The extant evidence, combined with the broader evidence base supporting integrative cognitive behavioral therapy for youth anxiety and depression (David-Ferdon & Kaslow, 2008; Silverman, Pina, & Viswesvaran, 2008), led us to extend the BA approach across diagnostic categories in a youth population. Group Behavioral Activation Therapy (GBAT; Chu et al., 2009) distills the most potent components of behavioral therapy into a single protocol. GBAT was originally developed in school settings and has been evaluated in open trials and a recent wait list-controlled randomized clinical trial (Chu, Crocco, Esseling, Areizaga, Staples, & Skriner, 2014). GBAT is completed in 10 weekly, hour-long sessions but can be delivered flexibly to accommodate school schedules and can be extended to increase in vivo exposure dosage. The first five sessions teach four core BA principles: (a) psychoeducation of anxiety and depression; (b) idiographic functional assessment of problem behavior, focusing on avoidance; (c) approach-oriented problem solving; and (d) graded exposures and behavioral activation. Graded exposures are embedded throughout treatment (as early as session 3) to provide group members with as much experiential practice time as possible.

The SKILLS acronym , taught in sessions 1 through 5, communicates the core skills (see Table 6.2). The first principle, “S” (See where I’m stuck), cues group members to conduct a self-assessment and determine the domains they would like to improve (e.g., school, friendships, family relationships, extracurriculars). The second skill, “K” (Keep active and keep approaching), teaches members the value of approach behaviors over avoidance. Group members complete a Goals Ladder while learning the “I” principle (Identify goals I want to achieve). The “L” principle (Look for ways to accomplish my goals) includes teaching TRAP (Trigger, Response, Avoidance Pattern) and TRAC (Trigger, Response, Alternative Coping or Active Choices) skills (Addis & Martell, 2004). TRAP and TRAC help group members dissect the patterns that perpetuate distress and generate alternatives to avoidant behavior. TRAP helps group members identify specific triggers that lead to problematic avoidance responses. For example, a student who is dreading a quiz in school may try to stay home from school. This avoidance “works” to alleviate distress in the short term but leads to negative consequences in the future (poor attendance, falling behind in school work). TRAC helps remind the youth to identify (through problem solving) more active choices to address problems. Group members are encouraged to favor solutions that solve the immediate problem even if it is distressing in the short run. The second “L” (Lasting Change) corresponds to the BA principle of barrier identification and problem solving to overcome barriers. The final principle, “S” (See what’s worked), focuses group members on reassessing their progress in reaching their goals.

Sessions 6 through 9 focus on exposure tasks (imaginal, in vivo) and behavioral experiments (role-plays, practice runs for homework). However, the number of sessions can be extended to increase the number of exposures students receive. The group selects one or two “lead” members each session to conduct an in vivo exposure. The group leaders help each lead member select an item off of his/her “challenge hierarchy” to practice in session. Items of a challenge hierarchy might include avoiding homework, tutoring, or seeking help from a teacher, if one is having difficulty in math class. Another item might focus on a student who isolates herself from friends after an argument instead of pursuing greater communication. Each item is rated (e.g., “0” not at all to “10” extremely) for the level of distress it causes and the degree of avoidance the student uses.

To conduct an in vivo exposure, one group member is identified as the “lead” member, and the remaining members become the supporting cast. The purpose of exposure tasks is to recreate the challenging situation as closely as possible and to help the lead member practice his/her TRAP and TRAC skills to navigate the problem in a more approach-oriented way. Exposure tasks can focus on specific situations and fears, such as giving a speech, asserting oneself in interpersonal conflicts, socializing at a party, asking a teacher for help, or negotiating demands with a parent. However, exposure tasks can also be designed to target more diffuse problems that are commonly associated with anhedonia (lack of interest in activities) and other general worries (e.g., “What happens if I don’t get into college?”). In the case of anhedonia, the key is to simply practice getting active even when one’s emotions and physiology are convincing one to act otherwise. Addis and Martell (2004) suggest that when one is feeling down or lost in unproductive rumination, this should be a “cue to action.” For example, if a youth tends to “crash” in his bedroom after a hard day of school, the group practices helping the youth do anything but isolate himself in his bedroom and sleep. In this case, the group members can practice alternative, active coping the youth will enact at home (e.g., call a friend, take a walk) instead of his typical avoidant response (e.g., take a nap, isolating in room). In a school setting, many exposure tasks may be confined to the group room (typically a classroom or counselor’s office); however, whenever possible, it is encouraged for exposures to take advantage of natural challenges and surroundings of the school. For example, there is no better exposure for a youth afraid of talking to new people, than to go to a crowded cafeteria and initiate a conversation. The group can serve as a place to prepare for the exposure and to process it afterwards, but the closer that exposures can come to real life challenge situations, the better. By the end of group, group leaders should endeavor to involve every member to be a lead member at least 2–3 times. While students are not serving as lead member, they can serve as role players, objective observers, or provide feedback.

The original GBAT protocol was adapted for use with bullied youth who experience anxiety and mood problems following a bullying incident (Chu, Hoffman, Johns, Reyes-Portillo, & Hansford, 2013). GBAT-Bullying (GBAT-B) teaches victims strategies to minimize the negative impact of bullying and builds social skills to minimize the risk of future bullying. GBAT-B contains four bullying-specific sessions to be completed prior to the traditional GBAT protocol (see Table 6.2). The first session (“Facts about School Life and Bullying”) provides definitions and psychoeducation around bullying, endeavors to normalize the experience of being bullied, and challenges misperceptions of bullying perpetrators and victims. Different forms of bullying (physical, verbal, relational, cyberbullying) are discussed, and group members use a “Bullying Thermometer” to identify varying levels of distress associated with different kinds of bullying. It is stressed that different responses (e.g., official school action, interpersonal support, assertiveness) may be required depending on the type of bullying event experienced. Next, group members learn the skill “Build Your Social Network.” This module was created in response to research suggesting that victims of bullying may be targeted because they are perceived as lacking social skills and have few reliable friends on which to depend (Fox & Boulton, 2006). To build their “Social Network,” group members assess existing sources and gaps in their social network. For example, one group member may realize that she has many acquaintances on the bus and in the classroom but few close friends to sit with in the cafeteria. The group brainstorms possible ways for each member to increase their social connections, including joining groups, approaching new peers in the cafeteria, or choosing someone to invite to the movies. The group then problem solves potential barriers to these suggestions.

In the third session (“Standing Up For Yourself”), group members are taught three main communication styles: aggressive (impulsive reactive style), passive (avoidant style), and assertive (proactive style). Bullied youth often respond ineffectively to bullying events, making them more vulnerable targets in the future (Schwartz, Dodge, & Coie, 1993). Group members are taught verbal and physical ways to communicate assertiveness and use role-plays to practice assertiveness over passivity or aggressiveness. However, group leaders do stress that assertiveness may not be appropriate when physical harm is a realistic threat—in such cases, escape and help from an adult is recommended. In the last bullying-specific session, group members practice the skill “Mobilizing Your Forces,” which help youth identify their preferred social supports in the event of bullying. Using the Social Network, group members select who they would contact in various situations. Peers and siblings may provide adequate support following mild forms of bullying (e.g., teasing in the classroom), but school personnel or parents might be preferred following more severe bullying incidents (e.g., being kicked in the hallway, cyberbullying). Upon completion of the bullying-specific sessions, the group resumes the traditional GBAT curriculum, where the focus shifts to preventing anxiety and mood symptoms following experiences with bullying.

Awareness of the rapid developmental changes throughout childhood and adolescence should guide practitioners in their assessment, case conceptualization, and treatment of anxious and depressed youth. For example, biological factors such as gender and pubertal changes may impact the type of issues youth are exposed to at different periods of time. For instance, the peak of pubertal development occurs 2 years earlier in most females when compared to the average male (Holmbeck et al., 2006). Such changes can impact the quality of family relationships and certain indicators of psychosocial adaption and psychopathology. Early-maturing girls, for example, are at risk for a variety of adaptation difficulties, including depression, substance use, eating problems and disorders, and family conflicts (American Psychological Association, 2002; Holmbeck et al., 2006). Practitioners should keep these developmental norms in mind and shape program goals around relevant developmental issues.

Interpersonal contexts such as family, peers, and school should be considered. For example, the school environment is a key context for the development of one’s personality, values, and social relationships (Holmbeck et al., 2006). It may be important to target issues unique to a particular school or its surrounding community, including recent bullying events, recovery from a natural disaster, high divorce rates in the community, unsafe neighborhoods, or poverty. Programs should be flexible to adapt to the school’s individualized needs and make content changes as necessary. In one of our studies, we modified the TRAP acronym to stand for “Anger Pattern,” in addition to Avoidant Pattern, which seemed to fit the response style and culture of the particular school (discussed more below).

Peer context is another critical variable, and it is important to understand the relative influence of peers and family members. In adolescence, the need for autonomy and personal choice commonly reaches a peak. School-based programs can help youth develop independence by teaching independent problem solving and decision-making while also identifying situations in which consultation from adults would be helpful.

The GBAT program has now been evaluated in a series of open trials and a small randomized controlled trial (Chu et al., 2009; Chu, Crocco et al., 2014), following recommended practice by the National Institute of Health. The intervention was developed in the schools where we ultimately hope it will be delivered. We actively consulted with school personnel and implemented early trials in schools, following recommendations of implementation and dissemination experts (e.g., Atkins, Frazier, & Cappella, 2006; Chorpita, 2002) who caution that the most important lessons do not emerge until the treatment itself is put into the community. Accordingly, treatment acceptability, therapist training, clinical supervision, and community beliefs were considered at each stage of development.