Cognitive-behavioral therapy for depressed girls: a qualitative analysis of the ACTION program
This study used a qualitative methodology to examine treatment outcome and mechanisms of change from the perspective of the participants in a group cognitivebehavioral therapy intervention for depressed girls (i.e., the ACTION program). Data were collected from seventeen participants using semi-structured interviews. Seventeen initial and seven follow-up interviews were conducted. Interviews were transcribed and analyzed using the grounded theory approach. A theoretical model emerged from the data that explained mechanisms of change in relation to treatment outcome and evaluation. Prior to treatment, all participants were diagnosed with a depressive disorder. At post-treatment, approximately 88% of the sample no longer met criteria for depression. Thus, the ACTION program demonstrated a high rate of efficacy. Additionally, all of the participants described treatment as helpful. Level of helpfulness varied from high to low, with most participants rating treatment as very helpful, and depended on the ways in which the intervention produced positive change in the following areas: stressors, stressor management strategies, emotions, cognitions, and social support. Participants evidenced high levels of pre-treatment stressors, particularly in the interpersonal domain, and low levels of social support. Passive, emotion-focused strategies were used to manage these difficulties; however, they were largely ineffective. Not being able to resolve stressors successfully led participants to experience unpleasant emotions and negative ways of thinking. Together, these variables resulted in high levels depression prior to treatment. At post-treatment, most participants experienced several positive changes, including decreased stressors, increased effectiveness of stressor management strategies, elevated mood, and a more positive outlook. These changes were attributed to the acquisition and application of the core treatment components by the majority of participants. Some participants also experienced an increase in social support, which was associated with characteristics of the treatment structure. Thus, the two most important variables in relation to treatment outcome and evaluation were specific mechanisms of change (i.e., treatment components) and non-specific therapeutic factors (i.e., treatment structure). In addition, treatment outcome was also influenced by participant characteristics. Participants that held unrealistic expectations, were not ready for change, or engaged in limited problem-sharing experienced fewer positive changes over the course of treatment.