Collaboration With Community Mental Health Service Providers

Abstract

Schools have played an increasingly central role in providing mental health services to youth, but there are limitations to the services that are available through school-based mental health professionals. Thus, collaboration with non-school-based community mental health providers is oftentimes necessary. As collaboration can address limitations of school-based services and enhance and complement school-based services, it has been identified as best practice in comprehensive mental health service delivery. This collaboration column provides a brief review that highlights the critical opportunities for collaboration between school- and non-school-based professionals. Potential barriers to effective collaboration are also discussed, and strategies are introduced to overcome these barriers in order to provide effective and complementary mental health services to students in need.

Keywords

collaboration counseling psychological services mental health

Less than one half of the 20% of school-age children in the United States who experience mental health problems receive mental health treatment (Centers for Disease Control and Prevention [CDC], 2013; Merikangas et al., 2010; National Institute of Mental Health, n.d.). With limited access and social stigma cited as primary explanations for this disparity (Kataoka, Zhang, & Wells, 2002; President’s New Freedom Commission on Mental Health, 2003), schools have a critical opportunity to serve as an important entry point in the provision of mental health services (Hoagwood & Johnson, 2003; Merrell, Levitt, & Gueldner, 2010). Moreover, schools appear to be the primary site of mental health service receipt among youth in the United States. Youth who receive mental health services of any kind receive them in schools at a greater rate than those who receive them in the mental health specialty sector (Green at al., 2013).

Students receiving school-based mental health services include those with disabilities receiving services in accordance with special education mandates (e.g., Individuals with Disabilities Education Improvement Act [IDEA], 2004). Remarkably, results of the National Longitudinal Transition Study-2 (http://www.nlts2.org/index.html) indicated that mental health services were the most common type of service received by students with disabilities at the secondary level (Levine, Marder, & Wagner, 2004). These services may be provided to any child with any disability, and students with emotional disturbance, autism, traumatic brain injury, and multiple disabilities are likely to receive them (Levine et al., 2004). Additionally, some schools address mental health needs through multitiered systems of support that are intended to provide services to all students who display risk factors or symptoms of mental health problems, not just those who have been formally diagnosed (Doll & Cummings, 2008).

Limitations of School-Based Mental Health Services

The ability to provide effective mental health services within school systems can be limited. School-based mental health professionals (e.g., school psychologists, school counselors) devote a majority of their time to duties unrelated to the provision of direct mental health services (Hosp & Reschly, 2002; Reschly, 2000), and a majority work with a greater proportion of students than is recommended by professional organizations (American School Counselor Association, 2012; Charvat, 2005; Jimerson, Stewart, Skokut, Cardenas, & Malone, 2009; Keaton, 2012). Additionally, some schools do not have active mental health service delivery systems; they may outsource a considerable amount of counseling and psychological services to non-school-based professionals. For example, a survey of parents indicated that approximately half of students with disabilities received related mental health services from nonschool professionals (Levine et al., 2004).

It is also important to note that not all school-based professionals feel prepared to deliver these services. In a national survey, approximately 40% of school psychologists reported that their training program prepared them somewhat poorly or not at all to provide counseling; nearly half reported feeling poorly prepared to respond to crisis situations (Hanchon & Fernald, 2013). This is especially problematic when attempting to work with students with chronic or severe difficulties, such as major depressive episodes. Additionally, when safety is a concern, students would most likely benefit from interventions that cannot be offered at schools (Merrell et al., 2010). For example, in situations where students are at serious risk for harming themselves or others, students are better served in intensive and controlled settings that allow for increased monitoring and a variety of treatment approaches, including pharmacological treatment. There also are certain situations, such as in cases of child maltreatment, that may require intensive family therapy and home visitation that school professionals should not be expected to provide.

Mental Health Collaboration Benefits and Opportunities

To provide effective and comprehensive mental health services, it may be necessary to involve and collaborate with non-school-based community mental health providers (CMHP). Collaboration is endorsed in the literature as best practice in promoting the comprehensive delivery of mental health services for youth (Natasi, 2000; National Association of School Psychologists [NASP], 2010; Talley & Short, 1995). Furthermore, numerous studies support the value of a collaborative approach. This is particularly evident in the evaluation of wraparound service models in which collaboration is considered a critical treatment component and has been shown to relate to improved academic and mental health functioning (Darlington & Feeney, 2008; Fries, Carney, Blackman-Urteaga, & Savas, 2012; Lee et al., 2013; Suter & Bruns, 2009). Some key components of these models that reflect collaborative efforts are that they are team based, utilize natural family supports, involve cooperation and sharing of responsibility among team members, and depend on community-based services (Suter & Bruns, 2009).

In addition, families benefit more from a collaborative approach. It has been suggested that simply referring families to CMHPs without collaboration offers insufficient direction and assistance (Fries et al., 2012), and consequently, families report a desire for treatment practices based on consistent service delivery and collaboration among providers (Ditrano & Silverstein, 2006; Lee et al., 2009; McLendon, 2008; Radohl, 2011). Moreover, it is important to note that many families with a child receiving mental health services are concurrently involved with multiple agencies. For example, the family of a child with a conduct disorder may be involved with professionals in schools, social services, juvenile courts, and the mental health specialty sector (Lee et al., 2009). It is critical that professionals from multiple organizations utilize effective communication and collaboration to help, rather than hinder, the treatment processes.

Thus, collaboration with a CMHP is supported. It also represents a critical opportunity for school professionals to (a) connect students and families with community mental health service supports, (b) assist with the transition and initiate direct communication with a CMHP to provide critical information, and (c) formalize communication and partnerships with a CMHP to ensure that school-based services complement community-based services and vice versa.

Connecting Families With Community Support

As many families are unfamiliar with available community mental health services, school professionals can serve as a critical bridge between families and CMHPs. This may be accomplished by compiling a contact list of local community agencies that can meet diverse mental health needs. This includes treatments, such as individual and family therapy, occurring in outpatient settings as well as intensive and residential therapeutic care centers for cases requiring greater mental health support. When compiling this list, school professionals should consider the diverse needs of the families that they serve. Depending on the community where they work, school professionals should be prepared to provide information for CMHPs that work on sliding fee scales to accommodate families with limited economic resources. Additionally, they should include CMHPs that can provide services in languages other than English.

An example of a comprehensive contact list that serves as a useful model is one that has been compiled by the Children’s Service Fund (CSF) of St. Louis County, Missouri. To assist with connecting families with appropriate services, CSF staff have created a list of CMHPs that includes contact information, a brief description of the programs or services offered, and suggestions for the types of youth (i.e., age range, disability type) that would be best served by each location. A version of this list, arranged by service area, is available online (http://www.stlouisco.com/csf/Funding/ServiceAreas). Additionally, the CSF has also created a map of St. Louis County that identifies service providers within different regions and school districts within the county. Together, these documents make identifying an appropriate CMHP an efficient process and reduce the time between the recommendation for services and initial contact. It is recommended that practitioners follow a similar model to assist those within their own communities.

Helping Families Transition to Treatment

After providing appropriate referral information, it is important that school professionals provide support, in the form of education, to families seeking these services in order to encourage follow-through with recommended treatment. This can be done by providing families information about the mental health treatment process. Useful information to discuss includes (a) the format of therapy, (b) typical length of treatment, (c) expectations for what will be discussed, and (d) the benefits of attending therapy. In providing this information and educative support, it is hoped that families will see the value of working with CMHPs and be less intimidated by the process. Notably, this information may be best received if school professionals have previously engaged in activities intended to develop strong family–school partnerships. To promote these partnerships, it is recommended that schools establish a relationship before concerns arise, provide a variety of opportunities for family–school interactions, and contact families at the first sign of a concern (Callender & Hansen, 2004). Additional suggestions, in the form of a practitioner-oriented handout, have been developed by the National Association of School Psychologists (NASP) (Callender & Hansen, 2004).

It may also be helpful to assist families in their initial attempt to gain therapeutic services; with the families’ permission, a school professional can make initial contact with relevant CMHPs, assist families with setting up initial appointments, and provide families with critical information from the school setting that may be useful for them to share with CMHPs. Such data may include

copies of past psychological evaluations completed at school,

attendance reports,

behavior reports,

classroom observation reports and data,

completed teacher rating scales, and

school-based treatment plans.

This information is not readily available to CMHPs, so providing it to parents to share with CMHPs is critical and may allow for a treatment approach that considers school functioning as well as functioning in the home and community settings.

Partnering With Community Agencies

Finally, it is recommended that school professionals maintain communication with CMHPs. Notably, it is necessary to discuss this with a child’s caregivers; it should not be assumed that all caregivers will want to share information obtained from a CMHP with school professionals and vice versa. In broaching this topic, it is important to highlight the reason for the request for reciprocal communication. School professionals should discuss the benefits of maintaining regular communication and the opportunities for coordinating services that it may enable. For example, many behavioral therapy programs include parent behavior management skills training that incorporates techniques for improving school behavior (Barkley, 2013). Specific techniques in this domain, such as the use of daily behavior report cards, require the cooperation of and frequent communication with school personnel. Consequently, having ongoing communication can be critical to both child functioning and the implementation of interventions by mental health providers, school professionals, and families.

In addition to sharing intervention materials, it is helpful to share information about progress. School professionals should feel free to share any progress-monitoring tools (e.g., behavior charts, behavior reports) already in place as well as narrative reports, based on general observations, of progress and functioning. However, it is also important to note that there are other readily available progress-monitoring tools that are specifically designed to assess mental health functioning over time. For example, the BASC-2 Progress Monitor (Reynolds & Kamphaus, 2009) is intended to allow for easy progress monitoring after conducting interventions; it can be completed by multiple raters (e.g., parent, teacher, child). Another regularly used scale for measuring treatment progress is the self-report Youth Outcome Questionnaire (Wells, Burlington, & Rose, 2003).

Effective Collaboration

The diversity and severity of student mental health needs, coupled with the fact that schools are often limited in the mental health services that they can provide, indicate that collaboration between school personnel and CMHPs is necessary. However, there are notable barriers to successful collaboration. For collaboration efforts to result in improved outcomes for students, school personnel should be aware of and understand ways to address these common barriers.

Privacy and Parental Involvement

As previously noted, it should not be assumed that parents have consented for information to be shared between professionals in different settings. Moreover, even if parents consent, it should not be assumed that appropriate permissions have been obtained. To address this issue, practitioners should first ensure that they have forms that clearly allow for the receipt and transmission of mental health information. Although these forms might not have been developed, a majority of schools will have forms that are used to transmit medical information; these can be easily adapted for use in mental health collaboration. If consent is obtained, it should be documented in a manner that allows for easy access so that forms can be readily provided to the CMHP. In those situations where parents refuse to provide consent, it is important to honor their boundaries but to also encourage them to directly share information between school professionals and a CMHP. Without consent, a school professional may not request private information from a CMHP, but a parent is free to deliver copies of such information to school professionals.

Attending to issues of consent represents only a minimal way to involve parents in the collaboration process, and it fails to provide meaningful information and assistance to parents. For example, even after providing consent for services and communication between providers, parents are often unaware of the full scope and diversity of mental health services, their role in treatment, their expected level of involvement, and the time commitment. Thus, when working with parents, it is especially important to assess their understanding of mental health services and of their roles; creating a contract or agreement that outlines expectations and responsibilities may help formalize this understanding and relationship.

Additionally, it is recommended that school professionals systematically involve parents and families as formal and active participants by inviting them to collaborative team meetings. When expanding from working with parents on an individual to a larger-scale basis, ways to involve parents in meaningful and relevant ways are to conduct open forums, parent–teacher conferences, and parent night activities where parents can learn about the scope and range of mental health services and at the same time voice their concerns, offer suggestions, and raise questions. The CDC has outlined additional strategies to increase parent engagement in issues related to school health (CDC, 2012).

Parallel but Distinct Diagnostic Systems and Training

While school-based professionals utilize regulations and definitions in the IDEA, CMHPs use the Diagnostic and Statistical Manual of Mental Disorders (DSM; American Psychiatric Association, 2013). The DSM is one of the most widely used systems for classifying mental health disorders, and a DSM diagnosis is commonly required for reimbursement and other administrative purposes in nonschool settings. The use of these parallel but distinct diagnostic systems can complicate collaboration between school professionals and CMHPs. For example, although some disabilities (e.g., learning disabilities) are defined in both systems, others (e.g., conduct disorder) are not defined by both categorical systems. Moreover, children who receive mental health diagnoses from a CMHP using the DSM may not be eligible for services under IDEA regulations. Therefore, there may be disagreement between CMHPs and school-based professionals regarding eligibility and appropriateness of special education and related services.

To overcome this barrier to collaboration, it is important to recognize that both diagnostic systems are legitimate and valid; therefore, professionals should become familiar with both systems. For school professionals, this necessitates continuing education regarding the DSM. Although this can be accomplished through attendance at formal workshops, professional organizations, such as the NASP, also regularly publish articles that describe the role of DSM diagnoses in the school setting and highlight recent changes to the DSM of which practitioners should be aware (Hart, Pate, & Brock, 2013). For CMHPs, becoming familiar with IDEA policies and procedures and learning the culture of the school setting is just as critical for effective coordinated care; school professionals can offer their expertise in this area.

Different training backgrounds and philosophical orientations can further complicate decision making and impede effective communication. For example, school professionals may focus on evaluation and treatments that target school behavior problems, while CMHPs may focus on improving family functioning. One way to address this barrier is to take the time to learn about service delivery from multiple perspectives and to recognize that school professionals and CMHPs possess unique skill sets that can be combined to provide more comprehensive services for students. Rather than focusing on differences in approaches as a hindrance to collaboration, it is better to reframe differences as allowing for more complete services because the strengths and expertise of different professionals may target different areas of functioning.

Time and Organization

School practitioners and CMHPs typically operate on different schedules, and both typically face large caseloads and high demands. This may result in the perception that there is not enough time to collaborate. Additionally, as CMHPs do not typically operate in school settings, the lack of physical proximity and presence may impede collaboration. This issue has been addressed through the development of school-based mental health centers that are staffed by both school professionals and CMHP professions where staff members typically work some overlapping hours, allowing for personal interactions and immediate collaboration efforts.

One such model is that of expanded school mental health services (ESMHS; Weist, Paskewitz, Warner, & Flaherty, 1996), where school mental health centers are strategically located in areas of most need and staffed by school specialists and CMHPs. Staff typically work 2 to 4 hrs, and coordinators work to schedule recurring briefings to discuss cases. Another example of a service delivery model that incorporates collaboration and mental health services is the Youth and Family Center (YFC) system of Dallas Independent School District (DISD) (http://www.dallasisd.org/Page/1427). YFCs are comprehensive health clinics that provide services, including mental health treatment, to students and families of students enrolled in DISD. YFC clinics are located in close proximity to schools and are situated throughout the geographic region served by DISD. Unique aspects of YFCs are that they not only provide services specifically to students in the district, but their organization also allows for school linkage, efficient communication with campus liaisons, and communication with student support teams.

In areas where such centers have not been established, it is nonetheless helpful to maintain regular collaboration meetings that occur at less frequent intervals, and it is important that all parties be flexible in service delivery hours when coordinating meetings and collaboration (Zambrano, Castro-Villarreal, & Sullivan, 2012). For example, a school might set up bimonthly or monthly collaboration meetings that are held at a time that is convenient for school professionals and CMHPs. Scheduled meetings can be modeled after child study teams that already regularly occur in schools, particularly in those implementing multitiered systems of support. School-based mental health professionals, CMHP professionals, and school faculty who have direct contact with children of interest should be involved in these meetings. In instances where regularly scheduled meetings at a central location cannot be organized, practitioners could utilize alternate forms of communication. For example, videoconferencing can be an appropriate alternative that does not require commuting to a physical meeting space. There are also secure, online file storage systems that can be used to share information and documentation when practitioners are unable to meet.

Active Participation

Although efforts at organizing collaboration meetings may be successful, the value of participation in these efforts may be limited if professionals do not believe that information that is collected and shared is relevant to practice needs in different settings. It may also be limited if meetings occur at irregular intervals and without a structured agenda; in these situations, time is wasted on getting different team members up-to-date information (especially if different amounts of information are needed for different members) and on determining goals for the meetings rather than on focusing on progress data and goals for the child and family.

To be most effective, meetings about the same students should occur at regular intervals and should be designed to provide brief updates on child functioning across multiple settings (e.g., home and school). This should include information about progress made in treatment, current functioning, and short- and long-terms goals for the student and family. As previously noted, both informal and formal progress-monitoring tools should be used. Additionally, collaborative teams should develop a consistent method for maintaining student information and notes. One example is the SOAP (i.e., subjective evaluation, objective evaluation, assessment, and plan) format that allows for clear and concise documentation (Cameron & Turtle-Song, 2002). If all team members (e.g., school psychologist and community psychologist) utilize the same methods for documentation, meetings will be more efficient.

Additionally, it is important to discuss how CMHPs and school faculty can support each other; this may include sharing treatment recommendations or coordinating treatment programs. Mutual support is critical; otherwise, practitioners working in different settings may question the importance of collaboration if they do not perceive any added value from participation in this process. It also is helpful to schedule communication between face-to-face meetings. Coordinating communication between regular meetings can be accomplished with the utilization of liaisons who are explicitly tasked with working with all professionals, coordinating services, and communicating critical information. Based on particular child needs, plans should also be made for student monitoring, sharing of student observation data, and medication dispersal.

Conclusion

School professionals and CMHPs have a critical opportunity to improve student mental health through engaging in coordinated and collaborative practices. Although efforts to establish collaboration with relevant CMHPs and assisting families in this process can be successful, barriers may limit the effectiveness of collaboration. For example, different diagnostic systems, limited time and opportunities for interaction, and issues of privacy and limited parent involvement may constrain collaborative efforts. Thus, these barriers, as well as suggestions for resolving the difficulties, were examined, but it is important to note that these resolutions require organizational support and additional efforts from individual practitioners. Fortunately, the noted evidence of the benefits of collaboration should encourage individuals to see the benefits of this work, and it is suggested that individuals share this information with administrators and leaders to help implement and improve collaboration practices.

Footnotes

Declaration of Conflicting Interests

The authors declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

Funding

The authors received no financial support for the research, authorship, and/or publication of this article.

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