Talk therapy during school helps teens with depression

Training school social workers to lead "talk therapy" sessions during the school day can help teens and pre-teens recognize and begin to overcome mild depression, anxiety and anger problems, research is showing.

A pilot study of the approach, presented earlier this year at a national meeting by a team from the University of Michigan, suggests that in-school therapy sessions could help address some of the unmet mental-health needs of young people. Previous studies have indicated that many students don't access or can't afford treatment in the community, even when it's recommended to their parents by teachers and counselors.

In all, the researchers reported results from 45 students who received individual sessions, and 60 who participated in group sessions, with three social workers at two middle schools and one alternative high school in Ann Arbor and Ypsilanti, Michigan. Each school has an in-school clinic operated by the U-M Health System under its Regional Alliance for Healthy Schools for uninsured and low-income students.

The therapy sessions were conducted by school social workers who were trained by the U-M experts to provide a modified form of a well-established and proven talk-therapy approach called cognitive behavioral therapy or CBT. The U-M team, which included members from the Department of Psychiatry, the School of Social Work and the School of Nursing who are all members of the U-M Depression Center, developed the modified CBT approach specifically for the project.

Over all, several standardized measuring tools showed significant improvement nearly across the board after students completed the multi-week program. Signs of improvement included better mood and cognitive skills among the depressed students, and decreases in angry feelings toward teachers and improvements in problem-solving ability among those who received counseling for anger issues.

But the authors caution that even though the study yielded promising results, further research is needed. They have developed a manual for school social workers who wish to try the approach in their own schools; it is now being shared with other Michigan schools. The results were most recently presented at the Society for Social Work and Research Conference, but have also been presented at meetings of national and state-level public health, school health and mental health groups.

The study, funded by the Michigan Department of Community Health, involved young people who are uninsured or have coverage under Medicaid program for low-income families. A sizable number of the participants were African-American or Latino.

“We're very encouraged by these first results, and we hope that additional schools will begin to implement this strategy for their own students, says Mary Ruffolo, Ph.D., an associate professor and associate dean at the U-M School of Social Work.

“Many studies have shown that cognitive behavioral therapy can help young people with mood and anger issues, but this is the first time that an adapted form of this evidence-based therapy has been shown to work in a school setting,” says co-author David Neal, M.S.W., an assistant professor in the U-M Medical School's Department of Psychiatry and former chief of the department's social work division.

“We've also shown that once a school social worker has been trained in this form of CBT and has conducted sessions under monitoring, he or she can go on to provide high-quality therapy within the school day to the students who need it most,” adds co-author Dan Fischer, M.S.W., an Adjunct Clinical Assistant Professor of psychiatry and clinical social worker who led the project before taking on the role of director of the Child & Family Life Program at the U-M C.S. Mott Children's Hospital.

As evidence of the need for in-school CBT, the authors point to the 2003 report of the President's New Freedom Commission on Mental Health, which recommended school-based mental health interventions for children and adolescents because of the low rate of follow-up on referrals to community-based resources.

“Children and adolescents are far more likely to take part in a behavioral health program that's offered at their school, compared with those offered in the community,” says Neal. “We need to bring these programs to the schools.”

Neal and Ruffolo report that most school-based social workers have the background that allows them to provide CBT, but need training in specific evidence-based techniques in order to provide it within the school day. That's why the adapted CBT framework was developed by the U-M team.

At the national meeting, the U-M team presented data from 60 students who took part in group therapy sessions – the majority of them focusing specifically on anger-management but some focusing on depression. The anger groups met five weeks in a row for 45 minutes each time; the depression groups met 9 times.

A majority of the youth experienced significant decreases in depressive symptoms, increased school engagement, and improved problem-solving skills by the end of their multi-week sessions. No differences were noticed between students of different genders and ethnicities.

In addition to measurements from standardized behavior surveys, the students themselves said the group sessions were helpful and that they would recommend them to other students. Anger-management students said they got into trouble less, and were less angry at teachers. Students who had been referred to the program for depression showed signs of better self-esteem and reported fewer negative moods.

CBT helps participants recognize and develop strategies for dealing with or overcoming the thoughts, feelings and actions that are involved in their depression, anxiety or anger. In addition to specific guidance from the CBT therapist, participants might keep mood diaries, take part in role-playing, and develop their own “cognitive change” strategies to help them avoid or confront the events that trigger their negative moods or angry outbursts.