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How Schools Can Bridge Mental Health Care Gaps with Cognitive Behavioral Therapy Tools

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School counselors help guide students with academics, college applications and social matters with other students. Increasingly, however, they are also helping students deal with mental health issues, such as anxiety and depression. School counselors, along with school social workers, may be children’s only access to some form of mental health care, since it’s estimated that only 20 percent of children with mental or behavioral disorders receive help from a mental health care provider.

“The vast majority of mental health services are actually delivered in schools," said Sharon Hoover, co-director for the National Center for School Mental Health. "Kids and families don’t make it consistently to community mental health settings.”

A challenge for schools is to efficiently incorporate the services that do exist, said Hoover. In most schools, you already have an established mental health care workforce, but they’re understaffed with caseloads of a few hundred students and may not partner well with community care providers.

However, a program through the University of Michigan is trying to address that challenge by partnering school staff with community counselors in a professional development program. The Transforming Research into Action to Improve the Lives of Students (TRAILS) program trains K-12 counselors and social workers to teach students how to manage their thoughts, feelings and actions with cognitive behavioral therapy.

CBT is a way to treat stress, anxiety and depression by identifying patterns in thinking that negatively affect emotion and behavior. One sample activity used by TRAILS is around a form of communication ubiquitous in a teen’s life: text messaging. Students are asked to imagine what they would think if a friend didn't text them back. What emotions would they feel and what actions might they take? The students are walked through the series of steps in order to identify and stop negative feedback at the thoughts stage, before that thinking can snowball into panic, depression or lashing out to others. Students would be encouraged to re-analyze their thoughts to not take the lack of communication as a personal slight or let those thoughts become negative feelings and behavior.


Greta Furlong, a social worker at Ypsilanti Community Schools in Ypsilanti, Michigan, has seen the positive impact of CBT. Furlong went through the TRAILS training last year and established a CBT group for students at Ypsilanti Community High School.

She recalled how one young man in a CBT group tended to hold in his feelings until he would explode in anger and frustration. But after learning some of the strategies in CBT, he learned how to take a step back, pause to take a moment and reflect on his negative thoughts.

“The CBT groups were teaching the students the connection between thoughts, feelings, behaviors and actions,” Furlong said. The student told Furlong that the CBT group “really helped him begin to manage his feelings better,” she said. Engaging in these group settings also helps people feel less alone in their struggles.


There is some evidence that more children are experiencing mental health problems, or at the very least awareness of it has increased. The percentage of children ages 6 to 17 who have been diagnosed with either anxiety or depression increased from 5.4 percent in 2003 to 8.4 percent in 2011–2012, according to the Centers for Disease Control and Prevention.

Christa Lindemer, a social worker at Chelsea High School in Chelsea, Michigan, sees the reality of students’ needs all day.

She had previously learned about CBT through her social work training, but TRAILS was more focused on methods and strategies to implement the program for students, she said. She is continuing CBT groups at her school.

“For some students, this is the only mental health support that they get,” said Lindemer.

The students she refers to the group meet up for an hourlong session once a week where they receive skills to cope with the anxiety and/or depression they experience.

One caution, noted Lindemer, is that staff need to be thoughtful in making sure the student personalities will blend well together when selecting students for a CBT group.

And, if a student needs intensive mental health support, the CBT group by itself may not be enough to address their needs, she added. The student would then be referred to the right provider of help.


Through TRAILS, school staff (usually nurses, social workers, counselors) participate in a daylong training event through the University of Michigan Depression Center. More importantly, participants are then connected to a counselor who serves as a coach in establishing CBT groups in schools.

All the materials for the course are available on the TRAILS website, so school staff can pick and choose different activities.

If they participate in the TRAILS training event, they are paired with a coach. TRAILS has a network of some 100 coaches throughout the state of Michigan. The coach visits the school once a week for the first semester of running a CBT group. In nine to 12 sessions, this coach helps model skills, provide feedback and demonstrate how to work with students.

Every school professional who participates is expected to run at least one CBT group with their students and coach. But afterward, they can run other groups on their own or just work with individual students as they need to, according to Elizabeth Koschmann, director of TRAILS.

Expanding TRAILS

Schools in Michigan have taken to TRAILS since it first started as a pilot program in 2013. School staff from almost every county in the state have been trained through the program.

Koschmann says they have just started a collaboration with K-12 Detroit public schools and are meeting with a collaborator from Harvard who wants to bring the program to Boston public schools.

The project is funded through grants, but finding enough money for their fast expansion is a challenge, says Koschmann. They will need to adjust materials so that it fits with programming for K-8. They also want to develop materials so more classroom teachers can use a condensed version of the curriculum, with 20-minute lesson plans.

Koschmann’s hope is that every single student in a K-12 building could get a 20-minute lesson introducing them to the basics of CBT and mindfulness. Every class could start the day with a mindfulness exercise, “some way it can be woven into the fabric of the school.”

However, students need to be at a developmental level where they can understand the curriculum, and staff need to be cautious about selecting students who will respond well to the group dynamic, said Furlong.

She uses some TRAILS activities on an individual level with some students at her middle school. Those students have behavioral problems and are not at a point to be reflective in a group setting. But TRAILS activities that promote self-reflection can help the students be less reactive, she said.

But for students facing everyday stresses, the CBT groups can make a difference.


“The kids really looked forward to coming,” said Furlong.

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