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Cognitive behavioral therapy for adolescent depression: implications for Asian immigrants in the United States of America Riddhi Sandil Published online: 12 Nov 2009.
To cite this article: Riddhi Sandil (2006) Cognitive behavioral therapy for adolescent depression: implications for Asian immigrants in the United States of America, Journal of Child & Adolescent Mental Health, 18:1, 27-32, DOI: 10.2989/17280580609486615 To link to this article: http://dx.doi.org/10.2989/17280580609486615
PLEASE SCROLL DOWN FOR ARTICLE Taylor & Francis makes every effort to ensure the accuracy of all the information (the “Content”) contained in the publications on our platform. However, Taylor & Francis, our agents, and our licensors make no representations or warranties whatsoever as to the accuracy, completeness, or suitability for any purpose of the Content. Any opinions and views expressed in this publication are the opinions and views of the authors, and are not the views of or endorsed by Taylor & Francis. The accuracy of the Content should not be relied upon and should be independently verified with primary sources of information. Taylor and Francis shall not be liable for any losses, actions, claims, proceedings, demands, costs, expenses, damages, and other liabilities whatsoever or howsoever caused arising directly or indirectly in connection with, in relation to or arising out of the use of the Content. This article may be used for research, teaching, and private study purposes. Any substantial or systematic reproduction, redistribution, reselling, loan, sub-licensing, systematic supply, or distribution in any form to anyone is expressly forbidden. Terms & Conditions of access and use can be found at http:// www.tandfonline.com/page/terms-and-conditions
Copyright © NISC Pty Ltd
Journal of Child and Adolescent Mental Health 2006, 18(1): 27–32 Printed in South Africa — All rights reserved
JOURNAL OF CHILD AND ADOLESCENT MENTAL HEALTH EISSN 1728–0591
Clinical Perspective
Cognitive behavioral therapy for adolescent depression: implications for Asian immigrants in the United States of America Riddhi Sandil
Downloaded by [University of Nebraska, Lincoln] at 07:56 29 December 2014
Doctoral Student, Counseling Psychology, 361 N Lindquist Center, Iowa City, IA 52242 e-mail: [email protected] Many interventions are available for treating adolescent depression. This paper attempts to present a summary of cognitive behavioral therapies/techniques that might be useful for treating depression in Asian immigrant adolescents. Articles were selected by conducting a literature search on Psyc-Info. Prevalence, symptoms and measures of adolescent depression are discussed. Summary of popular therapies like PASCET, CWD-A, Beck’s CBT are provided. A rationale for the use of these with Asian immigrants is hypothesized. There is no empirical evidence for the efficacy of CBT with this population. A need to validate the use of CBT with this population is asserted.
Introduction It is estimated that roughly 8.3% of adolescents in the United States of America (USA) suffer from depression (Depression in Children and Adolescents 2005). These numbers might not be an accurate reflection of adolescent depression as it may go undiagnosed or attributed to problems associated with normal development. Research has suggested that Cognitive Behavioural Therapy (CBT) might be the most effective for the treatment of adolescent depression (Braswell and Kendall 2003; Gaynor et al. 2003; Kolko et al. 2000; Szigethy et al. 2004). The purpose of this paper is to synthesize past research on the efficacy of CBT with depressed adolescents (between the ages of 12 and 17) and to discuss the implications of CBT when working with depressed Asian immigrant adolescents. For the purpose of this paper, Asian immigrant adolescents are teenagers from China, Vietnam, Korea and other east Asian countries between the ages of 13 and 17 who have recently moved to the USA and did not go through an American elementary school. Unlike Asian American adolescents, these adolescents are not citizens of the USA. Thus, it can be assumed that these adolescents are still in the process of acculturating and adapting to American culture. This paper will be structured in the following way: 1) The manifestations, symptoms and reasons for depression in adolescents will be outlined. 2) The measures used with adolescent depression will be listed. 3) Popular CBT methods for treating adolescent depression will be enumerated. As there are numerous treatments available, only those treatments that can be applied to Asian immigrant depressed adolescent will be highlighted. 4) Depression in Asian immigrant adolescents will be explored. As there is sparse research on the Asian
immigrant adolescents, past research on Asian Americans and international students will be used in this section. Depression in adolescents: manifestation and symptoms The Diagnostic and Statistical Manual of Mental Disorders (American Psychiatric Association 2000) does not specify diagnostic criteria for depression in adolescents. Diagnostic criteria for diagnosing depression in adults are often utilised when working with adolescents. As with adults, the most common symptoms of depression in adolescents are persistent sad mood, anhedonia, loss of energy, changes in sleep and appetite, recurring thoughts of death and suicidal ideation (Depression in Children and Adolescents 2005). Adolescents suffering from depression might also exhibit other symptoms like boredom, truancy from school, frequent somatic complaints such as headaches, increased irritability, social outbursts, rage, substance abuse and fear of rejection (Depression in Children and Adolescents 2005). These symptoms should persist for a period of two weeks before a formal diagnosis of depression can be issued. Aetiological factors in adolescent depression There has been considerable research on reasons for depression in adolescents. Certain factors that may influence adolescent depression have been identified. The most common reason for depression in adolescents is having a parent or family member suffer from depression (Harrington et al.1997). This might suggest that some adolescents may have a genetic predisposition to depression. Adolescents who have survived a serious illness or are chronically ill are also at risk for depression (Bennett 1994; Kovacs et al. 1995, as cited in Szigethy et al. 2004). These adolescents
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might experience physical pain, anxiety and have lower self esteem and thus be more prone to depressive thoughts. Studies have also suggested that attachment insecurity might increase the risk of adolescent depression (ColeDetke and Kobak 1996; Sund and Wichstron 2002, as cited in Shirk, Gudmundsen and Burwell 2005). A study done by Shirk et al. (2005) found that “representations of maternal figures as unavailable, unresponsive and unsupportive were significantly associated with higher levels of depressive symptoms in young adolescents” (Shirk et al. 2005, p.178). Thus, adolescents who are unable to form healthy attachments with their primary caregiver might feel neglected, unwanted and lonely and thus be at a higher risk for depression. Adolescents who are currently experiencing, or have been victims of, abuse are also at risk for depression. Brown, Cohen and Johnson (1999) found that adolescents who had experienced sexual abuse were very vulnerable to becoming depressed. Children who had been exposed to natural disasters or had lost a parent or loved one were also susceptible to depression in adolescence (Krug, Kresnow and Peddicord 1998). Other factors such as substance use, stress, conduct and learning disorders also increase the frequency for adolescent depression (Wells, Deykin and Klerman 1985; Lewinsohn, Rhode and Seeley 1998). Adolescence in itself is characterised as a period of change and development and factors such as the ones enumerated above might make a teenager more susceptible to depression. Measures of adolescent depression There are many measures of depression that are commonly used when working with adolescents. Scales such as Beck Depression Inventory and Center for Epidemiologic Studies Depression (CES-D), that are designed for adult measurement of depression, are frequently administered to adolescents. Research suggests that even though these instruments have not been validated for use with adolescents, they are an accurate measure of depression with this population (Depression in Children and Adolescents 2005). However, instruments like Children’s Depression Inventory (CDI) (Kovaks M 1992) might be more appropriate when working with adolescents. The CDI is a 27 item scale that measures negative mood, interpersonal problems, ineffectiveness, anhedonia and negative self esteem (Kovaks et al. 1995). This is a short and easy-to-administer measure and can used with adolescents up to the age of 17. It has been widely researched and has high measures of reliability and validity. The above instruments can aid the clinician in gauging the symptoms and severity of depression. They are also helpful in assessing which treatment might be most beneficial for the adolescent client. Overview of treatments This section will give a brief overview of Cognitive Behavioural Treatments that are employed with adolescent depression. Some of these treatments have been researched extensively but many have yet to empirically tested.
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The Primary and Secondary Control Enhancement Training (PASCET) PASCET is a CBT that is shown to have high efficacy with adolescents (Weisz et al. 1995). The PASCET assumes that adolescents are more prone to depression due to social skills deficits and negative thoughts in response to life stressors (Weisz, McCabe and Dennig 1994). This treatment attempts to increase the coping skills of adolescents by using a dual model of observed control, namely perceived and secondary control (Szigethy et al. 2004). Perceived control entails reducing the punishing or increasing the rewarding aspects of one’s environment whereas secondary control deals with changing the client’s beliefs and perceptions about certain events or objective conditions (Weisz et al. 1994). A study by Szigethy et al. (2004) attempted to study the efficacy of CBT when working with physically ill adolescents. The researchers used the PASCET with adolescents suffering from inflammatory bowel disease. It was found that there were greater reductions of depressive symptoms and increased perceptions of well-being in adolescents who were underwent the PASCET. As depression is highly correlated with physically ill adolescents (Depression in Children and Adolescents 2005), an efficient CBT is essential for treating this population. PASCET has shown to be effective for the same. The Adolescent Coping with Depression Course (CWD-A) CWD-A is a group-based intervention designed by Lewinsohn, Clarke, Hops and Andrews (1990). This CBT has been widely researched and evaluated and is shown to have high efficacy with adolescents (Lewinsohn et al. 1990). The CWD-A course typically includes 16 sessions (two a week) with each session lasting about two hours. Participants should be between the ages of 14 and18 years. The course covers topics such as relaxation, pleasant activities, cognitive therapy, social skills, communication negotiation, problem solving, life plan and maintaining gains (Clark, Lewinsohn and Hops, 1990). In a study done by Kaufman et al. (2005) the CWD-A was used with adolescents with comorbid major depression and conduct disorder. The researchers found that the CWD-A was able to reduce depression in adolescents by primarily reducing negative thoughts. Cognitive restructuring Cognitive restructuring methods are widely used in a number of cognitive behavioural treatments (Braswell et al. 2003). Developed primarily by Beck et al. (1979) and Ellis and Harper (1979) these methods attempt to change negative self-perceptions and beliefs (Braswell et al. 2003). Cognitive restructuring in adolescents is conducted similarly to that in adults. The counselor and client work on the client’s negative self statements and collaboratively try to examine the evidence that either supports or refutes these beliefs (Braswell et al. 2003). This technique might work well with adolescents as they might be at the point in their development where they are trying to learn more about themselves and explore their personality. Furthermore, adolescents might also be trying
Journal of Child andAdolescent Mental Health 2006, 18(1): 27–32
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to formulate their own world view during this time and this intervention might be beneficial given their developmental stage (Braswell et al. 2003). Beck’s Cognitive Behavioural Therapy (CBT) Beck’s CBT (Beck et al. 1979) is primarily utilised with adult populations. However, a number of studies have adapted this approach for adolescents (Kolko et al. 2000; Gaynor et al. 2003). This CBT emphasises “collaborative empiricism, importance of socialising the patient to the cognitive therapy model, and the monitoring and modification of automatic thoughts, assumptions and basic beliefs” (Kolko et al. 2000 p.606). When working with adolescents there is a further emphasis on problem solving and affect regulation to meet the requirements of adolescent depression (Kolko et al. 2000). As Beck’s CBT allows the client to be the expert of their problem and is a collaborative therapy process (Beck et al. 1979), this approach could work well with adolescents. Adolescents could gain empowerment from this process and thus raise their self esteem. By working with a therapist who is warm and supportive, adolescents might also be able to identify their self-defeating schemas and take an active role in identifying and combating their negative thoughts. Self-regulation approaches Asking the adolescents to keep track of their thoughts, moods and emotions is a widely-used approach in the management of depression. When working with depressed youth, having them track their moods might be an effective way for them to gain insight into the causes of their behaviour (Braswell et al. 2003). Often, adolescents might be asked to track their pleasurable activities as well. As pointed out by Braswell et al. (2003) this method might also “address the overly rigid or unrealistic standards for selfevaluation that such [depressed] youth may manifest (Stark 1990 as cited in Braswell et al. 2003 p.259). Having adolescents monitor their thoughts and feelings might make them more invested in the therapy process. These clients might feel a sense of responsibility and experience an increased motivation to change their negative thoughts or perceptions. By having logs of when depressive thoughts occur, adolescents might also be able to identify triggers that perpetuate their depression. By controlling these, they might be able to make changes in their environment and hence changes in their thinking and mood. Relaxation training Relaxation training is widely used with children and adolescents dealing with anger management concerns (Feindler and Ecton 1986, as cited in Braswell et al. 2003). It is also a component of widely used CBT’s like Beck’s treatment. Techniques such as progressive muscle relaxation and guided imagery are popular relaxation techniques for adolescents (Cautela and Groden 1978, as cited in Braswell et al. 2003; Kendall et al. 1992). A study by Kahn et al. (1990) found that relaxation training was as effective as other CBTs when working with depressed adolescents. Relaxation training also helped increase self esteem in this population (Kahn et al. 1990).
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Reynolds and Coats (1986) also compared the effectiveness of CBTs like self monitoring, self evaluation and self reinforcement with relaxation techniques. It was found that both treatments were equally effective at a five week follow up (Reynolds et al. 1986). Comparison of cognitive behavioural techniques with other approaches Studies have looked at the efficacy of CBT with other therapies when working with adolescent depression. In Barbe et al. (2004), CBT was compared with Systematic Behavioural Family Therapy (SBFT) and Non-directive Supportive Therapy (NST) with depressed clients at risk for suicide. It was found that NST was not an effective treatment approach when working with this population. CBT and SBFT were more effective in reducing the risk of suicide and also alleviating depressive symptoms in this population (Barbe et al. 2004). A study by Gaynor et al. (2003) obtained similar results. Adolescents that underwent CBT showed more decreased depressive symptoms and cognitive distortions than adolescents who were exposed to SBFT and NST (Gaynor et al. 2003). In this study it was also found that CBT was able to elicit more sudden gains, i.e. adolescents showed a more marked improvement by the second or third session than the other two treatment groups (Gaynor et al. 2003). Kolko et al. (2000) studied the efficacy of CBT, SBFT and NST over a period of time. At a two year follow up, they found that SBFT was most effective in reducing family conflict and improving parent-child relationships (Kolko et al. 2000). However, CBT was found to have a greater impact on reducing anxiety symptoms. Thus, SBFT might be an effective interpersonal approach to improve relationships but CBT might be a more effective approach in reducing depressive symptoms with this population. The role of family and school in adolescent depression An adolescent’s social environment can impact their depressive symptoms and the effectiveness of the CBT being employed. School-based programs are becoming popular for treating adolescent depression. However, there is a high dropout rate for such programs. Research suggests that stigmatisation experienced from their peers leads the depressed adolescent to discontinue the suggested/proposed interventions (Schochet et al. 2001). Stigmatisation also leads to difficulty recruiting for such programs. Schochet et al. argue that having a universal program during regular school hours might be more effective in increasing participation and retention (Schochet et al. 2001). In order to eliminate experienced stigmatization, Possel et al. (2004) employed a school-based intervention, LISA-T, with eight graders. LISA-T is a CBT that targets an adolescent’s cognitive and social aspects. This intervention aims to provide social competence skills, self assured behaviour and explore and change dysfunctional thoughts (Possel et al. 2004). Reduced depressive symptoms were found in depressed adolescents at the end of this intervention. Adolescents who had subsyndromal symptoms also reported fewer symptoms. These changes were not seen in
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the control group (Possel et al. 2004). This study suggests that CBT might also be helpful for adolescents who are not currently experiencing depression. Furthermore, including the entire cohort in the training program might help in reducing stigmatisation and increase awareness about depression and its consequences in adolescents. An increase in awareness might lead to a greater sensitivity and depressed adolescents might feel less isolated and disengaged from their peers. Family relationships also play an important role in adolescent depression. Research shows that contingency management might be an effective strategy to deal with depression in adolescents (Strayhorn 1988 as cited in Braswell et al. 2003). Parents play an important role in contingency management and can be included in the therapy process. This could further reduce possible isolation and increase social support and empathy experienced by a depressed adolescent. However, parental monitoring is necessary in this method in order to ensure that rewards are consistent and clear contingency patterns are established (Braswell et al. 2003). Multicultural applicability: the case of Asian adolescent immigrants There is sparse research on the applicability of CBT when working with depressed Asian adolescent immigrants. This section will provide arguments as to why CBT is an effective approach for this population. This section will draw on literature based on Asian Americans and Asian international students as research on Asian immigrants is sparse. Research suggests that depression rates among Asian Americans are comparable with depression rates among Caucasians, but Asian Americans are more likely to underutilise mental health services (Uba 1994). The suicide rates for certain Asian American populations is higher than that of the national sample and Asian American female adolescents report more symptoms of depression than other adolescent groups (Huang 1997). Thus, there is a need to address mental health concerns of Asians and Asian Americans. Asian adolescent immigrants might be experiencing many stressors that can predispose them to depression. Some of these are: moving to a new country, learning new customs, inability to speak English, being removed from friends and extended family, and perhaps not having economic security in the United States. Symptoms of depression in Asian adolescents might be sleep and appetite disturbances, poor performance in academics and somatic complaints like stomach and head aches (Huang 1997). The clinician’s lack of these cultural differences can lead to misdiagnosis or underdiagnosis of adolescent depression with this population (Gee 2004). Gee suggests that the counselor conduct extensive interviews beyond the scope of the assessment being employed. Interviewing primary caregivers and the adolescent’s extended family might also be beneficial in gathering information for the diagnosis of depression with this population (Gee 2004). This task might be particularly difficult as research suggests that Asians do not like to disclose family information to strangers and would prefer to keep their family matters to themselves (Sue and Sue 1990). Asian
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parents might also be reluctant to seek help for their children given their bias that psychologists are not official health professionals (Gee 2004). The clinician should be aware of these barriers when working with this population. Research suggests that Asians might prefer their counselor to be assertive and directive (Khoo and Abu-Rasain 1994). As most CBTs work at reducing depressive symptoms and are goal directed they might be effective with this population. Adolescents who have not been exposed to therapy before might welcome the structure that CBT provides and thus be more inclined to remain in therapy. CBT also allows family members to play a role in managing adolescent depression. Most Asian immigrants have a strong sense of collectivistism and might prefer their family’s support during this difficult time (Kim, Atkinson, and Umemoto 2001). Knowing that their family can be active in their therapy might offer relief for the adolescent and thus increase motivation for counseling. Family can be incorporated into various CBT treatments. They can assume the role of contingency managers and follow a fixed pattern of reward and punishment for the adolescent. They can also help in aiding the teen with relaxation procedures and do the exercises with them. Furthermore, family members can accompany the adolescent to therapy and take part in cognitive restructuring and Beck’s CBT (Beck et al. 1978) as a group. The focus on behaviour change and training in CBT might make this approach attractive to Asian adolescent immigrants. Most Asian cultures value being in control of one’s emotions and remaining strong in times of adversity (Uba 1994). As emotional breakdowns can be construed to be a sign of weakness, it is easy to imagine why Asian immigrants and their families might be reluctant to seek psychological help. However, CBT can be presented as a training model as opposed to psychological counseling. Adolescent immigrants and their families might feel more comfortable to know that they will learn how to deal with depression as opposed to understanding what it is. Thus, teaching skills like relaxation might be a concrete and non-threatening approach to treating depression in this population. School-based interventions, where all students are mandated to participate, might also be beneficial for this population. Research suggests that conformity to norms is a revered cultural value in Asian society (Kim et al. 2001). Knowing that their peers are also undergoing the same training might be encouraging and can help in normalising the experience for this population. Thus, interventions like the LISA-T and PASCET can be introduced into the curriculum in schools with a high Asian immigrant population. As these interventions are beneficial for non-depressed adolescents as well, they will be useful experiences for all the students involved. Conclusion and future implications There is a need to address the mental health concerns of Asian immigrants, particularly adolescents. As the U.S. becomes more diverse every year, more immigrant adolescents enter the school system and are exposed to a completely different way of life. Issues of acculturation, adjustment and assimilation can be stressful for Asian
Journal of Child andAdolescent Mental Health 2006, 18(1): 27–32
youth and could lead to symptoms of depression in this population. Furthermore, since depressive symptoms can be masked with somatic complaints in this group, it might be difficult to diagnose depression in this population. There is no empirical evidence of the efficacy of the above mentioned cognitive behavioural techniques with this population. There is also a lack of research on the validity of various measures of depression with this population. As the number of immigrants is increasing every year, there is an urgent need to address this issue. In order to effectively work with Asian immigrant adolescents, culturally appropriate measures and interventions need to be developed.
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Kaufman NK, Rhode P, Seeley JR and Clarke GN (2005) Potentials mediators of cognitive-behavioural therapy for adolescents with comorbid major depression and conduct disorder. Journal of Consulting and Clinical Psychology 73: 38–46 Kendall PC, Kortlander E, Chansky TE and Brady EU (1992) Comorbidity of anxiety and depression in youth: Treatment implications. Journal of Consulting and Clinical Psychology 60: 869– 880 Khoo PL and Abu-Rasain MH (1994) Counseling foreign students: a review of strategies. Counseling Psychology Quarterly 7: 117– 132 Kim BS, Atkinson DR and Umemoto D (2001) Asian Cultural Values and the Counseling Process: Current Knowledge and Directions for Future Research. The Counseling Psychologist 29: 570–603 Kolko DJ, Brent DA, Baugher M, Bridge J and Birmaher B (2000) Cognitive and family therapies for adolescent depression: treatment specificity, mediation and moderation. Journal of Consulting and Clinical Psychology 68: 603–614 Kovaks M (1992) Children’s Depression Inventory (CDI). Multi Health Systems, New York Kovaks M, Mukherji P, Drash A and Iyengar S (1995) Biomedical and psychiatric risk factors for retinopathy among children with IDDM. Diabetes Care 18: 1592–1599 Krug EG, Kresnow M and Peddicord JP (1998) Suicide after natural disasters. New England Journal of Medicine 338: 373–378 Lewinsohn PM, Clarke GN, Hops H and Andrews JA (1990) Cognitive-behavioural treatment for depressed adolescents. Behaviour Therapy 21: 385–401 Lewinsohn PM, Rohde P and Seeley JR (1998) Major depressive disorder in older adolescents: prevalence, risk factors, and clinical implications. Clinical Psychology Review 18: 765–794 Possell P, Horn AB, Groen G and Hautzinger M (2004) Schoolbased prevention of depressive symptoms in adolescents: A 6 month follow-up. Journal of the American Academy of Child and Adolescent Psychiatry 43: 1003–1017 Reynolds WM and Coats KI (1986) A comparison of cognitivebehavioural therapy and relaxation training for the treatment of depression in adolescents. Journal of Consulting and Clinical Psychology 54: 653–660 Shirk SR, Gudmundsen GR and Burwell RA (2005) Links among attachment-related cognitions and adolescent depressive symptoms. Journal of Clinical Child and Adolescent Psychiatry 34: 172–181 Shochet IM, Dadds MR, Holland D, Whitefield K, Harnett PH and Osgarby SM (2001) The efficacy of a universal school-based program to prevent adolescent depression. Journal of Clinical Child Psychology 30: 303–315 Stark KD (1990) Childhood depression: School-based intervention. Guilford Press, New York Strayhorn JM (1988) The competent child: An approach to psychotherapy and preventive mental health. Guilfrd Press, New York Sue DW and Sue D (1990) Counseling the culturally different: Theory and practice. Wiley, New York Sund AM and Wichstrom L (2002) Insecure attachment as a risk factor for future depressive symptoms in early adolescence. Journal of the American Academy of Child and Adolescent Psychiatry 41: 1478–1485 Szigethy E, Whitton SW, Levy-Warren A, Demaso DR, Weisz J and Beardslee WR (2004) Cognitive-behavioural therapy for depression in adolescents with inflammatory bowel disease: A pilot study. Journal of the American Academy of Child and Adolescent Psychiatry 43: 1469–1477 Uba L (1994) Asian Americans: Personality patterns, identity, and mental health. Guilford, New York
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Journal of Child & Adolescent Mental Health Publication details, including instructions for authors and subscription information: http://www.tandfonline.com/loi/rcmh20
Cognitive behavioral therapy for adolescent depression: implications for Asian immigrants in the United States of America Riddhi Sandil Published online: 12 Nov 2009.
To cite this article: Riddhi Sandil (2006) Cognitive behavioral therapy for adolescent depression: implications for Asian immigrants in the United States of America, Journal of Child & Adolescent Mental Health, 18:1, 27-32, DOI: 10.2989/17280580609486615 To link to this article: http://dx.doi.org/10.2989/17280580609486615
PLEASE SCROLL DOWN FOR ARTICLE Taylor & Francis makes every effort to ensure the accuracy of all the information (the “Content”) contained in the publications on our platform. However, Taylor & Francis, our agents, and our licensors make no representations or warranties whatsoever as to the accuracy, completeness, or suitability for any purpose of the Content. Any opinions and views expressed in this publication are the opinions and views of the authors, and are not the views of or endorsed by Taylor & Francis. The accuracy of the Content should not be relied upon and should be independently verified with primary sources of information. Taylor and Francis shall not be liable for any losses, actions, claims, proceedings, demands, costs, expenses, damages, and other liabilities whatsoever or howsoever caused arising directly or indirectly in connection with, in relation to or arising out of the use of the Content. This article may be used for research, teaching, and private study purposes. Any substantial or systematic reproduction, redistribution, reselling, loan, sub-licensing, systematic supply, or distribution in any form to anyone is expressly forbidden. Terms & Conditions of access and use can be found at http:// www.tandfonline.com/page/terms-and-conditions
Copyright © NISC Pty Ltd
Journal of Child and Adolescent Mental Health 2006, 18(1): 27–32 Printed in South Africa — All rights reserved
JOURNAL OF CHILD AND ADOLESCENT MENTAL HEALTH EISSN 1728–0591
Clinical Perspective
Cognitive behavioral therapy for adolescent depression: implications for Asian immigrants in the United States of America Riddhi Sandil
Downloaded by [University of Nebraska, Lincoln] at 07:56 29 December 2014
Doctoral Student, Counseling Psychology, 361 N Lindquist Center, Iowa City, IA 52242 e-mail: [email protected] Many interventions are available for treating adolescent depression. This paper attempts to present a summary of cognitive behavioral therapies/techniques that might be useful for treating depression in Asian immigrant adolescents. Articles were selected by conducting a literature search on Psyc-Info. Prevalence, symptoms and measures of adolescent depression are discussed. Summary of popular therapies like PASCET, CWD-A, Beck’s CBT are provided. A rationale for the use of these with Asian immigrants is hypothesized. There is no empirical evidence for the efficacy of CBT with this population. A need to validate the use of CBT with this population is asserted.
Introduction It is estimated that roughly 8.3% of adolescents in the United States of America (USA) suffer from depression (Depression in Children and Adolescents 2005). These numbers might not be an accurate reflection of adolescent depression as it may go undiagnosed or attributed to problems associated with normal development. Research has suggested that Cognitive Behavioural Therapy (CBT) might be the most effective for the treatment of adolescent depression (Braswell and Kendall 2003; Gaynor et al. 2003; Kolko et al. 2000; Szigethy et al. 2004). The purpose of this paper is to synthesize past research on the efficacy of CBT with depressed adolescents (between the ages of 12 and 17) and to discuss the implications of CBT when working with depressed Asian immigrant adolescents. For the purpose of this paper, Asian immigrant adolescents are teenagers from China, Vietnam, Korea and other east Asian countries between the ages of 13 and 17 who have recently moved to the USA and did not go through an American elementary school. Unlike Asian American adolescents, these adolescents are not citizens of the USA. Thus, it can be assumed that these adolescents are still in the process of acculturating and adapting to American culture. This paper will be structured in the following way: 1) The manifestations, symptoms and reasons for depression in adolescents will be outlined. 2) The measures used with adolescent depression will be listed. 3) Popular CBT methods for treating adolescent depression will be enumerated. As there are numerous treatments available, only those treatments that can be applied to Asian immigrant depressed adolescent will be highlighted. 4) Depression in Asian immigrant adolescents will be explored. As there is sparse research on the Asian
immigrant adolescents, past research on Asian Americans and international students will be used in this section. Depression in adolescents: manifestation and symptoms The Diagnostic and Statistical Manual of Mental Disorders (American Psychiatric Association 2000) does not specify diagnostic criteria for depression in adolescents. Diagnostic criteria for diagnosing depression in adults are often utilised when working with adolescents. As with adults, the most common symptoms of depression in adolescents are persistent sad mood, anhedonia, loss of energy, changes in sleep and appetite, recurring thoughts of death and suicidal ideation (Depression in Children and Adolescents 2005). Adolescents suffering from depression might also exhibit other symptoms like boredom, truancy from school, frequent somatic complaints such as headaches, increased irritability, social outbursts, rage, substance abuse and fear of rejection (Depression in Children and Adolescents 2005). These symptoms should persist for a period of two weeks before a formal diagnosis of depression can be issued. Aetiological factors in adolescent depression There has been considerable research on reasons for depression in adolescents. Certain factors that may influence adolescent depression have been identified. The most common reason for depression in adolescents is having a parent or family member suffer from depression (Harrington et al.1997). This might suggest that some adolescents may have a genetic predisposition to depression. Adolescents who have survived a serious illness or are chronically ill are also at risk for depression (Bennett 1994; Kovacs et al. 1995, as cited in Szigethy et al. 2004). These adolescents
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might experience physical pain, anxiety and have lower self esteem and thus be more prone to depressive thoughts. Studies have also suggested that attachment insecurity might increase the risk of adolescent depression (ColeDetke and Kobak 1996; Sund and Wichstron 2002, as cited in Shirk, Gudmundsen and Burwell 2005). A study done by Shirk et al. (2005) found that “representations of maternal figures as unavailable, unresponsive and unsupportive were significantly associated with higher levels of depressive symptoms in young adolescents” (Shirk et al. 2005, p.178). Thus, adolescents who are unable to form healthy attachments with their primary caregiver might feel neglected, unwanted and lonely and thus be at a higher risk for depression. Adolescents who are currently experiencing, or have been victims of, abuse are also at risk for depression. Brown, Cohen and Johnson (1999) found that adolescents who had experienced sexual abuse were very vulnerable to becoming depressed. Children who had been exposed to natural disasters or had lost a parent or loved one were also susceptible to depression in adolescence (Krug, Kresnow and Peddicord 1998). Other factors such as substance use, stress, conduct and learning disorders also increase the frequency for adolescent depression (Wells, Deykin and Klerman 1985; Lewinsohn, Rhode and Seeley 1998). Adolescence in itself is characterised as a period of change and development and factors such as the ones enumerated above might make a teenager more susceptible to depression. Measures of adolescent depression There are many measures of depression that are commonly used when working with adolescents. Scales such as Beck Depression Inventory and Center for Epidemiologic Studies Depression (CES-D), that are designed for adult measurement of depression, are frequently administered to adolescents. Research suggests that even though these instruments have not been validated for use with adolescents, they are an accurate measure of depression with this population (Depression in Children and Adolescents 2005). However, instruments like Children’s Depression Inventory (CDI) (Kovaks M 1992) might be more appropriate when working with adolescents. The CDI is a 27 item scale that measures negative mood, interpersonal problems, ineffectiveness, anhedonia and negative self esteem (Kovaks et al. 1995). This is a short and easy-to-administer measure and can used with adolescents up to the age of 17. It has been widely researched and has high measures of reliability and validity. The above instruments can aid the clinician in gauging the symptoms and severity of depression. They are also helpful in assessing which treatment might be most beneficial for the adolescent client. Overview of treatments This section will give a brief overview of Cognitive Behavioural Treatments that are employed with adolescent depression. Some of these treatments have been researched extensively but many have yet to empirically tested.
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The Primary and Secondary Control Enhancement Training (PASCET) PASCET is a CBT that is shown to have high efficacy with adolescents (Weisz et al. 1995). The PASCET assumes that adolescents are more prone to depression due to social skills deficits and negative thoughts in response to life stressors (Weisz, McCabe and Dennig 1994). This treatment attempts to increase the coping skills of adolescents by using a dual model of observed control, namely perceived and secondary control (Szigethy et al. 2004). Perceived control entails reducing the punishing or increasing the rewarding aspects of one’s environment whereas secondary control deals with changing the client’s beliefs and perceptions about certain events or objective conditions (Weisz et al. 1994). A study by Szigethy et al. (2004) attempted to study the efficacy of CBT when working with physically ill adolescents. The researchers used the PASCET with adolescents suffering from inflammatory bowel disease. It was found that there were greater reductions of depressive symptoms and increased perceptions of well-being in adolescents who were underwent the PASCET. As depression is highly correlated with physically ill adolescents (Depression in Children and Adolescents 2005), an efficient CBT is essential for treating this population. PASCET has shown to be effective for the same. The Adolescent Coping with Depression Course (CWD-A) CWD-A is a group-based intervention designed by Lewinsohn, Clarke, Hops and Andrews (1990). This CBT has been widely researched and evaluated and is shown to have high efficacy with adolescents (Lewinsohn et al. 1990). The CWD-A course typically includes 16 sessions (two a week) with each session lasting about two hours. Participants should be between the ages of 14 and18 years. The course covers topics such as relaxation, pleasant activities, cognitive therapy, social skills, communication negotiation, problem solving, life plan and maintaining gains (Clark, Lewinsohn and Hops, 1990). In a study done by Kaufman et al. (2005) the CWD-A was used with adolescents with comorbid major depression and conduct disorder. The researchers found that the CWD-A was able to reduce depression in adolescents by primarily reducing negative thoughts. Cognitive restructuring Cognitive restructuring methods are widely used in a number of cognitive behavioural treatments (Braswell et al. 2003). Developed primarily by Beck et al. (1979) and Ellis and Harper (1979) these methods attempt to change negative self-perceptions and beliefs (Braswell et al. 2003). Cognitive restructuring in adolescents is conducted similarly to that in adults. The counselor and client work on the client’s negative self statements and collaboratively try to examine the evidence that either supports or refutes these beliefs (Braswell et al. 2003). This technique might work well with adolescents as they might be at the point in their development where they are trying to learn more about themselves and explore their personality. Furthermore, adolescents might also be trying
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to formulate their own world view during this time and this intervention might be beneficial given their developmental stage (Braswell et al. 2003). Beck’s Cognitive Behavioural Therapy (CBT) Beck’s CBT (Beck et al. 1979) is primarily utilised with adult populations. However, a number of studies have adapted this approach for adolescents (Kolko et al. 2000; Gaynor et al. 2003). This CBT emphasises “collaborative empiricism, importance of socialising the patient to the cognitive therapy model, and the monitoring and modification of automatic thoughts, assumptions and basic beliefs” (Kolko et al. 2000 p.606). When working with adolescents there is a further emphasis on problem solving and affect regulation to meet the requirements of adolescent depression (Kolko et al. 2000). As Beck’s CBT allows the client to be the expert of their problem and is a collaborative therapy process (Beck et al. 1979), this approach could work well with adolescents. Adolescents could gain empowerment from this process and thus raise their self esteem. By working with a therapist who is warm and supportive, adolescents might also be able to identify their self-defeating schemas and take an active role in identifying and combating their negative thoughts. Self-regulation approaches Asking the adolescents to keep track of their thoughts, moods and emotions is a widely-used approach in the management of depression. When working with depressed youth, having them track their moods might be an effective way for them to gain insight into the causes of their behaviour (Braswell et al. 2003). Often, adolescents might be asked to track their pleasurable activities as well. As pointed out by Braswell et al. (2003) this method might also “address the overly rigid or unrealistic standards for selfevaluation that such [depressed] youth may manifest (Stark 1990 as cited in Braswell et al. 2003 p.259). Having adolescents monitor their thoughts and feelings might make them more invested in the therapy process. These clients might feel a sense of responsibility and experience an increased motivation to change their negative thoughts or perceptions. By having logs of when depressive thoughts occur, adolescents might also be able to identify triggers that perpetuate their depression. By controlling these, they might be able to make changes in their environment and hence changes in their thinking and mood. Relaxation training Relaxation training is widely used with children and adolescents dealing with anger management concerns (Feindler and Ecton 1986, as cited in Braswell et al. 2003). It is also a component of widely used CBT’s like Beck’s treatment. Techniques such as progressive muscle relaxation and guided imagery are popular relaxation techniques for adolescents (Cautela and Groden 1978, as cited in Braswell et al. 2003; Kendall et al. 1992). A study by Kahn et al. (1990) found that relaxation training was as effective as other CBTs when working with depressed adolescents. Relaxation training also helped increase self esteem in this population (Kahn et al. 1990).
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Reynolds and Coats (1986) also compared the effectiveness of CBTs like self monitoring, self evaluation and self reinforcement with relaxation techniques. It was found that both treatments were equally effective at a five week follow up (Reynolds et al. 1986). Comparison of cognitive behavioural techniques with other approaches Studies have looked at the efficacy of CBT with other therapies when working with adolescent depression. In Barbe et al. (2004), CBT was compared with Systematic Behavioural Family Therapy (SBFT) and Non-directive Supportive Therapy (NST) with depressed clients at risk for suicide. It was found that NST was not an effective treatment approach when working with this population. CBT and SBFT were more effective in reducing the risk of suicide and also alleviating depressive symptoms in this population (Barbe et al. 2004). A study by Gaynor et al. (2003) obtained similar results. Adolescents that underwent CBT showed more decreased depressive symptoms and cognitive distortions than adolescents who were exposed to SBFT and NST (Gaynor et al. 2003). In this study it was also found that CBT was able to elicit more sudden gains, i.e. adolescents showed a more marked improvement by the second or third session than the other two treatment groups (Gaynor et al. 2003). Kolko et al. (2000) studied the efficacy of CBT, SBFT and NST over a period of time. At a two year follow up, they found that SBFT was most effective in reducing family conflict and improving parent-child relationships (Kolko et al. 2000). However, CBT was found to have a greater impact on reducing anxiety symptoms. Thus, SBFT might be an effective interpersonal approach to improve relationships but CBT might be a more effective approach in reducing depressive symptoms with this population. The role of family and school in adolescent depression An adolescent’s social environment can impact their depressive symptoms and the effectiveness of the CBT being employed. School-based programs are becoming popular for treating adolescent depression. However, there is a high dropout rate for such programs. Research suggests that stigmatisation experienced from their peers leads the depressed adolescent to discontinue the suggested/proposed interventions (Schochet et al. 2001). Stigmatisation also leads to difficulty recruiting for such programs. Schochet et al. argue that having a universal program during regular school hours might be more effective in increasing participation and retention (Schochet et al. 2001). In order to eliminate experienced stigmatization, Possel et al. (2004) employed a school-based intervention, LISA-T, with eight graders. LISA-T is a CBT that targets an adolescent’s cognitive and social aspects. This intervention aims to provide social competence skills, self assured behaviour and explore and change dysfunctional thoughts (Possel et al. 2004). Reduced depressive symptoms were found in depressed adolescents at the end of this intervention. Adolescents who had subsyndromal symptoms also reported fewer symptoms. These changes were not seen in
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the control group (Possel et al. 2004). This study suggests that CBT might also be helpful for adolescents who are not currently experiencing depression. Furthermore, including the entire cohort in the training program might help in reducing stigmatisation and increase awareness about depression and its consequences in adolescents. An increase in awareness might lead to a greater sensitivity and depressed adolescents might feel less isolated and disengaged from their peers. Family relationships also play an important role in adolescent depression. Research shows that contingency management might be an effective strategy to deal with depression in adolescents (Strayhorn 1988 as cited in Braswell et al. 2003). Parents play an important role in contingency management and can be included in the therapy process. This could further reduce possible isolation and increase social support and empathy experienced by a depressed adolescent. However, parental monitoring is necessary in this method in order to ensure that rewards are consistent and clear contingency patterns are established (Braswell et al. 2003). Multicultural applicability: the case of Asian adolescent immigrants There is sparse research on the applicability of CBT when working with depressed Asian adolescent immigrants. This section will provide arguments as to why CBT is an effective approach for this population. This section will draw on literature based on Asian Americans and Asian international students as research on Asian immigrants is sparse. Research suggests that depression rates among Asian Americans are comparable with depression rates among Caucasians, but Asian Americans are more likely to underutilise mental health services (Uba 1994). The suicide rates for certain Asian American populations is higher than that of the national sample and Asian American female adolescents report more symptoms of depression than other adolescent groups (Huang 1997). Thus, there is a need to address mental health concerns of Asians and Asian Americans. Asian adolescent immigrants might be experiencing many stressors that can predispose them to depression. Some of these are: moving to a new country, learning new customs, inability to speak English, being removed from friends and extended family, and perhaps not having economic security in the United States. Symptoms of depression in Asian adolescents might be sleep and appetite disturbances, poor performance in academics and somatic complaints like stomach and head aches (Huang 1997). The clinician’s lack of these cultural differences can lead to misdiagnosis or underdiagnosis of adolescent depression with this population (Gee 2004). Gee suggests that the counselor conduct extensive interviews beyond the scope of the assessment being employed. Interviewing primary caregivers and the adolescent’s extended family might also be beneficial in gathering information for the diagnosis of depression with this population (Gee 2004). This task might be particularly difficult as research suggests that Asians do not like to disclose family information to strangers and would prefer to keep their family matters to themselves (Sue and Sue 1990). Asian
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parents might also be reluctant to seek help for their children given their bias that psychologists are not official health professionals (Gee 2004). The clinician should be aware of these barriers when working with this population. Research suggests that Asians might prefer their counselor to be assertive and directive (Khoo and Abu-Rasain 1994). As most CBTs work at reducing depressive symptoms and are goal directed they might be effective with this population. Adolescents who have not been exposed to therapy before might welcome the structure that CBT provides and thus be more inclined to remain in therapy. CBT also allows family members to play a role in managing adolescent depression. Most Asian immigrants have a strong sense of collectivistism and might prefer their family’s support during this difficult time (Kim, Atkinson, and Umemoto 2001). Knowing that their family can be active in their therapy might offer relief for the adolescent and thus increase motivation for counseling. Family can be incorporated into various CBT treatments. They can assume the role of contingency managers and follow a fixed pattern of reward and punishment for the adolescent. They can also help in aiding the teen with relaxation procedures and do the exercises with them. Furthermore, family members can accompany the adolescent to therapy and take part in cognitive restructuring and Beck’s CBT (Beck et al. 1978) as a group. The focus on behaviour change and training in CBT might make this approach attractive to Asian adolescent immigrants. Most Asian cultures value being in control of one’s emotions and remaining strong in times of adversity (Uba 1994). As emotional breakdowns can be construed to be a sign of weakness, it is easy to imagine why Asian immigrants and their families might be reluctant to seek psychological help. However, CBT can be presented as a training model as opposed to psychological counseling. Adolescent immigrants and their families might feel more comfortable to know that they will learn how to deal with depression as opposed to understanding what it is. Thus, teaching skills like relaxation might be a concrete and non-threatening approach to treating depression in this population. School-based interventions, where all students are mandated to participate, might also be beneficial for this population. Research suggests that conformity to norms is a revered cultural value in Asian society (Kim et al. 2001). Knowing that their peers are also undergoing the same training might be encouraging and can help in normalising the experience for this population. Thus, interventions like the LISA-T and PASCET can be introduced into the curriculum in schools with a high Asian immigrant population. As these interventions are beneficial for non-depressed adolescents as well, they will be useful experiences for all the students involved. Conclusion and future implications There is a need to address the mental health concerns of Asian immigrants, particularly adolescents. As the U.S. becomes more diverse every year, more immigrant adolescents enter the school system and are exposed to a completely different way of life. Issues of acculturation, adjustment and assimilation can be stressful for Asian
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youth and could lead to symptoms of depression in this population. Furthermore, since depressive symptoms can be masked with somatic complaints in this group, it might be difficult to diagnose depression in this population. There is no empirical evidence of the efficacy of the above mentioned cognitive behavioural techniques with this population. There is also a lack of research on the validity of various measures of depression with this population. As the number of immigrants is increasing every year, there is an urgent need to address this issue. In order to effectively work with Asian immigrant adolescents, culturally appropriate measures and interventions need to be developed.
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