School mental health services in Ontario follow a tiered model of support that capitalizes on the excellent positioning of schools for mental health promotion, prevention and early intervention services. While mental health promotion is good for all students (Tier One), a smaller proportion of students will require prevention and early intervention support (Tier Two). Fewer still will require more intensive or specialized assessment and therapy (Tier Three).

At Tier Two, students who are at risk and/or showing signs of emerging or escalating mental health concerns can access school-based prevention and early intervention services. This level of service provides more opportunities for individualized skill development and psychotherapeutic support than are possible within school- or-class-wide mental health promotion initiatives.

What the research tells us

• A range of Tier Two psychotherapeutic approaches have been shown to be effective in addressing mild to moderate mental health concerns among children and youth.
• Techniques related to Cognitive Behaviour Therapy, Motivational Iinterviewing, Acceptance and Commitment Therapy and Dialectical Behaviour Therapy have been particularly identified.
• Brief, goal-focused interventions are most appropriate for the busy school setting. Ideally, school mental health professionals would provide fewer than six sessions at a time, inviting the student to return if needed, or referring on to community-based mental health services. Longer, more intensive therapy is best provided in a clinical environment.
• In school mental health, psychotherapeutic approaches and related techniques have to be introduced flexibly, drawing on clinical judgement and aligned with student needs, strengths and preferences, within the context of a therapeutic relationship.
• Psychotherapy is a controlled act in Ontario, meaning that it can only be provided by a regulated health professional such as a psychologist, social worker or registered psychotherapist. However, many other school professionals play an important role while a student is engaged in psychotherapy .

Why this is important

Schools are well-positioned for prevention and early intervention services. When students seek help early at school, they can quickly get their needs met and can experience better mental health. To optimize this promise, brief, high-yield, responsive approaches need to be prioritized. When brief evidence-informed techniques are used, more students can access services, achieve their immediate goals and return to learning. Students who have created a positive connection with a mental health professional at school and experience a positive outcome can feel confident about reaching out for help again in the future when needed.

Roles

In a robust system of care for child and youth mental health, role clarity is important. The work within schools across the multi-tiered system of support is outlined in the resource document Every Student, Every School.

Within Tier Two, prevention and early intervention services are delivered by regulated school mental health professionals (registered with a professional college) who are trained to:

• Assess student needs to formulate an intervention approach for the student and their family to consider.
• Provide brief, evidence-informed interventions for students experiencing mild to moderate mental health problems.
• Offer guidance to school staff on how to support students within classroom and school environments.
• Help students towards additional needed services, as appropriate.

Every school board in Ontario employs regulated school mental health professionals. The responsibilities associated with these roles can differ between boards, depending on local structures and practices, but broadly speaking, these professionals and the services they provide may include:

School social workers provide brief evidence-informed, culturally relevant and identity-affirming individual and group therapy, engage in measurement-based care, provide consultation to school staff related to evidence-informed practices to support students, collaborate with parents/caregivers and connect students and parents/caregivers with community resources as appropriate.

School psychologists/psychological associates conduct psychological assessments (including assessments of learning and mental health), provide individual and group psychotherapy, engage in measurement-based care and provide consultation to school staff related to evidence-informed practices for the classroom.

Registered psychotherapists offer brief therapy, skills-based supports and consultation for school staff.
Mental health and addictions nurses provide support for students to, from and through hospital services, support medication management, help students with concurrent medical and mental health disorders and offer addictions prevention support.

School-based mental health professionals bring a deep understanding of school culture, priorities and student needs, which helps tailor supports that work in the school context.

While each professional group has distinct responsibilities set by their regulatory colleges, school staff can check their board’s service-delivery model to understand:

• who provides what type of service
• how to make a referral
• what supports are available within the school and system

If unsure, school staff can always reach out to their board’s board’s Mental Health Leader for clarification and guidance.

While prevention and early intervention services are delivered by regulated school mental health professionals, many others within the school district provide ongoing support when students are experiencing mental health difficulties.

Student support staff such as child and youth practitioners, graduation coaches, chaplains, guidance teachers, etc., are very well-positioned to notice when a student might be experiencing a mental health problem because of the day-to-day relationships formed over time. They are sometimes the first to observe changes in a student and can reach out with curiousity and care to check in on the student’s well-being. They can also provide needed listening, compassion and support, and suggest the need for prevention and early intervention services as appropriate. See the ONE-CALL Desk Reference for more information about how student support staff and others in the school community can help with early identification and support. 

Educators and school staff contribute to Tier Two support by:

• maintaining a stable and predictable school and classroom environment
• checking in with students daily to build strong relationships and trust
• reinforcing the skills and coping strategies students learn through intervention
• adjusting classroom expectations and removing learning barriers
• collaborating with mental health professionals to create consistent care across settings
• monitoring progress and celebrating small successes

Knowing your school board’s protocols and pathways for mental health support helps ensure that students are connected quickly and appropriately to the help they need at school or in the community/health sector when more specialized services are required.

System and school leaders also have an important role to play in prevention and early intervention services in that they lay the foundations for effective practice in this area.

System leaders show commitment to high-quality prevention and early intervention services, understanding that schools are best positioned to address student mental health concerns at this level, and that community and health settings are more appropriate for supporting children and youth with more significant mental health disorders. System leaders understand and communicate that schools are not clinics, and that their main job in the system of care relates to mental health promotion, prevention and early intervention. As such, they prioritize the uptake of brief evidence-informed protocols that are attuned to the needs of students served and alleviate pressures on school mental health professionals to provide deeper levels of therapeutic services that are beyond the scope of practice of schools. They also hold space and funding for school mental health professionals to train on high-yield brief protocols, and to receive ongoing clinical supervision to support their practice in this area.

School administrators support prevention and early intervention services by effectively discerning which students should be referred for school mental health services, and which should be referred for more intensive community mental health or hospital services. They also help to navigate the ongoing supports for students with mental health concerns of any intensity while they are at school, with consultation from the parents/caregivers and mental health professionals involved.

Explore this video series highlighting the important work of school social workers, psychologists and student support staff in early identification and support.

• Video / webinar

Tell Me More video series

Services

The process by which a student is referred to a school mental health professional for prevention or early intervention services may vary slightly across districts, but generally the referral process includes:

• meetings between school staff, parents/caregivers and the student (as appropriate) to discuss identified concerns and possible paths forward
• a referral for social work or psychological services, with consent from the parent/caregiver (in most instances) and/or older student with capacity to consent
• a referral package provided to the school mental health professional that includes a summary of concerns, observations, strengths and any prior assessments/clinical notes that can be shared
• a meeting between the school mental health professional and the student (and sometimes the parent/caregiver) to assess needs and strengths and to establish the scope of work together, including key goals for the brief intervention

In some cases, one professional may conduct an assessment (e.g., psychologist) and another may provide the intervention (e.g., social worker or psychotherapist).

This work begins with time to establish rapport and trust, as this is the cornerstone of effective practice, regardless of which clinical techniques and protocols are selected. Sessions often include some form of psychoeducation to help the student to understand how common mental health problems form and strategies that can help.

Together, the student and school mental health professional can create a plan for the brief intervention, rooted in the assessment the clinician has conducted, and the protocols that they feel would be most appropriate for the situation at hand.

What prevention and early intervention services in schools are:

For brief prevention and early intervention services, the goal is to help the student develop some strategies and ways of being that they will find supportive as they manage one or two identified areas of need, with the intention that these will generalize to other areas now and into the future.

Typically, brief interventions in schools are one to six sessions in duration. Sometimes, students will come for one to four sessions and will be invited to return for additional support as needed, so students may receive a higher dose of service over time, right-sized for their needs. If students require more intensive support or interventions of longer duration, appropriate referrals to community mental health settings can be made.

The main therapeutic techniques used for prevention and early intervention in Ontario schools are rooted in evidence-informed approaches such as:

• Cognitive Behavioural Therapy focuses on the relationship between thoughts, emotions and actions, and helping the student consider strategies to address problems in each of these areas that can help them enhance their mental health (e.g., challenging negative thinking patterns to see how this impacts their emotions and actions).
• Motivational Interviewing is centred on building motivation for change and strengthening commitment to change using techniques that actively empower the student to achieve the goals they set for themselves.
• Acceptance and Commitment Therapy helps the student to increase their psychological flexibility so that they can accept their thoughts and emotions without judgement, while mindfully pursuing actions that are in line with their values and goals.
• Dialectal Behaviour Therapy helps students manage intense emotions through strategies that balance acceptance and change, helping to improve their relationships with themselves and others. Note that standard DBT is not recommended for the school setting, but school mental health professionals may draw on related techniques like mindfulness, distress tolerance, emotional regulation and development of interpersonal effectiveness skills.
• Screening, Brief Intervention, and Referral to Treatment (SBIRT) is used for substance use prevention appropriate for the school setting and focuses on identification of substance use health problems, the use of brief interventions like Cognitive Behavioural Therapy and Motivational Interviewing and referral to addictions prevention services when needed.

These are the same approaches used in more intensive therapeutic services, but in schools the work is scoped to be more time-limited, goal-directed and relevant for the school environment.

School Mental Health Ontario has curated several evidence-informed implementation-sensitive protocols that are based on these therapeutic approaches and designed for the school setting. These protocols have been adapted for the Ontario context, field-tested and scaled through the Innovation and Scale-Up Lab . The use of protocols helps school mental health professionals provide brief high-quality intervention to students in ways that are amenable to the busy school setting.

In Ontario, training on these therapeutic approaches and related protocols is conducted within the Identity-Affirming School Mental Health frame , meaning that interventions are meant to be delivered in ways that are person-centred, strength-based and culturally responsive. School mental health professionals work closely with the student to design an intervention that builds on their existing knowledge, skills, resources and strengths. As noted, prevention and early intervention services in schools are grounded in relationship, and while the goal is to provide brief services so that many students can benefit from timely assistance, it can sometimes take more time to develop connection and trust depending on student circumstances.

What prevention and early intervention services in schools are not:

While supportive care may be part of brief intervention, it is not the core focus at this level. Many forms of supportive care are provided by others who have regular relationships with students (e.g., student support staff).

Schools are also not the right setting for intensive mental health services such as trauma-focused clinical treatment. These approaches require specialized clinical infrastructure and supports that schools are not designed to provide. In addition, students often need a setting outside of school to safely process complex or traumatic experiences.

Some students will require more urgent or intensive mental health support. School mental health professionals can play an important role in responding to these needs through crisis response, suicide risk assessment and management, supporting readiness for treatment, short-term clinical stabilization and bridging to community and/or hospital-based services. These are considered Tier Three school-based mental health services, not prevention and early intervention.

Access

When a student is struggling with their mental health, knowing where and how to access support within the school and district is an important step.

In Ontario, every school board has a system in place that helps school staff, administrators and families connect students with the right level of support at the right time.

These pathways ensure that care is coordinated, timely and student-centred, and that all school staff understand their role in helping students get the help they need.

If you are not sure about the circle of support or the service pathways within your school, you can consult your school administrator or your board’s mental health leader.

Students and parents/caregivers may feel most comfortable speaking with an adult that they know best in the school – an educator, guidance teacher, coach, chaplain, child and youth practitioner or school office staff – to share their concerns and to learn more about the help available.

At times, students may require more intensive support than can be offered at school. In these instances, a referral for community mental health or hospital care can be initiated.

Learn more about service pathways or find a centre directly.

Parents/caregivers may also wish to consult the By Your Side website for information about supporting a child who is experiencing a mental health problem, or the Children’s Mental Health Ontario Parents and Caregivers for Mental Health program website for information or to join a Caregiver Connections group.