Mental Health in Schools: Cognitive Behavioral Therapy

Welcome to the first in my series on therapeutic modalities and how to use elements of these practices safely in class to create a more mindful, mental health aware classroom! Mental Health in schools is an ever growing concern, and Cognitive Behavioral Therapy has many tools we can employ to benefit our student's mental health!


Disclaimer: This article is not a replacement for years of training, certification, and clinical supervision required to conduct ACTUAL Cognitive Behavioural Therapy (CBT) practice. It’s merely an overview of what CBT is, given that many of your students will be in treatment or have been in treatment, and to educate folks on how some CBT strategies can help to create a mental health aware classroom.


What is Cognitive Behavioural Therapy:

mental health in classrooms - cognitive behavioral cycle thoughts feelings behavior
Cognitive Behavioral Therapy

Cognitive Behavioural Therapy is all the rage in the anxiety treatment world. So much so, in fact, that elements of CBT treatment have made their way into mindfulness practices in the classroom!


CBT is a treatment modality that requires proper training and is best practiced in a therapeutic setting with registered counselors over the course of a treatment program that typically runs anywhere from 6-20 sessions with one session each week. For children and youth, this is often done in collaboration with parents/guardians, though not always. It can be done in one-to-one therapy sessions and worked into other therapeutic modalities, or it can be done as part of a manualized group therapy program.


However, with that said, there are many strategies we can employ in our classes that can be helpful to decrease the overall experiences of anxiety in our spaces!


As a therapist, I often use elements of CBT in my therapeutic practice AND in my classroom to support young people to manage their symptoms of anxiety and to feel more at peace in school. It involves identifying the connection between thoughts, feelings, and actions, and how we shift our thoughts to affect change in the other areas.


So here are some of the pro’s and cons of CBT practice, followed by some techniques you can employ if you so choose! The more info you’re armed with, the more you can make informed choices about the strategies you use in your classroom and the more you can employ these strategies safely!


PROS of CBT:


  • It’s brief and can be conducted in a short amount of time over several weeks (Cognitive Behavioural Therapy, 2019).

  • It’s manualized, so it can be replicated in a similar fashion by multiple therapists.

  • You don’t need to know the historical context of the anxious experiences or the inciting incidents/ past trauma to offer strategies to support one’s experiences of anxiety. (Cognitive Behavioural Therapy, 2020)

  • It’s versatile and can be done one-to-one or in group sessions, which lends itself well to using some of the strategies in classrooms.

  • CBT is goal oriented, so it allows participants to problem solve a specific feeling or behaviour pattern they would like to replace (What is Cognitive Behavioural Therapy, 2017).

  • It can be used to treat a host of challenges, not just anxiety and depression, so using some of these strategies in a classroom context could be helpful.

  • It’s the most widely researched therapeutic modality for treating behavioural responses and difficult thought patterns in children and youth ((Podell et al., 2013; Peris et al., 2014).


CONS of CBT:


  • It requires consistent use of a set of structured techniques and often includes “homework,” which for children and youth in particular, it can be challenging to commit to this reliably.

  • While current empirical research supports the use of CBT in the treatment of anxiety disorders in youth (Podell et al., 2013; Peris et al., 2014), at least one third of youth participants do not respond to treatment (Podell et al., 2013).

  • Most research entails the use of CBT in collaboration with antidepressants (SSRI’s), which begs the question of whether or not CBT is as effective if used solely as a non-medical intervention (Martin, 2011).

  • Note: The use of SSRI’s (antidepressants) to treat adolescent anxiety and depression is under studied. There’s limited if any longitudinal research that demonstrates potential long term side effects, and the use of SSRI’s to treat depression in adolescents has not yet been approved in Canada, though some medications have been approved in the United States (Caring for Kids, 2018).

  • For youth engaging in a CBT approach, it’s important to note the importance of parental involvement in successful use of strategies and homework completion (Manassis et. Al., 2014).

  • CBT training highlights the importance of consistency in delivery format, i.e. the therapist’s coaching style. However, research also states the importance in therapist-client relationship, which means that it’s not possible to rule out the individualization of approaches across the spectrum of those using the strategies (Peris et.al., 2014).

  • Exposure Therapy (a type of CBT that exposes the individual to the anxiety inducing situation or object for increasing durations of time in safe settings to help to desensitize them to the anxious feeling) is more effective with younger children than it is with older youth, though it is still a strategy often employed with all age groups (Peris et al., 2013).

  • Very little research assesses the efficacy of CBT across diverse populations, countries of origin, or ethnicity (Hoffman et.al., 2012).

  • Can be very invalidating for folks, in that the premise of CBT is guided on the principle that the individual requiring treatment has “faulty” ways of thinking (What is Cognitive Behavioural Therapy, 2017).


How this applies to non-clinical work with children and youth


Now that you have some of the basics of CBT and know some of the pros and cons, you may be wondering how this applies to school.


Many of the strategies used in Social Emotional Learning and Mindfulness are also employed in CBT practice.


Here are some CBT principles you can apply in your classrooms to help students shift their perspectives, calm their bodies and minds, and develop coping strategies for their stressful days! These are also some strategies you can employ for yourself on particularly stressful school days!


1. Feel your feelings and wait for them to pass


The Cool Kids CBT anxiety program calls this “ride the worry wave.” This means acknowledging that anxiety, depression, etc. are not inherently bad, but they are causing problems. Allow students to feel the feeling, and remember that feelings are temporary and will pass.


Take time to validate all students' experiences and emotions! They all have a time and place, and no feeling is ever ‘wrong’. Remind students of this, and give them as much language as possible to name various emotions so they don’t get trapped in the “mad, sad, happy” stages of naming emotions.


2. Deep breathing


When we enter a state of anxiety, we often begin to take shallow breaths and blood and oxygen are re-routed to our limbs so we can fight or flee. Box breathing can be a helpful tool to regulate the central nervous system.

  • Box breathing is a breath in for a count of 4, hold for 4, breathe out for 4, hold for 4, and repeat!

3. See/ Hear/ Feel


Have students identify 5 things they can see, 5 things they can hear, 5 things they can feel. This helps students to ground in the present moment.


4. Guided meditation


This can be done either by the teacher scripting a peaceful scenario and having students close their eyes while you guide them through, or you can find some great guided meditations on YouTube!


5. Fact vs. Opinion


When you notice a student becoming stressed about a particular situation, ask them whether or not the thoughts they’re experiencing are fact, or opinion. We do this often in high school English when we ask students to find evidence. We're merely asking them to find evidence of their experiences too!


For instance, if you look at this picture of a clown what do you see?:




We can say it has a blue, polka-dot bow tie, red nose, yellow shoes - those are facts. But if we begin to describe the clown as “scary” or “happy” - those are opinions. Not everyone will see happy or scary when they look at this clown. We can do the same thing with our thoughts!


If a student says “no one likes me because I wasn’t chosen for the basketball team.” we can fact/opinion with them by teasing out the realities of the situation. For instance, the fact may be that they weren’t chosen for the basketball team, but we can remind them that they missed the day before when teams were chosen, or we can highlight their many other commitments that make it difficult for them to commit to ongoing practices, etc. We can also remind them of the other instances in a day when they socialize with other classmates that demonstrates that the classmates do like them, and that their friendship isn’t dependent on them being on the basketball team.


6. Thought tracking/ journaling


You can do this after covering intense or heavy material, or when you notice an energy shift in the group that needs some grounding. You can also do this to help students connect to and empathize with characters in stories, etc. and have them journal the behaviours, feelings, etc. of the character in the difficult situation.


The Set Up: In a chart format, have 5 headings across the top: the situation, the emotion felt during the situation, what the negative thought was that first emerged, what evidence does not support this thought, and the preferred thought and feeling.


7. Identify how actions lead to thoughts and behaviours


Help students see this when you study a novel, story, or character in any context. Begin to dissect the character’s actions and identify what their thoughts are or might be, and what behaviours this leads to, and what comes of these thoughts and behaviours. This will help students understand this in their own lives too!


Encourage students to identify other thought patterns, to note differences in how people think and behave, and how characters could make different choices if their thoughts are also different.


It can feel like thoughts are uncontrollable - they often are! However, in CBT it's not about controlling every thought, it's about replacing unhelpful thoughts and acknowledging which thoughts help and which ones hinder!


8. Teach students how to break tasks into small, more manageable pieces (teachers are already really good at this!)


9. Encourage students to not shy away from situations that feel stressful, but don’t push them too hard!


When students are overwhelmed or stressed - think test anxiety! - encourage students to try, but help them try in situations you know they will find success before throwing them in the deep end!


Make allowances for them to work their way up to full tests in class. Gradually allow them to get exposure to tests successfully so that they can begin to build confidence in themselves!


In conclusion...


Above all, encourage students to see the school counsellors when they experience what appears to be increased or extreme mental health concerns. We need to de-stigmatize therapy and ensure that young people are getting qualified, trained support, and referrals to folks who can use the above methods in a therapeutic setting with the full CBT program in conjunction with other therapeutic modalities.







References:


Caring for Kids (2018, June) Using SSRIs to Treat Depression and Anxiety in Children and Youth. Retrieved Sept. 5, 2020, from (https://www.caringforkids.cps.ca/handouts/using_ssris_to_treat_depression_and_anxiety_in_children_and_youth#:~:text=While%20SSRIs%20have%20not%20been,risks%20of%20not%20using%20them.).


Cognitive behavioral therapy. (2019, March 16). Retrieved September 04, 2020, from https://www.mayoclinic.org/tests-procedures/cognitive-behavioral-therapy/about/pac-20384610


Cognitive Behavioural Therapy. (2020) Retrieved September 04, 2020, from https://www.camh.ca/en/health-info/mental-illness-and-addiction-index/cognitive-behavioural-therapy


Hoffmann, S.G., Asnaani, A., Vonk, I.J.J. et al. The Efficacy of Cognitive Behavioral Therapy: A Review of Meta-analyses. Cogn Ther Res 36, 427–440 (2012). https://doi.org/10.1007/s10608-012-9476-1


Manassis, K., Bennett, K., Mendlowitz, S., Saini, M., Bodden, D., Dadds, M.R., Ginsburg, G., Hudson, J.L., Liber, J., Nauta, M.H., Silverman, W., Spence, S.H., Wood, J.J., Lee, T.C., Zhao, X.Y., Duda, S., Barrett, P., Cobham, V.E., Flannery-Schroeder, E., Heyne, D., Kendall, P.C., Masia-Warner, C., Rapee, R. M., Siqueland, L., & Utens, E. (2014). Types of parental involvement in CBT with anxious youth: A preliminary meta-analysis. Journal of Consulting and Clinical Psychology, 82(6), 1163-1172.


Martin, A.M. (2011). Recent advances in the treatment of anxiety disorders. Canadian

Psychology/Psychologie Canadienne, 52(1), 1-9.


Peris, T.S., Compton, S.N., Kendall, P.C., Birmaher, B., Sherrill, J., March, J., & Piacentini, J. (2015). Trajectories of change in youth anxiety during cognitive-behavior therapy. Journal of Consulting and Clinical Psychology, 83(2), 239-252.


Podell, J.L., Gosch, E.A., Albano, A.M., Rynn, M.A., Sherrill, J.T., Birmaher, B., Kendall, P. C., Compton, S.N., March, J.S., Ginsburg, G.S., Keeton, C.P., & Piacentini, J.C. (2013). Therapist factors and outcomes in CBT for anxiety in youth. Professional Psychology: Research and Practice, 44(2), 89-98.


What is Cognitive Behavioural Therapy? (2017, July). Retrieved September 04, 2020, from https://www.apa.org/ptsd-guideline/patients-and-families/cognitive-behavioral