Psychological Treatment for AdolescentDepression: Perspectives on the Past,Present, and Future Louise Hayes,1,2 Patricia A. Bach3 and Candice P. Boyd41 School of Behavioural and Social Sciences and Humanities, University of Ballarat, Australia2 Ballarat Health Services, Child and Adolescent Mental Health Service, Ballarat, Australia3 Illinois Institute of Technology, Chicago, United States of America4 Orygen Youth Health Research Centre, University of Melbourne, Australia The objective of this review is to summarise the evidence for mindfulness andacceptance approaches in the treatment of adolescent depression. The articlebegins by summarising the outcomes of three broad approaches to the treatment ofadolescent depression — primary prevention, pharmacotherapy, and psychother-apy — in order to advocate for advances in treatment. With regard to psychother-apy, we restrict this to comparisons of meta-analytic studies, in order to cover thebreadth of the outcome literature. In the second half of this article, we introducethe reader to mindfulness and acceptance-based psychotherapy, with a particularfocus on Acceptance and Commitment Therapy (ACT) and the applicabilitywith adolescents. We provide an overview of the philosophical arguments thatunderlie this approach to psychotherapy and consider how each of these mightcontribute to treatment approaches for adolescents with depression.
Keywords: adolescent depression, adolescent psychotherapy Depression is a substantial health issue among adolescents. Epidemiological datafrom a large sample (N = 9,863) of school-based young adolescents revealed depres-sion rates of 18% overall, with considerably higher rates in females than males, 25%and 10% respectively (Saluja et al., 2004). Other studies have found rates of clinicaldepression among adolescents between 3% and 8% (Apter, Kronenberg, & Brent,2005; Merry, McDowell, Hedrick, Bir, & Muller, 2004). Furthermore, depressionrarely occurs without comorbid mental health problems, which can be as high as40% to 95% (Parker & Roy, 2001). The most common co-occurring conditions areanxiety disorders, followed by disruptive behaviour disorders (Parker & Roy, 2001).
Gender differences are evident, with rates similar for boys and girls until around theage of 13 to 15 years, when girls begin to show a disproportionate increase in depres-sion (Hyde, Medullas, & Abramson, 2008; Merry et al., 2004). We know little aboutwhy this shift occurs, nor how girls and boys might respond differentially to preven-tion and treatment (Merry et al., 2004). Of most concern is that the experience ofdepression in adolescence increases the likelihood of recurrent depression in adult- hood (Fergusson, Harwood, Ridder, & Beautrais, 2005; Keenan-Miller, Hamden, &Brennan, 2007) with a 40% cumulative probability of recurrent depression within Address for correspondence: Dr Louise Hayes, Department of Behavioural, Social Sciences and Humanities,University of Ballarat, PO Box 663, Mount Helen VIC 3353, Australia. Email: [email protected] Behaviour Change | Volume 27 | Number 1 | 2010 | pp. 1–??
Louise Hayes, Patricia A. Bach and Candice P. Boyd two years and 70% within five years (Parker & Roy, 2001). Into adulthood, the long-term effects of depression are poor physical health, higher health care usage, andwork impairment (Keenan-Miller et al., 2007). The burden of disease on societyshould not be underestimated.
Given the importance of this issue to the health of society, the purpose of this article is twofold. The first section examines the outcomes of three broadapproaches to the treatment of adolescent depression — primary prevention, phar-macotherapy, and psychotherapy — in order to advocate for advances in treat-ments. With regard to psychotherapy, we will restrict this to comparisons ofmeta-analytic studies, in order to cover the breadth of the outcome literature. Thesecond section aims to introduce the reader to mindfulness and acceptance-basedpsychotherapy, with a particular focus on Acceptance and Commitment Therapy(ACT) and its applicability to adolescents. We will provide an overview of twophilosophical positions that underlie psychotherapy and consider how each of thesemight contribute to treatment for adolescents with depression.
Treatment Evidence for Adolescent Depression
Effectiveness of Primary Prevention for Adolescent Depression
With youth depression at unprecedented rates, researchers have turned their atten-tion to the development and evaluation of new ways of teaching young peoplecoping strategies via school-based screening or intervention programs (Horowitz,Garber, Ciesla, Young, & Mufson, 2007; Sheffield et al., 2006; Young, MufsonLaura, & Davies, 2006). Prevention programs fall into two categories — universalor targeted (Mrazek & Haggarty, 1994). Universal programs are delivered in schoolsto all youths, frequently by teaching staff. Targeted programs are delivered to youngpeople that have been screened and have high levels of risk. These programs aredelivered in schools, usually in small group formats. Merry et al. (2004) conducted aCochrane review of universal and targeted prevention programs for young people upto 19 years of age, where the participants were not in the clinical range for depres-sion symptoms. The meta-analysis included 13 studies — nine using universal inter-vention and five using targeted interventions. For the universal interventions, theeffect size was not significant (ES = –0.21, 95%CI –0.48, –0.06). However, for tar-geted studies, Merry et al. reported positive treatment effects at posttreatment withan effect size of –0.26 (95%CI –0.40 to –0.13). Only two studies included an activecontrol group; both were universal PENN prevention programs (Pattison & Lynd-Stevenson, 2001; Shatter, 1997), and there was no evidence of effectiveness at post-treatment ES = –0.13, or at 12 months ES = 0.11. The review authors concludedthat although the evidence for targeted programs was promising, there was insuffi-cient evidence to support the use of targeted and universal programs to prevent theincidence of adolescent depression (Merry, 2007; Merry et al., 2004).
A second meta-analysis on universal and targeted prevention programs was con- ducted across 30 studies (Horowitz & Garber, 2006). This review also found thattargeted programs were more effective than universal programs. The effect sizeacross 30 studies was –0.62 to 1.51, with a positive statistic indicative of a positiveoutcome. These reviewers also found that at follow-up, few studies had a genuineprevention effect and only targeted programs held promise.
Succeeding the Horowitz and Garber (2006) review, Merry (2007) reviewed the six subsequent trials that have been published between 2004 and 2006. Again, for Behaviour Change
Psychological Treatment for Adolescent Depression universal approaches there was little effect on long-term depression rates. Somestudies have produced good effect sizes; for example, a universal intervention byHorowitz, Garber, Ciesla, Young, & Mufson (2007) achieved an effect size of 0.37for CBT and 0.26 for IPT-A when compared with a no-intervention control; and ata targeted level achieved effect sizes of 0.89 for CBT and 0.84 for IPT-A. However,once again these results were not maintained at the 6-month follow-up. Further, atthis universal and targeted level, the research continues to be hampered by weak-nesses in methodology. Most important of these is using self-report questionnairesdesigned to measure clinical change for participants with symptoms that are pre-dominately below the clinical range. Merry (2007) concluded that to prevent onecase of depression, 10 adolescents need to receive targeted prevention. The authorsdrew parallels with outcomes in the medical literature, where 833 people need to betreated with antihypertensive to prevent one stroke victim, or 67 people who havesurvived a myocardial infarction must take aspirin to prevent one subsequent death(Merry, 2007). In this light, targeted prevention efforts are easily justified.
Effectiveness of Pharmacotherapy Versus Psychotherapy for ClinicallyDepressed Adolescents The landmark study comparing CBT with pharmacological treatment is theTreating Adolescents Depression Study (The Treatment for Adolescents WithDepression Study, 2005). TADS required a major investment — the study lasted 6years, cost $17 million dollars, and ran across 13 sites (Apter et al., 2005).
Treatment outcomes were compared across four groups: combined CBT plus fluoxe-tine, fluoxetine alone, CBT alone, and pill placebo. TADS was delivered at tertiarymedical centres and community clinics (Kratochvil et al., 2005). Participants were327 adolescents aged 12 to 17 years with a primary DSM-IV diagnosis of majordepressive disorder (March et al., 2007).
Effectiveness of this trial varies, depending on the method and time point exam- ined. Effect sizes at 12 weeks on the Children’s Depression Rating Scale comparingto CBT were 0.71 for combination therapy, and 0.48 for fluoxetine. By 18 weeksthis was 0.55 for combination therapy, and 0.38 for fluoxetine, and by 36 weeks dif-ferences were negligible at 0.07 for combination therapy, and –0.01 for fluoxetine(March et al., 2007). Response rates show this same pattern. At 12 weeks 73%responded to combination therapy, 62% to fluoxetine, and 48% to CBT. At 18weeks, response rates were 85% for combination therapy, 69% for fluoxetine, and65% for CBT. At 36 weeks response rates were 86% for combination therapy, 81%for fluoxetine, and 81% for CBT (March et al., 2007). These rates of responserevealed an increase in the effects of CBT over time such that by 36 weeks, the out-comes for all treatment modes were approximately equal. After 12 weeks of treat-ment, only 23% (102 of 439) of adolescents had reached remission (Kennard et al.,2006). Adolescents who were younger, less chronic, and more highly functioning,with reduced comorbidity and suicidality benefitted most from the treatment (Curry et al., 2006). Poorer outcomes were seen when complexity, severity and chronicityincreased (Brent, 2006). The rate of adverse events was higher for the fluoxetinegroups, with adverse events experienced by 11% in the fluoxetine group, 5.6% ofthe combination, 4.5% in placebo, and 0.9% of the CBT group (Emslie et al.,2006). Suicidality was twice as common in adolescents treated with fluoxetinealone than with the combination or CBT only (March, Silva, & Vitiello, 2006).
The TADS authors concluded that combined treatment was better than CBT alone Behaviour Change
Louise Hayes, Patricia A. Bach and Candice P. Boyd or fluoxetine alone (March et al., 2007). However, others have argued that the ver-sion of CBT used in this trial may have been too highly structured, perhaps reduc-ing the capacity for experienced therapists to adapt the therapy to the needs ofspecific clients (Holon, Garber, & Shelton, 2005; Weersing, 2009).
Effectiveness of Psychotherapy for Clinically Depressed Youth Weiss, McCarty, and Valeri, (2006) examined 35 studies of treatment for child andyouth depression published between 1980 and 2004. Participants were all under 19years of age, and children were included in this analysis, but the majority of thestudies included adolescents (80%). Weiss and colleagues found overall, psychother-apy provides small to medium improvements, with an effect size of 0.34 (SD = 0.40)using weighted least squares method. The range of effects sizes was from –0.66 to2.02. On average, after treatment adolescents were at the 63rd percentile of thecontrol group (McCarty & Weisz, 2007). Follow-up assessment conducted within2–3 months showed continued good outcomes (ES = 0.30); however, follow-up datacollected closer to one year showed no significant treatment effects. This failure tomaintain effects at follow-up is the same pattern seen in prevention trials.
A second meta-analysis using the Cochrane collaboration method was conducted on 27 studies between 1986 and 2004 (Watanabe, Hunot, Omori, Churchill, &Furukawa, 2007). In this review, the primary outcome measure was response to treat-ment, calculated as relative risk (‘relative risk’ [RR] is a ratio where 1 indicates no dif-ference between treatment and control). There were 1744 participants involvedwithin the 27 studies. Twenty-five of these studies were included in the meta-analysisdiscussed above by Weisz et al. (2006). Eligible participants were aged between 6 and18 years, and studies were included if they used annualised or structured psychother-apy and had a comparison group (no treatment, waitlist, attention-placebo or treat-ment-as-usual). Excluded were nondirective therapies, such as counselling, familytherapy, art therapy, and psychodrama. The ratio of clinic-referred participants wasomitted but the review notes that a majority of participants were from schools (54%).
Twenty-five studies investigated cognitive behavioural therapy (CBT), two interper-sonal therapy (IPT), three behaviour therapy (BT), one study used problem-solvingtraining (PST) and one used supportive therapy. Only 3 of the 27 studies used a com-parison group described as treatment-as-usual or usual care.
In this meta-analysis the authors concluded that the relative risk was 1.39 in favour of psychotherapy (Watanabe et al., 2007). The results showed that half ofthe participants (49.6%) had responded to psychotherapy (450 of 907), while34.8% of participants in the control conditions had improved (267 of 767). Thenumber needed to treat was 4.3 when compared with no treatment controls. Thatis, 4.3 cases need to be treated to prevent one case of depression. Once again,improvements did not continue through to follow-up. For the treatment-as-usualstudies (n = 3) there were no significant differences between treatment (CBT/CT)and control conditions but dropout was significantly higher. For the attention- placebo studies (n = 8), outcomes favoured psychotherapy (RR = 1.48) with no sig-nificant difference in dropout. Finally, for the waitlist studies (n = 17) resultsfavoured psychotherapy (RR = 2.00) and again there were no significant differencesin dropout. In summary, approximately half the adolescents responded to psy-chotherapy, while a third of the control group responded. Passive control groups willshow stronger effects for psychotherapy. Treatment-as-usual was equivalent,although with a higher dropout the finding is ambiguous.
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Psychological Treatment for Adolescent Depression Klein, Jacobs, and Reinecke (2007) also used effect size analysis but restricted their comparison to adolescents with a diagnosis of depression. In contrast, theabove meta-analyses of Weisz et al. (2006) and Watanabe et al. (2007) allowedmilder symptoms of depression. The review included 11 RCTs of CBT, requiredrandom assignment, a comparison group, and a diagnosis of depressive disorders.
CBT was defined as an intervention that promotes emotional and behaviouralchange by teaching adolescents to change thoughts, thought processes, andbehaviours. All 11 studies included in the review (Klein et al., 2007) had beenincluded in the meta-analysis of Weisz et al. (2006). The post-treatment effect sizewas 0.53 (SD = 0.15). To evaluate the effects at follow-up, Klein et al., used a con-sistent 6-month lag and they found an overall effect size of 0.59 (SD = 0.23) infavour of psychotherapy. This contrasts with the results from Weisz et al. andWatanabe et al. and indicates that long-term effects continue for clinicallydepressed youth up to 6 months. The outcomes of psychotherapy for clinical depres-sion at 12 months remain unclear.
Although CBT and IPT-A have shown effectiveness, to date further examination ofhow therapies works is needed. Unfortunately, studies using mediational analyses foradolescent depression treatments are few (only three could be found for this review)and the results are contradictory. Kolko, Brent, Baugher, Bridge, and Birmaher (2000)re-examined data from a trial that compared CBT, ??systematic-behavioural familytherapy, and nondirective supportive therapy and found no significant mediationaleffects for the treatment types at post-treatment or the 2-year follow-up. Kaufman(2005) analysed group CBT against a life-skills comparison program (tasks includedcompleting job application forms, renting an apartment, and so on) and found thatchange at post-treatment on depression symptoms was mediated by change in auto-matic thoughts but not dysfunctional attitudes; again, there was no treatment effect atthe 6- or 12-month follow-up and therefore no mediation at follow-up. In contrast,Ackerson and colleagues (Ackerson, Scogin, McKendree-Smith, & Lyman, 1998)examined the mediation effects of a bibliotherapy compared to a waitlist control andfound that changes in depression were mediated by reductions in dysfunctionalthoughts, but not in automatic thoughts.
The few meditational studies have led researchers to use alternative methods of comparison. In a recent review of the mechanisms of action among depression treat-ments, Weersing, Rozenman and Gonzalez (Weersing, 2009) attempted to lookbeyond the few studies that have used formal mediational analysis by using descriptiveoutcomes from 16 trials, and found that CBT, IPT-A, and family therapy all hadeffects on cognitive processes. Finally, in a crude comparison of those studies that usedchanged cognitions and those that did not emphasise cognitive change, Weisz et al.
(2006) found nonsignificant but larger effect sizes for therapies that did not emphasisecognitive change (ES = 0.47, n = 13) than those that did focus on changed cognitions (ES = 0.35, n = 31). This suggests equally robust results from noncognitive efforts,albeit with a rather crude measure. In summary, the above results show that we do nothave sufficient information on the processes or differences among therapies.
Summary of Treatments for Adolescent Depression Overall, cognitive behaviour therapy for adolescents has had a major impact fromprevention through to treatment, but there is room for improvement. With regard Behaviour Change
Louise Hayes, Patricia A. Bach and Candice P. Boyd to universal prevention, the research shows positive short-term effects but no measur-able long-term effects. Universal work is particularly hampered by methodologicalissues, including the use of clinical outcome measures to assess change in predomi-nantly nonclinical samples. At clinical levels of symptoms, the outcomes show small-to-medium effects for psychotherapy in predominately laboratory-based trials, withsmaller effect sizes observed in clinical trials conducted in service settings. Withregard to psychopharmacology, the outcomes are positive in the short-term but overtime are equivalent to psychotherapy, with less chance of adverse effects. A majorchallenge is to demonstrate the effectiveness of psychotherapies as they are dissemi-nated into real world clinical services. Fortunately, cognitive behavioural approachesare not stagnant and there is continued growth in cognitive and behavioural treat-ments, particularly those that incorporate mindfulness and acceptance.
Advancing Psychotherapy with Mindfulness-Based Approaches
Mindfulness-based therapies include Acceptance and Commitment Therapy
(Hayes, Strosahl, & Wilson, 1999), Dialectical Behaviour Therapy (Linehan,
1993), and Mindfulness-Based Cognitive Therapy (Segal, Teasdale, & Williams,
2004). In this review we aim to highlight ACT and its philosophical and theoreti-
cal foundations. ACT grew from a theory of verbal behaviour called Relational
Frame Theory (Hayes, Barnes-Holmes, & Roche, 2001) and underpinned by the
philosophical assumptions of functional contextualism (FC). It is important to pro-
vide an overview at this foundational level in order to examine the potential contri-
bution to psychotherapy. So we begin with an overview of functional contextualism
(the philosophy), then briefly describe RFT (the behavioural theory), then discuss
ACT as a therapeutic approach, and finally present the empirical research to date.
Our purpose is to highlight how this basic knowledge and applied treatment
approach might build upon prevention and treatment work for adolescents.
Functional Contextualism: The Philosophical Foundation of ACT Functional contextualism (Hayes, 1993) is a philosophical position which allowsthe reader see the foundations of ACT treatment development. It is perhaps easiestto understand by contrasting it with a mechanistic approach, frequently used toexplain aspects of cognition.
From a mechanistic philosophical perspective, healthy functioning is the absence of pathological thinking. Cognitions are often described using themetaphor of a computer or machine — when something goes wrong there is a ‘part’to be fixed in order to make the ‘whole’ (person) function effectively. For example,Beck argued that ‘schema are cognitive structures within the mind’ (Beck, 1995, p.
166) and these hold the core beliefs. Thus cognitions such as ‘I must win’ can belabelled as false beliefs, automatic thoughts, or defective schema (Persons, 2001).
Using this approach, a therapist attempts to teach replacement of faulty or irra- tional cognitions with new more rational ones such as ‘I would like to win’ (Bach &Moran, 2008, p. 33). Furthermore, thoughts can be viewed as causes of feelings orbehaviours — irrational thoughts lead to negatively evaluated feelings and dysfunc-tional behaviour. When thoughts become more rational it is presumed that feelingsand behaviour will also improve. A mechanistic model is clearly evident in depres-sion theories; for example, Beck’s vulnerability model argues that in depressionthere are negative schemas of the self, world and future (Weersing & Brent, 2006).
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Psychological Treatment for Adolescent Depression A mechanistic approach to depression treatment in adolescence might aim to cor-rect the ‘parts’ that need to be improved, for example, using Socratic questioning toevaluate the validity of thoughts (Beck, 1995).
ACT literature overtly describes a functional contextual approach as essential to its development (Hayes, Luoma, Bond, Masudam, & Lillis, ??2004; Hayes, Masuda,Bieestt, Luoma, & Guerro, ??1996). The underlying premise is that of pragmatism;thus, there is no ‘right’ solution — only solutions that work. The subject matter isthe ‘act-in-context’, which considers behaviour along with stimuli and conse-quences as a whole unit. ‘We wish to understand whole organisms interacting inand with a historical and situational context … a psychological act-in-contextcannot be explained by an appeal to actions of the various parts of the organisminvolved in the interaction’ (Hayes, Strosahl, & Wilson, 1999, p. 18), so there areno ‘parts’ akin to schema or false beliefs that need to be evaluated or fixed in orderto get the ‘whole’ (person) working properly (Bach & Moran, 2008). Thoughts arenot viewed as causes of behaviours or emotions. Instead, thoughts are viewed ascovert behaviours, which like overt behaviours are elicited by environmentalevents, given the unique history of the individual; and the unit of analysis becomesthe environment–environment relationship. Put simply, behaviours (both covert andovert) are understood in the context in which they occur (Ciarrochi, Robb, &Godsell, 2005). With the act-in-context as the subject matter, suffering can be seen aseither normal or problematic, and health is not defined by an absence of suffering.
Depression, from a functional contextual approach, is described by Zettle (2007, 2008) as arising from, and being maintained by: (a) ruminating in order to try tofigure out and ‘get rid of’ unwanted thoughts and feelings; (b) unsuccessful attemptsto avoid unwanted thoughts and feelings that lead to limited activity and a decreasein opportunities for positive reinforcement; (c) fusion with negative self-evalua-tions, that is, seeing thoughts as describing reality rather than as mere thoughts; (d)lacking a clear sense of values and/or behaving excessively to please others whilenot attending to one’s own desires; (e) living in the regretted past and dreadedfuture rather than in the present moment where vitality might be experienced; and (f)avoiding failure or even fear of failure which leads to avoiding goal attainment. Eachof these points would of course be analysed functionally for any given individual.
Therefore, treatment for adolescent depression using a functional contextual approach relies on understanding the function of the adolescent’s behaviour, intheir present environment, given their unique history. The goals of functional con-textualism are to describe, predict, and influence behaviour. The target of change intreatment informed by functional contextualism is the function of thoughts — thethoughts themselves may or may not change. The function of thoughts is changedthrough experiential activities, each aimed at targeting the dysfunctionalbehaviours stated in the preceding paragraph, points (a) through (f). From a func-tional approach, thoughts and feelings are not viewed as irrational content to begotten rid of or changed, and are instead viewed as events to be observed and appre- ciated as natural outcomes of one’s unique history. Successful working is the out-come goal, and this is achieved when the individual attains valued living andachieves desired goals — and which may or may not include having unwantedthoughts and feelings (Bach & Moran, 2008).
We will now turn to a clinical example to clarify the approach that we are describing. We will use the example of an adolescent girl presenting with depressedmood; she has a history of being bullied on the school bus and moves schools to Behaviour Change
Louise Hayes, Patricia A. Bach and Candice P. Boyd avoid the bullies (as we progress with this clinical example we will examine Table1). From an FC view, the therapist would examine the adolescent’s behaviourwithin its context, in order to understand the functions of her problem behaviours,in this case within the context of the schools. The therapist might explore herbehaviour patterns with peers and how her behaviour may function to help heravoid unwanted private experiences, perhaps to avoid emotional hurt. From an FCperspective, thoughts and feelings might be considered psychological content, andthoughts would not be considered as causes of her behaviour.
Relational Frame Theory as the Theory Underpinning ACT The theory of human language and cognition upon which ACT is built is entitledRelational Frame Theory (Hayes, Barnes-Holmes, & Roche, 2001; Hayes, Strosahl,Bunting, Twohig, & Wilson, 2004). A thorough explanation of RFT as a theory oflanguage and cognition is beyond the scope of this paper (for a detailed theoreticaldiscussion of RFT the reader should refer to Blackledge, 2003; Hayes et al., 2001).
However, it is important be clear that ACT as a therapeutic model arose from RFT.
Key points are: (a) both RFT and ACT assume a functional contextualist philoso-phy, (b) RFT has its roots in Skinnerian operant conditioning, and the core princi-ples of reinforcement, punishment and extinction are applicable, and (c) RFTbuilds on operant conditioning by adding a newly argued principle for verbalbehaviour — that of ‘arbitrarily applicable derived relational responding’ (Hayes etal., 2001). In this term, relational responding refers to the capacity to ‘relate’ stimulias a generalised operant shaped by historical environmental experiences. The term‘derived’ refers to the capacity to infer from facts or premises as opposed to directexperience (Bach & Moran, 2008). For instance, an adolescent might learn to avoidpeers that are dressed in ‘Goth’ style, through a history of being told that‘Alternative looking people are bad’ and having a direct history of interacting withother ‘bad’ things, rather than through a direct experience of contact with someonewho dresses in ‘Goth’ style. And the term ‘arbitrarily applicable’ means that stimuliare related based on social convention or verbal history, rather than on formal prop-erties or ‘thingness’ of the stimuli. For instance, a girl is named Anne based entirelyon social whim; while she is labelled a ‘girl’ and ‘1.6 metres tall’ based on herformal/physical characteristics.
The above discussion of FC and RFT is included to provide the reader with an orientation to ACT and to attest that ACT is a therapy arising from sound scien-tific reasoning where the function of the act-in-context is central (Hayes et al.,1999). We now turn to a review of ACT and developing it for use with adolescents.
Acceptance and Commitment Therapy for Adolescent Depression ACT is a therapy that aims to increase psychological flexibility, which is ‘the abilityto contact the present moment more fully as a conscious human being, and tochange or persist in behaviour when doing so serves valued ends’ (Hayes et al. 2006).
There are six core processes used to develop flexibility and six parallel processes,which are conceptualised as contributors to psychopathology. The ACT therapistwould begin with a functional assessment of the presenting problems. The therapistwould then conceptualise which pathological behaviours are most evident, anddecide the most appropriate ACT process to begin treatment. In Table 1 the six pro-cess of psychopathology are shown as avoidance, cognitive fusion, and so on, whilethe six ACT process are often shown as beginning with acceptance, then cognitive Behaviour Change
Psychological Treatment for Adolescent Depression ractice experiencing a regular activity with full etaphor (Hayes et al., 1999), where her negative With the therapist, adolescent role-plays the passen gers on the bus metaphor (Hayes et al., 1999).
Acting out her life as a bus, her difficult thoughts are seen as akin to passengers, and attempts to throw the passengers (thoughts) off the bus or change them are futile. Instead she would role-play success ful driving of her life bus, while taking the passen Experience her thoughts as ‘thinking’ by engaging her in experiential activities to show how thinking is not experience; for example, saying ‘I can’ this pen’ while picking up a pen (Bach & Moran, awareness of external and internal sensations, for Facilitate a mindful exercise using the chessboard and positive thoughts and feelings are played out as black and white chess pieces, the content ‘I am a loser’ is merely one chess piece but she is the chessboard which holds all the pieces, that is, she is Core Process in Acceptance and Commitment Therapy and an Example of ACT for an Adolescen Behaviour Change
Louise Hayes, Patricia A. Bach and Candice P. Boyd Use clay to make a metaphorical model that repre sent important living; for example, she might make hands to demonstrate friendship, and a book for learning. Experiencing that the models can be easily lost if hidden away or they can be overt moti vators for committed action toward valued living.
Behavioural activation methods, including committed small steps, setting goals, skills training, ABLE 1 CONTINUED

Core Process in Acceptance and Commitment Therapy and an Example of ACT for an Adolescen Behaviour Change
Psychological Treatment for Adolescent Depression defusion, and so forth. ACT can begin with any of these six processes, depending onclinical judgment. While each process can be described as discrete, in practice thereis much overlap during treatment. To highlight the approach for adolescents, we willcontinue with our clinical example from above, of an adolescent girl who has bully-ing concerns. Each step described is also laid out in Table 1. A brief discussion ofeach step follows.
With regard to avoidance versus acceptance, ACT assumes that avoidance is a key factor in psychological problems. Avoidance is empirically established (Foa,McNally, Steketee, & McCarthy, 1991; Zinbarg, Barlow, Brown, & Hertz, 1992)and is evident when an individual is unwilling to remain in contact with difficultprivate experiences and takes steps to avoid the contexts in which they occur(Hayes et al., 1999). The ACT approach aims to foster willingness to experiencethese difficult thoughts and feelings, and to take steps toward life goals even thoughthese difficulties may be present. It assumes that acceptance is the alternative toavoidance. The adolescent would be engaged in a variety of experiences that aim todemonstrate that avoiding or trying to escape from unwanted thoughts and feelingsnarrows life. During treatment the adolescent is encouraged to make room for diffi-cult thoughts and feelings. In Table 1, the metaphor of ‘passengers on the bus’ isused in a role-play. The process requires using the client’s experiences to contact thecosts of avoidant behaviour and to contingently shape acceptance behaviours.
With regard to cognitive fusion and defusion, ACT assumes that thoughts and feelings are contextually controlled and therefore difficult to dismantle. An individ-ual cannot subtract content from his/her history. An individual who has had thethought ‘I am a loser’ cannot have the experience of never having had that thought.
In some contexts that thought may arise given his/her history of responding; forinstance, the thought ‘I am a loser’ may show up whenever she does poorly on anexam or is teased by friends. The ACT therapist would not attempt to stop difficultcognitions or override them with positive thinking. Instead therapeutic techniqueswould be aimed at lessening their power over overt behaviour through acceptanceand defusion, by living more in the present, and by creating change through experi-ence (Bach & Moran, 2008, p. 78). For instance, a therapist working with the ado-lescent who has the thought ‘I am a loser’ might use experiential exercises todemonstrate the futility of trying to control thoughts and feelings. Alternativelythey might explore how trying to avoid this unwanted thought and accompanyingfeelings leads the adolescent to avoid spending time with friends, thus trying toavoid unwanted thoughts, but also avoiding opportunities for positive reinforce-ment. The therapist might also point out that the adolescent can interact with herpeers even while having the thought ‘I am such a loser’.
In the next step, Table 1 shows how ACT contrasts the suffering that arises when an individual spends more time thinking about the past or fearing the future— living in their heads — than living in the present moment. This is most evidentwith worrying and rumination. ACT attempts to help individuals experience the present so they can contrast this as a different experience to worry and ruminationover the past or future. A range of mindfulness techniques would be used, manyadapted from other mindfulness work (e.g., see Hayes, 2004; Kabat-Zinn, 2005;Segal et al., 2004). In the present example, a simple mindful exercise is constructedwith the adolescent’s input, and with regular practice facilitates experiencing theworld directly. This direct experience would be reinforcing and therefore becomecontingently controlled.
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Louise Hayes, Patricia A. Bach and Candice P. Boyd The process, entitled ‘self-as-content versus self-as-context’, can be confusing for people trying to understand the ACT model. Self-as-content describes the conceptu-alised self, which is evident in the descriptors, labels, and images that an individualconstructs. For example, ‘I am right’, or ‘I am worthless’. The ACT model purportsthat when one is too attached to these conceptualisations they take on a regulatoryrole, reducing flexibility and inhibiting behaviour (Hayes et al., 2006). ACTapproaches this by using experiences that help an individual to gain perspective onthis process and to experience their ‘self’ as the context in which all thoughts andbehaviours arise. In other words, their thoughts come and go, but they are not theirthoughts. In the example shown in Table 1, a mindfulness exercise is used where theadolescent imagines that her thoughts and other ‘content’ are black and white chesspieces, but she is the chess board — unchanging and able to hold all the experiences,thoughts and feelings (metaphor adapted from Hayes et al., 1999).
Values work is the heart of ACT (Bach & Moran, 2008). Eliciting deep-seated values can provide the motivation needed for behaviour change and build willing-ness to experience unwanted thoughts and feelings that might accompany valuedaction. The model purports that lack of valued living, unclear values, excessive pli-ance, or avoidant tracking are all evidence of psychological inflexibility. Thesebehaviours share a commonality in that they all pull the client away from behaviourthat is self-fulfilling. For example, an individual that shows excessive pliance wouldbehave in socially expected ways in order to please the peer group, rather thanbehaviour that is personally meaningful. For adolescents, pleasing peers is particu-larly pertinent. The ACT therapist would help the client make overt what is trulyimportant in their life and to have them engage in behaviours that serve what theyvalue most. However, asking an adolescent a question such as ‘What do you reallycare about?’ can easily lead to a blank stare (this can happen with adults too!) or asocially expected response. So once again, an experiential exercise is used to helpthem express what is most important to them. These exercises aim to elicit what isimportant in their lives, rather than what they expect the therapist wants to hear.
In our example in Table 1 we have used clay, and the adolescent is asked to makesymbols of things in life that they value, these models can be quite powerful andbecome visual aids when goal setting. Values create meaning and direction in life.
The final process shown in Table 1 is committed action, which includes behavioural activation, skills training, exposure, and other techniques common tomany behaviour therapies. ACT purports that individuals who are psychologicallyinflexible behave impulsively, have difficulty taking goal-directed action, and fail tokeep commitments or avoid setting goals at all. The ACT therapist would use anindividual’s values as the reason to commit to action. From there basic behaviouralinterventions would be used, including small action changes, setting goals, andweekly homework.
In summary, we have attempted to show how ACT can be adapted for adoles- cents and that it can add value to current treatments for depression. ACT aims todevelop psychological flexibility and so the approach used is flexible. The startingpoint depends on the clinical issue presented. A range of techniques would be used,each aimed at using experiences to contingently control behaviour. Table 1 servesonly to demonstrate one example; the interested reader is encouraged to view themany practical texts (Bach & Moran, 2008; Greco, Blackledge, Coyne, &Ehrenreich, 2005; Hayes et al., 1999; Strosahl & Robinson, 2008; Zettle, 2007).
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Psychological Treatment for Adolescent Depression Effectiveness of Acceptance and Commitment Therapy The majority of ACT therapeutic trials have been with adults and it presents verynew territory for adolescent therapeutic work. There are some promising outcomesusing ACT with adolescents, although in the typical pattern there is a lag, so wewill first consider a brief overview of the larger body of work using ACT with adults.
ACT reviews have shown that for adults, this treatment can achieve positive long-term outcomes for depression, anxiety, psychosis, chronic pain, work stress,stigma and burn-out (Hayes et al., 2006; Hayes, Bissett et al., 2004). In the 2006review (Hayes et al., 2006), across 21 studies the weighted mean effect size was 0.66at post-treatment (N = 704) and this was maintained at follow-up with an effect sizeof 0.66 (N = 519). The effect sizes of 0.48 (N = 456) are large when compared withactive well-specified controls at post-treatment, and they remain large at follow-up0.63 (N = 404) suggesting good maintenance and continued improvement (Hayeset al., 2006). When compared with waitlist conditions, treatment-as-usual, orplacebo, the effect size is large at post-treatment, 0.99 (N = 248) and again this ismaintained at follow-up, 0.71 (N = 176). With regard to depression, the first ACTtrial (ACT was initially called comprehensive distancing) was a comparison ofACT and CT with adults (Zettle & Hayes, 1986). The results were superior forACT, showing an effect size at post-treatment of 1.28 (N = 18) and this continuedthrough to the 3-month follow-up with an effect size of 0.92 (Hayes et al., 2006). Asecond trial of group ACT therapy for depression also compared ACT and CT andfound both treatments produced similar positive outcomes (Zettle & Rains, 1989).
Although these results are for adults, they attest to the positive outcomes beingshown for ACT, and demonstrate that the treatment gains are maintained. Of inter-est is the finding that effect sizes have improved from post-treatment to follow-up intwo studies (Hayes, Bissett et al., 2004; Zettle & Rains, 1989).
In adult studies, the underlying principles of ACT have been demonstrated in correlational meta-analysis across 32 studies with 6,628 participants (Hayes et al.,2006). In this analysis psychological flexibility, as measured in ACT using theAcceptance and Action Questionnaire, was associated with improved quality of lifeand life outcomes. Psychological flexibility has also been correlated with lowerlevels of mental ill-health (Bond & Bunce, 2000, 2003; Donaldson-Feilder & Bond,2004); and longitudinally, greater levels of acceptance predict better mental healthone year later (Bond & Bunce, 2003). Mediational analysis to test the process ofchange in ACT treatment work is beginning to show that ACT processes mediatethe changes seen in therapy. For example, using the ??Hayes and Zettle (1986) dataon depression to test for mediation, Hayes et al. (2006) found that the believabilityof depressive thoughts taken mid-treatment were predictive of significantly differenttreatment outcomes for ACT when compared with CT. Whether ACT can deliveranything new to adolescents will remain unanswered, but the above suggests thatthere is a different process to be tested.
ACT research for adolescents is preliminary but encouraging. Empirical work on psychological inflexibility in adolescents (two samples, N = 513 and N = 675) hasshown that inflexibility is positively correlated with clinical measures of anxiety,somatisation, and behaviour problems; and negatively correlated with quality of life,social skills and academic competence (Greco, Lambert, & Baer, 2008). Withregard to treatment studies, Wicksell and colleagues trialled ACT on adolescentswith chronic pain across two studies, a randomised controlled trial (Wicksell,Melin, Lekander, & Olsson, 2009) and an earlier pilot study (Wicksell, Melin, & Behaviour Change
Louise Hayes, Patricia A. Bach and Candice P. Boyd Olsson, 2007) and found that ACT treatment resulted in significant improvementsin functional ability, pain intensity, and pain-related discomfort. Adolescentstreated with ACT reported less catastrophising and lowered perceived pain(Wicksell et al., 2009), providing some encouragement toward pursuing ACT as atreatment for depression. In the school setting, an RCT comparing ACT to passivecontrol with adolescents has reported significantly improved outcomes up to twoyears later on measures of stress and psychological flexibility (Livheim, 2004).
Finally, the first author of this present work has under review two publicationsshowing promising results using ACT with adolescents experiencing depressivesymptoms in two settings, a clinical population treated in community health, andan early intervention program in schools.
Epidemiological data implies that depression in adolescence continues to be asignificant problem in developed countries and that little headway has been madein reducing its prevalence at a population level. In schools, prevention effortshave shown promising results at post treatment, but the effects have been difficultto sustain over time. With regard to clinical treatments for adolescent depression,psychotherapy continues to show positive effect sizes and CBT remains therecommended front-line treatment for mild-to-moderate depression, withpsychopharmacology used for nonresponders and severe depression. Despite thisstrong evidence, mediational and moderations studies are needed to demonstratehow the therapy works and on whom. Dissemination studies are also needed todemonstrate the effectiveness of psychotherapy in real-world settings (Roberts,Lazicki-Puddy, Puddy, & Johnson, 2003). So long as there are large numbers ofnon-responders new interventions are needed for those who fail to respond toexisting treatments.
Acceptance and Commitment Therapy may be a valuable approach for working with adolescents. ACT has philosophical foundations that emphasise the functionof behaviours, and is based on a theory of verbal behaviour that continues to betested in laboratory studies. ACT as a therapeutic approach aims to increase psy-chological flexibility. ACT does not specifically target symptom reduction, althoughsymptoms often do decrease following treatment (Hayes, et al., 2006). Psychologicalflexibility is the capacity to be in contact with the present moment while changingand/or persisting in behaviour consistent with chosen values. Recent ACT outcomeand mediational studies, albeit with adults, suggests that psychological flexibilitycan be a target of treatment, that it can show positive outcomes that are maintainedat follow-up, and in some studies the effects continue to grow over time (Hayes,Bissett et al., 2004). Thus, it seems appropriate to consider if ACT can be useful forprevention and treatment work with adolescents. Perhaps psychological flexibility can provide an alternative to self-esteem building often used in prevention work.
This seems critical given the alarming rise in the prevalence of adolescent depres-sion and that a greater vulnerability in cognitive development co-occurs with theidentity formation phase of adolescence. Acknowledgments
This article was funded by beyondblue: the national depression initiative.
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