Helping the Helpers Address Youth Mental Health

ROBERT JOHNSON:
This is Public Health Review. I'm Robert Johnson.

On this episode: Wisconsin education and public health working together, helping frontline school staff with the training they need to improve student mental health.

JESSICA FRAIN:
We have the Resilient Wisconsin initiative, where we have public health officials that are helping to educate public sector workers, teachers, folks out in the field working with people and increasing their knowledge of trauma.

ALLISON BUDZINSKI:
We saw some great crossover, that there is a public health approach that is needed to support our educators, recognizing that they're the ones that are helping our youth and they then also need to be helped.

SHARON HOOVER:
We hear from teachers, "Please, don't just tell me to do more yoga or to just take better care of myself. You need to help shape the environment I'm teaching in to make sure it's less toxic and less stressful so that my well-being is taken care of."

JOHNSON:
Welcome to Public Health Review, a podcast brought to you by the Association of State and Territorial Health Officials. With each episode, we explore what health departments are doing to tackle the most pressing public health issues facing our states and territories.

Today: improving youth mental health by helping the people who work with our students—teachers, counselors and first responders all have a role to play. State education and public health leaders in Wisconsin are modeling an approach they call Helping the Helpers. Our guests are doing the work.

Allison Budzinski is the trauma and resilience coordinator at the Wisconsin Department of Health Services. Jessica Frain is a school mental health consultant with the Wisconsin Department of Public Instruction. Both are along later in the podcast.

But first, we hear from Dr. Sharon Hoover, co-director of the National Center for School Mental Health and a professor in the Division of Child and Adolescent Psychiatry at the University of Maryland School of Medicine.

HOOVER:
So, you know, we all know that our young people have had this great impact of COVID on them, really right along with the nation. But we've seen quite a big impact in terms of the mental health on K-12 students in particular.

So, when we think about our youngest learners, they've missed out on some of those key developmental milestones, especially their social-emotional development milestones, and so they're really struggling to catch up in the school environment. And then when we look at our adolescent population, many of them have missed out on some of those peer engagement opportunities and some of that individuation that happens as they become young adults. And so, we're seeing a mental health impact of those missed milestones.

But also, we know there's been a fair amount of mental health impact just because of that burden of COVID. Pre-COVID, we were also seeing some impact on mental health, and we were seeing a real worsening of mental health and adolescents—in particular with increased rates of suicidality and completed suicide, increased rates of anxiety and depression. And, unfortunately, those rates have only increased over the last couple of years.

JOHNSON:
How does that look in a classroom? What is it like?

HOOVER:
So, what we're hearing from our frontline educators is that, more than ever, they are seeing students with what we might call disruptive behaviors—so, it's disruptive to the classroom environment. They are not getting along with their peers, they are doing things that are disruptive to the classroom, whether it's walking out of class or being more fidgety—you know, when we think of as elementary students being more fidgety, not being able to attend to the learning environment.

But also, there are a number of reports of students who are just more withdrawn, socially isolated, what we might call internalizing symptoms. Those may be our kids who are suffering from anxiety or depression.

So, we're seeing teachers who are really struggling with how can they best teach the content, but also help the well-being of their young people who they see are suffering in the classroom.

JOHNSON:
Given where we are right now, do we need new approaches to this challenge?

HOOVER:
I think so. One of the things that we know is that when we have more people suffering as a whole in a population—and certainly in our child and adolescent population—we need to do what's called task shifting. And essentially, that means really having more helpers, right—more adults who can actually support the well-being and mental health of our young people.

I've heard the phrase, "We can't treat our way out of this COVID aftermath." And that really just speaks to the idea that there aren't enough child mental health specialists to provide treatment to every young person who may be suffering.

So, we need to take what might be thought of as more of a public health approach to what's happening right now, and really have mental health supports for more young people but provided by more adults and even peers in their environment.

JOHNSON:
What do you think of this idea of focusing on the education workforce, essentially helping the helpers?

HOOVER:
So, I love the expression "helping the helpers." And we can really think of that almost in two buckets.

There's one bucket, which really includes kind of better training, better equipping our frontline workforce—and that's our educators, our student support staff in the school building, even families—that we're equipping them with the tools that they need to both promote mental health and well-being in young people but also to identify and intervene when young people are struggling.

We need that because, again, simply there aren't enough mental health specialists, and we want to catch concerns early. And so, when we train our family members, our teachers, our students support staff to do that, we're much more likely to be able to identify and intervene at a point where we don't see the exacerbation or the worsening of symptoms. So, that's one bucket, right, that training and equipping.

The other bucket is really helping to take care of the mental health and wellbeing of the adults in our students lives, and we know that's important. There's actually a long history of research demonstrating that when our educators are unwell, when their mental health is suffering, when they're experiencing burnout, the students in their classrooms are much more likely to be suffering from things like anxiety and depression but also to be suffering academically.

So, we have to take care of the helpers, just as a mechanism for taking care of the students alone. Of course, we want our educators and our mental health workforce to also be healthy, but it's also a way to reach our students.

JOHNSON:
Is helping the helpers a new idea, or is it something that's been around for a while?

HOOVER:
The idea of helping helpers is not a new idea. There have long been efforts to support wellness. You know, there's Walking Wednesdays and Yoga Tuesdays, and there have been EAPs—employee assistance programs—around for a long time.

But what I would say is new is both the investment in this area of promoting well-being and mental health of staff. So, we've seen an expansion of EAP programs, we've seen really more systematic and universal approaches to promoting well-being of the adults in our young people's lives.

But there's also been a shift in focus, to add on to the focus of personal well-being, to really look at those organizational factors that contribute to the well-being of adults. And what I mean by that is, you know, we hear from teachers, "Please don't just tell me to do more yoga, or to just take better care of myself. You need to help shape the environment I'm teaching in to make sure it's less toxic and less stressful so that my well-being is taken care of." So, that's really the shift that we've seen more so in the last few years, really enhancing the personal well-being approaches but also expanding to include those organizational factors.

JOHNSON:
Later in the podcast, we'll hear about what's happening in Wisconsin between public health and education and how they're supporting their frontline education workers.

Is that sort of collaboration important?

HOOVER:
So, cross-system collaboration is absolutely essential when we think of the systems of care and support for our young people. We often say this needs to be a shared agenda. Nobody should hold on their shoulders the burden of young people's mental health alone. It shouldn't be the sole responsibility of families, nor of schools, nor the community mental health system. Really, everybody needs to play a role here.

And the same goes for training our educators. We have expertise within our public health and behavioral health systems for how to better support our adult workforce for how to reduce burnout. We need to be partnering to do that. And it's not just partnering in terms of training efforts, but really kind of taking a look at how do we finance and resource and staff these efforts, and where their points of intersection where we can kind of leverage the systems to support one another.

JOHNSON:
According to what you know about the work going on in Wisconsin, what do you like about it?

HOOVER:
So, Wisconsin has been a real exemplar in terms of helping the helpers. They have long—actually pre-COVID—they have really attended to this idea that we need to support the well-being of our educators and our school staff, and that this is a mechanism for supporting our students. They've used tools, compassion, resilience framework to support educators for many years now. And so, a lot of states have looked to them as a real exemplar for that.

They've also done a wonderful job of cross-system collaboration. And that's not easy, right? We have different funding buckets. We have different missions of these organizations. But Wisconsin has been very intentional, for many years now, about getting groups together, sitting down at the table, and figuring out how to partner on some of these efforts.

And at the kind of ground level—in the school building, for example—they've done a really nice job of having community behavioral health partner with schools to come in and to augment some of the supports that they offer to students in the school building.

JOHNSON:
Are there any other examples of collaboration that you've been keeping an eye on around the country that you think are worth mentioning here?

HOOVER:
So, there are a number of states that we've seen really expand in terms of their comprehensive school mental health systems.

Colorado has long had a statewide framework for school mental health that many states have turned to.

Massachusetts has been a wonderful example of both kind of ground-up and then top-down approaches to coming together to support student mental health. They have what's called the Massachusetts School Mental Health Consortium, or MASMHC, where they have districts all come together and share best practices. They also have a lot of state grants that go out to support districts for the whole multi-tiered system of student supports in schools.

So, there's a number of states that are doing great work and a number of local districts doing great work as well.

JOHNSON:
What about roadblocks barriers or obstacles? Are there any you can think of?

HOOVER:
One of the things that we know is really important, especially now, is partnership with families in this work. Sometimes, there's a misunderstanding that schools are trying to take over the mental health or the values of family systems when we talk about comprehensive school mental health systems. And we have long said that school mental health needs to be done as a family-school-community partnership.

When we ask most families, most parents, "Do you want your children to be learning social emotional skills in the school as well as at home," they say yes. But they want to be informed about it, they want a seat at the table. They want to be a part of kind of the planning, the implementation, the evaluation. So, one of the opportunities—but also a challenge, if not done well—is that partnership with families.

We also know that the workforce is a real issue right now in terms of just finding specialists to support the mental health of young people. So, there's a lot of workforce pipeline efforts that are going into place right now. We're also seeing a lot of educators and behavioral health providers leaving the field, so we have to contend with that burnout—that attrition—in the field by really supporting our workforce.

JOHNSON:
Last question: do you think it's possible to help our students get better without a strategy to help our education workforce?

HOOVER:
I would say no. I think if we don't attend to both, that training of our broader workforce to really support the mental health as a whole and promote well-being among students and also take care of our workforce—that is, do the things that we need to do to support their personal well-being and create environments, whether it's school buildings or behavioral health systems, that promote their mental health—the young people are going to suffer. So, we have to both train and take care of the well-being of our workforce for our young people to do well.

JOHNSON:
Allison Budzinski experience includes work in child welfare and juvenile justice. She coordinates the Resilient Wisconsin initiative for the Wisconsin Department of Health Services.

BUDZINSKI:
Resilient Wisconsin is a statewide initiative with a vision to help the helpers. So, the initiative recognizes that there are professional helpers—like social workers and first responders and our educators—but that we also have a lot of informal helpers and caregivers across the state that might not have professional titles but are in those helping capacities.

And so, Resilient Wisconsin wants to provide education, training, resource development, and kind of offer some cross-system collaboration that focuses on helping these helpers by implementing trauma-informed care principles and practices at the individual level, but also the system level of truly how our state operates. So, we want to look upstream, prevent trauma before it occurs, while at the same time addressing those impacts of our vicarious and secondary trauma as helpers, normalizing help-seeking behaviors of these helpers, and that it's okay to ask for help even if you're a helper.

JOHNSON:
Tell us why the school workforce is part of this initiative.

BUDZINSKI:
Yes, so, Help the Helper. That vision really aligns with so many different partnerships in our state. So, specifically with the Department of Public Instruction, we saw some great crossover, that there is a public health approach that is needed to support our educators, recognizing that they're the ones that are helping our youth and they then also need to be helped.

So, in Wisconsin, Resilient Wisconsin really focuses on our data from the Behavioral Risk Factor Survey. And in this data, we see that 60% of Wisconsin adults report at least one adverse childhood experience prior to the age of 18. So, these are our teachers, these are our educators that, you know, they have their own trauma histories and their experiences with trauma. So, we need to make sure we're helping them in their stories to then serve others as well.

So, we want to support all Wisconsinites, specifically finding those partnerships that support helpers, like Department of Public Instruction.

JOHNSON:
What would you like to see come from all of this work?

BUDZINSKI:
I think we're hoping to build community awareness and buy-in that our helpers also need help. And that really is kind of a call-to-action for communities to recognize the incredible influence our educators have on our youth, and that we need to kind of battle all signs of burnout and signs of secondary trauma and stress for our educators to ultimately build a strong community where they can support our youth in the classrooms.

JOHNSON:
Can you give us an example of how this collaboration is playing out in Wisconsin?

BUDZINSKI:
Yes. So, the Wisconsin Department of Health Services partnered with the Wisconsin Department of Public Instruction as part of the ASTHO school behavioral health learning community. And this learning community gave us an opportunity to also invite partners from other state agencies, other associations and councils, our partners at the Wisconsin Office of Children's Mental Health and our Department of Children and Families, and actual professors and educators that are kind of in the field.

So, bringing everyone together in one room was kind of that first step that helped us have these conversations and break down some silos. That we are all doing such great work already, so how can we kind of tap into one another and really rally behind the workforce of our educators.

So, through these site visits with ASTHO, two goals really emerged. One was to prioritize the staff and organizational well-being for current educators while also the recruitment efforts of educators for our future. So, how do we recruit a diverse group of professionals, and really support them in their mental health literacy in a non-clinical sense as they enter the education workforce.

JOHNSON:
Obviously, you're talking to educators and people who work in schools as part of this initiative, but you're also talking to first responders. Tell us why.

BUDZINSKI:
Yes, the Wisconsin Department of Health Services really launched Resilient Wisconsin with a first responder priority because we work alongside the overdose data to action team within the department, and this incredible team is committed to comprehensive and upstream prevention of the drug overdose epidemic.

So, it was really great to tie in how first responders are the frontlines of this epidemic—in addition to the pandemic—and how do we really elevate the profession of first responders, to know that it's not selfish for them to ask for help, for them to take breaks, and that we need to do all we can to fight signs of burnout and recognize the secondary traumatic stress of our first responders that are responding to kind of dual pandemics at this time.

So, that really began the conversation around helping the helpers that has now expanded into other helping roles like our educators.

JOHNSON:
What's going on with the project right now?

BUDZINSKI:
So, the specific work with the ASTHO learning community is in the early stages. So, we're in the stage of conducting a landscape assessment right now of what are the strengths, what are the challenges that school administrators are seeing in their schools. And what we can do next is take from those success stories and see is there something that's working that we can help duplicate, that we can champion. And really build perhaps some resources, some toolkits, and some assistance around that for other schools to take on similar work.

We're also trying to identify what are the big challenges and how can we offer some support to schools to tell their stories to their communities and to their school boards of what they need to better support the educators to then support the students. So, just a lot of storytelling and brand building for our schools, I think, is a big goal that will come from this learning community.

JOHNSON:
Do you think your work could become a model for other states and territories?

BUDZINSKI:
I definitely think so. I would love for Resilient Wisconsin to be this example that other states can turn to and look to replicate and see how a statewide approach of building a state that helps the helpers. And, you know, develops trainings and resources and just truly awareness building on what are adverse childhood experiences and how does that tie into the way I operate and navigate the world with my own trauma history. And then, also in my helping profession, how the vicarious and secondary trauma impacts the way in which I operate within the world.

So, just starting there and building those, you know, core foundational understandings of trauma and toxic stress can really take a state in a lot of incredible directions to build a more trauma-informed state.

JOHNSON:
ASTHO has been working with you on some of this. How important is that collaboration to the success of the project so far?

BUDZINSKI:
It has been critical. It has brought in so many different organizations and voices into one room to really agree and kind of head down a road of workforce well-being as the starting point. So, that involves kind of that educator piece, hearing the voices from our schools, and then also the state agency piece. So, how do all state agencies kind of rally behind educator workforce and how we can all contribute and tie to it even if we're not part of the Department of Public Instruction?

So, having ASTHO come and have us all in one room and facilitate conversation and offer that technical assistance has really gotten the work started in a new way.

JOHNSON:
Final question: why is it important to support the people who help our kids?

BUDZINSKI:
I think what was really impactful is, when we first started these conversations with ASTHO, a question of what would the headline be saying about this program in the future. And one of our learning community participants wrote in the headline of, "Regulation starts with adults. Teacher mental health is student mental health."

And this post, I think, is the heart of what we're doing. And what all states probably need is kind of a step back. And let's focus on the workforce first, and supporting them and rallying around them. And that will then help our school behavioral health model and help our youth and their mental health.

JOHNSON:
Jessica Frain is with the Wisconsin Department of Public Instruction. She's working to help schools in her state implement a comprehensive mental health system.

FRAIN:
We've known for a while that most young people are receiving mental health services at their school. And the difficult part about that is that schools rarely employ an actual clinician in their building. So, when we're talking about mental health services and supports, we're really talking about, you know, some of those universal supports. Some of those supports that are just kind of promoting well-being and supporting students, and less about that clinical side of things.

And what we also know is that youth mental health has really—there's been a lot of struggles, even pre-pandemic. We've seen a lot of increase in challenges. And then post-pandemic, and as we are moving forward through these increasing challenges, we're seeing that there's more and more needs in the community and with our young folks. So. there's just this increased need to really ensure that the adults that are around the children every day are equipped to handle some of these increased needs.

JOHNSON:
And the pandemic obviously did not help.

FRAIN:
It had a huge impact. In Wisconsin, we did some outreach and research to hear from students and from the young kids themselves, just asking how the pandemic impacted them. And what we learned was that there was an increase in depression and increase in anxiety. There was that increased sense of isolation—which is, I'm sure, as adults we can understand all of those things.

And we did also see some positive pieces. We saw that there was some resiliency factors. The pandemic also, you know, pushed some students to reach out to adults more so they they were able to identify they had one trusting adult. You know, they did more self reflection, that sort of thing.

But I'd say overall, we really saw a lot of the problems just exacerbated by the pandemic. And we're still seeing the impact of that.

JOHNSON:
Your department is education, and education in Wisconsin is collaborating with public health. Tell us how that's going.

FRAIN:
Yeah. So, you know, traditionally, in Wisconsin, we've always supported, you know, how we can increase school mental health services. And as somebody who works at the state agency, I've seen that and how that's developed over the years. And in the last year particularly, we have shifted how we're thinking about those services.

So, instead of just thinking about them in the silo of a school setting, we're really pushing districts to start to adapt to this more comprehensive school mental health system. And what that means is it's not just looking at how we're serving students within the building, within the school building or the district. We're looking at how we're collaborating outside of the district, how we're looking at community efforts, and how that we can start changing the way that we're even thinking about mental health.

Traditionally, when we think about, you know, school mental health services, we're thinking really only about treatment services, and we're trying to expand that. We're trying to show that mental health can be looked at as a community asset. You have a mentally well community, you're benefiting the entire community.

JOHNSON:
Talking about branching outside of the school environment, what does that look like and how is it working so far?

FRAIN:
What we see is public health folks really helping to increase mental health literacy of staff. So, that could look like, you know—in our district, we have the Resilient Wisconsin Initiative, where we have public health officials that are helping to educate public sector workers, teachers, folks out in the field working with people, and increasing their knowledge of trauma, how trauma impacts humans, how it impacts the brain brain development, how that in turn impacts behavior and mental health.

So, by increasing some of that knowledge, we're really helping to better equip some of the folks that are working directly with students in particular. So, that's one great initiative, is just helping to increase—fill the gap where a lot of our teachers who work with students every day don't have that background knowledge. They didn't get that in their program prep.

So, by having this partnership with public health that can step in and fill that gap, it's been a major success. They can also find other ways to partner with the school and help to build different collaborations to increase access to different resources in the community. So, a lot of times schools are relying on their school social worker to connect families to resources.

Well, what we know is that the social worker to student ratio is very, very low. It's recommended we have one social worker to every 50 students. Right now, we're looking at one social worker to every 1,130 students. So, we're very far behind. So, we can't be relying on these single folks to be doing that work.

So, the more we can collaborate with people in the field doing that public health work, the better. And that can, like I said, that's going to look different in every community. But we're really seeing a lot of great initiatives coming out from this work.

JOHNSON:
It seems like every time we turn around, we're asking our teachers to do more. How are they reacting to this idea?

FRAIN:
You know, it's hard. We get a lot of requests from teachers who are asking for this help because they don't have a choice. They're the frontline workers. We have these mental health professionals in the schools, but they're doing so many different things that it really comes down to the teachers having to be that frontline worker for students in mental health crises.

So, in Wisconsin, we do have a lot of these initiatives—different, like I said, mental health literacy opportunities. We have youth mental health, first aid training, lots of different things to kind of bring teachers up to speed on some of those basics—mental health 101, how to have these conversations.

But to go back to your question, do they have the space and capacity for that? So, that's kind of where we're trying to shift to systemic change here. Shifting the way we're approaching education to start to really incorporate some of this mental health, some of these initiatives, into what we're doing. This requires a system shift. It doesn't require adding more to our teachers' plates.

We're starting to look at partnerships with our higher education agencies, our colleges and universities, who are preparing our teachers and our teacher prep programs to really start partnering there as well, and starting to really rethink how we're going about how we're finding these services and how we're not burning out our teachers by adding to their plates. Because while they need these supports, it's still more work on them. And we need to be really careful about how we're supporting that from a top-down type lens.

JOHNSON:
And what about the reaction to the overall effort? How would you characterize it? Is it going well?

FRAIN:
We have public education, and then we have public health. Both are doing amazing work. Both have very similar goals, missions, values. Everything seems to be 100% aligned, and everyone wants to work together, nobody wants to work in silos anymore. Everyone shares that same drive to connect and collaborate.

The difficulty is that we're missing this connective tissue. We're missing the common language and the navigation materials and resources to actually learn how to connect and work together. Because these are two well-oiled machines that have been running on their own forever, and now we're asking them to load together and work on initiatives together. And it's really just a matter of learning each other's language, learning how we're functioning.

So, I am very hopeful that with patience, and with time, and continuing to just collaborate as best we can, we're going to start to learn each other's—how we're managing this, how we can actually connect, you know, their status quo. So, it's hard when you're trying to bring in a whole other entity into a structure that's just been going and going for so long.

So, there's definitely challenges. But I think what matters the most is that those challenges have nothing to do with the main purpose, right. Everybody's aligned. So, that's why I'm hopeful that with time and with patience, it'll run smoothly at some point.

JOHNSON:
Finally today, give us your best argument for this kind of collaboration.

FRAIN:
We know that a lot of our students—most of our students are receiving their mental health support in schools. And what we've seen in the last year is a lot of our educators—this is one of the highest dropout rates we've seen. We have a lot of educators leaving the field, the most we've had in a couple of decades now.

So, it's an issue. And this is a huge issue because, right now, that means that those students who are receiving that support in schools are lacking the folks that are there to give them that support. So, this is a serious issue that's impacting our youth today. And if we don't address this at that level, then that's where we're going to see the issues happening—at the student level.

So, my argument for that is just that if we don't start addressing the systemic change that needs to happen to empower our workforce, to provide them with the wellness materials they need, for the education they need to deal with this serious issue that's at hand, then we're going to continue to see folks leaving the field and that's only going to create more of the pattern we're seeing in the decline in youth mental health.

JOHNSON:
Thanks for listening to Public Health Review.

If you liked the show, please share it with your colleagues on social media. And if you have comments or questions, we'd like to hear from you. Email us at pr@astho.org. Once again, pr@astho.org. Also, you can follow us using the Follow button on your favorite podcast player.

This show is a production of the Association of State and Territorial Health Officials.

For Public Health Review, I'm Robert Johnson. Be well.