A qualitative study exploring adolescents’ experiences with a school-based mental health program

The students’ experiences with the school-based mental health program DISA are presented
below and illustrated by quotations from different focus group interviews. The results
are presented in three categories: (A) intrapersonal strategies, (B) interpersonal
awareness, and (C) structural constraints (see Table 3). Each category includes two to four subcategories. Most adolescents perceived the
need for a course such as DISA, and they believed that the age of 14 or 15 was a good
age for such a course because adolescents feel substantial pressure at this age and
are old enough to understand the message of the course. The results revealed the adolescents
faced many challenging demands and that a course such as DISA made it easier for them
to meet these demands, such as challenges related to their appearance, dress and performance.
The most important part of the program seemed to be the conversations. Good conversations
were characterized by trust and concerned deep matters, but laughter and humor were
still present.

Table 3. Categories and subcategories

Intrapersonal strategies

This category describes the intrapersonal strategies that students learned in the
course. The subcategories identified were directed thinking, improved self-confidence,
stress management, and positive activities. Most adolescents described a need for
a course such as DISA at school, and the majority claimed that the course had provided
them with beneficial strategies on an individual level.

Directed thinking

The subcategory of directed thinking describes how the course helped the students
to think more positively. According to the students, they learned to identify negative
thoughts and turn them into positive thoughts and to try to think positively after
having negative thoughts. This new ability made them feel happier and more alert:
“You think more positively and so…changing negative thoughts into positive thoughts.
One feels happier, more positive…more alert” (male, focus group 8). The students gave the example that if they felt too bored
to attend school, they could think of the pleasant experience of meeting their friends
and then feel better. Viewing things in a new light was highlighted as significant.
However, the students also stated that identifying negative thoughts made them feel
negative during the class. The link among thoughts, feelings, and behavior was mentioned.
The students mentioned the possibility of influencing one’s thoughts and emotions
with one’s choice of actions. The students indicated that they practice this on a
daily basis now because of their training through talking and course exercises:

It’s probably the conversations [that have a preventive effect]

But there are some good exercises too, which are good, about the triangle [the link
between thoughts, feelings and behavior], for example, which was good…

It is preventive for the future, and you think of it anyway (females, focus group 4)

Improved self-confidence

Improved self-confidence was another frequently mentioned aspect: “I actually learned a lot from it, self-confidence, empathy, and such things” (male, focus group 10). The effect of being satisfied with oneself and not attempting
to be someone else was highlighted. One participant expressed her feelings as follows:
“I feel much more confident in myself. You are good as you are. You don’t need to
be someone else” (female, focus group 1). In an experience emphasized as a positive experience in
several groups, the group members had to write positive comments about one another.
Knowing what the other students in the group liked about themselves was perceived
as a significant component:

We had to write what we thought about each other in the group

It was fun, and then you should say it yourself, kind of “I am…”

It felt a little egocentric

But it was good

You seldom compliment yourself

Often girls receive more negative comments than kind ones (females, group 4)

The role of the tutor was also regarded as an important and positive factor. One participant
summarized this view as follows: “[The tutor] has picked up, sort of, things that we are good at, sort of tried to
strengthen our self-confidence” (female, focus group 12).

Stress management

The stress management subcategory describes how the students were able to manage stress
and consider difficult situations in new and different ways after the course. The
students also expressed that they could use what they had learned in future stressful
events. According to the students, the insight that thoughts, emotions, and behavior
are linked together enabled them to change their behavior to create less stressful
conditions: “Thoughts, actions and feelings are linked together.… If you change your behavior,
then your emotion might change automatically and then your thoughts” (female, focus group 4). Students involved in sports mentioned that techniques for
coping with situations that were not going as expected (e.g., avoiding the event,
changing the event, or changing the way they reacted to the event) were good to use
in sports. The students also stated that they used the DISA techniques before stressful
exams. By telling themselves that they would perform well on the exam, they were able
to manage such situations better.

The students appreciated the course for helping them to think before talking or acting
and to think of the consequences of their words and actions. One participant summarized
this view as follows: “Thinking before doing something and not just acting before you have thought about
it” (male, focus group 11). The students also stated that the course helped them to manage
their anger and reduce violence, as illustrated by the following discussion:

It was useful for me. I can get angry sometimes.

Me too.

Before, I didn’t think before I acted…for example, I fought a lot before (males, focus group 10)

Positive activities

The adolescents described how the DISA course helped them to focus more on things
that they truly enjoyed and to choose positive activities that were good for them.
They learned what was good for them and what made them happy and found that they wanted
to do more of these activities: to feel good, they had to engage in activities that
that they enjoyed. Examples of activities that they had begun to participate in or
to spend more time doing differed among individuals, but listening to music, relaxing,
writing, and breathing calmly were frequently mentioned: “I love to write, and I have started to write more since the program” (female, focus group 2). Other students claimed that they learned of the benefits
of being physically active; even if they did not want to be active, they could still
try to be active because they knew that such activity is good for them: “I do sort of the same thing as before, but I am outdoors more often, going out with
the dog” (female, focus group 1). Being more socially engaged with their families and neighbors
was also mentioned. One exercise that they appreciated was listing what they liked
to do and examples of things that would make them feel better, such as taking a bath,
walking, or reading a book. Making such a list was experienced as a nice and comforting
activity, counterbalancing the parts of the course that focused more on negative matters.

Interpersonal awareness

The second category describes interpersonal awareness, implying a group-level impact
during and after the course. The subcategories identified were trusting the group
and considering others. Most of the adolescents referred to positive experiences on
an interpersonal level.

Trusting the group

The subcategory of trusting the group describes experiences of increased group cohesion
during and after the course. By openly speaking about their problems, the students
learned that they were not alone in having negative thoughts and doubts about themselves,
and this discussion made it easier for them to manage their negative thoughts and
doubts. The group became closer through their discussions with one another: “And you have become closer to your classmates” (male, focus group 11). In one focus group, students mentioned that before the course,
they had different friendship groups, whereas after the course, they could spend time
with anyone in the group:

Before, we were split into three groups of friends, but now there is better group
cohesion, just like the boys. Everyone can be with everyone.

We have come a little bit closer to each other than we were before the course (females, focus group 1)

Another good experience from the course that improved trust in the group was the exercise
in which the participants had to write down something positive about the others in
the group. The students appreciated becoming acquainted with new friends in the course:
“It has been good; you learn to know more people, and I’ve found it cozy” (female, focus group 7). The students liked when the tutors arranged the class to
ensure that they would sit beside someone with whom they did not often speak outside
of class. The students thus became acquainted in different ways and could see one
another from new perspectives. For example, a student might have thought that someone
was tough and cool but subsequently realized that he or she was actually a kind person.
The communication exercises in the program contributed to this realization. In one
course activity, the students each brought something that symbolized something important
to them and shared it with the others in the group. They appreciated the ability to
share something important with their classmates and to learn new things about one
another.

Most students reported that it was good for the groups to be separated by sex. Both
girls and boys claimed that they were able to speak more freely because of this separation.
However, they did not think the gender of the tutor was relevant; rather, the tutors’
personality was the most important factor. Both boys and girls stated that the group
was calmer when the sexes were separated. Although they felt that it was beneficial
to mix boys and girls in other subjects, they thought that the separation was good
in a course such as DISA that involves discussing emotions.

Considering others

The subcategory of considering others describes the knowledge gained from the course
related to awareness of the emotions and behavior of other people. The students thought
that their level of empathy improved because they learned how other people live. The
students claimed that they learned to be more tolerant and considerate as a result
of this insight: “And you learn how to tolerate” (male, focus group 11). The students also received tools to help other people, as
illustrated in the following discussion:

I would have said to [my little sister] anyway to take the course because I feel that
I understand other people much better now. Because you get to learn about how others
have it.

You have more consideration; you sort of get insight.

Yes, you also learn how to help that other person (females, focus group 3)

Students who were active in sports claimed that they learned to think more about how
to behave with one another and that all players on a team are equally important. In
one course exercise involving active listening, one student speaks while the other
students alternate between being disinterested and being alert. The students stated
that they learned a great deal about how much the listener influences the speaker.
They learned how frustrating it is to be ignored. One lesson from this exercise involved
looking people in the eyes and not speaking only about oneself. Another example of
changed behavior was beginning to speak more to the grocery store cashier rather than
using their mobile phones, as they realized that this person needed to be respected:
“I have started to talk more with the cashiers at the grocery store and not using
my mobile while shopping because you really meet another human being there, a cashier” (female, focus group 3).

Constraining structures

The third category describes the constraining structures. The subcategories identified
were negative framing and emphasis on performance. The students articulated the desire
for a more positive and health-promoting focus as well as more time for discussions
rather than written course assignments.

Negative framing

The subcategory of negative framing describes a frequently mentioned complaint regarding
the major focus on negative thoughts in the course. The students described the manual
as focusing on problems rather than opportunities. The students found it difficult
to identify their negative thoughts and then to hold onto them and count them. They
said that their thoughts were originally positive, but they felt as if they were forced
to bring forward negative thoughts and feelings of sorrow. Small problems became larger
than they should have been. The students stated that they felt more stress when they
had to think of such matters. At schools where the course was offered to girls only,
some girls interpreted this framing as the school expecting girls to have problems:
“Yes, there is [a need for a course like DISA], but it is strange that it takes for
granted that girls need it but not the boys.…It is taken for granted that girls will
feel bad” (female, focus group 3). The students articulated the desire for a more positive
focus. They stated that a course focused more on joy would enable them to better grasp
the serious content. Rather than focusing on how to eliminate negative thoughts, they
believed that it would be better for the course to focus on how to find and retain
positive thoughts: “Partly it helped. But I think that it would have worked better if instead of focusing
on how to get rid of the negative thoughts, you had focused more on how to get positive
thoughts. In that case, you might have been a little bit happier, and then it would
have worked better” (female, focus group 6). Some students even reported that they felt worse while attending
the course, but only until the session ended. When they left the classroom and met
their friends, the students felt normal again, but during the course, they found themselves
feeling unhappy or depressed for a while. They reported that they came to the course
feeling positive and happy, but they began to feel unhappy when being asked to search
for their negative thoughts and feelings during the course.

Emphasis on performance

The subcategory of emphasis on performance indicates a desire for more discussions
rather than the large amount of writing that needed to be completed during every session:
“[I wished] it was deeper, not just sitting and filling out paperwork” (female, focus group 9). The students considered the discussions (not the writing
assignments) to be the crucial part of the course. According to the students, learning
to know themselves was best accomplished by talking, not by writing. They indicated
that the writing assignments were overly superficial; it was during the conversations
that depth emerged, as illustrated in the conversation below:

The bad thing was that you sort of wrote the same thing every week.

You actually don’t need to write. I think that we are here to learn to know oneself,
yes, talking, not writing. You get bored and you can’t concentrate (males, focus group 11)

The students suggested that another method of addressing serious matters could involve
more practical exercises and games where they could move around and perhaps engage
in role-playing. Some students wanted to work more on what the group needed rather
than working on what the manual focused on for a certain session. The students wanted
to work with issues that were important to them rather than the issues specified in
the manual. However, some students found the manual to be a good support for the tutors.
One student noted that class discussions outside of DISA could be less focused and,
therefore, less meaningful: “It would not have been good [without the manual] because first we would talk a lot,
and then we would not have anything to say, and then we would have started to talk
about something else” (female, focus group 4). However, some students stated that the manual did not target
their age group. They found the exercises to be irrelevant and artificial and not
related to youths their own age: “I think some of the issues in the course were not related to us.…It would have been
better if it had been related to girls our age” (female, focus group 5).