The Rochester Review, University of Rochester, Rochester, New York, USA
By Sharon Dickman
The notion of "prevention" barely existed in the vocabulary of the mental health fields 40 years ago when a University psychologist started something he called the Primary Mental Health Project at Number 33 School on Rochester's east side.
Today that experimental program is renowned in journals of community and clinical psychology, both for its longevity and as a revolutionary step in mental health intervention: Its focus was on building wellness rather than on treating emotional damage after the fact. And it introduced a new kind of mental health worker--the "child associate," a warm and caring nonprofessional who works one-on-one with mild to moderately troubled primary school children to head off more serious problems later on. So admired is PMHP, as it is now universally known, that it has been adopted in more than 700 school districts around the world. More than a quarter of a million children have participated in the program over the years.
The project was born, as a joint enterprise with the Rochester City School District, to test a theory. Extensive research had pointed Rochester psychologist Emory Cowen toward a potentially effective, affordable way of helping children with minor school-adjustment problems who didn't need the professional help of a social worker or the school psychologist--yet. Perhaps all they needed was the comfortable, accepting support of an older "special friend," who could create a crucial relationship with these youngsters through informal sessions, chatting, playing, telling stories. Once trust was established, it was theorized, the children would open up about why it was that they felt alone, or sad, or distracted in school. And once the problem was identified, child associates (overwhelmingly women, with children of their own) could then help in resolving it.
Simply waiting for a troubled youngster to outgrow a problem had never made sense to Cowen. From what he had seen as a clinician, psychological help for adults with longstanding and deeply rooted troubles was often doomed to failure.
"If you're really committed to prevention, you're pretty much committed to two other things: a very heavy focus on young kids, and to serious work in the schools," he says. "School is probably the most accessible of the social institutions that are significantly involved in the shaping of young kids' lives. It's not the most important, but it is a terribly important one." That's why PMHP is a program based in the schools, where young children--kindergarten through third grade--can be observed and helped in their natural environment.
"To transfer information from the laboratory to the real world is a step we don't have to take," says colleague Dirk Hightower. "So once a program is effective, we already know it's effective in the real world." An associate professor of psychology, Hightower is director of PMHP and associate director of the Center for Community Study--an entity established in 1969 where Cowen and his colleagues work today on spin-offs of the original program and on new research based on the center's basic commitment to promote and build good mental health.
"Carl, who has never been able to function in a classroom situation, is miraculously learning to read.
"Dave, who didn't lift a pencil for three months, now asks permission to stay after school to finish his work.
"Tom had no regard for rules or the people who enforce them. Recently, he began to raise his hand instead of calling out, and he hasn't raced to be the first in line for months.
"Susan was working far below her ability and failing in more than one subject. I think a "C" will be her lowest grade for this last marking period.
"As for Gerald, he never looks up from his desk in the classroom and cannot speak above a mumble, but now he lifts his head and yells for joy when his child associate comes to pick him up."
Cowen may be modest about the evolution of PMHP, but others are not so modest for him. He has not just been ahead of the wave when it comes to advances in community psychology, he is the wave, colleagues say. Still an intellectual dynamo at 71, holding joint appointments as professor of psychology and of psychiatry, he has been recognized nationally for his work in preventing maladaptive behavior in children and building psychological wellness. That philosophy has spread among professionals in many fields and into public consciousness, even though Cowen still describes prevention as "small potatoes in relation to the standard let's-undo-where-we-can-undo approach."
From its beginning in 1957, the Primary Mental Health Project was not designed to work with the children who are the most difficult to control or whose behavioral problems are the most evident. Instead, it has focused on the kids hanging on the periphery--the ones exhibiting minor learning problems, poor concentration, or perhaps overly aggressive or withdrawn behavior.
Cowen and his colleagues believed that there could be real help for these children if, for a sustained period--half an hour or so once a week for 10 to 20 weeks is the norm now--they could spend time with a carefully trained paraprofessional associate in whom they could comfortably confide, and who in turn would help them express their feelings.
That child associate, of course, isn't operating alone. Backing her up is a behind-the-scenes team made up of the classroom teacher and the school-based mental health professionals who monitor the child's progress.
But the associate, Cowen says, is key to the program. "They work with many more children than a professional psychologist or social worker could ever hope to see, effectively stretching scarce resources." And the children, he adds, "respond well to their practical, jargonless approach to problems. They're not constrained by the rules of the trade, and they feel free to speak and act in a spontaneous, down-to-earth fashion. They are giving, and they identify closely and warmly with their charges."
Why their young charges are unsettled in class can be the result of many things: the death of a relative, a marital split, a parent's drug problem, or abuse at home. Ruth Miller, a PMHP parent, looks back on her son's school-adjustment problems of 10 years ago and believes he was in a vulnerable position because of turmoil in the family. "He needed a safe zone--a place where he could just say what he was feeling," says Miller, a high school teacher who lives in suburban Pittsford. "He needed someone to give him the tools to work his way through those feelings." He got that help early--in second grade--and still fondly remembers his special friend, the child associate who worked with him.
Without intervention from PMHP or some other reliable program, parents and teachers are wrong to think troubles will heal themselves, Miller confirms. In her own school, she sees students with a history of problems that were never addressed. "Their folders get thicker by the year," she says from experience. "If they had had attention earlier in their lives, maybe someone could have helped them."
Research shows that PMHP works. In the 40 years since that first experimental program, it has been thoroughly tested at Rochester and elsewhere, in countless studies. The Rochester group alone has added to the literature with a number of books and more than 250 articles in professional journals based on aspects of the PMHP model.
"The promise of what could happen to help the children was what got me excited about it," says Jean Conner Ferris '47, who spent 25 years with PMHP as a child associate. "By watching their play, we could see what was going on in their lives. And we could see that their problems really limited their ability to learn.
"What impressed me most was that you could actually see the child growing in self-esteem," she says. "And then he or she was more willing to try, more willing to learn, and more willing to trust.''
Ferris's experience was repeated with about 12,000 students last year in New York, PMHP's home state. But that's just the beginning. Every year there are another 20,000-plus children in California who participate in the program, and thousands more in Washington state and Connecticut, as well as Israel, Germany, and Canada. Such growth was unexpected in those early years.
"What happened," Cowen explains, "was that we spent a good 12 years or so working out the basic project and demonstrating its effectiveness. When we reached that point, we began to think, 'Hey, this is a new model. This is something that can help to bring about constructive social change.' So then we got into the business of dissemination.
"I can liken it to the growth and development of a child," this human development expert says, a bulletin board full of snapshots of babies behind him as he speaks. "At a certain point in time, you have to just let go and let the kid grow on its own."
Sharon Dickman is public information coordinator for the Office of University Public Relations.
Rochester Review--Volume 60 Number 2--Winter 1997-98