Liz,* a 14-year-old high-school student in Edinburg, Texas, is passing all her classes and enjoying going to school every day. She is thinking about college and professions where she can help other people.
Three years ago, however, these seemingly typical behaviors were very far from Liz’s reality. She was diagnosed at an early age with a range of behavioral disorders, and as she grew so did her challenging actions, both at home and in school. The middle child of five siblings, Liz did not stop and think before acting, did not accept consequences for her own behavior, and showed disrespect to her family members. She talked back to her teachers, skipped classes, was frequently suspended, and regularly engaged in risky behaviors like running away from home. Before she turned 12, Liz had been in a psychiatric hospital multiple times, including a hospitalization following a suicide attempt.
The changes Liz and her family have experienced are due in part to wraparound, an intensive and individualized care planning and management process that helps children like Liz reach their full potential while staying in their homes and communities (watch an animated video about wraparound).
“Wraparound targets children and families with the most intensive needs, many of whom are involved in multiple systems. They have mental health issues, but they might be also in trouble in school or with the law. The goal is to coordinate services, funding, and communication across these different systems, to maximize resources and make a real difference in families’ lives,” says Molly Lopez, director of the School of Social Work’s Texas Institute for Excellence in Mental Health (TIEMH).
TIEMH has partnered with the Texas government to lead the implementation and evaluation of wraparound through the state. To do so, TIEMH has been working with the National Wraparound Implementation Center, which offers a strong, evidence-based model to implement wraparound effectively.
The wraparound process
“Wraparound is a process that provides structured, creative, and individualized team planning for children, youth, and families,” Lopez explains. “It draws upon the strengths and resources of a committed group of family, friends, professionals, and community members.”
The wraparound process starts with a facilitator engaging the youth and family, with the intent of understanding their story, culture, and values.
“Families referred to wraparound usually have tough stories to tell and have tried many different approaches that didn’t work very well for them. It’s normal then that they are frustrated about services, and somewhat hopeless about their situation getting any better,” Lopez notes.
The wraparound facilitator takes a wider perspective that includes but goes beyond the crisis- or trauma-centered story that the family might tell. This reframed story emphasizes strengths that family members have, points to how the family has overcome difficulties in the past, and identifies the individuals that have supported them. To build this strengths-based story, the facilitator also gets the perspective of others important to the family, such as extended kin, neighbors, teachers, and counselors. All these people are invited to join the family in the wraparound team.
Once this groundwork is laid, the facilitator calls for a wraparound team meeting. The goals of this first meeting are to reach consensus on the family’s strengths and needs and to brainstorm about how to meet them.
One difference between wraparound and traditional mental health services is the focus on the needs of all family members, rather than solely on the needs of the child or youth. Another difference is that team members are actively encouraged to think outside the box to meet those needs, and to commit to be an active part of the solution for the family by taking part in specific tasks.
“Whereas in a traditional mental health care system a child might be diagnosed and sent to therapy, a wraparound team meeting brings many other possibilities to the table, based on the active collaboration of natural supports such as friends and teachers as well as system supports such as juvenile justice or foster care staff,” Lopez says.
For instance, during one of Liz’s wraparound team meetings, her teacher suggested that she join open gym during the summer and offered to monitor Liz’s school progress. The team also built upon Liz’s good relation with her little sister, and looked for programs they could do together. The fact that the family was about to be evicted from their house owing to Liz’s behavior was also discussed, and the case manager in the team helped Liz’s mother with a housing application.
To access a broader array of services than is usually available within public mental health options, wraparound teams in Texas may have access to a Medicaid waiver called Youth Empowerment Services (YES).
“The YES waiver allows wraparound teams to pay for non-traditional services for which there is not much available funding, such as respite care, mentoring, employment services, or non-traditional therapies,” says Erin Espinosa, who is leading the YES waiver expansion for TIEMH.
Through the YES waiver, for example, Liz had the opportunity to participate in animal-assisted therapy. Her work with horses and an equine therapist helped Liz improve her self-esteem, learn strong communication skills, and gain a sense of responsibility.
Finally, the wraparound team makes sure that the selected strategies don’t bring conflict among the different systems the child might be involved in.
“For example, the child welfare system may require that parents take a parenting class at the same time that the juvenile justice system requires that they or the child fulfill another duty,” Lopez explains. “Well, parents can’t do both, so these conflicting demands really set them up for failure. The wraparound team, which includes representatives of all the systems a child is involved in, identifies these conflicts from the start and finds alternatives.”
The wraparound team meets monthly. The facilitator keeps track of outcomes and progress, checks with team members to find out how things are going with their respective tasks, and makes sure that everybody is able to do what they planned to do.
“In the long-term, the idea is that the family moves away from having these formal system supports, such as case managers and therapists, and towards having more natural supports—friends, neighbors, pastors, etc.,” Lopez concludes.
Wraparound in Texas
Wraparound has been implemented in communities throughout the United States with good results. Studies have shown that wraparound reduces costly hospital and residential care, improves youth functioning, reduces emotional and behavioral problems, and results in greater community adjustment.
Like with any complex new practice, the implementation of wraparound in Texas has many components, such as training, capacity building, and evaluation (see graph).
Since 2013, TIEMH has trained more than 500 facilitators or supervisors across Texas, using the curriculum developed through the National Wraparound Implementation Center.
TIEMH also offers both in person and virtual coaching to facilitators and their supervisors, to help them improve their skills, work through barriers, and build community capacity. TIEMH has identified coach candidates from across the state to apprentice under the national expert. The intent is to develop a local cadre of certified trainers and coaches that can provide ongoing support throughout Texas, and train new facilitators as needed.
Finally, TIEMH is also supporting the measurement of practice fidelity and outcomes, so that agencies can identify both strengths and weaknesses in their current practice and work to improve and sustain their programs over time.
Wraparound is currently available statewide in Texas, mostly through community mental health centers. The YES Waiver, available in nine regions now, is expanding to be available statewide by September 2015.
For youth like Liz and their families, the YES waiver and wraparound has offered a new way to strengthen their family and move forward toward the future they all want.
“When organizations embrace a culture of high quality practice, families are more successful,” Espinosa says. “It is imperative that organizations see wraparound as a way of partnering with families in the world they live in, building on the families’ resiliency, and coordinating services and supports to help them achieve their vision.”
*Name has been changed
By Andrea Campetella