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Exploring the effectiveness of Cognitive Behavioural Therapy (CBT) psychoeducation in secondary schools: A Quasi-Experimental study.
With one in three secondary students displaying mental health problems (Cypnow, 2019), there is a growing reliance on teaching staff to make early identification of student’s mental health problems and to refer for appropriate support (Rothì, Leavey and Best, 2019), (NHS Health Advisory Service, 1995)
Cognitive behavioural therapy (CBT) is recommended as an effective early intervention however many adolescents do not seek treatment (Partners, 2019). Stigma and poor mental health literacy have been found to be one of the key barriers to help-seeking (Gulliver, Griffiths and Christensen, 2010).
This research aims to investigate the efficacy of CBT psychoeducation in reducing stigma surrounding mental health, and improving mental health literacy amongst students, and increasing self-referrals for appropriate support, thus reducing the strain on an already overburdened teaching force.
A school-based study carried out over a 12-month period, this study will measure and compare the number of self-referrals made in the 6 months following delivery of a 5-week CBT psychoeducation programme to students aged 12 – 17 years. Two schools will be invited to participate in the study; with only one school receiving the CBT psychoeducation input.
Introduction and literature review
The landscape of youth mental health challenges
School leaders throughout the UK are reporting an alarming rise in youth mental health problems such as stress, anxiety, panic attacks, depression, self-harm and eating disorders. According to a National Association of Schoolmasters Union of Teachers survey in 2017, 98% of teachers and school leaders reported that they had engaged with students considered to be experiencing mental health problems (Open Access Government, 2019).
Half of all mental health problems in adulthood begin before the age of 14, yet 70% of children and adolescents who experience mental health problems have not had appropriate interventions at a sufficiently early age. (Mental Health Foundation, 2019). Thousands of young people struggle to get the help they need with over 7,000 young people being turned away from CAMHS services in the last year (Mentalhealth.org.uk 2019).
Children and young people’s mental health and wellbeing is a priority for the Scottish Government. Their health strategy focuses on early intervention and prevention and reviewing the role of counselling services in schools (Gov.scot, 2019). Research undertaken by SAMH for their 2017 ‘Going To Be’ echoed this mission aiming to give young people the opportunity to understand their mental health and normalise help-seeking. (Samh.org.uk, 2019).
Much of the literature in this area suggests that youth mental health problems are reaching critical levels, and that for improvements to be achieved, a strategy of prevention and early intervention measures need to be adopted.
Barriers to help-seeking
A systematic review of fifteen qualitative and seven quantitative studies by Gulliver, Griffiths and Christensen, (2010) found that mental disorders such as depression and anxiety to be greatest among young people aged 16-24 than at any other age yet were coupled with a strong reluctance to seek professional help. Problems recognising symptoms, poor mental health literacy and perceived stigma were found to be the most important barriers to help-seeking.
The writer found this systematic review of both quantitative and qualitative research from over twenty-two published studies to be wide reaching and broad, and the age and gender of participants sufficiently varied. Additionally, sufficient exclusions controls appear to have been applied, in this case the removal of duplicate records and studies that did not address barriers to help-seeking. The review however only employed only three databases therefore some relevant journals may not have been found and having been carried out in 2010, is now outdated and would be beneficial to replicate for a more recent time period.
A cross-sectional online survey of young adults aged 18–25 from the general UK population by Salaheddin and Mason, (2019) found that stigma and negative perceptions surrounding mental health and help-seeking may explain why young people are reluctant to approach others for help.
This study offers rich qualitative and quantitative information although the small sample size may impose some limitations on the quantitative results.
Much of this literature suggests that strategies for improving help-seeking by adolescents and young adults should focus on improving mental health literacy, reducing stigma, and considering the desire of young people for self-reliance.
Evidence for adopting school-based CBT Psychoeducation
One approach for preventing and reducing depression in adolescents is school-based delivery of mental health psychoeducation. Such programs are considered to deliver benefits particularly for youth with current symptoms or for those with a risk for depression (Merry et al., 2004).
There is a distinct lack of journals evidencing the efficacy of school-based CBT psychoeducation, however O’Kearney et al., (2009) is an example of an effective psychoeducational intervention. This study evaluated the benefits of a self-directed internet intervention for depression (MoodGYM) delivered as a part of the high school curriculum therefore draws similarities to this research proposal
One hundred and fifty-seven girls, aged 15 and 16 years, were allocated to undertake either MoodGYM or their usual curriculum. Results demonstrated the positive effects of the psychoeducation input. Suitable controlled methods were taken when undertaking this study however evaluating different age groups and genders would add more weight to this study which is limited in this area.
A quantitative study by Taylor & Francis,(2019) investigated the impact of an 8-week social anxiety psychoeducational group programme on socially anxious youths. Pre and post test data from 3 groups conducted over the course of 3 months were combined for a total of 40 participants. Results indicated that the psychoeducation input led to a significant decrease on scales measuring social anxiety.
The lack of a control group limited the study’s validity. The long-term effects of the programme are unknown as the study did not include any follow up assessments.
The lack of papers suggests that more research should be take place on the impact such interventions can deliver, thus adding weight to the importance of this research proposal. CBT as an intervention is recognised by (NICE, CG90, Oct 2009) as the first line treatment for depression and anxiety. This therefore suggests that low intensity CBT for adolescents would also prove effective.
Schools are an ideal setting to promote positive mental health and evidence suggests that targeted school-based interventions have led to improvements in wellbeing and mental health (Bannerjee et al,. 2014), (Bacp.co.uk, 2019)
(Core.ac.uk, 2019) reported that school-based interventions are a good fit for offering the lower-level intervention that can be hard to access through formal CAMHS, but which can prevent problems subsequently becoming more serious. School is also where young people already are during the day and is where they say they want to access services: over two-thirds say they would rather see a counsellor at their school as opposed to outside. Because schools are a universal service, accessing provision in schools can help to overcome any perceived stigma or reluctance to attend mental health services.
For these reasons, school-based services such as counselling tend to have high take up, and there is evidence that young people are more likely to access school-based mental health services when compared with non-school-based ones.
Insights gathered from this literature review adds weight to the benefits of this research study as a suitable approach that will positively contribute to the mental health crisis in young people.
Research question aims and objectives
“Does Cognitive Behavioural Therapy (CBT) psychoeducation in secondary schools lead to an increase in the number of students ‘self-referring’ for mental health support?
This research aims to evidence that by improving mental health literacy amongst secondary school students, there will be an increase in the number of students seeking mental health support services in school.
This will be measured by the number of students self-referring to the counselling coordinator (or equivalent school representative) over a specified time period following delivery of the CBT psychoeducation input.
The study will take into consideration the CORE 10 scores of all self-referring students to ascertain the number who met the criteria for receiving additional support.
In order to achieve this, the research will meet the following objectives:
1) Collect data on the number of students who have self-referred in the previous school year from both participating schools. Date of referral, presenting issue, age of student and CORE 10 rating will be collected. This data will be used for benchmarking purposes.
2) Deliver a structured CBT psychoeducation programme to students between 12 – 17 years of age. Input delivered to one of two participating secondary schools. The ‘control’ school receives no CBT input.
3) Collect data on number of self-referrals made to the counselling coordinator (or equivalent representative) in the 6-month period following the completion of the CBT psychoeducation input. Date of referral, presenting issue, age of student and CORE 10 rating and attendance to the CBT psychoeducation programme will be included. Data to be collected from both schools.
4) Analyse self-referral CORE 10 rating, age of student, date of referral, and presenting issues and apply appropriate categorisation to further analysis of data.
5) Using data collected, evidence whether CBT psychoeducation has been an effective intervention to encourage self-referrals from students requiring mental health support, and how many of these self-referrals met the criteria for additional support.
6) Generate useful data and insights that may influence further studies in this area.
The hypothesis for this study is that the Independent Variable (programme of CBT psychoeducation) will result in changes to the measured Dependant Variable (number of self-referrals).
Research Design and Method
The study will compare levels of self-referral in students who received the CBT psychoeducation with that in another school sharing similar characteristics who did not receive this intervention (the control group). A Quasi-Experimental research design has therefore been selected as most appropriate design.
Quantitative methodology will be employed. At this stage, the research aim is to demonstrate the impact CBT psychoeducation has had on the number of self-referrals, rather than the ‘reason’ for self-referral. Reason for self-referral will be captured at referral stage however which opens up opportunity for further analysis if required.
Nominal statistical measures will be the primary measurement tool e.g. ‘student self-referred = 1’, ‘student was referred = 2’, ‘student self-referred + CBT group = 3’, ‘student was referred + CBT group = 4’.
Ordinal and Interval statistical measurements will be used as a secondary measure to analyse CORE 10 scores and Likert scale outcomes from the researcher designed questionnaire. The CORE 10 score analysis will allow self-referrals to be categorised by cut off score to identify how many self-referrals then met the criteria for additional support.
While the study is not reliant on the researcher designed Likert questionnaire, it is believed it will be useful in taking additional insights that may inform further research in this area.
As a pilot study, non-probability sampling method will be employed for ease of access and convenience. Participants will be recruited from two private secondary schools in the greater Glasgow area. These schools have been specifically selected to mitigate variables such as socio-economic factors as it can be assumed that students attending the schools on which the study will be carried out, will be from a similar middle to upper class background. Ideally, and if resources and time allow, a baseline demographic check will be carried out to understand levels of consistency between both schools.
It is acknowledged that this method does not account for and rule out all other explanations, therefore is limited, however in the event that the hypothesis of this study is proven, the study could be widened to other schools to work with a larger sample size and Probability (Representative) Sampling methods adopted.
Inclusion and exclusion criteria
Participants will be between 12 – 17 years old. This age range has been selected on the basis that adolescents within this age group are considered to be mature enough to understand and engage with the CBT psychoeducation input, and because the number of mental health disorders within this age group have reported increases over the last 10 years (Ajmc, 2019).
All genders will be invited to participate in the study. No exclusions will be made for transgender students and those who do not identify with a specific gender.
Students wishing to participate in the study will complete a CORE10. Students with a moderate score (>20) will be included in the study. This will ensure that students who appear most in need of CBT psychoeducation will be prioritised. Students within the same age range at the control school wishing to be part of the study will also complete a CORE 10 as a baseline comparison.
Students already receiving mental health treatment, or who have self-referred, or been referred to the counselling coordinator (or equivalent school representative) in previous 12 months, and who have a CORE 10 score of >20 will not be excluded from receiving the CBT input. However in the event of a second self-referral following CBT input, their referral will not be counted in the data findings so as not to skew the findings.
The study will be advertised via school newsletter, student intranet, announcement at school assembly, and on the school website and social channels. Students wishing to participate in the study will be asked to register their interest by emailing a dedicated email address monitored by the school administrator.
A combination of standardised measures; the CORE 10 (appendix 1) and researcher developed measures (specifically designed questionnaire) will be used in this study.
Students participating in the study will complete a CORE10 questionnaire before CBT psychoeducative input is given, again mid-way through programme, and finally at the end of the programme. This will assess their total and means score prior to, during and after CBT psychoeducation is given allowing for additional analysis to be carried out on % of students displaying at the mild and moderate cut off, versus the number who go onto self-refer. This may influence further research in this area. Students at the control school will complete CORE 10 questionnaires at the same time for consistency and comparison.
A specifically designed questionnaire to garner students’ current level of awareness about mental health disorders, support services within the school, and their openness towards self-help and seeking support will also be carried out prior to the commencement of the CBT psychoeducation programme (appendix 2). The will allow a better understanding of any variables that may have prevented previous self-referrals e.g. student was not aware they could self-refer, student was not aware services were available, student was unlikely to open up.
Both participating schools will use their existing password protected database to log all self-referrals made in the 6 months following completion of the CBT programme. At assessment of self-referral, student will be asked to confirm if they had attended the CBT psychoeducation input (if applicable) and an assessment CORE 10 will be carried out to assess if the student meets the criteria for additional support. Statistical analysis comparing the number of self-referrals for both schools will then be carried out.
Central to this study is the CBT psychoeducation program. It will comprise of five sessions delivered once a week over 5 weeks. There will be a maximum of 15 participants per session, 60 participants in total for the study.
The programme will commence January 2020. Each session will run for between 90 – 120 minutes and will include a comfort and refreshment break. Sessions will begin at the end of the school day, approximately 3:45pm.
The programme will be delivered and facilitated by two qualified cognitive BABCP accredited CBT behavioural therapists, one of whom will hold a relevant teaching qualification.
A series of approved psychoeducational interventions will be used when delivering the CBT psychoeducation programme. The programme will be developed by a BACBP accredited CBT therapist and will include interventions specifically designed for a youth audience. Examples can be found in appendix 3.
Approval for the study will be requested from the appropriate committee, Director of Education for the council authority and if required, the Head Teachers at the participating schools.
Participation to attend the study will be voluntary and no incentives will be offered to take part. Written consent will be obtained as required from all parents and caregivers of adolescents attending the study. Letters of informed consent will emphasise that participants, or participants parents / caregivers have the right to withdraw from the study at any time without need for explanation (appendix 4).
Personal confidentiality will be agreed with the group attending the CBT input, and a working agreement will be developed collaboratively in the first session, agreed by, and signed by all attendees.
Participant data will be kept confidential except in cases where the researcher is legally obligated to report specific incidents. These incidents include, but may not be limited to, incidents of abuse and suicide risk.
CBT early intervention for youths is expected to be successful therefore it would be unethical to withhold the intervention to students in the ‘control’ school. Those who do not receive the CBT input will be invited to attend the 5-week course on completion of the study. They will be under no obligation to attend.
Students who wish to participate in the study, but who were not deemed suitable will be added to a waiting list and invited to attend a subsequent CBT input at the end of the study after appropriate risk assessment has been carried out.
None of the psychoeducative elements or interventions used in the study are considered to carry any risk to participants. Indeed, it is believed that participants will benefit from participation in the study. In the event that risk to any participants is identified during the psychoeducation programme, the risk policies and procedures of the school will be adhered to, and participants will be referred to suitable mental health services for additional support. .
Names of any self-referring students who participate in the study will be anonymised and referred to by a numerical ID, stored in a locked filing cabinet that only counselling staff / pastoral care have access to. All data collected will be confidential and held in accordance with the participating school’s data protection policies.
Group supervision will be mandatory for the CBT therapists delivering the psychoeducation input. This will ensure consistency between facilitators and maintain the integrity of the psychoeducation input, particularly for therapists with no experience working with young people in an education environment.
Research can run the risk of being meaningless unless steps are taken to actively disseminate the outcomes of a study (Vossler and Moller, 2015). The dissemination strategy for this study hopes to change the practice of CBT psychoeducation in schools. It also hopes to provide the opportunity for feedback and evaluation, thus helping enhance the validity of its findings. Because it is a pilot study, the dissemination also seeks to create new opportunities for different perspectives, leading to new research ideas on this topic.
Principles of good dissemination will be followed, and the findings aim to be shared with and made openly available via published journal article available online. A stakeholder engagement strategy will be developed to ensure findings are distributed to core audiences consisting of teaching staff, educational leadership and CBT practitioners. This will be achieved using a combination of reports, posters and conference presentations (Nihr.ac.uk, 2019).
Refer to appendix 5.
Refer to appendix 6.
Discussion of findings
It is acknowledged that there are limitations in this study. The non-treatment group are not ‘controlled” in the experimental sense, but they are a pragmatic comparison group and socio-economic variables were considered in the design. With more resources, the variables would be managed more robustly; for example, using a control group with the same number of participants who had all completed the same assessments, controlled through baseline assessments of mental health and previous referrals. Additionally, a larger study, comprising of more than two schools over a longer period of time would offer more robust insight and offer more insights into the long-term effects of the programme. Adopting qualitative data collection and analysis methods would provide additional insight into attitudinal variables in deciding to self-refer or not.
CBT has been recommended as an early intervention for adolescents and the hypothesis is expected to be successful. This will provide opportunity for future test programmes to be rolled out across a larger number of schools. There is future potential to use this type of study to focus on specific mental health disorders affecting adolescents e.g. self-harm, eating disorders, or other school related challenges e.g. absenteeism due to anxiety/depression.
Finally, one of the most common disorders amongst adolescents, Social Anxiety Disorder (SAD), takes adults up to 15 years to seek treatment and by then the potential for change is low. This study, beyond testing the impact of a specific programme, has the potential to change cultures amongst young people, making it acceptable to seek help (Nice.org.uk, 2019).
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