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Adolescent experiences of seeking and receiving support at school for significant mental health concerns Semchuk, Jaime 2016

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	   	       ADOLESCENT EXPERIENCES OF SEEKING AND RECEIVING SUPPORT AT SCHOOL FOR SIGNIFICANT MENTAL HEALTH CONCERNS   by   Jaime Semchuk     A THESIS SUBMITTED IN PARTIAL FULFILLMENT OF  THE REQUIREMENTS FOR THE DEGREE OF  MASTER OF ARTS    in     THE FACULTY OF GRADUATE AND POSTDOCTORAL STUDIES   (School Psychology)     THE UNIVERSITY OF BRITISH COLUMBIA   (Vancouver)      October 2016   © Jaime Semchuk, 2016  	   ii	  Abstract The purpose of the present study was to gain an understanding of adolescent perspectives of seeking and receiving support at school for significant mental health challenges. A review of the literature substantiates that adolescent mental health problems require the attention of researchers, policy makers, and professionals. Currently many adolescents require mental health supports, but do not receive them. The school has been identified as an important access point where mental health supports can be integrated; this has led to the development of many frameworks and programs to allow the school to serve this role.  The concept of socially valid research and practice emphasizes the need to determine the acceptability and perceived helpfulness of services by eliciting consumer perspectives.  However, there remains a great deal of uncertainty regarding how to most appropriately assess consumer satisfaction for the range of mental health supports. A qualitative approach to inquiry that employs in-depth interviews can address this uncertainty by asking open-ended questions; this approach provides the potential to gain important perspectives that may not be elicited by surveys or other methods of inquiry.  Interpretive Phenomenological Analysis (IPA) was the methodological approach used to explore the meaning of adolescents’ experiences seeking and receiving support at school for significant mental health concerns. Four students in Grades 11 and 12 participated in in-depth, semi-structured interviews about their experiences of support. Interviews were audio recorded, transcribed, and analyzed following Smith and colleagues (2009) step-by-step approach for beginning IPA analysts. Three broad themes, seven related sub-themes, and two interwoven themes were identified. Participants discussed both formal and informal experiences of school supports related to supportive 	   iii	  relationships, a flexible learning environment, and the school’s potential role as a support system. Interwoven throughout these categories were the guiding values of acknowledging students as individuals, and meeting students where they are at when supporting them at school. Scientific rigor of exploration was ensured through debriefing, member checking, an external audit, and researcher reflexivity. The results are discussed in relation to extant literature, implications for practice, and recommendations for future research.    	   iv	  Preface          This thesis is the original, unpublished, independent work of the author, Jaime Semchuk, under the advisement of her research supervisor, Dr. William McKee. The research study involved human participants, and was reviewed and approved by The University of British Columbia’s Behavioural Research Ethics Board (BREB). The original UBC BREB Certificate of Approval number pertaining to this study is: H15-01396.	  	   	   	   v	  Table of Contents Abstract	  ....................................................................................................................................................	  ii	  Preface	  .....................................................................................................................................................	  iv	  List	  of	  Tables	  .......................................................................................................................................	  vii	  List	  of	  Figures	  .....................................................................................................................................	  viii	  Acknowledgments	  ...............................................................................................................................	  ix	  CHAPTER	  ONE:	  Introduction	  and	  Study	  Rationale	  ....................................................................	  1	  Purpose	  and	  Research	  Question	  ................................................................................................................	  4	  CHAPTER	  TWO:	  Literature	  Review	  .................................................................................................	  5	  Why	  Provide	  School-­‐‑Based	  Mental	  Health	  Services	  and	  Supports?	  ..............................................	  5	  What	  Do	  School-­‐‑Based	  Mental	  Health	  Services	  Look	  Like?	  ..............................................................	  7	  Why	  Do	  We	  Need	  the	  Youth	  Perspective	  Represented	  in	  School-­‐‑based	  Mental	  Health	  (SBMH)	  Research?	  ..........................................................................................................................................	  8	  How	  Do	  We	  Elicit	  Youth	  Voices	  in	  SBMH	  Research?	  ..........................................................................	  10	  Chapter	  Summary	  .........................................................................................................................................	  11	  CHAPTER	  THREE:	  Method	  ..............................................................................................................	  12	  Epistemological,	  Theoretical	  and	  Methodological	  Assumptions	  ..................................................	  12	  Phenomenology.	  ...........................................................................................................................................................	  13	  Hermeneutics	  .................................................................................................................................................................	  13	  Idiography	  .......................................................................................................................................................................	  14	  Data	  Collection	  Procedures	  .......................................................................................................................	  14	  Recruitment.	  ...................................................................................................................................................................	  14	  Screening	  Process.	  .......................................................................................................................................................	  15	  Participants.	  ....................................................................................................................................................................	  16	  Interviews.	  ......................................................................................................................................................................	  17	  Data	  Analysis	  ..................................................................................................................................................	  18	  Step	  One:	  Transcript	  Immersion	  ...........................................................................................................................	  18	  Step	  Two:	  Preliminary	  Comments	  ........................................................................................................................	  18	  Step	  3:	  Bringing	  Together	  Emergent	  Themes.	  ................................................................................................	  18	  Step	  4.	  Identifying	  Patterns	  Across	  Cases.	  ........................................................................................................	  19	  Step	  5.	  Writing-­‐‑Up	  the	  Results.	  ..............................................................................................................................	  19	  Ensuring	  Scientific	  Rigor	  ............................................................................................................................	  19	  Debriefing.	  .......................................................................................................................................................................	  20	  Participant	  Review	  of	  Themes.	  ...............................................................................................................................	  20	  Independent	  Audit.	  ......................................................................................................................................................	  20	  Researcher	  Reflexivity.	  ..............................................................................................................................................	  20	  Personal	  Reflection	  ......................................................................................................................................	  21	  Ethical	  Considerations	  ................................................................................................................................	  22	  Chapter	  Summary	  .........................................................................................................................................	  23	  CHAPTER	  FOUR:	  Findings	  ...............................................................................................................	  25	  Broad	  Theme	  One:	  Flexible	  Learning	  Environment	  .........................................................................	  26	  Flexible	  Structures.	  ......................................................................................................................................................	  27	  
	  	    	   vi Individual	  Adaptations.	  .............................................................................................................................................	  29	  Broad	  Theme	  Two:	  Supportive	  Relationships	  ....................................................................................	  30	  Teachers	  Who	  Show	  They	  Care.	  ............................................................................................................................	  31	  Awareness	  of	  Mental	  Health	  and	  Mental	  Illness.	  ............................................................................................	  32	  The	  Negative	  Impact	  of	  Bullying.	  ..........................................................................................................................	  35	  Broad	  Theme	  Three:	  Schools	  as	  Support	  Systems	  .............................................................................	  36	  Network	  of	  Available	  Supports.	  .............................................................................................................................	  36	  Someone	  to	  Talk	  to.	  .....................................................................................................................................................	  38	  Interwoven	  Theme	  One:	  Students	  as	  Individuals	  ..............................................................................	  38	  Interwoven	  Theme	  Two:	  Meeting	  Students	  Where	  They	  Are	  At	  ...................................................	  40	  Chapter	  Summary	  .........................................................................................................................................	  41	  CHAPTER	  FIVE:	  Discussion	  .............................................................................................................	  42	  Discussion	  of	  Findings	  with	  Reference	  to	  Extant	  Literature	  ..........................................................	  42	  Individualized	  and	  Flexible	  Learning	  Environments	  Are	  Key	  Elements	  of	  Support.	  .....................	  42	  Supportive	  Relationships	  at	  School	  Are	  Characterized	  by	  Awareness	  and	  Caring.	  ........................	  44	  Schools	  can	  Function	  as	  Support	  Systems.	  .......................................................................................................	  47	  Acknowledging	  ‘Students	  as	  Individuals’	  and	  ‘Meeting	  Students	  Where	  They	  Are	  At’	  are	  Guiding	  Values	  When	  Supporting	  Youth	  with	  Mental	  Health	  Difficulties.	  ..........................................	  48	  Considerations	  for	  Psychologists,	  Educators,	  and	  Policy	  Makers	  ................................................	  49	  Considerations	  for	  Individual	  Education	  Plan	  (IEP)	  Development.	  .......................................................	  49	  Implementation	  of	  Mental	  Health	  Literacy	  Curricula	  in	  High	  Schools.	  ................................................	  50	  Facilitating	  Caring	  Relationships	  Between	  Students	  and	  Teachers.	  ......................................................	  51	  Policy	  that	  Facilitates	  Inter-­‐‑Ministerial	  Collaboration	  for	  Supporting	  Adolescent	  Mental	  Health.	  ..............................................................................................................................................................................................	  51	  Study	  Strengths	  and	  Limitations	  .............................................................................................................	  52	  Limitations.	  .....................................................................................................................................................................	  52	  Strengths.	  .........................................................................................................................................................................	  53	  Considerations	  for	  Future	  Research	  ......................................................................................................	  54	  Concluding	  Remarks	  ....................................................................................................................................	  55	  Researcher	  Final	  Reflection	  ......................................................................................................................	  55	  References	  ...........................................................................................................................................	  58	  Appendix	  A:	  Interview	  Script	  .........................................................................................................	  67	  Appendix	  B:	  Guardian	  Informed	  Consent	  ..................................................................................	  69	  Appendix	  C:	  Participant	  Informed	  Assent	  .................................................................................	  72	  Appendix	  D:	  Recruitment	  Poster	  .................................................................................................	  75	  Appendix	  E:	  Participant	  Risk	  Screener	  for	  Guardians	  ..........................................................	  76	   
	  	    	   vii List of Tables Table 1. Participant Characteristics……………………………………………………………17   
	  	    	   viii List of Figures Figure 1: Organization of Themes……………………………………………………………….26   
	  	    	   ix Acknowledgments  First, I would like to express my gratitude for the participants who contributed their time, valuable perspectives, and stories to this research project; this study would not have been possible without them. Second, I would like to thank my research supervisor, Dr. William McKee for his valuable guidance and support throughout my graduate studies. I would also like to thank my committee member, Dr. Rachel Weber, and external examiner, Dr. Rhea Owens for their valued feedback on this study. Finally, many thanks to my friends, family, and the members of my cohort for their ongoing support throughout my graduate program.	  	   	   	   1	   CHAPTER ONE: Introduction and Study Rationale The McCreary Centre Society (2013) recently completed a series of focus groups, surveys and interviews with 70 youth from British Columbia between the ages of 15 and 25 asking them about their experiences accessing and navigating mental health services. One of the key messages identified was that “young people do not feel heard or engaged in their treatment planning or transition processes. Youth’s voices should be included in all decisions which affect them” (p. 5). This discontent is concerning, especially in light of the fact that an estimated 14-25% of adolescents will experience some form of mental illness (Canadian Institute for Health Information, 2009; Waddell, Offord, Shepherd, Hua, & McEwan, 2002; Waddell, Shepherd, Chen, & Boyle, 2013), and the majority will not receive the support that they need (Offord et al., 1987a; Rohde, Lewinsohn & Seeley, 1991; Waddell et al., 2013).  Researchers have found that the stigma attached to mental illness often deters adolescents from seeking help (Manion, Davidson, Clark, Norris, & Brandon, 1997; Schachter et al., 2008). Additionally, limited availability of services and challenges associated with service accessibility further limits the utilization of mental health services among youth (Kirby & Keon, 2006).  Studies that have elicited youth perspectives on mental health services echo these findings and raise a host of challenges faced by adolescents when they consider seeking support for mental illness (Buston, 2002; Cox, Smith, Poon, Peled, & McCreary Centre Society, 2013; Genier, 2013; Persson, Hagquist, & Michelson, 2016; Plaistow et al., 2014). For example, the previously mentioned McCreary Centre Society report provides some striking examples of the barriers faced by young people across British Columbia when accessing mental health services (Cox, et al., 2013). In focus groups and interviews, youth identified experiencing denial of treatment due to long wait lists, or treatment options that required leaving one’s community and support network. 
	  	    	   2 Additionally, when youth attempted to access services, they were confronted with a complex and confusing process that made navigation of the system extremely difficult. Young people expressed receiving contradictory messages about treatment, and feeling uncertainty about which services were relevant to them. Participants also acknowledged feeling ill-prepared to access services due to a lack of available information about what to expect with regards to the process of mental health service delivery. These experiences paint the picture of young people attempting to interact with a mental health services system that is fragmented, confusing, unwelcoming, and scary for them. Unfortunately, some youth also expressed that these previous experiences led them to reconsider seeking support at all (Cox, et al., 2013). These perspectives illuminate a serious problem that requires attention. Young people are in need of cohesive and accessible mental health services that they perceive as helpful. While this has not yet been achieved, there is evidence that stakeholders are beginning to recognize this need.   A key example of stakeholder recognition is “Evergreen: A Child and Youth Mental Health Framework for Canada,” a document put forth by the Mental Health Commission of Canada that provides several values and recommendations for enhancing child and youth mental health supports in the country (Kutcher, & McLuckie, for the Child and Youth Advisory Committee, Mental Health Commission of Canada, 2010). This document was developed in consultation with youth who have experienced mental illness, their families, and mental health professionals. This collaborative approach values not only the expertise afforded by professional training, but also the expertise that stems from lived-experience. A strong theme identified in the document is the importance of having mental health supports integrated into schools, which includes embedding mental health promotion and literacy material into the curriculum, and employing more mental health professionals in school settings.   
	  	    	   3 Past research supports the recommendations for implementing school-based mental health supports as well. For example, Farmer and colleagues (2003) found that schools are the most common entry point for youth receiving mental health services.  Additionally, when focus groups compared community-based and school-based mental health prevention and intervention services, participants reported that school-based programs provided greater acceptability and fewer problems with accessibility than the community-based services (Massey et. al., 2005).  Recently, the School-Based Mental Health and Substance Abuse Consortium (2013) completed a national environmental scan and literature review to clarify the current state of school-based services in Canada. This project identified several schools and districts in Canada currently implementing mental health programs and practices: 85 school-based programs and 58 school-linked programs participated in the final sample, which included representation from all provinces and territories. The majority (75%) of these programs were developed in response to needs identified internally by schools and school districts, which indicates that a cohesive framework for development of school-based mental health services is currently not being utilized in Canada. Another key finding from this environmental scan was the acknowledged importance of establishing partnerships with stakeholders, including youth and families in the development and implementation of school-based mental health programs. These stakeholder partnerships were identified as key for enabling program success and sustainability over time. However, the actual reported involvement of youth and their families in the development and implementation of current programs was limited. Valuing youth voices and perspectives when researching school-based mental health supports can be considered one mechanism to addressing this discrepancy and facilitating partnerships with youth.  
	  	    	   4 Purpose and Research Question While youth perspectives regarding their overall experiences with mental health services has been touched upon previously (e.g. Kutcher et. al., 2010; Cox, et al., 2013), an in-depth exploration of adolescents’ experiences of seeking and receiving supports for significant mental health concerns at school has not yet been accomplished.  Gaining a better understanding of this populations’ experiences at school will help to further inform the call to action put forth by the School-Based Mental Health and Substance Abuse Consortium (2013) for an integrated vision of what effective mental health services in schools look like. Youth perspectives have the potential to play an important role in the development and implementation of school-based mental health services by illuminating the particular successes and challenges associated with experiencing significant mental health difficulties while at school. Additionally, gaining an understanding of youth experiences will continue to elicit the expertise afforded by lived-experience.  The purpose of the present study was to gain an understanding of adolescent perspectives regarding their experiences with school-based mental health services and informal supports, and was explored by asking the following Research Question: What is the meaning of adolescents’ experiences of seeking and receiving support at school for a significant mental health concern?   
	  	    	   5 CHAPTER TWO: Literature Review Why Provide School-Based Mental Health Services and Supports? There is increasing recognition that student mental health issues should be considered a priority (e.g. Millar, Lean, Sweet, Moraes, & Nelson, 2013). It has been widely acknowledged that adolescents experience significant mental health problems and many of those adolescents do not receive the services and supports they need.  This is concerning because mental health problems are related to a host of negative outcomes for both individuals and society. School-based mental health services provide a potential avenue for tackling this issue and there is promising evidence that this approach has a positive impact.  Statistics Canada (2002) reports that adolescents and young adults between the ages of 15 to 24 years, experience the highest incidence of mental illness of any age group in Canada. It is also documented that 70% of mental illnesses initially occur during childhood and adolescence (Government of Canada, 2006), with 14% of Canadian children and adolescents between the ages of 4 to 17 year experiencing serious mental health problems (Leadbeater, 2010). However, only 5% of Canadian children currently receive psychological services, and only 1-2% of those children obtain services from mental health specialists (French & Mureika, 2002).  These number suggest that a substantial number of children do not receive the support that they need, which is concerning given the established relationship between mental health and various other factors related to overall well-being.  Mental health problems have been broadly shown to negatively impact child and adolescent development, and peer and family relationships (Fergusson & Woodward, 2002; Fleming, Boyle, & Offord, 1993). Mental health is also directly linked to students’ learning and school success, influencing school readiness, attendance and academic achievement (Coleman et. 
	  	    	   6 al., 2009; Fergusson & Woodward, 2002; Fleming, et. al., 1993). Additionally, several stakeholder organizations such as the National Association of School Psychologists (NASP, 2006) have identified the significant barriers to learning that mental health concerns present. Positive mental health can be considered a prerequisite for learning, which is a central function of the school.   Given the conceptualization of mental health problems as a barrier to learning, it is not surprising that stakeholders identify the potential central role of the school in the provision of child and adolescents’ mental health supports (Kutcher, et al., 2010). In Canada, the majority of adolescents spend approximately 30 hours each week at school (Bowlby, 2005; Wei, Kutcher, & Szumilas, 2011); this uniquely positions schools as an important access point for mental health services for adolescents. While there is historical evidence that a majority of children who require mental health services do not receive them, the children who do receive supports tend to receive them from school (Burns et al, 1995). There is also evidence that when school-based mental health supports are available, students are significantly more likely to seek help (Slade, 2002).   School districts, in collaboration with researchers, have begun to implement and evaluate school-based mental health services, and initial evidence supports the positive impact of these programs. Reported positive results include reductions in office referrals and suspension rates across the school year, improvements in ratings of school climate, increased mental health literacy among students and educators, and a reduction in the utilization of special education services for students emotional and behavioural challenges (Ballard, Sander, & Klimes-Dougan, 2014; Bruns et. al., 2004; Greenberg et. al., 2003; Kutcher & Wei, 2013; Nabors et. al., 2000). Current research has clarifed that school-based mental health services have the potential to 
	  	    	   7 ameliorate the effects of some mental health concerns, and also provide supports that enable to students to more successfully engage in learning activities What Do School-Based Mental Health Services Look Like?  Given their identified potential to positively impact school and student functioning, it is not surprising that there has been a recent increase in the development of frameworks and recommendations for implementing school-based mental health services in Canada and beyond. While there is variability between these frameworks, many of the general principles remain consistent. School-based mental health initiatives largely recommend a population-based or tiered approach, with an emphasis on cross-sector collaboration with schools, families, and community service providers, and use of evidence-based interventions (e.g. Wei, et. al., 2011; Wolpert et. al., 2015)  In British Columbia’s (2010) ten-year plan to address mental health and substance abuse, the Ministry of Health Services and the Ministry of Child and Family Development utilize a population health approach in identifying service delivery needs. Within this framework, at Tier One, mental health services target the general population through mental health promotion strategies. At Tier Two, individuals at risk for mental health problems are served through targeted prevention and risk- or harm-reduction strategies, and at Tier Three, individuals with mild to complex mental disorders are treated with therapeutic interventions at varying levels of intensity.  The school is situated to play a role at all identified levels of support. The general population can be targeted through mental health literacy curriculum. Students at-risk for mental health concerns can access targeted school-based interventions, and students experiencing 
	  	    	   8 current mental health difficulties can access intensive school-based supports and are provided with links to community mental health service providers that collaborate with the school.  The “School-Based Pathway to Care Model” is an example of a framework and program currently being piloted and evaluated in school districts across Canada (Wei, et. al., 2011; Kutcher & Wei, 2013). This model involves the school in evidence-based practice at all three tiers of service. The program includes a mental health literacy curriculum that can easily be delivered by teachers and maps onto learning objectives in the curriculum for secondary students across Canada.  A model for cross-sector collaboration in targeted mental health service delivery is also incorporated into the framework. First, key educators who are most likely to interact with youth in need of mental health supports are identified and receive training in identification of mental disorders, responsibilities, triage procedures, and building connections with community mental health service providers. Second, stakeholders from both the school and community agencies take part in the same training workshops as a means of building relationships, facilitating collaboration, and instilling a common language. The School-Based Pathway to Care is one of several models developed to allow for the incorporation of mental health supports into the school environment. As these initiatives are put into place it is important to value the youth perspective when considering the efficacy and acceptability of school-based supports.   Why Do We Need the Youth Perspective Represented in School-based Mental Health (SBMH) Research?  In the context of school-based mental health services, adolescents are the primary consumers, whereas educators and families can be considered secondary. Given adolescents’ primary role, it is imperative that their voices and experiences contribute to the development and evaluation of these services, especially because it is possible that youth perspectives are different 
	  	    	   9 than that of other stakeholders. Social validity theory provides a supporting rationale for eliciting consumer voices in applied research (Wolf, 1978). Montrose Wolf (1978) initially proposed the concept of social validity as a means of establishing the consumer perspective on the importance, utility and acceptability of applied behavioural areas of research focus. This concept stemmed from the recognition that in applied research significant results must be conceptualized more broadly than measurable statistical significance. According to Wolf (1978), the ultimate goal of applied research is that it be considered applicable and useful in society, so that must factor into an assessment of significance as well. Increasingly, the concept of socially valid services is being incorporated into policy and practice as well. For, example the American Psychological Association Presidential Task Force on Evidence Based Practice (2006) conceptualized quality services as those that combine research evidence with clinical expertise, emphasize collaboration, and take into account consumer preferences, choice and cultural factors. In order to learn about the social validity of a service, one must ask the consumer; this is what the present study seeks to carry out. With recent increased attention on the school’s potentially central role in mental health service delivery for youth, the time to highlight the consumer voice is now. Talking to adolescents about their experiences with mental health supports in schools will allow their perspective to further guide the development and implementation of school-based mental health frameworks, rather than waiting to hear the consumer voice post-hoc. It is also important to learn about youth perspectives surrounding mental health services because there is evidence that perceptions of services impact consumer behaviour; for example, consumer perspectives influence participation in treatment activities, affect one’s likelihood to remain in treatment, impact adherence to recommendations, and future 
	  	    	   10 involvement in mental health services (Brinkmeyer et. al., 2004; Kazdin, & Wassell, 2000; McKay & Bannon, 2004; Meyer, et. al., 2002; Morrissey-Kane, & Prinz, 1999). Eliciting youth voices is especially important given findings that youth attend to different factors than other stakeholders when evaluating their experiences with mental health services (Aarons, et. al., 2010; Garland, et. al., 2004). For example, Aarons and colleagues (2010) found differences in responses during in-depth interviews when they asked youth and their caregivers separately about positive and negative aspects of their experiences with community mental health services. Specifically, youth were more likely to talk about positive outcomes of treatment, whereas caregivers’ positive comments primarily addressed specific components of the program and characteristics of the treatment providers. Youth are the primary consumers of school-based mental health services, who have a unique perspective that differs from other stakeholders; thus, it is imperative to elicit youth voices in order for research and practice to establish evidence of its social validity. How Do We Elicit Youth Voices in SBMH Research?  Traditionally, consumer satisfaction with health and mental health services has been assessed with brief surveys, due to their efficiency and the ability to administer them in a non-intrusive manner (Aarons et. al., 2010). However, Garland and colleagues (2000; 2003) point out that the meaning of consumer satisfaction with regards to mental health services is still rather ambiguous, as research findings in this area are variable and often opposing.  Given that there is still considerable uncertainty as to what factors impact consumer satisfaction, it is possible that important questions are not being asked on surveys. Additionally, there are inherent limitations to survey data, as often no explanations or elaborations are provided for the answers that participants offer and the breadth of experiences addressed is limited (Aarons et. al., 2010).  
	  	    	   11  Qualitative approaches to inquiry that employ in-depth interviews provide an alternative to satisfaction surveys for learning about consumer perspectives of mental health services. Aarons and colleagues (2010) suggest that in-depth interviews with consumers regarding their experiences can provide valuable insight into the ways consumers evaluate services, improving the value of consumer input. This approach will be utilized in the present study and will be discussed further in the next chapter.  Chapter Summary  A review of the literature supports adolescent mental health problems as an issue that requires attention. Currently many adolescents require mental health supports, but do not receive them. The school has been identified as an important access point where mental health supports can be ingrained, which has led to the development of many frameworks and programs to allow the school to serve this role. When emphasizing socially valid research and practice, questions surrounding treatment acceptability and perceived helpfulness become important.  However, there is still a great deal of uncertainty regarding how to assess consumer satisfaction for mental health supports. A qualitative approach to inquiry that employs in depth interviews can address this uncertainty by allowing for open-ended questions to be asked, which can lead to identification of themes that may not be elicited by questions asked during typical methods of inquiry such as surveys.    
	  	    	   12 CHAPTER THREE: Method  Epistemological, Theoretical and Methodological Assumptions  The goal of the present study was to gain an understanding of the meaning of adolescents’ experiences seeking and receiving support for mental health difficulties at school. This necessitates a particular approach to inquiry that values the voices of participants and their lived experiences. The qualitative research methodology Interpretive Phenomenological Analysis (IPA) allows for this form of exploration, and was employed to answer the present research question.   IPA is a methodological approach to research that can be informed by the epistemological assumptions of social constructionism (Crotty, 1998). Social constructionism posits that knowledge is constructed in a social context as human beings interact with the world and attribute meaning to reality based on available language, symbols and culture. This can be contrasted with a post-positivist approach to knowledge, which holds that an objective reality exists and can be uncovered (albeit imperfectly) through objective inquiry where bias is consciously minimized.  In order to employ a social constructionist approach in the present study, the active role of the researcher in constructing meaning was acknowledged; I engaged in personal reflection regarding how my own experiences and perceptions surrounding school-based mental health supports and mental illness impacted not only the questions I asked, but also my interpretation of the information gathered.  A personal reflection section is included following the discussion of the theoretical basis of IPA. The IPA approach to inquiry is grounded in the theoretical underpinnings of phenomenology, hermeneutics and ideography (Smith, Flowers, & Larkin, 2009).  
	  	    	   13 Phenomenology. Phenomenology is the study of the lived experience and stems from the work of philosophers Husserl and Heidegger. The work of Husserl informs the shift in the focus of inquiry from the object to one’s perceptions or experiences of the object.  For example, in the present study the focus of inquiry was on adolescents’ experiences of mental health supports at school versus focusing on the actual formal and informal mental health supports themselves. A key difference between IPA and Husserl’s phenomenology is that his goals were descriptive and post-positivist in the sense that he wished to uncover broadly generalizable aspects of perceptions of a phenomenon or experience. In contrast, Heidegger’s philosophical work emphasizes the aspect of social construction involved in inquiring about lived experiences, thus recognizing the interpretive nature of phenomenological inquiry. This philosophical stance more closely aligns with the IPA approach that will be employed in the current study (Smith, et al., 2009).  Hermeneutics. As previously stated, Heidegger recognized the interpretive nature of phenomenological inquiry and thus became known as a hermeneutic phenomenologist. Hermeneutics refers to the theory of interpretation, and is the second major theoretical underpinning of IPA. When employing the IPA methodology in the present study, data was gathered from participants through semi-structured interviews and transcribed to take the form of transcripts. As the researcher I applied hermeneutic principles to analyze and interpret the data, and gain an understanding of the meaning of the lived experiences of adolescents seeking and receiving support for mental illness at school.  One such principle that informed data analysis was the hermeneutic circle, which refers to the dynamic process of transitioning back and forth between the specific and the whole during interpretation. Concretely stated, this means cyclically 
	  	    	   14 evaluating how the experiences shared by individual participants related to and diverged from experiences shared by other participants.  Idiography. The focus on the particular is conceptualized as idiography, which is the third major theoretical underpinning of IPA (Smith et. al., 2009). Typically, in post-positivist psychological research the voices and perspectives of individuals are lost to the goals of quantifying and making generalizations about a group or population. A goal of the present study was to acknowledge the expertise provided by the lived experience by making it the focus of analysis. IPA allowed for this by committing to the particular through the in-depth and detailed analysis of experiential accounts. Smith and colleagues (2009) state, “IPA is committed to understanding how particular experiential phenomenon (an event, process, or relationship) have been understood from the perspective of particular people in a particular context” (p. 29); IPA studies typically employ small, homogeneous samples of participants with shared experiences to allow for the in-depth analysis of the experiences of individuals.  Data Collection Procedures Recruitment. Participant recruitment began at the school district level. Three school districts administrators in the lower mainland of British Columbia were contacted by phone or email and asked if they would permit students within their schools to be recruited for participation in the research study; two school districts approved recruitment, and the third district did not respond to the request. In one school district, high school principals were emailed information about the study, but the researcher did not receive any responses. In the second school district, the district administrator facilitated direct contact with a high school principal who met with the researcher and approved recruitment at the school. This school was described by the district and school administrators as providing the most intensive school-based mental 
	  	    	   15 health supports available within the district and had a student population that included a high proportion of the students in the school district who were receiving mental health supports. Noteworthy characteristics of the school included small class sizes with low teacher to student ratios (~1:15), a partnership with a regional health authority that offered intensive mental health treatment at school, multiple counsellors on staff daily, and school values that included a commitment to individualized learning, and emphasis on development of the whole student.  Recruiting all students from the same school aligned well with IPA methodology, which calls for a homogeneous sample of participants who have a shared experience. To recruit student participants, a teacher privately distributed the recruitment information to students who met inclusion criteria for participation (See Appendix D). Students who were interested in participating in the study let the teacher know and she collected guardian contact information to pass on to the researcher for preliminary screening and to obtain guardian informed consent. The same teacher also scheduled the initial interview between participants and the researcher. Screening Process. The researcher contacted the guardians by phone to discuss the study and obtain informed consent. Guardians were provided with the option to schedule an in-person meeting, but all preferred to speak over the phone.  A brief screening questionnaire procedure was also conducted with the guardian during this phone conversation to help assess the risk for participant harm potentially associated with the study (See Appendix E). This screening helped to determine whether students were likely to experience significant distress from discussing their experiences with mental health supports at school, or whether the student had recently been hospitalized for a psychological crisis; these factors would result in exclusion from participation in the study. However, no interested students were excluded from participation in the study on 
	  	    	   16 this basis. After the initial phone conversation, the researcher emailed the letter of informed consent to the guardians and provided them 48 hours to review the letter and make a decision. After 48 hours, the researcher contacted the guardians again by phone to obtain formal consent and answer questions. Signed guardian consent letters were sent to the school with the students (See Appendix B). The researcher spoke with the guardians of seven students who had indicated interest in participating; five guardians consented, two declined. Participant informed assent was obtained during the initial meeting with the researcher; the assent form (see Appendix C) was reviewed in detail, participant confidentiality, and the limits to confidentiality were discussed. All five participants whose guardians consented also assented to participation. Participants. The goal of recruitment was to identify four to six students to participate in the study; this is consistent with Smith and colleagues (2009) recommendation to recruit a small, purposive sample in IPA studies in order to remain consistent with the idiographic method. The first inclusion criterion for participants was that they were a current high school student enrolled in Grade 11 or 12. The rationale for recruiting older adolescents was that they had been in school longer, so likely had greater opportunity for a variety and depth of experiences related to seeking and receiving support for mental health difficulties at school. Secondly, participants were required to self-identify as experiencing significant mental health difficulties and a diagnosable mental illness (e.g. anxiety disorder, mood disorder, ADHD etc.) for which they required support. Additionally, participants were required to speak English and to be willing to participate in an in-depth interview discussing their experiences of seeking and receiving supports for a mental health concern at school. These inclusion criteria were confirmed with the participant during a brief background interview conducted during the initial meeting with the researcher. During the background interview with one participant it became apparent that he did not self-
	  	    	   17 identify as experiencing mental health difficulties, so it was determined that participation in the study was not an appropriate fit. A sample of four students between the ages of 16 and 17 participated in the interviews. All participants identified as female. Table 1 describes participants’ age, grade, and self-identified diagnosis at the time of interviews.   Table 1. Participant Characteristics Name* Age Grade Self-identified diagnosis Barbara 17 11 Depression, Anxiety  Nicole 17 12 Depression, Anxiety Stephanie 16 11 Depression, Anxiety, Borderline Attention Deficit-Hyperactivity Disorder (ADHD), Borderline Obsessive Compulsive Disorder (OCD) Turtle Bean 17 12 Depression, Anxiety, Depersonalization *Pseudonyms used to protect participant confidentiality Interviews. Data was collected through individual, confidential, semi-structured interviews that were audio-recorded and later transcribed by the researcher for analysis. Interviews were conducted in an empty classroom at the students’ school. A list of open-ended questions was prepared in advance (See Appendix A) to guide the interview, though additional probes were added during the interview based on the information provided by the participants. It should be noted, in the IPA approach to inquiry the interview script is considered a guide and the participant is regarded as a storyteller who ultimately controls the direction of the interview (J.A. Smith & Osborn, 2008). As such, not all questions from the interview script were asked verbatim or in the same order to each participant. Interviews ranged in length from 40 to 90 minutes, with the average interview lasting 64 minutes. Participants had the opportunity to ask questions after 
	  	    	   18 the interview and were provided with a list of community resources should they feel they needed support following the interview (see Appendix). Data Analysis The overall goal of the IPA approach to data analysis is to gain an in depth understanding of how participants make sense of their experience. Data was analyzed according to the steps put forth by Smith, Flowers and Larkin (2009) to guide researchers who are new to the IPA methodology, and was considered an iterative process. Step One: Transcript Immersion. This stage of analysis involved listening to the interview audio recordings, transcribing the interviews, and reading and re-reading an individual interview transcript several times, line by line. This process allowed the researcher to become immersed in the data and gain familiarity with a participant’s account of their experience.  Step Two: Preliminary Comments.  During this stage, initial notes on the transcript were made, and specific quotes were highlighted in an attempt to get a sense of the ways the participant talked about and understood their experiences. The analyst looked for contradictions and consistencies within a transcript, and statements that were reiterated or emphasized. Smith and colleagues (2009) suggest it can be helpful to differentiate between comments at this stage as either descriptive, linguistic, or conceptual. Descriptive comments primarily focus on what the participant says, whereas linguistic comments pertain to specific language used by the participant. Conceptual comments begin to move beyond what the participant explicitly states and often include questions that arise as the analyst works through the text. Preliminary comments were noted by hand in the margins of transcripts that had been printed.  Step 3: Bringing Together Emergent Themes. During this phase of data analysis, the analyst began to identify and map patterns or emergent themes throughout each transcript. 
	  	    	   19 Emergent themes are a reflection of both the participant’s words and the analyst’s interpretation. Identified themes were given concise titles (codes), through which the analyst intended to encompass the meaning of the patterns in the transcript. Interview transcripts were coded on the computer using word processing software; excerpts were highlighted and the related code was noted using the ‘New Comment’ function in the ‘Review’ settings. The Microsoft Word highlighter tool was also used to colour code themes in order to provide the analyst with an additional visual cue of the dispersion of themes within a transcript. Step 4. Identifying Patterns Across Cases. After each transcript had been individually coded, the analyst moved beyond individual transcripts and began to identify the commonalities and differences in emergent themes across participants. This involved reorganizing and bringing emergent themes from different interviews together, resulting in a hierarchical structure with some themes being organized into broader categories and providing a framework for discussion of the research findings. A spreadsheet was used to organize excerpts from transcripts into related broad themes and sub-themes. Each broad theme was allotted its own spreadsheet with sub-themes organized into columns.  Step 5. Writing-Up the Results. Analysis was completed through writing-up a narrative of the results, found in Chapter Four.  Ensuring Scientific Rigor  Multiple procedures were utilized to ensure the commitment to quality, trustworthiness, and scientific rigor of the research findings. Selection of these procedures was guided by the underlying research paradigm (Morrow, 2005); specifically, the current study was grounded in a social constructionist epistemology, which recognizes the role subjectivity plays in the research process and the active role of the researcher in constructing meaning (Crotty, 1998). The 
	  	    	   20 strategies utilized included debriefing, participant review of themes, peer auditing, and researcher reflexivity practices, which were carried out throughout the data collection and analysis phases of research.  Debriefing. To debrief, the researcher met with my research supervisor regularly to discuss my interpretation of the interviews and any methodological or logistical challenges that arose.  Participant Review of Themes. This procedure involved meeting with participants a second time after their transcripts had been analyzed, and broad themes and sub-themes had been identified. 15 to 30 minute interviews were conducted with participants in person where they provided feedback on the themes and indicated the extent to which the themes reflected their experiences. Three out of four participants indicated that they recognized their experiences in the themes; the fourth participant was not available for follow-up.  Independent Audit. As recommended by Smith and colleagues (2009), an independent audit was completed by a school psychology graduate student with experience using the IPA methodology. During this process, the auditor traced the path made by the researcher from the interview to the emergent themes by reviewing a participant transcript with notes and codes, and the final organization of the participant excerpts into broad themes and sub-themes. The purpose of the audit was to have an individual who was not a part of the study evaluate whether the path from the interview to the thematic organization of interview excerpts was logical and remained grounded in interview data. The auditor provided the researcher with verbal feedback and confirmed that results seemed reasonable and logical.  Researcher Reflexivity. Finally, I engaged in researcher reflexivity throughout the study, which involved continually considering how my experiences and assumptions may have 
	  	    	   21 impacted my exploration of the research question. Researcher reflexivity highlights the importance of context in the research process, specifically the role the interaction between researcher and participants plays in data collection (Morrow, 2005). A summary of my personal context and potential biases that I considered while conducting the study is included in the Researcher Reflection section of the chapter. Additionally, I continued to self-reflect by journaling my impressions before and after interviews, and during interpretation. This process helped to further increase my awareness of my own role and influence in the emergence of the findings.  Personal Reflection  Prior to conducting this piece of research it was important to reflect upon how my own experiences and perspectives have the potential influence both the questions I asked and interpretation of the data that I collected. The initial reflection statement I wrote prior to beginning data collection for the study follows below, and can be considered an example of researcher reflexivity. Being a Psychology Major since my undergraduate degree with a keen interest in the field of study, I know that my education thus far has shaped my understanding of mental health and mental illness. While I recognize the shortcomings and complexities of diagnosing disorders based on profiles of reported symptoms, I do believe in the utility of this approach. I realize that not everyone shares these views, so I must remain cognizant of this during data collection and analysis because differences in understandings of mental illness could impact rapport with participants.   I must also acknowledge that I am entering into this project with my own ideas about the current state of mental health services in Canada based on experiences I have had in the 
	  	    	   22 communities I have lived and worked. In my support work at an emergency shelter for at-risk youth and role on the psychology services team at a community living program for adults with intellectual disabilities and behavioural disorders I have witnessed the fragmentation of the mental health services systems and the intense frustration and misunderstanding that stems from siloed services.   In my training as a School Psychology Master’s student I have learned about the role of schools in supporting students’ social-emotional development and learning. I have worked with students who have experienced various social-emotional and learning challenges and have a desire to help these students. My research on school-based mental health services thus far has led me to believe that implementing these frameworks and services in schools is a worthwhile pursuit for supporting the positive development of students. Remaining aware of these potential biases was important as I conducted interviews and analyzed the data.  Ethical Considerations  Ethical approval for the study was granted by the Behavioural Research Ethics Board at the University of British Columbia. The present study required that vulnerable individuals (adolescents with mental health difficulties) take part in in-depth interviews about potentially sensitive subject matter, which means there were several important ethical implications to consider.  A thorough discussion of informed consent took place with guardians and adolescents prior to participation in the interview, including a discussion of the limits of confidentiality. Participants and their parents were provided with a detailed explanation of what to expect from the interview, the purpose of the research, and the outcomes. It was emphasized that participation was voluntary and consent could be withdrawn at any time. If participants chose to withdraw 
	  	    	   23 from the study, they had the option to remove previously collected data from analysis and the final document.  Participants were asked to speak about their experiences of seeking and receiving support for a mental illness at school, which had the potential to result in the discussion of distressing or uncomfortable subject matter. To address this possibility, interviews were scheduled with enough time to allow for breaks should the participant require some time away from the subject matter. Additionally, in consultation with school staff a list of community mental health resources was compiled that students were provided with. The researcher was also available to discuss ways to access the resources if needed. Maintaining participant anonymity was also a priority. Participants chose a pseudonym and no identifying information was included in the final document. Identifying information such as participant contact information was stored separately from the data and all transcripts were coded using the pseudonyms. Given that all participants came from one school, further measures were taken to preserve participant anonymity under the assumption that school staff would have access to the final research paper; participant excerpts included in the results were not attached to a pseudonym so that the narratives of individuals could not be reconstructed, making it less likely for excerpts to be attributed to individual students. Chapter Summary  Interpretive Phenomenological Analysis was used to explore the meaning of adolescents’ experiences seeking and receiving support for a mental health concerns at school. Four students in Grades 11 and 12 took part in in-depth, semi-structured interviews on the topic of interest. Interviews were audio recorded and transcribed for analysis. Data analysis followed Smith and colleagues (2009) step-by-step approach for beginning IPA analysts. Scientific rigor of 
	  	    	   24 exploration was ensured through thick and rich description, debriefing, member checking, an external audit, and researcher reflexivity.  
	  	    	   25 CHAPTER FOUR: Findings The purpose of this research was to gain an understanding of the meaning of adolescents’ experiences of seeking and receiving support at school for significant mental health concerns. In-depth interviews were conducted with four adolescents and analyzed using IPA. This chapter presents the results of the analyses. Findings are organized into three broad themes, seven subthemes, and two interwoven themes that relate to each of the three broad themes (See Figure 1).  The last grouping of themes was conceptualized as interwoven rather than overarching because they can be considered a common thread contained within the broad themes, but do not fully encompass or relate to all aspects of each broad theme.  In discussing the phenomenon of seeking and receiving support at school, participants identified a range of positive and negative experiences. A seemingly important facet of participant’s experiences was that they had all attended different elementary schools and high schools prior to their current school. Generally, participants indicated that they felt better supported at their current school than previous high schools. As such, participants were able to compare and contrast an array of experiences where they felt supported and experiences where they did not; this appeared to be an important mechanism through which participants made sense of their experiences.  Throughout the findings section, several participant quotes (extracts) are included to provide thick and rich description, and illustrate the themes to the reader. This practice helps to ensure that the themes remain grounded in the original participant interviews. This is their experience, in their own words, and participants’ own meaning making that is represented here.  To assist with readability, some extracts were minimally edited to remove filler words, repetitions made by participants, and short responses made by the interviewer (e.g. mmhmm, 
	  	    	   26 okay). Ellipsis points (…) indicate information that was omitted from extracts and a dash (-) indicates that the participant took an extended pause. Broad Themes Flexible Learning Environment Supportive Relationships Schools as Support Systems Related Sub-themes Flexible Structures Teachers Who Show They Care Network of Available Supports Individual Adaptations Awareness of Mental Health and Mental Illness Someone to Talk To  The Negative Impact of Bullying  Interwoven Themes Students As Individuals Meeting Students Where They Are At Figure 1. Organization of Themes  Broad Theme One: Flexible Learning Environment  This broad theme represents participants’ descriptions of their learning environment and how it contributes to their experiences of support at school. All participants identified that when dealing with significant mental health difficulties it was important to feel like it was still possible to be successful and productive in their learning. Participants highlighted that rigid structures and expectations at school acted as barriers to feeling supported; in contrast, a flexible learning environment provided an opening for opportunities to engage in learning and facilitated feelings of accomplishment and productivity. Within this broad theme, two subthemes were identified. First, participants discussed how the flexible structures in place at school (e.g. time table, approach to deadlines and attendance, and Student-Teacher ratio) played an important role in their perceptions of feeling supported. Second, participants identified the importance of individualized adaptations to their academic program. 
	  	    	   27 Flexible Structures. Participants discussed the impact of school-wide structures when dealing with significant mental health difficulties. One participant highlighted how a flexible attitude towards attendance helped her to feel supported when experiencing anxiety, Definitely the flexible schedule…you can come halfway through the day and it doesn’t matter. Like you won’t have to walk into a class awkwardly and interrupt because everyone’s coming in at different times so it doesn’t matter. So if you’re not having a great morning you can just sit the morning out and just stay at home, go in later in the afternoon.  If you’re not having a good afternoon, you can go home. Which I think is really helpful for someone that struggles with anxiety because sometimes you just don’t have good days and you don’t want to have to be suspended cause then you’ll…umm like (other schools), if you miss a certain amount of days you’re suspended, which I would be so screwed (laughs)…  In addition to flexibility regarding attendance, a participant also identified the importance of flexibility regarding assignment deadlines, Before this school, I…well even here, I missed, I ended up missing a lot, like huge chunks of time because I just I can’t get out of bed. Like, I’m so physically exhausted that I can’t move. And then it gets worse because I just, I get scared that I’m missing all this stuff, and I don’t know how to catch up, and then I don’t have the stuff to hand in so I don’t want to go. And then I’m missing more and more. So I’m extraordinarily lucky now that it’s, you know, I’m on my own time, and so I’m able to do things at my own pace and not have like strict deadlines. 
	  	    	   28 Participants identified that a flexible approach to deadlines and attendance allowed them to feel productive without being overwhelmed by the pressure of rigid structures and expectations at school; a participant related, It was nice to feel like we were actually getting something done, rather than being at home and not doing anything. So having something, but not having the pressure of having to finish…I think it made me finish faster just because I didn’t feel so stressed out about it.  Most participants perceived flexible deadlines that allowed them to “work at your own pace” as contributing to increases in productivity. One participant reported, “I worked faster here than I’ve worked before at anywhere else.” Overall, this self-directed approach to learning allowed the school schedule to be “flexible to your life and your needs” and provided room for the inevitable difficult days that occur when dealing with mental health challenges, “if you’re having a really bad day, it’s like, they’ll understand.” Additionally, participants identified class composition as an important structural component that influenced their perceptions of feeling supported; specifically, smaller class sizes with greater opportunity for one-on-one instruction from teachers helped a great deal: You also get so much one-on-one time here…because the classes are so much smaller. And I think you learn so much better cause they can actually teach you instead of just standing up in front of the class in front of 30 people…  Conversely, one participant identified an experience at school when she was expected to be around large crowds of people and how it negatively impacted her mental wellbeing: And I hate being in rooms full of people. I cannot bring myself to walk in a room with more than like 20 people in it. It’s just like, a big no-no for me. And it’s like the first day 
	  	    	   29 of school, there is like 50 people in that room and I couldn’t bring myself to do it. I was in the hallway and I just started crying… Individual Adaptations. Participants also discussed their distinct learning styles and how important it was to them that teachers in their learning environments were open to adapting expectations and teaching methods to meet their individual needs. All participants also identified experiences where adaptations were not incorporated into their learning. These experiences resulted in significant frustration and contributed to their feeling a lack of support at school. A participant expressed, It was really hard in elementary school, cause um, like the way I concentrate is by like drawing. And teachers wouldn’t like understand that, so whenever I’d draw they’d get mad at me and take my things away. And then I couldn’t concentrate on class. Another participant described a similar experience she had when her math teacher was not able to adapt his teaching style to meet her learning needs, and how this contributed to her feeling like she was struggling in school: Well it’s like I’m actually smart, like I understand math. So it’s like this is super frustrating for me to not be able to understand what I’m trying to, cause it’s like I’ve been really good at math for all these years that I’ve been in school…I need step-by-step and he just does the steps for me, does the whole question, and it’s like I don't learn like that. So it’s like, I'm really struggling with Math right now. Participants identified an increased need for flexibility and adaptations at school in order to effectively support them when dealing with mental health issues. One student highlighted that her current “school is very flexible for any mental health issues…you throw anything and they’ll 
	  	    	   30 adapt to it…”   In the following excerpt, a participant related strong feelings of appreciation for teachers when they took the time to get to know students’ individual learning needs, So it’s cool that they will adjust how they normally would teach to fit you, which I feel is…most teachers would find that kind of hard to do. They’re very flexible with…especially because there are a lot of kids that have completely different needs. And they remember what each kid needs, which is…that blows my mind. Because they try to remember which kid likes this and which kid can’t do this…So they know each kid’s needs, and their individual strengths and weaknesses, which is really helpful.  Like if a test is stressing you out, like a certain subject that you’re not very good at, they will let you have a couple cue cards or let you do it open book. Or you can ask questions, which is so helpful especially when you’re just anxious about everything.  Participants also identified experiences when teachers found opportunities to incorporate their personal interests into their learning,  The teachers are like, oh you’re interested in this. Let’s go do more of that stuff. And like let’s look at professional people that are doing that stuff. While other schools just like, like they don’t care… Like the art teacher booked an appointment with a tattoo artist because she thought that would be a cool job for me. And then I had talked to one, and like, it was really awesome.  Broad Theme Two: Supportive Relationships  This broad theme represents participants’ descriptions of their relationships at school, and how day-to-day interactions with other members of the school community played an important role in their experiences of support. Within this broad theme, participants discussed in depth the positive impact of teachers who show they care. Participants also identified that 
	  	    	   31 interacting with individuals at school who have an awareness of mental health and mental illness helped them to feel supported. Finally, several participants discussed the negative impact of bullying, which is included within this broad theme because it can be considered the inverse of a supportive relationship.  Teachers Who Show They Care. When participants talked about their experiences of being supported at school they discussed various relationships, including relationships with peers and counsellors. However, they spoke in the greatest depth about their relationships with teachers and how supportive, caring interactions could have a significant positive impact on their experiences at school. One participant emphasized, They actually truly care, which I find is hard to find, like a whole group of teachers that care so much about individual students. And just everyone as a group, and how everyone is functioning, how everyone’s feeling, it’s just like a huge group of like counsellors that can teach you. So it’s like a huge support group in one building. And ya, so good, so helpful, I think that needs to be everywhere. One participant reported that when a teacher opened up with her and was willing to interact with her on a more personal level that helped her to feel supported and connected in their relationship, “And she is open about her life also. I can tell her about a personal experience, and she will tell you about one of her personal experiences... So like you know, she will actually relate to you rather than just being another teacher.”  Participants also highlighted that teachers show they care by providing encouragement and showing they are invested in their students’ educational success, “They genuinely care about you and your education. And the only thing they want you to do is graduate and become successful. And they’re always trying to encourage you.” 
	  	    	   32 Conversely, all participants also discussed negative interactions and relationships they had with teachers. Participants expressed that these negative interactions led them to perceive that teachers “hated” them or were singling them out, and contributed to feeling a lack of support. One participant reflected on her past experiences in middle school and early in high school, “Well, I was always that kid that like the teacher picks on to make all the other students scared to like obey them or something, it was always me.” Another participant related, “Yah, elementary school was really hard and I had like the most crazy teacher I have ever…she was nuts. She hated me for some reason. She had very specific favourites and not favourites (laughs)…and she didn’t like me.” This particular participant emphasized that the year she had the difficult teacher aligned with when she began to miss a significant amount of school; while there were many factors that contributed to her absence at school including challenges at home, she acknowledged that the perceived lack of support from her teacher played a role in her missing school.  Awareness of Mental Health and Mental Illness. All participants identified that in their relationships at school, when others had an awareness and knowledge about mental health and mental illness this strongly contributed to their feeling supported. In describing her current school, one participant highlighted, “The teachers are really nice and they understand what mental disorders are (laughs) - and they like, wanna help.” Another participant observed that her current teachers are not only aware of mental health and mental illness more generally, but they know their individual students well enough to recognize the signs of when they may be in need of extra support,  And the teachers are always very aware, like they can notice if something’s different in you that day. And if you are, they recommend that you should go home and come back 
	  	    	   33 tomorrow, or maybe you want to go lie down, or maybe you want to talk to the counsellor or you know, just put your head down for a few minutes. And so I think they’re very observant with that ‘cause they can see how a student regularly acts on a regular day. And sometimes if like a student, if I have a friend who’s schizophrenic uhh, most days never has an act up but if he did, they would be very like, they would know what to do. Which is same I think if you’re bipolar or have anything that’s a little bit harder to deal with, where sometimes it can have worse act ups…sometimes you can have worse days. And I think they know their students well, which is so helpful cause sometimes you don’t even recognize that you’re acting different…you don’t recognize that something’s not right, you just kind of feel not great, but then when you have someone kind of point it out, you’re kind of like…oh, yah, I am not feeling super great right now. And it’s nice to have someone else who is kind of there to look out for you.  Participants also highlighted that having friends and peers at school who have also experienced mental health difficulties helped them to feel supported because they may have shared common struggles, and thus also have an awareness of the challenges associated with mental health and mental illness. One participant expressed, “Yah, having my friend (Jane) around really helps me too. Because I’ve known her for so long that we’ve just struggled with depression and anxiety together for like quite a couple years, like since elementary school.” All participants identified that they had peers who also experienced mental health difficulties or personal struggles; this suggests that students feel they are able to be open, which can further promote awareness. A participant emphasized that having an awareness of everyone coming from their own place of struggle provided a common ground for others to support each other,   
	  	    	   34 Everyone’s come from some place of struggle, and everyone can relate on that part. I mean some people in this school have such, like, rough lives, and like, you just can’t even imagine how they’re even functioning at school, and then other people just have a particular anxiety, but everyone can rely on each other. Another participant observed that having an awareness of individuals’ differences helps to promote an accepting environment at school, “People here are all like kind of different I guess, so it’s like, you can’t like judge anyone - umm, it’s just really accepting.”   In reflecting on previous experiences, all participants also discussed times when they felt that school personnel had a lack of awareness and knowledge about mental health and mental illness; they identified that when there was no awareness, it was not possible to get appropriate supports. For example, one participant identified that the counsellors at her previous high school were not equipped to support students experiencing mental health difficulties, In high school before, you know we had counselors in place, but they were mostly just to help you get ready for transitioning to postsecondary. They weren’t really good for going to if you have serious mental health concerns or like issues like that, you couldn’t really talk to them about that - So yah, I would go in a couple of times and they’re like, Are you ready for university? Umm, no (laughs). Another participant expressed that when she tried to talk to friends about any issues she might be struggling with, it was difficult to feel supported when they had a lack of awareness of mental health and mental illness, Well I had friends in high school, so I’d just like go to them, but they were really like - I don’t know, they kind of didn’t really understand me either. They were just like, Oh yah, I have the same thing.  And then they wouldn’t have the same thing, and then I was like, 
	  	    	   35 That’s not it dude (laughs). And just like, Oh, I have the same thing and it’s easy, you just have to like get over it. And it’s like, I don’t know- All participants indicated that they began to experience their mental health difficulties as young as elementary school and they perceived there to be an exceptional lack of awareness and resources surrounding mental health supports for those age groups. One participant related, Like when I started Kindergarten, it’s like looking back at it now, like all the signs that I had when I was younger of anxiety, and no one else picked up on them at all. And so it’s frustrating because I see it, but nobody else saw it.  The Negative Impact of Bullying. Three of the four participants identified the detrimental impact of bullying in the school environment; they conveyed that bullying negatively impacts mental health and contributes to feeling a lack of support at school. One participant suggested that students with mental illness have a greater risk of being bullied and emphasized that schools should take an active role in addressing it,  Umm, stop bullying and stuff. Like actually step in and do something about. Cause like that’s actually a really big factor in mental illness. People who have depression or anxiety or like schizophrenia, they get bullied a lot at school.  She highlighted that when dealing with a mental illness it can already be difficult to come to school; bullying can act as an additional barrier and make the environment feel less safe,  A lot of kids at this school struggle with mental illness, it’s anxiety for a lot of kids. If they’re getting bullied, people are already having trouble coming to this school, it’s not gonna make them, it’s just pushing them away even more. It’s just like, they’re going to struggle even harder. It’s not like teachers care about that at all. It’s like they care about 
	  	    	   36 the kids that are here, but not the kids that are struggling to come to school. And it’s just like, it’s not a safe place anymore.  One participant related that a combination of severe bullying and anxiety contributed to her being homeschooled for a year, “And then I got bullied really bad, and then I couldn’t go to school because of my anxiety.” Another participant reflected on what she might change looking back on her experiences at school, and expressed, “Well I wouldn’t really change anything because if I didn’t go through all that stuff I wouldn’t be the same person…. But, - those years and years of bullying really weren’t rad (laughs).”  Broad Theme Three: Schools as Support Systems This broad theme represents participants’ descriptions of how schools can function as support systems when meeting the needs students with mental health difficulties. In this regard, two subthemes were identified. First, participants expressed that it was helpful when a network of supports was available at school that they could easily access (e.g. a counsellor, youth worker, or supportive student group). Second, participants emphasized that knowing there are individuals at school who students can trust and talk to promoted feeling supported when dealing with mental health concerns.  Network of Available Supports. Participants identified that when schools functioned as support systems by providing a network of readily available supports, this promoted feelings of connectedness. As one participant relates, “Most helpful is probably the amount of connection that we have here, like it’s really, you need help, there’s always someone available.” To illustrate, she quickly listed some of the support options at her current school,	  We have a huge network of support systems here. We have a couple of counsellors that are here all the time. There’s another that is here two days a week because she’s just 
	  	    	   37 starting out. We have a music therapy program, art therapy, umm, we have a therapeutic day program, which is really good for kids that have come from really strenuous backgrounds and it’s an easier way to integrate into the normal (well normal for here) classrooms and stuff, where they get group therapy sessions and one on one support - and everything - it’s been really, really excellent - We have a couple of youth workers here all the time - we also have youth workers from three, four different groups that come in, so we have two or three on a daily basis that just come for check ins and also for groups. We have this wonderful craft group on Tuesdays at lunch where we get to, we’re doing embroidery right now, which is really fun. Another participant related that in addition to counsellors, teachers and peers also function as important members of the network of available supports,  Usually we have our counsellors down there… so you can go down there at any point in the class, or if you want to pull a teacher aside that you like to talk you can take them out of class, which is nice. I’d be comfortable talking with any teacher really, or there’s two counsellors. Sometimes (the principal) will even take to time just to hang out and talk, which is really nice. So there’s always some sort of support that you can get, even the other students are very, very supportive.    Participants also reflected on past experiences when they felt there was no support network in place at school, “In the past school’s been really difficult. Like here, there are great support systems. And there are tons of them in place. Umm, but a lot of other schools there aren’t. Like especially elementary schools - it was really bad.” Participants identified a lack of available supports in elementary school especially, which is consistent with the lack of awareness and knowledge about mental illness in the elementary years that participants also 
	  	    	   38 identified. One participant expressed that having no mental health supports in place at school contributed to feeling like she was alone with her challenges, “I needed extra help since I was little, but like no one ever helped me. So I like had to struggle all by myself.”	  Someone to Talk to. When discussing schools as support systems, participants highlighted that it was helpful feeling like there was someone or multiple people they could talk to at school. One participant related,  If I need someone to talk to, I need some help with whatever, I usually go down and see the counsellors or sometimes the youth worker that is here all the time. And I also have like a ton of youth worker phone numbers, like a bunch of others that are around all the time. So if you need someone to talk to, there’s always someone around and it’s really, it’s really nice. Another participant identified a daily routine where she met with a particular teacher, “She really helps me too. I talk to her every morning about stuff. And like she’ll sit there and kind of like counsel me about it.”  Participants also discussed past experiences where they felt that there was no one who they could talk to at school and how that contributed to feeling a lack of support, Through like elementary and (my previous high school) and stuff, it would have been really nice to have someone trustworthy that’s just really open that you can just - can just go and talk … Elementary school was really hard, elementary we didn’t have anybody. Interwoven Theme One: Students as Individuals This interwoven theme highlights the importance participants placed on being acknowledged as individuals first and foremost when being supported at school. The significance of acknowledging the individual needs and interests of students was identified in relation to all 
	  	    	   39 three broad themes, including the learning environment, relationships, and the school functioning as a support system.   For example, participants noted that a flexible learning environment allowed learning to be tailored to students’ individual interests and learning style, “teachers are like, oh you’re interested in this, let’s go do more of that stuff” and “they will adjust how they normally would teach to fit you…but so they know each kid’s needs and their individual strengths and weaknesses, which is really helpful.”  Additionally, participants identified that when teachers took the time to build relationships with their students and got to know them as individuals, they were able to recognize when someone might be having a rough day and be in need of extra support,  The teachers are always very aware, like they can notice if something’s different in you that day. Sometimes you can have worse days and I think they know their students well, which is so helpful cause sometimes you don’t even recognize that you’re acting different. Schools also met the individualized needs of students by providing various options within the support system, so that students were more likely to feel there were supports that fit their personal interests and needs. For example, one participant related, Yah, there’s always things you can do. If you can’t go to class, you can usually go to the art room or go in and check in with counsellors. Tuesdays we have Jam Group, Jam Session, you just go down, you can play guitar or whatever, we’ll all sing songs together. They’re really fun.  
	  	    	   40 Interwoven Theme Two: Meeting Students Where They Are At Participants identified that in order to feel supported, it was helpful when schools were able to respond to, and accept them based on where they were at, or their current functioning. Again, this theme can be considered interwoven because it was a common thread that ran through the three broad themes. For example, a flexible learning environment where attendance and class schedules are not rigidly enforced allowed teachers to meet students where they are at. This participant illustrateed this notion, “And the teachers are always so open. If you need to take a break and go walk around for a little bit, or if you need to go see someone, say, ya, Can I just go see someone? And they’re always so, so open about it.”  Another participant powerfully compared various relationships with adults whom she was supposed to be able to talk to at school, and the positive difference it made when these helpers were able to meet her where she was at and not force or “rip” information out of her.  The participant identified a specific counsellor,  Yah, she’s able to help me stop thinking about all the negative things in my life. She won’t even like remind me of the positive things in my life. I could be sitting there crying and she’ll say something, like ask me a question about my cats or something and she gets me off topic on the positive things and then I think about that instead.  She contrasted this experience with other school staff who push her to talk about her problems, And just like (my other teachers and counsellors) have no training in that or anything. And all they do is, it’s like basically them ripping it out of me. And like it’s just string or whatever ripping it out of your body and like just leaves it there basically (gesturing with her hands a ripping motion from her chest), but like, (my counsellor), like picks the mess of string up and puts it back inside you, and it’s like, you’re fine. 
	  	    	   41  With regard to the final broad theme, when schools functioned as support systems this allowed them to meet students where they were at because mental health supports were incorporated into the school day and supporting student mental health was considered a function of the school. When support systems were able to flexibly adapt to the needs of individual students and situations that arise, this further allowed students to be supported where they are at in school. One participant discussed an experience she had at her current school where friendship challenges with peers led her to miss school for several days. She related that her support system at school was able to plan and accommodate for her return so that she was able to feel safe and comfortable, “When I came back they were very accommodating just with what I needed. So like, they make sure that I have a separate room or they separate me from the situation, which is really nice.”  Chapter Summary  This chapter summarized the findings from the analysis of the data generated during participants’ interviews. Three broad themes, along with corresponding sub-themes, and two interwoven themes were identified based on in-depth interviews with four high school students regarding the phenomenon of seeking and receiving support at school for significant mental health concerns. Participants highlighted the impact of Supportive Relationships, a Flexible Learning Environment, and Schools as Support Systems in their experiences of support at school. The interwoven themes Students as Individuals and Meeting Students Where They Are At represent re-occurring facets of participant experiences that relate to the three broad themes.   
	  	    	   42 CHAPTER FIVE: Discussion The purpose of this study was to learn about adolescents’ experiences of seeking and receiving support at school for significant mental health concerns. The qualitative methodology Interpretive Phenomenological Analysis (IPA) was used to gain an in-depth understanding of participants’ experiences. To investigate this topic, four female students (Age 16-17) who self-identified as primarily experiencing significant anxiety and depression participated in individual, semi-structured interviews. All participants attended the same suburban high school in lower mainland British Columbia, but had previously attended different high schools and elementary schools. District and school administrators reported that the school district’s most intensive social-emotional supports were centralized at the participants’ current school. As such, participants were able to compare and contrast a range of positive and negative support experiences across different educational settings. Understanding the experiences of adolescents who seek and receive support for mental health difficulties at school can offer important considerations for researchers, school administrators, educators, and mental health practitioners. By using an exploratory methodological approach, youth participants identified and highlighted the aspects of the phenomenon that were important and meaningful to them. In this section, these findings are discussed in relation to the existing literature, and reflect the researchers attempt to make sense of the findings. Study strengths and limitations, considerations for policy and practice, and directions for future research are also discussed.  Discussion of Findings with Reference to Extant Literature Individualized and Flexible Learning Environments Are Key Elements of Support. When asked about their experiences of mental health supports at school, participants related the 
	  	    	   43 importance they attributed to their learning environment. In a supportive learning environment, flexibility was key. The notion of a flexible learning environment was related to both school structures and instructional methods. Flexibility regarding school structures included a self-directed approach to coursework which allowed rigid deadlines to be eliminated, and openness and understanding regarding attendance expectations. For participants, these considerations functioned to reduce barriers to actively participating in school. Flexibility concerning instructional methods included the provision of adaptations and accommodations based on students’ individual learning styles, and differentiated instruction that allowed a students’ strengths and interests to be taken into account. These approaches identified by participants are consistent with best-practice in teaching, and facilitated participants’ engagement in learning activities.   The strong link participants made between supports related to learning and academics and their mental health was a somewhat surprising finding because learning supports are not commonly encompassed under the umbrella of school-based mental health services in the literature.  While the perceived academic needs of high school students who experience significant mental health difficulties have not been previously researched, the negative impact of academic stress on students’ mental health has been well established (e.g. Bouteyre, Maurel, & Bernaud, 2007). If stress related to academic performance has the potential to negatively impact a student’s mental health, it logically follows that measures should be taken to reduce academic stress for students already experiencing mental health difficulties. For participants in this study, a flexible learning environment adapted to their individual needs helped to reduce stress and anxiety related to attendance, deadlines, and academic performance, and allowed them to feel successful and productive in their learning despite experiencing ongoing challenges related to 
	  	    	   44 their mental health.  The importance of flexible school structures and individualized instruction is consistent with findings from research conducted with different populations of adolescents as well. A review of alternative education programs in British Columbia revealed that a majority of students preferred a self-paced approach to instruction, that included opportunities for hands-on learning and one-on-one support (Smith et al., 2007). These findings were further echoed in a qualitative study examining the school experiences of adolescents with ADHD, in which participants reported flexible deadlines, opportunities for hands-on learning, and a willingness to adapt and accommodate instruction to meet their individual learning style as the educational ideal (Wiener & Daniels, 2015). Given these findings, it is promising that the British Columbia Ministry of Education (2015) emphasizes personalized learning for all students first and foremost in their most recent document describing the province’s education plan. This plan seeks to increase student engagement and investment in learning, by focusing on the needs, interests and strengths of individual students, and by increasing opportunities for self-directed and interdisciplinary approaches to instruction. Findings from the present study suggest that the authentic adoption of these curricular changes has the potential to significantly and positively impact the school experiences of students with significant mental health difficulties, who are often considered some of the most difficult students to engage in learning.  Supportive Relationships at School Are Characterized by Awareness and Caring. Participants in this study indicated that supportive relationships at school play an important role in their experiences of support when experiencing mental health difficulties, including their relationships with teachers, other caring professionals, and peers. This theme is consistent with findings from previous research exploring youth perspectives on mental health supports, in 
	  	    	   45 which youth consistently emphasized relational aspects of services (Buston, 2002; Genier, 2013; Nabors, Reynold, & Weist, 2000; Persson, Hagquist, & Michelson, 2016; Plaistow et al., 2014); across these studies, adolescents identified the positive impact of being supported by caring, friendly, kind, empathetic, and approachable mental health professionals in clinical, community, and school settings. A unique contribution of the present study is that in addition to caring mental health professionals, participants identified caring relationships with teachers as an important facet of their experiences of support for mental health difficulties at school. Of all the relationships discussed in the present study, participants spoke in the greatest depth about the impact of teachers who show they care, which is perhaps not surprising given the present study’s focus on school experiences of support and the frequent interactions that occur between students and teachers. This finding highlights an important role for teachers in supporting student mental health at school. Previous studies have explored the role of teachers in supporting student mental health at school, and have found that teachers consistently encounter student mental health issues and play a role in implementing school-based interventions (Franklin, Kim, Ryan, Kelly, & Montgomery, 2012; Phillipo & Kelly, 2014). However, teachers report uncertainty regarding their role in supporting students, and there is variability related to teacher willingness to be actively involved in supporting student mental health (Phillipo & Kelly, 2014).  The youth perspective on the significant role of teacher relationships in supporting student mental health is a unique contribution from this study, and highlights the importance of providing the appropriate resources and training for teachers so they are able to develop caring relationships in order to effectively support and educate students who experience mental health difficulties.  
	  	    	   46 Another key finding from the present study was participants’ emphasis on awareness of mental health and mental illness as an important component of supportive relationships at school; this finding warrants discussion surrounding previous literature examining the role of stigma in youth perspectives of school-based mental health supports. In the present study, participants did not discuss experiencing stigma at their current school or situations where they felt embarrassed about getting support for mental health difficulties. Rather, participants described a school culture where teachers and other students were aware, knowledgeable, and open about mental health and mental illness; this meant that: conversations about mental wellbeing were a regular occurrence in the classroom, students were able to come and go in the classroom when they were in need of support and this was considered the ‘norm’ by classmates, a teacher might notice a student appeared to be having a difficult day and ask them about it, and students were aware of the mental health difficulties that their peers experienced and felt they were able to support and understand each other.  The above scenario marks a sharp contrast to findings from other studies examining youth perspectives on mental health services, in which participants overwhelmingly reported the negative impact of stigma (Huggins et al., 2016; Plaistow, et al., 2014).  For example, participants felt embarrassed about the idea of experiencing a mental health problem, worried about being stereotyped as ‘crazy’ or ‘insane’ if others knew they were receiving mental health services, and identified stigma surrounding mental health issues as a major barrier to accessing supports, and a reason not to seek help at all (Huggins et al., 2016; Plaistow, et al., 2014). While it is not possible to draw any cause and effect conclusions from the present study, participants clearly articulated how awareness of mental health and mental illness in their relationships with teachers and peers at school facilitated them feeling they were able to be open about their mental 
	  	    	   47 health difficulties and seek the support they needed without feeling embarrassed or ashamed. Similarly, in a study exploring the school experiences of adolescents with ADHD, participants also reported they found it helpful when teachers had an understanding of their diagnosis (Wiener & Daniels, 2015).  Schools can Function as Support Systems. The findings of this study revealed that it is possible for the school to function as a support system for students experiencing mental health difficulties; for participants, this meant students knew about the mental health supports and services available at school, felt they could easily access supports when needed, and had people at school that they knew they could talk to when in need of support. These findings relate to previous research findings regarding the accessibility of mental health supports for adolescents. Accessibility of supports is a frequently cited challenge for adolescents when they discuss their perspectives and experiences regarding mental health services in community, hospital, and school settings (Buston, 2002; Cox et al., 2013; Genier, 2013; Persson et al., 2016; Plaistow et al., 2014). Previous studies identified a host of logistical barriers faced by adolescents when attempting to access mental health services, including travel requirements, and scheduling difficulties due to lack of flexibility of services (Buston, 2002; Cox et al., 2013; Genier, 2013; Persson et al., 2016; Plaistow et al., 2014). Adolescents also commonly reported that a lack of knowledge about existence of services, and confusion regarding what services were relevant to them served as a barrier to accessing supports (Cox, et al., 2013; Genier, 2013; Huggins et al., 2016; McCutcheon et al., 2014; Plaistow et al., 2014). In the present study participants reported that in their current setting, school-based supports were easily accessible, which suggests that centralizing mental health supports in schools can help to address the accessibility challenges experienced by adolescents. However, having support available in schools is necessary, but not 
	  	    	   48 sufficient for the school to function as a support system. Previous research findings highlight the importance of effectively promoting available supports because youth frequently report that they do not know about services that are available (Genier, 2013; Huggins et al., 2016; McCutcheon et al., 2014). In the present study, participants indicated they were aware of the supports at school and how to access them, but they did not explicitly discuss how services and supports were promoted. It is essential that youth are made aware of the different supports available, and know how to access services if needed.  Acknowledging ‘Students as Individuals’ and ‘Meeting Students Where They Are At’ are Guiding Values When Supporting Youth with Mental Health Difficulties. Two interwoven themes or common threads were identified during the analysis that relate to different aspects of the three broad themes. The themes ‘Meeting Students Where They Are at,’ and acknowledging ‘Students as Individuals’ can be considered general guiding values for supporting students who experience mental health difficulties at school. There is also evidence that adolescents may appreciate these values in other settings as well. For example, similar themes arose in a larger scale qualitative study on youth perspectives of community and hospital mental health services in Sweden (Persson et al., 2016). A key theme from their focus group discussions and open-ended survey responses was the importance of ‘Being Heard and Seen,’ by mental health professionals when accessing services. Participants in this study identified that it was helpful when clinicians showed interest in them as a whole person and saw beyond their problems. Being heard and seen also meant taking an individual’s interests and capacities into account when planning session activities. An additional facet of ‘Being Heard and Seen’ was ease of communication; participants related that it was important for clinicians to create an open 
	  	    	   49 environment and not push participants to disclose things too quickly, but rather meet adolescents where they are at with regards to what they feel comfortable discussing.  Considerations for Psychologists, Educators, and Policy Makers  The goal of this study was to explore a shared experience for a group of individuals. Utilizing IPA methodology allowed for an in-depth, exploratory approach to gain an understanding of the experiences of adolescents who seek and receive support at school for significant mental health concerns. To gain depth of understanding, the breadth of generalizability of findings was sacrificed. However, when one considers the findings of this study within the context of the larger body of literature focused on school-based mental health and youth perspectives on mental health services, it is possible to make tentative recommendations that have broader applications beyond the group of participants involved in this study. The following implications should be considered with the recognition that the findings from this study are based on the experiences of a small number of adolescent girls who received school mental health supports in a unique school context where the district’s most intensive mental health supports were centralized. While the following considerations may apply to a broader group of adolescents, the methodology utilized during this study does not allow for widespread generalizability.  Considerations for Individual Education Plan (IEP) Development. Findings from the present study related to the importance of a flexible learning environment highlight considerations for educators when developing Individual Education Plans (IEP) for adolescents who experiences mental health difficulties (e.g. students in British Columbia who have an educational designation under the category of “Students Requiring Behaviour Support or Students with (Severe) Mental Illness, Code R or H”).  IEPS should focus not only on 
	  	    	   50 behavioural and emotional supports, but also consider the instructional needs of the students, with the aim of reducing academic barriers and facilitating academic engagement. Some useful online resources can be consulted when considering the classroom and instructional needs of students who experience mental health difficulties, including The Ministry of Education in Ontario (2013) document, Supporting Minds: An Educators Guide to Promoting Students’ Mental Health and Wellbeing. Findings also support the recommended best practice of facilitating adolescents’ active involvement in the IEP development process and discussions surrounding attendance, deadlines, assessment, and approaches to instruction so that their needs as individuals remain at the forefront of planning and practice.   Implementation of Mental Health Literacy Curricula in High Schools. Study participants identified the value of having relationships at school with staff and peers who have knowledge and awareness surrounding mental health and mental illness; these findings support the potential benefits of implementing mental health literacy curricula in high schools. Mental health literacy is the knowledge and skills that facilitate recognition, management, or prevention of mental health challenges (CAMIMH, 2007). Mental health literacy competencies can increase awareness of the needs of students who experience mental health difficulties, promote knowledge of mental health services available in schools and communities, and reduce stigma associated with help seeking. To develop mental health literacy, educators can consult written resources such as the guides mentioned in the previous section or participate in workshops such as the Mental Health Commission of Canada’s, Mental Health First Aid for Adults Who Interact with Youth. Curricular guides have also been developed for educators to facilitate lessons with youth, such as Talking About Mental Illness: A Guide for Developing an Awareness Program for Youth (Centre for Addiction and Mental Health, 2001) and the Mental Health and High School 
	  	    	   51 Curriculum Guide (CMHA, 2010). Pre-service teacher training is an opportune time for educators to build mental health literacy competencies and gain familiarity with these resources.   Facilitating Caring Relationships Between Students and Teachers. The findings from this study support the importance of having structures in place at school that facilitate the development of caring relationships between teachers and students. Often the structures and schedules of high schools are at odds with student-teacher relationship development; on a semester system a student may spend as little as an hour a day for half the school year with any given teacher, so there is little time to get to know individual students. A potential avenue for addressing this issue is to assign all students a teacher advisor, who meets with students individually throughout the year to build rapport, and check-in on a students’ learning and social-emotional needs (Phillipo & Kelly, 2014). Additionally, a school-wide emphasis on connectedness and positive interactions between teachers and students can be fostered through universal programming, such as Positive Behavioural Intervention and Support (PBIS); these initiatives can help to create a school climate conducive to the development of caring student-teacher relationships. Policy that Facilitates Inter-Ministerial Collaboration for Supporting Adolescent Mental Health. Findings from this study support the potential for the provision of school-based mental health services as a means to reduce the significant accessibility barriers that adolescents face when seeking and receiving support for mental health difficulties. A noteworthy feature of the high school where study participants attended was collaboration with a regional health organization, and many community service providers in order to provide holistic social-emotional supports for students. Because supporting youth mental health falls under the authority of many providers, it has been acknowledged that coordinated efforts are required at provincial, 
	  	    	   52 regional, and local levels in order to provide comprehensive services in more schools across Canada (Santor, Short, & Ferguson, 2009). It is hoped that findings from this study inform policy development that supports inter-ministerial collaboration and the central role of the school in supporting student mental health.  Study Strengths and Limitations Limitations. A potential limitation of this study is that the researcher chose not to review participants’ educational records, including any psychological diagnoses, educational categorical designation, or IEPs. This decision was made in order to reduce potential biases or the development of preconceived notions about participants; the goal was to facilitate the researcher’s interview questioning and data analysis remaining grounded in participants’ experiences. However, this means that any information related to participants’ diagnoses and services received included in this study was based solely on participant self-report. For example, it is possible that their perception of their diagnoses is different than what is documented in their educational records. Second, all participants in the study identified as female and as experiencing anxiety and depression as their primary mental health difficulties. While it was not the purpose of this study to generalize the findings across the adolescent populations, there is no way of knowing whether adolescents who identified as male or as experiencing different types of mental health challenges would have shared similar experiences with the study participants. It may be important to consider the fact that only adolescent girls volunteered to participate in the study within the context of the literature on gender difference in help seeking for mental health services; specifically, adolescent girls have been found to be twice as likely as boys to be willing to use mental health services (Chandra & Minkovitz, 2006). This finding suggests that adolescent girls’ 
	  	    	   53 experiences of seeking and receiving mental health supports at school could in fact be very different than adolescent boys. The fact that all participants attended the same school may also be considered a limitation due to homogeneity of the setting. When considering theoretical transferability, these similarities across participants pose definite limitations; however, in keeping with IPA methodology, these similarities allow for the composition of a recommended homogeneous sample and facilitate a shared experience across participants (Smith, et al, 2009).  A third possible limitation of this study was that the sampling procedure employed was not random. It is possible that the adolescents who volunteered to participate had different perspectives on seeking and receiving support at school for mental health difficulties than those who did not volunteer. Additionally, the gatekeeper sampling approach in which a teacher identified students who met criteria for participation and provided them the opportunity to participate may have skewed the sample based on relationships students had with a particular teacher.  Strengths. Despite the limitations of this study, there are several noteworthy strengths that should be highlighted. An important strength of the present study was that the IPA methodology allowed the voices of adolescents to be elicited in a non-directive, exploratory manner so that experiences considered meaningful to participants were explored in depth. This approach to inquiry aligns with the U.N.’s Convention on the Rights of the Child (1989), Article 12, which posits that children should be given the opportunity to express their views regarding matters that affect them. Additionally, the exploratory approach to inquiry allowed participants to draw on a range of experiences and discuss both formal SBMHS and informal supportive practices. Supportive relationships with teachers, instructional approaches, and the flexibility of 
	  	    	   54 structures in the learning environment arose as strong themes in participants’ experiences of support.  Another significant strength is that this study explored the perspectives of an understudied population. Previous research in this area has focused on adolescent perspectives of community or clinically based mental health services, adolescent perspectives on a particular school-based mental health intervention, or the general school population’s perspectives on SBMHS. The participant voices and experiences represented in this study are distinct from previous literature in that adolescents who identify as experiencing significant mental health concerns discuss their experiences of seeking and receiving mental health supports at school in a manner in which they were free to draw on the experiences that were meaningful to them.   A fortuitous strength in the eventual composition of the study sample was that all participants had attended different elementary and high schools prior to their current school. This allowed them to compare and contrast an array of positive and negative experiences related to getting support for mental health difficulties and seemed to facilitate participants’ ability to discuss their experiences with considerable breadth and depth. Finally, this study employed several procedures to ensure the scientific rigor and quality of the findings.  Considerations for Future Research  Given the lack of previous research conducted with this population, there are several potential avenues for exploration in future research. Possibilities include conducting similar exploratory studies with students in different school settings, for example schools with fewer resources and less explicit social emotional supports in place. Additionally, reviewing student educational records post hoc in future studies on this topic could provide valuable information and for students’ perspectives on services to be compared to what is documented in their IEP. 
	  	    	   55 Findings from this research also highlight the need to further study the academic needs of students who experience significant mental health difficulties. British Columbia’s new curriculum emphasizes a shift to individualized learning, which is in keeping with participants’ expressed benefits of a flexible learning environment in the present study; as the new curriculum is implemented in classrooms in the forthcoming years, this will provide fertile ground for exploring through research the impact of the curricular changes for students who experience mental health difficulties. Additionally, findings from this study could be further explored through quantitative methods with larger, randomized, and representative samples in order to assess their generalizability with broader populations.  Concluding Remarks  The purpose of this study was to gain an understanding of the lived experiences of adolescents seeking and receiving support at school for significant mental health difficulties. Participants discussed both formal and informal experiences of school supports related to supportive relationships, a flexible learning environment, and the school’s potential role as a support system. Interwoven throughout these categories were the guiding values of acknowledging students as individuals, and meeting students where they are at when supporting them at school. These findings contribute to the literature focused on the development and implementation of school-based mental health supports, and identify important considerations for school administrators, educators, mental health professionals, and policy makers when supporting adolescents at school who experience significant mental health difficulties. Researcher Final Reflection  Conducting this research and having the opportunity to talk with youth about their experiences of seeking and receiving support at school for their mental health difficulties was an 
	  	    	   56 invaluable experience, and will certainly impact my own professional practice and the future directions I take as a researcher. When I began my interviews, I was pleasantly surprised by my participants’ willingness to reflect on their experiences with such thoughtfulness; they were incredibly open to sharing their perspectives, discussing the various personal struggles that they faced, and identifying their successes and what worked for them. Engaging with my participants as they shared their stories wholly reinforced the value of conducting research involving in-depth, open-ended interviews focused on the lived experience, as some of the most salient facets of participants’ experiences I considered to be unexpected findings. During the data collection and analysis phase of the study I came to realize that at the outset of this project I was very focused on formal school-based mental health services. You may recall that a great deal of my literature review was focused on the rationale for school-based mental health services and their potential impact on student outcomes; and thus, I must admit that I expected students to talk primarily about these types of formal services. While formal school-based mental health services did play an important role in my participants’ experiences of support, during their interviews they introduced a more holistic or multi-faceted perspective of support at school.  For example, my participants emphasized that despite experiencing mental health difficulties, they were primarily at school to learn and complete their course requirements, so structures and adaptations that promoted success and engagement in learning were central components to feeling supported. My participants also highlighted the importance of supportive relationships at school beyond therapeutic relationships with mental health professionals, and identified teacher relationships as a crucial contributor in receiving support for their mental health difficulties.  I am extremely grateful to my participants for their willingness to take part in this study and for allowing me to highlight their voices with direct quotes throughout this document; it is 
	  	    	   57 my hope that their perspectives serve to reinforce what we know about best practices in education and mental health supports, point to promising practices in school-based mental health initiatives, and expand our perceptions of what constitutes a supportive school environment for adolescents who experience significant mental health difficulties.    
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	  	    	   67 Appendix A: Interview Script Interview Orienting Statement  Thank you for agreeing to participate in this interview. As I mentioned last time we spoke the purpose of this study is to gain a better understanding of adolescents’ experiences of seeking and receiving support for a mental illness at school. Currently there is a lot of research being conducted that looks at how the school can do a better job of supporting the mental health of students, but it is hard to know how closely this research relates to what students want and need. I am interested in learning about your perspective on this. Specifically, my goal is to listen to your story and gain an understanding of your experiences. Do you have any questions for me before we get started? Interview Schedule 1.   Tell me about what it is like having (your diagnosis). 2.   Tell me about what it is like having (your diagnosis) and being at school. 3.   How do you think having (diagnosis) impacts your experiences with school? a.   Tell me some examples of (diagnosis) impacting your experience at school 4.   Tell me about your experiences of getting support for (diagnosis) at school.  a.   How do you know what supports are available at school? b.   How did you end up getting support? c.   Tell me about your feelings during these experiences. 5.   I think we have probably all had times at school when we have felt like we needed a connection and some extra support. When you are at school and feel like you are in need of support, what is that like for you? a.   Who, What, When, Where, How 6.   What do supports for your mental health problems look like at school? 
	  	    	   68 a.   Tell me about the activities  i.   What do you do? ii.   What do others do? b.   Tell me about the people involved c.   Tell me about the places involved d.   Tell me about the steps that led to supports 7.   You have been through this…Tell me about any suggestions you have that could make your own or others experiences at school better. a.   If you could, what would you change about your experiences? b.   Tell me about your experiences that you would keep the same  c.   Tell me about what you would like to see more of. 8.   What does getting support at school for (diagnosis) mean to you? 9.   Is there anything that I didn’t ask you about that you think I should have? Are there any other experiences you would like to tell me about? 
	  	    	   69 Appendix B: Guardian Informed Consent  Guardian Informed Consent Principal Investigator:  William McKee, Ph.D.
 Assistant Professor/Director of the Psychoeducational Research and Training Centre
 Department of Educational & Counseling Psychology, & Special Education
                     Phone: (XXX) XXX-XXXX Email:  Co-Investigator:
 Jaime Semchuk      Masters Student, School Psychology  Department of Educational & Counseling Psychology, & Special Education
 Phone: (XXX) XXX-XXXX
 Email:    Adolescents’ Experiences of Seeking and Receiving Support at School for a Diagnosed Mental Health Concern   Dear Guardian,  This is a request for your adolescent to participate in a research study. Please read this form carefully because it provides details about the study.   Purpose of the Study: The purpose of this study is to learn about your experiences of seeking and receiving support at school for a diagnosed mental health concern. Gaining a better understanding of your experiences and perspective can provide us with important information about how appropriate school mental health supports can be developed.   This Is What Participating in the Study Will Involve for Your Adolescent:  Note: In the list below, “you” refers to your adolescent  1.    Participation in the study is voluntary. You may stop your participation at any time during the study without repercussions.  2.  You will take part in an hour-long one-on-one interview and 30 minute follow-up interview.  3.  Interviews will take place in a confidential room at your school, home or at the University of British Columbia.  4.    The interviews will taped with an audio recorder and later transcribed into a written script so that we don’t miss anything you say.  5.   The transcriber will not have access to any of your identifying information. The transcriber will also be bound by a signed confidentiality agreement, which means they will not discuss the interviews with anyone.   6.    You can read your interview transcript if you like.  
	  	    	   70  7.    You will be provided with a summary of the results of the study once it is completed.  8.    You will receive a $15.00 gift card for your participation in the study.  9.    You will be reimbursed for travel costs (if any) associated with the study (e.g. bus fare, parking fees to travel to UBC).  10.  Participation in the study is confidential. We will protect your identity by using a pseudonym (different name that you choose) when communicating the results of the study. It is important you select a pseudonym that other will not be able to use to identify you. For example, it is best not to choose a nickname.   11. Your identity will also be protected on your interview transcript by using a code number. Only the researchers (Dr. McKee and Ms. Semchuk) will have access to your transcript, which will be stored in a locked cabinet.   12. There are limits to confidentiality. If something you talk about leads the researcher to be concerned for your safety or the safety of anyone else, the researcher is required to report this information to the authorities.  13.  This research study is a Master’s Thesis at the University of British Columbia.  Possible Risks of the Study:  •   It is possible that you may feel uncomfortable during some of the questions I ask you or find that they trigger some emotions. That is the only risk associated with participating in the study.  Possible Benefits of the Study:  •   A possible benefit of participating in the study is having the opportunity to reflect on your experiences related to mental health supports at school and what these experiences mean to you.  •   Participation in this study will help us to gain a better understanding of adolescent experiences of getting support at school for a diagnosed mental health concern. These experiences may provide us with important information about how appropriate school supports can be developed for students with diagnosed mental health concerns.  If you have any questions about the study, you may contact the researchers (Dr. McKee and Ms. Semchuk) at any time using the contact information above.   Contact for Concerns about the Rights of Research Participants: If you have any concerns or complaints about your treatment or rights as a research participant, you may contact •   Research Participant Complaint Line in the UBC Office of Research Services at 604-822-8598  •   Long distance: e-mail to RSIL@ors.ubc.ca or call toll free 1-877-822-8598.  
	  	    	   71  Please check one of the following:  ________________________Yes, I consent to my adolescent participating in the study.  _______________________ No, I do not consent to my adolescent participating in the study.    Student  Name (Please Print)   Guardian’s Name (Please Print)   Guardian’s Signature (Please Sign)      	  	   	   72	   Appendix C: Participant Informed Assent  Participant Informed Assent  Principal Investigator:  William McKee, Ph.D.
 Assistant Professor/Director of the Psychoeducational Research and Training Centre
 Department of Educational & Counseling Psychology, & Special Education
                     Phone: (XXX) XXX-XXXX Email:  Co-Investigator:
 Jaime Semchuk      Masters Student, School Psychology  Department of Educational & Counseling Psychology, & Special Education
 Phone: (XXX) XXX-XXXX
 Email:   Participant Informed Assent  Adolescents’ Experiences of Seeking and Receiving Support at School for a Diagnosed Mental Health Concern   Dear Participant,  This is a request for your participation in a research study. Please read this form carefully because it provides details about the study.   Purpose of the Study: The purpose of this study is to learn about your experiences of seeking and receiving support at school for a diagnosed mental health concern. Gaining a better understanding of your experiences and perspective can provide us with important information about how appropriate school mental health supports can be developed.   Participating in the Research Study Will Involve:  1.    Participation in the study is voluntary. You may stop your participation at any time during the study without repercussions.  2.  You will take part in an hour-long one-on-one interview and 30 minute follow-up interview.  3.  Interviews will take place in a confidential room at your school, home or at the University of British Columbia.  4.    The interviews will taped with an audio recorder and later transcribed into a written script so that we don’t miss anything you say.  5.   The transcriber will not have access to any of your identifying information. The transcriber will also be bound by a signed confidentiality agreement, which means they will not discuss the interviews with anyone.   
  	  	   73	  6.    You can read your interview transcript if you like.   7.    You will be provided with a summary of the results of the study once it is completed.  8.    You will receive a $15.00 gift card for your participation in the study.  9.    You will be reimbursed for travel costs associated with the study (e.g. bus fare, parking fees).  10.  Participation in the study is confidential. We will protect your identity by using a pseudonym (different name that you choose) when communicating the results of the study. It is important you select a pseudonym that other will not be able to use to identify you. For example, it is best not to choose a nickname.   11. Your identity will also be protected on your interview transcript by using a code number. Only the researchers (Dr. McKee and Ms. Semchuk) will have access to your transcript, which will be stored in a locked cabinet.   12. There are limits to confidentiality. If something you talk about leads the researcher to be concerned for your safety or the safety of anyone else, the researcher is required to report this information to the authorities.  13.  This research study is a Master’s Thesis at the University of British Columbia.  Possible Risks of the Study:  •   It is possible that you may feel uncomfortable during some of the questions I ask you or find that they trigger some emotions. That is the only risk associated with participating in the study.  Possible Benefits of the Study:  •   A possible benefit of participating in the study is having the opportunity to reflect on your experiences related to mental health supports at school and what these experiences mean to you.  •   Participation in this study will help us to gain a better understanding of adolescent experiences of getting support at school for a diagnosed mental health concern. These experiences may provide us with important information about how appropriate school supports can be developed for students with diagnosed mental health concerns.  If you have any questions about the study, you may contact the researchers (Dr. McKee and Ms. Semchuk) at any time using the contact information above.   Contact for Concerns about the Rights of Research Participants: If you have any concerns or complaints about your treatment or rights as a research participant, you may contact •   Research Participant Complaint Line in the UBC Office of Research Services at 604-822-8598  •   Long distance: e-mail to RSIL@ors.ubc.ca or call toll free 1-877-822-8598.” 
  	  	   74	    Please check one of the following:   __________________________ Yes, I agree to participate in the study.    __________________________ No, I do not agree to participate in the study.    Participant’s Name (Please Print)    Participant’ Signature (Please Sign)    Date       	  	   	   	   	   75	   Appendix D: Recruitment Poster  DO YOU HAVE A DIAGNOSIS OF:  ADHD, DEPRESSION, AN ANXIETY DISORDER, OCD, SCHIZOPHRENIA,  OR ANOTHER MENTAL HEALTH CONCERN?   If you: §   Are a current high school student in Grade 11 or 12 §   Are willing to participate in two interviews where you talk about your experiences (each lasting 30-60 minutes)  Then we invite you to participate in an interview study looking at the experiences of adolescents seeking and receiving support at school for a diagnosed mental health concern.  If you would like to participate in this study or request more information, please contact: Jaime Semchuk by email XXXXXXXX  This study is being conducted by Jaime Semchuk as part of her master’s studies under the supervision of Dr. William McKee XXXXXX    
  	  	   76	  Appendix E: Participant Risk Screener for Guardians Participant Risk Screener for Guardians   After reviewing the Interview Schedule, do you have any reason to believe that participation in the research study will cause your adolescent significant distress?  __________________________ Yes  __________________________ No   My adolescent has recently been hospitalized for a mental health crisis.  __________________________ Yes  __________________________ No   If yes, please indicate how recently:      Student  Name (Please Print)    Guardian’s Name (Please Print)    Guardian’s Signature (Please Sign)    Date     

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