AWARE builds self-esteem and coping skills in adolescents overcoming behavioral health challenges

September 1, 2011

More than 60 percent of the population of Passaic, N.J., is Latino. Many families hail from Chile, Peru, Ecuador and other South American countries as well as Mexico. The poor, urban city also has a sizable Ukrainian and Orthodox Jewish population.

The children and adolescents of this melting pot city suffer from the same sort of mental illnesses that devastate many American teens — bipolar disorder, depression, anxiety and obsessive-compulsive disorder.

Passaic's St. Mary's Hospital serves immigrant children and others through an intensive therapy program called AWARE. Participating children, age 11 through 21, meet for four hours every weeknight to address their troubled relationships and lives.

Founded in 1988, and funded by Medicaid and private insurance billing, the AWARE program originally served those receiving inpatient mental health care. But as the program built ties to school districts and local aid organizations, community referrals increased. Last year, 56 individuals from both the community and St. Mary's six-month residential program for adolescents with mental health issues participated in the voluntary program. AWARE itself is not a residential program.

Culture clash
As new immigrants settled in Passaic, St. Mary's adapted AWARE to address culture clashes in the home. "Our mission is to change as our community changes," says program director Samantha Commarato. "When kids are relocated (from a different country) there a lot of adjustment issues. They acclimate fairly quickly in many cases, but then there is a cultural divide between the way they think things should be and what their parents are still trying to instill. So we see the family system gets thrown off."

Case manager Femy Garcia says family participation is key to an adolescent's recovery. Even if a family is not part of the problem, it must be part of the solution. Parents must attend at least two monthly AWARE workshops, and it can be challenging to get that up - front commitment. Sometimes families from other cultures do not understand mental illness or are wary of therapy, she explains.

"We need the parents to be with us," says Garcia, who communicates with families one to three times a week. "It can be a challenge because their beliefs are very strong, and it's hard to integrate the American culture with their own. I let them know I'm not trying to change their beliefs.

"When I first meet parents, I avoid giving (diagnostic) labels because that tends to push people away. That's why I focus on the behaviors as opposed to the diagnosis," Garcia says. "I let them know we can't go from arguing all the time to everything is perfect in the next two days. So we discuss, what is something you can do with your child — just the two of you? Is it going for a walk or cooking something?

"It's about finding the steps that are comfortable for them," Garcia says.

Strength in numbers
The program is intense. After check-in, participants engage in four, 45-minute therapy sessions per night with a 30-minute dinner break in between. Staff uses interactive play, structured conflict resolution and behavioral therapy.

AWARE provides a range of group therapy programs that focus on coping, daily living skills, communication and decision making. Participants also meet with a psychiatrist and attend a weekly nurse-led psycho-education class to explore various diagnoses and medications.

"Our approach is really blended," says Commarato. "We don't always have them in a circle. If one of the kids is having a hard time, we may drop what we had planned and talk about that. Or we might read an Aesop Fable like the bundle of sticks story. We'll hand out a stick to everybody and say try to break this in half. Then we'll have a pile of sticks and say, 'Try to break them.' And you can't. It's a way to talk about the strength of being part of a group and each person's role."

Drawing out emotions
Art therapy also is an important component to the AWARE program. Caregivers find that teenagers, in particular, often can address difficult feelings through visual expression.

"At this age, adolescents are very aware of the things they are saying and the way they physically present themselves," says Garcia. "They are at an age where they are trying to determine who they are and how they want people to see them so they tend to be very guarded. But when you put things in front of them, like an art assignment, and let them be free to play, they have fun. They are not talking about the things they try very hard to hide."

Fifteen-year-old Tristan says art therapy sets this program apart from others he has attended in the past. For a recent project, he and other group members were asked to draw a nest, which can evoke feelings about family. One participant drew a nest full of eggs but no bird to protect them; another placed the nest next to a squirrel hole. Tristan's nest was overshadowed by a factory.

"Instead of just drawing a nest, I looked at the whole picture and said, 'Sure, there may be a nest, but it's not always just the one little happy part,'" says Tristan, whose last name is not being used to protect his privacy. "Sometimes there is the bad side. That's why only one part was the tree, and the rest was factory and pollution."

One day, he'd like to be an architect or chef. Right now, however, Tristan is trying to make sense of his depression. Caregivers say he has made progress since he was admitted to St. Mary's residential program in the spring.

"It's been helping with my relationship with my mother and my communication skills," Tristan says of his participation in AWARE.

Commarato expects Tristan, like many clients, will need additional therapy once they complete the AWARE program. But most report feeling less anger, anxiety and depression after the program.

"Some people need individual therapy. Some need in-home family therapy. Other things we recommend are nontherapeutic like an art class or extracurricular activities," Commarato says.

Recent surveys, taken at three, six and 12 months after completion, show AWARE participants have made noticeable strides. Disruptive behaviors declined. All clients remained in school, and 92 percent had not been re-hospitalized. In addition,

92 percent are living at home, a huge accomplishment given that 40 percent of clients start the AWARE program while living at St. Mary's adolescent residence.

"There is a lot of hard work that happens here," Garcia says of AWARE. "The idea is you want to be here because you want to make changes. It's hard when kids are losing their summer vacation or free time, but six months is a very short time if you want to change the rest of your life."


Copyright © 2011 by the Catholic Health Association of the United States
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