Positive intervention for depression and teacher–student relationship in Iranian high school girl students with moderate/mild depression: a pilot randomized controlled trial

Depression is one of the most common mental illnesses among high school students [24]. A study in Iran has shown that nearly 34% of high school students experience depression and 25% of male and 39% of female students have depressive symptoms [40]. Normal stress of adolescence has been commonly known to be the cause of depressive symptoms among high school students [21]. Its symptoms have been misdiagnosed for primary conduct and attentional problems and substance abuse or else seen as the youth’s going-through stage [48]. Suicide rates increased (37%) from 1999 through 2014 (from 1.9 to 2.6) for females aged 10–14 and an increased suicide risk has been reported to be induced by depression [14]. In addition to their enhanced suicide risks, depressed Iranian students are involved in higher risks of mental disorders, including conduct disorders and stress, sexual abuse as well as using alcohol or other drugs [18] and it is more probable that they engage in unsafe sexual intercourses or any other risk behaviors as compared to other students [59]. Moreover, such students may experience difficult relationships with their teachers. However, this problem has not been well understood [46].

Therefore, now researchers are trying to focus their attention on teacher–student relationship (TSR) development [7]. This diversely emerging field of study has theoretically included the positive and negative dimensions of emotional support and conflict followed by involvement and alienation in the definitions of students’ supportive and non-supportive relationships with their teachers, respectively [41]. TSR quality is one of the critical factors within the school environment that predicts high school students’ immediate and future outcomes including students’ academic achievement, affect, behavior, and motivation [28, 56, 57]. However, depressed students perceive their teachers as less supportive, and show more academic failure [20, 55]. It’s important to address TSR in treating adolescent depression, because evidence has shown that quality of interpersonal relationships can significantly predict depression [39] and interpersonal relationships plays a significant role to prevent and overcome adolescent depression [25].

The research in this field is indicative of the presence of less personal and more formal, evaluative, and competitive relations between teachers and high school students with depression [35]. So, these challenges can lead to undesirable self-evaluations and negative attitudes towards classroom learning [56] because the evaluative and non-personal natures of TSR qualities in high schools do not correspond to the depressed students’ communicative needs [45]. Hence, there is a need for some supportive and professionally appropriate interventions in hope of finding some ways to counteract some of the factors that may destroy the relationships between teachers and students and adversely affect the qualities of educations provided for students in turn [12]. Furthermore, even if TSR are causally associated with only a fraction of the student benefits they are correlated with, successful interventions for improve TSR and reducing depression symptoms would be a excellent boon to any high school [7].

Students’ depressive symptoms have been attempted to be relieved through various interventions, such as cognitive behavioral therapy, cognitive therapy based on self-help mindfulness treatment, qigong movement therapy, electroacupuncture, and regular exercise [6, 9, 16, 26, 34]. Nevertheless, these standard methods have been associated with a variety of challenges. Although most traditional therapies have been interesting for depressed people, they have aimed at improving personal deficits by focusing on only depressive symptoms [22]. Furthermore, these therapies exclusively stressing treatments of deficient thoughts and behaviors and some people may withdraw during their treatments. Most importantly, students’ mental health might be improved by only few interventions as their personal assets and strengths are appropriately targeted [11]. Therefore, their outcomes may merely include disappearing of only depressive symptoms, while little emphasis is placed on positive attributes. These symptoms have been seriously lagging behind amelioration of students’ positive emotions and relationships with their teachers, constructive behaviors, and social bonds in schools [32, 49].

Positive intervention (PI) was initially developed by Seligman, Rashid, & Parks, for depression as a target condition in need of intervention following the hypothesis that depression can be treated not only by effectively reducing its negative symptoms, but also by primarily and directly building positive emotions, feelings, character strengths, engagement, and meaningfulness in the involved patients [52]. PI is a modern, structured, and therapeutic approach broadly based on the principles of positive psychology [44]. It is intended to induce and maximize positive effects by minimizing them and enhance subjective well-being and happiness by elevating optimism and gratefulness [43]. Seligman [53] described the 3 elements of positive emotion, engagement, and meaning for ‘happiness’ as the ultimate goal of positive psychology. Positive emotions, including optimism, confidence, trust, hope, satisfaction, and pride, counteract negative and detrimental emotions in physiology [19]. Engagement is defined as construction of an engaged life via involvement and assimilation at leisure and work times, as well as in close relationships [13]. Meaning is related to pursuing a meaningful life by pertaining and serving anything greater than oneself when one is encouraged to use his/her talents and strengths of character [52]. PI seeks to alleviate them as the causes of depression by primarily and directly using students’ personal assets and strengths and building their positive emotions, engagements, and meanings instead of targeting only depressive symptoms, as well as, due to having a focus on the positive aspects of human experience [15, 51], PI was theorized to induce some positive changes in TSR in this research. Studies have shown that PI can promote interpersonal relationships, and communication skills in students [32]. One study revealed that positive Iranian-Islamic therapy had a greater impact on the reduction of depression of high school girl students with social anxiety compared to positive existential therapy [38]. According to the results of four recent meta-analyses [5, 8, 23, 54] PI dicreases depression symptoms. Nevertheless, the studies that entered the meta-analyses also highlighted one group that was not dealt with. Surprisingly, exploring the one meta-analyses revealed that only 3 out of the 74 studies focused on high school students with depression symptoms (i.e., used samples with a mean age under 18 years). In addition, it was found that these studies were RCTs with common control groups (untreated groups) and small effect sizes. Exploring the one of the studies that entered the meta-analyses showed that positive group psychotherapy helped improve self-esteem, interpersonal relationships, and communication skills in 33 students [32]. Exploring the mean age of the participants in the studies that entered the meta-analyses revealed that majority of them focused on older participants–frequently college students. Therefore, information on the applicability and efficiency of such interventions in samples aged 18 and younger is quite incomplete.

To date, no comprehensive studies have been done to assess the effect of PI training on TSR among high school students. In addition, we do not have enough data about the standard treatment protocol with PI for high school students in terms of TSR and depression symptoms and a pilot randomized controlled trial should be conducted to nominate PI for an improved TSR and reduced depression. Therefore, the effects of PI on depression and TSR of Iranian high school girl students with moderate/mild depression, was investigated using a pilot randomized controlled trial. So, we hypothesise that participants receiving the intervention will experience, compared to the control group, an improvement in depression symptoms and TSR.

This study followed the objective of determining PI efficacy in the depression and TSR of Iranian high school students with depression through IT-SR. The results revealed that PI was able to exert effective changes on IT-SR, i.e., increased communication and trust and decreased alienation in IT-SR after PI training (p < 0.05; Table 4).

The literature review showed that this study was the only investigation dealing with PI effects on communication, trust, and alienation among high school students. Notwithstanding, consistent with previous studies, there is a report that show positive group psychotherapy helped improve self-esteem, interpersonal relationships, and communication skills in 33 students [32]. The content of the program was partly similar with this PI. The contents include emotional expression, finding merits, self-disclosure and sharing memories about family members, one’s past, present and future [32]. Although, PI sessions does not directly address TSR and this is a positive side effect of the skills that were taught, but it seems that Lee measures communication skills and PI program, described in Table 1, would impact the teacher student relationship. Its confirmation will require further research.

Additionally, our results showed that the 8-week PI training significantly alleviated depression symptoms among high school students with depression, which is consistent with other studies [22, 50, 52]. A meta-analysis of school-based intervention programs targeted at reducing symptoms of posttraumatic stress disorder and depression suggest that intervention provided within the school setting can be effective in helping students following traumatic events and depression symptoms. Only 8 out of the 19 studies that entered the meta-analyses used art therapy, narrative therapy, cognitive–behavioral therapy, eye movement desensitization and reprocessing, and meditative & bioenergetics exercises [47]. The overall effect size for the 8 studies was d = 0.54, indicating a large effect in relation to reducing depression symptoms, which is consistent with our findings (d = 0.37).

Regarding results in pervious studies and obtained results in present research, it would be mention that PI effectiveness on depression appears to be associated with the mechanisms of change described by Lyubomirsky and Layous. These researchers suggested that positive psychotherapy interventions due to increased positive emotions, behaviors, thoughts, satisfaction, psychological needs such as autonomy, love and belonging and communication boost the people’s mood [37]. Further research is needed to prove any change mechanisms association with PI sessions though similar change processes can be hypothesized to have involved our study population.

In this study, the small to medium effect sizes obtained in the repeated measures MANOVA for the main effect of the through IT-SR, while large effect size was attained for depression through BDI-II measures. The average effect size was F²= 0.18, which is considered a medium effect size. Indeed, most of the effect sizes are smaller than that reported in meta-analysis results for PI [54]. In terms of clinically significance, it indicates a greater difference between the PI and control groups, yet the sample sizes in this research were smaller, which would lead to a lower statistical power in comparison with the study accomplished by Sin and Lyubomirsky [54].

In this investigation, we attempted to enhance TSR and decrease depression symptoms with 8-week PI program. As a result, PI efficacy in improving communication and trust and reducing alienation and depression among high school students with mild-moderate depressive symptoms was documented. Therefore, this intervention could function as an unspecific component of a stepped care approach for teenage girls suffering from depression. It’s hard to say whether there were other factors at play, so at this point this is promising information but not conclusive. There may be other issues not accounted for, such as school climate, selectivity of the sample, etc. Note that these interventions are not going to replace current treatment techniques for students, and they may serve supplementary purposes. As a pilot study, it is expected that our findings could help future research to design better PI for depression symptoms and TSR in high school.