The only way out is to revolutionize how we approach mental health care.

04/14/21 – BOSTON, MA: Chieh Li, associate professor in the School Psychology Program, poses for a portrait on April 14, 2021. Photo by Ruby Wallau/Northeastern University

English class started differently for ESL students at a public high school in Hawaii in the spring of 2019. Instead of launching into a PowerPoint presentation or instructing students to open their textbooks, the teacher pressed play on an audio track.

“Gently close your eyes,” said a voice from the speakers.

The daily five-minute-long meditations were part of a 10-week research experiment aimed at reducing stress and anxiety experienced by students.

“Enjoy the flow of the music for a few minutes. The music will relax your body and mind,” said the voice.

The study was guided by Chieh Li, an associate professor in the Department of Applied Psychology at Northeastern, and conducted on the island by her Ph.D. student Ned Kimble and the school psychologist. The researchers were particularly excited about this high school because its student population was so diverse — Native Hawaiian, Asian, Hispanic, Black and Native American. As the American classroom gets increasingly diverse, Li and her team want schools to have the tools to support each and every one of their students.

It’s just one of the handful of schools to see a piece of Li’s philosophy for mental health promotion come to life. Without acknowledging mental health issues and addressing them in the classroom, “we neglect to educate our students — from elementary to graduate school — as a whole person,” says Li.

The U.S. Centers for Disease Control and Prevention found that the percentage of students who feel persistent sadness or hopelessness has been rising for at least a decade, and researchers have found that levels of anxiety and depression in teens have been on the rise around the globe. Studies are increasingly finding that these issues are exacerbated by a dangerous concoction of social media, academic competitiveness and the wreckage left behind by the COVID-19 pandemic. To combat this, Li hopes to develop preventative interventions to address student mental health through two guiding principles: one, to meet students where they’re at, we ought to address it in the classroom, and two, in order to do it effectively, we need a culturally-sensitive approach. What works for a student from one culture may not work for another.

Traditionally, schools have focused only on academics, with mental health often as an afterthought — the National Center for Education Statistics found that 87% of public schools did not strongly agree that they could effective provide mental health services to all students, and the Pew Research Center found that, for half of schools, inadequate funding majorly limited what they could provide.

In 2007, the year of the first iPhone release, only about 20% of teens were using social media every day. Today, it’s 97%, with almost half saying they’re online “almost constantly.” The shift came faster than school policy could track — and the effects on teen mental health haven’t been small. An authoritative 2020 review on the subject found that extensive time spent on social media, constant messaging and addictive online behavior were all prominent risk factors for anxiety, depression and psychological stress.

As teens navigate virtually unfettered access to social media, they’re also struggling to survive in an academic environment that is getting increasingly competitive. While the number of teens applying to college has doubled between the 1970s and 2010s and has only continued to grow, both the number of colleges and their sizes have changed very little. High school students and their families say the increased competitiveness has increased their anxiety.

“We have more and more students from elementary school to graduate school having different kinds of stress problems, anxiety problems, depression and other kinds of difficulty … because of all kinds of unaddressed issues in school, society and family,” says Li.

If the stress of an increasingly digital and competitive world for young people was a crack in the foundation of the traditional education system, COVID-19 was the reality-shifting earthquake that brought it crashing down. And while coverage in the news has subsided, the education system never really recovered.

“It’s not just the students,” says Kimble. Teachers and staff are stressed, too, and “students can feel when their teachers are stressed like that.”

For Li, the only way out is to revolutionize how we approach mental health care — not just in the counselor’s office, but in our classrooms, too.

The study in Hawaii was just one of the early steps. Around 60% of the students found the meditations useful, helping them relax and stay more focused in class.

“I could talk with friends easier and feel less scared,” one student reported in the study.

While the rest of the students had mixed opinions about the meditation, they provided constructive feedback about what would’ve worked better for them.

“The high schoolers we worked with, a lot of the feedback we got was they were really interested in having it more customizable for them,” says Kimble. “I think that’s great. It really got me thinking about the next step, which is how do you then individualize this … so that students can kind of feel more of a sense of ownership.”

Li’s research team is developing a diverse toolset for addressing mental health in the classroom and creating community for an equally diverse range of students. She starts with cultural review to make hypotheses about what interventions might work for certain groups of students, then she puts them to the test.

In addition to meditation practices for ESL kids, Li — along with a diverse set of faculty and student collaborators — has studied the applicability of mindfulness for Muslim Americans, the effectiveness of cognitive-behavioral therapy for Asian American patients, multicultural school counseling for Black and immigrant students, home-school partnerships with Hmong families and social-emotional learning programs for schools in Pakistan. Now, in a new project funded by the National Institutes of Health, her lab is developing targeted support for Asian American students at risk for severe depression and suicide as victims of increased violence since the COVID-19 pandemic.

Li envisions a three-tier approach to mental health. The first level focuses on the school’s whole community, providing daily mental health practices to the classroom. The second level helps students who need extra support, through school counseling, support groups and self-help technology such as phone apps. The third level is for the most extreme and acute needs: targeted and immediate care through psychologists, mental health facilities and emergency responders, and around-the-clock treatment for students with severe mental health issues.

In an environment with unprecedented stressors on students, Li thinks the second tier is only a skeleton of what it ought to be, and the first is barely even a ghost. It means some students never receive help, and many only do once their mental health situation has gotten so dire that they end up falling straight into emergency care.

Kimble resonates with Li’s philosophy. During one of his first meetings with Li, he shared a Chinese parable that encapsulated these ideas for him: “Those who take medicine and neglect diet, waste the skills of the physician.” “Diet” represents the other systems that inform mental health, like community.

“We don’t just happen to be in this high school together where fate dropped us,” says Kimble of his time in Hawaii. “We’re here for each other.”

To bring basic and accessible mental health support to individuals (tier one and tier two), Li is using teens’ free access to the internet to her advantage. In a 2023 study, she partnered with Lixia Cui — a professor at Capital Normal University in Beijing and a former visiting scholar at Northeastern — and Cui’s graduate students to test a smartphone app students might use to practice therapeutic techniques. It would be a supplement or an alternative to traditional forms of therapy, which can at times be difficult to access — especially in a culture with significant stigma around therapy, like in China.

The app uses an up-and-coming form of therapy called cognitive bias modification, which presents patients with difficult social situations and trains them to have more realistic interpretations of them, instead of defaulting to negative assumptions.

In another 2023 study, Li and Cui explored ways to improve the effectiveness of the treatment for anxiety. Instead of presenting text descriptions of situations, they used an approach that encouraged participants to visualize the situations and incorporate their own memories for a more visceral experience. With this modification, participants were more likely to interpret an ambiguous situation as positive than the control group, and less likely to interpret the situation as negative.

Li’s choice to conduct her research both in the U.S. and China — for the cognitive bias studies and beyond — was not arbitrary. The two countries create a unique dichotomy that highlights how cultural and political differences change the needs of students and the commonalities despite those differences.

“The major thing that I’m addressing that energizes me is working with our international community, not just within the United States,” says Li. “We are not alone in having this challenge.”

In China, the collectivist culture leads students to have a stronger sense of community, whereas in the U.S., students tend to have more self-confidence. As Li explains in a 2016 study, both of these traits are important for resilient mental health, but the cultural differences mean that while helping U.S. students build up community support may be effective, in China, strengthening self-confidence may be more effective. Yet in both countries, economic and urban-rural divides share commonalities, Li says. Wealthy American and urban Chinese students tend to feel more acute stress about performance, while poorer American and rural Chinese kids often feel stress about their overall safety and security.

For Li, it’s a powerfully insightful lens that informs the mental health support approach for each, and it provides teachers and mental health providers with a diverse toolset that allows them to take care of each and every student in classrooms that are becoming increasingly diverse.

“We’ve seen that we need to do things [in a] culturally and developmentally sensitive way,” says Li.

As the American classroom continues to get more and more diverse, COVID-19 suddenly revealed some of the tensions that had grown between students’ unaddressed differences. Hate toward Asian Americans is rising faster than any other marginalized group, and out of the thousands of hate crimes reported to Stop Asian Hate, almost one in 10 have targeted youth between the ages of 12 and 17.

Li is taking action. With new funding from the NIH, she’s using the tools she’s developed over the past two decades and her intimate knowledge of the differences and interactions between American and Chinese cultures to create a framework of support for these marginalized students.

Working with software developers, Li is developing yet another app — this time targeting the most vulnerable. In a time of extreme need, creating apps allows Li’s team to ride the upward trend of internet use instead of attempting to change the classroom culture all at once.

“I’m excited, and I’m energized … by the potential to help more people,” says Li. “I know my students are energized, and my collaborators, too.”

Story from the Science Media Lab.

Last Updated on May 14, 2024