(p. 16) Selecting Adolescents to Participate in IPT-AST
Before beginning an Interpersonal Psychotherapy – Adolescent Skills Training (IPT-AST) group, the leader needs to identify adolescents who would be appropriate for and benefit from the program. The process through which the leader identifies appropriate group members will differ depending on the setting and the number of groups that can be offered at a given time. For our indicated prevention groups in schools, we have identified adolescents through a two-stage process. First, we screened large numbers of adolescents, using a self-report measure of depression. In our own work, we have utilized the Center for Epidemiological Studies Depression Scale (CES-D; Radloff, 1977). The CES-D is in the public domain, so it is available at no cost. Other self-report depression questionnaires, such as the Children’s Depression Inventory (Kovacs, 2003) or the Reynolds Adolescent Depression Scale (Reynolds, 2002), are also appropriate screening tools. In the second stage, we invited adolescents with elevated scores on the self-report measure to complete a more in-depth diagnostic assessment to determine whether they were appropriate for a prevention program or required more intensive services.
The benefit of the first stage is that it allows us to identify adolescents who might otherwise go undetected, creating a larger pool of youth to enroll in groups. The second stage provides important additional information to determine suitability for prevention groups. However, a larger screening followed by a diagnostic interview may not be feasible in certain settings and may not be the best approach if the goal is to identify a limited number of adolescents.
For universal and selective groups that occur outside school settings, we have invited families from the community to participate without any knowledge of their level of risk. The benefit of this process, as opposed to the one described previously, is that these families are interested in prevention, so less work needs to be done to persuade them of the possible benefits of participating. In these situations, we conduct a diagnostic assessment before group to make sure the adolescent is not currently depressed or does not have another emotional problem that would make the adolescent inappropriate for (p. 17) group. This process would translate well to settings that serve a particular community, where all youth could be invited to participate. IPT-AST groups could be implemented with adolescents who are interested in participating and who are deemed appropriate for prevention based on a clinical interview. It would be important to have other services available on site or referrals for outside services if families are interested in participating in an IPT-AST group but the clinical interview determines that the adolescent would benefit from more intensive services.
Conducting a Clinical Interview
As discussed, screening measures can be helpful to determine youth who may benefit from a prevention group. However, even if using a screening measure, it is important to conduct a clinical interview to determine whether a particular adolescent would be appropriate for a prevention group. This interview should include a thorough assessment of depression symptoms as well as a brief review of other mental health problems to determine if a prevention program is appropriate or if the adolescent requires more intensive services. For indicated or selective groups, leaders should look for adolescents who are experiencing elevated depressive symptoms or who share a common stressor that puts them at risk for depression. If IPT-AST is being used as a stand-alone prevention program, adolescents who need more intensive services should not be included.
Prior to initiating the clinical interview, the leader should review the limits of confidentiality with both the teen and parent(s). The review should include psychoeducation about confidentiality, explaining to them that most of what the teen discusses with the leader is confidential between the two of them unless the leader feels that the teen may be a danger to self or someone else or when the teen is in danger. In those situations, the leader is obligated to break confidentiality and share these concerns with a parent or other authority. Importantly, in such instances, the leader will discuss with the teen the need to break confidentiality due to these reasons before speaking with the parent. The leader also explains to the teen that there may be other times when the leader feels that something they have discussed would be beneficial to share with the parent to improve the teen’s mood or situation; the leader will discuss that with the teen first and obtain permission to share it before doing so. Situations like this may come up in the initial clinical interview as well as during the mid-group session when parent and teen are together to discuss progress in group and to address specific interpersonal issues.
The leader should conduct a verbal assessment of the symptoms of depression, described further in this section, as part of an initial interview. The adolescent must endorse at least five symptoms, and these symptoms would have to persist for at least 2 weeks to meet criteria for a diagnosis of depression. For each of the symptoms of depression, the leader should ask one or two questions to determine whether the adolescent is experiencing this symptom and how often. It is also helpful to assess whether any depressive symptoms are impairing the teen’s functioning at home, school, or with peers. To be included in a prevention program such as IPT-AST, it is acceptable for a teen to endorse several symptoms. However, if a teen reports that he or she is experiencing five or more (p. 18) of these symptoms, and they occur every day and last the majority of the day for 2 weeks or more, the teen likely would benefit from more intensive services. Typically, teens in an indicated or selective program may endorse some sad mood or irritability or anhedonia, some sleep difficulties, and one or two more symptoms intermittently. The following are common symptoms of depression and questions that the leader can ask to assess each of these symptoms:
Depressed or irritable mood.
One of the core symptoms of depression is sad mood. Unlike adults, adolescents may experience their mood as irritable, rather than feeling sad. Helpful questions include the following: How has your mood been the past few weeks? Do you feel sad or bored or blah? Are you more irritable toward people, or do you get bothered by little things a lot more than usual? How often do you feel sad or irritable? How long do these feelings last?
Loss of interest or pleasure in activities.
Many adolescents with depressive symptoms or a depression diagnosis report anhedonia, which refers to a loss of interest or pleasure in activities that they usually enjoy. Normative changes in interests (e.g., “I don’t like dance anymore, but I started playing softball”) should not be considered signs of anhedonia. The leader can ask: What kinds of things do you enjoy doing when you are not in school? Has your interest in or motivation to do these things decreased lately? If you push yourself to do that activity, do you find it enjoyable?
Difficulties with sleep.
Sleep disturbances can include trouble falling asleep (early insomnia), waking up in the middle of the night (middle insomnia), waking up earlier in the morning than necessary and being unable to fall back to sleep (late insomnia), or sleeping too much (hypersomnia). To assess difficulties with sleep, the leader can ask: How has your sleep been in the past 2 weeks? Do you have trouble falling asleep or staying asleep or waking up too early? Are you sleeping more than you used to?
Fatigue or low energy.
Feeling tired or having little energy is another symptom that teens may experience. Questions to ask include the following: Do you feel more tired than usual? How does it feel when you go to do things like getting up for school? Does it feel like everything takes a lot of effort? When did you start feeling this way? How long have you been feeling this way?
Feeling slowed down or restless.
Some teens may feel either slowed down or more agitated than usual. To be considered a symptom of depression, teens should exhibit behavioral changes rather than only subjective feelings of psychomotor retardation or agitation. To assess feeling slowed down, the leader can ask: Have you noticed that you are not moving as fast as before? Have you noticed that your speech is slowed down? Have others noticed these changes? Questions to ask about agitation include the following: Have you found it more difficult than usual to sit still or noticed that you feel restless? Do you find that you are fidgeting more than usual? Have others noticed these changes?
Change in appetite.
Appetite changes can include either loss of appetite or an increase in appetite that may be accompanied by weight loss or gain, respectively. The leader can ask: Have your eating habits changed so that you are eating more or less than usual? Have you felt less or more hungry than usual? Have you lost or gained weight? Could this be related to feeling sad or down, or are you purposefully trying to lose or gain weight?
(p. 19) Concentration difficulties or indecision.
Having trouble concentrating can be a symptom of depression. It is also a symptom of other common mental health problems. It is helpful to determine whether the concentration difficulties began at the same time as the depressed or irritable mood. The following are questions to assess concentration difficulties: How are you doing in school? Are you having trouble concentrating, or have your grades gone down in the past few weeks since you have been feeling sad or down? Indecision is a related symptom of depression, particularly difficulty making decisions about small choices, such as what to wear or what to do after school. To assess indecision, the leader might ask: Is it hard to make decisions? Big decisions can be hard for anyone; how difficult is it to make little decisions like what to do after school or what to wear? Has this become more difficult since you have been feeling sad?
Feelings of guilt or low self-worth.
All people experience feelings of guilt at some point in their lives, particularly when they have done something wrong. It is considered a symptom of depression when an adolescent reports feelings of guilt that are out of proportion to the trigger. The following questions assess feelings of guilt: Do you feel guilty for things that you have done; do you feel guiltier than others might feel in a similar situation? How long do these feelings last? A related symptom of depression is worthlessness, or feeling inadequate. To assess self-worth, the leader might ask: How are you feeling about yourself lately? Do you like most things about yourself or often wish you were different? How often do you feel badly about yourself in general compared to your peers?
Thoughts of death or suicidal ideation/behavior.
Having thoughts of death or thoughts of wanting to hurt oneself is a symptom of depression, although these thoughts also occur with other mental health issues. The assessment of suicidal ideation or behavior is important in evaluating whether a teen is appropriate for the prevention group. Even if the teen does not endorse a lot of other symptoms, it is still necessary to assess suicidality because it can be present even when significant depression symptoms are not reported. A leader needs to assess for several aspects of suicidality and should ask: Do you have any thoughts about life not being worth living? The leader is looking for information about whether these thoughts are passive, such as “Sometimes I wish I wouldn’t wake up in the morning,” or active, “I am thinking about taking some pills.”
If the teen endorses thoughts of suicide, the leader should ask additional questions to gather information about the frequency and extent of the suicidal thoughts, any planning that may have occurred, and any prior suicide attempts. These questions include the following: How often do you have these thoughts? How long do they last? Can you make these thoughts go away, and if so, how do you do that? Have you thought of a plan to kill yourself, and do you have access to carry out this plan? When is the last time you had these thoughts? How close have you ever come to acting on these thoughts? Do you feel you want to act on these thoughts? Have you told anyone about these thoughts? Have you ever tried to hurt yourself in the past?
If an adolescent has had suicidal ideation in the past but not currently, or if the individual reports fleeting and infrequent thoughts of wanting to be dead without intent, the leader can decide on a case-by-case basis whether to include the teen in the prevention group if he or she does not meet criteria for a depression diagnosis. If the teen is included in IPT-AST, it will be important for the leader to monitor the teen’s suicidal ideation closely, verbally (p. 20) assessing current suicidal thoughts in the individual sessions (pre-group, mid-group, and booster) and checking the suicidal ideation item on the depression checklist during each group session. If an adolescent endorses having current active thoughts of harming him- or herself with intent to die, the adolescent is in need of a formal psychiatric evaluation, and the leader should refer the teen for more intensive services.
Assessing nonsuicidal self-injury.
Similarly, the leader should assess for nonsuicidal self-injury (NSSI), which refers to self-harm that is not accompanied by thoughts of wanting to die when engaging in the behavior. While a prior history of a suicide attempt is a strong predictor of future suicide attempts, recent findings also point to the significant role of NSSI as a risk factor for suicidal behavior (Brent et al., 2013). Moreover, research suggests that adolescents are often uncertain of their intent when engaging in self-harming behaviors, which contributes to NSSI being considered a significant risk factor for suicide attempts and to the importance of thoroughly assessing self-harming behavior. To find out about NSSI, the leader should ask questions such as these: Have you ever had thoughts of harming yourself? If so, what were those thoughts? How often do they occur? Have you ever tried to harm yourself? What did you do? When was the last time you injured yourself? Have you ever received medical attention for an injury? When you were doing that, were you having any thoughts of wanting to die or be dead? If so, what stopped you from continuing to harm yourself? What were you feeling or thinking when you were engaging in these behaviors?
There is a continuum of severity for behaviors that are considered as NSSI, and these behaviors can range from scratching oneself with a paper clip or picking at skin until it bleeds to burning oneself with a cigarette or cutting one’s arm or wrist with a knife. Typically, if an adolescent reports any percentage of his or her thoughts at the time of self-harm as hoping to die or wanting to be dead, it is no longer considered NSSI but rather suicidal behavior. However, as stated previously, teens have a difficult time describing their thoughts and feelings in these situations, so it is better to err on the side of caution if the leader is unsure and to refer for a second evaluation. In addition, NSSI not only is found in conjunction with depression but also can be manifest with other disorders, such as anxiety or other mood disorders.
For the purposes of the prevention program, the leader can decide to include the adolescent if the leader concludes that the NSSI is superficial and infrequent. If such adolescents are included in the groups, it is important to closely monitor the NSSI behaviors and refer for more intensive services if the behavior becomes more frequent or high risk. In these cases, NSSI can be assessed during the individual sessions and can be incorporated into the depression checklist as an additional symptom to assess weekly during the group. Alternatively, the leader can arrange to check in individually with the teen before or after the group sessions to monitor NSSI.
Assessing other mental health problems.
Often, adolescents at risk for depression due to subsyndromal depression symptoms may have symptoms of other disorders or may have a comorbid disorder. The most common comorbid disorders are an anxiety disorder and attention deficit hyperactivity disorder (ADHD). Comorbid anxiety symptoms are common among adolescents with depression or elevated depression symptoms as they are often a precursor to the depression. Our studies have shown that the anxiety symptoms tend to remit with the depression symptoms as an outcome of participation in the prevention groups.
(p. 21) While anxiety symptoms or even an anxiety disorder would not necessarily prevent the adolescent from participating in the prevention group, it is important to assess whether an anxiety disorder is impairing enough that it should be treated first or whether the teen should be receiving additional treatment for the comorbid disorder. Specifically, the leader needs to assess whether enough anxiety symptoms are present to suggest the presence of an anxiety disorder and whether the depression symptoms are a result of the impact of the anxiety on functioning. If the leader finds either of these situations to be the case, it would suggest that the anxiety disorder is the primary diagnosis leading to the adolescent’s difficulties. In these situations, the leader should refer that teen for treatment for anxiety as the first intervention.
For an adolescent who is really struggling in the classroom with untreated ADHD symptoms, an evaluation of the ADHD behaviors would be recommended to determine whether the adolescent would benefit from medication or another type of intervention for the ADHD-related impairments. If the ADHD is being treated through medication or through another intervention, IPT-AST may be helpful to address any current depressive symptoms or to prevent future depression.
In addition, the leader may want to briefly assess other mental health difficulties and exposure to stressful life events, as this may have an impact on the decision about whether IPT-AST is the most appropriate intervention. This includes an assessment of substance abuse and other risky behaviors, as well as exposure to traumatic events, physical or sexual abuse, and bullying. If the adolescent is abusing substances or has significant symptoms related to trauma, IPT-AST may not be the most appropriate intervention. The group leader may also want to consider excluding youth who would be very anxious or uncomfortable in group, be significantly disruptive to the group process, or would have a difficult time relating to other adolescents. In particular, the leader should be alert to the possibility of any iatrogenic effects for other group members. This can occur when an adolescent has significant behavioral or conduct problems or engages in significant high-risk behaviors that may negatively influence or impact other group members. Similarly, adolescents who meet criteria for autism spectrum disorders may not be appropriate for the group because they are likely to require an intervention with a longer duration to be able to effectively incorporate the strategies into their repertoire. Teens with autism spectrum disorders also may not be able to relate to the other interpersonal situations being discussed in group, which could exacerbate feelings of social isolation or not fitting in. However, some high-functioning teens with autism spectrum diagnoses may benefit from IPT-AST.
Assessing interpersonal relationships.
Another issue to consider when deciding whether IPT-AST is the best fit for an adolescent is whether the teen is experiencing any interpersonal difficulties. IPT-AST may feel less relevant for adolescents with universally strong and positive relationships or those with well-developed communication and interpersonal problem-solving skills. On the other hand, IPT-AST may be particularly beneficial for youth with current relationship difficulties. Interpersonal psychotherapy posits that most individuals with depression can be classified into one of four interpersonal problem areas: role disputes, role transitions, interpersonal deficits, and grief (Mufson, Dorta, Moreau, et al., 2004; Weissman et al., 2000). The interpersonal skills taught in IPT-AST are particularly (p. 22) relevant for adolescents with interpersonal conflicts (role disputes), for teens with recent life changes that have affected their relationships (role transitions), or for teens who have difficulty making and maintaining close relationships (interpersonal deficits). The strategies may also be relevant for adolescents who have depressive symptoms in response to a death (grief), although grief is not explicitly addressed in group sessions.
It is important to note that IPT-AST was not specifically developed to address bereavement. Thus, it is up to the leader to decide whether IPT-AST is the most appropriate intervention for an adolescent who has recently lost someone close to him or her. In making this decision, the leader should determine whether there are other interpersonal goals that an adolescent can work on in group. In addition, the leader should consider how it would feel for the grieving adolescent to listen to other youth discussing interpersonal problems with their relatives when the teen is grieving the loss of a significant relationship. From our experiences, this is particularly an issue with the loss of a parent but is less of a concern with the loss of other relatives or friends. Therefore, we typically only include youth who have lost a more distant relative or friend or where grief is secondary to other relationship challenges.
Based on this clinical interview, the leader will have a good understanding of the adolescent’s baseline depression symptoms and other mental health concerns, as well as a preliminary idea of the teen’s interpersonal relationships. This information will inform the decision of whether a given adolescent will benefit from participating in IPT-AST and the appropriate level of prevention. Furthermore, this information will be valuable as the intervention progresses. Given this knowledge, the leader can be alert to significant increases in depression symptoms or other mental health problems during the course of IPT-AST that might indicate that an adolescent would benefit from more intensive services. In addition, the preliminary assessment of the adolescent’s interpersonal relationships during the clinical interview informs the interpersonal inventory that will be conducted in the pre-group sessions.
Considerations for Group Composition
Aside from considerations related to each individual group member, group composition issues are also important to consider. The first issue to consider is the age and gender makeup of the group. As discussed in Chapter 1, we recommend that groups comprise similarly aged adolescents, given the large developmental differences that occur between ages 12 and 17. Given the higher rates of depression in female adolescents, some prevention and intervention programs have been developed specifically for girls. IPT-AST, on the other hand, is designed for girls and boys. We have run both single-sex and mixed-gender IPT-AST groups. When we implemented IPT-AST in single-sex parochial schools, the groups naturally consisted of all boys or all girls, and these groups ran smoothly. We have also run successful mixed-gender groups. Groups composed of boys and girls allow teens to gain multiple and diverse perspectives from other group members, which can be particularly helpful when discussing peer issues. If the leader decides to run a mixed-gender group, we recommend that the group composition be relatively balanced between boys and girls. Although we have had groups with only one boy or one girl, teens are often more comfortable when the gender composition is relatively balanced.
(p. 23) Another thing to consider is whether potential group members have close positive or negative relationships with each other, particularly in settings where individuals are likely to know each other (e.g., schools). Typically, it is not realistic to exclude adolescents who know each other outside the group. However, we think it is important to ensure that siblings and others with close family relationships (e.g., cousins, etc.) are in separate groups. This is because adolescents are asked to discuss problems in relationships with the group, and often these include problems in relationships with parents, siblings, or other family members. When siblings are in the same group, they may be reluctant to discuss issues in their family relationships, which may limit their ability to benefit from the intervention. Those who are close friends or romantically involved may similarly be unable to discuss difficulties in that relationship with the group. This may be more or less problematic for the adolescents, depending on whether the relationship becomes a target of change. The presence of close friends or couples in the group may influence the group dynamic more generally if two individuals remain aligned with each other and do not connect as well to the rest of the group.
Therefore, the leader may want to consider the pros and cons of having close friends or couples in the same group. In our own work, we have permitted these dyads to be in the same group and remained alert to any issues that may arise for specific group members and the larger group dynamic. However, we feel more strongly about not including individuals with intensely negative relationships (such as between a bully and a victim) in the same group. The presence of a bully in the group is likely to inhibit someone who has been victimized by that person from participating, which would reduce the benefit to the teen and possibly be harmful if it increases his or her exposure to bullying.
For these reasons, it is advisable to pay close attention to information gathered from adolescents about their relationships in the clinical interview and the pre-group sessions. This way, the leader can be alerted to potential issues and make decisions about group composition on a case-by-case basis. If issues related to group members’ relationships arise later in the group, these issues can often be addressed individually or in the context of the group. However, the leader may in rare cases decide to remove someone from the group (e.g., if a bully in the group is aggressive toward other group members and strategies to manage aggressive behavior are unsuccessful). This is discussed in greater detail in the chapter on common clinical issues (Chapter 12).