycle Teacie is referring to is

one of incarceration. Both Patrick' s father and several uncles have been in and out of prison.

Teacie is very worried that her only son will follow in their footsteps.

She sees the troubles Patrick is having at school as an indication that he may be heading

down this path. She said, "By him getting kicked out of school today I felt as if the only thing

they wanted me to do...was go to some dope dealer and buy him a package of rocks and a pistol

and let him hang with his pants down below his ass and let him stand on the corner". She said










* The mismatch between client's immediate needs and therapists' goals.

* The idea that clients are often so overwhelmed by multiple problems that interventions
suggested by clinicians may seem insignificant.

* A lack of understanding by middle class therapists of the inherent privileges and insulation
they possess, which Smith calls classistt distancing".

* The cultural stigmatization of mental health services.

These issues, combined with possible financial and transportation problems emphasize the

need for careful listening on the part of mental health and school counselors when working with

low income families.

Arcia and her colleagues (2004) found that low income Hispanic mothers often delayed

seeking treatment for their children's behavioral problems until the problems escalated to a point

where the stress was untenable. These mothers reported they lacked knowledge about services

available in their area, pointing out the need for school counselors to be more concrete and

thorough in sharing information about health care options, at least for Hispanic parents. Arcia

and colleagues (2004) described the help seeking of the group of parents they studied as being

similar to pinballs in a game, where they appeared to bounce around from agency to agency

seeking help for their children, without seeming to have a plan or method for obtaining help. All

of these issues may be compounded for low-income African-American families, who often have

negative perceptions of formal helping networks in general (Logan, 2001).

African-American Families

According to the United States Census Bureau (2004), 12.7% of the total population of the

country lived in poverty. However, 24.7% of African-Americans versus only 8.6% of whites

lived in poverty. The highest percentage of poor people (14. 1%) lived in the southern part of the

country as compared to 1 1.6% in the north and Midwest. The number of African-American










journals in the past 10 years have been devoted to issues of multiculturalism, diversity, and race.

However, there have been no special issues devoted to oppression and poverty issues as they

relate to counseling.

Even the "Dimensions of Personal Identity Model", which describes multiple internal and

external factors shaping a person's identity, does not explicitly include social class, although it

does include level of education, work experience, and historical context (Arredondo, Rosen,

Rice, Perez, & Tovar-Gamero, 2005). Arredondo, Rosen, Rice, Perez, & Tovar-Gamero, (2005)

state in the conclusion of their analysis of the Journal of Counseling and' Development from

1995-2005 that: "No longer can multiculturalism be relegated to one course, mentioned as a

passing comment in a publication or presentation, or avoided by educators and administrators..."

(p. 160). This powerful statement would be strengthened by the explicit inclusion of

socioeconomic class. A review of the contents of the Professional School Counseling from 1997

to present revealed similar ratios. However, the j journal's recent special issue entitled,

"Professional School Counseling in Urban Settings" (2005) does include articles on poverty-

related issues.

In Liu and colleagues (2004) review of three j ournals, The Journal of Counseling

Psychology, The Journal of Counseling and Development, and The Journal of2~ulticultural

Counseling and Development from 1981-2000, discovered that social class was only made a key

variable in 1.4% of all empirical research articles, even though social class data was collected on

participants in 17.5% of studies. Social class was referred to more often in theoretical/conceptual

articles, and was at least mentioned as a variable in 33.5% of them. In total, between 20 and 30%

of all 3915 articles reviewed mentioned social class in some form. However, only a very small

percentage made social class a focus of the research. These findings highlight the need for far




































O 2007 Catherine Tucker










In Liu' s (2001) social class worldview model, social class was divided into three

components. First, people tend to live up to expectations placed on them by their local

environment in order to maintain homeostasis both cognitively and emotionally. Failure to meet

the expectations of the other members of a persons' social class causes a form of cognitive

dissonance, which Liu refers to as "internalized classism." Liu further divides the economic

culture' s demands into three types of cultural capital: social (networks of contacts), cultural

(tastes and preferences), and human capital (abilities and skills).

The second component of Liu' s social class worldview model is the "intrapsychic

framework." A person uses his or her intrapsychic framework as a lens through which he or she

examines and makes sense of the economic and social cues and demands of class. The lens is

used to filter information about the social and economic environment, and respond appropriately

within it. Manners, economic choices, relationships to property, and choice of peers are all

filtered through the lens of the intrapsychic framework.

The third component of Liu' s social class worldview model is classism. In this sense,

classism is a social psychological construct whose purpose is to encourage people to engage in

behaviors congruent with his or her perceived social class. Classism can be upward (e.g. feelings

against those one considers to be 'snobs') downward (e.g. feelings against those one sees as

'trashy' or 'common') or lateral (e.g. keeping up with the neighbors). Classism can be

experienced as external pressure, (e.g. peer pressure to engage in class-appropriate behaviors), or

as internal pressure (e.g. pressure within the individual to behave consistently with group norms).

How internal models of class and feelings of classism affect people seeking mental health

care has not yet been explored in the professional literature. However, the social class worldview

model was chosen as the conceptual framework for this study, since current research










get help for her son, while not getting any help for herself. Both Joy and Teacie reported feeling

intense internal pressure to see their sons "go to college and not prison" (Joy) and to "end the

family cycle" of going to prison (Teacie). The referral to the mental health center was especially

stressful for Teacie, who had negative memories of going to the same center when she was a

child. Joy, however, saw the referral as the key to Einding out "what is wrong with" Tyree,

something she had been searching for many years.

The other participants also felt isolated and blamed by the schools, but seemed more able

than the younger single mothers to access other forms of support. Anna found church and

community members to help George, Sherry relied on her adult children, and Felicia and James

have each other to lean on for support. However, these participants were also distressed by the

process of finding out their son had a problem and being referred for treatment. All four of these

participants also mentioned increased strain at work due to frequent trips to school. Joy does not

work, and Teacie left her j ob due to pressures from her boss to resolve her "son problems". All

participants felt at least some sense of isolation and lack of support from the schools.

The lack of support for families manifested a different way for Joy, who has spent hours

seeking help for her son, Tyree. She reports that she has repeatedly told Tyree's teachers that she

thinks "there's something wrong with him" but got no help. This began to shift when Tyree got

in a Eight at school and was going to be suspended for ten days. When Joy got to school to pick

him up, she met the school counselor. Following their conversation, Tyree was not suspended,

and for the first time was given the name and phone number for a mental health center that takes

Medicaid. Sadly, out of all of the participants in this study, only Joy felt helped and supported by

the school staff.









the idea of getting some kind of mental health services for their sons, although some of them had

serious concerns about the safety of medications. In fact, some of the caregivers were desperate

for answers about their sons' behavioral problems. However, some parents did have memories of

negative personal experiences with being teased for attending counseling when they were

children which were not addressed by the school counselor during the referral process. Others

had concerns about paying for services, finding time to go to appointments, and other practical

concerns. To increase the likelihood that the referral is appropriate for the caregivers' view of the

problem, school counselors should explore existing concerns with caregivers prior to making

referrals in order

The most consistent complaint about the referral process from caregivers in this study

was the manner in which the referral was made. In the maj ority of cases, the caregivers felt either

that they were forced to get services in order to avoid punishment (suspensions, expulsion, or

transfer to alternative schools) or were expected to go along with suggestions in order to "not

make waves" (Erford, 2003). Even the caregivers who wanted help for their sons were put off by

the way the school counselor approached the issue of mental health services. Only one caregiver

reported a positive experience with the process. Much of the negativity of these interactions was

predicated on the poor quality of existing relationships between school staff and parents.

Carefully creating warm, egalitarian relationships with caregivers prior to the development of a

problem can go a long way to preventing negative outcomes. School counselors need to learn

these skills in their graduate programs. Specific training regarding structural constraints of

poverty and racial discrimination has been shown to increase counselor trainees' sensitivity to

race and class based oppression (Toporek & Pope-Davis, 2005) and should be included in

master' s level multicultural counseling coursework. Ideally, the thread of multicultural training,









do I now, that the parents who did not follow up on mental health referrals were being malicious.

However, I was unsure as to why some families did make it to the clinic, and others did not.

Participants

The study participants were six individuals representing five low income African-

American families from elementary schools in a community in north central Florida. Four of the

participants were single parents, and two were an unmarried partners who were co-parenting

their children from previous relationships. Five participants were women. One was a

grandmother, one was an adoptive mother, the male participant was a stepfather, and the other

three were biological mothers. All participants had legal and physical custody of the children in

question, with the exception of the 'step father' who was co-parenting with the child' s mother,

and did not have any legal rights to the child, but was interviewed in the company of the mother.

The sons who were the focus of the interviews attended four different elementary schools in the

local public school system. One child changed schools between the first and second interviews

with his mother. All of the children attended majority African-American schools; although

recruitment was open to all elementary schools in the local public school district.

Families were recruited after they experienced their first referral for mental health

services for their sons by their school counselors. School counselors asked families if they were

interested in participating in the study after they referred the family to treatment, regardless of

the families' plans to attend or not attend mental health services. If the family agreed to

participate, the school counselor secured appropriate informed consent documents and relayed

contact information to the researcher.

To participate in the study, caregivers had to meet the following requirements:

*Child eligible for free or reduced lunch at school, meaning that the family was living at or
below the federal poverty line.










caregivers in the study mentioned increased stress levels when trying to find appropriate care for

their sons.

A final, but often compelling, barrier to services for low-income families is the fear of

losing custody of their children (GAO, 2003). Families with children who have severe mental

illness sometimes relinquish custody to the state because they can not afford the high costs of

inpatient or group home treatment. One estimate suggests that parents of up to 20% of children

with severe and persistent mental illness had to relinquish custody to child welfare agencies in

order to have their children qualify for needed services (Children's Defense Fund, 2005). None

of the caregivers in this study faced the possibility of losing custody of their sons in order to

qualify them to receive services. However, if any of the boys were to develop severe and

persistent mental illness, the families interviewed here could very quickly run through all

available financial resources, and be forced to choose between retaining custody and obtaining

treatment for their sons.

African-American Males and Schools

The African-American boys discussed in this study faced many of the barriers to academic

success commonly written about in the professional literature. Two of the five boys were in

special education programs due to developmental delays, while all five had suffered negative

academic consequences as a result of behavioral problems. All of the boys had been repeatedly

suspended from school, often for what their caregivers saw as minor infractions of school rules,

which parallels national trends in the over-representation of African-American male students

among the total numbers of suspended and expelled students (National Center for Educational

Statistics, 2001).

The caregivers' concerns for the futures of their sons are supported by educational

research. African-American males comprise a maj ority of the United States prison population









The frequent phone calls from the first school about Patrick' s behavior problems along

with the lack of family support have been very frustrating and discouraging for Teacie. Her

coping skills seem to be pushed to their limits. As she put it, "Mama is tired".

Textural Description: Joy

Joy is the single mother of three children, two boys and one girl. Tyree is the youngest. He

is in the third grade and is nine years old. Both of Tyree' s siblings also attend his school. Joy is

unemployed. Joy describes Tyree as thoughtful and loving.

The Search for Answers

Joy's search for help for her son began well before he ever entered a public school.

Although her story did not begin with a referral from a school counselor, it did end with one, and

the journey to that point is poignant and telling. This first section of description gives the reader

some further background and insight into Joy's situation leading up to the referral from the

school counselor. Joy recounted seeing her son, Tyree; experience long, loud, and frequent

tantrums beginning around age two or three. She recalled thinking, "there's something wrong

with him, he' s not just angry". Around that time Tyree also experienced seizures, but the doctors

did not recommend any treatment for him.

Joy was very concerned about her son's behavior, and called the Health Department for

help. This was her first step on the long journey to getting help for Tyree. The person she talked

to at the county Health Department told her, "he' s just angry, spend more time with him". When

Joy countered, "He's only 5, what can he be so angry about?" She was told there was nothing the

Health Department could do for her.

During the period when Tyree was between 3 and 5, his behavior grew steadily worse. He

was aggressive with his older siblings, told his mother he heard voices, ran away from home

several times, and grew paranoid, "Everybody's out to get me'". Joy could not Eind sitters or










2004). The impact of poverty on the emotional well-being and educational outcomes of African-

American children is staggering. According to Chow, Jaffee, & Snowden (2003), African-

American children living in high poverty neighborhoods were significantly more likely than their

middle-class peers, or than white, Hispanic, or Asian children in poverty, to be referred for early

mental health intervention services. Low income African-American children were found to be

over represented in special educational categories for children with severe emotional disturbance

(Colpe, 2000).

Poor African-Americans were more likely to be hospitalized for mental health problems

and to be diagnosed as schizophrenic. African-Americans in general are less likely than whites to

receive mental health counseling and more likely to receive pharmacotherapy at mental health

clinics (Richardson, Anderson, Flaherty, & Bell, 2003). African-Americans are also more likely

to be referred coercively to services, meaning there are negative consequences resulting from

non-attendance than are white or Hispanic children, such as; removal from home, entry into

group homes, Juvenile Justice or other punitive settings (Stevens, Harman, & Kelleher, 2005;

Takeuchi, Bui, & Kim, 1993).

African-Americans in counseling are sometimes perceived by White therapists as guarded,

reluctant, or hostile due to differences in language and social norms (Logan, 2001). Negative

perceptions may go a long way in explaining both why African-Americans frequently leave

counseling early and are less likely to attend in the first place. As a result of generations of

powerlessness and rebuke, many African-Americans feel more comfortable seeking help from

informal networks than from formal institutions, in spite of recent changes towards a more

enlightened and multicultural society (Logan, 2001). Additionally, some African-American

families, particularly those living in poverty, often have negative perceptions of mental health









over the number reported in 2000 (Children's Defense Fund, 2005). Of course, financial need is

one of many defining characteristics of poverty.

Poverty is detrimental to the mental health of children. Research reveals that children

who live at or below the federal poverty line are significantly more likely to report increased

levels of anxiety, depression, and antisocial behaviors (Samaan, RA, 2000; Caughy, O'Campo,

& Muntaner, 2003; African-American & Krishnakumar, 1998; Myers & Gil, 2004).

Additionally, children in low-income families tend to exhibit a greater incidence of behavioral

difficulties and a lower level of positive engagement in school (National Survey of America' s

Families, 1999). The negative effects of poverty seem to hold even when racial and ethnic

variables are controlled; poverty appears to be a more critical factor in the development of

negative outcomes in children than is race and ethnicity (Samaan, RA, 2000; Chow, Jaffee, &

Snowden, 2003; Takeuchi, Bui, & Kim, 1993).

Children living in poverty are also less likely to have access to health care services,

including mental health care, than are their peers from higher socio-economic levels (Boothroyd

& Armstrong, 2005; Busch & Horowitz, 2004; Colpe, 2000; Howell, 2004 Stevens, Harmon, &

Kelleher, 2005). Moreover, poverty limits children's accumulation of social capital, that broad

group of intangibles such as family support, educational opportunities, and enrichment activities,

which is reported to impact school achievement (Caughy, O'Campo, & Muntaner, 2003;

Christenson & Sheridan, 1997).

Parity Issues in Children's Mental Health Service

Health care in the United States is in a state of turmoil as state and federal agencies

struggle with providing care to the swelling rolls of indigent patients. According to the US

Census Bureau, as of August 2004 (www. census.gov/Press-Release), 1 1.4%, or 8.4 million, of

all children in the US were uninsured. Foreign born Hispanic children had the highest proportion










teacher did not like Jaquan, had no patience with him, and made discipline referrals for minor

rule infractions.

Their perception of a lack of compassion also extended to their dealings with other school

staff members. They did not feel that anyone on the faculty was interested in j oining with them

to help Jaquan succeed. Rather, they were treated with professional detachment and a lack of

warmth. Felicia and James felt the school staff "took us seriously" and were respectful, but did

not make allowances for their work schedules or for providing any new ideas for helping Jaquan.

Their approach was very business like and rigid. This was frustrating to both caregivers, who

perceived the school staff as unfriendly and only interested in "forcing him out" and not helping

Jaquan.

Failure to Communicate

The lack of communication Felicia and James discussed was two fold. First, the school

staff only provided one-way communication, following the separation paradigm of parent

involvement in schools (Amatea, 2007). The school staff members were quick to call Felicia or

James if Jaquan was having a problem, but never reported any progress he was making. They

also expected Felicia and James to agree with any and all requests from the school.

Secondly, the school staff members did not adequately explain to Felicia and James what

resources might be available to help Jaquan. Although the school counselor did give them

information for making an ADHD evaluation appointment, she did not provide any information

on educational resources, such as Section 504, special education, or other locally available

services. This reflects the school centered mindset discussed in other participants' interviews.

All in all, the dearth of two- way communication between the school staff and the

caregivers was not only frustrating to Felicia and James; they also felt that it impeded their

ability to help Jaquan. Not having open communication and sharing of ideas, "bites everybody"









discounting of her input set Darrien up to fail during his first days of kindergarten. Their

disregard for her concerns also frustrated Sherry and made her feel unsupported.

Structural Description: Sherry

School Centered Solutions

One of the most frustrating aspects of the entire situation with Darrien was, for Sherry, the

fact that the school staff members initially created an intervention plan without any input from

her. Worse, the plan was a serious infringement on Sherry's ability to do her j ob, and did not

seem to make any changes in Darrien's behavior.

Sherry readily acknowledged that Darrien' s behavior was unacceptable and stated she was

willing to work with the teacher to help him. However, before she had a chance to make any

suggestions, a plan was decided on and she was told how the situation was going to be handled.

Her exclusion from the decision making process made Sherry feel unwelcome and angry. The

imposition on her of an amended schedule for Darrien was highly inconvenient and left her

feeling "depressed".

No Support for Caregivers

Sherry's interactions with the school in years past had always been very positive. She had

always volunteered to help in her children's classrooms and was hoping to do so again for

Darrien. However, when his first year of kindergarten started with numerous suspensions and

calls about behavior problems, she found that the friendly atmosphere at the school changed, and

that she suddenly felt like an unwelcome interloper.

Instead of treating Sherry like a valued part of a problem solving team, the school staff

treated her as if she was causing Darrien's problems, or was holding back the key to solving

them. As she said, "I felt like they were out to get me".










Therefore, when the school counselors made referrals to mental health, some of the

caregivers were skeptical of its usefulness. Some only complied with the referral out of

desperation to avoid having their sons expelled. "Anything to keep him in school" was a

common reply. None of the caregivers initially saw the school as a place of refuge or help for

their son' s problems. Only one came to see the school as a place of hope and help after

interaction with the school staff (and in particular, the counselor).

Most of the participants viewed themselves as involved parents and were shocked by the

lack of compassion they received from the school staff during the meetings about their son's

misbehavior. Several caregivers reported having been active volunteers at the school prior to the

behavior problems developing and were dismayed by what was described as the attacking

posture of the staff during meetings. This lack of respect for the caregiver' s input lead to further

feelings of alienation and divisiveness. Some participants were able to "prove we were

concerned" after several meetings, and after complying with staff suggestions. However, they

still felt that the school staff saw their sons as "bad and out of control" and felt the school staff

"just want him out...don't want to work with him". All but one of the caregivers retained

feelings of being disrespected and isolated throughout the process. They reported feeling

frustrated and exhausted by the end of the interviews. This deep sense of isolation and

disenfranchisement did nothing to help caregivers, boys, or schools. In fact, one speculation that

could be made here is that the caregivers' sense of isolation from school staff during their child's

elementary school years may be a factor contributing to low parent involvement at the secondary

education level.

Fear and Guilt

One of the most prominent emotional states in the caregiver' s accounts of the referral

process was fear. The caregivers expressed fear that their sons would be suspended or expelled









in that situation may illuminate the phenomenon in new and novel ways, such that understanding

is widened and enhanced across other settings.

As described by Moustakas (1994, p. 181), a synthesis is achieved by: "Intuitively-

reflectively integrate(ing) the composite textural and composite structural descriptions to develop

a synthesis of the meanings and essences of the phenomenon or experience." This is the final

step in Moustakas' (1994) transcendental method and is roughly equivalent to the production of

an essence statement in other types of phenomenological analysis (McLeod, 2001). The essence

statement is normally a few sentences describing the universal commonalities that make an

experience what it is (Wertz, 2005). This is the culmination of the phenomenological reduction,

but is not necessarily the only useful product resulting from it. Textural and structural

descriptions may also be of use in constructing implications from the data.

Validity and Trustworthiness, Reliability and Consistency

Applying the concepts of validity and reliability to qualitative research is a contested

practice among qualitative researchers (Merriam, 1995; Wolcott, 1990). Some researchers follow

the quantitative model for establishing validity and reliability while others may eschew these

concepts altogether (Wolcott, 1990). In this particular study, the classic quantitative concepts of

validity and reliability are not used, but are also not rej ected out of hand. Instead, the concepts of

trustworthiness and consistency are employed. These concepts are widely, although not

uniformly, used in qualitative research.

The first of the two pillars of research evaluation in the quantitative model is validity. In

quantitative work, researchers use the term validity to discuss how accurately a study measured

what it intended to measure (Merriam, 1995). This concept is predicated on the positivist notion

that an external, relatively stable reality exists. However, when working from a

phenomenological vantage point, the concept of validity clearly becomes problematic.









Failure to Communicate with Parents

During the many visits they made to the school this past fall (which they estimated to

number around three or four per week), Felicia and James felt that even though they had a lot of

conversations with school staff members, the communication was largely one-way. The school

staff told Felicia and James their version of events and expected them to agree. They expressed

frustration at only being contacted when Jaquan was having a bad day, never when he was

improving.

Both of Jaquan' s caregivers were under what they called "tremendous stress" with their

small business and felt that the schools frequent phone calls and demands to come pick Jaquan

up early added to their frustration. Although they tried to give the teacher suggestions for dealing

with Jaquan more effectively, she was not open to their ideas. James perceived that the teacher

simply wanted, "Jaquan out of her class, period" and that she was unwilling to hear his

suggestions.

In spite of James and Felicia' s high level of concern and involvement, they both still felt as

if the school staff had a "biased view...they have one way of thinking about Jaquan...no matter

what we tell them." They felt that their repeated requests for accommodations fell on deaf ears

until the mental health counselor told Felicia that Jaquan would qualify for a 504 plan. Felicia

had never heard of Section 504. She and James were upset that no one at the school had ever

mentioned this as one way for Jaquan to get accommodations for the FCAT. James said, "We

don't have the information...or the knowledge of what' s available, and that bites everybody." He

went on to say that after they met with the teacher to request a 504, she agreed to write a plan for

Jaquan, but several weeks had gone by with no follow up. James was very frustrated at the lack

of communication from the school, and even more frustrated at their lack of willingness to listen

to him and Felicia. As he put it, "everything is about communication".









individual states may limit access to such services under the state-administered health care

program (CDF, 2005).

Alongside the tangle of state and federal regulations and difficulties in policy alignment,

families who live in poverty face more quotidian barriers to accessing care. Cultural-contextual

issues, such as a stigma against help-seeking, negative expectations, financial barriers, and a lack

of perceived need for services hamper some groups of families from receiving care, as found in

Bussing, Zima, Gary, & Garvan' s (2003) study of help-seeking behavior for families with

children diagnosed with ADHD. Lack of information about how to access services, what services

are available, and denial of the severity of a child' s need for help are also common among low-

income mothers (Arcia, Fernandez, Marisela, Castillo, & Ruiz, 2004). Families in rural areas

may have difficulty finding transportation to appointments (Meyers & Gill, 2004). Homeless

families often face the additional difficulty of not having an address or telephone number to

receive communications from heath care providers (French, Reardon, & Smith, 2003).

Additionally, many families are referred for mental health services by school personnel who may

not be aware of the difficulties facing low income families in following through on their

recommendations (Apter, 1992). As an additional hurdle to understanding low income families

experiences, social class is not a well defined construct in social science research (Liu, Ali,

Soleck, Hopps, Dunston & Pickett, 2004).

Perhaps the most insidious trend in families' reluctance to seek out mental health services

for their children is highlighted in a report from the U.S. General Accounting Office (2003). The

GAO report outlines the phenomenon of parents having to give up custody of their children to

the state in order to access mental health care for more serious, chronic problems. The GAO

estimated in that in 2001, more than 12,700 children were placed in the custody of state agencies









tolerance" for him and was not willing to work with her. She said she simply felt as is she were

"being attacked" by the school's staff.

Felicia and James had a similar feeling about Jaquan's teacher. They felt that her lack of

compassion for Jaquan led to him being sent to the office for "little stuff" they felt could have

been handled in the classroom. After several meetings with the school staff, Felicia and James

came to the conclusion that Jaquan needed "a better classroom" and not more effective

medication. Teacie felt that Patrick' s school was also blaming her for problems created or at least

fueled by their handling of his behavior. She reported that her requests for different management

strategies also went unfulfilled, while she was being pressured to medicate Patrick.

Lack of Compassion for Caregivers

All of the participants also reported feeling alone in their search for solutions, as well as

feeling blamed for their son's problems. As Sherry put it, "I thought they were out to get me. I

was trying to support them and I was like, where' s y'all support for me?" Participants relayed

feelings of disappointment in the level of practical and emotional support they received from

school staff members. Most of the participants (all except for Felicia and James) are parenting

the boys alone and reported feeling "tired" (Teacie), "depressed" (Sherry) and "stressed" (Anna)

when faced with the daunting task of finding mental health care for their sons. Anna was the only

participant who consciously built a social support network for herself and her son during these

trying times. She asked male friends from church and the community center to help her get and

keep George "on track" by checking in with him about his progress.

The younger single mothers in the group, Teacie and Joy, seemed to lack any support from

their own families and reported feeling especially let down by the initial response from the

schools regarding their sons. Joy was eventually able to find an ally at school, but Teacie was

still searching at the time of the last interview. She reported feeling "alone" and "pressured" to










problems, the school staff did not reciprocate her support. As she put it, "I was trying to support

them, and I was like, where y'all support for me?" Sherry felt that her years of volunteering and

helping teachers meant nothing in this new circumstance. She had to rely on friends and

neighbors to help get Darrien to school during the half day schedule, and felt that she was getting

no help at all from the school.

None of the staff members at the school offered her any emotional support while she was

trying to find help for Darrien. In fact, one teacher even remarked that if Sherry was so stressed,

maybe she should send Darrien back to live with his mother. Sherry found this remark to be

hurtful and insensitive.

The School Decides which Problems are Legitimate

When Sherry first enrolled Darrien in kindergarten, she asked the teachers about special

education services at the school. She felt there was a good chance that Darrien had a "mental

disability" similar to his mothers'. However, she was rebuffed and told that if there was a

problem, the teacher would find it later.

Instead of taking Sherry's concerns seriously, asking for family history or reasons for her

questions, the teacher simply assumed Sherry's point of view to be of no educational value.

Obviously, Sherry was right about Darrien' s disabilities. If the first teacher she approached had

welcomed Sherry's input, the school year might have started very differently for Darrien.

In Sherry's words, "things got a lot better when they realized Darrien had a real problem".

Once the school staff members were convinced, through academic performance measures,

psychological testing, and a diagnosis of ADHD that Darrien' s problems were "real" they were

much more flexible in working with Sherry. Certainly, the data gathered by the school

psychologist, teachers, and psychiatrist shed more light on the exact nature of Darrien' s

limitations. However, the staff members lack of response to Sherry's initial concerns and









interview. Allowing for a series of interviews rather than a single discussion with each

participant deepened understanding of participants' experiences. The first interview occurred as

soon as possible after the family was referred by the school counselor for treatment. The second

interview took place about three to four weeks after the first, and the third, three to four weeks

after the second, at the mutual convenience of both parties. Each interview took about an hour,

although the first interview was typically the longest. All interviews were digitally recorded.

Interviews followed a semi-structured format (Appendix A).

The purpose of the first interview was to develop rapport with the participant. It was

crucial to establish as much of a partnership of equals as possible during this phase so that the

participants felt comfortable in sharing personal information (Fontana, 2002). Establishing a

warm, respectful relationship was the primary underlying task of this interview. To create an "I-

Thou" relationship (Seidman, 1991) with the research participants, the researcher first

emphasized how important first hand experiences are to the research process. Participants were

asked to choose a name for the written report, which could be either their real name or a

pseudonym. All participants were told they will be acknowledged in any publications of this

research. The first interview also provided a time for the researcher to answer any questions he

or she may have about the study and gather background data. Finally, during the first meeting,

participants were asked to begin to tell the story of how he or she came to be referred to

counseling, with a focus on events in the past leading up to the present (Seidman, 1991).

The second interview took place a few weeks after the first to allow time to transcribe the

first interview. The focus for the second interview was to examine current events in the life of

the family surrounding their experiences with the mental health care system, if any (Seidman,

1991). This interview included topics such as; the child's current behavior, any change from the









ACKNOWLEDGMENTS

The completion of this work would not have been possible without the continuing support

of my parents, David Tucker and Mary Moseley Tucker. The beginning of it would not have

been possible without the inspiration, both in life and in afterlife, from Todd Owen Carter. I

consider the continuation of my work with children in poverty a small repayment of my eternal

debt to him.

Partial funding for this research was provided by a grant from the Chi Sigma lota

Counseling Academic and Professional Honor Society International.









are not well understood (Arcia, Fernandez, Marisela, Castillo, & Ruiz, 2004; Bussing, Zima,

Gary & Garvan, 2003; Earls, 2001; French, Reardon, & Smith, 2003; Renk, 2005).

Smith's (2005) argument that classistt distancing" (p. 693) hampers the effectiveness of

mental health services is echoed by Van Galen (2004) in her call for more voice to be given in

the professional literature to poor clients. She posits that middle-class researchers too often speak

for poor people, and although the intentions of the researchers may be noble, the poor are still

left voiceless.

More information about when, how, and why low-income parents seek help for their

children' s mental health problems is needed. A greater understanding of the process of help-

seeking from the parents' point of view is also needed. Gaining a clearer picture of the reasons

low income parents decide to access mental health services, and their difficulties in doing so,

would help counselors more effectively engage low-income clients, and perhaps contribute to

helping clients remain in counseling until their goals are reached. Understanding more fully what

low income parents experience in seeking out mental health services would also be helpful to

referring agents, such as school counselors, family medical professionals, and social workers. By

making more relevant and effective referrals, the referring agents might reduce the "pinball

effect" of delaying help seeking until the problem becomes untenable (Arcia, Fernandez,

Marisela, Castillo, & Ruiz, 2004).

Purpose of the Study

The purpose of this study was to describe the phenomenon of low-income African-

American boys being referred to mental health services by school counselors from the point of

view of their caregivers. Understanding the essence of the experience of African-American

families who are referred to mental health services by school counselors would enhance our

current understanding of the dynamics of how, where, and when poor African-American









recommended interventions. The caregivers wanted to advocate for their children by opposing

interventions they perceived to be either impractical or inappropriate, but feared negative

repercussions for disagreeing with or questioning educators. Caregivers clearly felt

disempowered and unwelcome during meetings with school staff members.









& Garvan, 2003). During this delay, children's problems often worsen, and parents feel

overwhelmed and frustrated by the time they reach the clinic.

Race and Class Issues in Academic Settings

In academic settings, African-American children continue to struggle, regardless of family

income. African-American students account for 33.4% of all suspensions from school and 14.7%

of dropouts (Day-Vines & Day-Hairston, 2005). African-American children in American public

schools are lagging behind their white and Asian peers on many academic success indicators,

although Hispanics continue to have a higher drop out rate than African-Americans. According

to the Educational Trust, African-American students made significant gains in both reading and

math during the 1970's and 1980's, only to lose ground again in the 1990s. The achievement gap

between African-American and White children in 2005 was 10% greater than in 1990. In a recent

study conducted by the Educational Trust, African-American students in the 12th grade had math

and reading skills commensurate with the math and reading skills of white eighth graders

(www.edtrust.org ; retrieved 7/26/06).

As in the family counseling literature, there is a body of work that attempts to explain

some of the academic achievement gaps between African-American and White children. Many

theorists invoke Bourdieu's cultural capital idea, which claims that children learn the invisible

rules of various social classes from parents and other adults. They can then use these "signals"

such as styles, attitudes, ideas, jargon, and preferences to help them enter high-status social

groups (Bourdieu, 1977). The purpose of the "signals" was purported to be maintenance of the

status quo among those occupying the higher strata of society.

Around the time Bourdieu was writing about social capital, anthropologist John Ogbu was

writing about social caste in the United States and its role in African-American life. Ogbu's

theory was that African-American achievement suffered due to the history of repression and









daycares that could handle Tyree and had to leave several jobs for this reason. Joy repeatedly

tried to get health professionals to help her, but was deflected.

When Tyree started kindergarten, his behavior problems ("biting, spitting, hitting") caused

him to be suspended and eventually moved to another class. Apparently during kindergarten,

Tyree was evaluated by a school psychologist. Joy said, "I think he was seen by a psychiatrist-

some guy from (local university) came and talked with him at school". She did not understand

who this person was or what the outcome of the sessions were until 3 years later, when a

counselor at another school explained that Tyree had been identified as Specific Learning

Disabled in kindergarten and had an IEP.

In the middle of his first grade year, Tyree moved to a nearby town to live with his father

and stepmother. Joy hoped that spending more time with his father would help Tyree, however,

"I want to say it was a bad mistake...there was a lot of things going on in that home". Joy says

that his father told her that the school staff in that town "diagnosed him as Manic-Depressive and

schizophrenic". She eventually found out from the current school counselor that he was too

young to be diagnosed with either of those disorders. However, Joy did not discount the

possibility that Tyree may have a serious mental health disorder. She stated, "His genes are bad",

but "Nobody can tell me what is wrong with him and that' s the part that scares me".

Building the Team

When Tyree came back from staying with his father (and later, his grandmother, who

seemed to do well with him) he started attending the school where he is now. Joy's quest for help

for him at this school began after he got into a fight with his sister one morning during breakfast.

She came to the school and met with the staff, including the counselor. It was during this

discussion that Joy explained her desire to get help for Tyree, and the counselor gave her a name

and phone number to call for a mental health evaluation. Joy said of this counselor "Hinds an









communication", and that they now realize they have to "stay on top of the school to get

anything done".

Joy and Sherry had similar experiences with advocacy. Joy said, "Tell me where to go

from here...I'm ready for him to get some counseling, anything, something." She and Sherry

both asked repeatedly for help until the counselor gave them the number for the mental health

center. They both also later asked for academic help from the school, and both boys are now

placed in special education. Joy characterized the entire process of getting mental health help for

Tyree as "a big run around" and often felt "angry and embarrassed" about Tyree's behavior, but

she was able to persist and eventually got help.

Teacie had a more difficult time communicating her concerns to her son' s school, and

realizes now that switching schools may not have been the best idea. She said, "I immediately

went into defensive mode when I should have remained calm. I didn't want to hear it because the

truth was hurting" when the first school's principal said "Think you might need some

counseling?" However, she changed schools in an effort to help Patrick be successful and not

become "one of those boys on the corner." She continues to advocate for him at the new school

even though she admits she is "tired...and frustrated."

Composite Structural Description

Alienation of Caregivers

A sense of "us versus them" ran through all of the stories in the study. Of all participants,

only one was eventually able to forge supportive relationships within the school to assist her in

her search for help for her son. All of the others were left with the feeling that, "If you don't say

the right things, you're out the door." Participants talked of feeling attacked, judged and snubbed

by educators. These feelings were fueled by the school staff' s creation of untenable

interventions, ignoring caregiver input and refusal to make needed modifications.









solely to make them eligible for expensive mental health treatments, primarily in residential care

facilities. Obviously, families with fewer existing financial resources are more likely to have to

make drastic custody decisions to receive treatment for their children. However, with residential

treatment for mental health problems costing in excess of $250,000 per year in some cases, this

is an issue that extends to middle class families as well.

Barriers to Children's Mental Health Services in Florida

According to the Children's Defense Fund (2005), there are 704,817 children in the state

of Florida living at or below the Federal Poverty line. Most of these children (63.8%) under age

6 live in families where all adults are in the labor force. In Florida, 677,000 children under 18 do

not have health insurance, which constitutes 16.6% of the entire population of children ages 0-1 8

in the state.

During the fiscal year 1997-98, the most recent year for which statistics are available, The

Division of Children' s Mental Health in Florida served 45,595 children (Department of Children

and Families, 2000). Half (22,104) of these children were classified as children and adolescents

with a "severe emotional disturbance", (SED), the others were classified as having "emotional

disturbance", (ED) (13,101) or 'being at risk of developing an emotional disturbance' (10,390)

(DCF, 2000). By far, the maj ority of the state funding spent on Children' s Mental Health

Services (CMH) in 1997-98 was focused on the SED population, disproportionate to the number

of children in this category who received services.

The three categories above were established in 1998 as part of the Comprehensive Child

and Adolescent Mental Health Services Act (Chapter 98-5, Laws of Florida). The 1998 law set

up the three categories of care, called for that care, whether residential or outpatient, to be family

and community centered, and required providers to track client progress. The bill also cleared the

way for the highly controversial privatization of CMH services (DCF, 2005).









other staff members or by the caregivers themselves. For example, school counselors could

conduct workshops for parents on communication skills, child advocacy, and their rights under

special education law. School counselors could also conduct small group or individual coaching

sessions with caregivers about how to negotiate with school staff on behalf of their children.

Caregivers, as the oppressed group in this scenario, may have less formal power than do

school staff members, but they are certainly not completely powerless. Many of them showed

evidence of great personal power in the course of recounting their struggles to obtain appropriate

care for their sons. If they were to apply this personal strength to the larger context of family-

school relationships, the caregivers could initiate large scale changes in the mental models and

practices of the schools in their communities.

Training for Administrators and Teachers

Although school counselors may lead the change in family-school communication, they

can not do it all (Bryan, 2005). School counselors are, of course, not present during every

interaction between a caregiver and educator at any given school. However, they can work to

insure that all educators at their school are trained to interact in a culturally responsive way with

all caregivers. This may be accomplished by conducting regular in-service workshops for

teachers and administrators on culturally congruent communication skills (Bryan, 2005) and by

modeling good communication skills.

Training all school personnel, including administrators, to use collaborative

communication methods with parents is especially important in working with disenfranchised

caregivers. Low-income parents are more likely than middle class parents to have negative

assumptions about school personnel (Lott, 2001) and are more likely to stay away from the

school if they perceive the atmosphere to be unwelcoming (Winters, 1993). School counselors

can help other school staff members to understand the conflicting mental models of caregivers









The blaming stance of most of the educators seemed to cause these later fears. As African-

American parents of boys, all of the study participants were aware of the potential for their sons

to face negative outcomes in school and in later life. The perceived intolerant, unfriendly stance

of the school staff brought these worries to the fore and caused the caregivers to become

seriously concerned about their sons being lost to prison, drugs, and school drop out as the long

term consequence of early negative school experiences.

Powerlessness and Transformation

Low-income, minority caregivers negotiating with the formal power structure of a public

school often perceive themselves as powerless (Brantlinger, 1993; Friere, 1970/2003; Kozol,

1991; Majors, 2001; Winters, 1993). This appeared to be true of the caregivers who participated

in this study. Caregivers reported that they felt desperate to comply with the wishes of the school

staff, no matter how inappropriate they thought those interventions were. Participants saw the

school as the gatekeeper to better life opportunities for their sons, and did not want to endanger

their futures by resisting the school staff' s demands.

In spite of their fears, feelings of alienation, and sense of powerlessness, all six caregivers

managed to find ways to make their voices heard with the school staff members. Their

transformations from powerless spectators to advocates took many paths. Some parents took

matters in their own hands, pre-empting the school staff in recommending treatment for their

sons. Others found allies in the community or within the school to bolster their leverage. Yet

others chose to move their children to other schools. All of these acts required bravery and

persistence. What is compelling about these caregivers' transformations into advocates is that the

educators involved seemed not to appreciate their efforts to intervene on behalf of their children.

Some educators apparently would have preferred the parents to have remained passive and









tested. Sherry agreed to have the testing done for the learning disability. At that same meeting,

the school counselor suggested Sherry take Darrien to the local mental health center for an

ADHD evaluation and counseling. Sherry said she felt "all up for it, he's always been real

hyper".

Once the team had decided to further investigate the possible causes of Darrien' s behavior,

they also agreed to allow him to start coming to school all day again, with a plan in place for

dealing with any misbehavior without sending him home. What baffled Sherry about this process

was "why they didn't do that in the first place" instead of requiring Darrien to attend half days,

which was a burden on her, and did not seem to help him.

As it turned out, Darrien was diagnosed with ADHD and was placed on stimulant

medication. Sherry said of the medication, "it made a big difference". She added that his

behavior at school improved tremendously. Sherry also reported that Darrien was identified as

having a learning disability and was able to get extra help with academics. Again, if the school

staff had discussed a broad array of possible solutions to Darrien' s problems in the first place

instead of assigning one intervention for their own convenience, Sherry would not have felt so

distressed and the underlying issues might have been identified sooner.

No Support for Caregivers

During the first few months of Darrien's first year at school, Sherry said she felt that the

school staff "was out to get me". She recounted the distress she felt when she would get called at

work about Darrien's behaviors, and the huge problems that the half day schedule caused her.

Sherry said of those first meetings, "It was depressing to talk to them".

Sherry had other children who attended the same school in the past and had never had any

behavior problems. She had been a class volunteer with all of the other children, and felt she was

a strong supporter of the school. However, when her grandson began exhibiting serious










purpose of the "signals" was purported to be maintenance of the status quo among those

occupying the higher strata of society.

Around the time Bourdieu was writing about social capital, anthropologist John Ogbu was

writing about social caste in the United States and its role in African-American life. Ogbu's

theory was that African-American achievement suffered due to the history of repression and

enslavement of Africans in the United States. According to Ogbu (1978) the enduring legacy of

racial discrimination resulted in lower expectations of African-Americans for success in

traditionally white middle class American institutions, such as schools and corporate workplaces.

Ogbu pointed to the differences in expectations of the possibility of success in the United States

held by recent immigrants of African extraction versus those of African-Americans who

descended from slaves. Recent African-American immigrants tended to be more hopeful about

their ability to achieve success in America, while those descended from slaves tended to be more

mistrustful of white middle class culture and institutions and less hopeful about their chances of

achieving middle class success. Furthermore, among African-Americans who were not recent

immigrants, being successful in mainstream white America could be perceived by peers as

"acting white" and betraying one' s culture (Ogbu, 2001). The idea that African-American youth

lower their expectations and desire for achievement became known as "oppositional culture

theory" (Carter, 2003).

Recently, researchers have contested the idea that African-American youth do not share

the same aspirations as American youth of other races (Carter, 2003). Carter and others (Hall,

1992; Lareau, 2000) argued that instead of opposing achievement in traditional terms (going to

college, getting a good j ob), African-American youth "resist the cultural default... of white

middle class standards of dress, musical taste, and interactional styles" (Carter, 2003, p. 137).









CHAPTER 5
DISCUSSION

Introduction

This study was undertaken to answer one primary research question: What are the lived

experiences of low-income African-American caregivers referred for mental health services for their

sons? The question was subdivided into two parts: a) What are the initial reactions (thoughts,

feelings, and actions) of the caregivers to the school counselor's referral of their child to mental

health services, and, b) How do the caregivers perceive the school staff making the referral during

and after the referral meetings? Chapter Five addresses the findings of the study in relation to the

original questions, links the findings to current literature, and outlines potential future research

related to this topic. Limitations of the study design and application are also examined.

Overview of Findings

The experience of having a son referred for mental health treatment by the school counselor

was generally a negative one for the study participants. The actual referral itself was difficult for the

caregivers to separate from the surrounding events; such as being contacted by the administrators and

/or teachers about discipline problems, and having to go to school for meetings with various school

staff members. The phenomenon in its totality was difficult for the caregivers. However, in this

particular group of people, the hardships they encountered caused them to find inner and community

resources they had not previously tapped. The transformative power of the experience in creating

advocacy skills in the caregivers is a credit to their resiliency and strength.

Alienation of Parents

The caregivers in the study, many of whom were long time school volunteers, were

severely disappointed by how they were treated by school staff during meetings regarding their

sons' behavioral problems. They described feeling attacked, blamed, and isolated. School staff

members were apparently frustrated with the actions of the boys and took out their frustrations









Children living in poverty were less likely to have access to health care services, including

mental health care than their peers from higher socio-economic levels (Howell, 2004).

Approximately one in ten children in the United States have a 'serious' mental health need at any

given time. As of 2002, children living in poverty were twice as likely as are middle and upper

class children to demonstrate serious mental health needs (Pottick, Warner, Isaacs, Henderson,

Milazzo-Sayre, & Manderscheid, 2002). While children living in poverty were more likely than

are their non-poor age mates to find themselves in need of mental health care services they were

much less likely to receive adequate help (French, Reardon, & Smith, 2003; Potter, et al, 2002;

McKay, Lynn, & Bannon, 2005; Huang, Stroul, Freidman, Mrazek, Freisen, Pires, & Mayberg,

2005; Bussing, Zima, Gary, & Garvan, 2003). As explained by Simpson, Scott, Henderson, &

Manderscheid (2002), children with the highest level of perceived unmet medical needs or who

were unable to afford counseling were those who were uninsured, living in families with income

below 100% of the poverty level, or who lived with a single parent"(p. 1 17).

The number of uninsured children, who are most at risk for not receiving adequate care, is

increasing in the United States. According to the US Census Bureau, as of August 2004

(www.census.gov/Press-Release), 8.4 million, 1 1.4% of all of the children in the United States,

were uninsured. Foreign born Hispanic children had the highest proportion of uninsured

members with 32.7%, followed by African-American children with 19.5% uninsured, and white

children with 11.1% uninsured. These numbers have increased over the past several years in

spite of expansions of government programs and the recent development of the State Children' s

Health Insurance Program (SCHIP) which "make nearly half of all children potentially eligible"

to receive public health insurance benefits (Howell, 2004, p.1). However, since not all of the









for each agency, and then asked Joy the next time Joy was at school if she had any difficulty

arranging appointments.

The school counselor' s intervention was a huge relief to Joy. She was now able to call for

appointments, and could rely on the school counselor to help her navigate roadblocks. When Joy

needed help getting information for Medicaid, she knew she could count on the school counselor

to provide the help she needed. The school counselor provided the first spoke in the wheel of

support Joy eventually built.

The Run Around

Although Joy does fear the possibility of the mental health counselors blaming her for his

problems, she is adamant that she wants to know what is wrong and what can be done to help

Tyree. She is concerned that he will end up in an alternative education program for children with

behavior problems, or later, in prison. Her persistence in the face of so many roadblocks and run-

arounds is astounding.

Joy's story is a sad, but probably not uncommon, illumination of the gulf that stands

between those inside the run around and those needing to break in. She repeatedly gave

permission for various people to test and/or counsel Tyree without understanding fully the

implications of those actions. She is desperate to get help for him, since she is very aware of the

possible negative consequences of Tyree growing up without any intervention. However, she

neither understands how to break into the run around, nor what entering that system might entail.

Textural Description: Sherry

Sherry is Darrien's maternal grandmother. She is also caring for two of her granddaughters

while another of her daughters is in prison. She also still has a teenage son at home. Darrien is

six and is repeating kindergarten. Sherry works fulltime at a clerical j ob at a maj or hospital. She

is married, but her husband was not present for the interviews. He is also employed full time.









APPENDIX A
POSSIBLE INTERVIEW QUESTIONS

Interview 1: History of the family and child leading up to the referral that shape the caregiver' s
perceptions and reactions, story of the referral.

As you know, I'm curious about what you thought about and how you felt when your son was
referred to for help. Today, I'd like to talk with you about how you felt when
was referred. I'd like to hear a little about your son, and his history at school so far.
Then we can talk about the process of being referred for mental health help.

1. Now let' s talk a little about your son, Tell me a little about what kind of a
child he is--what he likes to do, what he's good at, who he favors.

2. How has his school experience been so far? What does he like about school? What's been
tough for him?

3. Describe what happened the day that the school counselor talked to you about your son getting
help.

4. How did you feel? What thoughts went through your head?

5. How did you decide what to do about the referral? Did you talk to anyone? Who? What advice
did they have?

6. If you could go back in time to the day of the referral, is there anything you' d like to change
about how it was handled?

7. Between that day and now, what kinds of things have you thought about regarding the idea of
going to ?

Interview 2: Caregivers' current perceptions of the referral of the child to mental health services
by the school counselor.

I will send the transcript from interview one to the participants in advance of interview two, and
will check with them about the accuracy of the transcription before we continue.

Last time, you told me some of your family's past experiences. Today, I'd like to talk about
what' s going on now with the referral to


1. Have you seen any changes in your son? Can you give me some examples?

2. How has school been for since then?

3. How are you feeling about all that now?









on the caregivers. Instead of asking the caregivers to j oin with school staff to find mutually

agreeable solutions, educators instead assigned total responsibility for finding help for the boys'

problems on the caregivers. This way of handling parent relations resulted in feelings of anger

and alienation for the caregivers and did nothing to aid the boys.

More often than not, the caregivers would go along with the requests of school officials to

avoid possible negative consequences (suspensions, expulsion, and alternative school) not

because the caregiver was engaged with the intervention. Erford (2003) calls this passive

behavior in parents the "don't make waves" role. Erford contends that parents often agree with

school staff members in order to avoid negative outcomes that might derive from their active

resistance to interventions. The perception by parents that they should remain quiet and do as

they are told by school officials comes from a power imbalance. In contrast, when school staff

members work with parents collaboratively, power is shared equitably between both parties.

Collaboration results in the creation of interventions palatable to both parties, and eliminates

feelings of alienation of caregivers

Feelings of Fear and Guilt

To varying degrees, all of the caregivers expressed feelings of fear and guilt. Many also

experienced feeling that they were blamed for their sons' problems by school staff members.

These fears were initially related to not understanding why their sons were acting out at school

(and sometimes at home as well) and fears that their son's problems would get worse. During the

process of negotiating possible consequences of their sons' behaviors with the school staff

members, a second set of fears emerged; the fear of their sons being expelled, sent to an

alternative school, or suffering other negative consequences.










more research in the general area of social class in counseling literature. Liu and colleagues

(2004) also found no agreed upon definition of class among the articles reviewed.

In a separate content analysis of the Journal of Counseling Psychology from 1 973 1999,

(1999), Buboltz, Miller, & Williams found that most (56%) social class research in the past thirty

years has been carried out using college students as research participants, greatly lowering the

diversity of the samples. Counselors' understanding of the impact of dual forms of cultural

capital, and multiple lenses of social class worldviews among African-Americans has not been

explored thus far.

The maj ority of research conducted to date on poor families in counseling falls into two

general categories: 1) Programmatic research focus issues such as: numbers of people served by

race, age, gender, and other demographic variables, and what types of services agencies and

states offer poor families in need of service (included here would be policy initiatives and

insurance programs). 2) Client focused issues, such as: reasons families seek services,

perceptions about services and service-providers, and satisfaction with the outcome and process

of getting services.

Programmatic Research Focus

The vast maj ority of research on mental health services for poor families falls into this first

category. Within the broad area of structural-collective issues, four maj or sub-categories

emerge.


* Race/ethnicity specific research on service use.

* Research focused on agency issues, such as specific programmatic choices.

* Research focused on rural and/or urban settings and their impact on mental health.

* Research on funding of services, such as SCHIP and Medicaid.









of the possible explanations and essences of the experience from many different points of view

(Moustakas, 1994). Imaginative variation seeks to answer the question, "how did the experience

come to be what it is?" (Moustakas, 1994, p. 98). To arrive at answers to this question, the

researcher imagines as many explanations as possible, including all possible polarities,

juxtapositions, and perspectives as possible.

According to Moustakas (1994, p. 99), there are four stages within Imaginative Variation.

These are: 1) systematic varying of the possible structural meanings that underlie the textural

meanings, 2) recognizing the underlying themes or contexts that account for the emergence of

the phenomenon, 3) considering the universal structures that precipitate feelings and thoughts

with reference to the phenomenon, such as the structure of time, space, bodily concerns,

materiality, causality, relation to self and others, and 4) searching for exemplifications that

illustrate the invariant structural themes and facilitate the development of a structural description

of the phenomenon. Using Imaginative Variation allows the researcher to explore some of the

endless possible meanings of the experience. Once this exercise is completed, the researcher

writes the structural description of the experience of each participant. The structural descriptions

are then combined into a composite structural description for all participants, which describe the

meanings and causes of the experience.

Synthesis of Meanings and Essences

The final step in transcendental -phenomenol ogi cal analy si s i s the synthesi s of meanings

and essences. According to Husserl (1931), the essence of an experience is the characteristic that

makes it what it is, and without which, the experience would not be the same. It is important to

note that essences may change over time and context, so that a description of meanings and

essences is only applicable at one point in time, in one place, and through the eyes of one person

(Moustakas, 1994). However, the intersubj ective knowing that is present in the essences as seen










Although each of the participants had unique fears, the common thread of being afraid was

clear throughout the group. They all feared negative outcomes for the boys, and were all aware

that these fears were not far-fetched, since many of the caregivers mentioned male relatives who

had suffered similar life outcomes. The caregivers feared that if they were not able to Eind

adequate help for the boys early in life, they would not succeed in school, and would be as one

parent put it, "one of those boys on the comer with his pants hanging below his ass selling

rocks." These fears were realistic and palpable in the group. Their initial experiences with the

school system had not done much to allay their fears or give hope for alternative outcomes

without a lot of perseverance from the caregivers.

Powerlessness and Transformation

The Einal common thread running through the participants' experiences was their perceived

lack of power. Caregivers felt themselves to be in a one-down position in relation to school staff

and mental health professionals. Several caregivers talked about feeling pressured to follow the

school's recommendations about behavior management. Others were threatened with their son's

expulsion from Magnet programs if they did not stop their son' s negative behaviors. Two felt

pressure to medicate their sons, even though neither of them saw the benefit of using medication.

While one of them was able to deflect the pressure to medicate, the other gave in, saying, "He' s a

doctor, I'm only a Mom." She later stopped the medication due to her concerns about

complications.

Participants also talked about their lack of information about available services at school.

They saw their lack of "knowledge about what' s there" as a stumbling block for their sons and in

their negotiations with the school staff. Another caregiver talked about the school counselor

explaining to her that her son was identified with a disability and had an IEP. Apparently, he had

been placed two years previously, but she was not aware of the disability or the accommodations











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They feel that the teacher is exaggerating Jaquan's behavior problems, and is referring him

to the administrators at the school over "little stuff". They describe this teacher as being "all by

the book" and inflexible. They say she has, "one way of seeing Jaquan. She thinks he's just

messmng up."

Unfortunately, once Jaquan is in the office and his parents are called, this "straight and

narrow" attitude continues. When Felicia and James come to the school to discuss Jaquan's

behavior, they feel that, "they've already made up their minds before they get the whole story...I

wish the school would be more open instead of judgmental." They feel that as parents, they have

very little impact on the decisions of the school staff regarding Jaquan' s discipline or his

education in general.

When the school counselor suggested that Jaquan might need an ADHD evaluation, Felicia

was in agreement. As she says, "he's very hyper". Jaquan was prescribed medication, and is

taking it. However, he still has some (although fewer) behavior problems at school. When Felicia

suggested that perhaps he needed a "more sympathetic teacher", the principal asked if he was

taking his medication every day.

Felicia and James found this remark offensive. They readily acknowledge that Jaquan does

have ADHD, and are treating him for it, but do not think that ADHD is the only problem. They

see the teachers' lack of compassion and unwillingness to accommodate his differences as a

maj or impediment to Jaquan' s education. The school's staff as a whole does not acknowledge

that any changes need to be made to help Jaquan. Now that he is on medication, their answer is

always, "have his meds adjusted". To that, James replied, "He doesn't need more meds; they

need to fix what's going on in school." He said he would prefer for the teacher to, "See that he

has some problems, work with him, be more understanding".









The next part of Freire's (1970/2003, p. 54) first step, "through praxis commit themselves to

action" would follow. There are many ways the caregivers could make a commitment to action

to resolve the imbalance of power they perceive in the schools. Some possibilities would include;

developing formal or informal groups of concerned parents that could organize a reform effort,

networking with other institutions in the African-American community such as churches and

civil rights organizations to lobby the schools on their behalf, and taking individual action as

needed.

Once the caregivers chose to take some action to correct the imbalance of power in the

schools, the stage is set for the second step. According to Freire (1970/2003, p. 55) the second

step of the pedagogy of the oppressed is, "the expulsion of the myths created and developed in

the old order, which like specters haunt the new structure." In this stage, the transformation of

the relationship between oppressor and oppressed has occurred, and now the two sides can

engage in egalitarian dialogue to negotiate a new relationship.

This step can also be framed as a shift in the mental model of how schools work (Senge,

Cambron-McCabe, Lucas, Smith, Dutton, & Kleiner, 2000). Shifting the mental model of how

schools and parents interact entails "bringing tacit assumptions and attitudes to the surface so

people can explore and talk about their differences with minimal defensiveness" (p. 67). Senge

and his colleagues also talk about a two step process of transformation, which they call

"reflection and inquiry" (Senge, Cambron-McCabe, Lucas, Smith, Dutton, & Kleiner, 2000, p.

68). The reflection process requires people to think about their thinking, to carefully consider

how they have formed the opinions they hold about a situation, while inquiry requires a dialogue

between various members of a community or organization to identify and bridge

miscommunications and imbalances of power. This effort may be begun by school counselors or









the case, but was hoping for fewer calls to come pick him up, which has been the case so far. He

is not on medication, and his new teacher seems to be managing his behavior with less

intervention from the principal or school counselor, which results in fewer calls home. Although

the reduced number of calls is helpful, Teacie is still worried and distressed about Patrick' s

behavior and its impact on his academics. This constant worry is wearing her out. She reports her

feelings as, "Sometimes I want to give up. I really do...I feel bad about saying it...but I just get

tired".

Teacie: Structural Description

The Fight to Keep Her Son Enrolled

Teacie is a single mother raising her only son without much family support. The fact that

the boy has behavioral problems makes raising him alone even more trying. She says,

"Sometimes I want to give up. I really do...I feel bad about saying it...but I just get tired". She

seems to put a lot of pressure on herself to raise him to be a "family man" and not continue the

family cycle of incarceration. However, the lack of support she feels makes this far more

difficult. She felt pressured to do whatever the school staff requested of her in order to keep

Patrick in the school, and feared expulsion if she challenged their authority.

Anger and Stigma

Teacie' s past haunted her dealings with Patrick' s school. Her own experiences with being

teased by classmates for going to the same mental health center where Patrick was referred

colored her perceptions of help seeking. Along with her fears about Patrick' s health in relation to

medication, she also worried about him being teased at school for taking medication or going to

counseling. These fears caused her to react negatively to the principal, in particular, whose

suggestion of counseling was apparently not very tactful.











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Even forty years after the American Civil Rights Movement, African-American children

were still more likely than children of all other racial groups to be removed from their homes due

to abuse or neglect, and were more likely not to be returned to their families by social service

agencies (Ghose, 2006). African-American children made up only 15% of the entire child

population of the United States in 2004, yet constituted 27% of children living in foster care

(Ghose, 2006). Even though African-American children had far more contact with social service

agencies than white children, they were far less likely to receive adequate mental health care

(Angold, Erkanli, Farmer, Fairbank, Burns, & Costello, 2002; Takeuchi, Bui, & Kim, 1993).

African-American Males

African-American males were over represented in almost every negative category of

outcomes in America at the dawn of the 21s~t century. Fifty two percent of African-American

males who left school without graduating have prison records before the age of thirty (Day-Vines

& Day-Hairston, 2005). African-American men were over-represented in the prison population

in the United States with 3218 out of every 100,000 African-American men in prison in 2005, as

compared to 1220 of every 100,000 Hispanics and 463 of every 100,000 White men (U. S.

Department of Justice, 2006). African-American boys were more likely to be adjudicated and

face serious more consequences in juvenile court than white boys (Breda, 2003). African-

American men lead the nation in unemployment, new HIV infections, suicides, and homicide

deaths (Noguera, 2003).

These disturbing negative trends extend into academic performance as well. African-

American boys were dramatically over-represented in special education classrooms. While

comprising only 15% of the population of the United States in 2001, African-American children

were over-represented in specific learning disabilities (18%), mental retardation (34%), and

emotional disturbance (28%) categories (OSEP, 2005). African-American males made up a










CHAPTER 2
REVIEW OF THE LITERATURE

Introduction

This chapter summarizes the current level of knowledge in the counseling field about the

pathways to mental health services for African-American children in poverty. Mental health

service issues, as well as ways families are referred to services are discussed. Since many

children are referred to mental health care services by school counselors, their referral practices

are reviewed, as are more general educational issues concerning low-income African-American

students.

Research on the programmatic aspects of mental health care delivery to poor children in

the United States, and in Florida in particular, is reviewed. Professional literature examining

client issues affecting mental health care is discussed. Client focused issues include: cultural

contextual and historical issues specific to African-Americans, caregivers' and children's

perceptions of mental health care, barriers to finding and entering mental health care services for

children, and how parents report making decisions about accessing mental health care for their

children.

School Counselor Referral Practices

One of the primary roles of school counselors is to help students' families find and access

a variety of community services (Baker, 1996; Erford, 2003 Ritchie & Partin, 1994). School

counselors often play a critical role in students' families accessing mental health services,

however, there is limited professional literature available to help school counselors understand

the complex issues involved in making these referrals. In particular, there is a dearth of literature

for school counselors regarding making referrals for low-income families of color, even though

these families comprise the maj ority of patients at mental health clinics (Bussing, Zima, Gary, &









the school in order to ameliorate the problem. Problems may vary in severity and duration.

However, this must be the first attempt by the current school counselor to refer the family for

treatment. Parents may or may not choose to access mental health services.

Mental Health Counseling: "Mental Health Counseling is the provision of professional

counseling services, involving the application of principles of psychotherapy, human

development, learning theory, group dynamics, and the etiology of mental illness and

dysfunctional behavior to individuals, couples, families, and groups, for the purposes of treating

psychopathology and promoting optimal mental health.

The practice of Mental Health Counseling includes, but is not limited to, diagnosis and

treatment of mental and emotional disorders, psycho educational techniques aimed at the

prevention of such disorders, consultation to individuals, couples, families, groups,

organizations, and communities, and clinical research into more effective psychotherapeutic

treatment modalities." (American Mental Health Counselors Association, 2007).










not yet clear, but what is apparent is that poor children, particularly those of color, are more

frequently referred for services.

A closely related set of variables which have been studied in some detail are rural and

urban dwellers' patterns of mental health problem incidence and service use. Both rural and

inner-city populations are more likely than suburban populations to live in high poverty areas

(African-American & Krishnakumar, 1998) making both rural and inner-city children more

likely to experience mental distress than children in suburban areas. One innovative longitudinal

study followed 550 families who moved from inner city public housing to private housing in

more affluent neighborhoods. At the three-year follow up, adults reported much lower levels of

stress, and children (boys in particular) reported much lower levels of anxiety and depression

than did families who remained in public housing (Leventhal, 2003). Other studies found that the

increased stress levels associated with living in high poverty rural areas (Costello, Keeler, &

Angold, 2001) and in high poverty urban areas (African-American & Krishnakumar, 1998;

Leventhal, 2003; McKay, Nudelman, McCadam, & Gonzales, 1996) appear to contribute to

negative mental health outcomes for children and adults.

The final two areas of programmatic types of research are closely related. Policy decisions

frequently drive changes in how agencies operate based on changes in funding, and policy is

sometimes shaped by research regarding use patterns and epidemiological data. Of particular

interest in the recent past has been the issue of uninsured and underinsured people, and how the

lack of adequate insurance coverage impacts their use of health care services. Researchers from a

variety of professions (Boothroyd & Armstrong, 2005; Busch & Horowitz, 2004; Howell, 2004;

Raphael, 2005; Willging, Waitzkin, & Wagner, 2005) have studied under- and uninsured

children and have found that lack of coverage negatively impacts service access. Howell's









demonstrates dramatic differences in use patterns of health care between social classes and racial

groups, with low income African-Americans being least likely to access services (Bussing, Zima,

Gary, & Garvan, 2003; Chow, Jaffee, & Snowden, 2003; French, Reardon, & Smith, 2003;

Harden, 2005; McKay, Lynn, & Bannon, 2005; Huang, Stroul, Freidman, Mrazek, Freisen, Pires,

& Mayberg, 2005; Potter, et al. 2002 ).

Phenomenological Theoretical Framework

Since little is known about the subj ective, internal process of making decisions about

mental health care among poor African-American parents (Van Galen 2004), a qualitative

methodology was chosen for this study. Qualitative research allows the researcher to learn about

the lived experience of the population of interest. Instead of collecting large amounts of data at a

superficial level from a large sample of families, qualitative inquiry yields rich, deep, and often

unexpected information from the first person perspective in a smaller number of families

(Strauss & Corbin, 1990).

To learn about the actual lived experience of families in poverty who are referred for

mental health care for their children by school personnel, phenomenological research methods

were used in this study. The goal of all phenomenological research is to return to the "things

themselves" (Husserl, 1970). In other words, the purpose of conducting research is to,

"understand phenomena in their own terms, to provide a description of human experience as it is

experienced by the person herself' (Bentz & Shapiro, 1998, p. 96). The phenomenological

researcher' s task is to understand the subj ect at hand from the point of view of the participant, in

the most direct way possible.

In phenomenological research, the investigator enters the life world of the participants by

leaving behind his or her preconceived ideas of how things should be (Wertz, 2005). The

researcher then gathers data, usually via interviews, and/or archival means, and reflects on the












TABLE OF CONTENTS


page

ACKNOWLEDGMENT S .............. ...............4.....


AB S TRAC T ......_ ................. ............_........8


1 INTRODUCTION .............. ...............9.....


Social Class and Access to Mental Health Care in the United States .................. ...............13
African-American Families ................. ...............16......__ ......
African-American Males ....._._ ................ ..........._..........1
Cultural and Social Capital Theory .............. ...............19....
Conceptual Framework............... ....... .........2
Phenomenological Theoretical Framework ................. ...............24........... ....
Need for the Study ................. ...............25.......... ....
Purpose of the Study............... ...............26.
Research Questions .............. ...............27....
Definition of Terms .............. ...............27....


2 REVIEW OF THE LITERATURE .............. ...............29....


Introducti on .................. ........ ... ...............29.......
School Counselor Referral Practices .............. ...............29....
Race and Class Issues in Academic Settings .................. ............ .......... ..........3
Intersecting Issues of Race and Class in Mental Health Referrals ................. ................ ...34
Parity Issues in Children's Mental Health Service ............... .. .. ........... .............. .....3
Barriers to Mental Health Treatment for American Children in Poverty ............... .... ...........40
Barriers to Children's Mental Health Services in Florida ................... ...............4
Low-Income Families in Counseling............... ...............4
Programmatic Research Focus .............. .. .......... ... ..........4
The vast maj ority of research on mental health services for poor families falls into
this first category. Within the broad area of structural-collective issues, four
major sub-categories emerge. ............. ...............46.....
Client Focused Issues .............. ...............50....
Summary ................. ...............53.................

3 RESEARCH METHODS .............. ...............55....


Chapter Overview............... ...............55
Theoretical Framework............... ...............5

Subj activity Statement ................. ...............57........... ....
Participants ............... .. ...............59...
Data Collection M ethods .............. ...............61....
D ata Analysis........................... ..........6
Phenomenological Reduction ................. ...............64.................
Imaginative Variation ................. ...............64.................










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including issues of social class, should be integrated into counseling coursework rather than

being isolated in one course (Patton & Day-Vines, 2004).

In addition to creating collaborative relationships with families, school counselors need to

insure that caregivers understand precisely what the referral entails. Many times in this study,

caregivers remarked that they did not fully understand what services were provided by various

agencies, or which person was responsible for which intervention. This was especially true of

caregivers whose sons had already been identified as having special needs. Caregivers were

baffled by the array of terms and forms they had heard of and seen in meetings, and had no

useful working knowledge of what any of it meant in terms of their sons' education. School

counselors need to take the time to be sure caregivers understand what is being said in referral

meetings, and need to be available for caregivers' answering questions that may come up after

the meeting.

Recommendations for Parents

In this study, low-income African-American caregivers revealed that they perceived

themselves as alienated from mainstream public education in the United States. They also

reported feeling that they had less power in decision making than the school staff members. The

caregivers in this study recognized that an imbalance of power existed between themselves and

the public school officials. When the caregivers talked about the school staff members, "not

listening", "not caring", "stressing me out", and "being biased" they were acknowledging their

own lack of power. Even though the caregivers thought of themselves as the less powerful group,

they can nonetheless take action to equalize the imbalance of power. Paulo Freire (1970/2003)

explains that power can be redistributed in unequal situations in two steps: "In the first step, the

oppressed unveil the world of oppression and through praxis commit themselves to its

transformation." (p. 54).









CHAPTER 3
RESEARCH METHODS

Chapter Overview

Chapter Three describes the epistemology and general philosophical assumptions of

transcendental phenomenology, the research method chosen for this study. The selection of

participants and the methods of data collection are explained. Data analysis methods, including

steps the process of analysis are fully explained.

Theoretical Framework

Edmund Husserl, a philosopher who lived and worked in Europe in the early part of the

twentieth century, is generally acknowledged as the founder of the phenomenological movement

(Crotty, 1998; Giorgi & Giorgi, 2003; Wertz, 2005). Although Husserl was not a psychologist,

he devoted much of his career to questions of human experience and perception.

Phenomenology's distinctive focus on the individual's first hand experience of life and the world

deviated sharply from the focus of other psychological studies conducted during this period that

focused on overt behavior and physical processes (Wertz, 2005). Later therapists who embraced

the existential therapies, such as Victor Frankl, Irving Yalom, and Gordon Allport were heavily

influenced by Husserl's work (Halling & Nill, 1995), as were existential philosophers Jean-Paul

Sartre, Martin Heidegger, and Maurice Merleau-Ponty (Giorgi & Giorgi, 2003).

At its core, phenomenological inquiry is concerned with gaining insight into lived

experience with as little interference from outside schemas as possible (Wertz & Shapiro, 1998).

Phenomenological researchers are concerned with learning about how human consciousness

interacts with the world in order to create meaning (Wertz & Shapiro, 1998). "Phenomenologists

search for the essential or fundamental structures underlying experience", usually by listening to










The current study clearly showed a disconnect between low-income African-American

caregivers and middle class educators parallel to the findings in previous research. Interestingly,

this was true in cases where the school counselor was African-American just as often as when

the school counselor was White. In both instances, the race of the school counselor seemed not to

be as important as his or her methods of connecting to parents. The school counselor who helped

Joy connect to community services was White. That school counselor was effective in her

communications with Joy largely because she took the time to listen to Joy's point of view

regarding her son's behaviors and did not immediately construct school-centric interventions for

him.

The grave importance of treating low-income and minority caregivers with respect and

giving credence to their points of view is emphasized over and over in the professional literature

from the fields of education, counseling, and psychiatry (Amatea, 2007; Bemak & Chung, 2005;

Boyd-Franklin, 1989; Brantlinger, 1993; Brunious, 2002; Christenson & Sheridan, 2001; Dogra,

2005; Lott, 2001; Noguera, 2007; Smith, 2004). In order to effectively reach low-income and

minority caregivers, educators are encouraged to take the following steps:

* Acknowledge and build on wisdom already present in the family.

* Treat the caregivers as equals, not subordinates.

* Avoid blaming the caregiver for the students' difficulties.

* Establish consistent, two-way communication that is not problem-based (Amatea, 2007).

Creating a social climate in the school where effective family-school communication

with low-income and minority families is possible requires a shift in the paradigm guiding the

schools' leadership, including the school counselor (Amatea, 2007; Christenson & Sheridan,

2001; Lott, 2001; Senge, Cambron-McCabe, Lucas, Smith, Dutton & Kleiner, 2000). All of the

schools in this study appeared to operate under a paradigm called "remediation" by Amatea










organizational skills, high expectations for achievement, and positive attitudes were very strong

and gave them some hope for good academic outcomes for their sons, in spite of problems the

sons had experienced in the past. This hope for positive outcomes mirrors findings of other

researchers (Clark, 1983; McCaleb, 1994; Swap, 1995) who reported that family functioning

appears to be more important than family structure or circumstance in determining the level of

engagement of caregivers in children's schooling.

Implications for School Counseling Practice and Education

The findings in this study affirm results of other research that highlights the high frequency

of miscommunication between caregivers from low-income African-American families and

school personnel, including the school counselor. The roots of this disconnection seem to be

cultural; most public schools in the United States appear to operate from a cultural world view

based on middle-class White values. The cultural dissonance between the schools and low-

income African-American families may cause families and students to feel disrespected and

unwelcome in the social system of the school (Applebaum, 2002; Day-Vines & Day-Hairston,

2005; Monroe, 2005; Noguera, 2003; West-Olatunji, Baker, & Brooks, 2007; Winters, 1993).

While this disconnection is most likely unintentional, bridging the distance between the White

middle-class world of the school and the African-American low-income world of some families

and students needs to be examined in an intentional, direct manner in order to improve

communication.

The cultural disconnection between low-income African-Americans and the nation's

public schools not only skews family-school communications, but also limits academic

achievement and students' career options (Carter, 2003; Lee, 2005; Noguera, 2003). School

counselors are key figures in the current struggle to close the achievement gap between African-

American and White students (Bemak & Chung, 2005). Part of the task of raising African-










extra effort to help White researchers understand what they intend to communicate, while when

African-American researchers interview them, the African-American respondents may assume

the researcher already understands their experiences. Thus, gaining access is a greater chore for

White researchers, while participants may be more careful to fully explain their thoughts and

feelings. This finding seemed to be valid with this study. However, access was made easier due

to the pre-existing relationships between school personnel and participants. The phenomenon of

African-Americans assuming researchers of their own race may understand more than White

researchers is certainly worthy of further thought and study.

Bracketing all preconceived ideas about the referral of young African-American males to

mental health services by school counselors was difficult for me, since I have worked as both a

school counselor and a mental health service provider. However, all attempts were made to leave

prior knowledge out of the interview and analysis process in order to allow for the participants'

experiences to drive the formation of the essence statement.

Two participants, Sherry and Felicia, were not available for final interviews. However,

they provided substantial information in earlier interviews. Ideally, all participants would have

been interviewed three times, but due to the heavy work and parenting responsibilities of these

participants, three interviews were not always a possibility.

Recommendations for Further Research

Further studies examining low-income African-American caregivers' perspectives on both

schooling and on mental health care are needed. Social class in particular, is not a well

understood construct as it relates to counseling theory and practice. The education and mental

health professions would benefit from both more theoretical writing and research into how social

class functions as a variable in people's decision making. Research on social class as it relates to

race and ethnicity is also needed. Combinations of low or middle class status among African-









both over 45 years old and reflect census data and occupational categories from the 1950's. In a

separate content analysis of the Journal of Counseling Psychology from 1973-1999 (1999),

Buboltz, Miller, & Williams found that most (56%) social class research in the past thirty years

has been carried out using college students as research participants, greatly lowering the diversity

of the samples. Therefore, even our 'obj ective' understanding of social class as a variable in

counseling research is highly questionable.

Many variables of family poverty and health care have been examined by various agencies

and researchers. However, the voices of African-American families in poverty are still silent in

the professional counseling and psychology literature (Moreira, 2003; Sue & Lam, 2002; Smith,

2005; Van Galen, 2004). The actual lived experience of being referred to mental health care for a

African-American child in a low-income family in the United States has not yet been adequately

explored (Smith, 2005). To better inform future policy making and counseling practice, this

study addressed this gap in knowledge.

Much is known about the negative effects of poverty on children and families, but little is

known about the lived experiences of African-American families in poverty who are referred by

school personnel to mental health care services for their children. The voices of the people most

impacted by poverty and mental health care policy are missing from the current literature.

Also absent from the school counseling literature are guidelines for school counselors

about making effective referrals for low income families to outside agencies. Very little has been

published in recent years about the referral practices of school counselors, although making

referrals is an important aspect of the school counselor' s j ob (Baker, 1996; Brown & Trusty,

2005; Davis, 2005). School counselors make an average of thirty referrals per year, primarily for

help with emotional and family concerns (Ritchie & Partin, 1994). Although the counselors










By engaging families in a collaborative, mutual sharing model of communication instead of a

more traditional one-way, educator-as-expert mode, school counselors can begin to overcome

some of the negative expectations about school staff held by some low-income and minority

parents .

Caregivers in this study lamented the lack of input they felt they had in decisions

regarding their sons' education. They also talked about feeling that school staff members did not

listen to their concerns, and were very distressed by the lack of power they felt they had in

meetings to influence the decision making of school staff. Implementing a system of

collaborative communication with all parents would help to assuage these feelings. Collaborative

communication would help equalize power between low-income minority parents and the

middle-class education professionals who serve them. Recalling Liu' s (2001) intrapsychic model

of classism, school counselors need to be aware of possible internalized classism when working

with low-income and/or minority parents. Low-income and/or minority people may have

difficulty 'reading' social cues common in middle-class environments, such as schools. Care

should be taken to fully explain all school-related issues and avoid professional jargon so that

caregivers have a clear understanding of all possible interventions and alternatives.

Sharing power and giving caregivers more voice at school would also help reduce what

Erford (2003, p. 197) calls the "don't make waves" role parents sometimes play when they feel

they do not have equal power in school decisions. This role, wherein caregivers will agree to

anything suggested by school staff for fear of negative consequences, was prominent in

participants' responses in this study. Caregivers' fears of potential suspension, expulsion, or

transfer to alternative schools led them to agree to interventions they did not feel were









Garvan, 2003; Pottick, Warner, Isaacs, Henderson, Milazzo-Sayre & Manderschied, 2003).

Many current school counseling texts offer some information for beginning counselors regarding

making referrals to outside agencies. Ritchie and Partin (1994) recommended that school

counselors give parents as much concrete information as possible when making referrals to

outside services, such as contact names, telephone numbers, cost of services, and types of

treatment available.

Another model for school counselors to consider when making referrals to community

agencies is outlined in Apter (1992). The direction model was originally developed to assist

families with disabled children to navigate the complex system of medical and social helping

agencies. In this model, counselors develop a trusting relationship with parents, then talk with

parents to ascertain what types of help they want, give parents choices about which services to

access, give specific information about what each agency does and how to make contact, and

then provides follow along and follow up assistance (Apter, 1992, p. 495). When this model was

developed and implemented in New York State, over 70% of families reported being able to find

and access needed services for their disabled children (Musumeci & Cohen, 1982).

Also absent from the school counseling literature are guidelines for school counselors

about making effective referrals for low income families to outside agencies. Very little has been

published in recent years about the referral practices of school counselors, even though making

referrals is an important aspect of the school counselor' s j ob (Baker, 1996; Brown & Trusty,

2005; Davis, 2005). School counselors make an average of thirty referrals per year, primarily for

help with emotional and family concerns (Ritchie & Partin, 1994). Although the counselors

Ritchie & Partin surveyed twelve years ago reported mostly positive experiences with making









Instead of exploring George and Anna' s abilities and resources, the school staff (in particular the

administrators) appear to have spent most of the meeting time explaining in detail everything

George had done wrong. Anna felt isolated from the school staff and alone in her quest to help

her son. She felt that the school staff were "caving in on me", which was very stressful and

frustrating .

Problem Solving is the Parents' Job

The school staff, in spite of being educational professionals, did not offer Anna any

possible resources or suggestions initially. The result of this approach was to make Anna, a

single parent, feel as if she was alone in trying to help her son. She felt as if the school staff "had

done about all they were going to do" and that it was now up to her to affect change. She

perceived the message from school staff to be, 'Your child is bad and out of control, what are

you going to do".

Even though she generally sees herself as a responsible and involved parent, being set the

task of helping George with no support from the school staff was a frustrating and stressful

experience for her. She said she kept thinking, "What can I do?" She also felt the teacher ignored

her suggestions and "wasn't really trying" to help him.

Mom Takes the Initiative

Once Anna had the idea of getting counseling for George, it seemed that the school staff

became more engaged in the process of helping her. When she asked the school counselor about

the idea of seeking outside help, the counselor was able to provide a name and phone number for

her to call. Whether the counselor would have suggested this at some point later is unknown.

However, Anna' s perception was that all of the school staff at the meeting seemed "to like that

idea". She wondered if they were planning to talk to her about going, and were putting it off,

fearing she would not react well to the idea. It may be that the hesitation on the part of the school










to focus instead on its subj ective manners of appearance and givenness- the lived through

meanings and subjective performances that subtend human situations", (Wertz, 2005, p. 168).

The second epoche is essentially a shift in thinking for the researcher, away from the collection

of raw observational data about the obj ective world, and towards a subj ective or intrapersonal

interaction with the collected data. The second epoche asks the researcher to, "empathetically

enter and reflect on the lived world of other persons in order to apprehend the meanings of the

world as they are given in a first-person view" (Wertz, 2005, p. 168). The researchers own biases

and pre-conceived ideas about the obj ect of the study are bracketed, or put aside, so that the

researcher is able to enter the life-world of the research participant as fully as possible

(Moustakas, 1994). Bracketing requires the researcher to be aware of his or her own biases and

to develop an empathic, open relationship with the participants and the data (Wertz, 2005).

Once a researcher has entered the epoche, and has put aside his or her prejudices and

unexamined bi ase s ab out a thing, he or she then turns to Transcendental -Phenomenol ogi cal

Reduction to begin to describe it (Moustakas, 1994). In this context, the word transcendental is

meant to denote that the researcher is moving away from the everyday, to bracket away previous

ideas, and see the data anew (Moustakas, 1994). This process is described in detail in the data

analysis section.

Subjectivity Statement

In this work, I acknowledge my status as an outsider. I am not the child of a poor family,

nor did I need mental health intervention as a child. My family is White and middle class. While

I was growing up, we lived in a small Southern city in the United States, and always had health

insurance. I attended public schools during the early years of desegregation, but was never

bussed far, and was generally in the maj ority population demographic at school. I never

experienced learning or behavioral problems, although some of my peers did. I attended school




Full Text

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1 LOW-INCOME AFRICAN-AMERICAN CARE GIVERS EXPERIENCE OF HAVING A SON REFERRED TO MENTAL HEALTH COUN SELING SERVICES BY THE SCHOOL COUNSELOR By CATHERINE TUCKER A DISSERTATION PRESENTED TOTHE GR ADUATE SCHOOL OF THE UNIVERSITY OF FLORIDA IN PARTIAL FULLFILLM ENT OFTHE REQUIREMENTS FOR THE DEGREE OF DOCTOR OF PHILOSOPHY UNIVERSITY OF FLORIDA 2007

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2 2007 Catherine Tucker

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3 Dedicated to the memory of Todd Owen Carter

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4 ACKNOWLEDGMENTS The completion of this work would not have been possible without the continuing support of my parents, David Tucker and Mary Mose ley Tucker. The beginning of it would not have been possible without the inspiration, both in li fe and in afterlife, from Todd Owen Carter. I consider the continuation of my work with children in poverty a small repayment of my eternal debt to him. Partial funding for this research was provi ded by a grant from the Chi Sigma Iota Counseling Academic and Profession al Honor Societ y International.

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5 TABLE OF CONTENTS page ACKNOWLEDGMENTS...............................................................................................................4 ABSTRACT....................................................................................................................... ..............8 1 INTRODUCTION................................................................................................................... .....9 Social Class and Access to Mental Health Care in the United States....................................13 African-American Families.............................................................................................16 African-American Males.................................................................................................18 Cultural and Social Capital Theory........................................................................................19 Conceptual Framework...........................................................................................................22 Phenomenological Theoretical Framework............................................................................24 Need for the Study............................................................................................................. .....25 Purpose of the Study........................................................................................................26 Research Questions.........................................................................................................27 Definition of Terms.........................................................................................................27 2 REVIEW OF THE LITERATURE............................................................................................29 Introduction................................................................................................................... ..........29 School Counselor Referral Practices......................................................................................29 Race and Class Issues in Academic Settings..........................................................................32 Intersecting Issues of Race and Cl ass in Mental Health Referrals.........................................34 Parity Issues in Childrens Mental Health Service.................................................................37 Barriers to Mental Health Treatment for American Children in Poverty...............................40 Barriers to Childrens Mental He alth Services in Florida......................................................43 Low-Income Families in Counseling......................................................................................44 Programmatic Research Focus........................................................................................46 The vast majority of research on mental health services for poor families falls into this first category. Within the broad ar ea of structural-collective issues, four major sub-categories emerge.......................................................................................46 Client Focused Issues......................................................................................................50 Summary........................................................................................................................ .........53 3 RESEARCH METHODS...........................................................................................................55 Chapter Overview............................................................................................................... ....55 Theoretical Framework.......................................................................................................... .55 Subjectivity Statement......................................................................................................... ...57 Participants................................................................................................................... ..........59 Data Collection Methods........................................................................................................61 Data Analysis.................................................................................................................. ........63 Phenomenological Reduction..........................................................................................64 Imaginative Variation......................................................................................................64

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6 Synthesis of Meanings and Essences..............................................................................65 Validity and Trustworthiness, Reliability and Consistency............................................66 4 FINDINGS....................................................................................................................... ...........69 Textural Description: Anna.................................................................................................69 School versus Parent........................................................................................................69 Problem Solving is the Parents Job................................................................................70 Mom Takes the Initiative.................................................................................................71 School Makes the Rules, the Parents must Follow..........................................................72 Structural Description: Anna..................................................................................................72 School versus Parent........................................................................................................72 Problem Solving is the Parents Job................................................................................73 Mom Takes the Initiative.................................................................................................73 School Makes the Rules, Parents Must Follow...............................................................74 Textural Description: Teacie..................................................................................................74 The Fight to Keep Her Son Enrolled...............................................................................75 Anger and Stigma............................................................................................................75 Worries for the Future.....................................................................................................76 The School Staff Will Not Listen....................................................................................77 Teacie: Structural Description................................................................................................78 The Fight to Keep Her Son Enrolled...............................................................................78 Anger and Stigma............................................................................................................78 Worries for the Future.....................................................................................................79 School Staff Will Not Listen...........................................................................................79 Textural Description: Joy...................................................................................................... .80 The Search for Answers..................................................................................................80 Building the Team...........................................................................................................81 The Run Around..............................................................................................................82 Structural Description: Joy.................................................................................................... .83 The Search for Answers..................................................................................................83 Building the Team...........................................................................................................83 The Run Around..............................................................................................................84 Textural Description: Sherry..................................................................................................84 School Centered Solutions..............................................................................................85 No Support for Caregivers...............................................................................................86 The School Decides which Problems are Legitimate......................................................87 Structural Description: Sherry................................................................................................88 School Centered Solutions..............................................................................................88 No Support for Caregivers...............................................................................................88 The School Decides which Problems are Legitimate......................................................89 Felicia and James: Textural Description.................................................................................89 No Compassion...............................................................................................................89 Failure to Communicate with Parents.............................................................................91 No Flexibility................................................................................................................. ..92 Structural Description: Felicia and James..............................................................................92 No Compassion...............................................................................................................92

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7 Failure to Communicate..................................................................................................93 No Flexibility................................................................................................................. ..94 Composite Textural Description.............................................................................................94 School Centered Perspective...........................................................................................94 Lack of Compassion for Caregivers................................................................................96 Schools Are Rigid Systems............................................................................................. 98 Parents as Advocates.....................................................................................................100 Composite Structural Description.........................................................................................101 Alienation of Caregivers................................................................................................101 Fear and Guilt................................................................................................................102 Powerlessness and Transformation...............................................................................104 Textural Struct ural Synthesis.............................................................................................105 5 DISCUSSION..................................................................................................................... ......108 Introduction................................................................................................................... ........108 Overview of Findings...........................................................................................................108 Alienation of Parents.....................................................................................................108 Powerlessness and Transformation...............................................................................110 Links to Current Literature...................................................................................................111 Family-School Communication.....................................................................................111 Minorities and Mental Health Care...............................................................................114 African-American Males and Schools...........................................................................116 Implications for School Counse ling Practice and Education........................................118 Collaborative Relationships with African -American and Low-Income Families.........119 Making Culturally Responsive Referrals......................................................................121 Recommendations for Parents.......................................................................................123 Training for Administra tors and Teachers....................................................................125 Limitations of the Study.......................................................................................................126 Recommendations for Further Research..............................................................................127 APPENDIX A POSSIBLE INTERVIEW QUESTIONS..............................................................................129 B STEPS IN DATA ANALYSIS............................................................................................. 131 C CONSENT FORM A ND IRB APPROVAL......................................................................... 132 LIST OF REFERENCES.............................................................................................................134 BIOGRAPHICAL SKETCH.......................................................................................................145

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8 Abstract of Dissertation Pres ented to the Graduate School of the University of Florida in Partial Fulfillment of the Requirements for the Degree of Doctor of Philosophy LOW-INCOME AFRICAN-AMERICAN CARE GIVERS EXPERIENCE OF HAVING A SON REFERRED TO MENTAL HEALTH COUN SELING SERVICES BY THE SCHOOL COUNSELOR By Catherine Tucker August 2007 Chair: Ellen Amatea Major: School Counseling and Guidance The intersecting factors of so cial class and race are essent ial markers of place and shapers of behavior and perception in the United States. In this pheno menological study, six low-income African-American caregivers were interviewed about their expe rience of having a son referred for mental health care by the sc hool counselor. Issues of how the participants viewed the school, mental health care, and the process of being referred were explored. Key findings of the study included; the car egivers experiences of alienation and powerlessness in the face of a rigid, hierarchical system for parent involvement in educational decision making, caregivers perceived lack of pow er in relationship to school staff members, and caregivers lack of understa nding of school administrative processes. Other findings, as well as implications for practice a nd research, were examined.

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9 CHAPTER 1 INTRODUCTION School counselors are key figures in the referral of children to mental health care facilities (Baker, 1996; Ritchie & Partin, 1994). School c ounselors job descriptions have long included referral of students to outside se rvice providers for a large array of health and social service needs (Baker, 1996; Brown & Trusty, 2005; Erfo rd, 2003). However, limited literature is available for assisting school counselors in unde rstanding the dynamics of referring low-income African-American families for outside help. Poor African-American families make up a disproportionately large number of referrals to mental heath agencies, yet there is mounting evidence that African-Americans view help seeki ng differently than Whites. More research is needed to uncover the reasons behind these trends (Boyd-Frank lin, 1989; Liu, et al, 2004; Logan, 2001; McMiller & Weiscz, 1996). Yet, in a search of the tables of contents of the Journal of Counseling and Development from 1995-2005, only 9 article titles included terms that directly indicate an emphasis on class and/ or poverty issues. Words such as at-risk, marg inalized, elitism, disadva ntaged, social justice, and lack of money were included in this cate gory. Many of these terms are poorly defined and change from one article to the next. For exampl e, the term at-risk may or may not include children who live under the poverty line, children whose parents are incarcerated, or children whose siblings have left school without gradua ting. By contrast, 90 arti cles had titles that included terms related to race, culture, nati onal origin, ethnicity, or multiculturalism. Three special issues in the pa st 10 years have been devoted to issues of multiculturalism, diversity, and race, but none have dealt dire ctly with issues of poverty and class based oppression. Not even the Dimensions of Persona l Identity Model, which takes into account multiple internal and external factors in the sh aping of a persons identity, explicitly include

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10 social class, although it does incl ude level of education, work expe rience, and historical context (Arredondo, Rosen, Rice, Perez, & Tovar-Gamer o, 2005). Arredondo, and her associates (2005) go on to say at the conclusion of their content analysis of the Journal of Counseling and Development from 1995-2005, No longer can multicultura lism be relegated to one course, mentioned as a passing comment in a publication or presentation, or avoided by educators and administrators (p.160). This already power ful statement would be strengthened by the inclusion of class. In a review of tables of contents for the Professional School Counseling from 1997 to the present, similar ratios were found. However, the journals recent special issue entitled Professional School Counseling in Urban Settings (February, 2005) did include articles on poverty related issues. Liu and colleagues (2004) reviewed three journals, The Journal of Counseling Psychology, The Journal of Counseling and Development and The Journal of Multicultural Counseling and Development from 1981-2000, and discovered that social cl ass was a key variable in only 1.4% of all empirical research articl es, even though social class data was collected on participants in 17.5% of the studies. Social class was referred to more often in theoretical/conceptual articles, and was at least mentioned as a variable in 33.5% of the studies. In total, between 20 and 30% of all 3915 articles reviewed mentione d social class in some form. However, only a very small percentage made social class a focus of the rese arch. These findings highli ght the need for more research in the area of social class in the counseling literature. In particular, the subjective experience of social class has been excluded from previous work, in spite of the evidence that subjective accounts of social clas s are more reliable and robust th an available objective measures (Liu, et al, 2004). The two most frequently used objective indices of social class, the Hollingshead Index of Social Position (1958), and the Duncan Socioeconomic Index (1961) are

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11 both over 45 years old and reflect census data and occupational cat egories from the 1950s. In a separate content analysis of the Journal of Counseling Psychology from 1973-1999 (1999), Buboltz, Miller, & Williams found that most (56%) so cial class research in the past thirty years has been carried out using college students as re search participants, grea tly lowering the diversity of the samples. Therefore, even our objective understa nding of social cla ss as a variable in counseling research is highly questionable. Many variables of family poverty and health car e have been examined by various agencies and researchers. However, the voices of African-American families in poverty are still silent in the professional counseling and psychology litera ture (Moreira, 2003; Sue & Lam, 2002; Smith, 2005; Van Galen, 2004). The actual lived experience of being referred to ment al health care for a African-American child in a low-income family in the United States has not yet been adequately explored (Smith, 2005). To better inform future policy making and counseling practice, this study addressed this gap in knowledge. Much is known about the negative effects of poverty on children and families, but little is known about the lived experiences of African-American families in poverty who are referred by school personnel to mental health care services for their children. The voices of the people most impacted by poverty and mental health care polic y are missing from the current literature. Also absent from the school counseling lit erature are guidelines for school counselors about making effective referrals for low income fa milies to outside agencies. Very little has been published in recent years about the referral pr actices of school counselors, although making referrals is an important aspect of the school counselors job (Baker, 1996; Brown & Trusty, 2005; Davis, 2005). School counselors make an averag e of thirty referrals per year, primarily for help with emotional and family concerns (R itchie & Partin, 1994). A lthough the counselors

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12 Ritchie & Partin surveyed twelve years ago re ported mostly positive experiences with making referrals to outside agencies, a significant num ber (48%) also reported occasional frustration with parents not following through on their recommendations (Ritchie & Partin, 1994). Most current school counseling textbooks offer some variation on the following advice to new professionals about ma king out-of-school referrals: Be aware of laws and policies rega rding sharing confid ential information. Develop collaborative working relationships with the care prov iders in your area. Keep some record of the dates and places families were referred to service providers (Baker, 1996; Brown & Trusty, 2005; Er ford, 2003; Ritchie & Partin, 1996). Some texts also offer models for problem-so lving with families in crisis (Baker, 1996; Erford, 2003) which could be employed when ma king referrals. However, only Erfords text offers a chapter on helping what is termed at-risk students; none of the texts seemed to include any guidance on working with families in pover ty per se ( Brown & Trusty, 2005; Davis, 2005 both include chapters on multicultu ral counseling, but focus only on race and heritage issues, not class). Additionally, most texts do not differentiate between subgroups within races, such as MexicanAmerican versus South or Central Am erican or Caribbean Hispanics, or between Haitian and African-Americans. Conversely, a large percentage of children seen in mental health facili ties have a history of school problems and are initially referred by scho ol counselors or teachers. The research that does exist on the process poor families experience between initial referra l for and entry into mental health services suggests that there is often a long dela y between the two (Chow, Jaffee & Snowden, 2003; French, Reardon, & Smith, 2003; Potter, et al, 2002; McKay, Lynn, & Bannon, 2005; Huang, Stroul, Freidman, Mrazek, Freisen, Pires, & Mayberg, 2005; Bussing, Zima, Gary,

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13 & Garvan, 2003). During this delay, children s problems often worsen, and parents feel overwhelmed and frustrated by the time they r each the clinic. Understa nding the essence of the experience of African-American families who are referred to mental health services by school counselors would add enhance our current underst anding of the dynamics of how, where, and when poor African-American careg ivers access mental health car e services for their children. Social Class and Access to Mental He alth Care in the United States Although vast changes have occurred in bot h standards and methods of care for the mentally ill over the past two centu ries (Grob, 1994), social class di sparities are still reflected in access to mental health care (Busch & Ho rowitz, 2004; Howell, 2004; Leventhal, 2003). Differences in access to care occur among rural and urban populations, between wealthy and poor people, and between various racial groups. Perhaps the gr oup most affected by lack of access to care is children living in poverty, re gardless of race and location (Chow, Jaffee, & Snowden, 2003; Samaan, 2000; Take uchi, Bui, & Kim, 1993). As defined by financial parameters, 16% of American children lived in poverty in 2002 with one in four families in the United Stat es with young children earning less than $25,000 a year (Child Welfare League of America, Oc tober 23, 2005). The federal poverty level (FPL) for 2004 was $19,157 per year for a family of four. Lo w income was calculated as 100-200% of the FPL for a family of four (US Census Burea u, 2005). In terms of raw numbers, over 13 million children in the United States lived at or belo w the poverty line in 2004, an increase of 12.8% over the number reported in 2000 (Childrens Defe nse Fund, 2005). Financial need is but one of many defining characteristics of poverty. In this study, poverty was defined more globally as; A condition that extends beyond the lack of income and goes hand in hand with a lack of power, humiliation and a sense of exclusion, (Raphael, 2005).

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14 Children living in poverty were less likely to have access to health care services, including mental health care than their peers from higher socio-economic levels (Howell, 2004). Approximately one in ten children in the United Stat es have a serious ment al health need at any given time. As of 2002, children living in poverty were twice as likely as are middle and upper class children to demonstrate serious mental health needs (Pottick, Warner, Isaacs, Henderson, Milazzo-Sayre, & Manderscheid, 2002). While children living in poverty were more likely than are their non-poor age mates to find themselves in n eed of mental health care services they were much less likely to receive adequate help (F rench, Reardon, & Smith, 2003; Potter, et al, 2002; McKay, Lynn, & Bannon, 2005; Huang, Stroul, Frei dman, Mrazek, Freisen, Pires, & Mayberg, 2005; Bussing, Zima, Gary, & Garvan, 2003). As e xplained by Simpson, Scott, Henderson, & Manderscheid (2002), children with the highest level of perceive d unmet medical needs or who were unable to afford counseling were those who were uninsured, living in families with income below 100% of the poverty level, or who lived with a single parent(p. 117). The number of uninsured children, who are most at risk for not receiving adequate care, is increasing in the United States. According to the US Census Bureau, as of August 2004 (www.census.gov/Press-Release), 8. 4 million, 11.4% of all of the children in the United States, were uninsured. Foreign born Hispanic childr en had the highest pr oportion of uninsured members with 32.7%, followed by African-American children with 19.5% uninsured, and white children with 11.1% uninsured. These numbers have increased over the past several years in spite of expansions of government programs and the recent development of the State Childrens Health Insurance Program (SCHIP) which make nearly half of all children potentially eligible to receive public health insura nce benefits (Howell, 2004, p.1). However, since not all of the

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15 potentially eligible youth are enro lled, their access to all forms of health care, including mental health care, remains problematic. Children without health insurance coverage we re three times less likel y to receive mental health services than were children who had Medicaid or other insurance (Howell, 2004), reinforcing the idea that the children most in need of mental health services were the least likely to get them. Possible causal explanations for the delay or failure to receive services have been many and complex. Causes ranged from parents lack of confidence in professionals and a preference for seeking help from family and nei ghbors, to parental worries about stigma (Arcia, Fernandez, Marisela, Castillo, Ruiz & Part in, 2004;French, Reardon, & Smith, 2003; McMiller & Weisz, 1996; Smith, 2005) to lack of income a nd transportation (Arcia, Fernandez, Marisela, Castillo, Ruiz & Partin, 2004; Bussing, Zima, Ga ry & Garvan, 2003), to fear of reprisal from social service agencies (USGAO, 2003). Conf using Medicaid and insurance regulations (Boothroyd & Armstrong, 2005; Howell, 2004) were also identified as a cause of parents failing to seek treatment for their children. Researchers report that parents perceptions of mental health care have been an important factor influencing childrens attendance versus n on-attendance at health car e facilities. Parenting a child with mental health needs can be very stressful and frustrating (Foldemo, Gullberg, & Ek, 2005; Harden, 2005; Renk, 2005; Scharer, 2002). Pare nts may avoid treatment because they felt blamed by health care professionals for their childrens problems (Harden, 2005), perceived a lack of support from professional staff (Schar er, 2002), and/or lacked a clear understanding of treatment protocols and prognosis (Scharer, 2002). Low-income families in particular experienced specific barriers to seeking help for their children. Smith (2005) identified four barriers frequently presented by low-income client s that seemed to be ignored by clinicians.

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16 The mismatch between clients imme diate needs and therapists goals. The idea that clients are often so overwhelm ed by multiple problems that interventions suggested by clinicians may seem insignificant. A lack of understanding by middle class therapists of the inhere nt privileges and insulation they possess, which Smith calls classist distancing. The cultural stigmatization of mental health services. These issues, combined with possible financ ial and transportation problems emphasize the need for careful listening on the part of mental health and school counselors when working with low income families. Arcia and her colleagues (2004) found that lo w income Hispanic mothers often delayed seeking treatment for their childre ns behavioral problems until th e problems escalated to a point where the stress was untenable. These mothers re ported they lacked knowledge about services available in their area, pointing out the need fo r school counselors to be more concrete and thorough in sharing information about health care options, at leas t for Hispanic parents. Arcia and colleagues (2004) described the help seeking of the group of parents they studied as being similar to pinballs in a game, where they a ppeared to bounce around from agency to agency seeking help for their children, without seeming to have a plan or method for obtaining help. All of these issues may be compounded for low-inco me African-American families, who often have negative perceptions of formal helpin g networks in general (Logan, 2001). African-American Families According to the United States Census Bur eau (2004), 12.7% of the total population of the country lived in poverty. However, 24.7% of African-Americans versus only 8.6% of whites lived in poverty. The highest per centage of poor people (14.1%) lived in the southern part of the country as compared to 11.6% in the north and Midwest. Th e number of African-American

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17 families living in extreme poverty, which is defined as a family of three with an annual income below $7,610, has increased precipitously si nce 2000 (Childrens Defense Fund, 2005). The impact of poverty on the emotional well -being of African-Am erican children is staggering. According to Chow, Jaffee, & Snow den (2003), African-American children in high poverty neighborhoods were significantly more likel y than their middle-class peers, or than white, Hispanic, or Asian children in poverty, to be referred for ear ly mental health intervention services. Moreover, low income African-American children were f ound to be over represented in the special education diagnostic cat egory of children with severe emotional disturbance (Colpe, 2000). Poor African-Americans of all ages were more likely to be hospitalized for mental health problems and to be diagnosed as schizophrenic. African-Americans in general were less likely than whites to receive mental health counseling and more likel y to receive pharmacotherapy at mental health clinics (Richardson, Anderson, Fl aherty, & Bell, 2003). One study estimated that African-American adults received approximately 50% less outpatient mental health services of any type than their white counterparts (Lasse r, Himmelstein, Woolhandler, McCormick, & Bor, 2002). This result held true even when income variables were controlle d (Alegria, Canino, Rios, Vera, Calderon, Rusch, & Ortega, 2002). Africa n-American adults seeking treatment for substance abuse or mental health problems were found to have greater unmet needs than whites (Wells, Klap, Koike, & Sherbourne, 2001). African-American children were also more likel y than were white or Hispanic children to be referred coercively to services, meaning th ere were negative conse quences resulting from non-attendance such as; removal from the home and placement in group homes, Juvenile Justice or other punitive settings (Stevens, Harman,& Kelleher, 2005; Takeuchi, Bui, & Kim, 1993).

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18 Even forty years after the American Civil Rights Movement, African-American children were still more likely than child ren of all other racial groups to be removed from their homes due to abuse or neglect, and were more likely not to be returned to their families by social service agencies (Ghose, 2006). African-American childr en made up only 15% of the entire child population of the United States in 2004, yet cons tituted 27% of children living in foster care (Ghose, 2006). Even though African-American childre n had far more contact with social service agencies than white children, they were far less likely to receive adequa te mental health care (Angold, Erkanli, Farmer, Fairbank, Burns, & Co stello, 2002; Takeuchi, Bui, & Kim, 1993). African-American Males African-American males were over represented in almost every negative category of outcomes in America at the dawn of the 21st century. Fifty two per cent of African-American males who left school without graduating have pris on records before the age of thirty (Day-Vines & Day-Hairston, 2005). African-American men were over-represented in the prison population in the United States with 3218 out of ever y 100,000 African-American men in prison in 2005, as compared to 1220 of every 100,000 Hispanics and 463 of every 100,000 White men (U.S. Department of Justice, 2006). African-American boys were more likely to be adjudicated and face serious more consequences in juvenile court than white boys (Breda, 2003). AfricanAmerican men lead the nation in unemployment, new HIV infections, suicides, and homicide deaths (Noguera, 2003). These disturbing negative trends extend into academic performance as well. AfricanAmerican boys were dramatically over-represe nted in special education classrooms. While comprising only 15% of the population of the Un ited States in 2001, African-American children were over-represented in specifi c learning disabilities (18%), me ntal retardation (34%), and emotional disturbance (28%) categories (OSEP, 2005). African -American males made up a

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19 majority of students identified as emotionally disturbed in th e United States (Colpe, 2000). African-American male students were far more lik ely than their white or female peers to be suspended, expelled, or subjected to corporal punishment (National Center for Education Statistics, 2001). Conversely, Af rican-American males were di sproportionately absent from advanced courses and college campuses (Noguera, 2003). There have been many possible causes for thes e discrepancies put forward by researchers. African-American boys who attende d schools in high poverty areas we re more likely to be taught by poorly prepared and inexperienced teacher s (Day-Vines & Day-Hairston, 2005). For those African-American males who lived in poverty, h ealth concerns may have fueled excessive absences which interfered with learning (Rothstein, 2004). Childre n in poverty in general also tended to receive less help and support from thei r parents for academic issues. However, not all underperforming African-American males were fro m poor families, thus seeming to underscore the influences of race and gender as potentially more powerful variables than social class and wealth. There are many theories as to why African-A merican males suffer negative life outcomes in such large numbers. Three of these theories including social and cultural capital differences, social class world view theory, and oppositional cu lture theory are discussed in the next section. Cultural and Social Capital Theory In examining issues of poverty, social cl ass, and race a discussion of cultural capital theory is helpful in understandi ng how these factors pe rvade everyday life, in cluding health care and education. In the 1970s sociologist Pierre B ourdieu coined the term cultural capital to refer to an individuals access to signals such as styles, attit udes, ideas, jargon, and preferences that either help or hinder people from enteri ng high-status social groups (Bourdieu, 1977). The

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20 purpose of the signals was purported to be maintenance of the status quo among those occupying the higher strata of society. Around the time Bourdieu was writing about so cial capital, anthropologist John Ogbu was writing about social caste in the United States and its role in Afri can-American life. Ogbus theory was that African-American achievement su ffered due to the history of repression and enslavement of Africans in the United States. According to Ogbu (1978) the enduring legacy of racial discrimination resulted in lower expect ations of African-Americans for success in traditionally white middle class American instituti ons, such as schools and corporate workplaces. Ogbu pointed to the differences in expectations of the possibility of succ ess in the United States held by recent immigrants of African extrac tion versus those of African-Americans who descended from slaves. Recent African-American im migrants tended to be more hopeful about their ability to achieve success in America, while those descended from slaves tended to be more mistrustful of white middle class culture and in stitutions and less hopeful about their chances of achieving middle class success. Furthermore, am ong African-Americans who were not recent immigrants, being successful in mainstream white America could be perceived by peers as acting white and betraying ones culture (O gbu, 2001). The idea that African-American youth lower their expectations and desire for ach ievement became known as oppositional culture theory (Carter, 2003). Recently, researchers have c ontested the idea that African-American youth do not share the same aspirations as American youth of other races (Carter, 2003). Carter and others (Hall, 1992; Lareau, 2000) argued that instead of opposi ng achievement in tradi tional terms (going to college, getting a good job), African-American yout h resist the cultural default of white middle class standards of dress, musical taste, and interactional styl es (Carter, 2003, p. 137).

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21 Instead, African-Americans (and perhaps other minorities) developed both dominant and nondominant cultural capital (Carte r, 2003). That is to say, Afri can-American people develop and maintain their ability to employ differential standa rds of dress, speech, and behavior in order to function differently in va rious cultural contexts. In a recent qualitative study of forty four African-American adoles cents, Carter (2003) learned that all of the study participants used both non-dominant (African-American) cultural capital and dominant (white) cultural capital in their daily lives. In most cases, the students used dominant social capital for instrumental purposes (to please teachers or to make good grades) and non-dominant social cap ital to express themselves and gain acceptance from other African-American youth as authentic memb ers of the African-American community. Balancing both sets of cultural capital succ essfully, although difficult, seemed to allow participants to be successful both in the white world a nd in their racially-identified communities. Continually reading social signals f iltered through two very different lenses and deciding which set of social sk ills to apply was reported to be a source of stress by the adolescents in Carters study. African-American males in academic settings often experienced the cultural disconnect between themselves and their teachers as a lack of respect (Ladson-Billings, West-Olatunji, Baker & Brooks, 2007). Some researchers asserted that African-American males greatly value being respected, and when they feel they are no t respected at school, this feeling can lead to disruptive behavior, disengagement, and academ ic failure (Noguera, 2003). It seems possible that in attempting to view the world through multiple and conflicting lenses, African-American males may experience great distress and dissonance.

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22 In applying Lius (2001) construc t of social class world view to the concept of dominant and non-dominant forms of cultura l capital, it is possible to s ee that African-Americans could feel a nearly constant sense of cognitive dissonance by rejecting the dominant worldview for the non-dominant, and vice-versa. Not having a si ngle set of lenses through which to judge appropriate versus inappropriate actions for any given setting could lead to frustration and confusion. This may be especially problematic when the dominant and non-dominant cultures demand nearly opposite reactions to similar situ ations. Furthermore, it would seem that younger African-Americans and/or those who have greate r difficulty switching between cultural lenses may experience more conflict and distress about having two sets of intrapsychic frameworks by which to judge cultural and social situations. To what extent this duality of cultural and class framing affects African-Americans who are maki ng decisions about seeking help for their childrens mental health problems remains unknown. Conceptual Framework When conducting research with people in pove rty, it is helpful to distinguish socioeconomic status (SES) from social class in order to clearly define what is being studied. Both SES and social class are importa nt factors in examining the li ves of people. Social class, although less well defined in counseling and psychol ogical literature, was of greater interest in this study. According to Liu, Ali, Soleck, Hopps, Dunston & Pickett (2004) a person in an, SES framework is assumed to occupy a temporary pos ition because he or she is socially mobile around the hierarchy (p. 15), wher eas social class impacts a pe rsons life long world view. For example, an aristocrat may lose all of his money, yet re tain the bearing, opinions, and attitudes of the upper class, while a child from a very poor fam ily may grow up to be wealthy, yet retain his or her original outlook on life, values, and attitudes.

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23 In Lius (2001) social class worldview m odel, social class was divided into three components. First, people tend to live up to expectations placed on them by their local environment in order to maintain homeostasis both cognitively and emotionally. Failure to meet the expectations of the other members of a persons social class causes a form of cognitive dissonance, which Liu refers to as internalized classism Liu further divides the economic cultures demands into three types of cultural ca pital: social (networks of contacts), cultural (tastes and preferences), and human capital (abilities and skills). The second component of Lius social cl ass worldview model is the intrapsychic framework." A person uses his or her intrapsych ic framework as a lens through which he or she examines and makes sense of the economic and soci al cues and demands of class. The lens is used to filter information about the social a nd economic environment, and respond appropriately within it. Manners, economic choices, relations hips to property, and choice of peers are all filtered through the lens of th e intrapsychic framework. The third component of Lius so cial class worldview model is classism. In this sense, classism is a social psychologica l construct whose purpose is to encourage people to engage in behaviors congruent with his or he r perceived social class. Classi sm can be upward (e.g. feelings against those one considers to be snobs) downward (e.g. feelings against those one sees as trashy or common) or la teral (e.g. keeping up with th e neighbors). Classism can be experienced as external pressure, (e.g. peer pressu re to engage in class-a ppropriate behaviors), or as internal pressure (e.g. pressure within the individual to behave consistently with group norms). How internal models of class and feelings of classism affect people seeking mental health care has not yet been explored in the professional literature. Howe ver, the social class worldview model was chosen as the conceptual framew ork for this study, si nce current research

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24 demonstrates dramatic differences in use patterns of health care between so cial classes and racial groups, with low income African-Americans being least likely to access se rvices (Bussing, Zima, Gary, & Garvan, 2003; Chow, Jaffee, & S nowden, 2003; French, Reardon, & Smith, 2003; Harden, 2005; McKay, Lynn, & Bannon, 2005; Huang, St roul, Freidman, Mrazek, Freisen, Pires, & Mayberg, 2005; Potter, et al. 2002 ). Phenomenological Theoretical Framework Since little is known about the subjective, internal process of making decisions about mental health care among poor African-American parents (Van Galen 2004), a qualitative methodology was chosen for this study. Qualitative re search allows the res earcher to learn about the lived experience of the populatio n of interest. Instead of collec ting large amounts of data at a superficial level from a large sample of families, qualitative inquiry yiel ds rich, deep, and often unexpected information from the first person perspective in a smaller number of families (Strauss & Corbin, 1990). To learn about the actual lived experience of families in poverty who are referred for mental health care for their children by school pers onnel, phenomenological research methods were used in this study. The goal of all phenomenol ogical research is to return to the things themselves (Husserl, 1970). In other words, the purpose of conducting research is to, understand phenomena in their own terms, to provid e a description of human experience as it is experienced by the person herself (Bentz & Shapiro, 1998, p. 96). The phenomenological researchers task is to understand the subject at hand from the point of view of the participant, in the most direct way possible. In phenomenological research, the investigator enters the life world of the participants by leaving behind his or her preconceived ideas of how things should be (Wertz, 2005). The researcher then gathers data, us ually via interviews, a nd/or archival means, and reflects on the

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25 meanings and subjective realities of the phe nomena under considerati on (Wertz, 2005). The phenomenon is perceived and described in its to tality, in a fresh and open way (Moustakas, 1994, p. 34). Through a series of reflections on the meanings within the data, the researcher constructs a portrait of the experience of the participants. Need for the Study Although the intervening years have seen the advent of important multicultural scholarship regarding ther apeutic biases around other aspects of difference, classist bias has gone largely unexamined, and psychologists know little mo re today about the th erapeutic experiences of poor people today than they did decades ago (Smith, 2005, p. 687). Much of the current research examining poor childrens experiences in mental health ca re is actuarial in nature; it focuses on large numbers of children from vari ous racial, ethnic, or income groups accessing care (Busch & Horowitz, 2004; Bussing, Zima Gary, & Garvan, 2003; Chow, Jaffee, & Snowden, 2003; Howell, 2004; Samaan, 2000; Simp son, Scott, & Henderson, 2002; Pottick, et al., 2002; Stevens, Harman & Kelleher, 2005). Although the interplay between ke y variables such as race, et hnicity, income, and mental health is by no means clear-cut; th e results of the research has established that children in lowincome neighborhoods, particularly those of color, s eem to be referred to services more often and more coercively, and seem to eith er drop out prematurely or never attend couns eling at all. This circumstance may be due at least in part to convoluted nature of insurance and Medicaid rules, which change often and can be difficult to negotiate (Boothroyd & Armstrong, 2005; Howell, 2004; Johnson, Knitzer, & Kaufman, 2002; Puma reiga, Nace, England, Diamond, Fallon, & Hanson, 1997; Willging, Waitzkin & Wagner, 2005) However, the factors underlying the inability or unwillingness of low-income parents to bring their children for mental health service

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26 are not well understood (Arcia, Fe rnandez, Marisela, Castillo, & Ruiz, 2004; Bussing, Zima, Gary & Garvan, 2003; Earls, 2001; French, Reardon, & Smith, 2003; Renk, 2005). Smiths (2005) argument that classist distan cing (p. 693) hampers the effectiveness of mental health services is echoed by Van Galen ( 2004) in her call for more voice to be given in the professional literature to poor clients. She posits that middleclass researchers too often speak for poor people, and although the intentions of th e researchers may be noble, the poor are still left voiceless. More information about when, how, and why low-income parents seek help for their childrens mental health problem s is needed. A greater understanding of the process of helpseeking from the parents point of view is also needed. Gaining a clearer picture of the reasons low income parents decide to access mental heal th services, and their difficulties in doing so, would help counselors more eff ectively engage low-income clie nts, and perhaps contribute to helping clients remain in couns eling until their goals are reached. Understanding more fully what low income parents experience in seeking out ment al health services woul d also be helpful to referring agents, such as school counselors, family medical professionals, and social workers. By making more relevant and effective referrals, th e referring agents might reduce the pinball effect of delaying help seek ing until the problem becomes unt enable (Arcia, Fernandez, Marisela, Castillo, & Ruiz, 2004). Purpose of the Study The purpose of this study was to describe the phenomenon of low-income AfricanAmerican boys being referred to mental health services by school counselors from the point of view of their caregivers. U nderstanding the essence of the experience of African-American families who are referred to mental health se rvices by school counselors would enhance our current understanding of the dynamics of how where, and when poor African-American

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27 caregivers access mental health care services for their childre n. Caregivers feelings, thoughts, and perceptions of the referral were explored. Research Questions 1) What is the lived experience of low-in come African-American caregivers referred for mental health services for their sons? A) What are the initial re actions (thoughts, feelings, a nd actions) of the caregivers to the school counselors referral of th eir child to mental health services? B) How do the caregivers perceive the school staff making the referral during and after the referral meetings? Definition of Terms Poverty: A condition that extends beyond the lack of income and goes hand in hand with a lack of power, humiliation and a sense of exclus ion. Defining it solely from the income level or as an inability to acquire basic food and shelter limits our ability to understand its true nature and make effective interv entions (Raphael, 2005). Phenomenology : to describe things in themselves, to permit what is before one to enter consciousness and be understood in its meanings a nd essences in the light of intuition and selfreflection. The process, involves a blending of what is really pres ent from the vantage point of possible meanings; thus a unity of re al and unreal (Moustakas, 1994, p. 27). Low-income: Participants in this study will have family income sufficient to qualify their children for free or reduce d school lunch, as determined by federal guidelines. Mental health services referral : Children of the participants in this study will have experienced some sort of behavioral or emoti onal problem at school which has prompted school counselors to request that the parents of the child arrange for mental health treatment outside of

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28 the school in order to ameliorate the problem. Problems ma y vary in severity and duration. However, this must be the first attempt by the current school counselor to refer the family for treatment. Parents may or may not choos e to access mental health services. Mental Health Counseling: Mental Health Counseling is the provision of professional counseling services, involvi ng the application of princi ples of psychotherapy, human development, learning theory, group dynamics and the etiology of mental illness and dysfunctional behavior to individuals, couples, families, and groups, for the purposes of treating psychopathology and promoting optimal mental health. The practice of Mental Health Counseling includes, but is not limited to, diagnosis and treatment of mental and emoti onal disorders, psycho educatio nal techniques aimed at the prevention of such disorders, consultation to individuals, couples, families, groups, organizations, and communities, a nd clinical research into more effective psychotherapeutic treatment modalities. (Ame rican Mental Health Couns elors Association, 2007).

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29 CHAPTER 2 REVIEW OF THE LITERATURE Introduction This chapter summarizes the current level of knowledge in the counseling field about the pathways to mental health services for Afri can-American children in poverty. Mental health service issues, as well as ways families are referred to services are discussed. Since many children are referred to mental h ealth care services by school counsel ors, their referral practices are reviewed, as are more general educational issues concerning low-income African-American students. Research on the programmatic aspects of mental health care delivery to poor children in the United States, and in Florida in particular, is reviewed. Professional literature examining client issues affecting mental health care is discussed. Client focused issues include: cultural contextual and historical issu es specific to African-Americans, caregivers and childrens perceptions of mental health care barriers to finding and entering me ntal health care services for children, and how parents report making decisions about accessing mental health care for their children. School Counselor Referral Practices One of the primary roles of school counselors is to help students families find and access a variety of community services (Baker, 1996; Erford, 2003 Ritchie & Partin, 1994). School counselors often play a critical role in stude nts families accessing mental health services, however, there is limited professi onal literature available to help school counselors understand the complex issues involved in making these referrals In particular, there is a dearth of literature for school counselors regarding making referrals for low-income families of color, even though these families comprise the majority of patients at mental health clinics (Bussing, Zima, Gary, &

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30 Garvan, 2003; Pottick, Warner, Isaacs, He nderson, Milazzo-Sayre & Manderschied, 2003). Many current school counseling texts offer some information for beginning counselors regarding making referrals to outside agencies. Ritchie and Partin (1994) reco mmended that school counselors give parents as much concrete info rmation as possible when making referrals to outside services, such as cont act names, telephone numbers, cost of services, and types of treatment available. Another model for school counselors to cons ider when making referrals to community agencies is outlined in Apter (1992). The direc tion model was originally developed to assist families with disabled children to navigate the complex system of medical and social helping agencies. In this model, counselors develop a trus ting relationship with parents, then talk with parents to ascertain what types of help they wa nt, give parents choices about which services to access, give specific information about what each agency does and how to make contact, and then provides follow along and follow up assi stance (Apter, 1992, p. 495). When this model was developed and implemented in New York State, ove r 70% of families reported being able to find and access needed services for their disabl ed children (Musumeci & Cohen, 1982). Also absent from the school counseling lit erature are guidelines for school counselors about making effective referrals for low income fa milies to outside agencies. Very little has been published in recent years about the referral prac tices of school counselors, even though making referrals is an important aspect of the school counselors job (Baker, 1996; Brown & Trusty, 2005; Davis, 2005). School counselors make an averag e of thirty referrals per year, primarily for help with emotional and family concerns (R itchie & Partin, 1994). A lthough the counselors Ritchie & Partin surveyed twelve years ago re ported mostly positive experiences with making

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31 referrals to outside agencies, a significant num ber (48%) also reported occasional frustration with parents not following through on their recommendations (Ritchie & Partin, 1994). Most current school counseling textbooks offer some variation on the following advice to new professionals about maki ng out-of-school referrals: Know what resources are av ailable in your community. Be aware of laws and policies regard ing sharing confidential information. Develop collaborative working relationships with the care provid ers in your area. Keep some record of the dates and places families were referred to service providers (Baker, 1996; Brown & Trusty, 2005; Er ford, 2003; Ritchie & Partin, 1996). Some texts also offer models for problem-so lving with families in crisis (Baker, 1996; Erford, 2003) which could be employed when ma king referrals. However, only Erfords text offers a chapter on helping what is termed at-ri sk students, which is a broadly used and ill defined term; none of the texts seemed to incl ude any guidance on working with families in poverty per se ( Brown & Trusty, 2005; Davi s, 2005 both include chapters on multicultural counseling, but focus only on race and heritage issu es, not class). Additionally, most texts do not differentiate between sub-groups within races, such as MexicanAmerican versus South or Central American or Caribbean Hispanics, or between Haitian and Afri can African-Americans. Conversely, a large percentage of children seen in mental health facili ties have a history of school problems and are initially referred by scho ol counselors or teachers. The research that does exist on the process poor families experience between initial referra l for and entry into mental health services suggests that there is often a long dela y between the two (Chow, Jaffee & Snowden, 2003; French, Reardon, & Smith, 2003; Potter, et al, 2002; McKay, Lynn, & Bannon, 2005; Huang, Stroul, Freidman, Mrazek, Freisen, Pires, & Mayberg, 2005; Bussing, Zima, Gary,

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32 & Garvan, 2003). During this delay, children s problems often worsen, and parents feel overwhelmed and frustrated by the time they reach the clinic. Race and Class Issues in Academic Settings In academic settings, African-American children continue to struggle, regardless of family income. African-American students account for 33.4% of all suspensions from school and 14.7% of dropouts (Day-Vines & Day-Ha irston, 2005). African-American ch ildren in American public schools are lagging behind their white and Asia n peers on many academic success indicators, although Hispanics continue to have a higher drop out rate than Africa n-Americans. According to the Educational Trust, African -American students made signifi cant gains in both reading and math during the 1970s and 1980s, only to lose ground again in the 1990s. The achievement gap between African-American and White children in 2005 was 10% greater than in 1990. In a recent study conducted by the Educa tional Trust, African-Amer ican students in the 12th grade had math and reading skills commensurate with the math and reading skills of white eighth graders (www.edtrust.org ; retrieved 7/26/06). As in the family counseling literature, there is a body of work that attempts to explain some of the academic achievement gaps betw een African-American and White children. Many theorists invoke Bourdieus cult ural capital idea, which claims that children learn the invisible rules of various social classes from parents and other adults. They can th en use these signals such as styles, attitudes, ideas, jargon, and pref erences to help them enter high-status social groups (Bourdieu, 1977). The purpose of the signals was purporte d to be maintenance of the status quo among those occupying th e higher strata of society. Around the time Bourdieu was writing about so cial capital, anthropologist John Ogbu was writing about social caste in the United States and its role in Afri can-American life. Ogbus theory was that African-American achievement su ffered due to the history of repression and

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33 enslavement of Africans in the United States. According to Ogbu (1978) the enduring legacy of racial discrimination results in the low exp ectations of African-Americans for success in traditionally white middle class American instituti ons, such as schools and corporate workplaces. The idea that African-American youth lower thei r expectations and desire for achievement became known as oppositional culture theory (Carter, 2003). Together, the theories of cultural capital a nd oppositional culture theory have been coopted to create a deficit model of minority stude nts. Some writers, such as Ruby Payne, have distilled the complex theories of Bourdieu and Ogbu down to a model of weakness and remediation (Payne, 1996). According to the defi cit view of cultural capital, minority and poor students would be able to achieve more academically if the schools explicitly teach them the hidden signals of middle class culture (Payne, 1996). Recently, researchers have cont ested the idea that African-American youth do not share the same aspirations as American you th of other races (Carter, 2003) Carter and others (Hall, 1992; Lareau, 2000; Majors, 2001) argue that instead of opposing achie vement in traditional terms (going to college, getting a good job), African-Ame rican youth resist the cultural default of white middle class standards of dress, musical taste, and interactional styles (Carter, 2003, p. 137). Instead, African-Americans (and perhaps ot her minorities) develop both dominant and non-dominant cultural capital (Carter, 2003). That is to say, African-American people develop and maintain the ability to employ the standards of dress, speech, and behavior in order to function differently in va rious cultural contexts. In her recent qualitative study of 44 African-A merican adolescents, Carter (2003) learned that all of the study participants used both non-dominant (African-Ame rican) cultu ral capital and dominant (white) cultural capital in their daily lives. In most cases, the students used

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34 dominant social capital for in strumental purposes (to please teachers, make good grades) and non-dominant social capital to express themselv es and gain acceptance from other AfricanAmerican youth as authentic members of th e African-American community. Balancing both sets of cultural capital succe ssfully, although difficult, seemed to allow participants to be successful both in the white world and in their racially-identified communities. Continually reading social signals filtered th rough two very different sets of lenses and deciding which set of social skills to apply was reporte d to be a source of stress for th e adolescents in Carters study. In applying Lius (2001) construc t of social class world view to the concept of dominant and non-dominant forms of cultura l capital, it is possible to s ee that African-Americans may experience a nearly constant sens e of cognitive dissonance by reje cting the dominant world-view for the non-dominant, and vice-versa. Not having a single set of lenses through which to judge appropriate versus inappropriate actions for any given setting, but a double set from which to choose would likely lead to frustration and conf usionparticularly when the dominant and nondominant cultures demand nearly op posite reactions to similar situ ations. Further, it would seem that younger and/or those African-Americans for whom switching between cultural lenses is more difficult may experience more conflict and di stress about having two sets of intrapsychic frameworks by which to judge cult ural and social situations. Whet her or not, or to what extent, this duality of cultural and class framing af fects African-Americans when making decisions about whether and how to seek help for mental health problems remains unknown. Intersecting Issues of Race and Class in Mental Health Referrals In spite of hints in the litera ture that both race and class impact both how people perceive and access mental health care in the United States it is not clear how e ach factor influences peoples ideas and actions regardin g mental health care. As disc ussed in Chapter One of this document, African-Americans are vastly over represented among the poor (US Census Bureau,

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35 2004). The impact of poverty on the emotional well-being and educationa l outcomes of AfricanAmerican children is staggering. According to Chow, Jaffee, & S nowden (2003), AfricanAmerican children living in high poverty neighborhoods were signifi cantly more likely than their middle-class peers, or than white, Hispanic, or As ian children in poverty, to be referred for early mental health intervention services. Low inco me African-American children were found to be over represented in special educational categories for children with severe emotional disturbance (Colpe, 2000). Poor African-Americans were more likely to be hospitalized for mental health problems and to be diagnosed as schizophrenic. African-Ame ricans in general are le ss likely than whites to receive mental health counseling and more likely to receive pharmacotherapy at mental health clinics (Richardson, Anderson, Flaherty, & Bell, 2003). African-Americans are also more likely to be referred coercively to services, meani ng there are negative conse quences resulting from non-attendance than are white or Hispanic child ren, such as; removal from home, entry into group homes, Juvenile Justice or other punitive settings (Stevens, Harman, & Kelleher, 2005; Takeuchi, Bui, & Kim, 1993). African-Americans in counseling are sometime s perceived by White therapists as guarded, reluctant, or hostile due to differences in la nguage and social norms (Logan, 2001). Negative perceptions may go a long way in explaining both why African-Americans frequently leave counseling early and are less likely to attend in the first place. As a result of generations of powerlessness and rebuke, many Af rican-Americans feel more comfortable seeking help from informal networks than from formal institutio ns, in spite of recent changes towards a more enlightened and multicultural society (Loga n, 2001). Additionally, some African-American families, particularly those living in poverty, ofte n have negative perceptions of mental health

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36 agencies based partly on confusion about the role of mental health faci lities versus social services agencies. These families sometimes believe that going to counseling can lead to the loss of custody of children or other negative cons equences (Boyd-Franklin, 1989). This view is complicated by the fact that African-American families are sometimes referred to treatment by the courts or social services and are in fact in danger of losing custody of children or facing other negative consequences for non-compliance in counseling (Chow, Ja ffee, & Snowden, 2003; Ghose, 2006). At the intersection of race and family, therapists often find families with multiple problems and need to be aware that basic needs such as food and shelter may need to be attended to prior to intervening in family systems or other i ssues (Boyd-Franklin, 1989; Madsen, 1999). Failure to recognize or address these issues can lead to a mismatch between therapist and family goals and dissatisfaction with counseling (Smith, 2004). Therap ists are often not trai ned to attend to basic needs in multi-stressed families, nor are they often trained to be aware of different ways AfricanAmericans in America may perceive themselves with in the context of race and class, thus further hampering the therapists ability to join eff ectively with the family (BoydFranklin, 1989; Madsen, 1999). Mental Health Needs of Low-Income Children As defined by financial parameters, 16% of American children lived in poverty in 2002, and one in four families in the United States with young children earned less than $25,000 a year (Child Welfare League of America, October 23, 2005). The current federal poverty level (FPL) is $19,157 per year for a family of four. Low inco me is calculated as 100-200% of the FPL for a family of four (US Census Bureau, 2005). In terms of raw numbers, over 13 million children in the United States were reported to be living at or under the povert y line, an increase of 12.8%

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37 over the number reported in 2000 (Childrens Defe nse Fund, 2005). Of course, financial need is one of many defining ch aracteristics of poverty. Poverty is detrimental to the mental health of children. Research reveals that children who live at or below the federal poverty line ar e significantly more likely to report increased levels of anxiety, depression, and antisocia l behaviors (Samaan, RA, 2000; Caughy, OCampo, & Muntaner, 2003; African-American & Kr ishnakumar, 1998; Myers & Gil, 2004). Additionally, children in low-income families tend to exhibit a greater incidence of behavioral difficulties and a lower level of positive engageme nt in school (National Survey of Americas Families, 1999). The negative effects of poverty seem to hold even when racial and ethnic variables are controlled; poverty ap pears to be a more critical factor in the development of negative outcomes in children than is race and ethnicity (Samaan, RA, 2000; Chow, Jaffee, & Snowden, 2003; Takeuchi, Bui, & Kim, 1993). Children living in poverty are also less likel y to have access to health care services, including mental health care, than are their peers from higher socio-economic levels (Boothroyd & Armstrong, 2005; Busch & Horowitz, 2004; Colpe, 2000; Howell, 2004 Stevens, Harmon, & Kelleher, 2005). Moreover, poverty limits childre ns accumulation of social capital, that broad group of intangibles such as family support, educ ational opportunitie s, and enrichment activities, which is reported to impact school achi evement (Caughy, OCampo, & Muntaner, 2003; Christenson & Sheridan, 1997). Parity Issues in Children s Mental Health Service Health care in the United States is in a st ate of turmoil as state and federal agencies struggle with providing care to th e swelling rolls of indigent pa tients. According to the US Census Bureau, as of August 2004 (www.census .gov/Press-Release), 11 .4%, or 8.4 million, of all children in the US were uninsured. Foreign born Hispanic children had the highest proportion

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38 of uninsured members, with 32.7%, followed by African-American children, 19.5% uninsured, and white children, 11.1% uninsured. These numbers have been increasing over seve ral years in spite of the expansion of government programs and the recent development of State Childrens Health Insurance Program (SCHIP) which make nearly half of all children potentially eligible to receive public health insurance benefits (Howell, 2004, p. 1). About one in ten children in the United States used some form of mental health service in 2002, according to the National Survey of Americas Families. However, children with no health insurance co verage were three times less likely to avail themselves of mental heath services than were children who had Medicaid or other forms of insurance (Howell, 2004). Twenty percent of children in the US are estimated to have treatable mental health problem, while one in ten children is estimated to have a serious mental health need (Pottick, Warner, Isaacs, Henderson, Mila zzo-Sayre, & Manderscheid, 2002). However, children living in poverty are twice as likely to demonstrate serious needs as are middle and upper class children, and a bout 66% of all children with me ntal health needs do not receive treatment (Pottick, Warner, Isaacs, Milazzo-Sa yre, & Manderscheid, 2002). The review of the 1997 Client/Patient Sample Survey (CPSS) data conducted by Pottick, Warner, Isaacs, Henderson, Milazzo-Sayre, & Mander scheid (2002) for the Anni e E. Casey Foundation further revealed that although the numbers of children ac cessing mental heath care facilities increased by 87.1% between 1986 and 1997, increases do not appear to be equitable for children from poor families, poor neighborhoods, or minority groups. For example, African-American children, children in foster care, and children on public assistance are overrepresented in admission to inpatient and residential services as comp ared to their White, middle class peers.

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39 Race, class, and gender disparitie s in mental health care were reported again in a review of the National Health Interview Survey on Disa bility (NHIS-D) conduc ted in the mid-1990s (Colpe, 2000). This national study surveyed ca regivers of over 41,100 school-aged children in the US about childrens health and use of medi cal and mental health services. The NHIS-D data revealed that boys are far more likely than girl s to be identified as having mental health problems. Boys received a reporte d 67.3% of services, compared to 32.7% for girls. This data does not make it clear whether girls need fewer services, or simply have less access. Again, African-American and poor childr en were found to be over repres ented in categories of children with severe emotional disturbance (Colpe, 2000). Simpson, Scott, & Henderson (2002) found in a sample of over 26,500 children that the children with the greatest unmet perceived need fo r mental health services were those who lived in single parent families, were uninsured, and had family incomes of less than 100% of the poverty level. This study also re vealed that 8.8% of t hose children who had been diagnosed with depression and 5% of those chil dren who were diagnosed with ADD lived in families that could not afford counseling or other needed services. Location may also be a factor in childrens a ccess to mental health care. Chow, Jaffee, & Snowden (2003) found that minority children living in high poverty neighborhoods were significantly more likely than their middle-class p eers, or than white, Hisp anic, or Asian children living in poverty: a) to be refe rred for early mental health inte rvention services, b) were more likely to be hospitalized for ment al health problems, and c) mo re likely to be diagnosed as schizophrenic. African-Americans were also si gnificantly more likely than whites to be involuntarily brought in for care. This study also reported that white children living in high poverty areas were more likely to use mental hea lth services than white children living in low

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40 poverty areas, possibly confirmi ng the hypothesis that living in high poverty areas induces high stress, which then triggers mental distress. In another large scale quantitative study, Angold, Erkanli, Farmer, Fairbank, Burns, Keeler, & Costello (2002) surveyed 920 parent s of public school students in North Carolina about their childrens behavior. Similar num bers of white (21.9%) and African-American (20.5%) respondents met criteria fo r DSM IV diagnosis. However, white students were almost twice as likely to be engaged in mental health services as African-American students (6.1% vs. 3.2%). These results are reinforced by the work of Alegria, Canino, Rios, Vera, Calderon, Rusch, & Ortega (2002) using a national sample of 8,098 people. They found that even when insurance and income status were controlled, Af rican-Americans were almost half as likely as whites to receive mental health care. Barriers to Mental Health Treatment for American Children in Poverty Research reveals that although children living in poverty are mo re likely to need mental health care services, they are less likely to receive adequate help than their non-poor age mates (French, Reardon, & Smith, 2003; Pottick, Warner, Isaacs, Milazzo-Sayre, & Manderscheid, 2002; McKay, Lynn, & Bannon, 2005; Huang, Stroul, Freidman, Mrazek, Freisen, Pires, & Mayberg, 2005; Bussing, Zima, Gary, & Garva n, 2003). These findings are supported by both indepth qualitative studies (Arcia, Fernandez, Ma risela, Castillo, & Ruiz, 2004; French, Reardon, & Smith, 2003; Wilton, 2003) and by larger-scale qua ntitative studies (Busch & Horowitz, 2004; Bussing, Zima, Gary, & Garvan, 2003; Chow Jaffee, & Snowden, 2003; McKay, Lynn, & Bannon, 2005; Pottick, Warner, Isaacs, Milazzo-Say re, & Manderscheid, 2002; Takechi, Bui, & Kim, 1993). Several policy analyses confirm thes e findings as well (Howell, 2004; Huang, et al, 2005, Leventhal, 2003; Smith, 2005).

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41 The reasons for this are complex and not completely understood (ONeal, 1998; Bussing, Zima, Gary, & Garvan, 2003; African-American & Krishnakumar, 1998). Several factors have been identified as barriers to mental health service for poor children in the United States. According to the US Surgeon Generals Report on Childrens Mental Health (1999), the major types of barriers to mental health services for poor children are; service delivery issues including state and federal policies, and family difficulties. Each of these will be examined in some detail here. Service delivery issues in mental health ca re are broad ranging and complex. According to Dr. Michael Hogan, of the Pres idents New Freedom Commission on Mental Health (2002), a fragmented services system is one of several sy stemic barriers impeding th e delivery of effective mental health care. (Cited in Childrens De fense Fund Report on Child rens Mental Health Care, www.cdf.org accessed 10/01/2005). The report cites: a) a lack of coordination between agencies, particularly between Medicaid and privat e providers, b) a lack of resources, including lack of public funds for care, c) a lack of qua lified providers willing to accept low Medicaid reimbursement rates for services, and d) a la ck of communication between state and federal agencies, and conflicting policies, as major barriers to services. States abilities to design their own Childrens Health Insurance Programs give fl exibility to state level lawmakers, but also mean that there is no national standard for car e or coverage (Howell, 2004). Medicaid requires that children who are exhibiting symptoms of possible mental health problems receive comprehensive developmental screenings, but states have the flexibility to cover or not cover this service in their SCHIP plans (CDF, 2005). Additionally, although federal law requires children who receive screenings for mental health issues to be granted access to needed follow up care,

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42 individual states may limit acce ss to such services under the st ate-administered health care program (CDF, 2005). Alongside the tangle of state and federal regulat ions and difficulties in policy alignment, families who live in poverty face more quotidian barriers to accessing care. Cultural-contextual issues, such as a stigma agains t help-seeking, negative expectations financial barriers, and a lack of perceived need for services hamper some groups of families from receiving care, as found in Bussing, Zima, Gary, & Garvans (2003) study of help-seeking behavior for families with children diagnosed with ADHD. Lack of informa tion about how to access services, what services are available, and denial of the severity of a childs need for help are also common among lowincome mothers (Arcia, Fernandez, Marisela, Castillo, & Ruiz, 2004). Families in rural areas may have difficulty finding transportation to appointments (Meyers & Gill, 2004). Homeless families often face the additional difficulty of not having an address or telephone number to receive communications from heath care providers (French, Reardon, & Smith, 2003). Additionally, many families are referred for mental health services by school personnel who may not be aware of the difficulties facing lo w income families in following through on their recommendations (Apter, 1992). As an additional hurdle to understanding low income families experiences, social class is not a well defined construct in social science research (Liu, Ali, Soleck, Hopps, Dunston & Pickett, 2004). Perhaps the most insidious trend in families reluctance to seek out mental health services for their children is highlighted in a report fr om the U.S. General Accounting Office (2003). The GAO report outlines the phenomenon of parents havi ng to give up custody of their children to the state in order to access mental health ca re for more serious, chronic problems. The GAO estimated in that in 2001, more than 12,700 children were placed in the custody of state agencies

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43 solely to make them eligible for expensive mental health treatments, primarily in residential care facilities. Obviously, families with fewer existing financial resources are more likely to have to make drastic custody decisions to receive treatmen t for their children. However, with residential treatment for mental health prob lems costing in excess of $250,000 per year in some cases, this is an issue that extends to middle class families as well. Barriers to Childrens Mental He alth Services in Florida According to the Childrens Defense Fund ( 2005), there are 704,817 children in the state of Florida living at or below the Federal Povert y line. Most of these children (63.8%) under age 6 live in families where all adu lts are in the labor force. In Florida, 677,000 children under 18 do not have health insurance, which constitutes 16.6% of the entire population of children ages 0-18 in the state. During the fiscal year 1997-98, the most recent year for which statistics are available, The Division of Childrens Mental Health in Florid a served 45,595 children (Department of Children and Families, 2000). Half (22,104) of these childre n were classified as children and adolescents with a severe emotional disturbance, (SED), th e others were classifi ed as having emotional disturbance, (ED) (13,101) or b eing at risk of developing an emotional disturbance (10,390) (DCF, 2000). By far, the majority of the stat e funding spent on Childrens Mental Health Services (CMH) in 1997-98 was focused on the SED population, disproportionate to the number of children in this catego ry who received services. The three categories above were established in 1998 as part of the Comprehensive Child and Adolescent Mental Health Se rvices Act (Chapter 98-5, Laws of Florida). The 1998 law set up the three categories of care, calle d for that care, whether residentia l or outpatient, to be family and community centered, and required providers to tr ack client progress. The bill also cleared the way for the highly controversial privatiz ation of CMH services (DCF, 2005).

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44 Under the Comprehensive Child and Adolescent Mental Health Services Act and Part III of Chapter 394 of the Florida Statutes, the State of Florida provides five types of CMH services: 1) Baker Act, or short-term involuntary commitment services, 2) non-residential mental health services including outpatient counseling, case management, and assessment, 3) residential servi ces including state hosp itals and group homes, 4) the Behavioral Network, a group of providers working with the Department of Children and Families (DCF) to meet the needs of children with SED, and 5) Juveniles Incompetent to Proceed Services, which helps young people with severe disabilities receive counseling, pharmacotherapy, and life skills training, along with assistance in residential placement in concert with the Department of Juvenile Justice (Department of Children and Families, 2005). Services in the first four areas are provided by private agencies under contract with DCF. Services for incompetent juveniles ar e provided under a separate contracting system. Much of the funding for CMH in Florida comes fr om federal Medicaid do llars. Other sources of funding may include block grants, ge neral revenue, and state trust funds. All totaled, the State of Florida spent $101 million on CMH in fiscal year 2005-6, not including expenditures for children receiving mental health services while in the custody of the Department of Juvenile Justice, or through schoo l funded programs. (www.oppaga.state.fl.us/profiles/5014 ). Low-Income Families in Counseling A review of the contents of the Journal of Counseling and Development from 1995-2005, revealed that only 9 articles in cluded terms that directly indica te an emphasis on class and/ or poverty issues. Words such as: at-risk, marginali zed, elitism, disadvantage d, social justice, and lack of money were used as search terms. By co ntrast, 90 articles had titles that included terms related to race, culture, national origin, ethnicity, or multiculturalism. Three special issues of the

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45 journals in the past 10 years have been devoted to issues of multiculturalism, diversity, and race. However, there have been no special issues de voted to oppression and poverty issues as they relate to counseling. Even the Dimensions of Personal Identity Model, which describes multiple internal and external factors shaping a person s identity, does not explicitly include social class, although it does include level of education, work experi ence, and historical context (Arredondo, Rosen, Rice, Perez, & Tovar-Gamero, 2005). Arredondo, Rosen, Rice, Perez, & Tovar-Gamero, (2005) state in the conclusion of their analysis of the Journal of Counseling and Development from 1995-2005 that: No longer can multiculturalism be relegated to one course, mentioned as a passing comment in a publication or presentation, or avoided by educators and administrators (p.160). This powerful statement would be st rengthened by the explicit inclusion of socioeconomic class. A review of the contents of the Professional School Counseling from 1997 to present revealed similar ratios. However, the journals recent sp ecial issue entitled, Professional School Counseling in Urban Settin gs (2005) does include articles on povertyrelated issues. In Liu and colleagues (2004) review of three journals, The Journal of Counseling Psychology, The Journal of Counseling and Development and The Journal of Multicultural Counseling and Development from 1981-2000, discovered that soci al class was only made a key variable in 1.4% of all empirica l research articles, even though so cial class data was collected on participants in 17.5% of studies. Social class was referred to more often in theoretical/conceptual articles, and was at least mentioned as a variable in 33.5% of them. In total, between 20 and 30% of all 3915 articles reviewed mentioned social cl ass in some form. However, only a very small percentage made social class a focus of the re search. These findings highlight the need for far

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46 more research in the general area of social cl ass in counseling literat ure. Liu and colleagues (2004) also found no agreed upon definition of class among the articles reviewed. In a separate content analysis of the Journal of Counseling Psychology from 1973-1999, (1999), Buboltz, Miller, & Williams found that most ( 56%) social class research in the past thirty years has been carried out using college students as research participants, greatly lowering the diversity of the samples. Counselors understand ing of the impact of dual forms of cultural capital, and multiple lenses of social class wo rldviews among African-Americans has not been explored thus far. The majority of research conducted to date on poor families in counseling falls into two general categories: 1) Programmatic research focu s issues such as: numbers of people served by race, age, gender, and other demographic variable s, and what types of services agencies and states offer poor families in need of service (included here would be policy initiatives and insurance programs). 2) Client focused issues, such as: reasons families seek services, perceptions about services and se rvice-providers, and satisfacti on with the outcome and process of getting services. Programmatic Research Focus The vast majority of research on mental health services for poor families falls into this first category. Within the broad area of structural-c ollective issues, four major sub-categories emerge. Race/ethnicity specific re search on service use. Research focused on agency issues such as specific programmatic choices. Research focused on rural and/or urban set tings and their impact on mental health. Research on funding of services such as SCHIP and Medicaid.

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47 Most of the research on progr ammatic research issues uses large-scale and quantitative methodologies, often drawing on census or national survey data. There are some qualitative and smaller scale studies, but they are cl early the minority of the research. Chow, Jaffee, and Snowden (2003), in their rese arch on the effect of race, ethnicity, and poverty on mental health service use, drew data from New York State Hea lth records and the US Census. They conducted a bivariate and logistic al regression analysis and found that AfricanAmericans, Hispanics, and Asians used more serv ices at younger ages than Whites, particularly in high poverty areas. African-Ameri cans in particular were more likely to be diagnosed with schizophrenia than other racial groups, and most lik ely to be referred to mental health services by juvenile justice or child prot ection agencies. Only in low poverty areas, Asian and Hispanic people were more likely than Whites to use inpatie nt services. By contra st, in high poverty areas, Asians and Hispanics were less likely to use inpatient services than Whites. In smaller scale studies, African-American yout h were referred more often for mental health services than were Whites and often more coercively, meaning that they were more likely to be threatened with negative outcomes for noncompliance, such as foster care placement or juvenile justice intervention th an Whites (Stevens, Harman, & Ke lleher, 2005; Takeuchi, Bui, & Kim, 1993). The interplay of race and poverty is still being untangled, with some findings showing that race is the primary factor in ment al health referrals (Cos tello, Keeler, & Angold, 2001; Stevens, Harman, & Kelleher, 2005; Takeuchi Bui, & Kim, 1993), while others claim that poverty is the key variable (C how, Jaffee, & Snowden, 2003; Samaan, 2000). Obviously, further research is needed to examine the effects of both race and poverty on childrens mental health. Which variable contributes more heavily to coer cive referrals and varied treatment outcomes is

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48 not yet clear, but what is appare nt is that poor children, particul arly those of color, are more frequently referred for services. A closely related set of variables which have been studied in some detail are rural and urban dwellers patterns of mental health problem inciden ce and service use. Both rural and inner-city populations are more likely than suburban populations to live in high poverty areas (African-American & Krishnakumar, 1998) making both rural and inner-city children more likely to experience mental distress than child ren in suburban areas. On e innovative longitudinal study followed 550 families who moved from inner city public housing to private housing in more affluent neighborhoods. At the three-year follow up, adults reported much lower levels of stress, and children (boys in particular) reporte d much lower levels of anxiety and depression than did families who remained in public housin g (Leventhal, 2003). Other studies found that the increased stress levels associated with living in high poverty rural area s (Costello, Keeler, & Angold, 2001) and in high poverty urban area s (African-American & Krishnakumar, 1998; Leventhal, 2003; McKay, Nudelman, McCadam, & Gonzales, 1996) appear to contribute to negative mental health outcom es for children and adults. The final two areas of programmatic types of research are closely re lated. Policy decisions frequently drive changes in how agencies ope rate based on changes in funding, and policy is sometimes shaped by research re garding use patterns and epidemio logical data. Of particular interest in the recent past has been the issue of uninsured and underinsured people, and how the lack of adequate insurance coverage impacts thei r use of health care services. Researchers from a variety of professions (Boothroyd & Armstr ong, 2005; Busch & Horowitz, 2004; Howell, 2004; Raphael, 2005; Willging, Waitzkin, & Wagner, 2005) have studied underand uninsured children and have found that lack of coverage negatively impacts service access. Howells

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49 (2004) review of data from the National Survey of Americas Families data found that mental health service use by children w ith Medicaid and State children s health insurance programs (SCHIP) coverage was significantly higher than service use among the uninsured (13.1% versus 4.5%). Howell (2004) also found that although childre n with Medicaid or ot her health insurance used services at nearly three times the rate of uninsured children, they did not have higher reported rates of behavioral or em otional problems, indicating that health insurance coverage is a key variable in helping families of all income levels access appropriate services. There is also a growing body of research addressing the outcomes of varying delivery systems to provide treatment. In particular, th e various forms of managed care and systems of care policies have been under sc rutiny (Huang, Stroul, et al 20 05; Pumariega, et al., 1997; ONeal, 1998; Simpson, Scott, Henderson, & Manderscheid, 2002; Tolan & Dodge, 2005). Most of these researchers argue for a systemic approach to integrated services for families across a broad spectrum of need levels. This idea is ec hoed in the recommendations from the Presidents New Freedom Commission on Mental Health (2003). Highlighted in that report are ten interrelated values aimed at improving access a nd service delivery to children in the United States, based on research from various state a nd national programs. The ten values and their corresponding standards of care are as follows: 1) Comprehensive home and community based services and supports: Endeavors to keep children out of institutional settings, and provi de care in natural settings, such as homes and schools, rather than in hospitals or group homes. 2) Family partnerships and supports: Enga ging families and/or caregivers in treatment planning and decision making is seen as a crucial element in mental health care reform. Seeing families as valuable partners rather than as marginal players is another key concept of this value. 3) Culturally competent care: Services that are responsive to divers e cultures and beliefs are seen as important to reform.

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50 4) Individualized care: A stre ngths-based program of serv ices should be individually designed for each family, not packaged in a one-size fits all manner. 5) Evidence-based practices: Families should be informed about the scientific evidence supporting treatment choices. 6) Coordination of services, re sponsibility, and funding: Services should be linked together and in communication with each other. Adult and child services should be coordinated to best serve families. 7) Prevention, early identifica tion, and early intervention: Prev ention should be emphasized to minimize later problems, and enhance healthy development. 8) Early childhood intervention: Early intervention is needed to reduce negative outcomes associated with risk factors documented by the literature. 9) Mental health services in schools: Schools should be suppor ted to create and maintain healthy social and academic environments. 10) Accountability: Agencies s hould be required to report evidence of service delivery and effectiveness to a central collection agent to reduce ineffective, inadequate service delivery, and foster continual improvement. State programs that more closely follow th e ideals of these recommendations appear to have more positive outcomes than those whose programs are not as well integrated and systemic (Howell, 2004; Willgin, Waitzkin, & Wagner, 2005) These recommendations have only been published in the last two years, and research is ongoing to de termine the most appropriate methods of design and delivery of services. Client Focused Issues Research on internal client ba sed issues falls into three broad categories: client perceptions of care, parental perceptions of care, and referral process issu es. The least studied of these internal-process issues is that of the child clie nts perceptions of the care they receive. Adult experiences of mental health care are onl y slightly better understood (Wilton, 2003). Whether this is due to lack of access by researchers to ment al health care consumers, lack of interest in client experiences, or some other factor is unkno wn, however, it is clear th at very little is known

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51 currently about the clients pe rceptions and experiences of ca re (Claveirole,2004; Dogra, 2005; Wilton, 2003). What is known about childrens a nd adolescents perceptions of mental health care is that youth, parents, and therapists ofte n have differing goals and expect ations of couns eling (Garland, Lewczyk-Boxmeyer, Gabayan, & Hawley, 2004). A dditionally, several researchers found that young people need to feel they can trust the th erapist (French, Reardon, & Smith, 2003; Shelton, 2004; Smith, 2004), and want more information about the services (French, Reardon, & Smith, 2003; Street, 2004). Young people also expressed a desire to be involve d in decision-making about services (Dogra, 2005; Shelton, 2004; Str eet, 2004). This may be a particularly salient point in light of Garlands ( 2004) finding that of 170 adolesce nts interviewed; only about onethird were in agreement with their caregivers about the goals of treatment. This finding supported Yeh and Weiszs 2001 research. They asked 381 child and parent dyads in an outpatient mental health clinic to list the chil ds target problems. Sixt y three percent did not agree on a single item. Disagreement among key st akeholders about the desired outcomes of counseling is likely to limit the young persons engagement in counseling and hinder positive outcomes. Slightly more research has been conducted on pa rents perceptions of health care for their children. This work has primarily examined perceptions of care among parents of children with serious psychiatric problems (Foldemo, Gullb erg, & Ek, 2005; Harden, 2005; Scharer, 2002). Harden (2005) conducted interviews with 25 pare nts of children and adolescents with diagnosed mental illnesses in Scotland. She reported that th ese parents were frustrated trying to balance their role as family experts with that of learning about their childs illness. In particular, the parents voiced concern over the lack of sensitivity of doctors to their plight and their desire for

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52 knowledge, the lack of emotional support from psychi atrists, and the lack of clear answers about their childs condition. Many of these parents also mentioned feeling blamed by health care professionals for their childs mental problems. In a similar study conducted in the United States, Scharer (2002) reported that parents of children in mental hospital settings wanted more information about their childs condition and tr eatment, greater emotional support from health care staff, and more information on managing the child after he or she returned home. Interestingly, a qualitative study conducted with parents of obese children found similar concerns about their interactions with health care st aff (Edmunds, 2005). These research findings may indicate that the problems of communication between parents and medical staff extend beyond the arena of mental health problems. Mental health problems in children are, however, particularly stressful to families. A Sw edish study involving over 700 parents of nonschizophrenic and schizophrenic children rev ealed a lower quality of life rating, a higher perceived level of stress reported by families wi th schizophrenic children (Foldemo, Gullberg, & Ek, 2005). Another aspect of childrens mental health treatment whic h needs further study concerns how parents decide to seek services for th eir children. Renk (2005) found that mothers who brought their children to a mental health clinic had significantly higher reported parenting stress and reported higher levels of acti ng out behaviors in their children than did mothers in a control group of Latino children without behavioral problems. Arcia, Fernandez, Marisela, & Ruiz (2004) found that out of 62 Latin a mothers interviewed, about ha lf (32) reached the mental health clinics door a lmost by happenstancethe mothers search looked like a pinball in a game (p.1225). About half of the mothers in the study (31) were directly referred either by a school, or a medical professional, or a social worker, or family member and once referred, made

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53 arrangements for services. Six of the Latina moth ers were self-referred; ou t of concern over their childs behavior (these mothers had significantly more education at 16.1 years on average, than did the rest of the sample, at 11.9 years). In c ontrast, those mothers who delayed treatment often reported that increasing actions by the school (s uch as suspension of the child), increased concern by relatives, or an escalation in the child s difficult behaviors fina lly caused the mothers to make an appointment for services. Whether thes e findings would be consis tent in other ethnic groups is unknown, however, the important impli cation from Arcia, Fernandez, Marisela, Castillo, & Ruiz (2004) is that direct referrals may help facilitate mothers accessing mental health services, and may reduce the time and worry of the pinball effect. Summary In examining the current professional literatu re on school counselors referral practices, mental health parity issues, and the specialized needs of low-income African-American families, it becomes clear that there is very little research that directly addresses the intersection of these related issues. While literature does exist that examines each st rand of this puzzle individually, there is a lack of literature to guide school couns elors referral practices with diverse families. This is problematic when viewed in c ontext. African-American males make up a disproportionate percentage of students with serious behavioral problems which impede their academic and social development (Colpe, 2000) However, African-Americans are also less likely to receive mental health counseling than are Whites (Richardson, Flaherty, & Bell, 2003). How much of this disparity is due to barriers to service that might be ameliorated by improved referral practices is unknown. It does seem possibl e that at least some of the African-Americans who are in need of, but who are not receiving, mental health care, could be linked with needed services by school counselors who have training in reaching out to low-income families of color and are using culturally re sponsive referral practices. This is i ndicated in past research (Arcia,

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54 Fernandez, Marisela, & Ruiz, 2004; Ghose, 2006; Logan, 2001; Madsen, 1999) and will be examined further in the remainder of this study.

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55 CHAPTER 3 RESEARCH METHODS Chapter Overview Chapter Three describes the epistemology and general philosophi cal assumptions of transcendental phenomenology, the research method chosen for this study. The selection of participants and the methods of data collection are explained. Da ta analysis methods, including steps the process of analysis are fully explained. Theoretical Framework Edmund Husserl, a philosopher who lived and work ed in Europe in th e early part of the twentieth century, is generally acknowledged as the founder of the phenomenological movement (Crotty, 1998; Giorgi & Giorgi 2003; Wertz, 2005). Although Husse rl was not a psychologist, he devoted much of his career to ques tions of human experience and perception. Phenomenologys distinctive focus on the individu als first hand experien ce of life and the world deviated sharply from the focus of other psyc hological studies conducted during this period that focused on overt behavior and physical processe s (Wertz, 2005). Later therapists who embraced the existential therapies, such as Victor Fra nkl, Irving Yalom, and Gordon Allport were heavily influenced by Husserls work (Halling & Nill, 1 995), as were existential philosophers Jean-Paul Sartre, Martin Heidegger, and Mauric e Merleau-Ponty (Giorgi & Giorgi, 2003). At its core, phenomenological inquiry is c oncerned with gaining insight into lived experience with as little interference from outside schema s as possible (Wertz & Shapiro, 1998). Phenomenological researchers are concerned with learning about how human consciousness interacts with the world in or der to create meaning (Wertz & Shapiro, 1998). Phenomenologists search for the essential or funda mental structures underlying expe rience, usually by listening to

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56 the lived experiences of particip ants and seeking to describe th e most basic essences of the experience (Wertz & Shapiro, 1998, p. 98). Phenomenology assumes that although there is an objective reality, it is only made meaningful via interac tion with human perceptio n. Therefore, the epistemological basis for phenomenology is both subjectivism and objectivis m. The purpose of phenomenological inquiry is not to form theories or test ideas, but to di scover and describe the li fe worlds of individuals. According to Wertz (2005), phenomenology is a low-hovering, in-dwelling, meditative philosophy that glories in the concreteness of person-world relations and accords lived experience with all its indeterminacy and ambiguity, primacy over the known (p. 175). Reality does not need to be constructed for the phenomenologist, merely described. Husserls famous phrase, Sachen selbst or to the things themselves (Husserl, 1931) is a keystone of phenomenological thought, and is the cornerstone of his first epoche. Epoche is a Greek word meaning to stay away or abstai n from (Moustakas, 1994, p. 85). The first epoche, which Husserl called the epoche of the natura l sciences (Husserl, 1939 /1954, p. 135) brings the researcher to the every day lived experience, wi thout reflection or analys is. If the researcher wishes to learn about the natu ral world via observation withou t considering the element of human consciousness and its inter action with the observe d world, the first e poche is sufficient (Wertz, 2005). However, if the researcher wishes to learn about the in teraction between the observable, objective world and human experience, he or she must employ the second epoche; the epoche of the natural att itude (Husserl, 1939/1954). Mousta kas (1994) does not mention two distinct epoches in his work, but combines them. Wertz describes the second epoche as, a me thodological abstention used to suspend or put out of play our nave belief in the existence of what presents itself in our life world in order

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57 to focus instead on its subjective manners of appearance and givennessthe lived through meanings and subjective performances that su btend human situations, (Wertz, 2005, p. 168). The second epoche is essentially a shift in thinking for the resear cher, away from the collection of raw observational data about the objective world, and towards a subjective or intrapersonal interaction with th e collected data. The second epoche asks the researcher to, empathetically enter and reflect on the lived world of other pers ons in order to apprehend the meanings of the world as they are given in a first-person view (Wertz, 2005, p. 168). The researchers own biases and pre-conceived ideas about the object of the study are brackete d, or put aside, so that the researcher is able to enter the life-world of the research participant as fully as possible (Moustakas, 1994). Bracketing requir es the researcher to be aware of his or her own biases and to develop an empathic, open relationship with the participants and the data (Wertz, 2005). Once a researcher has entered the epoche, a nd has put aside his or her prejudices and unexamined biases about a thing, he or she th en turns to Transcendental-Phenomenological Reduction to begin to describe it (Moustakas, 1994) In this context, the word transcendental is meant to denote that the researcher is moving aw ay from the everyday, to bracket away previous ideas, and see the data anew (Mous takas, 1994). This process is de scribed in detail in the data analysis section. Subjectivity Statement In this work, I acknowledge my status as an outsider. I am not the child of a poor family, nor did I need mental health in tervention as a child. My family is White and middle class. While I was growing up, we lived in a small Southern c ity in the United States, and always had health insurance. I attended public schools during the early year s of desegregation, but was never bussed far, and was generally in the major ity population demographic at school. I never experienced learning or behavior al problems, although some of my peers did. I attended school

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58 from first through eighth grade with children who lived at the local childrens home. These children had often been placed at the home due to abusive conditions at home, and many of them experienced difficulties at school. I heard from them about their awful experiences, and I believe that learning about the harshness of some of my frie nds and classmates lives so early in my own life helped me to develop empathy. As a member of the White, middle class, na tive born, educated, American cultural group, my personal beliefs about seeking mental health care reflect those of other members of my demographic group. I generally trust professionals to be helpful and honest, and I believe that some one who is educated in a particular field is better at helping me with a problem in that area than some one who is not. For example, if I felt anxious or depre ssed, I would think of consulting a therapist before talking to my aunt s or my neighbors about my feelings. Doing this work has helped me understand how much my cu ltural context influences these feelings and beliefs. I worked as an elementary school counselor for nine years, eight of which were spent in a semi-rural high poverty school. The school had ar ound seven to nine hundred students, about 80% of whom qualified for free or reduced lunc h, 70% were African-Ame rican, and a significant number were new immigrants from Central Am erica or Mexico. While at that school, I met many families whose plight is very similar to those interviewed in this study. As a school counselor, I was often puzzled and frustrated by families who did not follow through on referrals from me, other educators, and medical profession als. The child clearly had problems and we told the parents where to go for help. Why did they not follow through? I help ed parents to arrange transportation and child care, to apply for the state health insurance, and even made the appointment for counseling with them. Why the l ack of follow through? I did not think then, nor

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59 do I now, that the parents who did not follow up on mental health referral s were being malicious. However, I was unsure as to why some families did make it to the clinic, and others did not. Participants The study participants were six individuals representing five low income AfricanAmerican families from elementary schools in a co mmunity in north central Florida. Four of the participants were single parent s, and two were an unmarried partners who were co-parenting their children from previous relationships Five participants were women. One was a grandmother, one was an adoptive mother, the ma le participant was a stepfather, and the other three were biological mothers. Al l participants had legal and phys ical custody of the children in question, with the exception of the step father who was co-parenting with the childs mother, and did not have any legal rights to the child, but was interviewed in the company of the mother. The sons who were the focus of the interviews attended four different elementary schools in the local public school system. One child changed sc hools between the first and second interviews with his mother. All of the children attended majority Af rican-American schools; although recruitment was open to all elementary sc hools in the local public school district. Families were recruited after they experienced their first referral for mental health services for their sons by thei r school counselors. School counselo rs asked families if they were interested in participating in the study after they referred the family to treatment, regardless of the families plans to attend or not attend mental health services. If the family agreed to participate, the school counselor secured appropriate informed consent documents and relayed contact information to the researcher. To participate in the study, caregivers ha d to meet the following requirements: Child eligible for free or reduced lunch at schoo l, meaning that the family was living at or below the federal poverty line.

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60 The caregiver must be the legal and physical guardian of the child. The caregiver had to have a male child who had been referred to mental health care by the school counselor due to beha vioral problems at school. The caregiver had to be self-i dentified as Af rican-American. The caregiver had to be fluent in English. The caregiver could not be under investigation for child abuse or neglect. The caregiver had to agree to participate in a minimum of two and a maximum of three interviews. Interviews took place at any location of the caregiv ers choosing. Most preferred to talk in their homes, but the researcher did meet with two care givers at their children s schools. Participants received compensation for completing interviews in the form of gift cards to a local grocery store chain. Gift cards were given at the end of each interview. Funding for participant compensation was drawn from a Chi Sigma Iota research excellence grant. African-American caregivers were chosen fo r interviews due to the higher rate of coercive referrals for mental health care for ch ildren, and boys in partic ular, in that group (Chow, Jaffee & Snowden, 2003; Colpe, 2000) and a need to eliminate as many possible variations in the sample as possible (Kuzel, 1999). Boys were ch osen instead of girls due to the need to homogenize the participants a nd the volume of literature av ailable on the disproportionate referral of African-American boys to mental health and special education services. Family composition varied. Due to legal issues around informed consent, only families in which one or both biological or adoptive pa rent (s) was the legal and phys ical guardian were included. Students might have been receiving specialized educational services at school, or might have been undergoing treatment for other medical conditi ons (e.g. asthma, bedwetting, allergies, etc.). The boys might have had some sort of mental he alth intervention or evaluation before, but not due to a school referral.

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61 Sampling Criteria Participants were chosen by matching several cr iteria so that this sample represented the local African-American low-income population. In order to qualify for participation, people had to be: African-American caregiver s with sons in elementary school that had been referred to mental health services by the school counselor. The children had to be eligible for free or reduced lunch to qualify as low income in the study. Caregivers had to be the legal and physical guardian of the child in order to give consent to participate. School counselors were give a list of these criteria and made initial contact with families based on these criteria. Once the family was contacted for the first interview, th e criteria were reviewed to insure a homogeneous sample. In phenomenological research, a homogenous sample is criti cal to the outcome of the analysis (Moustakas, 1994). Met hodappropriate sampling methods are crucial to doing solid qualitative research (Gubrium & Holstein, 1997) According to Kuzel (1999), a homogenous sample is one that, focuses, reduces, and simplif ies (p. 39). To insure that participants are homogenous enough to conduct a trustworthy phenom enological analysis from the data they provide, as many obvious differences in demogra phics (race, socio-econo mic class, geographic location, age of child being referred, involvement with agencies, custody status) as possible will be eliminated. A chart containing basic demogr aphic information about the participants is included in Appendix C. Data Collection Methods The caregiver(s) from each family were inte rviewed either two or three times between December 18, 2006, and February 20, 2007. Three interv iews were requested of each participant, but not all participants could be reached for the final interview. Three participants, Sherry and Felicia and James, could not be located via telephone or postal ma il requests for a third

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62 interview. Allowing for a series of interviews rather than a single discussion with each participant deepened understanding of participants experiences. The first interview occurred as soon as possible after the family was referred by the school counselor for treatment. The second interview took place about three to four weeks after the first, and the third, three to four weeks after the second, at the mutual c onvenience of both parties. E ach interview took about an hour, although the first interview was t ypically the longest. All interv iews were digitally recorded. Interviews followed a semi-str uctured format (Appendix A). The purpose of the first interview was to de velop rapport with the participant. It was crucial to establish as much of a partnership of equals as possible during this phase so that the participants felt comfortable in sharing pers onal information (Fontana, 2002). Establishing a warm, respectful relationship was the primary underlyi ng task of this interview. To create an IThou relationship (Seidman, 1991) with the re search participants, the researcher first emphasized how important first hand experiences are to the research process. Participants were asked to choose a name for the written report, which could be either their real name or a pseudonym. All participants were told they will be acknowledged in any publications of this research. The first interview also provided a time for the researcher to answer any questions he or she may have about the study and gather b ackground data. Finally, du ring the first meeting, participants were asked to begin to tell the st ory of how he or she came to be referred to counseling, with a focus on events in the past leading up to the present (Seidman, 1991). The second interview took place a few weeks after the first to allow time to transcribe the first interview. The focus for th e second interview was to examine current events in the life of the family surrounding their experiences with the mental health care system, if any (Seidman, 1991). This interview included topics such as; the childs current behavior, any change from the

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63 previous interview and to what the parent attributed the change how he or she felt about the services at the clinic, how the school worked with the family regarding the childs issues, and the parents current experien ces of treatment. Also during the second interview participants were asked to review the transcript from the first inte rview and make any changes or clarifications he or she felt necessary in orde r to bolster the trustworthin ess of findings (Kvale, 1996). During the final interview, the focus was on the future and reflection on the meaning of the process of being referred for mental health care (Seidman, 1991) .The final interview took place several weeks after the second one to allo w time for transcription. Possible questions for the third interview included: wh at would you say to summarize your experiences with the clinic, have you seen any changes in your child since we first met, have there been any changes in reports from school, has the treatment (if any) matched your expectati ons, and what are your plans now? Transcripts from the second intervie w were reviewed in this session to gather participant feedback and to insure accuracy. Afte rwards, the third transcript was made available even though there was not anot her interview scheduled. Copies of the final product of the research may be sent to the participants upon request. Data Analysis Data was analyzed according to Moustakas (1994) transcendent al phenomenological method. Phenomenological analysis of data may be divided into three stages: phenomenological reduction, imaginative variation, and synthesis of meanings and essences (Moustakas, 1994). A list of stages and sub stages of analysis ma y be found in Appendix B. During all stages of analysis, an audit trail was crea ted to establish the consistency of the findings (Merriam, 1995; Wolcott, 1990). In addition, member checking, both in terms of asking participants to review transcripts, and asking for feedback from other qual itative researchers were utilized to establish the dependability of results (Merriam, 1995).

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64 Phenomenological Reduction In the process of transcendental-phenomenol ogical reduction, the first step is for the researcher to note all of the unique characte ristics of the data, describing the observable information that defines the phe nomenon. In interview st udies, this usually means transcribing the recorded interviews verbatim. The data is th en examined for horizons, or the invariant, unique and defining constituents of the phenom enon (Moustakas, 1994, p. 97). Horizons are given codes, or titles to make data easier to manage (Wertz, 2005). During this process, it is crucial for the researcher to adopt a posture of wonder and put aside any preconceived ideas of what the participants experience might include (Mousta kas, 1994). Adopting this posture defines the analysis as transcende ntal, since the researcher is seek ing to transcend ordinary, taken for granted explanations of the phenomenon of interest. Horizons are then clustered into themes, and from the themes, a text ural description of the data is written for each individu al data set, or interview. The te xtural descripti on is a coherent description of the participants report of his or her experience. According to Moustakas (1994), creating a textural description, uncovers the nature and meani ng of the experi ence (p. 96).All horizons and individual textual de scriptions are considered togeth er, and a coherent description of the experiences of the entire group is created. This composite textural description aims to organize the lived experiences of all participan ts into a cohesive co mmon description of the phenomenon of interest (Moustakas, 1994). Imaginative Variation Once textural descriptions of the data are fo rmed, the researcher then examines the data for the structural essences of the experien ce (Moustakas, 1994, p. 35). In order to identify these structural essences (or meanings and cause s of an experience), the researcher employs a form of brainstorming called Imaginative Variation. In this exercise, the researcher imagines all

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65 of the possible explanations and essences of the experience from many di fferent points of view (Moustakas, 1994). Imaginative variation seeks to answer the question, how did the experience come to be what it is? (Moustakas, 1994, p. 98). To arrive at answers to this question, the researcher imagines as many explanations as possible, including al l possible polarities, juxtapositions, and persp ectives as possible. According to Moustakas (1994, p. 99), there are four stages within Imaginative Variation. These are: 1) systematic varying of the possible structural meanings that underlie the textural meanings, 2) recognizing the underlying themes or contexts that account for the emergence of the phenomenon, 3) considering the universal stru ctures that precipitate feelings and thoughts with reference to the phenomenon, such as th e structure of time, space, bodily concerns, materiality, causality, relation to self and others, and 4) search ing for exemplifications that illustrate the invariant structural themes and facilitate the development of a structural description of the phenomenon. Using Imaginative Variation allo ws the researcher to explore some of the endless possible meanings of the experience. Once this exercise is completed, the researcher writes the structural description of the experience of each participant. The structural descriptions are then combined into a composite structural description for all participants, which describe the meanings and causes of the experience. Synthesis of Meanings and Essences The final step in transcendental-phenomenologi cal analysis is the synthesis of meanings and essences. According to Husserl (1931), the essen ce of an experience is th e characteristic that makes it what it is, and without which, the experien ce would not be the same. It is important to note that essences may change over time and cont ext, so that a descri ption of meanings and essences is only applicable at one point in ti me, in one place, and through the eyes of one person (Moustakas, 1994). However, the inte rsubjective knowing that is pres ent in the essences as seen

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66 in that situation may illuminate the phenomenon in new and novel ways, such that understanding is widened and enhanced across other settings. As described by Moustakas (1994, p. 181), a sy nthesis is achieved by: Intuitivelyreflectively integrate(ing) the composite textural and composite structural descriptions to develop a synthesis of the meanings and essences of th e phenomenon or experience. This is the final step in Moustakas (1994) transcendental met hod and is roughly equivalent to the production of an essence statement in other types of pheno menological analysis (McLeod, 2001). The essence statement is normally a few sentences describing the universal commonalities that make an experience what it is (Wertz, 2005 ). This is the culmination of the phenomenological reduction, but is not necessarily the onl y useful product resulting from it. Textural and structural descriptions may also be of use in c onstructing implications from the data. Validity and Trustworthiness, Reliability and Consistency Applying the concepts of validity and reliabi lity to qualitative research is a contested practice among qualitative researchers (Merriam, 1995; Wolcott, 1990). Some researchers follow the quantitative model for establishing validity and reliability while others may eschew these concepts altogether (Wolcott, 1990). In this partic ular study, the classic quantitative concepts of validity and reliability are not use d, but are also not rejected out of hand. Instead, the concepts of trustworthiness and consiste ncy are employed. These concep ts are widely, although not uniformly, used in qua litative research. The first of the two pillars of research evalua tion in the quantitative model is validity. In quantitative work, researchers use the term valid ity to discuss how accurately a study measured what it intended to measure (Merriam, 1995). This concept is predicated on the positivist notion that an external, relatively stable real ity exists. However, when working from a phenomenological vantage point, the concept of validity clearly becomes problematic.

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67 Phenomenologists are less concerned with external realities than with how a person describes a situation just as it has been experienced w ith all its various meanings (Wertz, 2005, p. 169). Since phenomenology is concerned primarily with the subjective, changeable perceptions of human beings as they encounter various life experiences, a positivist measure does not fit on an epistemological level. However, it is important to insure that phenomenological research is rigorous and thoughtful. The concept of trustworthiness is of ten used in its place in qualitative work to describe thorough, thoughtful work (Glesne, 199 9). In Merriams words (1995, p. 52), The question of trustworthiness becomes how well a part icular study does what it is designed to do. In order to create trustworthy qualitative work, re searchers need to make their methods of data collection and analysis transpar ent and show how they arrived at conclusions. Wolcott (1990) terms this process letting readers see fo r themselves. Creswell (1998, p. 201-203) specifies methods for creating trustworthy and transparent research are nu mbered below. These methods were implemented in the following manner: Prolonged engagement and persistent observation : participants were interviewed more than once, several weeks apart. Triangulation : using multiple sources, theories, investigators, or methods to develop conclusions: during phenomenological reduction, multiple ideas and possible interpretations of data were considered. Peer review and debriefing : Meeting with member of the dissertation committee provided regular feedback. Inclusion of subjectivity statement. Member checking : Participants read and edited transcripts for accuracy. Create rich, thick descriptions : The descriptions in Chap ter Four are complex and lengthy. External audit : The dissertation committee and editorial boards of journals will audit the materials.

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68 Although Creswell also mentions searching for n egative cases to refine working hypotheses, this particular method is not congruent with phenomenology, hence was omitted in this study. The second pillar of empirical research eval uation is reliability. In quantitative terms, reliability refers to the like lihood that repeating an experime nt will yield similar results (Merriam, 1995). Phenomenology, however, is not c oncerned with replicable results but in the unique experiences of individuals and in fi nding commonalities between people (Wertz, 2005). According to Merriam (1995, p. 56), qualitative re searchers should be concerned with whether the results of a study are consistent with the da ta collected. Similar to the establishment of trustworthiness, consistency ma y be achieved in qualitative research by creating detailed, transparent steps of data transf ormation from raw transcripts to finished product. Merriam (1995) suggests that qualitative researchers use triangul ation, peer examination, and an explicit audit trail to establish consis tent results. In this study, the steps of data collection and analysis were explicitly described, establishi ng a clear audit trail. Particip ants facilitated consistency by reviewing transcripts. Peer revi ewers carefully reviewed steps in data analysis and study design in order to insure that the results of th e study were consistent with the raw data.

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69 CHAPTER 4 FINDINGS "I am a man of substance, of flesh and bone, fiber and liquidsand I might even be said to possess a mind. I am invisible; understand, simply because people refuse to see me. Ellison, R. (1952/2002, p. 3) This chapter delineates the findings of the re search project. Prior to each individuals description, a brief background narr ative is provided. The partic ipants individua l textual and structural descriptions open the chapter, fo llowed by the composite textual and structural descriptions and essence statement. The com posite descriptions incl ude the voices of all participants. Chapter Four concludes with an es sence statement which attempts to answer the primary research question se t out in Chapter One. Textural Description: Anna Anna is a single parent of two boys, John who is in his twenties and lives on his own, and George, who is nine. Anna has a cl erical job at a local health ca re facility and works full time. George is in the third grade this year. Anna describes him as bright, sociable, and musically talented. School versus Parent Anna described herself as a concerned pare nt. When her son, George, began to have behavior problems at school duri ng the third grade, she felt she ha d to take action to straighten him out before things got out of control. She learned of his problems via negative report s first from his classroom teacher, then from the assistant principal a nd principal. When she got phone calls or attended meetings at school about his behavior, Anna sa id she felt that she was being attacked by school staff. When she went to the school for the first meeting about his behavior problems, the staff described his

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70 negative behaviors in detail, but offered no solu tions. George was subsequently suspended from school for 10 days, causing his mother to miss wo rk for several days, and pay a sitter on other days. Problem Solving is the Parents Job Anna recalled, It was true, the things they ha d been saying, but I felt like, it was caving in on us because there was the counselor, the teacher the principal, and myself and everybody was sitting there telling me what my son does. Sh e did not deny the facts of the school staffs accusations, but stated that she felt that they expected her to make her son behave on her own, and that they were not taking equal responsibil ity for the problems. Anna reported the school staff kept drilling her son for answers as to w hy he had done the things he did. She felt this was unfair because she says children arent always aware of why they do things. She felt the school staff expected her to correct the problems at home without help from them. She also said she felt they were blaming her for her sons pr oblems and not being supportive of him. She felt her son was being blamed for not onl y his share of the pr oblems, but also for problems that may have arisen from classroom ma nagement issues. She fe lt that the school staff was not attempting to help her find solutions to the problems George was having, but were instead blaming her for the problems. She percei ved the message to be, Your child is bad and out of control. Weve done all were going to do. What are you going to do now? The school staff members were very capable of telling he r the details of the problems her son was having, but appeared unable or unwilling to help her find solutions to resolve the problems. By the time of the second meeting, a few week s after the first, Anna had already thought about taking her son to counseling. She had a fr iend who had been throug h a similar experience with her son and counseling had been helpful. She told the school counselor she had been thinking of taking George to counseling, and the couns elor gave her a name and number to call.

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71 During that same meeting, Anna told the teacher about strategies that Georges previous teachers had used effectively to help him. Ev en though Anna tried to demonstrate her concern about her sons behavior, she said still felt that the school left all of th e solutions in her hands, without offering much help or support. Anna strongly felt that the teachers ineffective management skills were a part of Georges probl ems, but did not feel that the teacher, or any other school staff members, was willing to attempt to improve the classroom structure to help him. She said that the teacher dealt with childrens behavioral problems by, cutting them off because it was nothing else she could doshe just didnt have any tolerance for them instead of trying different strategi es to help the child. Mom Takes the Initiative Anna was aware that there was in fact a prob lem with her sons behavior and realized she would have to take some action to straighten it out. She ha d a friend whose son had similar problems and counseling had helped him. Anna sa id that although some parents may think that counseling is, brainwashing, she had no negativ e perceptions about counseling, possibly due to the positive experiences her friend had. She decided on her own, without guidance from the school, to seek c ounseling for George. She did not want him to be e xpelled, and since it was obvious to her that the school had, done about all they were going to do to work with George, she took the initiat ive to find outside help for him. She recounts, I sat dow n and really looked at the whol e picture as far as him having a behavior problem and I dont want him to be expelled from schoolso I thought, what can I do? She said she thought the school counselor was re lieved when she said she wanted to take George for counseling, Since they were probably going to menti on it anyway. When she told the school counselor she wanted to go to couns eling, she was given a contact number and name.

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72 When Anna told the school st aff during the third and final me eting (about six weeks after the first meeting) about Georges behavior and that she had called to make an appointment for him with a counselor, They liked that idea. Although they were glad to hear that she was taking George for counseling, the school staff still compla ined about his behavior and did not offer any ideas for ameliorating the problems. School Makes the Rules, the Parents must Follow Anna said that if she had not demonstrated he r concern and willingness to be very involved in her sons schooling, he might not have been al lowed to stay at that school. Once the school staff recognized that she was being proactive a nd involved their judgments of her changed. Anna was careful to make her involvement and concern very evident during all three meetings with the school staff members involved in resolv ing Georges behavioral problems. During the several weeks when Georges beha vior was problematic, she often visited the school and sat in the classroom to observe him. Anna was also careful to ask George for his behavior report every day and calls the teacher if he has a bad report. She felt that the school staff observing her sitting in the classroom, calli ng the school gave George a better chance of staying there until 5th grade. Anna made it clear to the princi pal that she wanted her son to stay in that magnet program, and was willing to do whatever she had to in order to help him. She felt that if she had not done this, he would have been expelled. Anna st ated that volunteering to take George for counseling was the key to him be ing allowed to remain at that school. Structural Description: Anna School versus Parent Although Anna considered herself to be an invol ved and concerned parent, she felt as if the school staff treated her as an adversary instea d of an ally. When Anna went to the school to meet with staff about her sons behavior, she fe lt pressured and like I was being attacked.

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73 Instead of exploring George and Annas abilities a nd resources, the school staff (in particular the administrators) appear to have spent most of the meeting time explaining in detail everything George had done wrong. Anna felt isolated from th e school staff and alone in her quest to help her son. She felt that the school staff were cav ing in on me, which was very stressful and frustrating. Problem Solving is the Parents Job The school staff, in spite of being educa tional professionals, did not offer Anna any possible resources or suggestions initially. The result of this approach was to make Anna, a single parent, feel as if she was al one in trying to help her son. She felt as if the school staff had done about all they were going to do and that it was now up to her to affect change. She perceived the message from school staff to be, Y our child is bad and out of control, what are you going to do. Even though she generally sees herself as a responsible and involved parent, being set the task of helping George with no support from the school staff was a frustrating and stressful experience for her. She said she kept thinking, Wh at can I do? She also felt the teacher ignored her suggestions and wasnt really trying to help him. Mom Takes the Initiative Once Anna had the idea of getti ng counseling for George, it seemed that the school staff became more engaged in the process of helping her. When she asked the school counselor about the idea of seeking outside help, the counselor was able to provide a na me and phone number for her to call. Whether the counselor would have suggested this at some point later is unknown. However, Annas perception was th at all of the school staff at the meeting seemed to like that idea. She wondered if they were planning to ta lk to her about going, and were putting it off, fearing she would not react well to the idea. It may be that the he sitation on the part of the school

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74 counselor in mentioning mental h ealth help contributed to Anna s feelings of isolation and frustration with the process. After the meeting when she asked about couns eling, Anna also began coming to school to observe in Georges classroom. She also began a more structured appr oach to rewarding or punishing him based on his daily behavior report from school. Which, if any, of these actions changed the way the school staff reacted to her is not known. However, Anna felt that the school staff became more receptive and friendly toward s her after they saw that she was a concerned parent. Once she demonstrated her resolve to k eep him in that school, the school staff seemed more supportive and helpfulto a point. School Makes the Rules, Parents Must Follow Even after Georges behavior began to impr ove, Anna reports that she had to call the teacher to get information about his behavior, and that no one called to let her know if the strategies they were trying were working. She fe lt that someone should have called but did not. Annas determination to play along with the sch ool rules, even when staff members refused to listen to her point of view was crucial in keep ing her son at that sc hool. She believed strongly that if she had not toed the line, he would ha ve been expelled from the magnet program. Again, Anna felt that the school had an us-versus-them mentality when dealing with her. The staffs inability or unwillingness to support her efforts to help her son was extremely frustrating and difficult for her. Textural Description: Teacie Teacie is the single parent of five children, four girls and one boy, Pa trick. Patrick has two older and two younger sisters. His father is inca rcerated. Teacie was wo rking part time for a private elder care agency, but quit when Patrick s problems at school began to demand much of her time. Teacie describes Patrick as funny, friendly, and smart.

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75 The Fight to Keep Her Son Enrolled The day of Teacies first interview, she ha d just withdrawn Patrick from his first elementary school. She was extremely frustrated with how she and her son had been treated at that school, especially by the principal. She was planning to enroll him in another school the next day and was hoping to be treated better there. For Teacie, withdrawing Patrick was an act of anger and outrage. Until this point, she had b een desperately trying to avoid Patrick being kicked out of this school. These feelings of desperation began early in Patricks kinderg arten year (the current school year). Teacie estimates that she had to go to school ten or fifteen times in six weeks due to his disruptive behavior. During this time, she re ports feeling pressure d by the school staff, particularly the principal, to take Patrick to a psychiatrist and have him placed on medication. She allowed Patrick to take medication for a while even though she disagreed with the idea because, Hes a doctor and Im just a mom. She al so felt that if she refused Patrick would be expelled. Teacie remembers thinkin g, I did not want him to get ki cked out of school and thats what was happening. I was willing to try whatev er to avoid expulsion. Teacie was desperate to keep Patrick in school, and was willing to comply with any suggestions from the faculty in order to accomplish that goal. Anger and Stigma When the school principal said, Dont you th ink you need some counseling? Teacies first reactions were shock and anger. She r ecalls thinking of saying some bad words in response, but her desperation to keep Patrick in the school overrode her initial anger. She agreed to go to counseling. In spite of her agreement to attend counseling, Teacie remain ed concerned that the school staff thought her son was crazy. Even though she acknowledges, thats not how he (the

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76 principal) said it, thats what I heard. She felt the school sta ff was judging her and her son and implying that he was crazy and needed some help. Teacie attributes her angry reaction to the sugge stion of counseling to the fact that she had a negative experience with counseling when she was a child. Teacie had a troubled childhood (she did not remember much of it) and went to counseling at the same facility Patrick was being referred. Although she did not remember what ha ppened in the actual counseling sessions, she does remember being teased by children at her sc hool about being in the psych ward. The teasing got so severe that she, moved back to Miami, and that was why. These childhood experiences are what she belie ves caused her to be so angry when the principal asked her about counselin g. When she reflects on that conversation, Teacie says, I immediately went into defensive mode when I should have remained calm and heard (the principal) out, but I didnt want to hear it because the truth was hurting. Worries for the Future Teacie feels a great deal of pressure to keep Patrick on the straight and narrow path. She explains, I dont want to ruin his life. I dont want him to ruin his life and I dont want no one else to. I dont want him to be one of those boys on the corner I want to have him running up and down the field, that loves football like he does already and (is) pr oductivenot that cycle thats already on both sides of his family. I want to stop that. The cycle Teacie is referring to is one of incarceration. Both Patrick s father and several uncles ha ve been in and out of prison. Teacie is very worried that her only son will follow in their footsteps. She sees the troubles Patrick is having at sc hool as an indication that he may be heading down this path. She said, By him getting kicked out of school today I felt as if the only thing they wanted me to dowas go to some dope deal er and buy him a package of rocks and a pistol and let him hang with his pants down below his a ss and let him stand on the corner. She said

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77 she knows that is not what the school staff want s for Patrick, but she feels strongly that the frequent suspensions over every little thing are sending him the message that he is bad. In addition to her concerns about Patricks fu ture, Teacie also worries about his health. She describes him as heavy set. At age 6, he is 4 and weighs about 110 pounds. When Teacie first began giving him stimulant medication for hi s ADHD this fall, his eating habits bloomed. Teacie began to fear that continuing with the medication would lead to obesity and complications. She discontinued the medication because she would, rather him have a crazy head than a bad heart. At least he can live wi th a crazy mind, but you cant live too long with a bad heart. Her ongoing conflicts with the princi pal at the first school about medication led to her decision to withdraw him and tr ansfer him to another school. The School Staff Will Not Listen Teacie felt as though she got no support from th e first school Patrick attended. She felt as though the principal was only interested in helpin g her if she medicated Patrick, which she did not want to do. She said of the staff there, Iv e talked all I can talk, but Im not being heard. Maybe they hear me, but theyre not listening. He r frustration with Patr icks behavior and the school staffs lack of support lead to her decisi on to move him to another school. She said of the first schools staff, Ive tried everything. Ive tried it your way, Ive trie d it my way, give me something back. I feel as if Im stuck. Im r eally stuck. I dont know where else to turn. She felt that the only solution th e first schools staff had for Pa tricks behavior was either medication or suspension. His frequent suspen sions caused her trouble at work and further frustration, I cant be at school all the time. Im the sole provider for my family. However, moving Patrick to a new school with harsher teachers has not completely ameliorated his behavior problems. She said she had thought, You tend to him at school, Ill tend to him at the house, well get along fine.jus t leave me alone. She knew that would not be

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78 the case, but was hoping for fewer calls to come pi ck him up, which has been the case so far. He is not on medication, and his new teacher seem s to be managing his behavior with less intervention from the principal or school couns elor, which results in fewer calls home. Although the reduced number of calls is helpful, Teacie is still worried and distressed about Patricks behavior and its impact on his academics. This c onstant worry is wearing her out. She reports her feelings as, Sometimes I want to give up. I re ally doI feel bad about saying itbut I just get tired. Teacie: Structural Description The Fight to Keep Her Son Enrolled Teacie is a single mother raising her only son without much family support. The fact that the boy has behavioral problems makes raisi ng him alone even more trying. She says, Sometimes I want to give up. I really doI feel bad about saying itbut I just get tired. She seems to put a lot of pressure on herself to rais e him to be a family man and not continue the family cycle of incarceration. However, the l ack of support she feels makes this far more difficult. She felt pressured to do whatever the sc hool staff requested of her in order to keep Patrick in the school, and feared expuls ion if she challenged their authority. Anger and Stigma Teacies past haunted her dealings with Patr icks school. Her own experiences with being teased by classmates for going to the same me ntal health center where Patrick was referred colored her perceptions of help seeking. Along with her fears about Patricks health in relation to medication, she also worried about him being teas ed at school for taking medication or going to counseling. These fears caused her to react negatively to the pr incipal, in particular, whose suggestion of counseling was apparently not very tactful.

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79 Although Teacie was eventually ab le to realize that her initial reaction was angry and defensive due to her own histor y, the negative feelings toward the school staff lingered. Their rather abrupt referral of Patric k to mental health services did not take into account the potential for caregivers to have emotiona l reactions to such news. Worries for the Future Instead of stepping in to support her in her de sire to raise her son well, the school staff pressured her to medicate him, which she did no t want to do. She said of her experiences meeting with them, Maybe they hear me, but th eyre not listening. She felt that the principal only wanted Patrick medicated and was not wil ling to try any other me thods of helping him improve his behavior. The continued requests to have Patrick medicated despite his health problems was extremely frustrating to Teacie. She felt that her concerns were ignored and discredited because, Im only a Mom. She saw the staff at that school as acting only in their own interest, wanting Patrick to comply with the rules. Teacies concerns about Patricks health and the negative effects of the medication on it were brushed aside. When he wa s on medication, Teacie saw no real change in his behavior, except for increased appetite and le thargy. She did not feel these results merited the risks involved. School Staff Will Not Listen The school staff members were not responsiv e to Teacies suggestions for a different approach to classroom management for Patrick. She repeatedly requested a firm teacher for him, but the school administration did not seem to regard her request as a serious possibility. Teacie chose to move Patrick to another school in an attempt to find him a more firm teacher. She generally felt disregarded by th e staff of the first school.

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80 The frequent phone calls from the first sc hool about Patricks be havior problems along with the lack of family support have been ve ry frustrating and discouraging for Teacie. Her coping skills seem to be pushed to their limits. As she put it, Mama is tired. Textural Description: Joy Joy is the single mother of three children, tw o boys and one girl. Tyree is the youngest. He is in the third grade and is nine years old. Both of Tyrees sibli ngs also attend his school. Joy is unemployed. Joy describes Tyree as thoughtful and loving. The Search for Answers Joys search for help for her son began we ll before he ever entered a public school. Although her story did not begin with a referral from a school counselor, it did end with one, and the journey to that point is poignant and telling. Th is first section of description gives the reader some further background and insight into Joys situation leading up to the referral from the school counselor. Joy recounted seeing her son, Tyree; expe rience long, loud, and frequent tantrums beginning around age two or three. She recalled thinking, theres something wrong with him, hes not just angry Around that time Tyree also expe rienced seizures, but the doctors did not recommend any treatment for him. Joy was very concerned about her sons beha vior, and called the Health Department for help. This was her first step on the long journey to getting help for Tyree. The person she talked to at the county Health Department told her, h es just angry, spend more time with him. When Joy countered, Hes only 5, what can he be so angry about? She was told there was nothing the Health Department could do for her. During the period when Tyree was between 3 an d 5, his behavior grew steadily worse. He was aggressive with his older siblings, told hi s mother he heard voices, ran away from home several times, and grew paranoi d, Everybodys out to get me. Joy could not find sitters or

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81 daycares that could handle Tyree and had to le ave several jobs for this reason. Joy repeatedly tried to get health professionals to help her, but was deflected. When Tyree started kindergarten, his behavior problems (biting, spitti ng, hitting) caused him to be suspended and eventually moved to another class. Apparen tly during kindergarten, Tyree was evaluated by a school ps ychologist. Joy said, I think he was seen by a psychiatristsome guy from (local university ) came and talked with him at school. She did not understand who this person was or what the outcome of th e sessions were until 3 years later, when a counselor at another school e xplained that Tyree had been identified as Specific Learning Disabled in kindergarte n and had an IEP. In the middle of his first grade year, Tyree move d to a nearby town to live with his father and stepmother. Joy hoped that spending more tim e with his father woul d help Tyree, however, I want to say it was a bad mistakethere was a lot of things going on in that home. Joy says that his father told her that th e school staff in that town dia gnosed him as Manic-Depressive and schizophrenic. She eventually found out from the current school counselor that he was too young to be diagnosed with either of those di sorders. However, J oy did not discount the possibility that Tyree may have a serious mental health disorder. She stated, His genes are bad, but Nobody can tell me what is wrong with him and thats the part that scares me. Building the Team When Tyree came back from staying with his father (and later, his grandmother, who seemed to do well with him) he started attending the school where he is now Joys quest for help for him at this school began after he got into a fight with his sister one morning during breakfast. She came to the school and met with the staff, including the counselor. It was during this discussion that Joy explained her de sire to get help for Tyree, and the counselor gave her a name and phone number to call for a mental health eval uation. Joy said of this counselor finds an

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82 outlet for every little thing you need. So now, its like I have somebody on my sidemy own little support team building up. Interestingly, two other participants had very different experiences with the same person. For the first time, Joy had someone who coul d help her navigate the alphabet soup of educational programs and related services. She learned that her son has had an IEP since kindergarten, and is aware of what that means in terms of services he is able to receive. However, she was still not sure what, if any, mental health disorder he may have or what courses of treatment are possible. When Joy made the pe rsonal connection with th e counselor at Tyrees school, things began to change for her. The school counselor was able to make helpful referrals and also followed up with Joy to be sure she was ab le to access the services at the referral sites. The Run Around In between the second and third interviews, J oy was finally able to get Tyrees Medicaid card and arrange an appointment for him at the lo cal mental health center. However, as of our last conversation, he still had not been seen. This follows four years of her trying to get help for her son, whom she want(s) to see him in college, not in prison. Of the process of getting a Medicaid card, she said, I had to fight to get him a card. Joy had to be very persistent in calling and checki ng on the status of the a pplication, and waited two months to receive a temporary card. According to Joy, all of the dead ends she encountered while seeking mental health care for her son cons titutes a big run around. The run around was eased significantly when Joy found an ally in Tyrees school counselor. The school counselor was able to talk with Joy to determine what sorts of se rvices Tyree might need (and Joy might want for him) and was able to help Joy locate service pr oviders. She also helped Joy make appointments, gave her phone numbers to call about various Me dicaid problems, and generally helped Joy to make contact with the service providers Tyree ne eded to access. Without the help of the school

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83 counselor, Joy fears she would have been stuck in an eternal run around. She is now waiting for her appointment at the mental health center. She is, ready for him to get some counseling, something, anything. Structural Description: Joy The Search for Answers Joy has been trying to the best of her ability to get help fo r her often violent and out of control son for almost five years now. She has been extremely frustrated by the process of help seeking. With the notable exception of the current school counselor, Joy has been dismissed and disempowered by professionals from whom she sought help. The tangled system has not allowed her son to receive treatment to this point, although she clearly is desperate to find out wh at is wrong with her son. It is possible that if Joy knew more about how the system works, she may well have been able to access services much earlier. For example, she did not know that Tyree had an In dividualized Education Plan (IEP) or what that meant. No one had explained the special educatio n process to her in a wa y that she understood it, even though she most probably received a handbook of parents rights when he was initially identified. Further, had she been more able to ex plain to the staff at the Health Department what sort of evaluation he needed, or was able to pa y for a private evaluation, things might have been very different. Building the Team Once Joy was befriended by her sons school couns elor, her situation began to change. The school counselor in this situation acted as one might hope a sc hool counselor would act. She first listened to Joys story carefull y, asked questions to clarify he r understanding, and then offered appropriate referrals to commun ity agencies. She gave Joy telephone numbers and contact names

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84 for each agency, and then asked Joy the next tim e Joy was at school if she had any difficulty arranging appointments. The school counselors intervention was a huge re lief to Joy. She was now able to call for appointments, and could rely on th e school counselor to help her navigate roadblocks. When Joy needed help getting information for Medicaid, she knew she could count on the school counselor to provide the help she needed. The school counsel or provided the first spoke in the wheel of support Joy eventually built. The Run Around Although Joy does fear the possibility of the me ntal health counselor s blaming her for his problems, she is adamant that she wants to know what is wrong and what can be done to help Tyree. She is concerned that he will end up in an alternative education pr ogram for children with behavior problems, or later, in prison. Her pers istence in the face of so many roadblocks and runarounds is astounding. Joys story is a sad, but probably not unco mmon, illumination of the gulf that stands between those inside the run around and those needing to break in. She repeatedly gave permission for various people to test and/or counsel Tyree without understanding fully the implications of those actions. She is desperate to get help for him, since she is very aware of the possible negative consequences of Tyree grow ing up without any intervention. However, she neither understands how to break into the run arou nd, nor what entering that system might entail. Textural Description: Sherry Sherry is Darriens maternal grandmother. Sh e is also caring for tw o of her granddaughters while another of her daughters is in prison. She also still has a teenage son at home. Darrien is six and is repeating kindergarten. Sherry works fulltime at a cleric al job at a major hospital. She is married, but her husband was not present for th e interviews. He is also employed full time.

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85 School Centered Solutions Sherry was the only participant who was a gran dparent raising a grandchild. Sherry gained custody of her grandson, Darrien, just prior to hi s kindergarten year beginning. Sherry had spent a lot of time with Darrien prev iously, but said she did not unde rstand how serious his behavior problems were until he came to live with her. Darriens mother (Sherrys daughter) has an unspecified disability according to Sherry that made it impossible for her to properly care for Darrien. When Darrien started attending kindergarten, his behavioral problem s were immediately evident. The first day of school, he was sent home for biting other children. Along with biting, Darrien was also hitting other children and defying adults. After sending him home for the day multiple times during the first two weeks of school, the principal requested a meeting with Sherry about Darriens behavior. At that meeting, the principal, the counselor, Darriens teacher, and the Behavior Res ource teacher told Sherry that they were going to put Darrien on a half-day sc hedule. This meant that Darrien would come to school at 10 and leave at 2 with the other children. Apparently, the school staff had chosen to ch ange Darriens schedul e without input from Sherry. She recalled thinking, It wa s terrible. I thought Id have to give up my shift (at work). I was trying to support them, and I was like, where yall support for me? Sherry worked at the local hospital from 6am to 2pm. During the time that Darrien was on half days, she had to leave work, drive across town to get him, take him to school, and return to work. She said of this schedule It was stressing me; I was missing lots of work. Sherry finally went back to the school after about two months of half days and met with the team again, and asked them to find another solution. During that meeting, the teacher told Sherry that she thought Darrien mi ght have a learning disability a nd that she wanted him to be

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86 tested. Sherry agreed to have th e testing done for the learning di sability. At that same meeting, the school counselor suggested Sherry take Darrie n to the local mental health center for an ADHD evaluation and counseling. Sherry said she felt all up for it, hes always been real hyper. Once the team had decided to further investig ate the possible causes of Darriens behavior, they also agreed to allow him to start coming to school all day again, with a plan in place for dealing with any misbehavior wi thout sending him home. What baffl ed Sherry about this process was why they didnt do that in th e first place instead of requiri ng Darrien to attend half days, which was a burden on her, and did not seem to help him. As it turned out, Darrien was diagnosed with ADHD and was placed on stimulant medication. Sherry said of the medication, it made a big difference She added that his behavior at school improved treme ndously. Sherry also reported that Darrien was identified as having a learning disability and was able to get extra help with academics. Again, if the school staff had discussed a broad array of possible solutions to Darrien s problems in the first place instead of assigning one intervention for their ow n convenience, Sherry would not have felt so distressed and the underlying issues mi ght have been identified sooner. No Support for Caregivers During the first few months of Darriens first y ear at school, Sherry said she felt that the school staff was out to get me. She recounted the distress she felt when she would get called at work about Darriens behaviors, and the huge pr oblems that the half day schedule caused her. Sherry said of those first meetings, I t was depressing to talk to them. Sherry had other children who attended the same school in the past and had never had any behavior problems. She had been a class volunteer with all of the other children, and felt she was a strong supporter of the school. However, when her grandson began exhibiting serious

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87 problems, the school staff did not reciprocate her support. As she put it, I was trying to support them, and I was like, where yall support for m e? Sherry felt that her years of volunteering and helping teachers meant nothing in this new ci rcumstance. She had to rely on friends and neighbors to help get Darrien to school during the half day schedul e, and felt that she was getting no help at all from the school. None of the staff members at the school o ffered her any emotional support while she was trying to find help for Darrien. In fact, one teacher even remarked that if Sherry was so stressed, maybe she should send Darrien back to live with his mother. Sherry found this remark to be hurtful and insensitive. The School Decides which Problems are Legitimate When Sherry first enrolled Darrien in kinde rgarten, she asked the teachers about special education services at the school. She felt ther e was a good chance that Darrien had a mental disability similar to his mothers. However, she was rebuffed and told that if there was a problem, the teacher would find it later. Instead of taking Sherrys con cerns seriously, asking for family history or reasons for her questions, the teacher simply assumed Sherrys poi nt of view to be of no educational value. Obviously, Sherry was right about Darriens disab ilities. If the first teacher she approached had welcomed Sherrys input, the school year might have started very differently for Darrien. In Sherrys words, things got a lot better when they realized Darrien had a real problem. Once the school staff members were convince d, through academic performance measures, psychological testing, and a diagnos is of ADHD that Darriens probl ems were real they were much more flexible in working with Sherr y. Certainly, the data gathered by the school psychologist, teachers, and psychiatrist shed more light on the exact nature of Darriens limitations. However, the staff members lack of response to Sherrys initial concerns and

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88 discounting of her input set Da rrien up to fail during his firs t days of kindergarten. Their disregard for her concerns also frustrated Sherry and made her feel unsupported. Structural Description: Sherry School Centered Solutions One of the most frustrating aspects of the enti re situation with Darrien was, for Sherry, the fact that the school staff member s initially created an interventi on plan without any input from her. Worse, the plan was a serious infringement on Sherrys ability to do her job, and did not seem to make any changes in Darriens behavior. Sherry readily acknowledged that Darriens behavior was unacc eptable and stated she was willing to work with the teacher to help him. However, before she had a chance to make any suggestions, a plan was decided on and she was to ld how the situation was going to be handled. Her exclusion from the decision making process made Sherry feel unwelcome and angry. The imposition on her of an amended schedule for Da rrien was highly inconvenient and left her feeling depressed. No Support for Caregivers Sherrys interactions with the school in years past had always been very positive. She had always volunteered to help in her children s classrooms and was hoping to do so again for Darrien. However, when his first year of kinde rgarten started with numerous suspensions and calls about behavior problems, she found that the friendly atmos phere at the school changed, and that she suddenly felt like an unwelcome interloper. Instead of treating Sherry like a valued part of a problem solving team, the school staff treated her as if she was causing Darriens probl ems, or was holding back the key to solving them. As she said, I felt like they were out to get me.

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89 The School Decides which Problems are Legitimate Sherry warned the teacher prior to school star ting that she thought Darrien might have a learning problem. Although he did not bite or h it other children at home, he was real hyper. The teacher dismissed Sherrys concerns until Da rrien started to misbeh ave in her classroom. Instead of referring Sherry to the school counselor to preven t potential problems at school, the teacher waited until she saw th e proof. Even then, when Darri en was biting and hitting other children, it took more than one meeting of the behavior interv ention team at the school for anyone to refer Sherry to a mental health clin ic for Darrien. Perhaps the school staff members were being cautious about making a referral for an ADHD evaluation, but the delay cost everyone valuable time. Darrien is now repeatin g kindergarten, partially because he missed so much time last year due to suspensions. It seem s reasonable that if Sherry had been given the name and number of a mental health clinic sooner, Darriens behavior might have improved more quickly. Felicia and James: Textural Description Felicia and James are co-parenting Felicias adopted son, Jaquan, who is 10 years old and is in the fourth grade. Felicia adopted Jaquan as an infant. James, her fianc, has been a father figure to Jaquan for three years now. James has children from a previous marriage who live with their mother. Felicia asked James to participate in the interviews because he was present at most of the meetings at school about Jaquan. Felic ia and James run a small business together. No Compassion The fourth grade has been a very trying year for Jaquan and his parents. Jaquan has had some difficulty during each year of school, but th is year has been the worst to date. Felicia and James attribute Jaquans increased problems to hi s fourth grade teachers lack of compassion. James said flatly, shes a grouch.

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90 They feel that the teacher is exaggerating Jaqu ans behavior problems, and is referring him to the administrators at the school over little stuff. They descri be this teacher as being all by the book and inflexible. They say she has, one way of seeing Jaquan. She thinks hes just messing up. Unfortunately, once Jaquan is in the office a nd his parents are calle d, this straight and narrow attitude continues. When Felicia and James come to the school to discuss Jaquans behavior, they feel that theyve already made up their mind s before they get the whole storyI wish the school would be more open instead of judg mental. They feel that as parents, they have very little impact on the decisions of the sc hool staff regarding Jaqua ns discipline or his education in general. When the school counselor suggested that Jaquan might need an ADHD evaluation, Felicia was in agreement. As she says, hes very hyper. Jaquan was prescribed medication, and is taking it. However, he still has some (although fe wer) behavior problems at school. When Felicia suggested that perhaps he needed a more sympat hetic teacher, the principal asked if he was taking his medication every day. Felicia and James found this remark offensiv e. They readily acknow ledge that Jaquan does have ADHD, and are treati ng him for it, but do not think that ADHD is the only problem. They see the teachers lack of compassion and unwill ingness to accommodate his differences as a major impediment to Jaquans education. The sc hools staff as a whole does not acknowledge that any changes need to be made to help Jaqua n. Now that he is on me dication, their answer is always, have his meds adjusted. To that, Ja mes replied, He doesnt need more meds; they need to fix whats going on in school. He said he would prefer for the teacher to, See that he has some problems, work with him, be more understanding.

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91 Failure to Communicate with Parents During the many visits they made to the schoo l this past fall (which they estimated to number around three or four per week), Felicia a nd James felt that even though they had a lot of conversations with school staff members, th e communication was largely one-way. The school staff told Felicia and James their version of even ts and expected them to agree. They expressed frustration at only being cont acted when Jaquan was having a bad day, never when he was improving. Both of Jaquans caregivers were under what they called tremendous stress with their small business and felt that the schools frequent phone calls and demands to come pick Jaquan up early added to their frustration. Although they tried to give the teacher suggestions for dealing with Jaquan more effectively, she was not open to their ideas. James perceived that the teacher simply wanted, Jaquan out of her class, pe riod and that she was unwilling to hear his suggestions. In spite of James and Felicias high level of c oncern and involvement, they both still felt as if the school staff had a biased viewthey ha ve one way of thinking about Jaquanno matter what we tell them. They felt that their repe ated requests for accommodations fell on deaf ears until the mental health counselor told Felicia that Jaquan would qualify for a 504 plan. Felicia had never heard of Section 504. She and James we re upset that no one at the school had ever mentioned this as one way for Jaquan to get accommodations for the FCAT. James said, We dont have the informationor the knowledge of wh ats available, and th at bites everybody. He went on to say that after they me t with the teacher to request a 504, she agreed to write a plan for Jaquan, but several weeks had gone by with no follo w up. James was very frustrated at the lack of communication from the school, and even more fr ustrated at their lack of willingness to listen to him and Felicia. As he put it, ev erything is about communication.

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92 No Flexibility In addition to not taking the caregivers i nput seriously and not appearing to have compassion for Jaquan, the school also maintained extremely rigid expectations. James said he felt that the principal and teacher in particul ar took a tough love, my way or the highway approach with Jaquan. According to Felicia and James, the school staff did not seem willing to work with Jaquan and make allowances for his ADHD. Felicia said of the school staff, We got ma d with themwe felt like they were giving up on him. At one point, the principa l mentioned the possibility of sending Jaquan to an alternative school if his behavior did not improve. James fe lt that the principal wa s trying to force him (Jaquan) out of the school. Both James and Feli cia relayed that they felt the school staff would rather send Jaquan to an alternative school rather th an to be flexible in th eir expectations for his behavior. Even in light of Jaquans ADHD diag nosis and medication, the school staff did not seem willing to try to accommodate his needs. Ra ther, they expected Jaquan to conform to the schools way of doing things. This rigid expectation seemed to apply to the parents as well. James said he felt that the school expected parents to come wh en called but not to have an e qual voice in the decisions that were made. He said of the school staff, They take us seriously, but then they want us to understand their biased thinking about how hes a mess up. Structural Description: Felicia and James No Compassion Felicia and James expressed strong feelings a bout Jaquans teachers l ack of compassion in the classroom. They perceived her as being bia sed in her appraisal of the boy and unwilling to make any changes in her approach to meet him halfway. Felicia and James thought that the

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93 teacher did not like Jaquan, had no patience with him, and made discipline referrals for minor rule infractions. Their perception of a lack of compassion also extended to their dealings with other school staff members. They did not feel that anyone on the faculty was in terested in joining with them to help Jaquan succeed. Rather, they were treated with professional detachment and a lack of warmth. Felicia and James felt the school staff t ook us seriously and were respectful, but did not make allowances for their work schedules or for providing any new ideas for helping Jaquan. Their approach was very business like and rigid. This was frustrating to both caregivers, who perceived the school staff as unfriendly and only interested in forcing him out and not helping Jaquan. Failure to Communicate The lack of communication Felicia and James discussed was two fold. First, the school staff only provided one-way communication, foll owing the separation paradigm of parent involvement in schools (Amatea, 2007) The school staff members we re quick to call Felicia or James if Jaquan was having a problem, but ne ver reported any progress he was making. They also expected Felicia and James to agree with any and all requests from the school. Secondly, the school staff members did not adeq uately explain to Felicia and James what resources might be available to help Jaquan. Although the school counselor did give them information for making an ADHD evaluation appoin tment, she did not provide any information on educational resources, such as Section 504, special education, or ot her locally available services. This reflects the school centered mindset discussed in other participants interviews. All in all, the dearth of twoway communication between the school staff and the caregivers was not only frustrating to Felicia and James; they also felt that it impeded their ability to help Jaquan. Not having open communi cation and sharing of ideas, bites everybody

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94 as James put it. If the school staff had used a more open, friendly communication style, Jaquans needs might have been met s ooner and with less frustration. No Flexibility The third major source of frustration for Felicia and James was the school staffs lack of flexibility. They described the classroom teacher straight and narrow in her dealings with students. This approach clearly did not work for Jaquan, whom his parents describe as a child who needs a sympathetic teacher who can be flexible in approaching Jaquan. They said they knew he needed to be responsible for his actions, but that this teachers inflexibility discouraged him. The pattern of inflexibility applied to the rest of the school staff and their dealings with Felicia and James. They recalled feeling that th e overall message from the school staff was our way or the highway. They also felt that school st aff, particularly the pr incipal and the teacher, had a biased view of Jaquan and only sa w him as a mess up and were unwilling to recognize him as a child with special needs in need of a less rigid environment. Composite Textural Description School Centered Perspective All of the caregivers who participated in this study felt that the staff at their sons schools expected the family to find and carry out solu tions to the boys problems, mostly without any assistance from school. Prior to, during, and after th e actual referral to a mental health agency was made, the caregivers felt that they were being blamed for their sons problems, and that they alone were responsible for fixing it. There was a sense that the school st aff developed ways of dealing with the boys misbehaviors that were most convenient for the school staff without taking into account the needs or wishes of the caregivers. As Fe licia and James pointed out, their sons school staff are biasedt hey have one way of thinking of Jaquan. They think hes

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95 messing up. No matter what we tell them, they sa y were not seeing the te achers side, and we say youre not looking at Jaquans! This bias seemed to lead the school staff to make decisions that were sometimes extremely difficult for caregivers to manage. In Sherrys ca se, the school staff d ecided Darrien could only attend school from 10-2 since his worst behavior occurred in the mornings. This schedule was implemented while Sherry was waiting for an appoint ment at the mental health center, which she had made at the request of the school counselor. Sherry missed a lot of work because of this new schedule and recalls, It was te rrible. I was thinking Id have to give up my shift. In Teacies case, the insistence that her son Patr ick be medicated in spite of her misgivings about the health implications of using stimulants for him led he r to believe the school staff was not listening to her. She felt th is pressure to medicate Patrick inferred that he was crazy and needed some help. She said of the staff at th e school, Ive talked all I can talk, but Im not being heard. Maybe they hear me, but theyre not listening. Her frustration with Patricks behavior and the school staffs lack of support lead to her de cision to move him to another school. She said of the first schoo ls staff, Ive tried everythi ng. Ive tried it your way, Ive tried it my way, give me something back. I feel as if Im stuck. Im really stuck. I dont know where else to turn. In a similar vein, Anna perceived the message from Georges school to be, Your son is bad and out of control. Weve done all were going to do. What are you going to do now? Anna describes feeling as if they were all caving in on us because here was the teacher, the principal, and myself, and everybody was sittin g there telling me what my s on does. Anna did not feel the school staff were willing to help her find solution s to Georges problems, and in fact, ignored her request that different strategies be used with him in the classroom. She felt his teacher had no

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96 tolerance for him and was not willi ng to work with her. She said she simply felt as is she were being attacked by the schools staff. Felicia and James had a similar feeling about Ja quans teacher. They fe lt that her lack of compassion for Jaquan led to him being sent to th e office for little stuff they felt could have been handled in the classroom. After several mee tings with the school staff, Felicia and James came to the conclusion that Jaquan needed a better classroom and not more effective medication. Teacie felt that Patric ks school was also blaming her fo r problems created or at least fueled by their handling of his behavior. She repo rted that her requests fo r different management strategies also went unfulfilled, while she was being pressured to medicate Patrick. Lack of Compassion for Caregivers All of the participants also reported feeling al one in their search for solutions, as well as feeling blamed for their sons problems. As Sherry put it, I thought they were out to get me. I was trying to support them and I was like, where s yall support for me? Participants relayed feelings of disappointment in the level of pr actical and emotional s upport they received from school staff members. Most of the participants (all except for Felicia a nd James) are parenting the boys alone and reported feeli ng tired (Teacie), d epressed (Sherry) a nd stressed (Anna) when faced with the daunting task of finding mental health care for their sons. Anna was the only participant who consciously built a social support network for herself and her son during these trying times. She asked male friends from church and the community cente r to help her get and keep George on track by checking in with him about his progress. The younger single mothers in the group, Teacie a nd Joy, seemed to lack any support from their own families and reported feeling especial ly let down by the initial response from the schools regarding their sons. Joy wa s eventually able to find an ally at school, but Teacie was still searching at the time of the last interview. She reported feeling alone and pressured to

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97 get help for her son, while not getting any help for herself. Both Joy and Teacie reported feeling intense internal pressure to s ee their sons go to college and not prison (Joy) and to end the family cycle of going to prison (Teacie). The refe rral to the mental health center was especially stressful for Teacie, who had negative memories of going to the same center when she was a child. Joy, however, saw the referral as the ke y to finding out what is wrong with Tyree, something she had been searching for many years. The other participants also felt isolated and blamed by the schools, but seemed more able than the younger single mother s to access other forms of support. Anna found church and community members to help George, Sherry reli ed on her adult children, and Felicia and James have each other to lean on for support. However, these participants were also distressed by the process of finding out their son ha d a problem and being referred fo r treatment. All four of these participants also mentioned incr eased strain at work due to fre quent trips to school. Joy does not work, and Teacie left her job due to pressures from her boss to resolve her son problems. All participants felt at least some sense of isolation and lack of support from the schools. The lack of support for families manifested a different way for Joy, who has spent hours seeking help for her son, Tyree. Sh e reports that she has repeatedly told Tyrees teachers that she thinks theres something wrong with him but got no help. This began to shift when Tyree got in a fight at school and was going to be suspended for ten days. Wh en Joy got to school to pick him up, she met the school counselor. Following their conversation, Tyree was not suspended, and for the first time was given the name and phone number for a mental health center that takes Medicaid. Sadly, out of all of th e participants in th is study, only Joy felt helped and supported by the school staff.

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98 In Joys case, the school couns elor acted as a link between her and various services the school and mental health system could offer fo r Tyree. Not only did the counselor provide Joy with the name and telephone number of a mental health counselor, she also began the special education paperwork for academic testing for Ty ree and helped Joy fill out Social Security paperwork. This multi-layered help is in contrast to Felicia and James situation where they say their mental health counselor advised them to request a 504 plan for Jaquan, and the school counselor has not returned their phone calls. They are bewildered at the school counselors lack of intervention on Jaquans behalf. As James put it, He doesnt need more meds; they need to fix whats going on in school. Schools are Rigid Systems Another sentiment shared by all participants wa s the schools expectati on for caregivers and their sons to conform to the schools plans, with no room fo r compromise. The schools our way or the highway (James) mentality was especially frustrating for the caregivers who were aware that their sons had medical diagnoses that influenced their behavior at school. Sherrys frustration with the schools expe ctation that Darrien behave exact ly like all of his classmates was expressed as, a child with ADHD is going to be fidgety and you cant punish him for it. Sherry had already taken Darrien to the psychiatrist, had him di agnosed, and was giving him the medicine as prescribed. The staff at Darriens school did not seem to make any allowances for his condition. The lack of flexibility was extremely frustr ating for Sherry. However, once Darrien was placed in exceptional student education classes for a developmental delay, she felt the staff became more willing to forgive his behavior. She rry had tried to convince the school staff earlier in the year that Darrien had a disability like his mother but this notion was not given any credence until formal testing was carried out near the end of the school year.

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99 This dual ordeal of knowing the child has a problem and not getting any help from the school and the school not yielding to the childs needs is echoed in Felicia and James story. Felicias son, Jaquan, was adopted as an infant from a birth mother who was using drugs. When Jaquan started school, Felicia told the school staff th at she felt his mothers drug use had affected Jaquan. She felt the school ignored this information until Jaquan began having serious academic and behavioral problems. Felicia took Ja quan to have him assessed for ADHD. He was diagnosed and prescribed me dication. Although Felicia give s Jaquan his medication as prescribed, she feels the school pressures her to ask the psychiatrist to increase his medication any time he has a behavior problem rather than to work with him to find other solutions. Felicia says she wishes the school staff would. Work w ith him, be more understanding. She feels that they are trying to push Jaquan into an alternat ive school to avoid having to help him succeed where he is. James said he feels that the sc hool is unbending, all by the book, straight and narrow. This approach is not working for Jaquan. Both Felicia and James feel that if the school staff were more sympathetic he would have more success. Teacie experienced similar frustrations with Pa tricks first school. She did take him to the mental health center as requested, but refuse d to put him on medication. The ensuing struggle between her and the school princi pal over the medication led to he r decision to move Patrick to another school. Again, Teacie had explained to the t eacher early in the year that she felt Patrick would respond better to a differe nt style of discipline than th e teacher was using. She felt her input was discounted, and that th e school staff was only interested in seeing Patrick medicated. This frustrated Teacie, I have never in all my many little years seen a principal encourage a mother to put their child on something they di sagree withand I felt she wasnt in the best interest of my child, so I blew up and withdrew him.

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100 Anna and Joy also experienced the round hol e, square peg phenomenon. When Anna first met with the school staff she str ongly felt they were trying to e xpel her son. She felt that, if you dont say the right things, youre out the door. Again, her sugge stions about how the school could help her son were ignored. When Anna said she would take her s on to counseling, she felt they (the school staff) liked th at idea. They were happy for A nna to take action, but were not willing to make any changes themselves. Joy also f eared her son would be expelled or sent to an alternative school. She had been trying to get he lp for Tyree for years for his anger problem and had repeatedly been told by educators a nd medical professionals that she should spend more time with him, hes just mad. However, when his problems became more visible at school, he was quickly referred for mental health intervention. Parents as Advocates The struggles the caregivers faced in finding he lp for their sons left them exhausted, but also helped them become more effective advo cates for their children. The advocacy skills they have acquired were born out of necessity. Once the caregivers rec ognized that the schools were not going to bend, they began looking for othe r sources of support. Anna decided to take George for counseling before the school counsel or mentioned it, although Anna says, I think they were going to talk to me about it anyw ay. The counseling George received was really helpful in helping him get himself back on trac k. Anna also recruited friends from church and the community center to help support Ge orge in his behavior changes. Felicia and James learned from Jaquans mental health counselor that he might be able to get accommodations on the FCAT through a 504 plan. They contacted the school and requested a 504 meeting. They said they have learned now that We dont have all of the information...of whats availableand that bites everybody. Jame s added that he has le arned its all about

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101 communication, and that they now realize they have to sta y on top of the school to get anything done. Joy and Sherry had similar experiences with advocacy. Joy said, Tell me where to go from hereIm ready for him to get some counseling, anything, something. She and Sherry both asked repeatedly for help until the counselor gave them the number for the mental health center. They both also later asked for academic help from the school, and both boys are now placed in special education. Joy ch aracterized the entire process of getting mental health help for Tyree as a big run around and often felt angr y and embarrassed about Tyrees behavior, but she was able to persist and eventually got help. Teacie had a more difficult ti me communicating her concerns to her sons school, and realizes now that switching schools may not have been the best idea. She said, I immediately went into defensive mode when I should have re mained calm. I didnt want to hear it because the truth was hurting when the first schools principal said Think you might need some counseling? However, she changed schools in an effort to help Patrick be successful and not become one of those boys on the corner. She continues to advocate for him at the new school even though she admits she is tiredand frustrated. Composite Structural Description Alienation of Caregivers A sense of us versus them ran through all of the stories in the study. Of all participants, only one was eventually able to forge supportive re lationships within the sc hool to assist her in her search for help for her son. All of the others were left with the f eeling that, If you dont say the right things, youre out the doo r. Participants talk ed of feeling attacked, judged and snubbed by educators. These feelings were fueled by the school staffs creation of untenable interventions, ignoring caregiver input and refusal to make needed modifications.

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102 Therefore, when the school counselors made referrals to mental health, some of the caregivers were skeptical of its usefulness. Some only complied with the referral out of desperation to avoid having their sons expe lled. Anything to keep him in school was a common reply. None of the caregiver s initially saw the school as a place of refuge or help for their sons problems. Only one came to see th e school as a place of hope and help after interaction with the school staff (a nd in particular, the counselor). Most of the participants view ed themselves as involved parents and were shocked by the lack of compassion they received from the sc hool staff during the meetings about their sons misbehavior. Several caregivers reported having b een active volunteers at the school prior to the behavior problems developing and were dismay ed by what was described as the attacking posture of the staff during meetings This lack of respect for the car egivers input lead to further feelings of alienation and divi siveness. Some participants were able to prove we were concerned after several meetings, and after co mplying with staff suggestions. However, they still felt that the school staff saw their sons as b ad and out of control and felt the school staff just want him outdont want to work with him All but one of the caregivers retained feelings of being disrespected and isolated throughout the pr ocess. They reported feeling frustrated and exhausted by the end of the in terviews. This deep sense of isolation and disenfranchisement did nothing to help caregivers, boys, or schools. In fact, one speculation that could be made here is that the caregivers sense of isolation from school staff during their childs elementary school years may be a factor contribu ting to low parent involve ment at the secondary education level. Fear and Guilt One of the most prominent emotional states in the caregivers accounts of the referral process was fear. The caregivers e xpressed fear that their sons would be suspended or expelled

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103 from school, that he would end up in prison, and that their decisions now would hurt their sons later in life. Perhaps because the boys in this study are from low-income African-American families, and their chances of being incarcerated are higher than their chances of going to college, their caregivers are more vigilant about keeping them on the str aight and narrow than they might have been if the boys were of another social class or race a nd had experienced similar problems at school. All of the participants reporte d that the school staff had ment ioned the possibility of the boys being transferred to an alternative school, which all of them saw as a negative place. Caregivers were worried that if their sons were reassigned to an alternative school, the negative peer pressure from the other students would make their behavior pr oblems worse. They expressed a desire for the regular education setting to be adapted to meet the needs of their children, not to have their children sent away for specialized services. This sense of fear drove them to feel even more distressed and isolated. Many participants shared strong concerns that thei r sons would follow in their fathers footsteps and go to prison instead of college They also expressed concer ns about the long term effects of medication, particularly the possi bility of addiction. One of the greatest fears expr essed by participants was th at they would never find the answers they sought about their sons problems: No one can tell me whats wrong with him, and that part really scares me. In searching for answers, participants also feared they might be blamed for the boys condition: I just dont want somebody to say, Its all your fault because then I have to deal with the guilt and I already feel guilty enough, like if I had done this or if he hadnt been in that situation, but I mean, he needs help.

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104 Although each of the participants had unique f ears, the common thread of being afraid was clear throughout the group. They all feared negative outcomes fo r the boys, and were all aware that these fears were not far-fetched, since many of the caregivers mentioned male relatives who had suffered similar life outcomes. The caregivers feared that if they were not able to find adequate help for the boys early in life, they w ould not succeed in school, and would be as one parent put it, one of those boys on the corner with his pants hanging below his ass selling rocks. These fears were realistic and palpable in the group. Their initia l experiences with the school system had not done much to allay thei r fears or give hope for alternative outcomes without a lot of persever ance from the caregivers. Powerlessness and Transformation The final common thread running through the part icipants experiences was their perceived lack of power. Caregivers felt th emselves to be in a one-down pos ition in relation to school staff and mental health professionals. Several caregiver s talked about feeling pressured to follow the schools recommendations about be havior management. Others were threatened with their sons expulsion from Magnet programs if they did not stop their sons negative behaviors. Two felt pressure to medicate their sons, even though neither of them saw the benefit of using medication. While one of them was able to deflect the pressu re to medicate, the other gave in, saying, Hes a doctor, Im only a Mom. She later stopped th e medication due to her concerns about complications. Participants also talked about their lack of information about availabl e services at school. They saw their lack of knowledge about whats there as a stumb ling block for their sons and in their negotiations with the school staff. Another caregiver talked about the school counselor explaining to her that her son was identified with a disability and had an IEP. Apparently, he had been placed two years previousl y, but she was not awar e of the disability or the accommodations

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105 in the IEP. She did not know the name of the di sability he had, nor did she know what services for which he was eligible. One caregiver also talk ed about testing for something that had been conducted at school, but was unclear about the outcome. Only two of the caregivers were able to say what their sons were diagnosed with (bot h were diagnosed with ADHD) and seemed to understand the diagnosis. The lack of knowledge a bout the inner workings of the school and mental health care systems added to the sense of powerlessness and inequality for the caregivers. The Byzantine labyrinth of forms and procedur es was also disempowering to caregivers. Joy called the help seeking process, a big r un around. One caregiver admitted feeling like giving up after trying for two years to find help for her son. The others all reported feeling frustrated about school rules and procedures. This lack of knowledge seemed to fuel the caregivers view of themselves as outsiders in the school sy stem: outsiders who were not necessarily welcomed, but who were expected to pl ay by the rules and fix their sons behavior. However, in spite of the exhaustion and oppressi on they felt, none of the caregivers gave up on their sons. They persisted and found ways to either convin ce the educators involved to hear them, or they found ways around the system Moving the child to a new school for a fresh start was one example of going around a schools ri gid power structure. These caregivers were passionate about advocating for a ppropriate care education for th eir sons. The rigid, blaming, and often isolating school power struct ures did not deter them from s eeking what they felt the boys needed in order to surmo unt the odds against them. Textural Structural Synthesis The most consistent, pervasive thread within the data was the l ack of collaborative communication in the schools, which resulted in caregivers feeling excluded from and unwelcome in encounters with educators. Care givers felt alienated from the decision-making process when working with educators in school s that employed the remediation paradigm of

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106 communication (Amatea, 2007). Caregivers felt that the school staff members were not listening to them when deciding on interventions for problem behaviors. Low-income African-American caregivers fe lt disconnected from the school community during the time when their sons were experienci ng behavioral difficulties. Caregivers expressed feelings of frustration with a nd alienation from the people in the school who had the power to determine their sons educational future. Caregivers felt that they were not viewed as equal partners in their sons education. Caregivers talked about not unders tanding what services were avai lable at school for their sons, or what services might be appropriate. Caregive rs were desperate to do anything necessary to keep their sons at their current schools but did not feel empowered to demand that the school staff make any changes. Instead, the caregivers felt pressured to fix their sons. Some participants felt added pressure to find help for their sons in order to break a cycle of negative outcomes for men in their families. However, the caregivers were pers istent in their support of thei r sons and in their quest to find help for them. Caregivers were able to tran sform their negative feeli ngs about staff members and school policies into a catalyst for learning to advocate for their sons. Essence Statement The essence of the phenomenon of being referred for mental health ca re for their sons by the school counselor was the caregivers experiences of alienation and powe rlessness in the face of a rigid, hierarchical system for parent invo lvement in educational decision making. Caregivers felt that school staff members were not interested in listening to their opinions or relevant past experiences. Caregivers felt that they had no pow er or voice in decisions concerning their sons futures, and that the school staff members expected them to quietly acquiesce to all

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107 recommended interventions. The caregivers want ed to advocate for their children by opposing interventions they perceived to be either impr actical or inappropriate but feared negative repercussions for disagreeing with or questioning educators. Caregivers clearly felt disempowered and unwelcome during m eetings with school staff members.

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108 CHAPTER 5 DISCUSSION Introduction This study was undertaken to answer one primary research question: What are the lived experiences of low-income African-American caregivers referred for mental health services for their sons? The question was subdivided into two part s: a) What are the initial reactions (thoughts, feelings, and actions) of the caregivers to the school counselors referral of their child to mental health services, and, b) How do the caregivers pe rceive the school staff making the referral during and after the referral meetings? Chapter Five addres ses the findings of the study in relation to the original questions, links the findings to current literature, and outlines potential future research related to this topic. Limitations of the study design and application are also examined. Overview of Findings The experience of having a son referred for mental health treatment by the school counselor was generally a negative one for the study participants. The actual referral itself was difficult for the caregivers to separate from the surrounding events; such as being contacted by the administrators and /or teachers about discipline problems, and having to go to school for meetings with various school staff members. The phenomenon in its totality was difficult for the caregivers. However, in this particular group of people, the hardships they encountered caused them to find inner and community resources they had not previously tapped. The transformative power of the experience in creating advocacy skills in the caregivers is a credit to their resiliency and strength. Alienation of Parents The caregivers in the stu dy, many of whom were long time school volunteers, were severely disappointed by how they were treated by school staff during meetings regarding their sons behavioral problems. They described feeling attacked, bl amed, and isolated. School staff members were apparently frustrated with the acti ons of the boys and took out their frustrations

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109 on the caregivers. Instead of asking the caregiver s to join with school staff to find mutually agreeable solutions, educators instead assigned to tal responsibility for finding help for the boys problems on the caregivers. This way of handling pa rent relations resulted in feelings of anger and alienation for the caregivers and did nothing to aid the boys. More often than not, the caregivers would go al ong with the requests of school officials to avoid possible negative consequences (suspens ions, expulsion, and al ternative school) not because the caregiver was engaged with the in tervention. Erford (2003) calls this passive behavior in parents the dont ma ke waves role. Erford contends that parents often agree with school staff members in order to avoid negative outcomes that might derive from their active resistance to interventions. The perception by pa rents that they should remain quiet and do as they are told by school officials comes from a po wer imbalance. In contrast, when school staff members work with parents collaboratively, powe r is shared equitably between both parties. Collaboration results in the creation of interventi ons palatable to both parties, and eliminates feelings of aliena tion of caregivers Feelings of Fear and Guilt To varying degrees, all of the caregivers expr essed feelings of fear and guilt. Many also experienced feeling that they were blamed fo r their sons problems by school staff members. These fears were initially rela ted to not understanding why their sons were acting out at school (and sometimes at home as well) and fears that their sons problems would get worse. During the process of negotiating possible consequences of their sons behaviors with the school staff members, a second set of fears emerged; the fe ar of their sons bei ng expelled, sent to an alternative school, or suffering other negative consequences.

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110 The blaming stance of most of the educators se emed to cause these later fears. As AfricanAmerican parents of boys, all of the study particip ants were aware of the potential for their sons to face negative outcomes in school and in later life. The perceived intolerant, unfriendly stance of the school staff brought these worries to th e fore and caused the ca regivers to become seriously concerned about their sons being lost to prison, drugs, and school drop out as the long term consequence of early negative school experiences. Powerlessness and Transformation Low-income, minority caregivers negotiating with the formal power structure of a public school often perceive themselves as powerless (Brantlinger, 1993; Friere, 1970/2003; Kozol, 1991; Majors, 2001; Winters, 1993). This appeared to be true of the caregivers who participated in this study. Caregivers reported that they felt desperate to comply with the wishes of the school staff, no matter how inappropriate they thought th ose interventions were. Participants saw the school as the gatekeeper to bett er life opportunities for their sons and did not want to endanger their futures by resisting the school staffs demands. In spite of their fears, feelings of alienation, and sense of powerlessness, all six caregivers managed to find ways to make their voices he ard with the school staff members. Their transformations from powerless spectators to advocates took many paths. Some parents took matters in their own hands, pre-empting the sc hool staff in recommending treatment for their sons. Others found allies in the community or with in the school to bolster their leverage. Yet others chose to move their children to other sc hools. All of these acts required bravery and persistence. What is compelling a bout these caregivers tr ansformations into advocates is that the educators involved seemed not to appreciate their efforts to intervene on be half of their children. Some educators apparently would have preferre d the parents to have remained passive and

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111 compliant, while others seemed to ignore the caregivers change. N one were reported to congratulate the caregivers on their persistence, bravery, or caring. Paulo Freire (1970/2003), although he was refe rencing impoverished Brazilian farmers in this quote, sums up the experience well; Education either functions as an instrument which is used to facilitate integr ation into the logic of the present system and bring about conformity or it becomes the practice of freedom, the means by which men and women deal critically and creatively with reality and discove r how to participate in the transformation of their world. (p. 35). Certainly, the caregivers in this study learned to deal criti cally and creatively with their sons problems and the education system. Each of them were all able to point out shortcomings in the educational system, yet were also able to navigate within or around it in order to meet the needs of their children. Links to Current Literature The findings in the study have strong links to current professional literature in three major areas; family-school communication, minority disenfranchisement in mental health care, and the experiences of AfricanAmeri can males in public schools. This section will highlight relationships between this study a nd previous research. Links betw een the findings of the current study and various theories of education, culture and social class will also be examined. Family-School Communication The professional literature regarding e ffective communication between families and schools is very consistent in its emphasis on the importance of open, non-judgmental, two-way communication (Amatea, 2007; Apter, 1992; Christ enson & Sheridan, 2001; Finders & Lewis, 1994; Lareau, 2000; Martin & Hagan-Burke, 2002; McCaleb, 1994; Shockley, Michalove & Allen, 1995). This follows a larg e and growing body of research which indicates that parent

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112 participation in education is a key to student academic achieve ment (Amatea, 2007; Christenson & Sheridan, 2001; Swap, 1995). Although the professional l iterature clearly show a strong link between student achievement and family involvement in schoolin g, many schools in the United States remain biased against low-income and minority fa milies (Dodson, 1998; Kozol, 1991; Lott, 2001). In their qualitative study of low-income Hispanic parents who were not visibly active in their childrens schooling, Finders and Lewis (1994) found th at parents generally wanted to be present at school, but were not sure how to go about ge tting involved. This lack of cultural insight may make reaching low-income and minority parents mo re difficult for educators. In an extensive review of the literatu re, Lott (2001) concluded that there is a lack of research about how educators and low-income parents communicate, but the available research indicates that, lowincome and working-class parents, as compared with middle-class parents, receive less warm welcomes in their childrens schools; their inte rventions and suggestions are less respected and attended to; and they are less able to influen ce the education of thei r children (p. 249). Adults who are members of marginalized groups often have nega tive histories with schooling and are often suspicious of educat ors motives. Overcoming their negative past experiences requires a conscious effort on the part of the school faculty to invite caregivers to be involved in explicit and consistent ways (Bla ir, 2001; Finders & Lewis, 1994; Lott, 2001; Winters, 1993). Brantlinger (1994) found that mi ddle school students per ceive their teachers biases about social class: students from upper-i ncome families were almost twice as likely to think their teachers liked them as were their low-income peers. In a related study by the same author, low-income parents were found to be deeply interested in their childrens education, but reported feeling powerless to impact educators (Brantlinger, 1993, p. 143).

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113 The current study clearly showed a disconne ct between low-income African-American caregivers and middle class educator s parallel to the findings in pr evious research. Interestingly, this was true in cases where the school counsel or was African-American just as often as when the school counselor was White. In both instances, the race of the school counselor seemed not to be as important as his or her methods of connect ing to parents. The school counselor who helped Joy connect to community services was White. That school counselor was effective in her communications with Joy largely because she took the time to lis ten to Joys point of view regarding her sons behaviors and did not immedi ately construct school-ce ntric interventions for him. The grave importance of treating low-income and minority caregivers with respect and giving credence to their points of view is emphasi zed over and over in the professional literature from the fields of education, counseling, and psychiatry (Amatea, 2007; Bemak & Chung, 2005; Boyd-Franklin, 1989; Brantlinger, 1993; Brunious, 2002; Christen son & Sheridan, 2001; Dogra, 2005; Lott, 2001; Noguera, 2007; Smith, 2004). In or der to effectively reach low-income and minority caregivers, educators are encour aged to take the following steps: Acknowledge and build on wisdom already present in the family. Treat the caregivers as equals, not subordinates. Avoid blaming the caregiver fo r the students difficulties. Establish consistent, two-way communication th at is not problem-based (Amatea, 2007). Creating a social climate in the school where effective family -school communication with low-income and minority families is possi ble requires a shift in the paradigm guiding the schools leadership, including th e school counselor (Amatea, 2007; Christenson & Sheridan, 2001; Lott, 2001; Senge, Cambron-McCabe, Lucas, Smith, Dutton & Kleiner, 2000). All of the schools in this study appeared to operate under a paradigm called remediation by Amatea

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114 (2007, p. 8). In the remediation paradigm, edu cators acknowledge the importance of parental involvement in their childrens education, but pla ce strict limits on the level of engagement they foster with parents. Parents ar e seen as non-experts whose primar y role in schooling is to help the teacher support his or her cu rriculum and provide for the childs basic needs. Communication within the remediation model is primarily probl em-centered: Caregivers are called only when there is a problem. Once caregiver s are contacted about a problem by the school staff, caregivers are then expected to fix the problem right away in the way prescribed by the school staff. There is little give-and take in the remediation pa radigm, it is school-centr ic and hierarchical. The paradigm prescribed in the literature as being more effective in partnering with families, particularly low-income and minority families, is called collaborative by Amatea (2007, p. 11). School faculties usi ng a collaborative approach to engaging caregivers establish consistent, two-way communication prior to problems developing so that if and when they do develop, the teacher and caregivers have already established trust. Collaborative communications also require that the educators view caregive rs as experts on their own children. Had the educators in this study been operating under a coll aborative model, intervention would have been far less adversarial and caregiver input would have been more highly valued. A collaborative frame would have also helped ease the caregiver s concerns about being blamed for their sons problems and would have replaced alienation wi th a sense of team work and community. Minorities and Mental Health Care The experiences of the participants in this study closely resembled t hose of the low-income Latina mothers interviewed by Arcia, Fernandez, Marisela, Castillo, & Ruiz (2004). The path from recognition of a problem needing treatment to the actual door of the mental health clinic was often very long and indirect. Two of the part icipants in this study s eemed better able to marshal resources than did the Latina mothers Ar cia interviewed, but others struggled to find and

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115 access services. Joys story of help seeking was extr emely similar to those of the Latina mothers. One possible explanation for the di fference is that older, more experienced participants fared better than younger, less experien ced caregivers, so that maturity and life experience may make finding appropriate care easier. Caregivers in this study struggled with c oncerns about the cons equences both of not finding mental health care for their sons as we ll as concerns about th e effects of going for treatment. Several participants also expressed concerns about lack of treatment resulting in a downward spiral for the boys, ending in prison and/or substance a buse. Other worried that their sons would be teased by their peers for goi ng to counseling or for taking medication. These concerns are echoed in the prof essional literature (Black & Krishnakumar, 1998; Brunious, 2001; Winters, 1993). The professional literature reflects the mu ltiple barriers facing low-income families seeking mental health care for their children, ma ny of which were reporte d by caregivers in this study. According to the Childrens Defense Fund (re trieved 09/01/2007) major barriers to mental health care for low-income families include: Lack of agreement among health care providers about when and how to screen children Lack of coordination between multiple service providers and funding sources, Lack of accessible resources. Too few qualified service providers and in adequate reimbursement for services. Additionally, low-income families face increased stress levels, often have fewer coping strategies and social supports, and may have diffi culty getting to service centers even when they exist (Black & Krishnakumar, 1998; Colpe, 2006; French & Reardon, 2003). Joy mentioned encountering the first three items in the list of barriers in seeking care for her son. All of the

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116 caregivers in the study mentioned in creased stress levels when tryi ng to find appropriate care for their sons. A final, but often compelling, barrier to services for low-income families is the fear of losing custody of their children (GAO, 2003). Fam ilies with children who have severe mental illness sometimes relinquish custody to the state because they can not afford the high costs of inpatient or group home treatment. One estimate suggests that parents of up to 20% of children with severe and persistent mental illness had to relinquish custody to chil d welfare agencies in order to have their children qualify for needed services (Childrens Defense Fund, 2005). None of the caregivers in this study faced the possibil ity of losing custody of their sons in order to qualify them to receive services. However, if any of the boys were to develop severe and persistent mental illness, the families interv iewed here could very quickly run through all available financial resources, a nd be forced to choose between retaining custody and obtaining treatment for their sons. African-American Males and Schools The African-American boys discussed in this st udy faced many of the barriers to academic success commonly written about in the professional literature. Two of th e five boys were in special education programs due to developmenta l delays, while all five had suffered negative academic consequences as a result of behavioral problems. All of the boys had been repeatedly suspended from school, often for what their caregivers saw as minor infractions of school rules, which parallels national trends in the over-representation of African-American male students among the total numbers of suspended and expelled students (National Ce nter for Educational Statistics, 2001). The caregivers concerns for the futures of their sons are supported by educational research. African-American males comprise a ma jority of the United St ates prison population

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117 (U.S. Department of Justice, 2006). The major ity (52%) of all Afri can-American males who leave school without a high school diploma have pr ison records before thei r thirtieth birthdays (Day-Vines & Day-Hairston, 2005). The caregivers hopes for their sons to attend college are common among parents of all races in the United States, but the chances for African-American males to enter a four-year college are far less likely than for any other race or gender combination (Noguera, 2003). The caregivers perspectives on the ways in wh ich the school staffs chose to intervene with them and their sons also echoes the professional literature. Care givers felt that their sons teachers did not have enough patience, compassion, or training to appropriately help their sons. This may have resulted from interacting with less well prepared teachers. Day-Vines and DayHairston (2005) document the tre nd of staffing schools in high pove rty areas with teachers who are not as well prepared to work with high need s students than their peers in more affluent schools. Another common conjecture as to why Afri can-American males do not perform well in school seemed to be only partially true in this study sample. The caregiver s in this sample were stressed by the demands of raising multiple children (and sometimes grandchildren, nieces, or nephews), working long hours at one or more jobs and stretching slim financial resources to cover expenses. Some researchers have postulate d that these multiple demands, combined with single and/or teenage parenting, can lead to a deficit in family support for academic achievement (White, 1982). However, in this study, the parent s were all engaged extensively with the schools their sons attended and reported making time regul arly to check homework. The caregivers also talked about having high levels of stress, a nd the difficulties they faced in finding help and support. In spite of those difficulties, in this gr oup of caregivers, their own perceptions of their

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118 organizational skills, high expectations for ach ievement, and positive attitudes were very strong and gave them some hope for good academic outcome s for their sons, in spite of problems the sons had experienced in the past. This hope for positive outcomes mirrors findings of other researchers (Clark, 1983; McCaleb, 1994; Swa p, 1995) who reported that family functioning appears to be more important than family struct ure or circumstance in determining the level of engagement of caregivers in childrens schooling. Implications for School Counseling Practice and Education The findings in this study affirm results of ot her research that high lights the high frequency of miscommunication between caregivers from low-income African-American families and school personnel, including the school counselor. The roots of this disconnection seem to be cultural; most public schools in the United States appear to oper ate from a cultural world view based on middle-class White values. The cultu ral dissonance between the schools and lowincome African-American families may cause fam ilies and students to feel disrespected and unwelcome in the social system of the school (Applebaum, 2002; Day-Vines & Day-Hairston, 2005; Monroe, 2005; Noguera, 2003; West-Olat unji, Baker, & Brooks, 2007; Winters, 1993). While this disconnection is most likely unintentio nal, bridging the distance between the White middle-class world of the school and the African-American low-income world of some families and students needs to be examined in an inte ntional, direct manner in order to improve communication. The cultural disconnection be tween low-income African-A mericans and the nations public schools not only skews family-school communications, but also limits academic achievement and students career options (C arter, 2003; Lee, 2005; Noguera, 2003). School counselors are key figures in the current struggl e to close the achieveme nt gap between AfricanAmerican and White students (Bemak & Chung, 2005). Part of the task of raising African-

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119 American student achievement overall is to be tter connect with caregivers, which this study clearly highlights as being problematic, at least in these particular cases. As Bemak and Chung (2005, p.197) make clear, the school c ounselors role now entails a duty to, pay close attention to social, political, and economic realities of fa milies, with an aim to simultaneously address these as critical elements within the school couns elors role. For school counselors to ignore the impact of inherent power structures that contribute to the achieveme nt gap is to participate in the insidious cycle of low performance and failure for poor students and students of color. One critical step towards closing the achievement gap for low-income African-American students is to create better working alliances with their fa milies; a need which this research clearly shows was not being adequately addressed. Collaborative Relationships with African-American and Low-Income Families Effective communication between families and sc hools is not a one-size fits all structure. Schools must consider the racial, ethnic, economic, and cultural backgrounds of the families they serve in order to create a ppropriate programs of communica tion (Applebaum, 2002; Comer, 1989). To effectively reach low-income African -American families, school counselors should draw from existing literature to better inform their practices of engaging these families. School counselors can begin to shift the family-school comm unications paradigm in the schools they serve from one of remediation to one of collabor ation by instituting the following changes: Acknowledge and build on the wisdom already present in the family. Treat the caregivers as equals, not subordinates. Avoid blaming the caregiver fo r the students difficulties. Establish consistent, two-way communication th at is not problem-based (Amatea, 2007).

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120 By engaging families in a collaborative, mutual sharing model of communication instead of a more traditional one-way, educator-as-expert mode, school counselors can begin to overcome some of the negative ex pectations about school staff held by some low-income and minority parents. Caregivers in this study lamented the lack of input they felt they had in decisions regarding their sons edu cation. They also talked about feelin g that school staff members did not listen to their concerns, and were very distresse d by the lack of power they felt they had in meetings to influence the decision making of school staff. Implementing a system of collaborative communication with all parents would help to assuage these feelings. Collaborative communication would help equalize power betw een low-income minor ity parents and the middle-class education professionals who serve th em. Recalling Lius (2001) intrapsychic model of classism, school counselors need to be aware of possible internalized classism when working with low-income and/or minority parents. Low-income and/or minority people may have difficulty reading social cues common in middl e-class environments, such as schools. Care should be taken to fully explain all school-related issues and avoi d professional jargon so that caregivers have a clear understanding of a ll possible interventions and alternatives. Sharing power and giving caregivers more voi ce at school would also help reduce what Erford (2003, p. 197) calls the dont make waves role parents sometimes play when they feel they do not have equal power in school decisi ons. This role, wherein caregivers will agree to anything suggested by school staff for fear of negative consequences, was prominent in participants responses in this study. Caregive rs fears of potential suspension, expulsion, or transfer to alternative schools led them to ag ree to interventions they did not feel were

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121 appropriate for their sons. If the schools ha d been operating from a collaborative model, caregivers might have felt empowered to voice their concerns about these interventions. Creating collaborative communication with low-income and African-American families is not a one-time exercise (Comer, 1989; Wint ers 1993). School counselors need to spend time intentionally creati ng and fostering relationshi ps over a long period of time in order to make a real impact on the alienation and disenfranchise ment felt by many parents in that population. In addition to the suggestions from Amatea (2007) about building collabo rative communications with parents, Lott (2001, p. 255) suggests the fo llowing steps to reach low-income families: School personnel must take the initiative in cr eating relationships with parents. Educators should not expect parents to come to them, but should intentionally find ways to reach out to families. Find ways to involve low-income parents other than as conse nt-giver. Invite parents to participate as collaborators, innovators, and critics. Encourage informal communication with families. Coordinate services with community agencies so that schools can be seen as community centers, or hubs of information and services. Provide training for all school personnel on reaching and collaborating with diverse families. As educational leaders, school counselors should be at the forefront of implementing such changes in how schools interact with lo w-income and minority fa milies. School counselors have specialized training in interpersonal commun ication and in systems change issues, therefore making them the ideal agents of change in family-school communica tions (Erford, 2003). Making Culturally Responsive Referrals School counselors making referrals for low-income African-American families, particularly to mental health services need to be aware of cultural stigmas and fears, as well as practical concerns, facing these parents. Caregive rs in this study were generally not opposed to

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122 the idea of getting some kind of mental health services for thei r sons, although some of them had serious concerns about the safety of medications. In fact, some of the caregivers were desperate for answers about their sons beha vioral problems. However, some parents did have memories of negative personal experiences with being teas ed for attending counseling when they were children which were not addressed by the school counselor during the referral process. Others had concerns about paying for services, finding tim e to go to appointments, and other practical concerns. To increase the likelihood that the referral is appropriate for the caregivers view of the problem, school counselors should explore existi ng concerns with careg ivers prior to making referrals in order The most consistent complaint about the refe rral process from caregivers in this study was the manner in which the referral was made. In the majority of cases, the caregivers felt either that they were forced to get services in orde r to avoid punishment (suspensions, expulsion, or transfer to alternative schools) or were expected to go along with suggestions in order to not make waves (Erford, 2003). Even the caregivers who wanted help for their sons were put off by the way the school counselor approached the issue of mental health servi ces. Only one caregiver reported a positive experience with the process. Much of the negativity of these interactions was predicated on the poor quality of existing re lationships between school staff and parents. Carefully creating warm, egalitaria n relationships with caregivers prior to the development of a problem can go a long way to pr eventing negative outcomes. School counselors need to learn these skills in their graduate programs. Specifi c training regarding stru ctural constraints of poverty and racial discrimination has been shown to increase counselor trainees sensitivity to race and class based oppression (Toporek & Pope -Davis, 2005) and should be included in masters level multicultural counseling coursewor k. Ideally, the thread of multicultural training,

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123 including issues of social class, should be in tegrated into counseling coursework rather than being isolated in one course (Patton & Day-Vines, 2004). In addition to creating collaborative relationshi ps with families, school counselors need to insure that caregivers understa nd precisely what the referral entails. Many times in this study, caregivers remarked that they did not fully unde rstand what services were provided by various agencies, or which person was responsible for wh ich intervention. This was especially true of caregivers whose sons had already been identifi ed as having special needs. Caregivers were baffled by the array of terms and forms they had heard of and seen in meetings, and had no useful working knowledge of what any of it me ant in terms of their sons education. School counselors need to take the time to be sure care givers understand what is being said in referral meetings, and need to be available for caregiver s answering questions that may come up after the meeting. Recommendations for Parents In this study, low-income African-American caregivers revealed that they perceived themselves as alienated from mainstream public education in the United States. They also reported feeling that they had less power in deci sion making than the school staff members. The caregivers in this study recognized that an imba lance of power existed between themselves and the public school officials. When the caregivers talked about th e school staff members, not listening, not caring, stre ssing me out, and being biased they were acknowledging their own lack of power. Even though the caregivers thought of themse lves as the less powerful group, they can nonetheless take acti on to equalize the imbalance of power. Paulo Freire (1970/2003) explains that power can be redist ributed in unequal situations in two steps: In the first step, the oppressed unveil the world of oppression and through praxis commit themselves to its transformation. (p. 54).

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124 The next part of Freires ( 1970/2003, p. 54) first step, through praxis commit themselves to action would follow. There are many ways the caregivers could make a commitment to action to resolve the imbalance of power they perceive in the schools. Some possibilities would include; developing formal or informal groups of concerne d parents that could orga nize a reform effort, networking with other institutions in the Afri can-American community such as churches and civil rights organizations to lobby the schools on their behalf, and taking individual action as needed. Once the caregivers chose to take some ac tion to correct the imbalance of power in the schools, the stage is set for th e second step. According to Fr eire (1970/2003, p. 55) the second step of the pedagogy of the oppressed is, the ex pulsion of the myths created and developed in the old order, which like specters haunt the new st ructure. In this stage, the transformation of the relationship between oppre ssor and oppressed has occurred and now the two sides can engage in egalitarian dialogue to negotiate a new relationship. This step can also be framed as a shift in the mental model of how schools work (Senge, Cambron-McCabe, Lucas, Smith, Dutton, & Kleine r, 2000). Shifting the me ntal model of how schools and parents interact enta ils bringing tacit assumptions and attitudes to the surface so people can explore and talk about their differences with minima l defensiveness (p. 67). Senge and his colleagues also talk about a two step process of transformation, which they call reflection and inquiry (Senge, Cambron-McCabe, Lucas Smith, Dutton, & Kleiner, 2000, p. 68). The reflection process requires people to thin k about their thinking, to carefully consider how they have formed the opinions they hold about a situation, while inqui ry requires a dialogue between various members of a community or organization to identify and bridge miscommunications and imbalances of power. Th is effort may be begun by school counselors or

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125 other staff members or by the caregivers them selves. For example, school counselors could conduct workshops for parents on communication sk ills, child advocacy, and their rights under special education law. School counselors could also conduct sm all group or individual coaching sessions with caregivers about how to negotiate with school staff on behalf of their children. Caregivers, as the oppressed group in this sc enario, may have less formal power than do school staff members, but they are certainly not completely pow erless. Many of them showed evidence of great personal power in the course of recounting thei r struggles to obtain appropriate care for their sons. If they were to apply this personal strength to the la rger context of familyschool relationships, the car egivers could initiate large scale changes in the mental models and practices of the schools in their communities. Training for Administrators and Teachers Although school counselors may lead the change in family-school communication, they can not do it all (Bryan, 2005). School counselors are, of course, not present during every interaction between a caregiver a nd educator at any given school However, they can work to insure that all educators at their school are trained to interact in a culturally responsive way with all caregivers. This may be accomplished by co nducting regular in-service workshops for teachers and administrators on culturally cong ruent communication skills (Bryan, 2005) and by modeling good communication skills. Training all school personnel, including administrators, to use collaborative communication methods with parents is especially important in working with disenfranchised caregivers. Low-income parents are more likel y than middle class parents to have negative assumptions about school personnel (Lott, 2001) a nd are more likely to stay away from the school if they perceive the atmosphere to be unwelcoming (Winters, 1993). School counselors can help other school staff memb ers to understand the conflicting mental models of caregivers

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126 versus school personnel. By framing the imbalan ce of power as a culturally driven disconnection in mental models, school counselors can lay the groundwork for less blaming and divisive discussions of these issues. In this study, caregivers were unable to differentiate between various roles of school staff members. They understood the role of the cl assroom teacher, but many of them did not understand the role of the school counselor versus that of assistant principal or principal. To these caregivers, the school personnel we re a homogenous seeming group, not distinct individuals. This perception underscores the impo rtance of all school personnel being trained to work in a collaborative manne r with diverse families. Limitations of the Study Qualitative research of this variety is limited in its generalizabilty, which is not the goal, but which may be desired by some readers. This study aimed to describe th e lived experiences of a certain group of people within a specific time place, and context. Descriptions are rich and thick, full of possible essences and meanings. Ho wever, what was essential about an experience in 2006 in the southern United States may or may not be essential about the same experience in a different place and time, or for a di fferent group of people (Wolcott, 1990). My race (white) may or may not have limited disclosure by participants. Special care was taken to develop rapport with participants, however, due to a long histor y of oppression and mistreatment of African-Americans by Whites, participants may have remained reluctant to fully disclose thoughts and feelings. There is also a possibility I did not understand subtle language and posture clues due to difference in culture. According to Gibson and Abrams (2003), Wh ite qualitative researchers interviewing African-American people are likely to have diffi culty getting access to par ticipants and building trust. However, Gibson and Abrams (2003) also found that African-American participants take

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127 extra effort to help White researchers understand what they intend to communicate, while when African-American researchers in terview them, the African-American respondents may assume the researcher already understands their experien ces. Thus, gaining access is a greater chore for White researchers, while particip ants may be more careful to fully explain their thoughts and feelings. This finding seemed to be valid with this study. However, access was made easier due to the pre-existing relationships between school personnel and participants. The phenomenon of African-Americans assuming researchers of th eir own race may understand more than White researchers is certainly wort hy of further thought and study. Bracketing all preconceived id eas about the referral of young African-American males to mental health services by school counselors wa s difficult for me, since I have worked as both a school counselor and a mental heal th service provider. However, a ll attempts were made to leave prior knowledge out of the interview and analysis process in order to allo w for the participants experiences to drive the formati on of the essence statement. Two participants, Sherry and Felicia, were not available for final interviews. However, they provided substantial information in earlier interviews. Ideally, all participants would have been interviewed three times, but due to the h eavy work and parenting re sponsibilities of these participants, three interviews were not always a possibility. Recommendations for Further Research Further studies examining low-income African -American caregivers perspectives on both schooling and on mental health care are needed. Social class in part icular, is not a well understood construct as it relates to counseling theory and practi ce. The education and mental health professions would benefit from both more theoretical writing and rese arch into how social class functions as a variable in peoples decisi on making. Research on social class as it relates to race and ethnicity is also needed. Combinations of low or middle class status among African-

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128 American males and how membership in various social classes might impact their academic performance would be of help to educators and policy makers working to close the Achievement Gap between African-Ameri can and White students. The ability of the caregivers in this study to transform th e negative experiences into a lesson in advocacy was fascinating to witness. Whet her this ability was borne out of their shared African-American culture or some other factor was not made clear. However, studying the ability of low-income African-Americans to ove rcome and transform trying experiences would be of great use to the helping professions.

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129 APPENDIX A POSSIBLE INTERVIEW QUESTIONS Interview 1: History of the fam ily and child leading up to the re ferral that shape the caregivers perceptions and reactions, story of the referral. As you know, Im curious about what you thought about and how you felt when your son was referred to _______ for help. Today, Id like to talk with you about how you felt when __________ was referred. Id like to hear a little about your son, and his history at school so far. Then we can talk about the process of being referred for mental health help. 1. Now lets talk a little about your son, _____________. Tell me a little a bout what kind of a child he iswhat he likes to do, what hes good at, who he favors. 2. How has his school experience been so far? What does he like about school? Whats been tough for him? 3. Describe what happened the day that the school counselor talked to you about your son getting help. 4. How did you feel? What though ts went through your head? 5. How did you decide what to do a bout the referral? Did you talk to anyone? Who? What advice did they have? 6. If you could go back in time to the day of the referral, is there anything youd like to change about how it was handled? 7. Between that day and now, what kinds of thin gs have you thought about regarding the idea of going to _______? Interview 2: Caregivers current pe rceptions of the referral of the child to mental health services by the school counselor. I will send the transcript from interview one to the participants in advance of interview two, and will check with them about the accuracy of the transcription before we continue. Last time, you told me some of your familys past experiences. Today, Id like to talk about whats going on now with the referral to ____________. 1. Have you seen any changes in your son? Can you give me some examples? 2. How has school been for _______ since then? 3. How are you feeling about all that now?

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130 4. Is there anything else you wa nt to be sure I know? Do you have any questions for me? Interview 3: Referral of the child to ment al health services and future plans. I will send the transcript from interview two to the participants in advance of interview three, and will check with them about the accuracy of the transcription before we continue. Today, as a way of wrapping up our time together, Id like to fo cus on your thoughts and feelings about how youre feeling about the referral in light of our previous talks, and find out what your plans are for the near future. 1. Lets review some of how you were thinki ng about the referral last time. Has anything changed in your mind since then? 2. How have things been going for you a nd your son since last time I saw you? 3. How (if at all) has this referral pr ocess affected your family or yourself? 4. Describe how youre feeling about your sons schooling today. 6. What are your hopes for your son fo r the rest of the school year? 7. How would you like the school to in teract with you in the future? 8. Is there anything youd like to be sure I know? Do you have any questions for me?

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131 APPENDIX B STEPS IN DATA ANALYSIS Steps for performing transcendental phenomenol ogical analysis of da ta (Moustakas, 1994): 1) Scouring data for meaning units. Meani ng units are discrete, non-repetitive, nonoverlapping statements. 2) Connected meaning units are grouped together into themes. 3) Each individual participants data is review ed for themes. A textual description is written which describes the individuals objective statements about the experience. Quotes are used liberally to support contentions. 4) Each participants data is then reviewed for structural descriptions. These are the researchers interpretation of the internal subjective experiences of the participant. During this step of analysis, the research er considers imagina tive variations or possible explanations and theories ab out the internal processes at work. 5) Once all of the individual data sets ar e described, group portra its are constructed. Composite textual and compos ite structural descriptions are written, compiling the experiences of all group members, while st ill referring back to original sources. 6) A textual-structural synthe sis is written, combining essential elements of the composite structural and textual descriptions. 7) Finally, an essence statement is derived from the synthesis. This is a brief statement of the essential nature of the phenomenon at study.

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132 APPENDIX C CONSENT FORM AND IRB APPROVAL

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133

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134 LIST OF REFERENCES Algeria, M., Canino, G., Rios, R., Vera, M.., Calderon, J., Rusch, D., & Ortega, A. (2002, December). Inequalities in use of specia lty mental health services among Latinos, African Americans, and non-Latino whites. Psychiatric Services, 53 (12), 1547-55. Allen, C. (2003, October 21). Reliev ing poverty for mental health. Psychology Today, 25-27. Amatea, E. (2007 (in press). Building culturally responsive family-school partnerships. Boston: Allyn & Bacon. American School Counseling Association. (2003). The ASCA National Model: A framework for school counseling programs. Alexandria, VA: Author. Angold, A., Erkanil, A., Farmer, E., Fairbank, J., Burns, B., Keeler, G., et al. (2002, October). Psychiatric disorder, impairment, and servic e use in rural African American and white youth. Archives of General Psychiatry, 59 (10), 893-901. Applebaum, P. (2002). Multicultural and dive rsity education. Santa Barbara, CA: ABC-CLIO. Apter, D. (1992). Utilization of community resources: An im portant variable for the homeschool interface. In S. Christenson, & Conoley (Ed.), Home School collaboration: Enhancing children's academic and social competence (pp. 487-498). Silver Spring, MD: NASP. Arcia, E., Fernandez, M., Marisela, J., Castil lo, H., & & Ruiz, M. (2004, November). Modes of entry into services for young child ren with disruptive behaviors. Qualitative Health Research, 14 (9), 1211-1226. Arredondo, P., Rosen, D., Rice, T., Perez, P., & Tovar-Gamero, Z. (2005, Spring). Multicultural counseling: A 10year conten t analysis of the Journal of Counseling and Development. Journal of Counseling and Development, 83 (2), 155-161. Baker, S. (1996). School Counseling for the Twen ty-first century (2nd ed.). Englewood Cliffs, NJ: Prentice-Hall. Beam, A. (2001). Gracefully Insane: The rise and fall of America's premier mental hospital. New York: Perseus Books. Beers, C. (1980). A Mind that found itself. Pittsburgh, PA: University of Pittsburgh Press. Bemak, F. (2000). Transforming the role of coun selor to provide leader ship in educational reform through collaboration. Professional School Counseling, 3 (3), 323-331. Bemak, F., & Chi-Ying Chung, R. (2005, February). A dvocacy as a critical role for urban School Counselors: Working towards e quity and social justice. Professional School Counseling, 8 (3), 196-202.

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135 Black, M., & Krishnakumar, A. (1998). Children in low income, urban settings: Interventions to promote mental hea lth and well-being. American Psychologist, 53 (6), 635-646. Blair, M. (2001). The education of black children: Why do some school do better than others? In R. Majors (Ed.), Educating our black children: Ne w directions and radical approaches (pp. 28-44). London & New York: Routledge. Boothroyd, R., & Armstrong, M. (2005). Co mo rbidity and unmet service needs among Medicaid enrolled children with identified disabilities. Journal of Emotional and Behavioral Disorders, 13 (1), 43-51. Bourdieu, P. (1977). Reproduction in education, society, and culture. Beverly Hills, CA: Sage. Boyd-Franklin, N. (1989). Black families in therapy. New York: Guilford. Brantlinger, E.A. (1993). The politics of social class in secondary school. New York: Teachers College Press. Brantlinger, E.A. (1994). The social class embeddedness of middle sc hool students thinking about teachers. Theory into Practice. 33(3), 191-198. Breda, C. (2003, December). Offender ethnicity and mental health service referrals from juvenile courts. Criminal Justice and Behavior, 30 (6), 644-667. Brown, D., & & Trusty, J. (2005). Designing and leading comprehensive school counseling programs. Belmont, CA: Brooks-Cole. Brunious, L. (2002). Constructing social realit y: Self-portraits of black children living in poverty. New York: Routledge. Bryant, J. (2005). Fostering educational resili ence and achievement in urban schools through school-family-community partnerships Professional School Counseling, 8(3), 219-227. Buboltz, W., Miller, W., & Williams, M. (1999). Cont ent analysis of research in the Journal of Counseling Psychology (1973-1998). Journal of Counseling Psychology, 46, 496-503. Busch, S., & Horwitz, S. (2004, June). Access to me ntal health services: Are uninsured children falling behind? Mental Health Service Research, 6 (2), 109-116. Bussing, R., Zima, B., Gary, F., & Garvan, C. (2003). Barriers to detection, help-seeking, and service use for children with ADHD symptoms. Journal of Behavioral Health Services & Research, 30 (2), 176-189.

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136 Caughy, M., O' Campo, P., & Muntaner, C. (200 3, July). When being alone might be better: Neighborhood povert y, social capital, and child mental health. Social Science & Medicine, 57 (2), 227-237. Childrens Defense Fund (2005). Childrens Mental Health Resource Kit. Retrieved September 1, 2006, from http://www.childrensdefense.org/site /DocServer/cmh_resource.pdf?docID=1361. Chow, J., Jafee, K., & Snowden, L. (2003, May). R acial/ethnic disparities in the use of mental health services in poverty areas. American Journal of Public Health, 93 (5), 792-797. Christenson, S., & Sheridan, S. (2001). Schools and families: Creating essential connections for learning. New York: Guilford. Claveirole, A. (2004). Listening to young voices: Challenges of res earch with adolescent mental health service users. Journal of Psychiatric Mental Health Nursing, 11, 253-260. Colpe, L. (2000). Estimates of mental and emotional problems, functional impa irments, and associated disability outcomes for the US child population in households. In R. Manderscheid & M. & Henderson (Eds.), Mental Health, United States, 2000 (pp. 269278). Washington, DC: USDHHS. Comer, J. (1989). The school development program: A psychosocial model of school intervention. In: Black students: Psychosocial is sues and academic achievement. Berry, G.L., & Asamen, J.K. (Eds.). Thousand Oaks, CA: Sage. Costello, E., Keeler. (2001, September). Poverty, race/ethnicity, and psychiatric disorder: A study of rural children. American Journal of Public Health, 91 (9), 1494-1498. Creswell, J. (1998). Qualitative inquiry and research design. Thousand Oaks, CA: Sage. DayVines, N., & & Day-Hairst on, B. (2005, February). Cultura lly congruent strategies for addressing the behavioral needs of ur ban, African-American adolescents. Professional School Counseling, 8 (3), 236-243. DeLashmutt, M., & Rankin, E. (2005, July/Augus t). A different kind of clinical experience: Poverty up close and personal. Nursing Education, 30 (4), 143-149. Department of Health and Hu man Services. (2000, June). Report of the Surgeon General's conference on children's mental health: A national action agenda (Olin, S., Ed.). Retrieved August 5, 2005, from http:/surge ongeneral.gov/topics/cmh/childreport.htm. Dodson, L. (1998). Dont call us out by name: The unt old lives of women and girls in poor America Boston: Beacon.

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145 BIOGRAPHICAL SKETCH Catherine Tucker is a school counselor and mental health counselor specializing in childrens issues. She is a graduate of the Univ ersity of North Carolina at Greensboro and holds degrees in public health Edu cation and counseling. She works w ith children in high poverty areas in the United States and abroad and plans to continue her work as a child advocate and as an educator of counselors and teachers.