Cognitive behavioral group therapy for depressed, low-income minority clients: Retention and treatment enhancement

COGNITIVE AND BEHAVIORAL PRACTICE 5,

65-80,

1998

Cognitive Behavioral Group Therapy for Depressed, Low-Income Minority Clients: Retention and Treatment Enhancement

Jason M. Satterfield

University of California, San Francisco

Despite the ever-increasing clinical needs of "underserved populations" research, practice guidelines, and clinical training programs have focused primarily on treating middle- and upper-middle-class nonminority clients. This paper highlights the mental health needs of low-income minority patients, pointing out specific risks, obstacles to service utilization, reasons for treatment failures, and significant opportunities for clinical interventions and innovations. Countertherapeutic patient and therapist beliefs and attributions are discussed. A pilot cognitive-behavioral depression group specifically designed for low-income minority patients is used to demonstrate practical interventions and guidelines for working with this population. Preliminary results suggest that premature attrition and clinical outcomes can be significantly improved. Group structure, content, and special attention to group processes were thought to be responsible for positive findings. T h e low-income sector of our communities is rapidly expanding, with little relief in sight (Healey, 1995; Holmes, 1996; Schnitzer, 1996; U.S. Bureau of the Census, 1996). In fact, the income inequalities in the United States far outstrip any other industrialized nation and is likely to worsen (Holmes; Kerbo, 1996). Although poverty cuts across cultural and ethnic lines, the proportion of poor individuals a m o n g blacks and Hispanics is more than three times higher than a m o n g whites and is especially high in female-headed households (Danziger, Sandefur, & Weinberg, 1994; Wilson, 1991). The term "minority" all too often follows "low-income." This social and economic p h e n o m e n o n should be of special interest to the 65 1077-7229/98/65-8051.00/0 Copyright 1998 by Association for Advancement of Behavior Therapy All rights of reproduction in any form reserved.

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mental health field given the relatively stable, inverse relationship between socioeconomic status (SES) and psychopathology (Bruce, Takeuchi, & Leaf, 1991; Dohrenwend et al., 1992; Holzer et al., 1986; Kessler et al., 1994; Saraceno & Barbui, 1997). More specifically, poor adults have a 1.92 greater probability for the development of a new Axis I psychiatric disorder than the nonpoor, even after controlling for gender, ethnicity, and other demographic variables (Bruce et al., 1991). Depressive symptoms were especially prevalent in lower SES patients independent of ethnicity (Biafora, 1995; Roberts, 1987). O f special concern is the growing phenomenon of persistent poverty where cumulative and sometimes unavoidable adversity significantly enhances risks for psychopathology even further (Turner & Lloyd, 1995). Unfortunately, past and recent research suggests low-income clients are less likely to seek out and/or remain in mental health services regardless of need (Cheung & Snowden, 1990; Dworkin &Adams, 1987; Sue, 1977). Sue, McKinney, and Allen (1976) found a 23% dropout after session 1, with 70% dropping out by session 10. Organista, Mufioz, and Gonzfilez (1994) found a 58% dropout rate in depression groups for low-income patients in comparison with the mean premature termination rate of 35% taken from a review of the group therapy literature (Bostwick, 1987). Conversely, education and high SES have been found to predict continuation of treatment (Rabin, Kaslow, & Rehm, 1985). Clinical services researchers have made some theoretical and empirical advances in understanding service delivery problems with underserved populations (e.g., Parron, 1982; Yeatts, Crow, & Folts, 1992). Parron explains these problems with utilization by looking at the availability, accessibility, acceptability (based on cultural and other expectations and needs), and accountability of the services we provide. Other service use frameworks have examined predisposing factors (e.g., race, gender, education, age), enabling factors (e.g., income, perceived availability, cost, transportation), and perceived need for help to better understand why services are or are not used by those in need (Yeatts et al., 1992). To date, there has been little consensus on which factors are most important in utilization decisions; however, it appears that SES plays a great role. Unfortunately, few practical resources are available that discuss how to address utilization barriers. Despite the persistent and increasing need for a sufficient response from the mental health community, none has been forthcoming. The 1996 update to APA's Division 12 review of "empirically validated psychological treatments" recognized the "dearth" of work with cultural and ethnic minorities and acknowledged the embarrassing fact that not a single selected study included tests of efficacy for ethnic minorities. In fact, only 7 out of 41 studies made even a passing reference to ethnicity. There is no mention of low-income patients (Chambless et al., 1996). Given the great diversity of the patients we treat, these omissions seem intolerable. Recent sources have offered useful suggestions on how to address the special problems of doing clinical research with these

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populations (Miranda, Azocar, Organista, Mufioz, & Lieberman, 1996; Sue, Zane, & Young, 1994; Thompson, Neighbors, Munday, & Jackson, 1996). In this paper, I hope to provide concrete, clinical suggestions on how to retain low-income minority patients in treatment, with attention to improving and evaluating clinical outcomes. While important, issues of initial recruitment/ outreach, community education, and culture-specific treatment adaptations will be beyond the scope of this paper (see Azocar, Miranda, & Dwyer, 1996; Davis & Padesky, 1989; Organista & Mufioz, 1996; Purcell, Campos, & Perilla, 1996; Yeatts et al., 1992). I will first discuss countertherapeutic patient and therapist beliefs that might contribute to service underutilization and premature terminations. Using a pilot group program built from these theoretical ideas, I will demonstrate that modified cognitive-behavioral group treatment can successfully retain, treat, and satisfy low-income minority patients. In addition, I will suggest that processsensitive group treatment has a special utility with this population. Recommendations will include a pregroup training protocol, adaptations to standard cognitive behavior therapy (C BT) interventions, modifications to standard group structure and procedures, and the integration of CBT and group dynamics. While true that many of my suggestions might be useful for patients of any SES level, I will argue that low-income patients who struggle with severe and chronic stressors, disempowerment, social isolation, and stigma will be the greatest beneficiaries.

Patient Belief and Expectations Given the diversity of the low-income community, no given set of beliefs regarding psychological treatment is possible and few empirically based surveys exist to offer guidance. However, I will offer several intuitive speculations based on past clinical observations, literature reviews, and input from patients in our group programs (Friedman, Patterson, & Gomez, 1983; Heitler, 1976; Lorion, 1974; Schnitzer, 1996). Endemic to the experience of poverty are feelings of hopelessness, devaluation, disempowerment, and stigmatization. Many low-income patients have ceased the struggle to find work or improve their condition as one door after another has closed. It becomes difficult not to internalize societal prejudices that label many low-income persons as unintelligent, immature, criminal, drug abusing, or lazy. The cycle of negative experiences, beliefs, and expectations becomes a downward spiral as low-income individuals endure more and more negative, devaluing experiences and become less able to cope with objectively severe stressors. In a sense, low-income and minority patients develop a sort of learned helplessness based on their perception that negative environmental events are noncontingent on their efforts--no matter what they do, things will not change. Attributing their adversity to internal (it's my fault, my race, my

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lack of intelligence), stable, and global causes only serves to exacerbate and maintain their condition (Uomoto, 1986). Low-income clients frequently report accumulated negative experiences with health care providers and other authority figures or institutions who either act disrespectfully or unempathically or are simply unable to provide adequate treatment or relief. Treatment often begins with the low-income patient already on the defensive, expecting not to be believed, understood, or relieved. These fears might be exacerbated in the mental health setting, where the patient fears additional stigma, stereotyping, or characterological blame. Patients are afraid to develop trust or hope given their past negative perceptions and experiences that suggest these are luxuries they cannot afford. Patients may implicitly search for evidence to confirm these negative beliefs or behave in ways to confirm these negative self-fulfilling prophecies. In other words, a missed phone message or lost referral might become "proof" that, once again, the patient will not be respected and taken seriously. Heitler (1976) and others suggest low-income patients expect the clinician to be active, somewhat directive, and advice-giving. Formality, therapeutic neutrality, and a nonsymptom-focused approach might be off-putting. Patients expect symptom relief in a relatively short time period and appreciate demonstrations of practical interventions. Failure to address these expectations, regardless of their veracity, might result in low patient satisfaction and premature terminations.

Therapist Beliefs and Expectations Even well-intentioned therapists (who usually do not come from low-income backgrounds) often harbor countertherapeutic beliefs and expectations about their low-income patients. In the now classic New Haven study, surveyed mental health providers regarded lower-class patients as crude, volatile, passive, apathetic, and uninterested in clinical improvement (Hollingshead & Redlich, 1958). Frustrated therapists saw low-income patients as disorganized, irresponsible, entitled, or simply unwilling to work for their own mental health (Schnitzer, 1996). O f special importance are the attributions therapists make regarding the "countertherapeutic behaviors" of their low-income clients (e.g., missing appointments, showing up late, not doing homework assignments). Stable attributions that habitually place blame on the client breed resentment and frustration while impairing therapist motivation to "go the extra mile" What we so easily forget are the extraordinary day-to-day demands low-income patients face in a sometimes unimaginably chaotic life (e.g., the struggle to provide adequate food and shelter, the demands of low-income single-motherhood, concerns for personal safety, etc.). One of our CBT depression group members, Paula, provides a good example of unusual adversity. Paula, a 57-year-old African American grandmother with

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poorly managed diabetes, high blood pressure, and emphysema, cares for her three grandchildren (ages 4 to 9) on a severely limited income. H e r daughter, the mother of the children, abuses crack cocaine and often breaks into Paula's house to steal money, food, or anything she can pawn for drug money. To get to our 10 a.m. group, Paula has to get up at 5 a.m., prepare the children, take her first bus to get the oldest two children to school and their free breakfast, take her second bus to line up early for a free church breakfast for herself and her youngest granddaughter, take her third bus to preschool, then take a free shuttle to our clinic, which requires this woman with limited mobility to climb a rather steep hill. Paula missed one group and was tardy t w i c e - behavior that was correctly attributed to her difficult circumstances and not to her motivation for treatment. While this paper will focus on interventions for patients and not for therapists, several suggestions can be offered. First, the detection and treatment of burnout should be incorporated into the standard operating procedures of any practice that sees low-income patients. Burnout is common, perhaps unavoidable at times, but it can be alleviated with the same cognitive-behavioral skills we use with our clients (Farber, 1990; Grosch & Otsen, 1994; Raquepaw & Miller, 1989). Second, we must recognize and evaluate the reality and usefulness of our own expectations regarding therapy with low-income patients and the attributions we make when things don't go according to the ideal (Murdock & Altmaier, 1991; Persons, 1991). Finally, work with low-income patients often requires a flexibility and openness not typically taught in our training institutions. Unusual methods are needed for unusual circumstances (Azocar et al., 1996; Schnitzer, 1996).

CBT Depression Group Pilot Project Building on the theoretical work of Satterfield (1994), a process-sensitive cognitive-behavioral depression group was selected as the modality of treatment. CBT was chosen given past research demonstrating its efficacy with depressive disorders in individual and group formats (e.g., Beutler et al., 1987; Comas-Diaz, 1981; Dobson, 1989; Elkin et al., 1989; Free, Oei, & Sanders, 1991; Organista et al., 1994; Shaffer, Shapiro, Sank, & Coghlan, 1981). Past work furthermore suggested that low-income patients would respond well to more present-focused, concrete interventions (Acosta, Yamamoto, & Evans, 1982; Azocar et al., 1996; Heitler, 1976; Lorion, 1974; Organista, Dwyer, & Azocar, 1993; Organista et al., 1994). A process-sensitive group was chosen given the belief that specific attention to group dynamics and cohesion would afford enhanced opportunities for normalization, social reinforcement, identification, and motivation needed to interest and retain low-income patients (for further discussion, see Satterfield). Pragmatically, the group format allowed our clinic to see a larger number of patients in need without compromised quality of care.

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Patients The 23 patients in our pilot group program were low-income, primary care patients who met Diagnostic and Statistical Manual of Mental Disorders (DSM-III-R; American Psychiatric Association, 1987) diagnostic criteria for major depressive episode. Many patients had concomitant diagnoses of medical disorders, anxiety, recent substance abuse, and personality disorders reflecting a realworld patient sample. Our sample was 47% African American, 35% Caucasian, 12 % Latino, and 6% "other." Fifty-two percent were male and ages ranged from 19 to 57. Average income was $441.00 per month. Referrals The patients involved in our pilot group program were referred by their primary care physicians or other county health center employees. Regular outreach and education were provided for the primary care physicians and nurses to improve the detection of major depression and to teach ways to successfully present or "sell" a referral to a patient. Referrals were immediately made by phone while the patient was present and an appointment was scheduled within 10 days. Ideally, a clinic volunteer (often a past patient or low-income community member) would escort the patient to our program to set up the appointment in person. Our clinic is located near the medical clinic in a low-income neighborhood and has multiple bilingual and/or bicultural staffto help patients feet at ease and understood. Patients were called with a reminder the night before their initial appointment and were encouraged to share any questions or reservations. Clinicians problem-solved with patients around transportation, child care, and other obstacles to attendance often encountered by low-income patients. We encouraged a high tolerance for "no-shows" which were always followed by both personal letters and phone calls. Intake clinicians would often consult with the referring care-giver to assist in connecting with hard-to-reach or ambivalent patients. If possible, an intake appointment was scheduled to immediately follow a medical appointment. At times, a home visit was used to develop rapport with a patient and explain our services. Treatment often began by assisting patients with case-management issues such as completing social security paperwork or applying for general assistance. Once referred, the patient had an "open door" to request services at any time. For patients who were not interested or ready for treatment, referring sources used a stages-of-change model and motivational interviewing techniques to better prepare patients for future treatment (Miller & Rollnick, 1991). Consultation and recommendations were regularly provided. Pregroup Training Since negative-outcome-related events were thought to occur early in the treatment process, special attention was given to the early stages of treatment

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(Jacobs, Charles, Jacobs, Weinstein, & Mann, 1972). An individual pregroup training session was provided following the standard diagnostic intake. Research on pregroup training has demonstrated the advantages and effectiveness of pretraining strategies, particularly in the alleviation of anxiety, reduction of premature attrition, and improved outcome reports (Beutler, Crago, & Arizmendi, 1986; Dies & Teleska, 1985; Orlinsky & Howard, 1986; Piper, Debane, Bienvenu, & Garant, 1982; Piper & Perrault, 1989; Vinogradov & Yalom, 1990; Yalom, 1985). Typical pregroup training sessions include basic education about group roles and process, rationale for treatment, introduction of group rules and guidelines, role inductions, and the instillation of hope. All information was informally presented in accessible language using feedback from past clinic patients. Group therapy was often framed as a special hands-on class to help with everyday stress and strife. The goal of the pregroup session was to significantly address the issue of acceptability by explicitly and experientially challenging countertherapeutic beliefs about therapy and to enhance our clinic's accountability by creating a forum for patients to evaluate and alter our services as needed. This was in part achieved by the following elements: (a) provide verbal and written information and explain the patient's diagnosis and treatment format in familiar terms, (b) explain and provide the rationale for CBT, making explicit links to patientspecific stressors, (c) expose and familiarize the patient with the clinic and ethnically diverse staff, use moderate self-disclosure to create identifications, (d) foster a sense of collaboration, empowerment, and accountability by frequently asking for feedback, give patients forms and direct phone numbers to voice opinions, and sign a written contract specifying services offered, (e) elicit and address patient expectations/goals (e.g., "wish list") and concerns regarding therapy and the group, (f) perform a"role induction" procedure within the actual group room demonstrating what to expect and how to behave in group, and (g) foster the instillation of hope using personal success stories from past group graduates who closely matched the current patient. When possible, all pregroup training sessions were performed by the assigned group leader to facilitate rapport and increase the likelihood of attendance to the first group meeting. General Principles M y goal was to provide quality CBT group therapy through the group rather than simply in a group format (Satterfield, 1994; Whitney & Rose, 1989). I hoped to maintain the content and integrity of standard CBT interventions for depression while enhancing treatment adherence, clinical outcomes, and patient satisfaction with a heightened sensitivity to group processes. I hoped to minimize attrition and tardiness while enhancing efficacy by explicitly harnessing group dynamics and fostering group cohesion. This paper will discuss the concepts of group cohesion, multilevel interventions (isomorphisms), and a here-and-now focus.

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The definition and understanding of group cohesion has grown more sophisticated over the past few years (Braaten, 1991; Budman et al., 1989; Budman, Soldz, Demby, Davis, & Merry, 1993; Kaul & Bednar, 1986). Group cohesiveness has roughly been equated with the therapeutic alliance in individual therapy and manifests itself differently depending on the stage of the group. Multiple studies and meta-analyses of group cohesion have shown a strong positive correlation between cohesion, performance, symptom reduction, and other clinical outcomes (Budman et al., 1987; Budman et al., 1989; Evans & Dion, 1991; Hand, Lamontagne, & Marks, 1976). Although cohesion is important in every group, it was thought to be critical for low-income patients who are at a high risk of prematurely discontinuing treatment and who typically feel they are not valued and do not belong. Group structure, content, and in-session exercises were used to foster cohesion. Although patients were heterogeneous in some respects, special effort was made to highlight their similarities (e.g., diagnosis, psychosocial stressors, family issues, anxieties, etc.). A "buddy" or senior group m e m b e r was explicitly paired with a new m e m b e r to aid in the transition to group and speed identification and cohesion. Shared group tasks (e.g., creating activity schedules) were used to create a sense of cooperation and mutual struggle. The therapist used his connection to, and knowledge of, each individual (established in the pregroup training sessions) to begin building dyads and subgroups, then moving to group-as-a-whole interventions (e.g., creating a group identity by always using "we" statements, specifying uniqueness of this particular group, etc.). The therapist modeled self-disclosure in the beginning of each treatment module by sharing appropriate personal information and assisting patients to share personal information with the group. New members were explicitly told participation was a personal choice. If a member failed to attend group, a personalized "missing you" letter was signed by each consenting m e m b e r and mailed to the absent member's home address before the next group. In a group setting, interventions can target the individual, a dyad or pair, a subgroup, or the group-as-a-whole. Limited research suggests the selective use of these multiple layers of interaction can facilitate cohesion, modeling, group and personal growth, and clinical outcomes (Dies, 1993; Falloon, 1981; H a n d et al., 1976; Karterud, 1989; Kaul & Bednar, 1986). More group-asa-whole interventions were used in the early stages of the group to foster a sense of group identity and ownership of the group. Dyadic interventions were used for new members to create an immediate subgroup and facilitate identification and modeling. Subgroups were used to complete in-session homework assignments and brainstorm disputations of automatic thoughts. Individual work included homework assignments and weekly check-ins. Although the group worked to maintain a practical focus in helping patients cope with everyday problems, here-and-now interventions were considered important because of their power to actively demonstrate CBT concepts and pro-

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vide skills practice while patients are affectively aroused. Examples of hereand-now interventions included capturing automatic thoughts during group role plays, expressing anger at other members and negotiating conflict, and openly discussing the anxiety inherent to termination. Role of the Therapist The therapist was seen as the patient's personal advocate. Between-session contact, case-management interventions, brief family meetings, and consultation with primary care providers were not uncommon. Great effort was expended to keep the patient in treatment by first using group members and the draw of social support and then moving to a more one-on-one level of outreach. As with other CBT groups, the therapist facilitated group work by collaboratively setting an agenda and moving the group through relevant exercises to build coping skills and challenge depressogenic thinking. In the processsensitive group format, the therapist is not necessarily forced to make decisions between pursuing CBT content or group process, but tries to use the two synergistically. In other words, the group process is used to demonstrate and vitalize the CBT content (Satterfield, 1994). Group Structure Patients attended 16 weekly, 2-hour, partially manualized group sessions. Each group was composed of 6 to 10 clinically depressed patients and one junior and one senior group facilitator. The group consisted of three 4-week modules focusing on activities, thoughts, and social contacts. In their last 4 weeks, patients repeated their first module and did treatment review and relapse prevention work. Patients completed a Beck Depression Inventory (BDI; Beck, Ward, Mendelson, Mock, & Erbaugh, 1961) before each session and more comprehensive measures at pre-, midpoint, post-, and 3-month follow-up time points. The explicit treatment contract, shorter time frame, and definite end point were thought to enhance the pragmatic focus, speed therapeutic work, improve commitment to treatment, and more closely match low-income patients' expectations. The clinical research measures were billed as a way to provide important clinical feedback to the program and used to shape future interventions based on individual needs. Patients were given a group manual containing an outline and homework forms for the 16 sessions (Mufioz, Miranda, & Satterfietd, 1996). Members often added or altered pages to create a more personalized manual they could keep and review after treatment ended. Basic group guidelines and suggestions for group behavior were listed in the manual, but each group was given the opportunity to create their own "group rules." The group manual was adapted from Control YourDepression (Lewinsohn, Mufioz, Youngren, & Zeiss, 1986) and influenced by other sources (Beck, Rush, Shaw, & Emery, 1979; Burns, 1980;

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Freeman, Pretzer, Fleming, & Simon, 1990; Greenberger & Padesky, 1995; Satterfield, 1994; Yalom, 1985). The manual was written using accessible language with examples reflecting common problems of low-income living (e.g., no money or transportation to do pleasant activities). With the manual, patients knew what to expect each session and were invited to become a part of the treatment planning process. The group format was partially open. Space allowing, new group members could enter the group at the beginning of each 4-week module and senior members might "graduate" at the end of any given module. Pragmatically, this model allowed us to better manage patient flow and reduce wait-list time. Clinically, senior group members often "sold" the group to incoming members, sharing their initial feelings when starting group and the progress they had made over the past several sessions. Senior members also helped teach CBT skills to newer members and were thus able to further solidify their grasp of the material while bolstering self-esteem and self-efficacy. Newer patients felt more welcomed, hopeful, and showed greater group cohesion, modeling, and skill learning. Group facilitators purposefully paired senior members with newer members to encourage this teaching and sharing through explicit exercises and implicit statements highlighting similarities between two individuals or the group-as-a-whole. This pairing and provision of social support provided a powerful experience of caring and mentorship that worked to indirectly disconfirm beliefs about unlovability and worthlessness. Group Content The goals of the activities module were to demonstrate the link between pleasant activities and mood, monitor and increase daily activities, improve recognition and recall of seemingly minor yet reinforcing daily activities, and to collectively brainstorm on how to increase activities given the limitations of poverty, medical illnesses, and unsafe neighborhoods. In-session exercises included creating lists of free local events and activities, identifying obstacles to increased activity, behavioral rehearsal, and basic stress-reduction techniques. Homework included regular monitoring of daily moods, activity levels, and completing exercises on goal setting. Patients practiced basic problem-solving skills of identifying a problem (e.g., finding aflordable housing), listing alternatives (e.g., applying for federal assistance, searching the rental ads), weighing pros and cons, and devising a solution. In the social contact module, patients learned and tested the connection between positive social contacts and mood. Each patient first diagramed and evaluated his or her social support network. Classes then focused on how to increase the size of the network and/or how to enhance relationships with existing network members. Exercises included social-skills training, assertiveness, and conflict resolution. Role plays of relevant social situations (e.g., conflict with a welfare worker) and here-and-now group examples were used whenever

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possible. Patients were able to practice giving and receiving positive and negative feedback from other members. In each group, the members spontaneously recorded the names and numbers of other graduating group members to maintain social contacts after the group ended. In general, group provided a unique and useful way to make new social supports and prevent isolation. In contrast to standard group models, between-session and posttreatment socializing was not discouraged. Most members had little to no social contacts and greatly benefitted from the new contacts made in group. Group was used as a way to forge healthy connections, and the new relationships were seen as opportunities to practice new social and communication skills. The thoughts module explored the link between positive and negative cognition and mood. The ideas of the "management of reality" and "balancing your thoughts" are central. Exercises include Ellis's '~ABCD" (Ellis & Grieger, 1977), "yes . . . but:' thought stopping, and refraining. Patients were taught basic skills of scheduling worry time, using distractions, identifying cognitive distortions, and beginning to uncover underlying assumptions and compensatory strategies. All skills were taught and then practiced repeatedly in a relaxed, low-pressure atmosphere. Patients initially found it much easier to challenge one anothers' thoughts then to challenge their own. Nearly all patients put their homework (e.g., ABCD or dysfunctional thought record) on a chalkboard during each group. While this initially raised anxiety for some members, it soon became part of the group culture and greatly improved adherence, modeling, and social reinforcement. Patients with low literacy skills were assisted by a more literate group member who acted as a "volunteer tutor." Patients repeated a modified version of their first module in the last 4 weeks. This time was used to review concepts and skills and to prepare a post-group coping plan. This time was especially important in eliciting automatic thoughts about self-efficacy, beliefs about the future, and specifying both short- and longrange goals. Members were careful to realistically view continuing stressors (e.g., living in high-crime neighborhoods) but created lists of coping strategies to challenge the feelings of helplessness. Continuing members were able to witness and participate in the "graduation process~' hence better preparing them for their upcoming termination.

Results The goals of the CBT depression group pilot were to decrease dropouts and show greater remission of depressive symptoms as measured by the BDI and other measures. The results were encouraging. Of patients enrolled in the pilot group treatment program, 74.6% completed all 16 sessions, yielding a dropout rate of only 25.4%. This is in comparison to Organista et al. (1994), who worked with similar patients in the same clinic and showed a 58% group dropout rate, and in contrast to the 35% standard dropout rate for most group psychotherapy

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(Bostwick, 1987). Pilot group patients were on average only 2.89 minutes late for each 90-minute session. Brief satisfaction surveys showed high patient satisfaction and group cohesion. Over 90% of pilot group patients endorsed the statements, "I nearly always felt included by the group" and "I liked group very much." Over 80% endorsed "the group was very helpful in treating my depression" and "the other members were an important part of my treatment" As was found in Organista et al. (1994), changes in B D I scores were more modest than reported with middle-income patients. O n average, pilot patients showed a 33.03 % reduction in depressive symptoms at completion of the group. More encouragingly, pilot patients still showed a 29.78% reduction in BDI scores at a 3-month follow-up. This represented a modest improvement over our clinic's average BDI reduction of 27.7% from pre- to posttreatment (includes treatment completers and dropouts; Organista et al.). To ascertain whether this level of symptom reduction was clinically significant, I also included measures of social activity level and pleasant activities (Mufioz & Ying, 1993), and hopelessness (Beck, Weissman, Lester, & Trexler, 1974). Pilot group patients were found to be 16.2% more behaviorally active, 24.5% more socially active, and 33.3% less hopeless. Gains were maintained at a 3-month follow-up. In summary, the group structure, content, and explicit focus on group dynamics appears to have greatly improved retention of low-income patients and modestly improved clinical outcomes that were maintained at a 3-month followup. We were able to address Parron's (1982) concerns with availability, accessibility, acceptability, and accountability by using flexible group models to reach more patients, coordinating and consulting with primary care clinics for referrals, altering our appointment scheduling and outreach system, providing reminders and problem-solving obstacles to attendance, making treatment more acceptable by using pregroup training by diverse staff and altering group content and format, capitalizing on natural group processes, and allowing patients ample opportunities to provide feedback and see their feedback in use. Undoubtedly, these ideas and interventions need to be evaluated using more rigorous methodologies. Hopefully, the pilot depression group project has demonstrated that this work can and should be done.

References Acosta, E X., Yamamoto,J., & Evans, L. A. (1982). Effective psychotherapyfor low-income and minority patients. New York: Plenum Press. American Psychiatric Association. (1987). Diagnostic and statistical manual of mental disorders (3rd ed., rev.). Washington, DC: Author. Azocar, F., Miranda, J., & Dwyer, E. V. (1996). Treatment of depression in disadvantaged women. 146men and Therapy, 18(3), 91-105. Beck, A. T., Rush, J. A., Shaw, B. F., & Emery, G. (1979), Cognitive therapy of depression. New York: The Guilford Press.

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