Depression school: a three-session group crisis stabilization intervention.
(Care and treatment)
Cognitive therapy (Health aspects)
Cognitive therapy (Social aspects)
|Publication:||Name: Annals of the American Psychotherapy Association Publisher: American Psychotherapy Association Audience: Academic; Professional Format: Magazine/Journal Subject: Psychology and mental health Copyright: COPYRIGHT 2010 American Psychotherapy Association ISSN: 1535-4075|
|Issue:||Date: Fall, 2010 Source Volume: 13 Source Issue: 3|
|Topic:||Event Code: 290 Public affairs Canadian Subject Form: Cognitive-behavioural therapy; Cognitive-behavioural therapy|
|Geographic:||Geographic Scope: United States Geographic Code: 1USA United States|
The rapidly changing mental health care environment has many treatment and financial implications for therapists and clients. The changes place new and acute demands on providers and caregivers to meet their clients' needs with time-limited, innovative therapies without compromising care. Innovative perspectives in clinical practice should stimulate research on practical therapeutic interventions developed by clinicians that depend on their own creativity and resourcefulness to help clients. In this article, the process and protocol of Depression School, an innovative three-session depression group for crisis stabilization of depressed clients, is presented. Also included are examples of the clients' written work, and a tangible form of accountability, the results of a before-and-after Beck Depression Inventory (BDI) taken by each client as evidences of the initial depth of their depressions and of successful treatment.
The number and kinds of authorizations for therapy have changed as a result of rapid changes in the mental health care environment. Due to economic considerations, authorizations of brief treatment models with the reduction of the number of therapy sessions have increased. There has also been an increase in group therapy authorizations, although the evidence that group therapy is more cost-effective than individual therapy is still debated (McCrone et al., 2005; Shapiro, 1982; MacKenzie, 1995; Tucker & Oei, 2006). Additionally, hospitalization authorizations by health maintenance organizations for mental health problems have decreased. These changes place new, acute demands on therapists to meet their clients' needs without compromising quality of care.
It is far beyond the scope and purpose of this article to review the ever-growing amount of financial research and clinical-use literature on the above topics. It is the author's hope that this perspective in clinical practice will stimulate research on practical therapeutic interventions developed by clinicians who depend on their own creativity and resourcefulness to help clients.
In the following article, this author-facilitator of the group presents the instructions and process for facilitating a three-session depression group and gives the protocol of the group. The group, whose members were selected by the intake therapist and who agreed to participate in this innovative crisis stabilization group treatment, was named Depression School by the initial clients, and the name stuck. The group members met weekly for crisis stabilization of their depression before they were transferred to five sessions of individual therapy. Also included in this article are examples of the clients' written work, and a tangible form of accountability, the results of a before and after Beck Depression Inventory (Beck, Rial, & Rickets, 1974; Burns, 1992) taken by each client as evidence of the initial depth of their depression and of positive treatment outcomes. An additional bonus is that the clients can use this instrument at home to gauge their moods and ward off depression.
After the three-session group, the clients participated in five weekly sessions of individual therapy as a time-limited treatment and were then discharged. Treatment was completed in eight weeks (60 days).
Building the Group
Depression School is a name coined by the first group of clients who participated in a new and innovative three-session crisis stabilization group therapy model for depression, as part of an eight-session therapy plan developed by this author as a time-limited treatment. The remaining five sessions were individual ones. This name, Depression School, has been accepted by all subsequent groups conducted by this therapist/writer. The group members can be a mix of ages, races, and sexes, or women's and men's groups can be formed. Groups of children and adolescents can also be established. Extremely psychotic clients would not be appropriate for this model because of the level of group participation necessary to make the workbooks and interact effectively with the other clients in developing their own treatment.
The Beck Depression Inventory
The BDI is actively used today in numerous statistical efficacy studies: among many others, ENRICHD investigators (2003) and Thompson et al. (2001).
BDI results in Depression School are gathered to gauge therapy outcomes and to help the clients use this instrument at home to assess their depression if they are using the Feeling Good book (Burns, 1992). The intent of using the BDI in Depression School is not to obtain statistical data but rather as client work that can be used at home by the clients to help them become active participants in their treatment. It also gives them a preventive tool to help them manage their moods.
Each client should have two scores: one score from the beginning of therapy and one after the third session. Each client's BDI results are put on individual graphs and added to his or her workbook.
The group's goal was established by this therapist/writer--understanding, managing, and defeating depression through group effort-and the objectives were defined.
* Gain an understanding of depression and develop a group definition of depression.
* Understand, through group sharing, what circumstances brought you to therapy.
* Explore, as a group, your old ways of handling depression, which have not been helpful (labeled "bummers").
* Develop and explore, as a group, new ways of dealing with depression.
* Try these new ways in real life.
The first session starts with an introduction by the therapist about his or herself and about the upcoming group work, followed by an invitation for the clients to introduce themselves and make a short statement about what they would like to accomplish individually and as a group. The BDI is then explained and given to each client.
After the BDI is taken, the clients are asked to describe their depression to the group, generate a group definition, and develop a motto. Clients also share with the group what had happened in childhood and along life's way to set the stage for their depression. The therapist, co-therapist, or a selected group member should record the definition and motto. Recording a few key words of the clients' description of depression and what has happened in childhood and along life's way to set the stage for their depression is also necessary. After generating lists of current and childhood experiences that the clients feel caused their depression, the group members extract main themes from the information. The designated scribe also records these. These records are then used in development of the group's workbook. Computers may be used, which are especially welcomed and effective when working with teenagers. This means that client writings are generated right in the group. Kelly (1990) and Oppawsky (2001) suggest that client writings in therapy can enhance their cognitive awareness. For homework, the clients are asked to think about how their workbooks could be embellished with artwork, photographs, or poems and to bring anything they would like included in their workbooks to the next session. The process of this type of group usually initiates a significant amount of group interaction, and the clients are asked to give and receive feedback and support from their peers. Personal items help clients share personal information and help them discover or elaborate on any negative or positive thoughts. The clients are encouraged to discover the universality of any items brought in for their workbooks, such as a photograph of a client as a child laughing, playing, or with siblings or family, or of a pet. This task helps clients discover how well they can identify with others. This connectiveness also helps bridge social and cultural lines, leading to positive cross-cultural interactions within the group (Oppawsky, 2009).
Session one should close with an exploration of any issues arising from the session and a safety check, meaning a danger-to-self and a danger-to-others check and an affirmative statement from each client about themselves.
The group opens with a short round-about, with each client telling about his or her week and relating his or her mood patterns during the past week. The clients are then invited to explore old ways of dealing with depression that have been counterproductive or have not worked, and generate a "bummer list." The word "bummer" to describe this list was client-initiated and has stuck. This part of the group work usually generates significant interaction among the group members, and this interaction should be encouraged. Again, the bummers are recorded for the workbook.
After the bummer list is generated, the group is invited to explore and develop new ways of dealing with depression and to generate a "new ways" list. This list may be made up of things that have worked for the clients in managing their depressive moods in the past or things that they would like to try. Accepted cognitive behavioral techniques such as negative thought stopping, journaling, and identifying triggers that lower moods can be introduced by the therapist (Corey, 2001). These are also recorded for the workbook. After generating the new ways list, each client contracts to try a new way in vivo in the next week.
Again, session two closes with an exploration of any issues arising from the session or during the week, a safety check, and an affirmative statement by each client about themselves.
Session Three starts with the group members sharing how they made out using new ways during the past week. This usually generates significant group interaction. Group support is imperative if one or the other client was not successful in adopting a new way. If a client was not successful, the client selects another new way to be tried in viva in the following week.
Clients are then asked to retake the BDI and compare their results to their initial BDI. A group discussion of their results follows, again with group and therapist support if a client's mood has not risen and encouragement and support if it has.
The clients are then asked to make their workbooks, using supplies usually provided by the therapist and/or agency. Some supplies that are useful are colored cardstock or construction paper for the cover and yarn or colored thread to bind the workbook. The clients often bring pictures or poems to embellish their book, and a cover page is made by them with these items. Children and teenagers may like to put their own picture on the front or draw a picture for the cover. This writer usually generates copies of the individual BDI results, the objectives, the group motto, the bummer list and the new ways list on a computer and provides these to clients for their workbooks. Frequently, a group member will do this as homework.
The group closes with each member giving another member a positive affirmative of something he or she has observed about the member during the three weeks. An exploration of any issues arising from the group or during the group's duration follows. A safety check is made, and the clients are transferred to their individual therapists for their remaining five individual therapy sessions. The group members are encouraged to take their workbooks with them to their first session of individual therapy.
Suggestions for Follow-up
Each client is transferred from Depression School to individual therapy. After five sessions of individual therapy, the clients are usually discharged with continued improved moods and having attained their treatment goals. The clients are asked in individual therapy to make a commitment to monitor their moods at home and continue using the new ways developed in Depression School in individual therapy and after discharge. The clients are usually encouraged by the individual therapist to join a self-help depression group or a bereavement group in the community. A list of community resources should be given.
Therapists should initially assess the clients for danger to others and/or dangers to self. These assessments should be done throughout the duration of therapy as well. Clients who are suicidal or have vague threats of harming others can participate in this innovative model with proper precautions, such as no-suicide and no-harm-to-others contracts. Clients who have active intentions to harm themselves or others are not appropriate for this group. Clients who become seriously suicidal in the group with a plan and/or means to commit suicide, or make serious threats in group to identifiable others, which trigger a Tarasoff response, should be referred out of the group to appropriate services. Occasionally, some clients may experience deepening depression or mental decompensation while in the group and should be transferred immediately to more intensive care.
Vignette Protocol of a Depression School Therapy
The following is the protocol of an authentic Depression School that includes the group's definition of depression, the motto of the group, the themes from the group, the bummer list, the new ways list, and the results of their before-and-after BDI.
All eight participants, five women and three men of different ethnic backgrounds (white, African American, and Hispanic), ranging in age from 25 to 58, had a psychiatric diagnosis of major depression, severe or moderate, determined during their biopsychosocial intake assessment at an outpatient crisis intervention and brief treatment facility. All participants had denied suicidal ideation or homicidal ideation during intake. All the clients had had previous suicidal ideation but no attempts. Some had had vague thoughts of harming others in the past but with no plan or intent. All of them signed no-harm contracts. All the participants refused medication. Each client was granted eight sessions of brief treatment by his or her mental health provider and agreed to participate in this innovative plan for therapy.
The group's definition of depression was "A depressed person is one who is not able to deal with things in life, who feels down all the time, who is not able to make decisions, has mood swings, is angry, who is tired all day, and wants to kill/hurt someone."
The group selected "Find your own life" as its motto. "Depressed people are sensitive, we feel, it hurts, it is risky--but we wouldn't have it any other way, but without depression, look inside, listen to self."
After generating lists of current and childhood experiences that the clients felt had caused their depression, several main themes were extracted from the list by the group members:
* Depression associated with loss of love and loneliness
* Depression associated with financial problems
* Threatened autonomy
* The need for unconditional love or unconditional acceptance
A bummer is something a client had used to deal with depression that had not worked. Sharing bummers with each other in the group helped the clients to avoid those they had not already tried because they heard from other group members that they did not work. Group support also helped clients relinquish steadfast bummers. The following are examples of bummers generated in the group:
* Drinking and drugs
* Not crying
* Letting people back/drive one into a hole, not standing up for yourself
* Sleeping all the time, boredom
* Hurting yourself or others
* Fighting and domestic violence
* Losing sight of yourself and your needs
* Hooking up with people or getting married to someone you don't love out of feelings of neediness
* Making poor decisions
* Settling for less
* Not being able to accept reality
* Letting depression immobilize you
* Running from situations
* Setting yourself up for bad things
* Engaging in work activities that don't have anything to do with your dream/ staying in a bad job or poor work atmosphere
* Absorbing problems instead of dealing with people
The new ways list contained examples of things that group members had successfully used in the past to manage and defeat depression or ones they wanted to try. Each client then selected a new way from the list and made a commitment to try a new way between the second and third session. Each client also committed to relinquishing his/ her bummers and using new ways during individual therapy and after discharge. The new ways were:
* Crying and grieving; grief work
* Activities such as music, church, art, reading helpful powerful books, hobbies, fitness, participating in groups such as Divorce Recovery or Parents without Partners
* Doing something innovative despite a lack of money
* Validating yourself and your feelings/not letting yourself be put on the back burner (take affirmative action)
* Reaching out to others
* Making a plan and carrying it out
* Taking time out for yourself, enjoying time to yourself
The BDI results were gathered to judge therapy outcomes and to help the clients use this instrument at home to gauge their depression if they were using the Feeling Good book. Each client had two scores, one score from the beginning of therapy and one after the third session. All the clients were in the moderate, severe, or extreme depression categories initially, except one client with mild mood disturbances. All responded to the therapeutic effects of this group intervention with improvement in their moods. Six out of eight clients showed more improvement in their moods on their inventories than the other two. The one client who scored in the mild mood disturbance category reported that she was feeling better, and her score did not rise within the category. Each client's BDI results were put on individual graphs and added to their workbook.
Discussion of Depression School and the Vignette
The BDI was designed as a standardized tool to assess the depth of depression and is widely used throughout the United States and Canada as well as abroad (Corey, 2001). It is a formal screening tool for depression with good reliability and validity (Beck, Rial, & Rickets, 1974). A review of evidence-based studies shows that both the BDI and the BDI-SF (Short Form) are used (McFarland, 2005). The BDI and the assessment scale are published in Burns' (1992) self-help book, making it an accessible and affordable resource for clients. Many clients have the book at home. Many mental health centers have it available for clients and therapists to use, and it is readily available in most public libraries.
In Depression School, the depth of depression for each client was assessed in the first few minutes of therapy. The initial results stressed the clients' reality without disputing or prescribing to their symptoms. The final BDI was a tool of accountability of therapy, a tangible product of what really went on in therapy, as well as a measure of positive outcome.
The rapidly changing mental health environment, in which the number of therapy sessions is reduced, should awaken therapists to a need for innovative and new ways to increase the effectiveness and efficiency of therapy, as well as aid in the accountability of therapy without compromising care. Enrolling depressive clients in crisis in a weekly three-session Depression School for crisis intervention and stabilization before they are transferred to individual therapy is warranted.
The makeup of Depression School viewed the clients as active agents who were able to derive meaning out of what they were going through and helped them to take action to modify their depression. Their written work and BDI results enriched this model for the clients by encouraging processes of self-expression, which were documented. Additionally, their written work helped the clients understand their therapy and the therapeutic process. Their workbook became a tangible form of accountability for them. The universality of the group members' problems and their interactive approach to understanding, managing, and defeating their depression helped the clients acquire effective strategies in dealing with their mood in a timely fashion. Indeed, all clients whose participation is described in the vignette, except one with mild mood disturbances initially, who retained the same results, showed improvement in their depression. Six of the eight clients showed more improvement in their moods than the other two.
Therefore, Depression School, as a crisis intervention/stabilization therapy, with its goals of understanding, managing, and defeating depression, worked for these clients. By divorcing themselves from bummers and using new ways, the Depression School actually became a coping skills program for clients in crisis and paved the way for successful individual therapy.
After the three sessions, the eight clients presented in the vignette were transferred to five sessions of individual therapy, in which the clients' problems, past or current, leading to their depressions were explored in greater depth and their commitments to understanding, managing, and defeating depression were reaffirmed. All the clients' BDI scores had improved by the end of the three sessions, with the exception of the one client whose BDI showed mild mood disturbances initially. Her BDI stayed in that range. At the time of discharge, after eight sessions (three group sessions and five individual sessions), all clients were in the mild mood disturbances range of the BDI, substantiating significant improvements in their moods. The one client who was in the mild mood disturbance range initially and stayed there reported that she felt significantly better, having moved higher within her range. The clients were discharged by mutual client/therapist agreement.
Research Possibilities and Multiplication Factors
Serious psychotherapy is a blend of art and science. Experienced therapists understand that the need for brief treatment modalities calls for creative, innovative interventions. These therapists also know that they must use what works. This model of treatment was designed by the writer from her significant experiences practicing psychotherapy in agency settings in Arizona, where resources and the number of sessions the clients are allowed are limited. The use of this innovative and creative practice illuminated the need for research on this group model. It is the author's hope that this perspective in clinical practice will stimulate research on practical therapeutic interventions developed by clinicians who depend on their own creativity and resourcefulness to help clients. For example, on this group model, statistical tests on the results of the BDI could be done to determine if the changes the clients recorded were statistically significant. The number of group sessions compared to individual sessions was chosen by this writer based on her experience with and need for brief therapies. Further research could address the exact number of group versus individual sessions needed to stabilize moods. Furthermore, the use of this model with children and adolescents could be practiced and researched.
This writer has since successfully conducted many one- to three-session Depression Schools with medicated and non-medicated adult clients with major depression, dysthymia, and bipolar disorder. After stabilization, these clients were transferred to various services, such as meds-only groups, case management services, primary care physicians, self-help groups, and to individual therapies of different lengths of time.
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JOLENE OPPAWSKY, PhD, a diplomate psychotherapist and licensed professional counselor in Arizona and an approved clinical supervisor, is a University of Phoenix faculty member and supervisor in the graduate counseling program in Tucson, Arizona. Formerly, she taught for Boston University in its graduate overseas counseling program. She has taught psychology and psychotherapy at the University of Warsaw and at the University of Lithuania. She practices psychotherapy on a contract basis in Tucson, Arizona, and she has several professional publications to her credit.
By Jolene Oppawsky, PhD, LPC, ACS, DAPA
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