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Running head: CBT PROGRAMS IN EDUCATIONAL SETTINGS TO MENTAL WELLNESS
Promoting Mental Wellness in Education with Cognitive Behavioral Therapy Interventions
Gaudencio Powell Paguibitan
Peabody College- Vanderbilt University
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Abstract
The purpose of this paper is to argue for the implementation of an education program that
is effective at preventing mental disorders and promoting mental wellness. This interdisciplinary
paper between the fields of education and clinical psychology expands upon the use of effective
cognitive behavioral therapy (CBT) components in educational settings. National statistics on
mental disorders in American adolescents are first discussed in order to raise awareness for the
severity of the mental disorder epidemic in America. This paper will then address the
misperception of mental health and call for a paradigm shift to mental wellness in order to
remove the deficit mindset of mental health in education. A comprehensive literature review
focusing on the use of CBT within adolescents diagnosed with depression and anxiety will be
examined. Next, the best practices of standardized CBT manuals like the Coping Cat, Penn
Prevention Program (PPP), Adolescent Coping with Depression course (CWD-A), Treatment For
Adolescents With Depression Study (TADS), and Taking ACTION will be reviewed.
Substantial data driven evidence for curricular suggestions were found within the categories of
CBT goals, assessments, homework assignments, teacher student relationships, classroom
environments, and flexibility. These components are suggestions to be used in future manuals
promoting CBT in school settings. Each suggestion detailed is proposed within the framework
of mental wellness in education for a population without with mental diagnoses. Finally, future
implications for the field of clinical psychology and education are made with a proposal of a new
empirical study that addresses literature gaps.
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Promoting Mental Wellness in Education with Cognitive Behavioral Therapy Interventions
Mental Disorders Epidemic in America
The National Institute of Mental Health (NIMH) reported in the National Comorbidity
Survey Replication (NCS-R) that approximately 56% of US citizens will meet criteria for at least
one mental disorder at some time in their lives; 43% will meet diagnostic criteria within the past
12 months (Kessler, Berglund, Demler, Jin, Merikangas, & Walters, 2005). The US Surgeon
General describes mental disorders as, “serious deviations from expected cognitive, social, and
emotional development” (U.S. Department of Health and Human Services, 1999). While mental
disorders are certainly a societal issue, perhaps most alarming is the prevalence in American
youth. Kessler et al. (2005) reports that roughly half of all lifetime mental disorders will begin
by age 14, while three-fourths will have begun by age 24. However, only 20% of all mental
disorders in children will go reported (US Public Health Service, 2000; Collins, Westra, Dozois,
& Burns, 2004). This is consistent with the Methodology for Epidemiology of Mental Disorders
in Children and Adolescents [MECA] (1996) which states approximately one in five US children
and adolescents, aged 9 to 17, will experience at least minimum impairment to daily functioning
in the form of a diagnosable mental disorder. Thus unfortunately, most mental disorders in
children and adolescents will go unreported and subsequently untreated until they are severe
enough to cause serious damages either because of the stigma associated with mental disorders
or lack of access to treatment options (Collins et al., 2004). However, if mental disorders are
identified and addressed at its onset, children and adolescents can be effectively treated
(Mennuti, Christner, & Freeman, 2012). There is hope for the mental disorder epidemic
afflicting America’s youth if preemptive action is taken accordingly.
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Many recommendations have been made regarding nationwide mental health issues. The
World Health Organization (WHO) defines mental health as, “…not just the absence of mental
disorder. It is defined as a state of well-being in which every individual realizes his or her own
potential, can cope with the normal stresses of life, can work productively and fruitfully, and is
able to make a contribution to her or his community” (WHO, 2007). The National Advisory
Mental Health Council Workgroup on Child and Adolescent Mental Health Intervention
Development and Deployment (2001) advised that treatment initiatives supersede current
symptom reduction models and incorporate assessment and functionality of everyday
environments (i.e. school, family, and community situations). The President’s New Freedom
Commission on Mental Health (2003) reported that early recognition and intervention can reduce
the likelihood of future mental disorders. Furthermore, the report claims mental health should be
promoted in youth and schools should improve their assessment and ability to integrate treatment
options. Finally, WHO (2009) proposes that in addition to increasing mental health care
availability, mental health should be promoted at a self care and community care level in order to
maintain the long term effectiveness of a desired mental health policy. WHO (2005) further
suggests programs should provide young people with appropriate knowledge and skills to
address resiliency and psychosocial functioning. These suggestions all propose that it is not
enough to merely cure mental illnesses, but proper action must be taken in order to prevent their
occurrence in the first place.
Instead of viewing mental health through a deficit mindset of disorders, a paradigmatic
shift to promote mental health is needed. Despite WHO’s definition of mental health, the
general perception is merely more than the absence of a mental illness, an antonym of mental
illness (Keyes, 2002). I recognize that the data above uses the phrase “mental health,” but for the
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sake of this paper, I will employ the term “mental wellness.” I suggest practitioners utilize the
term “mental wellness” because mental wellness is a complex, multifaceted, and processoriented term that suggests lifelong competencies and skills. Rather than focusing on the
negative stigmas of mental disorders that only afflict 56% of the population (Kessler et al.,
2005), wellness incorporates competencies that all individuals can strive to attain. Furthermore,
mental wellness suggests an attitude of prevention rather than a goal to simply treat mental
illnesses. I believe that addressing mental wellness will be a more effective and enduring
approach at resolving the mental disorder epidemic. The aforementioned policy suggestions
assert that mental wellness initiatives must affect daily life, be promoted in youth, provide skills
of resiliency and psychosocial functioning, and be maintained on an individual and community
level. One environment that substantially addresses all these concerns and is consistent with the
mental wellness ideology is education. Education and mental wellness have already converged
through Cognitive Behavioral Therapy (CBT) Interventions. Before I define CBT, I must first
explain why CBT is relevant to my argument.
Framework of the Paper
I began my paper with a heavy emphasis on national statistics from mental health
organizations and reports in order to draw attention to the severity of the mental disorder
epidemic in America. When these statistics are framed within educational contexts, mental
wellness becomes almost impossible to ignore. The U.S. Department of Education’s 23rd annual
report (2001) that states that the largest high school dropout rate of any disability are students
affected by mental disorders at an alarming rate of approximately 50%. In addition to high
student dropout rates, Epstein and Cullian (as cited in Mennuti et al., 2012) found that emotional
and behavioral issues are associated with higher levels of truancy, suspension, tardiness,
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expulsion, attention seeking behavior, and poor social relationships. Thus, my argument’s main
goal is to advocate for the implementation of an education program that is effective at preventing
mental disorders. Yet, while valid suggestions have already been made for mental health in
educational contexts, I believe one of the main barriers to addressing this epidemic is the deficit
lens of mental disorders rather than the more holistic ideology encompassed in mental wellness.
As a result, I will complete a literature review of one of the more widely accepted and therefore
more widely implemented modalities to therapy and framework for educational programs--CBT.
CBT is a natural fit in education because it is structurally similar to school settings. They
both set an agenda, promote psychosocial skills, assign homework between sessions, monitor
progress, and encourage adaptive behavior to deal with real or perceived stressors (Mennuti et
al., 2012). I will focus my literature review on school based CBT interventions within
adolescent populations (ages 11-17). However, I will also look at successful clinical treatments
that have a manual as many of them have been, or can be transferred, to educational settings. As
an educator I will frame my findings with a focus on learners and learning contexts in order to
create a CBT curriculum with an educational focus rather than a traditional clinical focus. I will
then assess CBT goals, assessments, homework assignments, teacher student relationships,
classroom environments, and flexibility within manuals for what aspects a comprehensive CBT
curriculum should include.
Finally, I will propose where future research can be directed and
how mental wellness can be promoted in education.
Defining the Cognitive Behavioral Therapy Model and Other Constructs
Throughout my paper I will utilize the construct of CBT that evolved from Aaron T.
Beck’s Cognitive Therapy (CT) that emphasizes the significance of cognition (underlying
beliefs, attitudes, and assumptions) as the main etiology of psychological disorders (Beck, Rush,
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Shaw, & Emery, 1979). The goal of CT is to teach clients the following: “(1) to monitor his
negative, automatic thoughts (cognitions); (2) to recognize the connections between cognition,
affect, and behavior; (3) to examine the evidence for and against his distorted automatic
thoughts; (4) to substitute more reality-oriented interpretations for these biased cognitions, and
(5) to learn to identify and alter the dysfunctional beliefs (and behaviors) which predispose him
to distort his experiences” (p. 4). In addition to Beck’s original conception of CT, I will include
the Greenberger and Padesky (1995) diagram model that emphasizes the interconnected areas of
thoughts, affects, behaviors, physiological reactions, and environment in CBT (see figure 1). It
is important to recognize the dynamic nature of various factors and their interplay together in
order to form a more comprehensive picture of clients’ issues.
The terms referring to the broad category of mental disorders and specific internal
disorders (depression, anxiety, and substance abuse) will be defined by individuals who meet the
necessary criterion for mental disorders as defined by the Diagnostic and Statistical Manual for
mental disorders, Fourth Edition, Text Revision (DSM-IV-TR; American Psychiatric
Association, 2000). Major Depression Disorder is classified as five (or more) of the following
symptoms during the same 2-week period and represent a change from previous functioning; at
least one of the symptoms is either (1) depressed mood or (2) loss of interest or pleasure. Other
criteria include (3) Significant (>5% body weight) weight loss or gain, or increase or decrease in
appetite, (4) Insomnia or hypersomnia, (5) Psychomotor agitation or retardation, (6) Fatigue or
loss of energy (7) Feelings of worthlessness or inappropriate guilt, (8) Diminished concentration
or indecisiveness, (9) Recurrent thoughts of death or suicide.
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CBT in Adolescents
I have focused my literature review on adolescents (children aged 11-17) because of the
aforementioned epidemic of mental disorders in this population. Furthermore, adolescence is a
formative period in emotional development marked by greater fluctuations in emotions.
Although adolescents are in the process of developing greater emotional awareness and coping
skills, many do not develop the necessary tools and may become more prone to mental disorders.
Adolescents with mental disorders are at greater risk for academic issues, drug abuse, eating
disorders, or juvenile delinquency (Santrock, 2007). Cognitive Behavioral Therapy (CBT) based
interventions are among the most widely practiced and best empirically supported methods of the
psychosocial interventions (Elkins, McHugh, Santucci, & Barlow, 2011; Weisz, McCarthy, &
Valeri, 2006). Over the past few years, the wealth of literature concerning CBT use with
adolescents in therapeutic environments has expanded significantly (Weersing & Brent, 2006).
While CBT has been used with younger children (Beidas, Benjamin, Puleo, Edmunds, &
Kendall, 2010), children in the formal operational stage of Piaget’s cognitive development (older
than 11) benefit the most from CBT interventions because they have fully developed the
competencies of decentration, reversibility, infer causal reasoning, and elimination of
egocentrism (Grave & Blissett, 2004). This research further raises awareness to the importance
of mental wellness and the critical juncture of adolescence.
CBT is one of the most prevalent treatments for mood disorders because its strong foci on
internal cognitions and expectations, reinforcing behaviors, and subsequent emotional
consequences that dictate general dispositions. CBT, or variations of CBT, have shown
effectiveness at reducing symptoms of anger (Sukhodolsky, Kassinove, & Gorman, 2003),
borderline personality disorder (Linehan et al., 2006), bipolar disorder (Lam et al., 2003), eating
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disorders (Fairburn et al, 2009), obsessive-compulsion disorder (Salkovskis, 1999), and
alcoholism (Morgenstern & Longabaugh, 2000). There is strong evidence in support of the
effectiveness and efficacy of CBT with adolescents in the treatment of internalizing disorders
such as depression (Horowitz & Graber, 2006; Lewinsohn & Clarke, 1999) and anxiety (Kendall,
2006; Hollon, Stewart, & Strunk, 2006). As cited in Kavanagh et al. (2009) and Shirk,
Kaplinski, & Gudmundensen (2009), depression is associated with functional impairment, low
academic achievement, poor social relationships, substance abuse, self harm, and suicide.
Depression is often a comorbid disorder associated with anxiety. Velting, Setzer, and Albano (as
cited in Mennuti et al., 2012) found an connection between anxiety and academic
underachievement, under employment, substance abuse, and low levels of social support. These
internalizing disorders can have large implications, as maladaptive beliefs can negatively affect
cognitive, social, emotional, behavioral, and physical aspects of adolescents’ lives. I believe that
education’s main goal is to promote these skills; therefore, it is critical that students operate at
optimal levels in order to achieve their maximum potential.
In order to concretely demonstrate how depression and anxiety may present themselves in
regards to learners in learning contexts, I will provide comprehensive examples of each mental
disorder. Imagine James, an 11 year old White boy. Although he appears bright, James is
extremely shy and rarely participates in class discussions or activities. He avoids answering
questions and never asks for clarification when he is confused about material or assignments.
Rather than present in front of the class or collaborate with others in group settings, James
accepts failing grades. He appears to have limited interaction with his peers and is rarely
discussed in teacher staff meetings. James meets sufficient criteria for Social phobia. Now
imagine Shannon, a 13 year old girl Black girl. At one point Shannon was a high achieving and
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engaging student that was active with her peers and teachers and rarely misbehaved. However,
over the past three months Shannon has been apathetic and disinterested in almost all activities.
She sleeps in class and is lethargic when she is awake. She has difficulty concentrating and has
failed her most recent exams. When the teacher attempts to remediate, Shannon claims that she
is worthless and not smart enough to do well. Shannon meets sufficient criteria for a Major
Depressive Disorder of Major Depressive Episode. Both James and Shannon provide concrete
examples of how depression and anxiety can affect learners and educational settings. Clearly the
students in these examples are not reaching their maximum potential. I believe CBT can help
them overcome these limitations, providing the students an opportunity to be happy, healthy, and
wise.
CBT in Educational Settings
In this section I will discuss the educational components of popular CBT programs used
in educational settings with specialized populations. Programs like Coping Cat, Penn Prevention
Program (PPP), Adolescent Coping with Depression course (CWD-A), Treatment For
Adolescents With Depression Study (TADS), and Taking ACTION are among the most popular
CBT intervention manuals used in school (Mennuti et al., 2012). Mennuti et al. (2012) further
explains each manual fits the American Psychology Association (APA) standards for best
practices founded on evidence based practices. I will synthesize the curricular components of
CBT in the areas of goals, assessment, homework, student/teacher relationships, classroom
environment, and personalization/flexibility in order to build a more comprehensive
understanding of what components have been effective and need to be included in a complete
CBT curriculum to promote mental wellness. It is my hope that this literature review can easily
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converted into a new curriculum or manual that accounts for educational factors in addition to
clinical factors.
Because CBT is a therapeutic intervention designed to treat mental disorders, its use in
school has been used with primarily specialized populations. Specifically, adolescents who
display overt symptoms of emotional disturbance like depression, anxiety, substance abuse,
ADHD, school refusal, and behavioral disorders are often the targets of current mental health
assessments and subsequently receive treatment (Mennuti et al., 2012). This certainly has
obvious benefits to this population as delivering mental wellness services in school settings helps
provide treatment options to a larger population of individuals who may otherwise be limited by
transportation, costs, or scheduling conflicts (Elkins et al., 2011). Thus the wealth of literature
among CBT in specialized populations is growing. However, there remains a large deficit of
research among the majority of adolescents who are not diagnosed with mental disorders. By
addressing mental wellness, all children can begin to receive potentially beneficial CBT
interventions and we can begin to correct another hidden achievement gap that plagues the
American educational system.
CBT Goals in Education.
The goal of CBT interventions is to help individuals demonstrate how they can control
and regulate their own emotions by identifying automatic thoughts, examining the accuracy of
their beliefs, and changing behaviors to reinforce new beliefs (Beck et al., 1979). Thus, the
cognitive piece of CBT should be the main focus of interventions with the affective and
behavioral components as secondary components. This is consistent with findings from
Sukhodolsky et al. (2004) that problem solving treatments that focused on learning how to think
through causes and consequences were more effective at reducing internalized emotions than
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interventions that relied solely on relaxation and positive imagery education. In addition,
changes in negative automatic thoughts were the strongest mechanisms of change in depression
symptoms (Kaufman, Rohde, Seeley, Clarke, and Stice, 2005). Furthermore, sufficient changes
in automatic thoughts had consistent effect sizes for more extensive periods of time in follow ups
(Kaufman et al., 2005). One effective manner to teach core tenets of CBT is through cognitive
distortions, or thinking errors that can lead to maladaptive misinterpretations of reality (Mennuti
et al., 2012). Cognitive distortions and other cognitive components are a major mechanism of
CBT and can easily be taught to students using traditional pedagogical strategies since they have
a large academic element.
While CBT school interventions remain primarily cognitive, there are other components
that affect treatment outcomes. Interventions with ten or more sessions were more effective than
shorter programs (Kavanagh et al., 2009). As a result, CBT should be taught over time with
periodic reinforcement afterwards. Other issues regarding scope and curriculum settings were
the time of year interventions were delivered. Treatment responses were greater for
interventions that began during the school year and continued into the summer only if
participants reported a greater number of school related problems. Otherwise interventions in the
summer had no other effect (Shamseddeen et al., 2011). Thus, school problems are relevant to
the treatment of depression and must be accounted for in treatment plans. Kennard et al. (2005)
often explicitly taught social skills training in the form of assertiveness training, social
interactions, and communication skills to help students build social interaction and peer support.
Students with social anxieties or depression that are made worse with communication issues
would benefit from these components. Overall, the goal of CBT should remain primarily
cognitive, but social factors amongst participants should also be accounted for.
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Assessment
I have elaborated on the desired results of CBT as the recognition of maladaptive beliefs
and the subsequent substitution of new interpretations of reality which allow individuals to think
and act more adaptively accordingly to stress (Beck et al., 1979), I will now explain how CBT
has been measured in school settings. Instead of launching into a literature review of successful
components of CBT curricula, it is critical that practitioners understand how success has been
determined. This sequence is consistent with Wiggins and McTighe’s (2005) backwards design
framework where the assessment stage precedes lesson components.
CBT was developed with the purpose to treat mental disorders, and thus it has primarily
been used with specialized populations. As a result, assessments typically gauge effect sizes of
CBT interventions in regards to clinical progress, not cognitive or academic progress. Broad
surveys, focus groups, self report measures, coded observations, and interviews are typically
used to assess changes in mood or cognition. Specifically the Beck Youth Inventories, Second
Edition (BYI-II), Behavior Assessment System for Children, Second Edition (BASC-2), and
Center for Epidemiologic Studies Depression Scale (CES-D) are common screening and pretest/post-test data collection methods (Mennuti et al., 2012). While these assessments accurately
gauge the absence or presence of mental disorders, they do not assess other skills that all
individuals can strive to attain. There is a significant gap of evidence based research on
assessing CBT interventions is school settings (Mennuti et al., 2012). Due to this lack of
research, I will propose components of assessment that can be used to evaluate school based
mental wellness programs.
Much like the main concept behind mental wellness, a proper assessment of CBT tasks
should include a comprehensive picture of the client’s strengths and weaknesses. (David-Ferdon
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& Kaslow, 2008). This will better serve practitioners to make appropriate treatment decisions
more efficiently and effectively. Using students’ strengths will then increase student
engagement and help instructors more accurately assess knowledge (David-Ferdon & Kaslow,
2008). For example, a student with strong verbal skills should be asked to explain their thoughts
and emotions with others, not write about them in thought records. Role play with individuals in
the TADS helped provide students with natural contexts where their maladaptive ideations would
commonly manifest themselves (Kennard et al., 2005). Since these role plays involve simulated
settings of real restraints, they provide accurate assessments in the form of a performance task
(Wiggins & McTighe, 2005). More complete assessments will lead to greater desired results and
increase the effectiveness of CBT interventions. A consistent task among many CBT
interventions that involves a formative assessment piece is homework.
Homework Component
Assigning homework in CBT is a fundamental element as it helps individuals construct
their own understanding and increase the likelihood of transfer in more natural contexts.
Greenberger and Padesky (1995) have a comprehensive workbook often used as homework that
includes thought records, worksheets to recognize automatic thoughts, questionnaires that ask for
evidence, and activity scheduling. Not surprisingly, greater compliance with homework is
associated with better treatment outcomes (Kennard et al, 2005). Students that attended CBT
groups and completed more homework assignments had an increase in other class participation
and also achieved higher grades (Ruffolo & Fischer, 2004). In addition to increasing class
participation, completing homework tasks without the help of parents helped students increase
their levels of accountability and self confidence, which are often issues amongst depressed and
anxious individuals (Kendall & Barmish, 2007). While CBT homework can increase agency
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through intrapersonal skills, interpersonal skills are also an important competence. Compliance
with assignment completion was associated with a higher levels of reported therapeutic
relationship (Kennard et al., 2005). Overall, homework is a critical piece that must be included
in CBT interventions for additional practice with core concepts, increases in self confidence, and
development of student teacher relationship.
Relationship of Teacher and Student
One of the most influential components of education is the relationship between student
and teacher. CBT is no different as the therapeutic relationship has profound effects on
treatment (Beck et al., 1979). The teacher-student relationship is particularly important in
dealing with adolescents. Auger (as cited in Ruffolo & Fischer, 2009) suggests having a trusted
adult to confide in and discuss issues helps students cope with depressive symptoms. While any
caring adult can potentially fill this role, interventions provided by existing school staff appeared
to have a greater effect than those administered by non school psychologists or researchers
(Kavanagh et al., 2009). While CBT experts (psychologists, social workers, and researchers)
may have more practice with the therapeutic relationship, they have little to no actual rapport
with students; interactions are typically limited to the amount of sessions available. However,
teachers and school staff are more familiar with students and their culture. They do not need to
devote time towards developing the therapeutic relationship; it already exists. However teachers
do need additional training and providing teachers with the necessary tools to recognize overt
signs of internalizing disorders will help identification of students who may be at risk for CBT
interventions (Elkins et al., 2011). School teachers and staff can use CBT interventions as a tool
to increase parental and community involvement in student’s academic lives.
Classroom Environment
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The development of a rich, safe, and community driven environment is of the utmost
importance in learning (Bransford, Brown, & Cocking, 2000). Collaboration between students,
families, and therapists is critical in classrooms that strive view learning as a process. When
students have a growth oriented mindset (Dweck, 2007) they prescribe to key tenets of mental
wellness- a goal to strive for maximum potential. CBT Interventions that encourage mental
wellness were explicit in their instructional policies. Instructors made clear that activities would
not be evaluated for grammar or spelling, would not be graded, and had no right or wrong
answers were effective at reducing anxiety (Kendall & Barmish, 2007). Furthermore, teachers
openly expressed attitudes where symptoms were viewed as manifestations of a disorder, not a
direct fault of any single individual (Kennard et al., 2005). However, instructors did not just
express their attitudes, they fostered an environment where students shared positive attitudes and
cooperated together. Ruffolo and Fischer (2004) indicated that the group settings of CBT group
sessions helped increase social bonds and engagement among students. These positive attitudes
helped create opportunities for families to communicate with educators and schools.
When families and communities are viewed as equal partners in education, both students
and schools benefit. David-Ferdon and Kaslow (2008) found that parental and family support
increases the effectiveness of CBT treatments, especially when used to treat youth from various
cultural and ethnic backgrounds. This finding is particularly important since internalizing
disorders have a large social component which can be further damaged with phenomena such as
stereotype threat (Steele & Aronson, 1995). Mental wellness is made even more complex when
practitioners and students have cultural conflicts. However, these cultural conflicts can be
addressed by establishing trust, learning the family system, and collaborating with family
members (Mennuti et al., 2012). Adolescents with higher reported levels of stress pre treatment
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were more likely to maintain depression diagnoses (Shirk et al., 2009). Therefore it is important
to recognize how issues of race, culture, gender, and sexuality in CBT interventions affect
student stress levels. Regardless of race, collaboration with families is beneficial to a good
classroom environment.
Personalization and Flexibility
School-based CBT needs to be flexible and account for students’ needs (Elkins et al.,
2011; Kendall & Barmish, 2007; Kennard et al., 2005). When manuals are flexible, they can be
personalized and better address student needs. One key pedagogical strategy involves being
aware of students’ knowledge, skills, and attitudes to make material relevant to individual
learners (Bransford et al., 2000). Because CBT interventions typically involve adolescents who
are depressed or anxious, students may have significant cognitive impairment due to the nature
of mental disorders. They may need more time to complete tasks or repetition with instruction.
As a result, teachers should remain patient and provide multiple forms of instruction, especially
when dealing with issues regarding affective pieces (Kennard, Ginsburg, Feeny, Sweeny, &
Zagurski, 2005). Creative and interactive formats can help increase client engagement and
comprehension Elkins et al., 2011). Individualized plans that helped students walk through
anxieties using graduated exposure tasks were used in the “Show That I Can” (STIC) homework
tasks (Kendall & Barmish, 2007) and in the TADS Manual (Kennard et al., 2005). Activities in
TADS were personalized to help determine the adolescent’s thoughts, emotions, and behaviors
that that commonly caused students problems. By utilizing actual student issues manuals were
more specific and yielded larger results
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Future Implications
While CBT interventions with specialized populations are widely available, these studies
still approach CBT as a clinical treatment. Very few educational implications could be drawn as
the goal is to still diagnose and treat mental disorders. There is a sparse amount of research with
CBT curriculums in populations of individuals without a diagnosed mental disorder. I have
conducted a comprehensive literature review of the best practices in CBT interventions with
adolescents in hopes that a full CBT curriculum can be delivered to all populations students.
Elkins et al., (2011) reported that there were no known negative effects in non-diagnosed
individuals of a universal CBT program. While this is a good start, this evidence is still framed
through the generally held deficit mindset of mental health. I have purposefully set up my paper
through the lens of mental wellness in order to help promote competencies that may eventually
prevent mental disorders, rather than solely treat them.
Although the field of CBT in education is growing, further evidence must be gathered.
Demographic issues of race, socio-economic status, gender, ethnic background, and sexuality
have yet to be researched thoroughly and will have a huge effect on how CBT interventions are
delivered. Furthermore, I did not encounter any longitudinal studies that spanned across many
years. One potential empirical investigation that may be of interest to researchers may include a
longitudinal study of an existing CBT manual with non diagnosed students. This could be
compared with another population at the same school of children with diagnosed mental
disorders or who are considered to be at risk.
CBT Programs in Education
Figure 1.
(Adapted from Greenberger & Padesky, 1995)
Environment
Thoughts
Physical
Reaction
houghts
Behaviors
Mood
19
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References
American Psychiatric Association. (2000). Diagnostic and Satistical manaual of Mental
Disorders (4th ed., text revision). Washing, DC: Author.
Augustyniak, K.M., Brooks, M., Rinaldo, V.J., Bogner, R., & Hodges, S. (2009). Emotional
regulation: considerations for school-based group interventions. Journal for Specialists in
Group Work, 34, 326-350.
Beck, A. T., Rush, A. J., Shaw, B. F., & Emery, G. (1979). Cognitive therapy of depression.
New York: Guilford Press.
Beidas, R.S., Benjamin, C.L., Puleo, C.M., Edmunds, J.M., & Kendall, P.C. (2010). Flexible
applications of the coping cat program for anxious youth. Cognitive and Behavioral
Practice, 17, 142-153.
Bransford, J.D., Brown, A.L., & Cocking, R.R. (Eds.) (2000). How People Learn: Brain, Mind,
Experience, and School. Washington DC: National Academy Press.
Calear, A.L., & Christensen, H. (2010). Systematic review of school-based prevention and early
intervention programs for depression. Journal of Adolescence, 33, 429-438.
Collins, K.A., Westra, H.A., Dozois, D.J.A., & Burns, D.D. (2004). Gaps in accessing treatment
for anxiety and depression: Challenges for the delivery of care. Clinical Psychology
Review, 24, 583-616.
David-Ferdon, C., & Kaslow, N.J. (2008). Evidence-based psychosocial treatments for child and
adolescent depression. Journal of Clinical Child and Adolescent Psychology, 37, 62-104.
Dweck, C.S. (2007). Mindset: The New Psychology of Success. New York, NY: Ballantine
Books.
CBT Programs in Education
21
Elkins, M., McHugh, K., Santucci, L., & Barlow, D. (2011). Improving the transportability of
CBT for internalizing disorders in children. Clinical Child Family Psychology Review,
14, 161-173.
Grave, J., & Blissett, J. (2004). Is cognitive behavior therapy developmentally appropriate for
young children? A critical review of the evidence. Clinical Psychology Review, 24, 399420.
Greenberger, D., & Padesky, C. A. (1995). Mind over mood: Change how you feel by changing
the way you think. New York: Guilford Press.
Hollon, S. D., Stewart, M. O., & Strunk, D. (2006). Cognitive behavior therapy has enduring
effects in the treatment of depression and anxiety. Annual Review of Psychology, 57,
285-315.
Horowitz, J.L., & Garber, J. (2006). The prevention of depressive symptoms in children and
adolescents: A meta-analytic review. Journal of Consulting and Clinical Psychology,
74, 401-415.
Kaufman, N.K., Rohde, P., Seeley, J.R., Clarke, G.N., & Stice, E. (2005). Potential mediators
of Cognitive behavioral therapy for adolescents with comorbid major depression and
conduct disorder. Journal of Consulting and Clinical Psychology, 73, 38-46.
Kavanagh, J., Oliver, S., Lorenc, T., Caird, J., Tucker, H., Harden, A., Greaves, A., Thomas, J.,
& Oakley, A. (2009). School-based cognitive-behavioural interventions: A systematic
review of effects and inequalities. Health Sociology Review, 18, 61-78.
Kellner, M. H., Bry, B.H., & Salvador D.S. (2008). Anger management effects on middle
school students with emotional/behavioral disorders: Anger log use, aggressive and
prosocial behavior. Child & Family Behavior Therapy, 30, 215-230.
CBT Programs in Education
22
Kendal, P.C., & Barmish, A.J. (2007). Show-that-I-can (homework) in cognitive behavioral
therapy for anxious youth: Individualizing homework for Robert. Cognitive and
Behavioral Practice, 14, 289-296.
Kennard, B.D., Ginsburg, G.S., Feeny, N.C., Sweeny, M., & Zagurski, R. (2005)
Implementation challenges to TADS cognitive-behavioral therapy. Cognitive and
Behavioral Practice, 12, 230-239.
Kessler, R., Berglund, P., Demler, O., Jin, R., Merikangas, K., Walters, E. (2005). Lifetime
prevalence and age-of-onset distributions of DSM-IV disorders in the National
Comorbidity Survey Replication. Archives of General Psychiatry, 62, 593-602.
Keyes, Corey (2002). The mental health continuum: From languishing to flourishing in life.
Journal of Health and Social Behaviour, 43, 207–222.
Koch, S.P. (2010). Preventing student meltdowns. Intervention in School and Clinic, 46, 111117.
Lewinsohn, P.M., & Clarke, G.N. (1999). Psychosocial treatments for adolescent depression.
Clinical Psychology Review, 19, 329-342.
Mennuti, R.,B., Christ, R.W., & Freeman, A. (Eds.). (2012). Cognitive Behavioral
Interventions in Educational Settings: A Handbook for Practice (2nd ed.). New York,
NY: Taylor & Francis.
Morgenstern, J., & Longabaugh, R. (2000). Cognitive-behavioral treatment for alcohol
dependence: a review of evidence for its hypothesized mechanisms of action. Addiction,
95, 1475-1490.
CBT Programs in Education
23
The National Advisory Mental Health Council Workgroup on Child and Adolescent Mental
Health Intervention Development and Deployment, (2001). Blueprint for Change:
Research on Child and Adolescent Mental Health. Washington, D.C.
Pickover S. (2010). Emotional skills-building curriculum. Journal of Addictions & Offender
Counseling, 3, 52-58.
Phillips, J.H., Corcoran, J. & Grossman, C. (2003). Implementing a cognitive-behavioral
curriculum for adolescents with depression in the school setting. Children & Schools,
25, 147-58.
Rait, S., Monsen, J.J., & Squires, G. (2010). Cognitive behaviour therapies and their
implications for applied educational psychology. Educational Psychology in Practice,
26, 105-122.
Rogers, G.M., Reinecke, M.A., & Curry, J.F. (2005). Case formulation in TADS CBT.
Cognitive and Behavioral Practice, 12, 198-208.
Ruffolo, M.C., & Fischer, D. (2009). Using an evidence-based CBT group intervention model
for adolescents with depressive symptoms: Lessons learned from a school-based
adaptation. Child & Family Social Work, 14, 189-197.
Santrock, J.W. (2007) Adolescence (11th ed.). New York, NY: McGraw Hill.
Shaffer, D., Fisher, P., Dulcan, M. K., Davies, M., Piacentini, J., Schwab-Stone, M, . E., Labey,
B. B., Bourdon, K., Jensen, P. S., Bird, H. R., Canino, G., & Regier, D. A. (1996). The
NIMH diagnostic interview schedule for children version 2.3 (DISC-2.3): Description,
acceptability, prevalence rates, and performance in the MECA Study. Methods for the
epidemiology of child and adolescent mental disorders Study. Journal of the American
Academy of Child and Adolescent Psychiatry, 35, 865-877.
CBT Programs in Education
24
Sahmseddeen, W., Clarke, G., Wagner, K.D., Ryan, N.D., Birmaher, B., Emslie, G., Asarnow,
J.R., Porta, G., Mayes, T., Keller, M.B., & Brent, D.A. (2011). Treatment-resistant
depressed youth show higher response rate if treatment ends during summer school
break. Journal of the American Academy of Child and Adolescent Psychiatry, 50, 11401148.
Shirk, S.R., Kaplinski, H., Gudmundsen, G. (2009). School-Based cognitive-behavioral
therapy for adolescent depression: A benchmarking study. Journal of Emotional and
Behavioral Disorders, 17, 106-117.
Shirk, S.R., & Karver, M. (2003). Prediction of treatment outcome from relationship variable in
child and adolescent therapy: A meta-analytic review. Journal of Consulting and
Clinical Psychology, 71, 452-463.
Squires, G. (2010).Countering the argument that educational psychologists seed specific
training to use cognitive behavioural therapy. Emotional & Behavioural Difficulties,
15, 279-294.
Steele, C.M., & Aronson, J. (1995). "Stereotype threat and the intellectual test performance of
African Americans". Journal of Personality and Social Psychology, 69, 797–811.
Sukhodolsky, D.G., Kassinove, H., & Gorman, B.S. (2004). Cognitive-behavioral therapy for
anger in children and adolescents: A meta-analysis. Aggression and Violent Behavior, 9,
247-269.
Treatment for Adolescents With Depression Study Team. (2004). Fluoxetine, cognitivebehavioral therapy, and their combination for adolescents with depression: Treatment
For Adolescents With Depression Study (TADS) randomized controlled trial. Journal
of the American Medical Association, 292, 807-820.
CBT Programs in Education
25
U.S. Department of Education, (2001). Twenty-third annual report to Congress on the
implementation of the Individuals with Disabilities Education Act, Washington, D.C.
U.S. Department of Health and Human Services (1999). Mental Health: A Report of the
Surgeon General. Rockville, MD: U.S. Department of Health and Human Services,
Substance Abuse and Mental Health Services Administration, Center for Mental Health
Services, National Institutes of Health, National Institute of Mental Health.
U.S. Public Health Service (2000). Report of the Surgeon General’s Conference on Children’s
Mental Health: A National Action Agenda. Washington, DC: Department of Health
and Human Services.
Wiggins, G, & McTighe, J. (2005). Understanding by Design. Alexandria, VA: Association for
Supervision and Curriculum Development.
Weersing, R.V., & Brent, D.A. (2006). Cognitive behavioral therapy for depression in youth.
Child and Adolescent Psychiatric Clinics of North America, 15, 939-957.
Weisz, J.R., McCarthy, C.A., & Valeri, S.M. (2006). Effects of psychotherapy for depression in
children and adolescents: A meta-analysis. Psychology Bulletin, 1, 132-149.
Wolfe, V.V., Dozois, D, J., Fisman, S., & DePace J. (2008). Preventing depression among
adolescent girls: pathways toward effective and sustainable programs. Cognitive and
Behavioral Practice, 15, 36-46.
World Health Organization (2005). Child and Adolescent Mental Health Policies and Plans.
Geneva, Switzerland: World Health Organization.
World Health Organization (2007). What is mental health? Retrieved from
http://www.who.int/features/qa/62/en/
CBT Programs in Education
26
World Health Organization (2009). Improving Health Services and Systems for Mental Health.
Geneva, Switzerland: World Health Organization.
Zyromski, B. & Joseph, A.E. (2008). Utilizing cognitive behavioral interventions to positively
impact academic achievement in middle school students. Journal of School Counseling,
6.