A COGNITIVE-BEHAVIORAL-BASED GROUP THERAPY MANUAL FOR

ADOLESCENTS WITH DEPRESSION

Nikki B. Sarmiento
De La Salle University
Graduate School
PSY524M
September 2013

Table of Contents

I.

Introduction and Review of Related Literature . . . . . . . . . . . . . . . . . . . . . . . . . . .

A. Social View of Adolescence . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

B. Adolescent Depression Versus Adult Depression . . . . . . . . . . . . . . . . . . . . . . .

C. Psychological Definition of Depression . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

D. Global Prevalence of Depression and Suicide . . . . . . . . . . . . . . . . . . . . . . . . .

E. Mental Health of Adolescents in the Philippines . . . . . . . . . . . . . . . . . . . . . . .

F. Roots of Adolescent Depression . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

10

G. Effective Interventions . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

12

II.

Overview of the Nature of the Group . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

14

III.

Target Clients . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

15

A. Inclusion Criteria

...............................................

15

B. Exclusion Criteria . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

15

C. Recruitment Process . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

15

IV.

Group Norms

.....................................................

18

V.

Group Sessions . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

19

A. Group Therapy Goals . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

20

B. Essential Elements of the Group Therapy Process . . . . . . . . . . . . . . . . . . . . . .

21

C. Summary of Objectives and Interventions . . . . . . . . . . . . . . . . . . . . . . . . . . . .

21

D. First Session

...................................................

23

E. Second Session . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

26

F. Third Session

28

..................................................

G. Fourth Session

.................................................

30

H. Fifth Session . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

33

I. Sixth Session . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

35

J. Seventh Session . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

36

K. Eighth Session

38

.................................................

L. Ninth Session . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 41
M. Tenth Session . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 43
N. Eleventh Session . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

46

O. Twelfth Session

46

................................................

P. Thirteenth Session

..............................................

47

Q. Fourteenth Session

..............................................

50

VI.

References . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

51

VII.

Appendix . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

53

I.

Introduction and Review of Related Literature

Social View of Adolescence

According to a cross-cultural study conducted by Offer et al. (1988, as cited in
Santrock, 2007, p. 8), adolescents were globally self-confident and optimistic about their
future. Majority of adolescents residing in different countries, or approximately 73
percent, perceived themselves positively and maintained high levels of happiness, life
enjoyment, self-control, career and school orientation, security in ones sexuality,
pleasant family dynamics and strong coping strategies. This is in contrast with G. Stanley
Halls (1904, as cited in Santrock, 2007, p.9), the father of the scientific study of
adolescence, notion that adolescence is primarily a stage of storm-and-stress. Various
factors may have contributed to this negativistic view of the adolescence period. The
biased perception that adults have of adolescents based on personal experience may be
one. Another is the unaccurate portrayal of the media that may have helped develop the
stereotype among adolescents as being more troubled, less respectful, more selfcentered, more assertive, and more adventurous than the previous generations. Positive
psychologists such as Seligman and Csikszentmihalyi (2000, as cited in Santrock, 2007,
p. 9) believed that the field of psychology has emphasized on the negative side of the
individual for too long and proposed the time has come to turn the tables and focus on
interventions that capitalize on the character strengths of people, such as hope, optimism
and creativity.

There may be one major challenge to the well-meaning goal of utilizing so-called
character strengths to enhance and fulfill an individuals potential for growth.
Contemporary literature on the study of adolescence has acknowledged sadness or
depression as one of the most common reasons for recommending adolescents to seek
psychological treatment. This phenomenon is especially applicable among young females
(Santrock, 2007, p. 464). According to Birmaher et al. (1996, as cited in Haugaard, 2001,
p. 67), depression has became a widespread issue among adolescents and has been
affecting different aspects of their development, most notably in social relations.
Depression may be disguised as laziness or growing pains, making it difficult to notice
and address appropriately.

Adolescent Versus Adult Depression

Psychoanalysts initially proposed that children and early adolescents are
incapable of experiencing real depression, attributing the development of depression with
the maturity of the superego which begins in late adolescence. The concept of masked
depression supported the belief that depressive disorders can also occur in childhood and
adolescence albeit expressed differently. Instead of depressed mood, adolescents with
depression may manifest hyperactivity, conduct problems, and learning disabilities
(Haugaard, 2001, p. 69). Irritability is also considered as a depressive symptom specific
to adolescents (Nilsen, 2012). Eventually, several studies have found that the depression
experienced by adolescents is similar to that experienced by adults and that depression
in adolescence often continued into adulthood in the same form. In 1966, depression
was acknowledged as a mental disorder among adolescents and in 1980, depression

became part of the Diagnostic and Statistical Manual of Mental Disorders-III list of
disorders among children and adolescents (Haugaard, 2001, p. 69). The findings of
present studies confirmed that adolescence is a high-risk period for the emergence of
depression. Depressive symptoms and disorders become more frequent in late chilhood
and early adolescence, and reach their peak during middle to late adolescence (Nilsen,
2012).

Psychological Definition of Depression

The term depression may be often used to describe momentary feelings of sadness
or a temporary decreased mood, but in the field of psychology, depression may serve as a
label for mood disorders such as major depressive disorder (MDD) and dysthymia, which
are common diagnosed disorders among adolescents. MDD refers to a serious mental
condition that has significant negative impact on the well-being of an individual suffering
from it (Haugaard, 2001, p. 67). Affected adolescents may suffer from pervasive
depressed mood, anhedonia or lack of pleasure in activities once enjoyed, extremely high
or extremely low appetite than usual, sleep disruption, low energy level, notable periods
of restlessness or inactivity, feelings of worthlessness or guilt, concentration problems
and suicidal ideations. For an adolescent to become diagnosed with MDD, he or she must
be suffering from five of these symptoms, including depressed mood or anhedonia, for a
period of at least two weeks (Haugaard, 2001; Santrock, 2007; Nolen-Hoeksema, 2008).
Dysthymia, on the other hand, is a less severe but long-term form of MDD that may be
present among adolescents experiencing mild depressed mood for at least two years,
possibly with other symptoms (Haugaard, 2001). The symptoms of depression may

suggest the presence of hopelessness, including ideas that such grim and low condition
will not get better with any kind of intervention. This poses the challenge of increasing
hope as a character strength.

Aside from MDD and dysthymia, adolescents may also be diagnosed with
adjustment disorder with depressed mood. This happens when a young individual is faced
with a stressful life event and lacks effective coping strategies to deal with it. In an
adjustment disorder with depressed mood, the afflicted individual usually suffers from a
limited set of moderate symptoms such as sadness, tearfulness, and hopelessness for up
to a period of six months (Haugaard, 2001). Since issues with adjustment in the
adolescent stage are usually considered by adults as normal experiences, it may be
particularly important to distinguish a normal adjustment problem from an adjustment
disorder that already affects the functioning of the adolescent.

Global Prevalence of Depression and Suicide

The World Health Organization (as cited in Bromet et al., 2011) recognizes
depression as the fourth leading cause of disability globally while it is estimated to
become the second leading cause by year 2020. At present, depression continues to affect
approximately 350 million people around the world. About 1 in every 20 people from 17
countries who participated in the World Mental Health Survey experienced a depressive
episode during the past 12 months. Depression frequently develops at a young age
(World Health Organization, 2012, as cited in Marcus et al., 2011) and Compas and

Grant (1993, as cited in Santrock, 2007, p. 465) reported there are more cases of
depression among young people in their adolescent years than those in their elementary
school years.

The lifetime prevalance for depression among adolescents aged 13 to 18 years in

the United States is 11.2% (Merikangas et al., 2010) however evidence from a national
survey of the Substance Abuse and Mental Health Services Administation (SAMHSA)
suggests a variation by age, wherein adolescents aged 16 years (11.6%) reported a
considerably higher prevalence of depression than adolescents aged 13 years (3.9%)
(SAMHSA, 2008). Haugaard (2001) also noted that adolescents report more depressive
disorders and symptoms than children, and older adolescents report more depressive
disorders and symptoms than younger adolescents.

In addition, gender plays an important role in adolescent depression as by the time

adolescent females reach the age of 15, they tend to develop depression twice as likely as
adolescent males. Various factors are attributed to this trend namely pubertal changes,
coping strategies, and gender-role expectations (Nilsen, 2012; Santrock, 2007; Haugaard,
2001).

The World Health Organization (2012) recognizes that generally, at its worst,
depression can lead to suicide (para. 1). According to the Centers for Disease Control
and Prevention, National Center for Injury Prevention and Control (2010), suicide
remained as the tenth leading cause of death among people aged 10 years and older. An

analysis of age group differences revealed that suicide is the third leading cause of death
among people aged 15 to 24 years. From year 2005 to 2009, a majority of people from all
race and ethnicity groups aged 10 to 24 years attempted suicide and suffered from fatal
self-harm injuries through firearm use, followed by suffocation and poisoning. However,
males aged 10 to 24 years were more likely to choose firearms as the suicide method
while females aged 10 to 24 years tend to use suffocation. Gender differences also extend
to attempted suicides and the actual completion. Despite the fact that females are more
prone to depression and suicidal thoughts than males, the latter are four times more likely
to attempt and complete suicide. One significant factor may be accounted for the males
most common yet most lethal suicide mechanism.

Mental Health of Adolescents in the Philippines

According to the results of the Global School-based Student Health Survey
(GSHS) in the Philippines 2003-2004 as reported by the World Health Organization
(2013), depression, anxiety and mood disorders were found to be common mental
problems among youth (p. 7). Among the students who participated in the study, 10.5%
experienced long periods of loneliness in the past 12 months, 14.6% suffered from severe
insomnia due to anxiety during the past 12 months, 42% experienced strong feelings of
sadness or hopelessness that led to the disruption of their daily activities during the past
12 months, 17.1% seriously considered a suicide attempt during the past 12 months and
16.7% actually made concrete plans in committing suicide during the past 12 months.
Based on further findings, female 15 to 19 year olds (16.3%) had more suicidal thoughts
than male 15 to 19 year olds (6.4%). However, both sexes in the same age range engaged

in the same frequency of attempted suicides (22.4%). A considerable increase in

symptoms of depression among adolescents were contrasted by low figures in physical
activity status. During a typical or usual week, only 9% of the students were engaged in
physical activities for a total of at least 60 minutes each day while 29.3% spent a typical
day doing sedentary activities (e.g. sitting) for a period of three hours or more.

The findings of the 2002 Young Adult Fertility and Sexuality Study, commonly
referred to as YAFS 3 of the University of the Philippines Population Institute and the
Demographic Research and Development Foundation (UPPI-DRDF), showed similar
statistical findings about the prevalence of suicide and depression among the Filipino
youth. Additional data showed that young individuals who committed their first suicide
attempt had a mean age of 16. The newest update on the study which is called the YAFS
4, has already started last September 2012 and estimated to be finished by July 2014. The
update will tackle relevant issues that arose in the modern technological age, such as the
youths use of social media and cellular phones as well as cyberbullying.

Roots of Adolescent Depression

Tracing the root cause of an individuals clinical depression may be helpful in
distinguishing the most appropriate ways to treat the symptoms. However, doing so may
prove to be difficult due to the complex nature of such disorder. No single factor can
effectively account for the development of adolescent depression. Instead, an integrated
perspective backed up by research must be adopted to enhance our understanding of
depression symptomatology. Nilsen (2012) noted that adolescence is a critical time for

10

examining symptoms of depression, both regarding predictors to and consequences of

such symptoms (p. 1). Internalizing and externalizing problematic behaviors that started
during childhood may be risk factors for adolescent depression. The former refers to
feelings of sadness and fearfulness while the latter pertains to overt childhood behaviors
such as temper tantrums (p. 9). Maternal distress is also considered as a mediator between
problematic behaviors and the development of depressive symptoms, suggesting the
influence of biological and genetic mechanisms on adolescent depression. Mothers who
experienced feelings of anxiety and depression during pregnancy coupled with ineffective
parenting and poor mother-child interactions during childrearing may encourage the
development of problematic childhood behaviors that consequently lead to depression (p.
10). In developing countries, maternal distress may influence the poor development
among children (Rahman et al., 2008, as cited in Marcus et al., 2012). However, there is
also evidence suggesting that genetic factors are more instrumental than environmental
factors (e.g. family environment) in the development of moderate adolescent depression.
Meanwhile, adolescents with severe depression are more likely to be influenced by the
environment (Rende et al., 1993, as cited in Haugaard, 2001, p. 73).

Beck (1979, as cited in Haugaard, 2001, p. 74) noted that adolescents with
depression tend to develop patterns of negative thinking that influence their views of
themselves, their world, and their future, also called the cognitive triad of depression.
Adolescents with negative views of themseles tend to have poor self-esteem and their
negative views of the world reinforce their negative perception of events that
continuously happen in their lives. Their negative views of the future bring feelings of

11

hopelessness as well. Altogether, these thoughts lead the adolescents to depression and to
social withdrawal. By withdrawing from their world, they have less time to experience
pleasant activities and more time to ruminate about their weaknesses and unhappiness.
When the patterns of negative thinking became so pervasive and ingrained, adolescents
find it extremely difficult to view themselves positively. Studies have established that
adolescents with depression possess significantly more negative cognitions than those
who do not have depression. Moreover, these negative cognitions are significantly
associated with depression and anxiety, which suggests that negative thinking patterns are
risk factors for several disorders other than depression.

The stress-exposure model also suggests that adolescents who are exposed to
stressors become at risk for developing depression (Nilsen, 2012). However, males and
females differ in their ways of coping with the stressful events that they encounter in their
environment. Evidence suggests that females tend to cope with stress by rumination or
excessive thinking and by forming negative perceptions about themselves while males
tend to engage in activities that serve as distration and to express hostility against others
(Haugaard, 2001).

Effective Interventions
The World Health Organization (2012) states that prevention programs decrease
the incidence of depression and the development of symptoms (para. 10). Among
adolescents, school-based interventions that strengthen cognitive, problem-solving and
social skills may be the most effective. In terms of treatment, psychosocial interventions

12

are the most effective and suitable first line treatment for mild forms of depression.
Although antidepressants combined with psychotherapy are usually suited for moderate
to severe forms of depression (para. 11), antidepressants are discouraged from being used
as the first line of treatment among adolescents (para. 12). This may be in relation to the
updated black box warning proposed by the U.S. Food and Drug Administration (2007)
to be included in the labeling of antidepressants. The said warning pertains to the
increased risks of suicidal thinking and behavior, known as suicidal thinking and
behavior, known as suicidality, in young adults ages 18 to 24 during initial treatment
(para. 1). Celexa, Lexapro, Prozac and Zoloft are some of the most commonly prescribed
antidepressants that are included in the list subject to revision of product labeling (para.
10). In addition, antidepressants may be ineffective in reducing pervasive faulty
cognitions related to depression (e.g. negative automatic thoughts, selective attention,
overgeneralization, personalization), which may be better addressed by cognitive therapy
coupled with social skills training. Therefore, such combination appears to be the most
effective for long-term treatment (Haugaard, 2001).

According to Lewinsohn and Clarke (1999, as cited in Haugaard, 2001, p. 83),

cognitive therapy appears to be effective in treating the depression among children and
adolescents. Beck et al. (1979, as cited in Haugaard, 2001, p. 83) stated that the cognitive
therapist helps the adolescent identify negative cognitions and equip him or her with the
skills needed to challenge and change them so that in the end, negative cognitions are
replaced by healthier ones.

13

Although cognitive therapy may help correct the negative thinking patterns of
adolescents, if the social skills of the adolescent are weak, it may eventually trigger and
reinforce negative evaluations of oneself (Haugaard, 2001). Poor social skills may also
lead the adolescent to become vulnerable to psychosocial problems when faced with
various stressors in ones ever-changing environment (Nilsen, 2012). This indicates that
social skills training may be also valuable to the treatment of adolescent depression.

II.

Overview of the Nature of the Group

Harbingers of Hope (HoH), the proposed name of the group, will be a closed
psychotherapy group which utilizes cognitive-behavioral interventions and social skills
training for adolescents with depression in public and private high schools (equivalent to
grades 7 to 12) in Metro Manila. Ideally, the group may be composed of at least 6
members to 10 at the most. Yalom (2005) contended that the ideal size of an
interactional therapy group is approximately seven or eight to as high as twelve.
However, Grantham, Budnik and Musham of The Skills Development Service argued
that group size plays an important role in the success of the group therapy. Based on the
preliminary results of their research, it was reported that adolescents worked better with
smaller numbers. e.g. 4 8 (Grantham, Budnik & Musham, n.d.). In the event that the
number of good candidates significantly exceeds the ideal group size, more than one
group may be established. The group therapy will run for 14 one-hour sessions held
weekly for about 5 months or one school semester. The sessions may be conducted on
Fridays after school hours.

14

III.

Target Clients

A. Inclusion Criteria

a. Group member should be in high school (grades 7 to 12) or around 12 to 17

years of age.
b. Group member should be suffering from mild to moderate depression, as
measured by a score of 14 to 28 on the Beck Depression Inventory-II.
c. Group member should have sufficient comprehension skills that would allow
the mastery of materials presented in the sessions.

B. Exclusion Criteria

a. Group member suffering from a mental disorder that would remarkably hinder
the therapeutic process, such as bipolar disorder, panic disorder, or conduct
disorder.
b. Group member suffering from a suicide crisis.

C. Recruitment Process

This manual will be marketed to the Department of Education for use in

public high schools in Metro Manila, then to the guidance offices of private
educational institutions in the same vicinity. The implementation of this manual will

15

also be subject to the approval of the school administrators. The initial projected cost
for 14 group therapy sessions for 8 public high school students, including the
materials, is PhP99,456 or P888 per person, per session. The psychological tests,
which may be provided by the guidance office or purchased by the researcher at the
schools expense, are excluded from the projected cost. The administration and
interpretation of the tests may be conducted by the schools licensed psychometrician
or psychologist, or by the researcher at a fixed professional fee of PhP500 per hour
(e.g. 5 hours incurred in psychological assessment, regardless of the number of
students, cost PhP2,500). For private educational institutions, the costs are higher and
may vary from one school to another upon agreement.

Before the actual recruitment of group members is attempted, a depression

awareness campaign is highly encouraged to gain the interest of the students and
parents and to reduce the stigma against depression. Teachers and guidance
counselors may work together to organize seminars that aim to educate the students
and their parents about the symptoms of clinical depression and effective
interventions, which will include the proposed therapy group. Engaging activities,
such as poster design-making contests, that support mental health awareness may also
be conducted. Such campaign may be implemented for at least a duration of 4 to 5
months, or equivalent to one school semester, to sustain the interest of the students in
the subject. Recruitment and referral may be led by the teachers and guidance
counselors. Parents may volunteer to subject their children to an assessment by a
licensed psychometrician or psychologist. The students, with the consent of their

16

parents, may also decide to undergo the screening if they think they are a likely
candidate for group therapy or if they believe they need help.

For the assessment or screening of students for group therapy, the following will
be used: interviews, questionnaires or tests (e.g. Beck Depression Inventory-II,
Dysfunctional Attitude Scale and Beck Scale for Suicide), and academic achievement
records (e.g. grades). The Beck Scale for Suicide is optional and is recommended to
be administered to students who obtained a score of 1 to 3 on the ninth item of the
Beck Depression Inventory-II or those who are believed to be at risk for suicide based
on clinical observation. Psychological assessment will be strictly conducted in private
to protect the students best interests.

During the pre-group preparation, recruited members and their parents will be
asked to complete and sign assent and consent for treatment forms that indicate the
adolescents voluntary participation in the group therapy. The forms will also include
details regarding the therapy process, the rights of the student and other legal
information.

As part of the pre-group preparation, the 96-item Values in Action (VIA)

Survey for Youth will be administered to assess the character strengths of each
recruited student. This information will be relevant in the fifth session where the
members will be able to determine their most valuable traits and be able to use them

17

to their advantage in relating with others. The test may be taken online at
http://viasurvey.org at no cost.

IV.

Group Norms

Attendance

Exercise a sense of commitment towards the group therapy process. Strive to

attend every session and dont drop out.

Be punctual. In case you wont be able to attend a session, inform the designated
person.

Confidentiality

Personal things (e.g. personal experiences) that are shared within the group are
not meant to be shared outside the group.

You are encouraged to share your learning experience to your family, friends and
other people in your communities. This may include your learning about
depression and the strategies we use in sessions to improve ourselves (e.g. use of
thought record, activity scheduling). Avoid sharing insight that touch upon the
personal issues of other members.

Group Participation

Allow everyone to have the chance to talk and while a member is talking, offer
support by listening.

18

Offer constructive feedback as much as possible and refrain from giving

judgmental comments (e.g. use of the word should, labeling an attitude or
behavior as right or wrong).

Dont force others to talk or do something if they dont want to.

Personal Efforts

Practice what you learn and do the homeworks. If you think you will find it
difficult to finish a homework, be open about it and discuss it in session.

Bring up any concern that you have in the group as soon as possible (e.g.
problems with the process, issues with other members) so they can also be
addressed immediately. The group is here to help, not serve as an additional
source of anxiety for you.

Outside Sessions
Be courteous to one another.
Avoid asking for personal favors from each other. If you have areas you need help
about, discuss them in session.

V.

Group Sessions

One of the strengths of Cognitive-Behavioral Therapy lies in its high structure.

Presented below is a list of the goals of the group therapy and the essential elements that
are consistently present in each session. A summary followed by detailed description of

19

what may transpire in each session, including the objectives and interventions, is also
showed. It is important for the group therapist to note that despite the structure, a certain
level of flexibility may be judiciously exercised to accommodate various spontaneous
factors that arise during the duration of the group therapy process, especially those that
render the objectives and/or interventions irrelevant or inappropriate to the actual needs
of the members at the time the session is held. To counterbalance the significant weight
of psychoeducation as a treatment strategy, the group therapist is expected to encourage a
great deal of sharing from every member (e.g. verbalization of insights or learning,
focused on cognitions and emotions, after every topic in psychoeducation). Social skills
trainings are also appropriately distributed across the group therapy sessions to increase
the value and effectiveness of the cognitive-behavioral interventions post-therapy.

When the group therapy commences, resources intended for the personal use of
the students may be sent electronically (e-mail or file transfer) for easy access and
reproduction.

Group Therapy Goals

Reduce depression to a level that no longer poses a risk to ones well-being (i.e. a
score of <14 on the Beck Depression Inventory-II)
o

Measured by Beck Depression Inventory-II

Gain mastery of insight on the influence of cognitions on ones emotions and

behavior

20

Measured by thought journal

Modify dysfunctional automatic thoughts into functional ones

o

Measured by thought journal

Modify core belief

o

Measured by core belief worksheet and thought journal

Improve social skills and maintain satisfying and meaningful relationships

o

Measured by personal report and direct observation

Essential Elements of the Group Therapy Process

Mood Check

Setting the Agenda

Review of Homework

Homework Assignment

Summary

Feedback

Summary of Objectives and Interventions

Session
1

Objectives
To understand the goals of the group
therapy and the group norms
To become acquainted with other group
members
To understand the cognitive model
To learn basic CBT concept: Automatic
Thoughts
To understand how thoughts affect your
mood in relation to depression

Interventions
Social Skills Training
Psychoeducation

Psychoeducation

21

10

11

To grasp the filling out of the mood diary

and thought journal
To learn basic CBT concepts: Intermediate
Beliefs & Core Beliefs
To distinguish automatic thoughts from
emotions
To learn a relaxation technique and apply
them in reducing anxiety from unhelpful
cognitions
To learn basic CBT concepts: Cognitive
Distortions (Part 1)
To acquire effective communication skills
when meeting new people
To learn basic CBT concepts: Cognitive
Distortions (Part 2)
To determine ones character strengths and
learn how to maximize them in social
interactions
To learn basic CBT concept: Coping
Strategies
To identify pleasant activities that can
considerably increase ones mood and that
one can personally commit in doing
To develop a daily life activity schedule
To identify and aim for a SMART goal
To identify and aim for additional SMART
goals
To learn how to start and end a conversation
To identify ones social support system
To identify positive and negative automatic
thoughts
To learn how to promote healthy thinking
To evaluate negative automatic thoughts
To learn how to respond to automatic
thoughts
To learn how to communicate effectively
through active listening and self-disclosure
To learn how to modify core belief (Part 1)

Psychoeducation
Relaxation Technique

Psychoeducation
Social Skills Training
Role-playing

Psychoeducation
Social Skills Training
Role-playing

Psychoeducation
Behavioral Activation

Behavioral Activation
Activity Scheduling
Behavioral Activation
Social Skills Training
Role-playing

Guided Discovery
Psychoeducation

Psychoeducation
Social Skills Training
Role-playing

Guided Discovery
22

12

To learn how to modify core belief (Part 2)

13

14

To learn another relaxation technique

To construct a life plan by the help of
guided imagery
To evaluate ones progress
To terminate the group therapy and ease the
transition by socialization

Cognitive Structuring
Guided Discovery
Cognitive Structuring
Relaxation Technique
Guided Imagery

First Session
Group Therapy Goals

Reduce depression to a level that no longer poses a risk to ones well-being (i.e. a
score of <14 on the Beck Depression Inventory-II)
o

Measured by Beck Depression Inventory-II

Gain mastery of insight on the influence of cognitions on ones emotions and

behavior
o

Modify dysfunctional automatic thoughts into functional ones

o

Measured by thought journal

Modify core belief

o

Measured by thought journal

Measured by core belief worksheet and thought journal

Improve social skills and maintain satisfying and meaningful relationships

o

Measured by personal report and direct observation

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Group Norms
Attendance

Exercise a sense of commitment towards the group therapy process. Strive to

attend every session and dont drop out.

Be punctual. In case you wont be able to attend a session, inform the designated
person.

Confidentiality

Personal things (e.g. personal experiences) that are shared within the group are
not meant to be shared outside the group.

You are encouraged to share your learning experience to your family, friends and
other people in your communities. This may include your learning about
depression and the strategies we use in sessions to improve ourselves (e.g. use of
thought record, activity scheduling). Avoid sharing insight that touch upon the
personal issues of other members.

Group Participation

Allow everyone to have the chance to talk and while a member is talking, offer
support by listening.

Offer constructive feedback as much as possible and refrain from giving

judgmental comments (e.g. use of the word should, labeling an attitude or
behavior as right or wrong).

Dont force others to talk or do something if they dont want to.

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Personal Efforts

Practice what you learn and do the homeworks. If you think you will find it
difficult to finish a homework, be open about it and discuss it in session.

Bring up any concern that you have in the group as soon as possible (e.g.
problems with the process, issues with other members) so they can also be
addressed immediately. The group is here to help, not serve as an additional
source of anxiety for you.

Outside Sessions
Be courteous to one another.
Avoid asking for personal favors from each other. If you have areas you need help
about, discuss them in session.

Getting-To-Know-Each-Other Activity
To reduce the members tension in their first ever group therapy session, a getting-toknow-each-other activity may serve this purpose. Discuss with the group the ways in how
they can show friendliness and make a list of their ideas on a writing board or large sheet
of paper for everyone to see (e.g. making eye contact with people as they speak and as
you listen, smiling, saying positive things and disclosing things about yourself). Assign
pairs of group members to engage in a getting-to-know-each-other conversation.
Encourage the members to practice the discussed ways on how they can show
friendliness. You may provide each member with the Conversation Questions for
Getting to Know Each Other Handout as a conversation guide or topic starter.

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Cognitive Model
Present and discuss an easy-to-understand PowerPoint presentation of the cognitive
model. Ask members to give their own examples of situations that can be looked at in
two different ways: positively and negatively.
For example, getting a poor grade in an exam may be looked at in two ways: (1)
as a reflection of ones incompetence or weakness in academics in general or in
the particular subject or (2) as a motivation to exert more efforts to understand the
lesson, including asking help from teacher. In the first perspective, the student
may tend to feel sad and frustrated, while in the second one, the student is more
likely to feel determined and optimistic.

Second Session
Eliciting Automatic Thoughts
To elicit a members automatic thoughts, recognize situations or stimuli that can evoke
automatic thoughts, which may be any of the following:

External event (or series of events)

Stream of thoughts

Cognition (thought, image, belief, daydream, dream, memory, flashback)

Emotion

Behavior

Physiological or mental experience

Then, ask What was going through your mind?

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If members find it difficult to answer the question, Beck (2011) suggests the following:
1. Ask them how they are/were feeling and where in their body they experienced
the emotion.
2. Elicit a detailed description of the problematic situation.
3. Request that the member visualize the distressing situation.
4. Suggest that the member role-play the specific interaction with you (if the
distressing situation was interpersonal).
5. Elicit an image.
6. Supply thoughts opposite to the ones you hypothesize actually went through
their minds.
7. Ask for the meaning of the situation.
8. Phrase the question differently.

Eliciting the members automatic thoughts are still relevant for the subsequent sessions
The therapist may follow this guide to identify additional automatic thoughts.

Influence of Thoughts on Mood

Provide each member with the How Thoughts Affect Your Mood handout and run
through each bullet while asking questions to the group. It is important for the members
to recognize the symptoms of clinical depression and understand how they are influenced
by underlying thoughts and emotions.
The following are questions for discussion and sharing (adapted from Muoz &
Miranda, 1996):

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What kinds of thoughts go through your mind when you feel depressed?

What do you do when you are depressed?

How do you get along with people when you are depressed?

What do you think is the cause of your depression?

What problems would you like to work on?

What are your goals for therapy?

Mood Diary and Thought Journal

Introduce the members to the use of a mood diary and thought journal and how it will
help them achieve the second therapy goal. Encourage the members to fill out their mood
diary daily and to write on their thought journal at least once or twice a week. Let each
member have a copy of the Mood Diary and Thought Journal sheets. It may be helpful to
let each member keep an envelope where they can store all paperworks starting from this
session.

Third Session
Distinguishing Automatic Thoughts from Emotions
To enable the members to differentiate between automatic thoughts and emotions, it is
helpful for them to distinguish among emotions, to label emotions and to rate the
intensity of emotions.
For instance, the group therapist may say:

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Feelings are what you feel emotionally usually theyre one word, such as
sadness, anger, anxiety, and so on. Thoughts are ideas that you have; you think of
them either in words or in pictures or images (Beck, 2011).

For this session objective, ask the members to fill out the Emotion Chart.

Jacobson Relaxation Technique

The following are the instructions for this progressive muscle relaxation technique
developed by Dr. Edmund Jacobson (as cited in Clarke, Lewinsohn & Hops, 1990):
1. Tense your arms and hands. Tighten your fists. Dont clench your teeth just
focus on your arms and hands. Make the muscles in your arms as tight as you
can. (after 5-7 seconds) Now relax your arms and hands. Imagine all the
energy going out of your arms through your fingertips. Your arms are as
relaxed as spaghetti noodles. You couldnt lift a feather.
2. Tense your face and head. Lift your eyebrows, squint your eyes, clench your
teeth. Make every muscle in your head as tight as you possibly can. (after 5-7
seconds) Now relax your face and head. Let your jaw relax, your eyelids
close, and your eyebrows relax. Now all of the energy is leaving your face.
3. Tense your shoulders and back, chest, and stomach. Take a deep breath and
hold it. Make your shoulders and back as tight as you can. Pull your stomach
muscles up tight. Dont tighten your arms, just your chest and main body.
Hold it. Keep it tight, tight, tight. (after 5-7 seconds) Now relax. Breathe out

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and let yourself breathe normally. Relax all of those muscles. Notice your
deep, rhythmic breathing and the pleasant sensations it produces.
4. Tense your legs. Tense your thighs. Lift your legs slightly off the ground.
Press your knees together. Tighten your calves. Press your toes against the
floor. Tighten your feet. Turn them up and point them toward your head. (after
3-5 seconds) Now relax. Let all the tension in your body go out through the
tips of your toes. Every last drop of energy is gone from your body. You are
totally relaxed. Imagine yourself on a warm beach with the sun shining on
your totally relaxed body. You dont have a care in the world.
5. (For 3-5 minutes, give occasional instructions to keep breathing regularly and
to relax tight muscles)
6. Slowly open your eyes. Move your arms and legs, wiggle your fingers and
toes. Slowly bring your body back to normal.

Fourth Session
Cognitive Distortions Part One

All-or-nothing

thinking

(also

called

black-and-white,

polarized,

or

dichotomous thinking): You view a situation in only two categories instead of

on a continuum.
Example: If Im not a total success, Im a failure.

Catastrophizing (also called fortune-telling): You predict the future negatively

without considering other, more likely outcomes.

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Example: Ill be so upset, I wont be able to function at all.

Disqualifying or discounting the positive: You unreasonably tell yourself that

positive experiences, deeds, or qualities do not count.
Example: I did that project well, but that doesnt mean Im competent; I just
got lucky.

Emotional reasoning: You think something must be true because you feel
(actually believe) it so strongly, ignoring or discounting evidence to the
contrary.
Example: I know I do a lot of things okay at work, but I still feel like Im a
failure.

Labeling: You put a fixed, global label on yourself or others without

considering that the evidence might more reasonably lead to a less disastrous
conclusion.
Example: Im a loser. Hes no good.

Magnification/minimization: When you evaluate yourself, another person, or a

situation, you unreasonably magnify the negative and/or minimize the
positive.
Example: Getting a mediocre evaluation proves how inadequate I am.
Getting high marks doesnt mean Im smart.
(as cited in Beck, 2011)

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Developing Communication Skills

Acquaint the members on how to develop effective communication skills to reduce the
tension and gain control in social situations, especially when meeting new people. The
following demonstration exercise was cited from Clarke, Lewinsohn & Hops (1990) for
this purpose:
Ask members to volunteer in role-playing five possible approaches to selfintroduction (1 negative, 4 positive):

Look shyly at your feet and dont say anything.

Make eye contact.

Smile.

Say a greeting.

Use the other persons name.

After the role-playing, ask the members to give comment on the approach that made the
best impression (most likely the fourth one). For the next activity, ask the members to
think and practice their greetings. Some guidelines to remember:

Its easier to start a conversation if you have thought of something to say

beforehand.

Its much better to include your conversational partners name when saying a
greeting.

Shaking hands may also be a good way to greet a person youve just met.

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Then ask the members to role-play using the four positive approaches when meeting
someone. Ask for the groups feedback after the exercise. Encourage positive remarks
and constructive criticism, if any. For the next one, describe a scenario where the member
is being introduced to an adult where the shaking of hands becomes appropriate. Ask
members to role-play again the four introduction skills together with handshaking.

For the last activity, ask the members to imagine themselves seating to a stranger on their
right. Ask the members to role-play how they are going to introduce themselves. Instruct
the conversational partner (acting as the stranger) to assume a different person including
a different name to give the role-playing a more realistic feel. To promote effect
modeling, ask the member who showed the best performance in the earlier exercises to
start the introduction. Ask what the members think and feel afterwards.

Fifth Session
Cognitive Distortions Part Two

Mental filter (also called selective abstraction): You pay undue attention to
one negative detail instead of seeing the whole picture.
Example: Because I got one low rating on my evaluation [which also
contained several high ratings] it means Im doing a lousy job.

Mind reading: You believe you know what others are thinking, failing to
consider other, more likely possibilities.
Example: He thinks that I dont know the first thing about this project.

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Overgeneralization: You making a sweeping negative conclusion that goes far

beyond the current situation.
Example: [Because I felt uncomfortable at the meeting] I dont have what it
takes to make friends.

Personalization: You believe others are behaving negatively because of you,

without considering more plausible explanations for their behavior.
Example: The repairman was curt to me because I did something wrong.

Should and must statements (also called imperatives): You have a

precise, fixed idea of how you or others should behave, and you overestimate
how bad it is that these expectations are not met.
Example: Its terrible that I made a mistake. I should always do my best.

Tunnel vision: You only see the negative aspects of a situation.

Example: My sons teacher cant do anything right. Hes critical and
insensitive and lousy at teaching.
(as cited in Beck, 2011)

Identifying Character Strengths

Prior to the start of the first session, the members have accomplished the Brief Strengths
Test that determine their character strengths. Provide each member a summary report of
his or her character strengths and discuss what each of the character strength means. Let
each member share his or her character strengths and ask for the rest of the group to think
of ways on how that member may be able to maximize his or her character strengths in

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relating with other people. As their homework, assign the members to emphasize on at
least one of their character strengths in a social-related task.

Sixth Session
Coping Strategies
Coping strategies are behavioral stategies that people develop and use to deal with an
irrational core belief. Although majority of coping stategies are normal, overuse of these
behaviors may impair the persons coping mechanism and may defeat the purpose of the
coping strategy in the first place, which is to reduce anxiety or tension. Some common
coping strategies provided by Beck (2011) consist of the following:

Avoid negative emotion

Try to be perfect

Be overly responsible

Avoid intimacy

Seek recognition

Avoid confrontation

Try to control situations

Act childlike

Try to please others

Display high emotion (e.g. to attract attention)

Purposely appear incompetent or helpless

Avoid responsibility

Seek inappropriate intimacy

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Avoid attention

Provoke others

Abdicate control to others

Act in an authoritarian manner

Distance self from others or try to please only oneself

Pleasant Activities
Implement behavioral activation by asking the members to make a list of activities, called
pleasant activities, which can help them feel better. This aims to break the downward
spiral trend that is usually experienced by people with depression. Ask the members to
think of activities that provide them enjoyment and promote a positive mood they need
not be special activities, they can be activities that one performs daily (e.g. drinking
coffee outdoors every morning, helping prepare the dinner, bathing the pets). As much as
possible, ask them to avoid sedentary activities (e.g. watching TV, browsing the Internet).
Activities that involve interacting with others are preferred. Provide each member with
the Pleasant Activities worksheet.

Seventh Session
Activity Schedule
Have the members come up with an activity schedule that can help them plan and
schedule their daily activities at the same time keep track of their mood after doing these
activities. Provide each member with the Activity Schedule worksheet. On the
worksheet, ask the members to fill out each timeslot with either a pleasure or mastery

36

activity. Pleasure activities (what we want to do) refer to those that provide enjoyment or
pleasure, such as solving crossword puzzles, reading books, or exploring new places
while mastery activities (what we need to do) refer to tasks that dont necessarily give us
pleasure but are important to perform, such as studying for an exam, doing the household
chores, or dressing up to go to school. As a homework assignment, accomplish the rating
column after doing the activities. For pleasure activities, assign a P followed by your
rating on a scale from 1 (minimal pleasure) to 10 (extreme pleasure). The number
describes the amount of pleasure you felt after doing that activity. For mastery activities,
assign an M followed by your rating on a scale from 1 (minimal sense of achievement)
to 10 (great sense of achievement). The number reflects your sense of achievement,
taking into consideration the difficulty of the activity and your feeling at the time.
Analyzing your activity schedule after a week may provide insight regarding mastery
activities that have a poor sense of achievement and pleasure activities that provide a low
level of pleasure.

SMART Goal
Ask each member to come up with a personal SMART (specific, measurable, attainable,
realistic, time-bound) goal that they must fulfill before the next group therapy session.
The SMART goal should refer to a pleasant activity that involves interacting with other
people (e.g. write a 3-stanza poem and recite it to a good friend at 4 oclock on Monday,
play basketball with classmates for 2 hours on Saturday). If a member is having difficulty
constructing his or her goal, other members may help by coming up with suggestions. It
is important for the member to be willing to fulfill his or her personal SMART goal. To

37

increase the motivation of the members, a contract may be written by each member
stating the goal and their commitment to it. Then, the members may specify something in
the contract that serves as their reward for themselves when their goal gets fulfilled (e.g.
expensive food treat).

Eighth Session
Additional SMART Goals
Now that the members were able to engage theirselves in aiming for a SMART goal or
pleasant activity, they are asked to come up with one or two more goals that they can
focus on for the rest the remaining sessions. Encourage them again to aim for goals that
involve interacting with others.

Joining and Leaving a Conversation Group

Members who wish to fulfill goals that require them to demonstrate effective
interpersonal skills may find this part valuable. Starting conversations with one or two
people may be easier and poses less risk than joining a group of several people. The
following demonstration exercise is performed by discussing the instructions and asking
several members to role-play (adapted from Clarke, Lewinsohn & Hops, 1990):
Joining a Conversation Group
Instruct several volunteers to form a standing conversation group and ask three
members to role-play the three approaches in joining a conversation group.

Go up to the group and push someone aside.

Stand far away.

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Stand near the group.

For each approach, ask the volunteers who are included in the initial conversation
group to demonstrate what they will do or feel in response to the member who
wishes to join their group.
For instance, the volunteers may be less likely to invite the member who
uses the second approach or stands far away. Meanwhile, the volunteers
are more willing to open up the circle of their group when a member
stands behind them or near the group.

Once the member is in the conversation group, discuss that he or she doesnt need
to talk or participate in the conversation right away rather he or she can merely
listen. When the member wishes to say something relevant to the topic, he or she
can begin by:

Asking a question.

Offering a fact.

Telling a story.

Leaving a Conversation Group

When other members in the group are still actively engaged in the conversation
and you need to leave the group:

Simply say Excuse me and leave with a smile or a nod

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After the exercise, ask for more ideas on how to join and leave a conversation
group. Have each member with an idea to role-play their approach and gather the
feedback of everyone on what approaches seem the most effective and least
effective.

Identifying Social Support System

Ask each member to make a list of the people or groups of people that comprise ones
social support system. The list may include but not limited to:

Family members (mom, dad, brother, sister, aunt, uncle, cousin and so on)

Friends

Members in a religious organization (priest or pastor, spiritual group

leader, churchmates)

Members of the school (guidance counselor, teachers, classmates, school

doctor, school librarian)

Members in a school club (club adviser, clubmates)

Members in any school organization

Members of the community (neighbors)

Members of the therapy group (therapist and co-members)

Anyone else you trust

The therapy group is also part of the members social support system. In a short activity,
hand out coloring pens and Post-Its of various colors to each member. Ask each one to
write down a short encouraging or positive statement for each member of the group, one

40

Post-It for each member. Afterwards, call out the name of the first member and ask the
rest stick their Post-Its on the person. Wait until all the members have been called out
before allowing the members to read their Post-Its. Facilitate a discussion about what the
activity made the members think and feel. Provide each member with a large corkboard
(use Cartolina paper as alternative) and more Post-Its to take home and as the homework
assignment, ask them to perform the same activity with all the people included in their
social support system. Let them arrange their corkboard on a conspicuous area of their
bedroom and use it to hold the Post-Its that include encouraging and positive statements
people wrote for them.

Ninth Session
Identifying Positive and Negative Automatic Thoughts
In a short group exercise (adapted from Clarke, Lewinsohn & Hops, 1990), ask the
members to worry covertly for 20 seconds. They may think of things that they do not
wish to happen, unpleasant experiences or present sources of anxiety. Next, have them
think positive thoughts for forty seconds. Encourage them to recall pleasant
experiences, their favorite things or their commendable traits. Give examples if
necessary. After the exercise, gather feedback about their experience. Discuss their mood
change and emphasize that they just deliberately exerted control over their thinking.

For the next activity, ask each member to come up with a list of their positive and
negative automatic thoughts. After about five to ten minutes, ask them to count the
positive and the negative thoughts. Ideally, positive thoughts should be twice as many as

41

the negative thoughts. When the number of negative thoughts are greater than the positive
ones, the member may learn to decrease negative thoughts by identifying the common
theme of the negative thoughts or those that occur frequently.
For instance, a member with negative thoughts such as:

I wont be able to get a grade higher than 80.

I wasnt able to read the assigned material again. I will surely be embarassed
by the teacher.

This topic is too hard, I cant understand it.

is most likely preoccupied with feelings of incompetence at a particular subject

and finds it hard to get past the thinking that he or she will not succeed.

Healthy Thinking
Provide each member with the Healthy Thinking handout and discuss each way of
increasing thoughts that produce a better mood and reducing thoughts that make us feel
bad. Let the members identify what way will work for them best or they think is the most
helpful.

Evaluation of Automatic Thoughts

The evaluation of a persons automatic thoughts may help him or her modify his or her
dysfunctional thinking. Beck (2011) proposes the following questions be used in
questioning automatic thoughts:
1. What is the evidence that supports this idea?
What is the evidence against this idea?

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2. Is there an alternative explanation or viewpoint?

3. What is the worst that could happen (if Im not already thinking the worst)?
If if happened, how could I cope?
What is the best that could happen?
What is the most realistic outcome?
4. What is the effect of my believing the automatic thought?
What could be the effect of changing my thinking?
5. What would I tell __________________ [a specific friend or family member]
if he or she were in the same situation?
6. What should I do?

Tenth Session
Responding to Automatic Thoughts
Ask the members to think of a situation that happened recently and that brought
unpleasant emotions that they found difficult to dismiss. Allow the members some time
to focus on that situation in preparation for the activity. Next, provide them with the
Testing Your Thoughts worksheet and go through each question together at the same
time.

Active Listening
Demonstrate active listening as an effective way to respond to what someone else is
saying. State the three rules for active listening and conduct the following exercises as
suggested by Clarke, Lewinsohn & Hops (1990):

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1. Restate the senders message in your own words.

2. Begin your statements with phrases like You feel..., It sounds as if you
think..., or Lets see if I understand what youre saying...
3. Dont show approval or disapproval of the senders message.

Ask the members to role-play active listening by following the three rules. Decide on a
speaker and a listener and repeat the exercise several times. Afterwards, obtain feedback
from the speaker on what he or she thought of and felt in the conversation. Have the
members engage in a role-playing exercise. This time, ask the speaker to make three
statements: one about himself or herself, one about the other persor (listener), and one
about the relationship between the two of them. Next, ask the listener to use active
listening skills and restate the speakers statements using his or her own words. Have the
pair switch roles and perform the same exercise. Finally, raise the following questions:
1. How did it feel to make a statement and have your partner restate it?
2. How did it feel to repeat the statement made by your partner in your own
words?
3. When you were the one who was listening, did you find that you had difficulty
understanding the message?
4. When you were the one talking or sending, did you find that the listener didnt
receive the message as you intended?

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Self-Disclosure
Introduce self-disclosure as another effective way to communicate with others. Selfdisclosing involves stating positive feelings and negative feelings. Provide each member
with the Self-Disclosure handout to serve as pointers for the self-disclosure exercises.

Ask the members to pair off with a member that they havent had the chance to work
with often. Ask the speakers to think of a problem situation to present to their partners
who will act as the active listeners. The speaker should present his or her problem
situation by making a statement about himself or herself, about another person or about
their relationship. Ask the listener to role-play the other person involed in the problem of
the speaker and use active listening to state in his or her words what the speaker has said.
Have the roles reversed afterwards. Raise the following questions afterwards:
1. How did it feel to make a self-disclosing statement and have your partner restate
it?
2. How did it feel to restate the feeling statement made by your partner?
3. When your partner was the speaker, was it difficult to understand his or her
message?
4. When you were the speaker, did you find that your partner had trouble receiving
your intended message?

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Eleventh Session
Identifying Core Beliefs
Beck (2011) states that core beliefs are ones most central ideas about the self and tend
to be global, rigid and overgeneralized. To help the members identify their core beliefs,
present them with the three categories of core beliefs and specific examples by providing
them the Categories of Core Beliefs handout. Core beliefs may be identified by
assessing the pattern or theme in ones automatic thoughts.

Provide members with the Core Belief worksheet and ask them to fill out the first part
(Identifying Themes from Thought Journal). Once the core belief is identified, proceed
to the challenging of core beliefs.

Challenging Core Beliefs

For the second part of the worksheet, ask the members to evaluate and challenge their
identified core belief by making a list of experiences that show that this belief is not
completely true all time. Encourage them to complete all 10 items. Afterwards, have the
members come up with a balanced core belief or an alternative belief after considering
the things that they have written down.

Twelfth Session
Behavioral Experiments
As continuation for modifying core beliefs, have the members fill out the third part of the
Core Belief worksheet. Ask them to think of specific tasks where they could put their

46

core beleifs to the test. Then have them write down what they predict would happen in
the outcome of each of the task if the core belief is assumed to be completely true. As
homework assignment, ask the members to carry out the tasks in their list and make a
record of what actually happened in each of the tasks. For the conclusion, have them
write down what they have learned from the experiment and the alternative, balanced
core belief.

Coping Cards
Provide the members with 3x5 unlined index cards and pens. On each card, have them
write down a dysfunctional automatic thought on one side (labelled as negative) and a
matching functional thought on the other side. Ask the members to include the most
frequent automatic thoughts. The members can insert these coping cards inside their
wallet or purse and carry them around all the time so that they can retrieve these cards
and read the positive, self-affirming statements when the dysfunctional automatic thought
gets triggered.

Thirteenth Session
Benson Relaxation Technique
Teach another relaxation technique that can also be used to reduce negative mood. The
technique was developed by Dr. Herbert Benson and the following instructions were
adapted from his book The Relaxation Response (2000):
1. Sit quietly in a comfortable position.
2. Close your eyes.

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3. Deeply relax all your muscles, beginning at your feet and progressing up to
your face. Keep them relaxed
4. Breathe through your nose. Become aware of your breathing. As you breathe
out, say the word, one, silently to yourself. For example, breathe in... out,
one, breathe in... out, one, etc. Breathe easily and naturally.
5. Continue for 10 to 20 minutes. You may open your eyes to check the time, but
do not use an alarm. When you finish, sit quietly for several minutes, at first
with your eyes closed and later with your eyes opened. Do not stand up for a
few minutes.
6. Do not worry about whether you are successful in achieving a deep level of
relaxation. Maintain a passive attitude and permit relaxation to occur at its
own pace. When distracting thoughts occur, try to ignore them by not
dwelling upon them and return to repeating one.
7. With practice, the response should come with little effort. Practice the
technique once or twice daily, but not within two hours after any meal, since
the digestive processes seem to interfere with the elicitation of the Relaxation
Response.

Guided Imagery & Life Plan

For the guided imagery exercise, ask the members to close their eyes and focus on your
voice. Ask them to imagine themselves walking down a flight of stairs leading down to a
path or road. Ask them to walk for some time and appreciate the nature around them then,
somewhere along the way let them encounter a fork in the path, splitting the road in two.

48

Both of these paths lead to their future 10 years from now. Assume that the left path leads
to a negative outcome while the right path leads to a positive or successful one. Ask them
to enter the left path first. Reassure them that you will be guiding them along the way and
that they will just be spectators in the negative version of their future. Ask them to
visualize a future in the next 10 years where their worries came true and their fears
materialized. Remind them that they are just visiting this path and that this is the last time
they will walk through it. Lead them at the end of the road and ask them to imagine being
transported to the path fork again. Now, let them take the right path. Ask them to
envision the future that they would like to have in the next 10 years. They might imagine
themselves on graduation day, getting praised by their parents, getting hired for a job or
meeting their future wives or husbands. Spend considerably more time in this path.
Eventually, lead them not to the end of the path but to a flight of stairs going up. When
they reach the door, ask them to turn the doorknob gently and ask them to open their eyes
slowly as they open the door.

For the next exercise, provide each member with a large white drawing paper (ex.
Cartolina) and coloring materials. Allow them to work on the ground if they wish and
encourage the sharing of art tools. Ask the members to illustrate on their drawing papers
how their right paths look like, including the emotions that they felt while experiencing
walking down it. They may feel free to get as creative as they can. When all members are
finished, let each member share his or her work. Give emphasis on what they thought and
felt during the experience.

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Fourteenth Session
Evaluation of Progress
Readminister the Beck Depression Inventory and Dysfunctional Attitude Scale prior to
the last group therapy session. Then during the session, evaluate each members progress
by asking the following questions:

Are you remembering to accomplish your mood diary every day?

Have you noticed any improvement in your mood?

Did you find any opportunities to practice your active listening skills? What
happened?

Have you tried using your active-listening skills while the other person was
stating a negative feeling?

Did you find opportunities to self-disclose? What happened?

What pleasant activities did you find the most helpful and engaging?

Did you use a relaxation technique to reduce tension? What happened?

Closing the Session

Utilizing the remaining time to socialize with the members. Schedule a meeting with any
member needing further intervention based on evaluation.

50

VI.

References
Bromet, E., Andrade, L.H., Hwang, I., Sampson, N.A., Alonso, J., de Girolamo, G., . . .
Kessler, R.C. (2011). Cross-national epidemiology of DSM-IV major depressive
episode. BMC Medicine, 9, 90.
Clarke, G., Lewinsohn, P. & Hops, H. (1990). Leaders manual for adolescent groups:
Adolescents coping with depression course. Retrieved July 20, 2013 from
http://kpchr.org
Centers for Disease Control and Prevention, National Center for Injury Prevention and
Control (2010). Web-based injury statistics query and reporting system
(WISQARS). Retrieved August 29, 2013 from http://www.cdc.gov/injury/
wisqars/index.html
Grantham, P., Budnik, J. & Musham, P. (n.d.). What is the ideal group size for a
therapy group? Retrieved August 21, 2013 from http://www.skillsdevelopment.
co.uk/files/GroupSizeReportEdited.pdf
Haugaard, J.J. (2001). Problematic behaviors during adolescence. New York: McGrawHill.
Marcus, M., Yasamy, M.T., van Ommeren, M., Chisholm, D. & Saxena, S. (2012).
Depression: A global public health concern. Retrieved August 29, 2013 from
http://www.who.int/mental_health/management/depression/wfmh_paper_depressi
on_wmhd_2012.pdf (Depression: A global crisis, 6-8)
Merikangas, K.R., He, J., Burstein, M., Swanson, S.A., Avenevoli, S., Cui, L... &
Swendsen, J. (2010). Lifetime prevalence of mental disorders in U.S. adolescents:

51

Results from the National Comorbidity Study-Adolescent Supplement. J Am Acad

Child Adolesc Psychiatry, 49 (10), 980-989.
Muoz, R. F. & Miranda, J. (1996). Group therapy manual for cognitive-behavioral
treatment of depression. Retrieved July 20, 2013 from http://rand.org/
Nilsen, W. (2012). Depressive symptoms in adolescence: A longitudinal study of
predictors, pathways and consequences (Doctoral dissertation).
Santrock, J.W. (2007). Adolescence (11th ed.). New York: McGraw-Hill.
World Health Organization (2012). Depression fact sheet N369. Retrieved August 29,
2013 from http://www.who.int/mediacentre/factsheets/fs369/en/ index.html
World Health Organization (2013). Health of adolescents in the Philippines. Retrieved
August

28,

2013

from

http://www.wpro.who.int/topics/adolescent_health/

philippines_fs.pdf
University of the Philippines Population Institute & Demographic Research and
Development Foundation (2006). The Filipino youth: 2002 YAFS Datasheet.
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28,

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filipino%20 datasheet.pdf
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thinking, behavior in young adults who take antidepressant medications.
Retrieved August 29, 2013 from http://www.fda.gov/NewsEvents/Newsroom/
PressAnnouncements/2007/ucm108905.htm

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VII.

Appendix

Wallet-Sized Copy of Group Norms

53