It was just a few days into her freshman year of high school in Palo Alto this past fall when Robin had to withdraw from school and check into a residential treatment facility for depression and suicidal ideation.
Having been hospitalized due to mental illness multiple times in the past, Robin last fall ended up spending roughly six weeks receiving in-patient treatment before transitioning back home and attending an intensive outpatient treatment program. (Robin is a pseudonym that the Weekly is using at the student's request to protect her privacy.)
She didn't return to campus until the spring semester. Since she's been back, Robin has met with a therapist on campus as needed, in addition to continuing to receive care outside of school. The school's support services have been effective, Robin said, helping to create a smooth transition back to school this spring. But she's concerned that her classmates aren't getting the kind of help she received, both because many don't realize counseling is available on campus and because the district's staffing is limited.
"I think that the therapist has the potential to be really overwhelmed if students are aware (she's there) and then decide to see her," Robin said. "I don't think that one therapist is capable of treating about 2,000 students."
Palo Alto and Gunn high schools are each supposed to have three full-time therapists provided by Counseling and Support Services for Youth (CASSY) as part of a contract that the Milpitas nonprofit has with the school district. However, because of staffing shortages, there were periods this school year when each high school only had one CASSY therapist on campus, district staff said.
The lack of staffing comes at the same time that the pandemic and resulting school closures have exacerbated mental health challenges among young people.
In response to these increasing needs and staffing concerns, Palo Alto Unified is looking to reimagine its mental health program next school year by hiring more of its own mental health clinicians rather than relying on outside contractors.
CASSY will no longer serve the district's elementary and middle schools but instead will staff the high schools with three therapists each, as both Gunn and Paly are supposed to have. The district will hire its own staff to serve younger students. The district hasn't decided whether to eventually hire its own high school therapists, and administrators say that choice will be partially based on how things pan out at the lower grades.
By employing mental health staff directly, district administrators hope to create a program that is collaborative and able to more quickly adapt to changing circumstances, with a focus on proactively addressing students' and staff's wellness before things reach a crisis.
"What we're trying to do is build a wellness team, where all of these people come to the table and talk about the needs around health and wellness," Assistant Superintendent of Equity and Student Affairs Yolanda Conaway said.
Palo Alto is not alone in the challenges it has seen this school year. Youth mental health has been in the spotlight nationally as schools have reopened following pandemic-induced closures.
The mental health of kids was already a growing concern before COVID-19 hit, but anxiety and depressive symptoms doubled among youth during the pandemic, according to research cited in a report from the U.S. Surgeon General last year. The study covered 80,000 young people globally and found that 25% experienced depressive symptoms and 20% experienced anxiety symptoms.
The shortage of qualified mental health staff is also far from a local phenomenon. There were only enough mental health professionals in California, even before the pandemic, to cover roughly 30% of the state's needs, State Superintendent of Public Instruction Tony Thurmond said in a March press release.
"CASSY's experiencing the same thing every agency is — there's just a lack of therapists in the Bay Area," CASSY Executive Director Marico Sayoc said. As long as the kids' needs are being met, Sayoc said she doesn't mind whether the work is being done by CASSY, another agency or the school district.
Mental health has always been a big issue, especially locally, but District Mental Health Specialist Genavae Pierre Dixon said that as a result of the pandemic, kids who were already experiencing mental health challenges now report more severe issues, and kids with no prior history are showing symptoms of conditions like anxiety and depression.
For some kids, like those with social anxiety, positives came from the pandemic, Pierre Dixon said, but for many others, the isolation and lack of engagement had a negative impact.
With schools reopened this year, that impact has manifested itself on campuses. In younger grades, kids had trouble with social interactions like sharing, and teachers saw more yelling and tantrums, Pierre Dixon said.
"Every site, every principal is reporting that they are seeing an increase in behavioral outbursts, emotional dysregulation — those things that really are those precursors to more serious problems if we're not in a position to address them," Conaway said.
The pandemic also impacted students unevenly, Pierre Dixon said. During school closures, students who come from families with fewer resources were less likely to have their own room, and many of their parents had to continue going to work.
Certainly it has disproportionately impacted our families that are under-resourced and our families of color," Pierre Dixon said. "It's really frustrating as a person of color to see that happen and to know that our system as a whole ... is not really supportive of those families."
There are also existing factors driving mental health challenges, beyond the pandemic.
Gunn High School senior Annika Bereny, who serves as a student representative on the school board, said that many students feel an unhealthy amount of stress around their academic success and college prospects.
"Conflating your self-worth with your grades is a huge problem in our district," Bereny said.
With student mental health needs on the rise, staffing challenges made a tough situation even tougher this year.
Palo Alto Unified's current contract with CASSY calls for a mental health provider at each elementary school who works between two and five days per week, depending on the campus.
When the school year started, there were roughly four elementary schools without a therapist, Pierre Dixon said. To compensate, therapists rotated between school sites.
The district's three middle schools fared better, with CASSY able to staff the one therapist at each site that is outlined in the contract, district administrators said.
The high schools, on the other hand, saw substantial challenges, with CASSY unable to find enough therapists to fulfill the contract.
"They were not able to staff at that level," Conaway said. "It just did not meet the needs. Our staff was very frustrated. Our students were frustrated."
Beyond CASSY's staff, the district works with Asian Americans for Community Involvement (AACI) to offer counseling services in Mandarin and Stanford Child Psychiatry Fellows to provide one-time consultations on specific high-need cases. Because of an increase in cost, Conaway said, the district will no longer work with AACI next school year but is instead looking to hire a therapist who speaks Mandarin.
The district also already has some of its own staff, such as school psychologists, but these employees generally have separate responsibilities, like helping students with disabilities, rather than providing therapy to the broader student body, Conaway said.
This year, these staff members often ended up stepping up to work with students. Wellness coordinators at the high schools, who typically run the wellness centers, began seeing individual students, as did the school psychologists. Pierre Dixon herself pitched in to meet with students. Telehealth therapists were also used to fill the gaps.
Staff worked to triage which students to see first, prioritizing anyone with concerns related to safety, a history of mental health diagnoses or an acute issue like the loss of a family member, Pierre Dixon said.
"Any kid (where) there is an emergency, we are doing everything that we can," she said. "Truly it is all hands on deck — we're dropping what's happening right now and we're going to focus and support that student."
Even in less serious cases, Pierre Dixon said, the district still worked hard to ensure everyone was seen, adding that if a student couldn't get an appointment within 24-48 hours, staff would make sure to check in with the child and their family.
Despite the efforts, Conaway said, some kids still ended up on a waiting list and didn't get served in the time frame that the district needed.
Another challenge was finding outside providers with the availability to see students who required continuing care. The schools generally operate on a short-term model of care, in which students see a therapist on campus for as many as 12-14 sessions, Pierre Dixon said. While individual circumstances may differ, generally students with ongoing needs are referred out to community providers.
"That transition was very challenging in the first semester because there was just not as much space," Pierre Dixon said.
Things were particularly difficult for middle-income families, who don't qualify for the state Medi-Cal program but also don't have the resources to pay hundreds of dollars per hour for private therapy. The district does offer Care Solace, an online resource for finding local mental health care.
When Robin returned to high school this semester after attending in-patient treatment in the fall, she was able to see a therapist on campus when she needed help. Robin said that the therapist was nice, qualified and generally available when needed.
Her father, however, expressed some criticisms of the district's services, saying that he felt the school's mental health support was limited at the beginning of the year. He also raised concerns about why his daughter wasn't able to attend school part-time while in outpatient therapy after she exited the residential facility in the fall. However, he added that being able to stop by the wellness center has been valuable for her this spring.
Robin's mom said she has been impressed by the school staff's training and knowledge of her daughter's individual needs, as well as the level of support that's been available. She credited her daughter's successful reintegration into high school in large part to the district's efforts.
"Everything was so much better than my wildest expectations," Robin's mom said. "Truthfully, now that I'm thinking about it, my only concern would be with the amount of staff they have, can they really give that level of attention to every kid who needs it?"
The district is already in the process of finding its own staff for this next school year. Roughly a half dozen therapists have been hired thus far, Conaway said.
The district's goal is to have 10 full-time therapists for the elementary schools next year plus clinicians to operate wellness centers at each of the middle schools.
While acknowledging that the market to recruit staff is competitive, Conaway said that she believes the district will succeed in part because of the benefits attached to working for a school district, like having summers off, and also because of the positive working conditions that Palo Alto Unified provides.
"We have a lofty goal," Conaway said. "We've made some pretty hefty promises to our community, and we're committed to delivering on those, as we are with all of our initiatives."
One of the district's goals in shifting to in-house staff is to expand wellness support and services for the broader student population, not just those in need of individualized resources.
Bereny said she is hopeful that the shift can help to destigmatize mental health at younger ages and make it more likely that by the time kids reach high school, they will be better prepared to handle stress and have a healthier sense of their self-worth.
Robin noted that reaching out for care can be scary and said she hopes the district proactively works to build trust with students and encourage them to seek out mental health care, as well as spread awareness about what mental health disorders can look like.
"It's very scary to open up to a new person," Robin said. "It's scary at first because you don't know if you can trust them."
According to Conaway, the district will focus on creating a sense of belonging and connectedness at school, with staff working to build relationships with all students, not just those already seeking care.
The district also believes that with therapists on staff, it will be able to more quickly pivot and make changes as needed rather than having to work through cases with outside contractors.
"We need people who can jump in when they need to jump in, and that's what we're hoping to create with this in-house approach," Conaway said.
The district has also been working to provide more wellness support for its teachers and staff, who have faced heavy workloads since the pandemic began. That includes hosting trainings on staff mental health and providing outlets for staff to talk through their feelings, Pierre Dixon said.
"We want to make sure they are safe and have what they need, so they can be present for everyone else too," she said.
Any person who is feeling depressed, troubled or suicidal can call 800-784-2433 to speak with a crisis counselor. People in Santa Clara County can call 855-278-4204. Spanish speakers can call 888-628-9454. People can reach trained counselors at Crisis Text Line by texting RENEW to 741741.
Read more: How to help those in crisis