Journal of School Psychology

41 (2003) 77 – 82

Challenges and opportunities in moving toward a

public health approach in school mental health
Mark D. Weist *
Center for School Mental Health Assistance, Department of Psychiatry,
University of Maryland School of Medicine, 680 West Lexington Street, 10th Floor, Baltimore, MD 21201, USA

Abstract

These three outstanding papers are important for the discipline of school psychology, the field of
school-based mental health, and more generally for systems of education and mental health for
children and adolescents. As the authors emphasize, there is an unprecedented focus on improving
programs that remove barriers to learning and enhance development, health, and mental health in
youth, in the most universal natural setting—the schools. The authors also correctly highlight that
school psychology is uniquely positioned to play a leading role in this reform and change effort. Two
interconnected themes of the public health approach—applying the evidence base and moving
toward preventive and population-focused interventions—are emphasized in these papers, and while
they focus on school psychology, the issues discussed are generalizable to the many disciplines that
operate within educational and mental health systems. In the following discussion, I react to the
papers’ two major themes, discuss realities that should be addressed for progress to be made, and
comment on their implications for school psychology.
D 2002 Society for the Study of School Psychology. Published by Elsevier Science Ltd. All rights
reserved.

Keywords: School-based mental health; Reform; Interventions

Applying the evidence base

In the child and adolescent mental health research literature, evidence-based practice
(EBP) has perhaps become the most dominant topic. In reflecting on the work that has
been carried out on EBP, Hoagwood and Johnson (this issue) write: ‘‘In some respects,
what may ultimately constitute the major contribution of these efforts will be photo-

* Tel.: +410-706-0980; fax: +410-706-0984.

E-mail address: mweist@psych.umaryland.edu (M.D. Weist).

0022-4405/02/$ - see front matter D 2002 Society for the Study of School Psychology. Published by Elsevier
Science Ltd. All rights reserved.
doi:10.1016/S0022-4405(02)00146-2
78 M.D. Weist / Journal of School Psychology 41 (2003) 77–82

graphic negative—the holes, gaps, and absences of knowledge that can shape future
research agendas’’ (pp. 3 –21). Indeed, while some progress has been made, in reality we
are in the early stages of research on EBP. A major issue that is well summarized by
Hoagwood and Johnson (this issue) is the significant gap between evidence-based
research and practice, and the reasons for this gap. As they present, scientific efforts
to develop criteria for EBP are seen as ‘‘an academic exercise with little applicability to
real-world concerns’’ for mental health providers (pp. 3 – 21). Further, the bias of
scientific research towards internal validity means that variables essential to implement-
ing programs in context are basically ignored. Hoagwood and Johnson (this issue) lay out
important research avenues on EBP to explore issues of context, to engage in two-way
adaptation of programs and the settings they are applied in, and to move from the current
primitive understanding of diffusion issues.
We are fortunate to have a local and national perspective on mental health in schools
and using the evidence base through a program that operates in 22 Baltimore schools and a
national center, the Center for School Mental Health Assistance (CSMHA) that provides
technical assistance and training and conducts research to advance the field. Both the local
program and national center reflect an approach that we term ‘‘expanded school mental
health,’’ involving partnerships between schools and community organizations to provide
a full continuum of mental health promotion and intervention services for youth in regular
and special education (Weist, 1997).
In our School Mental Health Program, for a number of years we have asked all
clinicians to build interventions based on evidence of positive impact, and through this
experience, we have learned how hard it is to use evidence-based programs. School-based
clinicians, whether they are school-employed professionals like school psychologists, or
staff from community programs (e.g., clinical social workers and psychologists) usually
operate in schools with insufficient levels of administrative support. This is particularly
true for staff coming into the school from community programs. Almost all formally
developed evidence-based programs are labor-intensive and require considerable resources
to implement. Adding demands of implementing these programs to clinicians who
typically have significant demands on them related to managing cases (see Strein et al.,
this issue) in a context where they may not even be able to access a copy machine, is a
recipe for (or perhaps guarantee of) poor compliance. An additional related issue is that
funding for ESMH has been tenuous at best, which has led to some reliance of the
programs on fee-for-service, which means negotiating significant bureaucratic demands, a
major barrier to clinical and preventive efforts and using evidence-based programs. These
experiences are consistent with emerging research that is documenting that for evidence-
based programs to be successfully implemented, significant implementation support, in the
form of training, technical assistance, and resources (to name just a few factors), is
necessary (Graczyk, Domitrovich, & Zins, in press). In general, such support is not
available to staff who work in schools, pointing to a major need for advocacy, policy
improvement, and resource enhancement.
At the CSMHA, we have completed a comprehensive literature review of evidence-
based programs that can be applied in school-based mental health (Schaeffer, Weist, &
Goldstein, 2002). Both our review and Hunter’s excellent review (this issue) emphasize
that while some progress has been made, the evidence base still has significant gaps (e.g.,
 M.D. Weist / Journal of School Psychology 41 (2003) 77–82 79

to address disruptive behaviors among high school youth). Further, viewing the evidence
base from the perspectives of formal programs developed for disorders is limiting. We
argue that using the evidence base means not only using manualized programs, but also
building interventions to reduce stress/risk factors, to enhance protective factors, and to
train youth in skills that have been broadly documented to lead to positive outcomes (e.g.,
relaxation, self-control, problem-solving). This approach helps to make EBP more user-
friendly, and is consistent with more flexible criteria for what constitutes EBP as discussed
by Hoagwood and Johnson (this issue).
In addition, there is often a significant tailoring agenda necessary for an evidence-based
program to be successfully implemented in the setting of interest. We are currently
involved in a project to tailor the Australian MindMatters program (a whole-school
approach to mental health education and promotion; Sheehan et al., 2002) for application
with suburban, rural, and urban youth in Maryland and Virginia. The tailoring agenda,
which is planned for six months, involves focus groups to more globally review and
provide feedback on the program and its operational details, and a steering committee to
intensively review and make recommendations for language changes. As we move to
expand evidence-based programs and enhance their use, research strategies for tailoring
need to be developed and refined, parameters for appropriate tailoring should be
established, and ongoing resources and technical assistance for tailoring by local programs
need to be amplified significantly.

Moving toward preventive and population-focused interventions

All articles in this special series present the promise of the public health approach and
the reality that we are very far from implementing it in schools or in any other setting in
the U.S. (see U.S. Public Health Service, 2000). This is related to the fundamental biases
that underpin how we approach mental health in this country. In general, training,
approaches, and funding are focused on disorders within individuals. With increasing
stridence, advocates for school-based mental health programs are calling for approaches
that are focused on environmental factors, and strengths in children, adolescents, and
families; however, research and practice is lagging behind the advocacy (Weare, 2000).
This is related to contingencies in both realms that promote a continued focus on disorders.
Much of the research in EBPs is disorder-focused, which reflects established paradigms
(e.g., measurement is biased toward finding pathology) and priorities of federal funders
and other sources. In practice, fee-for-service is the dominant method of funding child,
adolescent, and adult mental health care, with mental health diagnosis as the first step to
receive services. Furthermore, the status quo of disorder-focused research and practice is
promoted by training that emphasizes individual psychopathology and by the status quo
(we do what we are used to doing).
As highlighted by Strein et al. (this issue), these are issues that call for significant
paradigmatic change, and paradigmatic change is hard. An important opportunity to
escalate the pace of this change is through international dialogue, and this dialogue
often place aspects of the U.S. approach in negative contrast. For example, it under-
scores the fact that we really are very far from a public health approach in the U.S.,
80 M.D. Weist / Journal of School Psychology 41 (2003) 77–82

with the system better characterized as an ‘‘illness care’’ than health care system. The
World Health Organization’s (1995) model of health promoting schools, emphasizing
population-based health promotion at the base, and treatment for youth with serious
problems at the apex, is essentially inverted in the U.S. As a consequence, staff who
work in schools are contending with a flood of serious problems and crises, making the
implementation of preventive and health promoting services very difficult. We need to
look to examples from other countries such as Australia, Cuba, and many of the
Western European nations that are prioritizing broad mental health promotion strategies
for all youth in schools (Mrazek & Hosman, 2002; Rajala, 2001; Rowling, 2002). In
addition, there are a number of important international groups that are advancing this
dialogue, such as the Clifford Beers Foundation, the World Federation for Mental
Health, the International Union for Health Promotion and Education, and the Society for
Prevention Research.
Along with a consortium of people from the U.S. and other countries, we are working
to establish the International Network for Child and Adolescent Mental Health and
Schools, which will promote global dialogue on critical issues being confronted in the
school mental health movement as it advances around the world (Weist, Lowie, Lever,
Johnson, & Rowling, 2002).
Thus, international dialogue is critical to advance the paradigmatic change associated
with moving from an individual psychopathology perspective to a broad mental health
promotion perspective. Such dialogue should help to fuel advocacy, which will lead to
policy change, resource enhancement, improved capacity, and improved infrastructure for
evidence-based and health-promoting actions in the schools (Weist, 2001). Such advocacy
needs to take head on issues related to the way we finance mental health care, in particular
the issue of privatized public health services (an extreme oxymoron).
Another issue related to advocacy and policy change that receives almost no attention is
the increasing local control of education and health agendas for youth, leading to
thousands of experiments that often lack sustainability as leadership changes, ideas
become old (rapidly) and new ideas come into vogue (usually temporarily). This
contributes to a very complex picture in most communities and a lack of generalizability
even on basic issues (e.g., whether some professionals can receive third party payments).
Local variability makes the agenda to develop advocacy and improve policies particularly
hard. Learning how to be an effective advocate and policy change agent is generally not
covered in graduate training programs for school psychology or any other discipline in
mental health or education, but should be.

Implications for the discipline of school psychology

The three papers in this issue appropriately emphasize the important value and
advantages of the discipline of school psychology in advancing a public health approach
in schools. The discipline is unique in the way that it spans the education and mental
health fields. In our writings, we have emphasized that school-employed mental health
professionals, including school psychologists, are natural leaders for schools as they
develop partnerships with community organizations to expand and improve mental health
 M.D. Weist / Journal of School Psychology 41 (2003) 77–82 81

promotion and intervention programs (Weist, 1997; Weist, Evans, & Lever, in press).
However, as the Strein et al. (this issue) paper correctly observes, positions often constrain
school psychologists and other school-employed mental health professionals into roles that
discount many of their professional skills. As school and community mental health
professionals come together in this work, systematic needs assessment, resource mapping,
and collaborative discussion on who will do what, along the prevention continuum is
essential. Since community providers may have more pressure to fund themselves through
some level of fee-for-service, school psychologists are in an advantageous position to
focus on school-wide mental health promotion programs. But, as Strein et al. (this issue)
emphasize, for school psychologists to assume this important role will require strategic
action to free time from casework responsibilities.
Strein and colleagues (this issue) also observe: ‘‘As a scientific specialty, school
psychology has deep scientific roots. Yet school psychology practice often rests on
unexamined tradition’’ (pp. 23 –38). This commentary is relevant not only for school
psychology, but for all applied psychology disciplines, including clinical and counseling.
There is a clear need for interdisciplinary efforts that alter paradigms to focus more on
environmental factors, enhancing strengths and promoting mental health in natural
environments such as schools. Given the progressive development of expanded school
mental health programs, which bring community psychologists, psychiatrists, social
workers, and other individuals into schools to work closely with school-employed staff,
there are clear training needs to ensure that this system integration proceeds well. These
needs include training on interdisciplinary collaboration, working closely with school and
community stakeholders (youth, families, teachers, community members), and on under-
standing systems issues (e.g., for special education, community mental health; Weist et al.,
in press). As emphasized by Hunter (this issue), this training agenda should also include
teachers to both promote their acceptance and buy-in of mental health programs, and
to equip them to better handle emotional and behavioral issues that they confront in
the classroom.
Finally, issues of discipline-related tensions and turf cannot be ignored. We have
argued that community providers should never be brought into schools if doing so
threatens any position of a school-employed mental health professional. The term
‘‘expanded school mental health’’ is meant to convey that community resources and
services augment the very important work in mental health being done by school-
employed staff. And around the nation, there are growing examples of programs that are
effectively joining education and mental health systems and staff in the move toward
ESMH (Weist et al., in press). However, turf perpetuates. Strein et al. (this issue) provide
one example of this in the initial exclusion of school psychologists in developing criteria
for EBPs. Policies and practices by organizations, whether they be state or local
psychological associations, or national membership organizations that promote splintering
or competitiveness between psychological disciplines need to be reexamined and
changed.
The authors of the three papers are to be commended for their thought-provoking
dialogue that should help to propel needed paradigmatic change in the discipline of school
psychology, and to more broadly influence interdisciplinary mental health promotion and
intervention efforts in schools.
82 M.D. Weist / Journal of School Psychology 41 (2003) 77–82

Acknowledgements

This work was supported by cooperative agreement U93 MC 00174 from the Office of
Adolescent Health, Maternal and Child Health Bureau (Title V, Social Security Act),
Health Resources and Services Administration, with co-funding by the Center for Mental
Health Services, Substance Abuse and Mental Health Services Administration.

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