EdLab Podcast: Supporting Students' Return to School After a Mental Health Hospital Visit

Edited for clarity.

Audrey Breen: Welcome back to EdLab. When it comes to supporting students’ mental health, schools and communities provide a wide span of resources. But if best practices suggest we bridge school-based and community-based support, how do we do that, especially for students returning to school after a visit to the hospital for care during a mental health crisis? 

EdLab is a podcast of the University of Virginia School of Education and Human Development, where we talk to the people behind the school’s transformative research, innovative teaching, and thriving partnerships. In each episode, we aim to help demystify some of the big questions being asked in education, policy, health and human services. 

I'm your host, Audrey Breen. 

Today, I'm so excited to talk with Lora Henderson Smith, assistant professor and licensed clinical psychologist. Lora works at the intersection of clinical psychology and schools, which is how UVA first showed up on her radar, as it turns out. She's here today to share with us how schools and community organizations can work together to support the mental health needs of students. 

Welcome, Lora.

Lora Henderson Smith: Thanks for having me.

Breen: So, we typically start these conversations off with a question about your own journey. How did you get here?

Henderson Smith: Yeah. So, there are a few different things from my childhood that I can bring up. One of those being volunteering with the Special Olympics as a high school student. At that time, I was interested, I think, in being a developmental pediatrician. And then ultimately, I went to college and majored in psychology and really fell in love with that.

After college, I did Teach for America. I had always wanted to work with children, didn't think I wanted to be a teacher, but ended up in the classroom. And during that time, it confirmed that I did not want to be a teacher,

Breen: That’s helpful.

Henderson Smith: But that I really did enjoy working with youth, and the things that I enjoyed most were related to meeting students’ social-emotional learning needs.

I started to observe mental health challenges in some of my students, challenges that their families experienced, things in the community. And that led me to pursue a master's in counseling and mental health services. During that time, I really reflected a lot about how much I loved schools, and I was interested in clinical psychology, too, and became aware of the clinical and school psychology program here at UVA. So, I didn't have to choose between clinical or school. 

So, I started my training here in the program that I'm now a faculty member in, in 2013, and I've been a few different places, but ultimately ended up back here in a faculty position a few years ago. And so now I'm able to continue to pursue my love of all things at the intersections of clinical psychology and school psychology, while also, teaching and sharing what love with the students in our program.

Breen: That's so great. I'm so glad you're here. 

I'm really excited about this conversation and ready to dig in to hear more about your scholarship. Can you give us, sort of, a general overview and then we can dig into, I know, a couple of projects that really will sort of illustrate, I think, more of some of these questions you're asking.

Henderson Smith: So, my work is grounded in the Interconnected Systems Framework, which connects multi-tiered systems of support in schools with community-based services to meet students’ mental health needs. So, when I'm talking about multi-tiered systems of support, or MTS, that's tier one interventions or supports that all students get: the general curriculum, social emotional learning lessons, things that all students have access to.

At tier two, those are things that only some students get. So, small groups—maybe a small group for social skills or small group for executive functioning—for some students who need a bit more support. 

Breen: Got it. 

Then once we get to tier three, that’s students who are in need of more intensive, individualized services to meet their needs. Maybe one-on-one counseling with a school counselor or some other school mental health professional.

So that's on the school side of the Interconnected Systems framework. But on the other side, there are community-based resources. So, that could be a health system that the school partners with. That's a standard referral source for students who may need to visit the emergency department, or it may be a community-based, outpatient mental health care provider who the school or district is able to easily make referrals to for their students and families.

Sometimes that looks like a community organization actually coming into the school and providing individual counseling or group counseling services. So, it really kind of expands upon the services that schools are able to offer in terms of mental health services and supporting students’ overall needs when they're able to use this expanded framework that incorporates community-based resources and services into what they're doing.

Breen: In the context of some of these larger conversations about teen mental health, youth mental health, especially coming out of the pandemic, how do these, you know, the interconnectedness of these systems, benefit students? As we are all, I think, grappling with some of these questions about how to provide, care for youth and adolescents.

Henderson Smith: So, connecting systems proactively can help promote continuity of care for youth. So if a counselor or school psychologist or some other school staff member notices that a student is in need of services that go beyond what can be provided at school, it's great if they already have a starting point of, these are the community-based outpatient mental health care providers that we typically refer to, or these providers hold spots for our students. They've got X number of spots on their caseload for kids from our district. 

It's much easier to start from there than to have a student in front of you who needs mental health services, and you don't have a resource map or any connections or partnerships to help meet the student's needs. Then you're Googling, trying to figure something out. You don't know who takes their insurance, who maybe doesn't take insurance, who doesn't have availability or waitlist. 

But if you have existing partnerships, that can really help to facilitate the process. And we know that in this country, in our area, there is a shortage of mental health care providers. And even in areas like ours where there are a lot of providers, maybe some don't take insurance. And so that's a hindrance for some people in our community. 

So having established partnerships can provide, kind of standing referral sources to meet students’ mental health needs.

Breen: That is great. And we will return to the topic of partnerships a little bit later on. Can you tell us a little bit about some of the specific projects you're working on?

Henderson Smith: One line of my research focuses on supporting students returning to school after a psychiatric hospitalization. And so, we've got the schools side of things, they're at tier three. Those are students who need the most intensive services during a time of crisis. On the other side of things, they're coming from the hospital. And so, if we can create, open lines of communication sometimes that through memorandums of understanding or releases of information that can facilitate a more positive transition back to school for these students.

So, if schools connect with community resources, that makes everything better in terms of meeting these students’ needs. So, I have that line of work around hospital school transition. 

While doing that work, I realized that most students actually aren't hospitalized. The majority of them go to the emergency department and come right back to school. So, I have some work in that area too, where we're developing a training for school mental health professionals to develop skills and learn strategies for supporting that transition back to school. And so those are, they both span the school side and the community side, right. 

And then I have another line of community-based work with an indigenous community where we are developing an after school cultural learning program to promote overall well-being. And so that's on the community-based side of things.

Breen: Got it. Can you describe for me the difference between a hospitalization and an emergency department visit, what that typically looks like for a student?

Henderson Smith: Yep. So, for a hospitalization, it starts in the emergency department. They are typically referred by school or some other community provider. Or maybe their parents realize something isn't quite right and they send them to the emergency department or take them to the emergency department. From the emergency department, you're either discharged back home, admitted to the hospital, or maybe transferred if the emergency department that you went to is attached to a hospital that doesn't have an inpatient psychiatric unit.

Breen: Okay.

Henderson Smith: So, for an emergency department visit, you usually undergo a clinical evaluation where they determine if you need additional care or not. If you need additional care, you're hospitalized. If not, you're discharged.

Breen: Got it.

Henderson Smith: And discharge doesn't necessarily mean that you're not in need of mental health services. It's just that you're not in need of services that require a hospitalization at that point. But can still be in crisis.

Breen: Right, right. And that's where that network of community support is really important.

Henderson Smith: Yeah. And that's why my work really focuses on schools, because all kids are going back to school, even if they don't have an outpatient mental health provider or some other services in place, they're going to school. And so, we want to make sure that schools are able to meet these students’ needs.

Breen: What makes that period so critical and sensitive.

Henderson Smith: Yeah. So, when kids are coming back to school after an emergency department visit, it's a very sensitive time where we want to ensure their safety. We want to really promote social connections, identify strengths in the individual, in the family system, identify hopes for living to make sure that we're able to support the child or adolescent and their family during what can be a really scary and challenging time.

Breen: Could you tell us a little bit more about the trainings you're developing?

Henderson Smith: Yeah. So, for a while I was presenting at conferences on hospital-to-school transition and more recently emergency department-to-school transition. And during these sessions, I found that school mental health professionals always wanted more information and had lots of questions. So, we decided to develop some training so that they could get this information outside of the conference setting, and pretty much at any time they would want to receive it.

So, what we did, me and my graduate students, we developed trainings. The first one was on hospital-to-school transition and then as we talked about, learned more about this gap in services, an emergency department-to-school transition. So, we then developed a training around that, too. And both trainings followed the same type of format. They’re content-based training modules. They're hosted on canvas, where there are videos to watch. There's content to read and click through, questions to answer, to just kind of make it engaging. But we had these content-based modules that participants complete asynchronously on their own. 

And then the really novel piece is that we have a mixed-reality simulation, which is like a roleplay. So, the participants get on Zoom with a live avatar and they practice applying the skills that they learned from the content-based modules.

So, they're able to have a conversation with the student as they return to school after a mental health crisis. And it's really nice because they get to practice the skills that they learned in the training modules immediately, and they don't have to wait to apply those skills when they actually have a student in their office. So it’s a really nice time to just practice applying the skills that they've learned.

Breen: And I imagine in the real scenario there are, you know, it's kind of a high-stakes moment. And so having an opportunity to practice that with an avatar may provide just some chances to practice in a more low-stakes environment.

Henderson Smith: Definitely. And for our first pilot we've gotten some preliminary data back. And the majority of participants are reporting that the mixed reality simulation is helpful. They're a little nervous and not quite sure what to expect going into it, but on the back end, they say that it's helpful and that they would recommend it to a colleague and that it helped them to really consolidate the skills that they learned in the training.

Breen: That's cool. What are some of those skills that you're hoping they either develop or just expand on with the trainings?

Henderson Smith: Yep. So, we want them to understand the needs of students when they return to school. So, there are the academic needs, or the social emotional needs there, the ongoing mental health needs in terms of making sure they're getting the school mental health services that would be helpful to them but also providing them with maybe referrals or recommendations to community-based resources that could be helpful as well.

Breen: Got it. 

Henderson Smith: So, in the mixed-reality simulation, they're having a conversation with the student about their academic, social-emotional needs and about community and school-based resources and also doing some work around risk assessment—just kind of making sure that they're back on track, feeling good and safe to be in school and have a plan for if they do feel unsafe again.

Breen: That is so cool. Earlier in our conversation, you mentioned partnerships and I said we would return to the topic. Can you share a little bit more about what partnerships mean for you and your work?

Henderson Smith: Yeah, partnerships have been everything in my work. So, as I'm piloting these interventions with school mental health professionals in Virginia, it's taken partnerships to get the word out and to get participants. So, it was really important to be able to partner with the Virginia Association of School Psychologists, also the Virginia School Counselor Association. Both of those organizations were able to share information about the training to identify school mental health professionals who would be willing to participate. And so, without those partnerships, there would be no pilot of the work that I'm doing. 

On the other hand, my community-based work, I have a native led nonprofit Nis'to Incorporated that I've worked with to do different projects in their community. And being that I'm here in Virginia and that work takes place out in the Northern Plains region, that work would absolutely not take place without my community partners who are very engaged in recruitment. Even when we're doing programing, when I'm out there, they're engaged and picking kids up and bringing them in, feeding them and all of the different, important things that it takes when you're doing community-based work with children.

Breen: We do end the podcast with the same question. And you can sort of take this in whatever direction you want, but let's assume it's been ten years. We are back and we are having a conversation. What do you hope that you will know in ten years that we don't know?

Henderson Smith: So currently, there are no evidence-based practices or intervention to support students returning to school after a mental health crisis. So, in ten years, I hope to be able to share a list of evidence-based practices in intervention that school mental health professionals can use to support students during this really sensitive and critical period.

Breen: I'm so grateful for the work you are doing and when I hear that there is no evidence base about work that you are now pursuing, I really am grateful for the questions you're asking and the way that you are generating new knowledge and contributing it so that when we hit that threshold in ten years, we will have some real evidence of ways to support kids in areas we just aren't sure about right now.

Lora, thanks for spending some time with us today. I really appreciate you being here.

Henderson Smith: Thanks for having me. I'll be back in ten years.

Breen: Good. I will pencil it in.

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