Abstract
In recent years, the rates of children and adolescents hospitalized for suicidal thoughts and behaviors have increased, necessitating that schools be prepared to support students as they return to school after hospitalization. Yet, recent research shows that most schools do not have formalized policies and procedures to support students during their re-entry and reintegration. Further, although school counselors are often the members of the school community charged with organizing and implementing accommodations and interventions in support of these students, the field of school counseling has not adequately addressed the need for formalized re-entry and reintegration plans or the role that school counselors have in leading this process. To meet the needs of students returning after hospitalization for suicidal thoughts and behaviors, schools benefit from formalized and individualized re-entry and reintegration plans that are grounded in a larger framework of support. Further, school counselors are well positioned to take a leadership role in this process, and specific and practical strategies are available to guide them. We organize these recommendations using the evidence-based school counseling model.
As the rates of children and adolescents experiencing depression have increased to unprecedented levels in recent years (Barendse et al., 2023; Curtin, 2020), so too have the rates of children and adolescents requiring hospitalization for suicidal thoughts and behaviors (Farah et al., 2023; Marraccini et al., 2021). However, despite students in crisis receiving medical help, the need to support students in crisis does not end with in-patient treatment. Schools serve as the primary discharge environment when children and adolescents leave intensive care after a mental health crisis, and school counselors are often the primary mental health support for students in the school building. Therefore, school counselors should be prepared to support students upon re-entry and during reintegration after hospitalization for suicidal thoughts and behaviors.
Despite this increasing need, research shows that many schools are not adequately prepared to meet this demand. In one study of 172 school mental health professionals from 84 schools in 27 different districts across one state, only 57% of participating schools had any procedure for re-entry or reintegration after hospitalization for suicidal thoughts and behaviors (Marraccini et al., 2022a). What constitutes a procedure varied greatly; although 57% of schools reported having a policy, only 32% had any written policy, with the remaining 25% having only an informal policy (Marraccini et al., 2022a). This same study found that schools in rural areas were less likely to have any protocols and procedures in place for reintegration when compared to schools in urban and suburban areas (Marraccini et al., 2022a). Yet, research from the perspective of psychologists has indicated that having a clear reintegration plan is positively associated with students’ perceived quality of support during the re-entry and reintegration process (Marraccini et al., 2019).
Within this context, school counselors, as professionals with specific competencies around suicide prevention, could take action to lead the development of re-entry and reintegration plans for students returning to school after suicide-related hospitalization. Schools can use evidence-informed strategies for creating, implementing, and assessing re-entry and reintegration plans. However, to date, no publication has provided school counselors with comprehensive recommendations for developing and implementing re-entry and reintegration plans for students returning to school after hospitalization for suicidal thoughts and behaviors. In fact, re-entry or reintegration receive scant mention in any of the school counseling literature, with no articles discussing any strategies or policies for re-entry appearing in the journal Professional School Counseling. In fact, only one Professional School Counseling article mentioned that school counselors are primary providers of mental health support for students during re-entry (Marraccini et al., 2022c). In the field of school counseling, understanding the research that is beginning to emerge from other fields would aid school counselors in implementing evidence-informed strategies for supporting students as they transition back to school after hospitalization for suicidal thoughts and behaviors.
Re-entry and reintegration are two separate yet related concepts. Re-entry is a term that depicts students’ physical arrival back at school after suicide-related hospitalization (Vanderburg et al., 2023). This typically involves a meeting between school officials, the student, and the student’s parents/guardians, where support and accommodations are discussed. Re-entry is one step in a more extensive reintegration process in which, over time, students begin to feel as though they are emotionally and physically safe in the school and have a sense of belonging (Marraccini et al., 2019). Reintegration involves providing the student with continued support beyond the re-entry meeting. Recent research has shown that this process involves identifying school stressors, providing support and interventions, focusing on the school environment, developing a reintegration plan, and holding a re-entry meeting (Marraccini et al., 2019).
Understanding the Needs of Stakeholders
Even before the COVID-19 pandemic, children and adolescents struggled with mental health concerns at an unprecedented rate. After years of relative stability, suicide rates among adolescents increased by 57% from 2007 to 2018 (Curtin, 2020). By 2019, one year prior to the start of the global pandemic, 19% of high school students considered suicide, 16% had a plan, 9% attempted suicide, and 2.5% required medical treatment (Hedegaard et al., 2019). The statistics were similar for middle school students, with 22% considering suicide, 17% having a plan, and 10% reporting at least one suicide attempt during the past year (Hedegaard et al., 2019). During the pandemic, the statistics became even more alarming, with 30% of U.S. high school students reporting seriously considering suicide during 2021 and 13% of adolescents reporting a suicide attempt that same year (Wilkins et al., 2023). Ultimately, each day in the United States, more than 5000 suicide attempts occur among children and adolescents aged 12–18 (Granello et al., 2023).
As the number of suicide attempts and completions for children and adolescents continues to rise, so too has the number of psychiatric hospitalizations. Each year in the United States, more 60,000 children and adolescents are hospitalized for suicidal thoughts and behaviors (Doupnik et al., 2017). Hospitalizations for suicidal youth increased 42% from 2019 to 2020 (Zima et al., 2022). This dramatic increase occurred with a corresponding 30% decrease in residential psychiatric beds available for adolescents over the last two decades (Substance Abuse and Mental Health Services Administration, 2019). Ultimately, more children and adolescents require more intensive treatment with fewer beds available. As a result, they spend less time in intensive psychiatric care and return to school while receiving less support and treatment for their mental health. The reality for many students is that they return to school after a psychiatric emergency, and very little has changed. They are facing many of the same stressors and returning to many of the same patterns of behavior that existed when they left school just a few days earlier, requiring schools to respond to greater need.
Perspectives and Needs of Stakeholders
Despite the lack of protocols and procedures within the school counseling literature for students’ successful reintegration, efforts to establish best practices within schools have originated from the medical and psychiatric professions (Clemens et al., 2010, 2011) and from school psychology (Marraccini et al., 2022a; Vanderburg et al., 2023). Together, these studies have contributed to our understanding of the important factors that serve as barriers to or positively contribute to successful re-entry and reintegration. These studies have explored re-entry and reintegration through the perspectives of relevant stakeholders, including the students transitioning back to school, their parents, and the schools responsible for their care. The lessons learned from these studies provide valuable insight into the elements required for successful re-entry and reintegration.
Students
Properly supporting students in their transition back to school after hospitalization for suicidal thoughts and behaviors requires understand of their perceptions of their needs during reintegration. Even before their discharge from the hospital, many students are concerned about re-entry to school (Preyde et al., 2017). Their primary concerns include anticipated interactions with teachers and peers, their academic standing, and their continued management of their emotions (Preyde et al., 2017). In a study by Preyde et al. (2017), these students specifically identified a need for continued support from mental health professionals and school personnel, academic support or accommodations, and emotional and social support from friends and family. Another study found that students’ negative perceptions of connectedness to school and learning during hospitalization predicted suicidal ideation intensity 6 months after re-entry into schools (Marraccini et al., 2022a). Together, these results emphasize the importance of a strong connection between mental health professionals and schools during hospitalization, re-entry, and reintegration.
Similar themes have also been noted in studies that sought to understand students’ perspectives during their reintegration once they transitioned back to school after hospitalization for suicide-related concerns. In one study, over half of the participants reported difficulties transitioning back to school, citing specific concerns with managing social encounters with peers and teachers, catching up on academics, and continuing to regulate their emotions (Preyde et al., 2018). Further, students who reported negative transition experiences had significantly worse scores on self-reported scales concerning their emotions. Another study on perceptions of students on reintegration found themes around the importance of positive school relationships and school climate, collaboration and communication around reintegration, and clear processes and procedures for academics and for the re-entry and reintegration process (Marraccini & Pittleman, 2022). Together, these findings reinforce the need for strong leadership and communication from the school in partnership with students, their families, and mental health professionals to support student re-entry and reintegration.
Parents and Legal Guardians
Parents and legal guardians, referred to throughout the remainder of this article as parents, are critical collaborators for students’ successful re-entry and reintegration into school following psychiatric hospitalization (Blizzard et al., 2016; Vanderburg et al., 2023). As such, researchers have sought to understand their experiences of the reintegration process to better inform the support needed (Blizzard et al., 2016; Vanderburg et al., 2023). When surveyed about re-entry and reintegration, parents reported high personal emotional strain, concern around their child’s symptoms and behaviors, and low perceptions of support and empowerment (Blizzard et al., 2016). Some specific concerns regarding the school setting included challenges in monitoring their child’s social/emotional functioning and academic progress (Blizzard et al., 2016; Vanderburg et al., 2023). Parents also noticed breakdowns in communication between hospitals, schools, and home, which created additional barriers to successful reintegration (Vanderburg et al., 2023).
Vanderburg et al. (2023) noted specific recommendations for practice that emerged from the research on parent and guardian experiences during reintegration. Their recommendations fall into five main categories: communication, academics in the hospital, the re-entry meeting, systematic school-based accommodations, and universal support. We infuse these detailed recommendations into the recommendations for practice in the subsequent section. Across these recommendations, the significant themes regarding support for students and their families are that it be proactive and preventative, collaborative in development, comprehensive and systemic, and tailored to the specific needs of the student and their family.
Schools
Researchers have also sought to understand perspectives and needs within the school that contribute to the re-entry and reintegration process. Because many factors contribute to successful reintegration, including coordination among school personnel and the implementation of re-entry interventions, schools have countless responsibilities regarding re-entry and reintegration (Clemens et al., 2011). Further, in suicide intervention with individual students, schools are concerned with helping the student and their family feel supported, limiting the contagion of other students, ensuring that the teachers and staff know their specific roles, and helping students stay engaged in their learning (Granello et al., 2023). In light of these factors, the possibility that school personnel perceive current support for re-entry and reintegration as insufficient is unsurprising (Marraccini et al., 2022a).
One specific concern that schools have expressed is a need for more collaborative communication with the hospitals regarding students’ treatment and safety plans (Marraccini et al., 2022a). Schools are not necessarily ideal environments for mental health treatment, and they could use additional support and guidance when caring for students in crisis. Although schools are responsible for supporting students through re-entry and reintegration, they do not own sole responsibility for the students, and hospitals can aid the process by providing detailed discharge summaries with recommendations for supporting students that are realistic within the school setting (Marraccini et al., 2022a; Tisdale, 2014). These discharge summaries would be generated by the hospital, shared with the parent, and then, ideally, shared with the school to increase the continuity of care.
School Counselors
Researchers have identified
Recently, a small debate emerged within the field of school counseling around the appropriateness of school counselors’ involvement in suicide screening and prevention, specifically due to school districts’ reliance on quantifying suicide using students’ self-report data and due to a perceived lack of formal training on suicide prevention during graduate studies (Gallo & Wachter Morris, 2022; Stone, 2022; Wachter Morris et al., 2021). Despite this back-and-forth, it was agreed that school counselors are often among the only individuals qualified in a school to lead these efforts (Gallo & Wachter Morris, 2022; Stone, 2022). Specific to re-entry and reintegration, school counselors have been identified as the school professionals most commonly leading the process (Marraccini et al., 2019). This aligns with school counselors’ overall role as educator-counselors, identifying and addressing students’ mental health needs in schools (Wachter Morris et al., 2021).
Although previous school counseling literature has clarified the role of the school counselor in suicide prevention (Gallo & Wachter Morris, 2022; Wachter Morris et al., 2021) and emphasized the need for school counselors to lead comprehensive suicide prevention programs (Granello et al., 2023; Granello & Zyromski, 2018), the field of school counseling has been largely silent on the topic of re-entry and reintegration after hospitalization for suicidal thoughts and behaviors. Even as other fields have named school counselors as integral members that should lead these efforts (Marraccini et al., 2022a; Vanderburg et al., 2023), no research has yet explored how school counselors can effectively support students during reintegration after suicide-related hospitalization. Using the literature on school counselors’ role in implementing a comprehensive suicide prevention program and the literature on re-entry and reintegration, the following sections outline formalized recommendations for school teams, often led by school counselors, for developing, implementing, and evaluating school-wide reintegration policies and procedures for students returning to school after hospitalization for suicidal thoughts and behaviors.
A Formalized Re-Entry and Reintegration Framework
Considering both research on the current state of re-entry and reintegration procedures following hospitalization for suicidal thoughts and behaviors across the United States and research on the needs and perspectives of stakeholders impacted by reintegration has yielded evidence-supported strategies that can inform a formalized framework for students’ re-entry and reintegration into schools after such hospitalization. This model can be viewed as one aspect of a comprehensive, school-based suicide prevention program (Granello et al., 2023). Such prevention programs are school-wide in scope and ensure that students with suicide-related risk are identified and supported according to their level of need (Goodman-Scott et al., 2022; Granello et al., 2023; Granello & Zyromski, 2018). Schools that use a comprehensive suicide prevention program follow a multilevel prevention system that includes three tiers for prevention, intervention, and support (Goodman Scott et al., 2022; Granello et al., 2023; Granello & Zyromski, 2018). Tier 1 is identified as universal or school-wide approaches to prevention; examples include staff training on suicide or school-wide anti-stigma campaigns. Tier 2 is selective interventions, employing strategies and approaches to assist students who have been identified as at-risk. Examples include individual or group counseling to help students build coping skills or develop resilience. Tier 3 is for indicated interventions and consists of school practices and protocols designed to assist students who have been identified as at high risk for suicide and who need immediate assistance. Examples of Tier 3 interventions include protocols for engaging in suicide risk assessments and referrals to community resources. Re-entry and re-integration are considered within Tier 3 of a school’s comprehensive suicide prevention program (Granello et al., 2023).
Positioning a framework for re-entry and reintegration as an integral component of a comprehensive, school-based suicide prevention program provides the necessary weight to ensure the proper processes are in place to safeguard students. It also allows for shared responsibility across the school for all stakeholders, including the school counselor, other school-based mental health professionals, school administrators, and teachers (Granello et al., 2023). One of the critical components to implementing a comprehensive, school-based suicide prevention program is establishing a core team of educational stakeholders responsible for the program’s success. The core team responsible for the program would also be the individuals involved in establishing, implementing, and evaluating the re-entry and reintegration plan for a student returning to school after hospitalization for suicidal thoughts and behaviors (Granello et al., 2023). This team would be responsible for partnering with the student, their family, and community providers—including those involved during hospitalization (Goodman-Scott et al., 2022). Ideally, the team would share in the responsibilities associated with reintegration; however, often one individual on the team would oversee its functioning. This individual is often the school counselor, but it could be a different member of the team (Marraccini et al., 2022a).
The re-entry and reintegration framework proposed in this article contains three distinct stages: (a) hospitalization, (b) the re-entry meeting, and (c) implementing and evaluating the reintegration plan. However, we begin with a brief overview of the considerations that the school team should address in planning and the development of policies and procedures prior to any student hospitalizations for suicidal thoughts and behaviors. Overall, this framework provides school counselors with evidence-informed recommendations to better support all students as they re-enter and reintegrate after suicide-related hospitalization. These recommendations follow the basic stages of the evidence-based school counseling model: determining student needs, implementing a research-supported intervention, and evaluating the impact of the interventions (Dimmitt et al., 2007; Dimmitt & Zyromski, 2020). Supporting students through reentry and reintegration should follow this general model by relying on reports from the hospital and students’ needs according to self- and family reports, providing support and necessary interventions based on research, and evaluating the impact of these supports. Although many of these recommendations may also apply to hospitalization for other psychiatric concerns outside of suicidality, the research supporting them is focused primarily on hospitalization for suicidal thoughts and behaviors, and it is outside the scope of this article to make recommendations for situations extending beyond the research that provided this foundation.
Planning
Re-entry and reintegration plans and procedures should be both formalized and individualized (Tougas et al., 2023). More specifically, students benefit from the presence of a standardized process for ensuring that each student returning to school after hospitalization for suicidal thoughts and behaviors is supported, and the plans should all be uniform with the types of information provided. However, the details of each reintegration plan, which includes a plan for re-entry, must be individualized and tailored to the student’s specific emotional, social, and academic needs (Tougas et al., 2023). Formalized reintegration plans include a summary of the timing and location for the return to school, the social and academic services and accommodations that should be provided, and a plan for making up missed schoolwork (Marraccini et al., 2019). Reintegration plans are different from 504 plans because they are focused on students’ re-entry and reintegration into school, providing plans for managing school-related stressors, identifying supports and interventions, addressing the climate of the school, and developing a safety plan if one was not already developed during treatment (Marraccini et al., 2022a). In the development of a reintegration plan, one step could be evaluating whether the student already has or is eligible for an individualized education plan (IEP) or 504 plan (Marraccini et al., 2022a).
Ideally, a school would also have an established policy that details the roles of the specific team members involved in developing each reintegration plan. If the school has a preestablished comprehensive suicide prevention program, these individuals would most likely be the members of the core team; however, if no core team has been established, suggested collaborators in this process include the school counselor, teachers, and administrators (Marraccini et al., 2019). Although school counselors are often tasked with leading reintegration, other professionals, such as school psychologists, may oversee this process (Marraccini et al., 2022a). Re-entry and reintegration processes and procedures may differ from school to school because not all schools will have the same services, accommodations, or personnel. Most important is that these procedures are formalized so the team can act quickly if a student needs to re-enter after receiving psychiatric treatment for suicide-related concerns.
One of the most consistent findings from the literature regarding supporting students’ effective re-entry and reintegration is the importance of communication (Marraccini et al., 2022a). This includes communication between school personnel and parents, among school members who are part of the core team, and between the school and the hospital (Tougas et al., 2023). Detailed procedures are essential to ensure that communication is clear and consistent among these critical stakeholders and procedures and expectations must be in place before a student’s mental health crisis to ensure that no details are missed. Confidentiality within communication is critical, as is protection of the student’s and their parent’s rights, so all relevant stakeholders must also understand their responsibility to protect confidentiality, as appropriate. Schools benefit from having relevant forms and procedures in place to obtain a release of information agreement between the hospital, the school, the student’s parents, and any other relevant mental health agency (Tougas et al., 2023). This can bolster the coordination and level of support provided.
Stage One: Hospitalization
The first stage of the formalized re-entry and reintegration framework for school counselors occurs while the student is out of school, receiving in-patient treatment for suicidal thoughts and behaviors. One consistent finding across the literature on reintegration is that coordination between the hospital and the school must begin immediately after the student is hospitalized (Tougas et al., 2023). Once the student is admitted, and after a release of information agreement is provided by the parents, the school and the hospital should communicate regarding generating a shared understanding of the supports available within the hospital and school setting, including academic and emotional support (Tougas et al., 2023). This communication would also include conversations about releasing relevant confidential information between the school, hospital, and any mental health agencies (Edwards et al., 2015; Tougas et al., 2023). Early communication between the school and the student’s parents is also critical. From the perspective of the school, these conversations may be led by the person responsible for organizing the student’s reintegration plan, often the school counselor (Marraccini et al., 2022a).
During the treatment phase, another vital step is for the members of the core team to ensure clear leadership in coordinating an individualized plan for re-entry and reintegration (Clemens et al., 2011; Tougas et al., 2023). As stated earlier, in most cases, the re-entry and reintegration coordinator should be the school counselor (Clemens et al., 2011; Marraccini et al., 2022a; Vanderburg et al., 2023). Clear leadership from the outset is needed to ensure that communication is streamlined and appropriate support is provided to the student (Clemens et al., 2011). As the reintegration coordinator, the school counselor is not solely responsible for the reintegration process; instead, the school counselor is responsible for coordinating the multidisciplinary team to implement the plan (Clemens et al., 2011; Tougas et al., 2023).
The school counselor could plan for several further considerations prior to the re-entry meeting. First is determining whether the student already has an IEP or 504 plan (Marraccini et al., 2022a). If they do, the school counselor may consider how this may impact academic support for the student during treatment and how it may factor into their specific reintegration plan. Existing plans may need adjustments in light of new information from the student’s treatment or safety plan. Similarly, school counselors could consider whether any services might be available for the student upon their return (Tougas et al., 2023). This could include on- or off-site tutoring, peer mentoring, check-ins with a trusted adult, a dedicated transition space within the school, and individual or group counseling. Further, the school counselor should ensure an understanding of the specific accommodations available to the student so that they are prepared for the re-entry meeting (Clemens et al., 2010). These accommodations might include excused absences, a plan to attend school late or leave early, a reduced workload, missed work forgiveness, extended deadlines, and testing accommodations. Last, school counselors may also consider whether any specific school-related stressors or triggers can be mitigated for the student before their return (Marraccini et al., 2022b). This would look different for each student, but one example would be altering their class schedule to avoid peers or teachers that cause distress.
Before the re-entry meeting, the school will need as much information as possible about the student’s needs. As the reintegration coordinator, the school counselor can coordinate with the student, their parents, and their treatment provider to gain an understanding of several critical factors, including the student’s feelings about their transition back to school; the student’s academic, physical, and emotional needs; and specific coping skills that are being taught (Savina et al., 2014; Tougas et al., 2023). The school can also work to obtain a safety plan from the parents if one was developed during treatment (Marraccini et al., 2022a). Ideally, the school would obtain the safety plan, which is a document developed by the hospital detailing specific plans for how the student would respond to intrusive thoughts related to suicide, so as to avoid creating a redundant plan in the school (Roberts et al., 2018). This information, which the school counselor should view as data, will serve as the foundation for an evidence-based approach to supporting the student through reintegration (Dimmitt et al., 2007; Dimmitt & Zyromski, 2020). This data will provide the basis for the reintegration plan established during the re-entry meeting and details the specific, research-supported, school-based interventions supporting the student (Dimmitt et al., 2007; Dimmitt & Zyromski, 2020).
Stage Two: The Re-Entry Meeting
The re-entry meeting is the second stage of the formalized re-entry and reintegration framework for school counselors. Prior to the student’s return to school, the school counselor or other individual designated as the reintegration coordinator can organize the re-entry meeting, which is designed to clearly understand the student’s needs, define the reintegration plan, and clarify participants’ roles and expectations (Clemens et al., 2011). At a minimum, the participants in the re-entry meeting should include the student, their guardians, the school counselor, and the school nurse if medications are involved (Marraccini et al., 2022a). The student’s involvement in this meeting is important because it addresses plans directly related to their support, but additional conversations between the school and parents may be appropriate due to concerns related to the developmental level of the student. Depending on the school context, including other members of the core team in the re-entry meeting may be appropriate, including the school psychologist, school social worker, and administrator (Marraccini et al., 2022a). In accordance with ASCA Ethical Standard A.2.M., the student’s teachers would likely not be involved in the re-entry meeting to protect the confidentiality of the student (American School Counselor Association, 2022). However, upon the conclusion of the re-entry meeting, teachers should receive clear messages concerning any relevant academic or behavioral accommodations or supports that result from the meeting (Marraccini et al., 2019).
Overall, the goal of the re-entry meeting is to develop an individualized reintegration plan that outlines appropriate services, accommodations, and interventions as the student transitions back to school (Clemens et al., 2011). The re-entry meeting has several intended outcomes. The first is understanding the student’s specific needs (Tougas et al., 2023). These needs would be determined through conversations with the student and their parent(s) and by reviewing the safety plan outlined in the discharge paperwork. If the safety plan developed during treatment needs to be adapted to the specifics of the school context, these modifications will occur with the input of the student and their parent during the re-entry meeting (Marraccini et al., 2022a). If no safety plan was established during the student’s treatment, this would need to be developed during the re-entry meeting.
Another component of the re-entry meeting is conversations around specific strategies and services each team member provides to support the student’s needs (Tougas et al., 2023). This would include discussion of any specific accommodations that will be afforded to the student. Examples of accommodations that may be discussed include flexible school start and end times, modified attendance schedules, and schoolwork accommodations. Other intended outcomes of the re-entry meeting include: (a) establishing a plan for medication support (if needed); (b) discussing expectations of the student, including academics, behavior, and attendance; (c) discussing future expectations of all parties, including how to communicate if expectations change; and (d) establishing a follow-up date to evaluate the student’s progress (Marraccini et al., 2022a).
Even though reintegration accommodations and supports may differ from school to school and depend on the specifics of the individual student, a few general reintegration strategies have emerged from the literature. First, students have indicated that they believe it is important to have strategies for a gradual return to schoolwork (Marraccini & Pittleman, 2022). Because of this, the school counselor may wish to advocate for a gradual and supportive approach to helping the student catch up academically. This may involve collaborative conversations with administrators and teachers to ensure the student is not overwhelmed with make-up work.
Research also has emphasized the importance of the relationship between students and the adults in the school, including teachers, administrators, and school counselors. One well-documented reintegration strategy is students’ check-ins with a trusted adult. Research shows that students value these check-ins because they allow them to practice the emotional regulation skills they have been learning (Marraccini & Pittleman, 2022). Outside of the individual designated as the trusted adult, students indicated that having teachers check in with them was important, even if the teachers were not fully aware of the specifics regarding why the student was out of school (Tougas et al., 2023). This could involve a simple email or conversation where the teacher asks how they are doing and if they need anything as they transition back to school.
Considerations for Developing the Reintegration Plan
The development of the reintegration plan during the re-entry meeting requires several important considerations. First, in conjunction with the evidence-based school counseling model, the reintegration plan should be data driven and focused on research-based strategies and interventions (Dimmitt et al., 2007; Dimmitt & Zyromski, 2020; Marraccini et al., 2022a). In this regard, the reintegration plan should focus on a clear understanding of the student’s needs, which would be established through a combination of the discharge plan, treatment goals, safety plan, student screenings, and any other data available at the time of the re-entry meeting (Marraccini et al., 2022a). This data provides the foundation for the reintegration plan and will also be utilized as the baseline when re-evaluating the supports in place later in the reintegration process. Further, the team could consider specific research-based strategies and interventions for supporting students at high risk for suicide in the school setting. Although articulating these practices is beyond the scope of this article, specific recommendations can be found in Suicide and Self-Injury in Schools: Interventions for School Mental Health Specialists (Granello et al., 2023).
Schools will vary according to the potential services and accommodations available to them (Marraccini et al., 2022a) and no uniform list of services can apply to all school settings. Therefore, each team must have a clear understanding of the specific supports and accommodations available in their specific school context to ensure that they are not offering supports or accommodations they cannot provide. All recommendations must be appropriate and realistic, given the resources and structural limitations of the school system.
Stage Three: Implementing and Evaluating the Reintegration Plan
The third stage of the formalized framework for re-entry and reintegration comprises implementing and evaluating the reintegration plan. The specific responsibilities of this final stage of the framework include implementing the plan, monitoring the student’s well-being, monitoring the school environment, tracking the student’s academic and emotional progress, maintaining communication among the stakeholders, and re-evaluating the reintegration plan as necessary (Savina et al., 2014). The responsibilities of this stage fall on the team as a whole, but the efforts ideally would be monitored by the reintegration coordinator. This stage might include occasional check-ins with the student, occasional re-screenings for suicidality, and continued conversations with the parents, teachers, and other relevant stakeholders (Savina et al., 2014). Generally, this stage of the reintegration framework is well aligned to the evaluation stage of the evidence-based school counseling model, and school counselors are well positioned to lead these efforts due to their training in counseling, data collection, and program evaluation (Dimmitt et al., 2007; Dimmitt & Zyromski, 2020).
In some situations, the school may not be informed about a student’s hospitalization for suicidal thoughts and behaviors. In these cases, the first two stages of the re-entry and reintegration process may not occur. However, if the school learns that a student has been hospitalized for suicide-related concerns, engaging in this third stage of the framework is still important, regardless of whether the first two stages were completed, to ensure that the student receives support in their transition back to school.
Specific Considerations for Parent Partnerships During Implementation
Despite their critical role, parents also have several needs that the school must address to ensure the optimal amount of support for their child. As family engagement leaders within schools, school counselors can work toward collaborative relationships with parents throughout re-entry and reintegration (Bryan et al., 2019). To form collaborative relationships, school counselors should be aware of some potential barriers for parents when collaborating with schools or discussing mental health concerns (Bryan et al., 2019). This is particularly true with parents from a minoritized background (Bryan et al., 2019). School counselors can adopt and promote a strengths-based lens for working with all parents (Bryan et al., 2019), which involves seeking parents’ funds of knowledge or unique areas of expertise (Moll et al., 2005). It also includes recognizing that schools are not historically safe places for all parents—they may have had personal experiences of oppression within the school system and experience feelings of resistance when working with the school (Holcomb-McCoy & Bryan, 2010). Further, school personnel may encounter resistance when discussing mental health concerns due to cultural reasons (Abdullah & Brown, 2011). In all cases, school counselors should take a partnership-focused approach that applies an asset-focused lens, empathy, and cultural humility (Bryan et al., 2019).
A few themes have emerged regarding parents’ specific concerns during the reintegration process. Specifically, parents have reported concerns about their child’s social/emotional functioning, access to mental health services in and out of school, and a need for straightforward academic accommodations offered by the school (Blizzard et al., 2016; Vanderburg et al., 2023). School counselors can collaborate with other school officials to maintain an open line of communication with parents, ensuring that they feel supported and well connected to necessary resources in the community (Bryan et al., 2019). School counselors must also recognize that parents may not always be able to answer the question, “What do you need?” In many cases, the best approach is to provide a clear list of options for potential accommodations or supports.
Evaluating the Reintegration Plan
To ensure that the student is receiving appropriate interventions, accommodations, and supports through the reintegration plan, engaging in continual evaluation of the supports in place is a critical step by the school counselor (Dimmitt, 2009; Dimmitt et al., 2007). The three forms of evaluation most appropriate for evaluating the reintegration plan include formative evaluation, implementation evaluation, and outcome evaluation (Dimmitt, 2009). With formative evaluation, the school counselor can gauge initial feedback on the plan’s implementation by seeking informal feedback from the student, their parents, and other stakeholders involved in the process (Dimmitt, 2009). Questions like, “What seems to be working well?” and “What concerns do you have with the plan?” can help the school counselor understand if any amendments need to be made to accommodations or interventions. With implementation evaluation, the school counselor can determine the degree to which the accommodations and interventions have been implemented consistently and with fidelity (Dimmitt, 2009). This type of feedback can also be collected through informal conversations with students, parents, and educational stakeholders. Last, outcome evaluation is a more formal process that seeks to understand the quantifiable impact of the interventions and accommodations (Dimmitt, 2009). Examples of outcome evaluation for the reintegration plan could include re-screening the student for suicidality, using other research-supported scales on constructs like perceptions of support, and reviewing the student’s grades and academic progress.
Conclusion
Overall, school counselors are needed to take a leadership role in the re-entry and reintegration process for students returning to school after hospitalization for suicidal thoughts and behaviors and to offer a framework to support their efforts. Although other fields have named school counselors as leaders in the reintegration process (Marraccini et al., 2019), the field of school counseling has been largely silent in offering guidance to practitioners on how to lead this process. As the rates of students hospitalized due to suicide-related concerns continue to climb, school counselors should be equipped with the knowledge to lead the re-entry and reintegration process in their schools. Although the framework in this article is limited to reintegration following hospitalization for suicidal thoughts and behaviors, and is yet to be evaluated by researchers in the field, a formalized re-entry and reintegration framework offers school counselors research-based guidance for supporting students and their parents through this challenging transition.
Footnotes
Declaration of conflicting interests
The author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.
Funding
The author(s) received no financial support for the research, authorship, and/or publication of this article.
