Monthly Archives: September 2019

Voice of Experience: Confidentiality – The core of ethics

By Gregory K. Moffatt September 17, 2019

As my colleague and I chatted casually in the copy room about life’s odds and ends, she mentioned a client I had referred to her some months earlier.

“Thomas [not the client’s real name] is doing so well,” she commented absentmindedly. “Thank you for the referral.”

Nobody was around to hear us, but I couldn’t believe my ears. My colleague had just used a client’s name. Even though I had referred the client to her and I knew she was seeing him, I was shocked she had identified him so casually.

When we study counseling ethics, we often use phrases such as “do no harm” or “what is in the best interest of the client” as general landmarks for ethical dilemmas. In the 2014 ACA Code of Ethics, nearly all of the ethical standards, from Section A through Section I, in some way or another relate back to protecting the client from harm.

Although I use these benchmarks myself and often mention them to my supervisees and interns, I would suggest that confidentiality comes in at a close second place for the core of our ethical conduct.

Our informed consent, release of information documents, and testimony in court are all centered around the importance of maintaining the confidentiality of our clients. We don’t leave client files lying about on our desks or open on our computer screens.

Current common practice in office construction is to have windows in all office doors. The attorney for the university where I teach loves this practice. But this approach creates an ethical problem for us as counselors. We cannot maintain the confidentiality of our clients’ identities if passersby can easily glance in the window and see them.

When the Health Insurance Portability and Accountability Act (HIPAA) was first introduced to us, I resented it as another governmental intrusion into my work, but I came to realize its power to protect the confidential information of our clients — the very thing I am advocating here. While I don’t necessarily “love” HIPAA, I value it highly and comply with all of its requirements. I pay heed to HIPAA not simply to keep from getting into trouble, but rather to protect my clients.

The very words in this article model my respect for client confidentiality. I have changed the name of the client and a few of the specifics regarding the interaction between my colleague and me. If either of them happened across this article, there is little chance that they would recognize themselves. The gist of the story is true, but some details were changed to protect both the client and my colleague.

I drill a high regard for confidentiality into the minds of my clinicians. I want to ensure that they are so sensitized to this part of our ethics that even the smallest breach will scream at them.

While I certainly appreciate a word of thanks from a colleague if I refer a client, I don’t want to hear, “Thanks for referring Thomas to me …” Even the simple use of a client’s first name in a private conversation between colleagues is a big deal. If we allow that, what other slips will we allow?

I couldn’t let the situation pass. According to Standard D.1.d. of the 2014 ACA Code of Ethics, it is my duty to address ethical lapses within the field. This provision says that if we perceive an ethical violation, we should first approach colleagues directly to resolve it.

As awkward as it was, I gently told my friend it made me uncomfortable that she had used the client’s name. I had scarcely finished the sentence before her mouth dropped open and she quickly covered it with her hand upon the realization of what she had done. She apologized and said she knew better. Somewhat to my surprise, she also thanked me for modeling ethical conduct and for respectfully calling this out to her. She won’t make that mistake again, and I’m glad I did the right thing.

Thomas will never know what happened. But this isn’t just about Thomas. It is about a way of behaving that protects all of our clients, regardless of whether they will ever find out.

Basketball legend John Wooden has been credited with saying, “Character is how you behave when no one is watching.” Ethical behavior, including confidentiality, is perhaps most clearly reflected when no one is watching.

 

 

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Gregory K. Moffatt is a veteran counselor of more than 30 years and the dean of the College of Social and Behavioral Sciences at Point University. His monthly Voice of Experience column for CT Online seeks to share theory, ethics and practice lessons learned from his diverse career, as well as inspiration for today’s counseling professionals, whether they are just starting out or have been practicing for many years. His experience includes three decades of work with children, trauma and abuse, as well as a variety of other experiences, including work with schools, businesses and law enforcement. Contact him at Greg.Moffatt@point.edu.

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Opinions expressed and statements made in articles appearing on CT Online should not be assumed to represent the opinions of the editors or policies of the American Counseling Association.

From Combat to Counseling: Cultural competence in the military affiliated population

By Duane France September 11, 2019

There were two things that I learned in my degree program regarding cultural competence. The first was that there is a need for the counselor to develop an understanding of how culture influences the unique point of view of a particular client. The second was that it was the responsibility of the counselor to develop that understanding on their own, not put the burden on the client to teach it to them. I’m certain there were more things that I was taught, but those two stand out the most.

When it comes to serving the military-affiliated population, however, some counselors don’t consider these clients to be part of a different culture. Perhaps their perception of diverse cultures is based on geography (e.g., urban versus rural), ethnicity, religion or nationality. All of these cultural values are valid of course; any counselor working with a client whose life experience is rooted in a culture different from the counselor’s own can and should develop an understanding about them. Somehow, though, perceptions of cultural diversity do not usually include the military population. But they are of diverse geographic, ethnic and religious backgrounds, correct? Of course.

Added to that is the fact that serving in the military necessarily begins with an assimilation process. As I mentioned in the first article of this series, if you look at the various definitions of culture, they can be applied to life in the military. We have our own way of dressing, our own language (I’m fluent in “acronym” and often forget that others aren’t), and our own way of looking at the world.

 

Intergenerational transmission of knowledge

Merriam-Webster provides one definition of culture as “the integrated pattern of human knowledge, belief, and behavior that depends upon the capacity for learning and transmitting knowledge to succeeding generations.”

If that’s not a clear description of the traditions that are passed down through generations of military service members, then I don’t know what is. For example, the Army’s Drill and Ceremonies manual can be traced directly back to the Continental Army and Baron Friedrich von Steuben’s Regulations for the order and discipline of the troops of the United States. Tradition is also preserved through established customs and standards. The rules of service etiquette for the various military branches and their academies are outlined in a 562-page monster of a book. The long and rich history of military culture is conveyed through its customs and courtesies, and even in traditional aspects present in today’s uniforms.

The accumulation of cultural knowledge begins when the service member first reports to their basic military training and continues throughout their time in the service. Some aspects of cultural knowledge are unique to the various service branches. For example, all Marines are aware — and consider it a point of honor — that the Marine Corps was born in a bar.

 

A common way of life

Merriam-Webster provides a second definition of culture as “the characteristic features of everyday existence shared by people in a place or time.”

There’s no denying it: Service in or affiliation with the military has some unique characteristics. As an old Army slogan put it, “We do more before 9 a.m. than most people do all day.” A typical morning in the military starts by 6 or 6:30 a.m. (and, for leaders, even earlier). Then there’s the constant movement, for both the service member and the family. My wife and I lived in nine apartments in two states and two countries in the first 10 years of our marriage. The high number of different schools that military kids attend is so common that it’s almost cliché. For my two, it was four schools in five years.

U.S. Army photo by Sgt. Henry Villarama/defense.gov

The military is also very hierarchical in nature. One glance and a service member knows where they stand in that hierarchy: above, below or on the same level. Built on a foundation of mutually understood respect and obedience from senior to subordinate, the daily life of service members is typically planned and scheduled from the minute they stand in formation to the minute they are dismissed. Does it always work that way? Of course not, which is also part of the culture — no plan survives first contact with the enemy, etc.

 

A common set of values

A third definition of culture from Merriam-Webster is “the set of shared attitudes, values, goals, and practices that characterizes an institution or organization.”

The military is as much a values-driven organization as it is a mission-driven organization. Starting with the Oath of Enlistment or Oath of Commissioned Officers, the common goal — to support and defend the Constitution of the United States, to bear faith and allegiance to it, and to obey the orders of the officers appointed over them — is clearly stated and immediately understood.

Each of the branches of service has its own core values. The Army’s values form the acronym LDRSHIP: loyalty, duty, respect, selfless service, honor, integrity, and personal courage. The Marine Corps uses less words for its values in favor of going straight to the point: honor, courage and commitment.

For those who haven’t served, it may seem archaic to be so obligated to a set of values. For those who have served, however, these are values that are instilled as core beliefs. When actions are taken that violate these values, either by the service member themselves or by others, it can be as difficult to overcome as the violation of any other core belief that we help our clients with. Sometimes I help my clients see that the cause of distress in their post-military lives is their failure to live according to these values.

 

Military cultural competency is necessary for counselors

Although many counselors recognize the unique nature of military service, it’s also essential that they understand how important that culture is to a member’s self-image. When I joined the Army, I stopped being a suburban St. Louis kid and became a soldier; when I left the Army, I became a veteran. It has become as much a part of me as any other label, such as father, husband or son. It has become my identity —not all-consuming and not my entire identity — but a large part of it. Chances are, if you are working with a service member, veteran, or military family member, it will be a large part of theirs too.

 

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Duane France, LPC

Duane France is a retired U.S. Army noncommissioned officer and combat veteran who practices as a licensed professional counselor in Colorado Springs, Colorado. He is the director of veteran service for the Family Care Center, a private outpatient mental health clinic specializing in service members, veterans and their families. He is also the executive director of the Colorado Veterans Health and Wellness Agency, a 501(c)3 nonprofit that is professionally affiliated with the Family Care Center. In addition to his clinical work, he writes and speaks about veteran mental health on his blog and podcast at veteranmentalhealth.com. Contact him at duane@veteranmentalhealth.com.

 

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Opinions expressed and statements made in articles appearing on CT Online should not be assumed to represent the opinions of the editors or policies of the American Counseling Association.

Five social, emotional and mental health supports that teens need to succeed

By Dakota King-White, Sade Vega and Nicholas Petty September 9, 2019

Many teenagers have been exposed to traumatic events, and most experience regular life stressors. Exposure to violence and other traumatic experiences can have a lifelong effect on learning and may negatively impact academic achievement. Among examples of traumatic events that some teenagers experience are community violence, school shootings, the loss of a loved one due to death, parental incarceration, divorcing parents, a parent or caregiver with mental illness, and substance abuse in the home. Within the school setting, the negative influence of trauma on teens may lead to poor concentration, declining academic performance, school absenteeism, and the decision to drop out. These challenges create barriers for the success of teens in the academic setting.

Schools across the United States have recognized the importance of providing school-based mental health support because these services benefit students academically, socially and emotionally. However, questions regarding the issues facing teens and the types of mental health supports needed to deal with these issues require further examination. Implementing a needs assessment can assist schools in uncovering the answer to these questions. The findings can then help determine what programming should be implemented to improve students’ overall development, such as teaching them social skills to help them become productive members of their communities and school settings.

We wanted to learn more about the social, emotional and mental health needs of teenagers, so we conducted a needs assessment in which we surveyed 198 high school students in a Midwestern city. The teens in our study identified the types of emotionally stressful experiences they have faced since attending high school. They also described what schools could do to make them feel supported and better able to deal with the related challenges.

The following sections present the five top issues identified by the students we surveyed, along with recommendations on ways that schools can support teenagers socially, emotionally and mentally.

 

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1) Social media makes peer pressure a 24/7 problem. Teens today are confronting certain pressures that teens in the past didn’t face. A prime example: Social media has become an indispensable part of teenagers’ lives. According to a 2018 report written for the Pew Research Center by Monica Anderson and Jingjing Jiang, YouTube, Instagram and Snapchat are the most popular online platforms among those ages 13-17, and most teens have access to these apps on their smartphones. Anderson and Jiang note in the report that 95% of teens have access to a smartphone, with 45% of teens acknowledging that they are online “almost constantly.”

This constant mobile connection creates the conditions for teenagers to consistently be exposed to peer pressure even outside of the school environment. Mina Park and colleagues in 2017, in a journal article in Cyberpsychology, Behavior, and Social Networking, noted that hyperconnectivity to social media can also lead to depression, negative body image and eating disorders.

What schools can do to help: Teens must be given an outlet to discuss their frustrations when it comes to dealing with peer pressure. Students should be directed to their school counselors or other trusted adults in the school with whom they can share their feelings and pressures and get supportive, confidential advice in return. It is also helpful to allow for genuine conversations in the classroom about the importance of students being confident in who they are and embracing their differences. Safe spaces in schools allow teens opportunities to feel supported in a neutral environment, to accept who they are, and to embrace differences among their peers.

 

2) Bullying is a significant issue. Peer pressure is not the only problem arising from constant social media access. The other, and even more troubling, issue is bullying. Teens may experience, witness or engage in bullying situations, including cyberbullying, which is more prevalent among teens.

The Bullying Statistics website (bullyingstatistics.org) notes that cyberbullying may consist of teens sending cruel messages, spreading gossip or posting threatening messages on social media platforms, pretending to be someone else on a social media account, or sexting. According to recent statistics from the website, more than 25% of teenagers have been exposed to cyberbullying situations that have had a negative impact on them. Bullying can have a significant effect on teens socially, emotionally and academically. Some of the negative impacts include depression, anxiety, attendance problems, and decrease in academic achievement. However, many teens who experience cyberbullying do not tell their parents or guardians about these painful experiences.

What schools can do to help: October is National Bullying Prevention Month, and many schools across the United States take time to develop effective strategies to raise awareness about bullying and to prevent bullying incidents on their campuses. It is important for schools to create an environment in which victims of bullying/cyberbullying, or teens who witness the bullying of a peer, can talk to trusted adults about bullying situations. Help your students by providing safe places in schools where teens can disclose when they or their peers are being bullied, or even create a hotline for students to report bullying situations.

Additionally, offer professional development to teachers and other staff members on identifying the warning signs of bullying, and provide them with effective strategies to help students who are being bullied. Likewise, many parents are unaware of how to support their teens when they are being bullied, so invite parents to on-campus workshops where they can learn ways to address these issues with their teens. During the parent and family sessions, discuss the various types of bullying that take place, the warning signs of bullying, and school and community resources for victims of bullying and cyberbullying. Workshops for parents and families can add another layer of support for young people who are affected by bullying.

 

3) Students are concerned about their personal safety. In our study, the third top concern that students reported was anxiety about their personal safety. According to the National Institute of Justice, school safety is currently a common concern among educators and administrators across the United States. Teens may not feel safe in their schools because of gun violence on school campuses across the country or even violence in their own communities or neighborhoods. The National Institute of Justice has stated that more schools have increased their security measures to protect students. Many of these schools have instituted locked doors, security cameras, hallway supervision, controlled building access, metal detectors and locker checks.

More than half of the ninth- and 10th-graders and more than 70% of the 11th- and 12th-graders we surveyed reported that they had experienced a traumatic event while attending high school. These various traumatic events can cause students to feel concern about their overall safety in their schools and communities. This type of stressor can in turn affect how teens engage in their educational environments.

What schools can do to help: Trauma-informed methods must be put in place to support students and their overall safety. Trauma-informed approaches focus on ways to ensure that students feel supported, listened to, and safe. Among the trauma-informed approaches that counselors can create in their schools are to build trust and rapport with students and to collaborate with outside community resources to support students who have been exposed to traumatic events. By getting to know your students, you will notice when their behaviors change, and because you have built trust with them, you can approach them in a friendly way to address these changes.

In addition, provide training on trauma-informed methods for teachers, support staff and administrators at your school. This training will help them create resources aimed at the needs of teens. Additionally, educators can seek professional help for their own personal traumas so that they may better interact with students who are dealing with stressors. By ensuring that teachers and staff members have access to community resources and training about personal safety and trauma, schools are developing leaders who can help students socially, emotionally and academically.

 

4) Students need help coping with their emotions. Teens’ emotions run rampant during their high school years. Most experience a range of emotions, including anger, fear, frustration, disappointment and hurt. These emotions may mask some of the broader issues that students face and that ultimately affect their academic performance.

Some of the students in our study participated in a small group that focused on developing social skills. The single-gender support group addressed the students’ academic, social and emotional needs. The sessions offered teens a safe place to identify stressors in their lives and to discuss the emotions attached to those stressors. By talking about their emotions, students were able to identify yet other emotions that were hiding underneath their anger and aggression. Throughout this process, the teens learned how to effectively articulate their emotions and to identify the underlying factors that were fueling them.

What schools can do to help: Encourage a supportive environment and training for students, such as small support groups facilitated by school counselors, clinical counselors, school psychologists or social workers, as well as peer-to-peer support groups. Teach teens the proper social skills related to identifying their emotions, and explain that all emotions are OK to have.

Quite often, teenagers express only the basic emotions when talking to others, especially adults. However, challenging them to look deeper and to identify the true emotion can be effective. Teens need safe places at school where they can learn how to cope with their anger and the other uncomfortable emotions that they often face.

 

5) Dealing with grief is important. A final concern students reported centered on dealing with grief from the loss of a loved one. Those students in our study who had experienced the loss of a loved one or who had witnessed a friend going through such a loss reported needing a supportive outlet to deal with those losses. Students may experience various losses during their teen years, such as the death of a friend or family member, and they are often left to process their emotions about the loss on their own. If schools are unaware that students have experienced a loss, those students may go without the support that is needed to help them process their grief. A lack of support during this time can have a significant impact on teens succeeding within the academic setting.

What schools can do to help: Build rapport early in the year with students so that they will be comfortable sharing should they experience a loss. During times of loss, allow students to grieve. Provide additional assistance by forming support groups for students who have experienced loss. This type of support can be offered through collaboration with local counseling agencies, hospices or other entities that support families experiencing loss. It is also helpful to maintain a list of community resources that address grief and loss. This community resource guide can be shared with teens, parents or caregivers, and other stakeholders.

Transforming school into an emotionally responsive environment

Students who are well-equipped socially, emotionally and mentally at the beginning of their academic careers can better cope when hardships occur. As counselors, we can help our students succeed in school and in life by first learning to identify their social, emotional and mental health needs, and then providing resources such as social skills workshops and support groups for them. Additionally, we can lead by example by improving our own social, emotional and mental health through professional development workshops that emphasize social and emotional learning practices.

Remember, school is not just a place where students gain academic knowledge; it is where they prepare for life. By doing our part to create a safe and emotionally supportive environment, we can increase the odds that students will succeed beyond the walls of the classroom.

 

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Dakota King-White is an assistant professor in counselor education at Cleveland State University. Prior to that, she worked in K-12 education as a school counselor, mental health therapist and administrator. Contact her at d.l.king19@csuohio.edu.

Sade Vega is a student in health science at Cleveland State University. In 2018, she received the university’s undergraduate student research award for her research on assessing the social, emotional and mental health needs of high school students. Contact her at s.m.vega@vikes.csuohio.edu.

Nicholas Petty is the director of undergraduate inclusive excellence at Cleveland State University. Prior to working at the university, he was an administrator in the Cleveland Metropolitan School District, where he earned national attention for his innovative approaches to behavioral intervention and student motivation. Contact him at n.petty@csuohio.edu.

 

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Counseling Today reviews unsolicited articles written by American Counseling Association members. To access writing guidelines and tips for having an article accepted for publication, go to ct.counseling.org/feedback.

 

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Opinions expressed and statements made in articles appearing on CT Online should not be assumed to represent the opinions of the editors or policies of the American Counseling Association.

The case for universal mental health screening in schools

By Emily Goodman-Scott, Peg Donohue and Jennifer Betters-Bubon September 5, 2019

When I (Emily) was in elementary school, I vividly remember being screened for scoliosis. One day, all the students in my fifth-grade class marched down to the school library, and one by one, we were each briefly and privately evaluated by the school nurse. This was a form of universal screening: systematically screening every student for given criteria.

Universal screening continues to be commonplace today in our pre-K-12 schools. In education, we screen all students for academics: Are they reading on grade level? We screen all students for key health-related factors: Could their hearing or vision be impeding their academics? We provide universal screening for a variety of factors that can affect students’ school success … but what about screening for mental health?

Mental health concerns are prevalent in society, with approximately 80% of chronic mental health disorders beginning in childhood. The National Academy of Sciences estimates that 14% to 20% of youths each year are diagnosed with mental, emotional or behavioral mental health disorders. In addition, we are seeing substantial stress in childhood and adolescence. According to Dr. Sandra Hassink, a former president of the American Academy of Pediatrics, approximately one-third of children display signs of stress, while more than half of college students report overwhelming anxiety. Hassink categorizes stress as the “top health problem facing kids today.”

In addition to stress and anxiety, we remain concerned about the rates of suicide, self-harm, depression and school violence among pre-K-12 students. Despite the prevalence of mental health concerns, only 45% of youths with a diagnosis receive treatment. And less than 25% of those youths receive any form of treatment in the schools, despite the overwhelming evidence supporting early prevention and intervention.

In schools, it is often easier to identify externalizing behaviors such as aggression and rule breaking rather than internalizing behaviors such as depression, anxiety, isolation, suicidal ideation and so forth. In fact, in a 2008 study, Catherine Bradshaw, Jacquelyn Buckley and Nicholas Ialongo found that students with internalizing behaviors were substantially underserved in pre-K-12 schools compared with their peers with externalizing behaviors. This suggests that students with internalizing behaviors may fly under the radar of school staff, making them less likely to be identified and, thus, less likely to receive services.

Given the prevalence of mental health and behavioral concerns in students and the gaps in adequately identifying and serving students with elevated needs, there has been a call for change in pre-K-12 schools. After the devastating school violence and loss of life at Sandy Hook Elementary School in 2012, the Connecticut Office of the Child Advocate conducted a thorough investigation and made recommendations, the first of which was screening every student in a particular class, grade, school or district for criteria related to mental health or social/emotional indicators. Universal screening, also known as universal mental health screening (UMHS), has been recommended by a plethora of organizations, including the 2002 President’s Commission on Excellence in Special Education, the National Association of School Psychologists, the Institute of Medicine, the American Academy of Pediatrics, and A Framework for Safe and Successful Schools, which was authored or co-signed by a wealth of educational and mental health organizations.

Furthermore, burgeoning research supports the implementation of school-based UMHS, suggesting that it can increase the likelihood of identifying students with internalizing behaviors. Many of the schools we have talked to have echoed this sentiment, saying that after implementing UMHS, they identified students struggling with internalizing concerns who previously had not been identified by either the school or the family and thus were not receiving services. UMHS can help pinpoint student needs that are beyond the awareness of school staff and parents or guardians, thus ensuring that fewer students fall through the proverbial cracks.

Schools and school districts nationwide are considering UMHS, with more and more schools beginning implementation. At the same time, successfully facilitating this practice requires significant planning and time initially and having a system of resources readily available to serve the students, once identified. In 2018, the National Center for School Mental Health at the University of Maryland created a guide for operationalizing the steps to UMHS. We’ll describe those steps. 

Operationalizing UMHS

Step one: Create a multidisciplinary team and secure buy-in from key stakeholders. The UMHS team is responsible for designing and coordinating UMHS implementation. Because of the systemic nature of the process and the plethora of responsibilities, implementation should truly be a team effort rather than falling on one or two staff members. Team members could include school-based mental health providers such as school counselors and licensed mental health counselors, as well as school psychologists and school social workers. It is also important to include school-based and district-level administrators on the team, both for their expertise in school leadership and resource availability and to gain their buy-in. Some teams might have other stakeholders such as family members, school nurses, teachers, resource officers, and related community partners join the team to offer their unique perspectives. It might be helpful to develop district-level teams to discuss districtwide protocol and resources.

Once the team is assembled, it should collaborate with key stakeholders to gain momentum, support and resources. This buy-in can be developed by educating key stakeholders on the purpose and research behind UMHS and how UMHS can meet the specific needs of the school or district. The team can analyze the current concerns of the school or district by gathering corresponding data: Are students’ mental health needs being adequately identified and met? What are the most pressing issues in the school or district? For instance, has there been an increase in student suicide attempts or drug-related suspensions and use in the school and community? Is the team interested in prevention efforts to better identify students with internalizing concerns such as anxiety or depression?

Many of the schools and districts with which we have corresponded have reported that UMHS was supported and even driven by influential district-level stakeholders, such as a superintendent. It is important for counselors to understand that gaining buy-in for UMHS can take years and that it requires purposeful advocacy and education. When attempting to gain stakeholder buy-in, team members may find it fruitful to present UMHS as a tool to meet existing district priorities such as improving students’ social/emotional learning, enhancing college and career readiness, and removing barriers to learning.

Also, rather than presenting UMHS as “one more initiative,” team members can ask how this practice might tie into other programs that already exist in the school or district. UMHS is often implemented as part of multitiered systems of support (MTSS) such as response to intervention and positive behavioral interventions and supports. MTSS is widely implemented in all states nationwide, and its tiered focus on prevention for all students and identification and intervention for those with elevated needs is a natural fit with UMHS. Thus, teams could discuss UMHS within their school’s or district’s existing MTSS practices. Furthermore, in an effort to work smarter, not harder, consider whether an existing student support team is in place that could oversee UMHS, rather than creating a new team to do this.

This first step of garnering key stakeholder support may take some time. We’ve seen that using data to highlight school needs and connecting UMHS to district priorities and current programs generally assist with stakeholder buy-in.

Step two: Clarify the goals and purpose. Once the UMHS team is developed and has gained buy-in from instrumental stakeholders, the next step is confirming the goals and purpose of UMHS. During this step, the team can work with key stakeholders to continue reviewing school/district data and confirming the goals for UMHS. What is important to the stakeholders and the district? What are the most pressing needs for the school or district? It may take some time to reach consensus on the greatest need in the school or district.

Step three: Discuss resources and logistics. UMHS takes considerable planning as the team maps out its processes and procedures. Thus, much of the work for UMHS is done on the front end. Each school or district has unique needs and resources, so there is no one-size-fits-all approach for implementing UMHS. One question the team might ask during this step is which students are currently being screened or should be screened moving forward. We’ve seen some schools that screen for suicide and depression in high school health classes across all students, whereas other schools screen more broadly for strengths and difficulties at multiple grade levels, such as third, seventh and 10th grades. Still other schools may have the resources and desire to screen across every grade K-12. The answer to which students to screen may be based on a school’s or district’s resources and its driving purpose behind implementing UMHS.

Another consideration is garnering the support and consent of parents and guardians. First, the team might consider the overall readiness of parents and guardians for UMHS. Some schools recommend holding educational sessions for parents and guardians in which de-identified school-level data on student needs is provided, along with the rationale for using UMHS to meet those student needs. This may be a helpful time for the team to normalize mental health and UMHS by making comparisons to other school-based screenings for reading level, hearing, vision and so forth.

We also recommend demystifying UMHS by describing the procedures and perhaps showing examples of successful UMHS processes in other schools or districts. These information sessions can also describe how parents and guardians will be notified of their child’s results, especially for children identified with elevated needs. We have witnessed that parents and guardians are often supportive of UMHS when provided with ample and appropriate education and awareness, and when consideration is given to the unique culture of each school community.

Once schools have gained buy-in from parents and guardians, UMHS teams should engage in the consent process. Many schools have found success with a passive consent, notifying parents and guardians about UMHS through several means (email, automated phone calls, letters home, social media, etc.) and communicating that students will be included in the UMHS process unless the parent or guardian completes an opt-out form by a specified date.

When it comes to discussing resources and logistics for UMHS, two questions usually take precedence: How much will UMHS cost, and how much time will UMHS require? The UMHS team should work hand-in-hand with stakeholders, especially administrators who oversee the school or district budget and schedule, to address these concerns. School staff with whom we’ve spoken have reported that UMHS does take time and can have associated costs, especially in the beginning. However, these staff members have also expressed that the cost and time were absolutely worth it.

One cost associated with UMHS is the assessment or screener being used (we will discuss this in greater depth later in the article). Regarding time, the UMHS team should discuss how the school staff will be involved and the training required for their involvement. For example, who will administer and score the assessments/screeners? Who will communicate the results? Who will notify parents and guardians of elevated scores?

When considering time and costs, the UMHS team should also evaluate available resources for providing services to students identified with elevated needs. What school-based services will be offered? What referrals will be made for outside services? Teams typically map out the existing resources available within the school or district, as well as current and possible external partnerships. In anticipation of an increase in identified students and, thus, needed services, these partnerships and referral sources should be explored and confirmed prior to screening. In addition, teams need to create a plan for services based on student need and the level of immediacy (e.g., same-day supports for immediate/critical needs versus same-week supports for moderate needs). Relatedly, some schools secure grants and Medicaid funding to finance provision of services in the schools by community-based mental health professionals.

Other questions that come up frequently center on the issue of liability. For example, schools often ask us:

  • “What if we identify students with elevated needs, such as suicidal ideation, and the parents or guardians refuse services?”
  • “What if we have more students eligible than we have available services?”
  • “Legally, how do we document these results?”
  • “Regarding confidentiality: which school staff members should be aware of the results?”
  • “Do the results become part of a student’s permanent file?”

These are important questions to consider and talk through with the UMHS team, especially administrators and the school district’s legal experts. By establishing clear district policies and defining protocols proactively, the UMHS team can get ahead of many of these concerns. Furthermore, small-scale pilot screening can help teams predict schoolwide prevalence of students who will need intervention. Collecting and sharing de-identified screening data can also be an essential step in advocating for additional services and resources. 

Another important logistic to consider is time. As mentioned, teams usually spend considerable time planning for UMHS implementation, including designing a timeline. Within this timeline, teams often consider conducting a pilot screening, testing UMHS with a small sample of the school, such as a class in each participating grade. After this pilot, schools can collect feedback on the screening to guide changes to the process and procedures before rolling out UMHS throughout the school or district.

The team might also consider the time of year, week and day that UMHS will be implemented. It is often recommended to begin UMHS toward the start of the school year but to allow enough time for students to settle into their new routines and for students and teachers to have built rapport. This also provides time for follow-up screening to occur after the initial baseline. In addition, screening could take place early in the day, such as during an advisory or home room period, and early in the week. This allows time for immediate follow-up, particularly for students identified as having high needs. It also allows time to reach out to the student, parents or guardians, and school-based and community-based resources. In fact, some schools align their UMHS schedules with the availability of internal and external referral sources to ensure that mental health providers are on standby to assist immediately if needed.

Step four: Select a screening tool. Selecting an appropriate screening tool is a crucial aspect of UMHS. Because no two schools are alike, each team should consider its school’s specific needs, culture and resources. The National Center for School Mental Health recommends asking the following questions when considering screening tools:

  • Is the tool reliable, valid and evidence-based? In other words, has the tool been empirically tested and backed by research? Similarly, was this tool normed on a population that is similar to the school or district population? We want a tool that is culturally appropriate, valid and reliable, and, thus, as accurate as possible.
  • Is the tool free, or can it be purchased for a reasonable cost? Tools have a range of costs, which is important to consider based on the school’s or district’s budget and the number of students completing the tool.
  • How long will it take to administer and score the tool? Time is a precious commodity in education. Thus, the UMHS team should investigate the possible options for administering and scoring tools. Although paper-and-pencil tools exist, schools often prefer administering screening tools through online means (e.g., Google forms) or Scantrons. Electronic administering and scoring can lead to fewer errors and faster results.
  • Does the tool come with ready access to training and technological support for staff? As mentioned earlier, staff need to be trained on UMHS procedures, including administering and scoring screening tools. Furthermore, most tools have educational requirements, such as a master’s degree in specific fields, associated with administering and scoring them. Hence, some schools and districts have determined that school psychologists or school counselors are responsible for administering and scoring the tools because of their training and expertise.
  • Does the tool screen for what the school or district wants to know (e.g., type of mental health or behavioral concern)? Specifically, do the goals and purpose of the UMHS process align with the aim of the screening tool? If a school’s goal is to screen for internalizing mental health concerns (e.g., depression, anxiety, self-harm, suicidal ideation), does the selected tool actually screen for those concerns?

It is important to note that the developmental age of students should be considered when selecting a screening tool, as should the type of administration. Some tools are self-reports completed by the students, whereas other tools are completed by teachers or parents and guardians (this is especially the case when screening younger students). It is also important to discuss the meaning of specific scores for each tool in advance of data collection and analysis. For instance, what score constitutes a high risk in need of immediate follow-up? What score constitutes a moderate risk, and when should follow-up occur? What score constitutes little or no risk?

The following list includes common UMHS tools:

  • Systematic Screening for Behavior Disorders: Screens for internalizing and externalizing concerns (K-9)
  • Student Risk Screening Scale: Screens for seven externalizing behavioral criteria (lies, cheats, sneaks; steals; behavior problems; peer rejection; low academic achievement; negative attitude; and aggressive behavior) three times per year (K-12)
  • Behavior Assessment System for Children, Third Edition: Behavioral and Emotional Screening System: Identifies students with needs in both academic and social domains, including internalizing problems, externalizing problems, school problems and adaptive skills (pre-K-12)
  • Strengths and Difficulties Questionnaire: Screens broad behavioral domains, including emotional symptoms, conduct problems, hyperactivity/inattention, peer relationship problems and prosocial behavior (K-12)
  • Resiliency Scales for Children and Adolescents: Profiles personal strengths and vulnerability (ages 9-18)

Step five: Collect data, analyze and follow up. After implementation of the screening tool, UMHS teams will engage in data collection, analysis and follow-up according to their individualized plans. Follow-up may include further evaluation and services for students with elevated needs. It may also include monitoring students with elevated needs and providing additional screening at different points during the school year and subsequent school years. As emphasized by the National Center for School Mental Health, it is imperative that students with high risk to themselves or others receive follow-up the same day.

UMHS and counselors

Both school counselors and licensed mental health counselors (LMHCs) can play active roles in UMHS in several ways. First, school counselors run comprehensive school counseling programs that provide a range of student services, including direct counseling services. School counselors also provide consultation and collaborate as members of student support teams and schoolwide leadership teams. Thus, school counselors should be active members of their respective UMHS multidisciplinary teams, helping to design and implement the screening process, and sharing their expertise on mental health, equity, data-driven practices and culturally responsive systemic change. As part of a UMHS team, school counselors may also assist with analyzing the screening data, referring students to mental health services, and engaging in progress monitoring and continued evaluation. School counselors may also provide counseling services, although their counseling should be short term and time bound.

LMHCs can also be involved in UMHS screening in a variety of ways. School-based or community-based LMHCs may be invited to be members of a UMHS team because they can provide expertise on mental health needs and the services available in the school and community. In addition to consulting and collaborating on screening procedures and data analysis, LMHCs can provide further evaluation and long-term and crisis counseling to those students identified with elevated needs.

Again, we emphasize that counselors’ roles, and the corresponding procedures and services, may be different based on each school’s or district’s culture, resources and needs.

Challenges and benefits

There are both challenges and benefits to implementing UMHS. Among the challenges, there is no denying that screening takes time, resources, stakeholder support and substantial planning. The stigma surrounding mental health issues can also test stakeholders’ willingness to implement UMHS in schools. In addition, some educators and legislators have voiced concerns that UMHS could lead to the overdiagnosis and unnecessary stigmatizing of students, giving them labels that could last a lifetime.

School leaders are often hesitant to initiate a UMHS program if they lack the resources to meet identified needs without collaborating with outside agencies. Some school administrators in rural areas indicate that school-based mental health services are the only such services available for most families. Teams working to implement UMHS must be prepared to address resistance to universal screening in their communities as part of the implementation process. Hence the importance of seeking early education and buy-in.

At the same time, UMHS is associated with a wealth of benefits, including:

  • Prevention and early identification and treatment of mental health and behavioral concerns
  • The use of data to guide mental health interventions
  • A comprehensive approach that encourages systemic thinking and breaks down school/community/family silos
  • Collaboration across school-based mental health providers and between school-based and community-based mental health providers
  • Greater normalization and awareness of mental health issues within the schools

Schools and school districts have told us that implementing UMHS is worth the associated challenges. Many school-age youths struggle with mental health and behavioral concerns, yet their struggles are not always identified or treated, leading to larger long-term concerns. Because of the climbing rates of school violence, anxiety, depression, self-harm and suicide among our youths, we need a better system. We need a system in which fewer youths fall through the cracks. We need a system in which more youths are identified earlier and more accurately. We need a system that is comprehensive and that works. 

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For more information, we suggest the following resources:

  • The School Counselor’s Guide to Multi-tiered Systems of Support edited by Emily Goodman-Scott, Jennifer Betters-Bubon and Peg Donohue (2019, Routledge). This book discusses aligning comprehensive school counseling with MTSS, devoting a chapter to UMHS.
  • The SHAPE System (theshapesystem.com): The School Health Assessment and Performance Evaluation System is a free, private, web-based portal that offers a virtual workspace for school mental health teams to document, track and advance quality and sustainability improvement goals and to assess trauma responsiveness.
  • National Center for School Mental Health (csmh.umaryland.edu): The center is committed to enhancing understanding and supporting implementation of comprehensive school mental health policies and programs that are innovative, effective, and culturally and linguistically competent across the developmental spectrum (preschool to postsecondary) and three tiers of mental health programming (promotion, prevention, intervention).
  • Systematic Screenings of Behavior to Support Instruction: From Preschool to High School by Kathleen Lane, Holly Menzies, Wendy Oakes & Jemma Kalberg (2012): The authors show how systematic screenings of behavior, used in conjunction with academic data, can enhance teachers’ ability to teach and support all students within a response-to-intervention framework.
  • School-Wide Universal Screening for Behavioral and Mental Health Issues: Implementation Guidance (tinyurl.com/OhioPBISGuide): This document provides a general overview of considerations in implementing UMHS for behavioral and mental health issues.

 

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Emily Goodman-Scott is an associate professor, graduate program director and school counseling coordinator in the counseling program at Old Dominion University in Virginia. Prior to that, she was a school counselor and special education teacher. She is passionate about advocating for lower caseloads and greater resources for school counselors and schools. Her research interests include a range of school counseling topics such as multitiered systems of support (MTSS), counselor education, and counseling exceptional students. Contact her at egscott@odu.edu or on Twitter: @e_goodmanscott.

Jennifer Betters-Bubon is an associate professor of counselor education at the University of Wisconsin-Whitewater. Previously, she was an elementary school counselor for 11 years and a special education teacher. In addition to teaching future counselors, her work focuses on data-driven practice, advocacy and leadership in transforming the role of the school counselor within culturally responsive MTSS. Contact her at bettersj@uww.edu.

Peg Donohue is an assistant professor of counseling at Central Connecticut State University (CCSU) in the Department of Counseling and Family Therapy. Before joining the CCSU faculty, she spent 16 years working as a school counselor in Connecticut and California. Her primary research interests include fostering social and emotional learning, aligning school counselor preparation with MTSS, and universal screening for mental health concerns in schools. Contact her at peg.donohue@ccsu.edu.

 

For more resources and conversations on UMHS, follow the authors on Twitter:
@SchCouns4MTSS and Facebook: School Counselors for MTSS.

Knowledge Share articles are developed from sessions presented at American Counseling Association conferences.

 

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Opinions expressed and statements made in articles appearing on CT Online should not be assumed to represent the opinions of the editors or policies of the American Counseling Association.

Suicide, substance abuse and medical trauma

By Bethany Bray September 3, 2019

Gunshot wounds, injuries from automobile accidents, a fall from a ladder, cooking burns or other incidents, either self-inflicted or unintentional: These are a few examples of the medical trauma that brings patients to the Wake Forest Baptist Health (WFBH) Medical Center in Winston-Salem, North Carolina.

Elizabeth Hodges Shilling and Olivia Smith are part of a team of counselors who talk with trauma patients at WFBH and assess them for suicidality and alcohol or substance use. The counselors have a laundry list of questions to ask patients as part of the assessment, but patients are often reeling from the traumatic incident that brought them to the hospital. At the same time, the counselors have a limited amount of time to work with each patient because patients are usually under their care for only 24 to 48 hours.

The solution? Shilling and Smith say they use a lot of “tell me” or “tell me more” questions and prompts. It’s a gentle way of getting the information they need and connecting the patient to additional resources.

For instance, instead of directly asking patients whether they drink or use drugs, Smith might say, “Tell me about when you’ve used alcohol or drugs to help you calm down or when hanging out with friends.” These types of inquiries make patients more likely to respond and open up, according to Smith, a coordinator and counselor on the adult and pediatric trauma screening and brief intervention team at WFBH.

This can be especially true with teenagers and young adults, who can be quick to put defenses up. “Sometimes we preface our questions with, ‘I’m not here to try and stop you. I just want to understand and try and support you,’” Smith notes.

Shilling and Smith are both licensed professional counselors and licensed clinical addictions specialists. They say that framing their assessments as “conversations” can help to form a connection with patients who might be overwhelmed by all the questions they’ve been getting from doctors and other medical personnel.

“Tell me about” questions are a gentle way of building rapport and opening the door to get more information from patients, says Shilling, an assistant professor in the department of surgery at Wake Forest School of Medicine. It also lets patients know that the issues with which they might be struggling aren’t unusual; other individuals are struggling with them as well.

The counselors may use prompts such as, “Tell me about the last time you thought about hurting yourself” or “Tell me about the times you’ve tried to cut down on your drinking,” says Shilling, a member of the American Counseling Association.

“Just throwing it into the conversation and bringing it out in the open gets them thinking about it,” Smith says. “[Also,] it eases up on the stigma about these thoughts and normalizes that it happens. We often hear embarrassment, and [patients who say,] ‘I’m having these thoughts, and I don’t know what to do with them.’”

Roughly 50% of the trauma patients they see at WFBH are admitted because of an accident or incident related to alcohol, Shilling says. This includes suicide attempts while under the influence of alcohol, intoxicated driving or being a passenger in a car with an intoxicated driver, or a variety of injuries that occur after a person has been drinking. Hospitalwide, one-third of patients are admitted for a medical condition related to substance use, she says. This includes conditions exacerbated by long-term alcohol use, such as pancreatitis.

“We often see people who have never thought about making a change, or others who have been injured several times and it’s a wake-up call and they want to change. Alcohol use can be a big part of their situation but also a small thing, as they’re dealing with so many things at once,” Smith says. “Being in the hospital posttrauma really facilitates the opportunity to think about making changes in your life. … It’s a teachable moment and opportune time to reassess [your choices].”

 

Alcohol and suicide

Smith and Shilling urge mental health practitioners to include questions about alcohol and substance use when screening clients for suicidality. This is a vitally important area of risk that often gets overlooked in suicide assessment, Shilling says.

Substance use problems are one of many suicide risk factors included on a list on the American Foundation for Suicide Prevention website, afsp.org.

Substance use can increase a person’s impulsivity, and it numbs the parts of the brain that trigger thoughts and behaviors that keep a person safe, Shilling says. “We see patients who, when sober, say they would not have taken those pills or used their gun, etc. But when they drink, that rational piece [of brain function] gets overridden. Using substances puts you at particular risk.”

Additionally, substance use can have negative effects on the overall mental health and wellness of patients, even if they do not exhibit signs of a substance use disorder. Asking questions about substance use can help patients understand how their drinking or substance use affects the whole picture, including mental health and mood, Shilling says.

“Substances impact their mental health in a lot of ways. They may be using substances in a way that’s not risky per se, but it may be affecting their mental health,” she adds.

Shilling urges practitioners who want to learn more about substance abuse — especially those who work with vulnerable populations such as teens — to seek continuing education or even additional licensure (such as becoming an addictions specialist).

 

Asking the right questions

Smith and Shilling’s cohort at WFBH uses several screening tools to assess for substance use in the patients in the hospital’s trauma, burn and medicine units.

The first is the Alcohol Use Disorders Identification Test (USAUDIT) developed by the U.S. Substance Abuse and Mental Health Services Administration. Available to the public at ct.gov/dmhas/lib/dmhas/publications/USAUDIT-2017.pdf, the assessment places users into one of six categories, ranging from “low-risk alcohol use” (no more than 14 drinks per week for men and seven per week for women) to “alcohol dependence” (which includes a cluster of symptoms indicating dependence on alcohol).

The Wake Forest team also uses the CAGE Substance Abuse Screening Tool developed by the Johns Hopkins School of Medicine. Smith says this mnemonic screening tool helps prompt patients with open-ended questions:

Cut down: Have you ever felt you should cut down on your drinking?

Annoyed: Have people annoyed you by criticizing your drinking?

Guilty: Have you ever felt bad or guilty about your drinking?

Eye-opener: Have you ever had a drink first thing in the morning to steady your nerves or to get rid of a hangover?

Read more about the CAGE screening tool at hopkinsmedicine.org/johns_hopkins_healthcare/downloads/all_plans/CAGE%20Substance%20Screening%20Tool.pdf

 

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Call for help

The National Suicide Prevention Lifeline offers free and confidential support around the clock, seven days a week, at 800-273-8255 or via chat at suicidepreventionlifeline.org.

 

Read more about addressing the topic of suicide with clients in Counseling Today‘s September cover story, “Making it safe to talk about suicidal ideation.”

 

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Contact the counselors interviewed for this article:

 

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Bethany Bray is a senior writer for Counseling Today. Contact her at bbray@counseling.org

 

Follow Counseling Today on Twitter @ACA_CTonline and on Facebook at facebook.com/CounselingToday.

 

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Opinions expressed and statements made in articles appearing on CT Online should not be assumed to represent the opinions of the editors or policies of the American Counseling Association.