Understanding the perspectives of school-based mental health professionals: a qualitative study on approaches to implementing multi-tiered systems of support for mental health

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Content Understanding the Perspectives of School-Based Mental Health Professionals: A Qualitative
Study on Approaches to Implementing Multi-Tiered Systems of Support for Mental Health
by
Morgan Elizabeth Evans
A Dissertation Presented to the
FACULTY OF THE USC ROSSIER SCHOOL OF EDUCATION
UNIVERSITY OF SOUTHERN CALIFORNIA
In Partial Fulfillment of the
Requirements for the Degree
DOCTOR OF EDUCATION
May 2025
Copyright 2025 Morgan Elizabeth Evans

1
Dedication
To my family and friends, your unwavering support, patience, and belief in me have
sustained me through this process. I want to thank my husband, Brandon Evans, for holding
down the fort at home and being my source of strength and encouragement throughout my
doctoral journey. To my son Jonah, who was born while I was writing this dissertation, I am so
happy that you will only know me as a Doctor and not as a student.

2
Acknowledgments
This dissertation represents the culmination of years of learning and growth in the field of
school-based mental health, which would not have been possible without the support and
guidance of many individuals.
First, I would like to express my deepest gratitude to my dissertation committee, Dr.
Kimberly Hirabayashi, Dr. Emily Hernandez, and Dr. Marsha Riggio, for their invaluable
feedback, encouragement, and expertise. Your insights and guidance have been instrumental in
shaping this research, and I am incredibly grateful for your time and commitment to my
academic journey.
I also sincerely appreciate the school-based mental health professionals who participated
in this study. Your willingness to share your experiences and perspectives made this research
possible and contributed to a deeper understanding of MTSS implementation for mental health.
To my peers and colleagues in the USC Educational Leadership Ed Psych Concentration,
Tanya Mercado, Lydia Fernandez, Martha Chacon, Desiree Corona Ramirez, Larry Leach,
Jeanette Villanueva, Connie Rivas, Anna Heinbuch, and Linda Dang, thank you for your
camaraderie, support, and shared experiences throughout this journey. The discussions,
challenges, and victories we navigated together have been invaluable.
To my wellness team, Michael Williams, Alexandra Ruesga, and Melissa Ashton. Much
of this work was inspired by your leadership and by the powerful example you set of how mental
health can be supported through the true spirit of teamwork. You may never fully realize how
much I have learned and grown as a leader by watching you in action.

3
Finally, I dedicate this work to the students, educators, and mental health professionals
who tirelessly advocate for comprehensive mental health support in schools. May this research
contribute to creating more inclusive and supportive educational environments.
Thank you all for being part of this journey.

4
Table of Contents
Dedication 1
Acknowledgments 2
Table of Contents 4
List of Figures and Tables 6
Abstract 7
Understanding the Perspectives of School-Based Mental Health Professionals: A Qualitative
Study on Approaches to Implementing Multi-Tiered Systems of Support for Mental Health 8
Literature Review 9
Mental Health Needs in Schools 9
Multi-Tiered Systems of Support 11
Tier One 12
Tier Two 13
Tier Three 14
Benefits of MTSS for Mental Health 15
School-Based Mental Health Professionals and MTSS 16
Positionality 19
Methods 20
Research Question 20
Context of the Study 20
Participants 21
Instrumentation 22
Data Collection 22
Data Analysis 23
Findings 24
Mental Health as a Shared Responsibility 24
Emphasis on Tier Three Interventions 26
Barriers to Targeted Interventions 27
Lack of Coherence in Tier One Implementation 29
Variability in Training and Practices 31
Discussion 33
Implications and Recommendations for Practice 36
Limitations and Recommendations for Further Research 39
Conclusion 40
References 42
Appendix A: Interview Protocol 50

5
List of Figures and Tables
Figure 1: Multi-Tiered System of Mental Health Supports 11
Table 1: Participant Information 20
Table 2: Study Findings 23

6
Abstract
This study explored how School-Based Mental Health Professionals (SBMHPs) implement
comprehensive mental health plans using the Multi-Tiered System of Support (MTSS)
model. The study addressed the following research question: How do SBMHPs describe
their approach to implementing MTSS-based mental health plans? Participants included
school-based social workers, licensed marriage and family therapists, licensed professional
clinical counselors, school psychologists, and school counselors currently employed in a
mid-sized school district in Southern California. This study utilized semi-structured
qualitative interviews from SBMHPs to generate detailed descriptions of MTSS
implementation. Key findings revealed that SBMHPs collaborate within interdisciplinary
teams of administrators, teachers, and other SBMHPs to support student mental health as a
shared responsibility. However, the high demand for individualized tier three interventions
limits their capacity to provide tier one and tier two supports. Barriers in mental health
identification systems hinder data-driven decision-making, reducing the effectiveness of
targeted tier two interventions and limiting structured, preventative support. Inconsistencies
exist in the implementation of tier one universal interventions across school sites.
Additionally, variability in SBMHP training and practices leads to inconsistencies in
applying the MTSS framework for mental health. These findings highlight the need for
training and systemic support to enhance the effectiveness of MTSS-based mental health
interventions in schools.

7
Understanding the Perspectives of School-Based Mental Health Professionals: A
Qualitative Study on Approaches to Implementing Multi-Tiered Systems of Support for
Mental Health
Mental health needs in schools have become a growing concern in a post-pandemic
society. In 2020, one in six (16%) children aged five to sixteen were identified as having a
probable mental health disorder, a notable increase from one in nine (10.8%) in 2017 (Woolf,
2022). In response to this rise, schools are increasingly turning to multi-tiered systems of support
(MTSS) as a strategic and equitable framework for delivering mental health services. MTSS
supports prevention, early identification, intervention, and data-based decision-making across
academic, behavioral, and social-emotional domains (McIntosh & Goodman, 2016; Walter et al.,
2019). MTSS aids in ensuring access to care for racial and ethnic minority students through
inclusive tier one interventions that affirm identity and combat discrimination (Malone et al.,
2022).
Despite the promise of MTSS, research highlights that implementation is often
inconsistent and incomplete. Missing components frequently include universal screening, use of
data to guide interventions, interdisciplinary collaboration, leadership support, and ongoing
technical assistance (Forman & Crystal, 2015; Giles-Kaye et al., 2023; Splett et al., 2018). The
absence of universal screening, in particular, results in informal and inconsistent identification
processes, limiting schools’ ability to respond to students' needs appropriately. A school culture
that supports team-based mental health approaches is also essential, as a lack of resources and
support staff can negatively impact educators’ commitment to student mental health (Giles-Kaye
et al., 2023).

8
School-based mental health professionals (SBMHPs) play a critical role in successfully
implementing MTSS for mental health. However, there is limited research on how SBMHPs
describe their use of MTSS and the resources that support or hinder their intervention delivery.
This study aimed to explore SBMHP perspectives on which areas of MTSS for mental health
have been implemented, what has facilitated their work, and what additional support is still
needed. Understanding these perspectives can help mid-sized school districts in Southern
California strengthen their MTSS implementation strategies for mental health. The study used
semi-structured qualitative interviews with twelve SBMHPs to generate in-depth descriptions of
their approaches to implementing a comprehensive mental health plan within the MTSS
framework.
Literature Review
Mental Health Needs in Schools
Current statistics highlight the growing demand for mental health services amongst
students. One in six children aged five to 16 years old has a diagnosable mental health disorder
(Woolf, 2020). In 2021, 14.9% of school-aged children received mental health treatment in the
past 12 months (Zablotsky & Ng, 2023). About 8% of children took prescription medication for
their mental health, and 11.5% of children received counseling or therapy from a mental health
professional (Zablotsky & Ng, 2023). Schools uniquely meet students' mental health needs by
providing school-based mental health services that reduce care disparities and improve academic
outcomes (Larson et al., 2017; Sanchez et al., 2018). Additionally, school is where youth spend
the majority of their time and are six times more likely to receive mental health treatment in
schools than in a community setting (Jaycox et al., 2010; Wei et al., 2023). Mental health
programming in schools promotes knowledge, reduces stigma, encourages help-seeking, and

9
reduces stress (Wei et al., 2023). Mental health services can improve student attendance, increase
grade-level promotion, and lessen suspensions (Kang-Yi et al., 2013). School-based mental
health services are a resource for schools interested in reducing out-of-school suspension rates
(Kang-Yi et al., 2013).
In 2017, one in nine children had a diagnosable mental health disorder (Wolf, 2020). The
rate of mental health disorders has increased since the COVID-19 pandemic caused a nationwide
shutdown of schools in March 2020 (Zablotsky & Ng, 2023). In a survey conducted in April and
May 2020, one in four youth (ages 13–19) reported sleep loss due to worry, feeling unhappy or
depressed, feeling constantly under strain, and a loss of confidence in themselves (Margolius et
al., 2020; U.S. Department of Education, 2021). Additionally, between March and June 2020,
more than 25% of American parents reported that their child experienced declines in mental
health, and 14% reported increases in behavior problems (Patrick et al., 2020; U.S. Department
of Education, 2021). The varying experiences of marginalized youth also led to an increased
need for mental health equity. For instance, the COVID-19 pandemic led to the closure of many
childcare and early education facilities and limited interactions with extended family, depriving
children of critical social and cognitive stimulation and essential resources like meals (U.S.
Department of Education, 2021). While only 13% of children in poverty had access to in-person
preschool education, 38% of their higher-income peers were able to attend, further exacerbating
educational and developmental disparities (Barnett & Jung, 2021; U.S. Department of Education,
2021; Yoshikawa et al., 2020).
Additionally, the disproportionate rate of coronavirus amongst racial and ethnic
minorities led to increases in illness and death tolls for minority groups (CDC, 2020; U.S.
Department of Education, 2021). Children of color are half as likely to access mental health

10
support as their non-Hispanic white counterparts (APA, 2017). Additionally, hate crimes and
racial discrimination rose by 70% for Asian Americans during the pandemic (U.S. Department of
Education, 2021; United States Department of Justice, 2023). Survey data found that 70% of
LGBTQI+ youth rated their mental health as “poor” most of the time or continuously during the
COVID-19 pandemic. (The Trevor Project, 2021; U.S. Department of Education, 2021). The
post-pandemic landscape highlights the urgent need for equitable mental health practices in
schools, addressing the heightened mental health challenges faced by marginalized youth.
Students without access to technology, resources, or support during the pandemic now demand
the highest level of support to recover from learning loss and aid in school re-entry (Weisbrot &
Ryst, 2020). Schools that support the mental health needs of their students are better equipped to
help them learn and be successful.
Multi-Tiered Systems of Support
Multi-tiered systems of support (MTSS) offer a framework for addressing mental health
needs in schools, with tiered interventions ranging from early identification to intensive support
(McIntosh & Goodman, 2016; Raffaele Mendez, 2016). MTSS integrates several multiple-tiered
systems into one coherent, strategically combined system meant to address multiple domains or
content areas in education (e.g., attendance, behavior, literacy) (McIntosh & Goodman, 2016).
Response to Intervention (RtI) and Positive Behavioral Interventions and Supports (PBIS) laid
the foundation for the development of MTSS by emphasizing tiered service delivery models
based on student needs (Raffaele Mendez, 2016). RtI is an academic intervention framework,
particularly in reading, where all students receive high-quality instruction, and the students
struggling are provided with increasingly intensive, evidence-based interventions (Johnson et al.,
2006). This model was later extended to behavior through PBIS, providing universal behavioral

11
support to all students, while offering additional interventions for those requiring more assistance
(Raffaele Mendez, 2016). Over time, educators recognized the interconnectedness of academic
and behavioral performance, leading to the integration of RtI and PBIS into a more
comprehensive framework, MTSS. MTSS refines and expands upon these earlier models by
systematically aligning academic, behavioral, and social-emotional supports to optimize student
success through data-driven decision-making and resource allocation (Raffaele Mendez, 2016).
MTSS for mental health in schools is consistent with the public health model, where a continuum
of services is provided based on need, ranging from universal mental illness prevention and
well-being promotion for all, to individualized intervention for those few requiring intensive
treatment for severe mental health concerns (Raffaele Mendez, 2016).
Raffaele Mendez (2016) Multi-Tiered System of Mental Health Supports
Tier One
Tier one interventions aim to support 80% of students’ needs through universal mental health
prevention and skill-building (Raffaele Mendez, 2016). Tier one is a foundational intervention
system for all students, with needs assessed through a universal screening process (Marsh &

12
Mathur, 2020). Screening can consist of academic progress monitoring, behavior referral data,
school climate and safety assessments, and social-emotional screening assessments
(Brown-Chidsey & Bickford, 2016; Marsh & Mathur, 2020). Evidence-based universal mental
health screeners commonly used in school settings include the Patient Health Questionnaire-9
(PHQ-9), the Generalized Anxiety Disorder-7 (GAD-7), and the Strengths and Difficulties
Questionnaire (SDQ; Kroenke et al., 2001; Spitzer et al., 2006; Goodman, 1997). Data from
universal screening can be used to understand the strengths and needs of the school and aid in
understanding what the more significant school population needs in terms of preventative mental
health care (Raffaele Mendez, 2016). Tier one interventions can include social-emotional
learning (SEL) classroom “push-in” lessons and curriculum utilization, school-wide wellness
initiatives, or school-wide positive behavior intervention support (SWPBIS) (Marsh & Mathur,
2020; Raffaele Mendez, 2016). Tier-one interventions can be implemented by teachers,
school-based mental health professionals, and administrative professionals (Raffaele Mendez,
2016). Universal approaches to mental health are essential in schools because they align with a
public health approach, are more cost-effective than targeted/individual approaches, and can
identify students who would not otherwise access support (Evans et al., 2023). Students whose
needs are not addressed by tier one move to tier two interventions.
Tier Two
Tier two interventions are targeted support for 15% of students whose needs cannot be
met at the universal level (Raffaele Mendez, 2016). Students at this level require more intensive
small-group intervention because they are at risk for academic, behavioral, or social and
emotional issues (Marsh & Mathur, 2020; Raffaele Mendez, 2016). Tier two interventions differ
from tier one because (a) they are implemented with smaller groups of students, (b) students are

13
provided with more time for targeted instruction, and (c) there are more opportunities for
role-playing, guided practice, and feedback (Chiodo, 2006; Raffaele Mendez, 2016). Tier two
interventions typically involve grouping students with similar needs together to address topics
such as anxiety, anger management, or social skills (Raffaele Mendez, 2016). Tier two
interventions include check-in-check-out, mentoring, and peer counseling (Marsh & Mathur,
2020; Raffaele Mendez, 2016). Tier two interventions are implemented based on the analysis of
screening data to support students identified as at risk (Marsh & Mathur, 2020; Raffaele Mendez,
2016). The decision to provide tier two support, such as small group interventions, depends on
the prevalence of similar concerns among the student population. In the case where a substantial
portion of students exhibit the same challenge, a tier-one universal intervention may be more
appropriate, whereas a smaller group of at-risk students would benefit from targeted tier-two
support (Raffaele Mendez, 2016).
Tier Three
Tier three offers the most intensive support to address 5% of students who benefit from
individual interventions (Raffaele Mendez, 2016). Students at this level may benefit from
individual mental health services provided by an SBMHP or community agency, a functional
behavior assessment to develop an individual behavior plan, or possible identification for
evaluation for special education (Marsh & Mathur, 2020; Raffaele Mendez, 2016). It is important
to note that students at this level also receive tier one and tier two interventions in addition to
individualized support. MTSS allows SBMHPs to provide appropriately leveled interventions for
all students within a school setting while also extending their capacity to address mental health
needs.

14
Data-based decision-making and evidence-based interventions are essential to MTSS,
allowing schools to identify and intervene effectively. Data-based decision-making can include
screening to identify a target population, progress monitoring to measure intervention
effectiveness, or outcome data to generate MTSS team goals (Forman & Crystal, 2015).
Although vital, screeners are often a missing component of MTSS (Forman & Crystal, 2015;
Splett et al., 2018). One study found that the introduction of a screener increased referrals for
mental health services by 180%, and more boys were identified when only using school referrals
(Splett et al., 2018). Universal screening also engages families proactively through early
intervention and preventative referral processes (Garbackz et al., 2021). Evidence-based
interventions are another vital component of MTSS. Evidence-based interventions can include
social-emotional learning (SEL) curricula, manualized group curricula, or cognitive-behavioral
individual therapeutic interventions (Raffaele Mendez, 2016).
Benefits of MTSS for Mental Health
Embracing MTSS offers numerous benefits for mental health, including early
intervention, personalized interventions, and improved student outcomes. Mental health within
an MTSS model can aim to address mental health disparities amongst marginalized youth. Tier
one interventions can strive to create a positive racial school climate by creating culturally
affirming school environments (Malone et al., 2022). Tier two interventions can foster mental
health equity by implementing culturally responsive strategies that promote positive racial
identity development (Malone et al., 2022). Tier three interventions can reduce the mental health
stigma commonly faced by communities of color and introduce students to culturally responsive
therapy (Malone et al., 2022; Williams et al., 2023). MTSS for mental health within an urban
school district significantly enhances the capacity to provide mental health services across

15
prevention/promotion, early identification/intervention, and crisis management domains (Walter
et al., 2019).
Providing support for teachers within MTSS ensures they have the resources to address
students' mental health needs effectively. Educators have struggled to support students’ mental
health without adequate training or necessary resources (Giles-Kaye et al., 2023). Additionally,
teachers have emphasized the importance of a school culture that prioritizes mental health, while
acknowledging the need for support staff to sustain this culture (Giles-Kaye et al., 2023).
Teachers are an essential link between students and the available mental health resources and
services within the school environment. The presence of onsite therapists is associated with
increased teachers’ perceived awareness and knowledge of student mental health issues and
resources (Osagiede et al., 2018).
Enhancing family-school collaboration within MTSS strengthens support networks for
students, promoting a holistic approach to mental health. Engaging families in early intervention
through universal screening can foster family-school engagement prior to teacher-initiated
referral systems (Garbackz et al., 2021). Family-school interventions through enhanced
communication benefit students’ mental health and social and behavioral functioning (Sheridan
et al., 2019). They receive preventative mental health resources by fostering an increased student
support network.
School-Based Mental Health Professionals and MTSS
MTSS for mental health allows SBMHPs to extend their reach beyond the limitation of
seeing students individually. The standard model for therapy is for students to be seen
individually or in a group setting (Evans et al., 2023). However, with the increasing demand for
mental health interventions, services must fall from least to most intensive (Evans et al., 2023;

16
Woolf, 2020). When MTSS for mental health is implemented, 100% of students will receive
tier-one interventions that are preventive and proactive (Raffaele Mendez, 2016; Weist et al.,
2018). Without (tier one and two) preventative interventions, more students will need (tier three)
intensive interventions, and the mental health interventions become more reactive.
Five fields currently prepare qualified school-based mental health professionals: nursing,
social work, psychology, counseling, and marriage and family therapy. Within these disciplines,
clinical psychologists, licensed professional counselors, nurse practitioners, licensed clinical
social workers, and licensed marriage and family therapists do not have specified school-based
training requirements (Evans et al., 2023). There are a variety of characteristics that differentiate
SBMHPs from mental health clinicians. SBMHPs can offer a continuum of services, including
primary, secondary, and tertiary levels of support, whereas mental health services outside of
school settings provide intensive therapy (Evans et al., 2023). Additionally, SBMHPs operate in
and have some control over the environmental factors that can impact school climate, family
engagement, and teacher practices (Evans et al., 2023). For example, SBMHPs can use the
teacher as a conduit for implementing evidence-based interventions (EBPs), including classroom
management practices (Evans et al., 2023). SBMHPs can use EBPs by leading efforts to use data
to determine who will receive interventions, when additional interventions are needed, and when
intervention support can be terminated (Evans et al., 2023). Educational equity is a final
dimension differentiating mental health service provision in schools from other settings (Evans et
al., 2023). The disproportionality of discipline referrals, dropout rates, and impacts of teacher
racism and biases can all have profound effects on student mental health. SBMHPS must address
the needs of students by accounting for race, culture, language, and other varied and intersecting

17
identities (Evans et al., 2023). Without specific training and accountability measures, SBMHPs
are ill-equipped to meet the mental health needs in schools.
Without an established structure for mental health services in schools, community
clinicians will often come into schools and operate in silos, carrying small caseloads and not
being woven into the school community (Weist et al., 2022). An essential component of MTSS is
that SBMHPs interact with the whole school. Working within an interdisciplinary team,
including school and community mental health staff, aids schools in providing a full continuum
of mental health support (Bohnenkamp et al., 2023). Additionally, a universal approach to mental
health intervention aligns with the public health approach to mental health promotion; it is more
cost-effective than targeted/individual approaches, and universal approaches reduce stigma
(Evans et al., 2023).
This study examined how School-Based Mental Health Professionals (SBMHPs)
implement Multi-Tiered Systems of Support (MTSS) for mental health within the school setting.
A key finding was that mental health support is a shared responsibility, requiring collaboration
among administrators, teachers, and SBMHPs. However, many SBMHPs reported a strong
emphasis on tier three interventions due to high student needs and limited resources, making
prioritizing preventive tier one and targeted tier two interventions difficult. Barriers to effective
tier-two interventions included a lack of standardized data-driven methods for identifying
students in need, an over-reliance on teacher referrals, and inconsistencies in training and
professional development. Additionally, the absence of clear district guidance on MTSS for
mental health has resulted in varied implementation practices across school sites.
These findings align with prior research that underscores the significance of a
multi-tiered approach to mental health (Eagle et al., 2015; Dowdy et al., 2010). Studies have

18
shown that when MTSS frameworks are implemented effectively, they enhance student
outcomes by providing systematic, tiered interventions (McIntosh & Goodman, 2016). However,
like previous research, this study highlights persistent challenges related to resource allocation,
training gaps, and a reactive rather than proactive approach to mental health services (Forman &
Crystal, 2015).
Positionality
This study sought to understand the perspectives of SBMHPs regarding their use of
MTSS. The researcher was a colleague and peer to participants and maintained professional
relationships with participants outside of this study. As a licensed marriage and family therapist,
the researcher supervised students working toward their pre-licensed hours. When interviewing
pre-licensed participants, a power differential existed due to differences in training and
experience.
The researcher’s positionality as a white, middle-class, Jewish, cisgender female
influenced interactions with participants, many of whom came from different racial and religious
backgrounds. This dynamic may have impacted participants’ willingness to share their
experiences openly. Additionally, holding a post-master’s education as a doctoral student
introduced another potential power differential, as some participants had not pursued education
beyond their master’s degree.
To address these issues of power and positionality, the researcher prioritized building
rapport with participants and emphasized the collaborative nature of this research. Milner (2007)
highlighted how White researchers have historically extracted knowledge from communities of
color for personal or institutional gain. Acknowledging this history, the researcher ensured that
this study benefited both the participants and the students they served. Trust was fostered through

19
an empathetic and reflective approach, with interview questions framed in a way that encouraged
openness rather than judgment.
Furthermore, this study remained student-centered. While participants and the researcher
shared similar education and professional training levels, students did not hold the same power.
As Milner (2007) emphasized, researchers must critically examine how race and culture
influence access to services. In the context of MTSS for mental health, this included evaluating
who received services, who did not, and how referral patterns emerged. By focusing on student
well-being, this study aligned the researcher’s objectives with the participants', fostering a shared
commitment to improving mental health support in schools.
Methods
Research Question
This study aimed to research how SBMHPs described their approach to implementing a
comprehensive mental health plan using the MTSS model and to identify what components of
the MTSS model are currently being implemented by SBMHPs. This study utilized
semi-structured qualitative interviews to generate detailed descriptions of MTSS implementation.
This study aimed to answer the following research question: How are school-based mental health
professionals implementing comprehensive mental health plans using the MTSS model?
Context of the Study
The current study examined the perspectives of SBMHPs whose primary role is
addressing mental health needs in K-12 school-based settings. SBMHPs may include
school-based social workers, licensed marriage and family therapists, professional clinical
counselors, school psychologists, and school counselors. This study was limited to SBMHPs

20
currently serving in a single mid-sized school district as either school psychologists or clinical
school therapists within the Special Education Department.
Participants
This study employed a purposeful sampling approach, recruiting participants from a
single mid-sized school district in Southern California. Initial contact with participants was made
via email by the Director of Special Education, followed by direct email outreach from the
researcher’s USC email address. Recruitment materials outlined the participation criteria,
specifying that the study was limited to participants employed by the same school district.
Eligible individuals primarily served the mental health needs of students in a K-12 setting (e.g.,
school-based social worker, marriage and family therapist, professional clinical counselor, school
psychologist, or school counselor). Recruitment materials were limited to individuals employed
as school psychologists and clinical school therapists within the same district. The study
excluded graduate-level interns who were completing their fieldwork.
Table 1
Participant Information (N = 12)
Baseline characteristic n
Work setting
Elementary school 7
Middle school 3
High school 2
Current role
School psychologist 3
Clinical school therapist 9

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The current study completed twelve participant interviews. Participants’ fields of study
included school psychology, school counseling, counseling psychology, social work, marriage
and family therapy, and forensic social work. All participants hold the required credentials
through the state of California, authorizing them to practice under the professional titles of either
school counselor, school psychologist, or school social worker. Seven participants worked in an
elementary school setting, two in a high school setting, and three in a middle school setting.
Additionally, nine participants served as clinical school therapists while three were school
psychologists. All participants worked within the district’s Department of Special Education.
Participants' years of experience ranged from one to twelve years. Participants’ demographic
details were not disclosed to protect anonymity, as the small district and limited participant pool
could make identification possible.
Instrumentation
This interview protocol for this study is available in Appendix A. Questions began by
asking for general demographic data, including years in their role, educational training
background, and professional titles. The interview questions prompt SBMHPs to describe their
barriers, successes, and the factors attributed to their achievements and challenges in
implementing MTSS and its related components. This semi-structured interview asked
participants fifteen questions. Interview piloting was conducted to refine the questions and
ensure the clarity of participant responses.
Data Collection
The interviews lasted 60 minutes and were semi-structured. Questions were open-ended
and asked in the same order for all participants to maximize time efficiency and make responses
more straightforward to compare (Patton, 2002). The interviews were conducted virtually

22
through Zoom, and transcriptions were generated using Zoom AI. The interview protocol began
with demographic questions, then questions about general experiences, and then moved to
questions surrounding opinions and feelings. By structuring the interview in this order, there was
an opportunity for some grounding and avoiding questions that could be too jarring in the
beginning (Patton, 2002).
Data Analysis
Trustworthiness was ensured through peer review, where colleagues examined the study
and its interpretations (Merriam & Tisdell, 2016). The peer review process aimed to address
trustworthiness by involving diverse dissertation committee members to ensure a variety of
perspectives to enrich the researcher’s analysis. This study addressed credibility by using
triangulation, which consists of analyzing multiple sources of information (Merriam & Tisdell,
2016). This student used triangulation by asking similar questions differently, allowing responses
to be cross-referenced.
Data was analyzed through thematic analysis, a process by which qualitative data is
systematically coded, categorized, and interpreted to identify recurring patterns or themes that
are grounded in participants' experiences and perspectives (Lochmiller & Lester, 2017).
Thematic analysis is a valid approach to qualitative research because it allows researchers to
inductively generate themes grounded in participants’ own words and experiences, thereby
producing findings that are both systematic and meaningfully connected to the data (Lochmiller
& Lester, 2017).

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Findings
The following research question guided this study: How are school-based mental health
professionals implementing comprehensive mental health plans using the MTSS model? Table 2
is a summary of the study findings.
Table 2
Study Findings
Theme Description
Mental health as a
shared responsibility
SBMHPs collaborated within interdisciplinary teams of
administrators, teachers, and other SBMHPs to support student
mental health as a shared responsibility.
Emphasis on tier three
interventions
The high demand for individualized tier three interventions limited
SBMHPs’ capacity to provide tier one and tier two support.
Barriers to targeted
interventions
Barriers in mental health identification systems hindered data-driven
decision-making, reducing the effectiveness of targeted tier two
interventions and limiting structured, preventative support.
Lack of coherence in
tier one implementation
Inconsistencies existed in the implementation of tier one universal
interventions across school sites.
Variability in training
and practices
Variability in SBMHP training and practices led to inconsistencies
in applying the MTSS framework for mental health.
Mental Health as a Shared Responsibility
Findings from this study highlight that supporting students' mental health and well-being
requires a collective effort, with teachers, administrators, parents, and SBMHPs working together
to provide comprehensive support rather than placing the responsibility on a single role. Most
participants (8 out of 12) discussed collaboration amongst teachers, administrators, parents, and
other SBMHPs as a success factor in MTSS for mental health implementation within their school
site. Participant D expressed concern that mental health support is often viewed narrowly as just
therapy when a “comprehensive view of support” is beneficial. Additionally, Participant D’s

24
school adopted an “all our kids' mentality” whereby multiple school personnel can support any
student. Participant C reinforced this sentiment by sharing that their school site uses a team
mentality when addressing their students' behavioral and mental health needs. Participant L
expanded on this idea: “I think our role as [SBMHPs] is to build capacity among the school staff
to provide all levels of intervention that start from the universal, going all the way to the more
intensive part.”
The findings indicate that collaboration is occurring during regular team meetings within
their school site to discuss wellness and mental health support. Most participants (eight out of
12) hold regular meetings to discuss student concerns, interventions, and mental health trends.
Participant B explained, "We hold monthly or quarterly team meetings where we come together.
So it is our administrators, counselors, the CST, the Deans, and outside agencies. We all come
together and talk about trends we see." Participant D shared, “As a team, we brainstorm ideas on
the MTSS model to implement within the classroom and maybe outside of the classroom.”
Through their collaboration, the team decides to move to more intensive interventions when
necessary. Research supports these findings, which shows that teams with the most improvement
in their differentiated mental health programming focused on increasing interdisciplinary team
membership, avoiding duplication of services, and promoting a school culture that emphasizes
mental health support in a whole-school approach” (Bohnenkamp et al., 2023; Giles-Kaye et al.;
2023).
Collaboration, specifically with administrators and other SBMHPs, was highlighted as a
key factor in successful MTSS implementation. The role of administrators was crucial, with
seven out of 12 participants stating that administrative support was essential for successful
MTSS implementation. Participant I noted, "The administrator is extremely crucial. If you don't

25
have the support of the administration, then it's going to be impossible to get anything off the
ground." Research recognizes interdisciplinary collaboration between SBMHPs and leadership
as key organizational drivers for promoting MTSS (Eagle et al., 2015).
Collaboration is also occurring amongst other SBMHPs. Ten out of 12 participants
highlighted the benefits of working closely with other mental health professionals, making
universal interventions more feasible. Participant I shared their experience working with other
SBMHPs: “If we wanted to do a universal intervention, it's a lot more feasible to do that work in
teams." This finding contrasts with the research showing that SBMHPs often learn about
interdisciplinary collaboration and leadership in isolation from other SMHPs (Evans et al.,
2023). Overall, the findings align with research suggesting that successful MTSS implementation
relies on strong collaboration among all members of the mental health team, ensuring that mental
health support is a shared responsibility across the school community rather than the duty of a
single individual (Bohnenkamp et al., 2023; Giles-Kaye et al.; 2023). In summary, findings
reveal that SBMHPs are collaborating within interdisciplinary teams of administrators, teachers,
and other SBMHPs to support student mental health as a shared responsibility.
Emphasis on Tier Three Interventions
Findings reveal an emphasis on crisis response over preventative interventions, indicating
an imbalance in the implementation of tiered levels of mental health support. All participants
shared that they provide individual services as a tier-three intervention. Tier three interventions
include individualized mental health support, behavior support or intervention, special education
assessment, and crisis interventions, including risk assessment or child abuse reporting (Marsh &
Mathur, 2020). While the majority (nine out of 12) shared that they implement all three tiers of
mental health support, 11 participants expressed that the level of need for individual tier three

26
interventions prevents them from providing more tier one, universal interventions. Participant J
shared, "My job is therapy, so sometimes these tier-one activities may have to be done outside
my work hours or on my lunch.” Participant G expanded on this idea, sharing, “It feels like it's
been a lot of responding to crises or certain situations where I'm doing a lot more of the reactive
work.” A few (three out of 12) SBMHPs indicated that their primary focus remains on tier-three
interventions due to high student needs. Participant E shared that tier three interventions “take
away time from being able to implement some of the universal supports.” Participant D echoed
this sentiment by sharing, “We had a crisis on Monday, and I had all of these things scheduled to
have school-wide and tier-two supports, and that all kind of came down. And you just have to
focus on individualized support.” The literature suggests that transitioning to a preventative
model of mental health support can be challenging or overwhelming without sufficient resources
to address tier three needs (Nygaard et al., 2024). Additionally, preliminary research from a
peri-COVID era suggests that the estimate that 5% of students in a school require individualized
tier three support may be inaccurate, as it is based on the public health model (Weist et al., 2024).
Overall, the findings suggest that the level of need required for individual tier-three interventions
detracts from the SBMHP’s ability to provide tier-one and two levels of intervention.
Barriers to Targeted Interventions
The findings reveal significant barriers in targeted mental health identification systems,
particularly the underutilization of data-based decision-making, which hinders the
implementation of targeted interventions and results in a lack of structured, preventative support.
All participants reported that teachers are the primary source of student referrals for mental
health support. Participant J explained, "I'm relying a lot on the teachers," noting that teachers
are expected to complete referral forms and raise student concerns before contacting the

27
school-based mental health professional (SBMHP). Without data-driven tools like universal
screeners, teachers' perceptions and beliefs often become the primary obstacles preventing
students from accessing necessary mental health support (Giles-Kaye et al., 2023; Splett et al.,
2018). Teachers are uniquely positioned to notice changes in student behavior due to frequent
classroom exposure (Marsh & Mathur, 2020). Participant B explained, “When teachers see that
something is concerning, then they go ahead and refer.” Participant G emphasized that referrals
are based on "what a teacher is reporting that they're seeing in their classroom."
Despite these referral processes, barriers related to teacher buy-in were identified by
seven out of 12 participants as the biggest challenge to successful MTSS implementation.
Participants highlighted teachers’ lack of support for mental health initiatives in their classrooms
as a key issue. Participant B shared,
Sometimes, teachers will refuse to allow students to visit the wellness center, or don't feel
comfortable, maybe having conversations around mental health, or they don't relay the
message of the wellness center and the need to seek support or access resources.
Participant A added, "One of my struggles is again that buy-in and participation and
recognizing that mental health and social-emotional learning is just as important as academics."
Research highlights that teachers often lack confidence in identifying children’s mental health
needs, especially when they have not received proper training (Giles-Kaye et al., 2023).
An additional barrier identified in the findings is the lack of evidence-based practices
used for targeted tier-two interventions. All participants reported obstacles preventing them from
utilizing evidence-based practices, including the inability to meet students' specific needs (six out
of 12) and a lack of training and time allocated by the district (six out of 12). Participant K

28
explained, "I think the challenge would be that the district does not provide a lot of training in
evidence-based practices. They have, but I feel like it's limited."
Furthermore, effective MTSS for mental health intervention relies on data-based
decision-making through the adoption of universal screeners (Forman & Crystal, 2015).
Research indicates that universal screeners are a critical yet often overlooked component of
school MTSS (Splett et al., 2018). Without these tools, the reliance on teachers' perceptions and
beliefs, alongside the lack of evidence-based practices, creates significant barriers to
implementing targeted tier-two interventions and providing preventative mental health support.
In summary, the absence of universal screening, reliance on teachers' perceptions, lack of teacher
buy-in, and the limited use of evidence-based practices present substantial challenges in
effectively implementing MTSS and providing preventative mental health support. These
barriers in mental health identification systems cause data-driven decision-making not to be fully
utilized to implement targeted tier-two interventions, resulting in a lack of structured,
preventative support.
Lack of Coherence in Tier One Implementation
Although the district has established tier-one mental health supports, implementation
lacks consistency and data-based direction across schools. Tier one interventions are universal
support provided to all students within a school or district (Rafaelle Mendez, 2016). Tier one
interventions focus on developing social-emotional competencies and coping skills to ensure that
at least 80% of students respond effectively and do not develop a mental health disorder
(Rafaelle Mendez, 2016). Tier one interventions include implementing universal screening to
identify the most common needs among all students within a school (Marsh & Mathur, 2020).
Based on universal screening data, tier-one interventions may include social-emotional learning

29
(SEL) classroom lessons, parent education, curriculum implementation, school-wide wellness
initiatives, and school-wide positive behavior intervention and support (SWPBIS) (Marsh &
Mathur, 2020; Raffaele Mendez, 2016).
Interview findings indicated that eight out of 12 participants implemented tier-one
interventions by pushing into classrooms to provide lessons. Seven out of 12 participants
identified that they conduct tier-one interventions by leading whole-school campaigns or mental
health initiatives. Participant H shared, "I do make an effort to do some universal type of mental
health interventions, like some school-wide interventions to kind of decrease the stigma, or to
promote mental health awareness and accessing the resources that we have on campus."
However, seven out of 12 participants reported using needs assessments or teacher feedback to
determine the mental health needs of students, highlighting that there are inconsistencies in how
the topics are chosen. Additionally, most participants (eight out of 10) incorporate existing
school or district activities into their tier-one efforts, such as presenting at ELAC meetings,
parent workshops, PBIS family night, school assemblies, coffee with the principal, and Saturday
school. Participant I emphasized the importance of leveraging existing structures and sharing the
convenience of parents receiving parent training when they were already at school for campus
activities.
In contrast, Participant F stated that they often rely on teachers for tier one
implementation, saying, “I'm a firm believer that tier one should occur within the Gen. Ed.
setting,” highlighting that the district has recently adopted a SEL curriculum for teacher use. The
findings indicate that while most SBMHPs engage in tier one interventions, the specific activities
they implement vary. Research suggests that teachers can effectively lead tier one interventions
by implementing SEL curricula in the classroom (Zhang et al., 2023). Tier one interventions can

30
also encompass parent education, training, and universal campaigns, facilitated by SBMHPs due
to teachers' limited capacity (Giles-Kaye et al., 2023; Marsh & Mathur, 2020). In conclusion,
findings suggest that while tier-one mental health supports are established, their implementation
is inconsistent across schools, with many participants leveraging existing structures and relying
on teachers to ensure the effective delivery of interventions. Revealing inconsistency and a lack
of coherence in tier one, universal intervention implementation across school sites.
Variability in Training and Practices
Findings reveal that differences in SBMHPs' education and experience, combined with
the district's lack of clear guidance on MTSS for mental health, contribute to inconsistencies in
its implementation across school sites. Research indicates that variability in training backgrounds
among school mental health professionals leads to differences in practice, as the distinction
between school-based and traditional mental health services is often unclear and inconsistently
understood across individuals and groups (Evans et al., 2023). Findings reveal that participants'
education and experience related to MTSS for mental health were varied. Eleven out of 12
participants received training on MTSS outside of the district. This training primarily came
through graduate programs (five out of 12), previous employers (five out of 12), or professional
organizations (three out of 12). Participant I reflected on their training on MTSS in graduate
school, “We were taught about MTSS, and it was mostly taught through the frame of academic
support. And then, as I started my career, it grew and has now been a model that we use for
social-emotional functioning.” Alternatively, Participant E shared their experience in MTSS
through prior work experience: “We were taught a variety of interventions and how to implement
MTSS. There was also a lot of professional development, and we frequently consulted on our
systems.” In contrast, Participant G and Participant K shared that they were “not very familiar”

31
with MTSS or its specifics. The research supports these findings as there is considerable
variation in the level of training across degree programs that lead to careers as SBMHPs (Evans
et al., 2023).
Additionally, findings indicate the district’s lack of clear guidance on MTSS for mental
health further contributes to variations in practice across school sites. Most participants (seven
out of 12) received an overview of MTSS when they started their roles; however, five out of 12
mentioned that the district provided them with any training on the framework. When asked about
training provided on MTSS by the district, Participant H shared: “I don't think I've ever gotten
training here, and I feel like people lump PBIS under MTSS. Or they interchange the words.”
Most participants (ten out of 12) indicated the need for more training to successfully implement
MTSS for mental health. Participant K suggested,
I think everybody needs to be on the same page. So, if a school site or a district is going
to implement MTSS, I think there needs to be more training. There needs to be some
support throughout for implementation, and there needs to be some accountability.
Participant H reinforced this point by sharing, "I feel like if we got more training, it would be
helpful, especially if we really want to follow the true MTSS Model." Overall, findings suggest
an interest in greater consistency in training and clear district guidance to ensure that all
SBMHPs have the necessary knowledge and skills to implement MTSS for mental health
effectively.
In summary, this study examined how SMBHPs implement MTSS for mental health
within the school setting. A key finding was that mental health support is a shared responsibility,
requiring interdisciplinary collaboration among administrators, teachers, and SBMHPs.
Additionally, many SBMHPs reported a strong emphasis on tier three interventions due to high

32
student needs and limited resources, making prioritizing preventive tier one and targeted tier two
interventions difficult. Findings also indicated barriers to data-based decision-making, including
a lack of universal screening methods for identifying students in need, an over-reliance on
teacher referrals, and inconsistencies in training and professional development. Finally, the
absence of clear district guidance on MTSS for mental health has resulted in varied
implementation practices across school sites.
Discussion
Studies have shown that when MTSS frameworks are implemented effectively, they
enhance student outcomes by providing systematic, tiered interventions (McIntosh & Goodman,
2016). However, like previous research, this study highlights persistent challenges related to
resource allocation, training gaps, and a reactive rather than proactive approach to mental health
services (Forman & Crystal, 2015).
The current study and research show that interdisciplinary collaboration and leadership
are critical components in successfully implementing MTSS for school mental health
interventions. Research emphasizes the importance of situating these interventions within an
ecological framework that addresses students' individual needs through a team-based approach
informed by an intersectional lens (Evans et al., 2023). SBMHPs bring specialized expertise to
these efforts, making their role vital in the MTSS process (Forman & Crystal, 2015). Other
stakeholders, such as teachers, administrators, and community members, contribute valuable
insights and support with varying levels of power and influence (Forman & Crystal, 2015).
Collaboration in school mental health efforts can be hindered by persistent challenges, including
role confusion, competing professional priorities, and limited familiarity with school culture
among community-based clinicians (Bohnenkamp et al., 2023). Without explicit role delineation

33
and structured models for collaboration, school-based and community-based providers may
struggle to effectively integrate their efforts, limiting the overall impact of MTSS interventions
(Bohnenkamp et al., 2023).
The findings of this study reinforce the critical role of structured collaboration in MTSS
implementation. Participants emphasized the need for clearly defined roles and supportive
leadership models to bridge the gap between district expectations and site-based practices.
Additionally, the study revealed that the success of MTSS depends on effective communication
and goal alignment within interdisciplinary teams. While many participants reported leading
mental health initiatives at their school sites, interdisciplinary collaboration was not a consistent
practice across all cases. This finding aligns with previous research indicating that SBMHPs
often develop leadership skills in isolation, potentially hindering teamwork and overall program
effectiveness (Evans et al., 2023).
Structured collaboration also helps address the study's finding that SBMHPs primarily
focus on tier three needs in their schools. Research supports this finding, indicating that mental
health needs have risen post-COVID (Zablotsky & Ng, 2023). Additionally, the idea that MTSS
and tier three interventions should be limited to 5% of the school population is based on the
public health model and does not account for these increasing mental health needs. (Zablotsky &
Ng, 2023). When considering available options to address these growing needs, it is important to
recognize the limited funds of school districts in simply hiring more SBMHPs. Research
emphasizes the importance of collaboration with community agencies to support individual
mental health needs (Stephan et al., 2015). Mental health support from external community
agencies is often provided in isolation, with little consideration for the educational system in
which it operates (Stephan et al., 2015).

34
An additional consideration the findings of the current study revealed is that, in the
absence of universal screening practices, less effective methods are being used to identify
students needing support. For instance, this study found that SBMHPs primarily rely on teacher
referrals as the primary method for identifying students. Research highlights that universal
mental health screening (UMHS) is a key component of MTSS, designed to identify students
who may require interventions. UMHS involves screening all students based on agreed-upon
criteria such as depression, anxiety, substance use, and resilience to ensure students receive
appropriate resources (Lane et al., 2021). However, research suggests that UMHS data should be
considered alongside teacher referrals, office discipline referrals, academic performance, and
attendance records to create a more comprehensive identification system (Lane et al., 2021).
A critical factor in a district's decision to implement UMHS is the increased identification
of students who would benefit from mental health support (Splett et al., 2018). As identified in
the current study, SBMHPs primarily allocate their time to tier three individual interventions. If
UMHS were implemented in this district, additional SBMHPs would be necessary to meet the
increased student needs that screening would reveal. This is contrary to past research, which
suggests that the primary reasons schools have not implemented a universal screener were a lack
of awareness that such screening existed, not enough money in the budget, and a lack of access
to emotion/behavioral health screeners (Bruhn et al., 2014).
The findings highlight a lack of consistency in tier one interventions among SBMHPs
due to the absence of district-wide standardization of MTSS. This variability presents challenges,
as students within the same district may attend different schools and encounter inconsistent
universal approaches to mental health. While most SBMHPs engage in tier one interventions, the
specific activities they implement vary. Research suggests that teachers can be key in delivering

35
tier one interventions by incorporating SEL curricula into their classrooms (Zhang et al., 2023).
Tier one interventions can extend beyond the classroom to include parent education, training, and
universal mental health campaigns. Given teachers' limited capacity, SBMHPs are
well-positioned to facilitate these broader initiatives (Giles-Kaye et al., 2023; Marsh & Mathur,
2020).
The variability in training and educational backgrounds among SBMHPs presents a
challenge for district-wide standardization of MTSS. Professional organizations have established
clear practice standards within their respective disciplines. For example, the American School
Counselor Association (ASCA, 2019), the National Association of Social Workers (NASW,
2021), and the National Association of School Psychologists (NASP, 2020) provide MTSS
guidelines aligned with the roles of school counselors, social workers, and school psychologists.
However, the American Association for Marriage and Family Therapy (AAMFT, 2018) does not
offer specific guidance for Marriage and Family Therapists working in school settings. Despite
differences in educational backgrounds, participants in this study commonly held a Pupil
Personnel Services (PPS) credential, with authorization in school counseling, school social work,
or school psychology. This credential provided them with advanced training on how to apply
their clinical expertise within a school setting. Furthermore, the practice standards set forth by
national organizations such as ASCA, NASW, and NASP offer a framework that can support the
implementation of MTSS based on each discipline's specific training and professional scope.
Implications and Recommendations for Practice
Given these findings, several implications emerge for school districts and policymakers
seeking to improve MTSS implementation for mental health. First, districts must address the
need for adequate personnel and resources by forming partnerships with community agencies to

36
supplement school-based mental health services. Without adequate personnel and resources,
SBMHPs are often limited to providing intensive, individualized interventions, leaving little time
for preventive tier one and tier two supports. School districts should prioritize collaboration with
community agencies to supplement school-based mental health services to meet the demand for
tier three interventions. However, as research suggests, external mental health support is often
provided in isolation from the educational system (Stephan et al., 2015). Creating formal
partnership agreements with community providers can ensure services are aligned with MTSS
frameworks and delivered in a coordinated manner. Integrating school personnel with external
mental health professionals in structured leadership roles can further enhance collaboration and
ensure tiered supports are implemented comprehensively.
Second, establishing standardized school-based mental health leadership teams,
supported by clear guidance and leadership, can foster effective interdisciplinary collaboration.
Research suggests that successful MTSS implementation depends on cohesive leadership teams
that coordinate efforts across diverse stakeholders (Forman & Crystal, 2015). Districts should
provide structured guidance and leadership-focused professional development opportunities for
school-based mental health professionals (SBMHPs), equipping them to lead interdisciplinary
teams and facilitate collaborative decision-making (Evans et al., 2023). In the district in the
current study, however, structural and organizational barriers may be hindering such
collaboration. School counselors are housed in a separate department from school psychologists
and clinical school therapists, limiting opportunities for shared leadership and integrated service
delivery. Adopting the unifying term school-based mental health professionals and situating all
roles within a single departmental structure could promote a more cohesive and collaborative

37
approach. Additionally, regular mental health team meetings would further support coordination
and strengthen interdisciplinary efforts.
Third, the district should develop clear guidelines and accountability measures to address
barriers to identifying students in need of mental health support. Findings from this study
indicate that in the absence of standardized Universal Mental Health Screening (UMHS),
SBMHPs rely heavily on teacher referrals, which can be inconsistent and subjective.
Implementing UMHS would promote data-driven decision-making and enable earlier
intervention through standardized identification processes (Lane et al., 2021). Additionally,
UMHS is a tier one preventative measure that would shift MTSS implementation from a reactive
approach to a proactive, prevention-focused model. However, successful UMHS implementation
requires additional SBMHP staffing to meet the increased demand for services (Splett et al.,
2018). Collaboration with community agencies can help support tier three needs that emerge
from universal screening results.
Fourth, the district should work toward greater coherence and consistency in tier one
interventions across schools. The lack of district-wide standardization has led to disparities in
student access to early mental health supports. Research suggests that teachers can be key
players in delivering tier one interventions, such as Social-Emotional Learning (SEL) curricula,
while SBMHPs can lead broader mental health initiatives, including parent education, staff
training, and school-wide mental health awareness campaigns (Giles-Kaye et al., 2023; Marsh &
Mathur, 2020). Establishing district-wide expectations and frameworks for tier one
implementation can ensure that all students benefit from equitable access to preventive mental
health services.

38
Lastly, providing professional development in leadership for SBMHPs can further
enhance their ability to lead and collaborate effectively (Evans et al., 2023). There is a clear need
for increased training and professional development to address variability in SBMHP
preparation. The district should invest in structured training programs on MTSS that cover
evidence-based practices across all three tiers. Well-trained staff are essential for consistent and
effective MTSS implementation (Eagle et al., 2015). Additionally, interdisciplinary training
opportunities should be developed to foster collaboration between school-based and
community-based professionals, reinforcing the value of integrated support systems in mental
health service delivery (Evans et al., 2023). Graduate degree programs should consider
embedding advanced training in MTSS to better prepare professionals before they enter the
workforce. This training should also build coherence across counselor education programs,
including those for school social workers, school psychologists, and school counselors.
Limitations and Recommendations for Further Research
Given the scope and design of this study, several limitations should be acknowledged.
First, the study focused exclusively on school-based mental health professionals (SBMHPs)
within a single mid-sized school district in Southern California, limiting the generalizability of
findings. Only three participants were school psychologists, while the remaining were clinical
school therapists. Additionally, participant recruitment was restricted to clinical school therapists
and school psychologists due to the participant pool being limited to SBMHPs in the Department
of Special Education. Due to this structural challenge, the study excluded the perspectives of
school counselors and the additional support they might have contributed to MTSS
implementation. While it is a common misconception that school counselors focus solely on

39
academic support, social-emotional learning is an equally essential pillar of their practice. Based
on these limitations, findings may have an incomplete representation of SBMHP perspectives.
Another limitation concerns participant demographics. The gender distribution within the
sampled professional roles was primarily female, potentially limiting the diversity of
perspectives. Finally, the reliance on interviews as the primary data collection method introduces
potential subjectivity, as participants’ responses may be influenced by personal biases or their
current work environment.
Based on these limitations, future research should consider several areas of exploration.
First, longitudinal studies examining the long-term impact of structured MTSS training programs
on the effectiveness of mental health service delivery in schools could provide valuable insights
into best practices for professional development and implementation fidelity. Additionally, future
research should explore the perspectives of school counselors, teachers, and administrators
regarding their roles in MTSS implementation. Since this study focused on interviews only with
school psychologists and therapists, incorporating insights from a wider array of professionals
could provide a more comprehensive understanding of collaborative MTSS practices.
Comparative studies across districts with varying resource levels would also be beneficial in
identifying best practices and scalable strategies for broader MTSS implementation. By
analyzing how different districts navigate MTSS challenges and leverage available resources,
future research could inform policy and program development to improve school-based mental
health support at a systemic level.
Conclusion
This study contributes to the growing body of research on school-based mental health by
identifying both the successes and challenges SBMHPs face in implementing MTSS for mental

40
health. While schools differ in the mental health support they provide, services are shifting away
from the traditional model of direct individual therapy and moving toward integration within the
educational system. SBMHPs must apply their expertise within the school system's framework,
rather than imposing an individual therapy model that does not fit the school context. While
collaboration and shared responsibility are essential for adequate mental health support, gaps in
training, inconsistent implementation, and an over-reliance on tier-three interventions present
significant barriers. Addressing these challenges through targeted training, more transparent
policies, and improved collaboration with community agencies can help schools create a more
balanced and effective MTSS framework. A significant shortcoming in current practices is the
lack of data-driven decision-making, particularly the absence of universal screening. This lack of
proactive identification methods leads to mental health services being provided primarily in
response to externalizing behaviors, rather than through early intervention. By incorporating data
into the MTSS for mental health framework, schools can provide tailored supports that meet
students' specific mental health needs within the context of their community. This approach
fosters educational equity by ensuring that interventions are responsive and customized to the
unique needs of each student population. Given the increasing mental health needs of students,
the findings underscore the urgent need to strengthen school-based mental health support. We
must develop a proactive, sustainable system that benefits all students and provides the resources
they need to succeed.

41
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Appendix A: Interview Protocol
Introduction
Hello [Participant's Name], thank you for participating in our research study today. My name is
Morgan, and I'll be conducting this interview with you. How are you feeling? Before we begin, I
want to remind you that the purpose of this interview is to gather insights and information related
to the mental health interventions utilized within your role as a school-based mental health
professional. Your input is incredibly valuable, and it will help us better understand the various
interventions being conducted by individuals in your unique role within schools. The information
from today’s interview will also accompany survey data from other school-based mental health
clinicians. Your participation in this study is entirely confidential. The purpose of recording this
interview is to accurately capture the information you provide so that we can analyze it later.
Your responses will be anonymized and only used for research purposes. If at any point you feel
uncomfortable or would like to stop the interview, please let me know, and we can pause or end
it. I know this was covered in the consent paperwork, but I also want to reaffirm that your
participation is entirely voluntary. You have the right to skip any questions or withdraw from the
interview at any time without consequence. Do you have any questions before we proceed?
Lastly, I want to confirm that you're aware that this interview will be recorded, and your voice
will be captured. This recording will only be used by the research team and will be securely
stored. Do you consent to being recorded? (Yes or no response). Great, let’s get started.
Questions
1. What is your professional title and training background? For example, I am working as a
clinical school therapist and am trained as a Licensed Marriage and Family Therapist.
2. How long have you been in your role as a school-based mental health professional?
3. What grade level do you primarily work with?
4. What different types of mental health interventions are a part of your role?
5. How familiar are you with multi-tiered systems of support?
6. How do you see your role within the multi-tiered system of support (MTSS) framework for
mental health?
7. Can you describe your experiences with professional development and training related to
MTSS for mental health?
8. What factors do you think contribute to the successful implementation of MTSS for
mental health in your school?
9. How do you evaluate whether the MTSS framework is effectively addressing the mental
health needs of your students?

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10. What challenges do you face when implementing MTSS for mental health in your school?
11. How do you identify which students may benefit from mental health support?
12. There's a push in the field to emphasize the use of evidence and data in decision-making.
How would you describe successes or challenges with using data or research in general?
13. Please describe how you involve students’ families in your work.
14. How do you collaborate with teachers, administrators, and other school staff to
implement and maintain MTSS for mental health?
15. Is there anything that would help you to feel more supported in your work focusing on
mental health?
Closing
This concludes our interview. Thank you so much for sharing your insights and experiences with
us today. Do you have any questions about the interview? Your input is invaluable to our
research, and we genuinely appreciate your time and participation. Once again, I want to
reassure you that your responses will be confidential. After this interview, we'll analyze the data
along with other participants' responses to draw meaningful conclusions. If you have any further
questions or would like to follow up on anything discussed today, please feel free to reach out to
me. We wish you all the best and have a great day!

Asset Metadata

Creator Evans, Morgan Elizabeth (author)

Core Title Understanding the perspectives of school-based mental health professionals: a qualitative study on approaches to implementing multi-tiered systems of support for mental health

Contributor Electronically uploaded by the author (provenance)

School Rossier School of Education

Degree Doctor of Education

Degree Program Educational Leadership

Degree Conferral Date 2025-05

Publication Date 05/01/2025

Defense Date 04/29/2025

Publisher University of Southern California (original), Los Angeles, California (original), University of Southern California. Libraries (digital)

Tag barriers to MTSS implementation,interdisciplinary collaboration,mental health equity in education,mental health implementation,MTSS,MTSS for mental health,multi-tiered system of support,OAI-PMH Harvest,preventative mental health support,school-based mental health,school-based mental health professionals

Format theses (aat)

Language English

Advisor Hirabayashi, Kimberly (committee chair), Riggio, Marsha (committee member), Hernandez, Emily (committee member)

Creator Email morgane@usc.edu,morganevanslmft@gmail.com

Unique identifier UC11399KG23

Identifier etd-EvansMorga-13988.pdf (filename)

Legacy Identifier etd-EvansMorga-13988

Document Type Dissertation

Format theses (aat)

Rights Evans, Morgan Elizabeth

Internet Media Type application/pdf

Type texts

Source 20250505-usctheses-batch-1258 (batch), University of Southern California Dissertations and Theses (collection), University of Southern California (contributing entity)

Access Conditions The author retains rights to his/her dissertation, thesis or other graduate work according to U.S. copyright law. Electronic access is being provided by the USC Libraries in agreement with the author, as the original true and official version of the work, but does not grant the reader permission to use the work if the desired use is covered by copyright. It is the author, as rights holder, who must provide use permission if such use is covered by copyright.

Repository Name University of Southern California Digital Library

Repository Location USC Digital Library, University of Southern California, University Park Campus MC 2810, 3434 South Grand Avenue, 2nd Floor, Los Angeles, California 90089-2810, USA

Repository Email uscdl@usc.edu

Abstract (if available)

Abstract This study explored how School-Based Mental Health Professionals (SBMHPs) implement comprehensive mental health plans using the Multi-Tiered System of Support (MTSS) model. The study addressed the following research question: How do SBMHPs describe their approach to implementing MTSS-based mental health plans? Participants included school-based social workers, licensed marriage and family therapists, licensed professional clinical counselors, school psychologists, and school counselors currently employed in a mid-sized school district in Southern California. This study utilized semi-structured qualitative interviews from SBMHPs to generate detailed descriptions of MTSS implementation. Key findings revealed that SBMHPs collaborate within interdisciplinary teams of administrators, teachers, and other SBMHPs to support student mental health as a shared responsibility. However, the high demand for individualized tier three interventions limits their capacity to provide tier one and tier two supports. Barriers in mental health identification systems hinder data-driven decision-making, reducing the effectiveness of targeted tier two interventions and limiting structured, preventative support. Inconsistencies exist in the implementation of tier one universal interventions across school sites. Additionally, variability in SBMHP training and practices leads to inconsistencies in applying the MTSS framework for mental health. These findings highlight the need for training and systemic support to enhance the effectiveness of MTSS-based mental health interventions in schools.