Evidence from Darjeeling to support “Education as Mental Health Therapy” (Ed-MH) as an emerging therapy modality

Abstract

Objective

Community-Initiated Care (CIC) leverages existing community roles to support mental health, such as teachers supporting youth within their natural environments (e.g., schools). One such model, “Education as mental health therapy” (Ed-MH), first emerged when 19 teachers in a 2018 pilot study in Darjeeling, India were given a choice within protocol to deliver care via traditional 1-on-1 sessions, micro-doses fitted into teacher workflows, or some combination; of the 536 techniques teachers chose in 2018, 80% fit into their teaching workflow, supporting the potential emergence of Ed-MH as a novel CIC modality only teachers could deliver.

Methods

Using post-hoc qualitative content analysis, we explored in a 2019 pilot study in Darjeeling whether new teachers’ choices (n = 9) across their care for children (n = 17) similarly supported Ed-MH’s potential emergence.

Results

Of the 154 techniques used, 82% fit into their teaching duties, consistent with 2018 findings.

Conclusion

With 2019 findings supporting Ed-MH as a novel modality uniquely deliverable by teachers, illustrating a practical CIC approach, this model addresses social/environmental factors impacting child well-being, potentially offering an alternative to traditional treatment paradigms.

Keywords

education school mental health children teachers therapy

Worldwide, 10%–20% of youth have a mental health condition and up to 40% in some regions as a result COVID-19 pandemic policies.¹ Historically, care access has been poor; 80%–90% of youth in need do not receiving care, a “care gap.”^1,2 Today, the care gap is likely wider (but yet to be fully characterized) as mental health services have not concomitantly increased during the pandemic.¹ Insufficient professional human resources contribute to this gap in part.³ As targeting professional pipelines are time and resource-intensive, alternative models of care are urgently needed to bridge this gap.³

Task-shifting models expand mental health care access by training non-professionals, supervised by experts, to deliver specific interventions.¹ However, the magnitude of the global mental health need outstrips the capacity of task-shifting systems of care to sustain sufficient dedicated personnel.³ Addressing the full spectrum of community needs requires complementary approaches in addition to task-shifting, such as Community-Initiated Care (CIC), which activate and empower existing social networks and trusted community roles outside traditional healthcare.^3,4 CICs frequently emerge organically from a community’s efforts to support its mental health needs with the human resources and structures it has.³ Instead of relying on “full dose” 1-on-1 therapy sessions that require learning to deliver care formally, CICs incorporate micro-doses of support within the care deliverer’s routine activities and tasks.³ For instance, in “Going Off, Growing Strong” for Indigenous youth in Northern Labrador, Canada, suicide prevention occurs through mentorship from elders within the development of traditional vocational skills.⁵ While therapeutic techniques may be diverse, CICs may be more sustainable than traditional care, whether formal or task-shifted, since they are born from the processes and people ultimately using and delivering the care.³

For youth, in their everyday environment, teachers already have routine teaching and mentoring roles into which they may be able to integrate brief, supportive micro-doses of care, such as providing academic accommodations to address mental health or brief check-ins to build a therapeutic and trusting relationship.^6–8 This integrated approach may be particularly suitable for teachers; previous interventions in which they deliver traditionally structured care (i.e., 1-on-1 sessions) were inconsistently implemented given the challenging demands of their primary duty, teaching.^8–11 Reflecting CICs’ typically organic emergence, evidence for Tealeaf (Teachers Leading the Frontlines—Mental Health), a teacher-led model of child mental health care, grew from teachers being given a choice in how to deliver care.^6,7 Tealeaf allows teachers to choose how to deliver care, whether through one-on-one sessions, integrating micro-doses into their teaching or a combination of their choosing. Notably, in Darjeeling, India in a 2018 pilot trial, teachers consistently chose to deliver integrated micro-doses, leading to improved child mental health symptoms over 1 year.^6,7,12–18 This finding provided support for the potential emergence of “education as mental health therapy” (Ed-MH) as a novel therapy modality within Tealeaf that only teachers are able to deliver given the nature of their work and of the micro-doses.^6,7 Given this organic emergence, we sought to complete a qualitative post-hoc analysis of therapy techniques chosen by Tealeaf-trained teachers in Darjeeling in a 2019 single-arm, pilot acceptability trial to assess whether a similar consistent emergence occurred.

Methods

Setting

The study was in the rural Darjeeling Himalayas in West Bengal, India. Darjeeling’s ∼800,000 residents are largely Nepali and earn daily wages of ∼202 INR ($2.76 USD).¹⁹ Low cost private (LCP) primary schools (Grades Kindergarten through 4) were chosen to target children with poor access to care and government services.²⁰ No estimates of child mental health prevalence in Darjeeling exist; in a nearby rural area, prevalence is estimated at 33%.²¹

Participants

LCP schools were eligible if they did not receive government aid and served families with daily incomes <$10 USD. All teachers within enrolled schools were eligible except if they (1) were <18 years old; (2) taught for <1 year; or (3) were suspected or convicted of child-related misconduct. Thirteen teachers from 9 schools consented to participate. Children were selected by their teachers (n = 26; 2 students per teacher, pragmatically limited); guardians provided consent and children >7 years provided assent.

Post hoc, behavior plans (“4Cs”; Cause, Change, Connect, Cultivate; Additional File 1) that documented therapeutic techniques used were recovered in 2020 during the COVID-19 pandemic from 9 teachers for 17 students. 4Cs of teachers unable to be contacted during COVID-19 were not included (n = 4 teachers).

The research protocol and all informed consent forms were approved by the University of North Carolina at Chapel Hill Institutional Review Board (# 17-2608) and a Darjeeling-based Ethics Committee. Consents detailed participation in the study & publication of results and were sought as follows. (1) Schools: A study representative called principals of area schools to gauge interest. Interested principals discussed with their teachers their interest in intervention delivery, study participation, and permission to publish results. (2) Teachers: All eligible teachers in participating schools were invited to meet with study representatives to review study protocols individually and privately. Those interested in participating in the study voluntarily and permitting results to be published signed a written informed consent. (3) Caregivers: Study representatives individually privately met with each caregiver to review study protocols for their children. Those interested in having their children participate and permitting publication of results signed a written informed consent. (4) Children: Children greater than 7 years of age were verbally assented individually and privately by a study representative for participating in the study and publication of results. They were allowed to refuse to participate.

Measures

The 4Cs is a study-specific behavior plan that organizes teachers’ chosen therapeutic techniques (Additional File 1). Teachers chose techniques from a menu of evidence-based options or techniques learned in training (both distilled from Cognitive Behavior Play Therapy [CBPT] and adapted for classroom use; Additional File 2).²² Techniques are transdiagnostic, applying “the same underlying principles across mental disorders, without tailoring… to specific diagnoses.”²³ A research assistant translated and digitized the 4Cs.

Procedures

In Tealeaf, in brief, teachers attend a 10-day training (January 2019) and then deliver Tealeaf over 1 school year by: identifying children with mental health needs, conducting behavior analyses, and developing & implementing the 4Cs for targeted children.¹⁴ Teachers receive twice monthly supervision from local psychiatric social workers. The full procedures are detailed in a separate publication.¹⁵

Tealeaf has five categories of therapeutic techniques: academic accommodations, individual classroom behavior, relationship-building, self-regulation, and cognitive restructuring. In individual classroom behavior, teachers can shape child behavior in the classroom therapeutically.⁶ For instance, by setting behavioral limits and providing positive reinforcement through praise for appropriate behaviors, a teacher might provide consistent, predictable routines and limitations for the child. Academic accommodations within this context refer to the ability of the teacher to make academic modifications for the child that similarly increase the child’s sense of accomplishment and self-efficacy while addressing impairing mental health symptoms, such as being anxious or withdrawn.⁶ For example, reducing the amount of work required when a child is struggling with academics can foster a sense of success within the child, bolstering mental health.⁶ Relationship-building refers to techniques used to help the teacher develop a strong, positive relationship (akin to a therapeutic alliance) with the child, fostering growth, and supporting mental health.⁶ Self-regulation and cognitive restructuring techniques refer to more traditional cognitive-behavioral skills.^6,22 Examples of self-regulatory techniques would be teaching the child physical coping skills such as using a stress ball or engaging in physical activities to calm.²² Examples of cognitive restructuring include strategies such as working through worksheets to analyze core beliefs and reframe negative thoughts.²²

Academic accommodations and individual classroom behavior are “teacher-specific” techniques that only a teacher can provide (e.g., modifying homework).⁶ “Teacher-centric” techniques include teacher-specific techniques plus relationship-building techniques.⁶ While therapists also build relationships, teachers in the 2018 trial did so using techniques only they could use (e.g., delivering school papers with the student).⁶ By contrast, self-regulation and cognitive restructuring techniques are delivered similarly by therapists and teachers.⁶

Analysis

For qualitative description, 4Cs were coded post hoc to assess patterns in technique choices.²⁴ Using content analysis and NVivo 12, two research assistants pursued deductive coding with an unconstrained matrix, allowing for emergent codes to be added.²⁵ Techniques were coded and grouped into the same matrix of categories used in 2018 analyses.⁶ Per content analysis, codes were counted and summed per category.²⁵

Results

Teachers (n = 9) were predominantly female (89%); mean age was 31.7 years (Table 1). Demographics of teachers with available 4Cs did not differ from those whose 4Cs were unavailable. Teachers used 154 techniques across 17 4Cs (Figure 1). From most to least used techniques, teachers chose individual classroom behavior (n = 59; 38%), academic accommodations (n = 44; 29%), relationship-building (n = 23; 15%), self-regulation (n = 15; 10%), and cognitive restructuring (n = 13; 8%). When aggregated into “teacher-specific” and “teacher-centric” categories, 67% were teacher-specific (n = 103) and 82% (n = 126) teacher-centric.

Table 1.

Teacher demographics—comparing those who did and did not retain 4Cs plans

	Completed study activities (N = 9)	Did not complete study activities (N = 4)	p-value*
Continuous Variable	Mean (SD)	Mean (SD)
Age	31.7 (6.2)	25.8 (2.2)	0.097
Years teaching	9.1 (6.2)	3.6 (2.3)	0.12
Years at current school	5.6 (5.9)	3.6 (2.3)	0.55
Categorical Variable	N (%)	N (%)
Female gender	8 (89%)	2 (50%)	0.20
Language
Nepali	2 (22%)	3 (75%)	0.22
English	2 (22%)	2 (50%)	0.53
Level of education completed			0.25
Some primary	0 (0%)	2 (50%)
Some senior secondary	2 (22%)	0 (0%)
Finished secondary	1 (11%)	0 (0%)
Some undergraduate	3 (33%)	0 (0%)
Finished undergraduate	1 (11%)	1 (25%)
Some graduate/post-graduate	1 (11%)	0 (0%)
Finished graduate/post-graduate	1 (11%)	1 (25%)
Has formal training and teaching certificate	5 (56%)	0 (0%)	0.11
Grade level taught^a
Nursery/Kindergarten	6 (67%)	0 (0%)	0.07
Class 1	7 (78%)	3 (75%)	0.99
Class II	7 (78%)	3 (75%)	0.99
Class III	5 (56%)	3 (75%)	0.99
Class IV	5 (56%)	2 (50%)	0.99
Class V	3 (33%)	0 (0%)	0.50
Class VI	2 (22%)	1 (25%)	0.99

*p-value of t-test for continuous variables and fisher’s exact test for categorical variables.

^aSum is greater than 100% due to individuals speaking multiple languages or teaching multiple classes.

Figure 1.

Teacher choice of therapeutic techniques (n = 154)*, grouped by teacher-centric and teacher-specific.

Discussion

Teachers’ consistent preference for micro-dose techniques in 2019, mirroring 2018 findings,⁶ support the potential emergence of Ed-MH as a novel therapy modality. 4Cs findings here, with teachers choosing teacher-specific techniques 67% of the time and teacher-centric techniques 82% of the time, are descriptively similar to 2018 4Cs findings, where teachers delivered teacher-specific techniques 59% of the time and teacher-centric techniques 80% of the time.⁶ Teachers’ preferences exemplify CIC principles, where existing community roles organically adapt support strategies. This teacher-led Ed-MH approach, leveraging the school environment, improved child mental health symptoms in both 2018 and 2019 (as in separate publications).^6,15,18 An ongoing powered trial will further determine Ed-MH’s viability and impact.

As in 2018, teachers in this study in 2019 were given the freedom to choose which techniques to use when delivering care to their students. Their organic preference for certain techniques being similar to teachers in 2018 speaks to the tendencies of teachers to be inclined to deliver non-teaching tasks that are aligned with their primary duty of teaching, a hallmark of CICs and their potential for sustainability.³ Though perhaps unsurprising that teachers would choose to deliver therapy that can fit into their duties, teachers have historically been tasked in mental health care to deliver indicated care that is traditionally structured.^8,10 This potential mismatch between teacher preference for types of therapeutic techniques to deliver and the care they have been tasked to deliver may underlie why teachers have not consistently or sustainably delivered care.^8–11

When teachers delivered Ed-MH in 2018, children improved in their mental health symptoms; on Achenbach Teacher Report Form (TRF), Total Problem score percentiles improved from the 77th to the 60th percentile.^6,26 Similarly, in 2019, children receiving care from teachers in this 2019 trial also improved in their mental health symptoms per the TRF Total Problem score.^15,18,26 Taken together, these findings support that teachers are showing early signs of reliably improving child mental health symptoms within CICs, with care structured to fit within their teaching duties (i.e., Ed-MH).

Limitations

Data (4Cs) from four teachers were lost during the pandemic (no demographic differences noted, Table 1). The sample size (17 4Cs) potentially limits generalizability and insight into the full spectrum of organically chosen techniques within this CIC model. While teachers may not have recorded all techniques, fidelity checks were conducted by study staff. Applying a prior deductive codebook might risk bias, although new codes reflecting 2019 data were added.

Additionally, that this study was completed in 2019 may raise questions about continued relevance post-COVID-19. An original powered trial started in 2019 and was paused in 2020 during the pandemic while Darjeeling’s schools were closed. The ongoing powered trial started successfully in 2022 just following school re-openings. For this post-pandemic trial, Tealeaf did not require protocol modifications. Instead, schools anecdotally reported that Tealeaf helped them to support students transitioning back to in-person learning, suggesting the intervention’s continued applicability.

Conclusion

By leveraging community roles and environments to support child mental health, this study demonstrates Community-Initiated Care (CIC) in action. As in 2018, teachers again in 2019 primarily chose to use micro-doses to deliver care and naturally embed support within their existing roles. This practical application supports the potential emergence of “education as mental health therapy” (Ed-MH) as a CIC therapy modality. Its organic emergence supports this modality’s viability and its appeal to teachers. An ongoing powered trial will further assess Ed-MH’s potential to bridge care gaps in everyday settings, through every teacher-student interaction.

Supplemental Material

Supplemental Material - Evidence from Darjeeling to support ‘education as mental health therapy’ (Ed-MH) as an emerging therapy modality

Supplemental Material for Evidence from Darjeeling to support ‘Education as Mental Health Therapy’ (Ed-MH) as an emerging therapy modality by Priscilla Giri, Choden Dukpa, Juliana L. Vanderburg, Surekha Bhattarai, Arpana Thapa, Abhishek K. Rauniyar, Karen Hampanda, Bradley N. Gaynes, Molly M. Lamb, Rinzi Lama, Michael Matergia, and Christina M. Cruz in Australasian Psychiatry

Footnotes

Acknowledgments

We profusely thank Roshan Rai, Executive Director of Darjeeling Ladenla Road Prerna (DLRP) and Nima Choden, Dhiraj Rai, Maryam Subba, and Satyam Tamang, community health workers of DLRP, for their support of the implementation of the teacher-led task-shifted children’s mental health care studied in this manuscript. We also thank Emily Faley Honeycutt for assistance in preparing this manuscript for submission. We humbly thank the Mariwala Health Initiative for their generous support of DLRP.

Author contributions

CMC, KH, and MM designed the study. BNG was involved in study design. CMC, PG, and MM created the teacher training, intervention materials, and intervention and research protocols. PG, SB, and AT delivered the teacher training, provided supervision to teachers, and collected data. CD collected data. CMC, RL, and MM provided umbrella supervision for the supervision of teachers by PG, SB, and AT. MML and AKR performed quantitative data analysis while JV, CD, and CMC performed qualitative data analysis. CMC, MML, AKR, KH, PG, SB, AT, JV, CD, RL, and MM were involved in data interpretation. PG, CMC, CD, JV, MML, and MM drafted the manuscript. All authors revised and approved the final version of the manuscript before submission.

Declaration of conflicting of interest

The authors declared the following potential conflicts of interest with respect to the research, authorship, and/or publication of this article: CMC, PG, and MM hold the copyright to the training materials, decision support tools, and intervention materials for the teacher-led system of children’s mental health care at the center of this manuscript.

Funding

The authors disclosed receipt of the following financial support for the research, authorship, and/or publication of this article: The results from child participation in this publication were made possible through the American Academy of Child and Adolescent Psychiatry (AACAP) Junior Investigator Award, supported by Pfizer and Sunovion Pharmaceuticals; its contents are the responsibility of the authors and do not necessarily reflect the official views of AACAP nor the companies listed above. The results from teacher participation in this were made possible through the Early Career Award Program of the Thrasher Research Fund; its contents are the responsibility of the authors and do not necessarily reflect the official views of the Thrasher Research Fund. Data analysis for this publication was in part supported by Grants #2020-0143, #2021-0264, and #2023-0238 from the Doris Duke Foundation and generously through a grant from the Mariwala Health Initiative Partnership/Grant with Darjeeling LR Prerna. This publication’s contents are the responsibility of the authors and do not necessarily reflect the official views of the Doris Duke Foundation nor the Mariwala Health Initiative.

Clinical trial registration

The trial was registered with Clinical Trials Registry—India (CTRI), No. CTRI/2018/01/011,471, Ref. No. REF/2017/11/015,895; date of registration 2018-01-01.

Ethical Approval,consent to participate,and consent for publication

Schools: PG, a psychiatric social worker, called principals of area schools to gauge interest. Interested principals discussed with their teachers their interest in intervention delivery, study participation, and permission to publish results.

Teachers: All eligible teachers in participating schools were invited to meet with study representatives (PG) to review study protocols individually and privately. Those interested in participating in the study voluntarily and permitting results to be published signed a written informed consent.

Caregivers: Study representatives (PG) individually privately met with each caregiver to review study protocols for their children. Those interested in having their children participate and permitting publication of results signed a written informed consent.

Children: Children greater than 7 years of age were verbally assented individually and privately by PG for participating in the study and publication of results. They were allowed to refuse to participate.

ORCID iD

Christina M Cruz

Data Availability Statement

The datasets generated and/or analyzed during the current study are not publicly available due to the connectedness of the Darjeeling community, the relatively small sample size of teachers, caregivers, and students included where community members may be able to connect which children they know received services, and with mental health continuing to be stigmatized in the Darjeeling area. Participants did not agree to share their data publicly. Data sharing will be reviewed case-by-case by the corresponding authors upon reasonable request.

Supplemental Material

Supplemental material for this article is available online

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