School Mental Health Sustainability Guide for SS/HS Project Directors: Strategies to Build Sustainable School Mental Health Programs

This guide provides SS/HS project directors (PDs) with information on developing sustainable school mental health (SMH) programs. It presents strategies to consider when working with public and private community mental health (MH) agencies to implement SMH programs, and provides step-by-step guidelines for creating long-lasting SMH programs.

The guide focuses on four key issues for PDs to consider in their efforts to build sustainable, comprehensive SMH programs:

• The importance of SMH to SS/HS
• Reaching all students with SMH programs
• Choosing and working with SMH partners
• The components of sustainable SMH programs

Background

The SS/HS Initiative is federally funded through the U.S. Departments of Education, Health and Human Services, and Justice. The purpose of the initiative is for schools and community partners to implement a coordinated, comprehensive plan of activities, programs, and services that focus on promoting healthy student development and preventing violence and substance use among children and adolescents.

The SS/HS Initiative focuses on five elements:

1. Safe school environment and violence prevention activities
2. Alcohol, tobacco, and other drug prevention activities
3. Student behavioral, social, and emotional supports
4. MH services
5. Early childhood social and emotional learning programs

School districts are tasked with developing a comprehensive plan and coordinated programs around these elements. SS/HS can offer activities and evidence-based programs (EBPs) that promote a positive school climate, enhances and promotes MH and social and emotional skills, and prevents or addresses MH difficulties and diagnoses. These EBPs work across all five elements to increase positive student behaviors and academic outcomes and to decrease high-risk behaviors.

The Importance of SMH Programs

Safe and healthy schools are a concern for all communities. A mentally healthy student attends school ready to learn, actively engages in school activities, enjoys positive, mutually respectful relationships with peers and teachers, and is less likely to engage in high-risk behaviors, such as alcohol and other drug use and violence.^i,ii Schools are a natural environment for developing and implementing SMH programs to address the mental, emotional, and behavioral disorders that occur among students and to increase positive outcomes.

SMH programming has a number of positive effects:

• Boosting students’ academic achievement ⁱⁱⁱ
• Reducing multiple social issues in schools (e.g., decreasing violence and increasing student safety)
• Helping children, families, and schools build strengths that support their well-being
• Reducing mental health disorders in young people by teaching them coping skills^iv

Such positive outcomes can be sustained over the long term, thus transforming entire school districts and communities for the better.

SS/HS provides schools and communities with opportunities to develop comprehensive SMH programming to address the various MH needs experienced by students. SS/HS SMH programs offer students wraparound support and services to promote mental wellness and to assess and intervene with students experiencing MH problems. SS/HS Initiatives also provide resources to assist students and their families who are at higher risk for emotional and MH issues, including those living in poverty, those with histories of substance abuse, or those who have been victims of or witnesses to violence.

SS/HS Initiatives are based on national research that incorporates evidence-based approaches to the prevention of mental health disorders and the promotion of mental wellness among students. For example, a 2009 report from the National Research Council and the Institute of Medicine^iv recommends these multiple strategies to enhance young people’s emotional well-being:

• Strengthening families by targeting problems, such as substance use or aggressive behavior; teaching effective parenting skills; improving communication; and helping families deal with disruptions (such as divorce) or adversities (such as parental mental illness or poverty)
• Strengthening individuals by building resiliency skills and improving cognitive processes and behaviors
• Preventing specific disorders, such as anxiety or depression, by screening individuals at risk and offering cognitive training and other preventive strategies
• Promoting mental health in schools by offering support to children encountering serious stresses; modifying the school environment to promote prosocial behavior; developing students’ skills in decision making, self-awareness, and conducting relationships; and targeting violence, aggressive behavior, and substance use
• Promoting mental health through health care and community programs by promoting and supporting prosocial behavior, teaching coping skills, and targeting modifiable life-style factors that can affect behavior and emotional health, such as sleep, diet, activity, and physical fitness

SS/HS enables grantees to incorporate these sound principles into SMH programs.

Reaching All Students with SMH Programs

Comprehensive SMH programs focus on mental health promotion, prevention, early intervention, and treatment service provision to address the multiple needs of students and their families. To visualize the different levels at which SMH can reach students, the National Center for Mental Health Promotion and Youth Violence Prevention advocates a model called the Mental Health Promotion & Prevention Triangle:

• Red Zone: Targeted MH intervention and treatment services for students who are experiencing mental health difficulties or a diagnosis and need an intensive plan of treatment; who need substance abuse treatment; or who require assistance from a juvenile justice probation officer to remain in school. These programs aim to decrease current problems, increase social and emotional functioning, and alleviate future problems.
• Yellow Zone: Indicated early intervention programming for students at risk of mental health or emotional problems. Indicated programs include targeted interventions for students that focus on problem areas, such as anger management, grief and loss, or social skill development; mentoring programs; after-school programs; and short-term one-to-one counseling, from a school counselor, social worker, or school resource officer, to prevent further mental health issues and build skills and resiliency to promote mental health.
• Green Zone: Universal evidence-based curricula and interventions that address the whole school in order to promote a positive, safe, and nurturing school climate for students and staff. These strategies include bullying prevention curricula, cultural and linguistic competence training for teachers, and social-emotional learning (SEL) curricula.

SS/HS SMH programs deliver EBPs across this continuum through a public health approach. SMH prevention programs in schools provide those in the green zone with training and skills development to promote healthy behaviors and skills and to prevent unhealthy social issues, such as violence and substance abuse. Indicated programs target the at-risk students in the yellow zone who may display such antisocial behaviors as fighting or bullying, as well as a lack of social and problem-solving skills. MH intervention and treatment services reach students in the red zone, those who have emotional, behavioral, and MH issues, by providing intensive individual and family interventions.

Following are examples of SMH programming provided through school-community SS/HS partnerships that reach students at all levels of MH need:

• Universal (green zone):

• Community psychologists provide professional development to school administrative and professional staff on various MH topics.
• School guidance counselors and social workers are trained as trainers in SMH EBP delivery, provide training (initial and booster) for teachers and other professional staff, and provide coaching on classroom presentations.
• School nurses provide professional development on school health awareness and education for students.

• Indicated (yellow zone):

• District-employed staff provide early intervention programming during the school day or after-school hours in which small groups of students learn about anger management or skills for living, or parents learn about living productively with a child who has an emotional, behavioral, or MH disorder.
• School staff provide short-term (three to five) individual counseling sessions for students and parents.
• School nurses provide health awareness, education, and coping skills workshops for students with various health problems (such as asthma or diabetes).

• Targeted (red zone):

• Licensed MH counselors, such as school psychologists, clinical psychologists, and clinical social workers, provide screening, assessment, and individual and family counseling for students and their families who are experiencing mental and emotional difficulties.
• School social workers provide targeted interventions for students who have behavioral, emotional, or mental health diagnoses to help them improve specific coping skills, such as dealing with ADHD, depression, anxiety, post-traumatic stress disorder, or conduct disorders.
• Community nurse practitioners work in schools to provide medication monitoring for students with various MH disorders, and provide progress reports to the prescribing physician.

These examples can be refined for use in other SS/HS schools. To understand the specific needs and challenges of their populations, grantees should also conduct a needs assessment. These data will help individual grantees choose and the tailor the appropriate EBPs.

Partnering for SMH

SS/HS Initiatives maximize the effectiveness of SMH programs by enabling collaboration between schools and community providers of MH services.

SS/HS partnerships between schools and MH agencies allow the groups to work together to develop wraparound MH programs and activities at schools and in the community. School-based MH programs address MH issues for students and provide resources and skills to promote healthier functioning within the school setting, while community programs can provide complementary additional services for students and their families within the context of the local MH agency system.

There are many benefits to working with community MH agencies as part of an SS/HS Initiative. Community partners can do the following:

• Work with school partners to develop, implement, and evaluate SMH programs that address issues of school climate, crisis management, violence prevention, and alcohol and other drug prevention
• Provide training on MH issues and best practices for school staff, such as behavioral health training for teachers, administrators, nurses, and ancillary staff
• Work with early childhood school and community staff to provide prevention and early intervention programs
• Provide therapeutic interventions for students and their families

Many times, SS/HS grantees also partner with local or state public health agencies. These agencies can provide the initiative with financial support through county or state funds, and can help link school staff with local hospitals and other health-serving agencies. Public health agency personnel can also contribute their expertise in program planning, implementation, and evaluation.

Overcoming Challenges in Partnering

When schools enter into a partnership with an MH agency, it is essential that both organizations understand each other’s perspective. Both partners must acknowledge and work through any differences in roles, professional culture, funding, diagnostic and treatment processes, and terminology to effectively develop, implement, and evaluate comprehensive SMH program and services. For instance, while school MH professionals’ main foci are educational goals, objectives, and outcomes, community MH professionals may focus on assessment and treatment goals, objectives, and outcomes. Yet, both are working to achieve the best outcomes for the children, youth, and families they serve.

It is important to come to consensus on common goals, responsibilities, and accountabilities and determine a common vision. This way, both groups can truly work together to develop an SMH program that will serve the best interests of all—students, families, schools, communities, and community agencies.

To ensure that they are on the same page, here are some important roles, processes, and terminology for school and MH partners to consider:

• Guidance Counselors and Mental Health Counselors. As SS/HS grantees begin to work together on SMH programming, there may be confusion about the roles and responsibilities of school guidance counselors versus community MH counselors. Schools and MH agencies should clarify and define these roles and responsibilities early in the partnership in order to ensure that each counselor is used to his or her fullest potential and in the way best suited for the SMH program. Below are typical roles and responsibilities of guidance and MH counselors:

• Guidance counselors characteristically provide individual, group, and family counseling related to educational needs. In some settings, guidance counselors have advanced counseling skills and have obtained state or national certification or licensure as a professional counselor and can provide therapeutic counseling services. In these instances, a guidance counselor may have already developed and delivered SMH programming.
• Community MH counselors have earned master’s or doctoral degrees and are licensed clinical counselors trained in the provision of MH treatment. MH counselors may have specialized skills in a particular treatment area, such as family therapy in a clinical setting.

• Diagnostic Process. A screening and assessment is usually provided to students and families who are beginning treatment with a school-based or community MH provider. Typically, the assessment entails understanding the formative aspects of a student’s life (e.g., social, emotional, mental, and physical histories; substance abuse; school performance; relationships with peers and family; values and beliefs; coping strategies). The client and counselor determine goals and objectives for treatment and draft a treatment plan. A mental, emotional, social, or behavioral diagnosis may be assigned by a psychiatrist. The treatment team discusses the diagnosis with the student and parents, and proposes a plan of services and supports to be provided at school and in the community.

• Service Provision. Based on the student’s treatment plan, the treatment team (which may include an MH professional, other individuals asked by the family to be present, school personnel, and possibly a care coordinator or wraparound facilitator) determines the schedule of services and supports needed for the student and family. Traditional clinical sessions in an agency or clinic setting are usually 50 minutes in length. Treatment teams meet quarterly to assess the student’s progress, and treatment plans are updated to address current needs.

• Licensure Requirements for Counselors. With the exception of California, all U.S. states license professional counselors. State counselor licensure boards administer the application processes and procedures that have been established by law in each state, and determine the requirements for sitting for any examination, which vary from state to state. To acquire and maintain their licensure, counselors must obtain various types of supervision.

• Funding. Prior to SMH program development, it is important for the PD and MH agency representative to determine the type of services the agency can offer to the SMH program. The PD does not need to fully understand the MH reimbursement system to develop a sustainable SMH program; however, it is important to know the following:

• The MH agency services and supports that can and cannot be provided with SS/HS funding
• Funding reimbursement processes for specific services and supports provided by the MH agency
• Services and supports from the MH agency that are not reimbursable through Medicaid, insurance, or other third party billing sources

The PD needs to understand these basic funding issues in order to build a program that is sustainable through current reimbursable funding streams. For instance, SS/HS funds can be used for the MH agency for program development, prevention, and early intervention services. However, treatment services should be reimbursed through various third party billing and funding streams. (More detailed information on reimbursement can be found in Appendix 3.)

Developing Sustainable SMH Programs

Schools and MH agencies each have a wealth of professional skills that can be merged into a comprehensive system of programs, resources, and services that will have a positive impact on the children, youth, and parents in SS/HS communities. These agencies can work together to ensure that the essential successful functions of SMH programs are sustained through the following activities:

• Building an SMH continuum of services
• Planning for sustainability from the time the SS/HS funds are awarded
• Keeping the partnership strong, and continuing to meet after the initiative ends
• Working to integrate and institutionalize SS/HS-funded programs and activities that have proven successful
• Navigating the local, state, and federal funding systems to secure the financial support to maintain and sustain successful programs

These activities can help to ensure that the good work and positive results brought about by SS/HS SMH programming can continue well after the funding cycle concludes.

(Note: The remainder of this guide focuses on the first activity: Building an SMH continuum of services. The Center for Mental Health Promotion and Youth Violence Prevention’s Legacy Wheel and its supporting resources can assist PDs with the remaining activities.)

Building an SMH Continuum of Services

The PD and Core Management Team should begin by building a continuum of SMH services, focusing on the three distinct areas of interventions from the Mental Health Promotion & Prevention Triangle: universal intervention (green zone), indicated/selective intervention (yellow zone), and targeted intervention/treatment (red zone). The desired continuum of programs and services in SMH includes the following:

The following six guidelines can help PDs begin working with school and community agencies to develop a comprehensive set of SMH programs and services.

1. Create a shared vision, mission, goals, and objectives for the SMH program among the Core Management Team:

• Map all available resources:

• Assess school resources (staff, programs) to determine potential SMH services at the school level that can be incorporated into the SMH program
• Assess community resources to determine potential MH agency
• Assess school and community funding streams to support SMH services and/or programs

• Write vision and mission statements for the SMH program
• Develop goals and objectives for the SMH program
• Create measurable outcomes for the SMH program
• Meet with the school and MH agency to introduce the SMH program to be developed, and determine the community agency’s interest in being a partner for the SMH program

2. Develop a Memorandum of Agreement and contract to define the scope of work and funding for school and MH agency partners:

• Meet with the local MH agency to begin discussion on the scope of SMH work and contract development
• Enter into a contractual agreement specifying the type of services and resources (including staffing, office space, and funding) to be provided by the school district and the MH agency

Note: Typically, SS/HS grantees engage in one of the following types of contractual agreements:

• A school contract with a public MH agency (i.e., an agency that obtains financial support through state and/or county funds)—typical funding streams include Medicaid reimbursement at a state-designated service rate, federal or state-supported children’s health insurance, and county funds
• A school contract with a private MH agency (i.e., an agency that gets its financial support through private insurance funding streams)
• A school contract with a public health agency (i.e., an agency financially supported with federal, state, and/or county funds, such as a local public health department, school-based health center, or hospital)

3. Build mutual respect and trust between school staff and MH agency partners:

• Meet with the community MH agencies on a regular basis to understand their unique culture, strengths, and challenges
• Work with school and MH agency representatives to solve problems and mediate SMH programming discussions concerning budget, operations, professional liability, confidentiality, information sharing, etc.
• Introduce the SMH counselors and the services they provide to the school, parents, and community
• Meet regularly with school guidance counselors, community MH counselors, and MH agency personnel to discuss students’ needs, plan interventions, and solve SMH program challenges
• Schedule trainings for school staff by MH agency personnel on relevant MH topics during teacher meetings, planning periods, one-to-one meetings, and staff in-service days

4. Clearly define the roles and responsibilities of school staff and MH counselors:

• Work with school administrative staff (principal, guidance counselor) and MH agency staff to define rules for the engagement of the community MH counselor in the SMH program
• Work with the school guidance counselor to determine the roles and responsibilities of each SMH counselor in SMH program implementation
• Collaborate with the guidance counselor and community MH counselor to develop SMH program infrastructure: determine referral protocols, designate school-based office space for the community MH counselor, determine work schedules and appropriate times to provide consultation with teachers, plan student assistance and intervention team meetings, and designate times for student counseling sessions
• Meet with the school principal and guidance counselor to determine best avenues to introduce the community MH counselor to school staff, students, parents, and community members

5. Provide cross-training and professional development opportunities for school staff and community MH counselors:

• Work with the evaluator to survey each school to determine MH topics of interest, and discuss the results with the principal and guidance counselor
• Help the guidance counselor and community MH counselors develop a yearly plan for teacher education on MH topics
• Attend, with the Core Management Team, on-site or community professional development trainings (e.g., training on evidence-based interventions, MH topics of interest indicated by guidance and community mental health staff)

6. Develop systems to establish funding streams for SMH programs with the MH state oversight agency:

• Schedule a meeting to discuss the SMH program and sustainability options with the state agency that has administrative responsibility for children’s MH and behavioral health services
• Invite a state-level MH representative to be part of the Core Management Team to provide advice and consultation on program development

• Meet on an ongoing basis with the SS/HS evaluator to develop a system to collect data related to SMH outcomes, for example:

• How many students receive SMH?
• What types of professional staff provide SMH programming?
• Which services are reimbursable through a non-SS/HS funding source? Which services are not reimbursable?
• What services are students receiving in all three tiers of the continuum of programs/services: universal, targeted, indicated?
• What are the outcomes from each of these three levels of programming?
• How are the effects of EBPs measured?
• What measurement tool is used to determine individual functional outcomes?
• What are the functional and system outcomes for students receiving SMH programming and services? (Functional outcomes may include increases in school attendance, decreases in disciplinary problems, and decreases in anxiety, depression, and attention problems; system outcomes may include increases in community referrals that result in MH services, decreases in referrals that result in student placement in treatment facilities, and decreases in the number of students involved with law enforcement and juvenile justice agencies.)
• What do the client MH data show? Is the student progressing in treatment toward more positive outcomes, such as functioning better in school, at home and in the community?

• Develop a committee to research funding sources and mechanisms that may be able to sustain SMH services and programs
• Discuss SMH funding needs with local public and private sector representatives (such as community leaders, local government, like-minded agencies and organizations, school administrators, families, and youth) and explore SMH programming priorities, the political will of the community regarding SMH services, and options for local funding for SMH programs.
• Work with local and state representatives to determine the typical percentage of the budget that is allocated for issues related to children and youth, and make recommendations for additional funding for SMH.

Note: See Appendix 3 for examples of different funding streams and how SS/HS grantees have been able to use them to sustain SMH.

Conclusion

Many of the essential successful functions of SMH can be sustained after SS/HS funding ends. Promoting mental health and preventing emotional, behavioral, and mental health disorders requires building strong partnerships, delivering SMH EBPs with fidelity, developing staff capacity to deliver EBPs, continually evaluating and refining programs, and pursuing various avenues of funding. Following the recommendations and guidelines in this publication can help PDs leave a lasting legacy of positive outcomes in their schools and communities.

This prevention brief was developed by American Institutes for Research on behalf of the National Center for Mental Health Promotion and Youth Violence Prevention.