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LARS&LISA: a universal school-based
cognitive-behavioral program to prevent
adolescent depression
Patrick Pössel
*
, Eric Smith and Olivia Alexander
Abstract
Adolescent depression is a prevailing international mental health concern as up to 27% of adolescents experience
either subsyndromal depression or a major depressive episode by the age of 18. Depression in adolescence has
been found to negatively impact current and future academic achievement, functioning, mental health, and quality
of life. Accordingly, the authors emphasize the importance of proactively preventing depression (and its negative
outcomes) instead of waiting and having to “fix”the problems after they have already developed. The current article
begins with a discussion of the various types of prevention, including their respective advantages and disadvantages.
Further and more importantly, the article’s primary focus is to provide a summary of the theoretical basis, development
of, empirical support for, and content of a universal school-based cognitive-behavioral program to prevent adolescent
depression entitled LARS&LISA (Lust An Realistischer Sicht & Leichtigkeit Im Sozialen Alltag). As the program exists within
the overlapping realms of universal prevention, school-based programs, and cognitive-behavioral interventions, the
content of this article is relevant to all three areas and offers insight into the development of depression prevention in
general. Finally, empirical support for the positive effects of the program is presented and some ideas for further
research are discussed.
Keywords: Prevention of adolescent depression, Cognitive-behavior therapy, School-based
Introduction
Through a systematic review of epidemiological studies
on subsyndromal depression in adolescence, Bertha and
Balázs (2013) found that rates of subsyndromal depression
increase sharply around the mid-teen years and continue
to rise through early adulthood. As a result of this
increase, up to 27% of adolescents have a lifetime preva-
lence of either subsyndromal depression or major depres-
sive episodes by the age of 18 (Bertha & Balázs, 2013;
Kessler, Petukhova, Sampson, Zaslavsky, & Wittchen,
2012). Further, depressive symptoms are associated with a
wide range of negative outcomes in adolescents (Bertha &
Balázs, 2013; Kessler et al., 2012; Klein, Torpey, & Bufferd,
2008; Patel, Flisher, Hetrick, & McGorry, 2007). The high
prevalence and multitude of negative consequences make
subsyndromal and major depression in adolescents a ser-
ious international mental and public health concern. Thus,
one of the aims of this article is to emphasize the need for
preventative interventions to proactively curtail depression
(and its negative outcomes) instead of waiting to treat symp-
toms after they have already developed. A second aim of the
article is to describe the theoretical basis, development of,
empirical support for, and content of a successfully evalu-
ated universal school-based cognitive-behavioral program to
prevent adolescent depression. Given that the program
exists within the overlapping realms of universal prevention,
school-based programs, and cognitive-behavioral interven-
tions, the content of this article is relevant to all three areas
and offers insight into the development of depression pre-
vention in general.
Depression and its consequences—why are we
waiting?
According to a recent report, depression is now the
leading cause of Years Lived with Disability (YLD),
impacting an estimated 322 million people worldwide
(World Health Organization [WHO], 2017). Adolescent
* Correspondence: patrick.possel@louisville.edu
Department of Counseling and Human Development, University of Louisville,
2301 S. Third Street, Louisville, KY 40292, USA
Psicolo
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© The Author(s). 2018 Open Access This article is distributed under the terms of the Creative Commons Attribution 4.0
International License (http://creativecommons.org/licenses/by/4.0/), which permits unrestricted use, distribution, and
reproduction in any medium, provided you give appropriate credit to the original author(s) and the source, provide a link to
the Creative Commons license, and indicate if changes were made.
Pössel et al. Psicologia: Reflexão e Crítica (2018) 31:23
https://doi.org/10.1186/s41155-018-0104-1
depression is of particular concern (Patel, 2013)asitis
estimated that between 22 and 27% of adolescents have
experienced either subsyndromal depression or a major
depressive episode by the age of 18 (Bertha & Balázs,
2013; Kessler, Petukhova, et al., 2012). Alarmingly, there
has been an increasing trend in the prevalence of major
depressive episodes among adolescents in recent years.
In 2014, 11.3% of adolescents in the USA reported
experiencing a major depressive episode within the pre-
vious year, compared to 8.7% in 2005 (Mojtabai, Olfson,
& Han, 2016). Adolescent depression is associated with
decreased quality of life, serious emotional disturbances,
and poor to severe functional impairment (Bertha &
Balázs, 2013; Kessler, Avenevoli, et al., 2012). Adoles-
cents with depressive symptoms have been shown to
have higher academic failure, delinquency, interpersonal
distress, substance abuse, suicidality, and unemployment
(Klein et al., 2008; Patel et al., 2007).
Further, adolescent subsyndromal depression and
major depression are significant risk factors for subse-
quent depressive episodes (Bertha & Balázs, 2013;
Johnson, Cohen, & Kasen, 2009; Kessler, Petukhova,
et al., 2012; Klein, Shankman, Lewinsohn, & Seeley,
2009; Patel et al., 2007). Klein et al. (2009) reported that
67% of adolescents with subsyndromal depression devel-
oped major depression during a 15-year follow-up
period and 27% of people with lifetime major depression
experience their first episode in childhood or adoles-
cence (Kessler, Petukhova, et al., 2012). In the best-case
scenario, only 36% of the burden of depression could be
alleviated using state-of-the art knowledge and therapies
(Andrews, Issakidis, Sanderson, Corry, & Lapsley, 2004),
but it is estimated that prevention programs have the
potential to prevent an additional 21–22% of the incidence
of depression (Cuijpers, van Straten, Smit, Mihalopoulos,
& Beekman, 2008). This raises the question of why are we
not embracing the wisdom contained in the idiom “an
ounce of prevention is worth a pound of cure.”
Types of prevention
Based on the evidence and considerations outlined above,
effective programs that ameliorate currently existing de-
pressive symptoms and prevent normative increases in de-
pressive symptoms are needed (e.g., Horowitz & Garber,
2006). Prevention programs can be differentiated based on
the target group they are designed for and are usually sep-
arated into three categories: indicated, selective, and uni-
versal. Indicated prevention programs are designed to
help individuals with clear risk factors. Selective preven-
tion programs are aimed at subpopulations known to be
at increased risk for developing certain problems. These
two types of prevention programs are often collectively
categorized as targeted prevention. Finally, universal pre-
vention is intended for all individuals, regardless of their
risk for developing a problem. Each type of prevention has
advantages and disadvantages, which are discussed in de-
tail by Offord (2000) and Pössel, Schneider, and Seemann
(2006). Offord lists many advantages (n= 6) and disadvan-
tages (n= 8) for universal prevention but only two advan-
tages and six disadvantages for targeted programs. As a
detailed discussion of all advantages and disadvantages
would be beyond the scope of this paper, only the most
relevant points will be considered in the following.
One advantage of targeted programs is that they are
generally more cost-effective than universal programs
(Offord, 2000). Targeted prevention programs focus on
disorders or behavioral issues that might only impact a
small percentage of the entire population. Therefore, it
is theoretically most efficient to only offer preventative
interventions to this high-risk group, as opposed to all
members of a given population. Additionally, targeted
interventions can focus more intently on symptoms or
risk factors that are experienced by every member in a
group. However, targeted programs are not inherently
the most cost-effective in every circumstance given the
cost of screening for risk factors and the challenges asso-
ciated with correctly identifying individuals who would
benefit from such programs.
Not surprisingly, evaluation studies of targeted preven-
tion programs usually find higher effect sizes than studies
evaluating universal programs. The reasons for this are
that studies on the former tend to have (a) participants
with higher average levels of the target variables (e.g.,
depressive symptoms) and (b) a higher percentage of par-
ticipants with elevated levels of symptoms than what is
typical for participants in universal prevention programs.
Furthermore, individuals in targeted prevention programs
are generally more motivated to participate than the aver-
age person because of the distress being inflicted by the
target problem, which may contribute to the compara-
tively larger effect sizes found for these programs (Offord,
2000; Pössel, Schneider, & Seemann, 2006).
One potential disadvantage of targeted prevention pro-
grams is that individuals may experience stigmatization
based on their participation. Empirical literature indicates
that adolescents may experience stigmatization from their
family, teachers, and particularly their peers based on
mental health issues (Moses, 2010; Platt, Kadosh, & Lau,
2013). A systematic review found that fear of stigma and
embarrassment are primary barriers that prevent many
adolescents from seeking mental health care (Gulliver,
Griffiths, & Christensen, 2010). Therefore, it is clear that
worries about stigmatization are a particularly salient con-
cern for adolescents with regards to participating in an
intervention. For prevention in a school setting, if only a
small number of adolescents are selected to partake in a
targeted prevention program, they may feel labeled and
marginalized by their peers who were not recruited. The
Pössel et al. Psicologia: Reflexão e Crítica (2018) 31:23 Page 2 of 21
participants may experience not only negative subjective
effects of perceived stigmatization, but also objective
effects, such as a loss of social contacts (Moses, 2010).
Further, Harrington and Clark (1998) speculate that the
stigmatization that results from labeling might even lead
to a chronification of depressive symptoms. In other
words, it is possible that targeted prevention can actually
have an iatrogenic effect on the individuals participating
in such programs. While targeted prevention programs do
not automatically lead to stigmatization of the partici-
pants, special attention must be given to ensuring that
these programs do not lead participants to feel or actually
be singled out or labeled.
While adolescents may fear stigmatization as a result
of participating in targeted intervention programs, it
seems that school administrators have their own reserva-
tions. Studies have found that school principals (Miller,
Eckert, DuPaul, & White, 1999) and school psychologists
(Eckert, Miller, DuPaul, & Riley-Tillman, 2003) have
concerns about targeted programs. As a result, it may be
especially challenging to acquire the necessary approval
to implement targeted prevention in school settings. Ho-
rowitz, Garber, Ciesla, Young, and Mufson (2007) report
that their attempt to implement a targeted depression
prevention program was not approved by the school ad-
ministration. Thus, they had to deliver their program to
all students at the participating schools, turning it into a
universal prevention program.
Another drawback associated with targeted prevention
is that not all members of a high-risk group develop a
problem (e.g., major depression) and most individuals that
do develop a problem are not from a high-risk group (Off-
ord, 2000). This issue reflects the difficulty in screening
and accurately identifying which individuals will develop
mental health problems, such as depression. One possible
negative outcome of this issue is that individuals could be
stigmatized for participating in a program that they do not
actually need. The costs associated with screening a large
number of adolescents, combined with the problems in
accurately identifying which individuals would benefit
from participation in a targeted prevention program call
into question whether this type of program is truly the
most efficient and efficacious form of prevention, particu-
larly in school settings.
Although there are unique advantages and disadvan-
tages associated with each type of prevention, some of
the disadvantages of targeted prevention do not neces-
sarily apply to universal prevention. For example, given
that all students in a particular school or grade level
participate in universal school-based programs, prob-
lems related to identifying and recruiting participants,
and stigmatization may be mitigated. However, it is
worth considering that requiring all students to partici-
pate in a prevention program could have the unintended
effect of having those who need the intervention most
feel marginalized by putting them in a group of students
who are not experiencing the same symptoms. Students
experiencing a particular problem, such as depression,
may feel reluctant to share their experiences and partici-
pate in the group if they feel they are the only ones
dealing with that problem. In an evaluative study of a
school-based universal depression program in the
Netherlands, Tak, Lichtwarck-Aschoff, Gillham, Zundert,
and Engels (2016) hypothesized that the group climate
may have contributed to their finding that the program
was not effective for adolescents with high baseline de-
pressive symptoms.
While it is important to acknowledge that there is still
a potential for stigmatization associated with universal
prevention programs, these programs have an advantage
over targeted programs in that their intended purpose
may be less outwardly apparent. For example, in the
below described universal prevention program, LAR-
S&LISA, the trained skills are framed as helping the
adolescents to reach their personal goals. As a result,
students’apprehensions related to the stigma associated
with receiving mental health care can be quelled. Fur-
ther, while the programs focus on reducing cognitive
patterns and behaviors that contribute to the develop-
ment of depression, it is not necessary for students to
disclose information that would make them personally
vulnerable to benefit from the program. Although there
is still a potential for some students to feel marginalized
in universal prevention programs, the risk is diminished.
Another advantage of universal prevention programs
is that the inclusion of all individuals in a particular
group makes it likely that some group members already
have the skills that the program focuses on. These group
members can serve as peer role models for the members
who would benefit from improving such skills (Harrin-
gton & Clark, 1998; Lowry-Webster, Barrett, & Dadds,
2001). Further, by participating in universal prevention
programs, even individuals who are not at risk of devel-
oping the targeted problem benefit from the skills
trained in these programs (Harrington & Clark, 1998).
Building on this argument, Offord (2000) argued that
while the effects of targeted programs are bigger on indi-
vidual participants, universal programs can still have
enormous effects on a system (e.g., a school or society)
as they have (smaller) effects on a significantly larger
number of individuals.
LARS&LISA—the theoretical foundation
For the reasons described above, universal prevention
seems to be a beneficial type of prevention, particularly
for implementing in school settings. A majority of the
currently existing universal depression prevention pro-
grams apply cognitive-behavioral methods and focus on
Pössel et al. Psicologia: Reflexão e Crítica (2018) 31:23 Page 3 of 21
adolescents (Bastounis, Callaghan, Banerjee, & Michail,
2016; Clarke, Hawkins, Murphy, & Sheeber, 1993; Merry,
McDowell, Wild, Bir, & Cunliffe, 2004; Sawyer et al.,
2010; Shochet et al., 2001; Spence, Sheffield, & Donovan,
2003,2005). This article presents LARS&LISA (Pössel,
Horn, Seemann, & Hautzinger, 2004), a universal school-
based prevention program that is supported by research
produced over the past two decades. LARS&LISA uses
cognitive-behavioral strategies and is informed by Dodge’s
social information processing model (Dodge, 1993).
Table 1summarizes key details about the program and
research examining its effects.
While there are a multitude of models describing the
development and maintenance of depression, only a few of
these models originated from a developmental psychopath-
ology perspective. One such model is Dodge’s social infor-
mation processing model (1993), which in its first iteration
describes the development and maintenance of both de-
pression and aggression. In this model, behavior is viewed
as the product of a sequence of information processing
steps. This sequence, which is precipitated by a situational
stimulus, can be seen as a repeating, conscious, or uncon-
scious process in social interactions. The social information
processing model comprises five stages (Fig. 1).
First, in the encoding stage, relevant aspects of stimuli are
detected by a selective perception. In everyday life, individ-
uals are continuously being exposed to a multitude of sen-
sory input. To manage and make sense of this input,
individuals learn to selectively attenuate to the features of
their environment that they deem to be the most relevant,
which are then encoded into short-term memory. Adoles-
cents who become depressed tend to have an information
processing bias which leads them to select aspects of a
stimulus that are consistent with their negative self-schema
(Beck, 1976). In the following mental representation stage,
individuals attribute meaning to the aspects of stimuli that
they have encoded and stored in their short-term memory.
For instance, if an individual experiences a negative event,
they would ascribe a reason as to why that event occurred.
The subjective determination of meaning depends on a per-
son’sattributionstyleaswellasotherfactors(Abramson,
Alloy, & Metalsky, 1989). In this second stage, depressed
adolescents tend to interpret negative stimuli as global and
stable. Each interpretation is associated with multiple pos-
sible reactions, including affective change, arousal of the
autonomic systems, endocrine secretion, physical activity,
and verbalization. One or more of these possible reactions
are initiated during the response accessing stage of informa-
tion processing. While some responses occur automatically,
such as arousal of the autonomic nervous system, individ-
uals can elect to enact or withhold possible physical and ver-
bal responses. In the response evaluation and selection stage,
the processing individual evaluates the prepared reactions
on the basis of acceptability, anticipated consequences, and/
or moral values. Depressed adolescents tend to see social
withdrawal as the least negative response. If a prepared reac-
tion fulfills the evaluation criteria, it will be initiated in the
enactment stage.
Although presented separately, the stages of informa-
tion processing often occur simultaneously. Therefore,
adolescents process new information while they select
responses for and react to stimuli they were exposed to
earlier. However, like with all stage models, Dodge
(1993) proposes that the pathway from a stimulus to the
corresponding response is linear and the processing
steps for each stimulus follow the outlined sequential
order. While the most recent version of the social infor-
mation processing model focuses on aggressive behavior,
the iteration of the model presented here has been sup-
ported by several studies regarding depression (e.g.,
Harrist, Zaia, Bates, Dodge, & Pettit, 1997; Pössel, See-
mann, Ahrens, & Hautzinger, 2006).
LISA, LARS&LISA, and TIM&SARA—20 years of
change and consistency
History and development of the program
This program was first developed almost 20 years ago in
Germany under the name LISA (Leichtigkeit Im Sozialen
Alltag; Pössel, Baldus, Horn, Groen, & Hautzinger, 2005)
and underwent multiple revisions (LARS&LISA; Lust An
Realistischer Sicht & Leichtigkeit Im Sozialen Alltag; Pössel,
Horn, Seemann, & Hautzinger, 2004) and cultural adapta-
tions (e.g., USA: TIM&SARA, Together Initiating More
Socially Advantageous & Realistic Attitudes; Pössel, Martin,
Garber, & Hautzinger, 2013) since then. All versions of the
program are implemented in gender-homogenous groups.
The reason for this is that research indicates that gender-
homogeneous groups can create spaces where young people,
and particularly boys, can share their emotions and feelings
without embarrassment (Sukhnandan, Lee, & Kelleher,
2000). They are also likely to be less distracted, more open
and responsive, and can participate without the fear of com-
promising their image in front of girls (Warrington & Youn-
ger, 2003). Further, the authors report that a pilot study
revealed that adolescents worked more effectively and
openly as a team if no peer from the other gender was in
the room (Pössel, Horn, Seemann, & Hautzinger, 2004).
Originally, LISA included four main modules:
a) Reversible Spiral (associations among thoughts,
feelings, and behavior),
b) Think Tank (identification of dysfunctional
thoughts, reality check on dysfunctional thoughts,
development of functional thoughts, rehearsal of
functional thought process),
c) Just Do It (assertiveness training)
d) Making Contact (social competence training)
Pössel et al. Psicologia: Reflexão e Crítica (2018) 31:23 Page 4 of 21
After the first evaluation studies (Groen, Pössel,
Al-Wiswasi, & Petermann, 2003; Pössel et al., 2005; Pös-
sel, Horn, Groen, & Hautzinger, 2004; Pössel, Horn, &
Hautzinger, 2006; Pössel, Seemann, & Hautzinger, 2008),
the authors integrated the character LARS into the pro-
gram to provide a male main character with whom the
Table 1 Overview of LARS&LISA intervention
1. Brief name LARS&LISA—Lust An Realistischer Sicht & Leichtigkeit Im Sozialen Alltag
2. Why (rationale) The primary aim of this universal, school-based prevention program is to prevent the development or increase of depressive
symptoms among adolescents. Depression is a leading mental health concern for adolescents and is associated with a wide
array of negative outcomes, which highlights the need for preventative interventions tailored to this population. The
theoretical foundation for the program is Dodge’s(1993) social information processing model. Following this conceptual
framework, the negatively biased way in which some individuals perceive, interpret, and respond to environmental stimuli
contributes to the development of depression. Cognitive-behavioral interventions contained within the program are used to
teach adolescents how to identify maladaptive thought patterns and behaviors and replace them with more helpful and
realistic alternatives.
3. What (materials) LARS&LISA is a structured program with a manual that provides detailed instructions, examples, and tips for group leaders on
how to administer the intervention. The primary materials utilized in the implementation of LARS&LISA are handouts and
worksheets, which aid the adolescents in understanding and remembering elements of the program’s content. For example,
“Knowledge Checks”are worksheets that the students complete individually at the end of sessions, which are designed to
reinforce the concepts that were covered that day. These worksheets simultaneously provide group leaders with feedback
about the students’comprehension of the material. Poster sheets, a whiteboard or blackboard, and a projector can be
employed by the group leaders as visual aids to present guidelines, concepts, examples, etc. Candy or popular snacks can be
used to create a motivational reward system that encourages participation and observation of the group’s guidelines. Finally,
a few specific games and activities require additional materials. For instance, in the initial session, the participants compete in
a relay race that requires plastic cups, straws, and small candy-coated chocolates. The LARS&LISA manual can be requested
by contacting the authors of the program.
4. What
(procedures)
Each session of the program follows a similar structure and contains a number of common elements. Group leaders begin by
presenting the agenda for the day, providing feedback about last session’s Knowledge Check (described above), and asking
how the students might have used the skills taught in LARS&LISA since the last session. A majority of the session is spent on
group activities related to one of the five modules (Set Some Goals, Reversible Spiral, Think Tank, Just Do It, and Making
Contact). Within these modules, students learn how to generate useful personal goals; understand the interconnected nature
of thoughts, feelings, and behaviors; and replace maladaptive thoughts and behaviors with more helpful and realistic
alternatives. Group activities may include interactive conversations, the completion of worksheets, or the creation and acting
out of role-plays, depending on the session. Knowledge Checks are completed towards the end of most sessions. The group
leaders end each session by making connections between that day’s content and the content presented in previous sessions,
providing feedback about the observation of guidelines, and giving a preview of the next week’s session.
5. Who provided The intervention has been successfully implemented by psychologists and supervised students in graduate psychology
programs. A study was conducted to evaluate whether the program could be implemented by teachers, but like other similar
programs, teachers were found to be less effective as group leaders.
6. How (mode of
delivery)
The program is delivered in person in a group setting. The ideal number of participants is between 8 and 12, but the program
has been implemented with larger (n≤20) and smaller (n= 4) groups. It is recommended that two leaders co-lead a group, but
groups have also been led by individuals and triads.
7. Where LARS&LISA is designed to be a school-based intervention and therefore is generally administered in classrooms during
school hours.
8. When and how
much
The program was originally designed to be presented in 10, 90-min weekly sessions. However, the material has been
reorganized to accommodate the unique class schedules at various schools that have hosted the program. For example, it
has been adapted to be delivered in 16, 60-min weekly sessions for a school that had shorter class periods. The groups are
always gender homogenous.
9. Tailoring Given that each group presents a unique dynamic, minor accommodations are sometimes necessary to meet the specific needs
of individual groups. For example, some groups tend to prefer more group work whereas others prefer to process the material
individually. Additionally, some groups respond the best when leaders present content in a didactic manner, while others benefit
more from game-like and interactive delivery methods. The program’s manual contains a number of suggestions for alternative
ways to deliver the content and group leaders are encouraged to make adjustments to best meet the needs of each group.
10. Modifications LARS&LISA has been modified a number of times to make improvements and accommodate various populations. The program
originally contained four main modules, but a fifth was added to increase motivation and make the content more personally
relevant to adolescents without depressive symptoms. Additionally, changes were made to make the content more relatable for
male adolescents. Finally, the program was originally developed in German and was later translated into American English and
culturally adapted to be implemented in the USA.
11. How well
(planned)
To assure adherence to the manual, group leaders participate in a two-step training and while they implement the program in
weekly supervision sessions using video recordings of each session. During the first step of the training, future group leaders
participated in a mock version of the program, and in the second step, they study the manual, materials, and procedures and
discuss their questions with their supervisors.
12. How well
(actual)
This has not yet been addressed.
Pössel et al. Psicologia: Reflexão e Crítica (2018) 31:23 Page 5 of 21
male students can identify. In addition to being an acro-
nym for the title of the program, the names LARS and
LISA (or TIM and SARA in the American version) also
represent two fictional characters that are used to
present some of the program’s content. As an example,
LARS/TIM is one of the characters in scripted role-plays
used to model specific types of behavior to male stu-
dents, and LISA/SARA is featured in the role-plays used
with female students. Additionally, the fifth module “Set
Some Goals”in which the participants develop personal
goals was added while the content of the other four
modules was streamlined to keep the program limited to
10, 90-min weekly sessions (Table 2). Given that the
intervention is implemented in school settings, adjust-
ments have been made to the number and duration of
sessions to accommodate class schedules at certain host-
ing schools. For example, the program was adapted to
be delivered in 16, 60 min at a school that had shorter
class periods. Further, LARS&LISA was translated into
American English and modified for youth in the USA
where it is implemented under the name TIM&SARA.
However, publications regarding the American version
of the program still use the name LARS&LISA. The
modifications for American adolescents primarily in-
cluded the construction of culturally appropriate
role-plays in which relevant idiomatic expressions were
used (Pössel et al., 2013). While they are not reported in
this article, it is worth noting that LARS&LISA has
served as a model for the creation of prevention pro-
grams in other countries. LARS&LISA was one of the
templates used by researchers in Chile (Araya et al.,
2014) and Colombia (Gómez, Jimenez, & Restrepo,
2004) to develop similar programs that accommodate
their cultural backgrounds and language.
Theoretical foundation of LARS&LISA
The first module of LARS&LISA is “Set Some Goals,”
which is based on an approach developed by Kanfer, Rein-
ecker, and Schmelzer (1996). As described above, this
module was added later to help increase the motivation of
the adolescents to actively participate. Adolescents de-
velop personal goals, or at least share ones they already
have, and learn what they can do in the present to reach
these goals. According to Locke and Latham (1990), goals
should be specific, concrete, and divisible into subgoals so
that progress is measurable. The group leaders of LAR-
S&LISA point out at the beginning of each module how
the content and skills covered in the ensuing sessions can
help the adolescents to reach their personal goals. This
serves to motivate adolescents who have no depressive
symptoms, focus the participants on something positive as
opposed to just talking about problems, and connect all of
the modules with each other.
As mentioned above, the theoretical framework of
this school-based cognitive-behavioral depression pre-
vention program is grounded in Dodge’s social infor-
mation processing model (Dodge, 1993). The goal of
LARS&LISA is to work on all stages of social infor-
mation processing with the exception of the encoding
stage, as there are currently no known intervention
Fig. 1 Dodge’s Social Information Processing Model (1993)
Pössel et al. Psicologia: Reflexão e Crítica (2018) 31:23 Page 6 of 21
strategies targeting this stage. As described above, the
interpretation of social stimuli takes place in the men-
tal representation stage and the adolescents work on
their interpretations by identifying dysfunctional,
automatic thoughts (Beck, 1976) and replacing them
with more functional thoughts (as introduced by the
“Think Tank”modules). In order to develop an un-
derstanding of the key concepts and a motivation for
change, the group members explore the relationships
among cognitions, emotions, and behavior (as intro-
duced by the Reversible Spiral module). During the
response accessing stage, different reactions to social
stimuli are activated or generated. These responses
are then judged based on their potential consequences
and acceptability during the response evaluation and
selection stage. Finally, one of the response options
considered in the third and fourth stages of the
model is implemented in the enactment stage. Prob-
lems encountered by depressed adolescents during the
response accessing stage result in the production of
multiple problem-irrelevant responses (Mullins, Siegal,
&Hodges,1985) and only a few functional responses
(Frye & Goodman, 2000). In addition, while depressed
adolescents report more negative and less positive
expectancies of withdrawing behavior than their
non-depressed peers, they evaluate withdrawing be-
havior as more positive during the response evalu-
ation and selection (Garber, Quiggle, Panak, & Dodge,
1991). These problems are targeted within LAR-
S&LISA by the conscious generation of functional
responses and the demonstration of the positive con-
sequences of those new responses. Thus, to work on
those problems, the program applies widely used
effective methods of social competence trainings. In
particular, the self-assertiveness (Just Do It) and social
competence (Making Contact) modules provide train-
ing in behavior that is not compatible with social
withdrawal. Within these modules, role-playing pro-
vides the main method of change as they allow for
the simultaneous restructuring in both stages of infor-
mation processing. During role-plays, adolescents can
experiment with new, more functional response alter-
natives and observe their own and others’reactions
to these responses. At the same time, they learn to
Table 2 Content of LARS&LISA
Session Topic Objectives Content
1 Introductions,
Build Relationships
Explain guidelines; create a cooperative atmosphere; provide
overview and rationale for topics in the program
- Get to know each other
- Establish basic guidelines: fairness, respect, teamwork,
and a positive working atmosphere
- Consequences for breaking of guidelines
- Introduce program
2 Setting Goals Identify and develop goals - Define goals
- Setting realistic and achievable personal goals
3 Reversible Spiral-I Learn connections among feelings, thoughts, and
behaviors; teach concepts of “down”and “up”thoughts
- Define “feelings,”“thoughts,”and “behavior”
- Reversible Spiral: associations among feelings, thoughts,
and behaviors
- Introduce “down thoughts”(self-critical, action-blocking)
and “up-thoughts”(self-supportive, helpful)
4 Reversible Spiral-II Identify self-critical, action-blocking thoughts - Experience the Reversible Spiral
- Explore meaning of negative thoughts
5 Think Tank-I Question self-critical, action-blocking thoughts; generate
self-supportive, helpful, realistic thoughts
- Introduce the “reality check”
- Create one’s own counter thoughts (i.e., realistic
“up-thoughts”)
6 Think Tank-II Learn why self-supportive, realistic thoughts can be important
and how to integrate them into one’s life
- Review meaning of and rationale for “up thoughts”
- Identify daily situations in which “up thoughts”can
be integrated
7 Just Do It-I Learn differences among assertive, passive, and aggressive
behaviors and their consequences. Review connections
between thoughts and behavior
- Identify signs of assertive, passive, and aggressive
behavior
- Discuss pros and cons of different behaviors
- Explore associations among negative thoughts; counter
thoughts; and assertive, passive, and aggressive behaviors
8 Just Do It-II Practice assertive behavior
Practice not avoiding
- Demonstrate assertive behaviors
- Practice assertive behavior in role-plays
9 Making Contact-I Learn how to build and maintain friendships - Demonstrate verbal and nonverbal strategies to signal
interest in others
- Role-play “making contact”
10 Making Contact-II Practice building friendships. Obtain feedback about
the program
- Participants evaluate and provide feedback
- Hand out certificates of program completion
- Good-byes and celebration
Pössel et al. Psicologia: Reflexão e Crítica (2018) 31:23 Page 7 of 21
translate the new response options into actual
behavior.
Summarized, the five distinct modules of LARS&LISA
(Fig. 2) apply different standard cognitive-behavioral
methods. Thus, the findings presented below are not
only relevant for this particular program, but can also be
seen as relevant for cognitive-behavioral depression pre-
vention programs for adolescents in general. This is cru-
cial as most adolescent depression prevention programs
that are currently in existence use cognitive-behavioral
methods (Bastounis et al., 2016; Clarke et al., 1993;
Merry et al., 2004; Sawyer et al., 2010; Shochet et al.,
2001; Spence et al., 2003,2005).
Specific content within the five modules
Module 1: “Set Some Goals”
In accordance with the intended purpose of the “Set Some
Goals”module, group leaders help students to develop
Fig. 2 Modules of LARS&LISA
Fig. 3 Goal Guides
Pössel et al. Psicologia: Reflexão e Crítica (2018) 31:23 Page 8 of 21
goals that are individually meaningful, motivational, and
realistically attainable. Before the students develop their
own personal goals, they are presented with five “Goal
Guides”for making helpful goals. The students are taught
that their goals should be positive (things that the students
hope to bring about as opposed to things they hope to
avoid), independent (not reliant on someone else’sactions
to achieve), measurable (operationalized in such a way
that progress is easily identifiable), realistic (something
than can feasibly be accomplished), and divisible into
smaller, more manageable mini-goals. The handout that
the students receive outlining these goal guides can be
seen in Fig. 3. Examples are used to help the students fully
grasp the five guidelines. For instance, leaders ask the
group, “which of the following two goals is more measur-
able: ‘I want to get an A on the next math test’or ‘Iwant
to do better in school?’” Additionally, students have the
opportunity to practice breaking large goals into smaller
mini goals. A completed example of a worksheet used to
practice forming mini-goals is shown in Fig. 4.Mostactiv-
ities are completed at least once as a group, and then, the
students are able to practice the newly learned skills indi-
vidually on worksheets. Interspersing group activities with
individual work allows the group leaders to offer add-
itional instruction to specific students as needed.
Following the introduction of the goal-setting guide-
lines, group leaders help the students to form personal
goals, which are used to contextualize the material
presented throughout the rest of the program. It is
important for the students’goals to be well developed, as
these goals are used to show how the skills taught
throughout the program are salient and useful for every-
one. Students write down several personal goals as the
group leaders circulate and ensure that the goals follow
all of the guidelines. Each student indicates one goal that
he or she is willing to display anonymously to the rest of
the group. Prior to the next meeting, the group leaders
write each signified goal on a paper leaf and attach the
leaves to a large poster with a drawing of a tree. This
“Goal Tree”poster is displayed during all of the subse-
quent sessions so that leaders can refer back to specific
goals and discuss how LARS&LISA skills might be use-
ful in accomplishing that goal.
Another important aspect of the “Set Some Goals”mod-
ule is a discussion about potential barriers to accomplish-
ing goals. Preemptively identifying possible obstacles helps
students to anticipate challenges they will encounter as
they pursue their goals. Addressing these potential bar-
riers ahead of time allows the students to develop strat-
egies for coping with challenges as they arise.
Module 2: “Reversible Spiral”
The objective of the second module is to elucidate how
thoughts, feelings, and behaviors are all interconnected
and influence each other. Students are taught to recognize
the automatic thoughts that are triggered by stressful
Fig. 4 Example of a completed worksheet used to practice forming mini-goals
Pössel et al. Psicologia: Reflexão e Crítica (2018) 31:23 Page 9 of 21
situations and how these thoughts might impact how they
feel or behave. As a first step, the students are taught to
differentiate between thoughts and feelings. They are pre-
sented with the following strategy: “If we can question or
test it, then it is probably a thought. There is no way to
test the truth of a feeling.”To practice distinguishing
thoughts from feelings, the students are presented with ex-
amples and asked to identify them as either a thought or a
feeling. One such example found on a worksheet used in
this module reads, “Lars/Tim thinks he has really goofy hair
that makes him kind of depressed about the way he looks.”
Skills that are taught later in the program rely on the stu-
dents’ability to know the difference between thoughts and
feelings and identify certain types of thoughts.
A number of activities are used to demonstrate the
relation between thoughts, feelings, and behaviors in the
“Reversible Spiral”module. In one activity, the connec-
tions game, the students are presented with separate lists
of thoughts, feelings, and behaviors (Fig. 5). Each stu-
dent is asked to connect one thought from the list to a
corresponding feeling and behavior. The goal of this
activity is to demonstrate how thoughts, feelings, and
behaviors are associated and how different situations can
result in very different feelings and behaviors, depending
on the thoughts a person has. The “Reversible Spiral,”
which is depicted visually on posters and worksheets
(Fig. 6), also serves to illustrate the interrelated nature of
thoughts, feelings, and behaviors. Students are intro-
duced to “up-thoughts”(thoughts that are realistic and
helpful) and “down-thoughts”(thoughts that are not
helpful or realistic and/or have an action blocking ef-
fect). The group is asked to come up with down-
thoughts that might spawn from a given situation. This
module focuses primarily on identifying down-thoughts,
while the next module teaches students to actively re-
place down-thoughts with up-thoughts.
Down-thoughts are broken down into four distinct
categories, which are intended to make down-thoughts
easier to recognize and identify. Demanding down-
thoughts involve thinking that things must or have to be
a certain way. Generalizing down-thoughts are thoughts
that are too extreme or all-encompassing to be realistic.
Worst-case scenario down-thoughts involve adopting an
overly negative viewpoint, such as thinking something is
totally horrible or terrible. Finally, making mountains out
of molehills is when a small piece of evidence is used to
make a generalized, largely unsupported inference. One
way to familiarize group members with the four types of
down-thoughts is to split the students into two teams
and play the “Down-Thought Game.”In this game,
group leaders read out examples of down-thoughts, such
as, “No one will ever think I’m cool.”The two teams
compete to try and correctly identify which category the
down-thought would fall into (in this case the correct
answer would be generalizing based on the keywords “no
one”and “ever”). The idea behind identifying down-
thoughts is that it aids the students in recognizing their
own negatively biased automatic thoughts. This recogni-
tion is the first step in replacing maladaptive thinking
patterns with more helpful alternatives.
Fig. 5 Connections game
Pössel et al. Psicologia: Reflexão e Crítica (2018) 31:23 Page 10 of 21
Module 3: “Think Tank”
In the “Think Tank”module, group members are intro-
duced to the concept of the “Reality Check,”which helps
to stop the progression of down-thoughts. Through mul-
tiple activities, students learn to identify negative emo-
tions they may be experiencing and how to stop and
evaluate why they might be feeling such emotions. The
steps to completing a Reality Check are provided to the
group members in the form of a visual aid to facilitate
the process (Fig. 7). One important aspect of being able
to successfully complete a Reality Check is the ability to
identify a specific down-thought and find the evidence
Fig. 6 Example for the Reversible Spiral
Fig. 7 Reality Check worksheet
Pössel et al. Psicologia: Reflexão e Crítica (2018) 31:23 Page 11 of 21
for and against it. In another activity, group members
play the role of a Reality Check Detective and use their
knowledge about down-thoughts to find the evidence.
The ability to provide evidence for and against the
down-thought allows the group members to investigate
their reaction to an event or circumstance and decide
whether their reaction is an appropriate match to the
situation. The reality check also serves to decelerate the
automatic thought process that may lead to a downward
spiral of emotions and behaviors.
While the bulk of the “Think Tank”module is used to
practice doing reality checks, the remainder of the mod-
ule focuses on how to turn down-thoughts into up-
thoughts. As mentioned above, up-thoughts are defined
as helpful and realistic thoughts that support our pro-
gress towards a goal. Though it is important to be able
to identify a down-thought, it is equally as important to
be able to turn said down-thought into an up- thought.
Making a slight change in the wording of the thought
can have a drastic impact on the content of the thought,
as well as the connected emotions and behaviors we
exhibit thereafter. For example, changing a thought from
“Nobody likes me”to “Some people/NAME OF PAR-
TICULAR PERSON like (s) me”creates some hope. In
order for the change in semantics to be relevant, the
group member must also be able to understand how the
function of the thought is being transformed from an
unproductive and limiting down-thought to a helpful
and realistic up-thought. One activity that the group
members partake in to assist in this process is the down/
up-thought comic (Fig. 8). By drawing their own comic,
group members are able to use their creativity to illus-
trate the possible consequence of a down-thought versus
that of an up-thought. Participation in this activity al-
lows for group members to easily see the stark contrast
in the resulting behaviors that can emanate from differ-
ent ways of thinking about a given situation.
Module 4: “Just Do It”
The last two LARS&LISA modules focus on behavior
and how to implement all of the preceding content. Just
Do It connects thoughts and behaviors and addresses
the pros and cons of various types of behavior. Specific-
ally, passive, aggressive, passive-aggressive, and assert-
ive behaviors are discussed in this module. Multiple
role-plays lead by the group leaders are used as a way
to visually demonstrate the four types of behaviors
(Fig. 9). Additionally, the role-plays allow the group
members to observe and reflect on the response that
each type of behavior might elicit from another person.
For example, in the assertive role-play script, actors 1
and 2 make plans to go to the mall but actor 2 does not
show up. Actor 1 is upset about the situation and must
use assertive communication and behavior to attempt
to resolve the issue.
Group members are encouraged to adopt assertive be-
havior over the other three types of behaviors, and
therefore, more time is spent practicing and identifying
signs of assertive behavior. Acting assertively allows indi-
viduals to communicate more effectively and make
Fig. 8 Example of the down/up-thought comic used in the program
Pössel et al. Psicologia: Reflexão e Crítica (2018) 31:23 Page 12 of 21
progress towards their goals. While assertive behavior is
encouraged, it is recognized that each type of behavior
has both advantages and disadvantages. Individuals have
reasons for choosing to enact various behaviors, includ-
ing when they opt not to be assertive. Thus, to avoid
resistance while promoting assertive behavior, the pros
and cons of each type of behavior are discussed (Fig. 10).
Additionally, if brought up by group members, the rare
circumstances when acting assertively might not be the
most appropriate form of behavior are discussed and
acknowledged.
Following the group leader-led role-plays and the
discussions described above, group members practice
assertive behavior by creating and acting out their own
role-plays. In these role-plays, each group member par-
ticipates as the leading actor in the same scenario twice.
Repeating the role-plays offers students the opportunity
to implement two to three new behaviors that were ab-
sent from their first attempt and provides them with the
positive experience of seeing their behavior improve.
Module 5: “Making Contact”
The last module of LARS&LISA, “Making Contact,”fo-
cuses on another part of the behavior aspect of the
Reversible Spiral. This module allows the group members
to continue practicing assertive behavior in “real life”sce-
narios or situations they would likely encounter in high
school. “Making Contact”goes beyond the intrapersonal
impacts of displaying assertive behavior and extends to
identifying ways of showing interest in others and to
responding empathetically. Group members spend time
thinking about when it may be important to make contact,
why it is important, and how it is accomplished. Situations
from meeting a new friend to applying for a job are all
instances in which having the skills to make contact are
necessary.
The module begins with a discussion about the im-
portance of showing interest in others and responding
empathetically. Learning how to appropriately make
contact with others across settings is an important
skill that most people have to implement on a daily
basis (Fig. 11). Learning to communicate effectively
provides opportunities to establish positive relation-
ships with others, which is often rewarding because it
can lead to companionship or support. While the
possible reward for making contact could be new re-
lationships, success is not measured by the response
of others. Instead, success is measured by the person’s
attempt to be assertive and communicate effectively.
In the latter part of the module, group members have
a chance to practice making contact using their own
hypothetical scenarios.
Structure of the sessions
As is typical for a cognitive-behavioral program, each
LARS&LISA session follows the same structure (Pössel,
Horn, Seemann, & Hautzinger, 2004). Common ele-
ments incorporated into every session include making a
semi-circle, reviewing the group guidelines, reviewing
the knowledge check, presenting the session agenda,
working on the session-specific content, and providing
Fig. 9 Worksheet to collect signs of passive-aggressive and assertive behavior
Pössel et al. Psicologia: Reflexão e Crítica (2018) 31:23 Page 13 of 21
feedback regarding participation and observance of the
group guidelines at the end of the session.
The authors (Pössel, Horn, Seemann, & Hautzinger,
2004) recommend that the group sit in a semi-circle for
multiple reasons. One advantage is that a semi-circle cre-
ates an open atmosphere and encourages teamwork. Asso-
ciated with this, by sitting in the semi-circle, the group
leaders appear less like an external authority figure and
more like fellow members of the group. Further, the
semi-circle allows the group leaders to alter seating
assignments, including their own position in the group, as
they see fit. Not only is this conducive for some of the
activities, but it can also be utilized to reduce distractibility
and promote the adolescents’focus on the content.
Fig. 10 Worksheet to collect advantages and disadvantages of passive-aggressive and assertive behavior
Fig. 11 List of steps how to appropriately make contact with others
Pössel et al. Psicologia: Reflexão e Crítica (2018) 31:23 Page 14 of 21
In the first session, the group leaders introduce some
general guidelines to set expectations and promote the
desired atmosphere in the group (i.e., fairness, respect,
teamwork, working atmosphere; Pössel, Horn, Seemann,
& Hautzinger, 2004). While the group leaders should
keep the overarching goals of the guidelines in mind, the
adolescents are usually a good source for generating
their own guidelines that will promote cohesion and col-
laboration in the group and allow them to participate
fully without fear of judgment. For example, in some
groups, having a smart phone out might not be a prob-
lem, while in other groups, it could be a good idea to
collect them before the group starts. Thus, the guide-
lines should be set in a collaborative manner together
with the adolescents. It is beneficial to go over the
agreed guidelines at the beginning of the first few, if not
all, sessions. This serves as a helpful reminder and also
allows the group leaders and adolescents to introduce
new guidelines or adapt the existing ones if necessary.
This will seem like a natural process when the group
leaders regularly go over the guidelines and point out
what worked well in the last session and identify any is-
sues that need to be addressed.
Another structural element of LARS&LISA is what the
authors call a knowledge check (Pössel, Horn, Seemann,
& Hautzinger, 2004). This is a short quiz about the con-
tent of a session that is handed out to the adolescents at
the end of the session. By the next session, the group
leaders correct the knowledge check and provide posi-
tive feedback (positive reinforcement) to the whole
group at the beginning of the next session. The main
purpose of this structural element is to assess whether
the adolescents understood the material of the session
and to identify how much and what parts of the content
need to be reviewed. In addition, correcting the know-
ledge check ensures that each adolescent has the correct
answers to questions on the most important elements of
the content.
Next, it is recommended that the group leaders go
over the agenda of the session, which includes the topics
and the goals for the day (Pössel, Horn, Seemann, &
Hautzinger, 2004). This provides structure for the ses-
sion and informs the adolescents about what they can
expect, which provides them with some sense of control.
Beginning with an agenda also encourages the group
members to connect the material from former sessions
to what will be covered in the present session.
After working through the session-specific content,
the group leaders help the members to make connec-
tions between current and past session material, as well
as give feedback to the adolescents regarding their
participation and observance of the group guidelines.
The authors emphasize that making these connections is
crucial. Thus, in the making connections portion of the
session, adolescents are invited to find examples of how
they used what they have learned so far in the previous
sessions in their everyday life. The group members are
encouraged to think about and share how applying what
they learned can help them to reach their goals. Accord-
ing to the authors, this shows adolescents how the
program can influence their everyday lives, encourages
them to use the content of LARS&LISA, and maintains
their motivation to actively participate. In regard to the
feedback session, Pössel, Horn, Seemann, and Hautzin-
ger (2004) express that the feedback should always be
positive and reinforcing, using specific examples about
what guidelines were followed when and by whom.
Negative feedback is discouraged as it may provoke a
reaction from the students or deter future participation.
Groups and group leaders
In the published manual, the authors state that the ideal
group size is between 8 and 12 students but they also
implemented groups with fewer (n= 4) and more (n≤
20) adolescents (Pössel, Horn, Seemann, & Hautzinger,
2004). Further, LARS&LISA groups have been led by
one, two, and even three group leaders. However, the de-
fault is to have two group leaders to implement a group
as this allows:
–For small group work without leaving any group
unsupervised (unsupervised small group work is
usually associated with a drop in focused work,
independent of the age of the group members),
–One group leader to focus on teaching the content
of the program while the other one can keep the
adolescents focused and/or answer questions from
individual adolescents without slowing down the
whole group,
–The group leaders to switch things up and take
turns presenting the content, thus making it more
interesting.
Pössel and his team also make suggestions about the
knowledge, experience, and behavior group leaders should
have and show, respectively (2004). They suggest that
knowledge about cognitive and learning theory and of so-
cial skills trainings is helpful. Further, they emphasize that
experience with adolescents, as well as in running groups
and the dynamic of groups, is beneficial. When it comes
to the actual implementation of the groups, they suggest
that group leaders should be able to differentiate between
knowledge-related and personal questions and call on ad-
olescents to answer the former but rely exclusively on vol-
unteers when it comes to the later. Further, group leaders
must ensure understanding of theoretical background, be
transparent about the group goals, and handle “wrong”
answers appropriately by reframing and acknowledging
Pössel et al. Psicologia: Reflexão e Crítica (2018) 31:23 Page 15 of 21
the “correct”parts of answers. Positive reinforcement is
emphasized as a means of encouraging wanted behavior,
and difficult group situations should be addressed in a
way that supports the development of a collaborative,
positive, trusting, and work-focused group atmosphere.
Pössel et al. (2013) describe that group leaders are
trained in two steps. First, future group leaders partici-
pated in a mock version of the program. Second, they
study the manual, materials, and procedures and discuss
their questions with their supervisors. Further, when
they implement the program, they participate in weekly
supervision using video recordings of each session. This
serves to ensure adherence to the manual and further
training of the group leaders.
Does LARS&LISA work, for whom and when?
Multiple meta-analyses have indicated that youth de-
pression prevention interventions are effective (e.g.,
Brunwasser, Gillham, & Kim, 2009; Horowitz & Garber,
2006; Merry et al., 2011; Stice, Shaw, Bohon, Marti, &
Rohde, 2009). However, the effects of the programs
range from small to modest, and multiple factors moder-
ate the effects of these programs. These moderators in-
cluded the type of prevention program (i.e., universal,
selective, indicated), participant attributes (e.g., age, sex,
race), characteristics of the intervention (e.g., duration,
content), group leaders (e.g., level of training), and tim-
ing of assessments (e.g., post-intervention, follow-ups of
various lengths). The effect sizes also differ depending
on the type of control condition utilized. Studies com-
paring the effects of an intervention with a no interven-
tion or waitlist control condition tend to find larger
effect sizes, whereas studies that utilize an active or pla-
cebo control condition tend to find comparatively
smaller effect sizes (Cuijpers et al., 2008). These factors
involved with measuring the effects depression preven-
tion are relevant to the evaluations of the LARS&LISA
program discussed below.
When examining the effects of universal prevention,
two issues that are different from the evaluation of ther-
apy programs should be considered. First, as Pössel,
Horn, and Hautzinger (2006) point out, while the life-
time incidence of subsyndromal and major depression
are relatively high (Bertha & Balázs, 2013; Kessler, Petu-
khova, et al., 2012), the point prevalence of major de-
pression in the general population is not high enough to
examine the effects of a program by the prevention of
diagnosable depression without an unrealistically high
sample size. Thus, the main outcome variable in most, if
not all, studies examining universal prevention is not the
reduction of new cases of major depression, but the re-
duction or prevention of worsening of depressive symp-
toms. This leads to the second issue that is different in
studies examining universal prevention. The majority of
participants in studies examining universal prevention
will show no or only very low levels of depression at
baseline. Thus, contrary to therapy, which aims to re-
duce existing symptoms (therapy effect), the aim of uni-
versal prevention will often not be the reduction of
symptoms, but the prevention of an increase of symp-
toms (prevention effect). Both issues should be kept in
mind when reviewing the evidence to the different ver-
sions of LARS&LISA. To allow the readers to evaluate
the strengths of the effects discussed below, we present
effect sizes provided in the original articles. When the
authors did not provide effect sizes, we calculated
Hedge’sgbased on the information provided in the ori-
ginal articles if possible.
The original LISA program has been evaluated in
studies from two different research groups (Groen et al.,
2003; Pössel et al., 2005; Pössel et al., 2008; Pössel, Horn,
Groen, & Hautzinger, 2004; Pössel, Horn, & Hautzinger,
2006). The first evaluation study was conducted by the
developers of the program with German eighth grade
students and tested participant acceptance of LISA.
More than 2/3 of the adolescents rated LISA as good or
very good, and between 60.9% and 67.6% of the adoles-
cents reported they had learned something they could
use in their everyday lives (Pössel, Horn, & Hautzinger,
2003). While the authors interpreted these data as an in-
dication that the content and skills included in LISA are
acceptable to and understood by adolescents from the
general population, they still made the changes outlined
above to further increase the acceptability and applic-
ability of the program.
The first evaluation study also assessed the effect of
LISA on self-reported depressive symptoms (Pössel,
Horn, Groen, & Hautzinger, 2004). As to be expected
based on the prevention effect described above, adoles-
cents with minimal depression scores at baseline who
had participated in LISA did not experience significant
increases of their depressive symptoms during the fol-
lowing 6 months (g= 0.33, 95% CI = −0.03 to 0.69, cal-
culated for this article). At the same time, their peers in
a non-intervention control condition reported significant
increases in depressive symptoms (g= 0.87, 95% CI =
0.42 to 1.32, calculated for this article). Consistent with
these findings, the percentage of adolescents with only
minimal depression scores who participated in LISA in-
creased from baseline to 6-month follow-up from 40.7
to 64.3% indicating that a number of participants experi-
enced a decrease in depressive symptoms, whereas per-
centages in the control group remained stable (37.2% vs.
37.6%). As to be expected following the therapy effect
described above, adolescents with subclinical depression
at baseline who participated in LISA reported a signifi-
cant reduction of depressive symptoms from baseline to
6-month follow-up (g=−0.41, 95% CI = −0.74 to −0.08,
Pössel et al. Psicologia: Reflexão e Crítica (2018) 31:23 Page 16 of 21
calculated for this article), whereas the depression scores
of their peers in the control group did not change during
the same time period (g= 0.14, 95% CI = −0.24 to 0.51,
calculated for this article). Consistent with these find-
ings, the percentage of adolescents with subclinical
depression participating in LISA decreased from 52.0 to
31.2%, while percentages in the control group remained
stable (50.4% vs. 51.4%). Thus, in this study, LISA had a
positive effect on the depressive symptoms of adoles-
cents with minimal and subclinical levels of self-reported
depressive symptoms (Pössel, Horn, Groen, & Hautzin-
ger, 2004). Subsequent analyses using the data of the
same study to calculate moderation analyses have con-
firmed the positive effect of LISA indicating that the
program is particularly beneficial for adolescents with
low global self-efficacy (Pössel et al., 2005). To be more
precise, depressive symptoms in adolescents with low
self-efficacy in the control group increased over time (g
= 0.43, 95% CI = −0.09 to 0.95) and depressive symp-
toms in adolescents with low self-efficacy were signifi-
cantly lower in the group that participated in LISA than
in the control group (g= 0.75, 95% CI = 0.26 to 1.24).
Further, adolescents with minimal depression scores at
baseline who participated in LISA reported fewer de-
pressive symptoms than adolescents participating in an
active control group (g= 0.50, 95% CI = 0.22 to 0.77)
using an expressive writing paradigm (Pennebaker & Beal,
1986) and a non-intervention control group (g= 0.50, 95%
CI = 0.20 to 0.80, calculated for this article) at post-inter-
vention. Adolescents with subclinical depression at base-
line who participated in LISA reported significantly lower
depressive symptoms at post-intervention compared to
adolescents participating in the active control group (g
= 0.42, 95% CI = 0.12 to 0.72, calculated for this article)
and the non-intervention control group (g= 0.47, 95%
CI = 0.14 to 0.81, calculated for this article) at
follow-up (Pössel, Horn, & Hautzinger, 2006).
The second evaluation study of LISA was conducted
by an independent group of researchers with German
seventh grade students using a non-intervention control
condition for comparison (Groen et al., 2003). While
Dodge’s social information processing model (1993) ex-
plains the development and maintenance of depression
and aggressive behavior, this study examined the effects
of LISA on both. Consistent with the prevention effect,
the authors of this study found no changes in aggressive
behavior in the LISA group (g=−0.02, 95% CI = −0.30
to 0.26, calculated for this article), while aggressive be-
havior significantly increased the control group over
time (g= 0.23, 95% CI = 0.03 to 0.49, calculated for this
article). Further, aggressive behavior was significantly
lower in adolescents participating in LISA compared to
control group adolescents at follow-up (g=−0.42, 95%
CI = 0.15 to 0.69, calculated for this article). However,
Groen et al. did not find any significant changes or dif-
ferences in depressive symptoms. The authors explain
the lack of a significant effect of LISA on depressive
symptoms in this study with the finding that there was
no increase in depressive symptoms in the non-interven-
tion control group. Considering that the participants in
this study were seventh grade students (mean age =
12.50 years, SD = 0.63), Groen et al. propose that the
lack of increase in depressive symptoms in the control
group is associated with the age of the adolescents. This
is consistent with epidemiological findings that rates of
depression do not begin to increase dramatically until
the mid-teen years (for a systematic review see Bertha &
Balázs, 2013), which is beyond the mean age of the par-
ticipants in Groen et al.’
s study. Thus, no increase in de-
pressive symptoms could be prevented, and therefore,
no prevention effect on depressive symptoms could be
observed.
A study evaluating the revised program (LARS&LISA)
involving German eighth grade students indicated that
the program is similarly effective in adolescents with and
without comorbid anxiety symptoms and conduct prob-
lems (Pössel et al., 2008). However, analyses examining
possible gender differences revealed that female adoles-
cents benefited from participating in LARS&LISA inde-
pendent of their level of depressive symptoms at baseline,
while their male peers benefited if they had minimal levels
of depressive symptoms at baseline, but not if they had
subclinical levels of self-reported depressive symptoms
(Pössel et al., 2008). To expatiate, boys with minimal de-
pression scores at baseline in the LARS&LISA group re-
ported significantly more severe depressive symptoms
than their peers in the control group at baseline (g=0.53,
95%; CI = 0.06 to 1.00), but this difference became
non-significant at post-intervention (g= 0.40, 95%; CI = −
0.07 to 0.87) and remained non-significant at follow-up (g
= 0.15, 95%; CI = −0.29 to 0.60). Further, depressive symp-
toms in boys with minimal depression scores at baseline
increased significantly more among those in the control
group compared to those in the LARS&LISA group over
time (g= 0.51, 95%, CI = 0.04 to 0.98). For girls, depressive
symptoms decreased significantly over time among partic-
ipants in LARS&LISA, regardless of whether they had
minimal depression scores (g= 0.61, 95%; CI = 0.09 to
1.13) or subclinical depression at baseline (g= 0.52, 95%;
CI = 0.08 to 0.95) Meanwhile, depressive symptoms in
girls in the control group did not change over time. Fur-
ther examining the gender difference, Pössel, Adelson,
and Hautzinger (2011) found that knowledge about the
content of LARS&LISA, but not conduct problems, might
partially explain the difference. Thus, the authors sug-
gested further examining possible gender differences in
the effects of depression prevention programs in general
and LARS&LISA in particular.
Pössel et al. Psicologia: Reflexão e Crítica (2018) 31:23 Page 17 of 21
Besides focusing on gender differences, the purpose of
another evaluation study of LARS&LISA in German
eighth grade students was to examine if teachers could
implement the program successfully (Wahl, Adelson,
Patak, Pössel, & Hautzinger, 2014). Consistent with the
previous evaluations in which prevention programs were
implemented by psychologists and teachers in separated
studies (Penn Resiliency Program: Gillham, Hamilton,
Freres, Patton, & Gallop, 2006; Gillham et al., 2007; Re-
sourceful Adolescent Program: Harnett & Dadds, 2004;
Merry et al., 2004), the authors of this study found psy-
chologists to be more effective group leaders than
teachers. More specifically, a decrease in depressive
symptoms was observed over time for girls participating
in LARS&LISA when it was implemented by psycholo-
gists (g=−0.36, 95% CI = −0.68 to −0.04, calculated for
this article). However, no such effect was found in boys
(g= 0.30, 95% CI = −0.04 to 0.57, calculated for this art-
icle) or when LARS&LISA was implemented by teachers
(girls: g=−0.10, 95% CI = −0.40 to 0.20; boys: g=−0.10,
95% CI = −0.39 to 0.19, calculated for this article). Wahl
and colleagues concluded that their results, combined
with previous similar findings for other prevention pro-
grams (Gillham et al., 2006,2007; Harnett & Dadds,
2004; Merry et al., 2004), highlight a limitation to the
widespread dissemination of programs like LARS&LISA,
considering the likelihood of any school system hiring
enough psychologists to comprehensively implement
this type of prevention.
Finally, the purpose of the study using the American
version of LARS&LISA (TIM&SARA) was to overcome
a limitation of all previous studies examining this pro-
gram and most other depression prevention programs,
the lack of a structurally equivalent control condition
(Pössel et al., 2013). In their meta-analysis of psychother-
apy studies, Baskin, Tierney, Minami, and Wampold
(2003) found similar effects for specific (e.g., cognitive-
behavioral therapy) and nonspecific programs when they
had structural equivalence, which they defined as being
identical in regards to the number and duration of ses-
sions, settings (group vs. individual), level of therapists’ex-
perience, and adaptability of the therapy to the client. This
raises a question regarding whether a successful preven-
tion program has to be as complex as LARS&LISA or if
simpler programs (which might also be easier to imple-
ment) can be comparably beneficial. In their study with
American ninth grade students, Pössel and colleagues
found that adolescents participating in TIM&SARA re-
ported significantly lower depression scores compared to
the structurally equivalent non-specific prevention pro-
gram (g= 0.29, 95% CI 0.06 to 0.52) and a non-interven-
tion control condition (g= 0.30, 95% CI 0.07 to 0.53) at
4-month follow-up. However, these differences did not re-
main significant as the depression scores in the
non-specific prevention (8-month follow-up g=0.26; CI
0.03 to 0.48; 12-month follow-up g= 0.34, 95% CI 0.11 to
0.56) and non-intervention control (8-month follow-up
g=−0.32, 95% CI −0.10 to −0.55; 12-month follow-up
g=−0.28, 95% CI −0.05 to −0.50) groups decreased at
the later follow-ups as well.
LARS&LISA shows positive effects on aggressive be-
havior (Groen et al., 2003) and depressive symptoms for
American (Pössel et al., 2013) and German adolescents
(Pössel et al., 2005; Pössel et al., 2008; Pössel et al., 2011;
Pössel, Horn, Groen, & Hautzinger, 2004; Pössel, Horn,
& Hautzinger, 2006; Wahl et al., 2014). To be more pre-
cise, female adolescents benefit independent of their
level of depressive symptoms while male adolescents
with minimal levels of depression at baseline tend to
benefit more than males with higher levels of depressive
symptoms at baseline (Pössel et al., 2008). This differ-
ence is at least partially explained by knowledge of the
content of LARS&LISA (Pössel et al., 2011). Further, the
program benefits adolescents independent of comorbid
symptoms of anxiety and conduct problems (Pössel
et al., 2008), and it is superior to other programs (Pössel
et al., 2013; Pössel, Horn, & Hautzinger, 2006) as long as
it is implemented by psychologists (Wahl et al., 2014).
Conclusions
Based on the last 20 years, what are the next steps in the
ongoing iterative process between program develop-
ment, empirical studies, and feeding the empirical evi-
dence back into the program development? As the
comparison with the structurally equivalent non-specific
prevention program (Pössel et al., 2013) hints that the
effects of LARS&LISA are based on specific cognitive-
behavioral interventions, it seems logical to further
examine the underlying mechanisms of change. Elucidat-
ing those mechanisms might allow us to (a) understand
why male adolescents with elevated depressive symp-
toms at baseline seem not to benefit as much as other
youth, (b) improve the effects of the program (for all
participants), and (c) simplify the program by focusing
on the parts that make LARS&LISA effective and, with
that, maybe even reconsider teachers as possible group
leaders. In this context, the question raised by Wahl et
al. (2014) and other studies (Gillham et al., 2006,2007;
Harnett & Dadds, 2004; Merry et al., 2004) about the
feasibility of wide-spread dissemination of LARS&LISA,
or any similar program, if the program must be delivered
by psychologists is a valid concern, and elucidating the
mechanisms of change and thereby the reasons why
teachers were unable to effectively implement the pro-
gram is an important area for future research. Of inter-
est in this context are some findings from previous
studies. As mentioned above, Pössel et al. (2011) found
that the knowledge of cognitive and social parts of
Pössel et al. Psicologia: Reflexão e Crítica (2018) 31:23 Page 18 of 21
LARS&LISA partially explained gender differences in the
effects of the program. This raises the question of why
male adolescents seem to acquire or retain less of the
program’s content and how their understanding can be
improved. Further, Pössel and colleagues (2003) report
that immediately after the end of LISA (baseline-post
comparison) female adolescents reported using their pre-
viously existing social network more often while male ado-
lescents tended to increase their social network. Another
study showed that changes in cognitive errors seem to
mediate the effects of TIM&SARA (Pössel, Martin, Gar-
ber, & Hautzinger, Submitted-a). Unfortunately, in this
publication, adolescent gender was not considered. Finally,
in a publication to LARS&LISA, Pössel, Roane, and Haut-
zinger (Submitted-b) found that the program impacts
frontal brain activity in male but not female adolescents
while it influences depressive symptoms in female but not
male adolescents. Summarized, there is some evidence
that both cognitive and social elements make the program
effective, but it might be that both genders benefit differ-
ently from these two aspects. Consequently, a more sys-
tematic examination of possible change mechanism by
gender interactions seems necessary. Associated with this
consideration, an exploration of potential gender differ-
ences in the social information processing (Dodge, 1993)
of depressed adolescents might be beneficial. For example,
one could speculate that males tend to be more likely to
produce multiple problem-irrelevant responses on the
stage of response accessing, while females might evaluate
withdrawing behavior as more positive during the response
evaluation and selection stage. Based on the logic of the
program, role-plays should be helpful for both males and
females, but the purpose and therefore the focus of the
role-plays might be a crucial factor in maximizing benefits
for both genders. One possible outcome of an examin-
ation of the underlying change mechanisms might be two
programs that are similar but tailored to the specific needs
of the gender of the participating adolescents (LARS
and LISA).
An issue that many prevention researchers wrestle with
is that it seems unrealistic to expect schools can imple-
ment programs for each and every problem their students
might encounter. Thus, the above reported findings re-
garding aggressive behavior (Groen et al., 2003) are cru-
cial, but only an incipient first step. It seems only logical
that the authors of LARS&LISA currently examine the ef-
fects of the program on other outcome variables such as
academic indices (grades and suspensions) and physical
health (blood pressure, cortisol, and immune parameter in
saliva). This also makes sense given that depression is
known to be associated with academic (Humensky et al.,
2010; Lawrence et al., 2016; Naicker, Galambos, Zeng,
Senthilselvan, & Colman, 2013) and physical health issues
later in life (for a meta-analyses, see Nicholson, Kuper, &
Hemingway, 2006). Thus, findings regarding the effects of
LARS&LISA on those variables might be pivotal for a po-
tential dissemination of LARS&LISA and similar cogni-
tive-behavioral programs.
Authors of future studies should consider the possibil-
ity of erroneous intervention effects that can result from
the combination of using self-report measures of depres-
sive symptoms and a lack of a believable placebo or
active control condition. If adolescents are aware they
participated in a depression prevention program, it is
possible that they might answer questions regarding
depressive symptoms post intervention in a socially
desirable way, meaning they report fewer depressive
symptoms than they actually experience. As only the
participants in the prevention condition are likely to
experience pressure to respond in this way, it is possible
that erroneous intervention effects are observed. To
avoid this problem, parent-, teacher-, or clinician-report
measures of depressive symptoms should be collected in
addition to self-reports. Further, as adolescents in a
believable placebo or active control condition would
experience a similar pressure to answer in a social desir-
able way, the authors of future studies might want to
follow the example of Pössel et al. (2013) and to com-
pare a prevention program with an equally believable
placebo or active control program.
Obviously, there are many other topics related to
cognitive-behavioral depression prevention programs in
general and to LARS&LISA in particular that need to be
explored. Thus, while the journey to help prevent
depression in adolescents and the negative consequences
associated with this serious mental problem has just
begun, the last 20 years of program development and
collection of empirical evidence produced a program
that benefits most adolescents along with many insights
that are relevant beyond this one specific program. At
the present time, there is convincing evidence to support
the efficacy and utility of universal prevention programs,
including LARS&LISA. However, additional research is
still needed to make such programs equally effective for
all populations and increase the feasibility of widespread
implementation.
Abbreviations
LARS&LISA: Lust An Realistischer Sicht & Leichtigkeit Im Sozialen Alltag;
TIM&SARA: Together Initiating More Socially Advantageous & Realistic
Attitudes
Authors’contributions
PP wrote the first draft of the manuscript with the exception of the
subsections written by the two co-authors. Further, he edited the subsec-
tions of the two co-authors.
ES wrote the descriptions of the program modules 1 to 3 and co-edited the
complete manuscript. OA wrote the descriptions of the program modules 4
and 5 and co-edited the complete manuscript. All authors read and approved
the final manuscript.
Pössel et al. Psicologia: Reflexão e Crítica (2018) 31:23 Page 19 of 21
Competing interests
PP is also the first author of the described prevention program which is
published in German. ES and OA declare that they have no competing
interests.
Publisher’sNote
Springer Nature remains neutral with regard to jurisdictional claims in published
maps and institutional affiliations.
Received: 17 May 2018 Accepted: 12 August 2018
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