Psychoteraphy Student at Risk Out (2)

8/18/2019 Psychoteraphy Student at Risk Out (2)

1/8

RESEARCH REVIEWS 311

School-Based Group Psychotherapyfor At-Risk Adolescents

LORIE A. RITSCHEL, PH.D.

Layne, C.M., Saltzman, W.R., Poppleton, L., Burlingame, G.M.,Pasalic, A., Durakovic, E., et al. (2008). Effectiveness of a school-

based group psychotherapy program for war-exposed adoles-cents: A randomized controlled trial. Journal of the American

Academy of Child and Adolescent Psychiatry, 47(9), 1048-1062.

Stice, E., Rohde, P., Seeley, J.R., & Gau, J.M. (2008). Brief cog-nitive-behavioral depression prevention program for high-riskadolescents outperforms two alternative interventions: A ran-domized efficacy trial. Journal of Consulting and Clinical Psychol-ogy, 76(4), 595-606.

A dolescence is a critical period for the development of psycho-logical difficulties. Peak years for initial episodes of Major Depres-sive Disorder (MDD) are between 14 and 24 years of age (Kessler,Avenevoli, & Merikangas, 2001); similarly, anxiety-spectrum dis-orders often emerge during adolescence (Kessler et al., 2005). Asubstantial body of evidence supports the notion that recurrentepisodes of affective illness result in episode sensitization; that is,greater incidences of depressive or bipolar episodes are relatedto higher likelihood of additional future episodes (Kessing, Han-sen, Andersen, & Angst, 2004; Post, 2007). Furthermore, chil-dren and adolescents with a psychiatric illness are at increasedrisk for developing a comorbid disorder (Costello, Mustillo, Er-kanli, Keeler, & Angold, 2003). Taken together, these findingsaugur for the development of interventions aimed at mitigatingthe impact of psychiatric illness in youth. Given the known genet-ic contributions of both affective and anxiety disorders (Martin,Ressler, Binder, & Nemeroff, 2009; Sullivan, Neale, & Kendler,

2000) as well as the impact of trauma on mood (McEwen, 2008),


2/8

312 RESEARCH REVIEWS

it is particularly important to target at-risk youth.

School-based prevention programs capitalize on making use ofthe adolescent’s natural environment to provide needed mentalhealth services. This article reviews two randomized controlledstudies of school-based group therapy interventions designed totreat at-risk adolescents. In the first study, Layne and colleagues(2008) tested the efficacy of Trauma and Grief Component Ther-apy (TGCT) in a sample of adolescents at risk for the develop-ment of PTSD, depression, and grief based on their experiencesgrowing up in Bosnia during wartime. TGCT for adolescents

is a manualized, group-based intervention that comprises fourmodules: Module 1 provides psychoeducation about trauma andteaches emotion and behavioral regulation skills; Module 2 al-lows adolescents to process their traumatic experiences; Module3 focuses on healthy ways to cope with grief; and Module 4 helpsadolescents cognitively reappraise the trauma they experienced,engage in better problem-solving, address and reduce risky be-haviors, and build social skills. TGCT has been utilized with oth-er traumatized adolescent populations, and effectiveness studies

have been reported (see Layne et al., 2001); however, this study isthe first randomized controlled trial of TGCT with adolescents.Students at 10 high schools in central Bosnia were screened to

determine eligibility; those who endorsed high levels of traumaexposure along with increased distress, depression, and function-al impairment were included in the study. The final sample com-prised 127 adolescents who were randomized to either TGCT (n= 66; mean age = 15.9 years) or a psychoeducation-based compari-son condition (n = 61; mean age = 16.0). Participants in the TGCT

condition attended 17-20 group therapy sessions over the courseof the school year. Participants in the comparison condition re-ceived psychoeducation about common reactions to trauma, re-laxation training, social support, and problem solving skills. Theauthors hypothesized that: (1) participants in both conditionswould show significant reductions on measures of posttraumaticstress, depression, and maladaptive grief; (2) participants in theTGCT condition would show greater reductions on all symptommeasures and would have significantly lower general distressscores at post-treatment; and (3) participants in both conditionswould maintain their gains at 4-month follow-up.


3/8


Analyses comparing pre- to posttest results showed that scores

on measures of PTSD decreased significantly in both conditions.Only participants in the TGCT condition showed significant de-creases in depression and maladaptive grief reactions. Althoughfollow-up analyses were limited due to attrition, results showedthat PTSD and depression scores decreased significantly fromposttest to 4-month follow-up in both conditions. In terms of reli-able improvement from pretreatment to follow-up, odds ratiosindicated that outcomes favored TGCT over the comparison con-dition. That is, more TGCT participants than comparison groupparticipants improved over time (61% vs. 47% for depression;81% vs. 48% for PTSD), and fewer TGCT participants (0%) dete-riorated than in the comparison condition (7%).

Several points about this study merit discussion. First, the fourmodules in the TGCT intervention were flexibly implemented inorder to accommodate the strengths and weaknesses of each group(e.g., cohesiveness, marginalization); group therapists created les-son plans each week that were tailored based on group member-ship and dynamics. This represents a unique aspect of the proto-col in that therapists were given considerable latitude in adapting

the treatment. It is somewhat unclear, however, how the groupsdiffered and how the treatment was modified to accommodatethese differences. It should be noted that the supervision plan forthe TGCT condition was quite good; supervisors reviewed lessonplans and notes after each group to ensure treatment fidelity.

Second, this was a study of two active interventions; further-more, the treatment for the comparison condition was taken di-rectly from the TGCT manual. Thus, this may have more closelyapproximated a dismantling study in that the authors essentially

investigated whether the full TGCT package is needed for reduc-ing PTSD and depression symptoms or whether a portion of themanual suffices. In addition, the authors did not note how manysessions were offered to participants in the comparison condi-tion, and they did not evaluate a dose effect to determine if thenumber of sessions attended was related to treatment outcomes.Finally, no outcome measures were included to assess problem-solving or risky behaviors, both of which were treatment targets.In general, however, participants in both conditions derived ben-

efit from the treatments.


4/8


In another study, Stice and colleagues (2008) evaluated a

6-session Cognitive Behavioral Prevention Intervention (CB) foradolescents at risk for depression. Interested participants werescreened with the Center for Epidemiologic Studies-DepressionScale (CES-D; Radloff, 1977) and were included if they exhibitedelevated symptoms of depression but did not meet full criteriafor MDD. The final sample comprised 341 high school age ado-lescents (mean age = 15.6 years) who were randomized to one offour conditions: CB group therapy (n = 89), supportive-expressivegroup therapy (n = 88), self-directed bibliotherapy (n = 80), or an

assessment-only control condition (n = 84). The CB interventionfocused on increasing pleasant activities and positive cognitions,while the supportive-expressive condition focused on allowingparticipants to express their feelings in a nonjudgmental envi-ronment. Both groups met once weekly for 6 sessions, and eachgroup comprised 6-10 participants. Participants in the bibliother-apy condition read a self-help book called Feeling Good (Burns,1980), and participants in the assessment-only control conditionwere given a brochure to read about depression and completed

the same assessments as participants in the other three condi-tions. The comparison interventions (i.e., supportive-expressivegroup, bibliotherapy) were hypothesized to represent the activeingredients of the CB intervention; that is, supportive-expressivetherapy included the non-specific therapeutic factors thought toplay a major role in the change process (cf., Ilardi & Craighead,1994) but none of the active ingredients of CBT. Conversely, thebibliotherapy condition included most of the content of the CBintervention without the nonspecific therapeutic factors.

Results were reported from posttest and 6-month follow-up as-sessments. At posttest, CB participants had the greatest decreas-es in depressive symptoms when compared to the other threeconditions, and participants in the supportive-expressive grouphad greater symptom reductions than bibliotherapy. At follow-up, participants in the three treatment conditions had greatersymptom reductions than controls, and there were no differencesbetween the three active conditions. CB participants also hadbetter outcomes on measures of social adjustment and substanceuse. At follow-up, just over 7% of the full sample met criteria for


5/8


MDD, with significantly more control participants meeting MDD

criteria than any of the three active treatments.Several points about this study bear mention. First, althoughthis was a relatively brief intervention, effect sizes for reductionsin depressive symptoms (d = .46 at posttest; d = .42 at follow-up)in the CB condition were comparable to longer and more com-prehensive interventions (Horowitz & Garber, 2006). Second, theparticipant sample was relatively diverse (2% Asian, 9% AfricanAmerican, 46% Caucasian, 33% Hispanic, 10% Other/Mixedheritage), suggesting that the intervention may be generalizableto a wide range of youth. Finally, the authors noted that partici-pants attended just over half of the sessions offered (mean atten-dance = 3.3 of 6 sessions), suggesting that brief interventions forat-risk adolescents are beneficial.

Taken together, findings from these two studies suggest thatclassroom-based interventions represent a viable mechanism fordelivering group psychotherapy to at-risk adolescents. Althoughthese studies differed in numerous ways, both found that mentalhealth outcomes can be improved while harnessing the power ofadolescents’ natural daily environment: school. Because of the

long-term impact of mood and anxiety disorders on functionaloutcomes and quality of life, early intervention and preventionprograms are necessary. These findings suggest that classroom-based interventions are a feasible and effective way of providingtreatment for at-risk youth.

REFERENCES

Burns, D. D. (1980). Feeling good: The new mood therapy. New York: Har-perCollins.

Costello, E. J., Mustillo, S., Erkanli, A., Keeler, G., & Angold, A. (2003).Prevalence and development of psychiatric disorders in childhoodand adolescence. Archives of General Psychiatry, 60(8), 837-844.

Horowitz, J. L., & Garber, J. (2006). The prevention of depressive sym-ptoms in children and adolescents: A meta-analytic review. Journalof Consulting and Clinical Psychology, 74(3), 401-415.

Ilardi, S. S., & Craighead, W. E. (1994). The role of nonspecific factorsin cognitive-behavior therapy for depression. Clinical Psychology: Sci-

ence and Practice, 1(2), 138-155.


6/8


Kessing, L. V., Hansen, M. G., Andersen, P. K., & Angst, J. (2004). The

predictive effect of episodes on the risk of recurrence in depressiveand bipolar disorders—a life-long perspective. Acta Psychiatrica Scan-dinavica, 109, 339–344.

Kessler, R. C., Avenevoli, S., & Merikangas, K. R. (2001). Mood dis-orders in children and adolescents: An epidemiologic perspective.Social Biology and Psychiatry, 49, 1002-1014.

Kessler, R. C., Berglund, P., Demler, O., Jin, R., Merikangas, K. R., &Walters, E. E. (2005). Lifetime prevalence and age-of-onset distri-butions of DSM-IV disorders in the National Comorbidity SurveyReplication. Archives of General Psychiatry, 62(6), 593-602.

Layne, C. M., Pynoos, R. S., Saltzman, W. R., Arslanagić, B., Black, M.,Savjak, N. et al. (2001). Trauma/grief-focused group psychothera-py: School-based postwar intervention with traumatized Bosnianadolescents. Group Dynamics: Theory, Research, and Practice, 5(4),277-290.

Layne, C.M., Saltzman, W.R., Poppleton, L., Burlingame, G.M., Pasa-lic, A., Durakovic, E., et al. (2008). Effectiveness of a school-basedgroup psychotherapy program for war-exposed adolescents: A ran-domized controlled trial. Journal of the American Academy of Childand Adolescent Psychiatry, 47(9), 1048-1062.

Martin, E. I., Ressler, K. J., Binder, E., & Nemeroff, C. B. (2009). Theneurobiology of anxiety disorders: Brain imaging, genetics, and psy-choneuroendocrinology. Psychiatric Clinics of North America, 32(3),549-575.

McEwen, B. S. (2008). Central effects of stress hormones in health anddisease: Understanding the protective and damaging effects ofstress and stress mediators. European Journal of Pharmacology, 583, 174-185.

Post, R. M. (2007). Kindling and sensitization as models for affectiveepisode recurrence, cyclicity, and tolerance phenomena. Neurosci-

ence & Biobehavioral Reviews, 31(6), 858-873.Radloff, L. S. (1977). The CES-D Scale: A self-report depression scalefor research in the general population. Applied Psychological Measu-rement, 1(3), 385-401.

Stice, E., Rohde, P., Seeley, J.R., & Gau, J.M. (2008). Brief cognitive-be-havioral depression prevention program for high-risk adolescentsoutperforms two alternative interventions: A randomized efficacytrial. Journal of Consulting and Clinical Psychology, 76(4), 595-606.


7/8


Sullivan, P. F., Neale, M. C., & Kendler, K. S. (2000). Genetic epide-miology of major depression: Review and meta-analysis. American

Journal of Psychiatr y, 157, 1552-1562.

Lorie A. Ritschel, Ph.D. Atlanta, GA E-mail: [email protected]


8/8

Reproducedwithpermissionof thecopyrightowner. Further reproductionprohibitedwithoutpermission.

Psychoteraphy Student at Risk Out (2)

Documents

Transcript of Psychoteraphy Student at Risk Out (2)