Article

Teaching of Psychology
1-7
Effects of a Risk and Resilience Course ª The Author(s) 2016
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on Stress, Coping Skills, and Cognitive DOI: 10.1177/0098628316649457
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Strategies in College Students

Jess P. Shatkin, MD, MPH1, Ursula Diamond, MA1,

Yihong Zhao, PhD1, John DiMeglio, BA1,
Michaela Chodaczek, BA1, and Jean-Marie Bruzzese, PhD1

Abstract
This study tested the impact of the skills-building component of a two-semester risk and resilience (R&R) course on the stress, coping
skills, and cognitive style of 36 undergraduates compared to 62 students enrolled in a child and adolescent psychopathology course. In the
fall, students learned about risk taking and decision-making as well as coping skills and positive cognitive styles. In the spring, students taught
these skills to ninth graders. Upon completion of the fall semester, R&R students reported improvements in stress, coping, and dys-
functional attitudes. Although maintained, these gains did not increase after the spring semester. We conclude that the course, particularly
the fall semester, is an effective, practical classroom intervention for reducing stress and improving resilience in undergraduates.

Keywords
risk, resilience, stress, coping, college students

Emerging adulthood is the developmental period in which indi-
viduals in industrialized countries, aged 18 to 25, are likely to
be exploring their identity, undergoing transitions, focusing on
the self, and feeling a sense of both possibility and instability
(Arnett, 2000, 2005; Sussman & Arnett, 2014). Being between
adolescence and young adulthood, emerging adults have
achieved some independence from their parents, but they
have not taken on the full responsibilities of adulthood.
Concomitant with this sense of ambiguity is an increased
vulnerability to stress, which is particularly pertinent to col-
lege students who face a myriad of academic, social, emo-
tional, and financial stressors (Aselton, 2012; Brougham,
Zail, Mendoza, & Miller, 2009; DeRosier, Frank, Schwartz,
& Leary, 2013). Additionally, many college students report
experiencing above-average stress levels that affect their
academic performance (American College Health Associa-
tion, 2013). College stress is associated with maladaptive
behavioral, social, and health changes (DeRosier et al.,
2013), including suboptimal sleep quality (DeRosier et al.,
2013; Lund, Reider, Whiting, & Prichard, 2010), increased
depression (Aselton, 2012; Bayram & Bilgel, 2008),
decreased self-esteem (Dixon & Kurpius, 2008; Hudd
et al., 2000), physical illness (DeRosier et al., 2013;
Edwards, Hershberger, Russell, & Markert, 2001), reduced
exercise (Hudd et al., 2000), increased substance use
(DeRosier et al., 2013), increased consumption of soda and
junk food (Hudd et al., 2000), and attendance at fewer
social events or prayer or spiritual services (DeRosier
et al., 2013).
Paradoxically, emerging adulthood offers a unique opportu-
nity to intervene and build resilience. Planfulness, autonomy,
adult support, and the development of coping skills have been
shown to predict the development of resilience during emer-
ging adulthood (Masten et al., 2004). Moreover, the nature of
the college environment—namely, learning and developing
self-responsibility—further enhances the opportunity to teach
stress reduction and build resilience in college students (Con-
ley, Travers, & Bryant, 2013). However, college student mental
health services often do not meet students’ needs (Hyun,
Quinn, Madon, & Lustig, 2006) and are underutilized (Conley,
Travers, & Bryant, 2013; Eisenberg, Golberstein, & Gollust,
2007). Although most college campuses provide a variety of
mental health services and support, untreated mental disorders
are the norm in undergraduate student populations (Hunt &
Eisenberg, 2010). Only one third of college students with a
past-year diagnosis of a mood disorder, 16% with a past-year
diagnosis of an anxiety disorder, and 5% with a past-year diag-
nosis of an alcohol or drug disorder seek mental health services
on campus (Hunt & Eisenberg, 2010). Negative attitudes and
beliefs, such as stigma, a lack of perceived need, and social
1
Child and Adolescent Psychiatry, New York University School of Medicine,
New York, NY, USA
Corresponding Author:
Jean-Marie Bruzzese, Columbia University School of Nursing, 630 West 168th
Street, Mailcode 6, New York, NY 10032, USA.
Email: jb3958@cumc.columbia.edu

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2 Teaching of Psychology
context, are significant barriers to college students seeking help
(Eisenberg, Hunt, & Speer, 2012).
This Study
We developed a two-semester-long college course—risk and
resilience (R&R) in urban teens—that focuses on mental health
promotion, stress reduction, and resilience. The first semester is
didactic in nature, during which students learn about theories,
concepts, and evidence-based techniques to reduce stress and
improve resilience; the second semester is a service-learning
course, where the college students teach stress reduction and
coping skills to high school students. This study set out to
evaluate the impact of the skills-building aspect of the course
on college students’ stress and resilience. Comparing R&R
students to a control group, we hypothesized that, after one
semester, R&R students would demonstrate greater reduction
in stress and improvement in coping skills (e.g., increased cog-
nitive behavioral techniques [CBTs] and reduced negative
thinking). After two semesters, we expected that R&R students
would report greater additional improvement in stress, coping,
and cognitive style.
Method
Participants
We enrolled 98 students in the study, 36 from one section of
R&R and 62 control students enrolled from one section of child
and adolescent psychopathology. The two groups were similar
in terms of demographics, except for age where the R&R stu-
dents (M ¼ 21.23, SD ¼ 1.32) were slightly older than controls
(M ¼ 20.42, SD ¼ 1.04), t(223) ¼ –5.24, p < .001. The majority
were women (89.80%). Students self-identified as White or
Caucasian (50.00%), Hispanic or Latino (20.35%), Asian
(19.91%), Black (3.54%), and other (6.20%). Participants were
seniors (38.78%), juniors (29.59%), sophomores (26.53%), and
freshmen (5.10%).
Procedure
R&R course. R&R is a two-semester course taught over 1 school
year. During the fall semester, in addition to learning about
principles of effective public health programs and disease pre-
vention models, theories of behavior change, and theories of
adolescent risk-taking behavior and decision-making, students
also learned key skills in two areas associated with increased
resilience: positive coping strategies (DeRosier et al., 2013)
and positive cognitive styles (Maier & Seligman, 1976). Stu-
dents also learned about the core models of CBTs (Beck, 1971;
Ellis, 1970), the most common cognitive distortions (Burns,
1989), and the techniques to overcome cognitive distortions.
We structured the spring semester as a service-learning
course because research has shown that college students who
participate in service learning, as opposed to classroom lec-
tures, have greater opportunity to apply what they have learned
and to experience greater improvements in personal
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development (Schmidt, Marks, & Derrico, 2004). The students
delivered a manualized curriculum to teach a subset of the
techniques to ninth-grade students at one public high school
in New York City. The college course instructors trained the
college students on how to teach the class and provided weekly
supervision, including individualized feedback based on their
observations of the college students delivering the curriculum
to the high school students. A high schoolteacher was also
present in each classroom.
Psychopathology course. We chose child and adolescent psycho-
pathology as our control course because it controlled for the
potential impact of the instructor’s teaching style in that the
first author taught both courses. Also, both are offered as part of
the same undergraduate minor; thus, we controlled for the
potential impact of the type of student taking both courses. The
one-semester course uses lecture and discussion to engage stu-
dents in a critical review of common child and adolescent
psychopathology and to challenge social and cultural assump-
tions of what constitutes ‘‘normal’’ versus ‘‘pathological’’
behavior, cognition, and emotion. It includes a practicum com-
ponent where each student observes the clinical evaluation of a
pediatric patient. See Appendix for more details on both
courses.
Survey completion. Students who provided informed consent
completed the Time 1 survey at the onset of the fall semester,
the Time 2 survey just prior to the start of the spring semester,
and the Time 3 survey at the end of the spring semester; they
completed all surveys online. We compensated all students
US$15 for each survey they completed. The institutional
review board of the New York University School of Medicine
approved all study procedures.
Outcome Measures
We assessed stress using the Perceived Stress Scale (Cohen,
Kamarck, & Mermelstein, 1983). Participants indicated on a 5-
point Likert-type scale, from 0 (never) to 4 (very often),
how often they felt or thought a certain way over the past
month (Cronbach’s a ¼ .85); higher scores indicated more
perceived stress. Sample items included feeling unable to
control the important things in your life and feeling nervous
or ‘‘stressed out.’’
Students completed the Brief COPE Scale (Carver, 1997),
which assessed what they generally do and feel when experi-
encing stressful events. Students indicated on a 4-point Likert-
type scale, from 1 (I haven’t been doing this at all) to 4 (I’ve
been doing this a lot), the extent to which they do 28 things,
including using alcohol or other drugs to feel better and taking
action to try to make the situation better. Higher scores indi-
cated better coping. Cronbach’s a for this sample was .79.
We assessed dysfunctional attitudes using the Dysfunctional
Attitudes Scale (Form A) Revised (de Graaf, Roelofs, & Hui-
bers, 2009), a 17-item scale that measured the presence and
intensity of dysfunctional attitudes, such as performance
Shatkin et al. 3

evaluation, need for approval, and perfectionism. Participants Table 1. Distribution of Outcome Variables by Treatment Group and
indicated on a 7-point Likert-type scale, from 1 (totally agree) Time.
to 7 (totally disagree), the extent to which they agree or dis- Risk and resilience, Psychopathology,
agree with each statement as it pertains to them. Sample items LSM (SE) LSM (SE)
included ‘‘if I fail at my work, then I am a failure as a person’’
and ‘‘my value as a person depends greatly on what others think Perceived stress
of me.’’ Higher scores indicated more dysfunctional attitudes Baseline 27.11 (1.62) 25.83 (1.27)
End of fall 22.67 (1.75) 26.23 (1.35)
(Cronbach’s a ¼ .90).
End of spring 22.62 (1.96) 26.86 (1.44)
We wrote six questions to assess the use of CBT skills Coping skills
taught in class. Using a scale from 1 (never) to 4 (always), Baseline 77.94 (2.08) 78.55 (1.63)
students reported the frequency with which they used each of End of fall 82.05 (2.25) 78.07 (1.73)
six techniques in the past month: (a) identify irrational End of spring 83.73 (2.51) 76.74 (1.84)
thoughts; (b) triple column technique, a three-step process to Dysfunctional attitude
identify the automatic thought, find any cognitive distortions, Baseline 59.20 (3.48) 55.59 (2.73)
End of fall 48.28 (3.74) 56.79 (2.88)
and determine a more rational response; (c) challenging auto-
End of spring 48.11 (4.15) 60.81 (3.04)
matic thoughts by finding evidence that might support or dis- CBTs
prove the initial conclusion; (d) challenging the ‘‘should,’’ Baseline 2.36 (0.12) 2.37 (0.09)
identifying any self-imposed standards that may be impossible End of fall 2.59 (0.13) 2.46 (0.10)
to achieve; (e) positive thinking, writing affirmation state- End of spring 2.68 (0.15) 2.43 (0.11)
ments; and (f) opposite-action technique, a three-step process
Note. LSM ¼ least square mean; SE ¼ standard error; CBTs ¼ cognitive
to identify one’s current emotion, decide whether the emotion behavioral techniques.
is uncomfortable, and if so, to act in the opposite way of one’s
usual behavioral response. We computed the mean score across
these items; higher scores indicated greater use of the tech- is 0.20, a ‘‘medium’’ effect size is 0.50, and a ‘‘large’’ effect
niques. Cronbach’s a for this sample was .78. size is 0.80 (Cohen, 1988). We conducted analyses using SAS
software Version 9.3.

Statistical Analyses
We used two independent sample t tests to assess group differ-
ences with respect to demographic variables and baseline out-
come measures between study subjects in the intervention
group and those in the control group as well as between parti-
cipants who dropped from the study and those who did not. We
used linear mixed models with a random intercept to assess the
associations between the group assignment and the outcome
measures. We modeled the outcome variables as functions of
treatment group, time, and their interaction, controlling for age,
gender, and race. We included these covariates because each
has been found to be associated with stress and coping (Asel-
ton, 2012; Brougham et al., 2009; Pedersen, 2012; Turner &
Avison, 2003; Utsey, Chae, Brown, & Kelly, 2002) and have
the potential to impact study results. We tested whether the
change over time in intervention students is significantly dif-
ferent from that of control students. More specifically, we
tested (a) whether the changes in the outcomes from Time 1
to Time 2 differ between the intervention and control groups
and (b) whether the changes in the outcomes from Time 2 to
Time 3 differ between the groups.
We used two-sided hypothesis testing and set statistical sig-
nificance at level a ¼ .05. We reported p values without adjust-
ing for multiple testing because the reported results pertained to
prespecified hypotheses and tests. Effect sizes for significant
group differences were calculated using Hedges’s g, which is
an unbiased version of Cohen’s d, that corrects for possible
biases due to small samples (Hedges, 1981). Hedges’s g is
interpreted using Cohen’s d rules where a ‘‘small’’ effect size
Results
Comparison of Those Who Completed the Study to
Those Who Did Not
Over the year, 44 students dropped from the study (16 inter-
vention and 28 control students). Among the 36 R&R students,
15 dropped the course after one semester; 1 who completed the
full-year course failed to complete the Time 3 assessment.
R&R students who dropped the course informed the instructors
that scheduling conflicts precluded them from teaching and that
it was not due to disliking the course. The course was very well
received by students as indicated by their blinded fall course
evaluations conducted by the university. Overall, they rated the
course a 4.78 out of a possible 5. They indicated the course was
interesting (M ¼ 4.78), met their own expectations (M ¼ 4.67),
and that the course objectives were achieved (M ¼ 4.78); 100%
would recommend the course to a friend. Those who dropped
from the study did not differ significantly on demographic
factors, intervention status, or baseline values of outcome
measures.
Impact of the R&R Course
Table 1 shows the adjusted distribution of outcomes by treat-
ment group and time. There were significant Treatment Group
 Time interactions for perceived stress, coping, and dysfunc-
tional attitudes. Upon completion of the fall course, relative to
control students, R&R students had significantly more
improvement in perceived stress, F(2, 121) ¼ 6.52, p ¼ .002

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4 Teaching of Psychology
(16.38% reduction vs. 1.56% increase, Effect Size (ES) ¼
0.74); use of coping skills, F(2, 120) ¼ 5.83, p ¼ .004
(5.28% improvement vs. 0.6% worsening, ES ¼ 0.50); and
dysfunctional attitudes, F(2, 120) ¼ 12.64, p < .001 (18.45%
reduction vs. 2.15% increase, ES ¼ 0.79). There were no sig-
nificant improvements in the frequency of use of CBTs, F(2,
120) ¼ 2.14, p ¼ .123, among R&R students.
Relative to controls, R&R students did not demonstrate sig-
nificant improvement from the end of the fall semester to the
end of the spring semester (i.e., from Time 2 to Time 3).
Discussion
We tested the impact of the skills-building aspect of a two-
semester course—R&R in urban teens—in reducing stress,
improving coping skills, and reducing negative thinking in
college students. Results partially supported our hypotheses.
Consistent with prior research (Brown & Schiraldi, 2004; Con-
ley, Travers, & Bryant, 2013) and relative to controls, R&R
students reported improvements in coping with stress and
improvements in their mental health. Specifically, they
reported less perceived stress, better coping skills, and a reduc-
tion in dysfunctional attitudes. The effect sizes were considered
medium to large (Cohen, 1988), which is deemed a substan-
tially important effect (Institute of Education Sciences, 2013).
Unexpectedly, R&R students did not report using CBTs more
than controls. Students may need to exert a more conscious
effort to utilize the CBTs, with instructors giving greater
encouragement to practice the techniques outside the class-
room. Alternatively, role-playing, modeling, and reflective
practice, techniques found to enhance the learning of CB skills
(Bennett-Levy, McManus, Westling, & Fennell, 2009) might
have benefitted the R&R students. However, this was beyond
the scope of the course. Use of a nonvalidated measure of CBTs
might also have contributed to the nonsignificant finding.
We did not find ongoing improvements after the spring
semester—contrary to our second hypothesis. However, stu-
dents did maintain the positive intervention effects over the
second semester. Given that control students showed slight
declines from the end of the fall, it is plausible that the spring
R&R course helped to maintain the intervention effects, and
without it, the effects may have diminished. A one-semester
didactic course may have been sufficient for students to under-
stand, learn, and apply the new skills. The second semester
service-learning course offered students the opportunity to fur-
ther apply these skills, which in turn may have boosted reten-
tion and continued use of the skills. This interpretation is
further supported by the fact that the R&R students may have
experienced added stress related to the spring semester. The
two authors (Jess Shatkin & Ursula Diamond) who evaluated
students’ papers noted that many of the students felt anxious
about teaching. Additionally, seniors comprised nearly 40% of
the sample, with a slightly higher percentage in the R&R class.
Graduating seniors are more likely to experience heightened
stress as they approach the transition from college to the work-
force or to graduate school. Therefore, the added stress of
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teaching or the additional stress reported by the disproportional
number of graduating seniors may have precluded further
growth. However, the potential benefits of teaching high school
students may have contributed to the maintenance of the inter-
vention effects over the year. This warrants further investiga-
tion in future research.
Another possible explanation is that the spring course had
no effect. A service-learning component may not have added
value when instructors use active learning components for skill
development, as was done in the fall. In fact, given the chal-
lenges associated with having students make a two-semester
course commitment, we recommend a single-semester course
as more beneficial in terms of enrollment.
Three units of the fall semester course appear to have been
particularly helpful in contributing to the positive outcomes: (a)
resilience, (b) CBTs, and (c) stress response. These units are
well suited for adoption by other psychology courses or could
be used in shortened version of the course. Identifying and
encouraging personal strengths, emphasizing the triumvirate
of good health (e.g., exercise, sleep hygiene, and good nutri-
tion), and a focus on salient aspects of positive psychology,
such as gratitude, can be employed to foster resilience in stu-
dents. To integrate the CBT unit, instructors can teach students
about the cognitive triangle and the activating event–beliefs–
consequences model, the most typical cognitive distortions,
key techniques used in CBTs, and how to counter procrastina-
tion and perfectionism. Instructors can also teach students com-
ponents of our stress-response unit where they learn about
physiological stress responses, how to identify stressors, and
techniques for coping with stressful situations.
Insofar as limitations, we lacked a group of students who
only took the fall R&R course, our control group was a one-
semester convenience sample without a service-learning com-
ponent, and we tested the intervention using only self-report
measures in an urban setting. Future research might explore
other forms of service learning in nonurban settings, with
more objective assessments, multiple informants, and mea-
sures of content knowledge. Additionally, future research
might track students’ stress and resilience throughout their
academic career.
Although several questions remain for future research, our
findings may have important implications for improving the
mental health of college students. As an in-class delivered
intervention, the course offers advantages over small-group
interventions (Conley, Durlak, & Dickson, 2013). This format
may be more successful than a small-group intervention
because students are already familiar with learning new content
in this environment. They may also bring more effort and
motivation to the course because an instructor, who will eval-
uate them, facilitates the intervention. Additionally, because
this intervention is a course, it is both potentially less vulner-
able to attrition and more transferable and generalizable to
other groups of college students and campuses (Conley, Tra-
vers, & Bryant, 2013). As such, the course has the potential to
reach more students than small groups. Therefore, we recom-
mend other higher education institutions consider imbuing
Shatkin et al.
skills-based training into their arts and sciences curriculum and
consider adopting a similar resilience-building course.
Appendix
Detailed Description of the Intervention and Control
Courses
Both the risk and resilience (R&R) course and the psycho-
pathology course are part of the Child and Adolescent Mental
Health Studies (CAMS) undergraduate academic program
offered through the College of Arts and Sciences at New York
University (NYU) in conjunction with the Department of Child
and Adolescent Psychiatry at the NYU School of Medicine
(Shatkin & Koplewicz, 2008; Shatkin & Diamond, 2015).
R&R course. This two-semester course is taught over 1 school
year. During the fall semester, students met twice per week for
a total of 150 min. In addition to learning about principles of
effective public health programs and disease prevention mod-
els, theories of behavior change, and theories of adolescent
risk-taking behavior and decision-making, students also
learned key skills in two areas associated with increased resi-
lience: positive coping strategies (DeRosier et al., 2013) and
positive cognitive styles (Maier & Seligman, 1976). Specifi-
cally, students learned about adaptive and maladaptive somatic
responses to stress, how to identify stress symptoms, and a
series of coping strategies across four dimensions: active cop-
ing, avoidance coping, distraction coping, and social support
(Gonzales, Tein, Sandler, & Friedman, 2001). Techniques
included diaphragmatic breathing, progressive muscle relaxa-
tion, sleep hygiene, exercise, and nutrition (Davis, Eshelman,
& McKay, 2008). The students also learned about the core
models of CBTs (Beck, 1971; Ellis, 1970) and the most com-
mon cognitive distortions (Burns, 1989). The instructors teach
techniques to recognize cognitive distortions and negative
thinking patterns, to challenge these negative thoughts, and
to replace them with more realistic, positive thoughts. Instruc-
tional methods included practicing the techniques in class, par-
ticipation in seminar discussions, writing reflection papers, and
completing two in-class exams to encourage students to apply
what they learned and to permit consolidation of skills.
We structured the spring semester as a service-learning
course where students delivered a manualized curriculum to
teach a subset of the techniques to ninth-grade students at one
public high school in New York City. Ninth-grade students
were chosen because they often undergo a significant amount
of academic, emotional, and social stress as they transition
from middle school to high school. It is a time that is also
marked by increased involvement in risk-taking behaviors,
including alcohol and drug use, smoking, sexual behaviors, and
behaviors leading to intentional and unintentional injuries
(Crosby, Santelli, & Diclemente, 2009).
We held the high school sessions during the school day;
sessions were 45 min/week for 10 weeks. The undergraduate
students met twice per week for a total of 150 min with the
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5
course instructors—one session was to practice delivery of that
week’s class to the high school students and the second was a
debriefing session where the undergraduates reviewed and pro-
cessed their experiences as a group. The instructors also
observed the college students delivering the curriculum to the
high school students (45 min/week); they provided supervision
and gave individualized feedback based on their observations.
A high schoolteacher was also present in each classroom.
Because a key component of effective service learning is
reflecting on the experience (Prentice & Garcia, 2000), stu-
dents completed a midterm paper in which they critically
reviewed their experiences teaching the high school students
and a final paper in which they reflected on the combined, two-
semester experience.
Additional detail regarding the course, including the two-
semester syllabus, is available from the first author.
Psychopathology course. The child and adolescent psychopathol-
ogy course is a one-semester course. The course, which is
taught by practicing psychiatrists and psychologists, focuses
on disease etiology, epidemiology, phenomenology, nosology,
and diagnosis. Students learn to critically review common child
and adolescent psychopathology and to challenge social and
cultural assumptions of what constitutes ‘‘normal’’ versus
‘‘pathological’’ behavior, cognition, and emotion. Each student
completes one practicum by participating with a clinician in the
evaluation of a child or adolescent patient, including preparing
a formal write-up of the examination. Students also complete a
paper where they diagnose a character in a popular book; they
support this diagnosis with symptoms described in the novel
and with Diagnostic and Statistical Manual of Mental Disorders,
Fifth Edition criteria. The course syllabus is available from the
first author.
Declaration of Conflicting Interests
The authors declared no potential conflicts of interest with respect to
the research, authorship, and/or publication of this article.
Funding
The authors received no financial support for the research, authorship,
and/or publication of this article.
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