Depression School: A 3-Session Group Crisis Stabilization Intervention
Jolene Oppawsky, PhD, LPC, ACS, DAPA
University of Phoenix
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 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 who depend on their own creativity and resourcefulness to help clients.
In this article, we present the process and protocol of Depression School, an innovative 3-session depression group for crisis stabilization of depressed clients. Also included are examples of the clients’ written work, a tangible form of accountability, the results of a before-and-after Beck Depression Inventory taken by each client as evidence of the initial depth of depression and successful treatment.
The rapidly changing mental health care environment has acute implications for therapists and clients. The number and nature of authorizations for therapy have changed. Due to economical considerations, authorizations of brief treatment models, with a reduction of the number of therapy sessions, have increased. There has also been an increase in authorizations for group therapy, although the evidence that group therapy is more cost effective than individual therapy is still debated (McCrone, A. et al, Shapino, J. 1982, MacKenzie, C. & Ray, K., 1995, Tucker, M. & Oei, T. P.S. 2006). Additionally, hospitalization authorizations by HMOs for mental health problems have decreased. These changes place new and acute demands on therapists to meet their clients‘needs without compromising 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 and facilitator of the group presents the instructions and process for facilitating a 3-session depression group and gives the protocol for facilitating the group. The group, whose members were selected by the intake therapist, agreed to participate in this innovative crisis stabilization treatment. The group 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, A. T., Rial, W. Y., & Rickets, K. 1974; Burns, 1992 ) taken by each client as evidence of the initial depth of depression and 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 3-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 sessions. This name, Depression School, has been accepted by all subsequent groups conducted by this therapist/writer resulting in a permanent name for this writer’s groups on depression. 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 Investigations, 2003; Thompson, L.W., Coon, D. W., Gallagher-Thompson, D., Sommer, B.R., & Koin, D., 2001).
BDI results in Depression School are gathered to judge therapy outcomes and to help the clients use this instrument at home to gauge their depression if they are using The Feeling Good Book (Burns, D., 1992). The intent of using the BDI in Depression School is not to obtain statistical data, but rather to be used at home by clients to help make them active participants in their treatment. It also gives them a preventative 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 their workbook.
The group’s goal was established by this therapist/writer, that of understanding, managing and defeating depression through group effort, and the objectives were defined.
- To gain an understanding of depression and develop a group definition of depression
- To explore, as a group, your old ways of handling depression that have not been helpful (“bummers”)
- To understand, through group sharing, the circumstances that brought you to therapy
- To develop and explore, as a group, new ways of dealing with depression
- To 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 Beck Depression Inventory (BDI) is then explained and given to each client.
After the BDI is taken, the clients are asked to described their depression to the group, generate a group definition, and develop a motto. Clients also share with the group what happened in childhood and along life’s way to set the stage for depression. The therapist, co-therapist or selected group member should record the definition and motto. Recording a few key words of the clients’ descriptions of depression and what happened in childhood is also necessary. After generating lists of current and childhood experiences, which 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 the 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 cognitive awareness for clients. For homework, the clients are asked to think about how their workbooks could be embellished with art work, 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 just how well they can identify with others. This connectivity 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 him or herself.
The group opens with a short round-about with each client telling about his or her week. Then, clients are 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 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 him or herself.
Session three starts with 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 some of the members were not successful in adopting a new way. If a client was not successful, the client selects another new way to be tried in vivo 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 improved, and encouragement and support if it has improved.
The clients are then asked to make their workbooks with supplies usually provided by the therapist and/or agency. Some supplies that are useful are colored construction paper for the cover and yarn or colored thread to bind the workbook. The clients often bring pictures or poems to develop cover pages. Often, pictures are included inside the workbook, as well. Children and teenagers like to put their own pictures on the front of their workbooks or draw a cover picture. This writer usually generates copies of the individual BDI results, the objectives, the group motto, the bummer list, and the new ways list on the computer and then provides them to the 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 sessions of individual therapy.
Suggestions for Follow-up
Each client is transferred from Depression School to individual therapy. After five sessions of individual therapy, all clients are usually discharged having attained their treatment goals and with moods that are continuing to improve. 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 trigger a Tarasoff response, should be referred out of group to appropriate services. Occasionally, some clients may experience deepening depression or mental decompensation while in 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 the BDI, pre and post-treatment.
All the eight participants – five women and three men of different ethnic backgrounds, White, African American, and Hispanic, and ranging in age from 25 to 58 – had a psychiatric diagnosis of Major Depression, severe or moderate, determined during his or her biopsychosocial intake assessment at an outpatient crisis intervention and brief treatment facility. All participants had denied suicidal ideation or homicidal ideation during intake. All clients had had previous suicidal ideation but had made no attempts. Some had had vague thoughts of harming others in the past but with no plan or intent. All signed no-harm contracts. All the participants had 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 “a depressed person” was: “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.”
Their mottos were: “Find your own life,” and “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, which the clients felt had caused their depression, main themes were extracted from the list by the group members. The following themes were generated by the group:
- Loss of love
- Financial problems
- Threatened autonomy
- The need for unconditional love, unconditional acceptance
A bummer is something used to try to deal with depression that has not worked. Sharing bummers with each other helped the group avoid unsuccessful coping methods. Group support also helped clients relinquish steadfast bummers. The following were examples of bummers generated by the group.
- Drinking and drugs
- Not crying
- Anger – gets you nowhere
- Letting people back/drive you 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 being needy
- Making wrong decisions
- Settling for less
- Not being able to accept reality
- Letting depression immobilize you
- Running from a situation
- 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 shit” 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 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 and powerful books, hobbies, fitness, participating in groups, such as Divorce Recovery or Parents without Partners
- Do something innovative despite not having the money
- Validate yourself and your feelings, don’t let yourself be put on the back burner (take affirmative action)
- Reach out to others
- Make a plan and carry it out
- Take time out for yourself , enjoy 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 mood. Six out of eight clients showed more improvement in mood on inventories than the other two. The 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 workbooks.
Discussion of Depression School and the Vignette
The Beck Depression Inventory (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, K., 2005). The BDI and the assessment scale are published in Burn’s (1992) self-help book, making it an accessible and affordable resource for clients. Many clients come to therapy with the book or have the book at home. Many mental health centers have the book available for clients and therapists to use, and it is also 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 each client’s reality without disputing or prescribing 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 crises in a weekly 3-session Depression School for crisis intervention and stabilization before they are transferred to individual therapy is warranted.
In Depression School, clients were viewed as active agents who were able to derive meaning out of what they were going through and were helped to take action to modify their depression. Their written work and BDI results enriched this model by encouraging processes of self-expression, which were documented. Additionally, clients’ 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 depressions helped the clients to acquire effective strategies in dealing with their moods in a timely fashion. Indeed, all clients in the vignette, except one with initially mild mood disturbances who retained the same results, showed improvement. Six clients out the eight showed more improvement in their moods than the other two. Depression School, as a crisis intervention/stabilization therapy, with its goals of helping clients understand, manage, and defeat 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 who participated in the group and were presented in the vignette were transferred to five sessions of individual therapy, wherein the clients’ problems past and present problems leading to depression were explored in depth. Their commitments to understanding, managing, and defeating depression were reaffirmed. All the clients’ BDI scores 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 (3 group sessions and 5 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 reported that she felt significantly better having moved higher within her range. The clients were discharged by mutual client/therapist agreement with treatment completed.
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 and innovative interventions. These therapists also know that they must use what works. This model of treatment was designed by this writer from her significant experiences practicing psychotherapy in agency settings in Arizona, where resources and the number of sessions allowed to clients 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 arbitrarily picked by this writer based on her experience with and need for brief therapies. Further research on the exact number of group versus individual sessions needed to stabilize moods could be researched. Furthermore, the use of this model with children and adolescents could be practiced and researched.
This writer has since successfully conducted many 1-3 session Depression Schools with medicated and non-medicated adult clients with major depressions, 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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About the Author
Jolene Oppawsky, PhD, a Diplomate Psychotherapist, 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 their graduate overseas counseling program. She has taught psychology and psychotherapy at the University of Warsaw twice and at the University of Lithuania. She does psychotherapy on a contract basis in Tucson, Arizona. She has several professional publications to her credit.