Bringing Effective Mental Health Care to Students
Elizabeth Koschmann, Ph.D., is the director of the TRAILS program at the University of Michigan and assistant research scientist in the Department of Psychiatry at Michigan Medicine.
Can you share a little bit about TRAILS and what led you to create it?
KOSCHMANN: TRAILS (Transforming Research into Action to Improve the Lives of Students) launched in 2013 in response to a call for help from several Ann Arbor area schools. Mental health staff at these school knew how to form relationships with students, but they were overwhelmed by the severity and volume of mental health concerns students brought with them into the schools each day. The TRAILS model, built entirely to address this community need, initially trialed in three Ann Arbor schools involving six mental health professionals and 24 students. Statewide expansion efforts kicked off in 2017 and evolved further with an NIMH-funded research study, which brought the program to 145 schools. Today, more than 2,800 school staff and mental health care providers have attended TRAILS trainings, bringing the program to 370 schools, and impacting an estimated 90,000 young people in both school and clinical settings.
Every aspect of TRAILS is grounded in empirical evidence and best practice. TRAILS equips school staff to use cognitive behavioral therapy (CBT) and mindfulness techniques with the strongest research support for reducing symptoms of depression, anxiety, and PTSD. The TRAILS training model itself is comprised of mechanisms identified by implementation scientists as essential for promoting treatment fidelity and long-term sustainability: didactic instruction and follow-up coaching from a treatment expert. TRAILS core programs include three tiers: tier 1 – social emotional learning (SEL) for the classroom environment; tier 2 – early intervention to be delivered in small groups or individually by school mental health professionals; and tier 3 – suicide prevention. Finally, all TRAILS materials are developed by a team of U-M master’s- and doctoral-level clinicians, as well as two senior MD psychiatrists.
Why is it important to have TRAILS in schools?
KOSCHMANN: Among youth ages 10-24, suicide has become the second leading cause of death, killing 10,000 young people annually. Despite the critical need for behavioral health care, access to effective treatment is riddled with difficulty. While TRAILS seeks to reach all students, families contending with poverty or living in under-resourced communities face extraordinary barriers to effective care: a shortage of providers trained in evidence-based treatments; inadequate insurance coverage; lack of time and transportation to attend appointments; and a stigma associated with seeking clinic-based treatment. As a result, the vast majority of youth with emotional or behavioral health concerns never access effective care. This lack of treatment has profound and well-documented adverse consequences that disproportionately affect low-income and minority youth, as well as youth in rural communities that lack sufficient local healthcare providers.
School health professionals (school psychologists, social workers, counselors, and nurses) are uniquely positioned to identify students with mental illnesses early and provide prevention and intervention services. Among students who do access mental health services, more than 75% receive those services exclusively in school; and most school mental health staff report that they provide mental health care to students both individually and in groups. The TRAILS model supports this delivery of care to reach students in need.
Recognition that schools are ideally positioned to provide mental healthcare has led to development of many school-based service delivery models. However, these models almost universally rely on contracts with external clinicians who come to the school to provide treatment. This creates long-term dependence on outside funding sources and stakeholders, and perpetuates many of the same barriers observed in community-based care: not enough providers, limited expertise in evidence-based practices, and social stigma that deters many youth in need. TRAILS builds the capacity of salaried school staff who are already working in schools to deliver effective student services.
What are some successes you have seen so far?
KOSCHMANN: Today, more than 2,800 school staff and mental health care providers have attended TRAILS trainings. This has brought the program to 370 schools, impacting an estimated 90,000 young people. TRAILS continues to look for ways to increase capacity: in 2019, TRAILS received more than 250 requests for programming from schools across the country.
Materials, resources and trainings developed in response to COVID-19 saw an enormous increase in traffic to TRAILStoWellness.org. Page views from April 1 to May 31, 2020 were 165,721, a 250% increase over that same time period in 2019.
Evaluations of TRAILS, including data from 1000 students and 200 school professionals currently participating in a statewide clinical trial funded by the National Institutes of Health, demonstrate that school staff show increased knowledge, skill, and utilization of CBT and mindfulness; while students show increased utilization of adaptive coping skills and improvement in symptoms of depression and anxiety. Additionally, program participants consistently report that TRAILS is the most impactful and relevant school mental health program available, and that the resources are unparalleled. A proven track record of rapid program expansion and successful replication across Michigan lays a clear path for what TRAILS hopes to focus on next: national expansion.
How has COVID-19 impacted the work that TRAILS does in schools?
KOSCHMANN: In short, virtual groups/meetings replaced in-person groups that took place at schools.
In surveys submitted by school partners, it was clear that self-care was needed for school staff and mental healthcare providers. These two groups were put in a uniquely difficult position during COVID-19 school closures. Many were experiencing unprecedented professional challenges as they prepared and delivered remote lessons, made contact with students and families, navigated unfamiliar technology, and helped their students cope. Simultaneously, many school staff and mental health providers themselves were experiencing stress related to personal difficulties brought on by health risk or illness, shelter-in-place orders, loss of social connection, loss of financial stability, or competing demands of friends or family. For some, grief and traumatic stress were significant. TRAILS found that in addition to providing materials, resources to be used with students, the program also needed to take a step back and provide training and materials for staff and community partners to make sure they had the tools to take care of themselves while also serving students.
TRAILS understands that moving forward, strategies will be needed that are responsive to individual community needs. Some partner districts have faced massive local trauma and grief and staff will need focused, ongoing professional development and self-care support. Other districts may not need this as much. ALL districts will need significant support to develop strategies for supporting students, especially in a virtual-only return to learning scenario. In heavily impacted districts, students will have high rates of grief, loss, PTSD, depression, and fear. In relatively low-impact communities, students will still have high rates of anxiety and depression. In all cases, productive learning will require structured social-emotional supports for students. Teachers and support staff will need training, resources, and consultation support. Significant educational time will need to be devoted to SEL and processing, as well as learning how to move forward with continued uncertainty, risk, and loss.
How have you shifted amid the pandemic to continue providing services
KOSCHMANN: TRAILS spent much of March and April adapting existing materials and resources to enable virtual delivery of student support services during recent school closures. These tools are publicly available for free on the TRAILS website, www.TRAILStoWellness.org. TRAILS also offered several free trainings for school staff and mental health providers during this unprecedented time, drawing more than 2,000 registrants. Webinars focused on SEL lessons that teachers could offer to students virtually as strategies for coping with anxiety and depression, and techniques for self-care.
Prior to the pandemic TRAILS was conducting a small pilot of SEL materials with about a dozen teachers in Washtenaw County. When Washtenaw County schools transitioned to online learning, it was recommended that SEL be included within the online curriculum. Acknowledging this additional need, the TRIALS Clinical Team focused on making the full curriculum (20 lessons in the following grand bands: K-2; 3-5; 6-8; 9-12) available to additional partner districts within Washtenaw County and offered a free training on the new materials. More than 150 teachers in the county took part in this larger pilot group. TRAILS is now working closely with these teachers to gather feedback as part of a continual improvement process.
TRAILS also stays in close communication with school partners to ensure that materials, resources and trainings are meeting their needs. By periodically surveying partner districts and maintaining avenues of open communication, TRAILS is able to respond to current needs and identify future opportunities for support. These strong communication lines will be critical as fluctuations in the disease will continue to alter learning platforms.
Do you think the pandemic is taking an additional toll on students who rely on mental health services?
KOSCHMANN: Over the last decade, the United States has been overwhelmed by a public health emergency: skyrocketing rates of child and adolescent mental illness, with only 20% of those affected able to access treatment. Today, a second public health emergency has amplified the crisis: COVID-19 closed schools nationwide and cut off millions of students from critical support services, exactly as they are experiencing higher levels of trauma, anxiety, depression, and isolation than ever before. No one can predict the toll this will take on the mental health of young people, but we do know that when schools reopen, they will be facing a massive crisis.
For kids with depression/anxiety – teens in particular – the best treatment is to find a way to make days productive and filled with ample social engagement and physical activity. The pandemic negated many of these types of opportunities, so making sure students stay connected to mental healthcare in some format is vital.
While they don’t have access to in-person groups, TRAILS is working to ensure all school partners have the necessary support they need to run their groups virtually. Early in the pandemic, TRAILS also provided 20,000 printed resources to partner districts in Washtenaw and Wayne counties to be distributed at food pick-up sites.
A silver lining to this unprecedented time is that major social cultural inequities in healthcare access due to transportation, stigma, and scheduling are no longer barriers as we are normalizing virtual delivery of services that make it more accessible universally.
You were named to Governor Gretchen Whitmer’s COVID-19 Return to School Advisory Council. Were you excited for this appointment?
KOSCHMANN: Yes! Excited, honored, and deeply grateful to have this opportunity to serve on the advisory council alongside so many brilliant individuals.
I’m inspired by the level of expertise among the council members — epidemiologists, physicians, legislators, educators, administrators, and even a student representative. Every single person on the council is working hard and tackling tough questions. We’re working in a truly collaborative manner toward the common goal of helping Governor Whitmer solidify a plan that is safe, feasible, and responsive to many competing priorities, and above all, promotes equity across Michigan’s many diverse communities.
With the diverse representation on the advisory board, I’m confident that we will be able to look outward across the landscape of the entire state, understand that no two families face the same challenges, and advocate for what is best for the state as a whole.
What is your role on the council? What are the objectives of the council?
KOSCHMANN: The advisory board is a diverse group of 25 individuals, including leaders in healthcare and education, state policymakers and legislators, and community members, who will work closely with the governor to help ensure a safe and appropriate re-opening for schools across Michigan. The advisory council meets regularly to discuss strategies to enable a safe, equitable and efficient return to school.
As chair of the wellness and mental health subcommittee, of particular focus for me will be access to mental health supports for students and families across Michigan, especially those in areas that have been disproportionately impacted by negative social determinants of health and lack of equity in healthcare access.
The advisory board will be working towards a return-to-school plan that is responsive to many competing and interconnected challenges: promoting safety in a way that is feasible; ensuring families have the resources they need in a variety of possible scenarios; accommodating students with special needs; creating a plan that can be adapted as new information becomes available and Michigan moves between the 6 safe start plan phases. And fundamentally, promoting equity to ensure that those already facing the most significant hardships – such as poverty, housing and food insecurity, or local community violence – are not disproportionately impacted by school-related protocols and policies.