Student Mental Health: From Support to Treatment

A Massachusetts school district moves from disconnected services to a comprehensive system for students’ mental wellness

Most school-age youth in the United States with major depression do not receive any mental health treatment, according to a 2023 report by Mental Health America. In Massachusetts, that figure is 64 percent, leaving their schools to face the growing challenge of supporting unmet mental health needs.

Our suburban system, the 2,200-student Medway Public Schools west of Boston, in 2017, evaluated how it supported student mental health. The findings showed three critical elements needing improvement: a lack of student information, access to mental health services and scalability.

We’ve tried to address each of these elements, which allowed us to shift away from the traditional method of supporting student mental health needs by transforming our approach to a mental health treatment model.

Shifting Needs

School counselors have been part of public education since the early 1900s. Their primary role in the early years was to support vocational counseling. Over the past century, counselors evolved to meet the needs of students. The most recent iteration has school counselors guiding both college and career decisions and supporting students’ social-emotional challenges.

The traditional school counseling model is not designed to effectively address students’ social and emotional and mental wellness needs. While school-based counselors have worked with families to facilitate access to outside mental health resources, they were tasked with navigating a complicated system that often resulted in many weeks of waiting for professional services. Counselors did their best to support an increasing number of students.

Adopting a treatment model allows for adjusting to a practice where school counselors can effectively serve as a resource to help families gain timely access to the mental health system and to provide support to students.

Student Information

In Medway we were passively collecting student information during the evaluation of our mental health supports. We were alerted to particular students’ mental health needs through a behavioral incident or a parent’s concern or a teacher’s referral. This passive approach left us consistently in a reactionary mode to addressing student mental health and caused us to under-identify students needing support.

We instituted a K-12 universal screening system to identify and address student mental health needs proactively by screening students three times a year for social and emotional learning competencies. The screening results are used to guide tier-1 SEL curriculum development and to identify students who would benefit from tier-2 SEL interventions, such as small-group counseling and check-in, check-out counseling supports. We also implemented mental health risk factor screening in grades 7, 9 and 11 to identify students at risk for depression and suicidal ideations.

This combined approach of screening for SEL competencies and mental health risk factors allows us to identify students who would benefit from professional help before reaching a crisis.

Lack of Access

Prior to moving to a comprehensive mental health treatment model, our primary approach to supporting student mental health was to refer our students to local outpatient mental health providers. Although there are hundreds of mental health clinicians in and around Medway, our process relied on our school counselors to leverage relationships with providers to help our students access more timely care, due to long waiting lists. We recognized the lack of community services, and our time-consuming referral process required a lot of time and largely was ineffective.

To improve access to mental health support, we better used community resources and re-envisioned how to utilize our school counselors. Numerous access barriers exist for youth seeking outpatient mental health services, including the complexity of the referral process, transportation, limited after-school appointments and insurance coverage. We made several advances to address these barriers.

Creation of a mental health outpatient referral hotline. This service allows parents/caregivers or school counselors to place an outpatient mental health referral free of charge. The hotline agency identifies three provider options for the student that match the student’s needs and preferences (health insurance, distance from home, gender, specialty field, etc.).

Creation of a school-based outpatient therapy model. Outpatient mental health providers were provided meeting space in all four of our schools, allowing them to support students in grades K-12. The outpatient providers met with students individually during the school day when many providers who specialize in working with children were available. Students meeting the criteria for in-school outpatient therapy who had barriers such as transportation or insurance limitations were given priority when filling a clinician’s caseload.

Creation of before- and after-school SEL programming. Recognizing that not all students can receive the mental health support they need during the school day, we expanded our mental health support to before- and after-school programming to include play-based SEL opportunities at no cost. Our universal screening process identified students who would benefit from this type of extended day support.

Development of wrap-around services. The district prioritized providing wrap-around services to improve support to the family. Before this shift, our approach left a gap in mental health services related to in-home therapy, therapeutic mentoring and social services coordination. To fill this gap, the district hired a wrap-around service provider. This social worker expanded school mental health services for students in their homes, the community and outside the school day.

This approach also allowed our district to identify and better address student social service needs (housing, food, clothing, etc.) that were impacting their mental well-being.

Scalability

Our approach was to identify funding to hire additional staff to meet the needs of students directly. Due to its high cost, this was a reactive approach to supporting student mental health needs that did not allow for expansion and scalability. To achieve scalability, we proactively used student data to support student mental health with two components.

A proactive in-school brief intervention counseling model. As a result of gathering student information several times a year regarding students’ SEL competencies and mental health challenges, we were able to move toward instituting proactive mental health interventions. Students identified as needing support were offered brief group counseling sessions or module-based one-on-one counseling sessions.

Whole-school mental health education. In addition to proactively using student data to create short-term mental health interventions for individual students, we also used student data to identify population-based mental health needs. School counselors used this thematic data to identify mental health education needs by school and grade level. Our school counselors used this data to create and deliver several mental health lessons to the entire student population over the school year.

As a result of identifying and addressing how to most effectively meet students’ needs, we developed a public school mental health treatment model that included four critical components: universal screening, proactive brief intervention counseling, in-school outpatient therapy and wrap-around services. This treatment model has yielded significant mental health treatment outcomes for our students.

Sustainability

A real concern around expanding mental health support in schools is the increased costs and how those costs will detract from the primary responsibility of teaching and learning. Importantly, a school district that is not providing enhanced services for students in the area of social and emotional learning will find difficulty meeting all their students’ needs.

It also is likely if a district is not meeting the mental health needs of students, there will be increased costs in other areas as situations become more urgent.

A school district must identify untapped or realigned resources. To do that, a district must look outside typical pathways for funding enhancements to provide the resources for a service model that can respond to high demand and the unique needs of today’s students. It also is important to change the dialogue within your community. Providing mental health support is no longer a “nice to have” add-on but a necessity.

Outcomes

As a result of shifting to a school-based mental health treatment model, we saw favorable outcomes in access to services, persistence in treatment and care coordination.

Access to mental health services. According to the MetroWest Adolescent Health Survey, a survey of 26 suburban Massachusetts school districts, the percentage of high school students supported by a mental health professional rose from 17.7 percent to 23.2 percent within the region from 2018 to 2021. Over the same period, the rate of high school students supported by a mental health professional in Medway rose from 15.6 percent to 27 percent. This rise in high school access to care increased by 75 percent in Medway, as compared to 31 percent regionally, despite a rise in mental health concerns growing at a similar rate.

The survey also reported a 35 percent increase in students with depression/anxiety symptoms in the MetroWest Region and a 40 percent increase of students with depression/anxiety symptoms in Medway.

Persistence in treatment. Nationally, only 4 percent of students attend six or more outpatient therapy sessions, according to a 2018 Substance Abuse and Mental Health Services Administration survey. In contrast, as a result of our in-school outpatient therapy program and our partnership with mental health referral hotlines, 78 percent of Medway students attended at least six outpatient therapy sessions once care was initiated, which is the average minimum number of sessions needed for effective treatment to occur.

Care coordination. In 2016, Medway’s K-12 school counseling team spent an average of 156 minutes per counselor per week coordinating student outpatient mental health referrals. In 2022, this average was reduced to 35 minutes per week. The reduction in care coordination occurred despite a 60 percent increase in high school students with depression/anxiety symptoms in Medway during that time. The reduction equates to our school counselors gaining over 11 school days, or two hours per week, worth of time back to work with students.

Shift in Thinking

Insufficient and ineffective support for students with mental health challenges has a direct and tangible impact on their ability to achieve academic success. As educators, we must shift our thinking and take greater responsibility for supporting the mental health needs of our students.

Traditional models of practice in schools no longer work. We must shift our perspective and practice to ensure we meet all students’ mental health needs.

Armand Pires is superintendent of Medway Public Schools in Medway, Mass. Ryan Sherman is director of wellness of Medway Public Schools.