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Friedrich, Allison A.
School psychologists' provision of school-based mental health interventions :
b a qualitative study of perceived barriers
h [electronic resource] /
by Allison A. Friedrich.
[Tampa, Fla.] :
University of South Florida,
ABSTRACT: The primary purpose of this study was to elucidate factors that school psychologists perceive inhibit them from providing more mental health interventions within their professional roles. School psychologists' dual training in mental health and education renders them the logical choice to provide tier II and tier III interventions in schools (National Association of School Psychologists [NASP], 2003). School psychologists appear to be in agreement, as they indicate a desire to spend more time in the provision of roles such as counseling and consultation (e.g., Prout, Alexander, Fletcher, Memis, & Miller, 1993). However, school psychologists currently spend relatively little time in the provision of such services (e.g., Curtis, Hunley, Walker, & Baker, 1999).Although this contradiction provides a rationale for further investigation, previous lines of research have not fully identified why school psychologists are not providing their desired levels of time in the provision of mental health services. Research also suggests that significant differences exist among school psychologists of different ages and levels of experience pertaining to their roles within the school system (e.g., Curtis, Hunley, & Grier, 2002). Therefore, factors such as years of experience also should be considered when studying school psychologists' roles in the provision of mental health services. Thus, an additional purpose of the current study was to examine the frequency of the themes elucidated across each research question as a function of practitioners' levels of experience.Participants were 39 school psychology practitioners from two geographical locations, ranging in age from 26 to 61 years old (M = 41.92, SD = 11.22) and had from 1 to 32 years of experience (M = 11.89, SD = 10.49). Eleven focus groups, composed of two to five members each, were conducted. Participants responded to a set of openended questions, and the discussions were audiotaped and then transcribed verbatim. Within each question, several common themes emerged across the focus groups; however, differences between practitioners' level of experience was noted on several occasions. Implications for future research and practice are presented, specifically related to the training and professional development needs of school psychologists.
Thesis (Ed.S.)--University of South Florida, 2007.
Includes bibliographical references.
Text (Electronic thesis) in PDF format.
System requirements: World Wide Web browser and PDF reader.
Mode of access: World Wide Web.
Title from PDF of title page.
Document formatted into pages; contains 213 pages.
Advisors: Shannon M. Suldo, Ph.D. and Linda Raffaele Mendez, Ph.D.
Years of experience.
x School Psychology
t USF Electronic Theses and Dissertations.
School Psychologists Provision of School-Bas ed Mental Health Interventions: A Qualitative Study of Perceived Barriers by Allison A. Friedrich A thesis submitted in partial fulfillment of the requirements for the degree of Education Specialist Department of Psychological and Social Foundations College of Education University of South Florida Co-Major Professor: Shannon M. Suldo, Ph.D. Co-Major Professor: Linda Raffaele Mendez, Ph.D. Tony Onwuegbuzie, Ph.D. Date of Approval: October 24, 2007 Keywords: school psychology, psychotherapy, fo cus groups, training, years of experience Copyright 2007, Allison A. Friedrich
Dedication This manuscript is dedicated to my father, James Friedrich, my mother, Leslie Friedrich, and my dear sister, Lindsey Frie drich, for their conti nual support, love, and care throughout my educational career. Special thanks to my mentor, Dr. Shannon Suldo. Without her support, guidance, and continual efforts this work would not have been possible.
i Table of Contents List of Tables v List of Figures vi Abstract vii Chapter 1: Introduction 1 Statement of the Problem 1 Conceptual Framework 6 Purpose of the Current Study 8 Educational Significance 9 Research Questions 9 Definition of Terms 10 Mental Health Problem 10 Mental Health Assessment and Intervention 10 Delimitations of the Study 11 Limitations of the Study 11 Organization of Remaining Chapters 13 Chapter 2: Review of the Literature 14 Prevalence of Mental Health Probl ems in Children and Adolescents 14 Sources of Information on Preval ence Rates of Mental Health Disorders in Youth 15 Anxiety Disorders 18 Mood Disorders 18 Behavior Disorders 19 Eating Disorders 20 Substance Use Disorders 20 Child and Adolescent Ment al Health Services 21 Proportion of Children Receiving Se rvices From Various Sectors 24 Mental Health Services in the School 30 Mental Health Problems Refe rred for Treatment in Schools 31 School Personnel Providing Me ntal Health Services 33 Types of Mental Health Service in the Schools 34 School-Based Health Centers (SBHC) 39 School Psychologists Role and Function 41 Expectations for School Psychologi sts Involvement in Mental Health Services 41
ii National Association of School Psychologists 42 School Psychology Literature 43 School Psychologists Major Functions 44 Time School Psychologists Spend in Each Major Function 45 Geographic Differences in Functions 47 Trends in School Psychologists Role Sp ecific to Mental Health Services 49 Discrepancy Between Actual and Desired Involvement in Mental Health Services 51 Specific Mental Health Services Provided by School Psychologists 53 Role of Years of Experi ence on Professional Practices 55 Barriers to the Provision of Mental Health Services in Schools 58 School Psychology Graduate Training 63 National Association of School Psychologists 63 Division 16 (School Psychology) of the American Psychological Association 64 Training in Mental Health Interv entions During Graduate School 66 Conclusions 68 Chapter 3: Methods 71 Research Paradigm 71 Research Design 72 Participants 73 Selection of Participants 73 School Psychologists 74 Demographics 75 Composition of the Focus Group 78 Setting 81 Middle Florida County 81 Southern Florida County 81 Data Collection Setting 82 Measures 82 Demographics Questionnaire 82 Procedures 83 Ethical Considerations 84 Data Analysis 85 Credibility Measures 91 Limitations of the Current Study 93 Contribution to the Literature 94 Chapter 4: Results 95 Research Questions 97 Types of Problems for which Stude nts are Referred for Mental Health Assessment and Intervention 99 Anxiety 99
iii DSM disorders 101 Anger 102 Isolated Behavioral or Emotional Symptoms 103 Atypical/Bizarre Behavior 104 Learning Problems 105 Crisis Situations 105 Trauma 106 Adolescent Issues 106 Family Issues 106 Adults Mental Health Problems 107 Mental Health Assessment a nd Interventions School Psychologists Have Provided during Their Recent Practice in the Schools 111 Group Counseling 111 Individual Counseling 113 Crisis Intervention 114 Consultation to Individuals 115 Behavioral Interventions 116 Case Management 117 Social-Emotional Behavioral Assessment 117 Inservices (Consultation to Group) 118 Counseling Adults 118 Prevention 119 Family Services 119 The Role of Years of Experi ence in the Provision of Mental Health Servic es by School Psychologists 120 Factors that Prevent School Psychologists from Providing Additional Mental Health Assessment and Intervention 124 Problems Inherent to Us ing Schools as Site for Service Delivery 126 Insufficient Support From the Department and District Administration 128 Problems With School Personnel 130 Insufficient Training 132 Insufficient Time and Integr ation Into the School Site 133 Personal Characteristics 134 Caseload at School 134 Student Factors 135 Role Strain 136 The Role of Years of Experi ence in Barriers Perceived by School Psychologists 136 Specific Knowledge and Skill Areas that Additional Training Would be Helpful in Enab ling School Psychologists to Provide Mental Health Assessment and Interventions 141 Course-Work Training Needs 141 Experiential Activities 147
iv Professional Development 150 The Role That Year of Experience Plays in the Training Needs of School Psychologists 152 Chapter 5: Discussion 158 Examination of Results 159 Problems Referred 159 Mental Health Services Provided 164 Notable Group Differences 167 Barriers to Psychotherapeutic Service Provision 169 Notable Group Differences 174 Training Needs of School Psychologists 176 Notable Group Differences 180 Implications of Results for School Psychologists 182 Limitations of the Current Study 185 Suggestions for Future Research 187 Conclusions 188 References 190 Appendices 204 Appendix A: School Psychologist Consent Form 205 Appendix B: E-Mail Invitation 207 Appendix C: Demographic Form 208 Appendix D: Focus Group Protocol 210 Appendix E: Sample Form for Field Notes 213
v List of Tables Table 1 Descriptive Statistics for Participants in the Focus Groups 77 Table 2 Composition of Focus Groups 98 Table 3 Themes and Subthemes Re lated to the Common Types of Problems Referred for Mental H ealth Assessment and Intervention 100 Table 4 Frequency School Psychologi sts Mentioned Specific Referral Problem 109 Table 5 Themes and Subthemes Re lated to the Common Types of Mental Health Assessment and Intervention Serv ices Provided by School Psychologists 112 Table 6 Frequency each Group of School Psychologists Provided Specified Services by Level of Experience 122 Table 7 Themes and Subthemes Relate d to Barriers to the Provision of Mental Health Assessment and Intervention Identified by School Psychologists 125 Table 8 Frequency each Group of School Psychologists Identified Barriers by Level of Experience 138 Table 9 Themes and Subthemes Rela ted to Identified Training Needs 142 Table 10 Frequency each Group of School Psychologists Identified Training Needs by Level of Experience 154
vi List of Figures Figure 1 The Data Analysis Spiral 87 Figure 2 Percentage of Times With Which Each Specific Referral Problem Theme was Mentioned by Participants 108 Figure 3 Percentage of Times With Which Each Mental Health Service Theme was Mentioned by Participants 121 Figure 4 Percentage of Times Wi th Which Each Barrier Theme was Mentioned by Participants 137 Figure 5 Percentage of Times With Which Each Training Theme was Mentioned by Participants 153
vii School Psychologists Provision of School-B ased Mental Health Interventions: A Qualitative Study of Perceived Barriers Allison A. Friedrich ABSTRACT The primary purpose of this study was to elucidate factors that school psychologists perceive inhibit them from pr oviding more mental health interventions within their professional roles. School psychologists dual training in mental health and education renders them the logical choice to provide tier II and tier III interventions in schools (National Association of Sch ool Psychologists [NASP], 2003). School psychologists appear to be in agreement, as they indicate a desire to spend more time in the provision of roles such as counseling and consulta tion (e.g., Prout, Alexander, Fletcher, Memis, & Miller, 1993). Howeve r, school psychologists currently spend relatively little time in the provision of such services (e .g., Curtis, Hunley, Walker, & Baker, 1999). Although this contradiction provi des a rationale for fu rther investigation, previous lines of research have not fully identified why school psychologists are not providing their desired levels of time in the prov ision of mental health services. Research also suggests that significant differences exist among school psychologists of different ages and levels of experience pertaining to their roles within the school system (e.g., Curtis, Hunley, & Grier, 2002). Therefore, f actors such as years of experience also
viii should be considered when studying school psychologists roles in the provision of mental health services. Thus, an additiona l purpose of the current study was to examine the frequency of the themes elucidated acro ss each research ques tion as a function of practitioners levels of experience. Participants were 39 school psychology practitioners from two geographical locations, ranging in age from 26 to 61 years old ( M = 41.92, SD = 11.22) and had from 1 to 32 years of experience ( M = 11.89, SD = 10.49). Eleven focus groups, composed of two to five members each, were conducted. Participants responded to a set of openended questions, and the discussions were a udiotaped and then transcribed verbatim. Within each question, several common themes emerged across the focus groups; however, differences between practitioners level of experience was noted on several occasions. Implications for future resear ch and practice are presented, specifically related to the training and professional development n eeds of school psychologists. .
1 Chapter 1 Introduction Statement of the Problem Mental health in childhood and adoles cence is defined by the achievement of expected developmental, cognitive, social, and emotional milestones and by establishing effective coping skills, secure attachments, and positive social relationships (US Department of Health and Human Servi ces [US DHHS], 1999). Mentally healthy children and adolescents enjoy a positive quality of life; func tion well at home, in school, and in their communities; and are free of disabling symptoms of psychopathology (Hoagwood, Jensen, Petti, & Burns, 1996). As summarized in the Surgeon Generals Report (US DHHS, 1999), psychopat hology in childhood arises from: the complex interactions of specific characteristics of the child (including biological, psychological, and genetic factor s), his or her environment (including parent, sibling, and family relations, p eer and neighborhood factors, school and community factors, and the larger social-cultural c ontext), and the specific manner in which these factors interact w ith and shape each other over the course of development. (p. 7) Many children have mental health problems that interfere with normal development and functioning. According to a re cent report, almost 21% of U.S. children aged 9 to 17 years had a diagnos able mental or addictive disord er associated with at least
2 minimum impairment (US DHHS, 1999). In or der to prevent and reduce symptoms of psychopathology, mental health services must be provided (Ollendick, King, & Chorpita, 2005). Support for the use of mental health services for children has been evidenced through countless studies and four major meta-ana lyses that examined the effects of child therapy (Ollendick et al., 2005) In 1995 the Society of C linical Psychology Task Force on Promotion and Dissemination of Psychologi cal Procedures published a comprehensive review of empirically validated psychol ogical treatments, id entifying three wellestablished treatments and one probably effi cacious treatment for children (Ollendick et al., 2005). Since this report was published, add itional task forces have been established by the Society of Clinical Psychology and th e Society of Clinical Child and Adolescent Psychology and have identified additional e ffective psychosocial treatments for highfrequency problems encountered in clinical and other settings se rving children with mental health problems (Ollendick et al., 2005). A number of societal problems (Crock et, 2004) and legislat ive initiatives (e.g., Individuals with Disabilities Education Improvement Act) have resulted in more children in need of mental health services and, consequently, more children who go without treatment. Yet, studies across the decades illustrate that the majo rity of children and adolescents with a psychologica l disorder never receive mental health services (Burns et al., 1995; Farmer, Burns, Philip, Angold, & Costello, 2003; Kataoka, Zhang, & Wells, 2002; Leaf et al., 1996; Pandiani, Banks, Si mon, Van Vleck, & Pomeroy, 2005; Stiffman, Earls, Robins, & Jung, 1988). The provision of mental health services to children and adoles cents is dispersed across multiple systems and professions: school s, primary care, the juvenile justice
3 system, child welfare, and substance abuse tr eatment centers (Satcher, 2000). Over the years, a complex system for providing mental health services to children has evolved, driven by the multiple government initiatives and advocates for more comprehensive mental health services for children (Brown, 2002). Within this complex system, the education (i.e., school-based) system has emer ged as the foremost provider of mental health services to ch ildren (Burns et al., 1995; Farmer et al., 2003). School-based mental health services are provided by a range of personnel, including school psychologists. An original intent of the school psychologi st role within the school system was to conduct psychoeducational assessments for pl acement in special education (Fagan & Wise, 2000). Although this assessment role has been the primary function of school psychologists for decades, leaders in the fiel d have advocated for role expansion and respecialization (cf. Crespi & Politikos, 2004) to include additional roles such as the provision of mental health se rvices. While the assessment role has persisted across the twenty-first century, two additional major ro les for school psychologists have emerged: intervention and consultation. Assessment, as defined by the Nationa l Association of School Psychologists (NASP), is "the process of gathering information from a variety of sources, using a variety of methods that best address the r eason for evaluation; and is contrasted to testing which is limited to administration and sc oring of tests" (NASP, 2003, 1). The definition used by NASP places an emphasis on the difference between assessment and testing. Interventions may be directed to ward promoting well being and preventing the onset of problems (i.e., primary prevention), minimizing difficulties once they occur (i.e., secondary prevention), and stabilizing disa bilities and working to ensure basic and
4 needed services are provided to those who can be expected to manifest one or more disabling conditions over some years (i .e., tertiary prevention) (NASP, 2003). Consultation generally refers to the provi sion of school psychological services using indirect methods to deliver services. Consultation services may be offered to teachers and other educational personnel, other prof essionals, religious and other community leaders, parents, and government offici als; consultation often involves school psychologists participating as members of a team. Consultation services also may be directed toward enhancing the understanding an d ability of teachers, administrators, and parents to promote development (NASP, 2003). School psychologists should receive gr aduate training that provides the knowledge and skills necessary to perform the aforementioned functions, as well as lessfrequently provided roles such as resear ch and supervision (American Psychological Association, 2005; NASP, 2000a). Given thei r broad training and experience, school psychologists are well-qualified to provide co mprehensive and effective mental health services. In recent years, school psychology li terature has been inundated with a call for school psychologists to respond proactively with respect to providing mental health services to children in schools (Nastasi, 2000). Despite compelling factors, such as (a) the need for mental health services in the schools, (b) school psychologists expertise in mental health and education, and (c) calls for the expansion of school psychologists professional roles into additional involvem ent in mental health services, school psychologists currently spend less than one-qua rter of their time in the provision of mental health services (Curtis, Hunley, Wa lker, & Baker, 1999; Hosp & Reschly, 2002; Reschly & Wilson, 1995; Yates, 2003). Yet, the majority of school psychologists desire
5 to provide more mental health services within their roles in the school system (Prout et al., 1993; Reschly & Wilson, 1995; Yates, 2003). Given school psychologists desire to spe nd more time in the provision of mental health services and the still unmet need for treatment of childrens mental health problems, barriers must exist that prohibit school psychologists from intervening with these children. Through a survey response fo rm, Yates (2003) provided one of the few studies to examine barriers to the provision of one type of mental health service, counseling, by school psychologi sts. Yates found that re spondents endorsed a heavy emphasis on assessment (68.2%) and the fact that counseling was not part of their roles in the school (52.5%) as two common barriers. An additional barrier endorsed by a number of respondents was that counseli ng is not currently part of their identified/written job responsibilities (26.4%). Ot her barriers elicited through an other choice category included insufficient training in counseling, ot her job responsibilities, and the perception that their school district doe s not view counseling as a necessity. While this study is notable in that it provides an in-depth examination of barrier s, the research is limited by (a) a narrow definition of mental health (i.e ., counseling services; mental-health-related services as consultation were not examined), (b) use of a questionnair e that consisted of only closed and partially clos ed-ended questions, and (c) a fi nite list of re sponse options that limited participants to re sponding to their perception of only six barriers. Initial exploratory research is need ed using qualitative methods that allows respondents to identify the range of factor s they perceive prohibit thei r provision of mental health services in schools is needed.
6 Additional research is needed to ad dress factors that moderate school psychologists involvement in mental health services. Preliminary research suggests significant differences exist among school psychologists of different ages and experiences pertaining to thei r roles within the school syst em (Curtis, Hunley, & Grier, 2002). Therefore, demographic factors such as years of experience also should be considered when studying school psychologists roles in the provision of mental health services. In recent years, school psychol ogy has witnessed a graying of the field (Curtis, Grier, & Hunley, 2004, p. 7) in whic h the average age (and corresponding years of experience) of school psychologists is si gnificantly older than in past years. Therefore, the gap in years of experien ce between new graduates/recent hires and experienced practitioners is widening. Becau se of the recency of calls to expand the school psychologists role into mental hea lth services, school ps ychologists beliefs regarding their roles in providing mental he alth services may vary according to the number of years they have worked in the fiel d. Years of experience also may be relevant to school psychologists provision of mental health services due to changes over time in school psychology graduate training. Conceptual Framework NASP, founded in 1969, is a not-for-prof it association representing more than 23,500 school psychologists from across the Un ited States and other countries (NASP, 2000a). The mission of NASP is to repr esent and support school psychology with leadership to enhance the mental health a nd educational competence of all children. Consistent with this mission, NASP promotes educationally and psychologically healthy environments for all children and youth through the im plementation of research-based,
7 effective programs that prevent various problems and promotes optimal learning. This is accomplished through up-to-date research and training, advocacy, continual program evaluation, and caring professional service. Consistent with its mission, NASP has adopted and promotes an integrated set of comprehensive standards for preparation, credentialing, and professional practice in school psychology. NASP has been influential in setting the standards for school psychology practice in the United States since the first development of its first training guide lines in 1972 (NASP, 2000a). The Standards for Training and Field Placement Programs in School Psychology (NASP, 2000b), its most recent training guideline, contributes to the development of eff ective services through the identification of critical training experiences and competencies needed by candidates preparing for careers in school psychology. The Standards serve to guide the design of school psychology graduate education by providing a basis for program evaluation and a foundation for the recognition of programs that meet nati onal quality standards through the NASP program approval process (NASP, 2000b). The procedural standards supporting the comprehensive training of school psychologists identified within the Standards include providing school psychology candidates with the knowledge and skills needed to demonstrate entry-level competency in a number of domains of professional practice. Within the domain of Prevention, Crisis Intervention, and Mental Health, sch ool psychologists should be trained to provide or contribute to preven tion and intervention programs that promote the mental health and overall well-being of students (NASP, 2000b). In additi on to the identific ation of mental health training standards within the Standards for Training and Field Placement Programs in School Psychology NASP has published a position statement on the
8 provision of mental health services in th e schools. Within th is position paper NASP advocates for the implementation of school-bas ed comprehensive mental health services in order to help students overcom e barriers to learning (NASP, 2003). Given the standings of NASP within the field of school psychology and its influence on school psychology training programs, school psychologis ts should not only be providing mental health services within the schools but they should also be adeq uately trained and competent in providing such services. Purpose of the Current Study While most school psychologists express a de sire to provide more mental health services to children in schools, little is know n about why they are una ble to provide these services. There is currently insufficient info rmation regarding the t ypes of barriers that school psychologists perceive prohi bit them from provi ding more mental health services. In addition, there have been no peer-reviewed published studies that have explored this area of research. An additional gap in the literature pertains to the significance of demographic characteristics (e .g., years of experience) in f actors that prohibit mental health service delivery. Th e current study addressed these needs by expanding and improving upon the aforementioned research of Yates (2003), who examined the barriers to the provision of counseling services by sc hool psychologists primarily using a forcedchoice survey response form. Specificall y, the current study aimed to expand upon the list of factors that keep school psychologist s from providing addi tional mental health interventions through the use of qualitative research in which participants (school psychologists) identified perceived barriers.
9 Educational Significance This study is significant to the field of school psychology as it contributes to the literature pertinent to school-based mental health servic e delivery. Findings provide a current and comprehensive overview of school -based mental health service provision by school psychologists and a compre hensive list of fact ors that inhibit their ability to provide additional mental health interventions. Because of the studys focus on the training needs of current practitioners, it was expected that this st udy would aid trainers in determining the current need for additio nal education in mental health service assessment and intervention. Rich, descri ptive qualitative comparisons provide information about the significance of demogr aphic characteristics in the provision of mental health interventions. This study also is noteworthy to the field of school psychology as there is a paucity of qualitativ e research (Powell, Mihalas, Onwuegbuzie, Suldo, & Daley, in press). Research Questions To generate information regarding fact ors that prohibit the delivery of schoolbased mental health interventions, the fo llowing research questions were addressed through collecting and analyzing data from focus groups in which new and experienced school psychologists participated. 1. For which types of problems (e.g., a nxiety, depression) are students referred for mental health assess ment and intervention? 2. Which mental health assessment and interventions have school psychologists provided during their past few year s of practice in the schools?
10 a. What is the role that year of expe rience plays in mental health services provided by school psychologists? 3. Which factors prevent school psychol ogists from providing additional mental health assessment and intervention? a. What is the role that year of e xperience plays in the barriers perceived by school psychologists? 4. In which specific knowledge and sk ill areas would additional training be helpful in enabling school psychologists to provide additional mental health assessment and intervention? a. What is the role that year of e xperience plays in the training needs of school psychologists? Definition of Terms Mental Health Problem A mental health problem is defined as an environmental situation or within-child symptom(s) that is likely to prevent (or has already inhibited) a given child from achieving expected developmental, cognitive, social, and emotional milestones or from establishing effective coping skills, secure attachments, and positive social relationships (US DHHS, 1999); this includes psychiatric mental illnesses and mental disorders. Mental Health Assessment and Intervention Mental health assessment and intervention is defined as, following the identification of a given child at-risk for, su spected of, or diagnosed as having a mental health problem, any activity in which school psychologists purposefully engage in an effort to ameliorate the mental health pr oblem(s) within the identified child. Such
11 activities include the following: clinical or beha vioral assessment with intent to intervene; individual, group, or family counseling/psyc hotherapy; case management; consultation with adults including educational personnel and family members; crisis intervention; and mediation management/coordination of care w ith physicians. The following activities are excluded: assessment for special educationa l eligibility (without intent to provide interventions after placement); academic assessment/intervention for children without mental health problems; school-wide or clas sroom counseling; and school-level research and evaluation. Delimitations of the Study The proposed research design incorporat ed deliberate limitations. One of the delimitations of this study included the di fferentiation of the focus groups based upon years of experience. Practitioners with 0-5 years of experience a nd 17 or more years of experience were included while practitioners with 6-16 year s of experience were not the focus of the primary research questions. Pract itioners with 6-16 year s of experience were excluded in comparative analyses in order to provide two distinct groups of practitioners. Another delimitation of the study was the sole use of school psychologists from only two school districts in a si ngle state (Florida). Limitations of the Study For this study, several potential threats to the validity of the findings exist. Thus, limitations pertinent to this study are presente d. Instrumentation was a potential threat to internal validity (Gay & Aira sian, 2003). Instrumentation in cluded data entry errors (i.e., errors occurring during the process of transc ription) by the research group and data not reported or incorrectly reporte d by the participants. Threat s to descriptive validity, the
12 ability to record accurately what was stated during the focus group sessions, threatened the internal validity of the findings. For example, the ta ped recordings may not have captured all of the comments made by partic ipants. To diminish this threat, the researcher utilized a tape recorder co mplemented by the field note taker who was responsible for recording the di alogue of the participants. Another potentia l threat to validity involved the in terpretation of the data obtained from the focus groups (Maxwell, 2005). Therefore, the researcher exerted a conscious effort to avoid imposing her personal bias to the data. To complement this effort, open-ended questions were asked during the focus groups. The utilization of fo cus groups and the differential selection of participants also th reatened the credibility of the results (Maxwell, 2005). Finally, theoretical validity, the lack of collection of or perception of discrepant data, was a potential threat to the fi ndings (Maxwell, 2005). Several issues influenced the external va lidity of the findings. In this study, limited sampling potentially limited the ecologi cal validity of these results (Johnson & Christenson, 2004). Because th is study recruited partic ipants from only two school districts within Florida, the ecological validity of the results are limited. The limited sample size and the exclusion of a random sample within the study also impacted the generalizability of the findings via populat ion validity. Given these limitations, the results from this study should be generalized with caution. Findings apply only to the school psychologists involved w ithin the study and are not re presentative of all school psychology practitioners.
13 Organization of Remaining Chapters The remaining chapters are organized to provide information pertaining to the proposed study as well as previous research regarding mental health service needs and the provision of such services. Chapter 2 includes a review of the current literature relevant to this research study. Chapter 3 includes a description of the design and procedures used in this study. Chapter 4 prov ides an overview of the qualitative results. Chapter 5 presents a discussion of th e implications of the research.
14 Chapter Two Review of the Literature This chapter provides a review of the fr equency of mental health problems in children and adolescents and the insufficient me ntal health services available to address childrens social and emotiona l concerns. The provision of mental health services to children and adolescents is dispersed across multiple systems and pr ofessions: schools, primary care, the juvenile justice system, child welfare, and substance abuse treatment. In recent years, a growing school-based ment al health movement has emerged, largely to overcome barriers to access to childrens services. To this end, a comprehensive review of the mental health servi ces provided through the school system is presented in the chapter. Additionally, this chapter contains a discussion of the expansion of the school psychologists role and function, barriers to th e provision of mental h ealth services in the schools, and a summary of the current status of school psychology graduate training. A summary will conclude this chapter. Prevalence of Mental Health Prob lems in Children and Adolescents Fostering social and emotional health in children is a critical element in healthy child development. Many children have mental health problems that interfere with normal development and functioning. In th e United States, 1 in 10 children and adolescents suffer from mental illness severe enough to cause some level of impairment (Burns et al., 1995; Shaffer, Fisher, Dul can, & Davies, 1996). Bo th the treatment of
15 mental disorders and the promotion of mental health in children are therefore essential pieces of providing comprehensive services to children. Recent data that illustrate the alarming prevalence of mental disorders in you th support the need fo r increased attention to childrens mental health. Sources of Information on Prevalence Ra tes of Mental Disorders in Youth With a growing awareness in the United States regarding the immense burden of disability associated with me ntal illnesses, government agen cies have become advocates of mental health awareness, re search, and interventions. Case in point, in the past decade a collaboration was formed between two Fe deral agencies, The Substance Abuse and Mental Health Services Administration (SAM HSA) and The National Institutes of Health (NIH), and through this collaboration the Surgeon Generals Report on Mental Health (US DHHS, 1999) was published. The Surge on Generals Report on Mental Health provided an up-to-date, extensive scientific lit erature review of the prevalence of mental health problems and mental illnesses. The author s of the literature review indicated that almost 21% of U.S. children aged 9 to 17 y ears had a diagnosable mental or addictive disorder associated with at least minimum im pairment. In the Surgeon Generals Report on Mental Health, it was also suggested that approximately 6 million to 9 million children and adolescents in the United St ates had serious emo tional disturbances (Lavigne et al., 1996). In addition to this comprehensive review of literature, information regarding the prevalence of mental health problems in youth can be gleaned from the annual Youth Risk Behavior Surveillance System (YRBSS) a national school-bas ed survey conducted by the Center for Disease Control (CDC) (U.S. Department of Health and Human
16 Services Center for Disease Control [US DHHS CDC], 2006) The YRBSS involves state and local school-based surveys conducted by state and local education and health services (US DHHS CDC, 2006 ). The YRBSS monitors categor ies of priority health-risk behaviors, including behavi ors associated with ment al health problems. Other prevalence rate studies have focu sed on smaller geogra phical areas within the United States and within specific mental health service modalities. For instance, The Great Smoky Mountain Study of Youth (Costello et al., 1996) used a multistage, overlapping cohorts design, in which 4,500 of 11,758 children aged 9, 11, and 13 years in an 11-county area of the Southern Appalach ian mountain region of North Carolina were randomly selected for screening for psychi atric symptoms using the Child Behavior Checklist Parent Report (Achenbach & Ed elbrock, 1983). A final sample of 1,015 participants completed the Child and Adol escent Psychiatric Assessment (CAPA; Angold et al., 1995), an interview that elicits information about symptoms that contribute to a wide range of DSM-III-R (American Psychiatri c Association, 1987) diagnoses in order to determine the prevalence of psychiatric disorders and mental health impairment The researchers found that 27% of children 9, 11, and 13 years of age have mental health impairments and 20% have a diagnos able mental health condition. Several studies of childhood mental hea lth problems have relied on reports from primary care physicians in the pediatric setting, particularly studies that focus on children younger than 5 years of age. Kelleher, Mc Inerny, Gardner, Childs, and Wasserman (2000) utilized data from a 1979 study cal led the Monroe County Study (MCS), which included a sample of 9,612 4-to 15-year-old children who had visited a random sample of 30 pediatricians in Rochester, New York. Th ese data were compared to a more recent
17 dataset collected from the Child Behavior Study (CBS), a study supported by NIMH and conducted in the Pediatric Research in Office Settings network (PROS) and the Ambulatory Sentinel Practice Network (ASPN ), during 1995, 1996, and the first part of 1997. According to their results, the pr oportion of pediatric patients in which psychosocial problems are seen in primary car e has increased from 7% to 19% over the past 20 years. This more recent estimate (19 %) is consistent with Lavigne et al. (1996), who found that 21.4% of children aged two to fi ve years seen by pediatricians in Chicago met criteria for an Axis I disorder. Briggs -Gowan et al. (2003) conducted a similar study of 5to 9-year-old children seen in pe diatric settings in the greater New Haven, Connecticut area, in which the weighted estim ate for any child psychiatric disorder was 16.8%. Taken together, the aforementioned studies have indicated that between 16.8% and 27% of youth have mental health problem s. As pointed out by Robert, Attkisson, and Rosenblatt (1998), the body of literature on the prevalence of mental health problems is limited by differences in sampling (repres entativeness, sample size), data analyses, case ascertainment, case definition, and presen tation. Representative ness is problematic because the samples studied often do not represent the diversity of the child and adolescent populations. In a ddition, most prevalence studies focus on either a narrow age range (middle school, high school) or a spec ific age (e.g., age 3, age 8, age 11). In addition, prevalence studies use a range of assessment methods to determine the prevalence of mental disorders (e.g., syndrom e scales such as the Child Behavior Checklist, DSM-IV checklists of symptoms).
18 Given the various studies in which resear chers have attempted to estimate the prevalence of mental health pr oblems, it is difficult to determine if these findings have been consistent across studies. Therefore, estimates of the prevalence of the most common mental health problems and speci fic disorders in youth from the two government-funded large-scale sources of information (US DHHS, 1999; US DHHS CDC, 2006), as well as studies conducted by in dependent researchers, are summarized in the following sections. Anxiety disorders According to research in the Surgeon Generals Report on Mental Health (US DHHS, 1999), the combined prevalence of the group of disorders known as anxiety disorders is higher than that of virtually all other mental disorders of childhood and adolescence. The 1-year prevalen ce of anxiety disorders in children aged 9 to 17 years is 13%. Approximately 5.7% of children in the Great Smoky Mountain Youth Survey (Costello et al., 1996) exhibi ted an anxiety disorder, the most common diagnosis among the sample. One of the mo st common anxiety diso rders is separation anxiety disorder, which occurs in approxi mately 4% of children and young adolescents (American Psychiatric Association, 1994). The 1-year prevalence rate for all generalized anxiety disorder sufferers of all ages is approximately 3%. Social phobia is another commonly diagnosed anxiety diso rder, with lifetime prevalence rates ranging from 3% to 13%, depending on how many different situatio ns induce anxiety and the level of fear (American Psychiatric Association, 1994). Mood disorders The synthesis of literature indi cates that the most frequently diagnosed mood disorders in youth are major depressive disorder, dysthymic disorder, and bipolar disorder (US DH HS, 1999). At any one time, between 10% and 15% of the
19 child and adolescent population exhibits symptoms of depression (Smucker, Craighead, Craighead, & Green, 1986). The prevalence of major depression among all children aged 9 to 17 years has been estimated at 5% (S haffer et al., 1996). Estimates of 1-year prevalence in children range between 0.4% and 2.5%; and in adolescents, prevalence rates are as high as 8.3% (Garrison et al., 1997; Kessl er & Walters, 1998). The prevalence of dysthymic disorder in adol escents is around 3% (G arrison et al., 1997). Mood disorders substantially increase the ri sk of suicide, which is a matter of serious concern for professiona ls who provide mental health services to children and adolescents. The YRBSS indicated that 16.9% of students had seriously considered attempting suicide during the 12 months pr eceding the survey (US DHHS CDC, 2006). Regarding suicidal behaviors, 8.4% of students reported act ually attempting to commit suicide one or more times during th e 12 months preceding the survey. Some states and cities conducted a school-based Youth Ri sk Behavior Survey (YRBS) among middle school students (Whalen et al., 2005). In 2003, the proportion of mi ddle school students who reported suicidal ideati on ranged from 8.5% to 11.8% for sixth-grade students, 10.0% to 15.9% for seventh-grade student s, and 14.0% to 19.8% for eighth-grade students. Of note, this study was conducted on a much smaller scale than the nationwide YRBSS survey. Although the statewide sa mples were relatively large (1,179 to 7,709), the states and cities select ed were not necessarily repr esentative of the population. Behavior disorders In a national sample of 21,065 4-to 15-year-old children included in the Child Behavior Study (CBS), a prevalence rate of 4.4% for behavioral/conduct problems was found (Kelle her et al., 2000). In Lavigne et al.s (1996) dataset of 510 children aged 2 thr ough 5 years from the Chicagoland area, the
20 prevalence of behavior problems was 8.3%. As summarized in the Surgeon Generals Report (US DHHS, 1999), prevalence rates of oppositional defiance disorder range from 1% to 6%, depending on the population sampled and the way the disorder is evaluated; rates are lower when impairment criteria are mo re strict and when information is obtained from teachers and parents rather than from the children alone (Shaffer et al., 1996). The prevalence of conduct disorder in 9to 17ye ar-olds varies from 1% to 4%, depending on how the disorder is defined (Shaffer et al., 1996). The Great Smoky Mountain Youth Survey found the prevalence rates of c onduct disorders and oppositional defiance disorder were 3.3% and 2.7%, respec tively (Costello et al., 1996). Eating disorders As summarized in the Surgeon Generals Report (US DHHS, 1999), eating disorders are serious, at times lif e-threatening, conditions that arise most often in adolescence and dispr oportionately affect the fema le population. Approximately 3% of young women have one of the three ma in eating disorders: anorexia nervosa, bulimia nervosa, or binge-eating disorder (Becker, Grinspoon, Klibanski, & Herzog, 1999). Anorexia nervosa has the most severe consequence, with a mortality rate of 0.56% per year (Sullivan, 1995). Substance use disorders Substance abuse disorders are of particular concern because of their link with other mental disord ers. Approximately 51% of those with one or more lifetime mental disorders also have a lifetime history of at least one substance use disorder (US DHHS, 1999). The rate of s ubstance abuse disorder is highest in the older adolescents, particularly within the 15to 24-year-o ld age group (Kessler et al., 1994). According to the National Survey on Drug Use and Health (Substance Abuse and Mental Health Service Administration, 2006) in 2005 youth aged 12 to 17 years had a
21 rate of substance dependence or abuse of 8.0%. Approximately 10% of youth aged 12 to 17 years were current illicit drug users: 6.8% used marijuana, 3.3% used prescriptiontype drugs nonmedically, 1.2% used inhalant s, 0.8% used hallucinogens, and 0.6% used cocaine. The rates of alcohol dependence or abuse for youth aged 12 to 17 years was approximately 5.5% (SAMHSA, 2006). In sum, a sizeable number of children are diagnosed with mental health problems and di sorders. Numerous studies consistently have estimated the prevalence of mental hea lth problems in children and adolescents at approximately 20%. These findings support the essential need for mental health treatment for youth. Therefore, important lines of research are those that examine the proportion of children receiving mental health services and the common modalities for treatment. Child and Adolescent Ment al Health Services Just as there is evidence for the alarming prevalence of mental health problems in children and adolescents and the correspondi ng need for mental health treatment, evidence also supports the efficaciousness of providing such services to children. Support for the use of child psychotherapy ha s been evidenced through countless studies and four major meta-analyses that examined th e effects of child ther apy (Ollendick et al., 2005). A thorough review of the literature cons istently shows that therapy for children results in beneficial impacts on the lives of children and their families. In recent years a shift has occurred towards identifying effi cacious treatments for children who present with specific behavioral, emo tional, and social problems. The movement towards evidence-based pr actice in child psyc hotherapy led to the Society of Clinical Psychology Task Fo rce on Promotion and Dissemination of
22 Psychological Procedures publishing a comprehe nsive review of empirically validated psychological treatments in 1995 (Task For ce on Promotion and Dissemination of Psychological Procedures, 1995). In this repor t, three categories of treatment efficacy were defined: 1 ) well-established treatment s, 2 ) probably efficacious treatments, and 3 ) experimental treatments. The criteria for classification as a well-established treatment specified that the treatment should be shown to be superior to a psychological placebo, pill, or other treatment. Additionally, e ffects supporting a well-established treatment should be demonstrated by at le ast two different investigatory teams. To be classified within the probably efficacious treatment cat egory, the specified treatment should be shown to be superior to a wait-list or no-tr eatment control condition. For both of these categories, characteristics of the clients should be well specif ied and the clinical trials were to be conducted with treatment manuals. The final requirement was that the outcomes of treatment should be demonstr ated in good group design studies (i.e., reasonable to conclude benefits observed due to effects of treatment and not due to chance) or a series of controlled sing le-case design studies. The third category, experimental treatments, included treatments not yet shown to be at least probably efficacious. The purpose of this category was to include treatments frequently used in clinical practice or newly de veloped treatments that had not yet been fully evaluated (Ollendick et al., 2005). Using the aforementioned criteria for the three categories of treatment, the 1995 Task Force Report identified three well-e stablished treatments and one probably efficacious treatment for children. The three well-established treatments for children included behavior modification for developm entally disabled individuals, behavior
23 modification for enuresis and encopresis, a nd parent training progr ams for children with oppositional behavior. The one probably efficacious treatment identified was habit reversal and control techniques for children with tics and related disorders. Since this report was published, additional task forces have been established by the Society of Clinical Psychology and the Society of C linical Child and Adolescent Psychology to identify effective psychosocial treatments for high-frequency problems encountered in clinical and other settings serv ing children with mental heal th problems. Together they published a review of empirica lly supported treatment for children with autism, anxiety disorders, attention-defic it/hyperactivity diso rder (ADHD), depre ssion, and oppositional and conduct problem disorders in the Journal of Clinical Child Psychology (Ollendick et al., 2005). In summary, the movement towa rds evidence-based pr actice has led to the identification of a number of empirically valid ated psychological treatments that can be utilized across the multiple systems that curr ently provide mental health services to children and adolescents. The provision of mental health services to children and adoles cents is dispersed across multiple systems and professions: sc hools, primary care, th e juvenile justice system, child welfare, and substance abuse trea tment centers (Satcher, 2000). Prior to the 1980s, the traditional model of mental hea lth services for chil dren and adolescents consisted of office-based outpatient therapy and psychiatric residential placement, which were handled primarily through the medical a nd mental health systems (Satcher, 2000). Over the years, a much more complex system for providing services has evolved, driven by the multiple government initiatives and advocates for more comprehensive mental health services for children (Brown, 2002). Nevertheless, almost 20 years after Knitzers
24 (1982) landmark publication, Unclaimed Children: The Failure of Public Responsibility to Children and Adolescents in N eed of Mental Health Services the delivery of mental health services remains complicated and servi ces continue to be in accessible to children (Brown, 2002). Proportion of Children Receiving Se rvices From Various Sectors Several recent studies have attempte d to estimate the number of children receiving mental health services. This is an important area of inquiry given that in earlier studies researchers have suggested that at least two-thirds of the 20% of all children and adolescents with a mental health disorder neve r received mental hea lth services (Stiffman et al., 1988). Follow-up studies have provided professionals with a complex picture of the status of those children in need of receiving mental health service. Kataoka et al. (2002) examined the rates of mental health serv ices in three crosssectional nationally representative samples of more than 11,500 house holds with 3to 17year-old children. The most knowledgeable ad ult in the household ( 95% were parents) provided information about the sampled ch ild. Between 6.0% and 7.5% of youth across data sets reportedly received some type of me ntal health service; rates were consistently lower for preschool children (2%3% for child ren 35 years old). Across the data sets, a higher percentage of children with public insurance (e.g., Medicar e, Medicaid) used services (9%13%) than did the privatel y insured (5%7%) and uninsured (4%5%) children. The authors sugge st that the lower differences by insurance status among children could be partly due to the high le vel of unmet need across insurance groups among children.
25 The percentages of 6to 17-year-olds with mental he alth problems ranged from 15.2% to 20.8% across datasets. Thus, only 29% to 49% of children with mental health problems receive any treatment. Data from a ll three national surveys showed that greater levels of mental health need were associat ed with higher rates of receiving any mental health care among children, suggesting that ch ildren do not receive care until they are very symptomatic. Controlling for other factor s, the authors conclude d that the rate of unmet need was greater among Latino than White children and among uninsured than publicly insured children. Caution should be us ed when interpreting the data for children under age 6 year, because the sample size was relatively small ( n= 131 children). Data from the first wave of the Great Smoky Mountains Study of Youth (GSMS) were utilized to examine the number of childre n receiving mental health services and the role of other child service sectors in providi ng mental health care to children (Farmer et al., 2003). Clinical status was determined by whether or not a child met the diagnostic criteria for a mental disord er using the psychiatric clas sification system DSM III-R, (American Psychiatric Association, 1987) a nd whether or not he or she exhibited impaired functioning (inability to function in developmentally appropriate ways at school, at home, and with p eers) related to the reporte d symptoms. The diagnosis/no impairment category (9.1%) included children w ho met diagnostic criteria for at least one DSM-III-R condition but did not display impa ired functioning. Children with both a diagnosis and impairment (11.1%) constituted th e most severely affected category. Five sectors of mental heal th service use were included in this study: mental health (e.g., psychiatric hospital, residen tial treatment center, group hom e, detoxification unit, and private mental health professional); e ducation (e.g., guidance counselor/ school
26 psychologist, and special class); health (e.g., me dical inpatient unit, family doctor/ other nonpsychiatric physician); child welfare (e.g., so cial services counsel ing); and juvenile justice (e.g., detention center/ jail). The likelihood of a child having used mental health services within the three months preceding the initial interviews was strongly linked to the childs clinical status. Of children without a diagnosis or impairment (63.7% of the sample), only 1.6% reported us ing specialty mental health services during the three months prior to the interview, compared w ith 3.3% with a diagnosis but no impairment, 6.0% of children with an impairment but no diagnosis, and 21.6% with both a diagnosis and impairment. Among the 16% of children in the sample who reported receiving mental health care in any sector, 13% (81% of those served) receiv ed care in only one sector, and 3% (19% of those served) receiv ed care in more than one sector. Between 70% and 80% of children who received services for a mental health problem were seen by providers working within the education s ector (mostly guidance counselors and school psychologists). For the majority of children who received any mental health care, the education sector was the sole source of care. Approximate ly 11% to 13% of children receiving any mental health se rvices reported use of the gene ral medical sector for these services, with little differentiation by clini cal status. The child welfare and juvenile justice sectors provided mental health services to relatively few children in the sample. Because the Smoky Mountain and Blue Ridge Area Programs are recognized throughout the state for their well-developed, up-to-date se rvices for children and their families, the proportion of children receiving se rvices may be higher in this sample than in other regions.
27 A follow-up study was conducted with the GSMS participants to determine the persistence of use of mental health services (Farmer, Stangl, Burns, Costello, & Angold, 1999). Fewer than 10% of children in the samp le persisted in service use across multiple 3-month follow-ups. Among those who used specia lty mental health se rvices, nearly onehalf (47.3%) used services dur ing at least two of the 3-m onth periods. For education services persistence was much less common, with only 20% using services during more than one 3-month period. Importantly, the e ducation sector was the point of entry into mental health services that was least likel y to be followed by involvement with other sectors. In addition, the ma jority of youths who entered se rvices through the specialty mental health sector (62%) used services from additional sectors, including education (57.5%), general medicine (29.8%), and child welfare (20.6%). Leaf et al. (1996) conducted a similar study with the four community sites included in the National Institute of Me ntal Health (NIMH) Methods for the Epidemiology of Child and Adolescent Me ntal Disorders (MEC A) Study. The study consisted of 1,285 adult-child pairs, with youths aged 9 through 17 years surveyed concerning the existence of psychiatric symp toms, level of functioning, and risk factors for psychiatric disorders. Both parents and youths were interviewed with the NIMH Diagnostic Interview Schedule for Children (DISC), a highly structured diagnostic instrument (Shaffer et al., 1996). During the in terview, parents were provided lists of service settings and potential service providers and asked to indicate (a) whether the youth had ever been brought to any of these se ttings because of an emotional, behavior, drug, or alcohol problem, and (b ) the youth's contacts related to an emotional, behavior, drug, or alcohol problem. Using the reports of specific services and providers utilized by
28 the youth, outpatient service utilization was cat egorized into six types of services: (a) mental health specialty sect or (e.g., contacts with a psychi atrist, psychologist, social worker, or counselor in a priv ate office or psychiatric outpa tient facility), (b) medical services from a nonpsychiatrist physician or a nurse; (c) school-b ased services; (d) clergy; (e) social services; and (f) other or classifica tion unknown (e.g., spiritualists, herbalists, or faith healers). One-quarter of the children reported some mental health service contact during their lifetimes; 36.5% of youth who me t criteria for a psychiatric disorder reported use of a mental health servic e. In the past year, utilization of mental health services averaged 14.9% across community sites. Of those children who received services in the past year, 8.1% received serv ices from a mental h ealth specialist, 2.9% received services from a medical professiona l, 8.1% received services from the school system, 1.2% received services from the cl ergy, and 1.6% of childre n received services from the social service system. Of note, re ports of parents and th eir youths regarding the use of mental health and subs tance abuse services showed considerable inconsistencies, and parents and children frequently differed in their reports about the use of mental health services. Pandiani et al. (2005) conducted a compre hensive study of the utilization of mental health services within Vermont. Re sults reported in the st udy were based entirely on analysis of existing administrative databa ses, such as the state Department of Education (DOE). Eight sp ecial populations were exam ined, including three groups defined by school program participation or perf ormance: students with an Individualized Education Plan (IEP) for an emotional/behavio ral disorder, students with an IEP due to another disability, and students with poor school performance. Data for these groups were
29 obtained from the state DOE. Two groups we re defined by participation in economic programs, specifically the state Medicaid and welfare programs, with data being obtained from the relevant state agency. Two groups were defined by indication of social or emotional trauma with data obtained from state child protection agency and the state Office of Child Support. One group was defined by criminal/juvenile justice involvement, with data obtained from stat e juvenile justice agency, courts, and the Departments of Public Safety and Corrections Measures of utilization rates for young people in the eight special populations were based on information from additional public education and social service agencies. For each of these eight special groups, the proportion of children in the special populati on who received commun ity mental health services was determined by probabilistic population estimation (Banks & Pandiani, 2001). Overall, more than 1 in 20 children and adolescents were served by a public mental health childrens services pr ogram during 2002. Among the eight special populations, young people with an IEP for an emotional/behavioral disorder had the highest community mental hea lth utilization rate (44%), followed by youth with a history of abuse/neglect (30%), and youth involved in the cr iminal/juvenile justice system (28%). Children with poor school performance and children enrolled in the state Medicaid program had the lowest community mental heal th utilization rates (6% and 8%). In the combined sample, mental health servi ce utilization by young pe ople increased with increasing age from 2% of children under 7 ye ars of age, to 6% in the 712 age group, and 8% in the 1317 age group. Of note, Vermon ts system of care for young people with emotional or behavioral disorders is excepti onal in many ways, resulting in a rate of utilization of public mental hea lth services that may exceed that of most states. Therefore,
30 the data presented in this study may overestim ate the utilization rate of children in other geographic locations. Nevertheless, this st udys findings that only 44% of children who receive special education servic es due to severe emotional or behavior problems actually receive treatment is remarkable because, by definition, 100% of this group needs mental health services. A similar argument for the ex tensive need for services could be made for most of the other seven special popu lations studied in this research. In conclusion, the studies reviewed a bove support the notion that few children who have a mental health need actually recei ve psychological treatment. Studies across the decades illustrate that the majority of children and adolescents with a psychological disorder never receive mental health servic es (Burns et al., 1995; Farmer et al., 2003; Kataoka et al., 2002; Leaf et al., 1996; Pandiani et al., 2005; Stiffman et al., 1988). Variability in the methods used to identify (a ) youth with mental health problems and (b) types of mental health servic es provided, prohibits comparis ons across similar research. Nevertheless, the studies are consistent in the finding that of those children who do receive treatment, the majority receive services through the education system (Burns et al., 1995; Farmer et al., 2003). The following s ection provides a review of mental health services provided within the education system. Mental Health Services in the Schools In recent years, a growing school-based mental health movement has emerged, essentially to overcome access barriers to child rens services (Flaherty, Weist, & Warner, 1999; Hunter, 2004). A survey of school-based health clinics in 19981999 indicated that 57% offered mental health services as compar ed to only 30% seven ye ars earlier (Brindis, Klein, Santelli, Juszczak, & Nystrom, 2003). In fact, in recent years schools have been
31 come to be regarded as the de facto providers of mental health services for children and youth (Farmer et al., 2003), provi ding an estimated 70% to 80% of psychosocial services to those children who receive them (Rones & Hoagwood, 2000). Mental Health Problems Refe rred for Treatment in Schools Mental Health Services in the United States (Foster et al., 2005) is one of the most comprehensive examinations of the provision of mental health services within the educational system. A representative ra ndom sample of 1,147 schools in 1,064 districts across the country responded to a survey about the problems most frequently presented by students in their schools. Respondents rank ed the three most frequently seen problems for male and for female students out of a broa d list of 14 psychosocial or mental health problems. For both male and female students, the mental health problem category most frequently endorsed was social, interpers onal, or family problems (73% male, 80% female). The second and third most freque ntly cited concerns differed for males and females. Anxiety (41%) and adjustment issu es (36%) were cited as the second and third most frequent problems, respectively, for fema les. Aggression or disruptive behavior (63%) and behavior problems associated with neurological disorders (42%) were cited as the second and third most frequent problem s for males. For both boys and girls, depression and substance use/abuse were re ported more frequently as school level increased. The frequency of citing substan ce abuse as a major problem jumped sharply from middle school to high school for both male s and females (for males, from 4% of middle schools to 34% of high schools; for fe males, from 3% of middle schools to 19% of high schools).
32 Repie (2005) examined the pe rceptions of regular and sp ecial education teachers, school counselors, and school psychologists on presenting problems of students. The School Mental Health Issue Survey (Weist Myers, Danforth, McNeil, Ollendick, & Hawkins, 2000) was mailed to a random sample of school counselors, school psychologists, regular teachers, and special education teachers, yielding a final sample of 413 respondents from all 50 states. Respondent s rated the types of problems that were most critical in their schools, or most in need of services to be provided. Respondents rated impaired self-esteem, attention defici t/hyperactivity, and peer relationship problems as the most critical emotional and behavioral problems of students in their schools. They viewed suicidal thoughts and/or behavior s, inappropriate sexu al behaviors, and alcohol/drug abuse as least critical. Cons istent with previous research (US DHHS, 1999), high school respondents rated depres sion significantly highe r than did their elementary school counterparts. In add ition, high school and multiple grade level respondents rated suicidal thoughts significan tly higher than elementary persons. Whitmore (2004) surveyed a random samp le of 241 school psychologists on the types of referral problems that they encounter in the schools. The problems identified as occurring most frequently across all gr ade levels included academic problems, externalizing issues (e.g., ADHD, anger, conduc t), peer problems, and self-esteem issues. Respondents serving Grades 6-12 reported a hi gh occurrence of problem s also related to depression, motivation, school phobia, s ubstance abuse, and truancy. In conclusion, the most commonly referred mental health problems within schools include impaired self-esteem, interpersonal problems, family problems, and disruptive behavior problems. Because of the varying cate gories used to define the types of mental
33 health problems referred, it is difficult to compare studies with similar intent. Preliminary findings support differences in re ferral concerns across school level. With such a breadth of mental health problems be ing referred for intervention within schools, it is important to know which school personnel provide the appropria te mental health services. School Personnel Providing Me ntal Health Services In the Mental Health Services in the United States study (F oster et al., 2005), about one-third of school dist ricts reported that they ex clusively utilized schoolor district-based staff to provide mental health services, which the re searchers defined as those services and supports delivered to indi vidual students who ha ve been referred and identified as having psychosocial or mental health problems. Approximately one-quarter of school districts only contracted with out side providers for mental health services provided through the district, and approximate ly one-third of schools combined schooland district-based staff with outside provide rs. Approximately one-half of all districts (49%) used contracts or other formal agr eements with community-based organizations and/or individuals to provide mental health services to st udents. The most common types of district-based staff providing mental health services in schools were school counselors (77%), followed by nurses (69%), school psychol ogists (68%), and social workers (44%). Three-quarters of schools had at least one school counselor on st aff, more than two-thirds had a school psychologist and/or nurse, and 44% had a school social worker. School counselors reported spending 52% of their time providing mental health services, compared to 48% for school psychologists. School social work ers reported spending 57% of their time providing mental health se rvices and school nurses reported spending
34 32% of their time providing mental health se rvices. Most schools had between two and five staff providing mental hea lth services, but the distribu tion was broad, from no staff (3%) to 10 or more staff (6%). The most commonly reported number of staff was three (20% of schools). Of note, detailed info rmation on which specific services each staff member (e.g., school psychologist) provided was not sought. Therefore, it is impossible to determine whether school psychologists were providing mental heal th services in the form of emotional/behavioral assessment, for example, or group counseling. Types of Mental Health Services in the Schools Significant variation exists in the nature and types of me ntal health services (e.g., parent training, individual counseling, group counseling) de livered within the school system and by organizations closely affiliated wi th schools. This diversity of services is partially because of the multiple objectives of mental health services provided across the entire continuum of preven tion, education, and treatment (Adelman & Taylor, 2000). Individual school sites also have unique f eatures, such as the socioeconomic background of their students, that have to be consider ed when planning and ev aluating mental health services (Ringeisen, He nderson, & Hoagwood, 2003). In the School Mental Health Services in Foster et al.s (2005) United States study, respondents reported the types of serv ices provided to stude nts in their schools, either directly by the school or district or through community-based organizations with which the school or district had formal ar rangements. A high percentage of schools provided assessment for mental health problems (87%), behavior management consultation (87%), and crisis intervention (87%), as well as referrals to specialized programs (84%). Individual counseling, cas e management, and group counseling also
35 were frequently provided (by 76%, 71%, and 68 % of schools, respectively). In general, short-term interventions were more commonly provided than were serv ices that tended to be longer term (e.g., counseling). Less than one-half of all schools reported that they provided substance abuse counseling (43%), and medication/medication management was the least likely of all services to be pr ovided (34%). Schools also indicated that some services were more difficult to deliver than others. The service most frequently ranked as difficult or ver y difficult to deliver was family support services, followed by medication management, substance abuse counseling, and referra l to specialized program or services. The services most fr equently ranked as not difficult or only somewhat difficult to deliver were i ndividual and group counseling, followed by behavior management and crisis intervention. Heneghan and Malakoff (1997) reported the types of services provided within a sample of schools throughout the United States A survey was mailed to a sample of 221 principals or program directors from el ementary and middle schools, with some respondents representing affiliated preschool programs. All targeted schools had established at least one com ponent of the School of the 21st Century model, a movement to provide integrated services to children in the schools, and/or anticipated implementing new components. Of the 221 surveys mailed, 126 were returned (57% response rate). The survey classified mental health servic es as "short-term," defined as psychological testing or crisis counseling; or "chronic," defined as longterm counseling or psychiatric care. Fifty-one percent of schools provided s hort-term mental heal th services, whereas only 19% provided chronic mental health se rvices. Twenty-six pe rcent reported that psychological counseling was available on a da ily basis; 51% on a w eekly or bi-weekly
36 basis; and 10% on a monthly basis. Because the schools that participated in the survey were part of the Schools of the 21st Century, this sample may over-rep resent the range of services provided; thus, findings should not be generalized to le ss progressive schools. An analysis of data from the 19941995 National Longitudinal Study of Adolescent Health (Add Health) is one of a few studies that compares the types of mental health services provided acro ss geographic locations (Slade 2003). This study aimed to estimate the proportion of middle and high school s that offer school-based mental health counseling, physical examinations, and substanc e abuse services. The Add Health is a nationally representative survey of students in Grades 7 through 12 in the United States. Administrators from 125 schools were asked ab out the availability of a range of health services either at school or at another school within the same district. Overall, nearly onehalf of schools offered on-site mental heal th counseling and approximately 40% offered on-site substance abuse counseli ng. Larger schools were more likely to offer all three health services on-site. There were signi ficant regional variati ons in the on-site availability of mental health counseling. More than two-thir ds of schools in the Northeast (86.1%) and West (68.5%) offered counseling on -site, whereas less than one-half of schools in the South and less th an one-third of schools in the Midwest offered mental health counseling on-site. Schools with grea ter percentages of students from minority race and ethnic group backgrounds were significan tly less likely to offer all three health services on-site. The School Health Policies and Progra ms Study (SHPPS) 2000 assessed mental health and social services at the state, district, and school levels (Brener, Martindale, & Weist, 2001). State-level data were collected from all 50 st ates plus the District of
37 Columbia. District-level data were collected from a nationally representative sample of public school districts and from dioceses of Catholic schools included in the school sample (513 of 734 districts). School-level data were collected from a nationally representative sample of public and private elementary, middle/junior high, and senior high schools. Stateand di strict-level data were co llected by self-administered questionnaires completed by designated res pondents for each of seven school health program components. School-level data were collected by compute r-assisted personal interviews with respondents from 876 sc hools. The most common respondents were guidance counselors, psychologists, social workers, and principa ls. Results indicated that the three most common forms of mental health service delivery were individual counseling, case management, and evaluation/te sting. Almost two-thirds (62.8%) of schools offered a student assistance program (S AP), which provide services designed to assist students experiencing personal or so cial problems that can affect school performance, physical health, or overall well-b eing. More than three-fourths of schools provided each of the following services: cr isis intervention for personal problems; identification of or counseling for mental or emotional disorders; identification of or referral for physical, sexual or emotional a buse; and stress management services. In addition, more than three-fourths of sc hools provided alcohol and other drug use prevention, suicide prevention, and violence prevention in one-on-one or small group discussions, and more than three-fourths pr ovided case management for students with behavioral or social problems, as well as group and individual counseling. Approximately 1 in 10 schools (10.4%) had a school-based health center (SBHC) that provided mental health and so cial services to students. In addition, 51.6% of schools had
38 a contract, memorandum of agreement, or ot her similar arrangement with organizations or professionals to provide mental hea lth or social servi ces to students. In a survey of a national representative sample of school psychologists, special and regular education teachers, and school counselors, Repi e (2005) found that the most commonly cited services available as part of the school program were evaluation of emotional/behavioral problems (91%), individu al counseling services (84%), and crisis intervention services (81%). The most infr equently available services were family counseling services (28%), s ubstance abuse servi ces (38%), and education presentations to students on mental health (51%). The infrequency of family counseling services was further illustrated in Whitmores (2004) comprehensive study of th e family counseling practices of school counselors, school psychologists, and school social workers. A random sample ( n = 538) was obtained through each professions nationa l organization; the overall response rate was 62.9%. Only 10.9% to 12.7% of the three groups of school prac titioners reported providing school-based family counseling. Eigh teen percent of res pondents reported that family counseling was offered as a school-based service in their school districts. In the school districts providing family counseling, 34.9% of respondents reported that the service was provided by school counselors, 28.6 % reported that the service was provided by school psychologists, and 44.4% reported that the serv ice was provided by social workers. In addition to the provision of mental health services within a school by individual personnel, comprehens ive mental health programs, such as student assistance programs (SAP), and school based health centers (SBHC) are becoming common modes
39 of providing mental health serv ices in the school. With the recent increase in the number of SBHC within the U.S., the system in whic h mental health services are being provided has broadened. To this end, a discussion of sc hool-based health centers and the types of services provided within th ese programs is provided. School-Based Health Centers (SBHC) Over the past two decades, the number of SBHCs has grown rapidly. The movement towards more comprehensive schoolbased health and mental health services began in the 1980s and was driven by several national policy initiatives. According to Flaherty et al. (1999), in 1987 there were approximately 2,150 SBHCs nationwide. In 1993, the number had more than doubled to 5,000 SBHCs nationwide. Although the SBHCs were initially developed to provide primary health servi ces, the provision of mental health services quickly became an e ssential component of these clinics. In a national survey of school-based health cen ters in 1998, mental h ealth issues were reported as the second most fre quently cited reason for visits to a SBHC (Flaherty et al., 1999). Given the prevalence of mental health needs among children, many school districts began to implement SBHCs. SBHCs provide some type of treatment and assessment to all children within a school. Assessment may include mental h ealth evaluations, diagnostic interviews, classroom behavior observation, and screening for emotional or behavioral problems. SBMH programs may offer individual therapy, group therapy, or preventive services. One of the primary goals of a SBHC includes increasing access to mental health services and improving psychosocial functioning (Hunter, 2004).
40 The 1998-99 Census of School Health Ce nters provided information about the types of mental health serv ices provided in SBHCs ( National Assembly for School-Based Health Care, 2000). Data were collected through a questionnaire that was mailed to health centers; 806 school-based health centers (centers locate d in a school or on a school campus) responded, representing a 70% response rate. Ninety-two percent of the health centers employed a combination of physicians, ph ysician assistants, or nurse practitioners to provide physical health services. Physical health services staff collectively averaged 27 hours per week on-site. Mental health profession als were part of the clinical team in 57% of the health centers for an average of 33 hours a week. Mental health and counseling services provided by health centers included crisis intervention (79%), case management (70%), comprehensive evaluation and treatmen t (69%), substance abuse (57%), and the assessment and treatment of learning probl ems (39%). Group counseling was used by health centers to offer peer support (59%), grief counseling (53%), classroom behavior modification (49%), substance use prev ention and treatment (41%), and gang intervention (26%). Taken together, the aforementioned studies have found that schools often offer a breadth of mental health serv ices to their students, ranging from individual counseling to crisis intervention. The body of literature on the types of mental health services provided in schools is limited by differences in the defini tion of mental health services utilized in each study. In particular, studies vary across th e types of mental hea lth services included and the degree to which each service is detailed into a comprehensive list (i.e., counseling: substance abuse vs. family). A consistent finding across studies is that school psychologists often have a role in the provision of ment al health services in the
41 schools. However, a more thorough review of the professional practices of school psychologists within the schools reveals they spend relatively little time in the role of interventionist (Cur tis et al., 2004). School Psychologists Role and Function With the recognition of the importance of providing mental health services to children, including studies portraying a vast di screpancy between the number of children with mental health problems and those actually receiving services, schools increasingly have become the most common means by wh ich children are provided mental health services. Accordingly, the field of school psychology has recognized the importance of the provision of mental health services in the schools as well as the major role that school psychologists can play in pr oviding these services. To th is end, a review of school psychologists role in the sc hools is provided, particularly in the provision of mental health services, as well as th e amount of time currently spent and desired to be spent in the provision of ment al health services. Expectations for School Psychologists In volvement in Mental Health Services Several sources provide direction regardi ng the present and future courses of the field of school psychology, including the poten tial and essential roles that should be performed by school psychologists. Pr ofessional organizations and the school psychology literature are two such sources of direction. Professional organizations provide practitioners with a framework of their roles within th e school system through position statements. School psychology literat ure commonly provides the field with a research-based synthesis of how school psychologists can expand their roles within the school system.
42 National Association of School Psychologists. The National Association of School Psychologists (NASP) is an intern ational organization with more than 22,000 members that has been influential in setting the standards for school psychology programs and practice in the United Stat es (NASP, 2000b). NASP publishes position statements that describe the ideal functions and roles of school ps ychologists, including a statement on providing mental health services in the schools. As summarized in this statement, NASP acknowledges the importance of such factors in students' lives as psychological health, supportive social relationships, positiv e health behaviors, and schools free of drugs and violence in fac ilitating success in school (NASP, 2003). NASP advocates for the implementation of comprehens ive mental health services in the schools in order to help students overcome barri ers to learning, often stemming from poverty, family difficulties, and/or emotional and social needs. Regarding th e professional role of the school psychologist, NASP ( 2003) states the following: School psychologists are at the forefront of mental health service delivery in the schools. School psychologists ar e uniquely trained to integrate the knowledge and skill base of psychology with their specific training in learning, child development, and educa tional systems. Given this broad training and experience, school psychol ogists are well-qualif ied to provide comprehensive, cost-effective me ntal health services. (p. 1) Regarding specific activities provided through comprehensive mental health services, NASP notes school psychologists curren tly provide such services as assessment, counseling, implementation of prevention prog rams, behavioral c onsultation services, and crisis intervention. NASP states that school psychologi sts serve studen ts directly
43 through individual and group counseling/th erapy services, and as members of comprehensive school based mental health programs (2003, p. 1). Of note, out of NASP, the American Psychological Associat ion Division of School Psychology, and the Florida Association of School Psychologi sts (FASP), NASP was the only professional organization to provide a positi on statement on the provision of mental health services. School psychology literature Similarly, calls for the expansion of the role of the school psychologist through the delivery of mental health services have been made in the school psychology literature. For instance, Ehrhardt-Padgett, Hatz ichristou, Kitson, and Meyer (2004) argued that no matter what ro le a school psychol ogist currently haspractitioner, trainer, or stude nt-they must begin to conceptu alize their roles in service delivery differently. They call for school ps ychologists to take action by promoting the need for comprehensive mental health servi ces in the schools and to offer opportunities for professional development related to c onsultation, intervention, and mental health. Moreover, because school psychologists possess expertise and experience in mental health and education, they have been recognized as being uni quely qualified to fill the position of school-based mental health specialists (Nastasi, 2000; NASP, 2003). For example, Nastasi (2004) highlights school ps ychologists interv ention skills as a facilitator in devel oping and implementing classroom-ba sed programs, and small-group and individual interventions, and in developing educational programs for teachers, parents, students, and community members. In addition to possessing the skills required to provide mental health services, school psychologists have c onsistently voiced a desire to spend more time providing these servic es and less time in their current major functions, as discussed in the following sections.
44 School Psychologists Major Functions Despite calls to spend increased time in activities relevant to mental health intervention, the typical school psychologist spends more than one-half of his or her time in assessment activities related to special e ducation eligibility deci sions (Curtis et al., 2004). Indeed, the establishment of the school psychologist as a pr actitioner w ithin the school system was founded on the function of psychoeducational assessment for special education placement (Fagan & Wise, 2000). A lthough this has been the primary function of a school psychologist, for the past few decad es leaders in the field have advocated for role expansion and respecialization (Crespi & Politikos, 2004). Even with repeated calls for increased services over the past decades, the foundation of the assessment role has continued across the century but also has yi elded to two other major roles for school psychologists: direct interv ention and consultation, with the earliest mentions of intervention occurring in the 1930s (Fagan & Wise, 2000). Across the decades, these three roles have accounted for most of the school psychologists tim e (Crespi & Politikos, 2004). In addition, the traditional assessmen t role itself has broadened in scope as additional factors, such as environmen tal (e.g., home environment, classroom environment), have been acknowledged to c ontribute to the problems of children and their education (Fagan & Wise, 2000). Since 1970, social and educational move ments have strengthened the school psychologists identity and supported more expanded services and functions. For example, since the 1970s, practice has been largely defined by special education legislation and funding (Fagan, 1992). Duri ng this time period, a number of legal challenges to special education occurred and a number of legislative acts were passed, the
45 most important being PL 94-142 (Education for All Handicapped Children Act) in 1975 (United States Senate and House of Representatives, 1975). Most recently the Individuals with Disabilities Education Improvement Act (United States Senate and House of Representatives, 2004) was issued, which may change the assessment role of the school psychologist (Fagan, 2002). In the field of special education, towards the end of the 1980s the focus shifted to another target group, children at risk. With this shift, changes occurred in the provision of related services and instruction, and more recently toward functional assessment. A shift in the school psychologists role towards prereferral assessment, intervention, and sec ondary prevention for at-risk groups are additional potential indicators of changes in role and function (Furlong, Morrison, & Pavelski, 2000). More recently, there has been a resurgence of interest in consultation and an ecological approach to family assessment and intervention, including communication and collaboration between th e home and the school (Fagan & Wise, 2000). Due to these various external forces (i.e., legislation, social changes), a greater potential for school psychologist s to broaden their roles w ithin the school system has emerged. Importantly, job-site characteris tics (e.g., school psychologi st: student ratio; school system expectations) and what the pe rson brings to the job (e.g., professional skills and personal characteristics) also are in fluential factors in determining the role of each individual school psychologi st (Fagan & Wise, 2000). Time school psychologists sp end in each major function. In general, school psychologists spend more than two-thirds of their time in activities related to students who have identified disabilities and are part of the special educ ation system (Hosp & Reschly, 2002; Reschly & Connolly, 1990). Th e services that school psychologists
46 deliver are significantly oriented toward asse ssment, with an averag e of 52% to 55% of their time spent in psychoeducational assessm ent, 21% to 26% in direct interventions (e.g., counseling), 19% to 22% in consultation, and 1% to 2% in research and evaluation (Bramlett, Murphy, Johnson, Wallingsford, & Hall, 2002; Curtis et al., 1999; Hosp & Reschly, 2002). For example, a 19911992 survey of 1,089 NASP members and practitioners showed that sc hool psychologists devoted more than one-half of their time to psychoeducational assessment (55%), with considerably less time devoted to direct intervention (20%), problem-solving consul tation (16%), and systems-organizational consultation and research-evaluation (5 % or less) (Reschly & Wilson, 1995). Studies published in recent years show a similar allocation of time across the school psychologists roles, although ma ny recent surveys included an expanded, comprehensive survey of school ps ychologists roles and functions. Bramlett et al. (2002) solicited participation from 800 ra ndomly-selected members of NASP during the Spring of 1999, with a final sample of 370 school psychologists from 40 states A similar pattern of role functions was evidenced, as respondents indicated spending the majority of their time in assessment (46%), followe d by consultation (16%), direct interventions (13%), counseling (8%), confer encing (7%), supervision (3%), inservices (2%), research (1%), parent training (1%), and other (3%) Taken together, up to 22% of school psychologists time is spent delivering ment al health treatment, assuming that all interventions, counseling, and pa rent training services are ta rgeted at assisting children with mental health needs. A smaller propor tion was obtained in survey research by Hosp and Reschly (2002), wh ich indicated that school psychologists spent 6.5 hours per week on direct interventions (16.3% of a 40-hour work week).
47 Collectively, a consistent pattern with respect to the school psychologists role within the school system has sustained over th e last 20 years (Bramlett et al., 2002; Curtis et al., 1999; Fagan & Wise, 2000; Hosp & Reschly, 2002; Reschly & Wilson, 1995). School psychologists spend the majority of th eir time in assessment-related duties, and substantially less of their time involved in di rect intervention and consultation. Studies are limited by designs that preclude making statements specific to the provision of various and specific mental health services Although the profe ssional practices of school psychologist have remained constant, some factors significantly influence the proportion of time spent in various roles. Geographic differences in functions. Historically, researchers have found that the types of roles in which school psychologi sts engage vary according to the location and setting of their school distri cts. As summarized by Curtis et al. (2004), in general, the rural school psychologist historically provi ded a wider array of services and was more likely to be involved in activities at the syst ems level. For example, 20 years ago rural school psychologists were more likely to be invo lved in such activities as consulting with board members, conducting home visits, and designing school-wide programs than were school psychologists located in urban and subur ban locations. There was also a greater tendency for consultation to occur in subur ban school districts (C urtis et al., 2004). Differences in the definition utilized in st udies pertaining to the geographic location of practitioners have made it difficult to compare early studies with more recent research. For example, Smith (1984) defined locatio ns by regions of the U.S., as opposed to defining location by rural, suburban, and urba n settings, and found that the average role
48 in the Northeast NASP region (NE and MA cen sus regions) involved more time allocated to direct interventions than assessment. Hosp and Reschly (2002) surveyed a random sample of 1,056 practicing school psychologists from the 1997 NASP membership lis t. Respondents were categorized into region on the basis of the state where they received NASP correspondence, with a total of nine census regions (Northeast, Mid-Atlantic, South Atlantic East South Central, East North Central, West South Ce ntral, West North Central, Mountain, and Pacific). All census regions were represented by at le ast 44 respondents. The researchers found significant differences between regions in current hours spent in psychoeducational assessment. Number of hours ranged from ju st under 19 hours per week (Northeast and Mid-Atlantic) to more than 26 hours per week (East South Central) Differences also were found among regions for hours spent providi ng direct interventions, with the highest average in the Mid-Atlantic region (9.9 hours) which was more than all other regions except for the Northeast. Th e regions with the most hours spent in psychoeducational assessment generally had the least amount of hours per week spent providing direct interventions. Taken together, recent studies suggest that school psychologists on the East coast and those who serve urban and suburban populations are more likely to spend more of their workday providing direct interventions to students, in terventions that may include mental health services. School psychologists in rural areas and in th e central and western parts of the USA are more likely involv ed in conducting assessments for special education eligibility, which limits the time they have available to provide interventions. Rural school psychologists relatively limited pr ovision of direct interventions also may
49 be due to more involvement in systems-level activities (Curtis et al ., 2004). Notably, a call for frequently updated studies has been made (cf., Reschly & Wilson, 1995) due to shifts in employment setting, with an increase in the percentage of school psychologists working in urban school districts. The curr ent body of literature also is limited by the lack of a common definition of geography. Trends in School Psychologists Roles Specific to Mental Health Services School psychologists have been concerned with the mental health of school children since the beginning of the field, evidenced by the efforts of early school psychologists to establish comprehensive se rvices for children (Fagan & Wise, 2000). Federal law has mandated school psychologists involvement Specifically, in PL 94142, counseling is specified as a related se rvice that must be provided by a qualified social worker, school psychologist, or guida nce counselor when deemed necessary by a students IEP (United States Senate and Hous e of Representatives, 2004). According to IDEA, such services may be necessary to assist a child with a disability to benefit from special education. In addition to government policies, increased societal stressors have been identified that impact childrens me ntal health and subsequently the learning environment of children. Most recently, Croc ket (2004) summarized the critical issues facing children in the 21st century, whic h included poverty, violence, and serious behavioral and emotional issues. School ps ychology literature ha s published calls for school psychologists to respond proactively with respect to providing mental health services to children in schools (Nastasi, Varjas, Bernstein, & Pluymert, 1998) and to provide a continuum of mental health servic es in schools, addressing primary prevention
50 as well implementation of secondary and tertiary services that treat mental health needs in school children. Surveys suggest that some change in school psychology practice has occurred, although not among all practitioners. A 1994-1995 survey of NASP school psychologists revealed that the majority of the sample of 1,414 school-based practitioners provided a range of services, including psychoeduca tional assessment (97% of respondents), consultation (97%), individual and group c ounseling (82% and 53% respectively), and educational programs for parents, teachers, and others (78%) (C urtis et al., 1999). Similarly, a survey of 273 doc toral-level school psychologist s who were members of the American Psychological Association indicated that most of the responding practitioners provided an array of services including assessment (63% of the respondents), counseling (64%), and consultation (59%) (Short & Rosenthal, 1995). In addition to providing more mental health services within the traditional role in the school system, the shift occurring w ithin the field has allowed many school psychologists to carve out their own roles as a mental health provider within the school system. Nastasi et al. (1998) surveyed school psychologists who were engaged in a mental health program that had been iden tified as exemplary by NASP. Surveys were returned by 87 programs (repres enting 36 states), with 90% of the 87 mental health programs providing services in publ ic schools. With regard to responsibilities in general, the 87 school psychologists spen t 21% of their time in asse ssment, 20% in counseling, 27% in consultation, 16% in prevention, and 6% in research. These school psychologists devoted almost one-half (48%) of their tota l work time to the specific mental health program. Of note, the difference in amount of time spent in providing mental health
51 services in this study compared to previous studies mentioned may be due to the school environment and attitude towards the provision of mental health services. Despite small movements towards an expanded role for th e school psychologist a review of the literature demonstrates that school psychol ogists currently voice discontent over the amount of time currently spent pr oviding mental health services. Discrepancy Between Actual and Desired Invo lvement in Mental Health Services Early studies show that a majority of school psychologists provide at least some direct mental health services, and that most practitioners wish to increase their time spent in such activities. Smith (1984) found that pr actitioners spent approxi mately 11% of their time providing counseling servic es (7.3% of services provi ded to students and 3.8% to parents), but desired to spend approximat ely 18% of their time providing counseling services. Yoshida, Maher, and Hawryluk ( 1984) found that 60% of school psychologists that they surveyed reported providing indi vidual counseling servi ces (37% for 1-5 hours per week, 16% for 6-10 hours, and 7% for 11 hours or more per week) and 46% of the school psychologists reported provided parent counseling (41% for 1-5 hours per week, 4% for 6-10 hours, and 2% spent for 11 hours or more). When participants were asked to indicate to which of several activities they wished to devote more time, the two highest rated were counseling pupils (66%) and counseling parents (43%). A 1991-1992 survey of 1,089 NASP members a nd practitioners focused on their current and desired roles within the school system (Reschly & Wilson, 1995). These practitioners indicated a desi re for reallocation of their time, including a decrease in psychoeducational assessment to a preferred level of 32% of their time. Respondents indicated that they would like to increase thei r time spent in the following roles to the
52 following percentages: direct interven tion, 28%; problem-solving consultation, 23%; organizational-systems consultation, 10% ; and research and evaluation, 7%. A similar study specific to counseling wa s conducted with 178 members of NASP (Prout et al., 1993). In regards to their professional roles, 70% of the respondents indicated that counseling/th erapy services were specifi cally included in their job description. Respondents spent an aver age of 17% of th eir time providing counseling/psychotherapy services; 100% of respondents indicated provision of at least some services in this area. Respondents reported seeing an av erage of 6.4 students weekly for individual counseling and 10.3 stude nts weekly in group se ssions. Of note, 53.9% of the respondents indicated that they would like to undert ake more counseling, whereas 43.7% indicated that they would like to undertake about the same amount of counseling. A recent replication was conducted by Ya tes (2003) via survey of 500 randomly selected NASP members. The majority of respondents was from the Northeast (41.9%) and worked in a suburban school district. Approximately 72% of respondents indicated that they provided counseling. Respondent s indicated spending 17.2% of their time in counseling (vs. 49.8% in assessment, 9.4% prevention, 18.5% consultation, 17.7% administration, and 4.6% research). Responde nts indicated a desire to spend 22.0% of their time providing counseling services. In conclusion, the majority of researchers over the decades have found that school psychologists wish to spend more time in the provision of mental heal th services. Given that researchers have found that problems co mmonly referred within schools relate to mental health service needs (e.g., interpersona l problems, family problems), it is plausible
53 that practitioners desire to spend more time providing mental health services because they recognize the need for these services. A lthough the most recent study was conducted in 2003, the study focused on the provision of c ounseling services and did not examine other modes of mental health services, such as consultation with teachers and family members. Additional research is needed usi ng an expanded definition of mental health. To this end, the type of mental health services currently being provided by school psychologists is an important area of research. Specific Mental Health Services Pr ovided by School Psychologists Pryzwansky, Harris, and Jackson (1984) surveyed school psychologists in 18 Milwaukee schools. Fifty-eight percent of the 146 respondents provided some form of direct interventions in thei r schools. Of those school psychologists providing direct intervention services, 92% repor ted students as their client group, 52% reported working with parents, 27% reported working with families, and 30% reported working with teachers. Individual plus group sessions was the most common format used for counseling/therapy (47%), followed by individual sessions (20%). Of note, this study was published more than two decades ago and the amount of time spent in direct interventions may have change d slightly in line with findi ngs from national surveys (e.g., Curtis et al., 1999). This study also was lim ited by its use of participants from only one region, because roles and f unctions for school psychologists vary somewhat by geography. Finally, the sample consisted of some school psychologists who had a degree specialization in counseling psychology (12%). Hence, the results may have been skewed by both the samples demogra phics and degree specialization.
54 Recent research sheds light on the details of counseling services provided by school psychologists. Of the 72% of school psychologists who reported providing counseling services in Yates (2003) st udy, the most commonly cited theoretical orientations used in treatment were behavi oral/cognitive behavioral therapy (36.5%) and solution-focused behavior therapy (18.6%), wh ereas the use of Adle rian (1.2%), gestalt (1.2%), or psychodynamic (3.3%) approaches were least common. Regarding frequency of mental health services, approximately 62% reported providing individual counseling on a regular basis whereas 34.7% provided it at least on an occasional basis. Most individual sessions occurred weekly (54.4%), lasted from 30-45 minutes (73.3%), and involved five or more sessions (39.6%). Approximately 41.1% of the subset who endorsed individual counseling re ported that they provided group counseling for students on a regular basis and 32.9% indicated providing group counseling at least on an occasional basis. Most student group sessions occurred weekly (79.5%), with 1-5 groups (77.5%), and involved 5-16 sessions (54.2%). Approximately 18.2% provided classroom counseling (e.g., social skills training) and 19.1% provided family counseling. Although this study has been the most comprehensive one to focus on the provision of mental health services, the focus is on the provi sion of counseling services. Additional information gathered on the different forms of interventions (i.e., behavior management consultation, behavior intervention plans) w ould be beneficial. In addition, because this study relied solely on a survey, forced-c hoice answers were the mode by which participants gave informati on. Open-ended survey questions and/or interviews, which would allow participants to provide in-depth answers to questions, would be helpful.
55 Another gap in research involve s the lack of examination of the types of mental health services provided in relation to school psychologists years of experience. Role of Years of Experien ce on Professional Practices Due to societal, legal, educational, and pr ofessional trends, th e role of the school psychologist has expanded and the field of school psychology continues to challenge practitioners to provide more comprehensive se rvices. In response, changes have been made in graduate school training and more opportunities exist for continuing education. Importantly, the standards set by school ps ychology organizations have expanded to match both legislative changes and societal chan ges. It is therefore plausible that each generation of school psychologists has received slightly different training, corresponding to different philosophies of professional roles. In particular, because of the recent trend towards the expansion of the school psychologi sts role into the provision of mental health services, school psychol ogists beliefs regarding thei r roles in providing mental health services in schools ma y vary according to the number of years they have been in the field. It may also be difficult for school psychologists who have been practicing for several years to change their es tablished roles within the school, particularly if the change requires extensive training. Over the past decade research has shown a steady increase in the average age of school psychologists resulting in a growing ag e gap between most practitioners and new graduates. Between 1980-1981 and 1999-2000, th e mean age of school psychologists increased from 38.8 years (Smith, 1984) to 45.2 y ears (Curtis et al., 2002). In only 20 years the percentage of school psychologi sts 40 years of age or younger has declined from 43.2% to 31.2%, whereas those over 50 years of age increased from 20.2% to
56 32.8%. Almost one out of three school psychologists is now ove r the age of 50 (Curtis et al., 2004) In general, older practitioners have greater years of experience. Whereas the mean total experience (i.e., years of e xperience in school ps ychology and education combined) in 1980-1981 was 10.9 years, it increased to 16.7 years in 1998-1999. A survey of 370 practitioners conducted in 1999 found that the mean length of experience as a school psychologist was 18 years (Bramle tt et al., 2002). Ten pe rcent of the sample had been engaged in school psychology for less than 10 years, 43% for 1120 years, and 46% for more than 20 years. Between 1989-1990 and 1999-2000, the percentage of school psychologists with 20 or more year s of total experience more than doubled, increasing from 10.2% to 20.7% (Curtis et al., 2004). These trends in age and experience may c ontribute to increased variability in the professional roles of school psychologists due to the aforementioned ch anges in the field. However, an initial study conducted before the graying of our field and the push for expanded mental health services found that differences between recent and more experienced graduates were negligible with respect to specific skills and role functions for the conditions of actual and preferred job characteristics (F isher, Jenkins, & Crumbley, 1986). A more recent study examining experience as a variable influencing school psychologists role and function was c onducted using data from the 1994-1995 school year (Curtis et al., 2002). Survey res ponses from 1,411 practici ng school psychologists were analyzed to examine the association between nine professi onal practice factors, including experience, and each of the profe ssional practices. The number of years of
57 experience as a school psychologist was signi ficantly related to some professional practice activities. Specifical ly, school psychologists with more years of experience conducted more special education reeval uations, served more students through consultation, and conducted more in-service programs than did their less-experienced peers (Curtis et al., 2002). This study di d not find a relationship between years of experience and practitioners reports of the number of st udents they served through individual counseling or through group c ounseling. Although this study was published recently, the data analyzed are more than a decade old. As has been noted, the age of school psychologists has increased markedly in recent years and, therefore, a sample of school psychologists today may differ greatly from a sample in 1994. Differences also may be larger in current years due to th e continuing push for school mental health services. Yates (2003) examined relationships be tween those spending a high (more than 25%), medium (10% to 24%), or low (1% to 9%) percentage of thei r time in counseling (individual, group, family, and cl assroom) and the following de mographic characteristics: degree level, grade level served, school psychologist/student ra tio, type of school, number of buildings worked in, years of experience region of the country, and the number of assessments completed per year. Time spent in counseling was inversely associated with the following three dem ographic factors: number of assessments completed per year, psychologist/student ra tio, and number of buildings served; a positive association between grade level se rved and time spent in counseling was identified. Years of experience were unrelated to the amount of tie spent in counseling. In sum, few researchers have examined the relationship between provision of
58 mental health services and the number of years that a practitioner has been in the field. While Yates (2003) study is commendable as one of the few to examine this relationship, this study is limited by a na rrow definition of mental health (i.e., counseling services and did not include such services as consultation). The body of literature also is limited by a reliance on survey data; it is difficult to draw conclusions from forced-choice surveys because of the limited range of items/choices often included within the survey. Other methods of collecti ng data, such as focus groups or the use of open-ended questions in surveys, would allow researchers to identify the common themes that emerge with respect to types of mental health services provi ded and barriers to the provision of such services. Such barriers must exist given the still unmet need for treatment of childrens ment al health problems and sc hool psychologists clearly expressed desire to spend more time in providing psychothera peutic services. Preliminary quantitative studies have identified such barriers to the provision of mental health services in the schools. Barriers to the Provision of Ment al Health Services in Schools A review of the existing literature identifie d only a handful of ar ticles that have examined barriers that prevent school ps ychologists from providing the range and frequency of mental health services they desi re to provide. Out of these studies, only one directly addressed school psyc hologists perceived barriers to mental health services. Additionally, there have been no qualitative studies conducted to explore this topic. Meyers and Swerdlik (2003) discussed a num ber of external and internal barriers school psychologists may face in working in a school-based hea lth center (SBHC). A potential barrier may involve the confusion th at arises over the va rious terminology used
59 to refer to SBHCs, which could potentia lly negatively impact development, implementation, and research. Cultural and a ttitudinal factors, such as the stigma associated with mental health problems, may obstruct the development of SBHCs. Related to this, cultural, religious, or politic al climate of a given community may stand in the way of a SBHCs effort to implement ef fective preventive interv entions that address sensitive issues (e.g., adolescent sexuality, s ubstance abuse). Lim ited funding also could be a barrier, because very few schools have adequate resources to deal with the large number of students with mental health problems. A lack of integration and coordination of current school-based progr ams may inhibit effective implementation of services. Finally, two barriers are identified in relation to the school psychologist s role within the school. First, a narrow role of the school psyc hologist as the sole provider of assessment may inhibit them from providing mental health services. Second, in an effort to provide comprehensive services to all students, sc hools and practitioners may find themselves overextended and experiencing role strain. For any school psychologist, the expanded role opportunities in SBHCs provides an ave nue for professional development, but may also be overwhelming, leading to fe elings of stress and exhaustion. In the SAMHSA survey (US DHHS, 1999), schools ranked the extent to which 10 factors were barriers to the de livery of mental health servi ces, using a scale of 1 (not a barrier) to 4 (serious barrier ). Financial constraint of families (58%) and insufficient school and community-based resources (49%) were the factors most often reported as barriers or serious barriers. In open-ended comments, respondents discussed the financial constraints faced by students and their fam ilies in attempting to obtain medical health services. Explanations ranged from inadequa te Medicaid reimbursement to limitations in
60 benefits for those who are privately insured and a dearth of mental health services for the uninsured. Competing priorities for use of funds (46%), di fficulties with transportation (45%), and inadequate community mental heal th services (44%) also were considered barriers. Least often reported as seri ous barriers were protection of student confidentiality (8%) and langua ge and cultural barri ers (20%). A limita tion of this study includes the use of forced-choice in responding to the items pertaining to this topic within the survey. Of those barriers listed, most re flected external, system s-level barriers (e.g., funding) to the exclusion of internal, with in-person barriers (e. g., practitioners skill level). Because of the newness of this topic, the types of barriers included in the survey may not necessarily represent the entire range of factors that pr actitioners consider barriers to represent. In addition, responde nts were grouped into one large sample for this analysis. Because administrators, school counselors, and school psychologists responses were collapsed, it is impossible to determine which group of professionals viewed which barrier as being the greates t, which is unfortunate because school psychologists and administrators pe rceptions may vary significantly. Participants in Yates (2003) survey of school psychologists from preschool, elementary, middle, and high schools responded to a series of statements that listed factors that either facilitated more time spent on counseling or presented barriers to spending more time in the counseling role. The list of barriers included six categories and an other choice category which also provided space for additional comments and the words please elaborate. Participants were asked to check all th at they perceived as representing barriers. The barriers rated as most preventing practitioners from spending more time in counseling pertained to role responsibility. Spec ifically, respondents
61 endorsed a heavy emphasis on assessment (68.2 %) and the fact that counseling was not part of their roles in the school (52.5%) as two common barriers. An additional barrier endorsed by a number of respondents was that co unseling is not currently part of their identified/written job responsibilities (26.4%). Relatively few respondents indicated that low interest (6.6%), belief th at counseling should be provi ded outside of school (3.7%), or a low number of referrals (5.4%) were significant reasons preventing them from spending additional time on counseling. Ot her barriers elicited through the other choice included insufficient training in counseling, other job responsibilities, parent/student issues, and the perception that their school dist rict does not view counseling as a necessity. A number of participants elabor ated on barriers they listed in the other category in order to describe wh at prevents them from spending more time in counseling. Responses included the following:. (a)I dont fe el that I have received adequate training/supervision to provide counseling services in the schools,(b) school psychologists need more practicum experience rather than workshops on theory, and (c) close supervision or training specific to th e school setting would have increased my confidence. When asked to respond to time barriers, respondents replied that (a) case management and assessment impact my ability to provide counseling and (b) I have a large number of assessments that cause counseling to take a b ack seat. When asked to respond to district perception as a barrier, respondents indica ted that (a) counseling is a huge area of need, but budgets are tight, (b) m y district is not pro mental health, and (c) my state does not encourage school psychol ogists to provide counseling. While this is one of the few studies to focus on barri ers specific to schoo l psychologists, the questionnaire utilized cons isted of only closed-ended and partially closed-ended
62 questions and a minimal list of si x barriers. Because so little research has been conducted on this topic, it is difficult to know what are the most common barriers to the provision of mental health services. For example, in th is particular study insu fficient training was not listed as a barrier, yet it was noted by mu ltiple respondents in the other category. Therefore, a more appropriate method of st udying this issue would be in the form of open-ended questions that woul d allow respondents to identify the range of barriers in order to gather information on emerging themes Of note, although this sample was fairly representative of the field of school psychologists at that time, respondents who worked within only one school (31.5%) were over-sampled. In sum, only a few studies have examined what prevents school psychologists from providing needed and desired mental heal th services. Only one study (Yates, 2003) has examined why the gap between the amount of time school psychologists currently spend providing mental health services and their desired amount of involvement is occurring. Due to limitations of this pion eering study, there is insufficient information about the types of barriers that school psychologists perceive inhibit them from providing more mental health services within their roles. An additional gap in the literature pertains to the relationship between school psychologists demogra phic characteristics and the types of barriers that they may perceive. As mentioned ea rlier, research ers have found significant differences among sc hool psychologists of differe nt ages and levels of experience pertaining to their roles within the school system. Therefore, additional research is needed on how years of experi ence impact either the perceptions of, or reactions to, barriers. A pract itioners level of experience is potentially relevant due to changes that occur in school psychology gra duate training. Additionally, Yates (2003)
63 identified that the type and amount of training received by school psychologist are perceived barriers and facilitators in the provi sion of school mental health services. To this end, a review of the mental health trai ning required for accredit ation and a review of current research on the amount of mental health training sc hool psychologists currently receive is discussed in an effort to iden tify variability in trai ning that would support Yates preliminary findings. School Psychology Graduate Training There are currently approximately 22,000 school psychologists working nationwide in the field and approximately 200 school psychology training programs (NASP, 2000b). Most school ps ychologists have been traine d at the 60-hour educational specialist level or beyon d, with approximately 20% of prac titioners attaining the doctoral degree (Curtis et al., 2004). Both NASP and the American Psychological Association Division 16 (School Psychology) pr ovide standards that guide th e training and practice of school psychology, with a rigorou s accreditation process for program approval. National Association of School Psychologists While it is impossible to list exact co urses school psychologists take because programs are permitted great variability, accredited programs do have to address standards. In order to become a NASP-accredited program in school psychology, a program has to provide knowledge and traini ng in a number of domains of professional practice as indicated in the NASP Standards for Training and Field Placement Programs in School Psychology (NASP, 2000a). Programs must ensure that their students have a foundation in the knowledge base for psychol ogy and education, including theories, models, empirical findings, and techniques in each domain. Pertaining to the provision of
64 mental health services, NASP requires progra ms to provide traini ng in the domains of prevention, crisis intervention, and mental health ( NASP, 2000a, p. 30). This domain includes the following: School psychologists have knowledge of cu rrent theory and research about child and adolescent development; psychopathology; human diversity; biological, cultural, and social influences on behavior; societal stressors; crises in schools and communities; and other fact ors. They apply their knowledge of these factors to the identification and rec ognition of behaviors that are precursors to academic, behavioral, and serious pers onal difficulties (e.g., conduct disorders, internalizing disorders, drug and alcohol abuse, etc.). They have knowledge of effective prevention strategies and deve lop, implement, and evaluate programs based on recognition of the precursors that lead to childrens severe learning and behavior problems. School psychologists have knowledge of crisis intervention and collaborate with sch ool personnel, parents, and the community in the aftermath of crises (e.g., suicide, death, natural disasters, murder, bombs or bomb threats, extraordinary violence, sexual harassment, etc.). School psychologists provide or contribute to prevention and intervention programs that promote the mental health and physical wellb eing of students. (pp. 30-31) Division 16 (School Psychology) of the American Psychological Association The American Psychological Association provides accreditation of education and training programs in professional psychol ogy, including school psychology, consistent with their recognized scope of accreditati on practice, and thei r published policies, procedures, and criteria. Similar to NASP program accreditation process, to become an
65 American Psychological Association-approved program each program must fulfill certain requirements. Because of the breadth of professional psychology, accreditation guidelines are broader than NASPs guideline s. According to the Guidelines and Principles for Accreditati on of Programs in Professional Psychology (American Psychological Association, 2005), programs must provide knowledge and training in the following: the breadth of scientific psychology, its history of thought and development, its research methods, and its applicatio ns; the scientific, methodological, and theoretical foundations of practice in the substantive area(s) of professional psychology in which the program has its training emphasis; and diagnosing or defining problems through psychological assessment and measurement and formulating and implementing interventi on strategies (including training in empirically supported procedures). ( p. 14) In sum, all graduates of NASP or Amer ican Psychological Association-accredited programs should, by definition, rece ive training in mental health services. However, the amount and intensity of experiences is quite variable. A sample of school psychology training programs conducted via the Intern et on training sequences shows that some programs, for instance, University of Texa s-Austin, require up to eight courses and practicum in mental health interventions (University of Texas-Austin, 2005). Other programs, such as the University of Florida, require students to ta ke just one class in psychological counseling (Univers ity of Florida, 2005). Stud ies in the school psychology literature provide additional information on the range of mental health intervention training school psychology gr aduate students receive.
66 Training in Mental Health Inte rventions During Graduate School In a survey of 146 school psychologists, Pryzwansky et al. (1984) found that the sample had taken a relatively large number of courses in therapy and counseling. More than one-half of the participants had comple ted more than three courses in therapy and counseling and 36% had logged more than 100 hours of practicum experience in the psychological counseling or therapy areas. Pr out et al. (1993) repor ted that in a random sample of 178 school psychologi sts, the average number of courses in counseling or psychotherapy was 5.6 ( SD = 5.00). More recently, Whitmore (2004) surveyed a national sample of school psychologists, school counselors, and school social workers. When the 74 school psychologists were asked to indicate whether or not they had received university-level training in five topics related to family wo rk and family counseling, 80.5% indicated that they had received training. When asked if they had received training in family systems intervention, 63.5% of school psychologists indi cated that they had received training and approximately 55% of school psychologists reported taking a family therapy survey course. Approximately 30% of school psychol ogists reported having advanced family counseling coursework and 23.8% reported ha ving supervised practica in family counseling. School psychologists who reporte d practicing family counseling in the schools were asked what type of training th ey had received specifically in family counseling. Nearly 68% repor ted receiving training from seminars, workshops, or trainings sponsored by the school system, 53.3% reported receiving training from their university program, 40.0% receiv ed training from post-degree university coursework in family therapy, 20.0% received training from a family therapist apart from the school
67 system, and 13.3% received training from a free standing family therapy institute. Notably, this study is limited by its focus on family therapy and its small sample size (i.e., n = 74). Current data on other modalities of psychotherapeutic interventions (e.g., individual and group counselin g) would be helpful. In Yates (2003) survey of 500 school psyc hologists, participants responded to a series of questions concerning the type of training they had received in foundations of mental health problems and in counseling in terventions. The great est proportion (45.0%) of the respondents took betw een three and five graduate counseling courses; the remaining 27.5% indicated taking one to two co urses, 12.7% indicated taking six to eight courses, and 14.8% indicated taking more than eight classes. Cour ses frequently (more than 70%) noted in the counseling area incl uded: Behavioral In terventions (89.9%), Counseling Children (78.6%), Developm ental Psychology (88.2%), Psychological Theories (92.0%), Personality (82.4%), and Psychopathology (70.6%). Much less frequently (less than 50%) di d respondents note coursework in Multicultural Counseling (42.0%), Psychotherapy (45.8%), and C ounseling Children w ith Developmental Disabilities (30.3%). Approxima tely one-half (54.4%) stated that they had enrolled in a continuing education counseling workshop within the last five years. Respondents most often indicated spending 1% to 24% of thei r time in supervision discussing their counseling cases (57.9%), with 11.1% indi cating no time in supervision spent on counseling cases, 19.3% indicating 25% to 49% of their time, 8.2% indicating 50% to 75% of their time, and 3.4% indicating sp ending more than 75% of their time on counseling cases. Direct supervision most often included audio/video taping (56.4%), with one-way viewing (i.e., supervision through a one-way mirror) being the least
68 common (39.0%) When asked about the satisfac tion of the graduate training they had received in counseling, 65.5% indicated that insufficient time was spent on counseling during their training. This fi nding is of particular importa nce, because it shows that school psychologists do not feel adequately trained despite the majority of respondents taking four courses or more in foundations of mental health problems and in counseling interventions. More research is needed to determine the type and amount of coursework and the type and amount of training expe riences (e.g., didactic content, practica experience, live supervision during training) necessary for school psychologists to feel prepared to provide mental he alth services. Taken together, research indicates the amount of training in mental health services varies across training programs. This research is limited by a lack of consistency across studi es in defining menta l health coursework and mental health training. Additional re search needs to determine which specific content areas and experiences will allow school psychologists to feel sufficiently prepared to provide mental health services in the schools. Such training could be provided during graduate school but also impl emented in continued education courses, particularly in light of data illustrating practitioners reli ance on post-graduate seminars to receive additional training in mental he alth services (e.g., Whitmore, 2004; Yates, 2003). An additional gap in research involve s the variability in training throughout the country and across time in th e area of mental health. Conclusions The common path through which children and adolescents receive mental health services is through the education system (B urns et al., 1995; Farmer et al., 2003). Changes in government policy and societal in itiatives have underscored the need for
69 school psychologists to provide school-based me ntal health services However, school psychologists currently spend relatively little time in the provision of such services (Curtis et al., 1999; Fagan & Wise, 2000; Hosp & Reschly, 2002, Reschly & Wilson, 1995). The majority of researchers over the decades have found that school psychologists wish to spend more time in dir ect intervention with children with mental health needs (Prout et al., 1993; Resc hly & Wilson, 1995; Smith, 1984; Yates, 2003). Therefore, it is important to identify w hy school psychologists are not providing the desired and needed level of mental health services. One purpose of the current study was to elucidate factors that school psychologists perceive inhibit them from pr oviding more mental health interventions within their professional roles. This curre nt study expanded on th e research of Yates (2003), a study limited by a list of barriers in which response options did not appear sufficient given that themes such as knowle dge/skill/training defi cits emerged following examination of responses to the other option (i .e., other barriers other than those listed). To date, no published qualitative research has identified barriers perceived by school psychology practitioners. Existing research has not sufficiently e xplored the kinds of content knowledge areas and training experiences that would allow school psychologists to feel sufficiently prepared to provide mental he alth services in the schools. Identifying barriers related to knowledge and skill deficits may ultimately aid in the design and implementation of effective mental health trai ning in school psychology program s. Thus, the current study purposefully queried practitione rs about desired didactic a nd practical experiences in school-based mental he alth interventions.
70 Research also suggests that signif icant differences exist among school psychologists of different ages and levels of experience pertaining to their roles within the school system (e.g., Curtis et al., 2002). Therefore, factors such as years of experience also should be considered when studying school psychologists roles in the provision of mental health services. There is a grow ing age gap between most practitioners and new graduates (Curtis et al., 2004). Identifying differences between new graduates and experienced practitioners needs and perceptions may ultimately aid in the design of specific and deliberate professional development services for practicing school psychologists. Thus, an additional pu rpose of the current study was to examine perceived barriers as a function of pr actitioners levels of experience.
71 Chapter 3 Method Research Paradigm Creswell (1998) defines qualitative re search as an inquiry process of understanding based on distinct methodological tr aditions of inquiry that explore a social or humanistic problem (p. 15). Qualitative re search methods are typically designed with the objective of making generalizations about some social phenomena, creating predictions regarding those phenomena, and pr oviding contributory explanations (Glesne, 2006). A valuable use for qualitative research is as a means for exploring a topic or problem that has not been previously resear ched (Glesne, 2006). According to Strauss and Corbin (1990), qualitative methods can be used to unearth and provide understanding about a phenomenon about which little is ye t known. Additionally, Creswell (1998) has identified a number of rationales for choos ing a qualitative study. His justifications include such reasons as a topic needs to be explored, a need to present a detailed view of the topic, or to emphasize the researchs role as an active learner who can tell the story from the participants view. Onwuegbuzie and Leech (2007) have identified qualitative research as particularly app ealing to the field of school ps ychology given that it is useful for obtaining insights into regular or problema tic experiences and the meaning attached to these experiences of selected individuals and groups. Given the nature of the research
72 problem, qualitative research methodology wa s used to address the expressed purpose and corresponding research questions for this study. Research Design Collective case study was the framework for understanding and interpreting the information obtained from this study (Stake, 1995) Case study research is used to explore real life experiences a nd situations, when the research er is interested in both the phenomenon and the context in which it occurs Case study research seeks out rich, indepth information and it aims to investigate a particular topic in its context from multiple viewpoints through multiple methods and multip le data sources (Stake, 1995). Golby (1993) has pointed out that cas e study research can be a useful approach when studying professional practice and problems of practic al significance. Case study research can suggest to readers what to do, especially if they are in a similar situation (Merriam, 1998), and enable practitioners to re-conceptu alize a practical probl em and to understand more fully, that is, to relate theory and practice (Golby, 1993). In a case study, the case can be a person or several persons, an instit ution, an innovation, a pr ocess, a service, a program, an event or an activity (Creswell, 1998). When a re searcher decides to study a number of cases to gain a be tter understanding of a phenome non, the study is defined as a collective case study (Creswell, 1998). Stake (1995) defines a study as a collective case study when the researcher utilizes a number of cases that are studied jointly in order to investigate a phenomenon, populat ion, or general condition. Only one published study (Yates, 2003) has attempted to explain why the gap between the frequency with which school psyc hologists currently provide mental health services and their desired amount of involvement is occurring. In this study, the response
73 options did not appear sufficient, given th at themes such as knowledge/skill/training deficits emerged following examination of re sponses to the other option (i.e., other barriers other than those liste d) after multiple respondents identified common barriers. Thus, currently the professiona l literature contains insufficient information about the types of barriers that school psychologists perceive inhib it them from providing more mental health services within their professional roles. Gi ven the limited understanding of the research problem, collectiv e case study provided the means to derive inductively the greatest amount of information for why a gap currently exists betw een the amount of time school psychologists currently provide mental health inte rventions and their desired amount of involvement. Participants Selection of Participants In case study, achieving the greatest unde rstanding of the critical phenomena depends on choosing the case(s) well (Patton, 1990). The case (s) are often representative of some population of cases. For qualitativ e fieldwork, a purposive sample is drawn, building in variety and acknowledging opportun ities for intensive study. Even though the case is decided in advance, th ere are subsequent choices to make about persons, places, and events to observe. Creswell (1998) identif ies the purposeful select ion of participants as a key decision point in a qualitative study. Within this study, th e type of purposeful sampling utilized was stratified purposef ul sampling. The purpose of stratified purposeful sampling is to illustrate subgroups and to facilitate comparisons (Miles & Huberman, 1994). The rationale for using this sampling scheme was to illustrate the subgroups of practitioners utilized within the study as well as to facilitate the
74 comparisons needed between two subgroups, based upon the research questions of the study. Inclusion criteria were identified to f acilitate the selection of participants. School Psychologists Inclusion criteria for particip ation included the following: 1. Participants were required to have a graduate degree and professional credentials (e.g., National Certification of School Psychology [NCSP], Florida Department of Education [FL DOE] certification) in school psychology 2. Participants had to be practiti oners within a school setting 3. Participants had to be within the y ears of experience parameters described below 4. Participants had to sign a consent form (Appendix A) before data collection The participants used in the current study were part of a larger study investigating the perception of barriers by school psychologi sts in the provision of mental health interventions in the school s (Suldo, 2006). In April of 2006, The Southern Florida County School District granted permission for school psychologi sts to participate in the study. Approval to conduct the study was obtained from the Middle Florida County School District and the Univer sity of South Florida (USF) Institutional Review Board in September of 2006. Data were collected in October of 2006 by graduate students in the USF Department of Psychological and Social Foundations, under the supervision of the principal investigator (PI), a faculty memb er from the USF School Psychology Program. The author of this proposal was the c oordinator of the P Is research team. Recruitment of participants began wi th a phone call to the director of psychological services in both counties. Given that the two di rectors had already
75 provided written letters of s upport for the larger project fr om which these data were taken, the phone call consisted of a review of the purpose of the study and a description of the inclusion criteria for participants. Th e directors then provide d a list of the names and e-mail addresses of the school psychologist s working within their district who met the inclusion criteria. These school psychol ogists were sent an e-mail that included a description of the study, information on incenti ves, details regarding the amount of time requested, and contact information for those wh o were interested in participating (see Appendix B). Those who expressed an intere st in participating received a follow-up email that asked them to indicate multiple time frames during which they could participate in the focus groups. After a sufficient num ber of individuals expressed preliminary interest in participating, four to seven focus groups were sc heduled within each county. All participants were sent an e-mail the day before the scheduled focus group to remind them of the session and to conf irm their intention to attend. To compensate participants for their time, incentives for participation were offered. Incentives were paid for by funds fr om the award granted to conduct the larger study. Each participant received a $25 gift car d to one of several stores, provided in one dispersement after the focus groups had been conducted. Information about incentives was shared with prospective participants dur ing the recruitment pr ocess and was included in the initial e-mail to potential participants (see Appendix B). Demographics Participants in the larger study consis ted of 39 school psychology practitioners from two school districts in Florida. Data from the la rger sample were utilized throughout the data analysis proc ess and in the development of themes that recurred in
76 response to the research questions. To addr ess the research questions in the current study, data from only two subgroups of partic ipants, the experienced and new practitioner subgroups, were compared. Given the nature of the research questi ons, stratification of the participants into subgroups occurred usi ng the participants y ears of experience. Years of experience was differe ntiated by those practitioners who had been practicing for up to 5 years (i.e., new practitioners) and t hose who had been practicing for 17 or more years (i.e., experienced pract itioners). The differentia tion of the two groups was determined by research previously conduc ted on school psychologists demographic characteristics and the recent trend in sc hool psychology literature related to schoolmental health services. Previous research has indicated that the mean total experience was 16.7 years in 1998-1999 (Curtis et al., 2004 ) and 18 years in 1999 (Bramlett et al., 2002). Therefore, the average was taken between th ese two studies, indicating a break at 17 years of experience. In a review of the pub lished articles in the field, the majority of articles on the provision of ment al health services has been written in the last 5 years, including the aforementioned NA SP mental health service position statement. Therefore, in order to differentiate between those prac titioners who have experienced the societal and legal changes due to the me ntal health trend and those pr actitioners who have been in the field for a number of years, two definitive groups were established. The new practitioner subgroup contained a total of 15 participants and the experienced practitioner subgroup contained a total of 13 participants. As shown in Table 1, the majority of th e participants in th e larger study were female ( n = 29), had a specialist de gree in school psychology ( n = 19), and were from
77 Table 1 Descriptive Statistics for Pa rticipants in the Focus Groups Early school psychologists n = 15 Mid-range school psychologists n = 11 Experienced school psychologists n = 13 Total sample N = 39 Variable N % N % N % N % Gender Male 2 13 3 27 5 39 10 26 Female 13 87 8 73 8 61 29 74 Degree level Masters 1 7 3 30 4 31 8 21 Ed.S. 11 73 4 40 5 38 20 53 Ph.D. 3 20 3 30 4 31 10 26 School district Middle 12 80 4 36 9 69 25 64 Southern 3 20 7 64 4 31 14 36 School psychologist to student ratio 1: < 500 1 7 0 0 0 0 1 3 1: 500-999 4 27 1 10 2 17 7 19 1:1000-1499 5 32 1 10 1 8 7 19 1: 1500-1999 0 0 4 40 4 33 8 22
78 1: 2000-2499 1: >2500 4 1 27 7 3 1 30 10 2 3 17 23 9 5 24 13 the Middle Florida Coun ty School District ( n = 25). Participants in the larger study were 26 to 61 years old ( M = 41.92, SD = 11.22) and had from 1 to 32 years of experience ( M = 11.89, SD = 10.49). The average number of me ntal health courses taken was 8.54 ( SD = 4.02). The majority of participants in the larger study felt that their graduate school training sufficiently prepared th em to provide mental health assessment and interventions (53.2%). In the new practitioner subgroup, th e average age of participants was 32 years old ( SD = 7.4) and participants had an average of 2.4 years of experience ( SD =1.79). The majority of new practitioners felt that their graduate training sufficiently prepared them to provide school-based mental health services (57%). In the experienced practitioner subgroup, the av erage age of pa rticipants was 52.92 years old ( SD = 4.42) and participants had an average of 25.23 years of experience ( SD = 3.83). The majority of experienced practitioners al so felt that their graduate tr aining sufficiently prepared them to provide mental health services (54%). Composition of the Focus Group In the context of the present study, the purpose of the focus group was to obtain a comprehensive understanding of school psychol ogists perceptions of mental health interventions in the schools, barriers to providing these in terventions, and mental health training issues. According to Kreuger (2000) focus groups should be considered when the purpose of a study is to uncover factors re lating to complex behaviors or motivation.
79 When an area of concern relates to behavi or or motivation, focus groups can provide the insight into these complex topics (Krueger, 2000). According to Krueger (2000), a focus gr oup is characterized by homogeneity, but also needs a sufficient amount of variability among participants to allow for contrasting options. Krueger (2000) recommends s eeking homogeneity in terms of such characteristics as occupation, past use of a pr ogram or service, educational level, age, gender, education, or family characteristics. Given that all of the participants held the same occupation and similar educational levels homogeneity of the participant group as a whole already was established. Given the nature of the res earch questions, stratification of focus groups occurred using the particip ants years of experi ence to yield specific subgroups of participants (i.e., new practitioners and experienced practitioners). In order to gather information related to school psychol ogists at all levels of experience currently practicing in education, additional focus groups containing practitioners who had between 6 and 16 years of prac tice were conducted as part of the larger grant-funded study. One focus group in the Southern Fl orida County containe d only experienced practitioners (17 or more y ears), one group contained only recent graduates, and two contained only the mid-range group of practi tioners (6-16 years of experience). Three focus groups in the Middle Florida County c ontained only experienced practitioners (17 or more years), three focus groups contained only recent graduates (0-5 years of experience), and one group contained only th e mid-range group of practitioners (6-16 years of experience). Of note, only data from the recent graduates focus groups and the experienced practitioners focus groups were used in comparisons made in the current study.
80 Krueger (2000) recommends that when dealing with complicated topics or with knowledgeable participants, the ideal size of a focus group typically falls between 6 and 9 participants. Krueger further recommends u tilizing smaller focus groups (between 4 and 6) when working with participants who are sp ecialized in the topic area, when the intent is to get more in-depth insight s, and when participants have a great deal to share about the topic. Given the specialization of par ticipants, desire for in-depth insights from participants, and that the focus groups cal l for discussions about their daily work experiences, smaller focus groups, containing th ree to five participants, were conducted. One focus group consisting of two particip ants was conducted on a unique occasion due to time and planning constraints related to practitioners availability. A total of 11 focus groups were held, w ith four focus groups in the Southern Florida County and seven focus groups in the Middle Florida County. According to Krueger (2000), in focus group interviews, the first two focus groups held provide a considerable amount of new information, but by the third or fourth session a fair amount of information typically already has been c overed. Therefore, theo retical saturation has often occurred by the third session. Theo retical saturation, a concept from grounded theory, occurs when the information-gath ering sessions (e.g., focus groups) yield no new relevant data regarding a category, the category development is dense, and the relationship between categorie s is authenticated (Strauss & Corbin, 1990). Although the recommended rule of thumb by Krueger is th ree focus groups, he also advises following this rule conditionally, depending on the nature of the study. Therefore, because of the diversity of exposure by partic ipants to the issue of inve stigation, the number of focus groups held with each level of experi ence under study was four to five.
81 Setting Middle Florida County The Middle Florida County Public Sc hools contains a total of 197 schools consisting of one more grades from K-12. Of those schools, 130 are elementary schools, 41 are middle schools, 3 are Grades K-8, 23 ar e high schools, and 73 represent additional educational centers (Charter, Early Child, ES E, etc). In the 20 05-2006 school year, the Middle County Public Schools consisted of the following ethnic breakdown: 43.97% White, 22.36% Black, 25.90% Hispanic, 3.1% Indian, 2.70% Asian, and 4.77% Multi Racial. The total number of st udents enrolled in the school system during that year was 202,240. The Middle Florida County is considered to be an urban/big city environment. Southern Florida County The Southern Florida County Schools contai ns a total of 67 schools consisting of one or more grades from Grades K-12. Of those schools, 46 are elementary schools, 12 are middle schools, 9 are high schools, and 15 are additional educational centers (e.g., Charter, Alternative, ESE). In the 20052006 school year, The Southern Florida County Public Schools consisted of the followi ng ethnic breakdown: 67.0% White, 14.6% Black, 13.4% Hispanic, 1.4% Asian/Paci fic Islander, 3.4% Multir acial, and 0.2% American Indian/Native American. The total number of students enrolled in the school system during that year was 65,407. The Southern Florida County is considered a suburban environment. Compared to the urban envi ronment of the Middle Florida County, the Southern Florida County contains a much smaller student population, less diversity among the student population, and a smaller numbe r of schools within the district. Two
82 distinctly different settings were selected to address the fact that school psychologists professional practices can vary by type of setting. Data Collection Setting In deciding upon the location of the fo cus group interviews, Krueger (2000) recommends choosing a location that is easy to find. Sessions s hould be conducted in a private room free from outside distractions. Focus groups were therefore conducted on a school campus in each county in a conferen ce room location that was private and convenient to the participants. This allowe d the participants easy access to the location given that it was within thei r school district, and the room provided an environment free from distractions. Measures Demographic Questionnaire The demographic questionnaire (see Appendi x C) contained questions regarding the type of school served, uni versity attended, amount of tr aining received, the types of courses available in mental health services at their university, additional experiences available in mental health services (e.g., pr actica, assistantships), and types of (and frequency of involvement in) various me ntal health services. The demographic questionnaire was modeled after Yates ( 2003) survey of school psychology counseling practices and was modified to include addi tional information related to the broadened definition of mental health interventions. The demographic questionnaire was included in a pilot study of the focus group. Two que stions at the end of the pilot focus group pertained to the demographic questionna ire and changes were made following a conference with other members of th e research group. During the study, the
83 demographic questionnaire was given to partic ipants at the beginning of the focus group sessions immediately after they had provide d consent. The demographic questionnaire took approximately 10 minut es to complete and wa s immediately collected. Procedures Prior to commencing formal data collection, a pilot study of the focus group protocol was conducted. This provided a tes t-run of the focus group protocol, allowing for modification, removal, and additions of questions as necessary before beginning official data collection. In particular, the pilot focus group allowed the author of the thesis and other members of the research team to verify that the questions in the protocol elicited the information that they intended to gather. The focus group protocol (see Appendix D) was tested by the author of this thesis proposal and other members of the research team during a mock focus group w ith a convenience sample of five school psychologists in the Tampa Bay area. The five school psychologi sts were recruited through an internship seminar class being condu cted at a large southern university. After the research questions had been asked, p ilot participants were asked a list of predetermined questions that addressed such issues as the clarity of the questions. Following completion of the pilot focus group, modifications to the focus group protocol and demographic form were made before formal data collection began. Each of the 11 focus groups that were held took place for approximately 30 to 60 minutes. As participants a rrived at the setting where th e focus group occurred, members of the research team secured informed consent and administer ed the demographic questionnaire individually. The focus group protocol (see Appendix D) was used to move the group from a general di scussion of mental health in terventions to more specific
84 questions about barriers and th e type of mental health trai ning participants received. Specifically, the moderator defined mental heal th intervention servic es and then asked a standard set of open-ended que stions regarding (a) current provision of mental health interventions to students, (b) barriers to the provision of such interventions, and (c) perceptions of knowledge and ski ll deficits that contribute to the training/qualification(s) barriers. A single moderator (the author of this thesis) led all 11 focus groups to ensure a standardized questioning pro cedure. The moderators role included monitoring of the group, including allowing all participants an equal chance to participate in the focus group. The field note taker was responsible for recording the dialogue of the participants, what order the participants answered each question, and when each participant spoke. Please refer to Appendix E for a sample of the form that the field note taker utilized to document participants answers. Ethical Considerations Several precautions were taken to protect the participants. First, the Principal Investigator (PI) of the larger study obtain ed approval from the Institutional Review Board (IRB) at the University of South Florida, the Middle Florida County Public Schools, and the Southern Florida County P ublic Schools to conduct this research. Documentation of all possible precautions taken to protect human research participants were submitted prior to conducting any aspects of data collection A participant consent form was administered to participants upon ar rival at the data co llection setting. The participant consent form outlined the purpose of the study, the risks and benefits of the study, data collection methods (i.e., use of a ta pe recorder), and allo wed practitioners to
85 decline or agree to participate. The consen t form contained contact information for the research team in order for particip ants to ask any follow-up questions. Protection of participant id entity was upheld to the fu llest extent throughout the study. During the recruitment, data collecti on, and analysis phases, participants were assigned a code number rather than identifyi ng them by name. All interview summaries, audiotapes, and any other supporting documenta tion were labeled using this code number so as to protect the confidentiality and ident ity of all participants. Participants were informed of the use of an audiotape through the signed consent form and during the beginning of the focus group (see focus group prot ocol in Appendix D). Only the PI of the larger study had access to the locked file cab inet that was being used to store documents linking code numbers to part icipant names and any other personally identifiable information. Data Analysis As defined by Creswell (1998), two basic types of information were collected in this study. Data were generated through the followi ng two types of information: (a) field notes taken during focus groups by the field not e taker (see sample form in Appendix E) and (b) the completion of focus group intervie ws that were audiotaped, documenting the exact comments and interactions that occurred du ring the focus group sessions. Field notes documented participants responses to que stions and were recorded as faithfully as possible during the interview session, with no interpretation or themes noted on the interview protocol. After the focus groups we re conducted, the resul ting audiotapes were transcribed verbatim. Master copies of the transcriptions were kept in the aforementioned locked file cabinet. To addr ess the research questi ons of this study, data
86 were analyzed from Question 1, Question 2, Question 4, Question 5, and Question 6 from the focus group protocol. The remaining question was asked during the focus group sessions for the purpose of the larger study. Additionally, only the information obtained from the nine focus groups containing eith er (a) practitioners with 0-5 years of experience, or (b) practitioners with 17 or more years of experience, were analyzed during comparisons reported in Chapter 4. Al l 11 focus groups sessions were utilized in the development of themes reported. The data analyses strategies utili zed in this study were based on the recommendations of Creswell (1998). Creswell described the data analysis process as a progression that involves moving in analytical circles rather th an a fixed, linear approach. This process can be represented in a spiral im age, a data analysis spiral, represented by Figure 1.
87 Figure 1 The Data Analysis Spiral Creswell describes qualitative data analysis as the process of a researcher moving through four different procedures within the data analysis spiral. Each of the four data analysis procedures is represen ted by a separate spiral within the complete data analysis spiral. Creswell (1998) describes the data management procedure of the first data analysis spiral as the research er entering with data of text and exiting with an account or a narrative. Throughout this process the research er touches on several facets of analysis and circles around and around (Creswell, 1998). The data management spiral in this study involved the process of transferring raw data, or the focus group audiotapes, into a narrative of written words. Focus group audi otapes were transcribed verbatim into written documents in Microsoft Word. Follo wing completed transcriptions of the 11 Account Representing, visualizing Describing, Classifying, Interpreting Reading, Memoing Data Managing PROCEDURES Creswell, 1998 Data Collection
88 focus groups, the transcripts were printed and re viewed to get a first impression of the data, emerging themes, and to make prelimin ary notes. This procedure is defined as reading and memoing, the second loop of the data analysis spiral. In a general review of all the information, the author thoroughly read the transcripts and field notes from the study. Following this step, the procedure th at reduces the data began through describing, classifying, and interpreting the data (Creswell, 1998). Creswe ll (1998) describes this third loop of the data analysis spiral as th e process of describing the data in detail, developing themes or dimensions through so me classification system, and providing an interpretation in light of thei r own view or views of perspec tive in the literature. Within this spiral classifying of the data occurs, wh ich involves taking the text apart, looking for categories, themes, or dimensions information (Creswell, 1998). This process, defined as coding, represents the process by which th e information obtained was broken down, conceptualized, and put back together in a novel way (Strauss & Corbin, 1990). Specifically, three members of the research t eam were involved in the third loop of the data analysis spiral. Within this stage of the data analysis spiral, three members of the research group engaged in several careful r eadings of three transcripts and developed a short list of tentative codes for each of the re search questions that matched text segments within the transcript. Investigative perspective was used in the creation of categories and codes as the source of names used to identify given sets of categor ies and codes (Constas, 1992). All three members of the research gr oup read through the sa me three transcripts and developed a short list of tentative code s for each of the research questions that matched text segments within the transcri pt. These codes were expanded upon as the
89 three members of the research team re viewed and re-reviewed the focus group transcriptions. Categorical a ggregation occurred through this process, as research team members sought a collection of inst ances from the data (Stake, 1995). The three researchers then met to reach a consensus regarding the major and minor themes identified in the transcripts and to develop a codebook that would organize participant responses into disc rete categories. Each member served to cross-check and validate the codes identified by the other two members. In the event of a disagreement, all three members traced the segment of text back to its original location and determined the appropriate code after c onducting a more thorough review of the transcript and the context in which the comment was made. Th is procedure was an additional means to ensure the rigor of the met hods used in this study. Following the development of a codebook, a total of six res earch assistants applied the codebook to all 11 tran scripts; each transcript wa s analyzed by at least two researchers. The method of constant comparison, or consta nt comparative analysis, was also utilized to compare the themes menti oned within each of the focus groups (Glaser & Strauss, 1967). Constant comparison analysis is often used when the researcher wants to answer general questions of the data (Leech & Onwuegbuzie, in press). Constant comparison was undertaken inductively, or as codes were identified when they emerged from the data. During constant comparison, one focus group was analyzed at a time and then compared to the next focus group. This process allows for the examination of new themes as they emerged. When new themes no longer emerged from the transcripts read by each researcher, theoretical saturation had been reached. Throughout this stage, focus group transcripts were analyzed in a systematic, sequential, and verifiable process such
90 that the location of any given theme could be traced (Patton, 1990). This allowed for comparability among researchers when there we re differences of opinion about the codes assigned. If both research team members traced the segment of text back to its original location and were unable to agree upon the appropriate code after conducting a more thorough review of the transcript, an addi tional opinion was solicited from a third researcher. Researchers then entered the consensus of the coding into a qualitative software program (Atlas.ti), which provided a tool for organizing questions, codes, quotations, and groups of school psychologists. ATLAS/ti is a qualitative data assessment computer software package that assists in th e process of coding and analysis of datasets such as transcribed focus groups (Muhr & Friese, 2004). In the final procedure of the data analys is spiral, researchers present the data, a packaging of what was found in text, tabular, or figural form (Creswell, 1998). This final spiral is described as the process of repres enting or visualizing the data. Within this study, data are presented in text and tabular form. Data in text form included the representative quotes of the various themes that emerged within the study. Data in tabular form were represented through comp arison tables for each of the research questions. Comparison tables present the da ta in quantitative form through comparative data representing the themes in the study differentiated throug h the category of experienced practitioners or new practitioners. To provi de an understanding of the frequency with which the themes were used by new and experienced practitioners, the number of times each them and subtheme wa s described by participants was counted. These frequency counts represent the numbe r of times participants in each group provided a sentiment (i.e., quotation) that ex pressed the coded theme or subtheme. A
91 total index of the frequency with which the coded themes and subthemes were mentioned was created by summing the total number of times a strategy was mentioned in the total sample (i.e., 11 focus groups) as well as br oken down into total me ntions for the four focus groups of experienced practitioners and the four focus groups of new practitioners. To control for the fact that a few verbose participants could artificially inflate the frequency of a given them or sub-theme, a second index of frequency was created by calculating the proportion of groups in which a given them or sub-theme was mentioned at least once. Finally, naturalistic generali zations were developed, generalizations that people can learn from the case either for them selves or for applying it to a population of cases (Creswell, 1998). Credibility Measures In approaching reliability and validity issues in qual itative research, Merrick (1999) recommended following Li ncoln and Gubas (1985) delineation of parallel criteria, four criteria, which are discussed below, that parallel those of quantitative methods. These criteria, which increase the likelihood that cred ible findings and interpretations will be proposed, can be me t through the use of several techniques. Through the use of these techniques, the tr ustworthiness of the research can be established. A number of the suggested t echniques to meet the parallel criteria established by Lincoln and Guba (1985) were utilized within the study to establish the trustworthiness of the research. As summarized by Merrick (1999), the concep t of internal validity is paralleled by internal credibility. To increase the likelihood of credibilit y, the technique of prolonged engagement and persistent observati on was utilized with in the study. Through
92 the use of 11 focus groups, the researchers extend ed their time in the field. Triangulation, or the use of different sources, was utilized in this study (Merri ck, 1999). Field notes were taken during the focus groups in addition to taping, so as to provide two different sources of data through two observers. In a ddition, because this res earch is part of a larger study, collaborative wo rk occurred throughout the entire research process, which increased the likelihood that analyses a nd interpretations were not biased. The concept of external validity is parall el to transferability (Merrick, 1999). Transferability is defined as the research ers responsibility to provide the thick description necessary to enable someone interested in making a transfer to reach a conclusion about whether transf er can be contemplated as a possibility (Lincoln & Guba, 1985, p. 316). Transferability was reached through the collecti on of sufficiently detailed descriptions of data within the context of the study and through the report of sufficient detail and precision to allow judgments a bout transferability to be made by the readers of the study. Examining two different locations also increase s the trustworthiness of the common themes that emerged within the study (Glesne, 2006). The concept of reliability is parallel to dependability (Merrick, 1999). The latter is to be achieved by using an inquiry aud it, which involves th e examination of the process and product of the inquiry. To addr ess the issue of dependability, triangulation, the use of multiple data-collection methods, wa s utilized. In addition, an external audit occurred with a professor in the USF School Psychology Program. An external audit involves an outside person examining th e research proce ss and product through auditing the field notes, rese arch journal, and analytic al coding scheme (Merrick, 1999).
93 Finally, the concept of objectivity is pa ralleled to that of confirmability. Confirmability refers to the degree to which th e product is accurate and unbiased. It is the extent to which the auditor examines the product and attests that it is supported by data and is internally coherent so that the bottom line may be accepted and is known as leaving an audit trail (Lincoln & Guba, 1985, p.318). The research team left a trail of raw data through the documentation of iden tifiable raw data (e.g., field notes), data reduction and analysis products, process not es, data reconstruction and synthesis products, and instrument development informa tion (Lincoln & Guba, 1985). Peer review and debriefing was also utilized, which allowe d for external reflection and external input into the work that had been completed in the research proces s (Merrick, 1999). Limitations of the Current Study In this study, limited sampling may potenti ally limit the ecological validity of the results. Ecological validity is the ability of the researcher to generalize the results of a study across settings (Johnson & Christenson, 2004). Violations to ecological validity include the tendency of the researcher to dr aw erroneous conclusions to populations in different settings than th e population under study. Beca use this study recruited participants from only two school districts within Florida, th e external validity is limited. In addition, because of the relatively small si ze, participants are not likely to represent equally elementary, middle, and high schools. Each individual holds different views and values and employs them differently when work ing within his/her role in a school. As a result of this sampling, a considerable amount of variability in att itudes, beliefs, and practices may have gone unexamined.
94 Focus group questions may have elicite d ideas and thoughts that might not be suggestive of real life or may not have prom pted participants to think about the issues to be considered. Questions may not have se rved their purpose in pr ompting participants and eliciting answers related to the questions Participants may have added information that might not otherwise have been consider ed. Finally, it is possi ble that individuals within the focus groups may have altered their attitudes and be liefs based upon other participants responses. Results from this study, therefore, should be interpreted with caution. Contributions to the Literature Although there exists a need for school psychologists to expand their involvement in the provision of mental health services, informati on regarding the specif ic barriers that they perceive prohibit the implementation of mental health services is insufficient. If school psychologists are to respond to the cha llenges posed by the prevalence of mental disorders and psychopathology in youth, the fact ors that impede the provision of mental health services must be identified. The propos ed study attempted to identify the barriers perceived by school psychologists. In addi tion, because of the recent trend towards increased expansion of the school psychologists role in the provision of mental health services, school psychologists beliefs re garding their professi onal roles and their corresponding training may vary according to th e number of years they have been away from the university setting. It was expected that an understandi ng of the relationship between the barriers perceived by practitioners and the number of years they have been in the field would provide a more complete picture relating to the problem.
95 Chapter Four Results The primary purpose of this study was to elucidate factors that school psychologists perceive inhibit them from pr oviding more mental health interventions within their professional roles. In an effort to identify training-related barriers related to knowledge and skill deficits, the current study also purposefully queried practitioners about desired didactic and practical expe riences in school-based mental health interventions. Research also suggests th at significant differences exist among school psychologists of different ages and levels of experience pertaining to their roles within the school system (e.g., Curtis et al., 2002). Therefore, factors such as years of experience also should be considered when studying school psychologists roles in the provision of mental health services. Thus, an additional purpose of the current study was to examine the frequency of the themes eluc idated across each re search question as a function of practitioners levels of experience. Seven main questions were asked of th e participants in the 11 focus group sessions to gain their thoughts and feelings about providing mental health interventions within their professional roles; five of th ese questions were analyzed for the current study. Within each question, several common themes emerged across the focus groups; however, differences between practitioners level of experience was noted on several occasions. The five main questions were as follows: (a) For which type of problems are
96 students referred for mental he alth assessment and interventi on to either you or other school personnel?, (b) Which mental health assessment and interventions have you provided during their past few y ears of practice in the schools ?, (c) Which factors prevent you from providing additional mental health assessment and intervention?, (d) Which specific content areas that were taught in your graduate school or continuing education training most enable you to provide mental health assessm ent and intervention?, and (e) What types of training expe riences (beyond class work) that were included in your graduate school or continuing education tr aining most enable you to provide mental health assessment and intervention? Importantly, the analyses of responses from participants within the current study indicate that both consensus within the focus groups and th eoretical saturation across all five research questions was reached. In ge neral, consensus was reached in each of the focus groups, as participants exhibited a stat e of mutual agreemen t with all legitimate concerns of individuals ha ving been addressed to the satisfaction of the group. Furthermore, analyses of transcribed focus groups indicated that participants did not exhibit negative responses nor was there the presence of any negative cases. Theoretical saturation occurred during the analysis of te xt when no new themes were identified, the themes were dense enough to cover variati ons and process, and relationships between themes were delineated during text analys is (Strauss & Corbin, 1990). Theoretical saturation was achieved after eight focus gr oups, as no new themes emerged during the analysis of the 9th, 10th, and 11th transcripts. Substantiation of th eoretical saturation was also evidenced through the use of two investig ators in the process of examining each of the 11 transcripts.
97 The purpose of this chapter is to pres ent the themes that emerged from the analysis of the 11 focus group transcripts. Th e chapter is organized in relation to the specific research questions prev iously presented in Chapter 1. After the initial coding process of all 11 transcripts from the larg er study had been completed, this graduate student and two additional researchers from the research team collapsed codes into thematic families. The following section will provide a description of the (a) themes and subthemes related to problems referred, (b) themes and subthemes related to mental health services provided, (c) themes and subthemes related to barriers to the provision of psychotherapeutic services, and (d) themes and subthemes related to training needs and experiences. Below is a description of the salient themes, including representative quotations, and paraphrased statements; focus group numbers (FG) of the transcribed data are indicated as well. Table 2 presents th e composition of the fo cus groups within the current study. Research Questions Focus group data obtained in this study were transcribe d and analyzed relative to the four main research questions. Patterns a nd trends are discussed below, with sample quotes provided to illustrate specific experi ences. Following a discus sion of the general findings of each research question, frequency of themes is compared as a function of practitioners levels of experience for Research Ques tions 2, 3, and 4. Research Question 1 is not part of this secondary anal ysis process given that the referring agent has
98 Table 2 Composition of Focus Groups Focus group (FG) Number of participants Level of school psychologist FG 1 3 Mid-range FG 2 4 Experienced FG 3 4 Mid-range FG 4 3 New FG 5 4 Experienced FG 6 4 Mid-range FG 7 5 New FG 8 2 Experienced FG 9 3 New FG 10 4 New FG 11 3 Experienced no real control over which types of problem s are referred to school personnel; hence, referral problems should be similar across prac titioners levels of experience. However, the school psychologists receiving the referrals do have control over the types of services they provide, what they perceive are barri ers to psychotherapeutic service provision, and personal perceptions of the mental health training needs of school psychologists.
99 Types of Problems for which Students are Referred for Mental Health Assessment and Intervention The following section will provide a descri ption of the (a) themes related to problems referred and (b) subthemes within each category. Below is a description of all salient themes, including repr esentative quotations and pa raphrased statements; focus group numbers (FG) assigned are indicated as well. Table 3 presents a summary of themes and subthemes. Anxiety. The theme anxiety refers to student s who exhibit irrational fear or worry characterized by physical symptoms and feelings of stress that interf ere with a students ability to carry out normal or desired activit ies. Although anxiety is a diagnosable DSM disorder, the next theme to be discussed, part icipants described this referral problem as encompassing a variety of separate forms of anxiety-related issues. This theme included three subthemes from participants conversat ions: general anxiety or other clinical anxiety disorder, test anxiet y, and school phobia. General anxiety and other clinical anxiety disorder refers to those sentiments that indicated anxiety (FG 8) as a referral problem but were minimally described as well as descriptions of ot her anxiety problems, such as severe panic attacks (FG 9). Test anxiety refers to those sentiments that indicated receiving referrals fo r students anxious over tes ting situations. School phobia was identified as students who refuse to co me to school, very anxious about coming to school (FG 2).
100 Table 3 Themes and Subthemes Related to the Common Ty pes of Problems Referred for Mental Health Assessment and Intervention Theme Sub-themes (when applicable) Anxiety General anxiety or other clinical anxiety disorder; school phobi a; test anxiety DSM disorders Oppositional/defiant symptoms or behaviors; attention-deficit hype ractivity disorder symptoms or behaviors; bipolar symptoms or behaviors; depressive sy mptoms or behaviors, autism/Aspergers Anger The expressed emotion of anger, behaviors that convey aggression and violence Isolated behavioral or emotional symptoms Bullying; lack of empathy; self-esteem; cutting; interpers onal problems; eating problems; isolated internalizing symptoms; isolated externalizing symptoms; health concerns Atypical/bizarre behaviors Learning problems Work comple tion; study skills; motivation Crisis situations Suicidality; threat to harm others; grief or loss; school-wide tragedy Trauma Child abuse; sexual abuse
101 Adolescent issues Romantic re lationship problems; teenage sexuality; gender/sexual identity; substance abuse Family issues Divorce; foster ca re situations; parent absent from home; conflict with parent Adults mental health problems DSM disorders The theme of DSM disorders refe rs to those referral problems that can be characterized as a specific mental disorder including a clus ter of distinct signs and symptoms as described in the Diagnostic and Statistical Manual of Mental Disorders (American Psychiatric Association, 2000). This theme comprised five subthemes generated from school psychologists convers ations: oppositional/defiant symptoms or behaviors, attention-defic it hyperactivity disorder (ADHD) symptoms or behaviors, bipolar symptoms or behaviors, depressive sy mptoms or behaviors, and autism/aspergers. Within the subtheme of oppositional/defiant symptoms, students were described as exhibiting such behaviors as noncomplian ce (FG 1), trouble problem solving and taking ownership for behavior (FG 2), and not following directions (FG 3). One participant described the common types of ADHD behaviors teachers indicate when referring a student, including out of their seat, not following directions, inattentive, cant focus, is easily distracted, distracts others moving about the classroom, constantly going to the restroom, all those kinds of behavior s (FG 1). Many participants noted the prevalence of this referral problem, highlight ed by the following statement: I would just say that in my short time I have seen a lot of attention issues and in attention (FG 4).
102 Similarly, the prevalence of students with bipolar disord er was also noted by one participant: those [bipolar disorder and cutt ing] are two big areas that Im seeing too (FG 2). The complexity of identifying childre n with depression was noted by a number of participants, as one participant described receiving a lot for depression, but a lot of times, its manifested in differe nt ways (FG 8). Another pa rticipant indicated that it usually comes out later. Like a lot of th e aggression that is stemming from possible depression (FG 5). Similar to ADHD, multiple participants who discussed referrals for autism spectrum disorders (ASD) noted th e prevalence of this problem: I have a lot of what have later become e ither diagnosed or we all think and it is undiagnosed autistic or Aspergers. the teachers describe them as socially detached, inappropriate, just wandering. A ll those kinds of things. And later on through the process weve found that out. Hi gher than normal [referrals for ASD] I think. (FG 3) Anger The theme of anger refers to student s who exhibit an em otional state that varies in intensity from mild irritation to intense fury and rage, commonly coexistent with a behavioral reaction by the st udent. The category of anger emerged and was coded as a distinct theme because anger can be a symp tom of many DSM disorders. This theme included two subthemes generated from par ticipants conversati ons: the expressed emotion of anger and behaviors that convey violence. Students who expressed emotions of anger were described as having explosiv e behaviors volatile behavior(FG 2), angry outbursts in the classroom (FG 7), and when they get mad they disrupt the classroom, throw things, and the teachers don t know how to deal with that in their
103 general classrooms (FG 4). Behaviors that convey violence include d five or six year old kids who have battered a teacher or a nother kid (FG 2) and students having weapon at school (FG 2). Isolated behavioral or emotional symptoms The theme of specific, isolated behavioral or emotional symptoms refers to those mental health problems that were mentioned by participants that are relate d to a distinctive characteristic/symptom exhibited by a student. In particular, thes e symptoms did not, by themselves, constitute diagnosable DSM disorders. This theme included nine s ubthemes from participants conversations: bullying, lack of empathy, se lf-esteem, cutting, interpersonal problems, eating problems, isolated internalizing symp toms, isolated externalizing symptoms, and health concerns. Bullying problems included re ferrals for students who were victims of bullying as well as those who were the aggr essors. Participants described bullying referrals covering both physical and verbal bullying within the schools. A lack of empathy was described by one participant: I ve had a lot of kids they either fail to develop it or have lost like the empathic complex you know, they re ally just dont seem to have that emotional connection, that empathy for other people (FG 2). Self-esteem issues included such problems as low self-concept and low selfesteem. Participants described cuttin g with the following sentiment, cutting is basically (one of) the two big things that seem to generate the most business (FG 5). Regarding referrals for interpersonal problems, participants described students as lacking social skills, having difficulty with peer relations, and experiencing social isolation and/or peer rejection. Participants discussed referrals for eati ng problems in general terms by simply
104 reporting eating problems (FG 11) and not expanding on specific behaviors such as binging and purging. Isolated internalizing symptoms refe rs to students experiencing problems within the self (i.e., deal with problems in ternally) that do not meet all criteria for internalizing disorder diagnoses, such as mood or anxiety disorders. Referral problems within this sub-theme included st udents who appeared withdrawn, students who do not want to express feeli ng or emotion, and students who do not speak. Similarly, participants also described receiving refe rrals for students who displayed isolated externalizing problems, or beha viors directed outward (i.e., externally), that did not meet all criteria for a disruptive behavior disorder diagnosis, such as conduct disorder. Participants described problems related to disruptive classroom behavior including offtask behaviors and acting out behaviors. On e participant described such behaviors as disruptive, disrespectful, ta lking back, screaming, crying, ye lling, things like that (FG 9). Referral concerns were also mentioned for health-related issues as one participant noted receiving a referral for a student w ho has a condition where he defecates on himself (FG 7). Atypical/bizarre behavior The theme of atypical/bi zarre behavior refers to student behavior that deviates from what is usual or common or what is to be expected. Participants indicated that sometimes thes e problems were referred to them in broad terms, such as unusual and odd behaviors (F G 6) or as described by one participant, kids that are saying or doing things that are different than same-aged peers and what the teacher expects (FG 2). Othe r participants indicated specific behaviors, such as saying inappropriate comments that are sexual in nature (FG 7), drawing pictures with inappropriate content (FG 5), a nd eating non-nutritive items (FG 3).
105 Learning problems The theme of learning problems refers to a heterogeneous group of problems manifested by difficulties in the acquisition and use of listening, speaking, reading, writing, reasoni ng, or subject-related skills. This theme consisted of three subthemes generated from participants conversations: problem s related to work completion, study skills, and motivation. Partic ipants indicated receiving referrals for students who were not completing work (FG 3) and needed help with organizational skills (FG 2). Motivation issues were de scribed as students no longer caring about school, bright students failing their classes, and students just not wanting to do their work. Crisis situations. The theme of crisis situati ons encompasses the circumstances under which student(s) perceive a sudden loss of ability to use effective coping skills. This theme included four sub-themes from pa rticipants conversations: suicidality, threat to harm others, grief or loss, and school-w ide tragedy. A number of suicidal behaviors were identified as a reason for students bei ng referred, including s uicidal ideation (FG 8) and writing something or saying someth ing that makes somebody nervous about their intentions of hurting themselves (FG 11). S ituations in which a student threatened to harm someone else were described by participants: a student threatened to kill somebody and then drew a picture of it with the knife and everyt hing (FG 5) and a student brought a knife to sc hool (FG 5). When discussing referrals related to grief and loss, participants noted the prevalence of such problems: quite a few kids have lost parents (FG 2) and we deal with a lot of children who have been impacted or affected by family member, friend, sibling, parent that committed suicide (FG 2). School-
106 wide tragedies included such s ituations as when a child was hit and killed (FG 1) and a beloved teacher dies (FG 8). Trauma. The theme of trauma refers to probl ems that arise because a student has experienced something that is emotionally pa inful, distressful, or shocking, which can result in mental and physical problems. Th is theme contained two subthemes generated from participants conversations: child abuse and sexual abuse. Neither child abuse nor sexual abuse was elaborated upon by participan ts during the focus groups; instead they discussed referrals for these situ ations in general terms. Adolescent issues The theme of adolescent issues refers to problems that occur during the time of adolescent development th at are often triggered by physical, mental, and/or school changes. This theme include d four subthemes generated from participants conversations: romantic relationship problem s, teenage sexuality, gender/sexual identity, and substance abuse. Problems surroundi ng romantic relationships included such sentiments as problems with boyfriend/girlfr iend (FG 8) and dating (FG 7). Teenage sexuality was described as problems relate d to pregnancy (FG 11). Gender/sexual identity issues were descri bed as gender problems, how to do that, the issues (FG 5). Regarding substance abuse, participants indicated receiving refe rrals for students who were intoxicated or using drugs (FG 11). Family issues. The theme of family issues refers to student problems that arise due to problems occurring within the family and/or home environment. This theme included four subthemes generated from particip ants conversations: di vorce, foster care situations, parent absent fr om home, and conflict with pa rent. Divorce includes issues that may arise because of a current or past family situation involvi ng parental separation.
107 One participant described how this can beco me a problem in the schools, with those students whose mom and dad have just di vorced or mom has just remarried all those other issues kinda come into play (FG 8). Th e subtheme of foster ca re situations refers to student issues that arise when they are moved to out-of-home placements. One participant indicated that a large number of the referrals that Im getting are like emergency related referrals, these kids are in a temporary foster home (FG 8) or students who has some problems with adjusting to bei ng in a foster care situation (FG 7). Participants described receiving referrals because a parent is absent from the home: I have a lot of children whose one parent is incarcerated or both parents are incarcerated (FG 2) and parental rights were severed (FG 5). Discussions of students having conflicts with parents included such sentiments as his mother never listened to him, felt like his mother never believed him, was always yelling at him (FG 5). Adults mental health problems. The theme of adults mental health problems refers to problems brought to the attention of school psychologists th at are related to the personal problems that school personnel expe rience. The following participant described her experience with this problem: its the working with adult staff that ar e having major issues from principal, custodian, to the teachers not only about necessarily their personal issues but after youve been there awhile you become very accessible to them and they feel very comfortable coming to you (FG 5). Participants did not indicate a particular group of school personnel that they often encountered, as noted in the previous quotation.
108 Although this research question was not pa rt of the secondary analysis of the frequency of themes compared as a function of practitioners levels of experience, a total index of the frequency with which the ment al health problems were mentioned was created by summing the total number of times a problem was mentioned in the total sample (i.e., 11 focus groups). See Table 4 for a summary of the frequency with which specific referral problems were discussed w ithin the current study and Figure 2 for a graphic representation the pe rcentage of times with wh ich each specific theme was discussed within the current study. 20% 16% 13% 11% 11% 9% 7% 6% 4% 2% 1% Isolated behavioral or emotional symptoms DSM disorders Crisis situations Family issues Anger Anxiety Adolescent Issues Learning problems Atypical/bizarre behavior Adult's mental health problems Trauma Figure 2. Percentage of times with which each specific referral problem theme was mentioned by participants
109 Table 4 Frequency School Psychologists Men tioned Specific Referral Problem Referral Problem Total ( n =39) N % Family issues 28 73 Divorce 8 55 Foster care situations 3 25 Parent absent from home 3 18 Conflict with parent 3 18 Trauma 2 18 Child abuse 1 9 Sexual abuse 1 9 Adults mental health problems 4 9 Learning problems 15 55 Work completion 3 27 Study skills 2 9 Motivation 8 55 Atypical/bizarre behavior 9 55 Anger 28 73 The expressed emotion of anger 15 64 Behaviors that convey aggression and violence 13 45 Adolescent issues 16 64 Romantic relationship problems 2 18 Teenage sexuality 2 18 Gender/sexual identity 2 18 Substance abuse 8 55
110 DSM disorders 38 91 Oppositional, defiant symptoms or behaviors 6 45 ADHD symptoms or behaviors 10 45 Bipolar symptoms or behaviors 3 18 Depression symptoms or behaviors 16 82 Autism/Aspergers 3 18 Anxiety 22 82 General anxiety or other clinical anxiety disorder 16 82 School phobia 5 36 Test anxiety 1 9 Crisis situations 32 73 Suicidality 12 55 Threat to harm others 7 36 Grief or loss 10 64 School-wide tragedy 3 18 Isolated behavioral or emotional symptoms 48 100 Bullying 5 36 Lack of empathy 1 9 Self-esteem 4 27 Cutting 7 45 Interpersonal problems 7 45 Eating problems 3 27 Isolated internalizing symptoms 8 45 Isolated externalizing symptoms 13 55 Health concerns 1 9 Note N = number of times referral problem was mentioned across groups; % = proportion of groups in which the problem domain was mentioned at least one time.
111 Mental Health Assessment and Interventions School Psychologists have Provided During Their Recent Practice in the Schools The following section will provide a descrip tion of the (a) themes related to the types of mental health asse ssment and intervention services provided by participants and (b) subthemes within each category. Belo w is a description of all salient themes, including representative quot ations and paraphrased statements; focus group numbers (FG) assigned are indicated as well. See Table 5 for a summary of themes and subthemes. Themes will be presented in order of the frequency with which they were mentioned. Following a discussion of the ge neral findings of the research question, themes are compared as a function of participants levels of experience. Group counseling. The theme of group counsel ing refers to a form of psychotherapy in which a small, selected group of individuals meet with a school psychologist to discuss issues related to a particular problem area. This theme included nine subthemes generated from participants conversations: social skills group, study skills group, organization skills group, anger management group, motivation group, divorce group, anxiety group, grief group, and unsp ecified group. Participants described how social skills groups can be tailored to specific populations of students: Ive done some social skills groups Ill do a lot of [groups for] relational aggression in girls. So, I do a lot of skill building with girls as far as how to make and maintain friendships and how to get along with peers and how to handle when other kids arent nice to you and when they put you down or they exclude you from group. (FG 9)
112 Table 5 Themes and Sub-themes Related to the Common Types of Mental Health Assessment and Intervention Services Prov ided by School Psychologists Theme Sub-themes (when applicable) Group counseling Social skills group; study skills group; organization skills group; anger management group; motivation group; divorce group; anxiety group; grief group; unspecified group Individual counseling Crisis intervention Suicide assessment and immediate intervention; threat assessment; de-e scalation of individual problem; unspecified crisis intervention activity Consultation to individuals Parent c onsultation; school-staff consultation; problem-solving team consultation Behavioral interventions Case management Consultation with psychiatrist; consultation with outside therapist; re ferral to outside agencies/follow-up care; unspecified case management; consultation with police Social-emotional behavioral assessment Inservices (consultation to gr oup) Presentation to educatio nal staff; presentation to parents
113 Counseling adults Prevention School or class-wide screening; drug education Family services Parent support groups ________________________________________________________________________ Similarly, study skill groups, organizati on skills groups, anger management groups, motivation groups, and divorce groups we re all mentioned as different types of group counseling interventions provided, a lthough additional details regarding the content of or rationales behind the provision of the group were not prov ided. Participants described providing group interventions to treat general anxiety and specific anxietyrelated concerns, such as text anxiety (FG 1). The sub-theme of unspecified group included statements made by pa rticipants that did not indi cate the specific problem for which group counseling was being provided. Fo r example, one partic ipant said, Ill run groups, so if there seems to be a certain issu e thats coming up a lot, then Ill do some groups (FG 9). Individual counseling. The theme of individual couns eling refers to a form of psychotherapy in which an individual meets with a school psychologist on an ongoing basis to discuss current or past problems. Participants indicate d providing individual counseling for students with specific needs/ concerns and for students who may just be having difficulty in school. For example, one participant descri bed, right at phase one I dealt with a couple of cases last year where [we] pu lled them outside kind of like a pre-intervention and I did counseling with both of them like six sessions (FG 1). Contrastingly, another particip ant described a more structur ed and formal process: I
114 actually do one-on-one individual therapy with kids. I have f our kids that I see weekly and it is written in their IEP that they have counseling goals (FG 6). Similarly, participants described using both informal and formal processes during individual counseling sessions. A more informal process was described by one participant: Usually we just talk about th ings that are going on at school and home that they want to talk about. It is very low key because we do not have a prescribed mental health model that we follow (FG 2). Ot her participants indi cated using a specific counseling process such as client-centered ther apy or reality therapy. Following a specific program as part of individual thera py was also elaborated upon by a participant: Prepare Curriculum, I use that a lot. Typically, what I do is focused on teaching a skill within a content of a role play, you know, the Skill Streaming format. And then following it up with some kind of contingency, some monitoring system, classroom. (FG 9) Participants also described using individual counseling serv ices as a method to treat a variety of problems, ranging from ongoing suicidality to motivational issues. Crisis intervention services. The theme of crisis intervention services can be described as immediate, short-term help prov ided to individuals who experience an event that produces emotional, mental, physical, a nd behavioral distress or problems. This theme included four sub-themes genera ted from participan ts conversations: suicide assessment and immediate intervention, threat assessment, de-escal ation of individual problems, and unspecified crisis interven tion activities. The provision of suicide assessment and immediate intervention encompa sses a variety of services, including riskto-harm-self assessments, administration of suicidal ideation questionnaires, no suicide
115 contracts, contacting school re source officers and hospitalizin g a student, referrals to and consultation with crisis centers, consultation with parents, and short-term follow-up with the referred student. Threat assessment i nvolves assessing a student s risk for harming another person. One participant elaborated on the varying degrees with which this service may be needed, stating that I have to, sometimes, do an informal threat assessment and if Im picking up vibes that this kid is a threat to himself or others, I will pose a more formal threat assessment, but so metimes it ends right there (FG 8). The sub-theme of de-escalation of individual pr oblems involves those services provided by school psychologists on a short-term and immedi ate basis in an effort to work with a student having problems at that moment in th e school environment. As one participant described, theyll be lots of more short-te rm referral types of th ings, have a kid sent down because [they need] somebody that can ta ke a kid on a short-term, maybe just for that period and then deal w ith some of those issues (FG 2). Similarly, another participant described providing such services as a lot of just getting to class and trying to put out the little fire at the moment, kind of crisis management (FG 9). The final subtheme, unspecified crisis intervention activit ies, includes statements made by participants that were related to crisis in tervention activities that were broad and ambiguous, such as stating that they provide crisis intervention. Consultation (to individuals). The theme of consultation refers to a conference between two or more people to consider a particular problem. This theme comprised three sub-themes generated from participants conversations: parent consultation, schoolstaff consultation, and problem-solving team c onsultation. Participants described parent consultation across a broad range of discussion topics. One participant indicated that
116 Ive had a lot of interaction with parent s, and helping them understand their childs needs and, looking at strategies, you know, that they can try, resources that they have available to them (FG 2). Regarding school-staff cons ultation, participants described the process as someone is coming and sa ying what do I do about this, so you are really using your expertise in response to an issue (FG 11). Some commonly shared ideas also emerged within this sub-theme, such as the use of consultation with schoolstaff to emphasize the positive qualities within a student. As described by one school psychologist: Sometimes what I am really trying to do is really more therapeutic with the teacher to get the teacher to see a different side of the kid, to get the teacher to listen to the positive qualities that reinforce the kid, and then the teachers attitude turns around and then she likes the kid. (FG 6) School staff with whom participants me ntioned consulting included teachers and guidance counselors. The subtheme of problem-solving team consultation involves school psychologists working as part of an educational support team to determine a referred students problem, determine the ty pes of services needed, and implement interventions. Behavioral interventions. The theme of behavioral inte rventions refers to creating and/or implementing an informal or formal plan to reduce problem behaviors or increase desired behaviors. One participant elabor ated on the types of services provided, describing that they were putting kids on be havior contracts for so me of those issues they are having; especially aggression, th e acting out, or just completing work. The
117 motivational issues so writing behavior pl ans for kids (FG 7). Others indicated participating in FBAs and behavi oral intervention plans (FG 9). Case management The theme of case management can be described as a collaborative process of assessment, planni ng, facilitation and advoc acy for options and services to meet an individuals mental health needs through communication and maximum utilization of available resources This theme included five subthemes generated from participants c onversations: consulta tion with psychiatrist, consultation with outside therapist, consultation with police, referra l to outside agencies/follow-up care, and unspecified case management. Re garding consultation w ith psychiatrists, participants indicated sharing information for students that are on me dication (FG 5) or if we can give them feedback about how th e child is doing or what concerns we might see (FG 5). Participants did not elaborate on consultation with outside therapists and consultation with police, indicating only that they provided such services. The sub-theme of referral to outside agen cies/follow-up care includes t hose efforts made by school psychologists in order to provi de the referred students w ith appropriate services. Participants indicated maki ng outside referrals for family therapy services and counseling, as well as continuing to keep in touch with the re ferred service provider. The final sub-theme of unspecified case manage ment included those services that were mentioned only as case management, with no further description of activities. Social-emotional-behavioral assessment. The theme of social-emotionalbehavioral assessment refers to the process of gathering and discussing information from often multiple and diverse sources in order to develop a deep understanding of which factors contribute to and maintain an ope rationally defined referral concern; all
118 assessment activities are conducted with the in tent to provide inte rventions after the assessment phase. Participants described a number of services provided under this theme, including administering preand post-te sts, behavior rating sc ales, and projective measures, as well as conducting behavioral obs ervations, clinical inte rviews, and teacher, parent, and student interviews. Participants discussed administering measures to teacher, parent, and student and using a variety of assessment tools as part of the assessment process, including the use of broad indicator s (e.g., ask the parents a few questions) and narrow measures of problems (e.g., depression rating scales). Inservices (consultation to groups). The theme of inservices refers to training(s) provided for the purpose of educating individual s on a wide variety of topics. This theme included two sub-themes generated from participants conversations: presentation to educational staff and presentati on to parents. In describing presentations to educational staff, participants discussed broad topics, su ch as helping the facu lty with professional development in terms of how they can help fo ster the mental health needs of children (FG 2), whereas others focused on specific me ntal health issues, such as maybe the teacher doesnt know about Aspergers or whatever the mental health issue may be (FG 9). One participant elaborated on presen tation to parents, indicating that they were asked to come to parent meetings some times, PTA, and present on a myriad of different topics (FG 5). Counseling adults. The theme of counseling adults re fers to an informal and brief form of psychotherapy in which a school psyc hologist discusses curren t or past problems with school personnel. One participant el aborated on how school psychologists are involved in providing counseling to adults:
119 Whether it is for a teacher whos going through an emotional time, you know, or a student. I, last year, I had to collect some data and stuff, you know I went through my notes on how many, how many teachers I ha d seen, and here it was like, wow. I really didnt think that I, you know, had seen that many teachers, who were dealing with boyfriend issu es and boyfriends who we re psychotic and you know, things like that, and they didnt know what to do and other teachers have, you know, emotional needs. (FG 8) Although counseling adults is not a direct se rvice provided to students, participants discussed the indirect impact counseling adults can have on st udents. As one participant described, I still just feel like Im indire ctly helping the kids by helping the staff sometimes (FG 10). Prevention. The theme of prevention refers to the proactive provision of services that promote the well-being of students in a school environment. This theme contained two subthemes generated from participants conversations: school or class-wide screening and drug education. The subtheme of school or class-wide screening was described as a specified method that school ps ychologists implement in order to identify students at-risk, or in need of mental health services, w ithin their school. As one participant described, I generally worked with principals to find out which group of children they were most concerned about and th en what particular skills those children need (FG 2). Participants did not provide further specification of activities under the subtheme of drug education services. Family services. The theme of family services refers to interventions provided to families and/or significant others to address family relationship issues. This theme
120 included parent support groups. One part icipant described pr oviding parents group, for supporting the mental health needs of your child (FG 2). No participants reported providing family therapy. The role of years of experience in the pr ovision of mental health services by school psychologists. To provide a better understanding of the differences that emerged in relation to the type s of mental health services pr ovided by school psychologists as a function of practitioners levels of experience, the numbe r of times each mental health service was described by a pa rticipant was counted. These frequency counts represent the number of times participants in each gr oup provided a sentiment (i.e., quotation) that expressed the coded mental health service. A total index of the frequency with which the mental health service was mentioned was cr eated by summing the tota l number of times a service was mentioned in the to tal sample (i.e., 11 focus groups) as well as broken down into total mentions for the four groups of experienced school psychologists and the four groups of new school psychologist s (see Table 6) in an effort to compare frequency of responses between the two groups. Figure 3 provides a graphic representation of the percentage of times with which each barrier theme was discussed within the current study.
121 22% 19% 17% 13% 6% 5% 3% 3% 2% 1% Group counseling Individual counseling Crisis intervention Consultation to individuals Behavioral interventions Case management Social-emotional behavioral assessment Inservices Counseling adults Prevention Family servicesFigure 3. Percentage of times with which each mental health service theme was mentioned by participants As shown in Table 6, participants in both the new and experienced school psychologist groups reported th e provision of four mental health service themes at a relatively similar rate: indi vidual counseling services, group counseling services, counseling adults, social-emoti onal-behavior assessment, cons ultation to in dividuals, and crisis intervention services. Participants in the new sc hool psychologist groups were more likely to provide behavioral interventions (8 times, 75% of groups) than participants in the experienced school psychologist groups (2 times, 50% of groups). On the other hand, participants in the experienced school ps ychologist groups were more frequently
122 Table 6 Frequency each Group of School Psychologists Pr ovided Specified Serv ices by Level of Experience Services provided New school psychologists ( n =15 ) Mid-Range school psychologists ( n =11 ) Experienced school psychologists ( n =13 ) Total ( N =39 ) N % N % N % N % Individual counseling 10 100 10 100 12 100 32 100 Group counseling 10 100 17 100 11 75 38 91 Social skills group 3 75 3 66 3 25 8 55 Study skills group 1 25 2 33 1 25 4 27 Organizational skills group 1 25 0 0 1 25 2 18 Anger management group 2 25 3 66 1 25 6 36 Motivation group 0 0 0 0 1 25 1 9 Divorce group 1 25 0 0 0 0 1 9 Anxiety group 0 0 3 66 0 0 3 18 Grief group 0 0 0 0 2 25 2 9 Unspecified group 2 50 7 100 2 50 11 55 Family services: Parent support groups 0 0 0 0 1 25 1 9 Prevention 1 25 0 0 2 25 3 27 School or class-wide screening 1 25 0 0 1 25 2 18 Drug education 0 0 0 0 1 25 1 9 Counseling adults 3 25 0 0 2 50 5 27 Social-emotional behavioral assessment 3 25 3 33 3 50 9 45
123 Consultation (to individuals) 8 75 2 33 12 100 22 73 Parent consultation 2 50 1 33 4 100 7 55 School-staff consultation 6 75 1 33 3 75 10 64 Problem-solving team consultation 0 0 0 0 5 50 5 18 Inservices (Consultation to groups) 1 25 0 0 4 50 5 37 Presentation to school staff 1 25 0 0 3 50 4 27 Presentation to parents 0 0 0 0 1 25 1 9 Crisis Intervention 9 100 8 100 13 100 30 100 Suicide assessment and immediate intervention 3 50 1 33 4 50 8 45 Threat assessment 1 25 2 33 3 25 6 27 De-escalation of individual problem 2 50 0 0 3 50 5 36 Unspecified crisis intervention activity 3 75 5 66 3 75 11 73 Behavioral Interventions 8 75 5 100 2 50 15 73 Case management 2 25 2 66 6 75 10 66 Consult with psychiatrist 1 25 1 33 2 25 4 27 Consult with outside therapist 1 25 0 0 0 0 1 9 Referral to outside agencies, follow-up on care 0 0 0 0 3 75 3 55 Unspecified case management 0 0 0 0 1 25 1 9 Consultation with police 0 0 1 33 0 0 1 9 Note N = number of times service was mentioned in each group; % = proportion of groups in which the service domain was mentioned at least one time.
124 involved in the provision of inservices (4 tim es, 50% of groups) than participants in the new school psychologist groups (1 times, 25% of groups), with an emphasis on presentations to educational staff. Experien ced school psychologist groups also indicated more frequent involvement in case management activities (6 times, 75% of groups) when compared to new school psychologist groups (2 times, 25% of groups). Only participants in the experienced school psychologist groups indicated involvement in family services (1 time, 25% of groups). Factors that Prevent School Psychologists fr om Providing Additional Mental Health Assessment and Intervention The following section will provide a descri ption of the (a) themes related to barriers to providing mental health assessmen t and intervention and (b) subthemes within each category. Below is a description of a ll salient themes, including representative quotations and paraphrased statements; focus group numbers (FG) assigned is indicated as well. Table 7 presents a summary of themes and subthemes. Themes will be presented in order of the frequency with which they were mentioned. Following a discussion of the general findings of the research question, themes are compared as a function of practitioners levels of experience.
125 Table 7 Themes and Sub-themes Related to Barriers to the Provision of Mental Health Assessment and Interven tion Identified by School Psychologists Theme Sub-themes (when applicable) Problems inherent to using schools as site for service delivery Scheduling problems; space constraints; inconsistent treatment; termination; student attrition; maintaining student privacy; accountability for academic success only; overlapping responsibility among mental health care providers Insufficient support from the department and district administration Department assigned roles and responsibilities; department procedural requirements; department liability and legal concerns; lack of support from district-level administration Problems with school personnel Lack of support from building-level administration; teachers not supportive of counseling; teachers unaware of school psychologists mental health services; frustration with teachers Insufficient training Lack of confidence; lack of knowledge; inexperience Insufficient time and integration into the
126 school site Personal characteristics Burn out; apathy towards their job as a school psychologist; personal mental health problems; personal desire to provide traditional services rather than interventions Caseload at school overwhelming caseload; too many children in need of assessment Student factors Negative studen t characteristics; low parent support Role strain ________________________________________________________________________ Problems inherent to using school s as site for service delivery The theme of problems inherent to using schools as site for service delivery refers to the logistical and physical problems that arise related to the use of the school envir onment as the location of mental health service provision. This th eme consisted of eight subthemes from school psychologists conversations: scheduling pr oblems, space constraints, inconsistent treatment, termination, stude nt attrition, maintaining stude nt privacy, accountability for academic success only, and overlapping responsibility among mental health care providers. Regarding scheduli ng problems, one participant described a common conflict: The problem Im having is at the elemen tary school and the Middle school the academic time. You cant go in during th e academic time, which leaves a very limited amount of time to do this [provide direct mental health services], and yet
127 it takes a lot of time, it takes a lot of time. (FG 2) Other participants indicated how it is often difficult to get students together at the same time to run groups, particularly at schoo ls that adhere to a block schedule. With respect to space constraints, one particip ant noted, you have to have the right environment, and sometimes schools are not conducive no matter wha t; there is no space in some places, period (FG 5). Others indi cated the need for space due to safety, when you are counseling with a kid Im not going to be in a room where people cannot see in because I want people to be able to see in (FG 5), and in order to run group therapy sessions, what prevents me is, is space. If I wanted to do a group, I wouldnt have the space to do it (FG 8). Participants described how th e probability of inconsistent treatment led them to be less likely to provide me ntal health services: Its hard when you have an emergency te st and you have to change your day, its the most horrible thing in the world because the kids are used to you on Monday at 10 oclock and theyre li ke, where are ya? (FG 2). Participants indicated that the inabilit y to provide consistent treatment alone meant that they would not provide mental h ealth services: to be able to provide longterm or something [mental health service] that is in depth, it is just not feasible. It is absolutely not feasible. (FG 3) Factors relevant to termination include the concern over determining when to end therapy: to do comprehensive on-going, leng thy interventions: do you cut them loose after a half-dozen sessions, gi ve or take? (FG 8). Partic ipants indicated that student attrition, or the loss of clie nts throughout the school year was a barrier to providing
128 services: so, I have a lot of that, where they start in a group and they change schools three weeks into it thats not only me being consistent but c onsistently getting that child here (FG 10). Maintaining pr ivacy was another concern rais ed by participants: I was doing my [group] in the caf eteria at the Middle school sitting there ha ving a group with four kids talking about personal things and the people going to the c linic are stopping in and listening (FG 2). Regarding the issue of accountability for academic success only within the schools, one particip ant noted, and we keep putting a lot into academics and a lot of our goals focus on academics and job roles are based on academics, not necessarily mental health needs of childre n (FG 2). Overlapping responsibilities among mental health care providers involved partic ipants feeling uncomfort able when there was an overlap between the servic es they provided and the services provided by another person employed by their school. Participants indicated concern with stepping on others toes and crossing informal territorial boundaries. Insufficient support from the depar tment and district administration. The theme of insufficient support from the department and district administration refers to specific actions and/or behaviors exhibited by the depa rtment or district ad ministration that school psychologists perceive indicates a lack of support for providing psychotherapeutic services. This theme comprised four subthemes generated from participants conversations: department assigned roles and responsibilities, department procedures and requirements, department-level liability a nd legal concerns, and lack of support from district-level administration. Department a ssigned roles and responsib ilities refers to the professional practices that a school psychologist provides in a school, practices that are based upon the departmental definition of school psychological services and the
129 responsibilities assigned to school psychologists. Participants discussed the ambiguity of their departments definition of their roles as a mental health service provider and the exclusion of the role of mental health service provider as part of the districts definition. As one participant described, it is the job de scription itself (FG 2) that is a primary barrier. Another participant elaborated on th e ambiguity of her role in mental health service provision, stating Do you ever feel like sometimes our ro les are a little bit unclear when it comes to mental health? I find thats kind of sometimes the gray area in my role when it comes to mental health things (FG 10). Participants also discussed how having assigned responsibilit ies within a school can limit their ability to provide SBMH services: I mean right away I could see that student services and the special education were the ones that dictated and therefore were impediments to different roles...In other words, they defined and therefor e limited or expanded all the different roles. And I noticed that right from the moment I got here . as far as counseling unless you just said, look I want to do this nobody was asking you to. (FG 1) Regarding department procedures and requi rements, participants indicated that departments require cumbersome paperw ork to be completed when providing psychotherapeutic services. Additionally, participants described how the current evaluation procedures conflict with their abilities to provi de SBMH service: We spend so much time doing evaluations that have little dire ct link to actual interventions when you go down the list of evaluation requirements you get this big report and the recommendations are not related to anything (FG 9).
130 Liability and legal issues refers to the lega l responsibilities that come with providing psychotherapeutic services and the fear of causing legal probl ems for an individual or the department. As one participant reported, you not only [increase] your personal liability but the districts liability if you start working with kids that are suicidal sex offenders, homicidal, depressed. I mean you open up a whole new liability issue (FG 3). The barrier of insufficient support from dist rict-level administration often related to budget decisions made by the district: district administrators who are making decisions about budgets and dollars and hu man resources and staffing and we keep putting a lot into academics and our budgetary purchases go towards academics (FG 2). Another participant disc ussed how a general lack of funding for mental health services can prevent the provi sion of specific services: I started an anger management group at my school and I needed curriculum, and I found something I really wanted and [we] then had to try to scrape-up the money and go to different people, and beg I mean, you need materials, you need things so moneys not always readily available. (FG 10) Problems with school personnel. The theme of problems with school personnel refers to the problems that ar ise because of the need for support from and collaboration with other school employees in order to pr ovide SBMH services. This theme included four subthemes generated from participan ts conversations: l ack of support from building-level administration, teachers not s upportive of counseling, teachers unaware of school psychologists mental h ealth services, and frustratio n with teachers. Regarding insufficient support from admini stration, some participants mentioned a general need for administrative support within your school (F G 5), whereas others elaborated on how
131 building-level administration are not supportive of the provision of SBMH services. For instance, one participant di scussed the barrier of build ing administrations focus on testing: people are still holding on to that old thinking and still want that test them, test them, test them It is more like no, we need to test them. That is an ESE kid (FG 3). Another participant described the pressure that often comes from building administration to provide services other than mental h ealth interventions: a dministration you got the bad kid, they want him out, they want him ev aluated and we dont have them the time to give them the four week of STAT c ounseling that you want to (FG 7). Participants described how teachers may not be supportive of counseling services because the kids see me as an ally sometimes the teacher find that to be a negative thing because they feel like the kids are running to me (FG 7). Others indicated that teachers feel like its enabling the kids becau se they see them as socially maladjusted kids that are bad and they feel like they shoul dnt have that support (FG 7). Participants indicated that teachers often wish to have a student removed from their classroom or made eligible for services, as it places th e responsibility outs ide of their hands. Challenges related to teachers lack of awar eness of school psychologists mental health services was also described by participants: We have the school psychologist just te sting for years and years and years .and then [the] next generation comes and it s the same thing so then the perception of all those other support se rvices that work with you in ESE, departments and all like that is, oh, thats what they do, th eyre not experienced in this. So, then they start asking for a behavior speci alist to come in to do something that we very well could do (FG 1).
132 A number of teacher behaviors (e.g., tr eatment integrity when implementing interventions in the classroom, classroom management issues, lack of concern for procedures) was described by participants that led them to feel a ge neral frustration with teachers. Insufficient training The theme of insufficient training refers to a paucity of training in psychotherapeutic interventions th at then hinders a sc hool psychologist from providing SBMH services. This theme incl uded three subthemes from participants conversations: lack of confidence, lack of knowledge, and inexperience. Regarding a lack of confidence, one participant stated: I do think fear sometimes kind of gets in the way or lack of confidence. I mean Im affecting children s lives maybe I take it too seriously, but thats me and I have to be able to go to sleep at night [feeling] that I have not done anything in any way to aff ect this child. (FG 5) Insufficient training involved statements pertai ning to participants be liefs that he/she had too little exposure to import ant topics relevant to SBMH during graduate school. As one participant stated: wel l, without the training, I mean, it s tough (FG 6). Similar sentiments were expressed by another partic ipant in regards to a lack of training opportunities as a barrier to provi ding mental health services: We just dont have that leadership th ats providing the training. We have leadership right now thats assessing it, looking at it, studying it, but as far as moving forward, someone thats actually doing it on a regular basis and saying, here Ill train you, or let me work with you or let me refresh those skills and so forth. Thats an impediment to me, the f act that its just not there yet. (FG 1)
133 In addition to insufficient di dactic content, participants also voiced dissatisfaction with their opportunities to apply psychotherapeut ic interventions, resulting in uncertainty during practice: I am thinking, am I allowed to? Do I need to get consent first? Do I need to call the parent? So, y eah I am a little you know that is where I do get a little hesitant (FG 4). Likewise, another participant voiced how inexperience can lead to uncertainty: So I am interested in it but because I dont feel like I have enough experience, I am a little hesitant in moving forward (FG 4). Insufficient time and integr ation into the school site The theme of insufficient time and integration into the school site refers to participants frustration with schedules that prevented them from being known by, visi ble to, and accessible to school employees and students. The issue of not having e nough time in their day was elaborated upon by one participant: its definitely a balanci ng act, finding the time to actually do the counseling or to make extra time for a specif ic kid for a specific reason (FG 6). Other participants described how work ing in their school only a few days a week can lead to a lack of integration into thei r school site: and not being ther e enough: you are in a school two days a week [and] you cannot schedule so meones crisis on Monday because you are not there on Monday (FG 7). Similarly, othe rs voiced how a lack of integration into schools can lead to school personnel being unaware of both who they were and what types of services they can provide: I dont think a lot of people know what I do, what I can do I dont think the kids know who I am until I work with them or go in their classroom enough till they start to say, hey, you were in here the other day. (FG 9)
134 Personal characteristics The theme of personal characteristics refers to characteristics internal to a school psychol ogist. This theme included four subthemes from participants conversations: burn out, apathy towards job, personal mental health problems, and personal desire to provide tradi tional services rather than interventions. Burn out refers to the physical and emotiona l toll that providing me ntal health services often has on school psychologists. Participants indicated that it ta kes a big chunk out of you physically and emotionally, to do the counseling (FG 2) and that sometimes they just become exhausted and need to take a break. Apathy towards ones job included sentiments like, you know another thing is th e sense of urgency and I dont find that I have that sense of urgency as much as I us ed to (FG 5). Barriers related to personal mental health problems was described by one participant as, you may not be in a space to take on a serious long-ter m kind of counseling kind of relationship (FG 5). In describing school psychologists personal pref erence to provide traditional services, one participant stated that, they [school psychol ogists] enjoy the profession the way it is, the way it was...thats part of why they dont wa nt to change (FG 1). Other participants described how providing traditional services is perceived as being easier than providing mental health services. Caseload at school The needs of the students at a school psychologists school became a barrier when it resulted in an overw helming caseload for the practitioner and/or caused too many children to be in need of asse ssment. Participants indicated that they were often overwhelmed by the sheer number of students in need of mental health services:
135 Once I got the permission slips in, there were so many children who really wanted to participate I found that Ive had to break it down now until its individual. Im seeing them all individually from 12: 25 to 3:30 I have individual sessions and its still not enough. (FG 2) Others described how their current case load inhibited their ability to provide services: and a lot of times we handle crises because there are 2,800 students to counsel is very rare (FG 7) and another elaborated, stat ing, volume of referrals for me, sheer volume with two schools, my ratio is above 3,700 kids (FG 8). Regarding a large assessment case load, one participant expres sed, if you have 30 pending referrals you dont have time to do much of anything else (FG 5). Student factors The theme of student factors re fers to the characteristics of a referred student that cause a school psychologi st to be less inclin ed to provide SBMH services. This theme included two subtheme s from participants c onversations: negative student characteristics and low parent support. Regarding th e role of negative student characteristics, one participant noted: I tend to like the ones that are the victims of that as opposed to working with the ones that are the aggressors because theyre so .hard to work with, because they have no reason to ch ange (FG 9). Other student characteristics perceived as being aversive included poor hygiene and immatu re behavior. Participants indicated two particular pare nt behaviors that portrayed a lack of support for mental health service provision: parent s resistance to students recei ving mental health treatment and how low parent involvement can lead to ineffective service provision. One participant described the crucial need for pa rent involvement: but at the elementary school I dont think that you can do effective treatment without a family being involved
136 (FG 3). Another participant elaborated on pe rceived parent resistance: I can think of one girl that was referred to me this year for me this year .but the parent said absolutely not youre not going to meet with her (FG 10). Role strain Role strain refers to the numer ous roles that a school psychologist holds within a school that can in hibit their ability to provide mental health services. As one school psychologist described, this is your school and you have to be an expert in everything and thats not the reality (FG 5) Another school psyc hologist elaborated on the role strain that can occur in schools: I think that is one of the factors that hinder us or are a barrier for providing counseling because we wear so many ha ts in the school we end up having to pick up the slack from somebody else... we ar e so well-trained that we can fit into that mold and they know that so they push us there. (FG 7) The role of years of experience in barri ers perceived by school psychologists. To provide a better understanding of the differences that emerged in relation to the types of barriers perceived by school psychologists as a function of practit ioners levels of experience, the number of times each barrier wa s described by a participant was counted. These frequency counts represent the numbe r of times participants in each group provided a sentiment (i.e., quotation) that expr essed the coded barrier. A total index of the frequency with which the barrier was mentioned was created by summing the total number of times a service was mentioned in the total sample (i.e., 11 focus groups) as well as broken down into total mentions for the four groups of experienced school psychologists and the four groups of new school psychologists (see Tabl e 8) in an effort to differentiate responses between the two groups. Figure 4 provides a graphic
137 representation the percentage of times w ith which each specific training theme was discussed within the current study. 27% 17% 15% 14% 6% 5% 4% 3% Problems inherent to using schools as the site for service delivery Insufficient support from department and district administration Problems with school personnel Insufficient training Insufficient time and integration ito the school site Personal characteristics Caseload at the school Student factors Role strain Figure 4. Percentage of times with which each barrier theme was mentioned by participants As shown in Table 8, new and experienced school psychologists were equally as likely to perceive the five following themes as barriers to mental health service provision: insufficient support from district and departme nt administration, role strain, caseload at the school, insufficient time and integration in to the school site, and insufficient training. Participants in the new school psychologists groups were particular ly concerned with
138 Table 8 Frequency each Group of School Psychologi sts Identified Barriers by Level of Experience Barriers New school psychologists ( n =15 ) Mid-Range school psychologists ( n =11 ) Experienced school psychologists ( n =13 ) Total ( N = 39) N % N % N % N % Insufficient support from department and district administration 13 75 13 100 12 50 38 73 Department assigned role and responsibilities 6 50 11 100 7 50 24 64 Department procedures and requirements 3 50 0 0 1 25 4 27 Department liability and legal concerns 1 25 2 33 0 0 3 18 Insufficient support from districtlevel administration 3 50 0 0 4 50 7 36 Problems with school personnel 25 100 5 100 3 50 33 81 Lack of support from buildinglevel administration 5 75 3 100 1 25 9 64 Teachers not supportive of counseling 6 50 0 0 0 0 6 18 Teachers unaware of school psychologist mental health services 7 100 2 33 0 0 9 45 Frustration with teachers 7 75 0 0 2 25 9 36
139 Role strain 3 50 0 0 4 50 7 36 Caseload at the school 6 75 0 0 6 75 12 55 Overwhelming caseload 2 50 0 0 4 50 6 36 Too many children in need of assessment 4 25 0 0 2 25 6 18 Problems inherent to using schools as the site for service delivery 12 100 14 100 36 100 62 100 Scheduling problems 0 0 2 33 7 75 9 36 Space constraints 2 25 1 33 11 100 14 55 Inconsistent treatment 3 50 1 33 8 75 12 55 Termination 0 0 0 0 5 50 5 18 Student attrition 2 50 0 0 0 0 2 18 Maintaining student privacy 0 0 0 0 3 50 3 18 Accountability for academic success only 3 50 3 66 2 25 8 45 Overlapping responsibility among mental health providers 2 50 7 100 0 0 9 45 Insufficient time and integration into the school site 6 100 5 100 10 100 21 100 Insufficient training 8 50 16 100 8 75 32 73 Lack of confidence 2 50 2 66 2 50 6 55 Lack of knowledge 3 50 11 100 5 50 19 64 Inexperience 3 25 3 66 1 25 7 36 Personal characteristics 0 0 4 66 10 75 14 45 Burn out 0 0 0 0 3 75 3 27 Apathy toward job 0 0 0 0 2 25 2 9 Personal mental health problems 0 0 0 0 2 25 2 9
140 Personal desire to provide traditional services rather than interventions 0 0 4 66 3 25 7 27 Student factors 6 100 2 33 2 50 10 64 Negative student characteristics 4 50 0 0 0 0 4 18 Low parent support 2 50 2 33 2 50 6 45 Note N = number of times barrier was mentioned in each group; % = proportion of groups in which the barrier was mentioned at least one time. problems that arise when working with school personnel (25 times; 100% of groups) when compared to participants in the e xperienced school psychologists groups (3 times; 50% of groups), with more frequent indicati ons of concern across all four subthemes. Participants in the new school psychologist s groups also indicated more concern over student factors (6 times; 100% of groups) when compared to participants in the experienced school psychologist groups (2 tim es; 50% of groups). On the other hand, participants in the experien ced school psychologist groups we re particularly concerned with the problems that arise when using schools as the site for servi ce delivery (36 times, 100% of groups) when compared to participan ts in the new school psychologist groups (12 times, 100% of groups), with more frequent indications of concern across five of the seven subthemes. Participants in the experienced school ps ychologist group more frequently indicated concerns over personal characteristics that interfere with providing SBMH services (10 times; 75% of groups) as compared to participants in the new school psychologist groups (0 times; 0% of groups), wi th more frequent indications of concern across all four subthemes.
141 Specific Knowledge and Skill Areas in Which Additional Training Would be Helpful in Enabling School Psychologists to Provide Ment al Health Assessment and Interventions The following section will provide a descri ption of the (a) themes related to training needs and (b) subthemes within each category. Below is a description of all salient themes, including repr esentative quotations and pa raphrased statements; focus group numbers (FG) assigned is indicated as well. Table 9 provides a summary of themes and subthemes. Themes are discussed in order of the freque ncy with which they were mentioned. Following a discussion of the general findings of the research question, themes are compared as a function of practitioners levels of experience. Course-work training needs. The theme of course-work training needs refers to the specific content and didact ic areas that school psychologist s identified as relevant to their ability to provide SBMH services. This theme includes 24 subthemes generated from participants conversations: ethics a nd law, developmental psychology, personality, psychopathology, psychopharmacology, multicultural education, behavior interventions, empirically supported treatments, consultati on, systems consultati on, interpersonal and listening skills, crisis intervention, social -emotional-behavior assessment, advanced psychotherapy, advanced study of single orient ation, survey of multiple orientations, group therapy, family therapy, treatment planning, case documentation, counseling adults, social work/services, life-lon g learning, and working in schools.
142 Table 9 Themes and Sub-themes Related to Identified Training Needs Theme Sub-themes (when applicable) Course-work training needs Ethics and law; developmental psychology; personality; psychopathology; psychopharmacology; multicultural education; behavior interventions; empirically supported treatments; consultation; systems consultation; interpersonal and listening skills; crisis intervention; social-emotional-behavior assessment; advanced psychotherapy; advanced study of single orientation; survey of multiple orientations; group therapy; family therapy; treatment planning; case documentation; counseling adults; social work services; life-long learning; working in schools Experiential activities observing a master therapist; supervised practicum; in-class role plays; co-leading a group; self-review and critique of counseling; receiving personal counseling; working on a multidisciplinary team Professional development applied expe riences; supervision; consultation with peer colleague; working with interns;
143 participation in a professional organization; inservices Ethics and law addresses the need for cour sework that attends to the legal issues that arise when providing mental health serv ices in the school sett ing. One participant stated that you need to look at things like HIPPA, risk management (FG 3). Participants described coursework co vering developmental psychology as a good foundation (FG 11), particularly because we need to look at a kid and say what developmental task is he at right now (FG 6). Personality coursework included content related to theories of personality. Regarding psychopathology, participants described how knowing the DSM front to back has been extremely helpful (FG 3) and the importance of acquiring information about the disorders, internalizing disorders, anxiety disorders and just knowing what Im seeing (FG 11). The benefit of psychopharmacology coursework was described by one participant: It really allowed me to understand how the whole medication piece fit in (FG 9). Participan ts emphasized the importance of including multicultural education within school psychology graduate training: I think that we dont understand cultural differences and I think that is so critical in everything we do, I think that one thing that I may see as deviant may not be deviant to another person and it s critical that we understand differences that we dont condemn, that we understand, and that we go from there. (FG 11) Participants recognized the importance of lear ning about behavior interventions: Ive been doing coursework and training .in behavior analysis...and its really exposed me to
144 some more behaviorally based strategies (FG 9). Other bene ficial coursework mentioned under this subtheme included rel axation training role playing, skill streaming, and how to observe (FG 6). One participant illust rated the need for coursework on empirically supported treatm ents: I think an emphasis on specific programs that are successful having course s that would say, heres an excellent program for folks with this issue, heres an excellent program for this and we actually get training in that program (FG 1). Coursework subthemes emerged that emphasized content covering communication skills, including courses in in dividual consultation, systems consultation, and interpersonal and listening skills. System s consultation coursework was described as providing school psychologists w ith knowledge of how long it takes for things in the system to change (FG 7), just knowing sy stems and knowing how systems work, and how to enter a place and be successful (FG 11). With respect to interpersonal/listening skills, one participant note d the need for content cove ring the dos and donts of communication (FG 11). Consultation cour sework was identified as important as teachers are looking at us to he lp them. Hence, there is a need for school psychologist to know how to help them (teachers) not pull their hair out and how to help them make it through the day (FG 3). Regarding the need for coursework on cr isis intervention, participants focused on the need for training in suici de and threat assessment like how to assess (FG 9). Participants recalled important skills l earned within social-emotional-behavior assessment coursework, including techniques in interviewing (FG 3), RQC (FG 7), and rating scales (FG 7). The need for coursework in advanced psychotherapy, the
145 study of how to conduct individual ps ychotherapy, was indicated as well: I had really excellent training we did not only group process but we did individual and we would take them and video and critique them and we had a lot of courses that were real hands on not just theory and models (FG 1). In describing dida ctic training in an advanced study of a single orientation, one practitioner provided the following suggestion: I think that you c ould even have people who were really expert in certain fields come in and do modul es of training (FG 5). Contrastingly, participants deemed c oursework on a survey of multiple orientations as essential to increasing their ability to provide SBMH services: if there was someone in another department who c ould share that kind of knowledge just so you are exposed to more than just one orientation if you could at least have access to play therapy, sand play thera py, gestalt therapy (FG 5). Specific courses in group therapy and family therapy were mentioned as important training needs. Regarding the bene fit of having a course in group therapy, one participant indicated that I r eally just had one course that was solely dedicated and that was really for group counseling (FG 1). Coursework covering cas e documentation was described as covering counseling notes a nd how would you document it, those kinds of things, the nuts and bolts of it (FG 4). Regarding the need for courses that in cluded training in treatment planning, one participant described the following: In terms of training were doing a lot with CBM, CBA, where we can measure progress. I think with the counseling in terms of your progress notes, your goal, what are you doing, how do you measure that? I think training in those kinds of
146 areas would help us because then you can go in and feel w ith confidence I am making a difference or Im not (FG2). The need for coursework covering content abou t counseling adults in a school setting was indicated by participan ts, as people bring a ll their problems to you. And what to do with that? (FG 7). The desire for information on so cial work services addresses the need for content covering mental health agencies a nd resources within communities: and another thing I think we need to learn in our program is more about community agencies--what is out in the community (FG 7). Working in the schools addresses the need for content covering how to navigate working in the school environment. This content area includes knowledge related to the functions of the teach er, functions of various school personnel, and a better understanding of the classroom a nd school environment. One participant, for example, elaborated upon such coursework: I think we need a little b it more of the education com ponent classes in terms of what to expect of teachers, what to exp ect of administrators, things like that. If they could include at least one strong education class I think we need some, a little bit of educati on component (FG 7). Life-long learning refers to content covere d in courses that would provide school psychologists with the essentia l skills needed to continually acquire new information. One participant mentioned the need for gui dance on where you are going to find a lot of it [interventions] and the need for some guidance on where we could find things that are teacher-friendly (FG 7). The last s ubtheme identified as other coursework includes specific content areas mentione d only once during the focus groups. For instance, single participants discusse d the importance of coursework covering
147 neuropsychology, educational psychology, le arning theories, and children with disabilities. Experiential Activities. The theme of experiential activities refers to those activities within a training program that i nvolve the students in actively practicing or observing a skill needed for mental health service provision. Six subthemes were identified within the focus groups as increas ing participants ability to provide SBMH service: observing a master th erapist, supervised practicum in-class role plays, coleading a group, self-review a nd critique of counseling, rece iving their own counseling, and working on a multidisciplinary team. Co-leading groups refers to the experience of trainees activ ely facilitating a mental health group with an experienced practitioner. Experi enced practitioners identified by participants in cluded school-based counselors, psychiatrists, and practicum supervisors. One participant elaborated upon the benefits of this training experience: I have done some co-group situations with them [guidance counselors]. And that really helped a lot because their skills are much sharper in that area I kind of felt like the tin man; I just needed to be o iled. So that helped a lot. It was a real positive thing. (FG 3) Other benefits of co-leading were described by participants: I lik e to co-lead . because I like to watch their techniques and it really does help a whole lot. They know what works (FG 3). Participating in in-class role plays during school psychology training was another applied experiences id entified as helpful:
148 I can make a suggestion for programs that was helpful in my training. In one course in advanced therapy techniques we did mock therapy with each other, we had a partner, and we worked with each other and you taped it and transcribed it and it was critiqued by either the professor or TA that was pretty intense. (FG 6) With respect to the training benefits of receiving their own counseling, both individual counseling experi ences and group counseling expe riences were discussed as helping school psychologists fe el sufficiently-prepared to provide SBMH services. One participant elaborated on the process: I remember in one class we actually had to work with the folks ready to graduate from the counseling psych program, and we had to be the counselees. It was neat to go through the other side of that process and kind of go through that and feel that. (FG 3) Other participants indicated similar benefi cial experiences to receiving their own counseling: I think that was interesting that they [professors] focused so much on looking at yourself as the instrument but also l ooking at whether you bring the good things and maybe the not so good things that you bring to anything you do as a school psychologist and that was very powerful experience that I really went through there. (FG 5) A number of methods for observing ma ster therapists were identified by participants, including seei ng films about different counseling and observing someone (FG 3) and shadowing (FG 1). The benef its of observing a master therapist was discussed in detail:
149 You really need to go out there and get w ith someone who is really doing it and really watch them and see someone who is doing good counseling, good mental health services, and has a good system in place because that is the only reason that I have been able to do half the things with this new intervention process at my school. (FG 7) Self-review and critique of counselin g encompasses a number of activities, including watching a tape of an applied e xperience, listening to a tape, critique of personal skills by either the trainee or a superv isor, critique of anot her students skills, and discussing recommendations for future appl ied experiences with either other students or supervisors. One participant described a self-review as involvi ng the constant video taping, the watching of the vide otape, listening to audiotapes (FG 5). Another described this experience as we also taped counseli ng sessions with kids and then we viewed those tapes in class and what we were doing a nd what skills we needed to work on. It was very, very helpful (FG 6). Participants advocated for the inclusion of a supervised practicum as part of the school psychology training program: I had a great supervisor and so that was a wonderful experience. It just pushed me to do all sorts of things I dont feel like I could do now had I not had that training (FG 10). Working on a multidisciplinary team was described as a beneficial experiential activity: One thing that was really beneficial, is working on multidisciplinary, interdisciplinary teams I felt like that at those meetings, when we were discussing a case, I learned more then I fe lt I was ever contributing and I still feel
150 like that today but every time I go in a m eeting with different people, Im like, oh, you know, just absorb it, try and absorb everything I can. (FG 9) Professional development. The theme of professional de velopment refers to those activities that occur after a school psychologist has gra duated from a training program. Six subthemes emerged within the professiona l development theme: inservices, applied experiences, supervision, consultation with p eer colleagues, working with interns, and participation in a professional organization. The benefit of attending in-services was described as a beneficial professional development activity: When people come in and, I think its real ly great and its kind of that they do bring in good people and they come in with programs and things that can be implemented...They [department administra tion personnel] have brought in some good people with good training modules th at were encouraged to go to trainings. (FG 2) A second participant elaborated on the inclus ion of specific activities and information within in-services that they have found to be beneficial: They [department administration personnel] bring in a lot of different trainings based on a lot of different theories and th e training really helps, when they bring people in and we can go in and get training and they provide real-life experiences, hands-on type things, activitie s that we can do in the tr ainings that we can go out into the schools and do. (FG 2) Applied experiences refer to the school -based experiences that involve the application of recently acquired knowledge rele vant to the provision of SBMH services.
151 Applied experiences require the school psyc hologist to go beyond just learning a specific skill to actually practicing it. One participant described the possible benefits of having an applied experience in the school setting: Having the opportunity to go back and a pply that where you have a group or individuals where youre prac ticing the strategies, being able to come back and say, this is whats happening how can I improve it? things like that where you can get some feedback. (FG 2) Participants indicated a need for accountabi lity and follow-up as part of the applied experience. For example, one participant id entified the need for a performance-based activity that goes along with the profe ssional development activities (FG 2). Supervision was described as actu ally seeing someone who comes out and observes you in action (FG 5). The im portance of supervision was identified through one participants description of the lack of such experiences: In twenty seven years, I have never had one day of superv ision from anybody .the lack of supervision once we are school psychologists and once we are off the leash is incredible (FG 5). Another valuable professional developmen t activity for participants involved consultation with peers: We have such a wealth of knowledge in our staff because you can go to someone on the staff or someone else knows some thing about what I need and we work well together for the most part. I can call and say hey, I need help and vice versa. (FG 11) Throughout the focus groups, participants identif ied the benefit of consulting with fellow school psychologists, psychiatrists, and ot her school based sta ff (i.e., counselors).
152 Participating in a professional organiza tion was one of the few individualized professional development activities menti oned. One participant indicated that I joined NASP this year and .the online st uff that they have .its been well worth it already (FG 10). Working with interns was mentioned as a means through which practicing school psychologists can acquire novel skills and knowledge from school psychology students that will increase their ability to provide SBMH services: I supervised a group of stude nts so .I learned a lot from them, I learned a lot by showing them how to do it and what to do, so demonstrating and making sure that I was doing it right because I knew they were learning and I wanted them to learn it correctly and learning from them be cause students always know what is new that was really helpful to me. (FG 5) The role that year of experience pl ays in the training needs of school psychologists. To provide a better understanding of the differences that emerged in relation to the training needs of school psycholog ists as a function of practitioners levels of experience, the number of times each trai ning need was described by a participant was counted. These frequency counts represent th e number of times pa rticipants in each group provided a sentiment (i.e., quotation) th at expressed the training need. A total index of the frequency with which the tr aining need was mentioned was created by summing the total number of times a service was mentioned in the total sample (i.e., 11 focus groups) as well as broken down into total mentions for th e four groups of experienced school psychologist s and the four groups of ne w school psychologists (see Table 10) in an effort to differentiate responses between the two groups. Figure 5
153 provides a graphic representation the percen tage of times with which each specific training theme was discussed within the current study. 57% 24% 19% Didactic content taught through courses Experiential activities Professional development Figure 5. Percentage of times with which each training theme was mentioned by participants As shown in Table 10, participants fro m both the new and experienced school psychologists groups were equall y as likely to indicate a desi re for training in didactic content taught through courses, experiential activities, and professional development. However, differences in res ponses emerged between the participants in the experienced and new school psychologists groups in relation to the types of cont ent in coursework identified as beneficial. New school psychologists emphasized the need for coursework covering crisis intervention (7 times; 75% of groups), consultation (6 times; 75% of groups), systems consultation (3 times; 25% of groups),
154 Table 10 Frequency each Group of School Psychologist s Identified Training Needs by Level of Experience Training needs New school psychologists ( n =15 ) Mid-Range school psychologists ( n =11 ) Experienced school psychologists ( n =13 ) Total ( n =39) N % N % N % N % Didactic content taught through courses 69 100 51 100 40 100 160 100 Advanced study of single orientation 3 50 2 66 7 75 12 64 Survey of multiple orientations 5 75 3 66 5 100 13 82 Crisis intervention 7 75 0 0 2 25 9 36 Interpersonal/listening skills 1 25 1 33 1 25 3 27 Systems consultation 3 25 1 33 1 25 5 27 Psychopathology 9 100 7 100 4 50 20 82 Advanced psychotherapy 2 50 4 100 1 25 7 55 Family therapy 3 50 1 25 0 0 4 27 Group therapy 2 25 5 100 3 50 10 55 Developmental psychology 0 0 3 33 2 25 5 18 Psychopharmacology 3 50 0 0 0 0 3 18 Treatment planning 2 50 1 33 2 25 5 36 Social-emotional-behavioral assessment 3 50 1 33 1 25 5 36 Counseling adults 3 25 0 0 0 0 3 9 Working in schools 3 25 2 33 0 0 5 18 Behavior interventions 5 75 3 66 2 25 10 55
155 Life-long learning 2 25 2 33 0 0 4 18 Social work/services 3 50 2 33 0 0 5 27 Ethics/law 0 0 3 33 0 0 3 9 Empirically-supported treatments 0 0 3 33 3 50 6 27 Multicultural education 3 50 0 0 2 25 5 27 Case documentation 1 25 1 33 1 25 3 27 Other coursework 0 0 2 66 2 50 4 36 Personality 0 0 2 66 1 25 3 18 Consultation 6 75 2 33 0 0 8 36 Experiential activities 28 100 21 100 18 100 67 100 In-class role plays 5 75 3 33 4 50 12 55 Supervised practicum 15 100 5 66 6 100 26 91 Observe master therapist 3 75 4 66 2 50 9 64 Co-lead groups 1 25 3 66 2 25 6 36 Self-review and critique of counseling 2 25 4 66 2 25 8 36 Receive own counseling 0 0 2 33 2 50 4 27 Work on multidisciplinary team 2 25 0 0 0 0 2 9 Professional development 17 100 8 100 27 100 52 100 In-services offered through the district 11 100 4 66 12 100 27 91 Applied experiences following inservices 1 25 1 33 3 50 5 36 Work with interns 0 0 0 0 2 25 2 9 Participation in professional organizations 2 25 0 0 0 0 2 9 Formal supervision of services 0 0 2 33 2 25 4 18 Consultation with peer colleagues 3 50 1 33 8 50 12 45 Note N = number of times training course or experi ence was mentioned in each group; % = proportion of groups in which the training/coursework domain was mentioned at least one time
156 behavior interventions (5 times ; 75% of groups), life-long learning (2 times; 25% of groups), family therapy, psychopharmacology, c ounseling adults, work ing in schools, and social/work services (3 ti mes; 20-75% of groups), psychopathology (9 times; 100% of groups), and social-emotional-behavioral as sessment (3 times; 50% of groups) Under the theme of experiential activ ities, participants in the new school psychologist groups more frequently mentioned the need for s upervised practicum (15 times; 100% of groups) as compared to responses from experienced school psychologist groups (6 times; 100% of groups) and working on an interdisciplin ary team (2 times; 25% of groups) as compared to responses from the experienced school psychologist groups (0 times; 0% of groups). Under the theme of pr ofessional developmen t activities, partic ipants in the new school psychologist groups more frequently me ntioned the training ne ed of participation in a professional organization (2 times; 25% of groups) than did the experienced school psychologist groups (0 times; 0% of groups). Participants in the experienced school psychology groups emphasized the need for coursework covering the advanced study of a single orientation (7 times; 75% of groups), developmental psychology (2 times; 25% of gr oups), and empirically supported treatment (3 times; 50% of groups). Specific experien tial activities that pa rticipants in the experienced school psychologist groups more frequently mentioned included the need of receiving their own counseling (2 times; 50% of groups) as comp ared to new school psychologist groups (0 times; 0% of groups). Participants in th e experienced school psychologist groups more frequently indica ted the benefits of four professional development activities. Participants in th e experienced school psychologist groups more
157 frequently indicated the need for applied ex periences following inservices (3 times; 50% of groups) as compared to participants in the new school psychologist groups (1 time; 25% of groups). Similarly, experienced sc hool psychologist groups more frequently indicated the importance of c onsulting with peer colleagues (8 times; 50% of groups) as compared to new school psychologist groups (3 times; 50% of groups). Participants in the experienced school psychol ogist groups were the only pa rticipants to indicate working with interns (2 times; 25% of groups ), and formal supervision of services (2 times; 25% of groups).
158 Chapter 5 Discussion The purpose of the current study was to pr ovide the first qualitative examination of school psychologists provision of psychothe rapeutic services in the schools. The study aimed to explore those factors that schoo l psychologists perceive inhibit them from providing more mental health interventions with in their professional roles. An additional purpose of the current study was to examine act ivities and attitudes related to mental health service provision as a function of practitioners leve ls of experience. A focus group method was selected as a preliminary me ans to gather the important information that is lacking in the existing literature. As the participants expl ored their thoughts about mental health service provision in the school s, several themes emerged across the focus groups, with some differences between th e new and experienced practitioners. This chapter summarizes the results of th e current study and integrates findings with existing literature review presented in Chapter 2. The chapter is organized by the research questions addressed within the re search study. Following the examination of results and presentation of notable findings implications of the results for school psychologists are examined, limitations of the research study are reviewed, and suggestions for future research are discussed.
159 Examination of Results Problems Referred The purpose of this first research questi on was to gain a greater understanding of the types of mental health problems that are commonly referred for mental health services in school settings. Unique to th is study was the use of qualitative methods to elicit the types of common referral problems seen in schools. Responses from focus groups indicated that school ps ychologists receive a diverse a rray of referral problems. The student problems mentioned most frequently by participants were isolated behavioral or emotional symptoms (e.g., lack of empa thy, cutting, low self-esteem). Other common referral problems included DSM disorders, fam ily issues, crisis situations, and anger. Although not as prevalent within the focus groups, participants also discussed receiving referrals for adolescent issues, learning probl ems, atypical/bizarre behaviors, and adults mental health problems. These findings corroborate previous research ers findings that ha ve indicated that the types of problems referred within a sc hool setting include but are not limited to diagnosable mental or addictive disorders (Foster et al., 2005; Re pie, 2005; Whitmore, 2004). The implication of this finding (i.e., th at specific symptoms are seen more often than full DSM disorders) are important to consider. Current prevalence data on the mental health problems of children and adoles cents have been limited by the type of data collection method utilized within the research studies. As described in Chapter 2, the definition of what constitutes a mental hea lth problem is limited by case ascertainment, case definition, and presentation. Furtherm ore, prevalence studies use a range of assessment methods to determine the preval ence of mental diso rders (e.g., syndrome
160 scales such as the Child Behavior Checklist, DSM-IV checklists). As the results of this study indicate, many prevalen ce studies would not tap th e types of problems that participants discussed as the common mental health problems that are referred for SBMH services (e.g., divorce, isolated externalizing symptoms) in th at isolated symptoms would not be counted but are important enough to warrant psychologists attention. Several of the student mental health problems reported by participants in the current study are consistent with those identifie d in previous research. Similar to Foster et al.s (2005) and Whitmores (2004) fi ndings, anger/aggression was identified as a reason students were often referred to school ps ychologists. Results fr om this study also corroborate the findings of Foster et al. (2005), in which a re presentative sample of 1,147 schools in 1,064 districts across the country responded to a survey about the problems most frequently presented by students in their schools. Foster et al. (2005) found that the mental health categories frequently endor sed related to family problems, anxiety, depression, and substance abuse. The finding of referrals related to learning problems, which participants described as issues re lated to work completion, motivation, and study, skills, is consistent with th e findings of Whitmore (2004), in which a national sample of school psychologists identified academic probl ems as a frequently occurring referral problem. Additionally, the referral of st udents with problems related to trauma corroborates the findings of Slade (2003), in which a national sample of school administrators identified that schools receive referrals for physical, sexual, or emotional abuse and they help the referral student select outside serv ices for ongoing care. With the exceptions of the aforementioned similarities, the majority of referral problems that emerged from the current study were contradictory to previous findings.
161 Previous studies have consistently identifie d interpersonal problem s and self-esteem as representing common referral concerns (F oster et al., 2005; Repie, 2005; Whitmore, 2004), and although both referral concerns were mentioned by some participants in the current study, they were not emphasized (i.e., mentioned frequently or elaborated on to a deree). Whereas earlier research with t eachers, counselors, and school psychologists suggested that suicidality a nd substance use were among th e least critical issues in schools (Repie, 2005), participants from the curre nt study frequently id entified suicidality and substance use as reasons why students were referred for mental health services. One hypothesis for why these differences emerged rela tes to the sample utilized in each study. Given the severity of issues surrounding suicidality and substance use, these referrals may bypass teachers and counselors and be direc tly sent to school psychologists; hence, teachers and counselors would be less likely to be aware of such issues. More research is needed to flesh out the specific reasons why su ch differences emerged. In one of the few studies that exclusively studi ed school psychologists (Wh itmore, 2004), three out of the four most frequently identified referral c oncerns (academic problems, peer problems and self-esteem issues) were not emphasized by participants in the present study. A number of unique responses were noted by participan ts in the current study. Given that most research st udying the types of problems refe rred to school psychologists were based on forced-choice survey responses it was not surprising that a number of referral problems that have not been noted in the existing literature emerged when participants were provided the opportunity to identify the types of referral concerns that they receivedthat is, to construct their ow n responses. For example, participants described how referral problems regarding fam ily issues involved dealing with parental
162 divorce, placement in foster care, and conf licts with parents. Understanding the divergent issues that fall under the category of family issues is crucial to determining what relevant kinds of content knowledge areas and training expe riences would allow school psychologists to feel sufficiently prepar ed to treat the broade r referral problem of family issues. Participants in the current study differe ntiated between referral problems that could be characterized as representing a dia gnosable mental disorder and those referral problems that were isolated behavioral or emotional symptoms that could not by themselves constitute a diagnosable DSM di sorder. Thus, such issues as bullying, cutting, and eating issues emerged from par ticipants responses. Similarly, several participants described isolated internaliz ing symptoms such as a student appearing withdrawn or not wanting to express em otion. Participants expanded upon previous studies that had identified sc hool-based referrals for student s diagnosed with depression and ADHD (Foster et al., 2005; Repie, 2005) to include the following DSM disorders: oppositional defiant disorder, bipolar diso rder, and ASD. Statements made by participants helped to provide information re garding the complexity of receiving referrals for problems related to a DSM diagnosis. Pa rticipants indicated that, for example, depression often comes out later and when referred, can be manifested in different ways. Similarly, participants described the referral problem of anxiety as encompassing a variety of separate forms of anxiety-relate d issues. While previous studies have noted the prevalence of school-bas ed referrals regarding a nxiety (Foster et al., 2005), statements made by the present participants helped to provide information about the variety of forms of anxiety, namely test anxi ety and school phobia, that are referred for
163 mental health services. Participants responses also contributed to a greater understanding of the types of adolescent issues that are re ferred for services within schools. Issues related to romantic re lationship problems, teenage sexuality, and gender/sexual identity were all ment ioned as referral problems by focus group participants. Similarly, part icipants provided a greater understanding of the types of atypical and bizarre behaviors referred for ment al health services th at have previously been noted in the lite rature (Repie, 2005). While not seen in previous research, pa rticipants in the current study emphasized referral problems related to crisis situations, including threats of harm to others, personal grief, and school-wide tragedies. Participants discussion of referrals due to adult mental health problems was also unique to the current study. In particular, participants described how they were sometimes faced with school pe rsonnel eliciting their guidance in regards to personal issues. Importantly, this is the first time that it has been noted that school psychologists also play a role in worki ng with adults in a school setting. In general, these results attest to the importance of conducting research on students mental health by interviewing front -line service providers. The breadth of responses within the current study, and the uniqu e referral problems th at are currently not attended to in epidemiology studies, suggests that the topic of childrens mental health concerns should be addressed further in future studies. Knowledge of the common referral problems within schools is needed to develop and implement mental health services, including preventi on programs, family support services, and therapeutic interventions that meet the needs of children in modern society.
164 Mental Health Services Provided The purpose of the second research ques tion was to gain a greater understanding of the various types of mental health services that school psychologists currently provide. Unique to this study was the use of qualitative methods to elicit participants answers. Responses from focus groups indicated that sc hool psychologists provide a diverse array of mental health services. The activities identified most frequently by participants included group counseling, indi vidual counseling, and cris is intervention services, followed by consultation, behavioral inte rventions, case management, and socialemotional behavioral assessment. Although not discussed as often, some participants also reported counseling adults, as well as providing inservices, pr evention services, and family services. These findings are consistent with previous resear ch demonstrating that school psychologists offer a breadth of mental health services to their students, ranging from individual counseling to crisis interv ention (Pryzwanksy et al ., 1984; Repie, 2005; Yates, 2003). Of note, it is challenging to integrate pr evious research on services provided due to the diverse definitions of mental health services utilized in each study. With that caveat, findings in the current study can be compared with studies that queried an assortment of school personnel on the provision of psychotherapeutic services (Brener et al., 2001; Foster et al., 2005; Repie, 2005; Slade, 2003; Whitm ore, 2004) and studies that focused solely on the provision of psychot herapeutic services by school psychologists (Pryzwanksy et al.; Smith, 1984; Yates, 2003; Yoshida et al., 1984). In general, the emphasis participants in the current study plac ed on the provision of crisis intervention services--individual counseling, group c ounseling, case management, and social-
165 emotional behavioral assessment--corroborate the previous research of Foster et al. (2005), Whitmore (2004), Slade (2003), and Bren er et al. (2001), who also identified these services as some of the more frequently provided mental health services in schools. Regarding research examining psychotherapeut ic services provided specifically by school psychologists, the results from this study ar e consistent with earlier studies that highlighted the provision of individual and gr oup counseling services (Prout et al., 1993; Smith, 1984; Yates, 2003; Yoshida et al., 1984 ). Unique to the current study were participants statements that clarified the process of indi vidual counseling in the schools and the different types of group counseling provided. Specifically, individual counseling services ranged from addressing a targeted behavior to a general issue in school. Group counseling services addressed a vari ety of specific problems, ranging from organizational skills to grief. Consistent with previous research was the notable absence of the provision of family services. For instance, a national sample of school psychologists (Whitmore, 2004) and regular and special education teachers, school counselors, and school psychologists (Repie, 2005) indicated that the mental health service that they provided least often in school settings was the provisi on of family counseling services. Possible explanations for the limited provision of fa mily services may be gleaned from previous research that found family support services was the mental health service most frequently ranked as difficult or very difficult to deliver (Foster et al., 2005). This may be a relatively recent phenomenon, as some studies conducted in the 1980s using a sample of school psychologists from a northern state (Pryzawansky et al., 1984) and a national sample of school psychologists (Yoshida et al., 1984) identified fa mily services as a
166 common mental health service provided. Neve rtheless, the paucity of family services discussed in the current study is in line with resu lts of a more current study of school psychologists (cf. Yates, 2003). Participants in the current study also di d not report much provision of substance abuse services and prevention services (e.g., drug education) consistent with previous research suggesting that substance abuse se rvices and prevention services were not services commonly provided in the schools (Foster et al., 20 05; Repie, 2005). Perhaps other educational personnel ar e addressing such needs, as a national sample of guidance counselors, psychologists, social workers, and principals surveyed reported that many of their schools provided alcohol and other dr ug use prevention, suicide prevention, and violence prevention (Bre ner et al., 2001). Notably, participants within the current study did not emphasize the provision of social-emotional behavioral assessment, wh ich contradicts the la rge body of existing research that has consistently identified assessment/testing as a mental health service frequently provided in schools (Foster et al., 2005; Repie, 2005; Slade, 2003). One hypothesis for this inconsistency pertains to the current studys definition of mental health assessment and intervention. Participan ts received a detailed definition of mental health assessment and intervention that incl uded the following: clinical or behavioral assessment with intent to intervene. Excl uded from the definition of mental health assessment and intervention, and provided as a non-example of a me ntal health service for participants, was the following: assessm ent for special educational eligibility (without intent to personally provide interven tions after placement). Hence, assessment solely for the purpose of determining special education eligibility may be the type of
167 service in which respondents in previous studies were engaged, suggesting that assessment with intent to place in special education is more commonly provided in schools than assessment with intent to intervene. Given that most previous studies of the types of mental health services provided by school psychologists were ba sed on forced-choice survey responses and were often exclusive to a specific mode of services (e.g., individual counseling), it was not surprising that a number of mental health se rvices emerged from the current study that are absent from existing literature. For in stance, participants in the current study emphasized the provision of crisis interventi on services, including threat assessments and de-escalation of individual prob lems that arose in class. Th ese activities are in line with participants reports regarding the frequency with which they receive referrals for crisis situations. Participants also emphasized their roles in providing consultative services to educational staff. Pryzwanksy et al. (1984) and Yates (2003) had previously identified the role of school psychologists in worki ng with teachers; however, the current study elaborated on a variety of services that were being provided as consultation to individuals, including consulta tion to parents and participa tion on problem-solving teams. Other unique mental health services describe d by participants incl uded counseling adults in students lives, providing be havioral interventions, and of fering inservices. This new knowledge that school psychologists engage in such activities broadens the range of mental health services that school psychologists are know n to provide. Notable group differences. An additional purpose of the current study was to examine mental health service provision as a function of practitioners levels of experience. Identifying differences between th e types of services th at new graduates and
168 experienced practitioners provide can ultimat ely aide in determining where additional training may be needed for either new or experienced practitioners. Responses from focus groups in the current st udy indicated that differences do indeed exist between new and experienced practitioners in regards to the types of mental he alth services they provide, although there are a number of mental health services that they provide at a similar rate. New and experienced school psychologi st groups reported the provision of individual counseling, group counseling, and consu ltation to individuals at a similar rate. These findings corroborate Yates (2003) fi ndings that years of experience were unrelated to school psychologists roles in providing individual a nd group counseling and in providing consultation to individuals (Yat es, 2003). However, Curtis et al. (2002) found that more experienced school psychologi sts indicated more fr equent involvement in the provision of consultation services. Consis tent with previous research (Curtis et al., 2002) in which a national sample of school ps ychologists completed a survey regarding their professional roles in the schools, participants in the ex perienced school psychologist groups indicated more frequent involvement in the provision of in-service programs than did their less experienced peer groups. New and experienced participants in th e current study reporte d the provision of social-emotional-behavior assessment at a relatively similar rate. These findings are inconsistent with previous researchers findi ngs that years of experience were related to school psychologists roles in providing asse ssment services (Cur tis et al., 2002). However, Curtis et als (2002) findings were specific to c onducting special education reevaluations, which may account for the disc repancy noted in th e current study.
169 Findings indicated that differences also exist between new and experienced practitioners in regards to th e range of mental health serv ices they provide. New school psychologists revealed that th ey were more likely to provi de behavioral interventions than were experienced school psychologists. On the other hand, experienced school psychologists were more frequently involve d in the provision of case management activities and family services when comp ared to new school psychologists. One hypothesis for why these differences emerged w ithin the current study but not in previous research relates to the breadth of mental health services identified by participants within the current study. Previous research was lim ited to a forced-choice survey method that was not inclusive of such ment al health services as behavi oral interventions and case management. Implications of these differences in ment al health service pr ovision by level of experience pertains to the design of deliberat e professional developmen t services that are tailored to the specific knowledge and trai ning needs of new graduates and experienced practitioners. Such targeted trainings ma y increase practitioners capacity to provide mental health services that they are current ly not providing as fre quently as are their peers. Barriers to Psychotherapeutic Service Provision The purpose of this research question was to determine the specific factors that could be addressed so as to increase the likelihood that a scho ol psychologist would provide mental health services. Unique to this study was the use of qualitative methods to elicit participants answers. Respons es from focus groups indicated that school psychologists perceive problems inherent to using schools as the site for service delivery,
170 insufficient support from department and di strict administration, problems with school personnel, and insufficient training as most inhibiting their ability to provide mental health services. Other co mmonly identified barriers include insufficient time and integration in the school site, a large caseload at their schools, and ch allenges inherent to the referred student. Although not as prevalen t within the focus groups, participants also discussed barriers related to role strain. These findings corroborate previous researchers findings that school psychologists perceive both external (i.e., due to the systems in which the practitioner works and internal (i.e., specific to an indivi dual practitioners experiences and attitudes) barriers to the provision of school-based ment al health services. Although some unique barriers emerged from participants statements, many of the external and internal barriers within this study corresponded with those found in the exis ting literature (Yates, 2003). Participants in the current study empha sized how department-assigned roles and responsibilities (external barriers) limited th eir abilities to provide psychotherapeutic service provision. In particular, participants described how the job description itself is a primary barrier, particularly due to their responsibilities for fulfilling assessment duties within a school. This is consistent with Yates (2003) dissertati on in which a national sample of school psychologists endorsed wh ich of six factors presented barriers to spending more time providing counseling, as respondents most endorsed a heavy emphasis on assessment (68.2%), the fact that co unseling was not part of their roles in the school (52.5%), and the fact that counseling was not currently part of their identified/written job responsibilities (26.4%). Two other department-level factors that were unique to participants responses in th e current study include the departments and
171 districts roles in creating cumbersome proce dures and requirements as well as their roles in raising liability and legality issues. Taken together, these results underscore the significant role that the department plays in preventing school psychologists from providing mental health services. Notably, participants in the current study did not emphasize the barriers of role strain and bur n out to the same extent as Meyers and Swerdlik (2003) had previously identified, suggesti ng that current prac titioners may be more adept at balancing the di stricts mandates for their involvement in traditional roles (i.e., assessment) with their pe rsonal conviction to provide dir ect intervention services. Participants responses regarding the barri ers related to insufficient support from district administration are c onsistent with prior research in which school psychologists lamented a perceived lack of attention to stude nt mental health at the district and state levels (Yates, 2003). Another systems-level barrier that emerged in the current study involved insufficient support from department and district administration in regards to a lack of funding for mental h ealth services, which confirms findings from the SAMHSA survey in which schools ranked th e extent to certain factors we re barriers to the delivery of mental health services, using a scale of 1 (not a barrier) to 4 (serious barrier) (US DHHS, 1999). In contrast, whereas the SAMH SA study (US DHHS, 1999) indicated that the financial constraint of families and difficulties with transportation were two of the most frequently indicated barriers to mental health care, neither of these factors were mentioned by school psychologist s in the current study. One of the most notable differences be tween the current study and previous research was the emphasis participants placed on the logistical and physical problems that arise related to the use of th e school environment as the loca tion of mental health service
172 provision. Participants described how issu es such as space constraints, difficulty scheduling meetings with students, inconsis tent treatment largel y related to school psychologists competing responsibilities, and the exclusive focus of the school on academic success prevents them from providi ng additional mental health assessment and intervention. Another no table systems-level theme that permeated throughout participants responses regarded problems th at arise because of the need for support from and collaboration with other school employees Similar to the sentiments regarding insufficient support from the department a nd district, participants described how insufficient support from building-level ad ministration and teachers can lead school psychologists to provide fewe r mental health services. School psychologists in the current study provided a greater under standing of how teachers and building administrators convey a lack of support. For example, participants discussed how administrators focus on testing students suggest s this service is a pr iority over mental health service provision. Two notable school-based barriers were related to not having enough time and integration into the school site and the caseloads th ey carried at their schools. Participants felt that they did not have enough days at their school and on those days that they were there were on site th ey were overwhelmed by the number of students they needed to serve with both academic and mental health concerns, consistent with prior research in which virtually no school psychologists (only 5.4% of those surveyed) cited a low number of referrals as a reas on they could not spe nd additional time on counseling (Yates, 2003). This study also elucidated factors internal to school psychologists that limit their provision of mental health se rvices. Previous research had stumbled upon the important
173 role of professional training through providing an opportunity fo r participants to provide open-ended comments about other barrier s to providing counseling services not purposefully assessed in the study (Yates, 2003). The current investigation provided insight into how inadequate tr aining can lead school psychol ogists to feel unprepared to provide mental health services. In particular, participants not ed that insufficient training includes not only inadequate foundational co ntent knowledge and applied experiences, but also contributes to a lack of confidence. Insufficient tr aining was the primary internal barrier that emerged in the current study. Regarding other internal barriers, although some participants mentioned their own pers onal characteristics (e .g., burn out) and their perceptions of specific referre d children as preventing them from providing mental health services, these themes were not emphasized. For instance, just as less than 7% of school psychologists endorsed not having an interest in providing mental health services in Yates (2003) research, a preference for providi ng traditional services (e.g., assessment) rather than direct interventions was menti oned only on seven occasions in slightly more than one-quarter of the focus groups in th e current study. The belief that counseling should be provided outside of school did not em erge in the current study, consistent with a survey in which only 3.7% of school psychol ogists endorsed such an attitude (Yates, 2003). Taken together, this study suggests that ba rriers to mental health service provision exist across multiple levels and systems within education, as well as relate to the training experiences that individual practitioners possess. Relativ ely infrequent but nonetheless important internal barriers such as school psychologists apathy to wards their profession (i.e., to help children) or a preference in pr oviding traditional services, can further lead
174 school psychologists to provide fewer school-b ased mental health services. Working with others on an individual level, partic ularly teachers and st udents, can lead to frustration that diminishes the likelihood of school psycholog ists providing mental health services. At the school level, participants described issues ra nging from logistical concerns to the emphasis on academic success only. At the district and department level participants voiced feeling a lack of support through such actions as not providing enough funding for school psychologists to provide mental health services. Notable group differences. An additional purpose of the current study was to examine perceived barriers as a function of practitioners levels of experience. Identifying differences between new graduate s and experienced practitioners needs and perceptions may ultimately aid in determin ing the specific and deliberate actions that schools, departments, and distri cts can initiate to increase both new and experienced school psychologists provision of mental heal th services. Responses from focus groups indicate that some differences do indeed ex ist between new and expe rienced practitioners in regards to the factors they perceive inhibit them from providing more mental health interventions within their professional roles. In general, findings were unique to the current study because no previous research has examined perceived barriers as a function of practitioners leve ls of experience. Regarding differences that emerged, new sc hool psychologists voiced particular concern with problems that arise when working with school personnel as well as challenging student characteristics. New school psychologist also voiced concerns over a lack of support from building-level administration a nd a lack of support from teachers with respect to providing counseling servi ces. One hypothesis for why new school
175 psychologists were more likely to fe el unsupported by teachers and building administrators relates to the limited amount of time they have spent in a school; therefore, the amount of time spent building rapport with teachers and administ rators would have been limited. However, there were no diffe rences between new and experienced school psychologists in regards to th e barrier of insufficient time and integration into their school site. More research is needed to identify the sp ecific reasons why new school psychologists perceive such a lack of support. Other concerns related to the fact that teachers were unaware of their ability to provi de mental health serv ices and that because of certain teacher behaviors, they felt frustr ated when trying to work with teachers. Experienced practitioners did not discuss su ch barriers as often, perhaps due to their additional time and experience working with school personnel. As practitioners spend more time in schools, one would expect that their ability to co llaborate with school personnel and deal with frustrat ing school-related issu es would increase with experience. This hypothesis is consistent with results from the current study that indicated that new school psychologists were the only participants to mention th e value of a course covering content related to working in schools. Similarly, new school ps ychologists may have voiced more concern over challenging student characteristics because they have had limited time and experience in working with av ersive issues that arise when providing services to a student, such as negative behaviors. Participants in the experienced school psychologist groups were particularly concerned with the problems that arise relate d to using schools as the site for service delivery, as well as their personal characteri stics. Given that many of the personal characteristics described by participants incl uded such things as burn out, apathy towards
176 their profession, and personal desire to pr ovide traditional services rather than interventions, this result is in line w ith the number of years the experienced school psychologists have been entrenched in their roles. In regards to problems related to providing services in schools, the sheer number of schools with which experienced school psychologists have practiced may negativ ely affect their per ceptions. The number of schools to deal with which may increas e linearly with the number of problems associated with space and scheduling. Considering the findings of this study, it is clear that a prac titioners years of experience do play some role in their per ception of barriers to mental health service provision. In particular, ne w school psychologists groups voi ced greater concern over the lack of support from building administrati on and teachers, whereas experienced school psychologists groups voiced greater concern ove r problems inherent to using schools as the site for service delivery. These findings can ultimately aid in determining the specific and deliberate actions that schoo ls, departments, and district s can initiate to increase both new and experienced school psychologists provision of mental health services. Training Needs of School Psychologists The purpose of this research question wa s to determine the specific training activities that may ultimately aid in the design and implementation of effective mental health training in school psychology programs. Unique to this study was the use of qualitative methods to elic it participants answ ers. Responses from focus groups indicated that school psychologists emphasized a desire to receive training in didactic content taught through course s, experiential ac tivities, and professional development activities. Given that participants in th is study emphasized the barrier of insufficient
177 training, the breadth and depth of participant resp onses to questions regarding training needs is not surprising. Th ese results corroborate the findings of Yates (2003) dissertation in which 65.6% of a national sample of school psychologists surveyed identified that insufficient time was spent on counseling during their training, despite the majority of respondents taking four or more courses in foundations of mental health problems and in counseling interventions. Many of the didactic content areas, e xperiential activities, and professional development activities identified within th e current study correspond with those found in the existing literature (Whitmore, 2004; Yate s, 2003). However previous studies queried practitioners in regards to wh at type of mental health training experiences they had received from their school psychology pr ograms and from their time practicing as a school psychologist. The current study expa nded upon this area by querying participants regarding the type of coursewo rk and the type of training ex periences that they feel are essential for school psychologists to feel prepared to provide mental health services. In other words, whereas other studies have identifi ed the current status of training in mental health (but no differentiation as to their util ity in providing mental health services), the current study identified those areas of cour sework and experiential activities that would be most beneficial to provide to school psychologists so as to increase their ability to provide mental health services. Many of the didactic areas mentioned by participants in the current study have been noted in the previous literature examining univers ity-level training of school psychologists (Whitmore, 2004: Yates, 2003). Th is is an encouragi ng finding given that at least some of the beneficial coursework identified by participants within the current
178 study were recently noted as part of practit ioners training. Participants responses regarding coursework covering behavioral interventions, developmental psychology, personality, group counseling, neuropsy chology, multicultural education, and psychotherapy is consistent with prior rese arch in which a national sample of school psychologists responded to a series of questions concerning the type of training they had received in foundations of mental health pr oblems and in counseling interventions (Yates, 2003). However, participants within the cu rrent study placed a gr eater emphasis on the importance of coursework covering psyc hopathology, behavioral interventions, and group counseling. In regards to experiential activities, th e current results are in line with prior research that identified such training expe riences as observations of a trainer in a counseling session, supervision, a nd one-way viewing as part of mental health training (Yates, 2003). Participants in the current study expanded upon Yates (2003) research by providing a comprehensive and detailed unders tanding of the processes that can occur within each of the experiential activities. Fo r example, participants indicated that it was beneficial to observe a mast er therapist during a counseli ng session. Similarly, one-way viewing was encompassed within a broader tr aining experience of self review and critique of counseling, which included activities as receiving feedback from supervisors and trainees in addition to watching vide os of oneself providing counseling. Under professional development activities, a finding co nsistent with previ ous research was the advantage of attending in-services offered through school distri cts (Whitmore, 2004; Yates, 2003). Notably, the professional deve lopment activity of attending in-services
179 was emphasized by participants within the current study more than any of the other professional development oppor tunities that emerged. A number of unique responses rega rding training needs were noted by participants in the current study. Given that most research studying the types of mental health training school psychol ogists receive have been ba sed on forced-choice survey responses and were often excl usive to one type of couns eling (e.g., Whitmore, 2003), it was not surprising that a number of content areas emerged that have not yet been noted in the existing literature. In pa rticular, participants within the current study emphasized the need for coursework inclusive of a survey of multiple counseling orientations, advanced study of a single counseling orientation, crisis intervention, and consultation. Similarly, participants emphasized the need for experiential activities that involved in-class role plays and co-leading group c ounseling sessions. Although not as prevalent within the focus groups, additional experiential activitie s that emerged include receiving ones own counseling and working on a multidisciplinary team. Unique responses in regards to professional development activities included co nsultation with peer colleagues, engaging in applied experiences followi ng inservices, receiving formal supervision of services, working with interns, and participating in pr ofessional organizations. It is notable that participants placed a great deal of emphasis on having the ability to consult with peer colleagues. The implications of these findings ar e important to consider given that participants indicated that both graduate school and school districts can play a significant role in providing the content knowledge and tr aining experiences that would allow them to feel sufficiently prepared to provide ment al health services in the schools. Indeed,
180 such training could be provided during gr aduate school but also implemented in continued education courses, particularly in light of consistent findings illustrating practitioners reliance on post-graduate seminars to receive additional training in mental health services. Notable group differences. An additional purpose of the current study was to examine training needs as a function of practi tioners levels of experience. Identifying differences between new graduates and expe rienced practitioners needs will ultimately aid in the design of specifi c and deliberate professional development services for experienced practitioners and new practitioners based upon thei r individualized needs. Responses from some focus groups indicate th at differences do ind eed exist between new and experienced practitioners in regards to the kinds of content knowledge areas and training experiences that would allow them to feel sufficiently prepared to provide mental health services in the schools. In general, findings were unique to th e current study because no other studies have examined training needs as a function of practitioners leve ls of experience. Interestingly, new school psychologists indi cated the need for coursework covering a variety of topics (e.g., crisis intervention, consultation, beha vior interventions, family therapy) when compared to experienced school psychologists. One hypothesis for finding pertains to the changes that ha ve occurred in school psychology training programs. Because practitioners are provide d with more opportunities to take courses covering a variety of topics, they may become more aware of the benefit of knowledge in such areas. In respect to experiential activities, new school psychologists more
181 frequently mentioned the need for supervised practicum, working on an interdisciplinary team, and participating in a professional organization. Experienced school psychologists indicated the need for coursework covering advanced study of a single orientation, deve lopmental psychology, empirically supported treatments, and the experiential activities of receiving their own counseling more often than did new school psychologists. Expe rienced school psychologists placed greater emphasis on professional development activ ities, including a pplying experiences following in-services, working with interns, re ceiving formal supervision of services, and consulting with peer colleagues. One hypothesis for this find ing relates to the type of resource each group currently relies on to receive the skills and knowledge needed to provide mental health services. At this point in th eir professional career s, it could be that new school psychologists have re lied primarily on their formal coursework to provide them with the skills and know ledge necessary to provide SBMH services. In contrast, because experienced practitioners graduate training occurred more than 17 years ago they may rely more heavily on professional development activities to enhance their ability to provide SBMH services. Therefor e, each group would tend identify a different form of training that would allow school ps ychologists to feel sufficiently prepared to provide mental health serv ices in the schools. Taken together, it is clear that a practitione rs level does play a role in the types of training that would enable him or her to f eel sufficiently prepared to provide mental health services. In particul ar, new school psychologists voiced a greater desire to receive additional training in a variety of didactic content areas and in such experiential activities as supervised practicum. Experienced school psychologists voiced a greater desire to
182 receive additional training in so me didactic content areas, such experiential activities as co-leading counseling groups, and multiple pr ofessional development activities. These findings can ultimately aid in determining the specific, individualized training provided to new and experienced pract itioners based upon their fully recognized perception of training needs. Implications of Results for School Psychologists School psychologists are curren tly receiving referrals for students with a diverse set of problems. Thus, mental health prof essionals working with youth in diverse age groups must be knowledgeable of the etiology of a variety of mental health conditions in order to address students need s. It is not sufficient only to train students to understand and treat diagnosable disorders; students must also be prepared to deal with discrete symptoms and crisis situations. School ps ychology graduate trai ning programs and key stakeholders (e.g., department administrators ) must address the n eed for practitioners knowledge of the variety of mental health conditions identified in the current study. Furthermore, results from this study indica te that it is not suffi cient to train school psychologists to provide only one modality of psychotherapeutic service (e.g., individual counseling), as participants indicated provi ding a broad array of school-based mental health services, from group c ounseling to crisis in tervention. In order to ensure that effective and evidence-based services are being provided, graduate training programs and district-level trainers must fully prepare practitioners to provide the most effective approaches to treatment. Importantly, part icipants indicated a minimal role in the provision of certain mental health services such as family services and prevention services. If school psychol ogists are to fully reali ze their roles in providing
183 comprehensive mental health services, th ey must be provided with the training opportunities and knowledge needed to provide su ch important modalities of treatment. If school psychologists are to fully embrace their roles as mental health service providers, the factors affecting their ability to provide such services must be addressed. Participants described barriers to mental health service provision that exist across multiple levels and systems within educati on, as well as have to do with the personal training experiences that individual pract itioners possess. Therefore, school psychologists must be prepared to problem-s olve systems-level issues. Although school psychologists must be prepared to manage syst ems-level barriers due to such things as department-level decisions and/or a lack of support from building-level administration, results from this study indicate that it may be equally important to recognize the role that school, district, and department administration should play in ameliorating such barriers. Problem-solving efforts will need to be made regarding systemic issues, with involvement from administrators at all levels Thus, these key stakeholders will need to be apprised of the results from the current study in order for them to understand fully their role in affecting school ps ychologists ability to provid e mental health services as well as to address the differing needs of new a nd experienced practitione rs. In regards to notable group differences, in-services regard ing the purpose of counseling and the types of mental health services school psychologi sts could be provided to address the problems that new school psychologists disc ussed regarding school personnels lack of support and lack of awareness. Similarl y, providing experienced school psychologists with mental health days to address the problem of burn out th at experienced school
184 psychologists discussed may ultimately lead to increased mental health service provision by this group. Regarding the training needs of modern sc hool psychologists, the implications of these findings are twofold: (a) how can tr aining programs provide the content knowledge and experiences necessary for a school psychol ogist to enter a school prepared to provide comprehensive mental health services? and (b) how can administrators provide continuing education training to practicing school psychologists that will enhance the knowledge and skills necessary for mental health service provision in schools? Trainers might consider recognizing the need for comp rehensive didactic coursework covering content that not only enhances their knowledge of mental health (e.g., psychopathology) but also their knowledge and skills at provi ding school-based mental health treatments (e.g., group therapy, behavior interventions). Essential to the tr aining experience are experiential activities that allow students actively to practice and/or observe a skill needed for mental health service provision. In particular, the bene fits of supervised practicum, in-class role plays, and observi ng a master therapist were recognized within the current study. In terms of continuing education trai ning, school district s might consider recognizing the need for continual training on di dactic content areas. Such topics could be covered during in-services offered through the district, particul arly in light of consistent findings illustrating practitioners reliance on in-services to receive additional training in mental health services (Yates 2003). Continuing e ducation training also needs to involve experiential activities, su ch as role plays and observing a master therapist. In regards to pr ofessional development activitie s, experienced practitioners
185 noted the benefits of having the ability to consult with peer colleagues. Setting up a network within the district through e-mail or regularly-scheduled meetings to discuss mental health related-issues could offer pract itioners the opportunitie s needed to enhance the knowledge and skills necessary for mental health service provision in schools. Limitations of the Current Study Through the focus group method, several re search questions were asked of 39 practicing school psychologi sts during 11 focus groups. Participants responded to questions regarding their pers onal experiences in the prov ision of psychotherapeutic services in the schools and provided their pe rceptions of the barriers to providing such services. Although several precautions were taken to increase the likelihood that credible findings and interpretations were advanced, not all threats to the trustworthiness of the research can be controlled. Therefore, several limitations to the present study warrant consideration when interpreting the results and making suggestions for future research and practice. First, there is limited generalizability of the results due to the relatively small sample size and the geographic limitations of the population sampled (i.e., only two school districts in Florida). Additionally, because part icipation in the study was voluntary, it is possible that voices heard in each school district reflect the activities and perceptions of a subgroup of pr actitioners with a particul ar interest in providing psychotherapeutic services to students. An additional limitation resulted from the small number of participants in one focus group, which meant that theo retical saturation was not guaranteed in this focus group. Although effo rts were made to recruit an appropriate minimum number of participants for each focus group, the researchers could not control
186 for unexpected circumstances. However, althoug h the limited number of participants in that focus group may have reduced the bread th of information obtained because there were fewer voices heard, the small number of participants translated into more on-task conversation and greater depth of responses because more time was provided for each participants response. Limitations exist in regards to errors a ssociated with bias and subjectivity. Krueger (2000) pointed out that data analysis of focus groups is often difficult because it is based on the subjective inte rpretation of the research. In order to improve the reliability of the coding of the themes and le ssen the impact of research bias, multiple members of the research team coded the result s separately, with two researchers assigned to each transcript. In doing this, inter-rater reliability was computed in which the average agreement between the two members was appr oximately 95%. Also notable, an issue pertaining to transcri ption may also limit the findings of this study. Specifically, interviews were audio taped and then transc ribed for subsequent data analysis. Although trained research assistants transcribed diligently, some degree of error could be attributed to occasional deteriorations in the quality of audiotape playback (e.g., background noise) which is a threat to the desc riptive validity of the findings. Similar to research bias, a limitation of the current study is related to the subjectivity of the responses from the partic ipants. No methods were employed in this study to ascertain the truthfulness of the inform ation given by the participants. However, an advantage of focus groups is that the part icipants are placed in a more naturalistic setting to facilitate discussi on and to allow for the group me mbers to interact with one
187 another (Krueger, 2000). Additionally, effort s were made to homogenize groups through the characteristic of practitione rs years of experience. Suggestions for Future Research The purpose of the current study was to el ucidate factors that school psychologists perceive inhibit them from providing more mental health interventions within their professional roles and the kinds of content knowledge areas and trai ning experiences that would allow school psychologists to feel suffici ently prepared to provide mental health services in the schools. An additional purpose of the current study was to examine perceived barriers as a function of practitioners levels of expe rience. It is hoped that the results of this study can be used to guide fu ture research and pract ice and contribute to a better understanding of the mental health trai ning needs of school psychologists. Several implications for future research are noted below. This study was the first qualitative study to investigate school psychologists role in the provision of psychotherapeutic services and identify barriers perceived by school psychology practitioners. Although the findings of this study yield a great deal of potential for training efforts in school psychology programs a nd district programs, it is necessary to replicate these fi ndings with a nationally repr esentative sample of school psychologists before broad gene ralizations can be made abou t the barriers to mental health service provision and specific content knowledge areas and training experiences that would allow practitioners to feel suffi ciently prepared to provide mental health services. Because this study was conducted at only two school distri cts within the state of Florida, school psychologists who work in these districts may not be representative of all school psychologists in the state of Florida. Replication of these findings in practicing
188 school psychologists throughout Florida would confirm these results. Furthermore, research should be extended to other regi ons of the country, particularly given that regional differences are present in school a ssessment practices (Hosp & Reschly, 2002). It is suggested that a survey method may mo re effectively allow researchers to access information from a larger, more geographically diverse sample of school psychology practitioners. This study highlighted several signif icant differences between new school psychologists and experienced school psycholog ists. However, it is necessary to replicate these findings before broader genera lizations can be made about the role years of experience may play in perceived barriers to mental health serv ice provision and the mental health training needs of school psyc hologists. Although it was outside the scope of the present study, future research s hould examine the relationship between the provision of mental health services and ot her demographic variables. For example, differences may exist when examining the re lationship between research findings and the grade level that practitioners serve (i.e., elementary, middle, or high school). Similarly, future investigations should examine the re lationship between the provision of mental health service and the type of school district (i.e., ru ral, urban, or suburban). Conclusions This study has provided the first known qua litative study of the barriers to school psychologists provision of psyc hotherapeutic services in th e schools, the mental health training needs of school psychologists, and the unique differences between new and experienced practitioners. The study indicated that schoo l psychologists are currently receiving school-based referrals for a diverse set of student problems. Similarly, school
189 psychologists indicated providing a broad array of school-based mental health services, from individual counseling to crisis intervention. Changes in government policy and societal initiatives have underscored the need for school psychologists to provide school-based mental health services. In spite of the rising call for a more concerted effort in ment al health, however, cha nges within the field have been minimal (e.g., Curtis et al., 1999; Fagan & Wise, 2000; Hosp & Reschly, 2002). This study provided current informati on with respect to the mental health practices of school psychol ogists and elaborated upon the factors that school psychologists perceive inhibit them from provi ding more services and training that would allow school psychologists to feel sufficiently prepared to provide mental health services in the schools. If school psychologists are to fully realize their roles as mental health service providers, the factors affecting their ability to prov ide such services must be addressed. Similarly, the training needs of modern psychologists working in schools must be recognized by graduate training programs and profe ssional development services must be provided for practicing school psyc hologists to enhance the knowledge and skills necessary for mental health service provision in schools.
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205 Appendix A: School Psychologist Consent Form De a a r r S c choo l l Ps y yc h hol o o g g i is t t : : T T h h a a n n k k y y o o u u f f o o r r a a l l l l o o w w i i n n g g u u s s t t o o m m e e e e t t w w i i t t h h y y o o u u t t o o d d i i s s c c u u s s s s sch ool psychologists provision of mental health assessment and intervention services. O O u u r r g g o o a a l l i i n n c c o o n n d d u u c c t t i i n n g g t t h h e e s s t t u u d d y y i i s s t o o i iden t t i ify the types of st udents referred for mental health help, factors that facilitate and prohibit school psychologists from providi ng mental health assessment and intervention , a a n n d d t t h h e e specific knowledge and skill areas in which additional training would be helpful in order to enable school psychologists to provide mental health interventions. W W h h o o W W e e A A r r e e : : T T h h e e r r e e s s e e a a r r c c h h t t e e a a m m c c o o n n s s i i s s t t s s o o f f S S h h a a n n n n o o n n S S u u l l d d o o , P P h h . D D . , a a p p r r o o f f e e s s s s o o r r i i n n t h h e e C C o o l ll e e g ge of E d d u u c ca t t i ion at t t h h e e U U n niv e er s si t t y y of S S o o u uth Flo r ri d d a a ( U U S S F F ) ), a n n d d s sev e er a a l l d d o o c c t t o o r r a a l l s s t t u u d d e e n n t t s s i i n n t t h h e e U U S S F F S S c c h h o o o o l l P P s s y y c c h h o o l l o o g g y y P P r r o o g g r r a a m m . W h h y y W e e a a r r e e R R e e q q u ues t t i ing Y o o u ur P Par t t i ic i ipat i ion : Thi s s s t t u u d dy i is b b e e i ing c condu c cted a s s part of a a p p r r o o j j e e c c t t e e n n t t i i t t l l e e d d , S S c c h h o o o o l l P P s s y y c c h h o o l l o o g g i i s s t t s s P P r r o o v v i i s s i i o o n n o o f f M M e e n n t t a a l l H H e e a a l l t t h h A A s s s s e e s s s s m m e e n n t t a a n n d d I I n n t t e e r r v v e e n n t t i i o o n n s s . Y Y o o u u a a r r e e b b e e i i n n g g a a s s k k e e d d t t o o p p a a r r t t i i c c i i p p a a t t e e b b e e c c a a u u s s e e y y o o u u a a r r e e a a p p r r a a c c t t i i c c i i n n g g sc h h o o o o l l psyc h hol o o g g i is t t ei t t h h e e r r wi t t h hi n n a a d d i is t t r r i ic t t t t h h a a t t ex p p r re s ss e e d d i inte r res t t i in p p a a r r t t i i c ci p pati n n g g in t t h h e e s s t t u u d d y y , o o r r y y o o u u a a r r e e a a t t t t e e n n d d i i n n g g a a p p r r o o f f e e s s s s i i o o n n a a l l c c o o n n f f e e r r e e n n c c e e . Why You Should Participate : The information that we collect from school psychologists will help us understand factors associated with school psychologists provision of mental health assessment and interventions. Findings from this study may ultimately aide in the design and implementation of effective mental health training in school psychology programs. Please note that you will receive a $25.00 gift certificate for participating in the study. What Participation Requires : Participation will entail attending one 45-60 minute meeting in which we will conduct a focus group with small groups of practitioners. Focus groups will be conducted on a school campus in your county or at a professional conference. Participation will also require completion of a short demographic questionnaire. Please Note : Your decision to participate in this research study must be completely voluntary. You are free to participate in this research study or to withdraw from participation at any time. If you choose not to participate, or if you withdraw at any point during the study, this will in no way affect your relationship with your school district, USF, your professional organization, or any other party. Confidentiality of Your Responses : There is minimal risk for participating in this research. Your privacy and research records will be kept confidential (private, secret) to the extent of the law. People approved to do research at USF, people who work for the Department of Health and Human Services, and the USF Institutional Review Board may look at the records from this research project, but your individual responses will not be shared with people in the school system or anyone other than the research team. After the focus group session has been transcribed, the
206 Appendix A: (Continued) information that you provide during the focus groups and your completed demographic questionnaire will be assigned a code number after the transcription to protect the confidentiality of your responses Only the principal investigator (Dr. Suldo) has access to the locked file cabinet stored at USF that will contain all records linking code numbers to participants names. What Well Do With Your Responses : We plan to use the information from this study to aide in the design and implementation of effective mental health training in school psychology programs and school districts. The results of this study may be published. However, the data obtained from you will be combined with data from other people in the publication. The published results will not include your name or any other information that would in any way personally identify you. Questions? If you have any questions about this research study, please contact Dr. Suldo at (813) 974-2223. If you have questions about your rights as a person who is taking part in a research study, you may contact a member of the Division of Research Integrity and Compliance of the University of South Florida at 813-9745638 or the Florida Department of Health, Review Council for Human Subjects at 1850-245-4585 or toll free at 1-866-433-2775. Want to Participate? To participate in this study, sign the attached consent form. Sincerely, Shannon Suldo, Ph.D. Assistant Professor of School Psychology Department of Psychological and Social Foundations --------------------------------------------------------------------------------------------------------------------Consent to Take Part in this Research Study I freely give my permission to take part in this study. I understand that this is research. I have received a copy of this letter and consent form for my records. _______________________ ________________________ ___________ Signature of psychologist Printed name of psychologist Date Statement of Person Obtaining Informed Consent I certify that participants have been provided with an informed consent form that has been approved by the University of South Flor idas Institutional Review Board and that explains the nature, demands, risks, and benefits involved in participating in this study. I further certify that a phone number has been provided in the event of additional questions. ________________________ ________________________ ___________ Signature of person Printed name of person Date obtaining consent obtaining consent
207 Appendix B: E-Mail Invitation Dear School Psychologist Colleague: We are conducting a study of school psychologists provision of mental health assessment and inte rventions. We define mental health assessment and intervention as any activity in wh ich school psychologists purposefully engage in an effort to ameliorate th e mental health prob lem(s) within an identified child. Such activities include the following: counseling/ psychotherapy; clinical or behavioral assessment with inte nt to intervene; and consultation with adults includ ing educational personnel and family members. Our research group is cond ucting this research to identify systems-level and within-person fa ctors associated with school psychologists provision of mental he alth assessment and intervention. We would like you to be a participant in this study, regardless of the amount of time you currently spend providing me ntal health services. Participation will entail attending one 45-60 minute meeting in which we will conduct a focus group with a small group of practicing school psychologists. Focus groups will be conducted on a school ca mpus in your school district. All participant responses will be confidenti al. In part to compensate you for your time, participants will receive a $25 gift card at the focus group session. Beverages and snacks will also be provided throughout the activity. The study will take place within the ne xt few months. Dates and times for focus groups will be determined based on participants availability. If you are interested in participating in this study, please contact us at (e-mail address) and let us know days of the week and periods of time during those days in which you would be able to pa rticipate in a 45 60 minute meeting. We will respond shortly with an e-mail containing several options for meeting dates and times. Thank you in adva nce for your time and cooperation. Sincerely, Shannon Suldo, Ph.D. Principal Investigator, School-Based Mental Health Research Group Assistant Professor, University of Sout h Florida School Psychology Program firstname.lastname@example.org ; (813) 849 8213
208 Appendix C: Demographic Form Information about Training 1. Did your graduate training include specific coursework in the following areas: (please check all that apply) _____ Developmental psychology/child development _____ Behavioral diso rders/psychopathology _____ Psychopharmacology _____ Behavioral interventions _____ Counseling children/psyc hotherapeutic interventions _____ Group counseling _____ Family counseling _____ Multicultural counseling _____ Advanced counseling/psychotherapy _____ Personality/social-emotional-behavioral assessment _____ Mental health consultation _____ Practicum in mental health assessment _____ Practicum in mental health intervention _____ Other (please list a ny other courses that were available specific to mental health assessment and intervention) ____________________________________________ __________________________________________________ __________________________________________________ 2. How many graduate level courses that co vered the topics liste d above (i.e., mental health assessment and intervention) did you take? 0 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 >15 3. Did your practicum training include the oppor tunity to observe and/or sit in on the provision of mental assessment and inte rvention conducted by a school psychologist? ____ YES _____ NO 4. Did your practicum training include the opportunity to provide any mental health assessment and intervention? ____ YES _____ NO 5. Did your internship training include the opportunity to provide any mental health assessment and intervention? ____ YES _____ NO 6. Were there any other opportunities availabl e (e.g., assistantship) through your training that involved mental health assessm ent and interventi on (please list)? ________________________________________ ________________________________________
209 Appendix C: (Continued) 8. Do you think that your formal academic training provided sufficient emphasis on mental health assessment and intervention? ____ YES _____ NO 9. Have you attended any continuing educat ion programs during the past 5 years that were specifically focused on mental health assessment and intervention? ____ YES _____ NO 10. Please list any continuing education courses related to mental health assessment and intervention that you took w ithin the last 5 years. _______________________________________________________________________ _______________________________________________________________________ _______________________________________________________________________ Information about You 1. Where did you attend graduate school? _______________________________ 2. What was the highest de gree that you have earned? ____ MA/MS ____ PhD/PsyD/EdD ____ Specialist/EdS ____ Other (Please specify) _____________ 3. Was your graduate program accred ited by (check all that apply)? _____ NASP _____ APA _____ NCATE _____ State _____ Not accredited 4. How many years have you been practicing in the school setting? _____ 5. In your current position, how many different schools do you work in? _____ 6. In what type of school do you primarily work? _____ rural _____ inner city _____suburban _____ other (please specify) __________ 7. What are the grade levels of the students that you serve (please circle all that apply)? Preschool K 1 2 3 4 5 6 7 8 9 10 11 12 8. In your current position, what is the school psychologis t: student ratio? _____ 1: <500 _____ 1: 500-999 _____ 1: 1000-1499 _____ 1: 1500-2000 _____ 1: >2000
210 Appendix D: Focus Group Protocol Date of Group: _________________ Time of Group: _________________ Facilitator: _________________ Note-Taker: _________________ Focus Group Protocol Procedures and Questions for Focus Groups School Psychologists Provision of Ment al Health Assessment and Intervention Shannon Suldo, Ph.D. & Allison Friedrich, M.A. Instructions Welcome participants to session individually as they arriveimmediately make small talk. Hi! (introduce self) Thank you so much for comingwould you like a snack while you make a nametag for yourself? [make name tag][comment on outfit, plans for evening/weekend, etc.] o Give each participant 2 copies of consent fo rmsask to read then sign (collect the signed the; they keep extra copy for own records) o Give demographics sheet and marker After theyve completed the demographics questionnaire, ask them to draw something about themselves/interests on their name tag Introduction to moderator and note-taker. Thank you for attending. Purpose of todays discussion: Were interested in learning about what factors you perceive enable and limit your provision of mental health assessment and intervention in the schoolswe refer to the limiting factors as barriers. We define mental health assessment and intervention as, following the id entification of a given child at-risk for, suspected of, or diagnosed as having a ment al health problem, any activity in which school psychologists purposefully engage in an effort to ameliorate the mental health problem(s) within the identified child. Such activities include the following: clinical or behavioral assessment with intent to in tervene; individual, group, or family counseling/psychotherapy; case management ; consultation with adults including educational personnel and family membe rs; crisis intervention; and medication management/coordination of care with physici ans. The following activities are excluded: assessment for special educational eligibility (with no intent to personally provide interventions after placement); academic assessment/intervention for children without mental health problems; school-wide or cl assroom counseling; and school-level research and evaluation. Broad overview: For the rest of this period, we are going to ask you a series of questions regarding a number of issues related to providing mental health services in the school. There are no right or wrong answers, but probabl y some differing points of view. We are interested in hearing what each of you has to say, so please speak up and share your point of view no matter if it is the same or different from what others have said. However, if one or more of the questions does not apply to you, do not feel compelled to answer it. Keep in mind that were here to gather information only, not to reach agreement to a question; were also NOT here to tell you what to do or even to provide advice, just to listen.
211 Appendix D: (Continued) Confidentiality: Everything discussed today will be kept confidential (private, secret) to the extent of the law. Your specific respon ses will not be shared with administration or school staff. We are tape recording this session only as a tool to capture all information. After we have finished transcribing todays se ssion, you will not be identified by name in our work. o Turn on recorder Icebreaker. This session will last 45 minutes, and well ask 7 10 questions during that time. Lets begin. Everyone has a name tag onlets find out some more about each other by hearing about the pictures everyone drew on their nametags Questions 1. For which type of problems are students referred for mental health assessment and intervention to either you or other school personnel? (possible examples if no one responds: anxiety, depression) 2. Which mental health assessment and interventions services have you provided during your past few years of practice in the schools? 3. School psychologists spend varying amounts of time in their work week providing mental health assessment and intervention. What enables you to provide these services? PROBE: Which specific systems-level/external factors enable you to provide these services? (examples if no one responds: district-wide professional development, supervision) PROBE: Which specific individual or personal factors enable you to provide these services? (examples if no one responds: graduate school training, knowledge of mental health interventions) 4. Which factors prevent you from providing mental health assessment and intervention? PROBE: Which specific systems-level/external barriers prevent you from providing these services? (examples if no one responds: time constraints, lack of space) PROBE: Which specific individual or personal barriers prevent you from providing these services? (examples if no one responds: knowledge of mental health interventions, comfort level with counseling) 5. Which specific content areas that were taught in your graduate school or continuing education training most enable you to provide mental health assessment and intervention? (in other words, class work well talk about practical experiences next) (examples if no one responds: theories of counseling, case documentation, how to select EBIs)
212 Appendix D: (Continued) FOLLOW-UP: In which content areas would additional information increase the likelihood you would provide mental health services? 6. What types of training experiences (beyond class work) that were included in your graduate school or continuing education tr aining most enable you to provide mental health assessment and intervention? (examples if no one responds: role-plays, supervised practica, continuing s upervision/case consultation) FOLLOW-UP: Which additional training experiences would help you to feel adequately prepared to provide mental health services? 7. [Summarize responses] is that correct? Would you like to add anything?
213 Appendix E: Sample Form for Field Notes Focus Group # ______ Date: Time: Names Question 1For which type of problems (e.g., anxiety, depression) are students referred for mental health services to either you or other school personnel? 1) 2) 3) 4) 5) 6) 7) 8)