School-based Intervention for Mental Health Problems

School-based intervention environments and prevention practices have become essential in reducing the number of mental health problems that impact upon the learning and the social development of children (Dwyer, 2004). A group of researchers conducted a study where they examined the teachers’ perceptions of the mental health needs of the school, questioned their knowledge, their skills and challenged their training and training needs. They also explored the role of the teacher in supporting the mental health of the children within the school context (Graham, Phelps, Maddison, & Fitzgerald, 2011). The outcome of this extensive study supported their claims that teachers did, in fact, view school psychologists as having an integral role in almost all aspects of mental health. Teachers involved in this study viewed themselves as being responsible for the implementation of classroom-based behavioural interventions whilst the school psychologist’s role involved the teaching of social-emotional lessons.

Arguably, Burns says that the average youth spends a large proportion of their time in school. As such schools have been referred to as the ‘defacto’ mental health system for children and teens (Burns et al., 1995). However, it is clear that the vast majority of individuals, who receive any mental health services, receive them at school. 20% of children under the age of 18 have mental health concerns with an increase of up to 25% for children, who lived in adverse environments (World Health Organisation, 2004).

There is further evidence of the importance of establishing the social-emotional wellbeing balance within the educational system. Mark Prever argues that we as professionals within the school system, struggle to comprehend our own emotional agendas at times. He contrasts adult behaviours within the educational sector, to that of students’ and hypothesizes that adults often see students quite narrowly, as learners. Prever’s argument illustrates the increased focus on teaching and learning, however, there is little to be said about the part that emotions play (Prever & British Association for Counselling Psychotherapy, 2006).

Most of the Australian population will be directly or indirectly touched by mental illness at some stage of their lives (Australian Bureau of Statistics, 2015). A high proportion of these situations involve the brain and also stress. VanBergeijk, explores the work that Ratey undertook in 2008 whereby he determined the impact that exercise has upon the brain in terms of learning, attention, executive functioning, regulation of moods and the control of aggressive behaviours (VanBergeijk, 2014).

The social wellbeing boundaries and parameters of communities have become blurred and challenged in relation to the advent of social communications and interactions. Social interactions have now become accessible around the clock with access to social media networking sites and mobile phones, on the rise. This is in sharp contrast to the mind-body connection research proving that exercise is the best defense against mental health diseases  (J. J. Ratey & Loehr, 2011). Unfortunately, the extreme vulnerability of teenagers and the concern for their social and emotional wellbeing have now manifested within the small community of the school (J. Ratey, 2008).

Although schools are one of the primary providers of mental health services for children and adolescents (Burns et al., 1995), research has proven that young people often prefer to seek help from their peers in the first instance, rather than from their parents or other adults (Rotenberg, 1995). School guidance officers routinely deal with problems that, in some instances, require critical counselling. The complexity surrounding this form of acute counselling is, and has become more and more multifaceted (J. McCarthy & Salotti, 2006; Swank & Tyson, 2012). Suicide rates for adolescents have risen more than 300% since the 1950’s (K.A. King, J. H. Price, K.S. Telljohann, & Wahl, 2000). Further, Dacey, Kenny and Magolis (2006) supports this claim in their research evidence by the realisation that stress, anxiety, and depression in young people are on the increase in Western societies resulting in suicide ideation, attempted suicide and completed suicide (Dacey, Magnolis, & Kenny, 2006; Geldard & Geldard, 1999).

In 2005, approximately 28% of students attending high school reported that they experienced feelings of sadness and hopelessness daily over a two week period. 17% of students considered the aspect of suicide quite seriously whilst 13% contemplated suicide with thoughts of enactment over a 12 month period (Reis & Cornell, 2008). As a result, the need for school guidance counsellors is essential. Newton and Jenkins (2001) highlight the importance of a counsellor as a person in which the student can trust (Newton & Jenkins, 2001), provided they are have nothing to do with their parents, teachers or peers. Arguably, within a school, this is quite the opposite. The culture of the school generally typifies counseling as a place for ‘weirdos, psychos,’ or ‘students with problems’ (Luxmoore, 2013).

Establishing time restricted sessions and the development of reliance on guidance counsellors is on the increase, and has resulted in the efficient implementation of effective counselling sessions such as intentionality. This is described as the process where counsellors largely listen to clients and solve any problems later (Ivey, Ivey, & Zalaquett, 2014). In these sessions, students are taught positive behavioural adaptations so that they may have better control over themselves when they are exposed to stressful and traumatic situations (S. Luthar, D. Cicchetti, & B. Becker, 2000).

Further, creating a resilient cohort requires reliance programs to be conducted and implemented across year levels and in some instances, the entire schools. Education QLD has set out creating an Anti-Bullying Day and programs are conducted across the school in an attempt to combat Bullying (Safe and Supportive School Communities, 2018).

School counsellors in Australia have a thorough understanding of the curriculum within the school sector. They understand student behaviour as well as having an understanding of the classroom environs and the constraints of teachers. This understanding leads to counsellor’s establishing a range of workable recommendations to support students (Moon, 2015).

Case contextualization

Beyond Blue (2018) describes students who are suffering from depression and anxiety as the silent sufferers. This silence does not result in them being easily identifiable within the context of the classroom as these students do not generally exhibit behaviours that are disruptive. Thus, reliance and dependence on the teacher to recognize and identify the symptoms of early signs of depression are crucial. Unfortunately, when students exhibit poor emotional and social well-being with a flow on effect to suicidal ideations, this can cause a ripple effect, impacting upon the broader community, friends, and family (Beyond Blue LTD, 2016). In Australia, suicide is the leading cause of death for both sexes. Sadly approximately 7 people complete suicide per day (Beyond Blue LTD, 2016). The occurrence of suicide attempts is twenty times more common than completed suicides (Balaguru, Sharma, & Waheed, 2013). A broad range of research studies as well as the national statistics has established that people who engage in suicidal behaviours are substantially at risk of completing suicide (Balaguru et al., 2013).

Susie’s case study (Response Ability, 2010), defines Susie Watts as a young high school student who has attempted suicide by intentionally ingesting 40 Panadol. She was found the following day, vomiting and in pain. Susie’s mother and Susie’s friend Maryanne took her to the hospital, where the hospital staff treated and counselled her. Susie’s embarrassment was apparent in her verbal communication with her mother. It was clear she didn’t want the attention that she was receiving. Susie’s mother’s attack on the school with her claims that Maryanne had told everyone, including Paul, Susie’s ex-boyfriend, was a clear indication of concern for Susie. Teachers expressed genuine shock with Susie’s out of character behaviour, however they mentioned that she did seem down in class, due to the break-up.

Rationale for concern

Susie’s heightened feelings of hopelessness, her depression experiences and coupled with her negative self-concept and reduced problem-solving skills all contributed towards her suicidal attempt. The research further points to the impact that hopelessness has within the academic setting, including acknowledgments, motivations and delayed gratification (Kashani, Dandoy, & Reid, 1992). However, depression is described as a significantly impaired mood with a loss of interest or pleasure, in activities that are usually enjoyed. Depression can also be described as mild, moderate and severe (World Health Organization, 1992). Females are three times more likely to attempt suicide, than males (American Association of Suicidology) with the most common method being ingestion or overdose of medication.  Of immediate concern, is Susie’s overdose. Her suicide attempt is directly linked to the significant high-risk factors indicative of her age group, her gender, as well as Susie having experienced a traumatic life event. As such, when constructing and implementing an ecological wellbeing plan for Susie, a number of factors have to be taken into consideration for Susie and her family (Hoberman, Hoberman, Garfinkel, & Garfinkel, 1988).

Assessing the needs of a student requires a holistic approach which includes reviewing any predisposing, precipitating, perpetuating and protective factors (Havighurst & Downey, 2009). Bannan’s research describes the suicidal behaviour as a multifaceted problem resulting in complex interactions between social, biological and psychological factors (Bannan, 2010). Sophie’s social and emotional wellbeing and her development are directly influenced by her family.  It is necessary to consider the research of Porter who evidenced the link between social and emotional wellbeing and its inextricable link to family (Porter, 1998).  To gain a greater understanding of Susie’s situation, it is vital to check for predisposing factors of family history of mental illness, depression or trauma.  Adolescents have an inclination to develop negative thought patterns and self-depreciating ideas which can adversely affect their social-emotional well-being (Langton & Berger, 2011). Precipitating factors like Susie’s’ level of self-worth, the breakdown of her relationships and her drug overdose are all triggers. Unpacking Susie’s thoughts and behaviours will provide a solid basis for substantial counselling sessions and training in resilient behaviours.

Susie’s triggers are numerous; however, her strengths outnumber those triggers. As such, these protective factors need to be clearly outlined to her. It was noted by both Susie’s teacher and her friend Maryanne, that Susie generally demonstrated a high level of social and emotional competence. She has supportive friends and solid connections to adults who cared for her. Her primary caregiver, her mother, displayed a supportive, nurturing, positive relationship towards Sophie. Sophie also displays a coherent response whilst communicating with her mother in the hospital. Her attitude is positive and she is receptive to help. The preliminary assessment of the information on hand identified Susie’s current needs, several risk factors and her strengths, to support her to move forward.

Gathering information

Formulating a holistic response requires the careful collection of both in-depth and a more formal collation of knowledge in order to construct the initial assessment. Research has proved that when care is provided for an individual who is suicidal, this care is never conducted as a standalone, solitary process (Gordon, 2004). A prevention approach, which is community-based, where all information is disseminated, will be the best outcome for Susie (J. McCarthy & Salotti, 2006). Ethically, freedom of information is governed by the Australian laws and prior to any sharing, written consent must be obtained from Susie’s mother and any other therapist associated with her case (Doyle & Bagaric, 2005). Commencing with the hospital and establishing their referrals in place for Susie, will provide a solid foundation. A worthwhile consideration is the fact that teachers and parents are well positioned to have first-hand knowledge of the student, so their participation in the holistic approach is essential (Trudgen & Lawn, 2011). Explaining Susie’s rights at the commencement of the first session will ensure that she is informed of her rights to confidentiality unless there is the risk of harm or danger to herself or others (Australian Government, 2015; Hays et al., 2009).

Based on Susie’s’ sensitive emotional state and her heightened reactions in hospital, it is vital to ensure that all aspects of Susie’s life including that of outside school, is taken into consideration. Her embarrassment, her shame, coupled with her reluctance to resume schooling, would most certainly expose her vulnerability to the reactions and concerns of her peers. Having that in-depth understanding of her friendship group would identify the ecological changes that are necessary. An example of this may be changing the class that she shares with Paul, her ex-boyfriend. Talking to Susie in a supportive manner, using open-ended questions (Geldard & Geldard, 1999), about her school friends and support base, will ensure that a thorough check is conducted of any history of group self-harm or of suicide clusters. Adolescents are more likely to engage in suicide clusters, although the research is unclear as to the reasons why (Hazell & Hazell, 1993). It is presumed that they are more at risk once they have had an attempt (Cox et al., 2012).

It is clear that Susie wanted to survive, as she had disclosed to her mum, exactly what she had taken. Maryanne and Mum both exhibited positive and supportive behaviours towards Susie. Mum calling Paul to advise him of the attempt, may not have been what Susie may have wanted. Susie’s teachers expressed a level of disbelief towards Susie, as they had not realised that Susie allowed the situation with her ex-boyfriend to escalate to the level that it did. They generally felt that she was a positive student with a good supportive friendship group. However, most children want to be accepted by their peers and are highly susceptible to peer pressure (Geldard & Geldard, 1999), therefore it is vital to have Susie surrounded by positive peer relations.

Responding to the case

Conducting an interview with Susie and her mother would be the initial response. The availability of the support networks accessible to Susie at school would be outlined in this meeting. Her support network could include her guidance counsellor, the school-based nurse, a youth support coordinator, the community education counsellor, year level coordinators and possibly a few of her favourite trusted teachers. Susie’s return to school through the development of a wellness plan should be negotiated and co-developed and include both Susie and her mum (Ivey et al., 2014). Developing the wellness plan with all stakeholders will need to incorporate any re-entry to school concerns. This will also include any initial interventions and negotiated ideals such as ensuring that Susie has classes that align with those of her peer support group, her favourite teachers and may also include a possible class change to ensure minimal contact with Paul. Short-term strategies such as the development of intentionality, resilience, and actualisation should be incorporated into Susie’s wellness plan. Socialisation is important for Susie’s growth and this should be encouraged through prioritising her socialising with her friends and her family (Ivey et al., 2014). Popinhagen and Qualley explore the theories of creating a “no-kill contract”. This strategy could be implemented at the conclusion of the first session, in which Susie signs a written contract, promising not to inflict harm on herself before the next session (Popenhagen & Qualley, 1998). Further studies suggest that the waiting period is increased, suggesting that this contract results in a reduction of following through with suicidal plans (Pfeffer, 1996).

Following on from the wellness plan, and Susie’s return to class, a number of secondary measures can be put in place. Psychometric testing can be administered to obtain a more detailed profile. This would be dependent on the outcome of the initial interview as there are a few tests that would be beneficial in this case. The Child Behaviour Checklist is a test that parents, Susie and teachers complete to gain an understanding of the complexity of problems both at home and at school (T.M. Achenbach & Edelbrock, 1983). The Resiliency Scales for Children and Adolescents is another quick test that can be administered at Susie’s initial interview, to demonstrate her strengths (Pince-Embury, 2006). The results from these tests can be used to support Susie in her resiliency training and strength building (Seligman, 2004). These results will further help to provide Susie with the required skills to conquer adversity and take charge of her life (Frager & Fadiman, 1984; Patterson, 1996).

Most schools already run resiliency programs and attaching Susie to one of these programs can contribute to a reduction in her levels of depression, helplessness, and suicidal ideation. Groups like these often develop and promote problem-solving skills, which is particularly helpful for females who have self-poisoned (Bannan, 2010). Being aware that adolescents rarely initiate conversations with adults around their suicidal thoughts, however, when information is shared with a peer, less than 25% make contact with an adult for help (C. J. McCarthy, 1996). Ensuring the success of Susie’s wellness plan hinges on Susie being surrounded by a variety of support personnel and peers who will have the confidence to report, as well as being there for her when she needs someone to talk to.

Involving support

Collaboration to support the complexities of both school and home life for adolescents requires the investment and commitment of numerous agencies and professions (Walsh & Galassi, 2002).  The various stakeholders could include general practitioners, psychologists, child and youth mental health, online support services as well as headspace. Nominating a dedicated person at school to funnel and collate all the information could be in the form of the guidance counsellor.

Part of the role of the guidance office would be to work alongside the crisis team and support the development of individual and group counselling sessions, including classroom presentations for other students (Capuzzi, 2002). This will develop the capacity of teachers to beet understand warning signs, support student questions around suicide as well as assist in the application of reposting, prevention and crisis management programs across the school (Metha, Weber, & Webb, 1998).

For many students like Susie who attend school, the participation in a supported network of resiliency programs could greatly support her mental health. The support network could include the school nurse, the chaplain, youth coordinator and possibly the year level coordinator as well. The year level coordinator could provide the conduit across her classes and be that central point of contact of support. Most importantly the involvement of the family is crucial to the success of Susie’s schooling as this is directly connected to her safety net, her home (Langton & Berger, 2011).

Health Promotion

It is important for the school to have a nominated person to touch base with Susie’s home, in the event of the family requiring additional support.  Susie’s parent’s lack of knowledge of the support networks, coupled with their stress, could possibly impinge on Susie’s progress (Beyond Blue LTD, 2016). Supporting parents is a multitude of areas is the Positive Parenting Program. This is a Government funded, community-based program that provides a range of strategies to support families to raise happy healthy confident children (Queensland Government, 2016). In light of the family needs, an array of other services can be utilised. Services and external agencies accessible around the clock are Mind Matters, Lifeline, Youth Beyond Blue and Black Dog Institute.

The provision of holistic support for Susie, in conjunction with individualised guidance counselling, will connect her with small group sessions where sessions on socialisation and resiliency skills could be targeted (Pince-Embury, 2006). These skills would broaden her portfolio and increase her resiliency. A well-established strength based, resiliency program, designed specifically for young Australians is SenseAbility (Australian Guidance and Counselling Association, 2006). It would be recommended that Susie’s parents are being made aware of resources to support their needs. The Way Back, is a valuable resource for support for families recovering from attempted suicide (Beyond Blue LTD, 2016). Signs of Suicide (SOS) is another great tool administered through an educational program, which supports children in understanding the connection between suicide and undiagnosed mental illness.

To avoid confusion and being overwhelmed, the program should be selected together with the guidance counsellor, and be dependent on the cost involved and access and availability of staff to conduct the program.

Guidance Counselling

Finally, the role of the guidance office within the school sector must never be underestimated. Academic buoyancy as identified by Martin, is the students’ ability to successfully manage the setbacks and challenges that is typical of everyday life as a student. Therefore the demand is high for guidance counsellors to meet the increasing difficulties of students (Martin & Marsh, 2008).

In particular, students who have suicidal ideations invariably require extensive support in all aspects of their social and emotional wellbeing. The guidance counsellor will provide the direction of the holistic support for Susie, as well as lead the mobilisation of the network support system (Brown, 2015). It is vital that there is an understanding of the impact of the suicide attempt on the broader school community (Capuzzi, 2002) as well as Susie’s immediate family and friend. Sharing information and strategies across the teams of teachers, school personnel, support agencies, and parents would be strategic and as such the guidance officer would be in the best position to disseminate information to all parties involved with Susie’s holistic wellness plan. The guidance counsellors’ role would also include her being an advocate for Susie, providing the important regular counselling sessions, conducting pdsychoedcational assessments and supporting the development of the reliance strategies in order for Susie to effectively manage her day to day life.

As such, the management of Susie’s emotional and educational wellbeing (Capuzzi, 2002) will be in the hands of the guidance counsellor who will oversee any recommendations and changes to the educational support programs. This will also include the regular review and oversee of the whole school and cohort educational support programs as well as relevant teacher and parent support programs.

School counsellors play an important role in the educational environment. Because of their distinctive position and preparation, school counsellors understand the needs of students and their families within the context of the school community. As such, school counsellors have the capacity to plan and manage educational experiences to meet these needs (Coker & Schrader, 2004).

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