Research Reviews

311

School-Based Group Psychotherapy

for At-Risk Adolescents
Lorie A. Ritschel, Ph.D.
Layne, C.M., Saltzman, W.R., Poppleton, L., Burlingame, G.M.,
Pasalic, A., Durakovic, E., et al. (2008). Effectiveness of a schoolbased group psychotherapy program for war-exposed adolescents: A randomized controlled trial. Journal of the American
Academy of Child and Adolescent Psychiatry, 47(9), 1048-1062.
Stice, E., Rohde, P., Seeley, J.R., & Gau, J.M. (2008). Brief cognitive-behavioral depression prevention program for high-risk
adolescents outperforms two alternative interventions: A randomized efficacy trial. Journal of Consulting and Clinical Psychology, 76(4), 595-606.

dolescence is a critical period for the development of psychological difficulties. Peak years for initial episodes of Major Depressive Disorder (MDD) are between 14 and 24 years of age (Kessler,
Avenevoli, & Merikangas, 2001); similarly, anxiety-spectrum disorders often emerge during adolescence (Kessler et al., 2005). A
substantial body of evidence supports the notion that recurrent
episodes of affective illness result in episode sensitization; that is,
greater incidences of depressive or bipolar episodes are related
to higher likelihood of additional future episodes (Kessing, Hansen, Andersen, & Angst, 2004; Post, 2007). Furthermore, children and adolescents with a psychiatric illness are at increased
risk for developing a comorbid disorder (Costello, Mustillo, Erkanli, Keeler, & Angold, 2003). Taken together, these findings
augur for the development of interventions aimed at mitigating
the impact of psychiatric illness in youth. Given the known genetic contributions of both affective and anxiety disorders (Martin,
Ressler, Binder, & Nemeroff, 2009; Sullivan, Neale, & Kendler,
2000) as well as the impact of trauma on mood (McEwen, 2008),

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it is particularly important to target at-risk youth.

School-based prevention programs capitalize on making use of
the adolescents natural environment to provide needed mental
health services. This article reviews two randomized controlled
studies of school-based group therapy interventions designed to
treat at-risk adolescents. In the first study, Layne and colleagues
(2008) tested the efficacy of Trauma and Grief Component Therapy (TGCT) in a sample of adolescents at risk for the development of PTSD, depression, and grief based on their experiences
growing up in Bosnia during wartime. TGCT for adolescents
is a manualized, group-based intervention that comprises four
modules: Module 1 provides psychoeducation about trauma and
teaches emotion and behavioral regulation skills; Module 2 allows adolescents to process their traumatic experiences; Module
3 focuses on healthy ways to cope with grief; and Module 4 helps
adolescents cognitively reappraise the trauma they experienced,
engage in better problem-solving, address and reduce risky behaviors, and build social skills. TGCT has been utilized with other traumatized adolescent populations, and effectiveness studies
have been reported (see Layne et al., 2001); however, this study is
the first randomized controlled trial of TGCT with adolescents.
Students at 10 high schools in central Bosnia were screened to
determine eligibility; those who endorsed high levels of trauma
exposure along with increased distress, depression, and functional impairment were included in the study. The final sample comprised 127 adolescents who were randomized to either TGCT (n
= 66; mean age = 15.9 years) or a psychoeducation-based comparison condition (n = 61; mean age = 16.0). Participants in the TGCT
condition attended 17-20 group therapy sessions over the course
of the school year. Participants in the comparison condition received psychoeducation about common reactions to trauma, relaxation training, social support, and problem solving skills. The
authors hypothesized that: (1) participants in both conditions
would show significant reductions on measures of posttraumatic
stress, depression, and maladaptive grief; (2) participants in the
TGCT condition would show greater reductions on all symptom
measures and would have significantly lower general distress
scores at post-treatment; and (3) participants in both conditions
would maintain their gains at 4-month follow-up.

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Analyses comparing pre- to posttest results showed that scores

on measures of PTSD decreased significantly in both conditions.
Only participants in the TGCT condition showed significant decreases in depression and maladaptive grief reactions. Although
follow-up analyses were limited due to attrition, results showed
that PTSD and depression scores decreased significantly from
posttest to 4-month follow-up in both conditions. In terms of reliable improvement from pretreatment to follow-up, odds ratios
indicated that outcomes favored TGCT over the comparison condition. That is, more TGCT participants than comparison group
participants improved over time (61% vs. 47% for depression;
81% vs. 48% for PTSD), and fewer TGCT participants (0%) deteriorated than in the comparison condition (7%).
Several points about this study merit discussion. First, the four
modules in the TGCT intervention were flexibly implemented in
order to accommodate the strengths and weaknesses of each group
(e.g., cohesiveness, marginalization); group therapists created lesson plans each week that were tailored based on group membership and dynamics. This represents a unique aspect of the protocol in that therapists were given considerable latitude in adapting
the treatment. It is somewhat unclear, however, how the groups
differed and how the treatment was modified to accommodate
these differences. It should be noted that the supervision plan for
the TGCT condition was quite good; supervisors reviewed lesson
plans and notes after each group to ensure treatment fidelity.
Second, this was a study of two active interventions; furthermore, the treatment for the comparison condition was taken directly from the TGCT manual. Thus, this may have more closely
approximated a dismantling study in that the authors essentially
investigated whether the full TGCT package is needed for reducing PTSD and depression symptoms or whether a portion of the
manual suffices. In addition, the authors did not note how many
sessions were offered to participants in the comparison condition, and they did not evaluate a dose effect to determine if the
number of sessions attended was related to treatment outcomes.
Finally, no outcome measures were included to assess problemsolving or risky behaviors, both of which were treatment targets.
In general, however, participants in both conditions derived benefit from the treatments.

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

6-session Cognitive Behavioral Prevention Intervention (CB) for
adolescents at risk for depression. Interested participants were
screened with the Center for Epidemiologic Studies-Depression
Scale (CES-D; Radloff, 1977) and were included if they exhibited
elevated symptoms of depression but did not meet full criteria
for MDD. The final sample comprised 341 high school age adolescents (mean age = 15.6 years) who were randomized to one of
four conditions: CB group therapy (n = 89), supportive-expressive
group therapy (n = 88), self-directed bibliotherapy (n = 80), or an
assessment-only control condition (n = 84). The CB intervention
focused on increasing pleasant activities and positive cognitions,
while the supportive-expressive condition focused on allowing
participants to express their feelings in a nonjudgmental environment. Both groups met once weekly for 6 sessions, and each
group comprised 6-10 participants. Participants in the bibliotherapy condition read a self-help book called Feeling Good (Burns,
1980), and participants in the assessment-only control condition
were given a brochure to read about depression and completed
the same assessments as participants in the other three conditions. The comparison interventions (i.e., supportive-expressive
group, bibliotherapy) were hypothesized to represent the active
ingredients of the CB intervention; that is, supportive-expressive
therapy included the non-specific therapeutic factors thought to
play a major role in the change process (cf., Ilardi & Craighead,
1994) but none of the active ingredients of CBT. Conversely, the
bibliotherapy condition included most of the content of the CB
intervention without the nonspecific therapeutic factors.
Results were reported from posttest and 6-month follow-up assessments. At posttest, CB participants had the greatest decreases in depressive symptoms when compared to the other three
conditions, and participants in the supportive-expressive group
had greater symptom reductions than bibliotherapy. At followup, participants in the three treatment conditions had greater
symptom reductions than controls, and there were no differences
between the three active conditions. CB participants also had
better outcomes on measures of social adjustment and substance
use. At follow-up, just over 7% of the full sample met criteria for

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MDD, with significantly more control participants meeting MDD

criteria than any of the three active treatments.
Several points about this study bear mention. First, although
this was a relatively brief intervention, effect sizes for reductions
in depressive symptoms (d = .46 at posttest; d = .42 at follow-up)
in the CB condition were comparable to longer and more comprehensive interventions (Horowitz & Garber, 2006). Second, the
participant sample was relatively diverse (2% Asian, 9% African
American, 46% Caucasian, 33% Hispanic, 10% Other/Mixed
heritage), suggesting that the intervention may be generalizable
to a wide range of youth. Finally, the authors noted that participants attended just over half of the sessions offered (mean attendance = 3.3 of 6 sessions), suggesting that brief interventions for
at-risk adolescents are beneficial.
Taken together, findings from these two studies suggest that
classroom-based interventions represent a viable mechanism for
delivering group psychotherapy to at-risk adolescents. Although
these studies differed in numerous ways, both found that mental
health outcomes can be improved while harnessing the power of
adolescents natural daily environment: school. Because of the
long-term impact of mood and anxiety disorders on functional
outcomes and quality of life, early intervention and prevention
programs are necessary. These findings suggest that classroombased interventions are a feasible and effective way of providing
treatment for at-risk youth.

REFERENCES
Burns, D. D. (1980). Feeling good: The new mood therapy. New York: HarperCollins.
Costello, E. J., Mustillo, S., Erkanli, A., Keeler, G., & Angold, A. (2003).
Prevalence and development of psychiatric disorders in childhood
and adolescence. Archives of General Psychiatry, 60(8), 837-844.
Horowitz, J. L., & Garber, J. (2006). The prevention of depressive symptoms in children and adolescents: A meta-analytic review. Journal
of Consulting and Clinical Psychology, 74(3), 401-415.
Ilardi, S. S., & Craighead, W. E. (1994). The role of nonspecific factors
in cognitive-behavior therapy for depression. Clinical Psychology: Science and Practice, 1(2), 138-155.

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Research Reviews

Kessing, L. V., Hansen, M. G., Andersen, P. K., & Angst, J. (2004). The
predictive effect of episodes on the risk of recurrence in depressive
and bipolar disordersa life-long perspective. Acta Psychiatrica Scandinavica, 109, 339344.
Kessler, R. C., Avenevoli, S., & Merikangas, K. R. (2001). Mood disorders in children and adolescents: An epidemiologic perspective.
Social Biology and Psychiatry, 49, 1002-1014.
Kessler, R. C., Berglund, P., Demler, O., Jin, R., Merikangas, K. R., &
Walters, E. E. (2005). Lifetime prevalence and age-of-onset distributions of DSM-IV disorders in the National Comorbidity Survey
Replication. Archives of General Psychiatry, 62(6), 593-602.
Layne, C. M., Pynoos, R. S., Saltzman, W. R., Arslanagi, B., Black, M.,
Savjak, N. et al. (2001). Trauma/grief-focused group psychotherapy: School-based postwar intervention with traumatized Bosnian
adolescents. Group Dynamics: Theory, Research, and Practice, 5(4),
277-290.
Layne, C.M., Saltzman, W.R., Poppleton, L., Burlingame, G.M., Pasalic, A., Durakovic, E., et al. (2008). Effectiveness of a school-based
group psychotherapy program for war-exposed adolescents: A randomized controlled trial. Journal of the American Academy of Child
and Adolescent Psychiatry, 47(9), 1048-1062.
Martin, E. I., Ressler, K. J., Binder, E., & Nemeroff, C. B. (2009). The
neurobiology of anxiety disorders: Brain imaging, genetics, and psychoneuroendocrinology. Psychiatric Clinics of North America, 32(3),
549-575.
McEwen, B. S. (2008). Central effects of stress hormones in health and
disease: Understanding the protective and damaging effects of
stress and stress mediators. European Journal of Pharmacology, 583,
174-185.
Post, R. M. (2007). Kindling and sensitization as models for affective
episode recurrence, cyclicity, and tolerance phenomena. Neuroscience & Biobehavioral Reviews, 31(6), 858-873.
Radloff, L. S. (1977). The CES-D Scale: A self-report depression scale
for research in the general population. Applied Psychological Measurement, 1(3), 385-401.
Stice, E., Rohde, P., Seeley, J.R., & Gau, J.M. (2008). Brief cognitive-behavioral depression prevention program for high-risk adolescents
outperforms two alternative interventions: A randomized efficacy
trial. Journal of Consulting and Clinical Psychology, 76(4), 595-606.

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Sullivan, P. F., Neale, M. C., & Kendler, K. S. (2000). Genetic epidemiology of major depression: Review and meta-analysis. American
Journal of Psychiatry, 157, 1552-1562.
Lorie A. Ritschel, Ph.D.
Atlanta, GA
E-mail: Lorie.ritschel@emory.edu

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