Posted: October 20th, 2022

Capstone

Running Head: Capstone

Suicide Prevention for Hmong Adolescences with Depressive Symptoms
Table of Contents
Page

Introduction 4
Literature Review 7
Defining Suicide 7
Suicide Epidemiology 8
Defining Depression 10
Depression Epidemiology 11
Suicidality amongst Hmong Adolescents 13
Hmong Suicide within Fresno: A Case Study 13
Previous Interventions 16
SOS Suicide Prevention Program 17
Combined Cognitive-Behavioral Family Education Intervention 20
Bicultural Effectiveness Training 22
Proposed Intervention Approach 24
Implementation Strategy 24
Presentation of Theoretical Grounding for Proposed Intervention 26
Cognitive Behavioral Therapy 26
Narrative Therapy via Constructionism 31
Intervention Hypothesis 33
Detail of Intervention 33
Presentation of Way Proposed Intervention Incorporates CRT 38
Assessment Process 40
Description of Measures 41
Page
Assessment Protocol 44
Presentation of a Logic Model 45
Reference 46
Appendix 55
Figure 1 55
Figure 2 56
Figure 3 56
Figure 4 57
Student Satisfaction Survey 58
CBT Curriculum 62

Introduction
The term Asian American was a term first coined by Yuji Ichioka during the late 1960’s in the advancement of bringing diverse Asian groups together (Kang, 2002). It has become an umbrella term used to describe American citizens who are of Asian descent. It is important to note that Asian immigrants who are not necessary American citizens will also get lumped under this umbrella term. According to Baruth and Manning (2003), there are almost 50 distinct Asian American ethnic groups that reside in the U.S. with an estimated total of 30 distinct languages spoken among this highly diverse group. Pacific Islander groups are also occasionally included within the umbrella term. Suicide rates are prevalent within this highly diverse population.
Despite suicide being ranked as the 11th most common cause of death in the U.S., it is ranked as the 8th most common cause of death amongst Asian Americans (U.S. Department of Health and Human Services, 2007). Bartels et al. (2002) reported that Asian American elders involved in the primary care system have the highest rates of death and suicide ideation (at 56.8%) when compared to other non-Asian elderly groups. In 2007, young Asian American adults had higher suicide mortality, as the combined suicide rate of Asian American males and females between the ages of 20 to 24 (12.44 suicides committed per 100,000 population) exceeded the combined rate of all other racial groups except for Native Americans (30.48 per 100,000) (CDC WISQARS Injury mortality Reports). This startling suicide rate can be correlated to the high suicide ideation rates of Asian American college students (Lam, 2009).
According to Lam (2009), Asian American students make up between 10 and 30% of the student population in the best American universities. Despite the academic achievement seen in this group, Asian American college students are more likely to attempt suicide than their European American counterparts at these educational institutions (Leong et al., 2007). Between May 2009 and July 2009, three Chinese American students at the California Institute of Technology (Caltech) have committed suicide (Lam, 2009). Other instances of college related suicide can be seen at Cornell University. Between 1996 and 2006, there were a total of 21 suicide related deaths reported at Cornell University. Out of the 21 victims, 13 of them were Asian students. This incident sparked the university to from a special Asian Campus Climate Task Force to investigate the high suicide rate, as Asian American students only make up 14% of the Cornell student body (Lam, 2009). The top three triggers in the formulation of suicide ideation reported among Asian American college students who had considered committing suicide in the past year were pressure to do well in academics, family conflicts, and financial issues (Wong, Brownson, & Schwing, 2009).
Asian American students are expected (and pressured) to excel in academics through expectations set forth by their parents. According to Chang (1998), these expectations can result in Asian American students becoming obsessive in striding for perfection. Perfectionism “refers to a multidimensional phenomenon defined by excessive self-criticism associated with high personal standards, doubts about the effectiveness of one’s actions, concerns about meeting social expectations (typically those of the parents), and an excessive focus on organization and neatness” (Chang, 1998, p. 238). This behavior has been linked to risk of suicidal behavior, as seen in a study conducted by Hewitt, Flett, and Weber (1994) in which college students with perfectionistic tendencies reported being more suicidal (as cited in Chang, 1998). This behavior can be fostered by parents through rivalries of other parents as seen in Chin’s (n.d.) account of her parent’s academic expectation:
Excelling in our culture is based squarely on ‘being better than someone else, preferably someone whose parents your parents can’t stand.’ I grew up being constantly compared and contrasted with other kids. And my favorite [quotes coming from my parents]: ‘You scored a 99% on your test Why didn’t you get 100%’. We’re just never good enough.’ (Chin, n.d., para 8).

Although more attention is being paid to this topic in the recent years, information about suicide within the Asian American community is still scarce among certain Asian groups such as Southeast Asians. Southeast Asians are Asian groups that originated from the following countries: Brunei Darussalam; Cambodia; Indonesia; Laos; Malaysia; Myanmar; Philippines; Singapore; Thailand; Timor-Leste; and Vietnam (United Nations Statistics Division, 2011). Suicide statistics mentioned above for Asian Americans has mainly reflected Asian groups (e.g. Chinese, Japanese, and Filipino Americans) who have been in the U.S. for an extended period of time (Leong, 2007). Despite the lack of statistical information for the newer Asian groups residing in the U.S., 70% of Asians in the U.S. are first generation Americans (Cheng et al., 2010).
Southeast Asian groups that migrated into this country during 1970s and 1980s partially account for the high percentage of foreign-born Asians residing in the U.S (Lee, 1998). The vast majority of people within this group are refugees who have immigrated into the U.S. from Cambodia, Laos, Thailand, and Vietnam due to war conflicts such as the Vietnam War, Khmer Rouge conflicts, etc. Although there is a lack of research to convey the prevalence of suicide within Southeast Asian groups, there have been published studies indicating a high prevalence of Post-Traumatic Syndrome Disorder (PTSD) (which is a possible factor in triggering suicide) among this population (Hinton et al., 2004; Marshall et al., 2010; Oquendo et al., 2003).
Within Southeast Asian groups such as the Hmong, intergenerational conflict can be identified as one of the key triggers of depression amongst adolescents, as various studies have indicated that a clashing of opposing cultures between Hmong parents and adolescents is a contributing factor for depression amongst Hmong adolescents (Boulden, 2009; Castillo & Phoummarath, 2006; Juang et al., 2007; Lee et al., 2009; and Ying & Han, 2007). This type of conflict often exists within first generation Asian American families due to the acculturation differences between immigrant parents and their children (Cheng et al., 2010; Portes & Rumbaut, 2001). As it will be demonstrated in the Fresno case study below (on page 13), this clash of values within the family can cause a child to develop depressive symptoms and engage in suicidal behaviors if this conflict is not addressed promptly.
The purpose of this capstone is to propose a school-based group intervention curriculum geared towards addressing intergenerational conflict amongst Hmong adolescents between ages 14 to 19. This curriculum was created in response to the string of Hmong adolescent suicides which occurred in Fresno, Ca between 1998 and 2002. Cognitive Behavior Therapy and Narrative Therapy will be used in Helping Hmong adolescents in developing coping skills in dealing with intergenerational conflict with their parents. In addition, through Hmong adolescents participating in the group sessions, it is hoped that a social support will be formed amongst them.
Literature Review
Defining Suicide:
The term “suicide” is used to describe the purposeful act of self-destruction of a human being by means of that person causing his or her body to cease life function. The act of committing suicide can be seen as a way to deal with a person’s despair when they feel that they have exhausted all of their options in handling their predicament. This act can be triggered in a number of ways, such as hardships in the financial aspects of life, failed/difficult relationships, and any undesirable life situations. Health related issues such as bipolar disorder, drug abuse, depression, schizophrenia, and alcoholism may also factor in as a reason for taking one’s own life (Hawton and van Heeringen, 2009). While suicide is sometimes conducted as a means of political protest, this capstone will restrict its consideration to suicide reflecting difficulties with depression.
Suicide Epidemiology:
Suicide has become a leading contributor in the cause of death amongst various age groups and populations. An estimated total of more than 33,000 deaths as a result of suicide occur each year in the U.S., which equates to 91 deaths per day. Through the National Violent Death Reporting System, 16 states report that one-third of suicide victims were under the influence of alcohol. In addition, the use of heroin and prescription pain killers was found in 1/5th of these deaths.
As reported by the CDC (2009), the significance of suicide as a leading cause of death can vary amongst different age groups. Suicide was the third leading cause of death in 2009 for young adults between the ages of 15 to 24. It was estimated that for every successful suicide committed within this age group, there were approximately 100-200 attempts made. In a 2007 survey study, the CDC (2009) reported that 14.5% of high school students had given serious consideration in attempting suicide in the past 12 months. Of the students who were administered this survey, 6.9% had reported in having attempted suicide one or more times during the past 12 months. For older adults between the ages 25 to 34, suicide was the second leading cause of death (CDC, 2009). Moving up the age range from 35 to 44, suicide was the fourth leading cause of death. The prevalence of suicide can also be seen within elder adults, as the rate of suicide was 15.9 suicides committed per 100,000 people age 75 and over (CDC, 2009). In addition, CDC (2009) estimated for every four suicide attempts among persons aged 65 or older, there was one successful committed act.
From a gender perspective, suicide is the 17th leading cause of death for males and 16th for females (CDC, 2009). CDC (2009) data revealed that males are four times more likely to take their own lives as opposed to females, as 79% of all reported deaths by suicide in the U.S. having been committed by males. Although males are more likely to take their lives, females are about two to three times more likely than males to attempt suicide during their lifetime (CDC, 2009). The use of a firearm was attributed to 56% of all male related suicides. In contrast to males, poisoning was found to be the most common method for female (40.3%). The rate of suicide is highest for women within the ages of 45 to 54, while for males it is 75 and older (CDC, 2009).
Suicide is not only a social problem from a mental and physical health perspective, but also an issue from an economic standpoint. Suicide victims can incur a significant amount of direct and indirect monetary cost for society. According to Yang and Lester (2007), the direct costs incurred by the victim are associated with hospital cost and medico-legal cost (cost of autopsies and legal investigations). Indirect cost includes potential earnings (i.e. lifetime earnings) lost due to premature death and permanent disability. Estimates for indirect cost are determined by “both years of productive life lost and the corresponding estimated value of lifetime earnings” (Yang & Lester, 2007, p. 352).
The act of successful suicides can generate significant cost for society. In calculating the cost of suicide deaths that occurred during 1980, it was found that $4.2 billion were lost due to lost productivity. This loss of productivity comes to a loss of $260,691 per suicide victim (Yang and Lester, 2007). If this loss were to be converted to 2005 dollars, the cost of completed suicides is estimated to be $617,870. Yang and Lester (2007) gave an estimated total number of suicide deaths in 1980, which were 26,869 lives. From the estimated number of lives lost, total cost incurred by victims was $16.60 billion in 2005 dollars.
It was estimated by Yang and Lester (2007) that the individual cost (for people within the age range of 15 to 24) of successful suicides in 1980 cost was $431,600 from lost lifetime earnings. By converting this estimated lifetime cost to yearly earnings, an estimated $10,400 per year of productive life expectancy to age 65 was lost. In addition to the lost lifetime earnings, each death also incurred an addition cost of $1,750 for medico-legal matters. The cost of lost lifetime earnings in 2005 dollars would be an estimated total of $1,022,950. For each teenage suicide, the cost in 2005 dollars would be $4,150 for each death.
Unsuccessful suicide attempts also incur heavy cost. These cost stems from the crucial medical care needed to treat the survivor, the possible psychological and psychiatric cost in dealing with the mental state of the person, and the “loss to the labor force during this period, incurring additional economic cost” (Yang & Lester, 2007, p. 353). Yang and Lester (2007) provided some data collected from the accounting department at a small hospital in New Jersey. In 2001, 40 individuals were admitted into the hospital for attempted suicide. The reported average cost of the patients was $12,409, with the range cost being $1,811 to $61,803.
Defining Depression:
Depression can be defined from a simplistic standpoint as feeling blue, sad, miserable, and unhappy. From a clinical perspective, it is a mood disorder in which “feelings of sadness, loss, anger, or frustration interfere with everyday life for a significant period of time” (National Center for Biotechnology Information, 2010, para 2). Beck (1995) defined depression in terms of cognitive content and processing styles wherein a person with depression may have a “negative view of themselves, the world, and the future” (as cited in Vonk & Early, 2009, p. 243). It can be a debilitating and costly mental illness, as it can “adversely affect the course and outcome of common chronic conditions, such as arthritis, asthma, cardiovascular disease, cancer, diabetes, and obesity” (CDC, n.d., para 1). According to the DSM-IV-TR (American Psychiatric Association, 2000), symptoms of depression can include a combination of the following:
• Agitation, restlessness, and irritable mood
• a loss of interest or pleasure in activities that were once enjoyed
• Dramatic change in appetite, often with weight gain or loss
• Extreme difficulty concentrating
• Fatigue and lack of energy
• Feelings of hopelessness and helplessness
• Feelings of worthlessness, self-hate, and inappropriate guilt
• Thoughts of death or suicide
• Trouble sleeping or excessive sleeping

This mood disorder can be trigger in variety of ways which can include difficulties in family or partnership, occupational stress, traumatic events, etc. This capstone will restrict its consideration to depression reflecting difficulties caused by family conflict via intergenerational conflict between Hmong adolescents and their families, as demonstrated in the Fresno case study below.
Depression Epidemiology:
Depression is the fourth leading cause of disability worldwide, as 121 million people worldwide are affected by this disorder (World Health Organization, n.d; National Institute of Mental Health, 2006). It is predicted that it will be the second leading cause of disability by 2020 (National Institute of Mental Health, 2006). Within the U.S., approximately 14.8 million adults (6.7 percent of the U.S. population) have depressive disorders (National Institute of Mental Health, 2006). Depression has a significant impact on people and society as 70 percent of psychiatric hospitalizations and 40 percent of suicides were attributed to this disorder (National Institute of Mental Health, 2006). The total cost of depression in U.S. during the year 2000 was an estimated total of $83 billion, which included the cost of treatment ($26 billion) and losses related to absenteeism, reduced productivity at work, and the value of lifetime earnings lost due to suicide-related deaths ($57 billion) (National Institute of Mental Health, 2006; Greenberg et al., 2003).
According to the CDC (n.d.), the following groups were identified as being more prone towards having depression: people between the ages 45 and 64; women; people from ethnic groups; persons with less than a high school education; those previously married; individuals unable to work or unemployed; and persons without health insurance. Within a lifetime, depression will have affected 10 percent of men and 25 percent of women (National Institute of Mental Health, 2006). The prevalence of depression amongst women is higher than men, as they are 70% more likely to experience depression during their lifetime (Kessler et al., 2008; National Institute of Mental Health, n.d.). Depression can co-exist with other illness (anxiety disorders, alcohol/substance abuse, and medical illnesses) that can either “precede the depression, cause it, and/or be a consequence of it” (National Institute of Mental Health, n.d., para 1).
According to SAMHSA’s (2008) report, Major Depressive Episode among Youths Aged 12 to 17 in the United States: 2004 to 2006, the annual average of adolescents within ages 12 to 17 who had experienced at least one major depressive episode within the past year was 8.5 percent (2.1 million teens). There is a general pattern that can be seen on Figure 1 of the Appendix for the rate of past year major depressive episode, as the rates tend to increase from age 12 to 16 (SAMHSA, 2008). The report also indicated that 48.3 percent of adolescents surveyed reported being impaired in at least one of four domains (i.e. home, school/work, family relationships, or social life) (SAMHSA, 2008).

Suicidality amongst Hmong Adolescents:
Hmong Suicide within Fresno: A Case Study
The Fresno Bee Newspaper compiled a special documentary story, Lost in America, in 2002, which featured stories of eight Hmong adolescents who committed suicide in Fresno, Ca between 1998 and 2002. In addition, the compilation story featured several other stories from other Hmong suicide victims and Hmong adolescents who had engaged in self-harm activities. This compilation was made in an effort to understand and explain the string of Hmong suicides committed during the 4 year period. This string of suicides became the center of attention for Fresno County, as these deaths had accounted for nearly half of the county’s teen suicides during that time frame, despite the Hmong population being just 3% of the region’s population (Fresno Bee, 2002).
Victims featured in the compilation had a variety of similar backgrounds and behavior patterns which may have contributed to their untimely deaths. All of the adolescents were children of refugees who immigrated into the U.S. after the end of the Vietnam War in 1975 (Fresno Bee, 2002). A majority of the victims had relationship conflicts with their parents. These conflicts were a result of the parent and children’s values clashing with each other. One of the emphases in analyzing the lives of these victims were the victims’ struggles in maintaining the two contrasting worlds that they lived in. These two worlds were living their life as a Hmong child under their parents and living their life as an American teenager outside of the home. These two worlds would come into conflict with each as Hmong adolescents must often choose between embracing the values of their parents or the values of their school peers to whom they have become accustomed. Through the clashing of values between the parent and child, the compilation of stories in this newspaper ultimately correlated the suicides to intergenerational conflict and a clashing of two different cultures. In order to gain a better understanding of this correlation within the Hmong community, one needs to understand the migration history of the Hmong, and the consequences of the migration on Hmong adolescents.
Unlike past immigrant groups who came into the U.S. to seek new found fortune, the Hmong people immigrated to the U.S. to avoid political persecution due to their involvement in the Vietnam War. Originally from Laos, the Hmong population was recruited by the U.S. to fight against communism during 1960-1975 (The Split Horn, n.d.). A total of 30,000 Hmong men participated in the effort. Towards the end of the conflict, the Hmong had to flee the country in fear of backlash from the communist regime. It has been estimated that one tenth to a half of the Hmong population was lost in the war (300,000 to 400,000 Hmong were living in Laos before the war) (The Split Horn, n.d.). Due to the forced migration, “the Hmong people have experienced tremendous acculturative shock upon resettlement in the late 1970s and 1980s and have continued to face multiple social, cultural, educational, economic, and institutional barriers and challenges” (Lee et al., 2009, p. 549).
Hmong immigrant parents have to contend not only with the cultural barriers of acculturating into the American mainstream, but also the new shifting dynamics of the culture between them and their children. Hmong children born in the U.S. are more “readily and rapidly to acculturate to the mainstream American culture than their parents” (Lee et al., 2009, p. 549). As a child develops their own identity and begins to become integrated into society, “one of the normative tasks of adolescence involves developing a set of personal values, beliefs and behaviors” (Juang et al., 2007, p. 966). Through their development, adolescents are much quicker in acquiring the values and behaviors of the new culture than their parents (Kao, 1999). This rapid rate of acculturation within children can cause “intergenerational discrepancies in values and behaviors (dissonant acculturation)” (Lee et al., 2009, p. 549). While dissonant acculturation is not a-typical among immigrant communities, the greater the cultural discrepancies, the greater the anticipated strain. In addition, it is possible that the accommodations to dissonant acculturation parents have to make may be more challenging for populations that had to relocate involuntarily.
Intergenerational conflict is a result of the clashing of values and behaviors between the Hmong immigrant parent and their first generation offspring. Communication between the two parties is conflicted, as the parents are more “likely to retain the lifestyle, values, traditions, and customs of their homeland and less likely to uniformly adopt the mores of American society, particularly in regards to raising and socializing their children” (Lee et al., 2009, p. 549). In contrast to their children, parents are highly selective in terms of choosing aspects of their lives that they are willing to acculturate and/or assimilate.
Boulden (2009) notes that this selectiveness amongst the parents often leaves them “ill-equipped to guide or support the experiences of their children growing up in the U.S., thus creating this generational conflict within the Hmong community” (p. 140). This conflict can cause an identity rift for Hmong adolescents, as they are force to choose between being “Hmong” and “American”. As communication between the parent and child becomes conflicted, children are more likely to “show an assortment of adjustment problems, including psychological distress, acting out behaviors and poor academic performance” (Lee et al, 2009, p. 550). An example of how intergenerational conflict can lead an adolescent into destructive behaviors can be seen in the case of Melinda Lee, who is featured in the Fresno Bee’s compilation report.
Melinda Lee (who fortunately is not one of the suicide victims) is a Hmong teenager who struggled with balancing her duties as a Hmong daughter and her longing of being an “American”. At the age of 12, one of Melinda’s duties as a Hmong daughter was waking up early in the morning at 5am daily to prepare breakfast for her family. During the weekdays, Melinda goes to school and comes back home by 5pm (this is her curfew) to start on her chores. Her parents’ expectations for her are to clean the house, prepare meals, Help them, obtain an education, marry into a good family, and avoid shaming them. Despite her parent’s expectations, Melinda longs to live the life of a normal American teenager (Fresno Bee, 2002). She reported often arguing with her parents over issues such as dating, clothes and the company that she keeps.
Due to the high expectations of her parents, she reported ditching her high school classes at least twice a month to spend time with friends at the mall. As result of her ditching school, her grades began slipping. Melinda elaborated, “I guess I was just so determined to live my own life. It’s so hard to live the life my parents want me to. I feel like if I get in trouble, it’s worth it” (Fresno Bee, 2002, p. 64). She has reported having suicide ideation, as she has engaged in cutting herself with a razor blade and overdosing on pain relievers as her problems escalated.
Previous Interventions:
Two previous school-based interventions are analyzed in this section: 1) the SOS Suicide Prevention Program and 2) a combined cognitive-behavioral family education intervention for depression in children. In addition, a unique family intervention called Bicultural Effectiveness Training will be examined. In analyzing the components of each intervention, a Critical Race Theory (CRT) perspective will be taken in discussing the programs’ strengths and weakness. Critical Race Theory (CRT) is a study of power in which it explicitly examines how societies organize themselves into hierarchies using race and other social identity categories (Delgado, 2001). In studying the dynamics of power, it seeks to “transform the relationship among race, racism, and power” (Delgado, 2001, p. 2). CRT has built its theoretical foundations from critical legal studies and radical feminism (Delgado, 2001). CRT draws from “European philosophers and theorists, such as Antoino Gramsci and Jacques Derrida” (Delgado, 2001, p. 4), as well as from the American scholars such as W.E.B. DuBois (Delgado, 2001). Furthermore, it draws from the civil rights movement and the concern for “redressing historic wrongs” (Delgado, 2001). There are 6 basic tenets of CRT, which are as follows
1) Racism is “ordinary” in which it is an experience infused into our everyday lives (Delgado, 2001).

2) “Interest convergence” holds that certain groups within society will have an invested interest in maintaining the current systems of domination, as it works to their favor (Delgado, 2001).

3) “Social construction thesis” holds “that race and races are products of social thought and relations which are nether objective, inherent, or fixed” (Delgado, 2001, p. 7)

4) “Differential racialization” holds that “the way dominant society racializes different minority groups at different times, in response to shifting social needs” (Delgado, 2001, p. 8).

5) “Intersectionality and anti-essentialism” holds that “no person has a single, unitary identity” (Delgado, 2001, p. 9).

6) “Voice of color thesis” holds that those who have experienced oppression are able to “communicate to their white counterparts matters that the whites are unlikely to know” (Delgado, 2001, p. 9).

SOS Suicide Prevention Program
The SOS suicide prevention program is a school-based intervention targeted towards high school students (9th to 12th grade), as it blends 2 prevention strategies together (Aseltine & DeMartino, 2004). These 2 components are as follows: 1) structured curricula aimed towards raising suicide awareness amongst high school students; and 2) utilization of self-screening techniques for assessing depressive symptoms and other risk factors associated with suicidal behavior. The program materials consist of a video and discussion guide (Aseltine & DeMartino, 2004). According to Aseltine and DeMartino (2004), the video “features dramatization that depict the signs of suicidality and depression and the recommended ways to react to someone who is depressed and suicidal” (p. 446). In addition, the video contains “interviews with real people whose lives have been touched by suicide” (Aseltine & DeMartino, 2004, p. 446). The goals of this intervention are to: 1) “increase students’ understanding and recognition of depressive symptoms in themselves and in others and by promoting more adaptive attitudes toward depression and suicidal behavior” (Aseltine & DeMartino, 2004, p. 446); and 2) familiarizing students with self-screening techniques as to enable students to “assess and evaluate the depressive symptoms and the suicidal thoughts they (or their peers) might be experiencing and prompts them to seek Helpance when dealing with these problems (e.g. telling a school counselor)” (Aseltine & DeMartino, 2004, p. 446).
According to Aseltine and DeMartino (2004), the main strengths behind the SOS prevention program is its simplicity and its appropriateness with targeting this age group. As highlighted by Aseltin and DeMartino (2004), the program does not require intensive training or extensive knowledge of specific therapeutic interventions (e.g. CBT). Additionally, the implementation cost of the program is low and “does not unduly burden teachers, counselors, or administrative staff” (Aseltine & DeMartino, 2004, p. 447). The program is age appropriate as it takes into account the adolescence developmental stage. Adolescents in this stage tend to place high value on their peer groups, as it “becomes the primary sphere of social involvement and emotional investment for most youths” (Aseltine & DeMartino, 2004, p. 447).
Despite the highlighted strengths of this prevention program and its successful outcomes in significantly reducing self-reported suicide attempts (Aseltine & DeMartino, 2004), a flaw can be seen through the use of the CRT lens. Due to the program’s focus on a single subordinate-group identity (i.e. adolescence), students who possess multiple subordinate-group identities maybe rendered “invisible” (Purdie-Vaughns & Eibach, 2008). Although the focus of the program is on the adolescent’s strength within their peer group, the program neglected to include their strengths from other intersecting identities (e.g. religious affiliations, ethnicity, etc.). The multiple and intersecting identities of students must be taken into account as they may have other support groups which they may potentially draw from for emotional support, which may prove to be more effective than their adolescent peer groups (e.g. family, religious group, cultural support groups, etc.). As such, a recommendation for this intervention would be the inclusion of the adolescent’s multiple affiliations and identities.
In applying this intervention for Asian American groups, program coordinators need to be aware of the concept of “face”, as it may affect the program’s focus on the strengths of adolescent peer groups. “Face” is highly valued in Asian culture, as it is a “multi-faceted term, and its meaning is linked with culture, honor, and shame” (Castillo & Phoummarath, 2006, p.7). According to Castillo & Phoummarath (2006), the concept of “saving face” is significant in the Asian culture as it is defined as “refraining from public displays of disrespectful act towards others, or taking preventive actions so that an individual will not appear to lose face in the eyes of others” (p.7). Within the Chinese culture, “lien” is a related concept of “face” that “refers to the confidence of society in a person’s moral character” (Castillo & Phoummarath, 2006, p.7). A loss of “lien” would “result in a loss of trust within a social network” (Castillo & Phoummarath, 2006, p.7). An example provided by Castillo and Phoummarath (2006) would be a student gossiping about someone cheating on a test. This would affect the student as their peers would potentially come to distrust them, as they sold out one of their peers. Trust amongst Asian American adolescents within their peer groups needs to be taken in consideration, as they may not be as willing to report to a school official or anyone outside of the social circle about a peer’s depressive issues.
Combined Cognitive-Behavioral Family Education Intervention
This intervention was conducted by Asarnow, Scott, and Mintz (2002) to address the rarity of approaches to family interventions in treating depressed youth. It is a 10 session combined cognitive behavioral and family education intervention for children. This intervention has 3 distinct features: 1) the inclusion of a family education sessions that “encourage parents to support the learning that was achieved through the group sessions, and foster positive attitudes towards the skills emphasized in the intervention” (Asarnow, Scott, and Mintz, 2002, p.222); 2) the intervention’s consistency with “Meichenbaum and Biemiller’s (1988) emphasis on the importance of increasing levels of self-direction in moving from skill acquisition to mastery in CBT interventions” (as cited in Asarnow, Scott, and Mintz, 2002, p.222); and 3) addressing comorbid symptoms/discorders and adjustment problems observed among youth with depression with CBT techniques such as problem-solving and social skills training (Asarnow, Scott, and Mintz, 2002).
The depression group would meet twice a week for the 10 sessions. For 9 sessions, the children are taught to handle their depression issues through utilizing CBT techniques. In addition, the children are also filmed practicing these techniques through vignettes. The filming of the sessions is for the purpose of the 10th session, which will be shown to parents in giving them a clear understanding of what took place during the sessions (Asarnow, Scott, and Mintz, 2002). The final session concludes with the inclusion of the child’s parents. The strength of this intervention lies within this session, as the premise behind the final session is to not only give parents an overview of what occurred in the group sessions, but to encourage parents to help their child in nurturing their newly acquired skills (Asarnow, Scott, and Mintz, 2002). Additionally, this session gives the children a chance to feel good about themselves in what they have learned, as the children are given chance to teach the parents what they learned through the use of the filmed sessions (Asarnow, Scott, and Mintz, 2002). Asarnow, Scott, and Mintz (2002) report successes of this intervention as being signs of improvement in depressive symptoms, reductions in negative automatic thoughts, and less internalizing coping among the children.
Despite these successes, a CRT lens would suggest that additional consideration needs to be taken in fleshing out the parent/child interaction activities for this intervention. If this intervention was implemented within Asian American groups such as the Hmong population, the parent/child interaction component for the final session would need to be reworked. The acculturation levels between the child and parent would need to be examined, along with gauging the parent’s language proficiency.
There is a lack of understanding about the concepts of Western mental health within the Hmong communities amongst first generation Hmong immigrants (Gensheimer, 2006). This lack of understanding and the stigma that is attached to mental health can be seen through the use of a Hmong phase commonly used to identify mental health, “tshuaj vwm” (crazy medicine). Due to the surrounding stigma, Hmong parents may be less inclined to utilize mental health services. To address this obstacle, one method Castillo and Phoummarath (2006) suggested is the use of cultural brokering. This process involves exploring the following: “1) the perceptions and values regarding the parents’ and the adolescent’s roles; 2) the adolescent’s experience and behaviors in school; 3) the parents’ experiences and concerns; and 4) the pressure of outside demands on both the parents and the adolescent” (Castillo & Phoummarath, 2006, p. 13).

Bicultural Effectiveness Training
According to Szapocznik et al. (1986), bicultural effectiveness training (BET) was developed under the center for Family Studies as a bicultural effectiveness training intervention to enhance bicultural skills within members of immigrant families. It is a specific intervention designed for the purpose of enhancing intercultural adjustment in Cuban American families, by ameliorating the acculturation-related stresses confronted by two-generation immigrant families. (Szapocznik et al., 1984). According to Szapocznik et al. (1984), this treatment intervention is a “culturally sensitive intervention that targets on a specific problem area: intergenerational conflicts and conduct disorders in adolescents, either provoked or exacerbated by the stress of acculturation and cross-cultural adaptation” (p. 317). The modality of this intervention is to “capitalize on certain features of culture conflict in order to ameliorate acculturative stress” (p.317). By capitalizing on these features, it “enhances adjustment in Cuban American families and reduces conduct disorders in adolescents” (p.317) through the reduction of culture conflict and acculturative stress. In reducing culture conflict and acculturative stress, “BET teaches family members that skills for effective functioning in different value contexts (cultural or otherwise) can be viewed as complementary and enriching to the individual” (p. 317).
This intervention consists of 12 lessons, which takes place in three phases. According to Szapocznik et al. (1984), phase 1 introduces the family involved in the treatment to concepts of “biculturalism, culture, culture conflict, family development and system theory” (p. 333). These concepts are presented in “very simple form and in a language that is familiar to the family” (p. 333). The essence of phase 1 is to create a shared worldview amongst the family.
Phase 2 of the intervention targets four specific areas: “(a) Family Composition styles, (b) Family Relational styles, (c) Family Stress, and (d) Family Conflict” (p. 333). For each of the areas, “a common worldview is established, intergenerational conflict is detoured through culture conflict in order to displace the focus of the conflict from the intergenerational conflict” (p. 333). The greatest emphasis in this phase is placed on forming crossed alliances between generations and cultures for each of the content areas (Szapocznik et al., 1984).
Phase 3 is the final step as it “prepares the family to complete the BET sequence by establishing more firmly in the family a transcultural worldview, and by solidifying the gains made in both establishing culture as a common foe and fostering crossed alliances” (p. 333). In addition, psycho-education is provided about mental health concepts and care (Szapocznik et al., 1984). This in turn will provide families with a “positive growth oriented view of mental health care” (p. 333).
By analyzing this intervention through a CRT lens, the strengths of this intervention lies within empowering parents and their children to explore and embrace each other’s multiple and intersecting identities. Both the parent and child are brought closer to each other as the strategy behind BET is to “create the conditions that allow individuals and their families not to feel torn by competing cultural or value allegiances” (Szapocznik et al., 1984, p. 342). Differences between the two parties are instead embraced through utilizing “their knowledge of each seemingly incompatible world to elicit the best from each cultural situation” (Szapocznik et al., 1984, p. 342). By eliciting an ideal cultural situation between the two parties, BET is able to transition immigrant families from feeling caught two opposing worlds towards “an attitude similar to that which might be adopted by an ambassador to a foreign country: respect for one’s own as well as the other’s values and behavioral style; and an ability and willingness to bridge between two cultural worlds” (Szapocznik et al., 1984, p. 342).

Proposed Intervention Approach
The proposed intervention is a CBT curriculum for suicide prevention among Hmong adolescents (ages: 14-19). The curriculum is aimed at addressing Hmong adolesents’ depressive symptoms. The ideal location for this intervention would be the high schools at the Fresno United School District. The curriculum is adopted from Clarke’s (2003) The Adolescent Coping With Stress Course; it is modified by the inclusion of elements of Narrative Therapy and attention to potential cultural issues that the students may have (e.g. intergenerational conflict and school issues).
Implementation Strategies:
This intervention curriculum is meant to be used for the purposes of suicide prevention amongst Hmong adolescents who are exhibiting moderate to high levels of stress and depressive symptoms. The ideal location to put this intervention curriculum into use would be in high schools within the Fresno School District, since the city of Fresno has one of the largest Hmong populations in the U.S. (Lor, 2008). In order to recruit Hmong adolescents for this short-term intervention, it would be ideal to enlist the help of the Fresno School District. Upon receiving approval from the district, flyers would be made and passed out to all of the high schools to promote the program. The program would be promoted under the name “Stress Workshop for Hmong Students”. The flyer would elicit attention from Hmong students by inquiring if they are feeling stressed out, and “in need of a support system in learning ways to beat stress”. Referrals can also be made by school counselors for students who have reported having signs of depression and/or being stressed.
In ensuring that this intervention is effective in treating the specified group as noted in this capstone, a screening process will be conducted to make certain that participants entering into the program are the ideal candidates for this curriculum. The screening process will consist of 2 phases. The first phase is the self-assessment in which students would screen themselves for signs of depression, anxiety, hopelessness and the student’s coping skills through 4 different self-assessment tools as described below. The second phase is the clinician intake in which the treating clinician will interview the student using the Cultural Adjustment Difficulties Checklist (CADC) (as described below) in screening whether the source of the student’s depression stems from dissonant acculturation.
Students must meet the following criteria to be apart of the stress workshop: 1) student must show signs of depression, anxiety, hopelessness, and poor coping skills as indicated by the self-assessment tools during the first phase (described below in the Assessment section); and 2) student must show that their depression is due to dissonance of acculturation within their family as indicated by the Cultural Adjustment Difficulties Checklist (CADC) during the second phase. For students who fail to meet the criteria listed (e.g. anyone who manifests with an anxiety disorder), those students will be screened out and referred to alternative services, at the school’s counseling services, since this intervention is not designed for that level of intervention.
The “Stress Buster Workshop” will be held after school. Various workshops will be held within a classroom at each of the high schools, depending on the number of student recruits. The minimum number of students required for a high school to have its own workshop is 6. If however, recruitment is less than 5 at a particular high school, those students who are interested will be encouraged to attend the closest workshop at another high school to increase the number of participants.
Presentation of Theoretical Grounding for Proposed Intervention:
Cognitive Behavioral Therapy
CBT is a collection of related techniques that are geared towards having cognition “as the mediator of psychological distress and dysfunction” (Vonk & Early, 2009, p. 242). These specific collections of techniques are from the contributions of both Behavior and Cognitive Therapy. Behavior Therapy (BT) was developed by Burrhus Frederic Skinner during the 1950’s. BT was based upon various theories of learning (as will be discussed below), such as respondent (classical) conditioning, and operant conditioning (reinforcement/punishment). A third type of learning is modeling (aka observational learning), in which a behavior is learned vicariously through the observation of someone else performing a behavior (Kirk & Clark, 1996). Mental illnesses were redefined as behavioral problems in Skinner’s work, as they were “hypothesized to have arisen from faulty learning” (Vonk & Early, 2009, p. 242). Achievements in BT were the reduction of aggressive and oppositional behaviors accompanying anxiety disorders (Vonk & Early, 2009). BT aims at facilitating clients’ identification and modification of features of behaviors that may promote or worsen symptoms underlying a disorder, such as depression. Behavioral strategies can include: goal setting, activity scheduling, social skills training, and structured problem solving (Vonk & Early, 2009).
The learning principles utilized in Behavior Theory include respondent (classical) conditioning, as established by Ivan Pavlov. This type of learning process was demonstrated through his experiments with dogs. In his experiment, he conditioned dogs to salivate when a bell was rung. Through enough trials to pair the bell with food, it was shown that an unconditioned response (salivation) can be made into a conditioned response by associating it with a conditioned stimuli (ringing of bell), as seen in Figure 2 in the Appendix (Kirk & Clark, 1996). The bell initially does not have any significance to the dogs, while the presence of dog food would have significance to the animal in which an overt behavioral response would be triggered (dog salivating). Prior to the pairing, the dog food was the “unconditioned stimulus” and the behavioral response of salivation as the “unconditioned response” (Kirk & Clark, 1996). If the bell (neutral stimuli) was paired with the salvation (unconditioned response), this would result in the bell becoming a conditioned stimulus. If the bell (conditioned stimulus) and dog food (unconditioned stimulus) were to be continually paired together, the dog would produce a behavioral response (salivating) in response to the ring of the bell through the association of the conditioned stimulus (bell) and unconditioned stimulus (dog food) (Kirk & Clark, 1996).
A second key learning principle is operant conditioning, as discovered through observations made by Thorndike, Tolman, and Guthrie (Kirk & Clark, 1996). In their observations, it was noted that the consistency of a particular behavior would be greater if there was a reward to follow along with the act. This observation is coined as the ‘Law of Effect’, which notes that the frequency of a behavior is dependent to the consequences, whether positive or negative (Kirk & Clark, 1996). If the behavior results in a positive consequence, the behavior is more likely to be repeated. If a negative consequence occurs instead, the behavior is less likely to be repeated. Operant conditioning involves changing of behaviors through the use of “reinforcement” and “punishment”. The use of “reinforcement” and “punishment” as a consequence can be either positive in which strengthens a behavior, or negative (weakens a behavior). Depending on which of the two is used, the consistency of a particular behavior is greater if there is “reinforcement”, while vise-versa if there is punishment instead (Kirk & Clark, 1996). “Reinforcement” can be positive or negative, as is “punishment” (as in seen in Figure 3 in the Appendix). A behavior is more likely to occur if there is “positive reinforcement”, in which a reward (e.g. getting praised) follows after the behavior. “Negative reinforcement” results in the increase of behavior through the “omission of an anticipated aversive event” (Kirk & Clark, 1996). An example of “negative reinforcement” would be a MSW student’s anxiety level continually increasing until the student engages in the target behavior, such as finishing this assignment, thus lowering their anxiety level. “Positive punishment” involves the decreasing of a behavior through an aversive event, such as an electric shock. “Frustrative non-reward” results in a decreasing of behavior due to removal of an expected reward (e.g. reducing a child’s television time following their bad behavior, causing a decrease in their bad behavior) (Kirk & Clark, 1996).
A third key learning principle for Behavioral Therapy is Bandura’s work on observational learning, or modeling (Kirk & Clark, 1996). This type of learning involves an individual learning a particular behavior through observing another person (i.e. teacher) perform that behavior. This concept was further expanded though Bandura’s model of self-regulation called “self-efficacy” (Kirk & Clark, 1996). The premise behind this model is “that all voluntary behavior change was mediated by subjects’ perceptions of their ability to perform the behavior in question” (Kirk & Clark, 1996, p.10). Another advancement included was the concept of self-control, which is “based on a three-stage model of self-observation, self-Assessment (setting standards), and self-reinforcement” (Kirk & Clark, 1996, p.10).
Cognitive Therapy (CT) was formulated through the efforts of Aaron Beck and Albert Ellis in the 1960’s. The concepts of CT were based on the assumption that emotional and behavioral disturbances are not directly caused by a person’s response to an experience but “from the activation of maladaptive belief in response to an experience” (Vonk & Early, 2009, p. 242). The focus of CT is on exploring and challenging an individual’s negative assumptions and beliefs. Through exploring and contesting the negative idiosyncrasy of an individual’s distorted cognitions, the cultivation of helpful and balanced thoughts would follow. The premise behind cognitive therapy is to empower an individual to come to the realization that they are capable of influencing their mood through identifying and changing their thought and beliefs.
When utilizing CBT in assessing and treating various emotional and behavioral disorders, Vonk and Early (2009) states that there are three elements of cognition to take into consideration: 1) actual content of thoughts; 2) core beliefs; and 3) maladaptive and ingrained styles of processing information, or cognitive distortions. The first element deals with automatic thought. Automatic thoughts in us a most visible when these thoughts “come into our minds immediately as life unfolds” (Vonk & Early, 2009, p. 242). However, automatic thoughts that are invisible to us are thoughts that we refer to as rules or assumptions that influences how we act in response to our experience (Vonk & Early, 2009). An example given by Vonk and Early (2009) is the thought process of John. John may have an automatic thought in which he thinks to himself, “I can’t handle this situation” after receiving feedback from his work. From his automatic thought, Vonk and Early (2009) points out that the rule John subconsciously made for himself may be “I must be perfect at everything I do.”
Vonk and Early (2009) state that core beliefs are perceptions of one’s self and the world that have been “formed through early life experiences” (p. 243). Beck notes that these core beliefs are maintained through “a process of attending to information that is contrary to it” (as cited in Vonk & Early, 2009, p. 243). An example of John’s core beliefs is provided by Vonk and Early (2009). John experienced intense criticism from his father as a child and forms the core belief “I am totally inadequate”. As an adult, his core belief will cause him to be fixated at his flaws over his successes. At his work, John seems to discount his history of success in his career, and instead focuses on the few incidents he made a mistake.
There are various types of cognitive distortions. Vonk and Early (2009) provide an example of distortion, along with a case example of John, in which his core belief is “he is inadequate.” A type of distortion is catastrophizing, which is characterized by “pessimistic beliefs about oneself, others, and the future, in which one assumes that the worst possible outcome will occur” (Hassett et al, 2000, p. 2493). John in this case, may think to himself: “If my boss criticizes a piece of my work, I will lose my job, be unable to support my family, my wife will leave me, and I will end up homeless.”
In addressing the relevance of CBT for use in treating depression as a suicide prevention strategy, CBT is a structured psychotherapeutic intervention that is intended to empower individuals to lower symptoms of depression, and foster effective methods of dealing with hardships that contribute to their suffering (Blackburn & Davidson, 1990). Utilizing CBT techniques revolves around the following beliefs: 1) an individual’s thought patterns and emotions are considered to be highly affected by their actions; and 2) an individual’s emotions and behavior are influenced by their cognition (Neenan & Dryden, 2000; Wright, Basco, & Thase, 2006). Enabling individuals to begin the process of behavioral change is significant in utilizing CBT, as reflected through beliefs. In addition, CBT is an evidence based practice that has been shown to be effective in treating a wide range of medical and clinical disorders, including depression (Butler et al., 2006). Butler and colleagues (2006) methodologically rigorous meta analysis of 16 studies shows large controlled effect sizes found for CBT for unipolar depression, generalized anxiety disorders, panic disorders with or without agoraphobia, social phobia, posttraumatic stress disorder, and childhood depressive and anxiety disorders.
Narrative Therapy via Constructionism
Constructionism’s concepts originated from social psychology. Social psychology came about through studying various group interactions to observe how social identities are constructed and maintained (Payne, 2005). Although constructionism’s concepts would not make a significant impact in social work until the 1990s, elements were already being incorporated through the utilization of role theory and communication studies out of psychology and sociology, respectively (Payne, 2005). Further incorporation of constructionism theories in social work began in the 1990s with the development of constructive practice theories. This development spurred from the creation of critical psychology, which was an integration of postmodernist and social construction ideas (Payne, 2005).
Constructive practice theories in social work are de Shazer’s solution-focused therapy, White and Epston’s narrative therapy, and O’Hanlon’s possibility thinking (Payne, 2005). These approaches focus on human interaction through use of language and understanding how individuals construct their social world (Payne, 2005). Through understanding the person’s use of language and their social world construct, change can be initiated through reconstruction of the two. This review will focus on narrative therapy as the chosen approach to utilize in conjunction with CBT in this proposed intervention.
Narrative Therapy (NT) was initially developed in the 1980’s by social workers/family therapists Michael White and David Epston (Kelley, 2009). It was among one of the many ideas within the postmodern movement that “challenge the idea of absolute truth and grand theories that explain human behavior (aka modernism ideas)” (Kelley, 2009, p. 273). Worldwide attention to NT was garnered in the 1990’s corresponding to the development of constructive practice theories which became influential within clinical social work and family therapy (Kelley, 2009). White and Epston drew from ideas of constructivism and social constructionism in developing NT (Kelley, 2009). Constructivism places emphasis “on individuals’ perceptions and cognitions as shaping their views of reality” (Kelley, 2009, p. 273), as it is “affirming, respects our capacity for development and helps people via promoting ‘personal revolutions’” (Mahoney, 2003, p. 11). On the other hand, Social constructionism is “focused on the social and cultural narratives individuals internalize, taking them for granted as constituting ‘reality’” (Kelley, 2009, p. 273). Clients are the focal point in NT, as it is believed “that people create stories of their lives to make sense of all their lived experience” (Kelley, 2009, p. 273).
The end goal of NT is to Help clients to look for other “truths” within the “story lines around which they have organized their lives” (Kelley, 2009, p. 273). This is done through assessing the plot, characters, and timeline in the presented storyline for meaning (Kelley, 2009). The means to assessing and finding new “truths” in the client’s story is through respectful listening, and avoidance of labels. Therapist plays the role of “non-expert, not knowing” when listening to the client convey their story, as clients are the experts of their story (Kelley, 2009). The role of the therapist is not neutral, as they are partners with the client in breaking down the outcomes and consequences of the story (Kelley, 2009). In addition, therapist may “challenge the story through deconstruction and by assessing its origins” (Kelley, 2009, p. 275). The use of labels in clients is avoided as clients themselves are not the problem, but rather are “afflicted with a problem” (Kelley, 2009, p. 275). An example conveyed here would be a person who has a mental disorder such as schizophrenia. The person here in NT would not be viewed as schizophrenic, but rather as “a person suffering from a schizophrenic disorder” (Kelley, 2009, p. 275). Labels maybe discarded entirely by some narrative therapists, as the classification of labels can serve to objectify and oppress people (Kelley, 2009).
Intervention hypothesis:
The focus of this suicide prevention program is reducing depressive symptoms and stress amongst Hmong adolescences, ages 14 to 19. The program’s intervention hypothesis states:
If positive coping skills (e.g. being able to identify unrealistic thoughts) and peer support are provided to Hmong teen adolescences (ages 14 to 19) who have signs of depression, and if this is done in a culturally-competent manner attending to the role of acculturation strain, then we should see a reduction of depressive symptoms and stress, as well as in acculturation conflicts, in these participants.
Details of intervention:
The goals for this intervention are as follows:
1) For clients (Hmong adolescents) to develop positive ways of dealing with depression and stress as suicide preventive strategy.
2) For clients (Hmong adolescents) to develop positive ways of dealing with acculturation/intergenerational conflict in reducing depressive symptoms.
3) For Hmong adolescents to become more aware of depressive symptoms and stress.
4) For the Hmong adolescents participating in the group to form a peer support within the group sessions and outside of session.
The outcomes will be:
1) A reduction in depressive symptoms and stress as measured by The Beck Depression Inventory (BDI), The Beck Anxiety Inventory (BAI), The Beck Hopelessness Scale (BHS).
2) A reduction of acculturation/intergenerational conflict as measured by Cultural Adjustment Difficulties Checklist (CADC).
3) An increase use of positive coping skills in dealing with depression and stress amongst Hmong adolescences as measured by the Self-Report Coping Scale.
4) An increase in knowledge of the signs of depression and stress
These outcome objectives will be met through activities such as:
• A total of 13 group sessions will be provide for student in alleviating depressive symptoms and stress. The 13 group sessions will consist of 8 group CBT sessions for the purpose of providing psycho-education and Help in fostering positive coping strategies;
• 5 group Narrative Therapy sessions to give students a chance to further develop their coping skills by developing implementation strategies through storyboarding.
The key program tasks and activities within the group sessions will be replicating a preexisting short-term CBT group intervention model: Clarke’s (2003) POD and TEAMS’ The Adolescent Coping With Stress Course. This group intervention model contains eight 90 minute sessions (group capacity = 6 to 10 participants) that is geared towards preventing future occurrences of depression and stress in adolescents who maybe at risk. Along with utilizing this model, 5 additional sessions will be included to allow students as a group to practice their skills gathered from the adolescent stress course through two case scenarios (one assigned scenario and one scenario created by the student). These sessions incorporates elements of NT, as students get to construct a collective story of their struggles and issues within the case scenarios.
CBT is executively used in the first 8 session in order to adhere to Clarke’s (2003) recommendation of “delivering contents for the program as laid out in the manual” (p. x). Clarke (2003) stressed for therapist fidelity as Gillham et al. (2006) pointed out that “ongoing therapist fidelity to a prevention program is associated with better outcomes” (as cited in Clarke, 2003, p. ix). Despite Clarke’s (2003) recommendation, he acknowledged that mental health and allied professionals have a long history of personalizing their therapy approach for a variety of reasons (i.e. better cultural fit). Additionally, the executive use of CBT is aimed towards fostering student awareness of depressive symptoms and stress and familiarizing them with positive coping skills of how to handle these symptoms on a general level. Once students become familiarized with the symptoms and techniques used to alleviate these symptoms, student will have a better understanding of dealing with their depression and stress, as they begin to explore their own situation with the incorporation of NT in later sessions.
Clarke’s (2003) The Adolescent Coping With Stress Course has a rigorous agenda set in place for group participants. All participants will receive a workbook which will be utilized throughout the sessions, as it contains worksheets for the activities of the sessions and homework for students to complete outside of the sessions. A brief description of the sessions are as follows (please refer to the Appendix for full specific details of each of the sessions): In session 1, activities will include the following: getting the students acquainted with each other and the program; giving an overview of stress and depression; goal setting; measuring student’s mood via mood diary; and sharing activity in which 2 selected students for the week will bring in an object of significance to share with the group (sharing activity will occur on a weekly basis at the end of each session). Session 2 begins with setting guidelines for the group. After discussing the guidelines, the session will shift towards identifying negative thoughts. Session 3 will have students identify situations that make them sad and/or stressed, and introduce them to techniques in increasing positive thinking.
Session 4 will allow students a chance to practice identifying unrealistic thoughts, along with providing strategies in modifying them into realistic thought. Session 5 is a continuation of session 4, as students’ skills of identifying unrealistic thoughts is expanded by teaching them to identify underlying negative beliefs. Session 6 builds off of session 4 and 5 in having students continue with practicing how to identifying unrealistic thought A-B-C practice (A= identify “Activating Event”, B = Belief, C = Consequences). Session 7 moves students forward with teaching them how to interrupt unrealistic thoughts through the use of prompts and/or reminders. Session 8 concludes with relapse prevention and teaching students in maintaining their gains.
After the conclusion of the eight sessions, the entirety of Clarks’ existing curriculum, the NT group therapy component would begin. This component consists of five 90-minute group sessions in which students will have the chance, via storytelling, to practice the skills gained from the CBT portion within more specific life situations they face. The intervention utilized in these sessions draws upon Harper and Iwamasa’s (2000) review of Costantino, Malgady, and Rogier’s (1994) storytelling technique used with Puerto Rican adolescents. This storytelling technique involved utilizing pictures from the Tell-Me-A-Story (TEMAS) thematic apperception story to allow Latino youths within a group therapy setting to convey a collective story of the life situations that they face (Haper & Iwamasa, 2000). As the group formulated their story, the therapist would facilitate the group in analyzing their narrative and develop a strategy (i.e. finding health behavior and coping responses) in forming a resolution to the story. Upon figuring out the resolution to the story, the therapist would provide feedback for the group. Afterwards, the group would be filmed acting out the entire story. Once filming was complete, the group and therapist would gather together to watch the recorded story. The therapist would then provide feedback on the film (Haper & Iwamasa, 2000).
The purpose behind the inclusion of the second phase of sessions is afford students a chance to work together as a group in conveying their stories and struggles with depression and stress through storyboarding. Within the storyboarding process, the group will develop strategic responses based on what was learned through the CBT sessions. For Session 9, students will be randomly divided into two groups to work on an assigned case scenario. The case scenario material will consist of a picture displaying a possible life situation that the students may face (see Figure 4 on Appendix for example of pictures that will be used). In Figure 4, there are two pictures that will be used. The “sad girl at school” picture would be used to elicit any potential school problems that the student may be dealing with, while the “parents and child arguing” would elicit any potential relationship conflicts (e.g. acculturation issues) with their parents.
Upon receiving their case scenarios, the two groups would formulate a collective short-story based on the characters in the picture and the situation that the characters are in. Both groups are given freedom to interpret the picture as they see fit. Students would work on scripting a short-story for the characters based on their interpretations of the scenario picture. Students are viewed as the “experts” in conveying their group story. The therapist would elicit the group’s perspective about conflicts, behaviors, and coping responses from the story that they have scripted. The therapist during this time also would provide positive verbal reinforcement when group members describe the adaptive and healthy behaviors and attitudes used to solved the dilemma scripted in their story. While the therapist is eliciting the first group’s perspectives and providing them with positive verbal reinforcement, the other group would sit in and listen to the feedback. The other group would then be asked by the therapist to provide feedback to the receiving group. Once the therapist is finished with the first group, the process is repeated with the second group.
The storytelling process would then be carried over to session 10. In this session, both groups would then act out their story while being filmed. Each group would work separately in developing a 10 to 15 min short film based off the story that was scripted from the previous session. During the filming process, the therapist would be able to provide “verbal reinforcement for appropriate responses (e.g appropriate confrontation of feelings, proper behavior, adaptive coping techniques)” (Harper & Iwamasa, p. 41). The viewing of the group films would take place during the final session (session 13).
For session 11 and 12, the students and therapist would repeat the same process from session 9 and 10. However, students would be reassigned into two new groups. This will allow for all participants to collaborate with different members not in their previous assigned group. There is no pre-assigned case scenario for this portion, as students will be instructed to construct a collective story based the life situations that they have come across which caused them to be depressed and/or stressed. Clinicians will keep the group focused on acculturation-based strain with their families when the group is constructing their story. As with the session 9 and 10, students are afforded freedom in creating their collective stories. The therapist would again provide feedback and positive enforcement. Session 13 would be the final session, as the therapist and group would view the recordings together, which allows for the therapist to reinforce the skills learned for a final time (Harper & Iwamasa, 2000).
Presentation of way proposed intervention incorporates CRT:
This proposed intervention seeks to address depression among Hmong adolescents, with attention to cultural factors (intergenerational conflict with parents due to acculturation), and lack of peer support. The addition of the second phase of treatment to Clarke’s (2003) existing stress and depression course serves as a bridging tool to addressing issues specific to Hmong adolescents, while still adhering to Clarke’s (2003) recommendation of fidelity to the curriculum. The 5 narrative therapy sessions of phase two were created under the consideration that social and environmental factors have an influence in how adolescents may perceive CBT interventions based their interactions with their surrounding social environment (Harer & Iwamasa, 2000). Graber & Brooks-Gunn (1995) noted that “the changes which occur in the biological, psychological, and social spheres of the adolescent’s life often form complex matrices of interconnections that both influence, and are influenced by, behavior” (as cited in Harper & Iwamasa, p. 38). Bronfenbrenner’s (1994) Ecological Models of Human Development points out that adolescents interact with a multitude of social system in their environment, “ranging from microsystems (immediate environment) such as school and family, and macorsystems (institutional patterns of culture) such as the economy, customs and bodies of knowledge” (p. 37). The social context of these interactions may have “greater meaning and influence on minority adolescent’s psychological development” (Haper & Iwamasa, p. 38). Utilizing the Critical Race Theory (CRT) lens, issues of racism and discrimination play a significant role in shaping minority youth’s understanding of the social context that is presented to them, as it is an experience that is incorporated into their daily lives and made “ordinary” for them (Delgado, 2001).
Elements of CRT were incorporated into the NT sessions with the focus of providing Hmong adolescents an opportunity to not only empower them to use their CBT coping skills, but to provide students with an opportunity to build a support group amongst each other through group work. Tenets of CRT are incorporated in the design of this session. The “voice-of-color” thesis is incorporated, as it holds that people who have experienced oppression can speak about their experiences in ways that is unknown to those who have not experienced it (Delgado, 2001). This CRT tenet is integrated using Narrative Therapy, to allow the Hmong participants to draw commonalities of the social and cultural narratives that each have internalized as part of their reality. Students are able to share their stories through the case scenario to formulate a collective that best represents the group’s experiences. It also provides students a chance to discuss issues of intersectionality with each other through the case scenarios. In discussing the case scenarios, group members may have a different interpretation of the scenario presented based on their multiple and intersecting identities. Members may relate their own experiences into the characters and the setting in the scenario. Through the possibility of students providing different outlooks on a case scenario, new perspectives of similar situations that the student may have faced (i.e. family conflicts) can be shared and new insight can be fostered.
Assessment Process:
To ensure that this intervention curriculum will yield the most favorable outcome, a program Assessment will be conducted. The rationale using a program Assessment is as follows: “1) to assess the ultimate success of programs, 2) to assess problems in how programs are being implemented, or 3) to obtain information needed in program planning and development” (Rubin & Babbie, 2008, p. 306). Program Assessment protocols will be set into motion to assess the intervention’s “concept, design, planning, administration, implementation, effectiveness, efficiency, and utility” (Rubin & Babbie, 2008, p. 306). A goal attainment model would used in the program Assessment for monitoring the outcome and efficiency of this intervention. An internally valid quasi-experimental design would be utilized as part of this model to rule out possible bias in the measuring process. As stated by Rubin and Babbie (2008), this model takes into consideration the program’s goals, as they would be specified as the dependent variables. These variables would then be “defined in terms of measurable indicators of program success” (p. 316).
A logic model, as seen in the following logic model section, is used as a graphical representation in depicting “the essential components of program” (Rubin & Babbie, 2008, p. 327). Rubin and Babbie (2008) states that a logic models illustrates how “these components are linked to short-term process objectives, specifies measurable indicators of success in achieving short-term objectives, conveys how the how those short-term objectives lead to long-term program outcomes, and identifies measurable indicators of success in achieving long-term outcomes” (p. 327). As seen in the intervention’s logic model, three types of outcomes (short-term, medium-term, and long-term) that are expected to be in terms of the goals that are set in executing this curriculum. By analyzing all three outcome types, the purpose of executing this intervention curriculum is for empowering Hmong adolescents to develop a healthy coping system in dealing with their depression. In developing a healthy coping system, Hmong adolescents would be able to reduce intergenerational conflict between them and their parents.
The treating clinicians involved would act as monitors throughout the entire process of the intervention, which consist of the initial screening process, execution of the group sessions, and the post-screening process. This is done to ensure that the curriculum meets its projected goals. Collecting and compiling data and information is a crucial part of the Assessment process (Netting, Kettner, and McMurtry, 2008). According to Netting, Kettner, and McMurtry (2008), this involves tracking the performance of each participant in such a way to allow “for establishment of a baseline at the outset of the intervention and periodic measurement of progress” (p. 388). As Netting, Kettner, and McMurtry (2008) elaborate, this involves using pretest and posttest to “measure learning or a tracking of a single indicator such as a client being hired into a new job” (p. 388).
Description of Measures:
As a part of screening process, students will take 3 self-assessment tests for students which will also serve as some pre-test measures:
• The Beck Depression Inventory (BDI) (Beck, Rush, Shaw, & Emery, 1979): a 21 item self-report inventory that has been extensively proven to be a reliable and valid measure of depression within both clinical and non-clinical populations (Beck, Steer, & Garbin, 1988).

• The Beck Anxiety Inventory (BAI) (Beck, Epstein, Brown & Steer, 1988): a self-report tool consisting of 21 items which measures anxiety severity for the past week, including the day of completion. It is a reliable and valid measure that can be used in combination with the BDI, particularly for individuals with comorbid depression and anxiety (Beck & Steer, 1993)

• The Beck Hopelessness Scale (BHS) (Beck, Weissman, Lester, & Trexler, 1974): a 20-item self report questionnaire consisting of true/false questions regarding pessimism and hopelessness. The scores can vary from 0 to 20. Internal consistency of items is satisfactory (Cronbach’s alpha = .88) (Steed, 2001)

• Self-Report Coping Scale (Causey & Dubow, 1992): a 35 item decribing specific coping strategies. This scale ask the adolescent to indicate how they use each of these strategies within a given scenario (e.g. performing low in school) using a 5-point scale that ranges from never to always. This scale is based on the approach/avoidance conceptualization of coping. Five scales have been derived based on factor analyses and include two approach scales (seeking social support, problem-solving) and three avoidance scales (distancing, internalizing, and externalizing). The internalizing scale assessed internalizing symptoms/responses (depression and anxiety) and included items such as “go off by myself”, “worry about it”, “cry about it”, “feel sorry for myself”, and “get mad at myself for doing something that I shouldn’t have done”.

These four measures will also be used post-test to measure whether the outcome objectives (reduction in depressive symptoms and stress; increase use of positive coping skills in dealing with depression and stress; and increase in knowledge of depression and stress) were met, at completion of the program and at a 6 month follow up.

Another screening measure which also serves as pre-test measure is for dissonance of acculturation. This will also serve as a post-test measure for whether the outcome objectives (reduction of acculturation/intergenerational conflict) were met, at completion of the program and at a six month follow up. Dissonance of acculturation will be measured with the following scale:
• Cultural Adjustment Difficulties Checklist (CADC) (Sodowski & Lai, 1997): a 59-item measure that was designed to analyze the acculturation-induced stresses of Asians in the U.S. The assessment has two subscales: Acculturative Distress (contains 35 items) and Intercultural Competence Concerns (contains 24 items). The assessment measures interpersonal problems due to contextual dissonance, alienation towards one’s cultural reference group, and issues of self-efficacy in a white-dominant cultural context.

Sodowsky and Lai (1997) specified “acculturative distress” as an indicator of the quality of adjustment in the country of resettlement, as it analyzes general and cultural stress. The purpose exploring these two aspects of stress is to assess whether the student feels caught between two cultures (Stoll & Johnson, 2007). General stress would be assessed through the “student’s academic concerns (e.g. feeling overworked, and performance anxiety), affect (i.e. sadness, guilt, anxiety, and anger), behavioral (i.e. drinking, procrastination, suicidal ideation and attempts, and violence), and psychosomatic symptoms (i.e. backaches, headaches, and stomachaches)” (Stoll & Johnson, 2007, p. 628). Cultural stress measures “cultural conflicts with the majority culture and one’s own ethnic community or family, gender role confusion and feelings of discontent and anger toward either the majority culture or one’s own culture or origin” (Stoll & Johnson, 2007, p. 628).
Intercultural Competence Concerns in subscale 2 measures “one’s concern about social competence, academic and career competence, and cultural competence [i.e. the] pride in one’s culture, perception of acceptance by White American or people from one’s own cultural group, perception of the worthiness of one’s contribution to both cultures and perception of one’s adjustment to both cultures” (Stoll & Johnson, 2007, p. 629). Sample items in this subscale include: “‘Having pride in your own culture’, ‘Feeling accepted by White Americans’ and ‘Having friends among White Americans’” (Stoll & Johnson, 2007, p. 629).
Assessment Protocol:
Once the screening process is completed, participants will then be randomized to either the waitlist control group or intervention control group. A baseline will be created for each of the two groups. Assessment will also be conducted at two additional time points: 1) Posttest 1, after the intervention group has completed the intervention; and 2) Posttest 2, after the waitlist control group has completed the intervention.
During the posttest, the students would be reassessed by using the same measure as described above to see if there is a reduction in conflict with their parents and dissonance of acculturation, and if there is a increase in usage of positive coping skills. In addition, students will also fill out a client satisfaction questionnaire in which students will rate the effectiveness of the group in Helping them in fostering healthy coping strategies (please refer to the Appendix for satisfaction questionnaire). Furthermore, there will be a 6 month follow-up after the posttest process for each of the test groups, as the therapist and group coordinator would contact the participants to get an update of the student’s progress and status in maintaining the progress that was made in the stress workshop.

Presentation of a logic model:
Intervention Curriculum: Suicide Prevention for Hmong Adolescences with Depressive Symptoms Logic Mode

Problem Statement: Reduction depressive symptoms amongst Hmong adolescences

Goal: Providing Hmong adolescences with positive ways of managing their depression and reducing of acculturation/intergenerational conflict

Inputs
Outputs
Outcomes — Impact
Activities Participation Short Medium Long

One MSW Staff Members

Trained in CBT and Narrative Therapy

Depression

Intergenerational conflict with parents
Cognitive Behavioral Therapy

Narrative Therapy

Group Therapy

Address depression and stress caused by intergenerational conflict and school issues

Identify positive two coping skills
13 sessions of group therapy

2 hour per week

10 high school participants (Hmong adolescents)

Age range (14-19) years of age

Reduction in depressive symptoms

Learn coping skills

Utilize positive coping skills

Client demonstrates positive behaviors related to
treatment process

Reduced signs of depression

Have positive ways of dealing with their depression

A reduction of acculturation/intergenerational conflict.

Form a network of support amongst each other

Assumptions External Factors
Hmong adolescences will be able to learn new techniques
Hmong adolescences will engage in treatment process
Social/ cultural context
Geographic constraints

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Appendix

Figure 1
Source: The Substance Abuse and Mental Health Services Administration (2008) Major depressive episode among youths aged 12 to 17 in the United States: 2004 to 2006
Figure 2
Source: (Kirk & D. M. Clark, 1996) Cognitive Behavior Therapy for Psychiatric Problems: A Practical Guide
Figure 3
Source: (Kirk & D. M. Clark, 1996) Cognitive Behavior Therapy for Psychiatric Problems: A Practical Guide
Figure 4
Pictures that will be used for the case scenarios
Sad girl at school

Parents and child arguing
Student Satisfaction Survey
The purpose of this survey is to gather your impressions of how the group has Helped you in finding better ways of dealing with stress and depression. Please answer each item as best as you can. There is no right or wrong answer. All answers will be kept confidential. We are hoping that the information we get from this survey will help us understand how effective of the group is and how it can be improved. Thank you for completing this survey.

Please mark each box (0) with a  or 
1. What school do you attend________________________________

2. Grade:________

3. Age:__________

4. Gender
0 Female
0 Male
0 Transgender

5. How did you learn about the group
0 Teacher
0 Counselor
0 Classmate
0 Other (please specify):__________________________________

6. Do you believe that your participation in the group has helped you to develop better strategies in dealing with stress and depression
0 Yes
0 No
0 Somewhat
0 Don’t know / not sure

7. Has your group counselor been helpful in making sure you understand the material that is being taught
0 Yes
0 No
0 Somewhat
0 Don’t know / not sure

8. Would you recommend this group to your schoolmates
0 Yes
0 No

9. Rate your favorite session from 1-10 (1 is your favorite, 10 is your least favorite):
___ Getting to Know Each Other
___Coping With Stress
___Stressful Situations and Thinking
___ Examining Negative Thinking
___ Is it Really About Me
___ Coping With Activating Events
___ Techniques for Stopping Unrealistic Thoughts
___ Stressful Events, Preventing the Blues
___ Storyboarding Activities
___ Filming a Story
___ Night at the Movies
10. What is positive self talk
______________________________________________________________________
______________________________________________________________________
______________________________________________________________________
11. What is positive thinking
______________________________________________________________________
______________________________________________________________________
______________________________________________________________________
12. How are unrealistic thoughts triggered
______________________________________________________________________
______________________________________________________________________
______________________________________________________________________
13. What is the A-B-C model
______________________________________________________________________
______________________________________________________________________
______________________________________________________________________
14. What are some of the steps you can take in “jumping your hurdles”
______________________________________________________________________
______________________________________________________________________
______________________________________________________________________
15. What are some ways you can “get plugged in”
______________________________________________________________________
______________________________________________________________________
______________________________________________________________________
16. Why is it important for you to “see over the wall”
______________________________________________________________________
______________________________________________________________________
______________________________________________________________________
17. If you could change any part of the program, what would it be
______________________________________________________________________
______________________________________________________________________
______________________________________________________________________
______________________________________________________________________
______________________________________________________________________
______________________________________________________________________
Thank you for your time and effort!!!!

CBT Curriculum
Source: Clarke, G. (2003) The adolescent coping with stress course: adolescent workbook.

Session 1 Agenda & Summary
I. GET-ACQUAINTED ACTIVITY
In this section we’ll introduce each other, and get to know the people you’ll be meeting
with other the next few months.

II. WHAT IS STRESS
We’ll review stressful situations, how they make you feel, and what stress can lead to if it
isn’t dealt with.
III. WHAT IS DEPRESSION
One of the most common effects of long-term stress can be depression. We’ll review
how everyday depression is different from serious depression, and possible causes for
depression. We’ll also introduce the Depression Spiral and a triangle figure showing how
your mood and feelings are related to what you think and what you do.
IV. PERSONAL GOALS
What are you personal goals for this group
V. MOOD DIARY
You’ll learn how to keep track of your mood every day, in order to better understand
what helps you feel better, and what leads to stress and/or sadness.
VI. PRACTICE ASSIGNMENT
Each session will involve some practice of the new skills at home, between group
meetings.
V. SHARING ACTIVITY
Your therapist will share something about him or herself (a skill, hobby, talent, or
interest). Each session, a different group member will do the same thing. This will help
everyone get to know one another better, as well as learn what is important for each of
us.
Source: Clarke, G. (2003) The adolescent coping with stress course: adolescent workbook.
Session 2 Agenda & Summary
I. REVIEW
We’ll review topics we discussed in Session 1, and the associated home practice.
II. GUIDELINES FOR THIS GROUP
We’ll review rules that we’d like everyone to follow in this group, so the group runs
smoothly, and we can help each other out. If the group has other rules that everyone
agrees on, we’ll add those to the list, too.

II. IDENTIFYING NEGATIVE THOUGHTS
Our main approach to controlling stress and sadness is to examine our beliefs and
thoughts. Sometimes, we may “make things worse in our own head” by thinking really
negatively and unrealistically. Together, we will learn skills for challenging unrealistic
thoughts and forming realistic beliefs. Before we can test the accuracy of our thoughts
and beliefs, we must first become aware of them. We’ll identify both positive and
negative thoughts each of us has about ourselves and our life situation.

III. FEELINGS ABOUT THE GROUP
All group members will be asked to complete a questionnaire about how they feel about
the other group members and the therapist. All of your answers are confidential!

IV. MOOD QUESTIONNAIRE
You’ll be asked to complete a questionnaire about how you feel. This is similar to one
you’ve already filled out at your in-person interview. All of your answers are
confidential!

V. PRACTICE ASSIGNMENT
You’ll review your home practice for the next week. This includes keeping track of
negative thoughts happening in the next week.
VI. SHARING ACTIVITY
One of the group members will share something personally interesting – a
hobby, musical or artistic talents, or something else interesting to them.

Source: Clarke, G. (2003) The adolescent coping with stress course: adolescent workbook.
Session 3 Agenda & Summary
I. REVIEW
We’ll review topics we discussed in Session 2, and the home practice.
II. IDENTIFYING ACTIVATING EVENTS
When you discover that you are thinking negatively, you will also need to figure out
what situation or event triggered the negative thoughts. We call these situations
ACTIVATING EVENTS, because they “activate” or trigger the negative thoughts.
We’ll spend time trying to identify the most important activating events for each group
member.

III. INCREASING POSITIVE THINKING
It’s good practice to think realistic and positive thoughts about others and about
ourselves. In this exercise, each group member will come up with 1 or 2 positive
statements about the other group members, and share these. You’ll take these
statements home so you can read them again later.

IV. PERSONAL GOALS, REVISITED
We’ll check in with each group member: what personal goals do you have for this
group

V. PRACTICE ASSIGNMENT
You’ll review your home practice for the next week. This includes keeping track of
your daily mood, and your negative thoughts happening in the next week.

VI. SHARING ACTIVITY
One of the group members will share something personally interesting – a
hobby, musical or artistic talents, or something else interesting to them.

Source: Clarke, G. (2003) The adolescent coping with stress course: adolescent workbook.
Session 4 Agenda & Summary
I. REVIEW
We’ll review topics we discussed last session, and the home practice.
II. PRACTICE IDENTIFYING UNREALISTIC THOUGHTS
We’ll spend time looking for unrealistic thinking in example cartoons, and in our real lives. We’ll talk about exaggerations: noticing one wrong thing and then believing that
EVERYTHING is wrong. We’ll also practice uncovering the WHOLE belief, or
UNDERLYING belief. It often requires more “digging” and thinking about the underlying MEANING of your thoughts.

III. CHANGING UNREALISTIC THINKING to REALISTIC THINKING
Once you have identified unrealistic automatic thoughts and the underlying beliefs, you now can begin to examine their accuracy and come up with more realistic alternatives, or
counter thoughts. The basic approach is to EXAMINE YOUR OWN THOUGHTS—and put them to a sort of test. Instead of blindly accepting that all your thoughts are true, you “checkout” just HOW TRUE your thoughts really are—examine the evidence. If they aren’t true, or possibly aren’t true ALL THE TIME, then they may be unrealistic. We have a list of 6 Helpful Questions to ask (see page 4.3) to uncover whether a belief is realistic or unrealistic. We’ll then practice coming up with more realistic alternative thoughts and beliefs to challenge the unrealistic thoughts that lead us to feel sad, irritable, angry or tense. Your workbook refers to them as Counter thoughts.

IV. PRACTICE ASSIGNMENT
You’ll review your home practice for the next week. This includes keeping track of your daily mood, and your negative thoughts happening in the next week. Use the 6 Helpful Questions to test whether the beliefs are realistic or unrealistic.

V. SHARING ACTIVITY
One of the group members will share something personally interesting – a hobby, musical or artistic talents, or something else interesting to them.

Source: Clarke, G. (2003) The adolescent coping with stress course: adolescent workbook.
Session 5 Agenda & Summary
I. REVIEW
We’ll review topics we discussed last session, and the home practice.
II. DISCOVERING UNDERLYING NEGATIVE BELIEFS
It’s often easier to recognize unrealistic thinking when we can identify the whole thought. The whole thought is called the BELIEF. These are the beliefs that are below the surface (like the tip of the iceberg, or the inner layer of an onion). In this section we will practice finding the whole belief that is behind the immediate thought that occurs to us.

III. IS IT REALLY ABOUT ME
Sometimes when we react to a particular Activating event, we have a negative thought that involves someone or something else, but not ourselves. If nonpersonal thoughts make us feel down, they may be PERSONAL THOUGHTS IN DISGUISE – personal beliefs underlying the nonpersonal thoughts. In this section we’re going to look at nonpersonal negative thoughts to see why they might make us feel negative or down.

IV. PRACTICE ASSIGNMENT
Continue to record your negative thoughts, activating events, and realistic, positive
counterthoughts.

V. SHARING EXERCISE
One of the group members will share something personally interesting – a hobby, musical or artistic talents, or something else interesting to them.

Source: Clarke, G. (2003) The adolescent coping with stress course: adolescent workbook.
Session 6 Agenda & Summary
I. REVIEW
We’ll review topics we discussed last session, and the home practice.
II. MORE A-B-C PRACTICE or SOURCES OF BELIEFS
In this section the group will either:
a. Practice using the A-B-C method to identify and test unrealistic thoughts, and
create counterthoughts, or
b. Identify the sources of unrealistic beliefs: from TV, radio, movies, friends,
parents, and other places. Does this make it harder to challenge unrealistic beliefs
when many other important people in your life believe the same thing Which
approaches work best when trying to change to a new, more realistic way of
thinking that is different from the beliefs of people around you

III. USING PROBLEM SOLVING TO COPE WITH ACTIVATING EVENTS
Sometimes our reaction and beliefs about a problem situation are realistic. We aren’t making things any worse by how we think about them. In these situations, it can be helpful to use problem solving skills to try to change out circumstances. We’ll practice the three problem solving steps:
1. Brainstorm. Think of as many solutions as you can, even silly ones.
2. Pros and cons. Evaluate which solution is the “best.” Make a list of the advantages and disadvantages of each solution.
3. Try and try again. Try it out and decide if it worked. If not, go back to brainstorming.

IV. PRACTICE ASSIGNMENT
You’ll review your home practice for the next week. This includes keeping track of your
daily mood, and your negative thoughts happening in the next week.

V. SHARING ACTIVITY
One of the group members will share something personally interesting – a hobby,
musical or artistic talents, or something else interesting to them.
Source: Clarke, G. (2003) The adolescent coping with stress course: adolescent workbook.
Session 7 Agenda & Summary
I. REVIEW
We’ll review topics we discussed last session, and the home practice.
II. TECHNIQUES FOR INTERRUPTING UNREALISTIC THOUGHTS
During the last few sessions, we’ve been working on ways to counter or argue with
negative and unrealistic thoughts. In this session, we’ll learn some additional techniques
we can use to interrupt negative thinking (remember “Don’t Respond” as a choice for
coping with Activating Events).

These are very different techniques – not related to challenging unrealistic thinking.
However, some people find them useful because they are quick and easy. We like to
think of these as additional “tools” in your toolbox of techniques to deal with negative or
unrealistic thoughts. They include:
a. Thought stopping.
b. The rubber band technique.
c. Setting aside some “worrying time” for negative thoughts
III. USING A-B-C IN YOUR LIFE
In this section, we review how you can make the A-B-C methods work for you in your
everyday life. We will discuss what could go wrong, how negative thoughts might sneak up on you, and what you can do to prevent these problems from getting worse.
IV. PROMPTS or Catch Up
In this section we will either:
a. Try to identify prompts, or reminders, to use the A-B-C method in everyday life,
or
b. Catch up with any other exercises that were missed earlier

V. PRACTICE ASSIGNMENT
1. You’ll review your home practice for the next week. This includes using at least one of
the three Thought-Stopping techniques between now and next session. Each day, try to
fill out an A-B-C form when you catch yourself thinking a negative thought or when you
start feeling depressed.
VI. SHARING ACTIVITY
One of the group members will share something personally interesting – a hobby,
musical or artistic talents, or something else interesting to them.

Source: Clarke, G. (2003) The adolescent coping with stress course: adolescent workbook.
Session 8 Agenda & Summary

I. EMERGENCY PLANNING

We’ll start this session by working on plans to deal with both big and small stressors.
This will involve thinking ahead about how you might use the skills you’ve learned to
help yourselves during stressful times. What are the major stressful events that might
affect you in the near future Which ones might set-off negative thoughts for you and
lead to feeling down How will you deal with these

II. MAINTAINING YOUR GAINS

In order to prevent depression, try to build the techniques into your daily life so that you
can deal with everyday hassles effectively. What hassles (small, irritating situations) are
most likely to happen for you How you can remind yourself to use these skills on a
daily or weekly basis What kind of reminders work best for you

III. QUESTIONNAIRES

We’ll ask everyone to fill out two questionnaires: one about your mood (similar to the
one that you completed before) and another about your satisfaction with our program and
other medical care you may have received.

IV. LAST SHARING ACTIVITY

One of the group members will share something personally interesting – a hobby,
musical or artistic interests, or something else interesting to them.

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