This study contributes to the emerging literature on task-shifting children’s mental health care to schools as part of ongoing efforts to bridge the wide care gap, particularly in LMICs. Most studies show teacher involvement in school mental health confined to promotion or prevention curriculum delivery, limiting publications of assessments of teacher knowledge and attitudes to those with a different, perhaps less intensive focus. (8, 29) Only one group has explored whether teachers can be leveraged to deliver indicated care; the youth who received the study’s teacher-delivered care did not demonstrate changes to their mental health status. (8, 18) As previously discussed, the role of individual-level factors and whether they were modifiable were not explored as part of the study’s negative results. (18, 30, 31) This study assesses how training, supervision, and experience can influence individual-level teacher factors that may underlie teachers’ ability to deliver effective indicated child mental health care. It uniquely contributes to an exploration of whether teachers may be able to deliver indicated care to fill the care gap.
The results present a complex picture of the influence that mental health training, regular supervision, and working as a lay counselor have on teacher mental health knowledge and attitudes and their perceptions of serving as lay counselor. Findings from the qualitative data are discordant with the results from study-specific quantitative forms. Teacher knowledge as measured by a study-specific assessment did not appear to change when comparing PRE, POST, and INT. Semi-structured interviews at INT, though, revealed that teachers grasped knowledge from the training and supervision and further changed their own behavior, a demonstration of knowledge retention. Similarly, teachers’ mental health attitudes on a study-specific survey improved POST compared to PRE, but at INT appeared to revert to PRE levels. However, in semi-structured interviews at INT, a majority of teachers expressed that they underwent significant changes in their attitudes towards mental health and provided examples of being more inclusive of students with mental health struggles. Moreover, a majority of teachers expressed positive perceptions of being a lay counselor, expressed interest in continuing to serve as lay counselors, and encouraged study staff to expand the program to other schools.
Use of semi-structured interviews allowed teachers to share their experiences with little prompting, leading to insights that may not have been clear to ask about with closed-ended questions. By contrast, the study-specific surveys quantitatively evaluated the mental health knowledge and attitudes of teachers with questions determined a priori. Scant literature published exploring the mental health knowledge and attitudes of teachers who have served as lay counselors was available to guide question formation. Instead, these questions were based on the working hypothesis for the intervention’s mechanism of change that teachers grasped and retained knowledge, shifted attitudes, and changed their daily practice the way mental health trainees in a professional mental health training program would, as though their sole focus were to deliver care. (8, 18) Instead, the semi-structured interviews revealed that teachers grasped and retained mental health knowledge and changed attitudes towards mental health that were relevant to the way in which mental health techniques serve teachers’ primary goal of educating children, such as increasing empathy, building individual relationships and trust, and utilizing in-class accommodations.
Thus, the way in which a teacher as a lay counselor delivers care to students may hinge on the incorporation of basic therapeutic interactions into classroom instruction time, using mental health techniques as part of their knowledge transfer process. In other words, teachers appear to be modifying instructional methods as the “therapy” to improve the mental health of their students. Here, we coin the term “education as therapy” to describe this emerging model of care.
Certain forms of education, such as special education in HICs, similarly adjust teaching techniques to the special needs of students. (32, 33) Special education, however, focuses on knowledge transfer and addresses students’ non-academic needs just sufficiently to allow for knowledge transfer. (33) By contrast, in “education as therapy”, teachers appear to be making the knowledge transfer process therapeutic in and of itself, with an end goal of both knowledge transfer and improved mental health status. Accordingly, specific assessment questions evaluating teachers’ knowledge and attitudes about mental health as they serve as lay counselors should reflect the expected changes as they pertain to educating students, not as they pertain to a traditional care pathway rooted in an office-like model.
An “education as therapy” model of care relies on teachers shifting their professional practice to include mental health techniques. Teachers in this study reported notable shifts in their practice, including decreased use of (1) physical punishment, (2) authoritarian voices, and (3) speaking “roughly” or “rudely” with their students. These changes to practice have been difficult to instill broadly amongst teachers in India, serving as a potential barrier to teachers delivering care in this setting. (34, 35) Traditional teacher practices may be reflective of the attitudes of teachers in India towards mental health. (34, 35) Teachers in India have expressed mixed to negative attitudes towards children with behavioral struggles and their inclusion in the classroom. (23) Further, there has historically been some sentiment in India that children have limited human rights, with use of fearful means to “control” children seen as culturally acceptable by some despite being banned by law. (34, 35) In this study, teachers reported that, as a result of the training and supervision they received and having to act as a lay counselor, their attitudes changed and their practice evolved accordingly. Thus, an “education as therapy” model may be possible with the appropriate training and supports in place to encourage teacher attitude shifts and subsequently practice change.
By delivering care to children during their actual moments of struggle as part of a naturally occurring process in a child’s every day, “education as therapy” deviates from the traditional office-based therapeutic sessions in which activities are solely focused on examining thoughts, feelings, and coping skills in isolation. The findings from this study indicate that teachers accordingly may not grasp and apply knowledge in the same way or have similar attitude changes as lay counselors who are delivering care in office-like models. They in turn highlight a potential limitation of teacher-delivered care overall - whether teachers have the time and capacity to deliver traditional one-on-one care to children in need of mental health services in the same way in which non-teacher lay counselors have been shown to do. (6, 18) However, findings from this study indicate that an alternative form of care, “education as therapy”, may emerge from a teacher-delivered system of care that is in line with typical teacher duties while concurrently addressing students’ mental health needs. Whether this study’s findings are a precursor to an alternative, effective system of care warrants further investigation.
This study has a number of limitations. With a small sample size, the study results are exploratory and not conclusive; further studies with larger sample sizes may be able to more conclusively answer whether teacher knowledge and attitudes change under similar programming. Moreover, the teachers in this non-randomized pilot may have been highly motivated and thus may not be representative of the teacher population as a whole. Further, there may be a demand characteristic at play, where teachers may have subconsciously inflated the reported, qualitative degree to which the intervention has changed their cognitions and behaviors. It is possible that these findings may not occur across a broader population of teachers acting as lay counselors.
The lack of change in the quantitative measures of teacher knowledge and attitude may have been due to the intervention design and not a mismatch between survey questions and teacher experience. As a few teachers indicated the need for more time in training and the perceived utility of more frequent supervision sessions, teachers may actually be able to deliver office-like care with more professional support than provided during the study. It is also possible that the quantitative measures were assessing knowledge and attitude change expected at the level of a trainee in a mental health professional program that may have been more granular and advanced than what would be expected for a lay counselor with other significant job duties to achieve.