April 11, 2025 Read Time:
Mental Health
Find the full series of Craig's blogs here.
Time is the critical component of school-based mental health services. It is probably the most scarce resource within any school and how it’s spent is critical.
Figuring out when to start services is an easy question to answer–as soon as possible, of course! Through the strategies discussed in the right students articles the hope is that we can find students before they’re in crisis. By implementing the strategies in the right services articles, there can be a ready-to-go playbook of services and strategies developed that students can be slotted into. Combined, this should reduce the time between when symptoms first emerge and when a student first gets services. (Considering that the average amount of time between the onset of mental health symptoms and initial treatment is 11 years, anything we do is a massive improvement!) But the other side of that equation–figuring out how long services should last–is a much trickier question. No one wants students to get cursory services and then get dropped without adequate support. Nor can we realistically give unlimited services to all students. It would be an unsustainable system if we only added names to the list of students getting support without taking any off. That would mean we weren’t strengthening student skills to independence and instead were creating impossible work conditions for counselors.
So once again we’re faced with a significant need and extremely limited resources. To manage this well, we need to do two things: 1) We must first have a clear grasp on which students we’re serving at any given time, and 2) be serious about evaluating whether they’re getting better or not.
Of course, the first step involves more spreadsheets. The goal here is to have a running list of which students are being seen for counseling, as well as the approximate time spent serving them. It’s impossible to be 100% accurate in this, as we all know students may need extra support beyond what is explicitly planned for, but we want to have a good enough idea to map things out. I also know that some school counselors will be scratching their heads right now, thinking “Well, the entire student body is on my caseload. How do I map that?” Again, we’re aiming for good enough with this, not perfect! At least it should be known which students are getting consistent counseling or services. If that does not amount to a counselor’s entire schedule being completely full, that’s not only OK, but expected. This will not account for the various IEP, 504, college/career counseling, anti-bullying or SEL lessons, or any other miscellaneous meetings and should not be expected to account for counselors’ entire schedules. It is meant to track students and their progress, not staff efficiency.
We also want to build in review dates into this spreadsheet, as this will serve as a reminder that we must evaluate our progress. If we do not schedule this review and build it into the DNA of SST meetings, things tend to carry forward on their own inertia. Usually, that means that students will either receive services forever or things will revert back to seeing students on an ‘as needed’ basis. As we discussed last time, that will bias your support systems towards soothing students, instead of strengthening them. These review dates are times when an SST can take a holistic look at a student and make some critical decisions–does the student need more services? Different services? Or are they making enough progress that intervention can be faded and services decreased.
Progress Monitoring
How do we make decisions about the right timeline for a service? Well, that all depends on how the student is progressing. Measuring student progress is a tricky question, and one that has to be considered carefully. Making it even more difficult, the review also has to be simple and quick–it cannot be a process that is invented whole cloth for each student. We have to have some measures of progress and make it integral to the process.
Intentionally reviewing students’ progress is critical because if we’re stuck in crisis mode (as so often happens), it’s very hard to step back and assess how well we’re doing. I believe that we do a tremendous amount of good with school based counseling and bet that even counselors would be surprised at the amount of students who get better. Taking this into account and making it real is essential. I know as a counselor there were times I was really pessimistic about what I was doing–but the data is a powerful reminder of the good being done. There is also strong research evidence out there that using measurement based care in a collaborative manner with students and families significantly improves outcomes. Connors et. al. notes that “Systematic reviews show better and faster goal attainment and symptom reduction with [Measurement Based Care] as compared to usual care...” It’s a win across the board.
So how do we go about judging progress in something as nebulous as counseling? We need multiple methods so we can triangulate how the student is actually doing.
We can do this using two foundations:
- Evaluate functional outcomes
This means taking a look at how the student is actually doing in school, not what they or anyone else says or feels like they’re doing. In medical terms, these are signs, not symptoms, meaning that any observer would be able to evaluate these things objectively. This goes back to our first topic of finding the right students–the following questions should be familiar:
- Are kids attending school more?
- Are kids doing better in their academics?
- Are they getting in trouble less?
- Are they making observable progress on individualized goals? For example, a student with social anxiety that stops them from participating in class measures the amount of times they raise their hand to answer a question independently.
2. Evaluate symptom improvement
This means looking at how an individual is feeling. Since mind reading technology is not yet available, we have to use reports primarily from the student to guide us here. This is linked to mental health screening as discussed in the second Right Students article, since mental health screens are primarily focused around capturing symptoms. The following
- Use repeated standardized measures like the PHQ9 (depression) and GAD7 (anxiety)
- Use student, teacher and parent report (both standardized and qualitative)
To have the maximum impact, I highly recommend reading this article on Monitoring Client Progress and Feedback in School-Based Mental Health. It is extremely helpful in highlighting the benefits of progress monitoring and feedback. The primary principles identified as best practices are 1) choosing goals that are meaningful to the client, 2) monitoring more than just symptoms, 3) providing feedback to the client, and 4) providing feedback visually. I’ll summarize their findings, but everyone should go read the article, which gives a more in depth description of each principle:
- “Select Targets That Are Meaningful to the Client”
As discussed previously, that means choosing a specific goal collaboratively with the client so that it matters to them. That usually incorporates pairing a relevant standardized measure with more individualized measures.
- “Monitor More than Just Symptoms”
This underlines what was discussed above, but to get a deep understanding of the problem as well as degrees of improvement, functional outcomes are a necessary added dimension. Sometimes a student can start feeling better before they start doing better. Or, they might start doing better before it translates to them feeling better. Either way, that makes for a powerful counseling session. I had great success when I was able to show a student that they had increased their time in class more than 50% over the course of several weeks when they reported feeling like things were going significantly worse.
“Provide Feedback to the Client”
Another reinforcement to the ideas discussed last time, all this data gathering isn’t helpful on its own. It has to be shared with the client. This is especially important to help clients strengthen their own ability to self-monitor. However, there was evidence that this goes further than just helping the student–it actually helps clinicians improve their services by giving opportunity for them to reflect on progress when they shared it with their clients.
“Provide Visual/Graphical Feedback”
No, this is not a point about the myth of learning styles. But everyone learns better when there is an easy way to understand progress. It may be harder, especially for younger students, to understand when data is given in numbers or percents–but most people can understand when a line goes up or down!
So now that we have all this progress monitoring in place, when do we start fading services? I want to underline–this is a scary thing! There’s nothing more nerve wracking than working with a student for a good amount of time, getting into a good place, and then leaving them. However, if our goal is for students to be truly independent, as it should be for the significant majority of our caseloads, then every time we lessen services should be considered both a celebration and a real world measure of progress. Our goal is for our students to be their own clinicians and not need adult intervention to weather every emotional setback.
The process should involve a data review which includes discussing that student, the progress from multiple measures, and whether that student would benefit from moving to another less intensive service. Moving to another service should not just be the default, but it can be useful in some cases. For students who are not making progress, a discussion should be had about whether they need more intensive services or if they need a different approach to intervention. For example, a student where the team is working on attendance might shift to a mental health model or vice versa, or a student that’s been given CBT might benefit from a more solution focused approach.
Having some sort of structure for these conversations can be really helpful. The goal is to have a template that makes these conversations clearer, easier, and more equitable, without having things be so rigid that it’s draconian. Of course, here’s a sample spreadsheet that may be helpful! You might notice that I included both a section for mental health staff to give input, as well as additional notes. These are an acknowledgement that no matter how many measures we give, there may be elements that are not captured by our tools that are still important to weigh in our decision making.
Bringing it All Together
You may have noticed by now that this process is really just a dressed up way of saying that we need to do Multi-Tiered Systems of Support (MTSS). That’s absolutely true! The key parts of MTSS as described by MA DESE are as follows:
- All students are capable of grade-level learning with adequate support.
- MTSS is rooted in proactivity and prevention.
- The system utilizes evidence-based practices.
- Decisions and procedures are driven by school and student data.
- The degree of support given to students is based on their needs.
- Implementation occurs school-wide and requires stakeholder collaboration.
The right timing part of this is aimed to take counseling out of crisis mode and highlight the last three bullet points. It aims to make a system more equitable by giving students what they need in a way that matches what the system is best able to support. By baking in data reviews and progress monitoring into our system, we can better celebrate successes and move our students towards being truly independent. For our final article together, we’re going to consider when is the right time for schools to act on implementing all of these things. Spoiler alert–it’s now!
Questions for SST Discussion:
- What progress monitoring do you already do as part of your SSTs?
- Do you have the structures to bring all of this student data together in a time-efficient way?
- What do your mental health staff use to track student symptoms?
- Does your mental health staff feel fluent and comfortable with measurement based care? If there are questions, are there sources for professional development that can be identified?
- What is the current process for making decisions around the level of support students receive? What parts are working well and what parts could be improved?
