Challenges and Disparities in Providing Mental Health Services through School Counseling Programs in the United States on Policy Interventions at the State Level to Improve Access and Effectiveness: An Overview ()
1. Introduction
Mental health needs among school-aged youth in the United States are increasing and represent a critical and concerning issue in society. Each year, approximately 13% - 20% of youth will receive a diagnosis of a mental health disorder, representing one out of every five children (National Alliance on Mental Health, 2015). Moreover, an estimated 49.5% of adolescents (aged 13 - 18) reported having a mental health disorder at some point during their young life, and 22.2% of those with any mental disorder are severely impaired (Merikanges et al., 2010). Accordingly, a significant percentage of students enrolled in United States schools experience mental health issues every day.
Students face an array of adversities that compromise their ability to benefit from their education experiences. Specifically, 16% - 23% of children experience a mental health diagnosis, and incidence rates may be elevated for students of lower socioeconomic status as well as those with multiple adverse childhood experiences, with prevalence rates often increasing during teenage years (Ghandour et al., 2019; Joseph et al., 2020). Teachers often feel mental health challenges, as students’ wide-ranging needs commonly outpace teachers’ capacity to address them (Brown et al., 2019; Flower et al., 2017; Kirkpatrick et al., 2020; Mitchell & Bradshaw, 2013). For example, teachers are vulnerable to secondary traumatic stress, which can negatively impact both teacher health and performance (Essary et al., 2020; Hyden et al., 2015).
School Administrators are challenged with meeting the increased mental health needs of vulnerable students and providing appropriate school-based mental health programs. Students struggle with a variety of mental health and trauma-related concerns, which may contribute to educational, relational, and physical well-being and achievement. Although students are some of the more vulnerable populations in need of behavioral health services, limited research has been done to assess the effectiveness of interventions. A survey conducted by Eklund et al. (2017) shows that one in five children experience mental health-related problems requiring professional intervention. According to the National Center for Educational Statistics (NCES, 2018), of the over 50 million public school students in the U.S., nearly 11.2 million students are at risk for serious mental health issues.
A policy is a deliberate system of guidelines to guide decisions and achieve rational outcomes. It is a statement of intent implemented as a system. A governance body generally adopts policies in a political organization. Policies can be subjective and objective for decision-making in many ways. At varying levels, education governance may be shared between the local, state, and federal governments. Education policy includes laws, processes, and policies that educational organizations, regional districts, conditions, and nations implement to achieve academic goals.
Mental health conditions such as depression and anxiety in children are associated with increased risk of difficulties at home, school problems, and mental health conditions in adulthood and impact up to 20% of children in the U.S. (Bitsko et al., 2018; Centers for Disease Control and Prevention, 2013; Melnyk et al., 2018). However, less than half of all children who need children’s mental health services (CMHS) receive them (Centers for Disease Control & Prevention, 2013). Mental health counseling programs are important for the academic area. National mental health policies should not be solely concerned with mental disorders but should also recognize and address the broader issues promoting mental health. It includes mental health promotion into policies and programs in various sectors, including education, labor, justice, transport, environment, housing, welfare, and the health sector.
Mental Health America’s (MHA) policy believes in asking people what they need to live the lives they want and supporting them in getting there. Recovery is founded on the principle that people have meaningful roles in the community. Mental Health America’s goal is recovery for all. Nothing is more important than permitting everyone and those they care about to live the life they want with significant roles in society. The design of the policy can lead to an insufficient understanding of the problem, insufficient knowledge of the implementation context, and other supposed contradictory goals. Policy debate is an American form of debate competition in which two teams debate in many ways. Some advocate against the federal government’s change.
Policy limitations are factors that misinterpret policy to resolve society’s socioeconomic and political problems. Political problems or issues involve government or politics. The Journal of Policy History is an interdisciplinary journal that applies policy perspectives. Through a historical approach to public policy, policymakers are marked by the expanding power of the people and government. Throughout history, public policy leaders have contributed to the methods now seen in modern government. History takes place every day. In the policy-making evaluation, changes indicators that the implementation changes can be attributed to the policy. The history-informed approach can be more cognizant of the international context, result in less jerky and capricious policy making, and better evaluate what has worked in the past. Policies distill everything above them in the hierarchy, such as mission, values, strategic objectives, and the law. Policies articulate narrow goals rather than strategic objectives and identify limits, or boundaries, for behavior and actions necessary to complete those goals.
2. History of the Overview
In the history of treating people with mental health problems, our system has done a poor job of protecting people. The Mental Health Bell story reminds us that it cannot return to a system where people are shackled, mistreated, and otherwise forgotten. Since 1909, Mental Health America has fought to improve the system for individuals with mental health problems. Unfortunately, the fight is not over. Mental Health America affiliates continue to fight to ensure access to treatment, improve the quality of treatment, reduce homelessness and discrimination, and ultimately move the system towards a better mode where people are treated with dignity. Early intervention and prevention of mental health problems are prioritized.
The evaluation of school mental health services has occurred over a long time span and reflects social developments outside of education, changes in dominant philosophies and approaches to public education, and developments in professional fields related to school mental health.
Social Developments Aspects
School-based mental health services developed during the progressive era of the 1890s and continued until about 1930. Schools changed dramatically and began in the period. The average number of days in the school year increased from 135 to 173; the average days attended increased from 86 to 143; secondary school enrollment increased from 203,000 to 4.4 million; and public-school enrollment increased from 12.7 to 25.7 million (Fagan, 2000). The implications of urbanization and industrial changes they called upon schools to address matters that had previously been viewed as the purview of the home-health, industrial education, recreation, and ultimately mental hygiene (Hunter, 1904; Levine & Levine, 1992).
The progressive era of school-based mental health reflected four factors: 1) Compulsory education and laws restricting child labor services (Fagan, 1992: Richardson & Parker, 1993); 2) Immigration and concerns about social order (Rothman, 1980); 3) Urbanization and concerns about public health; and 4) Professional and scientific developments in psychology, social work, and education. The services developed during the progress era did not reach all students, were not accepted as part of the core of schools by educators, and changed over time (Kandel, 1924; United States Department of Education, 2000).
Educational Development Aspects
The progressive Era education reforms embodied competing ideological approaches (Hendrick & MacMillian, 1989; Lazerson, 1971), with four fundamental educational challenges: more students were attending schools, and they were not ready to learn; the presence of the students increased discipline problems for the teachers; there was an increasing cultural disconnection between school and school staff; and the failure to educate the students posed a public health and social control problem in the school. While fixing the school and students, the tension between adapting the school and fixing children was reflected in special education, where developments for children with mental health needs included the creation of nongraded and special classes. These developments had roots in concerns with students (Franklin, 1994), which increased in cities during the late 19th century. “An Experiment in Discipline”, by a San Franciso school principal, involved a “deportment class” created for students of such a type that the necessity of their segregation was admitted (U.S. Commissioner of Education, 1886). While reforms schools for special classes for children with mental retardation in order to develop each child fit or unfit the education, it was the increase in school enrollment and disciplinary concerns that drive practice that students with behavioral problems filled special education classes (Hendrik & Macmillan, 1989).
Evaluation of Mental Health Program Aspects
The growth of the community mental health movement coincided with the social activism and idealism of the 1960s; the movement was consistent with the war on poverty legislation that supported early intervention such as Head Start, improving the quality of schools that served economically disadvantaged communities, and the effective use of paraprofessionals (Riessman & Popper, 1968). In the community mental health paradigm, professionals were envisioned as consultants teaching and training others to carry out therapeutic interventions, thereby extending their effectiveness. The goal of mental health consultation in schools shifted from the assessment and treatment of individual students, along with helping teachers understand and deal with individual students on a case-by-case basis, to a more far-reaching goal of changing teachers’ functioning and altering the system. The efforts of community mental health centers to reach out to their communities, while not successful with healed, pave the way for later school-based and school-linked mental health centers (Flaherty, Weist, & Warner, 1996).
Policy and Funding Initiatives Aspects
The exclusion of over a million children with behavioral problems from public schools led to the passage of the Individuals with Disabilities Education Act (IDEA) of 1975. For the first time, a free and appropriate public education was to be made general to disabled children, including those with emotional and mental handicaps, in the least restrictive environment appropriate. The law allocated resources to support preservice and in-service efforts to increase the capacity of teachers and related service providers. The amendments have continued to attempt to define and modify this entitlement and encourage help to be provided to children with special needs to remain in regular education. While the IDEA transformed services for many students, it had less impact on children with emotional disturbance (Knitzer, Steinberg, & Fleisch, 1990) because they and their families were more likely to be stigmatized and because improving outcomes for them was contingent upon services from considerable services providers (Osher & Osher, 1996). The National Agenda for Improving Results for Children and Youth with Serious Emotional Disturbance (U.S. Department of Education, 2000) promoted prevention, early intervention, and collaboration. They were the base for much training and research in the 1990s. The agenda has seven targets, which are 1) to expand positive learning opportunities and results, 2) to strengthen school and community capacity, 3) to value and address diversity, 4) to collaborate with families, 5) to promote appropriate assessment, 6) to provide ongoing skill development and support, and 7) to create comprehensive and collaborative systems.
The 1997 amendments to the IDEA promote collaboration. For example, section 300.235a (2) permits local education agencies to use a portion of their federal special education funds to become involved in building a system of care, including incorporating IEPS into other individualized service plans and developing interagency financing strategies. Section 300.370a (7) authorizes using a proportion of state educational agency IDEA funds to support collaboration with other agencies.
3. Context
Mental Health America (MHA), founded in 1909, is the nation’s leading community-based nonprofit dedicated to addressing the needs of those with mental illness and promoting mental health and wellness. The commitment to promoting mental health is essential to wellness with prevention services for all, early intervention for at-risk people, and integrated care services. It supports those who need it, with recovery as the primary goal. The policy was developed as a theory from Harold Laswell’s work. The policy cycle is called, as the final evaluation leads back to the first stage (problem definition), thus restarting the process. The Policies and procedures from the organization’s vision and objectives are formed in strategic management meetings at the top level of any organization.
Congress is the lawmaking branch of the federal government. The bill becomes law, and the process differs in the House of Representatives and Senate. In response to the murder of George Floyd, Daniel Prude, and many other Black, Indigenous, and People of Color (BIPOC) individuals, Mental Health America is reviewing how its policy work could more effectively advance equity. With input from various mental health and racial equity stakeholders for over eight months, Mental Health America created an initial rubric that helps the policy team ensure its work promotes equity and a larger framework that provides more detailed guidance. Mental Health America as of March 4, 2021, to help us evaluate the development of and our potential support for policy initiatives affecting behavioral health through equity.
School mental health services have been shown to reduce barriers and limitations to treatment that are due to the many hours students are in school, limited transportation, and parental financial concerns (Langley et al., 2010; National Association of School Psychologists, NASP, 2015). One of the case study results of a state-wide implementation of trauma-focused intervention in Washington state suggests a significant reduction in child post-traumatic stress symptoms that necessitates scaling up of school-based interventions for children with experiences of trauma and post-traumatic stress disorders (Hoover et al., 2018). Additionally, lessons learned from school-based trauma and grief-focused treatment groups show promising results on early and sustained intervention efforts (Grassetti et al., 2018). The State of Washington’s Office of Superintendent of Public Instruction (OSPI) heeds advice from the National Child Traumatic Stress Network (NCTSN) that “becoming trauma-informed should be an essential component of the overall mission of the education system.” In fulfilling this directive, every behavioral health therapist utilizes trauma-informed school resources and receives specific training in Trauma-Focused Cognitive Behavioral Therapy to be implemented in their clinical interventions.
According to the CDC, among the New York State high school student population in 2017 (approximately 808,150 according to State Education Department data), 17.4% (140,618) considered suicide, and 10.1% (81,623) made non-fatal suicide attempts. With the stress brought on by the coronavirus 2019 disease pandemic since then, not to mention traumatic societal events, the mental health crisis for youth has reached a critical point. It has become a significant public health issue.
According to the New York City Department of Education (2022), to help confront the mental health crisis among youth in New York State, the Mental Health Association in New York State, Inc., a nonprofit organization, led a call to action for state laws that would require mental health instruction in the kindergarten-Grade12 health education curriculum. With the passage of the legislation, which amended section 804 of the New York Education Law (Education Law), effective July 1, 2018, New York became the first state to require that health education in schools include instruction in mental health. The Education law mandates all schools to ensure that their health education programs recognize the multiple dimensions of health by including mental health and the relation of physical and mental health to enhance student understanding, attitudes, and behaviors that promote health, well-being, and human dignity.
Mentally healthy students are more likely to go to school ready to learn, actively engage in school activities, have supportive and caring connections with adults and young people, use appropriate problem-solving skills, have nonaggressive behaviors, and add to positive school culture. According to the U.S. Department of Health and Human Services, one in five children and adolescents experience mental health problems during their school years. Examples include stress, anxiety, bullying, family problems, depression, learning disability, and alcohol and substance abuse. Mental health includes our emotional, psychological, and social well-being. It affects how we think, feel, and act and our determination, focus, and dedication toward education.
4. Analysis and Arguments
In the United States, mental health issues are far more common than many realize. According to the U.S. Department of Health and Human Services, one in five American adults has experienced a mental health challenge, and one in 20 Americans lives with serious mental illness. Access to mental health care is crucial to helping many individuals receive the support required to address their illness. However, more than half of adults with mental illness in the U.S. (a total of 27 million people) do not receive the treatment they need. The National Association of School Psychologists recommends a ratio of one school psychologist per every 500 students. Adolescents face issues with their mental health and do not receive the help they require. As the USA Today article explained, of the one in 5 children experiencing a mental health disorder each year, most do not receive treatment services Ab. According to the National Association of School Psychologists, 70 to 80 percent first accessed those services through their school.
Analysis of the nationally representative 2016 National Survey of Children’s Health found that the proportion of children with a mental health condition who did not receive treatment varied from 29.5% to 72.2% across states (Whitney & Peterson, 2019). Such variation creates inequities in access to needed mental health services based on a child’s state of residence, places an undue burden on families, and exacts societal costs because of untreated conditions that can increase the risk for later problems, including unemployment, under-employment, and shortened lifespans (Bitsko et al., 2018; Jonsson et al., 2011; Olfson et al., 2015).
Policies are influenced by various factors, including public opinion, economic conditions, new scientific findings, technological change, interest groups, NGOs, business lobbying, and political activity. Policies are formed differently by changing the types of taxes, the extent and composition of spending, and the degree and form of government borrowing, directly and indirectly influencing how resources are used in the economy.
The affected people who get an education have higher incomes, more opportunities, and tend to be healthier. Societies benefitted from the policy. Communities with increased education completion rates have lower crime and better health and involvement.
State mental health agencies (Bruns et al., 2019; Hernandez et al., 2017; Purtle et al., 2022) and advocates (Bushouse & Mosley, 2018; Kingdon & Stano, 1984; Teater, 2008) play a crucial role in shaping the children’s mental health agenda in their states through their involvement in the decision-making and implementation processes for policies that leverage a federal budget 125 million dollars allocated to CMHS (Department of Health and Human Services, 2021). Despite their significant influence on the policy design and decision-making process, only some studies have explored how these stakeholders perceive the importance of potential policy levers that may impact the use of CMHS in their states.
5. Policy Recommendations and Discussion
The approach that can be used to rectify the inconsistencies in the need and the use of services is through policies at the state level. Policies are defined as any instruments that could be applied by an organization such as an agency, nonprofit, school, or government such as municipal, county, state, or federal to influence the use of psychological services (Raghavan et al., 2008), may restrict or facilitate the utilization of mental health services by children who need treatment (Ghandour et al., 2012; Sturm et al., 2003). State-level policies may provide valuable insight into understanding inequities between states when utilizing CMHS.
Identify the state-level policies and policy domains that policymakers and advocates believe impact the utilization of CMHS and the policies and policy domains perceived as most important for this.
6. Key Recommendations
Develop a mechanism for monitoring schools’ curricula to ensure compliance with the Education Law.
Schools must ensure all staff interact with students daily and attend mental health awareness training.
Explore ways to maintain appropriate mental health professional staffing levels at all schools.
Explore ways to utilize a dedicated information system to collect, document, and analyze mental health-related information, such as referrals, services, and outcomes, allowing data-driven decision-making (Office of New York, 2022).
According to the New York City Department of Education (2022), today’s reality is that youth are experiencing unprecedented mental health stressors directly and indirectly. As the impacts of the pandemic and other traumatic societal events continue to mount, the mental health of all students is at increasing risk. Furthermore, although DOE has mental health supports and services, including social workers and school counselors, available at its schools, almost all schools fall below the recommended professional staff-to-student ratio, and students are not being fully served. Given the professional staffing shortages, mental health awareness training for all staff would be a helpful backup. Although there is no requirement mandating that school staff receive mental health awareness training, these individuals are engaged in students’ lives daily and adequately trained, which should be a valuable “first line of defense” to identify signs of mental health struggles among students.
According to the National Center for School Mental Health and the National Association of School Psychologists (NASP), comprehensive school mental health promotes well-being and social-emotional health for all students and staff while supporting those with mental health challenges. The success of a comprehensive school mental health and behavioral health program relies on educators, mental health professionals, other specialized instructional support personnel, and community health and mental health providers working across a multi-tiered system of support (MTSS) that delivers that all students, including those in both general and special education, can access an array of services and that all students have exposure to universal mental health supports.
7. Conclusion
Childhood mental health disorders are a significant public health concern in schools. Providing counseling to a student impacts students’ academic, personal, and professional success by supporting their emotional and developmental growth and mental stability. School counselors are increasingly being asked to participate in the new programs to ensure a safe and secure school environment, prevent or decrease distress through educational programming, and intervene and sometimes evaluate students who present as a danger to themselves or others than before times. If a mentally healthy person is determined to manage stress and endure a condition that is not favorable, he can make a healthy choice for his life. Mental health is important from childhood and adolescence through adulthood, even though higher levels of education have been associated with mental health issues. The reasons are that educated people have more choices, more control over their lives, and better security. So, these are the essential aspects of mental health services that benefit education.