Do classroom-based CBT interventions promote positive mental health?

MEEFRO April 13, 2023

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Poor mental health during adolescence has significant impacts and is associated with poor physical health, suicide, and self-harm (Zubrick et al., 2017). There is a need to develop interventions that promote positive mental health. One way of doing this is by enabling young adolescents to manage challenges and prevent the development of mental health difficulties.

Given that preventative interventions are offered en masse, schools are an ideal site for delivery as whole classes of adolescents can be targeted at once. Most of these interventions have tended to reduce mental health distress, for example, symptoms of depression or anxiety (Bastounis et al., 2016). However, not all have been effective in this aim (Kuyken et al., 2022).

However, it may be more appropriate to focus on promoting positive mental health, rather than reducing distress. One such intervention, process-based Cognitive Behaviour Therapy (CBT), developed by Martin O’Connor and colleagues in Dublin (2022) draws on key concepts from CBT including cognitive reappraisal and mindfulness. Sessions are 40 minutes long, and delivered weekly for 6 weeks, by school teachers trained to deliver them. Each classroom session includes an experiential exercise, a video, and individual and group activities. The focus of the current study was to evaluate this intervention.

Universal interventions designed to promote positive well-being in schools could be effective.

Methods

To see if this intervention had the intended effects, O’Connor et al carried out a cluster randomised control trial. They recruited 29 elementary schools in Ireland to take part, each of which was randomly assigned to either the intervention (n=15) or the 12-week waitlist control (n=14). Within the schools, participants were pupils aged 10-13 years (Grades 5 & 6).

Participants completed self-report measures of positive mental health, resilience, mindfulness, and emotional literacy online, before the intervention, immediately after the intervention had finished, and at a 6-week follow-up. Participants also reported their satisfaction with the intervention.

Results

In total, 604 students took part (44% of people invited), of which the majority were female (59.77%). 406 participants completed the intervention (or control) and measures at the 6-week follow-up; this means that around one in three did not complete follow-up measures, so we do not know if they benefit, or not. Significantly more participants dropped out of the intervention compared to the control group, however we do not know how many, as the authors have not stated that in the paper.

Reliability analyses of the content delivered in the intervention condition indicated very good agreement between the content delivered by teachers and the lesson plans. There were also encouraging findings in favour of the intervention from participants as they were satisfied with the intervention.

The authors were primarily interested in seeing whether those who received the intervention fared better in terms of ‘positive mental health’ than those who did not receive the intervention; they found that there were no significant differences between the groups (β=0.60, p=0.202). On the other outcomes of interest, the pattern of results was similar; there were no significant differences in the measures of resilience, mindfulness, or emotional literacy. When the authors specifically focused on those adolescents who were particularly struggling with their mental health (i.e., those with ‘languishing-to-moderate positive mental health’), those who received the intervention did make significant gains in mindfulness compared to those who did not receive the intervention.

The process-based CBT intervention did not improve well-being, but those struggling with their mental health did improve on mindfulness.

The process-based CBT intervention did not improve well-being, but those struggling with their mental health did improve on their mindfulness.

Conclusions

This study found that those young adolescents who received the process-based CBT intervention fared no better than those who did not receive the intervention on positive well-being overtime at up to 6-week follow-up. The same was true for resilience, emotional literacy, and mindfulness.

The only significant finding was that the intervention seemed to improve mindfulness in those adolescents who were struggling to begin with.

This process-based intervention, intentionally designed to promote positive well-being, was not found to be effective for early adolescents at the classroom level.

Strengths and limitations

Several aspects of this study are impressive; it was pre-registered on the public trials’ registry consistent with open science practices. Thorough training was provided to teaching staff to deliver session materials. There was good reliability between the session material and lesson plans meaning we can be confident that the intervention was delivered as intended.

However, there are some problems to highlight. Firstly, there is a disappointing lack of participants’ demographic information to enable us to contextualise the sample, such as ethnicity. It is not possible to tell whether marginalised groups were included in the study and/or engaged. This is important given that marginalised groups face significant barriers to accessing support for their mental health (Memon, 2016), thus universal, whole-class interventions in schools may be a useful way to access these populations and provide support. Secondly, and perhaps most concerningly, one-third of participants did not complete follow-up measures, and this was disproportionately so for participants in the intervention arm. It is not clear why, but it does beg the question of how the intervention was received and experienced. The authors reported that most participants were satisfied with the intervention, but this is based on those who completed post-intervention measures, rather than those who disengaged, meaning it is almost certainly positively skewed. Qualitative interviews post-intervention would have been helpful to understand how young people experienced the intervention and how it could be improved.

Furthermore, although the intervention was developed by an experienced clinical psychologist there was no consideration or inclusion of adolescents’ views on the content of the intervention. This is particularly relevant given the disengagement from completing study measures. Co-production is necessary to ensure the content and activities are practically viable and developmentally appropriate (Foulkes & Stapley, 2022).

The findings need to be interpreted with caution as a high proportion of participants did not complete the follow-up measures.

Implications for practice

Given that one in six young people experienced a mental health problem in 2021 (NHS Digital, 2019), there is an urgent need to provide more mental health support and provision to this population. Schools offer an important environment for adolescents to learn and develop life skills, including those related to mental health. It may be that schools that were allocated to the ‘no intervention condition’ in the current study were already doing well in providing mental health promotion activities. Thus there was no additional benefit from O’Connor et al.’s (2022) intervention. Or it may be that we are still fundamentally unsure of how to effectively equip adolescents with these skills, and/or how and when to meaningfully measure outcomes to detect the benefits that these kinds of interventions have.

Currently, there is no “gold standard” intervention for adolescents. A vast array of mental health interventions in schools have been trialled such as CBT, mindfulness, and mental health education with mixed results (Nawaz & Cross 2021 on Clark et al., 2021). Unfortunately, the current study adds to this confusing and rather disappointing picture. However, it is interesting to note that the current study found improvements in mindfulness in adolescents with ‘languishing-to-moderate’ positive mental health, suggesting that targeting at-risk adolescents may be a more effective approach than all adolescents of a certain age.

This study may be a confirmation that we all need to go back to the drawing board. We need to gather all relevant stakeholders and consider our aims, hopes and ways to achieve the identification and evaluation of an effective intervention. Prevention means we are playing the long game; short-term benefits might be what is most feasible to evaluate as a researcher, who has an end date to their project, funding, or resources, but long-term gains are really what we are trying to achieve.

Although many interventions are available and have been trialled at schools, the support is mixed and the path ahead is still unclear.

Although many interventions are available and have been trialled in schools, the support is mixed and the path ahead is still unclear.

Statement of interests

No conflicts of interest with the study reviewed here. However, Emily Hards (EH) is funded by the Economic and Social Research Council (ESRC Post-Doctoral Fellowship). The views in this publication are her own and not necessarily the ESRC. Dr Maria Loades (Development and Skills Enhancement Award, 302367) is funded by the National Institute for Health Research (NIHR) for this research project with EH. The views expressed in this publication are those of the author(s) and not necessarily those of the NIHR, NHS, or the UK Department of Health and Social Care.