When we have mental health crises, are our schools, churches or doctors offices prepared?

On one of his more challenging days, Johnathan refused to get on the school bus. 

He threw chairs and ran away from the teachers, fleeing to hide under a table at his elementary school.

He lay there, curled up and crying when his mom was called to come and pick him up. And when Shaunqueen Leatherman arrived, worried and stressed, her son was asleep on the floor in that same spot.

His mother and grandma, who works as a teaching assistant in Metro Nashville Schools, asked for help from the school and were connected with a school-based therapist.

For a year, Johnathan's behavior underwent a "dramatic change," Leatherman says. He saw Laurie Jackson, a therapist from Centerstone who worked full time at Rosebank Elementary. He learned calm-down techniques. And if he was having a particularly tough day, he had someone nearby at school who understood him well enough to help.

"It was nice having someone who knew him mentally being right there," Leatherman says. 

But this year, Johnathan changed Metro Nashville schools, and there is no longer a full-time therapist there to work with him. The 7-year-old's behavior is escalating again. He's becoming more jittery, and more wild, his mom says, leaving Leatherman — who is raising three kids on her own — to worry again about the mental wellness of her son.

"It's more difficult now because he doesn’t have that person to talk to every day," she says.

Johnathan is just one example of a significant and persistent need in Tennessee schools.

School-based therapy gives kids direct access to treatment, addressing behavior that may be disruptive or dangerous — often in the moments when a child needs it most.

But as the mental health needs of students reach unprecedented levels and fears about school and community violence escalate, experts say Tennessee schools have an inadequate number of psychological staff.

And that is a big problem.

Few districts meet recommendations

More than 265,500 kids in Tennessee ages 2 to 17 have been diagnosed with a mental health issue, according to estimates by the state Department of Mental Health and Substance Abuse.

Approximately 62,000 adolescents ages 12 to 17 have had a major depressive episode in the past year.

And very few districts in the state meet the recommended national guidelines of having one psychologist for every 1,000 students. This year some Middle Tennessee school districts cut funding for school psychologists; others simply don't have money in their budgets to hire enough to meet the student needs.

The National Association of School Psychologists recommends a ratio of no more than 1,000 students per school psychologist, in general, and no more than 500 to 700 students per school psychologist when more comprehensive and preventive services are being provided.

Most Tennessee school districts do not meet these standards.

In Dickson County, only four psychologists serve 8,400 students. In Sumner County, there are 21 school psychologists for 29,331 students; each psychologist serves two or more schools depending on the size of the school.

The Basic Education Program — the formula by which Tennessee calculates required funding for school needs such as psychologists, books and teacher pay — uses a ratio of one psychologist for every 2,500.

Statewide, schools employed 540 psychological personnel during the 2016-2017 school year, an average of one for every 1,784 students, according to the Department of Education's annual statistical report.

"We’ve seen shortages for a long time," says Kathy Cowan, communications director for the National Association of School Psychologists.

"Up until recently, many schools didn’t understand the importance of mental health in how it affects the school’s climate and how it interacts with safety."

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Outside help for students 

School systems across Tennessee have sought to address this gap, bringing in nonprofit organizations that provide their own mental health therapists to support students and stem behaviors that could be precursors to serious mental health issues. Those therapists often are funded through grants, TennCare or by billing a family's personal insurance.

Meanwhile, new statewide requirements go into effect this school year that require school counselors to spend 80 percent of their time one on one with students instead of proctoring exams, working cafeteria shifts or doing other administrative duties.

The goal is to alleviate some of the burdens on school psychologists who struggle to serve the mental health needs of hundreds of students.

"It provides a personal protection factor for many young men and women," says Rodger Dinwiddie, CEO of STARS, a nonprofit organization addressing bullying, substance abuse and youth violence. STARS has 60 school-based therapists in seven Middle Tennessee counties.

"If nothing else, being there where young people are is probably the most important ingredient — because many don't have access to services outside those hallways."

With the increased understanding of adverse childhood experiences, including trauma or abuse, additional social media stressers stressors such as bullying and challenges in accessing mental health resources, early intervention and support for kids and teenagers are paramount.

"Right now there are more children coming in than ever before with mental health issues,” said Denise Owens, a counselor at E. A. Cox Middle School in Columbia, Tennessee. “Sometimes we’re dealing with bipolar diagnoses or ODD (oppositional defiance defiant disorder), anxiety. Kids come to middle school already on medication in some cases.”

Add to that, the heightened awareness of school violence, and there is cause for concern when there are not enough people in schools trained to help.

"Major school crises, like school shootings, affect kids significantly and have potentially long-term and widespread psychological consequences," Cowan says. "School shootings have sadly been one of the key issues where people have paid attention to us over time. ... People recognized the need to have conversations on how to protect our kids.

"We haven’t made the progress we should have made if (the country) had stayed focused on mental health and mental health services."

In Nashville, one high-profile case outside school walls has kept the conversation focused on addressing a continued connection — legitimate or perceived — between mental health crises and the violence reported in heartbreaking news stories across the country.

In April, four people were killed in a mass shooting at an Antioch Waffle House.

On Wednesday, shooting suspect Travis Reinking appeared in court to face his charges for the first time and was deemed currently not fit for trial. A team that evaluated him at the Middle Tennessee Mental Health institute said he had schizophrenia so severe he would be unable to understand a criminal trial.

While only a very small percentage of violent criminal acts are committed by those with a diagnosed mental illness, early intervention and behavioral health support for students is seen as an important step in helping children become more mentally and physically well adults.

Divided responsibilities

Psychologists who work every day at schools often are so focused on administrative duties and Individual Education Plan responsibilities that only a small percentage of their time is spent face to face with students.

In Wilson County, the 11 school psychologists who serve about 18,800 students spend time "completing evaluations, writing reports, participating in IEP meetings, reviewing independent evaluations and reviewing special education transfer student files."

"When the ratio is really big, the school psychologist is limited to only doing assessments for special education under federal special education law," Cowan says. 

Schools often have a school psychologist do special education work and evaluations first before creating mental health programs, she says.

Metro Nashville Public Schools employs 70 full-time and two part-time psychologists for its 86,000 students. Only three Metro Nashville schools have a full-time school psychologist. A contract service provides psychologists for about 15 schools.

"We have not hired school psychologists at the rate we would hire if state funding was appropriate for the ratio of school psychologist to students," says Dawn Rutledge, Metro Schools public information officer.

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Costs can be a barrier to care

To fill the gaps, many Tennessee school districts create partnerships with nonprofit community health organizations, including Centerstone, the Mental Health Co-Op and STARS.

Centerstone provided therapists for about 300 Middle Tennessee schools during the 2017-18 school year, including 55 elementary and middle schools in Davidson County.

A steady presence makes it easier for school-based therapists to observe students. They are not a stranger in the hallways, which makes assessment, diagnosis and treatment more comfortable.

In general, the school systems have not paid for these services. TennCare is the most common form of payment for school-based therapy at Centerstone. There are self-pay and private insurance clients as well, plus some grant funding in select districts.

STARS supports its $4 million school-based programs in part through individual donor contributions, grants, United Way support and $1.6 million in contract services with Davidson, Rutherford, Sumner, Williamson and Wilson county schools.

In Maury County, Centerstone and Mental Health Co-Op therapists come in once a week. But mental health resources have not kept up with increased needs among children, says Owens, the counselor at E. A. Cox Middle School.

While children on TennCare can access a variety of mental health services, children on private insurance often face waiting lists to see private psychologists or limited coverage that leaves parents unable to pay copays. Children without insurance have an even greater challenge.

"There’s not much paid for by private insurance," Owens says. "A child who needs two or three sessions a week at $70 or $80 each may have insurance that pays just a few dollars of that. Many parents can’t afford to come up with the rest.”

Owens said school counselors often spend their time scrambling to find free or low-cost services for children, including faith-based services and local nonprofits.

There was a time only a couple of years ago when Leatherman, the Nashville parent, was attending college to get a medical assistant degree while working three jobs at Save-a-Lot, Hair World and McDonald's. She didn’t have time or money to take her son Johnathan to see a therapist outside of school.

Now that school-based therapy is no longer an option, she takes him to see a therapist at his pediatrician's office. But, she says, it is a challenge getting them to understand him.

"They don’t see him every day. They don’t know how he acts, because they aren’t there to see it."

Reach Jessica Bliss at 615-259-8253 and jbliss@tennessean.com or on Twitter @jlbliss.

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Religious people tend to turn to clergy for help and support in times of trouble. 

But when that trouble manifests as a mental health issue, odds are their pastor or rabbi is not well-equipped to respond effectively, said Jared Pingleton, a licensed clinical psychologist.

"They were trained in theology," said Pingleton, clinical director for the American Association of Christian Counselors.

"They're not trained to deal with that 2 o'clock call with a suicidal emergency," Pingleton said. "They're not trained to know how to care or cope with people who are in the throws throes of a serious depression controlled by an addictive substance or behavior or headed to a divorce lawyer." 

That is the reality for the Rev. Jim Hughes, who leads Belle Meade United Methodist Church.

It is not that Hughes doesn't want to help his 400 or so church members, but he knows from 43 years of ministry experience that professional counselors are far more effective than he could ever be at addressing mental health issues. 

"I tend to kind of limit myself to three conversations," Hughes said. "If whatever is going on with somebody can't be really addressed and gotten on a good path, if that can't be done in three, they need to be referred." 

Sermons on mental health, list of resources key

The stakes can be high for how pastors respond, too. An oblique or cursory response can leave someone feeling dismissed, intensifying a person's shame, Pingleton said. And a mental health crisis for someone who is suicidal can be a matter of life and death. 

But strides are being made in the faith community on how to recognize and address mental health needs.   

More and more, seminaries and Bible schools are introducing their students to mental health issues, Pingleton said. Churches, especially large, healthy and progressive congregations, are adding counseling staff to their ministry teams, he said. 

Just 14 percent of churches have a counselor on staff trained in mental illness and 13 percent train leaders to recognize the signs, according to a 2014 LifeWay Research survey of Protestant pastors. Only 27 percent have a plan to assist families affected by mental illness. 

Pastors need to preach about mental health, acknowledging the reality of the issues, Pingleton said. According to the LifeWay Research survey, 49 percent of pastors rarely or never speak about acute mental illness in sermons or large group messages. 

"When there is a sermon about mental and relational health needs, that ends the silence, it eliminates the shame and it erases the stigma," Pingleton said.  

Clergy members also need to build a list of trusted counseling professionals they can refer congregation members to in times of need, Pingleton said. 

"They need to learn the art of making an effective referral," Pingleton said. "You need to make sure the parishioner or congregant isn't offended or feels rejected."

At Belle Meade United Methodist, Hughes has a resource list for moments when needs go beyond his abilities.

The church also opened its doors in the last year to a counseling center led by a licensed clinical pastoral therapist. They see it as a ministry of the church, but it serves the wider community. The first visit is free for church members, and follow-ups are offered on a sliding scale. Hughes has already referred church members to it. 

To offset the financial cost of therapy, the church received a grant to help seniors pay for it. The rent the counseling center pays the church goes into a fund to assist those who need financial help. 

It is not just congregation members seeking help from the Belle Meade church, which is in an affluent part of the city and located on a bus line and major thoroughfare. Hughes receives calls and visits from those experiencing homelessness or those recently released from jail who are in need of help. Mental illness and addiction are present in both populations. 

"Most clergy are not equipped. We might pretend like we are, but we're not," Hughes said. "We need these resources. We need to be able to put people in the right hands." 

Reach Holly Meyer at hmeyer@tennessean.com or 615-259-8241 and on Twitter @HollyAMeyer. 

When a sick kid steps into the pediatrician’s office, it could be for just about anything: an ear infection, a twisted ankle or an upset stomach. And sometimes, behind all those outward symptoms, there is something deeper that needs attention.

Pediatricians and family doctors have long served a crucial but largely undefined role in American mental health care, diagnosing and treating depression and anxiety in addition to everyday physical injuries and common diseases.

Dr. Nathaniel Clark, chief medical officer at Vanderbilt Behavioral Health, described the task of primary care doctors as challenging: They are the Swiss army knives of medicine, expected to do a little of everything, but also a front-line defense in a growing mental health crisis.

“As health care has become more complicated, the pressure on family care providers to do it all has increased exponentially,” Clark said.

“The challenge for family practitioners and pediatricians is partly that, while they have excellent training, it’s not necessarily focused on behavioral health.”

Psychiatrists are in short supply throughout Tennessee and nationwide, so the vast majority of mental health disorders are diagnosed and treated by primary care doctors. Nearly all these doctors studied mental health at one point because a psychiatry rotation is mandatory in most medical schools. But once school is done, the amount of continuing education they get in the field of mental health varies broadly.

In Tennessee, the governor's office has led an initiative called "Building Strong Brains," funded with $1.25 million from state lawmakers the past two years, including grant funding for mental health education for pediatricians and other doctors.

Training primarily focuses on the link between early-age childhood trauma, officially known as "adverse childhood experiences," and teenagers with behavioral and physical health problems.

In addition to the Building Strong Brains program, the Tennessee Chapter of the American Academy of Pediatrics has launched the Behavioral Healthcare in Pediatrics training program,or BeHIP, in which doctors learn from real cases of children with complex mental health diagnoses.

The program started small, uniting about five pediatricians in the state’s northeast corner, but is now expanding into Knoxville. Organizers hope to expand it statewide, said Dr. Michelle Fiscus, BeHIP medical director.

Participating doctors discuss challenging mental health cases within Tennessee's children protective services system, Fiscus said. That experience should make the doctors' interaction with other patients with depression or attention deficit disorders "much less intimidating."  

Fiscus, a Franklin pediatrician, said she envisioned the BeHIP training program in part because of an uncertainty she felt when treating mental health patients years ago. Too many other doctors, she said, still feel the same way.

“Across the state, it’s not the biggest topic that pediatricians want to treat,” Fiscus said. “Because it’s so large and so broad, sometimes they don’t know where to start when it comes to mental health.”

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Jessica Bliss contributed to this report.

Brett Kelman is the health care reporter for The Tennessean. He can be reached at 615-259-8287 or at brett.kelman@tennessean.com. Follow him on Twitter at @brettkelman.