Schools turn to private therapists for troubled students

Private therapists enlisted to help troubled students

Nahid Yazdi and Josue Payano, 9, one of a half-dozen students that Yazdi counsels at the John F. Kennedy school in Boston.John Tlumacki/Globe Staff/Boston Globe

Child therapist Nahid Yazdi walked into an elementary school in Jamaica Plain one morning, hauling a large bag containing, among other things, Play-Doh jars, board games, and colored markers.

She headed down a wide corridor and into a small cluttered office, relieved to find nobody there. Sometimes staffers forget that she is here two days a week and is loaned this space, just off the busy cafeteria, for one-on-one sessions with young patients covered by their health insurance.

She set up two chairs and a small table, and hoped there would be no cancellations due to field trips or exams. The door has a makeshift sign reading “Counseling,’’ to keep people from barging in to use the office’s tiny bathroom when Yazdi is seeing patients. “It’s very disruptive,’’ she said.

Despite the challenges of creating intimate therapeutic space in a bustling school building, school officials in Boston and other cities are increasingly importing private clinicians to deliver much-needed mental health services to behaviorally troubled students. This arrangement helps districts avoid the expense of hiring more counseling staff while reducing the gap nationwide between the number of children who need psychological or emotional help and those who actually get it.

The Home for Little Wanderers, which employs Yazdi, has recently taken a lead role in expanding private one-on-one therapy sessions in Boston, expanding from 20 to more than 40 the number of public schools that it operates in over the past two years. The agency now has 38 mental health therapists serving some 600 students. Their sessions, typically about 45 minutes, are mostly billed to Medicaid, the government insurance program for low-income families.

Some private insurers also pay for mental health visits in school settings, though often with limits on the number of sessions or with large copayments. Children whose insurance will not cover the visits, or who are uninsured, cannot see the therapists unless special arrangements are made.

The role of private therapists is expected to grow as Boston school authorities plan to launch this fall an ambitious behavioral health initiative, attempting to identify what level of services each of its 55,000 students needs. Educators say many students, particularly those affected by poverty and violence, may benefit from classroom presentations focusing on how to manage anger or stress, or how to promote strong relationships with peers and adults - skills that may help them avoid mental health problems. Others may need small-group therapy or one-on-one sessions.

“Students can’t learn if their mental health needs aren’t met,’’ said Andria Amador, assistant director for behavioral health services in the Boston public schools.

Though there are no nationwide statistics on how many schools use private therapists, researchers say this model, which first entered the education scene in the 1990s, is expanding.

“There’s definitely a push toward providing mental health services in schools through fee-for-service and other mechanisms,’’ said Sharon Stephan, an assistant professor at the University of Maryland School of Medicine who studies school-based mental health services. “It’s a fiscal reality.’’

Numerous large studies have underscored the need to connect more children with mental health services. A government study by the National Institute of Mental Health last year found that 20 percent of youth had a diagnosable mental disorder, and roughly one in three of them had received treatment.

The advantages of private clinicians meeting with students in school go beyond its minimal cost to the districts. Parents do not have to shuttle children to appointments, and teachers and therapists have a better opportunity to collaborate. Also, students may feel less stigmatized when psychological struggles become one of many reasons - including speech delays, reading difficulties, handwriting problems - that cause young people to get pulled out of class for special help.

A 9-year-old boy, Josue Payano, who has been diagnosed and medicated for attention deficit hyperactivity disorder, is one of a half-dozen students that Yazdi sees at the John F. Kennedy Elementary School. The boy’s teacher and mother credit the combination of medication and therapy with helping the boy become more cooperative in class.

After finishing one session in January, the boy described his time with Yazdi as helping him “not get angry and control my body.’’ He said he and his “counselor’’ talked while playing a marble game, Mancala, and they read a book called, “What To Do When Your Temper Flares.’’

Josue’s mother, Marina McKinney, said she hopes that teachers and the therapist can work together to keep Josue performing at least at grade level, which he is now.

“I like the fact that everyone can communicate with each other,’’ she said.

Dialogue between educators and therapists can be strained, however. Schools have educational privacy laws that prevent them from sharing grades or school attendance with a therapist without explicit approval from parents. Also, privately employed therapists legally must treat the children as patients, not students. With federal patient confidentiality laws, private therapists, whose services are covered by insurance, can share with school staff only what is authorized in writing by the parent; school-based counselors are not typically constrained by this health-privacy law.

Researchers say some therapists, out of concern for privacy and trust, have failed to reveal a student’s disclosures about substance abuse or bullying behavior, much to the chagrin of school officials. Roughly 90 out of its 125 schools have a partnership with an outside mental health agency, though some focus on mental health education, while others provide intensive one-on-one therapy.

Amador said ideally there would be enough money for schools to hire enough staff to meet all the needs of their students, and every child could be seen regardless of insurance. But for now, she said, “the economic reality is that fee-for-service will always be part of things.’’