How Effective Is ACT In Outpatient Treatment for Teens With Depression?

Adolescents diagnosed with major depressive disorder (MDD) often resist treatment. They may resist because of the stigma attached to being diagnosed with a mental health disorder, or the misunderstandings around teen depression treatment. They may fear their diagnosis and not want to believe they have a real mental health disorder. In some cases, they attempt to ignore their symptoms and downplay the difficult – and often painful – emotions and patterns of thought associated with depression.

Treatment is not the only thing a teen with depression might avoid. A teen with depression – who resists any type of adolescent outpatient therapy – may isolate themselves from the world and avoid dealing with everything, from family, to school, to friends, to the activities they once loved. By avoiding treatment, and by withdrawing from potential sources of compassionate support and evidence-based treatment, they often unconsciously practice and reinforce negative thoughts and feelings that exacerbate their depressive disorder.

When this unconscious practice continues long enough, they may believe there’s no way out. They may think their current state of mind is simply how they are and don’t believe there’s any way to truly manage their symptoms. They may believe depression – along with all the pain and disruption it causes in their lives – is something they have no control over, and never will.

After stigma, that’s another reason many adolescents never commit to treatment: they don’t believe it’s going to work.

However, there’s a specific type of therapy that helps teens stuck in those cycles of thought. It’s a type of therapeutic approach designed to help them break free from patterns of thought that may undermine their confidence and self-esteem, impair their overall wellbeing, and prevent them from believing that with the right treatment, recovery is possible.

It’s called Acceptance and commitment therapy (ACT).

WHAT IS ACT?

Acceptance and commitment therapy is one of three types of mindfulness-based therapeutic approaches to the treatment of mental health, behavioral, substance use disorders that first appeared in the late 1970s and early 1980s.

We discuss the other two – dialectical behavioral therapy (DBT) and mindfulness-based cognitive behavioral therapy (MBCBT) – in separate articles. This article will focus on ACT and how it’s used the treatment of depression in adolescents.

ACT was created by therapist and psychology professor Steven Hays in 1986. Here’s a simple, straightforward way of thinking about ACT therapy, based on the acronym A-C-T:

Acceptance

The first step is accepting things that are hard to accept. This may include situations, personality traits, behaviors, or emotions. Teenagers with depression often avoid the hard facts in their lives. The acceptance element of ACT encourages teenagers to recognize that in order to move forward, they must accept reality as it is. Life is not always as they might wish it to be. In the case of teen with major depressive disorder that reaches the level of clinical diagnosis, they need to accept the diagnosis is real. They need to accept that the way forward is through evidence-based treatment.

Choice

Once a teenager with depression accepts reality as it is rather than as they wish it to be – also known as cognitive defusion – they can then align their behavior with their values. This implies that they identify their values and understand how their behavior – in the case of depression, the behaviors related to their symptoms – does or does not align with their values.

Take action.

ACT is about behavioral change. This step occurs when a teen with depression puts acceptance and choice are put into practice. The teenager who needs depression treatment accepts reality. They choose the values they want to embody. Then they take concrete, tangible steps to bring their values and behavior into agreement.

Acceptance and commitment therapy helps adolescents in depression treatment examine their character traits and understand how they affect their behavior. Two common counterproductive character traits of depression include avoiding issues and emotions instead of addressing them, and convincing themselves their depressive symptoms are not significantly problematic or disruptive when, in fact, they’re both. These habits can prevent a teen from committing to and participating in treatment– but ACT can help break that cycle.

Creating Positive Change

ACT also helps adolescents commit to treatment, but it also helps them make changes in their lives. If a teen in depression treatment gets stuck at a certain point, ACT helps motivate them and do the work necessary to keep their behavior and values on track. In the case of depression, on track means staying in treatment, building on treatment momentum and success, all with the ultimate goal of living a value-based, self-directed life that’s guided by choice, rather than dominated by the ups and downs of daily depressive symptoms.

ACT for Teens: Is it Different than ACT for Adults?

In essence, no. The goals and core principle of treatment are the same, but some of the details in how therapist use ACT might be modified to leverage the strengths and interests of teens.

While acceptance and commitment therapy was originally designed for adults, a growing body of research shows it’s an effective treatment for adolescent depression – with some adaptations. In the paper Applications and Adaptations of Acceptance and Commitment Therapy (ACT) for Adolescents, researchers identify and outline the following changes therapists can make to adult-ACT in order to tailor ACT to the adolescent population.

To adapt ACT for teen depression, therapists must ensure ACT includes

1. Developmentally Appropriate Material

• • This means in broad terms. Teens, as compared to adults, have more energy and are less focused. Therefore, teens need interactive exercises. They can include roleplaying, art/drawing, worksheets/workbooks, and group projects. The key to working with adolescents in any context is to keep them interested and engaged.

2. Adolescent-Centered Activities

• • This means therapists using ACT for adolescents should leverage the teen’s interests during treatment. More and more often during mental health treatment for teens, this requires accepting that most of our teens are digital natives. They thrive in online spaces and using online games and interactive technology. At the same time, teens still love typical, traditional hobbies, such as sports, music, comic books, and other pursuits or activities. The idea is for a therapist to learn what interests a teen and use that to support and enhance the therapeutic process.

3. Family and Peer Participation

• Family participation in adolescent ACT is important for many reasons. The first – and one which many don’t consider – is aligning expectations for treatment. Parents might expect one thing and the adolescent another: with family participation, a skilled therapist can bring these expectations into harmony. That’s crucial. With regards to peer participation, what we mean here is group ACT. We’re not talking about friends of the teen in treatment coming to therapy sessions. Direct feedback from peers with depression helps teens feel less alone. It helps them adjust their approach. It also helps them practice coping mechanisms and techniques in an almost real life setting. This helps when they take their skills into the world, or when they apply them irl.

That’s how therapists adapt ACT for teen depression treatment.

Now let’s take a look at the data supporting the use of ACT in adolescent outpatient therapy.

ACT in Outpatient Treatment for Adolescents: The Data

The precedent for using acceptance-based techniques for adolescents with chronic medical conditions – which depression is – did not begin with mental health. Previous research – identified in the article we link to above – shows that acceptance-based techniques were effective for teens with:

• Cystic fibrosis. When teens committed to their treatment plan, their functioning improved in social and emotional domains, including a decrease in depressive symptoms
• Chronic pain. Teens who engage in acceptance and commitment therapy went school more often and reported decreased symptoms of anxiety
• Teens with this condition engage in the obsessive practice of pulling out their hair. Teen with trichotillomania who engaged in ACT decreased hair pulling and reported reduced distress.

These results make sense on a practical level. Acceptance and commitment therapy asks the teen to accept their condition and commit to treatment. In short, it ensures they recognize the reality of their situation and know what they can do to help themselves. They go in eyes open, as it were. ACT mitigate the role of denial as much as possible, and – not matter what the condition – prepares the teen for the behavioral change ahead.

Now let’s take a look at the data on ACT for the treatment of depression in the outpatient context.

ACT for Teen Depression: Current Evidence

• In the study “Acceptance and Commitment Therapy for the Treatment of Adolescent Depression: A Pilot Study in a Psychiatric Outpatient Setting,” researchers performed a pilot study on 37 teens with major depressive disorder (MDD). Compared to patients who engaged in outpatient treatment as usual, adolescent patients who engaged in outpatient ACT showed:
• Significantly greater improvement statistically:
  • 58% showed clinically reliable change in favor of ACT
• Increasing improvement at 3-month follow-up
• Significantly improved overall functioning

In the words of the research team:

“…the results support conducting a larger trial of ACT for the treatment of adolescent depression.”

• In the study “The Effectiveness of Acceptance and Commitment Therapy for Adolescent Mental Health: Swedish and Australian Pilot Outcomes,” which combined Swedish and Australian teenagers, researchers compared the outcomes of teens who engaged in an 8-week, school-based ACT program to teens who engaged in 8 weeks of treatment-as-usual (TAU). Here’s what they found:
  • Reduced depressive symptoms with large effect
  • Reduced psychological inflexibility with a medium effect
  • Significantly decrease in stress with large effect
  • Marginally significant decrease of anxiety

In the words of the research team:

“…the ACT-intervention seems to be a promising intervention for reducing stress and depressive symptoms among young adolescents in school and should be tested in full-sized studies.”

• The study “Acceptance and Commitment Therapy For Adolescent Depression: Application With A Diverse and Predominantly Socioeconomically Disadvantaged Sample” examined the effect of ACT on teens from diverse social and economic backgrounds. Teens participated in three motivational interviewing session followed by 12 ACT sessions. Here’s what the researchers found. Compared to control groups, participants in ACT showed significant improvements in the on the following standard tests for depression and depressive-related symptoms:
  • The Children’s Depression Rating Scale
  • The Behavioral Activation for Depression Scale
  • The Beck Depression Inventory
  • The Health-Related Quality of Life Assessment
  • The Avoidance and Fusion Questionnaire for Youth-8

In the words of the research team:

“These data suggest the potential utility of ACT for youth from lower income families and from diverse backgrounds; however, given the small sample size and the simple phase-change design, additional research is clearly warranted.”

The use of ACT therapy for the adolescent population shows great promise. The programs already in action help teens. The data shows that clearly. One thing that we didn’t mention that appears in all three of these studies is the durability of the results. Researchers in the first study observed improvements still present after three months. Researchers in the third study observed improvements still present after five months.

That shows that an ACT program can help relieve symptoms in the short term. What’s more important is that it can help improve overall function in the long run.

Why?

The Importance of Acceptance

Acceptance and commitment therapy enables teens in depression treatment to understand themselves and get perspective on the new, default facts of their life after they receive a clinical diagnosis for major depressive disorder (MDD). This allows them to recognize and leverage their talents and strength. This, in turn, allows them to move past the cycles of sadness, loneliness,, and hopelessness that many teens with MDD experience.

Helpful acceptance strategies common to ACT include:

• Allowing feelings and thoughts to exist without acting on them
• Recognizing challenge but choosing to focus on strength
• Accepting that no one is good at everything, so the treatment process is rarely perfect – for anyone
• Acknowledging the difficulties in life without avoiding them
• Realizing that each person – teens with depression included – can learn to manage their own thoughts, feelings, and reactions to life circumstances

These acceptance strategies all work to empower teens with depression. They can help people in treatment discover – or rediscover – the independent choice and agency necessary to live life on their own terms, rather than terms dictated by the symptoms of their depression. That’s why ACT is often an important part of individualized treatment plans at high-quality adolescent treatment centers. When acceptance – the capital “A” in A-C-T – is combined with choice and taking action, it’s possible to make the sustainable behavioral changes that support long-term recovery, and lifelong health, healing and wellness.