School mental health (SMH) services are an essential element to supporting student academic, socioemotional, behavioral, and mental well-being (Kern et al., 2017; National Association of School Psychologists [NASP], 2016). School mental health broadly encompasses the array of services delivered in a school setting designed to meet the social, emotional, behavioral, and academic needs of students in the educational environment (Doll et al., 2017; Franklin et al., 2012). The provision of SMH services has consistently been linked to academic achievement, school completion, positive school climate, school safety, and the prevention of disciplinary problems (NASP, 2016; Suldo et al., 2014). In the school setting, MH services may be delivered by a variety of SMHPs such as school psychologists, school counselors, and school social workers (Zabek et al., 2023). SMHPs collaborate with school nurses, families, other educators (e.g., teachers), and related service providers (e.g., occupational therapists, speech language pathologists) to provide SMH services to youth while also coordinating services from community-based agencies such as child welfare, juvenile justice, and community-based mental health professionals (CMHPs; Doll et al., 2017; Heatly et al., 2023; Zabek et al., 2023).

Schools have become the primary provider of mental health (MH) services for youth (Eiraldi et al., 2015) and may be the only option for youth to access MH services (Eklund et al., 2017). Without the provision of SMH services, young people often go without the help they need (Kern et al., 2017). However, when SMH services are provided through school, this can serve as a critical access point for the delivery of MH services. For instance, a recent meta-analysis examining service provision locale found schools were the most common sector in which youth received MH services, with community MH agencies serving a close second (Duong et al., 2021). Despite this, schools face significant barriers to the implementation of SMH services. For instance, effective MH service delivery to students may be limited due to an insufficient number of school-based mental health professionals (SMHPs), limited access to licensed MH professionals, and significant constraints related to funding (National Center for Educational Statistics [NCES], 2022a; O’Malley et al., 2018).

Implementation Science and School Mental Health

Implementation science research has increasingly been applied to SMH research (Lyon & Bruns, 2019; Owens et al., 2014). Implementation science is defined as “methods to promote the systematic uptake of evidence-based practices into routine practice” (Eccles & Mittman, 2006, p. 2) and provides useful frameworks to support the successful implementation of SMH services (Forman et al., 2013). Several frameworks and models for implementation science have been developed over time (Owens et al., 2014). For instance, Normalization Process Theory is focused on how implementation occurs socially, and how the implementation of interventions become a normal part of work (May & Finch, 2009). While a useful framework for understanding implementation and normalization, it can be useful to combine Normalization Process Theory with determinant frameworks to help organize barriers and facilitators of successful implementation (Schroeder et al., 2022). For example, according to another model, the Consolidated Framework for Intervention Research (CFIR; Richter et al., 2022), outer (i.e., factors outside the school) and inner (i.e., factors within the school) setting barriers impact SMH implementation (van Vulpen et al., 2018). Additionally, individual-level factors related to personnel implementing SMH services are also considered (e.g., attitudes related to SMH service implementation, professional development, backgrounds of SMHPs implementing SMH services; Lyon & Bruns, 2019). For SMH to be implemented effectively, research suggests outer setting barriers like district-level support, state and federal funding, and limited personnel as well as inner setting barriers like communication and referral processes (Lyon & Bruns, 2019; Richter et al., 2022) must be addressed. School principals play a key role particularly within the inner setting (Lyon & Bruns, 2019; Owens et al., 2014) and are well-positioned between these two settings to address barriers and support the uptake of SMH initiatives (Arnold et al., 2021). Yet, there has been little research on principal’s perceived role in the implementation of SMH (Garbacz et al., 2023). We utilize the Normalization Process Theory lens to conceptualize the mechanisms in which SMH implementation is embedded in schools and the CFIR framework to assess the role school administrators—in particular, school principals—play in the integration of SMH in the school setting (Lyon & Bruns, 2019).

Administrator Role in the Implementation of School Mental Health

Administrative support for implementation of SMH is of utmost importance (Arnold et al., 2021). Prior to the global pandemic, principals indicated student behavior and MH were the greatest perceived needs within their schools, particularly at the secondary level (Iachini et al., 2016). Now, given the context of the COVID-19 pandemic, both student and teacher MH needs have significantly increased (NCES, 2022b). For instance, in a study of over 450 teachers from 41 public charter schools in New Orleans who were teaching remotely early in the pandemic, teachers who endorsed experiencing more stressors related to the pandemic (e.g.,, caregiving burdens, financial stressors, increases in workload) reported worse overall MH and found it “harder to cope” and “harder to teach” (Baker et al., 2021, p. 498) compared to pre-pandemic. Further, a national survey of 7,705 high school students via the Adolescent Behaviors and Experiences Survey administered from January to June 2021 found students endorsed increased feelings of sadness and hopelessness, suicidal ideation, and suicide attempts compared to rates prior to the pandemic (Jones et al., 2022).

These two constructs—teacher MH and student MH—must be examined separately as well as concurrently to better understand SMH and the principal’s role in SMH. Recent evidence has emerged to indicate there is a bi-directional nature of teacher and student MH (Eddy et al., 2020; Harding et al., 2019; Nygaard et al., 2023). For instance, in a large-scale study of over 3,000 children and 1,100 teachers in the United Kingdom, researchers examined the association between teacher and student well-being and MH. Results of random effects mixed modeling indicated higher levels of teacher depression were associated with lower levels of student well-being and higher levels of student psychological distress. Conversely, higher levels of teacher well-being were associated with higher levels of student well-being. Teacher presenteeism and the quality of student–teacher relationships were found to mediate the relationship between student well-being and psychological distress. Thus, the authors concluded that interventions targeting teacher wellbeing and mental health could likely improve academic and mental health outcomes for students (Harding et al., 2019).

In addition to supporting teachers’ own MH, there is a recognition of the importance and need for teachers to obtain valuable training about student MH (Iachini et al., 2016; Ohrt et al., 2020), a sentiment frequently endorsed by teachers themselves (Ormiston et al., 2021). Indeed, outer setting (e.g., district funding) and inner setting determinants (e.g., principal support for training related to relevant initiatives) operate in tandem to impact the availability and implementation of professional development for relevant SMH stakeholders (Lyon & Bruns, 2019). As such, administrators play a vital role in supporting teacher and staff professional development in relation to student MH, an important individual-level implementation factor (Lyon & Bruns, 2019). MH literacy for educators focuses on increasing teachers’ ability to recognize students’ MH needs and provides strategies related to how to manage student MH needs in the classroom (Splett et al., 2019). Teachers who receive MH training are better suited to identify symptoms of MH issues in students (Hussein & Vostanis, 2013) and serve as a valuable link to refer students to needed services (e.g., referrals to SMH personnel; Kern et al., 2017).

In addition to supporting professional development (Domitrovich et al., 2008), positive and supportive messaging, resource/personnel allocation, and the identification of sustainable funding sources to support SMH services all require administrators’ leadership and involvement (Domitrovich et al., 2008; Eiraldi et al., 2015; Kern et al., 2017; Lyon & Bruns, 2019; Moon et al., 2017). Positive messaging from administration can increase teachers’ willingness to implement new initiatives (Domitrovich et al., 2008), such as implementation of a new universal socioemotional curriculum. In terms of resource allocation, principals recognize the need to have additional SMH personnel to meet the needs of students while also endorsing the value and provision of early identification of students in need of MH support (Iachini et al., 2016; Kern et al., 2017). Principals have influence in this inner setting (Lyon & Bruns, 2019) to support student and staff schedule adjustments and through the reallocation of personnel to allow for SMH services to take place (Domitrovich et al., 2008; Eiraldi et al., 2015; Kern et al., 2017).

Another critical component to the provision of SMH services is the development of infrastructure and systemic policies and practices to support long-term sustainability of the services (Moon et al., 2017). To be specific, five elements of implementation of SMH practices have been found to be most effective toward sustainability efforts: (1) consistently implementing SMH program components; (2) including stakeholders in service development and implementation; (3) utilizing various modalities to implement SMH services; (4) integrating socioemotional and MH curriculum into general education content; and (5) ensuring SMH services are developmentally appropriate (Kern et al., 2017). Administrative support of SMH services operationalized through these components sends a valuable message to school staff which in turn increases teacher commitment to and sustainability of implementation (Domitrovich et al., 2008; Eiraldi et al., 2015).

Limitations of Previous Research on Principals’ Perspectives

Although connected to outer and inner setting factors that can impact SMH implementation (Lyon & Bruns, 2019; Richter et al., 2022), the voices and perspectives of school principals have historically been underrepresented in school improvement and SMH research (Garbacz et al., 2023; Iachini et al., 2016; Moon et al., 2017) or their perspectives were limited in scope. Researchers have recently begun to explore principal voice to help fill the gap. For instance, Blackman et al. (2016) evaluated principals’ perspectives for a program evaluation of a multi-system partnership examining SMH implementation. The qualitative study was useful in gathering administrator perspectives yet was limited to perspectives of principals with existing relationships via a university-school partnership and did not specifically examine administrators’ perceived role in the implementation of SMH services. In another study, Smith-Millman and Flaspohler (2019) examined principals’ knowledge of, compliance with, and implementation practices related to state laws regarding suicide prevention. The nationally representative sample of nearly 600 principals is distinct from our current study in that it narrowly examined MH related to suicide prevention rather than MH more broadly (e.g.,, anxiety, depression, trauma). Neal and colleagues (2020) utilized an implementation capital framework to conceptualize a study examining secondary school principals’ perspectives related to the social validity of early warning signs as a SMH intervention related to the reduction of school dropout. Recently, Garbacz and colleagues (2023) conducted an online survey of forced-choice and open-ended responses of over 670 principals within one Midwestern state. The open-ended responses were limited to perceived strengths and barriers to SMH implementation, perhaps leading to limited perspectives on the topic. Of note, the authors stated, “future research could utilize other information gathering techniques, such as semi-structured interviews…to allow principals the opportunity to share detailed opinions and for researchers to ask follow-up questions” (Garbacz et al., 2023, p. 750). Further, the authors specifically examined barriers and strengths related to SMH implementation and did not gather perspectives related to the principal’s role in that process. Thus, our study fills an important gap in the literature relating to the more comprehensive nature of the perspectives gathered and by also specifically examining the principal’s role in SMH implementation, important to inform the next steps toward normalization and implementation.

Present Study

Using a semi-structured interview format, the purpose of the present study was to examine principals’ perceptions of their role regarding the implementation of SMH services. In a previous study using interview questions from the same qualitative dataset, we elucidated barriers and facilitators that influence the normalization of SMH services as part of typical school practice (Carlock et al., 2023). Two frameworks, Normalization Process Theory (used to develop the interview guide and helped us focus on the social process that led to the normalization of SMH services) and the CFIR (used in the discussion to contextualize how the results apply to the inner and outer settings), guided the study. Thus, we sought to inductively analyze school principals’ perspectives on SMH to explore their current systems and beliefs regarding SMH to lay the groundwork for future research and practices that build upon school principal’s unique role in supporting student MH needs at school. Specifically, the following research questions were examined:

  1. (1)

    What are principals’ perceptions of SMH service provision?

  2. (2)

    What are principals’ perceptions of their role in the implementation of SMH services?

Methods

Participants

Participants consisted of 19 school principals working at public schools in a Midwestern state. They were recruited from a larger survey sample of 244 participants recruited using a purposive sampling method from a publicly available statewide database of school administrators (Carlock et al., 2023; Nardi, 2018). Out of the 244, 50 participants indicated a willingness to complete an interview. Of those participants, 25 responded to a follow up interview request, and 19 completed an interview. Participants were from a variety of locales and working in different school corporations throughout the state. Seven (n = 7) worked at the elementary level (e.g., kindergarten through fifth grade), one (n = 1) was employed at a school with students kindergarten through eighth, and the remaining participants (n = 11) were employed at the secondary level (e.g., grades 6–8 and/or grades 9–12). Participant gender included 12 (63.1%) males and seven (36.8%) females. Eighteen (94.7%) participants identified as White, and one (5.3%) participant identified as Latinx. This sample is largely representative of the states’ school principals, as demographic data from the NCES indicates that 92.1% of principals in the state identify as White, and 51.3% identify as male (Snyder et al., 2019). Participants’ highest level of education achieved included 15 (78.9%) with a master’s degree (e.g., M.A., M.S., M.S.Ed.), one (5.3%) with a specialist degree (i.e., Ed.S.), and three (15.8%) with a doctorate (i.e., Ph.D., Ed.D.). Participants’ work experience ranged from 4 to 23 years (M = 10.1) working as a teacher, 0–7 (M = 2.63) as an assistant principal, 2–26 (M = 8.84) as a principal, and 1–20 (M = 7.55) working in their current school building. Nine (47.4%) of the participants worked in schools with 500 or less students, seven (36.8%) in schools with 501–1,000 students, and three (15.9%) in schools with greater than 1,000 students. See Table 1 for participants’ demographics, school characteristics, and IDs. Participants received a $20 Amazon gift card for completing an interview. All study procedures were approved by and adhered to Institutional Review Board procedures; consent for completing and audio recording interviews took place prior to conducting the interviews.

Table 1 Interviewee school characteristics (N = 19)
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Procedures

An interview guide was developed to investigate school principals’ perceptions of the value of SMH services, their role in implementation, and barriers and facilitators to successful implementation, as described in Carlock et al. (2023). The interview guide directly asked questions related to the constructs previously mentioned and was rooted in the coherence construct of Normalization Process Theory (Wood, 2017). Coherence refers to the concept that practices are “made possible by a set of ideas about its meaning, uses, and utility; and by socially defined and organized competences” (May & Finch, 2009, p. 542). Semi-structured interviews were conducted by the third author with 19 participants and held over the Zoom platform. The interviews lasted from 25 to 67 min (M = 38.4). For this study, the analysis was limited to participants’ responses to the questions, “What do you see as the value of MH services in schools?”, and “What do you see as school principals’ role in the implementation of SMH services?” Participant responses were probed during the interview for further information to investigate their perspectives in depth; answers to probed responses were included and analyzed as well.

The interview recordings were then professionally transcribed and analyzed using framework analysis (Ritchie et al., 2013). The second and third author followed the first four steps of framework analysis including familiarization, developing an initial framework, indexing, and charting (Carlock et al., 2023; Ritchie et al., 2013). During the process we developed a framework matrix consisting of summaries of the participant responses. The framework matrix allows researchers to analyze qualitative data both within and across participants (Gale et al., 2013). The first author then performed the fifth step of framework analysis, abstraction and interpretation, where organizing themes were identified among the codes using the framework while also referring to the original data. During this phase, the first author examined the framework and codes as identified by the second and third authors in previous stages as a form of auditing. This ensured the codes and themes fit the data and were comprehensible by an outside reviewer, thereby strengthening our analyzes. The codes and themes were reviewed by the second and third authors at weekly research team meetings to reach a consensus and provide perspective on the coherence of the coding (Levitt et al., 2017). Coding and summarization were completed using the MAXQDA (2020) qualitative data analysis software.

Positionality

The research team conducting this study consisted of two doctoral students in school psychology and one school psychology faculty member within the same graduate program that emphasizes a social justice orientation at a research-intensive university. All members identify as White; two identify as female and one identifies as male. We acknowledge our positionality and the potential impact on this research (Braun & Clarke, 2022). The primary interviewer has a background working as a special educator in public schools and utilizes an implementation science orientation in his research. During interviews, it is possible his background influenced the follow-up questions he asked (e.g., “How are teachers involved in mental health at your school?”). One team member has experience providing MH (e.g., trauma-focused cognitive behavioral therapy) in school and a third member has experience working as a district-level behavioral consultant and licensed, school-based school psychologist. All members of the research team participated in SMH intervention implementation as part of a federally funded grant for that purpose. Additionally, each team member has a research agenda examining SMH service provision in schools. Considering our decision to utilize framework analysis (Ritchie et al., 2013), we acknowledge we conducted the interviews, coding, and data analysis through a school psychology and social justice lens. Throughout the reflexive process, we discussed the ways in which our positionality influenced coding, interpretation, and analysis of results and strived to ensure the process was centered on participants’ perspectives. For example, our backgrounds in school psychology and implementation science influenced us to look at systemic factors that contributed to principals’ views on SMH (e.g., see theme 4).

Results

Results of the framework analysis identified four main themes: (1) principals perceive SMH services to be beneficial due to increasing MH needs; (2) principal involvement in SMH implementation varies; (3) critical staff promote SMH; and (4) systemic complexities exist related to SMH implementation and sustainability. Note that as results are discussed, Participant 1, Participant 2, and so on will hereafter be referred to as “P01”, “P02”, and so on through “P19”. All themes and subthemes can be found in Table 2.

Table 2 Themes, subthemes, and codes
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THEME 1: Principals Perceive School Mental Health Services to be Beneficial Due to Increasing Mental Health Needs

Many principals indicated general support of addressing student MH and SMH services. For instance, principals stated, “I’m very much in favor of school-based mental health services” (P01), “I definitely think it’s a necessity” (P02), and “I think it's important. I think it's crucial” (P10). Although one principal specifically stated, “[E]veryone is starting to realize how real social emotional health is and how important it is for student success” (P06), others indicated varying levels of buy-in related to SMH despite a reported increase in student MH needs.

Student and Staff Mental Health Needs Are Increasing

Throughout many of the interviews, principals continually noted the increase in student and staff needs. They commented that these needs have changed over time, and reported seeing both students and teachers coming to school with increasing MH needs. Many principals noted seeing an increase in the MH challenges of teachers, often due to the context of the COVID-19 pandemic. As one principal stated, “I have noticed that there are teachers suffering [with] a lot more depressive issues…for the first time in their life” (P02). Another reported, “[T]eachers who I didn't worry so much about before, I am now” (P12). They suggested the importance of addressing teacher MH in order to best help students. As one principal stated, “[a] dysregulated adult cannot regulate a dysregulated child” (P08). Put another way, principals recognized “kids aren't going to learn. Teachers aren't going to be at their best to teach kids unless they are— their mental health… has been taken care of” (P15).

Overall, principals recognized that the MH needs of their students are increasing. As one stated, “I just think that there’s a lot more anxiety out there. And over time that creates a lot more mental health issues…This wasn’t the case even 10 years ago” (P02). Another stated:

We've seen…dramatic increases in anxiety…Our data is very clear that suicidal ideation has dramatically increased…The number of kids who are dealing with things…is completely different than 10 years ago…it impacts kids every single day. (P09)

Principals saw the importance of SMH to address increasing student MH needs in relation to concerns like anxiety (P02, P07, P09, P17), depression (P07, P17) suicide (P07, P11), and substance abuse (P07).

Principals reflected on not only student MH needs overall, but specifically on MH needs related to trauma (P01, P09, P10, P13, P14, P17), living in poverty (P05, P07, P10), and homelessness (P08, P13). Several saw the connection between being a trauma-informed school and its importance in supporting student MH: “I can't imagine now not being a trauma-informed school and not having mental health services because our kids need it, and our families need it” (P18). Indeed, there was also an indication that the MH needs of families are reflected in the MH needs of students and a lack of knowledge related to how to access services (P09). Many saw schools as crucial to providing SMH services to support student MH.

Benefits of Implementing SMH Services

Benefit to Teachers Participants indicated SMH not just reflected the importance of student MH, but teacher MH as well. For instance, principals reported actively seeking opportunities to support teacher MH by supporting self-care (P08, P15, P16). Some principals noted a bi-directional relationship such that student MH affects teacher MH and vice versa (P01, P02, P04, P08) and that “teachers benefit the most” when student MH is addressed (P01). They see SMH implementation as a mechanism by which to positively “impact the climate and culture of the classroom” (P12).

Student Socioemotional Functioning Principals perceived students experience both short- and long-term benefits (P01, P10, P13, P16) when MH services are implemented in schools. As one principal noted, “I think that students that are taught the tools that they need in order to maintain positive, feelings toward mental health efforts will ultimately be better off when they get to middle, high school, and even adulthood” (P16). Principals also found SMH has helped students develop adaptive coping and advocacy skills which they believed will help them “function in school [and] in public” (P01) and provides “students with a voice” (P08). Indeed, as one principal noted, “This is [as] important as learning mathematics skills or language arts skills" (P10). Principals also perceived SMH services to provide students with a sense of safety and security while at school (P01, P03, P05, P14). When schools provide SMH services, “the majority of our kids feel safe. They feel valued…when they're feeling good about themselves, when…they're feeling secure and safe and valued…it all goes well for them” (P14). If schools “don't take action when it comes to mental health care, then we'll be dealing with more safety issues” (P03).

Student Discipline. Several principals noted benefits in relation to decreased office discipline referrals (ODRs) and student behavioral challenges when implementing SMH services (P01, P11, P13, P17). Prior to implementation, one principal noted, “[O]ur discipline data was through the roof. And our significant meltdown behaviors, they were blowing up our classrooms. They were keeping our teachers from teaching. They were keeping our students from learning” (P17). Principals noted using the discipline data as a way to support implementation and monitor effectiveness of implementation: “Because usually once a student starts getting the services they need, discipline referrals to the office drop” (P01). Some also noted changes in the way disciplinary infractions are handled such that they are now seeking to understand root causes of behavior rather than immediately jumping to assigning consequences (P11). It was also perceived that students were more proactive and open to seeking out help before they engaged in a problematic behavior (P11). Indeed, principals see implementing SMH as “a preventative measure” (P12) to minimize behavioral challenges related to student MH.

Student Academics. Principals reported a need to prioritize student MH because they indicated when student MH needs are met, their academic achievement increases (P01, P04, P05 P11, P12, P15, P19). They discussed a need for a student to be “mentally well” (P11) in order to learn. “[A] student can't focus on learning if they're having some sort of anxiety or some other problem going on. So generally, if you get those obstacles taken care of, then you do see a jump academically” (P01). Principals also reflected on the notion that students bring with them varied lived experiences, family circumstances, and trauma histories that contribute to their MH needs (P04, P05, P06).

[H]ow many of our kids are preoccupied with what’s going on at home or the mental health issues that they have, that they’re dealing with? And that dominates their thoughts for a good chunk of the day and gets in the way of them really receiving their education like they should…I think they’re missing out on a lot of what we have to offer academically because of these mental health issues. (P06).

One principal noted some MH challenges may also be due to the perceived pressures students feel related to a need to achieve at a high level (P07).

THEME 2: Principal Involvement in School Mental Health Implementation Varies

Principals are Facilitators of School Mental Health Services

An important role principals take on in relation to SMH services relates to the “supervision” (P12) and facilitation of the services (P01, P02, P04, P05, P06, P07, P08, P10, P11, P12, P14, P17, P19), to be “somebody who helps make it happen. Somebody who holds the entities accountable for doing what needs to be done” (P10). Another principal stated, “I do much more managing now than I ever thought I would as a principal” (P02). One aspect is the importance of setting the tone for whom, and how, services are delivered. “I get to shape the philosophy about what our counseling department is, and if the counseling department is the ‘old school’ school counselors— guidance counselors, where they do scheduling, and that's it, then we're not meeting kids' needs” (P09). Principals saw their “role as not being a roadblock to providing mental health services for students that need them. My job is to clear the path” (P04). Another principal indicated they play an important role by “giving people the space and the equipment that they need, figuring out what it is that they need, drawing attention to certain things when necessary, and leading by example” (P02). Finally, principals indicated they played an active role in selecting which programming the school would use for school-wide MH services (P01, P02), particularly for programs that are evidence-based (P07, P08, P09, P11).

Principals Self-Identify Varying Levels of School Mental Health Expertise

Overall, principals reflected on the feeling that many times “we have to be too often jacks of all trade and masters of none” (P09). And while they do not necessarily feel they are experts (P03, P10, P17), they do recognize how much of their job relates to supporting student MH. In many instances, principals provide direct service to students:

75% of my job is working with kids on mental health issues. When I meet with students [it] almost always [goes] back to…something that's going on in their life …it's just there's not enough of us here, and so the administrators become sort of pseudo guidance counselors. (P19)

However, another principal indicated they believed they had a good deal of MH “expertise”. As one principal indicated, “depending on my relationship with the student, I sit down and talk with them. I would say that I'm definitely the most expert on the staff as far as treating mental health issues” (P02).

THEME 3: Critical Staff Promote School Mental Health

Critical staff members for SMH service delivery identified by principals included school psychologists, school counselors, social workers, teachers, and CMHPs working in the school setting. Several principals endorsed being members of their schools’ MH team (P01, P08) and others indicated working with students directly to address MH needs (P09, P11, P19). However, principals did acknowledge they “can’t be very involved with everything all the time” (P12) and referenced needing critical MH staff “because as a building elementary principal, I don't know how to do that [MH services]. I don't have the time to do that. But I need the people that can help” (P17). Principals suggested an increased presence of MH personnel on campus has helped to reduce the stigma of receiving MH services (P03).

Teachers

Principals noted the importance of teachers being “on board and [believing] in the services” (P01) to promote SMH services for students. While many teachers provide universal social and emotional learning (SEL) instruction (P01, P11, P12, P17, P19), some principals mentioned not wanting to “add one more thing to [the teacher’s] plate” (P05) and thus have SMH providers implement universal curricula. However, it was noted that teachers are often the first to notice if a student needs support, and while teachers do not need “to have direct knowledge of how to deal with every situation,” they do “need to know who to connect to” (P08). It was also noted that if teachers are not supportive of services, it “hampers…progress” (P01) and can be “meaningless if there's not a true belief system in place in your building” (P13).

School Mental Health Personnel

Principals see the importance of a counselor’s role in the provision of SMH services. “I think the counseling department is critical to making [SMH] a success. But they can't do it without the support of the principal” (P04). Another stated, “[o]ur counselors are an extremely important part of our work within our school” (P09). Many referred to counselors as being the ones to whom teachers often refer (P04) and may provide service to students via universal curriculum (P09), small groups (P19), one-on-one support (P10, P11, P14), or crisis intervention (P16, P19). Counselors oftentimes wear “so many hats” (P14) to integrate SMH services along with their role in coordinating scheduling and testing (P08, P11, P14).

Principals also expressed the importance of having a multi-disciplinary SMH team (P11, P14, P17) with social workers, counselors, and school psychologists working with the principal to support students.

We involve our school psych a lot. And we are very much a team here. There's not a day that ever goes by that I'm not talking to my school psych, or my school psych's not talking to me. Just because we're constantly working together for our kids. And same thing with our counselor. (P17).

Other team members included teachers, behavior specialists, and paraprofessionals (P01, P13). Some principals noted, however, that some schools do not have teams (P04, P06, P11, P15, P16) perhaps because they are too small to have comprehensive SMH teams (P02) or there is only a team at the district level (P03, P09, P14).

Outside Service Providers

Principals noted outside, community-based agencies are another key to equipping their schools with MH providers (P01, P10). Several mentioned having memorandums of understanding (MOUs) with community agencies (P10, P16, P18) who are “embedded” in the school (P17). Principals had mixed views of the outside agencies. Some felt the services were beneficial: “I’m so happy we are able to have them here” (P11), the outside providers “can really spend a little bit more time with the kids” (P04) compared to school-based providers, and the community providers can free up SMH personnel to serve students without insurance or Medicaid (P17). Conversely, others expressed the challenges of having the partnerships and noted they “have not always worked out” (P18). One principal, for instance, indicated, “[redacted name] is a disaster, just terrible services…to be quite frank, one of the reasons why we're so disappointed with [redacted name] is because their services, their communication is very, very lacking” (P10). Other limitations noted by principals included the services provided by outside agencies were only for students with more significant needs (P12), were only for students who were Medicaid-eligible (P05, P06) rather than the population at large, or there was a perceived “lag” in connecting students and families to community-based services due to logistics such as completing referral paperwork (P09).

THEME 4: Systemic Complexities Exist Related to School Mental Health Implementation and Sustainability

Implementing School Mental Health Services is Complex and Multifaceted

Implementation of SMH was challenging for many principals. For instance, some indicated their schools’ characteristics such as locale and size influence the implementation and availability of SMH services. As one principal stated, “we are behind in getting out a full implementation of mental health…part of this is because we're rural” (P16). Others shared factors such as being “isolated” (P02) in a “very rural” (P06) location contributes to the “struggle because we don’t have a lot of outside resources in our community” (P11) while others reported having to share resources with neighboring districts (P03). Additionally, identification of students in need was a challenge and universal screening and progress monitoring data was inconsistent at best. For instance, some principals reported using universal screening to identify students in need (P11, P17) while others reported administering climate surveys without mechanisms by which to universally screen students (P03, P06). One principal reported using ODRs as a means to track socioemotional functioning of students (P05). One principal noted they identify students in need “just by observation” and “[w]e figure whatever we’re doing is better than nothing” (P18). Finally, in regard to the current structure for connecting students to MH services, many indicated the referral process was not systematic (e.g.,, P04) and instead defaulted to discussing their process for crisis referrals, such as threat assessment (P03, P06), suicidal ideation (P09), or calls for child abuse (P08, P10, P14).

Principals Understand the Importance of the Sustainability of Services

Principals understand the importance of sustainability, particularly if the “district leadership” supports it, and if the system is “valuable, if it's working, if it's doing what it is that you want it to do, then I think that will sustain it over time” (P03). One principal noted the importance of having a systematic process in place to help with sustainability: “[s]o I guess part of the sustainability is just having a good process in place to identify students who need services” (P01). Principals understand the importance of embedding SMH services into the culture of the school, rather than having SMH services seen as a temporary program.

You have to create a culture that establishes a system or a program that becomes part of its fiber, so that it can survive the fact that you have principals that come and go or administration that comes and goes…the school has to commit itself to ‘this is important’ and ‘this is why it's important. And we don't care who the principal is.’ And the culture has to demand that it sticks around. (P04)

Funding, in particular, was an element that was highlighted as important to sustain the work of SMH. For many, the superintendent (P01, P02, P11) and school board (P11) were seen as important elements to supporting funds for SMH:

So to be able to have that buy-in is huge for us in the aspect that I think our board will, and they have started to, allocate funds that way. Being able to have a superintendent that is on board is huge as well. In her five year plan, SEL and mental health services is number one. So I think that that's huge to have a superintendent that feels that way because then she's going to push to allocate funds that way. (P11)

Funding for SMH services also included a variety of other sources, including grant funds (P06, P07, P10, P19) for training and personnel, general funds (P09) to support programming, Medicaid insurance billing (P01) for outside service providers, and partnerships with local and community agencies (P06, P15).

Discussion

This qualitative study examined school principals’ perspectives on—and their role in—SMH in one Midwestern state. Research elucidating school principal’s perceptions of SMH is warranted given the benefits of SMH (NASP, 2016) and the influence of school principals on deciding school priorities and effecting new school initiatives (Durlak & DuPre, 2008; Jones & Cater, 2020). School principals can bridge the outer and inner settings that impact SMH implementation (Lyon & Bruns, 2019; Richter et al., 2022) due to their unique positioning and administrative leadership role at the district and school level. Through qualitative interviews and framework analysis, we found participants view SMH as beneficial and are active in facilitating SMH initiatives. However, they recognize the need for more trained MH personnel, and seek support for initiative sustainability. As participating school principals mentioned, student and staff MH needs are increasing after the COVID-19 pandemic (NCES, 2022b) and participants consistently reported the effects of MH difficulties impact school functioning.

Fortunately, schools can serve as a hub for equitable access to comprehensive MH services (Eklund et al., 2017). School principals from this study recognized SMH benefits student socioemotional functioning and academic achievement, while at the same time reducing problem behaviors. Therefore, school principals from this study have witnessed the positive impacts of SMH firsthand and corroborate the benefits outlined in previous research (e.g., Kern et al., 2017). For example, SMH service use has been found to be associated with a decrease in the number of days absent from school and a decrease in rates of leaving high school due to dropout (Kang-Yi et al., 2023). Additionally, adherence to a county-wide model of SMH has been found be associated with reductions in social, emotional, and behavioral problems (Reinke et al., 2020).

Even more nuanced, participants emphasized the benefits of SMH on teachers. As detailed in the Teacher-Student Mental Health Interaction Model, a bi-directional relationship exists between teacher and student MH such that student MH impacts teacher MH and vice versa (Nygaard et al., 2023). This relationship can have detrimental effects on both students and teachers. For instance, teacher emotional exhaustion has been found to predict increased rates of office discipline referrals and use of in-school suspensions (Eddy et al., 2020). Relatedly, student MH challenges related to trauma for instance have been found to increase rates of compassion fatigue and secondary traumatic stress in teachers (Christian-Brandt et al., 2020; Ormiston et al., 2022). Participants emphasized the importance of supporting teachers through changing the educational structure and cultivating a climate of self-care and wellness, constructs supported in the extant literature (e.g., Benson, 2018; Carlock et al., 2023). Indeed, district-level administrators and building principals can make purposeful decisions in the outer and inner settings to support teacher MH via promotion of a work-life balance, support of mindfulness practices, and working to ensure the psychological needs of teachers is met (Ormiston et al., 2022).

The School Principal’s Role in School Mental Health

Overall, participant responses align with the conceptual model of factors that affect the implementation of school-based preventative interventions (Domitrovich et al., 2008) such that school organizational factors in the inner setting (i.e., principal’s priorities, resources, and school culture) and individual-level factors embedded within the inner setting (i.e., principal, teacher, student, and family perspectives of SMH) impact the current state of SMH programming. Because educational reforms have focused on measuring teacher success based on student academic achievement via standardized assessments, accountability standards prioritize academics over student MH and well-being (Berkowitz et al., 2017; Jones & Cater, 2020). If administrators share this belief (Zhang et al., 2022), then it makes sense that student MH is a lesser priority than academic achievement for teachers and school staff. However, school principals in this study viewed SMH as necessary and suggested a key part of their role is setting the priorities of the school and providing accountability to ensure SMH services are provided.

Principals who see MH as foundational to student success can make systems-level changes in the inner setting to alleviate teacher pressures and add incentives for SMH implementation. Hiring additional MH providers to meet the demand for services is one place to start, without adding to a teacher’s already “full plate” (Frey et al., 2022). However, we would be remiss to not mention the significant barriers in the outer and inner settings inherent in adding more staff in relation to federal and state funding, district regulations, personnel shortages (e.g., school psychologist shortages; Lyon & Bruns, 2019; O’Malley et al., 2018), and the like. One potential solution is for school principals to collaborate with other administrators in their district and in surrounding school districts for strategies for cultivating mindset and priority shifts salient to their school community. Connecting with district level administrators regarding consistent messaging and priorities can also be beneficial because if the leaders at the top of the system prioritize SMH, building level principals have a network of support that can drive building level roll out (Carlock et al., 2023; Durlak & DuPre, 2008), as seen with promoting academic improvement initiatives (Bottoms & Schmidt-Davis, 2010). Along the same vein, finding school “teacher leaders” who support SMH can be invaluable in expanding teacher buy-in (Fairman & Mackenzie, 2015).

Although most stated they are not experts in MH, and indeed many school principals do not receive training related to student MH (Owens et al., 2014), school principals described their role as facilitators of SMH and identified critical staff that promote SMH. School principals play a role in shaping the philosophy and priorities of their school through leading by example (e.g., modeling how to respond to students with MH difficulties) and messaging (e.g., using a common language; Meyers & Hambrick Hitt, 2017). Literature supports this description of a principal’s role to be that of a facilitator (see Jones & Cater, 2020). In a review of MH promotion interventions in schools, a similar sentiment was noted such that there is a need to delicately “balance prescriptive guidelines and flexible adaptations with school culture and ethos” (O’Reilly et al., 2018, p. 658). In example, we recommend school principals work with their SMH teams and consider whether the factors needed for school-wide programming success are in place (e.g., teacher buy-in, funding, sufficient MH providers) in making decisions about universal SMH programs. For example, if teacher buy-in for SMH is relatively low in the building, principals may consider asking a SMH provider, such as a school psychologist, to use their consultation skills to increase teacher buy-in and support (Eagle et al., 2015) such as through co-teaching lessons in one or two classrooms before expanding the roll out of universal programming.

School principals, although vital to the initiation and sustainability of SMH programs, are not the only school leaders necessary for successful SMH implementation. Rather, school-based MH providers like school psychologists, school counselors, and school social workers are also essential to MH service provision and system planning (Marsh & Mathur, 2020). Thus, we recommend administrators use distributed leadership to capitalize on other school personnel’s training and skills (Wood & Ellis, 2022). From teachers as universal curricula implementers and a referral source for students needing more intensive supports (Marsh & Mathur, 2020; Ormiston et al., 2021) to school psychologists facilitating the universal MH screening process (Wood & Ellis, 2022); school counselors implementing early MH interventions for students at-risk of academic, behavioral, and social/emotional difficulties (Iachini et al., 2015); and school social workers coordinating a continuum of wraparound services (Marsh & Mathur, 2020); every member of a school-based MH team is critical. In addition to school-based providers, SMH often includes partnerships with community agencies that contract with schools to provide intensive MH supports to students and families (DiGirolamo et al., 2021). Participants endorsed a range of views on these partnerships from viewing services as extremely beneficial to disappointment in failed partnerships or the limitations of their services as it relates to insurance requirements.

The School Principal’s Role in Facing the Complexities of School Mental Health

A well-trained, multi-disciplinary MH team can work with school principals to overcome the complexities related to SMH implementation and sustainability. In the current study, participants noted the scarcity of MH services in rural communities. This is consistent with the extant literature pointing to the need for continued efforts to recruit trained personnel in rural communities or train individuals already established there (Garbacz et al., 2022). Further systematization of universal screening is warranted, based on participants’ reported use of alternative screening methods such as climate surveys, ODRs, and informal observation. This aligns with survey results of school principals from over 400 school districts across the United States that found only 9% of participants endorsed implementing universal social, emotional, and behavioral screening in their schools (Briesch et al., 2021) despite this practice being viewed as an essential component of MTSS and key to improving the speed with which students receive SMH support (Wood & Ellis, 2022). MH referrals, as described by participants, often centered on crisis response rather than proactive approaches to connecting students to services. This suggests the current role of MH in schools may be more reactive than proactive in nature (Dowdy et al., 2010; Wood & Ellis, 2022). Collaboration with other key school leaders can help sure up these processes to focus on developing a system to meet student MH needs, through universal MH screening and tiers of support, rather than relying primarily on crisis referrals and ODRs.

For MH service delivery to be sustainable over time, a concern expressed by school principals in this study, participants reflected on the referral process, the importance of school culture in relation to SMH services, and securing funding to support implementation. These recommendations all fall within the scope of a school principal’s responsibilities (The Wallace Foundation, 2013) and align with recommendations for SMH procedures (Weist et al., 2014). Specifically, school principals act as a bridge between the outer setting (i.e., district level), inner setting (i.e., building level), and individual-level implementation factors (i.e., those service providers providing SMH services; Lyon & Bruns, 2019). Further, learning more about implementation science may be useful method for improving student outcomes, as research suggests that principals’ attitudes toward the implementation process can impact how much new practices are used, thus impacting student outcomes (Teerling et al., 2020). Therefore, we call for school principals to use their leadership through an implementation science lens to continue establishing SMH systems to meet the vast and intensive MH needs of the school community.

Limitations and Future Directions

Despite its contributions to the literature, this study is not without its limitations. First, the present study is limited by its narrowed scope of participants (i.e., only school principals from one Midwestern state). Participants were predominantly White and male, and although representative of individuals in the state (Snyder et al., 2019), the sample is not representative of the diverse demographics of educators and students nationally. Having a more diverse sample could allow for deeper exploration of patterns in principals’ experiences with SMH and/or differences by type and/or locale of the school that may influence administrators’ perspectives, intentions, and responses. Further, we analyzed the interview data collectively as one sample of school principals. We did not distinguish participants from one another by school level/age group served in our recruitment or data analysis. Future research could examine school principal perspectives on their role according to school level. Additionally, participants self-selected to participate in the interview portion of the study, and may have done so out of an expressed interest in the topic at hand—SMH. This could suggest participants held a more favorable view of SMH services and implementation compared to a broader school administrator population. Research examining principal perspectives on SMH across the United States could further expand our understanding of principals’ perspectives on, and their role in, SMH. The same can be said for examining other stakeholder’s perspectives on SMH, including school MH providers, teachers, students, families, and community MH providers. School principals from this study described their perceptions of others’ beliefs about SMH, however, directly interviewing these potential beneficiaries could enhance our conceptualization of the state of the field with regard to SMH implementation. Finally, we did not gather data related to the current school context from which the principals were reporting in terms of existing systems in place to support SMH, current hiring practices of SMH personnel, or staff training related to SMH. Additional research could explore the context and processes of the school environments to better understand how these principals' lived experiences help us understand their perspectives related to SMH implementation.

Conclusion

SMH services provide a critical link to providing services to youth in need of MH support (Eklund et al., 2017). Administrators play an important role in the implementation and sustainability of SMH services (Kern et al., 2017) particularly as both student and teacher MH needs have significantly increased (NCES, 2022b). However, little is known regarding school principals’ perspectives related to school improvement (Iachini et al., 2016) and SMH research (Moon et al., 2017). Thus, we used a semi-structured interview format to examine principals’ perceptions of their role regarding the implementation of SMH services. In general, administrators endorsed support for the implementation of SMH services in the context of increasing student MH needs and identified critical staff needed to successfully implement such services. In order to meet the continued MH needs of both students and staff, implementation and sustainability of SMH services is of utmost importance. SMH service implementation should be a critical discussion point at the local- and national-level to ensure student and staff needs are being met.