TTUHSC Provides Mental Health Services for Students in Schools

She was in her classroom closet with six students during her conference period. Students she’d found wandering the halls unsure of what to do. They’d never experienced a high-level lockdown before. But, then again, neither had she. Lights out. Doors locked. She knew very little of what was going on, other than administration suspected a student had brought a gun to school. Possibly more than one student. Possibly more than one gun. The doorknob to her classroom rattles, the door opens and someone yells, “Is anybody in here?” She said nothing and signaled the students to be silent. 

The person left. They came back. “Is there anybody in here? This is the SWAT team.” 

“We’re here,” she said. “In the closet.”

“How many?” he shouted.

“Seven,” she answered.

“OK, wait here, do not move, we will come back and get you.”

The classroom door slams shut.

Ninety minutes later, the SWAT team returns and opens the closet door. She exits first with hands behind her head and is immediately frisked by an officer. One by one the students exit in the same fashion — she was allowed to frisk the girls herself. The officer tells her, “You are to put your hands behind your head and walk in a straight line.”

They start walking — she tells me later it felt like marching. In a single-file line, hands behind their heads, surrounded by the SWAT team armed with machine guns. All of a sudden, motion is detected at the end of one of the hallways as they come to an intersection. “Get down!”  There’s more inaudible shouting as she throws herself on the floor — it was just another police officer. They keep moving. Finally, after what seems like the longest, completely silent seven minutes of her life, she’s outside. They get to the tennis courts where a paramedic hooks her up to a nebulizer; she hasn’t been able to use her inhaler in three hours. She sits on the tennis court for another three hours before she’s cleared to go. She texts me to say she made it home — I remember her routine of praying for safety every morning as she’s walking to the school entrance — and I stop and thank God my mom is safe.

The lockdown lasted roughly six hours. No one was hurt. No guns were fired. A peaceful ending compared to so many other threats turned gruesome realities at schools in other parts of the state and across the nation. 

The school shooting epidemic is a constant topic of conversation, with parents, teachers, students and politicians all demanding a solution. Following the Santa Fe High School shooting last spring, Gov. Greg Abbott mentioned a program during his press conference that he thought would help divert such a tragedy in the future: the Telemedicine, Wellness, Intervention, Triage and Referral (TWITR) Project developed and operated by the TTUHSC F. Marie Hall Institute of Rural and Community Health. 

“May 18, 2018, changed my life,” said Billy U. Philips Jr., PhD, MPH, TTUHSC executive vice president of rural health, director of the institute and leader of the TWITR Project. “The shooting at Santa Fe High School turned the TWITR Project from an academic endeavor to something very personal in an instant. Had I not come to TTUHSC, likely as not, my children would have been at that school; 10 years ago we owned a farm about one mile from the high school and many of the children in the 4-H group we led in the (Santa Fe) community were there, and one of them did perish (in the incident).”

The day after the shooting, five minutes after the governor spoke about TWITR at a press conference outside Santa Fe High School, Philips’ phone began to ring. It’s been ringing ever since. Reporters, school administrators, public health professionals and politicians all bombarding him with questions about TWITR. Can it really stop school shootings? Can TWITR be offered to my school? Is screening students in the schools a good idea? Additionally, Philips and his team have responded to four public information requests — extensive in nature — with explicit transparency for government officials who may be trying to spot error or inconsistency.

The people behind TWITR are not looking for shooters — many shooters don’t have mental illnesses. They’re not looking to deter school shootings — although it could be a byproduct of what they are focused on, which is serving as a behavioral health resource for the needs of students. They’re aiming to provide hope to students and parents alike who don’t see a way out of their struggles — a resource to those with nowhere else to turn.

After the Sandy Hook Elementary School shooting in 2012, Gov. Rick Perry and Texas Tech University (TTU) System Chancellor Kent Hance decided the state of Texas needed a plan to serve students’ behavioral health needs.

“Somehow my name came up,” Philips said. “I had worked in telemedicine as an epidemiologist, which they were aware of, so they wanted me to put together a preventive care program using this technology. When Dr. (Tedd L.) Mitchell (TTU System chancellor) asked me if we could do this, I said it would take something about like a miracle, but we’re on it. And many miracles have happened since then.”

PLANNING AND CONFIGURATION
The TWITR Project — funded by the Office of the Texas Governor Criminal Justice Division Juvenile Justice Grant Program, the Texas Health and Human Services Commission and TTUHSC matching funds — currently operates in 14 school districts within 60 miles driving distance of Lubbock. In 2018, the institute received a one-year $360,885 grant from the Texas Health and Human Services Commission, matched by a portion of TTUHSC funds, to begin what has been coined the “Amarillo expansion.” As of press time, five school districts in the Panhandle are participating. TWITR has three circuit-riding licensed professional counselors (LPCs) handling the project — one just moved to Amarillo full time to be more accessible to the school districts in this area.

“We need to make it easy for our LPCs to visit the schools, develop relationships and, when a referral comes, to respond if not the day of then within a day if it’s an urgent situation, so there’s a method to our madness (in the geographical organization of TWITR),” Philips said. 

The primary purpose of the TWITR Project is to screen, assess and provide referral services to students in schools where there are either vacancies in the counselor core, case overloads or a scarcity of mental health referral resources. It’s classified as a secondary prevention program since the process involves screening. When discussing the role TWITR could potentially play in schools, the institute needed to answer whether or not it was even necessary.

“We discovered a profound need for this service after facilitating a needs assessment, especially in rural communities, and rolled the program out in 2014 after six months of development,” Philips said.

Developing the program in six months wasn’t easy. Philips and his team were tasked with pioneering a new model of mental health service delivery. 

“It’s fair to say this is a revolutionary first-of-its kind model, though mental health screening in schools isn’t new,” Philips said. “Using LPCs was (an innovative) concept. Upon development of the program we discovered LPCs were the least expensive, most appropriately trained and plentiful provider in mental health in West Texas.”

The team looked at LPCs who had good clinical experience, a history with the population age group TWITR serves — ages 12 to 18 — and since the school systems were uncharted territory for the institute, the LPCs needed experience working in schools to bridge the gap.  

The LPC component worked well and TWITR launched successfully in 2014. While operations have been in place for several years now, Philips emphasized the program’s frequent evaluation including updates and maintenance. 

“We’ve tried hard to keep it current, perfected and operated with a high degree of fidelity — we don’t want to miss a child who is seriously ill,” he said.

THE PROCESS
The foundational component of TWITR taught to school personnel is recognition, which is the first step in referring a student.

The team spends time with school staff the week before the students start the new school year going over the referral processes and procedures — including what to look for in a student who may need mental or behavioral health resources.

Philips still remembers the first training meeting he did for Crosbyton Consolidated Independent School District (CISD).

“It stood out for a lot of reasons,” he said. “It was a January day, and I, just coming up from the Gulf Coast, had not dressed for the cold blizzard-like conditions of the day. As I carried my box of 32 folders into the school auditorium for the training, I was hoping I hadn’t brought too many (materials) and wishing I had an overcoat. When I walked into the auditorium, I looked up and saw every single seat filled with every teacher, administrator, bus driver, grounds crew member, coach, guidance counselor and even a few parents from the PTA. I had nowhere close to enough training materials, but we made it happen. They were so glad someone was coming to their school to help make the lives of their (children) better.” 

It’s easier to see the problems existing in and around a child after a traumatic event; noticing beforehand can be more difficult.

“Hindsight is 20/20,” Philips said. “However, proactivity has increased in the schools who work with us. We have gotten more referrals the first six weeks of this school year than we did all last year. Is it because there are more troubled students? No, not necessarily. It’s because teachers and school officials are knowledgeable on what to look for, and everyone is onboard with using any tools they have at their disposal to (avoid) tragedy and provide help for our children.” 

The referral comes from the counselor, teacher, administrator or sometimes even the parent, and is based on behavioral issues, a constellation of poor grades, absences, truancy, threats, delinquency and/or involvement with the justice system.

“Once a student is referred to us, we begin the assessment portion of the process,” said Shawn Marie Parrott, LPC-S, senior mental health professional for TWITR and the LPC assigned to the Amarillo expansion. “We follow school policy on checking in upon arrival, and TWITR protocol requires all students are screened with their parent or guardian present.” 

During the initial visit, TWITR LPCs can request student records — current grades, truancy reports, discipline referrals and any other pertinent information — to assist in understanding the student’s academic and social history and to monitor changes in the student’s behavior throughout the school year. The LPC receives all data for six weeks before TWITR intervention and every six weeks after intervention for the remainder of the school year, which is used in comparison to the initial assessment to determine any changes in student performance and well-being. Throughout the process both the student and the parent or guardian sign multiple consent forms in their prevalent language, Philips said.

“Often these are situations where something has changed in the student’s life and can be overcome (without) a long-term mental health intervention,” he added. “These are then triaged a variety of ways to appropriate help.”

Once the assessment is complete, the LPC sits down with a child and adolescent psychiatrist to develop recommendations for the student based on their assessment scores. These recommendations are then sent back to the school to be evaluated by the family.

“We almost always recommend telemedicine in our report,” Parrott said. “We feel it's important for the psychiatrist to set eyes on the student to ensure we plug them into an effective resource. We also follow up with as many referral options for the family as possible. We have a list of all available mental health resources in their community, and we work to educate the parent or guardian on the need to give the student a (therapy) outlet.”

The TWITR LPCs care about the student and their family — feeling a strong desire to strengthen the family unit and provide for the child’s needs. 

“I spent seven years working for Lubbock County where my counseling style revolved around strengthening the family (unit) as a whole, and I try to bring (this concept) to screening visits at the schools,” Parrott said. “I personally like to educate the parents and provide them counsel as well, and I hope (my efforts) strengthen the family bond. In my experience, the children and parents are willing to be screened with a sense of relief because they feel this is their last resort. These children need an outlet to tell their story.”

It can be difficult in some of the more rural areas to provide a plethora of resources, which is why telemedicine is beneficial and a major component of TWITR.

TELEMEDICINE
“Telemedicine works so well for TWITR for the same reasons it might work well for just about any application,” Philips said. “Easier access to care, convenient for anybody to use — both providers, patients and parents — it reduces the amount of time students are out of class and parents are out of work — even when screening they don’t drive to Lubbock. We take the 60-mile drive, they don’t, and it’s amazing to hear the clinicians relate how the students have an easier time telling their story (during a telemedicine session with a psychiatrist) when they’re not (in the same room) with a mental health provider.”

THE SCHOOLS
One of the biggest challenges to Philips when designing the program was getting into the schools. The team had to find a way to build trusting relationships with school administrations to offer service. Schools are mandated to provide personnel with annual suicide prevention training — Youth Mental Health First Aid is an approved program for this mandate by the Texas Education Agency (TEA), and the institute team happened to be certified to teach the course. 

“We decided to offer (the schools) our services, and while conducting the training, we mentioned TWITR as a preventive measure they could implement.”

It worked well as several schools signed up the first year.

“We enrolled in the TWITR Project in January 2014,” said Kenny Border, EdD, Shallowater Independent School District (ISD) superintendent. “We joined because we are continuously looking for additional services for our students. An increase in low socioeconomic students and families in Texas schools obligates (the school) to serve as a vehicle to help with physical needs, which must be met prior to educational needs.”  

Border said the biggest benefit to TWITR is it bridges a gap between the school setting and community resources and provides the school with access to telemedicine.

“I think (adolescent mental health) has always been a concern — it’s a growing concern,” he added. “I think many of our students are coming to school with mental health issues not previously addressed, and we have a (responsibility) to help our students.”

He’s not the only one who feels this way.

“I’m a huge advocate of TWITR — it’s part of our progressive response to addressing student need — it’s something we’ve met about as a leadership team,” said Chris Smith, Brownfield Independent School District (ISD) superintendent. “(We) understand the importance and significance of working with our kids, detecting things earlier and getting them the support they need.”

Smith said administrators have a responsibility to recognize students who may need help, too.

“As an administrator, sometimes you see behaviors even before classroom teachers do,” he added. “Students can behave differently in the classroom than they do walking through the halls or attending a sporting event, so we want our administrators to collaborate with our counselors when it comes to student concerns.”

When I walked through the doors of the Crosbyton CISD administration building, I was instantly reminded of the small rural school I grew up in. The atmosphere evoked a sense of small-town family and, turns out, this hits closer to home than you would expect. When I asked Shawn Mason, Crosbyton CISD superintendent, if I could visit with him, he told me his wife’s input would be valuable, too. “Stacy’s the school counselor,” he said.

Shawn and Stacy Mason are warm and friendly with a strong love for their students. While working together has to be interesting — when I asked, Shawn joked it’s hard to go home sometimes — they share a common bond extending past the marriage union. They are educators who pour their souls into Crosbyton students.

“(Children) do what is expected of them,” Shawn said. “You lower your expectations, that is what you’ll get. If a teacher shows they love the students, then those students will work their hearts out for the teacher.”

This love motivated school staff to participate in TWITR from the beginning of the project.

“I drop everything to take care of a student in need,” Stacy said. “However, I’m kind of a bandage in a way. I can stop the bleeding, but my care doesn’t extend beyond ‘first-aid’ care, which is why TWITR is so valuable to us.”

Since the governor’s announcement of TWITR in May, more than 100 school districts have reached out to Philips for access to the program.

“I would like to provide training for these school systems, and we are currently working on this in our (TexLa) Telehealth Resource Center (a federally funded program designed to provide technical assistance and resources to new and existing telehealth programs throughout Texas and Louisiana),” he said. “We received a supplement to our telehealth resource center grant funding, which will allow us to develop training and technical assistance for the schools (if approved by state Legislature).”

THE FUTURE
Currently, West Texas has multiple problems to address in the mental and behavioral health arena. Provider shortage, stigma, treatment options, etc. (Read more about TTUHSC’s response to mental and behavioral health needs online at ttuhsc.edu/alumni/pulse.) The TWITR Project has been an effective solution thus far, which is why the Texas House of Representatives Committee on Public Education included TWITR as a recommendation in their report prepared in response to the Santa Fe High School shooting. The recommendation is: “The legislature should ensure that LEAs (local education agencies) in rural areas or communities that have limited access to mental health services have the financial resources needed to participate in TWITR or similar programs utilizing telemedicine for psychiatric screenings.” 

Philips has hopes to train and teach the model in schools across the state. 

“We’d like to be a vendor and teach people how to do the screenings as done in the TWITR model,” he said. “We were originally asked to develop a model, demonstrate it works, and then provide training and technical assistance, which we have yet to do. I’ve made it clear to everybody from the beginning we don’t want to (operate) a statewide program. It’s not a one-size-fits-all program and needs tweaking depending on each region’s conditions and circumstances. I’m hoping the state Legislature will give the TEA the funding it needs, so they can provide these services whatever way they choose, as long as it’s there.

“And then I’m hoping they ask us to help since we’ve got a wealth of experience with it. Then we can get out of the business of running TWITR and into the business of teaching TWITR — it’s really what we ought to do in the future.”  

If you look at numbers, news articles and listen to news stations, our national situation is bleak. Mass shootings in general are increasing in number and intensity; bullying, truancy, detention, dropout rates all look bad. However, in West Texas, there are people at TTUHSC who aren’t satisfied with the status quo — who are working around the clock on positive solutions to grim realities. The fight to foster optimal adolescent mental and behavioral health in West Texas and beyond is at hand. Philips, who calls himself an optimist, put it this way:

“It’s (TWITR) not about school shootings — it’s about the welfare of students.”