Psychotherapy research often focuses on the client and the psychotherapist, but rarely on other stakeholders. This is reasonable given that the client and the psychotherapist are the sole players in a psychotherapy session; understanding how they each contribute to the session will illuminate a significant part of the process and outcome of psychotherapy. However, one may argue that other stakeholders also play an important role because their actions determine whether psychotherapy could happen in the first place. One such stakeholder is schoolteachers. Because most children and adolescents spend a large amount of time at school and interact with teachers almost daily, teachers are in the position to notice student problems and provide appropriate assistance (Department of Health, 2004). Given that children and adolescents may not always be aware or be able to articulate their mental health-related needs and seek help independently, the ability for teachers to refer students with such needs to mental health professionals (MHPs) is especially crucial. Understanding how teachers make referral decisions will inform psychotherapists about how they can be better collaborators with teachers and schools to improve referral practice and student mental health.

Method

In this study, 12 secondary school teachers (8 women, 4 men; age M = 44.0 years, SD = 7.5; teaching experience M = 20.8 years, SD = 7.7) were recruited to participate in an interview about referring students for professional psychological help. In particular, they were asked about situations when they considered referring students, factors that facilitated referrals, and factors that hindered referrals. The interviews were transcribed verbatim and analyzed using consensual qualitative research (CQR; Hill, 2012), which consists of three analytic steps: Domain, Core Ideas, and Cross Analysis. First, sections of a transcript were assigned to domains according to topic areas. Next, core ideas were extracted by summarizing the assigned section of the transcript that appeared in each domain. Finally, in cross analysis, categories comprising of common themes across transcripts were derived from the extracted core ideas.

Each step of the data analysis was conducted via consensual discussion among coders within the research team to minimize the influence of individual researcher bias. The research team coders consisted of a male counseling psychologist, a female educational psychologist, and a male research assistant with a Bachelor’s degree in psychology. The team’s coding was also sent to two external auditors who were female professors with a background in educational policy and qualitative research. Auditors reviewed the team’s work to ensure that the findings and interpretations were consistent with the data.

Findings

The teacher participants reported a number of factors that influenced their decision to refer students for professional psychological help. These included teacher factors (e.g., self-efficacy in handling student issue), student factors (e.g., problem severity and duration, willingness to be referred, familiarity with professional support, stigma of mental illness and help seeking), parent factors (e.g., beliefs about the usefulness of referral, level of trust and collaboration with teacher), and MHP factors (e.g., perceived effectiveness, frequency of interaction with students, quality of interaction with teachers). In this article, we elaborate on findings that are relevant to psychotherapy practitioners and researchers.

Student Factors

Teachers typically attributed students’ unwillingness to be referred to unfamiliarity with the mental health profession (e.g., “they do not have experience talking to a social worker”).  Teachers also perceived that students attached stigma to being referred to MHPs (e.g., “don’t want others to know,” “care about what their teachers or classmates think”).

Parent Factors

The teacher participants noted that although parents generally had positive reactions to their child’s referral, they typically had reservations about the need or the effect of referral as well. In terms of positive reactions, parents typically welcomed the teacher’s referral if they trusted the teachers. One teacher said, “Some parents, especially those from low SES families, really trust our school. They can be quite clueless about what to do with their children, and so they really depend on us and trust that we can handle it.”

With respect to parental resistance, one teacher said, “A parent would get defensive and say, ‘My daughter does not have a problem, so there is no need for a referral.’” In addition, some parents worried that their children might be discriminated if others found out about their need for mental health services.

Mental Health Professional Factors

The teacher participants generally reported that they referred students to MHPs so that the students could receive professional interventions, such as individualized guidance, medication, and academic accommodation, which they themselves could not provide. For example, one teacher said:

The social worker can do some parenting work with the parents…better for them to do it than teachers because they have a professional role…The educational psychologist will also help meet with the parents, and some parents of children with special educational needs may have emotional problems. The support is better when there is more professional guidance.

The teacher participants generally described having positive experiences working with MHPs, but they also reported having some negative experiences with them. In terms of positive experiences, the participants thought that the MHPs they worked with were effective. For example, one teacher said, “I feel that they are really irreplaceable…teachers can’t really take over their roles, in terms of time, or the counseling-related knowledge. I think that’s important.” The teachers’ positive impressions also stemmed from having supportive collaboration and communication with MHPs, as well as from learning that their students could have regular appointments with MHPs. On the other hand, teachers attributed their negative experiences working with MHPs to the MHPs’ ineffectiveness (e.g., “the effect was not very obvious,” “the condition was not ideal”) and the lack of communication. In particular, the teacher participants reported that it would be desirable if they could interact with the MHPs more frequently so that they feel comfortable consulting with MHPs on student issues when the need arises. They also noted that the high turnover of some MHPs prevented such interactions from happening and they felt less confident about the MHPs’ level of commitment to their students.

Discussion

Previous studies show that there are often delays between the onset of mental illness and the first appointment a person has with a MHP, and the shortening of this lag time is crucial to reduce illness burden and improve quality of life (MacDonald et al., 2018). The present study sought to uncover reasons that limit timely mental health intervention in school-aged adolescents, with attention on factors influencing teachers who often serve as mental health gatekeepers and first responders for students-in-need (Mo et al., 2018).

The findings show that teachers may hesitate to refer students if the students are resistant to the referral. Such resistance may stem from the stigma of mental illness and help-seeking and/or the lack of familiarity with mental health interventions. Indeed, adolescents’ striving for autonomy and in-group membership conflicts with the act of help-seeking, which signals one’s reliance on others and the presence of needs that the majority may not have (Bolton Oetzel & Scherer, 2003). Many adolescents also hold negative stereotypes about psychotherapy based on media portrayals (Midgley et al., 2016), suggesting that an inaccurate understanding of the psychotherapeutic process may partly contribute to their resistance.

In terms of parent factors, the teacher participants reported that the parents were more receptive to their referral recommendations when the teacher-parent relationship was strong. This finding is consistent with previous findings where the strength of the teacher-parent relationship predicted the effectiveness of teacher-led psychological interventions (Sheridan et al., 2012). Teachers therefore need to build better teacher-parent relationships to facilitate the referral process.

Teacher participants noted that when MHPs could meet with students regularly and have quality interaction with them (e.g., supportive and collaborative with good communication), they have more positive impression of the MHPs. This finding is supported in the literature, where teachers who perceive service availability are more likely to refer students (Hinchliffe & Campbell, 2016), whereas a low MHP-to-population ratio, long wait times, and brief and infrequent consultations are deemed to have negative effects on the quality of service (Fong & Wong, 2016). In addition, teachers are more likely to consult with MHPs in the future if they have experienced effective collaboration and communication with them in the past (Cholewa et al., 2016). Thus, the quality of the relationships that MHPs have with students and teachers may influence teachers’ referral decisions.

Implications

The findings point to numerous ways psychotherapists can collaborate with teachers and schools in mental health promotion. For example, psychotherapists may design and conduct seminars that focus on reducing the stigma of mental illness and help-seeking for students, parents, and teachers (Nastasi, 2000). Psychotherapists may also work with teachers so that teachers are more prepared to discuss the benefits of psychotherapy with students and parents who are resistant to referrals. For instance, they can educate teachers on what happens in psychotherapy sessions so that teachers can be more concrete when talking to students about what to expect from the referral, as the common lack of familiarity with the psychotherapy process among adolescents may drive them away from seeking help (Midgley et al., 2016). Psychotherapists may also provide training on effective communication skills to teachers so that they can be better equipped to strengthen the teacher-parent relationship and facilitate the referral process. In addition, psychotherapists may consult with schools to outline the criteria and procedures for teachers to make referrals and conduct screening to identify students who are experiencing difficulties. When engaging in these activities at school, the regular interaction that psychotherapists have with teachers promotes teacher-psychotherapist trust and collaboration, thereby increasing the likelihood of referral success and positive student outcomes (Sheridan & Gutkin, 2000).

Acknowledgements

This study was supported by the Hong Kong Research Grants Council – General Research Fund (Ref: 14603519). Findings from this study was presented in part at the 53^rd International Meeting for the Society for Psychotherapy Research in Denver, Colorado, in July 2022. I thank Sarah Luk, Koon Kan Fung, Yanghua Huang, Po King Choi, and Yi-Lee Wong for their contributions to this study.

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Harold Chui, Ph.D.

Harold Chui is an assistant professor in the Department of Educational Psychology at The Chinese University of Hong Kong. His research interests include psychotherapy process and outcome, therapist factors, training and supervision, multicultural counseling, and teacher and student mental health. He is currently the committee chair for psychotherapy research in the Society for the Advancement of Psychotherapy and an associate editor for Psychotherapy.