assigned to either cognitive-behavioral treatment, relaxation training, or a wait-list control ..... introduced to a framework of basic techniques for developing a self-.
Journal of Consulting and Clinical Psychology 1986, Vol. 54, No. 5,653-660
Copyright 1986 by the American Psychological Association, Inc. 0022-006X/86/M0.75
A Comparison of Cognitive-Behavioral Therapy and Relaxation Training for the Treatment of Depression in Adolescents William M. Reynolds and Kevin I. Coats University of Wisconsin—Madison This investigation examined the efficacy of cognitive-behavioral therapy and relaxation training for the treatment of depression in adolescents. Thirty moderately depressed adolescents were randomly assigned to either cognitive-behavioral treatment, relaxation training, or a wait-list control condition. Treatment subjects met in small groups for ten 50-min sessions over 5 weeks in a high school setting. Outcome measures included self-report and clinical interviews for depression as well as measures of self-esteem and anxiety. The cognitive-behavioral and relaxation training groups were superior to the wait-list control group in the reduction of depressive symptoms at both posttest and 5-week follow-up assessments. There was no significant difference between active treatments in their effectiveness for reducing adolescents' depression. Subjects in the cognitive-behavioral and relaxation training conditions went from moderate levels of depression at pretest to nondepressed levels at posttest, and they maintained these levels at follow-up. Improvements in anxiety and academic self-concept were also demonstrated by the active treatments. The findings demonstrate that these short-term group-administered therapies are effective in significantly decreasing depression in adolescents.
Research on depression in adolescents is beginning to emerge, although for the most part it has focused on diagnostic and phenomenological characteristics and on biological and biochemical sequelae and correlates (Reynolds, 1984, 1985a; Strober, 1983). To date, there are few treatment studies for the amelioration of depression in this population. The treatment literature consists of a number of pharmacotherapy studies (for reviews see Elkins & Rapoport, 1983) and a report by Anthony (1970) on psychoanalytic treatment. The current perspective holds that depression in adolescents is phenomenologically similar to depression in adults (e.g., American Psychiatric Association, 1980). Given the clinical commonalities noted by researchers, it seems logical to assume that current therapies designed for use with college, outpatient, and general adult populations may, with minor modifications, be efficacious for the remediation of depressive symptoms in adolescents. Reynolds and Stark (1983) noted that cognitivebehavioral therapies for unipolar depression demonstrated broad-spectrum efficacy with differing samples and were comparable in effectiveness with other forms of psychotherapy as well as with pharmacotherapy. However, Rush, Kovacs, Beck,
Weissenburger, and Hollon (1981) showed that differential symptom response may occur across treatments. Available evidence supports the use of both cognitive and behavioral therapies with outpatient samples of unipolar depressed adults (e.g., McLean & Hakstian, 1979; Rehm, Fuchs, Roth, Kornblith, & Romano, 1979; Shaw, 1977). The present study examined the efficacy of a brief cognitive-behavioral treatment for depression in adolescents. The experimental treatment, based largely on Rehm's (1977) self-control model of depression, was adapted from the work of Rehm and colleagues (Fuchs & Rehm, 1977; Rehm et al., 1979) as well as from research conducted by Lewinsohn (Steinmetz et al., 1979). Modifications made to the adult treatment protocols consisted of changes in language to accommodate adolescents and changes in activities to accommodate adolescents' lifestyles and school settings. Our major purpose was to establish whether the cognitive-behavioral treatment would be more effective in modifying depressive symptomatology than either a relaxation training treatment or a wait-list control group. Although relaxation training is nonspecific to the major, competing psychological theories of depression, it has been noted as an effective technique for the reduction of symptomatology associated with depression (Agras, 1983; Biglan & Dow, 1981). Furthermore, relaxation training has been used as a treatment condition (albeit viewed by the investigators as an attention control) in at least one therapy outcome study (McLean & Hakstian, 1979), where it was found to be as effective as psychotherapy and pharmacotherapy. Relaxation training has also been incorporated as a component in a number of treatment packages for depression (Blaney, 1981; Zeiss, Lewinsohn, &Munoz, 1979). There is sufficient evidence linking stress to depression to argue for relaxation training as an active treatment. This argu-
The writing of this article was facilitated by Wisconsin Alumni Research Foundation Grant 135-1503 to William M. Reynolds. The authors wish to thank Barbara Coats and Les Hynum for their assistance in this study and Karen Kraemer for typing the manuscript. The authors also thank Kevin D. Stark and Thomas R. Kratochwill for their constructive comments on an earlier draft. Authorship of this article was equal. Copies of the treatment manuals are available at cost from William M. Reynolds. Correspondence concerning this article should be addressed to William M. Reynolds, who is now at Western Psychological Services, 12031 Wilshire Boulevard, Los Angeles, California 90025.
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ment is strengthened by a number of environmental and social models that link depression to stress and strain (e.g., Aneshensel & Stone, 1982; Shaw, 1982). Furthermore, relaxation training provides the individual with a coping strategy for dealing with stress (Goldfried & Trier, 1974) and may provide a prophylaxis for the stress-related neurochemical changes that have been linked to depression (for a review of the latter issue see Anisman & Lapierre, 1982). We hypothesized that cognitive-behavioral treatment would produce a greater reduction of depressive symptoms than either relaxation training or a wait-list control condition and that subjects in the relaxation training group would demonstrate significantly fewer depressive symptoms than those in the wait-list control group. Furthermore, it was expected that the cognitivebehavioral treatment, compared with both the relaxation and the control conditions, would produce improvement in general and academic self-concept. We also hypothesized that the cognitive-behavioral and the relaxation conditions would produce greater reductions in anxiety than the wait-list control condition.
Method Subject Identification and Selection The pool of potential subjects consisted of approximately 800 adolescents who comprised a high school population. A multiple stage screening procedure similar to that described by Reynolds (1986a) was utilized for the identification of depressed adolescents. Stage 1. For the first stage, we screened the entire school with multiple depression measures, including the Beck Depression Inventory (BDI; Beck, Ward, Mendelson, Mock, & Erbaugh, 1961) and the Reynolds Adolescent Depression Scale (RADS; Reynolds, 1986b). The initial screening occurred during a morning instructional period. Students were asked by their teachers to complete preassembled packets of questionnaires. Preassigned identification numbers were used rather than names to insure confidentiality and to promote self-disclosure. Teachers kept a master list with student names and corresponding identification numbers. Students with known learning disabilities, emotional disturbances (other than affective disorders), or mental retardation were excluded. Valid data were obtained for 754 students. Stage 2. Students whose combined scores were 10 or greater on the BDI and 72 or greater on the RADS were identified, and letters were sent to their parents requesting permission for participation in a study designed to help adolescents feel better about themselves. Parental permission was received for 58 of the 121 students who met this criteria. The second stage consisted of individual readministration of the BDI and the RADS and of additional testing in measures of anxiety, general and academic self-concept, and the Bellevue Index of Depression (BID; Petti, 1978). The BID was administered by the second author who also served as therapist. To qualify for inclusion in the study, students were required to satisfy all of the following criteria: (a) a BDI score of 12 or greater; (b) a RADS score of 72 or greater; (c) a BID score of 20 or greater; (d) no current use of medication or other treatment for depression or related disorders; and (e) willingness to participate in a treatment program. Of the 58 students retested, 17 failed to meet criteria a and b and were eliminated. Of the remaining 41, 5 subjects scored 17 or less on the BID and were excluded. Although an initial BID score of 20 or greater had been desired for inclusion, 2 subjects with scores of 18 who met all other criteria were included. Six of the individuals who met criteria a, b, c, and d declined to participate in the study. The most frequently cited reason for refusal was the wish not to give up that much time.
The 30 remaining subjects were randomly assigned to one of three conditions (cognitive-behavioral, relaxation training, or wait-list control). Subjects in the wait-list control condition were given the opportunity to receive therapy after the termination of the study. Due to a scheduling conflict, one subject originally assigned to the cognitive-behavioral condition was reassigned to the relaxation training condition before receiving any treatment. This resulted in 9 subjects in the cognitive-behavioral condition, 11 in the relaxation training condition, and 10 in the wait-list control condition.
Subject Characteristics Subjects included 11 males and 19 females, with a mean age of 15.65 years. There were 8 freshmen, 7 sophomores, 7 juniors, and 8 seniors. All subjects were white. As with most treatment outcome studies of depression (Simons, Levine, Lustman, & Murphy, 1984), there was subject attrition at both posttest and follow-up assessments. At the end of treatment, 3 subjects had dropped out of each active therapy condition for a total loss of 6 subjects. Anecdotal information from dropouts suggested that the primary cause of attrition was peer pressure from friends at school. At follow-up, 2 subjects who had completed the relaxation treatment and 1 subject from the wait-list group declined to participate in assessment activities. At pretest, the mean BDI depression score for the 30 subjects was 18.23; according to Beck's classification scheme, subjects were manifesting a moderate level of clinical depression.
Design Subjects were tested at four times: initial screening; pretreatment assessment; posttreatment assessment; and 5-week follow-up assessment. The initial screening was held 3 weeks before pretreatment assessment. The pretreatment assessment was conducted 3-5 days before the start of the first session, and the posttreatment testing was conducted immediately after the final treatment session. A follow-up assessment was conducted 5 weeks later.
Therapist Therapy was conducted by the second author, a doctoral-level schoolpsychology graduate student who had been employed as a school psychologist for 4 years. The therapist's training was behaviorally oriented, and he was experienced in behavior therapy. Both for pragmatic reasons and to control for such variables as therapist personality, theoretical orientation, and style, one therapist was used to conduct all treatment sessions for both active conditions. The therapist was aware of experimental biases that could be introduced by variations in his behavior. Consequently, his behavior and his adherence to detailed treatment protocols and to structured interview measures were monitored via audiotape. Later, therapist behavior was evaluated by a senior level psychologist familiar with the treatment manuals and the interview format but blind to the hypotheses of the study and to subject treatment assignment.
Dependent Measures Depression. Two self-report measures and a structured clinical interview were used to measure treatment outcome. Self-report measures included the RADS (Reynolds, 1986b) and a modified version of the BDI (Beck et al., 1961); interviews were conducted using the BID (Petti, 1978). For further psychometric information on these measures see Reynolds (1985a) and Petti (in press). The modified BDI is a 20-item self-report scale designed to measure level of depression among clinical and nonclinical populations. This
TREATMENT OF DEPRESSION IN ADOLESCENTS differs from the original 21-item BDI only in the omission of one item judged by the investigators as reactive for adolescents (Item 21, which relates to loss of libido). In a study of depression in 675 adolescents (Reynolds & Coats, 1982), the 20-item BDI demonstrated an alpha reliability of .87. The RADS, developed to assess depressive symptomatology in adolescents, consists of 30 items reflecting Diagnostic and Statistical Manual of Mental Disorders (DSM-III; American Psychiatric Association, 1980) symptomatology for major and minor (i.e., dysthymia) depression. Reynolds (1985b, 1986b), in studies with over 8,000 adolescents, has shown the RADS to be a reliable (/•„ = .92 to .96, rtt = .80) and valid (r = .71 to .83 with self-report and clinical interview scales of depression) measure of depression in adolescents. The BID consists of 40 items that assess 10 symptom domains, and it uses a 0 (absent) to 3 (severe) point scale for rating severity. To be considered depressed the individual must exhibit at least some signs of dysphoric mood or self-depreciatory ideation and must have a total score of 20 or greater. Self-concept. Two self-report scales were included to measure both general self-concept and academic self-concept. The Rosenberg Self-Esteem Scale (RSES; Rosenberg, 1965), a measure of general self-concept, consists of 10 items and uses a 4-point Likert-type response format. A high score reflects a high level of self-esteem. The high school version of the Academic Self-Concept Scale (ASCS-HS; Reynolds, 1981) is a downward extension of the standard form of the ASCS developed by Reynolds, Ramirez, Magrina, and Allen (1980) and consists of 15 items. Reynolds (1981) reports internal consistency reliability for the ASCSHS of .89, correlations with high school grade point average of .62, and correlations with the RSES of .68. Anxiety. The State-Trait Anxiety Inventory (STAI) A-Trait Scale (Spielberger, Gorsuch, & Lushene, 1970) was used to measure trait anxiety. The STAI A-Trait Scale consists of 20 items and has been widely used in both clinical and research settings.
Treatments Elements common to both active treatment conditions. Treatment of depression was brief and intense; subjects were seen in four groups (two per treatment condition) for 10 (50 min) sessions during a 5-week period. Subjects in both groups received reinforcement (according to separate contracts) contingent upon their participation and attendance. Treatments were conducted at the high school students attended. Cognitive-behavioral therapy. The 5-week program consisted of three phases that emphasized the training of self-control skills, including selfmonitoring, self-evaluation, and self-reinforcement. Subjects were also introduced to a framework of basic techniques for developing a selfchange plan that they could use when applying the self-control skills. The general format of each session consisted of a presentation and a discussion of self-control principles relevant to the hypothesized deficits found in depression; remaining time was devoted to the assignment of homework exercises and to a review of the preceding session's assignment. Session 1 began with a general introduction to the program. A cognitive-behavioral rationale was presented both in learning terms and in colloquial language. The session focused on self-monitoring and stressed the importance of accurate self-observation in influencing mood. The tendency to over attend to unpleasant events was central to the discussion. Subjects were given daily log forms for monitoring each day's positive activities and moods. All subsequent sessions began with a short summary of the rationale and format of the last assignment. In Session 2, this was followed by a mood and activity exercise to show the relation between these two features of depressive behavior. Subjects were asked to graph the number of both positive activities and mood ratings for each day to help demonstrate the connection between activity and mood.
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Session 3 focused on the tendency of depressed persons to attend to immediate versus long-term effects of their behavior and activities. These distortions of self-monitoring are similar to Beck's (1967) concept of a negative view of the world and the future and to Lewinsohn's (1974) concept that depressed behavior functions to elicit immediate rather than more important delayed forms of reinforcement. To help subjects attend more closely to the delayed positive consequences of behavior, an immediate versus delayed effects exercise was presented. Session 4 began the self-evaluation phase of the program in which the importance of evaluating oneself accurately was stressed. According to cognitive theory (Beck, Rush, Shaw, & Emery, 1979), depressed persons often hold faulty beliefs about their responsibility for events. Subjects were taught to look closely at assumptions people make in assigning credit, blame, or responsibility for events. In Session 5, methods for developing a self-change plan were presented. These methods included: (a) specifying the problem, (b) collecting baseline data, (c) discovering antecedents and consequences, (d) setting goals, (e) contracting, and (f) obtaining reinforcement (Lewinsohn, Muiioz, Youngren, & Zeiss, 1978). Subjects were requested to identify a specific problem to work on and to begin collecting baseline data while paying attention to antecedent and consequent events. Session 6 focused on setting realistic and obtainable goals as part of a self-change plan. The therapist stressed choosing subgoals that were positive, attainable, overt, and within the control of the subject's own abilities and efforts. Subjects continued to collect baseline data regarding their target problems and to develop appropriate subgoals. Session 7 began the self-reinforcement phase of the program. The therapist presented general principles of reinforcement and related these to problems of depression. Subjects were shown how systematic errors in the thinking of the depressed person often lead to negative interpretations that result in too much self-punishment and too little self-reward. Subjects constructed a "reward menu" for use as part of their self-change plan, they began to monitor subgoal behaviors, and they administered rewards to themselves from the menu as points were earned. Session 8 included a brief presentation relating both covert self-reward and self-punishment to depression, followed by an activity on covert self-reward. Subjects were asked to monitor themselves and to use covert self-reinforcement in addition to other rewards according to their plans. The remaining two sessions were arranged to obtain information indicating how subjects had complied with treatment instructions, to work on remedial efforts, and to provide a review of the program. Subjects were encouraged to continue using cognitive-behavioral procedures in the future and were given extra copies of log sheets and related forms. Relaxation training condition. Session 1 began in the same manner as the cognitive-behavioral procedure with introductions, a review of confidentiality issues, and a general introduction to the program. A rationale was presented to highlight the relation between stress-related problems and depression. Subjects were asked to complete homework assignments between sessions (e.g., practicing relaxation). The therapist explained that the goal of relaxation training was for subjects to appreciate the relation between stress, muscle tension, and depression and to learn specific skills to facilitate self-relaxation. Sessions 2-5 focused on helping subjects learn to relax various major muscle groups following a procedure outlined by Jacobsen (1938). Sessions consisted almost exclusively of practicing standard progressive muscle-relaxation exercises and of reviewing homework assignment log sheets. The following sessions (6-9) were devoted primarily to helping subjects generalize these relaxation skills across situations noted for producing tension. In Session 10, a summary of the entire program was presented and subjects were encouraged to continue using their relaxation skills in future tension-producing situations. All sessions lasted
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the full 50 min and were directed almost exclusively toward the development of relaxation skills. Wait-list control condition. The wait-list group was included to control for therapeutic effects resulting from assessment procedures or time alone. Before the start of the program, subjects were informed in person that they had been accepted in the program but that the present groups were filled; they were assured of being seen but were told they would have to wait about 10 weeks before their groups would start. The subjects in this condition were expected to participate in all assessment procedures including follow-up testing.
Results Equality Among Groups To determine the degree to which the assignment created equivalent groups, conditions were compared on different variables of specific interest. In general, subjects presented moderate to severe levels of depression based on BDI, RADS, and BID scores. As a measure of subject involvement in both active treatment groups, data regarding the number of sessions attended and compliance to homework activities were obtained. Whereas the research protocol called for 10 treatment sessions over 5 weeks, the mean number of sessions attended by the cognitive-behavioral subjects was 8.16 (range = 6-10). Subjects in the relaxation training group attended an average of 8.25 sessions (range = 5-10). A one-way analysis of variance (ANOVA) revealed no significant difference in attendance between groups. Similarly, nonsignificant results were obtained between the cognitive-behavioral and the relaxation training groups regarding compliance to homework. The mean percentage rates for homework completion were 67% for the cognitive-behavioral group (range = 40%-90%) and 68% for the relaxation training group (range = 50%-90%). To evaluate whether treatment procedures could be discriminated and whether protocols were adhered to, 10 5-min segments from the 10 audiotaped sessions of each active treatment group were randomly selected and rated by a psychologist blind to the treatment conditions and to the hypotheses of the study. Each session was rated using a 4-point Likert-type response format (1 = never/very poor compliance, 2 = hardly every compliant, 3 = somewhat compliant, and 4 = compliance most or all of the time). Results suggest that the therapist followed the treatment formats with a mean compliance rating for both conditions of 3.8. Independent ratings were also obtained of 7 randomly selected segments from audiotaped BID interviews at post and follow-up assessment. High compliance (to the interview schedule) ratings were obtained for all samples at both assessment times, with mean ratings of 3.86 at posttreatment and 3.83 at follow-up (maximum score = 4.0). From the interview tapes, the rater was unable to distinguish the condition to which each subject had been assigned. Thirty depressed adolescents were accepted for inclusion in the study; of these, 24 completed the posttreatment assessments and 21 completed the follow-up assessments. Dropout proportions were tested for equality using the chi-square test with Yates' correction for continuity. Disproportionality was nonsignificant at both posttreatment and follow-up. A moderate percentage of dropouts from each group occurred at posttreatment and follow-up assessments. Consequently, the major analyses are based on a slightly reduced sample size.
Statistical Analysis A series of analyses were performed on each variable. Oneway ANOVAS were performed on all pretreatment data to verify that groups were equated by the random assignment procedure. The posttreatment and follow-up data were subjected to a univariate analysis of covariance (ANCOVA), using the pretreatment score as the covariate. These were the primary analyses that tested the relative efficacy of each condition. It was felt that the small cell size, particularly at posttest and follow-up, precluded the use of multivariate procedures. To control for Type I error associated with separate univariate analyses, the observed F values were evaluated against Bonferroni F critical values (as suggested by Huitema, 1980), based on a familywise alpha of .05 and computed for the three depression measures as one set of comparisons and for the two self-concept measures as another set. In addition, multiple comparisons were performed on the adjusted means using the Bryant-Paulson generalization (Qf) of Tukey's HSD (honestly significant difference) procedure (BPT; Bryant & Paulson, 1976). The BPT procedure is recommended specifically for testing differences between adjusted means with the ANCOVA (Huitema, 1980). Multiple comparisons performed on each dependent measure are reported in terms of adjusted group means. Depression Means and standard deviations of the three groups on all depression measures at the assessment periods are presented in Table 1. One-way ANOVAS performed on all depression measures at pretreatment revealed no significant differences between groups on the BDI, the RADS, and the BID. Based on the BDI scores, subjects in each condition fell within the moderate range of depression. Quantitative change. At posttreatment assessment, significant results were found between conditions on all depression measures, including the BDI, F(2, 20) = 11.78, p < .001; the RADS, F(2,20) = 5.85, p < .05; and the BID, F(2,20) = 47.73, p < .001. On the BDI, both the cognitive-behavioral group (Qp = 5.28, p < .01) and the relaxation therapy group (Qp 6.02, p < .01) had a significantly lower mean score than the wait-list group. The comparison between the cognitive-behavioral and the relaxation training groups was nonsignificant. Changes on the BID paralleled the BDI data, with the cognitive-behavioral group (Qp = 11.90, p < .001) and the relaxation training group (Qp = 11.44, p < .01) means significantly lower than the wait-list control. No differences were found between the adjusted means of the two active treatment groups on the BID. On the RADS, the cognitive-behavioral (Qp = 3.64, p < .05) and the relaxation training group (Qp = 4.19, p < .05) means were significantly lower than the wait-list group mean. Mean comparison between treatment groups was nonsignificant. At follow-up, the ANCOVA with pretreatment scores as the covariate indicated that differences between conditions were still evident 5 weeks later. Significant treatment effects were found on the BDI, F(2, 17) = 7.69, p < .05, and on the BID, F(2, 17) = 11.95, p < .01, but not on the RADS. The pairwise comparisons on the BDI data indicated that both the cognitive-
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TREATMENT OF DEPRESSION IN ADOLESCENTS Table 1 Means and Standard Deviations for Depression Measures Group Cognitivebehavioral Measure Pretreatment BDI BID RADS Posttreatment BDI BID RADS Follow-up BDI BID RADS
Relaxation
Wait-list
M
SD
M
SD
M
SD
21.11 50.33 85.67
7.75
19.6 8.40
17.09 46.27 80.09
6.36 20.42 6.99
16.90 36.90 80.70
5.48 12.17 3.58
6.36 16.00 66.74
3.15 17.83 7.47
5.77 19.45 65.80
4.0 11.97 9.52
18.31 52.36 81.12
9.82 14.73 13.46
1.81 6.52 62.60
3.94 10.25 19.33
4.18 13.97 54.73
3.35 6.24 11.3
16.01 32.00 72.25
11.86 14.56 13.09
Note. Adjusted means are reported for the posttreatment and follow-up assessment periods. BDI : Beck Depression Inventory; BID = Bellevue Index of Depression; RADS = Reynolds Adolescent Depression Scale.
behavioral (Qp = 4.99, p < .01) and the relaxation training (Qp = 4.16, p < .05) group means were significantly lower than the wait-list group means but were not significantly different from one another. Changes on the BID were consistent with the BDI at followup. The cognitive-behavioral group mean was significantly lower than the wait-list group mean (Qv = 6.83, p < .01). The relaxation training group mean was also significantly lower in comparison to the wait-list group mean (Qf = 4.83, p < .01). A mean comparison between the two active treatments was nonsignificant. Qualitative change. A major issue in evaluating any therapeutic study is the clinical, as opposed to the statistical, significance of changes produced. Therefore, it was important to examine the number of subjects from each group who at posttreatment and at follow-up had scores in a nondepressed range. On the BDI at posttreatment, 11 of 14 subjects (79%) who received treatment met the criteria for normalacy (BDI score less than 10). Of these, 5 were in the cognitive-behavioral group (83%) and 6 were in the relaxation group (75%); no subjects from the wait-list group met this criteria, x2(2, N = 24) = 14.60, p < .001. Essentially, between pretest and posttest, subjects uniformly went from BDI scores in the moderate clinical range of depression to BDI scores in the normal range. At the followup assessment, all subjects in the cognitive-behavioral and the relaxation training groups met the nondepressed criteria, whereas 4 of 9 wait-list subjects (44%) had scores in a normal range x2(2, N=20) = 8.75, p < .05. Substantial qualitative reductions in depression were also evidenced on the RADS and on the BID.
Anxiety Means and standard deviations on the STAI A-Trait Scale for the three conditions at each assessment point are shown in Table 2. An ANOVA at pretreatment yielded no significant differ-
ences between groups on the STAI A-Trait Scale. The ANCOVA of posttreatment data, however, resulted in significant differences between groups with pretreatment scores as the covariate, F(2,20) = 4.62, p < .05. Specific pairwise comparisons revealed that the relaxation training group had a significantly lower mean score than the wait-list group (Qp = 4.13, p < .05). No significant differences were found between the group means of the cognitive-behavioral and relaxation conditions nor between the cognitive-behavioral and wait-list conditions.
Self-Concept Table 2 shows the means and standard deviations for each group on self-concept measures. A one-way ANOVA of pretreatment scores yielded no significant differences between groups on the SES. The ANCOVA of posttreatment scores with pretreatment scores as covariates yielded nonsignificant group differences. At follow-up, slight gains were noted for subjects in each group that suggested improved general self-esteem, although differences between groups were nonsignificant. On the ASCS-HS, there were no pretreatment differences between groups. The ANCOVA at posttreatment yielded significant differences between groups, F(2,20) = 5.33 p < .05. Comparisons indicated that the relaxation training group (Qp = 3.95, p < .05) and cognitive-behavioral group (Qp = 3.61, p < .05) means were significantly higher than the wait-list group mean. The cognitive-behavioral and relaxation training group means were not significantly different. An ANCOVA at follow-up also revealed significant results on the ASCS-HS, F(2, 17) = 6.49, p < .05. The cognitive-behavioral group mean was significantly higher than the wait-list group mean (Qv = 4.84, p < .01). There were no significant differences between either of the two therapy conditions or between the relaxation training and the wait-list groups, although the latter comparison approached significance «2 P =3.21,p
