Preparing an entire city to respond to mental health emergencies

This article was originally published in The Notebook. In August 2020, The Notebook became Chalkbeat Philadelphia.

Jason Palaia, director of elementary and special education in the Coatesville Area School District in Chester County, recalls interrupting his walk across a high school campus to talk to a youth sitting on a curb who was obviously very distraught.

James Hills, a school board member who volunteers at an afterschool program in Coatesville, remembers counselors there overhearing two youths talking about possible suicide.

Barbara Bolton, a marketer and business developer, plans to volunteer at a local suicide hotline and wants to know more about the issue before starting there.

All three say they have seen the benefits for the Coatesville school district and the community to increase knowledge of mental health issues through the Youth Mental Health First Aid curriculum.

The curriculum is the focal point of a four-year, $630,000 effort by Coatesville’s school district, four foundations, and state, local, and federal agencies to increase community-wide awareness of behavioral health issues from school cafeterias to therapist offices. The training is basically the mental health equivalent of CPR.

Eventually, the project aims to train up to half of all school district personnel, plus other community members, using the eight-hour curriculum, says program evaluator Stacie Metz, an associate professor of social work at West Chester University.

Mental health first aid, which originated in Australia in 2001, has been used for years in schools and communities across the country. Coatesville is among roughly 115 school districts designated by the federal Substance Abuse and Mental Health Services to receive $100,000 in grants over two years for what are, in effect, saturation programs.

“We’re trying to create a culture,” says Frances Sheehan, president of the Brandywine Health Foundation, which heads the collaborative.

“We see this as a learning lab,” says Alyson Ferguson, director of grant-making for the Thomas Scattergood Behavioral Health Foundation, which started the effort along with Brandywine.

Ferguson says that working in a community the size of Coatesville, where the school district employs just under 1,000 people, allows for a controlled experiment that would not be possible in a city the size of Philadelphia, whose school district employs about 16,000.

“We do consider ourselves guineas pigs,” Sheehan said, jokingly.

Why Coatesville?

From the start, Coatesville was seen as an ideal target for the initiative.

The city has been economically depressed since the decline of the steel industry decades ago, and 53 percent of the students in its school district receive free or reduced-price lunches, a 10 percent increase from about a decade ago. About half the students are White, one-third African American and 15 percent Hispanic.

Although children in the city comprise just 2 percent of those in the county, they account for 29 percent of those involved with Chester County’s Department of Children, Youth and Families, according to the Brandywine Health Foundation.

Middle school and high school students in the district have reported depression symptoms at a higher rate than those in the county as a whole in the routinely collected Pennsylvania Youth Survey, and the gap has widened in the last two years. More than 41 percent of 10th graders and almost 37 percent of 8th graders reported feeling depressed.

“The community was ready and ripe to receive this,” says Brandywine’s Dana Heiman, who heads the youth mental health collaborative.

Hundreds trained

In the first year of the program, which started in June 2014, 321 people were trained in the Youth Mental Health First Aid curriculum. Just over half, 175, were school district employees, ranging from nurses, teachers, and mental health specialists to cafeteria workers and custodians.

The rest were members of the community at large, such as Bolton, a former teacher, who took the course before starting her work with the suicide hotline because “I wanted something more than my life experience.”

The philosophy behind the project is that knowledge of mental health should be widespread, at least in the school community and, hopefully, beyond that.

“It’s important that all people be able to reach out,” says Alison Distenfeld, a therapeutic support specialist who took the course. “The more people who take the workshop, the more people can help out. A student might be more comfortable approaching the janitor. A casual relationship might be safer.”

“We’re still in the early stages, but I do see a difference,” says John Reid, Coatesville’s director of pupil services. He reported cafeteria workers at a middle school noticing that one of the students was unusually withdrawn and reporting this to the administration.

“They said that a year ago, they wouldn’t have known what to do about it,” Reid says.

He says that, previously, Palaia might not have stopped to talk to the crying student he saw, although in that case it turned out to be a romantic issue rather than a mental health crisis.

The students talking about suicide, however, were apparently serious. A key segment of the training discusses warning signs, whether a youth is verbalizing it or not.

“If we don’t talk about it,” instructor Tracy Behringer told a recent class taking the training, “people are going to continue to die.”

Reid noted that the state is requiring suicide prevention training in schools starting with the 2015-16 academic year.

Looking for impact

According to the first-year evaluation of the program, a significant majority of those taking the course found it valuable.

Questionnaires given before and after the course found overall increases in participants’ confidence in recognizing and dealing with youth experiencing behavioral health challenges. Almost 80 percent said they would find the course useful in their workplace, whether in a school or elsewhere.

But members of the collaborative are also looking for specific improvements in areas such as responses on the Pennsylvania Youth Survey and increased referrals to local mental health providers, who have revised patient-intake questionnaire forms to help the evaluation.

Metz says they are still working on refining their evaluation methods: If Pennsylvania Youth Survey scores improve, for example, how will evaluators be able to determine how much of it is due to the Youth Mental Health First Aid initiative?

Or if referrals to social service agencies increase, how much can be attributed to this effort?

“We want to be able to tease out what’s happening with the referrals,” she says.

“Looking at all the different data together might give us a better picture of what’s going on.”