Introduction

The unmet mental health needs of youth have been well documented. It is estimated that up to 20 % of school-aged children in the United States have a diagnosable mental health condition (Merikangas et al. 2010a, b), yet only a fraction of these receive sufficient mental health services (Merikangas et al. 2010a; Power et al. 2005). Low treatment rates for children with mental health disorders are attributed to barriers such as transportation and financial difficulties, lack of access to mental health professionals, distrust of social service agencies among families, and perceptions of stigma (Stephan et al. 2007). These obstacles may also contribute to the estimated 40–60 % of families who actually begin treatment but end prematurely (Kazdin et al. 1997).

Mental health problems in children manifest in the schools through academic underachievement, behavior problems, and attendance issues (DeSocio and Hootman 2004; Ringeisen et al. 2003). Therefore, it is imperative that mental health problems be detected and treated early (Patel et al. 2007). Fortunately, US schools offer unparalleled access to youth (Paternite 2005) and provide a setting in which professionals can recognize symptoms of mental illness and respond appropriately (Reinke et al. 2011). Providing mental health services in schools can alleviate many of the barriers that often prohibit families from obtaining quality and consistent treatment, as schools are likely more familiar, less threatening, and more acceptable locations than other traditional community service settings (Armbruster and Lichtman 1999; Atkins et al. 2003; Stephan et al. 2007). Schools are not only a convenient access point to mental health services; however, interventions designed to address mental health needs often help schools better meet student learning goals (Cappella et al. 2008). In a review of the literature on school-based mental health programs, Hoagwood et al. (2007) found that the majority of interventions resulted in both improved mental health outcomes and academic gains for students.

Although the mutually beneficial outcomes and ease of access make schools well situated to effectively promote youth mental health (Short et al. 2011), numerous barriers often prevent the implementation and success of school-based mental health efforts. Obstacles include limited budgets, time, physical space, and personnel resources needed to operate new services (Splett and Maras 2011). A lack of formalized training regarding current youth mental health issues may impede school staff from effectively recognizing student mental health needs and implementing programs (Powers et al. 2011). In addition, school psychologists, social workers, and counselors are often unable to adequately serve students with mental health needs due to competing responsibilities. Though these professionals have specialized education and training regarding child development and mental health issues, factors such as serving multiple schools and a role emphasis on testing, attendance, or course scheduling often prohibit them from providing mental health interventions (Kratochwill 2007). As a result, students with untreated mental health needs are often inappropriately referred to special education (American Psychological Association Task Force on Evidence-Based Practice for Children and Adolescents 2008), either because the mental health needs are not recognized or because the special education system is the only existing possibility to receive individualized, school-based services.

Policy advocates as well as the extant literature recommend approaches that integrate mental health services into schools. Several examples of such approaches exist: models based on the integration of physical health services into schools via school-based health centers (Davis and Montford 2005); a public health model that aims to integrate all spheres of a child’s environment (Stiffman et al. 2010); and the system of care framework, used to guide coordination of school and community mental health resources (Stroul 2002). All of these approaches require formalized partnerships between school districts and community agencies. Such collaboration would assist vulnerable students and families within a community who otherwise may lack access to mental health services, while also benefiting all partner organizations. More specifically, locating mental health professionals from community agencies on school campuses to work directly with students and their families would provide schools with expertise and resources they need to better promote the mental health of their students and improve academic outcomes (Weist et al. 2006). Likewise, by utilizing office space at a school, the mental health professional from the community agency has better and more consistent access to many students who otherwise may not be able to visit the traditional community-based setting. As Cappella et al. (2008) note, school-based mental health partnerships may be particularly effective at overcoming barriers to service in urban or poor communities, where many families might lack the financial or practical resources (such as transportation) needed to obtain services outside of their neighborhoods.

Despite the benefits for all parties, collaboration between schools and community mental health agencies is often very difficult to initiate and sustain. Institutional barriers occur when existing policy, accountability, leadership, budget, space, and capacity-building agendas are not in sync or supportive of collaborative efforts (Sanders 2005). Limited finances in both schools and mental health organizations are a common obstacle to establishing school-based mental health partnerships (Stiffman et al. 2010). Also, it may be difficult at times for schools and community agencies to recognize their shared goals. System “silos” may exist that cause school administrators and staff to see their mission of education as completely separate from the community agencies’ mission of child mental health, and vice versa (Stiffman et al. 2010).

Personal barriers can also impede the implementation and success of school-based mental health efforts. Individual-level barriers often derive from practical deterrents, negative attitudes, and deficiencies of knowledge and skill (White and Wehlage 1995). These vary for participants but frequently include issues related to work schedules, communication skills, and understanding of differences in organizational culture (National Association of State Mental Health Program Directors & The Policymaker Partnership 2002). Such individual resistance may be further exacerbated without a functional infrastructure that encourages systems’ cooperation and resource sharing (Taylor and Adelman 2000). If such resistance exists on the parts of key school and agency leaders, school-based mental health efforts are likely to be poorly implemented and under-resourced (Bradshaw et al. 2009; Weist et al. 2009).

A New Multi-System Partnership for School-Based Mental Health

In spite of the well-documented obstacles that often prohibit the creation of sustainable multi-system collaborations, one such partnership was formed in July 2010 with the shared goal of providing school-based mental health (SBMH) services. The innovative 1-year SBMH pilot project was developed in order to initiate a new multi-system partnership between an urban school district in a mid-sized Southeastern city, the local management entity (LME) serving as the primary public mental health agency in the community, and a local university. The pilot project was designed to increase the capacity of one urban elementary school to recognize and meet the needs of students with mental health problems that threaten their school success. In the signed memorandum of agreement between these systems, the school district was responsible for providing access to students and office space in the school, and the LME agreed to provide a dedicated mental health professional to work at the school. The university faculty provided the initial grant funding for the pilot, which helped facilitate the three systems coming together on the project. In the partnership, the university team committed to providing mental health in-service training to school staff and to evaluate the results of pilot project.

The collaboratively designed SBMH intervention included five primary components. The first element was a school-wide training that provided an overview of mental health issues such as prevalence, common disorders, and barriers to treatment for families. This training was provided at the beginning of the school year and was designed to assist school personnel in recognizing signs and symptoms of mental health issues that necessitated a referral to the SBMH program (Powers et al. 2011). The second component addressed staffing of the project. A community-based mental health professional from the LME was located at the school for 1 year to provide a combination of direct and case management services to students and their families. Additionally, a parent liaison was placed in the school to assist with contacting and supporting parents of children referred to the mental health program. These two new staff worked closely with the current school social worker, counselor, and psychologist already employed by the district at the school site. An ecological assessment tool was administered for all students at the pilot school as the third part of the project. The Elementary School Success Profile (ESSP) provided useful information about areas of risk and highlighted students for intervention (Bowen and Powers 2011). The fourth component was implementing services for referred students. Services included individual and small group counseling, home visits, assisting families with accessing appropriate community-based agencies for students with more intense needs, and coordinating other school-based services such as tutoring and mentoring. The final component included evaluating results of the project to identify student improvement, as well as parent and teacher perceptions of program effectiveness (Wegmann et al. 2012).

The project required the support and approval from administrators and leaders in each organization prior to implementation because of their roles in making programming, staffing, and budgetary decisions. Obtaining the necessary approval was a difficult process due to the unique policies, protocols, and accountability standards of each agency. Administrators and leaders had to establish a foundation for connecting the school, families, and community. Authentic agreements and compromises were made in order to create a plan for providing SBMH services to families in a unique partnership. Although this took considerable time and resources, the importance of this aspect of the process cannot be overemphasized because failure to establish and successfully maintain effective collaborations is largely attributable to the absence of clear, high level, and long-term support (Bodilly et al. 2004). For example, the primary agenda for community agencies working with schools is commonly to gain better access to clients (Weist et al. 2005), whereas the school agenda is focused on raising test scores and closing the achievement gap (Warren 2005). Thus, leaders and administrators in both settings had to address this divide in ways that integrated all goals, contributed to each other’s missions, and elevated the work to a high priority.

The process of establishing a collaborative commitment resulted in a signed memorandum of agreement to officially implement the SBMH intervention. The pilot project was implemented at an elementary school within the large urban school district, providing students at the pilot school with increased access to consistent care. The university partner analyzed the results of the pilot study and presented the findings to the leaders and administrators from the school and LME in the summer following the 2010–2011 academic year. More than 75 high risk and vulnerable youth were served, and caregivers and teachers reported overwhelmingly that the project had made a positive difference for students in both academic and behavioral outcomes (Wegmann et al. 2012). Based on the positive results from the pilot year, both organizations chose to sustain the project and expand it to six new schools for the next academic year. However, in order to do this, both partners needed to find and allocate the necessary resources in their own budgets. The willingness and ability of the partners to earmark already limited resources spoke to their level of investment and commitment to the continuation of the multi-system SBMH intervention.

Prior to this pilot project, no formalized contract between the school district and mental health agency had previously existed in this community. In fact, the school district had been historically hesitant to address student mental health needs that fell outside of traditional exceptional children’s programming. The historical context further highlighted the need to identify the specific catalysts that encouraged these systems to successfully partner at this point in time. Better understanding the prior barriers to collaboration and how those were overcome to foster commitment to a collaborative intervention may be incredibly beneficial to other communities considering a multi-system partnership for promoting youth mental health.

Method

In order to obtain detailed information about leaders’ rationale for support of the SBMH project, exploratory qualitative methods were employed as part of the overall program evaluation. In-depth, one-on-one interviews were conducted with six key administrators and leaders from the school district and LME to better understand the mitigating factors that contributed the successful partnership. Information was sought regarding the reasoning and rationale for implementing the SBMH project, the sustainability of this program, and barriers that previously existed or currently needed to be overcome for the project to successfully continue (see “Appendix” for interview questionnaire). Individual, open-ended interviews are an especially appropriate technique for qualitative program evaluation because they allow the participant to provide feedback of a potentially sensitive nature in a confidential setting with the interviewer while also empowering the participant by letting him or her know that their personal experiences and knowledge are essential to the viability of the program (Greene 1998; MacDougall and Fudge 2001; Rubin and Rubin 2005).

Setting

The interviews took place in the diverse county in the Southeast region of the United States where the partnership was formed. The urban school district is the 8th largest district in the state. There are 55 public schools within the district, consisting of 30 elementary (K-5), 10 middle (6–8), two secondary (6–12), 12 high (9–12), and one hospital school. The racial/ethnic makeup of the student population during the 2010–2011 school year was 52.12 % African American, 21.13 % Caucasian, 20.97 % Hispanic, 2.44 % Asian, 0.29 % American Indian, and 3.05 % Multiracial with a total of 32,566 students (district website). In this district, 60.81 % of the students qualified for free or reduced lunch, which serves as an indicator of the overall district poverty level. According to the No Child Left Behind Act standards, school rankings in this district are 159th out of 180 districts in the state.

The LME, located in the same county as the school district, managed all local mental health, developmental disability, and substance abuse services. Although the LME does not provide services directly, it facilitates citizens’ access to quality services and supports, promoting client goals and independent living. Networks of private providers who contract with the LME deliver the services to which LME clients are referred.

Sample

The sample for the interviews was a purposive sample, chosen by the Principal Investigator (PI) of the pilot study. Participants were selected due to their administrative or leadership role in the partnering school and LME organizations. Each selected person was invited to participate in an interview. Six key leaders participated in the interviews. All of the participants were female, five were African American and one was Caucasian, with ages ranging from 46 to 62 years (mean age of 54). Participant job titles included Assistant Superintendent of Student Services, School-based Support Program Coordinator, School Board Chairperson, Director for At-risk Services, LME School Coordinator, and LME Director.

Data Collection

A total of six interviews were conducted and audiotaped. All interviews were facilitated by the PI or two of three graduate research assistants. Prior to beginning the interview, each participant reviewed the confidentiality agreement, was informed that she would not receive incentives for participation, and reminded that she could discontinue participation at any point. The interview questionnaire (see “Appendix”) was created to acquire participant perceptions about historical barriers that prevented adequate mental health access for youth in the school district, how and why this partnership was formed, how this project has changed the current school environment, and the sustainability of the SBMH project. Interviews lasted between 30 and 45 min each.

Coding and Analysis

Interview audiotapes were transcribed verbatim and checked for accuracy by two graduate assistants on the research team. First, the graduate research assistants independently reviewed and coded both sets of transcripts using Atlas.ti v. 6.2 (Scientific Software Development, 2002–2011) over a two-day period. Initial coding was done on a line-by-line basis using an open, inductive approach which has been cited as the most effective way to use qualitative analysis software (Greene 1998; Muhr 1991; Padgett 1998). Constant comparison (Padgett 1998, p. 77) enabled the natural emergence of themes and subthemes. The themes and subthemes were identified and labeled appropriately by the research team throughout the transcribed documents. Coding decisions were discussed and documented through handwritten notes and Atlas.ti’s memo feature (Anastas 2004). Any and all coding discrepancies between the coders were resolved through detailed discussion and mutual agreement. Following independent coding and subsequent labeling of themes and subthemes by the graduate assistants, the PI reviewed the coded transcripts, themes, subthemes and the relevant quotations associated with each subtheme. The use of two independent coders as well as review by the PI enhanced the fidelity and reliability of the study (Greene 1998; Padgett 1998). By having regular bi-monthly meetings to discuss the results, the research team added a safeguard against researcher bias. Member checking occurred between the research team and two of the interviewees providing further protection against researcher bias, enhancing the accuracy of the interpretations and conclusions drawn (Mays and Pope 2000; Padgett 1998).

Results

Common themes developed across multiple transcripts in the analysis, despite the various positions of the administrators in the school district and LME systems. Five major themes emerged: Perceptions of Project, Barriers to Collaboration, Motivating and Promoting Factors, Sustainability, and Lessons Learned. Several subthemes also arose within these major themes. Major themes and subthemes are illustrated in Table 1.

Table 1 Frequency of themes and subthemes in administrator interviews
Full size table

Perceptions of Project

The leaders and administrators discussed their personal perceptions of the project and its success and challenges. In many cases, these perceptions were related to the reasons stakeholders chose to support the project and engage in the partnership. The broad Perceptions of Project theme produced three subthemes: Project Significance, Beneficial Qualities, and Importance of Mental Health.

Project Significance

Leaders and administrators shared their views on the project’s importance and its meaning to the community and systems involved in the partnership. An LME representative discussed the project’s importance in regards to offering mental health and other supports, particularly for disadvantaged children, in order for them to be academically successful:

We want kids to succeed, that’s the bottom line, we want them to do well in school. … the kids in, um, in this community come with tremendous challenges. … and they come in here and we expect them to learn. Some come without the clothes or the, you know, the right tools to do the job. And so this project is important because it not only addresses the, um, mental health aspect of it.

The project’s placement in the school, as opposed to another traditional service delivery site, was seen as a way of increasing accessibility. Leaders and administrators generally felt that the project’s significance lay in offering a new way to meet the needs of students and families.

We have a place for kids to come and get continual, ongoing help and assistance. … Some of the families we worked with at [the pilot school], we were able to work with them over summer to keep them connected. But even with that, the school is the place that’s always going to be, they’re going to come back to it…

Beneficial Qualities

The beneficial qualities of the project to the students, families, partners, and community were recounted by every leader and administrator. There were multiple accounts of the benefits of offering holistic supports that included the family and environment. One decision-maker attributes the success of the project to the holistic approach:

[It] takes all elements of the process. It’s a family initiative, it’s not just student centered… to change the environment, you’ve got to do just that, the entire environment. So it deals with the family, … the school, and the student.

Family engagement was also mentioned specifically as part of the benefits of the needs assessment and comprehensive services offered by the project:

One of the things … which made it successful was the relationship building we did with the parents. Um, we were having a conversation with them not because there was something wrong at school, their child was misbehaving, nor perhaps that there was something wrong with them, that they weren’t doing in terms of working with their kids, we were asking what they thought. We asked them what they thought about school, we asked them what they thought about their community.

The relationships with parents and caregivers were seen as important components that led families to greater trust and utilization of services offered through the project.

Early intervention and access to services were also major successes of the project. One leader recounted that “one of the wonderful things about this project for [the county] is it’s been a way to identify early on, those students that are vulnerable, those families that are vulnerable and most at risk.” Another described the benefit of the quality and suitability of the services accessed through the project: “I think that, um, students are getting access to services, some of whom might not have. I think even more importantly though, is that they’re accessing the appropriate services.”

Importance of Mental Health

The leaders related their beliefs about the importance of mental health to students and families as well as the benefit of offering mental health services in the schools. The mental health needs of children and desire to address them were discussed: “we’re seeing more kids with severe mental health issues and needs and challenges. Um, teachers have been asking for years for help.” These needs were also shared as a reason why system administrators chose to support the project. One leader stated that the school board “[has] been saying that we needed to come up with something to address these issues and I think that this is probably the answer for us at this point.”

Participants repeatedly talked about the connection between academic success and mental health:

We put so much emphasis on, um, what happens in the classroom, and that’s fine. But I think what we have to do is begin looking at what happens before the child even gets to the classroom if we want to see success in the child.

Promoting academic success was also seen as investing in future success. As one leader said, “if you could get some of those supports in the school, they actually would have a better chance of succeeding, um, you know academically and, hopefully in the rest of their lives as well.”

Barriers to Collaboration

Despite largely positive views of the project, administrators and leaders described multiple barriers, both historical and current, to a successful collaboration between the systems. Three subthemes emerged within the larger Barriers to Collaboration theme: Resistance to Mental Health, System Silos, and Lack of Communication.

Resistance to Mental Health

This subtheme primarily refers to historical events that needed to be overcome in order to move forward with the partnership. Resistance on the part of past decision-makers was identified as a barrier:

…What I understood … the [school district] leadership at that time had just decided to bar, um, mental health services and those kinds of things from being in the school, um, except I think under very, very, very restricted circumstances… it had something to do with the school system really wanting to focus on their test scores and that kind of thing.

Past resistance to mental health was generally attributed to “people being closed-minded and not, um, being able to see that there was a connection between mental health and some of the behaviors that we were seeing in schools.”

Misunderstanding and persistent stigma associated with mental health, especially historically, was repeatedly discussed. One leader commented, “it was almost like people were embarrassed or ashamed to admit that some of our students actually had these issues.” Another echoed this idea:

We think mental health means crazy, that you are somehow, if there’s any kind of depression or something, it’s abnormal. When in fact … if we have a sore, or we had a broken wrist, we would treat it immediately and we would get attention for it and we would hold it up. We don’t do the same thing with mental illness. Illness is illness is illness. And so I think this [project] takes some of the stigma away from it.

System Silos

Leaders in both systems repeatedly raised the issue of silos and separations between the school and community systems as a barrier to collaboration. This subtheme was described as a historical obstacle and a barrier for current and future collaboration. One leader described the barrier by saying, “it’s just that the language is very different … and though they have similar goals they’re trying to reach, their missions are very different.” Based on the difference in language and mission, the “barriers are sort of understandable… they’re just two different worlds, and so what we’re going to do [in the partnership] is blend those worlds.”

School district and LME leaders felt barriers from each other’s systems were causing present tensions and could affect the future of the partnership. A school district leader commented:

I do wish that we had better support from our local mental health agency. I do think that has been a barrier, and it’s becoming more and more of a barrier. Because I don’t think they see the importance of their role. They’re the experts in this particular area, we are educators, they’re the experts in mental health. And that has been a difficult piece.

On the other side, an LME representative similarly assumed that the school district’s perspective was, “We teach. They in the community, they deal with mental health, and neither one should overlap.” The representative went on to say: “I think that’s been a big barrier. That, that frame of thought.” Both parties viewed the silos between systems as potentially challenging when moving forward in the partnership.

Lack of Communication

Communication issues were another barrier identified by the interviewees. These were often referred to as a historical barrier in partnerships between the systems, but leaders from the LME in particular also saw it as an ongoing challenge. An LME administrator described a lack of communication during the decisions regarding the project’s expansion:

We weren’t part of that process to say, what can you afford to help us with, here’s what we learned in terms of accessing services, what’s your provider network look like, it (the expansion) just [was decided] all of a sudden.

The same LME representative remarked that the lack of communication “kind of gives me pause.” Another leader described the need for communication as:

…it’s about there being willingness on both sides, there being openness to new ideas, and um, and I guess part of the willingness is to kind of understand the limitations that each system has and then just have that spirit of, being willing to explore and see what it is going to take, to get, like, even to the next step.

Motivating and Promoting Factors

In describing the challenges, leaders and administrators articulated multiple factors that helped overcome challenges and allowed the partnership to be successful. The factors were clustered into three subthemes: Stakeholders, Relationships, and Timing.

Stakeholders

The leaders interviewed repeatedly mentioned the importance of their own roles as well as those played by other participants in the partnership. The individuals and their roles were frequently referred to as main reasons the collaboration was successful, “because finally you have people, you have people in charge who are able to talk to each other and collaborate and make things happen.”

The primary players mentioned in the interviews were the superintendent, two high-level school district leaders, the project primary investigator (PI), and LME leaders. A school district administrator remarked on the importance of the superintendent “because he obviously has a very personal reason, or there’s something with him that’s driving him to push this too. … he is very, very passionate about this program.” A district administrator was recognized “for believing in [the project] and, and you know, it was always her belief to have …school-based mental health. As assistant superintendent it just put her more in the position to really shepherd this along.” Another leader discussed the importance of the project PI’s relationship with the school district because she “understood this population, understood this district.” The leaders’ and administrators’ efficacy was summarized by one participant:

[They were] able to sit all in that room and just talk, and hash things out, and then leave that meeting and have it, you know, people begin to marinate, you know, on the reality of it. It was, that was important to have that partnership … saying, you know, it’s worthwhile, let’s do this.

Relationships

In conversation about the importance of leaders, the relationships between the leaders themselves were identified as another driving force in the partnership. One leader remarked that, “when it’s all said and done, in the final analysis, it’s about relationships.” Participants discussed the value of the trust and understanding between individuals that allowed the two systems to partner. One LME leader discussed how that relationship made the collaboration easier and more successful:

They’ve gotten used to working with me over the past three or four years, so I mean I also think that, you know, there’s a certain amount of trust. You know, I’m not part of their system, but I think they do feel like I have a certain understanding about their system. And … I had a track record with them.

Timing

The fortuitous Timing of the partnership was another promoting factor that emerged in the interviews. Leaders and administrators remarked on the fortunate timing in combination with critical people and relationships within the community:

It was a collaboration. … We had a professional at [the pilot school]. We had a parent liaison right there at the school. We had social workers. We had [the university partner]. We had evidence-based results. It wasn’t a fly by night. Everything was in order and it all was centered at the heart of it. It was right there at the school. That was the tipping point. And when, when the board heard it, when [the PI] presented it … the affirmation was immediate.

The timing was also fortunate for the LME: “there was a little bit of fluidity going on there, and so the [LME] was in a place where they could say, okay, this is interesting.”

In terms of people in leadership positions, a district administrator spoke about timing having to do with a change in leadership that allowed her to be more proactive in addressing student mental health needs: “the fact that those people that were in authority were no longer, um, a barrier. Um, that in my position, I didn’t have to ask for permission, that I could push forward.” An LME representative also felt that the collaboration was possible because of the timing of people in certain positions:

I think what happened was again change in leadership in [the school district] last year. I think that helped. I think there was a new door that was opened or in the process of opening. Um, ‘cause if it happened two years ago, I don’t think it wouldn’t have happened.

Sustainability

The Sustainability of the partnership was a recurring theme from leaders and administrators. The theme focused on the future of the partnership and the elements necessary for continued success. Three subthemes emerged: Expansion, Funding, and the Need to Show Outcomes.

Expansion

Though the project had already added six new schools after the first year, further expansion was discussed as a goal and desire of many leaders and administrators. They spoke about the project becoming district-wide as an integral part of the school system. One leader remarked that a goal for expansion was for it to “become a part of every school. And it will just be by nature that you have, um, uh, a school-based support program in each school.” Another echoed similar sentiments: “I hope that we can build on the successes that we just discussed, that we can … internalize [the project] within the school structure.” In discussing the expansion, administrators reiterated their beliefs that the project was successful and beneficial:

I’m hoping that it is going to be replicated in more than the seven schools that we have it in right now. That, um, it’s a model, um, evidence-based model, that we can use in all of our schools. Especially in schools where we have, uh, populations that are needy. I think, I think that this is the way to go.

Funding

The importance of funding was consistently highlighted as one of the top challenges for sustainability of the project. One school district leader said, “It’s money. It’s all, it’s all resources… we have to be able to, uh, sustain this with funding.” This subtheme was repeated consistently by leaders and administrators from the school district and the LME. Funding was a source of tension expressed primarily by the LME leaders. One leader was concerned about funding in relation to the expansion and that “it gets to the point where, when it’s no longer a pilot and you have expanded it, maybe beyond, you know, your ability to ensure funding. Um, and it’s, it’s cause for some, a little bit of tension.”

Need to Show Outcomes

In order to sustain the project and its funding, school district and LME representatives pointed to the need to prove the project’s effectiveness with empirical outcomes. One leader described the importance of documenting and sharing the outcomes for the sustainability of the project: “if you keep proving your case, then it, it becomes harder for people just to say no. You know, you might lose pieces of it, but you don’t lose all of what you, your efforts.” Another LME representative reiterated the idea of demonstrating outcomes and proving the need for the program:

…eventually it comes into, you know, if we’re going to continue to contribute money, … county money, … eventually we have to look at um, you know, the, kind of the tangible cost savings and the cost benefit. So part of what I had to go back and ask [the project coordinator] to do was, alright, how many of these kids and families were referred to public services? Um, do you know, did they make their first appointment? Did they follow up? Did they complete treatment? Because that’s our world.

Lessons Learned

Leaders and administrators reflected on the Lessons Learned through the creation of the partnership and the pilot year of the project. They recounted what they would have done differently or advice they would have for another community developing a similar partnership. One leader shared these ideas:

…Of course funding is key. But leadership and collaboration are essential. That it can be done, um, that you may have to tighten your belts in some other areas, but it’s something that’s drastically needed for our children, for our families, to be whole.

Time and effort were named as important component of successful collaboration:

If one is really serious about all this, you know, collaboration work, is what one has to realize is that it takes a lot of time, it takes a lot of energy. Um, it takes patience.

Lastly, one leader remarked on the importance of dedication to the project, saying:

It will not be easy. There will be resistance from all corners, you know, from parents, from teachers, from students, from administrators … Stay focused on what it is that you have been charged to do.

Discussion

The primary goal of the new SBMH project was to increase the capacity of the school to recognize and meet the needs of students with mental health problems. However, implementing and sustaining this type of successful multi-system partnership requires the collaboration and commitment of the partnering organizations. In this study, administrators and leaders from both systems shared their perceptions of the newly forged collaboration and the importance of creating an authentic partnership. Several key factors for forging successful SBMH partnerships between systems were identified in the current study. These included developing strong relationships- especially among leaders in all systems; overcoming common barriers by consistently communicating openly with all parties; improving the potential for sustainability by documenting outcomes with data; and garnering support for the partnership from all of the stakeholders, among others.

Ultimately, the interviewees reported positively about the pilot project and described being pleased about the services that were now being provided to many vulnerable students who otherwise may not have had access to quality care. This is consistent with other research that describes schools as being a vital setting for service delivery to youth who may be compromised by poverty, language and transportation barriers (Cappella et al. 2008). Interestingly, participants also noted that collaboration and change in schools do not come easily. Past barriers such as a sense of “turf protection”, a lack of communication, and difficulties in collaboration between systems had previously prevented success. Participants also noted funding as a challenge and as a potential obstacle for the future. Interestingly, interviews identified several promoting factors that served to overcome many barriers. The current relationships between systems, new leaders who were willing to work together, and the timing of the pilot project were all critical to creating and maintaining a positive collaboration.

Limitations

Although the current study makes an important contribution to the literature by identifying catalysts for creating successful community partnerships, several limitations should be acknowledged. A primary limitation is that despite their key roles, it was not possible to interview the superintendent of the school district and the executive director of the LME due to conflicting schedules and time constraints. Their perspectives as key decision-makers would have added significant value to the study. Additionally, the faculty member at the local university who is the PI for this project was not included in the interview process. Though her input would have contributed to the results of the study, a possible conflict of interest may have arisen if she also participated as an interviewee as she is an integral part of the evaluation process.

Implications for Practice

Several implications for practice are associated with the results of the current study. Findings suggest a clear need for positive relationships and increased and open communication between systems that desire to collaborate. New mechanisms will likely need to be established to promote these types of change. One feasible way to strengthen relationships and increase communication between this urban district and the LME may be establishing a consistent team or advisory board with the key administrators from both systems in the initial negotiation and planning phases of collaboration. Through regularly scheduled meetings, both parties would have access to consistent and simultaneous information about the current program status from development through evaluation. Additionally, these meetings would establish a forum for all decision-makers to come together regularly to talk about the primary goals, current status, and next steps for the intervention and collaboration, which will hopefully lead to more trusting relationships and a reduction of the “system silos.”

An unmistakable need was expressed for data supporting a change in trajectories and outcomes for students involved in the intervention, as empirical evidence of success would facilitate the funding and sustainability of the project over time. This is supportive of current research that states empirical outcomes form school-based mental health efforts in social, behavioral, and academic areas are vital for sustaining programs (Weist et al. 2006). The original evaluation plan for the pilot project discussed here focused on collecting and analyzing data at the end of the academic year. However, modifications should likely be made to collect data from project schools quarterly or even monthly. More frequent data collection would allow the research and evaluation team to analyze data and produce regular reports for the system administrators to provide an updated project status. Providing more and regular updates that indicate successful progress may also further strengthen the resolve of the two systems to continue their partnership to promote mental health for youth.

Implications for Research

There is a distinct need for ongoing evaluations of the SBMH project, especially in light of the expansion of this pilot project to six new schools within the district. Quantitative outcomes such as the number and demographics of students served through the program, and changes in attendance, behavior, and academic performance must be measured. However, there is also a need for additional qualitative evaluation to better understand the perspectives of the principals, staff, students, and parents at each of the project schools. Interviews and focus groups with these key stakeholders would provide further insight about the implementation of the newly expanded intervention and aid in identifying areas for further improvement of the program. Finally, this study should be replicated in the future to identify how strategies may change over time for maintaining a successful multi-system partnership to provide SBMH services. As evidenced in this study and in other research, multi-system collaborations can be challenging to initiate and develop (Weist et al. 2006), thus gaining insight about how to do so in other diverse settings would add to the knowledge base and assist other communities interested in such an approach for mental health care.

Conclusion

The clear connection between student mental health and academic achievement (DeSocio and Hootman 2004) creates an impetus for school districts nationwide to be concerned about untreated mental health problems. SBMH programs are one solution to meeting this need because schools-based services reduce many of the barriers seen in traditional community mental health settings (Stephan et al. 2007). Multi-system collaborations between school districts and community mental health agencies provide an innovative SBMH model that may be beneficial in many communities.

In the current study, district and agency leaders identified five major themes that can inform new SBMH partnerships in other communities. Among the merging themes included positive perceptions of the pilot project due to the potential to meet the mental health needs of vulnerable and underserved youth. Study findings also identified promotive factors that encouraged and fostered the new collaboration such as good timing, positive relationships among key leaders and staff across systems, and having the right leaders in positions of decision-making power.

Not surprisingly, the current study also highlighted barriers and challenges inherent to creating partnerships among systems to improve mental health services for students. Challenges around communicating effectively across organizations were discussed. Participants wanted to feel apprised of current information from each system and wanted to be able to trust each other in the partnership. The need for funding and data supporting the effectiveness of the intervention was also discussed, and leaders from both systems agreed they were crucial for sustaining program efforts over time. Also, lessons learned such as the need for patience during the early stages of partnering were described. Goal setting and creating a merged mission for two separate organizations around a common interest such as mental health services for schools can take a great deal of time to work through.

However, despite the challenges inherent in these types of collaboration, the administrators who made the decision to pursue the described SBMH partnership wholly acknowledged its importance and success. They overwhelmingly agreed that project was enormously significant for the community and provided important benefits to students and families. In recognizing the significance, they articulated the urgent need for further addressing children’s mental health and the value in providing services within the schools. The themes from the interviews with administrators can provide valuable lessons and ideas for other communities seeking a similar program to promote student mental health in urban schools.