Engaging families in school-based mental health treatment.

Increasing populations of students are unprepared for learning due to emotional or behavioral problems. Yet, school-based mental health services are fragmented, marginalized, and underutilized. Despite the federal mandate to improve all student achievement and an increased ability to identify students needing mental health services, school-based mental health services are noticeably absent from school reform initiatives. The research clearly shows family involvement in school-based mental health services is effective in improving student academic performance. By understanding barriers to school-based mental health counseling services and strategies for increasing family enrollment and retention, mental health counselors can help increase students' academic readiness and the integration of mental health services into the structure of the nation's schools.

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Students' academic success is a determining factor in successful accomplishment of life tasks and depends greatly on the students' psychological health as well as academic abilities (Becker & Luthar, 2002; Cerio, 1997). Yet, the Surgeon General's 1999 report of children's and adolescent's mental health showed 21% of U.S. children from ages 9 to 17 have diagnosable mental health problems and 70% of those youths do not receive services (U.S. Department of Health and Human Services [USDHHS], 1999). Of the families who do receive services, 40% to 60% terminate prematurely. Researchers have looked at why students in need of mental health services are not receiving services and whether the services students are receiving are effective (USDHHS). Students' underutilization of mental health services has been due to structural barriers, including fragmented and marginalized school-based mental health services, and perceptual barriers (see Figure 1) due to beliefs about mental health problems and services (Adelman & Taylor, 2002a, 2002b, 2002c; Keys & Bemak, 1997). When students do use school-based mental health services, defined as any mental health services along the continuum from prevention to intervention that are initiated through the school, researchers have found family involvement is a key component to both service utilization and effectiveness (Cerio). Although the research on involving families in school-based mental health services has been limited, a review of the literature indicates mental health counselors who are aware of the barriers can increase effective service provision and family involvement. (Edwards, 2002; Fox, Dunlap, & Powell, 2002; Heyne, King, Tonge, & Cooper, 2001; Rones & Hoagwood, 2000).

Schools have several advantages in addressing the mental health needs of students. Schools have a stake in identifying students with emotional and behavioral problems because these issues significantly affect the students' academic performance (Adelman & Taylor, 2002a, 2002b, 2002c). Schools face recent federal and state governmental pressures since the federal legislation and state high-stakes testing were enacted to ensure that every child could meet mandatory academic standards. Schools also have professionals, including teachers, social workers, and school counselors, who can be trained to identify emotional and behavioral problems and are involved with the students most of the day. Schools also have the ability to access federal, state, and community resources to address students' needs (Brener, Martindale, & Weist, 2001; Keys & Bemak, 1997). For example, schools (a) can access federal funds to coordinate student support services since the U.S. Department of Education's Improving America's Schools Act; (b) have access to the two national training and technical assistance centers for improving school-based mental health (Brener et al.); and (c) have federal funding priority for school-based services (Keys & Bemak). Also, schools can plan with other service providers and helping institutions such as community mental health, juvenile justice, social welfare, faith-based groups, parks and recreation, and libraries (Keys & Bemak). Because children spend a large part of their lives in school, schools are able to be a focal point for service delivery (Adelman & Taylor, 2002a, 2002b, 2002c; Keys & Bemak; Rones & Hoagwood, 2000). Of those 30% of children and adolescents in need who received services and had both a diagnosis and impaired functioning, about 40% received services in the specialty mental health sector, about 70% received services from the schools, about 11% from the health sector, about 16% from the child welfare sector, and about 4% from the juvenile justice sector, according to the Surgeon General's report (USDHHS, 1999).

Clearly, it is vital for research to adequately explain the lack of parental use of and retention in available services to increase their children's success in school by decreasing emotional and behavioral problems. Research that can accurately predict factors that effect parental participation could guide schools in making decisions about the design, implementation, and management of student mental health programs. McCurdy & Daro (2001, p 113) suggested "parental decisions to enroll and remain in support programs are shaped by a variety of factors at different 'levels' of influence: individual characteristics of the parent and family, provider attributes, program characteristics, and neighborhood characteristics." Barriers to enrollment and retention can be categorized (Owens, Hoagwood, & Horwitz, 2002) as: (a) structural-lack of services, delays between service referral and initiation, no insurance or ability to pay, lack of transportation, conflicts between service hours and work, childcare conflicts; (b) perceptions of mental health problems-school or families inability to identify students need for mental health services, denial of problem severity, beliefs the problem can be addressed without treatment; and (c) perceptions of mental health services--lack of trust, negative experiences, stigma related to mental health, student refusal, belief that services are not effective. With the knowledge of barriers to family involvement in school-based mental health services, mental health counselors can increase the efficacy of current services and work toward quality school-based mental health services.

FAMILY INVOLVEMENT

A review of the family systems approach research shows it has been equally or more effective than other therapy, produces positive change quickly (20 sessions or less), and shows a 71% improvement in children's behavioral problems (Carter & McGoldrick, 1999; Cerio, 1997; Farmer, Quinn, Hussey, & Holahan, 2001; Mullis & Edwards, 2001). The family systems approach focuses on the interaction problems within the family, instead of on the individual as the problem (Cerio). A study of the use of family therapy for children with school phobia, who did not benefit from other interventions including behavior management and individual counseling, found a child had no reoccurrence of school phobia at 2 months and 2 years (Cerio). The focus of treatment was on the family and school system, not just the child. Additional researchers have found that involving families in treatment, whatever the approach (Rones & Hoagwood, 2000), has been effective in improving academic performance in students with problems including violence (Stein et al., 2002), attention-deficit/hyperactivity disorder combined type (Edwards, 2002), school refusal (Heyne et al., 2001), early childhood problems (Fox et al., 2002), adolescent problems, conduct disorder, and substance abuse (Rones & Hoagwood). Other research has demonstrated students improve behavior and have increased emotional development with parent involvement in school activities, without therapy (Gonzalez, 2002; Pena, 2000). Heyne et al. noted that parent distress or mental health impairment may negatively effect student outcomes and would require clinical intervention.

Yet, school employees may be reluctant to involve parents in their children's school-based mental health treatment (Cerio, 1997). Because school counselors, school psychologists, and school social workers are public servants, it can be difficult for them to ask parents to focus on the family as the solution to children's difficulties. The schools often focus on systems such as teachers, administrators, and social service agencies to "fix the child" (Cerio, p. 189). And finally, school counselors are not often trained in family systems counseling and so do not understand the efficacy of the approach (Cerio; Mullis & Edwards, 2001). School administrative level issues may also affect parent involvement in children's school-based mental health treatment (Armbruster, 2002). Each school has its own culture that affects employees' attitudes toward school-based mental health treatment. The administration may communicate beliefs about the value of mental health services that discourage referrals for those services. The administration may not provide training for school personnel on identifying students with emotional and behavioral health problems or mental health resources in the community. Individual schools may not be willing to refer students with behavioral or emotional problems to mental health services. And schools may not be open to providing access to students for services.

STRUCTURAL BARRIERS

The structure of school-based mental health services is one of the key barriers to families' participation in mental health services (Owens et al., 2002; Adelman & Taylor, 2002a). Students' lack of services has been attributed to the fragmentation of school-based mental health services, which are often developed to address specific issues and focus only on improving academic or career skills and decreasing disruptive behavior (Adelman & Taylor; Becker & Luthar, 2002). Decreases in resources and increases in student numbers have further frustrated schools' attempts to address the rising number of students who disrupt the academic environment or are unprepared to learn due to emotional or behavioral health problems (Keys & Bemak, 1997). These problems affect schools with predominately low socioeconomic student bodies disproportionately, with about 15% of students arriving at school ready to learn versus about 75% of students at schools with a majority of high socioeconomic status students (Adelman & Taylor). Yet schools across the nation do not appear to link barriers to academic achievement to the need to obtain emotional or behavioral health services for these students. Rather there appear to be no coordinated efforts to adequately assess the needs of students with emotional or behavioral health problems, design comprehensive mental health treatment programs for their needs, and determine if families will engage in and be retained in treatment until successful completion (Adelman & Taylor). Further, schools that do offer mental health programs often find them underused (McCurdy & Daro, 2001).

Currently mental health services in schools are focused on addressing mental health problems that disrupt the classroom or school environment. Advocates for school-based mental health reform have proposed redefining mental health in schools to include "promotion of social and emotional development and efforts to address psychosocial and mental health problems as major barriers to learning" (Adelman & Taylor, 2002a, p. 10). Rather than expanding the current structure of issue-focused services depending on diverse funding sources (Fox et al., 2002), school-based mental health reformers proposed "comprehensive, multifaceted approaches that help ensure schools are caring and supportive places that maximize learning and well-being and strengthen students, families, schools, and neighborhoods" (Adelman & Taylor, p. 8). A multifaceted approach would create a continuum of interventions that begins with a school district-wide promotion of health development and preventing problems. Individual schools would be able to identify mental health problems early and respond immediately. And the schools would have access to treatment for severe or chronic problems. The first step is to increase education reformers' understanding of the impossibility of raising student achievement scores without addressing social and emotional barriers to learning. The current view of many school administrators is that schools are not the appropriate place for mental health interventions and the services take time away from education and infringe on family rights and values (Brener et al., 2001). This view has increased with new school accountability laws and pressures for student academic achievement. Clearly this prevailing view creates a significant barrier to family participation in school-based mental health services.

Research has demonstrated that mental health problems ranging from skills deficits to mental illness profoundly effect academic achievement (Adelman & Taylor, 2002a). Conversely, mental health problems are exacerbated when students experience the resulting poor academic performance or punishment for behaviors associated with academic failure (Strein, Hoagwood, & Cohn, 2003). Many of the almost 91,000 public schools in about 15,000 school districts have taken advantage of funding initiatives to address some of these barriers to education including teen pregnancy, violence, and substance abuse (Weist, 2001). The result is a large body of research on mental health programs that range from prevention through positive emotional and social development to intervention for mental illness (Rones & Hoagwood, 2000). Many of the results are promising (Strein et al.), especially when parents are involved. Psychosocial interventions have shown benefits for schools such as increased attendance, reduced violence, and fewer dropouts (Taylor & Adelman, 2000). For society, the benefits of these interventions include increased employment, decreased needs for emergency health services, and fewer demands on social services. For individuals, psychosocial interventions have improved attention and effort.

Once school districts make a commitment to decreasing barriers to education through mental health services, they must include school-based mental health services as a "fundamental and essential facet of education reform and school and community agency restructuring" (Adelman & Taylor, 2002a, p.23). Making school-based mental health services an integral part of school reform means creating district-wide policy and practice based on children's mental health needs and resources in the community. Part of this approach would include integrating all categorical programs such as programs for emotionally handicapped students, safe and drug-free school programs, community mental health, etc. to assure steady funding for a comprehensive approach (Adelman & Taylor; Arellano & Arman, 2002). District-wide policy and practice based on community resources would include coordinating services with other mental health service providers and support programs including juvenile justice, community mental health, social welfare, faith-based groups, libraries, and parks and recreation (Keys & Bemak, 1997).

Once schools integrate mental health with ongoing school reform, the role of student services professionals and community-based mental health providers must be clarified to eliminate current conflicts (Adelman & Taylor, 2002a, 2002b, 2002c; Arellano & Arman, 2002). Student services personnel often view community-based mental health providers as threatening to their jobs and discounting their skills. Community-based mental health providers often are naive about the school culture and feel unappreciated due to conflicts over removing children from academics for services, space, confidentiality, and liability. Finally, community-based mental health providers often are in conflict with each other over limited funding resources. One center for mental health in schools supports changing the roles, functions, preparation, and credentialing of student services personnel, which includes school counselors, school psychologists, and school social workers (Adelman & Taylor, 2002c). Currently, student services personnel are often funded to carry out narrow mandates, are assigned to multiple schools, share limited space, and have many assigned duties outside of mental health services (e.g., lunch room duty, bus loop duty, testing for exceptional student education; Taylor & Adelman, 2000). Taylor & Adelman proposed student services personnel would have a central role in education reform as advocates for student and family needs and as facilitators of systemic reform within schools and school districts. Student services personnel would include work within the community to identify the mental health needs of students and make decisions for how resources would be allocated. These school personnel would plan mental health services in the schools, implement the services, and then assure the services were maintained and evaluated. Part of the implementation of services would include student services personnel creating partnerships with community providers of mental health services, and school personnel would also ensure mental health providers were using evidence-based and best practices in mental health services. Finally, student services personnel would ensure cross training of school personnel in mental health development, identification of risk factors and strengths, and information on mental health prevention and intervention.

With mental health policy and procedures in place, student services personnel will have the ability to provide early detection of risk factors and ongoing support for protective factors. Cunningham & Sandhu (2000) have identified the risk and protective factors that predict children's development or avoidance of emotional and behavioral problems. The risk factors occur at the individual, family, school, peer, community, and neighborhood levels. Specific risk factors were found to be important at specific developmental stages. For example, family conflict may be an important risk factor for preschool children, while academic failure may be the salient risk factor for older children. And when more risk factors were present, youth were more likely to exhibit problem behaviors across a range of problems such as violence, drug use, school drop out, delinquency, and teen pregnancy. Some of the risk factors include students' early initiation of problem behaviors, difficult temperaments, poor social skills, poor family management practices, low family bonding, family conflict, academic failure, low school bonding, siblings with problem behaviors, peers with problem behaviors, poverty, and low community organization.

The risk factors can be positively influenced by protective factors, including individual characteristics (e.g., gender, resilient temperament, positive social orientation, intelligence), attachment to larger systems (e.g., family, school, peer, community), and "healthy beliefs and clear standards for behavior" (Cunningham & Sandhu, 2000, p. 126; Dukes & Stein, 2001). These resilience factors in children and youth have been summarized as "social competence, autonomy, problem-solving skills, and a sense of purpose and future" (Cunningham & Sandhu, p. 127). To develop resilience factors in students, the research suggests strategies be used across the larger systems, including families. Further, research demonstrates that risk factors and resilience factors influence each other in an interconnected system of "correlated constraints" between the individual and the larger systems of the family, school, peers, and community (Farmer et al., 2001, p.117). Farmer et al. state:

   When the system is organized around positive factors, correlated
   constraints promote positive adjustment and protect against the
   development of problematic behavior patterns. Conversely, when the
   system is organized around risk factors, correlated constraints
   promote maladaptive behavior patterns and inhibit positive
   adjustment. (p. 117)

These findings should play an important role in student services personnel's decisions about appropriate service recommendation and communication with parents about children's emotional and behavioral challenges in school (Stein et al., 2002). This systemic influence on children and youth affects schools' attempts to improve students' emotional and behavioral problems through skills training alone (Farmer et al., 2001). These programs often have been ineffective due to the correlated constraints in a student's life, influencing the return or maintenance of the problem behavior.

There are current programs that have demonstrated the possibility of creating collaborative, multiagency programs that served the mental health needs of children and families as described in this article (Arellano & Arman, 2002; Stein et al., 2002). These programs have not, however, provided outcome research to determine the efficacy of the approach.

PERCEPTUAL BARRIERS

When schools do attempt to engage families in the treatment of their children's emotional or behavioral problems, many parents do not enroll in those services, or the programs have high attrition rates (McCurdy & Daro, 2001). The Surgeon General's report identified the most likely reasons for under-utilization as: "perceptions that treatments are not relevant or are too demanding or that stigma is associated with mental health services; the reluctance of parents and children to seek treatment; dissatisfaction with services; and the cost of treatment" (USDHHS, 1999, p. 180). The research on enrollment and retention in treatment has significant flaws due to a narrow focus on participant and provider characteristics (McCurdy & Daro; Owens et al., 2002). The focus on participant and provider characteristics has often provided contradictory results that are of little help in developing programs and policies to enhance parent enrollment and retention rates. The research has also focused on mothers, not fathers or other caregivers. The lack of males in research may account for more weight on attitudes about opinions of others and less on aversive emotions and attributions of efficacy of treatment (Wilson & Deane, 2001). "Most of the research on dropping out has focused exclusively on examining demographic or diagnostic correlates of dropping out, and few researchers have directly asked the children or their parents about their reasons for discontinuing treatment" (USDHHS, p. 180). The question of why parents do not enroll or are not retained in available programs is important in order to predict behavior from recruitment to program termination (McCurdy & Daro).

Recently, more researchers are identifying family attitudes as an important part of enrollment and retention (Fox et al., 2002). Researchers have begun looking at barriers to mental health services: program attributes, neighborhood characteristics or interactions across domains (i.e., individual, provider, program, and neighborhood; Fox et al.; Owens et al., 2002; Strein et al., 2003). Families may encounter barriers due to program attributes such as staff training, staff caseloads, staff fluctuations, location of services, program type (i.e., public, private, nonprofit), and stability of program funding. Families that encounter mental health providers who are not trained in evidence-based or best practices services may form a negative view of mental health services. If families experience undependable or disrupted service due to staffing problems, this discontinuity of services may add to negative perceptions of mental health services. Many families may view transportation and payment requirements as barriers to obtaining mental health services. When these barriers exist, parent characteristics such as psychopathology, unemployment, divorce, and parenting difficulties may increase the families' negative perception of services. Parent psychopathology may influence parents' ability to identify children's needs, parents' perceptions about mental health services and problems, and parents' ability to negotiate the mental health care system (Owens et al.). Studies of the interactions of provider and participant characteristics may also help understand keys to parent retention in services (McCurdy & Daro, 2001). Studies have identified communication styles and mutual understanding of the perceived problem as determinants in parent involvement, but have varied definitions and measurements of these constructs. Multicultural competencies are vital for communication with families and "to relate to the cultural context that defines the family" (Fox et al., 2002, p. 213).

The ability of the school-based mental health service provider to understand cultural differences may be "pivotal in recruiting family involvement and participation" (Fox et al.). School personnel and mental health providers would need to understand cultural differences in family structures; attitudes about mental health, school achievement, counseling services and styles of problem solving; and help-seeking behavior (Keys & Bemak, 1997). Research of adolescent help-seeking behavior has added relationships with mental health professionals and trust with those professionals as significant factors to overcoming barriers (Wilson & Deane, 2001).

Although parents express support for programs, they do not use them (McCurdy & Daro, 2001; USDHHS, 1999). While attitudes do not predict behavior, individuals' stated intentions toward a behavior help explain initiation of participation (McCurdy & Daro; Owens et al., 2002). So the first step in engaging parents would be to elicit their intention to participate (McCurdy & Daro). In a literature review of the health psychology field, McCurdy & Daro identified three constructs that predict intent. The parents' perception of the need for service, their child's at-risk status, is the first construct that partially determines the decision to engage in services. Second, theorists have pointed out that the parents' perception of costs versus benefits affects their decision process. Parents who perceive the benefits of a program (i.e., its effectiveness) to be great may be more likely to participate; whereas parents who believe their current support network is providing needed assistance are less likely to participate. Third, research found that the parents' readiness for change or action affects participation in programs. Research from addictions, primary care, and AIDS prevention suggests that some populations are more likely to participate if they are at the higher stages of change as defined in Prochaska and DiClimente's model (Prochaska & DiClemente, 1984). Their stages, ranging from low to high, are (a) precontemplation, not thinking about action; (b) contemplation, considering action; (c) preparation, readiness for change; (d) engagement, action; and (e) maintenance, preserving change. Also, research (McCurdy & Daro) has found that a parent's perception of a family's and friends' support for the decision will affect the parent's decision, and the parent's past experience with similar programs will also affect the parent's decisions. Finally, neighborhood characteristics that may effect parent involvement include the degree of interpersonal ties, neighborhood norms and sanctions, information, stability, opportunity, and quality of life.

Based on previous research, McCurdy and Daro (2001) proposed a theory of parent involvement that considers the effects of individual characteristics, provider attributes, program characteristics, and neighborhood context on the intent to enroll, enrollment, and retention. The theory proposes that different factors are more influential at different phases of parent involvement. The intent to enroll is affected by individual characteristics including the parent's internal beliefs, attitudes, and perceptions. Provider characteristics that affect parent decisions to enroll include the provider's cultural competence (Fox et al., 2002; Keys & Bemak, 1997; Pena, 2000) and service delivery style. The relevant service delivery style factors are communication style, a described focus of the service (i.e., parent, child or parent and child), and a match between the actual service and the presented service goal (e.g., support, parenting improvement, improved child functioning, or combination of these). Program factors that affect parent decisions include whether the services are state welfare, private, or nonprofit. Neighborhood factors include the social capital construct; that is, knowledge about and the ability to access similar services elsewhere, and social disorganization (e.g., poverty, crime, instability).

Parents' enrollment is influenced by both individual and program factors (McCurdy & Daro, 2001). Individuals' subjective norms, the stated values of family and friends, effect enrollment. Parents may refuse services if family members do not want a provider coming into the home; or if the family members remain neutral, parents may enroll so long as the service provider does not come into the home or does not ask family members to be involved. Program factors that effect enrollment are the length of time between enrollment and services beginning, with a longer time resulting in less retention. The longer time may allow new information to influence parent's attitudes, perceptions of the program's costs versus benefits, or understanding of subjective norms.

Once the parents participate in services, provider and program factors become stronger influences on retention than individual or neighborhood factors (McCurdy & Daro, 2001), retention depending on the parent's objective program experience, regular services, stable providers, and concrete service incentives of tangible goods (e.g., food, clothing, transportation services). Subjective judgments by parents also affect retention, with parents being influenced by initial presentation of goals, a strong match between program and personal goals, the provider meeting participants' expectations, service delivery being consistent with participant expectations, and perceived benefits continuing to outweigh costs. Provider factors that are important are provider's capabilities, especially cultural competence and service delivery style, with effective service delivery styles contingent on lower caseloads and comprehensive training. Program factors effecting retention are low supervisory caseloads that help support direct service personnel and avoid frustration and burn out; stable funding for smooth service delivery and reduced staff turnover; and tangible incentives. Although there is little research on the effect of neighborhood factors on retention, social cohesion (e.g., shared values, trust, favorable perceptions of the program) was proposed as a factor. Social cohesion includes shared values, trust and favorable perceptions of the program.

IMPLICATIONS FOR MENTAL HEALTH COUNSELORS

Now is an important time for mental health counselors interested in working with children and their families. The federal government's focus on school reform and meeting the mental health needs of students provides mental health counselors with the unique opportunity to work with school service personnel to advocate for effective and comprehensive mental health services in the schools. School-based mental health counselors must have the required training and supervision to be able to provide effective family services. For instance, mental health counselors may need additional training to increase their understanding of the school culture in order to work in partnership with school personnel to assess individual school service needs. The importance of mental health services becoming an integral part of school reform also requires adequate research into the best policies and practices to overcome barriers to families, including structural and perceptual barriers.

Perhaps most important, though, is that mental health counselors keep informed on barriers to family enrollment and retention and use that information with each new family served. During the initial contact and first session, mental health counselors can include assessment of structural and perception barriers and work to overcome them with the family. By understanding and assessing families' perception of the need for services, personal goals, the costs versus the benefits of services and stage of change, mental health counselors can better match their service delivery style to the families' unique characteristics and thereby optimize retention. Providing the best practices in mental health services, including cultural competency, and continuous assessment of progress may increase families' satisfaction, and progress. Satisfied families who share their experiences may be an important influence on other students' families.

The current research demonstrates the importance of mental health counselors working collaboratively with student service personnel by providing services and examining existing barriers in the schools (Adelman & Taylor, 2002a, 2002b, 2002c; McCurdy & Daro, 2001; Owens et al., 2002; Taylor & Adelman, 2000; USDHHS, 1999). Although some barriers may require school administration interventions, mental health counselors may be able to overcome many barriers through educating school staff and parents about mental health development, mental health risk and protective factors, efficacy of mental health treatments, and the relationship between mental health treatment and academic success. Also, mental health counselors can affect family perceptions by offering groups for students and parents on common mental health and parenting challenges identified as problem areas within the individual school as well as groups to promote mental health development and prevent problems. At the program level, mental health counseling supervisors can maintain reasonable caseloads, ensure cultural competence, provide evidenced-based family systems training and supervision, supervise for best practices, and support direct service personnel (Armbruster, 2002). It will be important also for supervisors to advocate within schools for adequate funding for services and minimal staff turnover, although funding issues may be a much broader based district, state, or federal political issue. Finally, mental health counselors can make significant contributions to meeting the mental health needs of students through continued education about and research into barriers to families' enrollment and retention in school-based mental health services, focusing on structural and perception barriers from family enrollment through retention. By following these recommendations to engage families in school-based mental health treatment, mental health counselors can help increase student's academic success and success in life.

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Stein, B. D., Kataoka, S., Jaycox, L. H., Wong, M., Fink, A., Escudero, P., & Zaragoza, C. (2002). Theoretical basis and program design of a school-based mental health intervention for traumatized immigrant children: A collaborative research partnership. The Journal of Behavioral Health Services and Research, 29, 318-326.

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Wilson, C. J., & Deane, F. P. (2001). Adolescent opinions about reducing help-seeking barriers and increasing appropriate help engagement. Journal of Educational And Psychological Consultation, 12, 345-364.

Linda M. Vanderbleek is a clinical supervisor, Circles of Care, Inc., and a doctoral student, University of Central Florida, Orlando. E-mail: [e-mail]