Author: Shawn Forrest Guiling

Correspondence concerning this article can be sent to sguiling@semo.edu

Abstract

Rural schools and communities face mental health concerns, often exacerbated by limited resources to address those concerns. Important collaborations between school counselors and community-based private practice or University-based mental health professionals. Implications of these types of collaborations will be addressed through consideration of a case application and a proposed best practice model for schools working with community-based mental health professionals. Further, the importance of increasing rural mental health care and the confidence of the rural mental health professional will be discussed.

Keywords: Psychological Services, School Counseling Support, Student Mental Health, Rural Mental Health

 

Supplemental Supports for School Counselors in Rural School Districts:

The Role of Private Practice and University-Based Mental Health Professionals

in Providing Student Mental Health Services

“Rural” often refers to a location’s land use or sparse population and sometimes to the particular social norms and beliefs of the people who live there (Sharma & Chaturvedi, 2020). Much of the world’s population lives in locations considered rural (Wodarski, 1983). From early on, many people living in rural communities have faced limited resources and other difficulties (Marotz-Baden, 1988). These difficulties include mental health concerns. The prevalence of mental health concerns is often similar in rural and urban communities but resources to address those concerns are less substantial in rural settings (Carey & Gullifer, 2021). Kelly et al. (2020) reported that rural areas may include a variety of mental health needs, including substance use, suicidality, self-harm, stress, and other physical and mental conditions that may give rise to pain and other distress. As with the surrounding community, often rural schools in those communities also face limited resources and fewer mental health services (Chalker, 1999). Further, community beliefs may not always find value in mental health services or may lead to stigmatization of such services (Sharma & Chaturvedi, 2020). Other barriers to increasing rural mental health can include confidentiality of care in a small community and cultural mistrust of services (Kelly et al., 2020).

Historically, because the school and its surrounding community was always seen as inextricably linked, it stood to reason that if mental health was seen as important to the community, then it would be seen as important for rural schools as well (Pittman, 1922). Early on, community-based mental health professionals provided consultation services in some rural schools due to the lack of appropriately trained staff already working in the schools (Gray, 1963). Therefore, a precedent was set for community-based mental health professionals to support the school when needed. Today, continued barriers to mental health services in some rural areas have led to important collaboration between school counselors and community-based private practice or university-based mental health professionals. Those mental health professionals may play supplemental or alternative support roles in rural school districts which may not have a school counselor or may have a school counselor who does not have enough time for student counseling (or psychological evaluation or consultation, depending on the situation). The availability and willingness of community mental health resources to step in as needed may be imperative to successful school functioning and student well-being. Because school mental health concerns are community mental health concerns, community professionals sharing their time and expertise with schools seems imperative in promoting optimal learning and well-being in students. Implications of these types of collaborations will be addressed. 

Mental Health in Schools in Rural Communities

Schools rely on collaborative relationships to better improve services to all school children and must identify needed resources for bringing about change (Weist et al., 2023). Schools and school staff play important roles in promoting mental health and well-being and require support from mental health professionals both in and out of the schools (Humphrey, 2023). Sutton and Pearson (2002) discussed that rural school counselors benefit from working with other members of the mental health community, which may include psychologists, social workers, and family and children’s service staff (Coleman, 2021). Additionally, the rural school counselor may also engage with school psychologists, school social workers, school nurses, physical therapists, occupational therapists, adaptive physical educators, general medical practitioners, psychiatrists, principals, general and special education teachers, speech language pathologists, parents/guardians, and students (Kelly et al., 2023). A balanced working alliance between mental health professionals in the school and the community, with an integration of wrap-around support treatment is important (Bhugra & Ventriglio, 2020).

Michael et al. (2023) reported that school mental health professionals needed to be prepared to practice ethically even without enough resources, understand the community and its relationship with the school system, practice cultural competence and humility in all situations, and recognize confidentiality and multiple role relationships likely to arise in the community. If the school counselor is seen as a resource by those outside the school, then the same professional may benefit from support from other community mental health professionals coming into the school to provide mental health services. Multiple other community resources (including teen centers and community counseling outside of the school setting) and professionals (including law enforcement and mental health providers) may be available to provide further supports to students but are not aware of the roles they may play or are not aware of how to access the rural school system (Braucht & Weime, 1990).

Hartman et al. (2017) indicated that students benefit greatly from these partnerships involving rural public-school staff and professionals from the surrounding community. Partnerships, including utilizing collaborative trainings and accessible children’s literature, benefit both school-based and community-based professionals, as well as the students served. Successful school and community partnership models have been shown to work in more targeted situations, such as teen pregnancy prevention (Barnes & Harrod, 1993), and very likely could with other needs such as mental health services as well. Developing and maintaining school based mental health services have been found to increase resources and access to resources for the rural community as well, allowing for back-and-forth collaboration between professionals in and out of the school (Capps et al., 2021).

Outside Mental Health Support for Schools in Rural Communities

Kelly et al. (2023) stated that a variety of professionals constitute school mental health practitioners and may provide counseling, assessment, consultation, and other psychological services such as early identification of mental health needs and family supports and home visits. To improve implementation of mental health services, these outside mental health professionals may include community-based private practice or University-based mental health professionals (Wargel-Fisk et al., 2023). While university-based support more often takes the form of research or technical expertise, private practice professionals are more likely to provide applied services such as counseling and psychological assessment (Wargel-Fisk et al., 2023). To enhance mental health service implementation, Wodarski (1983) suggested developing primary care networks that draw on health and mental health education for the community and school as well as training other professionals in the community to better recognize and help manage mental health needs. Further, role definition and work balance is necessary among these professionals, including training in appropriate treatments and interventions in the school setting as well as federal, state, and local education-related policies (Kelly et al., 2023). 

Barriers to this implementation included time commitments and establishment of clear role differences and expectations (Wargel-Fisk et al., 2023). Further, a lack of understanding of some of the differences that exist between the school setting and the community setting was a barrier to service implementation. This lack of understanding included collaboration with multiple professionals and clients in a multi-tiered system of support offering primary through tertiary preventions, considering school-based factors such as school climate and family engagement, and ensuring that all students can access services (Kelly et al., 2023).

Outside Mental Health Support for Schools in Rural Communities: A Case Application & Proposed Best Practices

To better explain the framework of outside mental health support in rural schools, as well as possible barriers to service, a case application is in order. Over the past 13 years, I have supported around five rural school districts, providing various mental health services as a licensed psychologist. I have worked with students from pre-Kindergarten through senior year of high school. These partnerships were formed somewhat organically, by word of mouth based on need. For instance, an administrator or special education director would have a need for a student evaluation with certain psychological tests, often including tests measuring cognition or personality. However, no one on staff at the school would have access to or expertise in using those tests. The school personnel would then call members in nearby communities and ask contacts if they knew of someone who was qualified to conduct such evaluations. One call would yield the name of a person who knew another professional and so forth until I would eventually receive a call.

In my case, I was one of the very few licensed psychologists in the region who performed psychological evaluations. Typically, I was asked if I was licensed, had the qualifications to giver particular tests, and possessed the tests in question, before being asked how much I would charge for the service and how soon I could schedule. Over time, as other psychological evaluation needs arose in other schools in the region, one school personnel would call another school personnel with whom I had worked, my contact information would be passed on, and I would receive more opportunities to provide mental health supports in the schools. The work was largely psychological evaluations to begin with. However, over time one larger school district asked if I was willing to provide ongoing counseling services (in addition to evaluations) to supplement their growing mental health needs and support their school counselors and school social workers, to which I agreed.

Having served in this role of supplemental mental health service provider, both community private practice and university-based, I can attest to the challenges (and successes) of contracting to provide psychological services across a variety of school settings. My points of contact at the schools, once established there, were special education teachers, school social workers, and school psychological examiners. I have interacted with school staff members including special education and general education teachers, principals, and special education directors, as well as many parents/guardians and students. While I provided services within my competence area, the individual schools largely dictated the work that I did. For instance, one district contracted with me mainly to complete multiple cognitive assessments and functional behavior analyses. Another district contracted with me mainly for counseling. I carried a therapy caseload of 10-15 students and met weekly with the students throughout the school years. The other districts contracted for a variety of therapy and psychological assessments.

My contract work in the rural school setting afforded me a great deal of enjoyment, working with numerous individuals with interesting stories and needs, making friends with various professionals in the schools, and seeing my role in aiding students and families to lead better more fulfilling lives after providing a better understanding of present behaviors. However, the work was not without its difficulties. Finding time to meet with the student and the family, coordinating my schedule with theirs in and out of the school setting was a barrier. In addition, it was often difficult to find time to meet with teachers for interviews about the students. There was often no consistent, or even appropriate, space for me to meet with the student. Many times, my services were conducted in storage closets or other rooms that happened to be available at the time (and rotated from week to week). My therapy sessions were periodically interrupted, and confidentiality was compromised by staff ignoring the “do not enter” sign to get some materials. It was even difficult on many occasions to access the school building because someone had forgotten to remind the school secretary I was coming. I would have to regularly explain myself and provide proof as to who I was and why I needed to be allowed to enter the building. While safety is important and resources and space are limited, over time that sort of rejection, of feeling like an outsider or being reminded that one is an outsider, takes its toll.

Because mental health professionals from community-based settings often work in rural school settings, and because a model does not exist when contracting psychological services in the school, I would propose a few best practice considerations for future consideration. First, as always, communication is paramount. Identifying a central point person at the school who would act as a liaison between the school and the outside mental health professional would decrease the confusion and lack of cohesion in service scheduling. Ideally, this person, possibly the school counselor the vice principal, or some other professional, would email or call as needed to communicate information. Arriving at a time to meet with the parents, a time to meet with the teacher, and a time to evaluate the student is a large hurdle prior to actual service implementation. In addition, this point of contact would either meet me at the door or alert the secretary or school resource officer that I am an approved professional who can safely enter the building. Second, once in the building for the scheduled appointment, a consistent and appropriate space to conduct psychological services is very important. While I and the student can be flexible, it is not best practice to have therapy interrupted or psychological assessments moved from room to room. Acknowledging that space is at a premium in the school setting, it would be most helpful to be able to count on a particular location for psychological services, especially if ongoing therapy. Rapport building includes the safety of the consistent meeting space. A communication from the principal that mental health is important and that the space is reserved would go a long way toward legitimizing services in the schools. Finally, being provided with the needed documentation and school records (test scores, Individual Education Plan (IEP) meeting documents, etc.) is necessary for the contracting mental health professional to do their best work. This material can be obtained from the point of contact and be provided ahead of time for the best preparation. These considerations provide a beginning framework for best practice in mental health services delivered in the school by a non-school employee.

Considerations and Conclusions

To increase rural mental health care, it becomes important to increase community knowledge about the need for mental health, better training of rural health care workers to identify mental health needs, encourage more professionals to relocate to rural areas, provide more facilities to address mental health, and provide a breadth of financial options such as sliding fee scales (Kelly et al., 2020). To entice mental health professionals to want to work in rural schools and communities, they may benefit from building connections with educational centers. In some rural areas, building connections may mean with the rural school system allowing them to provide training and teaching options and foster collaborations and other opportunities for continued professional growth (Chandra, 2020). To increase the confidence of the rural mental health professional, Hilty et al. (2022) emphasized that rural tele-behavioral health was important to consider expanding collaboration between mental health professionals and for said professionals to more easily consult with other professionals for continued education or case consultation. Cultural competence in care was also required, including better understanding of treatment seeking expectations, cultural and historical mistrust of treatment, stigma involving diagnoses, and self-education regarding cultural factors that impact mental health care in rural settings (Hilty et al., 2022).

In summary, lessons have been learned over years of psychological service contract work. First, once initial contact has been made between the school and the outside service provider, it is important to establish a consistent point of contact for that outside service provider (Geraldo et al., 2024). For example, if the vice-principal is the point of contact, then that person should remain the one who schedules evaluations with the outside service provider, greets them at the door, arranges space for them to work, and any other needs. This way, the outside service provider will be able to more successfully support the school personnel and students. Second, a designated space in which to perform psychological services is imperative (Wolk et al., 2019). This is often difficult to procure, but a consistent, secure location with table and chairs for psychological evaluations or therapy allows the outside service provider to be better prepared to meet the needs of the student being tested or counseled. Finally, needed documentation related to student records is necessary to ensure accurate evaluation of the student (Frey, 2019). Past testing sheds light on current evaluation procedures. As previously noted, this information would most smoothly be provided by the point of contact in order ensure consistent information and communication. With increased collaborations, supports, and self-efficacy, more community-based mental health professionals may continue to be available for future support service in the rural schools. This in turn further supports the mental health and well-being of all students, which after all, is the goal of the school- and community-based mental health professional in the first place.

 

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