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STEADY MANUAL
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STEADY PROJECT
INTERVENTION MANUAL
COLLABORATIVE CARE, COGNITIVE-BEHAVIORAL
PROGRAM FOR DEPRESSED YOUTH
IN A PRIMARY CARE SETTING
Version June 14, 2002
Authors:
Greg Clarke, Ph.D.
Lynn DeBar, Ph.D.
Evette Ludman, Ph.D.
Joan Asarnow, Ph.D.
Lisa Jaycox, Ph.D.
Acknowledgements (alphabetical): Lynnette Currie, M.A., Stephanie Hertert, B.A.,
Alison Firemark, M.A.
This manual borrows from several source manuals, including:
Lewinsohn, Antonuccio,
Steinmetz, Teri (1984).
The Coping With
Depression Course: A
Psycho-Educational
Intervention For [adult]
Unipolar Depression
Clarke, Lewinsohn, Hops
(1990)
.
Instructor’s
Manual For The
Adolescent Coping With
Depression Course.
Asarnow, Clarke, Hops,
Jaycox, Lewinsohn,
Rhode (1999). Cognitive-
Behavior Therapy For
Depressed Youth In A
Managed Care Setting:
UCLA.
Robinson (1993). A
Behavioral Health
Intervention for
Depressed Primary Care
[adult] Patients
Ernst, Brenneman,
Berg-Smith, Schwab
(1999) Brief
Negotiation: Skills to
Motivate Change
The present
program
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Table of Contents
Treatment Model Diagram
Guidelines for Counselors
Introduction, Choice Module
Fun Activities Module
Session 1: Tracking Mood and Activities
Session 2: Learning How to Change
Session 3: Setting Goals
Session 4: Making a Plan Work
Changing Your Thinking Module
Session 1: Thoughts & Feelings
Session 2: Arguing Against Negative Thoughts
Session 3: Practice in Arguing Against Negative Thoughts
Session 4: Other Ways to Handle Negative Thoughts
Appendices
Appendix 1: Negative Situations and Thoughts
Appendix 2: Common Cognitive Distortions
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STEADY Intervention Model Diagram
Active Phase, Stepped
Care Collaborative
Treatment
Introduction,
Choice module
(session 1)
First Choice
Skill Module
(sessions 2 - 5)
Ongoing Primary
Care Provider
consultation
Is youth
recovered,
as defined
(see p. 43)
No
Progress to remaining
module at next session
(Sessions 6 - 9)
Yes
Terminate Active
Phase treatment
Continuation Phase: monthly
phone calls, up to six optional
sessions as needed.
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Guidelines for Counselors:
1. Encourage Participation and Keep Youth Actively Involved.
The more active and involved youth are the more likely they are to process the
information provided in sessions. Rather than lecturing at youth try to convey information
in the form of questions and use real life examples they provide whenever possible.
2. Emphasize links between feelings, actions, and thoughts
in all modules.
Although the emphasis in different modules is on one of two components(thoughts or
activities), it is important to highlight the links between feelings, actions, and thoughts
across components. This is important for two reasons: 1) It is artificial to think of any
situation only in terms of one aspect of the situation. For example, different thoughts
about situations are likely to lead to different actions in a situation, which is likely to lead
to different outcomes. 2) Different youth will have different patterns of responding. For
some youth, it will be important to emphasize thoughts - for other youth actions may be
more critical. Consequently, by emphasizing the links between all components of the
intervention you will be more likely to address the needs of all youth.
3. Feedback on Medication
Never give medical directions specifically for that individual, unless you are asked to
convey a message by the primary care provider (PCP) or psychiatric consultant to the
study. When describing medication issues, be careful to state information in generic
terms. For example, rather than tell a given youth to stay on their anti-depressant
medications for six months, state "Usually, six months is the shortest time that doctors
want their patients to stay on medications - this gets people past the point where they are
most likely to fall back into depression." If pressed by youth or parent(s) for specific
recommendations, remind them that you are not a medical doctor, but that you are happy
to carry their question to their PCP, and relay the answer back to them.
4. Normalize Youth’s Experiences
A potentially curative aspect of these sessions is the normalization of each youth's
experiences. Assure your participant that depression is very common; it is the most
common emotional problem in both adolescents and adults, affecting as much as 25% to
35% of all persons at least once in their lifetime. Assure youth that they are "not crazy"
for feeling this way. Depression may be a normal reaction to life stresses, but one that
they may have become "stuck" in.
5. Following the Manual
The text in the therapist manual is meant to be a guide. The first few times you do the
intervention you may want to follow the text fairly specifically but once you become
familiar with the concepts just make sure that you cover these main points and feel free to
express the ideas in your own words. The important thing is that the general material and
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concepts are covered and that you are able to customize the specific examples to meet the
participants needs and not feel stilted in your presentation of the material.
6. Using Motivational Interviewing
There may be a number of times over the course of working with an individual that he or
she seems discouraged, resistant, and/or ambivalent (e.g., about how things are going
overall, continuing with the intervention, or taking his or her psychotropic medication).
Brief motivational interviewing techniques are useful ways to respond to such reactions.
These approaches give the counselor tools for helping the youth get “unstuck” without
getting into a push-pull process with the counselor cajoling and the youth resisting these
efforts. The aim is to build a collaborative relationship with the youth in which the youth
actively participates in setting the agenda for the intervention. Listed below are some
general motivational interviewing strategies that may prove useful.
General MI Strategies
FRAMES Components:
(Try to incorporate as many of the
FRAMES
components as possible into your
discussions with the youth. Acknowledge and express appreciation for the youth’s
willingness to discuss their perspective
on change)
F
eedback- Provide youth with personal feedback regarding their individual status and
where they stand in relationship to norms and standards.
R
esponsibility- Emphasize the youth’s freedom of choice and personal responsibility for
their choices.
A
dvice/Education- Provide clear recommendations or advice in a supportive, non-
threatening manner.
M
enu- Provide options for youth to chose from.
E
mpathy- Express empathy; accurate reflective listening, warm and genuine manner,
non-judgmental approach.
S
elf-Efficacy- Reinforce the youth’s sense of self-efficacy regarding their ability to make
or maintain behavioral or lifestyle changes.
General Guidelines for Discussion:
Share personalized feedback in a neutral manner. Offer professional advice/opinion in a
motivation-enhancing manner. Offer new information to help the teen’s decision making
process, for example:
“This is what we/your doctor recommends, and our experience is that
_(taking
medication/counseling)_
is one of the best ways people can improve/manage their mood.”
“We strongly encourage you to
(consider increasing your pleasant activities)
.
Experience has shown that this is one of the most important things a person can do to
help manage their moods.”
Some particular MI approaches to medication compliance issues
Assessing and Exploring Medication Adherence:
“On a scale from 0-10, with 0 being “not at all ready” and 10 being “very ready”, how
ready are you to consider taking your medication everyday?”
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