2014 APA Gold Achievement Award: A School-Based Transition Program for Adolescents Returning to High School After a Mental Health Emergency: Bridge for Resilient Youth in Transition, Brookline Community Mental Health Center, Brookline, Massachusetts

Every year, about 5% of Brookline High School’s nearly 2,000 students spend time in a psychiatric hospital or other intensive therapeutic setting. Typically, these stays are brief, and teens return directly to school, even after experiencing a major psychiatric episode. Many are being treated for depression and severe anxiety. Some students have been hospitalized for suicide attempts or suicidal thoughts.

The transition back to school can be an overwhelming challenge, according to Dr. White, who also serves as clinical director of BCMHC. “Teens return to the community at high risk of relapse,” he said, “expected to take on the task of recovery while managing all the social and academic pressures.” Often, their families are not able to navigate the various systems of care involved and may react to the child’s illness with fear, denial, and shame.

The BRYT program recognizes that both mental health and academic supports are necessary for recovery, according to Nancy J. Reed, M.D., who visited the Brookline program in August on behalf of the APA. Therefore, each clinical coordinator has the flexibility to provide an intensive set of services to students and their families. Focusing on six to eight students at any given time, the coordinator arranges for assessment, counseling, family support, case management, care coordination, and educational planning. Students are referred to the program by school guidance counselors or other staff; involvement is entirely voluntary.

The goal of treatment is to help students achieve a slow, steady transition, and the process begins even before the child’s return to school. Two school-based clinical coordinators work with Dr. White to create transition plans for students. A clinical coordinator meets with students and their families at school, their home, the hospital, or another community setting. The coordinator helps stakeholders reach consensus on short-term goals and plans, which can include discharge plans, schedule changes, referral to mental health or general medical services, educational assessment, and tutoring.

During their first days back at school, the students spend most of their time in the program’s “home base,” a classroom near the main lobby supervised by the clinical coordinators and a classroom aide. Gradually, as their condition improves, they spend more time in their regular classrooms, and class attendance gradually increases to 100%. With this support, most teens are able to reintegrate into their classrooms in four to eight weeks.

Once the student has returned to the classroom, the clinical coordinator provides ongoing assessment and emotional support for students and families while facilitating communication between school personnel, mental health and substance abuse treatment providers, pediatricians, court personnel, and staff from other agencies. The full-time classroom aide helps students organize and complete assignments and keeps teachers informed about students’ current status and capabilities. The school-based staff is supervised by Dr. White, and the program receives administrative support from BCMHC as well. Family members were instrumental in developing the program and now play an important role in oversight, communication, and even staff recruitment and hiring.

At about $2,500 per year, the cost per student in BRYT is a relative bargain compared with the $50,000 cost of an out-of-school placement. Staff estimate that the program has reduced out-of-school placements by four or five students each year, saving as much as $200,000 annually. The town of Brookline provides $100,000 per year, primarily for staff salaries, to fund the program. Additional grant funding and individual philanthropy to support the BRYT program are secured by BCMHC.

The program is located in two connected rooms known as home base. One, a converted classroom, is decorated with bright colors and has couches, tables for doing homework, and another table with two new computers for the students’ use, as well as desks and computers for the clinical coordinators. The other room is smaller, with a couch and chairs, and is used for conferences with students and teachers and for meetings with therapists or parents. Uplifting messages adorn the walls—one says, “I will not wait for a great day. I will make one.”

Conveniently located near the school’s main entrance, the home base often serves as a first step toward reintegration. It offers a safe and manageable respite between classes and a quiet work environment. Teens in the program can visit the rooms, no questions asked, whenever they feel the need to escape from daily pressures, confide in adults, or manage schoolwork. Some check in to get counseling and academic support. Sometimes students spend entire days there, doing schoolwork at their own pace, as their social workers listen, offer advice, and work with teachers to modify assignments. Some students listen to music, sip tea, or play board games during free periods.

To make visiting even easier, the program can be entered from the street without going through the school’s main entrance and atrium lobby. That is particularly comforting to kids who resist returning to school because of social phobia or school refusal, said Dr. Reed, and Dr. White agrees. “Because the program is fully integrated into the school environment, access is easy, acceptance of services by students and families is enhanced, and staff members are available immediately to respond to crises and emergencies,” he said. In fact, the program feels so safe that some students want to stay in it longer than the typical eight-week period, Dr. Reed noted. But “alumni” are encouraged to visit, she added.

Over a decade ago, school and BCMHC staff as well as family members began to recognize that students often need help reentering school after a mental health emergency or psychiatric hospitalization. They estimated that about 120 students were absent from school at some point during the year because of a mental health, substance abuse, or medical problem, and about 60 to 70 needed intense help with the transition back to school. At that time, there was almost no support for a child or family trying to navigate the various systems of care involved—hospital, mental health, medical, and education.

Schools are the right venue for providing services for these children, said Dr. White, because teens spend most of their time in school. But their complex needs require more support than most schools are able to provide, he said. “Returning to school after an absence or hospitalization due to a serious emotional disorder is a critical moment,” Dr. White believes. Without help, these students are disproportionately likely to drop out of high school, attempt suicide, abuse alcohol and drugs, and function poorly in a variety of areas, including home, school, family relationships, and social life. For many, the disruption of their education is the first episode of what may become a life-long mental disorder.

The program launched in 2004 with the goal of helping at-risk teens heal, build resilience, and complete high school. Initially funded by foundation grants, the program quickly established itself as a valuable addition to the continuum of care. As early as 2005, a Frontline Reports item in Psychiatric Services documented significant improvement in functioning among BRYT participants. Three months after joining the program, 88 of 99 students had remained successfully in the community for the entire period. Eighty-eight percent of students were attending school regularly.

Currently over 95% of BRYT students advance with their class to the next grade, graduate from high school, and pursue higher learning or vocational training. Hannah C. was one such child. As a freshman, she spent four months being treated for depression at local hospitals and entered BRYT in March. Social workers tracked her progress for four to eight weeks, acting as go-betweens with teachers to arrange make-up work and exams and providing a sympathetic ear when being in the mainstream became too tough. Hannah left school again after her father died to enter an off-campus therapeutic program, but she returned in her junior year, again finding a haven in the BRYT program. A child once described as “wrapped in sadness,” Hannah now walked with confidence, according to a clinical coordinator, and even testified at a state hearing about the need for more in-school services.

Brookline High School teachers welcome the program’s assistance. The challenge of supporting even one student with a significant mental health challenge is overwhelming, said one. “We don’t know what our students are dealing with,” she said.

For families, the program relieves stress associated with navigating a maze of medical and mental health systems. BRYT provides a link between them and the doctors, hospitals, teachers, and school administrators involved in their child’s treatment and education. Having a single, reliable point of contact improves relationships with the school and the other involved agencies. Families now have a person to call who will always answer the phone and respond to questions and concerns.

As the program has expanded, BCMHC has undertaken a formal, large-scale evaluation of BRYT. With help from the Center for Health and Healthcare in Schools at the George Washington University and funding from the Klarman Family Foundation, in 2013 BCMHC began a two-year study comparing social, academic, and health outcomes following a mental health–related absence at seven schools with a BRYT program and four schools that provide usual care. Data from year 1 found that BRYT had a large impact on student functioning: functional scores improved significantly, relapse rates were less than 10%, and 90% of students were able to graduate on schedule with their peers. As an added benefit, BCMHC developed a scalable, secure Web-based electronic medical record (EMR) for use in the study. It has become an important quality management and utilization review tool that facilitates program management, data collection, and analysis from remote sites. Ultimately, the EMR will be useful to all BRYT programs.

Writing in 2005, Dr. White predicted the program would be replicated widely, and he was right. “Our documented success in helping a population of students with great ethnic and clinical diversity suggests that this program design may be applicable to a broad range of schools and communities that are faced with the daunting task of reintegrating and caring for youths with very serious mental health disorders.” As expected, the 17 school systems that have implemented the BRYT model represent broad socioeconomic and ethnic diversity and urban and suburban locations. These programs serve a school population of 28,000 students and their families. To date, more than 1,500 teens and their families have been directly served by a BRYT program, each maintaining a graduation rate of 95% or better.

As in Brookline, many of these programs started with grant funding or “soft” money. In all cases, the school systems subsequently decided to allocate funds to make BRYT a regular part of the school district’s operating budget. Even more impressive, this expansion occurred during an economic recession, when other school programs were being defunded. More BRYT programs are on the way. Five communities, with an additional 6,000 students, are actively planning to launch BRYT programs in the next academic year, and nine more are in the initial planning phase.

Nevertheless, schools sometimes avoid acknowledging reentry problems facing students with extended absences. “There is a tendency for schools to look at the problem on a case-by-case basis rather than seeing it as a population needing support,” said Dr. Reed. Stigmatization of mental illness, even by teachers and administrators, can contribute to reluctance to examine problems associated with school reentry.

Outreach efforts by Dr. White are an important way to overcome some of these obstacles. “BRYT has found that having the professional weight of the psychiatrist at outreach discussions helps to overcome some of those obstacles,” Dr. Reed said. Dr. White leads monthly consultation groups that allow clinicians, teachers, and parents to share information and discuss the program’s effect on various stakeholders. He is also available to provide supervision and advice to the clinicians at other BRYT locations. For the past five years, BCMHC has hosted an annual symposium about the program.

Now the program is poised to assume a national presence. In 2013 the Robert Wood Johnson Foundation awarded $630,000 to BCMHC to create a strategy for national replication of the program. The first phase, a statewide expansion to 50 high schools, will launch this winter.

Dr. Reed is glad the program is gaining national exposure. “Once I heard what they are doing in Brookline, and now in many other places in Massachusetts, I couldn’t help but wonder why this program hasn’t always existed and why every school system in the country isn’t using it,” said Dr. Reed. “Not to be too dramatic, but it really saves lives, and at a very small cost.”