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Expanded School Mental Health: A Collaborative Community-School Example

Posted on: Sunday, 15 January 2006, 03:02 CST

By Weist, Mark D; Ambrose, Melissa Grady; Lewis, Charla P

School-based mental health programs are becoming increasingly prominent. This article presents an expanded school mental health framework involving school and community staff working together to enhance mental health programs in schools for youths in both general and special education. Success in this new framework requires staff from multiple disciplines to partner in planning and coordinating activities in ways that are consonant with the goals of the school and its many stakeholders. Challenges to such interdisciplinary collaboration, as well as strategies to overcome them, are presented with a real-world example.

KEY WORDS: collaboration; families; mental health; schools; youths

The mental health needs of children, adolescents, and their families are not being adequately met (Knitzer, 1982; Leaf et al., 1996; U.S. Department of Health and Human Services, 1999; U.S. Public Health Service, 2000). In traditional community settings, such as mental health centers and private offices, limitations and barriers to mental health care for youths include poor knowledge of mental health and stigma, financial barriers and transportation problems, limited availability of programs and poor system capacity, and insurance obstacles and excessive bureaucracy (Center for Health and Health Care in Schools [CHHCS], 2003; President's New Freedom Commission on Mental Health [PNFC], 2003;Weist, 1997;Weist, Paternit, & Adelsheim, 2005).There is also increasing awareness of limitations in mental health programs in schools. Almost all schools provide some level of mental health services, but in many communities, the more intensive services are limited to youth enrolled in or referred to special education (Weist et al., 2005).

It is in this context that schools and systems of education around the country are joining forces with community mental health and health systems, families, and community stakeholders to promote youth mental health and remove it as a barrier to learning. According to Flaherty and colleagues (1998), the goals of expanded school mental health (ESMH) programs include improving school attendance and achievement, and optimizing the health, mental health, and overall quality of life for all students. Achieving these goals requires going outside of the box, and the school building, enlisting professionals in mental health care agencies as well as parents in support.The partnership between schools and community agencies is mutually beneficial. Schools get increased support to address mental health issues through additional staff and added financial support. Furthermore, they enjoy the reduced stress and liability associated with being the sole provider of mental health care for the youths in the building. Community agencies and programs benefit by being able to reach youths whom they would otherwise be unable, or at least less likely, to reach (Greenberg et al., 2003; Weist, Evans, & Lever, 2003).

In addition to this increased awareness of need and mutual benefit, expanded school mental health programs are growing based on early evidence of their advantages. For example, these programs have demonstrated increased access, improved outreach to youths with less observable problems, and increased staff productivity (CHHCS, 2003; Hunter, 2001; Weist, Myers, Hastings, Ghuman, & Han, 1999). Despite their obvious benefits, instituting such programs is not without challenges. Stakeholders must maintain and uphold their equality as partners through a level of collaboration to which they may be unaccustomed. By their nature, these programs have to abandon the traditional "top-down" hierarchy often seen in the management of mental health programs. In addition, mental health professionals embarking in such a program need to prepare for cross-disciplinary work. For example, those working in private mental health facilities will need some training to bring their expertise to school settings. This shift, in turn, may engender hostility and turf battles if a foundation of partnership is not laid down and firmly instilled in the stakeholders. Furthermore, such programs represent an addition to the duties of professionals whose positions already require numerous other duties. This article, therefore, provides a blueprint for expanded school mental health programs that recognizes these obstacles, offers examples to eliminate or mitigate them, and lays a path toward success in collaboration.

COLLABORATION

Collaboration among education staff, community mental health staff, and school and community stakeholders is a hallmark of ESMH programs (Waxman,Weist, & Benson, 1999). All kinds of professionals have been providing mental health services in schools for decades, including school and clinical social workers; school, clinical, and counseling psychologists; school counselors; nurses; and child and adolescent psychiatrists. The expanded school mental health framework calls for these disciplines to increasingly interact with each other, with education staff, and with youths and their families (Weist, Proescher, Prodente, Ambrose, & Waxman, 2001). Streeter and Franklin (2002) emphasized that this work should be viewed as "transdisciplinary," wherein "professionals commit to teaching, learning, and working with other service providers across traditional disciplinary boundaries" (p. 615).

Work across Disciplines

In this transdisciplinary work, several issues are being confronted. First, there is a blending of roles in professional training and in practice (see Paavola et al., 1996). For example, school psychologists and clinical and community psychologists are increasingly involved in very similar work. This is a result of school psychology training programs that are increasingly emphasizing training in intensive therapies, and in working in other community settings (Nastasi,2000;Power,Manz,& Leff,2003). In turn, clinical and counseling psychology programs are increasingly emphasizing work in schools based on the recognition of limitations in traditional practice sites (PNFC, 2003; Weist, 1997). This same phenomenon is happening in social work, where social workers are being broadly trained to work in both school and other community sites, and practitioners are ever moving from practice in one context to another (Franklin,2000;Streeter & Franklin, 2002). Similarly, school counselors are increasingly being trained to provide intensive mental health care, and training in nursing is placing more emphasis on mental health (Flaherty et al., 1998; PNFC). Furthermore,child and adolescent psychiatrists are moving beyond traditional diagnostic and psychopharmacological roles to participate in team efforts that include therapy and prevention efforts (Flaherty & Osher, 2003). And for each of these groups, this trend toward blended role training is also reflected in blended roles in practice. Although these trends are growing and becoming best practices, this new landscape of service delivery may be unusual for some professionals and for them, transdisciplinary work may be perceived as problematic for numerous reasons.

Threats to Traditional Authority. This blended functioning called for in the ESMH program framework represents a challenge to traditional hierarchical approaches of mental health and educational practices in that it promotes greater interdisciplinary collaboration as people come together to mutually decide who will do what (Greenberg et al., 2003; Weist & Ghuman, 2002). Joint decision making, however, adds to the complexity of collaboration and runs the risk of obscuring unique strengths of the individual disciplines. For example, social workers bring expertise on family and system focus, psychologists bring assessment and behavior management, school counselors their knowledge of academic and career guidance, nurses their ability to conduct health-mental health integration, and psychiatrists their diagnosis and psychopharmacology expertise. With so much leadership potential, it may be difficult to fully infiltrate a teamwork approach without first doing extensive groundwork to establish goals, guidelines, and roles.

Turf Wars. It is important to acknowledge that issues of "turf," or concerns that one's discipline is moving into the territory of another, or worse, threatening a person s job, are real. Our experience, however, is that these issues can be avoided if a few ground rules are kept. First, a spirit of mutual respect and mutual desire to learn about the other discipline is a primary goal. second, in their collaborative ventures, school and community systems should never allow a provider from one system to be displaced so that a provider from another system can work in the school (for example, a school reduces its budget for school-hired mental health staff, then brings on contractual staS).Third, school- hired mental health staff members ideally should lead mental health expansion efforts because they are from the school, understand its workings, and know the issues of its students, families, and staff.

Constraints of Job Duties

It is also increasingly clear that other job demands can constrain the functioning of st\aff from different disciplines in their -work in ESMH programs. For example, in some school districts, school social workers have excess administrative functions, school psychologists have myriad other assessment functions, and school counselors at times can be inundated with academic advisement functions. Although professionals in education and health care are often multitask-minded people, their divided attention may lend to their being branded as somewhat uncommitted or even inconsequential to the ESMH program. It is important to recognize that the staff's positions are constraining their function, not their training or competence (Acosta.Tashman, Prodente, & Proescher, 2002; Flaherty et al, 1998). Knowledge of this issue should be translated into action, in a conscious effort by those who work in school mental health to avoid "typecasting" of people from other disciplines because of their position constraints in a school (for example, psychologist as "tester," social worker as "crisis manager"). Rather, it is necessary to plan for these eventualities for the long-term survival of the ESMH program.

SUSTAINING SCHOOL-COMMUNITY PROGRAM COLLABORATION

Another major obstacle to collaboration in expanded school mental health is related to the tenuous nature of funding, which in times of plenty brings many additional resources including external professionals to schools and in lean times dries up those resources. Staff members who have worked in schools for several years typically witness many people and programs from community agencies corne and go. This cycling can foster a jaded attitude about the "outside" people and programs. If the expectation is that community staff will only be in the school for the short-run, then they question the investment of energy in building a collaborative relationship.This is a legitimate concern given how busy people who work in schools are.

One way to address this concern is by establishing a strong alliance between leaders of the sending community agency or program and from the school (Acosta et al., 2002). For example, memoranda of understanding that formalize expectations on both sides that the community program's relationship with the school will be ongoing can be developed. As a follow-up to this agreement (whether it is formal or informal), the school principal and other school leaders should convey their strong support for the collaboration to the school's mental health, health, and educational staff. In turn, the community program leaders and staff should reach out to the school staff to convey and demonstrate their commitment to the school. In our University of Maryland (UM), School Mental Health Program (SMHP), which operates in more than two dozen schools in Baltimore, we have continued to provide services in all schools, except in two instances in which the principal requested that we discontinue services. For all of the schools, a goal is to not only continue to provide services but to expand staff coverage whenever possible.This vision, expressed in words and behavior in each school each year, has helped school-employed staff to view us as long-term partners in the school rather than "temporary outsiders."

IMPROVING COMMUNICATION, DECISION MAKING, AND MUTUAL SUPPORT

Effective communication is a key starting point for developing successful collaborative relationships. Channels of positive communication can be established early on by involving leaders and mental health staff from the school, and community leaders and mental health staff in initial planning for the expanded school mental health program. For example, this initial team could include the principal, mental health leaders from the school (for example, social worker, psychologist, or counselor), the community program director, and clinicians who will work in the school. This planning team can then discuss issues such as unmet needs of students and families in the school, gaps in services, problems that have been identified, and recommendations that have been made. These discussions would then lead to the development of preliminary plans for expanding and improving services. With a preliminary plan in place, feedback on it can be sought from teachers, families, students, community leaders, and staff (see Acosta et al., 2002; Waxman et al., 1999).

In these planning discussions, a useful strategy is to map services and programs in the school along a continuum, from school- wide approaches that seek to broadly promote student (and staff) mental health, to small group and classroom-based prevention activities, to efforts to identify youths in need and intervene early, to more intensive interventions. As gaps are identified, discussions can then be held on which school and community staff will be involved in efforts to fill them. The use of interdisciplinary teams is a frequent mechanism to facilitate communication and collaboration (Flaherty et al., 1998). Some schools have developed mental health teams in which school-hired staff and community professionals join together as one team to coordinate mental health services in the school. Ideally, this team should include all mental health providers in the school, administrators, school health staff, teachers, paraprofessionals, and others involved in promoting positive behavior in students (Waxman et al., 1999). It is important that these teams provide an ongoing forum for staff from different disciplines and employing agencies to develop relationships, enhance each other's knowledge about discipline-specific competencies, and provide mutual support (see Waxman etal.).

AN ESMH PROGRAM EXAMPLE

The SMHP provides expanded school mental health services to 28 elementary, middle, and high schools in Baltimore. At one elementary school, an experienced counselor with a master's degree in psychology works four days a week, along with a psychology extern (third-year doctoral student) who works one day a week in the school. Both are employed by the SMHP.They work closely with the school social worker, school psychologist, school counselor, principal, and assistant principal to establish an effective student support team (SST).The SST includes the principal (attending when she or he can), a teacher, a teacher with behavioral expertise, and the school nurse.

Bringing together the expertise of several disciplines and experiences (with some new and some more experienced staff), the team:

* develops procedures for the identification, referral, and disposition of students needing assistance

* holds forums with students, teachers, and families for their views on problems and concerns and to get their recommendations for addressing them

* coordinates the provision of prevention and intervention programs

* discusses the development of a mentoring program for the students

* develops and coordinates school assemblies

* discusses ongoing problems of students in treatment, sharing knowledge and recommendations to improve care

* provides mutual support and encouragement to team members.

In addition to the operation of the SST, school-employed and SMHP staff have formed close working relationships (and friendships) and often provide informal feedback, ideas, and support to one another. School social workers and psychologists share expertise with the UM staff on special education issues and crisis response, and UM staff members share expertise on community resources and evidence-based preventive interventions. School counselors assist UM staff in negotiating academic and career guidance issues with students and serve as co-leaders in prevention groups. All of these mental health staff members have close working relations with staff who work in a health center based in the school, including a nurse and nurse practitioner. As a team, the school mental health personnel also have close collaborative relations with school administrators, teachers, family volunteers, and student representatives. Team members often have lunch together and hold an annual off-campus social event.

Admittedly, this example reflects the vision for how student support teams and their collaborative processes should work. It took time to build this level of relationship. In reality, ESMH teams struggle to maintain regular meetings and to maintain time on the agenda to focus on efforts that improve the school environment, provide training, and build prevention programs. There is always a crisis or pressing issue to address. On some days, crises also get in the way of more informal interaction and support.There is no question that these teams require strong leadership and an abiding commitment from each participating member to function effectively.

The emerging expanded school mental health field is inherently collaborative as it represents the joining of families, schools, and major child-serving systems. Within this partnership, strategies for collaboration should be made explicit, efforts to actually collaborate should be prioritized, and an atmosphere of mutual respect and support should characterize the work. These are not easy tasks, as truly collaborative efforts take time and almost always result in some uncomfortable issues that need to be addressed. But with a demonstrated commitment by all team members to sustain the collaboration and work through the issues, the work itself will improve, as will the outcomes for students and schools.

REFERENCES

Acosta, O. M.,Tashman, N. A., Prodente, C., & Proescher, E. (2002). Establishing successful school mental health programs: Guidelines and recommendations. In H. S. Ghuman, M. D.Weist, & R. M. Sarles (Eds.), Providing mental health services to youth where they are: School- and community-based approaches (pp. 57-74). New York: Brunner-Routledge.

Center for Health and Health Care in Schools. (2003). Caring for kids is giving children the help they need at school:This is how it works.Washington, DC: George Washington University. (ERIC R\eproduction Document Service: ED480805)

Flaherty, L.T., Garrison, E. G.,Waxman, R., Uris, P. F, Keys, S. G., Glass-Siegel, M., & Weist, M. D. (1998). Optimizing the roles of school mental health professionals. Journal of School Health, 68, 420-424.

Flaherty, L. T., & Osher, D. (2003). History of school-based mental health services in the United States. In M. D.Weist, S.W. Evans, & N.A. Lever (Eds.), Handbook of school mental health: Advancing practice and research (pp. 11-22). New York, NY: Kluwer Academic/Plenum Publishers.

Franklin, C. (2000).What is in a name? Children & Schools, 22,194- 198.

Greenberg, M.T.,Weissberg, R. P., O'Brien, M. U, Zms, J. E., Fredericks, L., Resnik, H., & Elias, M. J. (2003). Enhancing school- based prevention and youth development through coordinated social, emotional, and academic learning. American Psychologist, 58, 466- 474.

Hunter, L. (2001, Spring).The value of school-based mental health programs. Report on Emotional and Behavioral Disorders in Youth, 1, p. 27-28, 46.

Knitzer, J. (1982). Unclaimed children: The failure of public responsibility to children and adolescents in need of mental health services.Washington, DC: Children's Defense Fund.

Leaf, P. J., Alegria, M., Cohen, P., Goodman, S. H., Horwitz, S. M., Hoven, C. W, Narrow, W. E.,Vaden-Kiernan, M., & Regier, D. A. (1996). Mencal health service use in the community and schools: Results from the four-community MECA study. Journal of the American Academy of Child & Adolescent Psychiatry, 35, 889-897.

Nastasi, B. K. (2000). School psychologists as health-care providers in the 21st century: Conceptual framework, professional identity, and professional practice. School Psychology Review, 29,540-554.

Paavola, J. C., Carey, K., Cobb, C., Illback, R.J.Joseph, H. M., Routh, D. K., &Torruella, A. (1996). Interdisciplinary school practice: Implications of the service integration movement for psychologists. Professional Psychology: Research & Practice, 27, 34- 40.

Power,T. J., Manz, P. H., & Leff, S. S. (2003).Training for effective practice in the schools. In M. D.Weist, S.W. Evans, & N. A. Lever (Eds.), Handbook of school mental health: Advancing practice and research (pp. 257-273). New York: Kluwer Academic/ Plenum Publishers.

President's New Freedom Commission on Mental Health. (2003). Achieving the promise: Transforming mental health care in America. Final Report. (DHHS Publication No. SMA-03-3832). Rockville, MD: Author.

Streeter, C., & Franklin, C. (2002). Standards for school social work in the 21st century. In A. R. Roberts & G. J. Greene (Eds.), Social workers' desk reference (pp. 612-618). New York: Oxford University Press.

U.S. Department of Health and Human Services. (1999). Mental health: A report of the Surgeon General. Rockville, MD: Author.

U.S. Public Health Service. (2000). Report of the Surgeon General's Conference on Children's Mental Health:A national action agenda. Washington, DC: Author.

Waxman, R. P.,Weist, M. D., & Benson, D. M. (1999). Toward collaboration in the growing education mental health interface. Clinical Psychology Review, 79, 239-253.

Weist, M. D. (1997). Expanded school mental health services: A national movement in progress. In T. H. Ollendick & R. J. Prinz (Eds.), Advances in clinical child psychology, Volume 19 (pp. 319- 352). New York: Plenum Press.

Weist, M. D., Evans, S. W., & Lever, N. A. (Eds.). (2003). Handbook of school mental health: Advancing practice and research. New York: Kluwer Academic/Plenum Publishers.

Weist, M. D., & Ghuman, H. S. (2002). Principles behind the proactive delivery of mental health services to youth where they are. In H. S. Ghuman, M. D.Weist, & R. M. Sarles (Eds.), Providing mental health services to youth where they are: School- and community-based approaches (pp. 1-15). New York: Brunner-Routledge.

Weist, M. D., Myers, C. P., Hastings, E., Ghuman, H., & Han,Y. L. (1999). Psychosocial functioning of youth receiving mental health services in the schools versus community mental health centers. Community Mental Health Journal, 35, 69-81.

Weist, M. D., Paternite, C, & Adelsheim, S. (2005). School based mental health services. Report to the Institute of Medicine, Board on Health Care Services, Crossing the Quality Chasm Project, Adaptation to Mental Health and Addictive Disorders Committee.

Weist, M. D., Proescher, E., Prodente, C., Ambrose, M. G., & Waxman, R. P. (2001). Mental health, health, and education staff working together in schools. Child and Adolescent Psychiatric Clinics of North America, 10, 33-43.

Mark D. Weist, PhD, is professor, Center for School Mental Health Assistance, Department of Psychiatry, University of Maryland School of Medicine, 737 West Lombard Street, 10th Floor, Baltimore, MD 21201; e-mail: tmvcist@psych.umarytand.edu.Melissa Grady Ambrose, LCSlV, is a clinical social worker in private practice in northeastern Connecticut. Charla P. Lewis, PhD, is postdoctoral fellow, University of Maryland School of Medicine. This research was supported by cooperative agreement U45 MC 00174-10-0 from the Office of Adolescent Health, Maternal and Child Health Bureau, Health Resources and Services Administration, with cofunding by the Center for Mental Health Services, Substance Abuse and Mental Health Services Administration. Appreciation is extended to Christina Huntleyfor her assistance in developing this article.

Accepted April 11, 2005

Copyright National Association of Social Workers, Incorporated Jan 2006

Source: Children & Schools

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